In Bowers’ (2014) Safewards Model, the staff team is one of six domains that is hypothesised to influence rates of conflict (i.e., patient aggression) and containment (i.e., coercive interventions). It is suggested that staff characteristics are modifiers in the sense that the way staff act in managing patients or their environment, initiating or responding to interactions with patients, can have the capacity to influence the frequency of conflict and/or containment. Emotional regulation, along with a positive appreciation of patients and providing an effective structure of rules and routine for patients, are the underpinning factors (Bowers et al., 2011). Bowers et al., (2014) argue that nurses’ emotional regulation can impact upon their implementation of ward routine and rules of patient conduct, and in the management of aggressive behaviour. It is proposed that staff emotion accentuates patient emotion and self-control ability, thereby hindering nurses’ ability to respond in the most effective and socially skilled way.
50 Indeed, this is supported by a study that indicated nurses’ anxiety and fear increased their propensity to use seclusion (Parkes, 2003).
The emotional and psychological effects of patient aggression on nursing staff are notable. Needham, Abderhalden, Halfens, Fischer and Dassen’s (2005) conducted a systematic review of 25 studies from eight countries. The rationale of the review was motivated by the prevailing view among nursing staff themselves, and the literature publication bias, that anything other than physical injury is insufficiently serious to warrant further investigation. It was found that anger, fear, guilt and shame were the most frequently reported effects. Whittington and Wykes (1991) found that staff felt irritable immediately following an assault. Deans (2004) conducted in-depth interviews with nurses about how they responded to such incidents. Professional incompetency, an expectation to cope and emotional confusion emerged as three overarching themes that conveyed the meaning of being victims of patient aggression. The ‘professional incompetency’ theme represented doubts, confusion and conflict about the ability to function as a competent professional nurse. The theme of ‘expectation to cope’ described the participants’ perception that colleagues, especially senior members of staff, believed that nurses should be able to cope with being a victim of patient aggression because it is an expected part of the job. A wide range of emotions experienced by nurses including fear, anger, guilt, humiliation and embarrassment, formed the ‘emotional confusion’ theme. The emotions were intensified by non-
supportive responses from senior staff and/or colleagues about being a victim of patient aggression. Despite the apparent importance of anger that is a sequelae of patient aggression, little is known about the subsequent impact on work productivity and quality of care.
Engin and Cam (2006) explored whether there is a relationship between nursing staff anger and job motivation. The study found that nurses who can appropriately verbalise difficult feelings such as anger have a higher level of job motivation compared to nurses who suppress their anger. Also, nurses who reported better organisational support as a result of being exposed to patient aggression reported higher levels of self- esteem (Nolan et al., 2001). Cutcliffe (1999) suggests that a formal support system for staff mediates the relationship between the exposure to patient aggression and staff’s ability to deal with incidents therapeutically. However, for nursing staff who experience
51 long term strain following an incident, it was found that support is mostly offered on an informal basis by colleagues in public or by family/friends at home (Whittington & Wykes, 1992). With nurses working in such pressurised environments and the risk of being or having been a victim of patient aggression, it is appropriate to question how this affects nurses’ wellbeing and subsequently the quality of patient care delivery.
Arnetz and Arnetz (2001) aimed to address the question of whether there is any measurable effect on staff’s reaction to being a victim of aggression. They propose that aggression exhibited by patients has a negative effect on staff, causing more negative attitudes towards work tasks and patients. Staff reported previous experiences of the nature of patient aggression and their reaction to it. Patients reported how satisfied they were with the quality of care provided by the members of staff in the study. It was found that aggression experienced by staff resulted in them feeling angry, sad, disappointed and fearful; staff’s feelings were associated with lower patient ratings in the quality of care received. Although this study was conducted in a general hospital and not in a mental health care setting, these findings could perhaps extend to nurses working in psychiatric hospitals given the prevalence of inpatient aggression (Bowers et al., 2011), and would therefore have implications for the quality of care provided.
Bowers et al., (2011) argued that if nursing staff become victims of patient aggression, their ability to effectively regulate emotional states and carry out work as effectively as possible may become compromised. The authors explain that this may be because of the struggle to attain positive moral commitments, engage in effective team work, and may even have their psychiatric philosophy impaired temporarily or even permanently. Paterson et al., (2011) discussed the effects of exposure to patient aggression over a long period on staff. It was suggested that repeated exposure could lead to frustration and anger in staff which may subsequently be displaced on patients. In such instances staff would be unlikely to recognise how their own emotional arousal has impacted on how they think, which can impair their ability to recognise and respond appropriately to the early signs of distress in patients. This process is synonymous with the Cyclical Model of Burnout and Vulnerability to Aggression proposed by Whittington and Wykes (1994): stress induced by patient aggression leads to impaired staff
performance and adoption of subsequent staff behaviours makes the re-occurrence of patient aggression more likely. Patterson et al., (2011) recommend nurses to openly
52 acknowledge and disclose their emotions, and for these to be managed in debriefing sessions and clinical supervision.
3.1.3. Review aim
In this context, nursing staffs’ emotional regulation requires further research attention, given that inpatient aggression is frequent and therefore can be distressing for nurses providing frontline care for patients. The aim is to conduct a review of empirical studies on nursing staff anger in order to understand its role in inpatient psychiatric settings.
53 3.2. Method
A systematic literature review was conducted and reported in accordance with relevant sections of the PRISMA (Moher et al., 2009).
3.2.1. Data sources and search
The purpose of the literature search was to locate all empirical studies that have investigated nursing staff anger in inpatient mental health services. The search
procedure had involved using multiple computerised databases (i.e., EMBASE, Medline, PsychINFO and CINAHL) with the following terms: Anger, Hostil*, Aggress*, Violen*, Inpatient, Psychiatric, Hospital, Ward. The search was supplemented by scanning the relevant articles’ reference list for further studies to be considered against the inclusion criteria.
3.2.2. Selection criteria
Studies were deemed eligible for inclusion if they investigated or reported on: anger in nurses who work specifically in psychiatric inpatient settings. The inclusion criteria were not limited by study design, as the purpose of the review was to map the relevant literature on nursing staff anger in inpatient psychiatric settings. Studies were excluded if they were non-empirical; anger was not investigated or not reported on, the study sample comprised staff other than nurse professionals, and articles written in non- English due to limited resources. Titles and abstracts were reviewed by the author. Full- text version of articles that potentially met the inclusion criteria were subsequently obtained for further examination.
3.2.3. Study quality assessment
The quality of quantitative and qualitative studies were assessed with guidelines and checklists provided by NICE (http://www.nice.org.uk/). The checklist based on the appraisal step of GATE (Jackson et al., 2006), as described in Chapter 2, was used to assess the quantitative studies. For qualitative studies, the checklist used is based on two sources (Spencer et al., 2003; Public Health Resource Unit England, 2006); which comprises six sections: theoretical approach, study design, data collection, validity,
54 analysis and ethics. There were 12 items in total across the six sections which have a 3- point rating option.
3.2.4. Synthesis of study results
Extracted data were collated and charted in tabular form. The columns
represented in Table 3.1. were the particulars extracted from each study, allowing for an overview description of the included studies. Studies included in the review used
various methods and measures thus it was not possible to synthesise the results via meta-analysis. Included studies were thus synthesised in narrative form (Popay et al., 2006). Descriptive statistics were employed to explore the extent, nature, geographic distribution of studies, and the research methods adopted. The way in which studies investigate or report on nursing staff anger was identified and organised thematically, according to study aims, measures used, results and author conclusions.
55 3.3. Results
3.3.1. Literature search
Figure 3.1. shows the literature search screening process. Thirty-four studies were identified at the title level; however, 17 studies did not meet inclusion criteria at the abstract screening level. Seventeen full-text articles were obtained to assess eligibility and subsequently a further ten studies were excluded at the full-text screening level. The reasons for excluding articles at each screening level are provided in Figure 3.1. The remaining seven studies fulfilled the eligibility criteria, as well as three relevant studies which were identified through hand searching reference lists of articles. In total, ten studies were included in the review.