De la Refinanciación de Créditos

The nurses in the current study tried to understand what violence meant to them and why patients could be violent. Supporting Cuttcliffe (1999) and Farrell’s (1997) studies, the nurses interviewed had different views of what constituted violence. This finding was consistent with Kelly’s (1963) Personal Construct Theory, which suggests that individuals attribute meaning to events based on their personal constructs and experiences. A new finding of the current study was that suicide was considered one of the most stressful violent acts for nurses to deal with. Racial abuse against staff, perpetrated by patients and staff members, was also a key issue drawn

from the findings and revealed the need to address this more broadly (Becares, 2009).

Consistent with Benson et al. (2003), nurses felt that violence could be attributed to the patient’s mental illness. Benson et al. (2003) found that nurses did not tend to perceive personality disorder as a ‘mental illness’, therefore having a personality disorder was not viewed as sufficient grounds for influencing the patients’ behaviour. The nurses I spoke to in the present study did not seem to have such misconceptions, perhaps demonstrating a better understanding of personality disorders. However, the nurses I interviewed did not consider other broader factors or psychological difficulties, such as conflict being a result of the service approach being used (Duxbury, Pulsford, Hadi & Sykes, 2013), behaviours being an expression of need (Kitwood, 1997), or behaviour as a result of attachment difficulties or trauma (Hunter & Maunder, 2016). This indicated the need for further education about these issues, as this could positively influence both the views of and treatment of patients (Scott, Ryan, James & Mitchell, 2010).

The present study supported existing literature that indicates that nurses view the segregation of gender on wards as contributing to violence and that women staff felt more vulnerable on male only wards (Hawley et al., 2013). Women patients were viewed as too sensitive and emotionally challenging by some nurses in this study and this was consistent with existing findings arguing that women are often misinterpreted and given ‘pathological labels’ for their needs, highlighting issues with a lack of gender sensitivity on these wards (Wirth, Galen & BodenHausen, 2009). Misconceptions of mental illness, led to denial of support for nurses, from

senior management and police officers and remains an issue that needs to be addressed (Hansson & Markstrom, 2014).

Supporting existing qualitative studies, the current findings conveyed that violence had an emotional impact on nurses, as nurses experienced a lack of control, anxiety, helplessness and empathy (Camuccio et al., 2012; Chambers et al., 2015; Ward, 2013; Zuzelo et al., 2012) and violence lowered their confidence and led to self- doubt (Ward, 2013). In addition to this, the current findings indicated that the impact of violence was broader and revealed further psychological, physical, occupational and relational responses to violence. These are discussed further below.

Analysis of the current findings highlighted a need to consider support for those who suffer traumatic responses to violent experiences (Bowers et al., 2011; Scott, Ryan, James & Mitchell, 2011; Wykes & Whittington, 1998). The nurses I spoke to described experiencing physical embodiment of their distress. Several authors, including Rothchild (2000), argue that the body and mind are not separate and trauma can be stored in the body’s nervous system. Therefore, when the individual is reminded of the traumatic incident, they recall this through bodily responses, for example physiological sensations or pain (Rothschild, 2000). This emphasises the importance of ensuring that nurses and managers are aware that psychological trauma can manifest itself in many ways in order that physical embodiment of distress is appropriately recognised and responded to.

The nurses I interviewed felt that the physiological sensations of adrenaline helped to prepare them to manage violence and seek help. Research supports the finding

that nurses need to feel prepared to be able to deal with violence (Cuttcliffe, 1999). Some nurses reported the debilitating effects of physical injury subsequent to violence, which is well supported by high rates of NHS staff sickness due to physical injury from patients (Bowers et al., 2011).

In line with previous research by Bonner (2012), nurses interviewed responded to the patient in numerous ways after experiencing violence. Of particular interest was that violence had strengthened some nurse-patient relationships. Yalom & Leszcz (2008) explain that when nurses demonstrate altruism, nurturance, modelling interpersonal skills and normalising human suffering, change within the patient is more likely to occur. It could be that some of the nurses in the present study utilised these skills, including showing altruism, trying to repair the therapeutic relationship and using one’s own difficult experiences to help the patient, which in turn helped to strengthen their rapport with them.

The nurses in this sample employed strategies to try to survive violence, including ‘soldiering on’, despite the impact that violence had on them. This reflected a wider systemic issue, whereby systems tend to encourage a ‘tough skin’ and carrying on despite adversity (Zuzelo et al., 2012). In addition to this, some nurses may have dissociated from distress in order to help them to continue to function at work and preserve themselves (Michelson & Ray, 1996). These findings identified a continuing issue, which was that nurses did not have the necessary time to reflect on and process the incidents (Cuttcliffe, 1999), which could be a result of the pressures of operating within the current resource stricken NHS (Gilburt, 2015). Analysis of the interviews also suggested that as a possible result of a lack of space to reflect on

violence and its impact, nurses tried to survive by attempting to re-gain power and control through opting to prosecute patients for their violent actions. This highlighted the need for assertiveness training, which could help nurses to feel more confident in directly managing conflict with patients.

The nurses in this study tried to find their own individual ways of coping, indicative of post-traumatic growth and self development after a traumatic incident (Joseph, Murphy & Regel, 2012). Furthermore, the influence of culture was relevant to how nurses managed the impact of violence. This supports the wider literature base that recognises that emotions are expressed and managed differently across cultures (Murphy-Berman & Berman, 2003).

Alongside individual development, and supporting research by Ward (2013), nurses tried to survive by supporting each other. The use of humour amongst fellow nurses within the present study highlighted efforts to increase confidence in the face of violence (McCreaddie & Wiggins, 2008), to manage feeling threatened (Geisler, 2010) and to create a cohesiveness between fellow nurses in order to feel secure and protected within the group (Beck, 1997). This cohesion is a particularly useful survival strategy in a currently resource limited and pressurised NHS.