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   Table of Contents      
ORIGINAL ARTICLE
Year : 2017  |  Volume : 22  |  Issue : 6  |  Page : 442-448

Challenges of nurses' empowerment in the management of patient aggression: A qualitative study


1 Department of Nursing and Midwifery, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
2 Community Based Psychiatric Care Research Center, Shiraz University of Medical Science, Shiraz, Iran
3 Faculty of Nursing and Midwifery School, Community Based Psychiatric Care Research Center, Shiraz University of Medical Science, Shiraz, Iran
4 Research Center for Psychiatry and Behavior Science, Shiraz University of Medical Sciences, Shiraz, Iran

Date of Web Publication3-Nov-2017

Correspondence Address:
Sakineh Gholamzadeh
Community Based Psychiatric Care Research Center, Shiraz University of Medical Science (SUMS), Zand Ave, Shiraz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.IJNMR_216_16

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  Abstract 

Background: Patients' aggression in the mental care setting is a global health problem with major psychological, physical, and economic consequences; nurse empowerment to manage this aggressive behavior is an important step in psychiatric nursing. The aim of this study was to explore psychiatric nurses' experiences of the challenges of empowerment in the management of patients' aggression. Materials and Methods: This qualitative study was performed among 20 nurses working in a major referral psychiatric center in Iran during 2014–2016. The purposive sampling method was used for selecting the participants. Data were collected through semi-structured interviews, observations, and filed notes. Inductive content analysis was used for data analysis. Results: Three categories and ten subcategories were identified: inefficient organizational policy (limited human resources, mandatory shifts, shortage of protective equipment, lack of motivational sparks); insufficient job growth (failure to implement training programs, insufficient effort for job competence, lack of clinical guidelines); and deficiencies in the organizational culture (inadequate autonomy and authority, lack of the culture of prevention, culture of fault and blame after an incident). Conclusions: Psychiatric nurses were not satisfied with organizational empowering conditions for the management of patients' aggression and reported low levels of access to learning opportunity, receiving support and essential resources that led to unnecessary use of containment measures. Managers must make every effort to create organizational context that make it possible to empower nurses for optimal practice.

Keywords: Aggression, inpatients, Iran, psychiatric nursing, power, risk management


How to cite this article:
Ramezani T, Gholamzadeh S, Torabizadeh C, Sharif F, Ahmadzadeh L. Challenges of nurses' empowerment in the management of patient aggression: A qualitative study. Iranian J Nursing Midwifery Res 2017;22:442-8

How to cite this URL:
Ramezani T, Gholamzadeh S, Torabizadeh C, Sharif F, Ahmadzadeh L. Challenges of nurses' empowerment in the management of patient aggression: A qualitative study. Iranian J Nursing Midwifery Res [serial online] 2017 [cited 2021 Apr 10];22:442-8. Available from: https://www.ijnmrjournal.net/text.asp?2017/22/6/442/217602


  Introduction Top


Patients' aggression has been known to be a major and developing problem in psychiatric settings.[1] The causes of patients' aggression are associated with mental illness, patient characteristics,[2] physical or social environment,[3],[4] and the interaction between the patient and others.[5] Patients' aggression is an area that needs attention, and its management relates to the safety of psychiatric setting.[6] Based on the cause, nurses apply a range of person-centered (de-escalation) cares and containment measures (restraint, seclusion, medication) to manage patients' aggression.[4],[7],[8] Despite the nurses perceived value of de-escalation approach, due to diverse causes of aggression, no single intervention is sufficient for handling aggressive patients to stay in control in the wards.[3] According to Steinert, in such circumstances where the nursing staffs do not have practical solutions to prevent an aggressive incident or when they face other challenges which may decrease their ability to work as effectively as possible, they use containment measures.[9] There is general disapproval of containment methods of aggression management as set out,[10] whereas the use of containment can itself give rise to aggression rather than successful prevention.[3],[4] For this purpose, the administrators of the organization must pay meticulous attention to details in nurses' empowerment, that leads to the promotion of productivity and effectiveness in aggressive situations.[11]

According to Kanter's empowerment theory, empowerment is defined as “employees' access to social structures within their work settings that enables them to accomplish their work in meaningful ways.”[12] The results of a study in psychiatric wards revealed that organizational empowerment was significantly related to nurses' work stress to control the situation, and pointed to the need for nurses empowerment and identifying obstacles that lead to the poor performance of psychiatric nurses for safe practices.[11],[13] Studies have shown that the inability of nurses to implement appropriate cares for the management of patients' aggression is attributed to inadequate training.[5],[10] Nevertheless, studies on the effects of staff training noted that while these programs increased the knowledge, confidence and attitude of nurses, they had little influence on reducing the rate of aggression. Researchers have reported that the ability of nurses to manage patients' aggression is not only affected by staff training but also by the overall approach of the organization.[14],[15],[16] These inconsistent results of quantitative studies are questionable. Regarding today's health care system, which emphasizes principles of clinical governance such as effectiveness, efficiency, and the use of appropriate approaches to improve the quality of patient care, especially in situ ations of risk, identifying the obstacles to obtaining needed healthcare is at the head of affairs. While the use of physical restraint in the psychiatric wards of Iran to control aggressive patients is common,[17] there are few studies on the recognizing of psychiatric nurses problems in the care of patients. The existing studies mostly focused on identifying the prevalence, causes, complications, and patient handling.[7],[8],[18] Therefore, identifying the challenges of nurses' empowerment in the management of patient's aggression from the nurses' point of view is a research requirement. It is believed that clinical issues are complex phenomena, and the qualitative study is the most appropriate method for such cases to reflect attitudes, emotions, and perceptions of nurses.[19] This study was designed with the aim of exploring psychiatric nurses' experiences of the challenges of empowerment in the management of patients' aggression. Identifying the challenges can help authorities to be aware of deficits, and nurses can have better efficacy in delivering optimal and safe measures. This will have an important subsidiary benefit of reducing the need of staff for containment measures.


  Materials and Methods Top


This descriptive qualitative study was carried out at a major referral psychiatric center, located in one of the major cities in Iran, and affiliated to the University of Medical Sciences, during 2014–2016. It renders psychiatric services to several cities in this region, and has 239 active beds in emergency, adult, and children wards.

The participants were 20 psychiatric nurses. Purposive sampling was used to select participants that was based on the principles of maximum variation to receive a vast range of experiences.[20] Nurses with diverse backgrounds in sex, age, marital status, ward, years of work experience, education and title backgrounds were enrolled. Inclusion criteria were: willingness to participate in the study, being in a good physical and mental health, having more than 1-year experience in the psychiatric settings, and having at least a bachelor's degree.

Deep semi-structured interviews with instructions for questions were used for data collecting.[19] Examples of key questions were: “Please tell me about your experiences in relation to challenges of empowerment in the management of patient aggression in this setting?” “How did you manage patients' aggression in this situation?” Based on the participants' responses, follow-up questions were asked for better perception of experiences. Based on the participant's request, face-to-face interviews were carried out two to three hours after starting their shifts in a private place in the psychiatric setting. All interviews, which lasted between 23 and 94 mins, were conducted by the first author. Observation was another method of collecting data. It was also used for completion and confirmation of data.[19],[20] Observations were conducted by the first author, on the days appointed for interviewing, or the other days. The researcher entered in the ward with permission of the head nurse. The major function was observing the interactions, situations, deficiencies and conducting training sessions. The observer interacted with staff, but was not involved in any formal nursing care, although at times the researcher cooperated with nurses to deal with the usual needs of patients (observer as participant). Totally, 11 observation sessions were conducted during the different time, shifts, and wards for 2 to 3 hours. Field notes were recorded during observations. Data saturation was attained when no new data code could be identified.[19]

Inductive content analysis (Graneheim and Lundman) was used for the analysis of data. In nursing research, inductive content analysis has been an important way of providing evidence for a clinical phenomenon.[21] All authors were active during the process of analysis. The recorded interviews were immediately transcribed word-by-word, and were used as the main data of research. The recorded voices were listened several times, and handwritten texts were frequently reviewed. The meaningful units in interviews, field notes and observational notes were abstracted and coded. Considering the participants' experiences, explicit and implicit concepts were identified in the form of sentences or paragraphs form the words and were then compressed to form new sentences. The outputs were coded and summarized. The codes were classified into subcategories based on comparing their similarities and differences. Three categories were formulated as the expression of the latent content of the text. An example of the process of analysis is shown in [Table 1].
Table 1: Example of content analysis process

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The trustworthiness were based on Lincoln and Guba' framework, including credibility, dependability, transferability, and conformability.[19],[21] Credibility was ensured via suitable relationship with the participants; prolonged engagements by sufficient time (2 years) devoted to data collection, notation, and constant comparative analysis of data; and repeated reading of the interviews; using different sources for data collection; checking the codes and confirming by research team (peer check). For dependability, the coded interviews were taken back to some of the participants to confirm (member checks); as encoding process and categories approved by experts of qualitative research (external check). In order to evaluate conformability, the research processes and the decisions made during these processes were recorded and reported in case others might wish to follow and audit the research results. Transferability was provided by sampling with maximum variation and rich explanation of the data. Hence, we tried to present participants' quotes as they were said.

Ethical considerations

The study was approved by the ethics committee of Shiraz University of Medical Sciences (Grant No. 93-7004). Official licenses were obtained from the psychiatric hospital administrators in the target city. The other research ethics were: explaining purpose of the study, ensuring participants' privacy, data confidentiality, obtaining informed consent, right of withdrawal from the study at any time, the right to ask for recording interviews and observation.


  Results Top


Demographic characteristics of the participants are presented in [Table 2]. Three categories and ten subcategories were found from the data analysis that is summarized in [Table 3].
Table 2: Demographic characteristics of participants

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Table 3: Categories and subcategories about challenges of nurses' empowerment in the management of patient aggression

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Inefficient organizational policies

Limited human resource

Participants expressed their thought that insufficient number of staff members, based on appropriate standards, such as: staff nursing, guard, psychologist, etc., can reduce the authority of nurses in the effective intervention for the management of patients' aggression. A head nurse stated: “A patient had problem with his father, he attacked him during visiting hours; we were surprised and did not know what to do… we later found that, the psychologist was informed of the patient's problems, but nurses were not informed.”

Staff shortage led to ignorance about patients' needs, the slow process of patients' treatment, fatigue, superficial and short relationships with patients, etc., which can cause patients to become aggressive or increase aggression. A head nurse said: “We were busy with other work, and couldn't continuously monitor our patient's. Suddenly; we noticed by the bustle in the ward that the patient had attacked the other patient.”

The shortage of male nurses and the placement of female nurses in the men's wards was an additional challenge. In addition to differences in physical strength and emotional responses, female nurses are limited in having direct contact with male patients, which emphasized the shortage of appropriate staff even more. One female nurse said: “This morning, we had three incidents of patients' aggression. We managed one with physical restraint. There are three females and one male nurse. We cannot comfortably interact with male patients and do not allow ourselves to touch the bodies of male patients.”

Mandatory shifts

Nurses stated that managers must refrain from mandatory shifts in work shift schedule for staff member to be successful in the management of patients' aggression: One of the clinical nurses stated: “mandatory shifts especially night works are really exhausting …… sometimes personnel do not pay attention to patient's demands, argue with him and immediately perform medication or patient isolation when he gets aggressive.”

Shortage of protective equipment

Protective equipment is necessary for the implementation of optimal practices and increased nurse's ability in the management of patients' aggression. Participants pointed to the lack of protective equipment, such as lack of a warning bell for quick response, lack of safe accessories to equip nurses, lack of non-standard safe rooms. One nurse stated: “If we had a safe room in the ward, we could calm the patient by isolating him; instead we had to physically restrain the patient to prevent him from harming himself or others.”

Lack of motivational sparks

Lack of financial and psychological motivation led to discouragement and reduced the willingness and the ability of nurses to perform high quality services and implement safety management measures. Matron said: “There is no provision for payment for overtime and nursing salary is inadequate. I observed some who were indifferent to the patient's complaint.”

Despite that, nurses try as much as possible to calm patients and take appropriate measures in the management of patients' aggression, but administrative, financial, and psychological determinants do not encourage nurses to develop and maintain good practices. A nurse stated: 'One night, three colleagues and I worked with sixty-three patients; none of us was able to rest because we had an aggressive addict patient. Afterwards, the psychiatrist thanked night shift resident. This depreciation can cause frustration for me, so I don't bother to provide a proper measure for patient control.”

Inadequate job growth

Failure to implement training programs

Participants stated that university educational content, orientation training and continuing training programs are inadequate for empowering staff members. Despite attending monthly training, nurses are faced with numerous problems related to this issue such as implementation of traditional methods, lack of inter-professional training program, no Internet access to provide appropriate information, and paper evaluations. A head nurse expressed: “The training sessions are theoretical. I sometimes felt that the teacher had no experience in communicating with an aggressive patient. Learning how to communicate with an aggressive patient is always an educational need of the staff members.”

Nurses expressed the performance evaluation is one of the important techniques that can use to empower staff members for proper practice, but paper evaluations created obstacle to their empowerment. A male nurse stated: “Assessment of skills was not performed to determine how nursing skill and performance have changed for the aggressive situations.”

Insufficient effort for job competence

Participants expressed that managers must ensure having skilful, competent, experienced, and knowledgeable personnel to manage of patients' aggression. They noted the long shifts for novice nurses, and nurses' assistants that do not have basic knowledge of psychiatry. Experiences of the participants and observations and field notes of the researcher indicated unfamiliarity with cultural background, conditions of patients, fear of patient, poor staff-to-patient interaction, low self-esteem, and lack of commitment have provoked patients' aggressive behavior. A head nurse, said: “One day, an aggressive patient threatened to beat a guard up, the new nurse said, why are you going to attack the guard? The patient attacked him instead, slapping him on the face.”

Some of the experienced nurses believed that sometimes lack of knowledge and practical abilities prevent them from implementing suitable intervention. A nurse with 10 years of experience expressed:” Frankly, I still have problems; for instance, I cannot calm an aggressive patient who is restless through muscle relaxation or giving advice.” A head nurse stated:” This hospital is a big referral center and has two or three nurses with psychiatric expertise (MS degree). They have much ability to manage aggression; when one of them is in the ward, I feel safe.”

Lack of clinical guidelines

Participants believed that aggression is a clinical risk and clinical guidelines of the ministry are an important tool to help staff make decisions, prevent error, and perform the latest standard interventions, when implementing measures that control aggression. Based on observations, field note and participants' experiences, lack of aggression assessment tools, forms such as nursing notes regarding aggression, report sheets for incidents, educational signs, posters, visual aids were among the difficulties. Quality improvement nurse said:” This is a psychiatric hospital and aggression occurs frequently; there are general clinical risk guidelines provided by the ministry, but there are no specific guidelines on the walls regarding aggression and how to control it.”

Deficiencies in the organizational culture

Inadequate autonomy and authority

Participants did not have independent ability and authority to make appropriate and quick decisions in unpredictable and risky situations. They worked within a physician's framework. A nurse said: “The doctor told me to check with the resident, if I wanted to give any information to the patient. The patient anxiously asked me about Electro Convulsive Therapy (ECT). I dare not respond and told the patient to wait for the resident to arrive. He punched me, and said: 'Idiot', what is your role here?”

Nurses had no authority to judge or make suggestions regarding the status of patients. A nurse stated: ” I informed the doctor, one of the patients told me he has a problem; is it not better to refer him to a psychologist? With a look and a pause indicating that, I should not interfere, he immediately responded: 'No.' Later that afternoon, that same patient became aggressive and attacked the staff.”

Nurses in emergency situations need more delegation of authority for rapid manage of patient. A nurse argued this as follows: “Residents and interns were in a conference hall when a patient asked to be sent for occupational therapy. I told him: You don't have a doctor's order; he got angry and very aggressive. In these situations, they should give authority to nurses to make decisions on their own.”

Lack of the culture of prevention

Nurses felt that strengthening the culture of primary prevention would have a positive impact on personnel performance, safety outcomes and reduce the use of containment measures, and authorities should support a preventive approach, and they should be role models for the staff. A nurse stated: “There is no follow up where there should be. We intend to institutionalize the culture of prevention in hospitals, but we understand that our managers don't want us to contribute.”

Participants reported lack of proper management style and poor quality of supervising in prevention of aggression. A nurse stated:” Supervisors never ask: How many aggressive patients did you have on this shift? Why did they become aggressive?. They say it is normal for a psychiatric patient to be aggressive, so the culture of prevention is not effective. This affects the attitudes of the staff and their behavior toward prevention.”

Culture of fault and blame after an incident

Participants stated that an inefficient situation such as assigning blame and no proper interaction after an incident by managers has effect on professional efficiency, psychological empowerment, and can reduced the quality of their work. A nurse expressed: “When we report a maleficent aggressive incidents, managers don't pay attention to our report about incident, and we are blamed most of the time. Therefore, we immediately perform patient restrain, because we are afraid of patient injury. In this regard another nurse said: “Managers blamed us in front of the patient. Do we have the power to stop patient from not repeating his behavior?”


  Discussion Top


Nurses frequently mentioned staff shortage, which led to ignorance about patient. Based on the literature, lack of manpower increases dissatisfaction and causes nurses to exacerbate patients' aggression through actions such as rushing through patients' treatment,[6],[22],[23] engaging in ward routines and ignoring patients, and lack of effective communication.[9],[24] While in Iran, due to the form of patients' admission in psychiatric units, and prolonged hospitalization, nurses are more likely to face staff shortage.[18] The shortage of male nurses and gender disparity in the care of the patients was another challenge, because female nurses were restricted in the control of aggressive male patients. Based on the researches conducted in the western countries, the presence of nurses of both genders in psychiatric wards is required. Such differences in perspective are justified for Iranian nurses as Muslims. Due to religious custom, nurses do not tend to communicate closely, touch, or have physical contact with patients of the opposite gender. On the other hand, mandatory shifts, lack of financial and psychological motivation were impressive in implementing appropriate measures to manage aggressive patients. This finding is also comparable to previous study, which reported heavy shifts increased fatigue and the rate of patients' or nurses' aggression.[9] Studies have also shown that adequate salaries and benefits, psychological support, encouragement and reward decreased emotional fatigue and increased job satisfaction and self-control of nurses in the workplace.[6],[13]

In our study, inadequate protective equipment led to implementation of no optimal practices. A few previous studies indicated that lack of protective equipment led to the use of physical restraining,[13],[23] and nurses who felt that their workplace was safe, experienced less patient aggression and felt more in control of the situation.[11] In Iran, psychiatric nurses are more concerned about assaults and damage of patients and themselves, because there are no forensic nurses.

Our results demonstrated that, educational programs were inadequate for empowering staff members. Unfamiliarity of instructors with advanced prevention skills and patient control,[22] non-usage of information technology for searching health information,[25] Non-implementation of training for role playing and case studies,[5] use of descriptions of actual events rather than video scenarios, need to monitor clinical performance and evaluate nurse interaction with aggressive patients,[10] are among the results of previous studies that are in line with the results of this study. Undoubtedly, ability of nurses to early detection of a patient's condition, and their ability to make appropriate decisions in patients' aggression can be improved by appropriate knowledge and skills. Reduced competency by non-experienced and surprisingly experienced nurses was a contributing factor to aggression and physical assaults in Iranian studies.[7],[18],[26] Based on American Nurses Credentialing Center (ANCC), gaining experience and skills through advanced training courses in a real environment and receiving license for employment are important at different levels of nursing practice.[23] Researchers observed a negative association between the presence of Registered Nurses (RN) and the likelihood of patients' aggression.[27] Whereas in Iran, psychiatric nurses do not have RN degree and receive no specialized training before working in psychiatric wards, nor they require the evidence of the skill and experience to work in psychiatric wards. Also, nurses are not correctly selected and some of uninterested nurses are forced upon work at scheduled shifts.[28] Participants believed that aggression is a clinical risk and according to clinical governance policies, updated standard clinical guidelines are an important tool to make decisions and standard interventions. Muinga et al. noted that nurses need appropriate dissemination of information for best practice by printing updated clinical guidelines.[25] Access of psychiatric nurses to tools that can aid the evaluation of aggression in patients more accurately, more quickly, and without the need to enlist the help of others is also necessary.[3]

Nurses stated that they must work within a physician's framework, and they do not have professional independence to make quick decisions regarding required measures. Although caring and taking necessary steps for mentally ill patients was dominated by the psychiatrist,[6] in one study, nurses stated that psychiatrists expect registered nurses to make decision only in hazardous situations.[29] The result of this documentary, for present study is noteworthy, because one of the important challenges was insufficient competence of personnel. Nurses referred to the belief of managers about normality of the aggressive behaviors of psychiatric patient and ignorance about preventive measures that increased the use of patient restraint. Duxbury et al. revealed that patients emphasized preventive measures and nurses believed that aggression is the nature of disease and used more containment measures, although they had been taught about the effectiveness of primary prevention. Researchers stated that attitudes of nurses about choosing the best way is influenced by the managers' behavior.[2] Also, one study in Iran showed that no action has been taken to pursue the incidence of aggression.[26] Currid emphasized that disregarding “zero tolerance” policies as a method of prevention is an important reason for escalating patients' aggression in psychiatric wards.[6]

Nurses also noted the culture of assigning blame after the aggressive incident and patient injury by managers. They described its impact on attitude of patient to nurse, and restraint of patient due to fear of patient injury. In one qualitative study, fear of blame regarding the consequences of aggression was a theme and nurses identified its impact on their performance in the control of patient.[30] Baby et al. stated that, reducing nurse's dignity and authority in front of the patient lead to increase in unpleasant patient behavior.[22]

The small sample size, limited geographical area, limitation in the nurse's memory in verbalizing experiences are limitations of generalizability that is common in many qualitative studies. But, it is noteworthy that the selected samples in this study were only psychiatric nurses which may raise a limitation that data on different categories of variability are not sufficient. Although nurses participated based on trust and cooperation, fear of revealing challenges or striving to highlight them, may have influenced the direction of the findings. Further studies with inclusion of other personnel and different psychiatric hospitals in terms of ownership, geographical status, cultural, and environmental conditions are suggested, because a survey can lead to national strategies for improving management of aggression by identifying challenges that may not have been captured by the limited scope of this study.


  Conclusion Top


Psychiatric nurses faced challenging situations, such as staff shortage especially man staff and gender disparity in the men's care, and lake of financial security as well as psychological supports. Insufficiency of training programs, lack of clinical guidelines, and consequently insufficient knowledge, attitude, and skills of the nurses led to reduced professional competence. Nurses were dissatisfied with the lack of a culture of prevention, inadequate authority, and one-dimensional view of the officials in accidents and blaming them. Discouragement, fear, fatigue, and insufficient capacity in judgment or decision making, etc., were of the consequences of these challenges which resulted in patients' aggression and unnecessary use of containment measures to management of patients. Therefore, managers should pay more attention to these factors such as the implementation of gender conformity care plan; training based on the needs and inter-professional requirements, continuous performance evaluation; attracting specialist nurses and creating conditions for academic upgrade. They should support preventive approach by following aggressive cases, understanding the root causes, finding solutions, and provide nurse's authority to take quick action based on knowledge and clinical judgment in aggressive situations without blaming them. In this study, we attained a broader understanding of what and how challenges in work conditions can lead to negative nurse's and patient's outcomes, and its impact on the nurses practice quality. It is noteworthy that despite emphasis on the risk situations in clinical governance and accreditation approaches, psychiatric wards in this Iranian region are not moving sufficiently toward high quality and safe practice.

Acknowledgement

Researchers express their gratitude and appreciation of authorities of Shiraz University of Medical Sciences for approve and the financial support, Presidency and the participants of psychiatric setting for their cooperation in study.

Financial support and sponsorship

Shiraz University of Medical Sciences, Shiraz, Iran (Grant No. 93-7004). Article was extracted from a nursing PhD thesis of first author Tahereh Ramezani.

Conflicts of interest

There are no conflicts of interest.

 
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