Mental health nurses’ emotions, exposure to patient aggression, attitudes to and use of coercive measures: Cross sectional questionnaire survey

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Abstract

Background

Mental health nurses are exposed to patient aggression, and required to manage and de-escalate aggressive incidents; coercive measures such as restraint and seclusion should only be used as a last resort. An improved understanding of links between nurses’ exposure to aggression, attitudes to, and actual involvement in, coercive measures, and their emotions (anger, guilt, fear, fatigue, sadness), could inform preparation and education for prevention and management of violence.

Objectives

To identify relationships between mental health nurses’ exposure to patient aggression, their emotions, their attitudes towards coercive containment measures, and their involvement in incidents involving seclusion and restraint.

Design

Cross-sectional, correlational, observational study.

Settings

Low and medium secure wards for men and women with mental disorder in three secure mental health hospitals in England.

Participants

N = Sixty eight mental health nurses who were designated keyworkers for patients enrolled into a related study.

Methods

Participants completed a questionnaire battery comprising measures of their exposure to various types of aggression, their attitudes towards seclusion and restraint, and their emotions. Information about their involvement in restraint and/or restraint plus seclusion incidents was gathered for the three-month period pre- and post- their participation. Linear and logistic regression analyses were performed to test study hypotheses.

Results

Nurses who reported greater exposure to a related set of aggressive behaviours, mostly verbal in nature, which seemed personally derogatory, targeted, or humiliating, also reported higher levels of anger-related provocation. Exposure to mild and severe physical aggression was unrelated to nurses’ emotions. Nurses’ reported anger was significantly positively correlated with their endorsement of restraint as a management technique, but not with their actual involvement in restraint episodes. Significant differences in scores related to anger and fatigue, and to fatigue and guilt, between those involved/not involved in physical restraint and in physical restraint plus seclusion respectively were detected. In regression analyses, models comprising significant variables, but not the variables themselves, predicted involvement/non-involvement in coercive measures.

Conclusions

Verbal aggression which appears targeted, demeaning or humiliating is associated with higher experienced anger provocation. Nurses may benefit from interventions which aim to improve their skills and coping strategies for dealing with this specific aggressive behaviour. Nurse-reported anger predicted approval of coercive violence management interventions; this may have implications for staff deployment and support. However, anger did not predict actual involvement in such incidents. Possible explanations are that nurses experiencing anger are sufficiently self-aware to avoid involvement or that teams are successful in supporting colleagues who they perceive to be ‘at risk’. Future research priorities are considered.

Section snippets

What is already known about the topic?

  • Mental health nurses’ attitudes to the use of restraint and seclusion are related to their approval of their use

  • Anger is also thought to play a role in nurses’ responses to and management of aggression but its role is poorly understood

What this paper adds

  • Mental health nurses who were more approving of restraint and seclusion also reported higher levels of anger, but were not more likely to be involved in these interventions

  • Reported exposure to verbal aggression of a targeted, demeaning or humiliating nature was associated with greater anger provocation

  • Nurses may require help to regulate their emotional responses to specific types of aggression

Participants and setting

The current study was one of a series of investigations into the role of anger and its constituent components in inpatient aggression, staff responses to and management of aggression, and staff-patient interpersonal relationships in a secure mental health inpatient setting. The present study was conducted in the medium and low-secure wards constituting the men’s and women’s adult mental disorder pathways at St Andrew’s Healthcare, a United Kingdom provider of specialist secure mental health

Results

In total, N = 68 qualified nurses (70.6% female) were recruited into the study. Participants were all ward-based nurses (see Table 1), some with additional managerial responsibilities (Ward Manager, Deputy Ward Manager). Most (n = 35; 51.5%) had more than five years’ experience and almost three quarters (73.6%) had more than two years’ experience.

Significant Shapiro-Wilk tests, kurtosis and skewness values, and examination of histogram plots, indicated that the Novaco Anger Scale – Provocation

Discussion

We aimed to explore relationships between mental health nurses’ emotions, most notably those related to anger, their attitudes to coercive management measures, and their exposure to various types of patient aggression. There are three main findings to report. First, exposure to a cluster of patient behaviours, identified as related through principal components analysis, including personal insults, name-calling, and discriminatory remarks that were perceived as having humiliating intent were

Conclusion

This study has found support for a positive relationship between nursing staff anger and exposure to patient aggression, specifically that which is perceived as personally valent. As well as research and clinical efforts focusing on reducing the risk of inpatient aggression, it should also consider the role of nurses within that and its impact on them as individuals, as a team and the ward atmosphere. The study has revealed associations between nursing staff emotion and attitude towards, and

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  • Cited by (0)

    This study was part of author RJs PhD funded by St Andrew’s Healthcare and the University of Northampton.

    1

    Present address: Birmingham City University, Department of Psychology, Curzon Building, Birmingham, B4 7BD, UK.

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