Violence towards Mental Health Nurses - Research Paper Example

?Introduction In Australia, mental health care has assumed a greater significance in the health care industry as the number of people with mental disorders is increasing day by day. The Australian Bureau of Statistics (2007, p. 7), in its National Survey of Mental Health and Wellbeing, has identified that one in five Australians is likely to experience mental illness in any year. Subsequently, occupational violence towards the registered nurses has become commonplace. In a survey among hospital-based nurses and community psychiatric nurses, Adams and Whittington (1995, p. 171) found that 29% of the target population experienced verbal aggression over a 10 week period, with 44% of the incidents involved threats and the rest consisted of abuses. In fact, the Australian Institute of Criminology has identified the health industry to be the most violent industry in the country, with registered nurses (RNs) recording the second highest number of violence-related workers compensation claims in year 1995 and 1996, ranking even higher than prison and police officers (Deans, 2004, p. 14). Patient violence on mental health care professionals not only leads to staff sickness and absenteeism but also to various psychological and mental distresses. Specific psychological problems include depression, anxiety, isolation, trauma (LeFlore & Bell, 2007, p. 147), post-traumatic stress disorders, loss of confidence, anger, fear, loss, distrust, and guilt (Whittington & Wykes, 1992; Doughty, 2005, p. 1). Understandably, these problems would adversely affect the therapeutic alliance between patients and HCPs (Watts & Morgan, 1994, p. 14; LeFlore & Bell, 2007, p. 147). In addition, this will also prevent optimal staff recruiting and retention of employees within the hospital (Doughty, 2005, p. 1). In a survey conducted by Duxbury & Whittington (2005, p. 469) on 80 mentally ill patients and 82 HCPs in three inpatient mental healthcare wards, it was found that that the patients regarded the poor facilities and communication as the two significant factors behind violence, whereas the nurses identified that the patients’ mental illness was the root cause for the violence. On the other hand, according to Glick and Fishkind (2008, p.117), the risk of violence in psychiatric care facilities include lower staff-to-patient ratio, higher percentage of female HCPs, and presence of staff without specific training in psychiatry or agression. The United States Department of Labor (2004, p. 7) also recognizes the lack of staff training as partly causing hostile and assaultive behavior of patients. Currently, the intervention strategies used to curb violence include stress management, rehabilitation of staff victims and providing them a work environment that is not conducive to violent behavior (Warshaw & Messite, 1996, p. 993). Stathopoulou (2003, p. 4) suggested that the preventive measures on violence towards health care professionals should focus on three areas: hospital organization, arrangement of the physical environment, and staff training and development. Significance of the study With the increasing number of psychiatric patients, the potential for occupational violence for HCPs in psychiatric facilities is on the rise as well. The adverse effects of these incidents on work performance and retention of employees make it imperative for health institutions to provide effective means to prevent and manage aggression from psychiatric patients. Theoretical framework for the research methodology Figure 1. Theoretical framework for this research study This research proposal predicts that providing appropriate knowledge regarding the management and prevention of violent behavior from psychiatric patients through training equips the HCPs the ability to protect themselves from the potential physical and psychological effects of aggressive behavior from their patients, and subsequently allows them to perform to the best of their abilities. Ultimately, the health institutions with trained HCPs benefit from increased work performance and retention of employees. Statement of the problem Research ideas The number of psychiatric patients in Australia continuously increases. Aggression from these patients partly causes the health industry to be the most violent industry in Australia. Violence leads to physical and psychological conditions that ultimately affect work performance. Statement of the problem Given these research ideas, the statement of the problem is, Because the potential threat to HCPs continuously rise with the increasing number of patients, the healthcare industry in Australia that cater to psychiatric conditions will suffer from poor work performance and retention of employees. Research questions The proposed research seeks to explore whether staff training helps in preventing or managing violence in mental healthcare settings. As such, the research questions for the study include. Does staff training reduce violence in mental healthcare units? And if so, How far do staff training programs contribute towards managing of preventing violence in mental healthcare units? Scope and limitations of the study This study will focus on the assessment of training HCPs of the psychiatric unit of Dandenong hospital regarding violence prevention and control in decreasing work-related violence incidents reported by HCPs. Although there are many strategies that are suggested to decrease incidents of violent behavior among psychiatric patients, only the effects of staff training will be analyzed in this study. Also, only a specific training program among a number of available ones will be used in this study. It will also only be able to assess one hospital in Australia, because of limitations in the resource. The study will also be largely based upon the subjectivity of HCPs participating in the surveys. Definition of terms In general, health care providers (HCPs) are licensed doctors, nurses, therapists, midwives, health workers, and medical technicians who work with patients to manage their health. In the case of this study, HCPs refer specifically to those who work in the psychiatric unit of Dandenong hospital to deal with patients admitted in the facility. Broadly, psychiatric patients is defined for this study as individuals diagnosed by licensed doctors of having a psychiatric illness. For this study, however, the definition will be limited to those who admitted in the psychiatric facility of Dandenong hospital. Violence is defined as the intentional use of physical force or power to sexually, physically and/or psychologically abuse as well as deprive oneself, another person, or a group, resulting to physical and psychological injury or death (Privitera, 2011, p. 5). According to Skibeli Joa and Morken (2012, p. 56), there are four types of violence that an HCP can experience from a patient, their friend(s) or family member(s). Violent abuse is defined as intentional offensive swearing or obscene gesturing given face-to-face or over the phone. Threats, on the other hand, are messages, through word or gesture, of doing harm in the future. These include pressuring the HCP of doing a specific task. Meanwhile, physical abuse involves attacks of bodily contact such as punching, slapping, kicking or hitting with an object with the goal of intimidating or causing bodily harm onto the HCP. Finally, sexual harassment is any form of unwanted sexual propositions or attention. It may be in a form of humiliating or offensive jokes and remarks with sexual connotation, suggestive behaviors, request for inappropriate and unnecessary physical examinations, touching, and grabbing. Review of Relevant Research and Theory Effectiveness of staff training Several studies have also looked into the effectiveness of staff training in allowing HCPs to effectively protect themselves against violence. When Calabro, Mackey & Williams (2002) offered 180 HCPs one-and-a-half day training in preventing and managing patient violence, they found through a pretest and posttest study design that the training increased the knowledge, attitude, self-efficacy and behavioral intention of the HCPs toward violence in the work place. Similar results were obtained from before-and-after studies by Whittington and Wykes (2001), when they provided six training sessions to 155 nurses from the thirteen wards with the highest levels of violence in two selected psychiatric hospitals, by Ilkiw-Lavalle, Grenyer & Graham (2002, p. 233) that used a two-day Intervention Training for Aggression Control Techniques (INTACT) Aggression Management Program on 103 psychiatric care staffs in Australia, and by Cowin et al. (2003, p. 72). In fact, the overall rate of violence fell by 31% after the training, with high compliance wards reducing the frequency of assaults by two-thirds after the training (Whittington & Wykes, 1996, p. 48). Methods of training Duxbury and Whittington (2005, p. 469) suggested fundamental therapeutic communication skills as the potential solution to violence. On the other hand, Doughty (2005, p. 1) wanted the staff training to focus on 1) the risk factors that lead to violence, 2) the preventive factors to diffuse violence, and 3) proper ways of reporting and recording incidence of violence. Meanwhile, Stathopoulou (2003, p. 4) recognize the importance of emphasizing communication skills, de-escalation techniques, conflict resolution, documentation, and physical restraining in teaching HCPs in psychiatry centers. In Australia, it is compulsory for HCPs to undergo training in violence management and prevention. The training program should tackle the needed policies and procedures in place, appropriate legal discussions, preparations for any aggressive and assaultive situations, emergency response processes, and documentation. However, restraint, seclusion and pharmacological management are not mandated. Among the 28 training programs in the world, 15 have been conducted in Australia. These fifteen are: 1) A safer place to work: Preventing and managing violent behaviour in the health workplace, 2) Crisis and Aggression Limitation Management (CALM), 3) Critical Incident Positive Outcome (CIPO), 4) Clinical Risk Management and Assessment, 5) Code Black , 6) Dealing with aggressive and potentially violent behavior, 7) INTACT, 8) MOVIAT program, 9) Nonviolent Crisis Intervention, 10) P3, 11) Professional Assault Response Training (PART), 12) Preventing and Managing Aggression in the Health Workplace, 13) Responding effectively to difficult or challenging behavior, 14) The De-escalation Kit, and 15) When it’s right in front of you: assisting health care workers to manage the effects of violence in rural and remote Australia. When ranked based on course content, CIPO was found to be the most comprehensive, since it discusses eleven out of the thirteen possible topics covered (Farrell and Cubit, 2005, p. 46, 50). Potential contribution of the study If found to be effective in helping HCPs manage and prevent violence in the workplace, staff training can be implemented by health institutions to avoid and control such incidents, and ultimately to increase work performance and retention of HCPs, especially those in the psychiatric field. Overview of Research Methodology This will be a three month duration study of the changes in knowledge, perception and practice of management and prevention of HCP-directed patient aggression before and after CIPO aggression management program. The research will be done to assess the effectiveness of staff training in improving work satisfaction, work performance and retention of employees in the psychiatric care unit of Dandenong Hispital. Questionnaires handed out before, immediately after, and two months after the training will be used to determine such improvements. The data will be analyzed using statistical tools Constant Comparison Analysis and Content Analysis. Target Population and Sampling Methods The subjects of this study will be HCPs in the psychiatric care unit of Dandenong Hospital in Melbourne who has any prior experiences of patient violence. Dandenong Hospital is one of the major hospitals in Australia providing a range of health services, catering to almost 100 patients. The list of HCPs in the psychiatric care unit of the hospital will be obtained from the human resources department of the said institution. To identify the potential subjects of this study, a preliminary questionnaire eliciting details such as designation, age, gender, years of experience, receipt of any prior staff training, and incidents of patient violence experiences will be sent out to all HCPs of the said department. Together with this questionnaire, a letter requesting for their participation and presenting an overview of the research study will be handed out on these HCPs. The respondents who do not have any prior experiences of patient violence will be eliminated from the study. Similarly, all those respondents who do not have at least three years of experience in mental health care will also be eliminated. The data will be presented in Table 1 and Table 2. Table 1. Demographics of the respondents who qualify in the inclusion criteria Percentage of respondents Percentage of respondents Age 20-30 Gender Male 30-40 Female 40-50 > 60 Designation Years of experience Doctor 3-5 Nurse 5-10 Medical Technician 10-15 Therapist 15-20 Therapist >20 years Aid Others Table 2. Violence and violence-training background of respondents Percentage of total respondents Percentage of total respondents Number of violence experienced Types of violence experienced 1-5 Violent abuse 6-10 Threats 10-15 Physical abuse 15-20 Sexual harassment >20 With prior aggression management training Details of data collection process Pre-evaluation For those respondents who qualify based on the inclusion criteria, an interview through a written questionnaire will be administered on these HCPs. A sample of the sampling and pre-training questionnaires is provided at the end of this proposal. During this phase, the frequency, type and nature of experienced violent behavior will be further questioned. In addition, their knowledge of, attitude toward, and practice of any violence management and prevention techniques will be determined through a Knowledge, Attitude and Practice survey (KAP1). This will allow the researcher to determine the baseline knowledge, perception and experience regarding protecting themselves against aggressive behavior from patients. A sample survey form can be found at the end of the proposal. Immediate post-evaluation After gathering these data, the Critical Incident Positive Outcome (CIPO) Training Program will be given to the participants. This program was used out of around thirty programs in the world, twelve of which available in Australia, because it has the most comprehensive curriculum, covering. Staff responses regarding their knowledge and attitude of the various intervention techniques immediately after the training will be conducted using a Knowledge and Attitude Survey (KAP2). This determines whether or not there have been any changes in the knowledge and attitudes of the participants regarding violence management and prevention due to the training. Evaluation two months after training Two months after the training program, another KAP survey (KAP3) will be administered on the participants to determine whether the staff training has brought about an overall decrease in the amount of violence. This will allow evaluation of the long-term effects of the training, especially whether or not 1) they applied the learning and 2) they were able to protect themselves against violence because of it. Proposed methods of data analysis The results of the KAP surveys will be expressed as percentage of total respondents. They will be analyzed using the SPSS program. For each categorical variable, differences between pre-training and post-training values using chi-square test. Data will be presented in Table 2. Table 2. Comparison of the responses of participants before, immediately after, and two months after training. Data are expressed as percentage of total respondents. Statistical differences through chi-square test will be indicated using a superscript. K1 K2 K3 Knowledge on Orientation to relevant policies and procedures in the workplace with regards to dealing with violence Cost of aggression in workplace Causes of violence Types of violence Risk assessment Proper communication toward patients Pharmacological intervention of violence Physical restraint of aggressive patient Self defense Risk of applying restraints Seclusion Legal implications of occupational violence Debriefing of victims How to properly record and report incident Belief of effectiveness of the following in management and prevention of violence Victim rehabilitation Safer physical facilities (no sharp objects allowed, maintaining certain distance away from the patient, etc.) Staff training regarding management and prevention of patient aggression Organization strategies (more healthcare professional-to-patient ratio, lesser percentage of female staff members, etc.) Physical restraint of patient Self defense Seclusion of violent patient Pharmacological treatment of aggression Practice of the following interventions Victim rehabilitation Safer physical facilities (no sharp objects allowed, maintaining certain distance away from the patient, etc.) Staff training regarding management and prevention of patient aggression Organization strategies (more healthcare professional-to-patient ratio, lesser percentage of female staff members, etc.) Physical restraint of patient Self defense Seclusion of violent patient Pharmacological treatment of aggression Cost estimation In Australian dollars COMPONENTS / ACTIVITIES Unit Cost Quantity Total cost Sampling and pre-training evaluation Questionnaire printing and distribution 0.5 50 25 Data collection CIPO Aggression Management Program 10 40 400 Questionnaire for immediate post-training evaluation 0.5 40 20 Questionnaire for evaluation two months after training 0.5 40 20 Total 465 Gantt Chart 1 2 3 Responsibility Output Indicator Approval of the proposal X To gain permission to perform the methodology Approved research proposal Handing out sampling and pre-training questionnaire to population X To identify possible participants Returned questionnaires Analysis of results of sampling survey X To identify qualifying respondents Qualifying respondents Analysis of results of pre-training survey X X To determine the participants’ baseline knowledge, attitude and practice regarding violence Analyzed data staff training X To teach participants how to manage and prevent violent behavior among patients Trained participants Immediate post-training survey X To identify improvements in knowledge, attitude and practice regarding violence Answered questionnaires Analysis of immediate post-training survey X X X To determine the short-term effects of the training Analyzed data Survey two months after training X To determine persistence of improvements in knowledge, attitude and practice regarding violence Answered questionnaires Analysis of data from survey two months after training X To determine the long-term effects of the training Analyzed data Paper writing X To integrate findings of the study Completed paper PRE-TRAINING SURVEY FORM Name Contact Details Age Gender Designation (please encircle one) Doctor Nursing Aid Nurse Medical Technician Midwife Therapist Medical Technician Others (please specify) Years of experience Please proceed when years of experience is more than three years Any prior training on managing and preventing patient aggression? (please encircle one) Yes No Any prior patient violence experience? (please encircle one) Yes No Are you willing to participate in a two-day training on violence management and prevention? Yes No Please proceed if answer to previous question is YES Throughout the course of your career in psychiatric care, how many times have you experienced violence? (please encircle one) 1-5 6-10 10-15 15-20 > 20 times Violence is defined as the intentional use of physical force or power to sexually, physically and/or psychologically abuse as well as deprive oneself, another person, or a group, resulting to physical and psychological injury or death (Privitera, 2011, p. 5). According to Skibeli Joa and Morken (2012, p. 56), there are four types of violence that an HCP can experience from a patient, their friend(s) or family member(s). Violent abuse is defined as intentional offensive swearing or obscene gesturing given face-to-face or over the phone. Threats, on the other hand, are messages, through word or gesture, of doing harm in the future. These include pressuring the HCP of doing a specific task. Meanwhile, physical abuse involves attacks of bodily contact such as punching, slapping, kicking or hitting with an object with the goal of intimidating or causing bodily harm onto the HCP. Finally, sexual harassment is any form of unwanted sexual propositions or attention. It may be in a form of humiliating or offensive jokes and remarks with sexual connotation, suggestive behaviors, request for inappropriate and unnecessary physical examinations, touching, and grabbing. What types of violence have you experienced? (please encircle all appropriate answers) Please rank 1-4 according to frequency, with 1 being the most experienced and 4 being the least experienced (please use the space on the right). Violent abuse Threats Physical abuse Sexual harassment Even prior to you answering this questionnaire, do you KNOW any intervention strategies a healthcare institution uses to protect a healthcare professional against violence from a patient, his/her friend(s) or relative(s)? (please encircle all appropriate answers) How were you able to know them? Through a previous training program, through a colleague? (please use the space on the right.) Victim rehabilitation Safer physical facilities (no sharp objects allowed, maintaining certain distance away from the patient, etc.) Staff training regarding management and prevention of patient aggression Organization strategies (more healthcare professional-to-patient ratio, lesser percentage of female staff members, etc.) Physical restraint of patient Self defense Seclusion of violent patient Pharmacological treatment of aggression Others (please specify) Which of the following do you THINK are effective? (please encircle all appropriate answers) Why or why not? Victim rehabilitation Safer physical facilities (such as no sharp objects within the facility) Staff training regarding management and prevention of patient aggression Organization strategies (more healthcare professional-to-patient ratio, lesser percentage of female staff members, maintaining certain distance away from the patient, etc.) Physical restraint of patient Self defense Seclusion of violent patient Pharmacological treatment of aggression Others (please specify) Which of the following are you CURRENTLY PRACTICING? (please encircle all appropriate answers) Victim rehabilitation Safer physical facilities (no sharp objects allowed, maintaining certain distance away from the patient, etc.) Staff training regarding management and prevention of patient aggression Organization strategies (more healthcare professional-to-patient ratio, lesser percentage of female staff members, etc.) Physical restraint of patient Self defense Seclusion of violent patient Pharmacological treatment of aggression Others (please specify) Which of the following did you find to be INEFFECTIVE, and are thus NOT PRACTICED anymore? (please encircle all appropriate answers) Victim rehabilitation Safer physical facilities (no sharp objects allowed, maintaining certain distance away from the patient, etc.) Staff training regarding management and prevention of patient aggression Organization strategies (more healthcare professional-to-patient ratio, lesser percentage of female staff members, etc.) Physical restraint of patient Self defense Seclusion of violent patient Pharmacological treatment of aggression Others (please specify) Will you be willing to undergo an aggression management program? (please encircle one) Yes No Which of the following do you think you need to learn from the training program? (please rank from 1-14, with 1 being the most needed and 14 being the least needed) Orientation to relevant policies and procedures in the workplace with regards to dealing with violence Cost of aggression in workplace Causes of violence Types of violence Risk assessment Proper communication toward patients Pharmacological intervention of violence Physical restraint of aggressive patient Self defense Risk of applying restraints seclusion Legal implications of occupational violence Debriefing of victims How to properly record and report incident ++End of Survey++ Thank you for your time! References Adams, J & Whittington, R. (1995). Verbal aggression to psychiatric staff: traumatic stressor or part of the job? Psychiatric Care, 2, 171– 174. Australian Bureau of Statistics. (2007). National Survey of Mental Health and Wellbeing: Summary of Results. Retrieved from: http://www.ausstats.abs.gov.au/Ausstats/subscriber.nsf/0/6AE6DA447F985FC2CA2574EA00122BD6/$File/43260_2007.pdf Calabro, K., Mackey, T. A., & Williams, S. (2002). Evaluation of training designed to prevent and manage patient violence. Issues in Mental Health Nursing, 23, 3-15. Cowin, L., Davies, R., Estall, G., Berlin, T., Fitzgerald, M., & Hoot, S. (2003). De-escalating aggression and violence in the mental health setting. International Journal of Mental Health Nursing, 12, 64-73. Deans, C. (2004). Nurses and occupational violence: the role of organizational support in moderating professional competence. Australian Journal of Advanced Nursing, 22 (2), 14-18. Doughty, C. J. (2005). Staff training programmes for the prevention and management of violence directed at nurses and other healthcare workers in mental health services and emergency departments. NZHTA Technical Brief, 4(2), 1-59. Duxbury, J. & Whittington, R. (2005). Causes and management of patient aggression and violence: staff and patient perspectives. Journal of Advanced Nursing, 50(5), 469–478. Farrell, G. & Cubit, K. (2005). Nurses under threat: A comparison of content of 28 aggression management programs. International Journal of Mental Health Nursing. 14, 44-53. Glick, R., Berlin, J., & Fishkind, A. (2008). Emergency psychiatry: principles and practice. New York: Lippincott Williams & Wilkins. Ilkiw-Lavalle, O., Grenyer, B. F. S., & Graham, L. (2002). Does prior training and staff occupation influence knowledge acquisition from an aggression management training program? International Journal of Mental Health Nursing, 11, 233-239. LeFlore, F. & Bell, M. (2007) Mental health matters for violence prevention: a multi-faceted approach to risk factors and solutions. Proceedings of Persistently Safe Schools: The 2007 National Conference on Safe Schools, 143-155. Skibeli Joa, T. & Morken, T. (2012). Violence towards personnel in out-of-hours primary care: A cross-sectional study. Scandinavian Journal of Primary Health Care, 30, 55-60. Stathopoulou, H.G. (2003). Violence and Aggression towards Health Care Professionals. Health Science Journal, 1(2), 1-7. U.S. Department of Labor. (2004). Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. Occupational Safety and Health Administration. Retrieved from: http://www.osha.gov/Publications/osha3148.pdf Warshaw L.J. & Messite J. (1996), Workplace violence: preventive and interventive strategies. Journal of Occupational and Environmental Medicine, 38, 993-1006. Whittington, R & Wykes, T. (1992). Staff strain and social support in a psychiatric hospital following assault by a patient. Journal of Advanced Nursing, 17, 48-486. Whittington, R., & Wykes, T. (1996). An evaluation of staff training in psychological techniques for the management of patient aggression. Journal of Clinical Nursing, 5, 257-261. 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