Nurses Attitude towards Psychiatric Patients with an Aggressive Behaviors at Saudia Arabia Psychiatric Hospital

^1*Faisal Wahaq D. Alotaibi, ²Faris Saeed Almalki, ³Faisal Raffaa H. Aljuaid,

⁴Yasir Mutlaq M. Al-zaidi,⁵Fahad Saud Alharthi, ⁶Hani Hilal S. Almalki,⁷Naif Mohmmed A. Alharthi,⁸Ghaidaa Khalid Khurmi,⁹Uthman Abdullah Mohammed Albeshi,¹⁰ Sultan Dhaifallah Awadh Alharbi,¹¹Khadra Abdullah Alawali,¹²Barakat Hussain Asiri, ¹³Mobarak Fadel Aldosary

Abstract

 Background: psychiatric nurses care for hospital patients with
behavioral health conditions.. 

Objectives:  The current study aimed to assess attitude towards Psychiatric,

 Patients with Aggressive Behaviors at Saudia arabia Psychiatric Hospitals.

 Materials and methods:    

Descriptive cross sectional hospital based design was used to conduct this study at a Psychiatric Hospital in Saudia arabia. The target population consisted of 60 nurses employed at the Saudia arabia Psychiatric Hospital. Structured questionnaires were distributed to the participants for data collection.  Data analysis was done using a Statistical Package for Social Science, version 24, and nominal as well as ordinal data was analyzed using descriptive analysis.  

Results: The study found that nurses had strong perception in environment perspective and managing aggressive respectively behavior of person with mental illness (PMI). Nurses trained in psychiatry have attitude regarding management of violent behavior. Hence it is recommended that nurses should inculcate behavioral change communication among psychiatric patients.

Conclusion:   The results of the study have indicated that nurses have acceptable attitude of psychiatric patient aggression and its management. Nurses should be given proper training to enhance their competencies in aggression management.

  Keywords: Attitude, Psychiatric, Saudia arabia psychotic hospital

1. Introduction:

Mental illness is becoming more common than many other illnesses such as heart disease cancer and diabetes. Patient aggression or violence against psychiatric nurses is a global problem.  (Ministry of Health, 2008) These nurses therefore face the following major challenges of provide nursing care to aggressive psychotic patients.

Nurses serve as the frontline care providers in a nation’s health care system.

   Nurse is necessary acquire the knowledge and skills necessary to manage aggressive patients with mental disorders without getting hurt in the process. To do this, we need to educate psychiatric nurses. They are also trained to understand mental illness and how it affects their behavior. (Ministry of Health, 2008) 

Mental illness has a significant impact on individual and collective health. Disability more serious than physical illness. Physical ailments include, among others risk of injury, cardiovascular disease, and HIV (human immunodeficiency virus) major contributors to disease burden (Corrigall et al., 2007). However, according to World Health Organization (2004), 5 of the 10 leading causes of disability in the world, it’s a mental illness. These include major depression, schizophrenia, Bipolar disorder, panic disorder, alcohol use disorder. This highlights the burden incurred due to mental illness in psychiatric services.

Attacks on mentally ill patients are seen as a major challenge nationally and internationally. Chen et al., (2005), reported those nurses’ experiences of aggression or patient violence is an internationally anticipated occupational hazard.  From a survey of mental health and learning disabilities in patient wards, nurses were consistently higher, with up to 86% of nurses being affected by violence and aggression patient behavior. Duxbury and Wright (2011) and American Psychiatric Nurses   Association (2007) adds that patient aggression in healthcare settings raises safety concerns for both patients and staff. Workplace violence in healthcare is seen as it is an epidemic by different authors because it has been reported in almost every country in the world (Kennedy et al.,   2009).  In a study conducted by Inoue et al. (2006) tudy at two hospitals in Japan to assess the psychological impact of verbal abuse or violence by patients on nurses working in psychiatric departments and to identify factors related to their impact. Findings from this study revealed that exposure to aggressive behaviour could lead to long term psychological effects, such as burnout and psychological distress of nurses, which would ultimately affect the quality of care provided to patients (Inoue et al., 2006). Also Papadopoulos et al., (2012) assert that violence and aggression cause a negative effect on staff performance including a high rate of absenteeism, high stress levels and low staff morale. In a South African study conducted by Kennedy and Julie (2013) on nurses‟ experience and understanding of workplace violence in trauma and emergency departments, the authors allude to nurses experiencing physical threats, verbal abuse, psychological and imminent violence on a regular basis. These authors also assert that nurses tended to normalize abusive behavior as it was perceived „to come with territory. The present study aimed to assess attitude towards Psychiatric Patients with an Aggressive Behaviors at Saudia arabia Psychiatric Hospital.

MATERIALS AND METHODS:

The study design was a quantitative descriptive cross sectional hospital study. 

STUDY AREA

This study was conducted in Altif Erada Complex and Mental health as psychotic hospital.

 The population chosen for this study includes registered nurses as well as nursing unit managers working in Altif psychiatric hospital. 

1. SELECTION CRITERIA

1.2.4.1. Inclusion criteria:

The inclusion criteria for those eligible for the study was include male and female registered nurses and nursing unit managers who have worked in Altif psychiatric hospital.  

1.2.4.2. Exclusion criteria:

Those who were not agree to participate in the study and those who are not found at the time of data collection.

1. SAMPLE SIZE AND   SAMPLING TECHNIQUES

The sample size was taken conviencely as 60 nursing in Altif psychiatric hospital.

 1.2.5.6. DATA COLLECTION

 Data collection is the precise, systematic gathering of information relevant to the
research purpose or the specific objectives (Burns et al., 2013). According to Polit and Beck (2008), a data collection plan for quantitative studies should yield accurate, valid and meaningful data that are maximally effective in answering research questions. The researcher used a self-designed, structured questionnaire, consisting of 30 closed ended questions, to collect data. Brink et al. (2012) define questionnaires as a self-report instrument where the participants respond to given questions. The questionnaire was developed by the researcher.

1.2.5.8. Data analysis:

Descriptive statistics are used to describe and synthesize data. This helps to set the stage for the understanding of quantitative research evidence (Polit and  Beck, 2012). The data was arranged into frequency distribution that is described by Polit and  Beck (2012) as a systematic arrangement of values from the lowest to the highest value, together with the number of times each value was obtained. 

1. Study findings:

  Fig.1: Distribution of nurses according to gender (n=60)

  Fig.2: Distribution of nurses according to age group (n=60)

      Fig.3: Distribution of nurses according to years of experience (n=60)

      Fig.4: Distribution of nurses by education level (n=60)

      Fig.5: Distribution of nurses by type of aggression (n=60)

    Table 1: Overall attitude of nurses towards psychiatric patients with an aggressive behavior in terms of Situational Perspective at Altif Psychiatric Hospital.

Situational Perspective	Strongly agree		Agree		Neutral		Disagree		Strongly disagree
	No.	%	No.	%	No.	%	No.	%	No.	%
Patients commonly become aggressive because staff do not listen to them	32	53.3	14	23.3	4	6.7	6	10.0	4	6.7
Poor communication between staff and patients leads to patient aggression	24	40.0	23	38.3	4	6.7	7	11.7	2	3.3
Improved one to one relationships between staff and patients can reduce the incidence of patient aggression and violence.	27	45.0	21	35.0	2	3.3	7	11.7	3	5.0
Patients are aggressive because of the environment they are in.	28	46.7	12	20.0	8	13.3	1	1.7	11	18.3
It is largely situations that contribute towards the expression of aggression by patients.	23	38.3	23	38.3	4	6.7	3	5.0	7	11.7
Overall  Situational Perspective	134	44.7	93	31.0	22	7.3	24	8.0	27	9.0

                      Mean score = Mean± SE=10.3 ± (.4)

    Table 2: Overall attitude of nurses towards psychiatric patients with an aggressive behavior in terms of environmental factors of regression at Altif Psychiatric Hospital.

Environmental perspective	Strongly agree		Agree		Neutral		Disagree		Strongly disagree
	No.	%	No.	%	No.	%	No.	%	No.	%
Patients are aggressive because of the environment they are in.	23	38.3	13	21.7	8	13.3	9	15.0	7	11.7
If the physical environment were different, patient	22	36.7	22	36.7	6	10.0	1	1.7	9	15.0
It is difficult to prevent patients from becoming aggressive or violent.	22	36.7	17	28.3	8	13.3	3	5.0	10	16.7
Overall environmental factors	67	37.2	52	28.9	22	12.2	13	7.2	26	14.4

                      Mean score = Mean± SE=12.4 ± (.4)

 Table 3: Overall attitude of nurses towards psychiatric patients with an aggressive behavior in terms of Management Perspectives of regression at Altif Psychiatric Hospital.

Management Perspectives	Strongly agree		Agree		Neutral		Disagree		Strongly disagree
	No.	%	No.	%	No.	%	No.	%	No.	%
Medication is a valuable approach for treating aggressive and violent behavior.	20	33.3	14	23.3	9	15.0	6	10.0	11	18.3
The use of negotiation could be used more effectively when managing aggression and violence.	27	45.0	17	28.3	5	8.3	9	15.0	2	3.3
Expressions of aggression do not always require staff intervention.	19	31.7	19	31.7	7	11.7	3	5.0	12	20.0
Alternatives to the use of containment and sedation to manage patient violence could be used more frequently.	21	35.0	18	30.0	6	10.0	11	18.3	4	6.7
Prescribed medication should be used more frequently to help patients who are aggressive and violent.	25	41.7	15	25.0	4	6.7	8	13.3	8	13.3
Overall  management perspectives	112	27.7	83	27.7	31	10.3	37	12.3	37	12.3

                      Mean score = Mean± SE=11.7 ± (.4)

Table 4: Overall attitude score of aggression

Domain	Mean	SE	Sig.
Situational Domain	10.3 (29.7%)	.4	.000
Environmental Domain	12.7 ( 36.6%)	.4	.000
Management Domain	11.7 ( 33.7%)	.4	.000
Total score	34.7	1.2	.000

1.4. DISCUSSION:

  This descriptive cross-sectional hospital based study was conducted among 60 nurse’s attitude in Altif Psychiatric Hospital.  The present study aimed to assess   attitude towards Psychiatric Patients with an Aggressive Behaviors at Altif Psychiatric Hospital.

  The nurses need to have appropriate skills to manage aggressive behavior of person with mental illness (PMI). Aggression and violence against nurses during working period is an important component in clinical nursing practice. When we compare nurses with other health care personnel they are the high risk group. Perception of nurses has a lot of impact in strategies they use for managing aggressive behavior of psychiatric patients. Hence need was felt for improving knowledge and skill of nurses for managing aggressive behavior. Before that it is important to know perception of nurses (Banerjee et al., 2021).

This study showed that the majority of participants were experienced   physical aggression 95%, 91.7% experienced verbal aggression while 51.7% experienced sexual aggression.

 Evidence suggests that nurses experience both physical and verbal forms of aggression but verbal aggression has been found to be the most common form of aggression experienced (Farrell et aI., 2006; McKenna et aI., 2003). Foster et al. (2007) found that for 145 cases of aggression reported by nurses, 84.1 % were verbal abuse and only 16.6% involved a nurse being pushed or being struck by a hand. Only one incident of violence was reported involving a patient pouring hot water on a nurse. In his study on the extent of aggression exposure and the effects of such exposure on the psychological health of nurses in Sydney Australia, Lam (2002) found that 40% of their sample (314 nurses) had psychological distress and 10% showed signs of mild to severe depression. In their study on the psychological impact of verbal abuse and violence by patients on nurses working in psychiatric wards in Japan, Inoue, Tsukano, Muraoka, Kaneko and Okamura’s (2006) showed that following exposure to verbal abuse, nurses suffered psychological distress. Richter and Berger (2006) assessed the course of post-traumatic stress disorder among members of the mental health hospital following patient assault over a period of six months in Germany. Of the 46 assaulted staff members who agreed to participate in their study 70% were nurses and others included others members of the health team i.e. physicians, social workers and housekeeping staff. About 10% of the participants suffered from post-traumatic stress disorder.

The present study showed that nurse had 29.3% perception of situational domain with mean of 10.3, 36.6% of environmental domain with mean of 12.7 and 33.7% of management domain with mean of 11.7%. he finding is lower than obtained by a study conducted by Marina Lepiesova et al on analysis of the MAVAS instrument to study also 83% nurses had stronger perception in environmental domain but 50% nurses had stronger perception in Situational domain. In case of total score 50% nurses had strong perception and 50% had lower perception in managing aggressive behavior (Lepiesonva and Tomagova, 2014 ).

Interviews with patients in Wijk’s (2006) study revealed that living in a dirty environment was frustrating while rigid limit setting and lack of privacy contributed significantly to the cause of inpatient aggression. Other patients attributed their outburst of aggression to poor living conditions such as boredom, inadequate bedding, inadequate food and the lack of appreciation by nursing staff for their cultural differences. Some patients also reported that the ward atmosphere was generally a contributor to their outburst of aggression. Patients presenting with different mental health problems were incarcerated together which in turn caused tension and frustration among patients, leading to aggressive outbursts. An assessment of both the staff and patients views on the causes and management of inpatients aggression and violence was carried out in England (Duxbury ND Whittington, 2005). A total of 82 patients and 80 nurses participated in the study. Both the nurses and the patients’ perceptions were captured using Management of Aggression and Violence Attitude Scale (MAVAS) questionnaire. Five nurses and five patients were further interviewed in order to explore in-depth the meaning of the issues raised in the questionnaire. The results revealed that both nurses and patients agreed with factors within the environment as the precursor to some of the inpatient aggression. Patients highlighted issues such as being locked up and treated like prisoners as problematic whereas nurses attributed aggressive outbursts to the ward design. In their study on the perceptions of staff and patients on aggression in mental health care units in Australia, Ilkiw-Lavalle and Grenyer (2003) found similar trends and results. Limit setting such as being refused leave to go home by the staff, was seen by patients as the reason for their aggression while nurses saw medication or treatment the clients receives as the cause of aggression.

Management of inpatient aggression includes preventative measures such as risk assessment, close observation patient teaching, interpersonal management of communication, listening skills, and the use of traditional methods objectively with both the client and nurse’s wellbeing and safety a priority (Duxbury et aI., 2008; Needham et al. 2004). Some researchers are of the view that nurses show a preference for the use of traditional methods over other methods and that choice of management is also dependent on who is affected and the severity of the problem (Foster et aI., 2007).

Conclusion:

   The Nurses had strong perception in environment perspective and managing aggressive respectively behavior of person with mental illness (PMI). Nurses trained in psychiatry have attitude regarding management of violent behavior. Hence it is recommended that nurses should inculcate behavioral change communication among psychiatric patients.

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