Minimizing Patient Aggression and Violence - Essay Example

Minimizing Patient Aggression and Violence by Minimizing Patient Aggression and Violence Abstract Research Question: How do nurses in acute mental health ward minimize and manage patient aggression and violence? Background: Cases of aggression and violence are a cause for concern among nurses in acute mental care wards. There is need for management measures that ensure the safety of nurses and other patients in the ward. Aim: The primary objective is to find out how nurses in acute mental health ward minimize and manage patient aggression and violence and what measures are most effective Research design: It is a qualitative study in order to collect information on measures adopted for controlling aggression. Data will be collected through observation and the use of semi-structured interviews. Sample: The sample is collected through random sampling. It consists of fifteen registered nurses that have worked in a mental care ward in a hospital in North London for at least five years. Data Analysis: The data will be analyzed through thematic analysis. Data collected will be transcribed and facilitated using Colaizzi’s seven steps especially interview transcriptions. This should lead up to production of a comprehensive report. Findings: It is the hope of the researcher that the study will reveal the most common management measures and the most effective. The findings should be applicable in acute mental care wards to prevent violence among patients or any forms of aggression. The expected outcome is a reduction in aggression, especially that which is directed toward nurses in these wards and hence improve on their safety. 1. Introduction Aggressive behavior in the acute mental health ward is a major concern in under mental healthcare. Turnbull and Patterson (2009) in their work, point out that nurses working in mental healthcare facilities often find themselves falling victim to assault at the ward, with at least one out ten being physically assaulted. The situation is dire. Healthcare providers in this setting are therefore tasked with finding means to manage this violence. Because of this, there has been focus around ways in which nurses in acute mental healthcare wards can minimize and manage patient aggression and violence (Chou, Lui and Mao 2002).This paper seeks to address the management of aggression and violence in mental care ward. Background There has been increasing attention towards violence in the mental health ward, given the escalation in the population of violent patients. These attacks, Anderson and West (2011) argue, are a reality and concern, much as the victims often think of them as a natural part of their jobs that cannot be avoided. The effects can be devastating. This fact forms the basis for this paper. 1.1. Literature Search The PICO model, as discussed by Davies (2011) will be employed in formulation of the research question that underpins the argument of this paper. This model is preferable to the SPICE model since it forms the basis for formulation of questions in studies that have qualitative elements mainly (Krueger, 2003), which is the nature of the study in this case, qualitative. Therefore, the major PICO elements are the patients in the mental health ward and minimizing and preventing violence and aggression. As such, the research question formulated is How do nurses in acute mental health ward minimize and manage patient aggression and violence? 2. Literature Review The following literature review is a summary of studies conducted on the minimization and management of patient aggression and violence in an acute mental health ward. From the literature, there are several approaches taken by various authors to the issue. This section discusses the approaches taken in five major articles that span the period between 2009 and 2013. In order to find these articles, the inclusion and exclusion method was used by employing a systemic review search was conducted. The following keywords were entered keyed into the search engines to locate relevant articles: mental health wards, aggression, and violence. The search led to looking through several electronic databases. The search yielded a wide variety of results, which necessitated the narrowing down of search results to the most relevant resources using Boolean operators (Miles and Huberman, 2004). The aims, methods, sampling criteria, and results of each of the five articles are summarized in table 2 within the appendix. The first article to be analyzed is by Duxbury and Whittington (2010). In their work, they report that a study into management and aggression among patients has to involve a look into the reasons for aggression. This view is held widely across literature on aggression in the mental care ward (Nijman et al., 2005). Duxbury and Whittington (2010) attribute aggression to poor environmental conditions and lack of open communication channels. Given this fact, management of aggressive tendencies involved training staff in mental care facilities on therapeutic communication. Apart from this, they advocated adoption of measures other than the use of medication such as sedatives. This, according to the paper, entails creating a comfortable environment for patients. However, in outlining the limitations of the study, the authors acknowledged that their use of a small sample may have affected the validity of the findings negatively. In addition to this, the findings may not be generalizable to specialist and non-inpatient areas. Stubbs and Dickens (2009) identify focused and consistently training staff in mental care facilities prior to registering them as the primary method of managing violence. According to the authors, trainers should focus on teaching about psychological interventions. They conduct this study in appreciation of the fact that aggressive behavior among mental patients can potentially put healthcare professionals at risk. Worse still, is that professionals are in most cases minimally trained on intervention procedures. Despite their findings, they agree that their research was limited and needs to be broadened to look into the efficacy of other interventions when it comes to minimizing and managing patient aggression. Abderhalden et al. (2012) discuss the effectiveness of certain interventions in managing violence among patients in acute mental inpatient settings. Their study mainly tests the effectiveness of training courses and systemic risk assessment on the incidence of aggressive behavior in selected wards. Their findings demonstrate that taken uniquely, measure that predicted risk did not reduce the incidence or severity of attacks in the selected wards. Training staff achieved much better results, with drop in both the frequency and severity of attacks declining. However, a combination of the two measures produces the optimum results where this was done. One of the limitations of this study is that it was a non-randomized study, for example, patients that recorded extreme aggression were excluded from the sample. Other limitations are the non-generalizable nature of the findings and the hindrances to validity. Arokia (2013) examines the reduction of violence and aggression in psychiatric units. The author argues that having patients participate in outdoor activities has been undervalued as a means of reducing aggression among psychiatric patients. This reinforces the findings of Barlow, Ilkiw and Grenyer (2005), who identify one of the precipitating factors for aggression in acute mental health wards as complete seclusion from the society. The study involved a control group, consisting of patients that were not allowed to take part in activities such visits to the zoo, computer, and gym sessions. In the control group, there was a rise in the aggressive incidences reported while those in the second group, patients that took part in these activities, exhibited less aggression. Another advantage to this was patients that were discharged from the second group felt well equipped to fit into society compared to those that were from the controlled group. The sample employed for this study was small, given resource constraints. A study by Foster, Bowers, and Nijman (2009) revealed that while the most prevalent form of aggression towards nursing staff in acute care wards is verbal, the staff is always aware of the threat of physical aggression. The study finds that the managing aggression among patients in most cases takes verbal intervention. Here, the staff gets an violent patient to calm down by talking to them. However, due to the imminent threat of physical attack, staff at the facilities was also prone to using physical restraint to manage violent patients, for example, using physical seclusion of the patient. 2.1. Strength of the Evidence The literature underpinning this particular research is reliable on several fronts. Roitman and Kalra (2007) report that one of the indicators of reliability is the source of literature. The articles are all taken from reputable medical journals, for example the Journal of Advanced Nursing. Another indicator of reliability, according to Briggs and Heath (2005) is the author of the article. The authors of these articles are medical practitioners, experts in their field. Thirdly, the sources listed by these authors are accurate and reliable, based on the criteria discussed. Despite these, most of the articles are subject to certain shortcomings that may interfere with reliability and applicability. For example, in some of the articles, the major limitation is a small sample frame. Other limitations have to do with generalizability and non-randomized sampling. Non-randomized sampling puts a strain on the extent to which literature is applicable (Briggs and Heath, 2005) The literature reviewed offers insights into areas for further research. For example, Abderhalden et al. (2012) point out the need for studies more studies on management of aggression and violence in acute metal care wards. This is because most studies available on managing violence are not based on acute wards (Aroika, 2013). Secondly, they recommend the use of randomized sampling in selecting samples. This would produce generalizable results. 3. Methodology 3.1. Aims and Objectives of the Study The primary objective is to find out how nurses in acute mental health ward minimize and manage patient aggression and violence. The specific objectives are threefold. They include Find out what factor act as catalysts for aggression To determine the how effective the discussed methods of management and prevention are. These are the methods outlined in the literature review. To analyze the perceptions of both patients and nurses on the use of measures discussed. 3.2. Research Design The first design that could be applied is the quantitative research design. This approach would entail objectively measuring variables or concepts (Steinert et al., 2005). Making the research a quantitative research means assigning dummy variables to the data collected since the data is qualitative in nature. An example would be using dummy variable ‘1’ to represent the use of restraint as method to prevent violence among patients. The second possible design for this paper is to adopt a qualitative research approach. Here, the design would permit the researcher to collect data on subjective experiences of the sample under study. For example, the researcher would be able to directly record any new methods not given under a dummy variable. In addition to this, the researcher can capture perceptions and opinions of patients and nurses (Gopee, 2011). This approach, given the nature of the study, is the most suitable. The researcher will rely mainly on observation as a method of data collection. A secondary data collection method that will apply is conducting semi-structured interviews directed to the staff. 3.3. Sampling The study will, in accordance to recommendation from reviewed literature, use a randomized sampling approach. The sample selected for observation and interviewing comprises fifteen nurses at a mental care ward in North London. These nurses are registered mental health nurses that have been working in the ward for at least five years. Their years of experience and general expertise on mental health matters improve on the chances for accuracy of information collected (Leonard and LeBrasseur, 2008). There will be a pilot study undertaken in a smaller ward in order to test the instruments of research (Miles and Huberman, 2004). In both the pilot and actual research, we will advise ward managers to alert patients on the presence of researchers. Even so, there will be minimal intrusion into the daily activities of patients and staff by researchers in order to allow them to operate in a natural setting (Rose, 2004). The interview will be conducted solely for clarification purposes. 3.4. Ethical Considerations Ethical considerations include taking care of confidentiality of subjects, non-malevolence, autonomy and informed consent (Watson et al., 2005). Concerning this, all participants will be made aware of the study and their rights. The researcher will seek approval from relevant parties such as the National Ethics Service, the hospital’s ethics committee, and the director of nurses at the hospital. Pseudonyms will be assigned in cases where the report has to make direct reference to participants to protect the confidentiality of nurses and patients (Lee et al., 2006). 3.5. Procedure and Analysis Data will be collected by way of interviews and observation. There will be four independent researchers observing operations in the ward. These researchers will note their observations and ask the nurses questions where there is need for further clarification. Apart from this, they will be conducting exclusive interview sessions with nurses to find out any measures that may not have been observed in the course of observing participants. In the course of interviews, researchers will record responses in written and audio form for ease of reference. In order to organize the findings into a comprehensive report, the data will be analyzed. Data analysis will be facilitated using Colaizzi’s seven steps (Gopee, 2011), especially interview transcriptions. This should lead up to production of a comprehensive report. 3.6. Limitations of the Study Despite efforts to produce a perfect research report, the research is likely to face some limitations as outlined. Resource constraints dictate that the sample size used be small (Royal College of Psychiatrists, 2008). While there are efforts to compile a representative sample, the sample has to remain small and may, in fact not be characteristic of the entire population. Potential participants may be unenthusiastic to cooperate in the study. This is especially due to time constraints on their part. 3.7. Reliability and Validity The researchers will be using semi-structured interviews to gather information. Rose (2004) gives leeway for paraphrasing questions in case the questions are too complex to be comprehended by interviewees. As such, it is expected that respondents will ask for clarification where necessary, improving on their chances of giving accurate responses and therefore enhancing validity. Reliability is also achievable, since the researchers conducting the study are experts in their field. Secondly, the study is based on observed interventions rather than the perceptions of participants. 3.8. Implications for Nursing The study will divulge the most common management measures and the most effective. The researcher anticipates that the findings will be applicable in acute mental care wards to prevent violence among patients or any forms of aggression (Smith and Humphreys, 2007). This should in turn lead to a reduction in aggression, especially that which is directed toward nurses in these wards and hence improve on their safety. 4. Conclusion Nurses working in acute mental care wards are not entirely safe. Despite this, it is indeed their duty to protect themselves and other patients in case of violent outbursts by any of those in their care. For this to be achieved, they need to be armed with information on safe but effective measures that they can take towards managing aggressive patients. This paper is one of the active efforts towards uncovering what kind of information the nurses need to be equipped with for optimum safety. Reference List Abderhalden, C., Meer, R., Dassen, T., Haug, H., Halfens, G., & Fischer, J. 2012, The effectiveness of two interventions in the management of patient violence in acute mental inpatient settings: report on a pilot study’, Journal of Psychiatric and Mental Health Nursing, vol. 11, no. 45, pp. 595–601 Anderson, A., & West, G. 2011, Violence Against Mental Health Professionals: When the Treater Becomes the Victim,’ Innov Clin Neurosci, vol. 8, no. 3, pp. 34-39 Arokia, A. 2013, ‘How can we reduce violence and aggression in psychiatric inpatient units?’ BMJ Qual Improv, vol. 2, no. 1, pp. 34-41 Barlow, K., Grenyer, B., & Ilkiw-Lavalle, O. 2005. ‘Prevalence and precipitants of aggression in psychiatric inpatient units’, Australian and New Zealand Journal of Psychiatry, vol. 4, no. 34, pp. 967-974 Briggs, L., & Heath, J. 2005. ‘Peer review for advanced practice nurses. What does it really mean?’ AACN Clinical Issues, vol. 16, no. 1, pp. 3-15 Chou, R., Lu, B., & Mao, C. 2002. ‘Factors relevant to patient assaultive behavior and assault in acute inpatient psychiatric units in Taiwan’, Archives of Psychiatric Nursing, vol. 16, pp. 187–195. Davies, K. 2011. ‘Formulating the Evidence Based Practice Question: A Review of the Frameworks’, Evidence Based Library and Information Practice, vol. 6, no. 6, pp. 75-80 Duxbury, J. & Whittington, R. 2010, ‘Causes and management of patient aggression and violence: staff and patient perspectives’, Journal of Advanced Nursing, vol.50, no.5, pp.469-478 Foster, C. Bowers, L. & Nijman, H. 2009, ‘Aggressive behaviour on acute psychiatric wards: prevalence, severity and management’, J Adv Nurs, vol. 58, no. 2, pp. 140-9. Gopee, N. 2011. The role of peer assessment and peer review in nursing. British Journal of Nursing, Vol. 10, no. 2, pp. 115-121 Krueger, A. 2003. Focus Groups: A Practical Guide for Applied Research. Newbury Park, Calif.: Sage Publications. Lee, S., Wright, S., Sayer, J., Parr, A., Gray, R. & Gournay K. 2006. ‘Physical restraint training for nurses in English and Welsh psychiatric intensive care and regional secure units’, Journal of Mental Health vol. 10, no.33, pp. 151–162. Leonard, V. & LeBrasseur, R. 2008, Individual assignments and academic dishonesty: exploring the conundrum, The Australian Educational Researcher, vol. 35, no. 1, pp. 37-56. Miles, B. & Huberman, H. 2004. Qualitative Data Analysis: An Expanded Sourcebook. 2nd Edition. Thousand Oaks, Calif.: Sage Publications. Nijman, I., Merckelbach, J., Allertz, F., & Campo, L. 2005. Prevention of aggressive incidents on a closed psychiatric ward. Psychiatric Services, vol. 48, no. 15, pp. 694–698. Roitman, J. & Kalra, S. 2007. Literature Update: Reliability, Validity, And Responsiveness Of A 2-Min Walk Test To Assess Exercise Capacity Of Copd Patients. Journal of Cardiopulmonary Rehabilitation & Prevention, vol. 27, no. 16, pp. 16 Rose, K. 2004. Unstructured and semi-structured interviewing. Nurse Researcher, vol.1, pp. 23–32. Royal College of Psychiatrists. 2008. Management of Imminent Violence. Occasional Paper OP41. London, UK: Royal College of Psychiatrists. Smith, D. & Humphreys, M. 2007. Characteristics of inpatients transferred to a locked ward in a Scottish psychiatric hospital. Health Bulletin, vol. 55, no.76, pp. 77–82. Steinert, T., Wolfe, M. & Gebhardt,P. 2000. Measurement of violence during in-patient treatment and association with psychopathology. Acta Psychiatry Scandinavica, vol. 102, pp. 107–112. Stubbs, B. & Dickens, G. 2009, ‘Prevention and managementof aggression in mental health:An interdisciplinary discussion’, International Journal of Therapy and Rehabilitation, vol. 15, No. 8, pp. 351-357 Turnbull, J. & Patterson, B. 2009. Aggression and Violence. London, UK, MacMillan. Watson, R., Stimpson, A., Topping, A. & Porock, D. 2005. ‘Clinical competence assessment in nursing: a systematic review of the literature’, Journal of Advanced Nursing, vol. 39, no. 5, pp. 421-431 Appendices Appendix 1 1.1 PICO Model Population Intervention Comparator Outcome Population- Mental Patients Intervention- Management of aggression Comparator- Prevention of violence Outcome-minimization and control of aggression 1.2  Table 1: Databases Searched Databases Number of Articles CINAHL 2005-2013 - Aggression (peer reviewed) 2844 CINAHL 2005-2013 - Aggression AND Nurses (peer reviewed) 274 CINAHL 2003 – 2013 Aggression AND Nurses AND Mental Health Nursing 10 Inclusion • Primary research in mental health  • Registered Mental Health Nurses • 2002 onwards • Mental Care wards Inclusion • Secondary research • Acute mental wards • Healthcare assistants • Student nurses • Pre 2003 Appendix 2 Table 2: Authors Study aims Methods/Sample Results Authors Study Aims Methods/ Sample Results Duxbury, J. & Whittington, R. 2010, ‘Causes and management of patient aggression and violence: staff and patient perspectives’, Journal of Advanced Nursing, vol.50, no.5, pp.469-478 To find out patient and staff perspectives on causes and management of patient aggression. Sample: 80 patients and 82 nurses from 3 mental healthcare wards. According to patients, poor communication and environmental conditions were the main cause of aggression. Nurses felt that aggression was due to mental illness but did not dismiss the role of an unsuitable environment in fuelling aggression. Stubbs, B. & Dickens, G. 2009, ‘Prevention and managementof aggression in mental health:An interdisciplinary discussion’, International Journal of Therapy and Rehabilitation, vol. 15, No. 8, pp. 351-357 (2009) To study the prevention and management of aggression and violence Investigates the prevention and management of patient violence psychologically, physically, and pharmacologically. Aggression is lowered through having health professionals undergo onsistent and focused training during pre-registration programmes. This is training on psychological interventions especially. Abderhalden, C., Meer, R., Dassen, T., Haug, H., Halfens, G., & Fischer, J. 2012, The effectiveness of two interventions in the management of patient violence in acute mental inpatient settings: report on a pilot study’, Journal of Psychiatric and Mental Health Nursing, vol. 11, no. 45, pp. 595–601 Studies the effectiveness of two interventions in the management of patient violence in acute mental inpatient settings Sample: two Swiss psychiatric admission wards. Method: A systemic aggression risk assessment, along with a standardized training course in the management of aggression was administered. The effectiveness was tested by gauging the frequency and severity of aggressive incidents. They conclude that the incidence of violence can be reduced using the systemic aggression risk assessment and training course. However, they appreciate that further studies should be conducted to test the effectiveness training exclusively. Arokia, A. 2013, ‘How can we reduce violence and aggression in psychiatric inpatient units?’ BMJ Qual Improv, vol. 2, no. 1. Explores the effect of outdoor activity on Aggression levels of patients Method: They created two groups, a treatment group and control group. Control group patients were restricted from taking part in activities such as gym session, computer, and zoo visits. In the control group, there was a rise in the aggressive incidences reported while those in the second group, patients that took part in these activities, exhibited less aggression. Another advantage to this was patients that were discharged from the second group felt well equipped to fit into society compared to those that were from the controlled group. Foster, C. Bowers, L. & Nijman, H. 2009, ‘Aggressive behaviour on acute psychiatric wards: prevalence, severity and management’, J Adv Nurs, vol. 58, no. 2, pp. 140-9. A study to find out the how prevalent inpatient aggressive behavior towards saff and other patients is. In addition to this, it investigates methods used by nurses to manage aggression. Sample: Acute inpatient ward nurses in one hospital. Method: Data collected on aggressive incidents and recorded on the Staff Observation Aggression Scale over a 10-month period. The most commonly targeted population in incidences of aggression is the staff, brought on by denying the patient things that they want mainly. Verbal aggression was most prevalent. Verbal intervention was the most widely used management strategy by staff. Another less but frequently used intervention is seclusion of the patient from other patients. Read More