Nursing Staff
In healthcare settings, aggressive behavior exhibited by acutely ill clients is a pervasive problem contributing to poor outcomes for both patients and medical staff. It is widespread in inpatient mental health units, where 7.8 cases are reported per 100 medical workers yearly, with nurses being the most likely victims (United States Bureau of Labor Statistics [USBLS], 2018). The agency further links the high risk of physical and verbal aggressive behaviors to a severe psychiatric diagnosis, use of restraints, substance abuse, and anticonvulsants taken by epileptic patients. Patient aggression towards the nursing staff is recognized as a significant impediment to quality care delivery in psychiatric hospitals. Odes et al. (2020) establish that the experience of violent acts has adverse physical and psychological effects on healthcare workers. Particularly severe instances of aggression may prompt the nursing staff to require time away from work, thus causing staffing issues for the unit. In fact, the data by the USBLS (2018) suggests that 69% of nonfatal patient aggression incidents remove nurses from active duty for at least some time. Therefore, aggression management training appears to be a significant point of improvement for the field.
Background
History/evolution of the Problem
Instances of aggression exhibited by psychiatric facility patients have been observed throughout the history of this field of research. Trifu et al. (2020) state that such cases are prevalent in most psychiatric settings, as conditioned by the pathology of the patients’ brain structures. These changes affect their behavioral and decision-making patterns, prompting a more aggressive response to treatment procedures. Furthermore, many of these patients are placed in psychiatric facilities involuntarily. While the prevalence of aggression has been reduced by updating treatment conditions and methods, the inherent inclination toward violence has persisted until today.
Statistics Associated with the Problem
In most cases, the instances of aggression are caused by the very nature of psychiatric treatment. Unlike other areas of healthcare, this field sees an increased number of patients who receive services involuntarily. According to the statistics provided by Wellens et al. (2021), the share of involuntary patients across psychiatric units varies from 21.5% to 100%, the average figure being over 60%. Furthermore, this research reports an average of 43.5% of patients involved in aggression incidence during the in-patient treatment phase (Wellens et al., 2021). These figures imply that the nurses involved in psychiatric care face a 50% chance of becoming the victims of patient aggression. Therefore, the problem at hand is quite prevalent within the current healthcare system, in spite of the major improvements in treatment conditions. It is possible that there is a certain minimum level to which patient aggression can be reduced by passive means. Therefore, a more efficient, proactive intervention needs to be designed and implemented to ensure further progress.
Significance
Impact of the Problem to Healthcare Systems
The problem in question has a direct impact on the healthcare system on several levels. First of all, aggression reflects the poor mental condition of psychiatric patients. Evidently, some of their cases imply such instances by default, as they are inherently related to the brain tissue damage. Nevertheless, other instances are likely to be the direct consequence of the hardships of being in a psychiatric unit. In spite of the recent improvements, such wards are associated with difficult conditions and constraints that prompt patients to become aggressive. As a result, nurses become the target for such assaults, which damages their ability to fulfill their duties. Aggression hurts nurses on a physical level, resulting in a variety of injuries and even risks to their lives. Furthermore, such experiences inflict mental damage, forcing nurses to take some time away from work or even withdraw from the field completely. This way, the efficiency and staffing of psychiatric care is affected in a highly negative manner.
Cost of the Problem
The problem becomes a costly ordeal for all parties involved and for the system, in general. From the patient’s perspective, acts of aggression may lead to the re-evaluation of their treatment progress, thus prolonging their stay at the facility. It can also lead to more legal charges resulting from their action. Whenever nurses withdraw from duty in the fallout of patient aggression, their units also experience financial damages First of all, in the most severe cases, the victims of aggression may be eligible for compensation on behalf of their employer. Second, the absence of a nurse is likely to undermine the unit’s ability to function normally. As a result, the operations are disrupted, causing financial losses for the organization by running at low patient census.
Problem Statement
Patient-initiated aggression is a significant problem in psychiatric units since patients are not likely to accept treatment voluntarily. While traditional methods such as seclusion and restraints may be used to curb aggressive behavior, they are less effective and exacerbate frustration, anger, and aggression (Weltens et al., 2021). Registered nurses (RNs) provide continuous direct care to patients admitted to psychiatric units, and thus, are at a higher risk of aggression than other healthcare workers. Aggressive behavior by patients negatively impacts nurses’ well-being and performance. The experience of violent acts may make nurses feel unsafe to deliver quality psychiatric care needed for recovery and increase burnout, which leads to high turnover (Weltens et al., 2021). Therefore, patient-initiated violence is an occupational hazard that impacts clinical outcomes for both patients and healthcare workers.
Nursing staff provide important therapeutic care required for the recovery of patients with psychiatric conditions. However, there is a knowledge gap on effective de-escalation and defense techniques for dealing with aggression to create a safe environment for both nurses and patients (Fröhlich et al., 2018). Providing an educational intervention focusing on risk identification, de-escalation, and communication is necessary to help enhance nurses’ perceptions of safety. As a result, they will be confident and competent in curbing aggression and reducing the risk of harm to themselves and the patient.
Literature
PICOT
In nurses working with psychiatric patients with a history of violence in an inpatient psychiatric hospital, how does an hour of aggression management training and a follow-up badge buddy with reminder on de-escalation techniques compared to no training affect their perception of safety within one month post-training?
Description of Search
In order to research promising interventions that can resolve the specified issue, a rigorous examination of the contemporary body of literature has been conducted. For this purpose, data was retrieved from the leading databases of academic knowledge, including Science Direct, ProQuest, and the U.S. National Library of Medicine. In addition, statistical data was sought across different federal organizations, such as the United States Bureau of Labor Statistics. The search was completed with the use of relevant key words: patient aggression statistics, psychiatric patient aggression (effect / nursing / nurse turnover / intervention), psychiatric patient de-escalation. As per the inclusion criteria, all reviewed sources were to be published within the past five years in English and be directly related to the subject matter.
Synthesis of Literature
This analysis will carefully assess the correlation between the presence of aggression management training in nurses’ experience working with mentally ill patients and their perception of safety. In this case, nurses’ perception of safety is the dependent variable. The independent variable includes the experience of attending the training and the time that has passed since it. Given the importance of the problem described above, this synthesis can provide critical evidence for the benefits of such training at different distances. Below is a more detailed description of the variables considered in this paper.
Perception of Safety
This dependent variable needs to be measured only through specially designed interviews or questionnaires that make it possible to assess the mental condition of nurses. The sense of security in activities with people with a mental health condition who have the potential for aggression can manifest itself in different ways (Dagenhardt et al., 2022; Hylén et al., 2019; Suchting et al., 2018). The synthesis of the literature shows that safety can become the foundation for the confident work of a nurse, for the implementation of professional and operational activities, the ability to make contact and maintain it, and also opens up the possibility of using various techniques and methods that are not available in case of a sense of danger. Questionnaires should be compiled so that all possible aspects in one way or another affecting the efficiency and quality of operational activities and the internal mental state of the nurse will be taken into account (Vincent-Höper et al., 2020; Tsaras et al., 2018). Nevertheless, the question of the objectivity of assessing the safety of the situation of working with a potentially aggressive patient remains open, and more specific mechanisms may be developed in the future, that have a form different from trainings and reminders.
Buddy Badge Reminder
The presence of a badge with a reminder of the potential hazard and the main countermeasures can serve as a proactive measure in preventing irreversible negative consequences for nurses’ health. However, the badge may not bring the desired result, so its impact must be evaluated in conjunction with the training. In essence, the research question, in this case, will test the effectiveness of the badge as an element of creating a safe environment in communicating with mentally ill patients and, accordingly, the need to use it after the training.
Aggression Management Training
Training differs in its approaches and depends on many external and subjective factors dictated by a particular situation. Just as the sense of security for each nurse is also a subjective measure, the presence of a threat can be assessed by nurses’ experience, their self-confidence, the presence of elements of a safe environment, and much more. In addition, the form of training should rely on the given conditions and assumptions indicated in the studies (Jalil et al., 2020; Ye et al., 2021; Odes et al., 2020; Razzani et al., 2020). As a result, creating a unique model at the system level will be a somewhat complex multi-criteria task, and therefore, at the first stage, it is proposed to implement those training methods that have already proven themselves on the positive side in research.
Strength of the Evidence
Research on this topic was conducted locally, with small samples and a relatively significant influence of external subjective factors. Nevertheless, each work on this topic covered various psychological aspects of the problem, creating a broad base for building complex universal approaches. The research also shows that as attention to the problem increases, more and more risk management approaches are being developed that can be further presented to nurses in the form of training. Cases of constant tension and incidents in the workplace lead to burnout and mental problems for nurses. In this regard, the emphasis in research is on nurses and their condition to mitigate risks. The problem of the emergence of aggression in patients also requires additional study, but it is more complex, involving many obstacles in the study. Finding a correlation between the benefits of training and the nurses’ sense of security may be more effective in clinical practice than delving into the specifics of psychiatry.
Purpose Statement
The purpose of this project is to prove the correlation between the presence of training in working with mentally ill patients who have been subjected to a history of violence in the experience of nurses and their sense of security after a certain period after these pieces of training.
References
Dagenhardt, R. D., Heideman, A., Knoche, V., & Freiburger, T. (2022). An evaluation of a de-escalation conflict management training in a behavioral health hospital setting.International Journal of Conflict Management, 33(1), 84-110.
Drukker, M. (2021). Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature.Plos One, 16(10), 1-34.
Fröhlich, D., Rabenschlag, F., Schoppmann, S., Borgwardt, S., Lang, U. E., & Huber, C. G. (2018). Positive effects of an anti-aggression and de-escalation training on ward atmosphere and subjective safety may depend on previous training experience. Frontiers in Psychiatry, 9, 134.
Hylén, U., Engström, I., Engström, K., Pelto-Piri, V., & Anderzen-Carlsson, A. (2019). Providing good care in the shadow of violence – An interview study with nursing staff and ward managers in psychiatric inpatient care in Sweden.Issues in Mental Health Nursing, 40(2), 148-157.
Jalil, R., Huber, J. W., Sixsmith, J., & Dickens, G. L. (2020). The role of interpersonal style in aggression and its containment in a forensic mental health setting: A correlational and pseudoprospective study of patients and nursing staff.International Journal of Mental Health Nursing, 29(3), 427-439.
Odes, R., Chapman, S., Harrison, R., Ackerman, S., & Hong, O. (2020). Frequency of violence towards healthcare workers in the United States’ inpatient psychiatric hospitals: A systematic review of literature. International Journal of Mental Health Nursing, 30(1), 1-20.
Razzani, B., Atashzadeh-Shoorideh, F., Jamshidi, T., Barkhordari-Sharifabad, M., Lotfi, Z., & Skerrett, V. (2020). The effect of education around ethical principles on nurses’ perception to patient safety culture in an Iranian mental health inpatient unit: A pilot study. BMC Nursing, 19(10), 1-7.
Suchting, R., Green, C. E., Glazier, S. M., & Lane, S. D. (2018). A data science approach to predicting patient aggressive events in a psychiatric hospital.Psychiatry Research, 268, 217-222.
Trifu, S. C., Tudor, A., & Radulescu, I. (2020). Aggressive behavior in psychiatric patients in relation to hormonal imbalance. Experimental and Therapeutic Medicine, 20(4), 3483-3487.
Tsaras, K., Daglas, A., Mitsi, D., Papathanasiou, I. V., Tzavella, F., Zyga, S., & Fradelos, E. C. (2018). A cross-sectional study for the impact of coping strategies on mental health disorders among psychiatric nurses.Health Psychology Research, 6(1).
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United States Bureau of Labor Statistics. (2021). Incidence rates of nonfatal occupational injuries and illnesses by industry and case types, 2020.
Vincent-Höper, S., Stein, M., Nienhaus, A., & Schablon, A. (2020). Workplace aggression and burnout in nursing—the moderating role of follow-up counseling. International Journal of Environmental Research and Public Health, 17(9), 3152.
Weltens, I., Bak, M., Berhagen, S., Vandenberk, E., Domen, P., van Amelsvoort, T., & Drukker, M. (2021). Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature. Plos One, 16(10), 1-34.
Ye, J., Xia, Z, Wang, C., Liao, Y., Xu, Y., Zhang, Y., Yu, L., Li, S., Lin, J., & Xiao, A. (2021). Effectiveness of CRSCE-based de-escalation training on reducing physical restraint in psychiatric hospitals: A cluster randomized controlled trial. Frontiers in Psychiatry, 12, 1-11.