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Exploring mental health nurses’ experiences of assault by patients in inpatient settings
Abstract
Mental health nurses working in inpatient settings are at increased risk of being assaulted by
patients. Systematic reviews have synthesised predominantly quantitative evidence relating to
the prevalence, contributing factors, effects and adverse outcomes of violence towards mental
health nurses. This article details a systematic review that used a meta-aggregative approach
to synthesise qualitative evidence on the experiences of mental health nurses who have been
assaulted by patients in inpatient settings.
The review found that nurses consider violence against them to be a significant and
unacceptable issue that can have pervasive effects on their personal and professional lives. Nurses
may avoid or suppress their emotions following an assault and may find it challenging to share
or report their experiences. Mental health nurses’ perceptions of factors that contribute to, and
can prevent, violence and assault include the environment, workforce, relationships, gender and
restrictive practices. By focusing on findings generated through qualitative research, this review
increases the depth of the existing evidence, using the voices of nurses who have experienced assault to enhance understanding of the issue.
... A better understanding is needed of how different ways of collecting data can impact study findings, such as how group interviews versus individual interviews on violence in mental health nursing may impact willingness to share, or how questions are worded (Ayres et al., 2023;Isobel, 2021). For qualitative studies focused on experiences of racism, a trauma-informed qualitative research approach is recommended for researchers (Alessi & Kahn, 2022). ...
Nursing staff engage readily with patients and associates in mental health/forensic inpatient settings. These settings are known to have instances of workplace violence directed towards staff and such violence includes racism. Racism is a
form of workplace violence that must be better understood and supported within this complex setting. Completing a systematic review to coalesce preexisting research and suggested interventions can be beneficial to supporting nurses.
Systematic review following PRISMA guidelines. CINAHL, PsycInfo, Medline, British Nursing Database and Web of Science databases were searched. Reviewers screened the papers for inclusion (29 articles out of 7146 were selected for inclusion)
and completed the quality appraisal using the Mixed Methods Appraisal Tool.
Subsequently, data extraction was completed, and findings were summarised through narrative synthesis. The way racism was conceptualised impacted how data was collected, reported and interpreted; racism was silenced or exposed depending on how studies were undertaken. If exposed, evidence indicates racism
is a problem but is not always acknowledged or acted upon. Some evidence determined racism led to negative work-related outcomes. The literature provided limited examples of interventions. These included changing education/orientation
for staff, openly discussing racist events and better planning for patients among colleagues and management. Increasing diversity within the workforce requires more research exploring and addressing issues related to racism towards nurses.
Narratives of racism being normalised and embedded in mental health/forensic settings need to be challenged.
Workplace violence towards psychiatric nurses by psychiatric patients is common, which can potentially affect care quality as well as nurses’ health. This study aimed to synthesize the literature on workplace violence towards psychiatric nurses and identify the prevalence and factors influencing workplace violence and related outcomes. PubMed, Cochrane Library, CINAHL, EMBASE and PsychINFO were searched for English articles on workplace violence against psychiatric nurses published from January 2011 to December 2020. Sixteen articles were selected for the systematic review. This was followed by quality assessment and data extraction. The workplace violence prevalence ranged 11.4–97.6%. Diagnosis of the patient; nurse‐related factors such as age, sex, marital status, education, emotional intelligence level and personality; and work shift were associated with the occurrence of workplace violence. Psychiatric nurses who experienced workplace violence had primarily poor mental health such as depressive symptoms and negative work‐related outcomes such as turnover intention. The results revealed that there were relatively few patient‐related factors associated with workplace violence and few reports on workplace violence‐related to nurses’ physical health, suggesting the need for a multi‐dimensional approach. Future studies are needed to develop standardized instruments for workplace violence investigation considering inpatients psychiatric settings. Effective workplace violence prevention strategies should consider comprehensive patient‐, nurse‐ and occupation‐related factors.
Workplace violence directed at nurses in healthcare settings is a common occurrence across the globe resulting in negative nurse and organizational implications that may impact the quality of care provided. Psychiatric nurses working on acute care psychiatric units are at an increased risk and are frequently subjected to patients’ violent and aggressive behaviors. These implications pose significant threats to the nurses’ emotional, physical, and psychological health. Efforts to reduce workplace violence on acute care psychiatric units requires an examination of psychiatric nurses’ lived experiences. A qualitative descriptive phenomenological inquiry was conducted using semi-structured interviews with 10 registered psychiatric nurses within a Western Canada health region to explore their lived experiences of patient-to-nurse workplace violence. The findings of this study highlight the implications of workplace violence and substantiates the urgent need to improve the safety on acute care psychiatric units.
There are over 41 000 vacant nursing posts across the United Kingdom’s National Health Service (NHS), with more people leaving the profession that joining it. Despite mental health being acknowledged as a priority area, some of the most significant staff shortages are occurring within mental health services. Urgent action is needed to retain the mental health nurses (MHNs) currently in post to ensure the profession is fit for purpose and aid future recruitment efforts. This review set out to identify the individual factors that affect the retention of MHNs. A systematic search of six databases was conducted (CINAHL, PsychINFO, MEDLINE, Web of Science (Core collection), EMBASE and the British Nursing Index). Studies were systematically screened for inclusion based on predetermined eligibility criteria. The studies were quality assessed using the Mixed Methods Appraisal Tool (MMAT). Findings were synthesized using Thematic Synthesis. A total of 23 studies consisting of a range of study designs were included in the review. Four key themes emerged from the synthesis: Individual characteristics, Working within mental health services, Training and skills and Work environment. The findings from this review suggest that MHNs encounter some factors unique to working in mental health services, which suggests that retention strategies should be specific to each nursing speciality. Beyond nursing speciality, the factors identified vary between clinical settings in mental health due to the differences in work environments and services they provide. Future studies should now set out to explore what factors exist in which clinical settings to inform better tailored retention strategies to generate better outcomes.
The consequences of workplace trauma among mental health staff can include physical injuries and somatic disorders, professional exhaustion and burnout, depression, anxiety, and other occupational stress injuries. For the well‐being of staff and patients, there is a need to understand mental health workers’ experiences following exposure to workplace trauma, any subsequent mental health problems, and the process of help‐seeking. The nuances of these experiences can best be captured through qualitative exploration. In this study, we explored inpatient mental health workers’ experiences of support and help‐seeking following workplace violence. Four overall themes emerged from interviews with 12 participants: (1) validation as motivation for help‐seeking; (2) stigma as a barrier to help‐seeking; (3) gaps in services provided; and (4) desire for accessible and effective trauma support and education. This study demonstrates the need for supportive management responses and peer support, access to specialized and confidential trauma‐informed mental health services, and reductions in stigma, victim blaming, and other barriers to help‐seeking among mental health workers.
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Introduction:
The present study aims to understand the experiences and characteristics of nurses caring for patients with mental disorders characterized by aggressive behavior.
Aim:
The study aimed to understand and interpret the physical and psychological experiences and positive and negative aspects associated with nursing practices of patients with anger and aggressive behavior.
Method:
The participants of this study were twelve nurses with over three years of experience working in a mental hospital. More specifically, all our participants had experience caring for psychiatric patients with anger and aggressive behavior. The collected data were analyzed using the phenomenological analysis method and the procedure proposed by Colaizzi (1978).
Result:
The nurses' experience was described in five categories: "fear of violence", "exposure to a poor working environment", "difficulty of emotional control", "career regrets", and "finding a solution to violence."
Discussion:
The hospital should encourage and provide training sessions to teach nurses how to use proper intervention technique regarding medication and seclusion.
Implications:
The results of the present study suggest the need for ongoing hospital support and program development, intervention studies, and improvement of the work environment to resolve the burden of mental and physical difficulties experienced by psychiatric nurses.
Aims and objectives
To examine nurses’ perceptions of physical and verbal violence perpetrated by patients and visitors and to investigate themes surrounding gender and the incidence of violence.
Background
The prevalence of violence towards nurses is a concern for nurses and hospital administrators. However, nurses who work in acute care and mental healthcare settings are particularly at high risk. This study examines the occurrence, type of violence and gender issues in a regional public hospital of Queensland Australia.
Design
An exploratory, qualitative design.
Methods
Focus group interviews with 23 nurses from Emergency Department (ED), Intensive Care Unit (ICU) and Psychiatry Department (PD) working in Queensland regional public hospital, Australia. Qualitative data were transcribed and thematically analysed manually and by NVivo. COREQ research reporting checklist followed.
Results
Participants reported frequent incidents of verbal and physical violence on a daily basis. Severe incidence included punching, kicking, biting and scratching, as well as threats of using weapons, such as knives. Patients were more likely to exhibit physical violence, especially towards male nurses, while hospital visitors including patient's family were more likely to exhibit verbal violence. Allocating male nurses in volatile areas and to care for violent patients raises concerns that the male nurses may be seen by their patients as “bodyguards” and not as a professional nurse.
Conclusion
Findings indicate that staff believe that violence is increasing, feel the burden to accept that violence as part of the job and that the bureaucratic processes of the organisation make it difficult to address violence or get support. Organisations need to be vigilant in ensuring assistance is accessible and simplified.
Relevant to clinical practice
This study contributes new knowledge to the discussion concerning of gender issues. Identifying gender issues could assist in developing the necessary interventions to reduce workplace violence.
The present article focuses on the meta-aggregative approach to qualitative evidence synthesis. Originally developed in Australia by the Joanna Briggs Institute, it mirrors the review process for reviews of effectiveness outlined by the international Cochrane and Campbell Collaboration, while remaining sensitive to the specific characteristics of qualitative research. Meta-aggregation is largely inspired by American pragmatism, hence its most distinct feature is that it produces synthesized statements in the form of ‘lines of action’ to be undertaken by practitioners and policy-makers. After a decade of implementing the meta-aggregative approach, we consider its challenges and outline how these can be dealt with in practice. We illustrate this by means of a worked example on experiences of pupils with special educational needs in inclusive education.
Patient or client aggression towards staff is a risk in healthcare. Healthcare takes place in a variety of settings, including hospitals, community, and Aged Care facilities. A minimal amount is known regarding the existence of safety and training measures available throughout the broad range of hospital and community healthcare services. A web-based survey of the type and frequency of violence experienced by healthcare staff was sent to unit managers working in mental health and older peoples' services of District Health Boards, Non-Governmental Organisations, and Aged Care facilities across New Zealand. One hundred and forty-one managers responded to the survey with a response rate of 79.21%. Managers reported high rates of verbal aggression and assaults against staff within their services. A total of 60% of respondents stated that an increase in assaults against staff was due to an increase in violent events and 43.1% related this to increased staff awareness and reporting of violent events to management. Communication skills and de-escalation training were provided across approximately 95% of organisations. The availability of safety measures including panic buttons, personal alarms, use of security personnel, and police assistance were more widely available and accessible within hospital settings and the community sector was found to mostly rely on police for assistance when violence occurs. The perception of violence is high in healthcare. Prevention and management training is provided in public hospital and aged care setting but not so much in NGOs. All areas of healthcare provision could benefit from increased evidence based aggression prevention programmes.
Violence against health care professionals in the workplace is underreported and understudied. Additional data are needed to understand steps that might be taken to reduce the risk.
Background
Patient violence against nurses in their work environments is a widespread global concern, particularly in the field of mental health care. A high prevalence of violent events impacts the well-being of nurses and may also impair overall ward climate. However, it has been proposed that nurses’ use limited techniques to prevent patient violence, and, therefore, more comprehensive methods for dealing with patient violence are needed. There is still restricted understanding of the ward climate during the occurrence of a violent event as well as how these incidents could be more effectively prevented. This study aimed to explore nurses’ experiences of violent events in psychiatric wards, give insight into ward climates and examine suggestions for violence prevention.
Methods
This study employed a descriptive, exploratory design including focus groups (n = 5) and open-ended questions. The participants were registered and enrolled nurses (n = 22) working on three closed psychiatric in-patient wards in one Finnish hospital district. Focus groups were tape-recorded, transcribed and analyzed with inductive content analysis.
Results
Nurses’ experiences of violent events included a variety of warning signs and high-risk situations which helped them to predict forthcoming violence. Patient-instigated violent events were described as complicated situations involving both nurses and patients. When the wards were overloaded with work or emotions, or if nurses had become cynical from dealing with such events, well-being of nurses was impaired and nursing care was complicated. Suggestions for violence prevention were identified, and included, for example, more skilled interaction between nurses and patients and an increase in contact between nurses and patients on the ward.
Conclusions
This study revealed the complexity of violent events on psychiatric wards as well as the implications of these events on clinical practice development and training, administration and policy. A routine process is needed through which nurses’ experiences and ideas concerning prevention of violent events are acknowledged.
Qualitative synthesis informs important aspects of evidence-based healthcare, particularly within the practical decision-making contexts that health professionals work in. Of the qualitative methodologies available for synthesis, meta-aggregation is most transparently aligned with accepted conventions for the conduct of high-quality systematic reviews. Meta-aggregation is philosophically grounded in pragmatism and transcendental phenomenology. The essential characteristics of a meta-aggregative review are that the reviewer avoids re-interpretation of included studies, but instead accurately and reliably presents the findings of the included studies as intended by the original authors. This study reports on the methodology and methods of meta-aggregation within the structure of an a priori protocol and standardized frameworks for reporting of results by over-viewing the essential components of a systematic review report.
Nurses working in acute care psychiatry settings experience high rates of patient violence which influences outcomes for nurses and the organization. This qualitative study explored psychiatric nurses' experiences of patient violence in acute care inpatient psychiatric settings.
An interpretive descriptive design guided this study that included 17 semi-structured interviews with a purposeful sample of 12 Canadian registered nurses who self-reported experiencing patient violence within acute care inpatient psychiatry. Thematic analysis and constant comparison techniques were used for analysis. A problem, needs and practice analysis was also used to structure overall data interpretation.
Thirty three unique exposures to patient violence among the sample of nurses were analysed. Nurses reported experiencing physical, emotional and verbal violence. For many, patient violence was considered "part of the job." Nurses often struggled with role conflict between one's duty to care and one's duty to self when providing care following a critical incident involving violence. Issues of power, control and stigma also influenced nurse participant perceptions and their responses to patient violence. Nurses used a variety of strategies to maintain their personal safety and to prevent, and manage patient violence. Nurses endorsed the need for improved education, debriefing following an incident, and a supportive work environment to further prevent patient violence. Present findings have implications for reducing the barriers to reporting violent experiences and the creation of best practice guidelines to reduce patient violence in the workplace.
Understanding the perspectives and experiences of nurses in acute inpatient psychiatry leads to greater understanding of the phenomenon of patient violence and may inform the development of interventions to prevent and to respond to patient violence, as well as support nurses working within the acute care setting.
Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
In one segment of a multifactor study conducted in 2011 at five psychiatric sites in three counties of Long Island, New York, 110 nurses were interviewed about their experiences with physical assault by psychiatric patients. Marked differences were identified between the male and female nurse participants who were assaulted. Women expressed feelings of inadequacy and questioned their competence. They felt blamed by administration and sometimes even colleagues. In addition, many did not report the incident for fear of reprisal. Women believed that violence was to be expected, and they considered it part of the job. On the other hand, men did not question their competency. They blamed external factors, such as poor staffing or unsafe design of the unit, or they stated that the patient was inadequately medicated and impossible to control. The male nurses did not feel blamed for the incident. All but one male nurse formally reported the incidents. They believed that violence in psychiatry is to be expected but should not be considered part of the job. These findings may be explained by Weiner's Attribution Theory. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].
Personal experiences of aggression or violence in the workplace lead to serious consequences for nurses, their patients, patient care and the organisation as a whole. While there is a plethora of research on this topic, no review is available that identifies types of aggression encountered, individuals perceived to be most at risk and coping strategies for victims. The aim of this systematic review was to examine occupational anxiety related to actual aggression in the workplace for nurses. Databases (MEDLINE, CINAHL and PsycINFO) were searched, resulting in 1543 titles and abstracts. After removal of duplicates and non-relevant titles, 137 papers were read in full. Physical aggression was found to be most frequent in mental health, nursing homes and emergency departments while verbal aggression was more commonly experienced by general nurses. Nurses exposed to verbal or physical abuse often experienced a negative psychological impact post incident.
Nurses' attitudes about the causes and management of aggression affects their choice of intervention. We aimed to compare the attitudes held by patients and staff in a forensic mental health service with the Management of Aggression and Violence Attitudes Scale, and examine the factor validity of the tool in this setting by conducting a prospective comparative questionnaire survey. Staff (n = 72) and patient (n = 98) attitudes differed to a limited extent. Confirmatory factor analysis refuted the previously reported structure of the tool. Exploratory factor analysis suggested three underlying factors related to modifiability of aggression, hands on management, and hands off management. Patients were more optimistic than nurses about the modifiability of aggressive behaviour. Male patients and those with diagnoses other than personality disorder were significantly more likely to agree about modifiability than controls. Forensic inpatients recognize the need for the use of a range of techniques to prevent and manage aggression and violence, but selected groups are most likely to believe that aggression is modifiable. Prevention and management of aggression training should emphasize the modifiability of aggressive behaviour. The development of measures of modifiability and management style would assist in the evaluation of training and would offer new avenues for research.
While studies into stress in mental health nursing are small, studies specifically looking at acute mental health nurses are even fewer. Acute mental health nurses work in environments that are challenging and unpredictable, and care for some of the most seriously ill patients. This area, therefore, needs staff that are physically and psychologically fit for purpose. However, little is known about this cohort of nurses.
In an attempt to address this imbalance, this study aims to ascertain the stressors--the lived experience and meaning--for acute qualified mental health staff.
Using a hermeneutical phenomenological tradition, eight qualified staff from a London mental health Trust were interviewed.
Heavy workloads and violent and aggressive behaviours were among the stressors giving rise to staff experiencing difficulties with switching off from work, poor support from management and fear of blame. These experiences culminated in feeling professionally compromised, less valued and struggling for recognition of the therapeutics of nursing interventions.
There is an urgent need to implement stress reduction strategies in this nursing specialty.
Introduction
Psychiatric nurses are at risk of workplace violence and posttraumatic stress disorder (PTSD). There is limited understanding of pre-trauma and post-trauma risk factors.
Aim
To review factors associated with workplace PTSD in psychiatric nurses.
Method
We searched quantitative and qualitative studies from 1980-2019 in 23 databases plus abstracts for studies on psychiatric hospital nursing staff, potentially traumatic workplace events, workplace factors, and PTSD. Following duplicate abstract (n=10,064) and full text (n=199) screening, data were extracted in duplicate from 19 studies. Using best fit framework synthesis, we identified workplace violence, pre-trauma, and post-trauma risk factors.
Results
Six variables yielded evidence in at least two empirical studies scoring at least 6/8 on a quality measure, or one such study plus more than one other study (“promising”: severe/injurious assault, cumulative exposure, burnout, poor mental health, low compassion satisfaction, neuroticism). Four were supported by at least one better quality study or at least two others (“suggestive”: gender, poor training, any physical aggression exposure, compassion fatigue).
Discussion
Pre-trauma measures, consistent definitions of workplace exposures, and thorough reporting of quantitative results are needed to improve research.
Implications for Practice
Violence prevention, and mental healthcare for exposed nurses, appear the most promising targets for PTSD prevention. Therefore, it is particularly important to understand workplace violence and mental health among nurses working in psychiatric hospitals.
BACKGROUND: When compared with all other health care professions, the psychiatric nursing profession has the highest prevalence of workplace violence. The effects of workplace violence can be psychologically and physically devastating. Supportive resources are not always available or fully utilized when available. Aims: The purpose of this study is to explore the true impact of workplace violence toward psychiatric mental health nurses, as well as their personal perspectives on the types of supportive resources necessary for future implementation. Additionally, this study strives to identify the facilitators and barriers to acquiring supportive resources. Methods: A qualitative descriptive study design was utilized. The theory of cognitive adaptation provided an underlying conceptual framework. Data were collected using REDCap software to identify the nature and extent of workplace violence in the study setting (Survey 1) and solicit detailed responses to focus group questions designed to address the study aims (Survey 2). RESULTS: Six pertinent themes were discovered: frequent exposure to workplace violence, attempt to understand workplace violence, the need for supportive means, barriers to accessing supportive means, increase administrative support, and workplace violence has a detrimental impact on various aspects of life. CONCLUSIONS: Although psychiatric mental health nurses express a desire for more psychological support postassault, the underlying meaning and cognitive adaptation following the workplace violence experience is not well understood, and there are barriers to the acquisition of services. The findings from this study are being used to inform a multifaceted program to effectively support psychiatric mental health nurses experiencing workplace violence.
Introduction
High rates of aggression and violence are a persistent problem in inpatient mental health environments. A comparison of staff’s and patients’ perceptions of the causes may provide novel insights.
Aim
To compare patients’ and staff’s perspectives on the causes of aggression and violence in inpatient environments.
Method
An integrative review of the literature was conducted with a search of Ovid (Medline, Embase, PsycINFO) databases and manual searching.
Results
Thirty articles met criteria for inclusion. Interactions prior to aggressive or violent incidents were characterised by patients as disrespectful and coercive, and by staff as indicative of the patient’s mental state or personality. Both groups identified the importance of patient‐centred communication skills.
Discussion
The review identified that patients and staff have differing perspectives on the causes of violence and aggression. There was an interactional dynamic between staff and patients that was shaped by the culture of the inpatient setting.
Implications for practice
Understanding how the inpatient culture plays a role in shaping a dynamic between patients and staff and developing communication skills that acknowledge this, may help reduce violence and aggression in inpatient settings.
Background
Forensic mental health is a challenging workplace, with nurses subject to various trauma exposures in their professional role.
Objectives
To identify the key concepts related to the nature, extent and impact of workplace trauma for forensic mental health nurses.
Design
A scoping review, informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) tool.
Methods
Sources of evidence were identified and assessed for inclusion using an explicit search strategy. Relevant information was extracted and synthesised to present a descriptive summary of existing evidence.
Results
Of the 16 articles on workplace trauma for forensic mental health nurses included in the review, nine reported data related to extent (incidence and severity) and 14 described the impact. The incidence (per bed/per year) of each workplace trauma type ranged from 0.95 – 7.15 for physical violence, 0.39 – 5.12 for verbal abuse, 0.03 – 0.12 for sexual violence, and 1.47 – 7.9 for self-harming behaviour. The proportion of incidents at the lowest severity rating ranged from 15.1% to 84.7%, and the range for the highest severity rating was 0% to 38.7%. In the single study that examined the incidence of vicarious trauma, 14.9% reported low levels and 27.7% reported high levels. Psychological distress was the most commonly reported impact of workplace trauma, identified in eight studies. Seven studies reported limited data for physical injury from workplace trauma. The impacts of exposure to workplace trauma reported in the remaining studies included needing to access psychological support, experiencing physiological symptoms, feeling less safe at work, and requiring time off work. With the exception of two studies providing limited data related to absenteeism, the impact for organisations was not explored in existing literature.
Conclusions
: While studies indicated that forensic mental health nurses are frequently exposed to various forms of workplace trauma, reports of severe assaults on staff were rare. Although limited, these findings suggest that cumulative exposure to workplace trauma over time, or exposure to more severe forms of physical violence, increase forensic mental health nurse vulnerability to experiencing detrimental impacts on their personal and professional wellbeing.
Mental health professionals frequently work in environments where stressful, unpredictable, and potentially volatile situations can arise. Staff responses to these, often violent events, can be severe and enduring. Psychological first aid provided by a colleague following exposure to such violence is gaining increasing acceptance as a means of assisting affected individuals. However, there has been little attention to how staff perceive this support. In this study, interviews were conducted with 13 staff employed in a secure facility and thematically analysed using content analysis. Four content themes emerged: responding to emotional distress, empowering staff through practical support, the good provider, and resilience. The results indicate that staff value and benefit from receiving support from peers following exposure to occupational violence. Most would access peer support again and would consider recommending it to others. A small number choose not to engage with the programme and the reasons for this are also discussed. This type of peer support could be applied in other high‐risk workplaces as a key element of an integrated and comprehensive workplace violence prevention and management strategy.
The purpose of this systematic review is to determine the frequency of violent or aggressive behaviour towards healthcare workers in inpatient psychiatric settings in the United States. To achieve this aim, five databases were searched to find English-language quantitative studies reporting prevalence or incidence data of violence or aggression directed towards staff members in inpatient psychiatric settings. No limitations were set based on publication date, and intervention studies were included only if baseline data were provided. Of 335 total studies found, 38 full-text articles were suitable for full-text analysis based on inclusion and exclusion criteria, and 14 were included in the final review. Years of data collection ranged from 1986 to 2018, and a range of psychiatric facilities were represented, from small, private hospital units to large forensic institutions. Researchers utilized surveys, real-time incident reporting tools, and government databases, or a combination of strategies, to collect data related to workers' experiences on the job. Included research indicates that workplace violence in the U.S. inpatient psychiatric setting is a widespread problem, with 25-85% of survey respondents reporting an incident of physical aggression within the year prior to survey, and statewide workers' compensation findings indicating 2-7 claims due to assault per 100 000 employee hours. There are substantial differences between findings based on measurement strategy, making it difficult to arrive at a single estimate of prevalence nationally. As management of this persistent problem receives continued attention from stakeholders, it becomes increasingly important to define and measure the problem with the most appropriate tools.
Background And Methods
In this study, we surveyed 761 psychiatric hospital staff (69% women, 71% full-time, 56% nursing) regarding their exposure to trauma in the workplace; symptoms of post-traumatic stress disorder (PTSD), depression, and anxiety; help seeking; and perceived barriers for help seeking.
Results
Significant proportions of staff met the screening cutoffs for probable PTSD (16%), depression (20%), and anxiety (16%). Comorbidity was high, with approximately half of those meeting the screening cutoff for PTSD also meeting the cutoffs for depression or anxiety. Only PTSD symptoms were uniquely associated with exposure to trauma in the workplace, but both PTSD and depression symptoms significantly predicted help seeking. Staff who met one or more screening cutoffs perceived more barriers to help seeking such as difficulty with accessing services.
Conclusion
Implications for supporting psychiatric staff exposed to trauma are discussed.
Background:
The therapeutic relationship is synonymous with mental health nursing and fundamental to the provision of nursing care, regardless of the setting in which care is provided. This literature review examines, from a nursing perspective, factors influencing the formation and maintenance of therapeutic relationships in forensic mental health settings.
Methods:
A systematic search of the literature, using a range of electronic databases, focusing on nurse-patient therapeutic relationships in forensic settings was conducted. Articles were Critical Appraisal Skills Programme quality appraised, followed by a meta-aggregative thematic approach to data analysis and synthesis to identify themes and, finally, a production of an "action" policy statement.
Findings and implication for practice:
Eight articles met the criteria for review inclusion. Nine themes were identified; seven were categorized as internal/interpersonal factors, and two were categorized as external/environmental factors (with some themes interconnected). Synthesis of findings resulted in the production of a policy statement encouraging forensic mental health nurses to be aware of intrapersonal influences on therapeutic relationships and the need to provide a safe and supportive clinical environment for these relationships to form.
Background
Workplace violence is defined as an aggression when staff members are abused, intimidated or attacked in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health. Violence against healthcare professionals is frequent, and constitutes a source of concern in the health system. Scientific literature highlights negative behavioral, emotional, cognitive and physical outcomes. The aim of this review is to examine the impact that exposure to workplace violence against healthcare professionals can produce, to improve healthcare professionals' knowledge about the consequences of workplace violence, and to guide future research in identifying strategies that could effectively reduce the incidence of workplace violence.
Method
We have conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic search for the literature on PubMed. Search terms related to WPV were (“Workplace violence”, “Aggression”, “Aggression department emergency”), and search terms related to WPV consequences were (“Mental health”, OR “Health care workers”, OR “Burnout”).
Initial search identified 1.434 articles. One-hundred publications have been selected and the relevant publications, appropriate to the topic review, was reduced to twenty-seven.
Result
According to examined literature, workplace violence mostly occurs in psychiatric departments, emergency services, polyclinics/waiting rooms, and geriatric units. Negative factors such as lack of information, insufficient personnel and equipment, and communication breakdowns increase the risk of violent behavior in healthcare services. Most violence in health institutions is perpetrated by patients and their relatives in the forms of verbal abuse, psychological violence, physical assault, and sexual abuse.
Conclusion
Workplace violence might lead to various negative impacts on health workers' psychological and physical health, such as increase in stress and anxiety levels; feelings of anger, guilty, insecurity, burnout.
Introduction:
Physical assaults perpetrated by patients in psychiatric hospitals against mental health staff (MHS) is a serious concern facing psychiatric hospitals. Assaulted staff reports physical and psychological trauma that affects their personal and professional lives. There is a dearth of literature exploring this phenomenon.
Purpose:
To explore MHS perspectives of assault by psychiatric patients.
Methods:
A transcendental phenomenological qualitative design was used to explore and analyze the perspectives of a purposeful sample of 120 MHS perspectives at an acute inpatient psychiatric hospital. Participants' age ranged from 22 to 63 years (mean age = 32.4). Moustakas' theoretical underpinnings guided the study.
Results:
Two patterns, 8 themes, and 19 subthemes were identified: (a) Psychological impacts revealed four themes-increase of anxiety/fear level, helplessness and hopelessness, flashbacks/burnout, and doubting own competency. (b) Physiosocial impacts revealed four themes-unsupportive superiors, stigmatization of staff victim, failure to report the incident, and environmental safety.
Discussion:
Participants verbalized that assaults by patients have instilled fear and trauma in them. Most of the assaults occurred when staff were performing their routine job functions and setting limits to patient's behavior.
Conclusion:
The study allowed MHS opportunities to narrate their lived experiences of being assaulted by patients and provided validation of their perspectives. Findings illuminated the phenomenon and may help to support policy changes in psychiatric hospitals.
We aim to quantitatively synthesise available epidemiological evidence on the prevalence rates of workplace violence (WPV) by patients and visitors against healthcare workers. We systematically searched PubMed, Embase and Web of Science from their inception to October 2018, as well as the reference lists of all included studies. Two authors independently assessed studies for inclusion. Data were double-extracted and discrepancies were resolved by discussion. The overall percentage of healthcare worker encounters resulting in the experience of WPV was estimated using random-effects meta-analysis. The heterogeneity was assessed using the I
2
statistic. Differences by study-level characteristics were estimated using subgroup analysis and meta-regression. We included 253 eligible studies (with a total of 331 544 participants). Of these participants, 61.9% (95% CI 56.1% to 67.6%) reported exposure to any form of WPV, 42.5% (95% CI 38.9% to 46.0%) reported exposure to non-physical violence, and 24.4% (95% CI 22.4% to 26.4%) reported experiencing physical violence in the past year. Verbal abuse (57.6%; 95% CI 51.8% to 63.4%) was the most common form of non-physical violence, followed by threats (33.2%; 95% CI 27.5% to 38.9%) and sexual harassment (12.4%; 95% CI 10.6% to 14.2%). The proportion of WPV exposure differed greatly across countries, study location, practice settings, work schedules and occupation. In this systematic review, the prevalence of WPV against healthcare workers is high, especially in Asian and North American countries, psychiatric and emergency department settings, and among nurses and physicians. There is a need for governments, policymakers and health institutions to take actions to address WPV towards healthcare professionals globally.
Aim
The study aimed to evaluate the reporting, monitoring, and use of workplace violence data in Victorian health services.
Background
Surveillance of workplace violence is important in understanding the circumstances in which workplace violence occurs, and development of relevant, appropriate, prevention and intervention strategies.
Method
A descriptive exploratory approach was used. Fifteen staff from Occupational Health and Safety, quality and safety, and Nurse Unit Managers, from five major metropolitan health services were interviewed. Recorded interviews were transcribed verbatim and thematically analysed.
Results
Three themes were identified: i) ‘under‐reporting of workplace violence’, ii) ‘inconsistent guidance’ caused subjective and variable data coding, and iii) ‘application of data’ described how health services used the data available to them, to inform the development and implementation of systems designed to prevent workplace violence.
Conclusions
Improved reporting systems may increase consistency in reporting, enable data sharing across organisations, and assist in planning of prevention strategies.
Implications for Nursing Management
Staff should be encouraged to complete incident reports for each episode of workplace violence. Incident reporting systems must be simplified to reduce the burden of reporting. Nurse managers should advocate for the sharing of health services workplace violence data, to enable improved prevention across all services.
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Mental health nurse are frequently subjected to patients' violent and aggressive behaviour. These assault experiences have given rise to mental health nurses' physical and psychological trauma, and negatively impact the quality of patient care. The purpose of the present qualitative study was to understand mental health nurses' experiences of being assaulted, the influences on their patient care, and their perspectives of the effectiveness of in-service, violence-prevention education. Ten mental health nurses from two different inpatient mental health facilities were interviewed using a semistructured interview guide. Thematic analysis of interview data found six themes: (i) violence is unpredictable; (ii) violence is normal; (iii) lasting psychological trauma; (iv) limited support from peers and the administrator; (v) violence prevention requires team cooperation; and (vi) doubting the effectiveness of in-service education on violence prevention. Psychiatric ward administrators should assess nurses' learning and skill needs to determine whether these needs are met by existing in-service training programmes. A culture of safety should also be promoted by building a warm and supportive ward climate for both staff and patients, which would include team cooperation and support for colleagues who suffer a violent incident.
This paper describes psychiatric mental health nurses’ (PMHN) experiences of patient assaults within mental healthcare settings using a thematic analytical approach. The aim of the study was to explore and describe psychiatric mental health nurses’ experiences of patient assaults. The major findings of the study related to the nature and impact of assaults and supportive strategies associated with violence perpetrated by patients against psychiatric mental health nurses. Perpetrator risk factors for patients include mental health disorders, alcohol and drug use and the inability to deal with situational crises. The injuries sustained by nurses in the context of the study include lacerations, head injuries, dislocations and bruises. Psychological harm has also occurred, including quite severe mental health problems, such as post-traumatic stress disorder. Protective strategies for combating negative consequences of workplace violence include practice of self-defence, social support and a supportive and consultative workplace culture with access to counselling services and assistance in all aspects, including finances. The paper concludes that while healthcare employers need to provide better support services to the healthcare professionals who are assaulted, the legal system also needs to acknowledge that assaults against nurses are a violation of human rights and violence should not to be tolerated as part of working in mental healthcare settings.
Overview:
This article is the second in a new series on the systematic review from the Joanna Briggs Institute, an international collaborative supporting evidence-based practice in nursing, medicine, and allied health fields. The purpose of the series is to show nurses how to conduct a systematic review-one step at a time. This article details the process of articulating a review question to guide the search for relevant studies and discusses how to define inclusion criteria for the study-selection phase of the review.
Violence carried out by patients against nursing staff unsettles and threatens coworkers as they care for individuals admitted to inpatient psychiatric units.
This study explored nursing staff's individual and group responses to violent incidents performed by patients against caregivers.
This qualitative study used focus groups to collect data from professional nurses and behavioral health associations (N = 19) recruited from urban, inpatient psychiatric unit. Data were analyzed thematically.
Sharing information about violence, intervening therapeutically, intervening nontherapeutically, recognizing team influences, experiencing emotions following violence, and understanding the work environment comprised the major themes of the experience.
Findings may stimulate discussions and education sessions that address strategies helpful to nursing staff so that incidents are prevented and staff is supported following such disturbing events. Events of workplace violence, including those occurring on behavioral mental health in inpatient units, require accurate individual and aggregate reporting to develop interventions and evaluate effectiveness of violence reduction strategies.
Hostile behaviour is becoming a way of life in South Africa. Hostility prevails at all settings, including in the health sector. In a forensic ward psychiatric nurses are subjected to hostile behaviour by the patients.
The aim of the present study was to explore and describe the psychiatric nurses' experiences of hostile behaviour by patients in a forensic ward and make recommendations for nurse managers to empower these psychiatric nurses to cope with the patients' aggression.
Qualitative, in-depth, phenomenological interviews were conducted with nine psychiatric nurses exposed to hostility from patients in a forensic ward. Recommendations were derived from the results from nurse managers to assist psychiatric nurses.
It became apparent from the findings that psychiatric nurses in a forensic ward work in a stressful environment. Hostile behaviour in the forensic ward is consistently experienced by the psychiatric nurses as hindering therapeutic relationships. The psychiatric nurses experienced being disempowered.
Psychiatric nurses experience hostile behaviour by patients in a forensic ward as disempowering. IMPLICATIONS FOR NURSE MANAGEMENT: Nurse managers can facilitate psychiatric nurses' empowerment by providing them access to: information, support, resources, opportunity and growth.
Ethical standards and current law demand that acute care psychiatric patients be treated with respect, using the least restrictive interventions. Unfortunately, as restraint use has decreased, assault and injury of mental health care workers has increased. Violence against those working in acute care psychiatry is a serious global issue that needs further examination. This study provides current, in depth information about the nature, frequency and severity of assaults and injuries of psychiatric nurses. This study also examined assault and injury in relation to the nurse's decision to restrain. The findings of this study were compared with findings of an earlier study carried out by one of the authors (Moylan) prior to the institution of policies, which are more restrictive in the use of restraint. In a sample of 110 nurses from five institutions, 80% of the nurses were assaulted, 65% had been injured and 26% had been seriously injured. Injuries included fractures, eye injuries and permanent disability. The number and severity of injuries have increased significantly since the 1996 study. Nurses who had been injured decided to restrain later in the progression of aggression than those who had not been injured.
The incidence of violence within the National Health Service is rising and attention to the issue is increasing. Due to the ramifications in terms of physical, psychological and economic cost, the need to understand all the dynamics and variables involved in violence becomes evident. If nurses can provide care that reduces the frequency, intensity and negative consequences of violence, then clients, nurses and the organisation all benefit. This study attempted to discover the lived experience of nurses who experience violence perpetrated by individuals suffering from enduring mental health problems. It adopted a hermeneutic, phenomenological, method and produced an emerging theory comprised of the three key themes; Personal construct of violence, Feeling equipped and Feeling supported. Furthermore, the author suggests relationships between exposure to violent incidents and the nurse's ability to deal with the incidents therapeutically and how formal support systems for nurses influence this relationship. Strategic plans that are concerned with caring for violent individuals need to consider this reciprocity, as staff who feel well supported may well have a substantial impact on the quality of care offered to these people.
The English National Service Framework for Mental Health stipulates that the highest quality of health care should be provided for mental health service users in the most efficient and effective manner. Incidents of aggression and violence militate against achieving that goal, yet such incidents are frequently reported in inpatient settings. Traditionally, research in this area has focused on the extent of the phenomenon, the individual characteristics of those involved and precursors to the incident. For the most part the literature reflects a dualistic, perpetrator/victim conceptualisation of incidents. This study aimed to address the lack of research undertaken from a more systemic perspective by examining how all those involved understood and attributed meaning to violent or aggressive situations and how these attributions justified individual perceptions, reactions and actions. Working from the position that all behaviour, including violent behaviour, has meaning to those involved and can be understood, 16 semi-structured interviews were carried out in one mental health unit. Because only one client was both willing and able to give a full account of an incident, we focus here on two incidents in which that client was involved. Discourse analytic techniques were used to examine her account of the two incidents and those of the staff members involved. Participants discussed key themes from the interviews in terms of several dilemmas: whether the violent or aggressive behaviour was 'mad' or 'bad'; predictable or unpredictable; and had resulted from 'personality' or ' mental illness'. The client and staff discourses were strikingly similar and in each case the central concern was with the attribution of blame. The findings have implications for the professional discourse of mental health care, including the discourse of the current policy agenda, a discourse itself constructed with the primary function of exoneration from and attribution of blame.
Psychiatric facilities struggle to maintain therapeutic environments made increasingly difficult by severe nursing shortages. Related safety concerns prompted a phenomenological inquiry about nurses' experiences working in environments with high risks of assault. Ten registered nurses participated in open-ended interviews. Analysis of interview transcripts generated four categories and 13 subcategories subsumed under the primary construct of "perilous work," providing the frame for the exhaustive description and essential structure of participants' lived experiences. Outcomes suggest that serious work-related hazards exist and provide insight into possible remedies and a springboard for follow-up studies.