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Factors associated with the perception of Angry and Aggressive Behavior among psychiatric

In document VIOLENCE INCLINICAL PSYCHIATRY (pagina 109-113)

nursing staff

Paper

Hanna Tuvesson RN, PhD

School of Health Science, Blekinge Institute of Technology, Karlskrona, Sweden Keywords: Aggression, in-patient care, psychiatry, staff, stress, troubled conscience

Introduction

During the last decades the psychosocial work environment in psychiatric in-patient care has been characterized by ongoing change and a demanding work situation for the staff (Cleary, 2004; World Health Organization [WHO], 2007). Angry and aggressive behavior is a commonly recognized problem in psychiatric in-patient care and the nursing staff is often engaged in aggressive encounters at work (Currid, 2008; 2009; Taylor & Barling, 2004). Moreover, several studies have found that the work in psychiatric care is stressful (Hamaideh, 2011; Leka et al., 2012; Sørgaard, Ryan & Dawson,. 2010) and may create Stress of Conscience (Dahlqvist, Söderberg & Norberg, 2009; Tuvesson, Eklund & Wann-Hansson, 2012).

This study addresses the relationships between the perceptions of Angry and Aggressive Behavior, and the work environment, Perceived Stress and Stress of Conscience, while also acknowledging the role of Moral Sensitivity, Mastery and nursing staff (registered nurses and nursing assistants) characteristics (age, gender, occupation, work experience). An understanding of the relationship between these aspects may contribute to new ways of reducing and managing aggression and improving the nursing staff’s working conditions. The aims of the study were to investigate in what way aspects of the work environment and stress were related to Angry and Aggressive Behavior among nursing staff in psychiatric in-patient care.

The aim was also to describe if there were any differences between how nurses and nurse assistants perceived Angry and Aggressive Behavior.

Methods

This study was approved by the Regional Ethical Review Board (No. 380/2008).

Sample

The participants were a convenience sample of registered nurses and nursing assistants from twelve general acute in-patient wards. All nurses and nursing assistants who worked daytime and had worked at the unit for at least two months were invited to participate in the study. The questionnaires were returned by a total of 38 registered nurses (response rate = 54.3%) and 55 nursing assistants (response rate = 50.5%). The average length of employment on the current ward for the total sample was 9 years and the average length of experience in psychiatric care was 18 years. The majority of the participants were females (78%), permanently employed at the ward (86%) and the mean age was 48 years (21-65 years).

Questionnaires

Personal information and work experience were obtained aboutparticipants’ occupational status, age, gender, type of employment, length of experience on current ward, and length of experience in psychiatric care.

Angry and Aggressive Behavior - Angry and Aggressive Behavior was assessed using a subscale from the revised Ward Atmosphere Scale (WAS) (Tuvesson et al, 2010), originally developed by Moos (1997).

The Angry and Aggressive Behavior subscale measures the level of which patients argue, become openly angry or display other aggressive behaviors. The subscale comprises nine items and and is rated on a four-point scale ranging from Totally disagree (0) to Totally agree (3).

Stress of Conscience Questionnaire - The Stress of Conscience Questionnaire (SCQ) was used to assess stress due to troubled conscience. The SCQ consist of nine items and a total Index of all nine items was used (Maximum score = 225), as well as two aggregated subscales, “Internal Demands” and “External Demands and Restrictions (Glasberg et al., 2006).

Perceived Stress Scale - The PSS was developed by Cohen, Kamarck and Mermelstein(1983) and comprises 14 questions. The participants rate their answers on a five-point scale, from Never (0) to Very often (4), with higher scores (maximum score = 56) indicating higher levels of perceived stress.

Moral Sensitivity Questionnaire - The revised Moral Sensitivity Questionnaire (MSQ) was used to assess an individual’s awareness and ability to sense the moral nature of a situation and the vulnerability of others.

The revised MSQ comprises nine statements and the participants answer on a six-point scale ranging from Total disagreement (1) to Total agreement(6) (Lützén et al, 2006). The MSQ was used as two subscales,

“Moral Strength” and “Moral Burden”, and two single items (number 1 and 9).

QPSNordic 34+ - Psychological and social aspects of the work environment were assessed using items from the short version (QPSNordic 34+) of the General Nordic Questionnaire for Psychological and Social Factors at Work (QPSNordic) (Dallner, et al., 2000; Lindström, et al., 1997; Lindström, et al., 2000).

Sets of items corresponding to subscales of the full version of the QPS Nordic were tested for internal consistency according to the criterion of a Cronbach’s alpha value of > 0.70. This procedure resulted in five subscales: Empowering Leadership, Role Clarity, Control at Work, Support from Superiors, and Organizational Climate. Each item is answered on a five-point scale, ranging from Very seldom or never (1) to Very often or always (5).

Mastery - Mastery was measured with the Mastery scale developed by Pearlin and Schooler (1978). The scale consists of seven items and assesses the respondent’s feeling of having control over his or her life.

The participants were asked to rate the items on a four-point scale ranging from Strongly agree (1) to Strongly disagree (4), and was used as an total index

Data analysis

The Statistical Package for Social Sciences (SPSS) was used in order to analyse the data. Nonparametric statistics were used including descriptive statistics to analyse characteristics of the participants and response distributions of the subscales. The Mann-Whitney U-test was used for detecting differences between nurses and nursing assistants, and Spearman rank correlations for analyzing relationships between variables and for identifying which variables to include in the multivariate analysis. Logistic regression analyses were used for the multivariate analysis.

Results

Nursing staff’s perceptions of Angry and Aggressive Behavior

The result showed that the mean score concerning the factor of Angry and Aggressive Behavior was 1.08 for the nurses and 1.07 for the nursing staff (theoretical range = 0-3). The nursing staff’s response distribution for each of the nine items of the Angry and Aggressive Behavior factor is presented in Table 1. The mean scores indicate a value at the lower to middle end of the scale for both staff groups. Lowest values were found for the items that involved aspects of the nursing staff (item nr 4, 7 and 8). The result of the Mann-Whitney U-test showed no significant differences between nurses and nursing assistants concerning Angry and Aggressive Behavior. There were also no significant differences between individual characteristics in terms of age, gender, and professional experience.

Table 1: Mean scores for the items (minimum=0; maximum=3) of the factor Angry and Aggressive Behavior Mean score

Nurses (n: 38) Nursing assistants (n: 55) Total sample (n: 93)

Patients often gripe 1.32 1.55 1.45

Patients often criticize or joke about the staff 1.53 1.46 1.48

Patients in this program rarely argue 0.95 1.07 1.02

Staff sometimes argue openly with each other 0.511 0.481 0.502

Patients sometimes play practical jokes on each other 1.08 0.852 0.952

It is hard to get people to argue around here 1.191 1.264 1.235

Staff here never starts arguments 0.841 0.821 0.822

In this program, staff think it is a healthy thing to argue 0.612 0.601 0.613

Patients here rarely become angry 1.68 1.55 1.60

1. 1 missing value. 2. 2 missing values. 3. 3 missing values. 4. 5 missing values. 5. 6 missing values

Bivariate analyses

The bivariate analyses are presented in Table 2. There were six significant associations between Angry and Aggressive Behavior and the independent variables. Three reached a level of p < 0.05 (Stress of Conscience, Organizational Climate, Internal Demands). Another three variables reached a level of p < 0.1 (Empowering leadership, Moral Strength, External Demands and Restrictions) and were kept as variables for the logistic regression analyses.

Table 2: Correlations between Angry and Aggressive Behavior and independent variables

Variables r-values

The six independent variables that showed an association with Angry and Aggressive Behavior (p < 0.1) were entered in a forward stepwise conditional logistic regression. The results are presented in Table 3.

The analysis of the factor Angry and Aggressive Behavior resulted in two significant factors: Internal Demands and Moral Strength. Belonging to a group that rated a high level on Internal Demands increased the likelihood of perceiving a high level of Angry and Aggressive Behavior by more than three times. Low scores in the Moral Strength factor were significantly associated with a high level of Angry and Aggressive Behavior, indicated by an odds ratio of 0.33.

Table 3: Variables of importance to Angry and Aggressive Behavior (AAB)

Dependent variable Independent variable p OR 95% CI for OR

AAB1 Internal Demands

Note: Analyses based on a forward stepwise conditional logistic regression (p = < 0.05).

The model exhibited acceptable goodness-of-fit (Hosmer-Lemeshow test, p > 0.05).

1) 20.1% explained variance (Nagelkerke R2)

Conclusion

The results indicate that low Moral Strength and Stress of Conscience made the nursing staff more vulnerable to perceiving high levels of Angry and Aggressive Behaviors. Taking these aspects into consideration when making improvements in the work place could help to prevent and manage aggression in clinical psychiatry. In clinical practice it is important to enable the nursing staff to develop their Moral Strength and to create a work place that focuses on preventing Stress of Conscience. One way of doing

this could be to create a work environment that stimulates moral discussion and reflection and supports the nursing staff in developing and sustaining their moral convictions.

References

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Correspondence

Hanna Tuvesson RN, PhD School of Health Science Blekinge Institute of Technology SE-371 79 Karlskrona

Sweden

Hanna.tuvesson@bth.se

Reporting violence in psychiatry to the police or

In document VIOLENCE INCLINICAL PSYCHIATRY (pagina 109-113)