Nibedita Banerjee, Sandhya Ghai, Renu Sharma

Abstract:

Background: Violent and aggressive behaviour represents most challenging phenomenon in psychiatric in-patient care. Aggressive behaviour follows injuries, fear, anger and destruction. These sufferings involve caregivers, patients, nurses and other health care professionals. It is important to assess perception, skill, and knowledge of nurses to manage aggressive behaviour in order to have better management of patients. Aim: To assess the perception of nurses about aggressive behaviour of person with mental illness. Material & methods: Quantitative research approach and descriptive design was used for this study.Total 12 nurses working in psychiatric ward were taken as sample by total enumeration sampling technique. Tool used for data collection was questionnaire comprised of a) Socio demographic prole of participants and b) Management of aggression and violence attitude scale (MAVAS). Data was collected by administering questionnaire to nurses which was taken back after one hour. Analysis was done by using descriptive and inferential statistics in SPSS version 20.0. Results: Out of 12 nurses, 33.3% subjects were in the age group of 26-30 years, 75% were females, 66.7% were graduates in nursing with mean working experience 2.46 years. Results for MAVAS scale showed that 50% of participants had stronger perception towards management of aggressive behaviour among person with mental illness. Half of participants had stronger perception in situational domain, and 50% had lesser perception in managing aggressive behaviour of person with mental illness. In environmental and biological domain, 83% and 67% participants had strong perception in managing patient. Conclusion: Most of the nurses have stronger perception towards aggressive behaviour among person with mental illness (PMI). They are aware about how to manage aggressive behaviour of psychiatric patients.

Keywords: Aggression, Perception and attitude, Persons with mental illness (PMI).

Address for correspondence:

Mrs Renu Sharma Tutor

NINE, PGIMER, Chandigarh

Introduction

Anger is a normal human emotion, if

handled appropriately and expressed assertively, can provide an individual with a positive strength to solve problems and take decisions concerning life situations. Anger becomes a problem when it is not expressed appropriately and violence occurs when individuals loose control of their anger. 1 Violent and aggressive behaviour represents most challenging phenomenon in psychiatric in-patient care. It may be followed by injuries, fear, anger and destruction. Suffering involved patient, caregivers as well as nursing staff, so, this phenomenon needs prompt attention. 2 A systematic review and meta analysis on the assessment and management of the violent patient in critical hospital settings reveals that episodes of violent behaviour is high in acute psychiatric wards of general hospitals. Results revealed that 1 among 5 patients, who are admitted in acute psychiatric units commit an act of violence. Psychiatric patient’s violence depends on age, gender, psychopathological condition, substance use etc. 3

Aggressive behaviour is most common among psychiatric patients because they have aggressive personality trait as well as inability to control anger due to their illness. In most of the cases, patient himself and care giver becomes victim. Nurses in psychiatric unit are at highest risk for becoming victims of this behaviour followed by psychiatrists. A study conducted in Israel hospital revealed that assaults on nurses by psychiatric patients is a serious problem, which not only affect staff but also to the other patients, care providers and organization. The study revealed two themes that both patient and provider have contribution on patient’s aggression. From intersection of these two themes four subthemes emerged: power struggle, therapeutic encounter, inverse power relations and victim to victim encounter.

These all have impact on patient’s cognitive, emotional and behavioural responses. 4 Duxburry, in his aggression model, embedded some causes of patient’s aggression towards psychiatric staffs and caregivers. He mainly focused on two types of model- internal model and external model. Internal model, which means some internal characteristics already within the individual include demographic variables like gender, age, histories of aggression etc. Another is external model like the setting of hospitals or environment which sometimes provokes the patient to become violent and aggressive. Some of the examples include limited number of staff, limited space in h o s p i t a l s , o v e r c r o w d i n g , r a i s e d temperature etc. He has also concluded that staff and client interaction also become a major cause for aggression of patients. If the staff-client interactions become poor then the client becomes more provoked to show violent behaviour. Sometimes the staffs are not aware of how to manage aggressive behaviour, and then it becomes a major challenge to control patient’s aggressive behaviour. 5

Even though violence towards mental health care professionals occurs at an alarming rate many critical care clinicians and nursing staffs are not adequately treated to deal with this behaviour.6 Nurses should be aware of using restraining and seclusion as a measure for managing violent behaviour. In reality, nurses use variety of strategies for maintaining their personal safety as well as preventing and managing violent behaviour of patient. Nurses need to improve education, knowledge of debrieng after the incident, and for creating supportive environment at work to further prevent patient’s violence.7

The nurses need to have appropriate skills to manage disturbed or violent behaviour in psychiatric inpatient setting. The prevention and management of violent behaviour of psychiatric patients presents a domain: situational, environmental, biological and management. MAVAS is a Likert scale with response options ranges from 1 to 5, where 1 represents “strongly agree” and 5 represents “ strongly disagree.” The lower the score, the greater the perception of the subject. The score ranges from 23- 115. Where 23 represents stronger perception and 115 represents major challenge to nursing practice. For lower perception of participants.5   Ethical this, there is a up growing need for improving knowledge and evaluation of comprehensive and proactive view on violence prevention, and management from the perspective of previous nursing practice. Before that it is important to know the perception of nurses towards aggression and violent behaviour among person with mental illness (PMI). Hence the need has felt for conducting present study.

Objectives: To assess the perception of nurses about aggressive behaviour of person with mental illness.

Material and methods: Quantitative research approach and descriptive design was used for this study. Total 12 nurses working in psychiatric ward who were willing were taken by total enumeration sampling technique. Questionnaire was used for data collection comprised of a) Participant’s socio demographic prole, b) Management of Aggression and Violence Attitude Scale (MAVAS). MAVAS is a standardized tool prepared by Joy Duxburry and used to assess perception of nurses towards management of aggressive behaviour of person with mental illness (PMI). Permission for using tool was taken from original author. This tool has four clearance was taken from Institutional Ethics Committee, PGIMER, Chandigarh. Permission was taken f rom head, department of Psychiatry, PGIMER, Chandigarh for conducting research and written informed consent was taken from each participant. Condentiality and privacy of each subject was maintained. Full autonomy was given to participant to be withdrawn from study at any time. Questionnaire was administered to the nurses in the ward during their free time and was taken back after one hour. The analysis was done by using SPSS version 20.0.

Results: Table no 1 describes personal prole of nurse participants. All the participants were in the age group of 26-53 years with mean age 36.92 years. One third (33.3%) subjects were in the age group of 26-30 years. Most of the participants (75%) were females. More than half of the participants (58.3%) were Hindus followed by 25% from Sikh religion. According to professional qualication 66.7% were graduates in nursing. All the nurses had work experience in psychiatry units between 1 to 6 years with mean experience 2.46 years. Two third of nurses (66.66%) had experience between 1-3 years.

Table: 1- Personal profile of nurses

N=12

nurses had below median score and stronger perception and 50% having above median score thus had lesser perception in managing aggressive behaviour of person with mental illness (PMI). In situational domain median score was 8.50, 50% nurses had score below median and have stronger perception whereas rest 50% had lower perception towards management of aggressive behaviour. In environmental domain median was 5 and 83% nurses had stronger perception and 16% nurses had lower perception. In biological domain 66% nurses had below median score and stronger perception and 33% had lower

 

S No. Variables n (%)
1. Age (in year)

a)  26-30

b)  31-35

c)  36-40

d)  41-45

e) >46

Sex

a)    Male

b)   Female

Religion

a)    Hindu

b)   Christian

c)    Sikh

Professional work experience

a)    G.N.M Nursing

b)   B. Sc Nursing

c)    M. Sc Nursing

Working experience in psychiatry (years)

a)  1-3

b)  4-6

 

04 (33.4)

  01 (08.3)
  03 (25.0)
  02 (16.7)
 

2.

02 (16.7)

 

03 (25.0)

 

3.

09 (75.0)

 

07 (58.3)

  02 (16.7)
 

4.

03 (25.0)

 

02 (16.6)

  08 (66.8)
 

5.

02 (16.6)

 

08 (66.7)

  04 (33.3)

 

Mean± SD (Range): Age- 36.92 ± 8.949(26-53), Working experience- 2.46 ± 1.270 (1-5)

Table no 2 depicts domain wise perception of nurses towards management of violent behaviour. According to total score 50%

perception. In management domain 58% nurses had score below 24 and 41% nurses had score above 24.

 

Table no 2: Domain wise attitude and perception of nurses towards management of violent behaviour

Domain Median No of participants scored below median (%) No of participants scored above median (%)
Situational Domain 8.50 6 (50) 6 (50)
Environmental Domain 5 10 (83) 2 (16)
Biological Domain 11 8 (66) 4 (33)
Management Domain 24 7 (58) 5 (41)
Total score 49 6 (50) 6 (50)

 

Table 3 depicts attitude and perception of nurses towards aggressive behaviour of person with mental illness.

Situational Perspectives: In this domain 75% nurses reported agree/ strongly agree with item other people make patients aggressive or violent and had stronger perception towards managing aggressive behaviour of person with mental illness.

and 91% participants reported disagree/ strongly disagree with item it is a largely situations that contribute towards the expression of aggression by patients and had lower perception in managing aggressive behaviour.

Environmental Perspectives: In this domain 66% nurses agreed with patients are aggressive because of the environment they

Table: 3- Attitude and perception of nurses towards management of violent behaviour

N=12

S

No.

Items Response f (%)
Strongly

Agree

Agree Neutral Disagree Strongly

disagree

A.

1.

2.

 

3.

 

4.

 

5.

Situational Perspective

Other people make patients aggressive or violent. Patients commonly become aggressive because staff do not listen to them.

Poor communication between staff and patients leads to patient aggression.

Improved one to one relationships between staff and patients can reduce the incidence of patient aggression and violence.

It is  largely  situations  that  contribute  towards  the

expression of aggression by patients.

1(8)

 

– 5(41)

 

1(8)

 

8(66)

3(25)

 

4(33)

 

 

 

 

 

1(8)

7(58)

 

7(58)

 

6(50)

 

10(83)

2(16)

2(16)

 

1(8)

 

1(8)

 

1(8)

B.

1.

 

2.

 

3.

Environmental perspective

Patients are aggressive because of the environment they are in.

Restrictive care environments can contribute towards patient aggression and violence.

If the  physical  environment  were  different,  patient

would be less aggressive.

– 2(16)

 

8(66)

 

8(66)

 

8(66)

 

 

 

4(33)

 

4(33)

 

4(33)

 

 

 

4(33)

C.

1.

 

2.

3.

 

4.

 

5.

Biological perspectives

It is difcult to prevent patients from becoming aggressive or violent.

Patients are aggressive because they are ill.

There appear to be types of patients who frequently become aggressive towards staff.

Patients who are aggressive towards staff should try to control their feelings.

Aggressive  patients    calm down  automatically  if  left

alone.

1(8)

 

3(25)

– 1(8)

5(41)

 

6(50)

6(50)

 

3(25)

 

1(8)

 

 

 

 

6(50)

 

3(25)

5(41)

 

6(50)

 

10(83)

 

– 1(8)

 

2(16)

 

1(8)

D.

1.

2.

3.

4.

 

5.

 

6.

 

7.

 

8.

 

9.

 

10.

 

11.

 

12.

13.

 

14.

Management Perspectives

Different approaches are used on this ward to manage patient aggression and violence.

When a patient is violent, seclusion is one of the most effective approaches to use.

Patients who are violent are often physically restrained to administer sedation.

The practice of secluding violent patients should be discontinued.

Medication is a valuable approach for treating aggressive and violent behaviour.

The use of negotiation could be used more effectively when managing aggression and violence.

Expressions of aggression do not always require staff intervention.

Physical restraints are sometimes used more than necessary.

Alternatives to the use of containment and sedation to manage patient violence could be used more frequently. Patient aggression could be handled more effectively on this ward.

Prescribed medication can in some instances lead to patient aggression and violence.

Seclusion is sometimes used more than necessary. Prescribed medication should be used more frequently to help patients who are aggressive and violent.

The use  of  de  escalation  is  successful  in  preventing

violence.

 

5(41)

 

2(16)

 

3(25)

 

– 1(8)

2(16)

 

1(8)

 

– 1(8)

5(41)

 

 

– 1(8)

 

1(8)

 

7(58)

 

3(25)

 

5(41)

 

5(41)

 

7(58)

 

6(50)

 

3(25)

 

2(16)

 

9(75)

5(41)

 

4(33)

 

2(16)

7(58)

 

10(83)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

– 7(58)

3(25)

 

5(41)

 

4(33)

 

3(25)

 

7(58)

 

8(66)

1(8)

 

1(8)

 

8(66)

 

9(75)

3(25)

 

1(8)

 

 

– 1(8)

2(16)

 

– 1(8)

1(8)

 

2(16)

 

1(8)

 

1(8)

– 1(8)

1(8)

 

 

are in and had stronger perception. For same item 33% nurses reported disagree/ strongly disagree.

Biological Perspectives: In this domain 75% nurses reported agree with item patients are aggressive because they are ill. And 83% nurses reported disagree with aggressive patients will calm down automatically if left alone.

Management Perspectives: In this domain 81% nurses reported agree/ strongly agree with alternatives to the use of containment and sedation to manage patient violence could be used more frequently and had stronger perception towards management of aggressive behaviour. And 66% nurses disagreed that prescribed medication can in

assess the management of patient’s aggression. Result revealed that instrument is applicable to use in comparative research studies. [8] For this reason in present study also MAVAS instrument is found to be effective.

A cross national comparative study was conducted by Duxburry, original author of MAVAS scale on perception of nurses towards aggressive behaviour among person with mental illness (PMI). Result revealed that Swiss nurses were, however, more likely to regard factors internal to the patient as contributory to aggression while United Kingdom nurses perceived environmental factors to be more important while both groups endorsed physical means

 

some instances lead to patient aggression of aggression management.5     In present and violence and had lower perception towards managing person with mental illness.

Discussion- The nurses need to have appropriate skills to manage aggressive behaviour of person with mental illness (PMI). Aggression and violence against nurses during working period is an important component in clinical nursing practice. When we compare nurses with other health care personnel they are the high risk group. Perception of nurses have a lot of impact in strategies they use for managing aggressive behaviour of psychiatric patients. Hence need was felt for improving knowledge and skill of nurses for managing aggressive behaviour. Before that it is important to know perception of nurses.

A study conducted by Marina Lepiesona et al on analysis of the MAVAS instrument to study also 83% nurses had stronger perception in environmental domain but 50% nurses had stronger perception in Situational domain. In case of total score 50% nurses had strong perception and 50% had lower perception in managing aggressive behaviour.

Conclusion- Nurses had strong perception in managing aggressive behaviour of person with mental illness (PMI). Nurses trained in psychiatry have knowledge regarding management of violent behaviour. Hence it is recommended that nurses should inculcate behavioural change communication among psychiatric patients.

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