Aggression Toward Psychiatric Nurses and It`s Relation With Patient`s Satisfaction About Quality of Care

Introduction

  International concern about violence and aggression in work place is increasing day after day because it is a major and serious worldwide public health problem that touching health services personnel (1). In Egypt about 250,000 nurses working in health services and thousands of nursing students graduate each year and join the medical field in order to introduce help and support to patients (2), but the conflicting idea is that a patient would want to harm a nurse or allied professional who are trying to help(3). Hospital workers have been found to have the greatest rates of non-fatal work place assault injuries when comparing with other workers from different jobs that result from aggressive acts by patients (4). Among hospital workers, the risk of aggression from patients is greatest toward nurses, mental health professionals and security staff (5). In psychiatric settings a dilemma arises from concerning aggression from psychiatric patient is a part of nurses work or being aggression should be stopped(6).

Nurses are more likely to have more interaction, involved in aggressive incidents with patients, and facing of all types of trauma, suffering, and life threatening events than other health care providers,that known to put them at greatest risk of aggression than others in the health care profession(7). Aggression in work place is a pressing concern for nurses in all settings and for psychiatric nurses in particular(8).

Aggression from patients even physical or non-physical has negative implications for employees health and safety and quality of patient care(9).Additionally to health problems from physical injury, worker responses to violence may negatively impact the work environment by creating fearfulness, low morale and productivity, absenteeism, and increase turnover(10).  Not only aggression and violence harmful to the person and the organization, it is also very expensive, in one recent year, over two million Americans reported being physically attacked at work resulting in $13.5 million in medical costs alone, there are also some international data regarding costs that are troubling (11).

The Joint Commission issued an alert regarding rude and disruptive behavior in health care settings .The Joint Commission states that intimidating and disruptive behavior can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes,and increased the cost of care (12). Safety and quality of patient`s care is dependent on more professional environments. Safety and quality of care requires teamwork, communication, and collaborative work environment. To ensure quality and to promote culture safety, health care organizations must address the problem of behavior that threaten the performance of health care team(13).

Significance of study

Inpatient aggression is a pressing concern for nurses in all settings and for psychiatric nurses in particular. When compared to other industries, the rate of aggression is the highest among hospital workers, 8.3 per 10,000 workers vs. 2 per 10,000 workers, and among this group nurses are the most ‘at risk’(14) . As much as 70% of abuse toward nurses may be unreported(15). This is because of the complexities that arise, in part, from a health care culture resistance to the impression that health care providers are at risk for patient-related aggression combined with complacency that aggression "is part of our job" (16) .

Psychiatric nurses commonly reported the effects of exposure to occupational aggression to be associated with reduced productivity, decreased job satisfaction, burn-out, increased use of sick days(17). Where health care workers report high stress and dissatisfaction in their work,  emotional exhaustion, depersonalization and inefficacy ,the patients also report a reduced level of care and autonomy and satisfaction when the relationship deteriorates.Low quality  of patient`s care may lead to low satisfaction, low compliance with treatment and little cooperation with staff (18) .

Aim of the study

This study aimed to assess prevalence of aggression toward psychiatric nurses and its relation to patients`satisfaction about quality of care.           

Research questions:

• What are the nurses’ perceptions of the prevalence of aggression in Minia psychiatric hospital?
• Is there a relationship between aggression toward psychiatric nurses and patient satisfaction about quality of care?

Research Design:

A descriptive correlational design was utilized to achieve the aim of the present study.

Setting:

This study was conducted at El. Minia Hospital for mental health and addiction treatment. It is a governmental hospital is affiliated to the ageneral syndicate for psychiatric health which is affiliated to the ministry of health (MOH). It serves all districts of Minia governorate. The hospital consists of inpatient departments (psychiatric wards, addiction ward) and outpatient clinics (children and adolescent clinic, psychiatric clinic, neurologic clinic); the capacity of the hospital is 53 (33 beds for psychiatric patients and 20 beds for addiction patients) and hiring 250 employees and 60 of them are nursing staff.

Sample:

The subjects of this study consisted of a convenience sample of (100) psychiatric inpatients from thosehospitalized during the study duration.Also, all nurses was working (on duty) in psychiatric wards (2018), their total number was (54) nurses.

Exclusion criteria :

• For psychiatric patients:Mental retarded patients, Addiction patients.
• For nurses: Nurses with experience less than one year.

Tools for Data Collection:

The following tools were used for collecting data in this study.

Tool I:Staff`s questionnaire:

Part 1: personal data sheetto obtain variables such as age, gender, education, ward, position, and duration of experience in mental health nursing.

Part 2:The Perception of Prevalence of Aggression Scale (POPAS):

It was developedbyOud, (2001).This questionnaire has been developed to assist individuals in identifying the frequency with which they have been confronted with aggressive or violent behavior during the last year in the course of their professional work as a health care worker in psychiatry. There are in total 17 questions. The POPAS rates experience with 16 types of aggressive behavior .For each form of aggressive behavior surveyed, a definition and examples were provided on the POPAS. It is rated on a 5-point Likert scale as 1= never, 2= occasionally, 3= sometimes, 4 = often, and 5 = frequently. The scoring system was categorized as follows:17:39 low prevalence, 40:61 moderate prevalence ,62:85 high prevalence(19).

Part (3): Impact of Patient Aggression on Careers Scale (IMPACS):

      It was developed by Neehdam, (2010), to measure negative consequences of patient aggression on nurses. It consists of 10 items included in three domains impairment of the relationship between patients and nurse (items 1,2,3,4,) , adverse moral feelings (items  5,6,7,8,), adverse feeling to external sources(items 9,10)respectively. It was rated on five points Likert scale (1=never, 2=rarely, 3=sometimes, 4=often and 5=always). The scoring system was categorized as follows:10: 23 low impact, 24:35 moderate impact, 36:50 high impact(20)

Tool II: Patient Questionnaire

• Part (1): personal datasheetto obtain personal data of the patients: such as patient's age, gender, residence, education and job.
• Part (2): clinical data sheet to obtain medical history: diagnosis, the number of admission, duration of illness and experience of violent behavior, ward.

Part (3): Rome Opinion Questionnaire for Psychiatric Wards’ (ROQ-PW): 

It was designed to measure patients` satisfaction and opinion about the quality of care given to them, it includes only 10 items on three domains professionalism of staff (items 1,2,3,4,10), availability of information (items 5,6,7,) ,and physical environment (items 8,9)respectively.It was rated on a 5-point Liker scale, with higher numbers indicating greater satisfaction. It is rated on a (1) ‘not very’; (2) ‘mildly’; (3) ‘sufficiently’; (4) ‘very, with some exceptions’; and (5) ‘very, with no complaints’. (21)The scoring system was categorized as follows:10: 23 low satisfaction, 24:35 moderate satisfaction, 36:50 high satisfaction.

Reliability

The tools were designed in its final format and tested for reliability by using, cronbach`s alpha coefficient test ,

Validity

Study tool were reviewed by five experts in the field of this study  atCairo university ,Asiut university, and AienShams university  to examine the content validity. Modifications were done according to the panel`s judgment on the clarity of sentences, appropriateness of content. Based on experts comments and recommendations of study supervisors minor changes had been made in the questionnaire.

Pilot study

The pilot study was conducted on 10% of the sample(10)Patients, and (6)nurses to investigate and ensure the feasibility, objectivity, applicability, clarity and adequacy of the study tools and to estimate the timeneeded for filling the tool .The pilot study sample was included because no modification donein the study tools.

Procedure:

To fulfill the aim of the study an official permission was obtained from the director of the health and population directorate and the director of Minia hospital for mental health and addiction treatment.  In order to conduct the study, the aim of the study was explained by the investigator to the subjects to get their approval prior starting their participation in the study.

In April 2018, the investigator submitted the questionnaire to the nurses and asked them to fill them out, enfold and cover them with provided wrapper, and return them to the head nurse within one week.

The patient`s sample data collected  throughstructured interview conducted in the patient`s  roomafter ten days of admission;The researcher assured the voluntary participation and confidentiality to each patient who agreed to participate.Measures were taken to protect patient's ethical rights. After explaining the purpose of the interview and getting agreement of the patient  to participate in the research, the questionnairewas read, explained to the patient and the responses were recorded by the investigator for eliminating the systematic error. Data were collected by using a socio-demographic data sheet ,Rome Opinion Questionnaire for Psychiatric Wards’ (ROQ-PW). The researcher collected data through three sessions in the week ,each session take form 10:20 minutes according to the patient`s condition.Data collection was conducted over a six months’ period extending from April,2018 to October,2018.

Ethical Considerations:

A written initial approval was obtained from the research ethical committee of the Faculty of Nursing, Minia University. Written informed consent was obtained from each participating patient and oral consent from nursing staff after explaining the nature and purposes of the study. Each assessment sheet was coded and participant`s name was notappearing on the sheets for the purpose of privacy and confidentiality.  The study sampleswere assured that there is no risk to study subjects during application of the research.The participant was assured that they can withdraw at any time from the current study without any effect on their treatment and care or their working condition.

Statistical Analysis:

The collected data were coded, categorized, tabulated, and analyzed using the Statistical Package for the Social Science (SPSS 20.0). Data were presented using descriptive statistics in the form of percentages, frequency, mean and standard deviation. In order to study the possible association between aggression reported by staff and perceived satisfaction about the quality of care by patients, it was necessary to connect the data sets from the POPAS and quality of care questionnaires. Hospital department was the one variable that was the same in both questionnaires, and thus provided the link between the two data setsInferential statistical tests of significance, such as T.test, Pearson correlation, and linear regression analysis were used to identify group differences and the relations among the study variables

Results:

Table 1:  distribution of personal data of nursing staff (n= 54).

Table (1): showed that, the majority of the studied sample was females 57%, while 43% were males.40.7% of the studied sample wasinthe age group of 31 to40 years with mean age 33.5± 5.4 years. 66.7% of the nurses had secondary (diploma) degree of education , 38.9% of themwere working in the free male ward, and 35.2% of them had 11:20 years' experience with mean experience years  12.8± 4.7 years.

Table (2):  Distribution of perception of prevalence of aggression scale among nurses: (n=54)

Table (2): revealedthat ,Verbal aggression was the highest form of aggression 74.1%, followed by non- physical forms of aggression which include Passive aggressive behavior ,humiliating aggressive behavior ,threatening verbal aggression ,proactive aggressive behavior, aggressive splitting behavior, 63.1%, 57.4%, 55.6 ,53.7%, 50% respectively. While the sexual intimidation and assault was the lowest 3.7%.  Also,about 61% of nurses who was facing aggression did not take sick leave after aggressive incidents.

Table (3): Distribution of Impact of Aggression on Carrer Scale among nurses (no=54).

Table (3): showed that the highest impact of aggression came in the item of nurses avoid contact with this patient (73.1%),followed by feel insecure in the  workplace(61.1%), or in working with patients (63%), dealing with societies problems (63.1%), while feeling of being afailure or ashamed of work came in the lowest level of impact (29.6%),(30.5%) .

Figure (1): distribution of levels of impact of aggression on carrer scale among nurses (no=54)

Figure (1) demonstrated that, (57%) of nurses perceived high impact of aggression, but only (11%) of them perceived low impact of aggression.

Table (4):distribution of personal and medical data of study sample (patients) (n=100)

Note: other diagnosis included borderline personality disorder, obsessive compulsive disorder

Table (4): illustrated that, majority of the studied sample were males(81%), where females were only (19%).  47% of the studied sample (patients) werein age group 20:30 years with mean age 33.5± 5. 42% of them were suffering from psychiatric disease from 6:10 years, 57%of them were diagnosed with schizophrenia, and 57% of them were admitted to hospital for 2:5 times.Also 65% of the studied sample experienced aggression acts toward staff.

Table (5):distribution of Rome Opinion Questionnaire for Psychiatric Wards’ (ROQ-PW) amongpatients (n=100)

Table (5) showed that,  the lowest area of satisfaction was dealing with agitated patients (57%), followed by staff kindness and politeness 47% .While  85%of studied sample represented sufficient satisfaction about information delivered to them , and 57% of them represent high satisfaction about the physical environment.

Table (6): distribution of Rome Opinion Questionnaire for Psychiatric Wards`s domains(n=100).

 Table (6) showedthat ,the lowest domain of patient satisfaction was staff Professionalism (M=10.4±2.3), but the highest domain of satisfaction was Physical environment (M=6.8±2.8)

Figure (2): distribution of levels of Rome Opinion Questionnaire for Psychiatric wards' (n=100).

Figure (2) illustrated that, 57% of the studied sample represented moderate satisfaction about the quality of care and only 22% of them represented high satisfaction.

Table (7): Correlation between total POPAS and total QOC-PW and total IMPACS.

** Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed).

Table(7) revealed that, there was a significant negative correlation between total POPAS and total QOC-PW, and positive correlation between total POPAS and total IMPACS.