Staff Training and Prevention of Violence in mental Health Care Units - Research Paper Example

? Staff Training and Prevention of Violence in mental Health Care Units Staff Training and Prevention of Violence in mental Health Care Units Part A:Literature Review The growing number of violence in the health care industry has evoked a variety of responses and those health care professionals who work in mental health care units are most vulnerable to workplace violence. There are a large number of studies that focus on the physical assault or verbal violence shown towards mental healthcare workers including nurses, physicians, psychologists and social workers. These studies emphasize the growing need to implement effective strategies to prevent and manage violence and aggression in the mental healthcare setting. While there have been many strategies implemented to manage and prevent violence in the mental health care units, the significance of effective staff education and training has been stressed by many researchers. However, there have not been many authentic studies that unearthed how far staff training contributes to the prevention of violence in the mental health care industry. In this respect, the U.S. Department of Labor identifies “lack of staff training in recognizing and managing escalating hostile and assaultive behavior” as a crippling factor in preventing violence in acute health care units (U.S. Department of Labor, 2004, p. 7). There are also studies that have highlighted the need to offer staff in-service training to the mental health care professionals. The literature review of this paper will focus on those studies that establish a relationship between such staff training and the management or prevention of violence in psychiatric and mental health care units. The growing statistics on violence towards the health care professionals in mental and psychiatric units is quite alarming and shocking. In this respect, Adams and Whittington (1995) conducted a remarkable study among a sample group of hospital based nurses and community mental health nurses. The results of the study showed that 29% of the target population experienced verbal aggression over a 10 week period; 44% of the incidents involved threats and the rest consisted of abuses (Adams & Whittington, 1995, p. 171). These shocking statistics point towards the need to offer timely staff training to the mental health care professionals. Duxbury and Whittington (2005) have successfully brought out the staff and patient perspectives on violence in mental and psychiatric health care units. The researchers undertook a survey among a sample of 80 patients and 82 health care professionals (3 ward managers, 10 charge nurses, 35 staff nurses and 32 nursing assistants) from three inpatient mental healthcare wards. The mental illnesses of the patients varied from chronic schizophrenia to depressive disorders. The results of the study showed that the patients regarded ‘environmental conditions and poor communication’ as the two significant factors behind aggressive behavior whereas the nurses identified that the patients’ mental illness was the root cause for the violence; however, both the groups were thoroughly dissatisfied with the ‘restrictive and under-resourced provision that leads to interpersonal tensions’ (Duxbury & Whittington, 2005, p. 469). The study also showed that both the patients as well as the nurses were also dissatisfied with the way violence and aggression has been managed. The researchers identified staff training in the use of fundamental therapeutic communication skills as the potential solution to this interpersonal tension. The adverse effects of patient violence on the mental health care workers are many and varied. Patient violence on mental health care professionals not only leads to staff sickness and absenteeism but also to various psychological and mental distresses. Whatever may be the underlying causes for violence, “a major consequence for individuals affected directly or indirectly by violence is often psychological pain, whether depression, anxiety, isolation, trauma or other reactions that affect the inner life and external functioning” and this psychological pain would adversely affect the therapeutic alliance between the patients and the mental health care professionals (LeFlore & Bell, 2007, p. 147). Researchers such as Whittington and Wykes (1992) have also observed that mental health nurses who are victims of extreme patient violence are also likely to demonstrate post traumatic stress disorders. The researchers also caution that these violent and aggressive behaviors shown towards the mental health nurses would result in such negative psychological and social consequences as high levels of stress; feelings of anger, fear, loss, distrust, and guilt; and can hamper their self-confidence and positive self-esteem (Whittington & Wykes, 1992). On the other hand, patient violence and aggression may change the attitude of the staff towards the mental patients in their care as well; this may lead to lack of appropriate care, hostility between the patient and staff and may culminate in the breakdown of the therapeutic alliance (Watts & Morgan, 1994, p. 14). It is worthwhile to review Doughty’s research article on staff training programs and the prevention and management of violence in mental health services and emergency departments as the author indulges in a thorough meta-analysis of the previous studies on the issue. Doughty (2005) has undertaken some remarkable studies on staff training programs for the prevention and management of violence. The author observes that staffs in mental and psychiatric health units need to be taught about the “risk factors that cause or contribute to assaults, ways to prevent, diffuse or de-escalate volatile situations or aggressive behavior, ways of developing and implementing workplace violence prevention policies and teaching staff procedures and policies for reporting and recording incidents” (Doughty, 2005, p. 1). In this respect, Doughty, reviewing a large number of literature, points out that the aftermath of the experience of violence include post-traumatic stress disorders, subsequent loss of confidence and self esteem, subsequent increases in sick leave and alcohol and drug usage and can adversely affect staff recruiting and retention within the organization (Doughty, 2005, p. 1). Thus, he underlines that specially trained nurses and heath care professionals in risk assessment and management of violence will be better equipped to respond to violence in mental health care workplaces. There have been many staff programs that have been proved to be extremely beneficial for the health care industry in managing violence. For instance, the Assaulted Staff Action Program (ASAP), a voluntary program introduced by the United States has been proved to be beneficial for the healthcare staffs. All these call for the need to identify how effective are staff training programs in preventing and managing violence among nurses and other healthcare workers in mental health. There are ample evidences in the literature to prove that effective staff training programs are capable of managing or preventing violence in mental health care. For instance, researchers such as Calabro, Mackey & Williams (2002) have conducted a remarkable before-and-after study design among 180 hospital staff in an acute care psychiatric hospital and their research outcomes are extremely useful for the current study. The researchers offered all staffs one and a half day training in preventing and managing patient violence. The training classes focused on two intervention programs-Nonviolent Crisis Intervention (CPI) and Handle with Care program. While CPI aimed at training staff how to prevent and control disruptive behavior of clients the Handle with Care program equipped the staffs with the necessary self-defense skills and restraining methods to tackle potentially violent patients. The authors resorted to a pretest and posttest study design and the results of the study proved that the training had positive outcomes on the knowledge, attitude, self-efficacy, and behavioral intention of the participants towards violence in the work place. It is also worthwhile to review the researchers conducted by Flannery, Anderson, Marks & Uzoma (2000) on the effectiveness of Assaulted Staff Action Program (ASAP) among the staff who work in mental health services. The researchers made use of a before-and-after-study design that evaluated the effectiveness of a peer-help post-crisis intervention program among mental health care professionals. At the end of the study the researchers came to the conclusion that ASAP is a competent intervention for reducing the frequency of assaultive behavior towards health care professionals. Whittington and Wykes (2001) employed a before and after study design among 155 nurses who worked in the thirteen wards with the highest levels of violence in two selected psychiatric hospitals. The violence towards the staff prior to the staff training was measured. The selected staff was offered six training sessions and after the completion of the training assaults on staff was again measured. The scores were compared with those of the non-attended staffs. The results of the study witnessed a considerable decrease in the amount of violence. The overall rate of violence fell by 31% after the training whereas in high compliance wards the frequency of assaults towards the health care nurses reduced two-thirds after the staff training from 40 to 12 (Whittington & Wykes, 1996, p. 48). Similarly, the research findings of Warshaw and Messite (1996) also emphasized that effective and timely intervention strategies are essential to uplift the health care professionals who have fallen as victims of patient violence and assault. These intervention strategies may include stress management, rehabilitation of staff victims and providing them a work environment that is not conducive to violent behavior (Warshaw & Messite, 1996, p. 993). Studies conducted by Stathopoulou (2003) will be useful for the proposed research as the research article deals elaborately with the negative consequences of violence on health care professionals and provides useful guidelines to the health care professionals as to how they can effectively interact with the patients’ families. The author is of the opinion that the preventive measures on violence towards health care professionals should focus on three areas: hospital organization, arrangement of the physical environment, and staff training and development (2003, p. 4). The research article identifies such staff training and development programs that would focus on the existing medical, psychiatric and social conditions, ‘effective use of communication skills and de-escalation techniques,’ ‘techniques for crisis intervention and conflict resolution,’ ‘reporting and documentation of all violent events,’ and ‘application of physical restraints’(Stathopoulou, 2003, p. 4). All these studies make the current research meaningful and enhance its scope and relevance. Researchers such as Arnetz and Arnetz (2000) depict the outcomes of a randomized controlled trial among healthcare professionals in psychiatric and emergency departments. The researchers have claimed that staff training and timely interventions have enhanced staff knowledge of risks for violence among the participants. It is also worthwhile to review the before and after study of Cowin, Davies, Estall, Berlin, Fitzgerald & Hoot (2003) as the authors elaborately deal with the benefits of teaching health care professionals the necessary de-escalation techniques and in-service training that would enhance their knowledge and better equip them to face incidents of violence in the psychiatric and mental health settings. The participants were offered in-service education session on the various important processes involved in successful de-escalation. The researchers could find a significant increase in de-escalation knowledge and awareness among the participants in managing incidents of violence (Cowin et al., 2003, p. 72). The research outcomes of the INTACT Aggression Management Program, the two-day intensive training program administered by Ilkiw-Lavalle Grenyer & Graham (2002, p. 233) among a group of 103 mental health staffs in Australia also makes it clear that prior staff training in aggression management is necessary for the prevention of violence in mental health care. It is also imperative to review Workplace violence in mental and general healthcare settings by Michael R. Privitera (2011) as this is a seminal book that offers theoretical insights on staff training and management of violence in acute health care units. The author elaborately deals with the definition and classification of violence, the impact of violence, the factors contributing to violence, the effects of violence on the staff, the quality of patient care, and the prevention of violence. The WHO has defined violence as “the intentional use of physical force or power threatened or actual, against oneself, another person, or against a group or community, that either results in or has a likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (Privitera, 2011, p. 5). As such violence in the health care setting can be categorized into self-directed violence, interpersonal violence, and collective violence whereas the modes of violence could be sexual, physical, psychological or deprivation. It is therefore essential to know how far staff training can tackle these various sorts of violence in the mental health care setting. Emergency psychiatry: principles and practice by Glick and Fishkind (2008) is yet another seminal work that throws light on the prevention of violence in psychaitric units. The authors hold that “violence in acute psychiatric care settings correlates positively with a lower staff-to-patient ratio, higher percentage of female staff, and presence of staff without specific training in psychiatry or agression” (p.117). Therefore, it is mandatory that mental health care professionals are offered timely staff training programs for effective intervention with the patients. In Australia, occupational violence towards the registered nurses has become commonplace. Mental health care has assumed a greater significance in the health care industry of the nation as the number of people with mental disorders is increasing day by day. The Australian Bureau of Statistics in its National Survey of Mental Health and Wellbeing in 2007 has identified that one in five Australians is likely to experience mental illness in any year: “one in five (20% or 3.2 million) Australians had a 12-month mental disorder” (Australian Bureau of Statistics, 2007, p. 7). With the increase of the mental patients violence towards the staff who works in mental and psychiatric units has also increased in the nation. The Australian Institute of Criminology has identified “the health industry to be the most violent industry in Australia, with registered nurses (RNs) recording the second highest number of violence-related workers compensation claims in 1995/96, ranking higher than prison and police officers” (Deans, 2004, p. 14). Therefore, it is quite meaningful to undertake a study on how far staff training reduces violence in mental health care in one of the mental or psychiatric units in Australia. To sum up the literature, there have been ample evidences in the literature to state that trained mental health professionals can considerably reduce the number of violent incidents that are more likely to happen in an acute inpatient psychiatric and mental units. The need to offer timely staff training programs to the healthcare professions for the prevention and management of violence has been pointed out by many authors as well. Similarly, the adverse effects and negative consequences of patient violence on mental health care workers have also been pointed out. The before and after studies conducted by researchers such as Calabro, Mackey and Williams (2002) have also revealed that staff training enhances the knowledge, attitude, self-efficacy, and behavioral intention of the participants towards violence in the work place. Training staff servicing in psychiatric and mental health care units are more likely to experience incidents of violence and therefore it is imperative that further researches are undertaken in this regard to identify how far staff training helps in preventing violence in acute health care units. A review of the literature clearly demonstrate that most of the previous studies on staff training and prevention and management of violence in health care units were before and after studies that focused on the performance of the mental health care professional before and after the training had been offered to them. However, most of these studies were conducted on relatively smaller sample populations. In light of the literature reviewed, there is a need to conduct further researches that clearly pinpoint how far staff training contributes to managing or preventing violence in acute inpatient psychiatric and mental units. Part B: Research Methodology The proposed research seeks to explore whether staff training helps in preventing or managing violence in mental health care settings. As such, the research questions for the study are “Does staff training reduce violence in mental health care units” and if so, “how far staff training programs contribute towards managing or preventing violence in mental health care units?” As pointed out by O'Leary (2009, p. 103) a sound methodological plan should have “logical links between aims, questions, and eventuating methodology.” Therefore, a qualitative research approach will be employed for the research as it best suits the topic under consideration. A case study, questionnaires and direct interviews will be made use of in the research methodology. A before and after research design will be administered on a target group of mental health care professionals who serve in the Dandenong Hospital in Melbourne. Case study, questionnaires, and interviews will be used for the data collection of the qualitative research. Case study will be administered on the mental and psychiatric health wards in the Dandenong Hospital in Melbourne. During the pre-study semi-structured questionnaires will be used to obtain self-reported information from the target group regarding past incidents of violence. A post study direct interview (which will consist of both closed and open ended questions) will also be administered on the participants. Dandenong Hospital in Melbourne has been selected for the proposed case study as it is a representative sample of the total mental health care units in Australia. The effectiveness of conducting a sample study on a representative sample population has been pointed out by many researchers. For instance, Offredy and Vickers (2010, p. 132) make it clear that “the possibility of achieving a much better response rate from a sample as opposed to a response rate from a population is greatly increased by limiting it to a fewer people”. Thus, this sample study among the mental health care professionals in Dandenong Hospital is sure to bring about more accurate and valid results based on direct responses from the respondents. Dandenong Hospital in Melbourne is selected for the study as it is one of the major acute hospitals providing a range of services to the mental health patients. Recently, the government has decided to offer $69 million for the redevelopment of the hospital increasing the inpatient beds number from 77 to 120 (Southern Health, 2009). This redevelopment plan seeks to improve the health and economic outcomes of the numerous mental health patients who find solace in the hospital. The results of the proposed study will be useful not only to the mental health professionals who work in the hospital but also to the whole health care industry in the nation. Once the location for the case study is identified it is essential to frame a well-knit research design for the study. For Kumar, “a research design is a procedural plan that is adopted by the researcher to answer questions validly, objectively, accurately and economically” (Kumar, 2010, p. 94). For this the researcher should have a clear cut plan regarding the study design, selection of participants, collection of data from the respondents, data analysis and finally how to drive conclusions from the data obtained. As the primary step for the study, it is essential to obtain the list of the participants for the study. For this, a list of all the staffs who work in the mental and psychiatric wards in the hospital is to be obtained and a preliminary mailed questionnaire will be sent to them. The questionnaire would elicit such details as their designation, age, gender, years of experience, receipt of any prior staff training, incidents of violent experiences etc. The respondents who do not have any prior experiences of patient violence will be eliminated from the study. Similarly, all those respondents who do not have at last three years of experience in mental health care will also be eliminated. However, respondents of all ages will be included in the study sampling. A telephonic interview will also be administered on these respondents to tell them of the nature of present research and to gain their willingness to attend the two-week staff training program. The unwilling respondents will also be eliminated. During this phase, the responses of the participants regarding their prior experiences of violence (which include the frequency, type and nature of violence) and knowledge regarding de-escalation techniques, risk assessment tools, and training in Nonviolent Crisis Intervention will be recorded. The next phase of the research methodology is the actual staff training on the prevention of violence. After the two-weeks staff training programs staff responses regarding their awareness of knowledge, attitude, de-escalation techniques, risk assessment tools, and training in Nonviolent Crisis Intervention will also be evaluated. The self-reported responses of the participants will be recorded and these will be coded using appropriate qualitative assessment tools such as Constant Comparison Analysis or Content Analysis. The next phase of the research methodology will consist of direct interviews with the participants after two months of the training. During the interview, the participants will be asked both closed and open-ended questions. During the interview, the interviewer can also resort to “informal patterns of questioning where the aim is to allow the interviewee to set the pace” (Silverman, 2010, p. 194). The interview would provide the researcher opportunities for direct quotation of the qualitative data. Similarly, the open ended questions would “permit the evaluator to understand and capture the perspective of program participants without predetermining their perspective through prior selection of questionnaire categories” (Paten, 1987, p. 11). The qualitative data thus obtained will be coded using appropriate qualitative assessment tools and they will be compared or contrasted with the self-reported data obtained from the participants before the staff training program. Similarly, another survey can also be administered on these mental or psychiatric health care units to identify whether the staff training has brought about an overall decrease in the amount of violence. The justification for the proposed methodology is that case studies, questionnaires and interviews are regarded as effective tools to elicit qualitative data. While the preliminary questionnaire would facilitate the researcher to identify the common dominant trends of the target population in-depth case studies will help one to have a more detailed and specific understanding of the research variables under consideration. Similarly, questionnaires (structured, semi-structured or non-structured) have long been identified as an effective qualitative assessment tool. The researcher needs to make use of the most appropriate qualitative assessment tools to analyze, to code and to interpret the data collected through the above mentioned means. For this, content Analysis can effectively be employed to examine the trends and patterns of the qualitative data and to identify, code, and categorize the primary patterns in the data. Researchers have highlighted the capability of content analysis ‘for examining trends and patterns in documents’ (Stemler, 2001, para. 4). Similarly, Constant Comparison Analysis can also be used as it has been proved to be an effective tool in categorizing data bits, comparing qualitative data and in refining categories. As such, these qualitative tools will be used for the data analysis of the research. References Adams, J & Whittington, R. (1995). Verbal aggression to psychiatric staff: traumatic stressor or part of the job? Psychiatric Care, 2, 171– 174. Arnetz, J. E., & Arnetz, B. B. (2000). Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. Journal of Advanced Nursing, 31, 668-680. Australian Bureau of Statistics. (2007). National Survey of Mental Health and Wellbeing: Summary of Results. Commonwealth of Australia 2008. Retrieved March 24, 2012 from: http://www.ausstats.abs.gov.au/Ausstats/subscriber.nsf/0/6AE6DA447F985FC2CA2574EA00122BD6/$File/43260_2007.pdf Calabro, K., Mackey, T. A., & Williams, S. (2002). Evaluation of training designed to prevent and manage patient violence. Issues in Mental Health Nursing, 23, 3-15. Cowin, L., Davies, R., Estall, G., Berlin, T., Fitzgerald, M., & Hoot, S. (2003). De-escalating aggression and violence in the mental health setting. International Journal of Mental Health Nursing, 12, 64-73. Deans, C. (2004). Nurses and occupational violence: the role of organizational support in moderating professional competence. Australian Journal of Advanced Nursing, 22 (2), 14-18. Doughty, C. J. (2005). Staff training programmes for the prevention and management of violence directed at nurses and other healthcare workers in mental health services and emergency departments. NZHTA Technical Brief, 4(2), 1-59. Retrieved from http://www.otago.ac.nz/christchurch/otago014021.pdf Duxbury, Joy & Whittington, Richard. (2005). Causes and management of patient aggression and violence: staff and patient perspectives. Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(5), 469–478. Flannery, R. B., Jr., Anderson, E., Marks, L., & Uzoma, L. L. (2000). The Assaulted Staff Action Program (ASAP) and declines in rates of assault: mixed replicated findings. Psychiatric Quarterly, 71, 165-175. Glick, R., Berlin, J., & Fishkind, A. (2008). Emergency psychiatry: principles and practice. New York: Lippincott Williams & Wilkins. Ilkiw-Lavalle, O., Grenyer, B. F. S., & Graham, L. (2002). Does prior training and staff occupation influence knowledge acquisition from an aggression management training program? International Journal of Mental Health Nursing, 11, 233-239. Kumar, R. (2010). Research Methodology: A Step-by-Step Guide for Beginners (3rd ed.). SAGE Publications Ltd. LeFlore, Fannie & Bell, Michael. Mental health matters for violence prevention: a multi-faceted approach to risk factors and solutions. Proceedings of Persistently Safe Schools: The 2007 National Conference on Safe Schools, 143-155. Retrieved March 21, 2012, from: http://gwired.gwu.edu/hamfish/merlin-cgi/p/downloadFile/d/19152/n/off/other/1/name/021pdf/ Offredy, M & Vickers, P. (2010). Developing a Healthcare Research Proposal: An Interactive Student Guide. Illustrated ed: John Wiley and Sons. O'Leary, Z. (2009). The Essential Guide to Doing Your Research Project (3rd ed.). SAGE Publications Ltd. Patton, M.Q. (1987). How to Use Qualitative Methods in Evaluation. Illustrated 2nd ed: SAGE. Privitera, Michael R. (2011). Workplace violence in mental and general healthcare settings. London: Jones & Bartlett Publishers. Silverman, D. (2010). Doing qualitative research (3rd ed.). London: Sage Stathopoulou, H.G. (2003). Violence and Aggression towards Health Care Professionals. Health Science Journal, 1(2), 1-7. Retrieved from http://www.hsj.gr/volume1/issue2/issue02_rev03.pdf Stemler, Steve (2001). An overview of content analysis. Practical Assessment, Research & Evaluation, 7(17). Retrieved March 22, 2012 from: http://pareonline.net/getvn.asp?v=7&n=17 Southern Health. (2009). Dandenong Hospital celebrates launch of new Mental Health Redevelopment. Retrieved March 24, 2012 from: http://www.southernhealth.org.au/page/Hospitals/Dandenong/Dandenong_Hospital_celebrates_launch_of_new_Mental_Health_Redevelopment/ U.S. Department of Labor. (2004). Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. Occupational Safety and Health Administration. Retrieved March 20, 2012 from: http://www.osha.gov/Publications/osha3148.pdf Warshaw L.J. & Messite J. (1996), Workplace violence: preventive and interventive strategies. Journal of Occupational and Environmental Medicine, 38, 993-1006. Watts, D & Morgan, G. (1994). Malignant alienation: dangers for patients who are hard to like. British Journal of Psychiatry, 164, 11-15. Whittington, R & Wykes, T. (1992). Staff strain and social support in a psychiatric hospital following assault by a patient. Journal of Advanced Nursing, 17, 48-486. Whittington, R., & Wykes, T. (1996). An evaluation of staff training in psychological techniques for the management of patient aggression. Journal of Clinical Nursing, 5, 257-261. Read More