Verbal aggression, such as personal insults, name-calling, and discriminatory remarks, by patients is linked with a higher level of anger among mental health nurses than physical violence, according to UK researchers.
They found exposure to targeted, personal and verbal aggression by patients can adversely affect mental health nurses’ decision-making regarding physical restraint.
“This study shows that anger seems to be a mechanism that plays a unique role”
While exposure to physical aggression and self-harm are known to have detrimental consequences for nurses in terms of staff sickness and trauma, the new study suggests those who are subjected to humiliating personal remarks experience higher levels of distressing emotions, including anger.
The researchers, led by Dr Rahul Jalil, conducted rigorous assessments with 68 mental health nurses working in three UK secure mental health units.
All were ward-based nurses, though some had managerial responsibilities, and more than half had more than five years’ experience and almost three quarters had more than two years’ experience.
Participants completed a questionnaire designed to measure their exposure to various types of aggression, their attitudes towards seclusion and restraint, and their emotions.
Information about their involvement in incidents involving restraint or seclusion was also gathered for the three-month period before and after their participation in the study funded and conducted by the University of Northampton and St Andrews Healthcare.
“Nurses who reported being the target of derogatory remarks reported higher levels of anger”
The researchers concluded that verbal aggression that appeared to be “targeted, demeaning or humiliating” was associated with higher experienced anger provocation.
In contrast, the found that exposure to mild and severe physical aggression was unrelated to nurses’ emotions.
Dr Jalil, a lecturer in forensic psychology formerly at Northampton and now at Birmingham City University, said the findings had real implications for education and training for staff in the prevention of violence and aggression.
“Nurses who reported being the target of derogatory remarks reported higher levels of anger than their colleagues,” he said. “What’s more, this was not true for those who had witnessed greater levels of physical aggression or self-harm.
“Moreover, the same nurses who experienced humiliating remarks were more likely to endorse coercive management techniques, such as restraint or seclusion,” he said.
But the study also revealed that, while individual staff exposed to such behaviour were more approving of coercive interventions, it did not translate into more use of restraint or seclusion.
Dr Jalil added: “It seems that existing checks and balances, perhaps including team support or nurses own self-awareness, act to prevent a spiral in which behaviour is dealt with coercively, which in turn might make patients more likely to insult the nursing staff.”
The study, published in the International Journal of Nursing Studies, formed part of his PhD studies.
Senior study author Geoff Dickens, professor in mental health nursing at Abertay University and also previously at Northampton, said: “We already knew that exposure to aggression seems to be related to nurses’ approval of these less desirable interventions.
Verbal aggression ‘angers nurses more than violence’
“What this study adds is that it is this particular type of insidious and seemingly less severe form of aggression that seems to play the largest role,” he noted.
Professor Dickens highlighted that training provision was largely focused at present on managing physical aggression through techniques such as de-escalation.
“While this is great, more attention should be paid to how nurses regulate their own responses to this behaviour,” he said. “This study shows that anger seems to be a mechanism that plays a unique role.
“While it is common to hear that nurses should ‘just deal with it’, it is unreasonable to believe that nurses are immune and can do this without help or support,” he added.
As recently revealed by Nursing Times, a Yorkshire trust is leading the way nationally in eliminating face down restraint from its inpatient wards, following the introduction of nurse-led training for all staff that focuses on defusing difficult situations.
The latest figures released by NHS Benchmarking show Sheffield Health and Social Care NHS Foundation Trust has the lowest level of face down restraint use across England and Wales.
Kim Parker, senior nurse for quality improvement, has spearheaded the trust’s new approach to preventing violence and aggression, and said it was “one of the best things I have done in my nursing career”.