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Verbal aggression ‘angers nurses more than violence’

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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”

Geoff Dickens

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”

Rahul Jalil

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.

Abertay University

Verbal aggression ‘angers nurses more than violence’

Geoff Dickens

“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”.

  • 3 Comments

Readers' comments (3)

  • In some areas, aggression in vulnerable, elderly patients with complex needs is addressed by some nurses and GPs (even those GPs in GP practices which are specialist in dealing with care homes) is now being "managed" by dosing up these patients with anti depressants which have sedative effects.

    From what I have witnessed in some care homes where person centred care is absent, the patient has every right to be depressed at the care they receive but their aggression is the consequence of being dehumanised by staff who are paid directly or indirectly by the state to know and practice better. Being prevented from practising better care is I believe a major reason for many knowledgable nurses leaving.

    If the patient needs a better person centred approach and the nurse enlists help from the GP who then inappropriately prescribes drugs that do harm without helping, then the situation becomes completely diabolical. And it is inexcusable in a society that purports to be civilised.

    The other screamingly obvious problem is dependence on the use of anti depressants that in themselves can cause horrendous mental health issues like increased aggression to themselves and others. Do GPs over-prescribe anti depressants? If using the "arty" side of the brain uplifts affective level, then why are less dangerous treatments not tried first? Why not prescribe methods like arts/ crafts/ dance to uplift the affective level simultaneously with adding a sense of purpose, like fund raising for something important to that particular patient?

    Few people feel ok without a sense of purpose and craft work has been recognised since Victorian times as something that uplifts the affective level. Craftwork is not restricted to the "feminine" crafts.

    Must we be cajoled and fooled by the big pharmaceuticals, their shareholders and our own stupidity into imagining that drugs are the harmless answer to everything?

    Maybe some nurses are right to be stung by personal criticisms directed at them. Maybe for some it should be regarded as a wake up call to deliver better person centred care in the first place and be less reliant on drugging people up or dumping the blame for difficult situations on to vulnerable people? Maybe they need to be more supportive to each other and less bullying?

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  • Expectations of patients and their relatives is immense, and complaint levels for anything possible, are at their highest that I have seen in my 34 years in nursing. Nurses are burning out - often in less than 2 years post qualifying, and either leaving the profession or displaying the symptoms of burnout - disengaging with relatives and their copious complaints, minimising face to face contact with patients who have a knee jerk reaction to a nurse`s presence of instant complaints and verbal outpourings of negativity about their often self made situations, and poorly funded services mean patients are placed in care establishments with staff not trained to deal with their and their relatives`behaviours, because people simply want to move people on - especially people they see as being "problems" or "hassle" because they are simply burnt out, too. This will simply create more burnout, errors, relatives will become increasingly angry and complaint focussed to gain a platform...and so it goes on. The answer? No easy fix. This was forecast 10-15 years ago but the government shoved it aside, as it didn`t generate tax in come for the state - rest assured, if it did, there would have been legislation in place pretty quick. Personally, I have reduced my hours to reduce exposure to it all. I simply don`t have the inclination to emotionally and psychologically manage people`s unrealistic expectations and issues that have been lifelong, taught through dysfunction and family discord - I did my sums and reduced the contact thus. Maybe that is the answer for some, if they can afford it? Stressed, drained staff are angry staff, and this leads to people turning on each other, in behaviours such as bullying. Never been a bully but have been bullied - by an insecure person who needed to feel "power" - it backfired as I had the strength within to address it, but many do not, once the bullying is established, and this can lead to more burnout and loss of staff....

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  • Very much agree with the above comment. The patient's charter raised patient expectations beyond the resources available to meet them. We talk liberally about bullying in the work place but since when does a patient or their relatives have the right to bully healthcare staff? It happens daily; abuse leveled at staff because they are not in a position to answer back. We are told 'remain professional; apologise that 'they feel that way'; listen sympathetically; de-escalate' etc etc. Nurses in particular have become targets for patient frustration as they realize that what they want or expect is simply beyond stretched resources. Programmes such as Holby City and Casualty show health care staff being screamed and abused and so it becomes the norm.
    It is incumbent upon NHS trusts to adopt a zero tolerance policy against patients and relatives who seek to undermine and abuse at every opportunity. And no, I am not talking about patients who have a genuine grievance or problems which might cause them to be verbally aggressive or abusive. I am talking about those who believe it is their right to bully and insult staff for no reason other than, they can.

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