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  International Journal of Nursing Studies 42 (2005) 649–655 The effect of a training course in aggression management onmental health nurses’ perceptions of aggression: a clusterrandomised controlled trial I. Needham a,  , C. Abderhalden b , R.J.G. Halfens c , T. Dassen d ,H.J. Haug e , J.E. Fischer f  a Head of Research Unit, University of Applied Science, Route des Cliniques 15, 1700 Fribourg, Switzerland  b University Bern Psychiatric Services, Bolligenstrasse 111, 3000 Bern 60, Switzerland  c Faculty of Health Sciences, Universiteit Maastricht, Universiteitssingel 40, 6200 MD Maastricht, The Netherlands d Department of Nursing Science, Humboldt-University, Schumannstrasse 20/21, 10117 Berlin, Germany e Schloessli, Private Hospital for Psychiatry and Psychotherapy, 8618 Oetwil am See, Switzerland  f  Department of Behavioural Science, Swiss Federal Institute of Technology, Turnerstrasse 1, ETH-Zentrum, 8092 Zurich, Switzerland  Received 18 July 2004; received in revised form 8 October 2004; accepted 14 October 2004 Abstract Nurses’ attitudes towards patient aggression may influence their behaviour towards patients. Thus, their enhancedcapacity to cope with aggressive patients may nurture more positive attitudes and alleviate adverse feelings emanatingfrom patient aggression. This cluster randomised controlled trial conducted on six psychiatric wards tested thehypotheses that a 5 day training course in aggression management would positively influence the following outcomemeasures: Nurses’ perception and tolerance towards patient aggression and resultant adverse feelings. A repeatedmeasures design was employed to monitor change. No effect was found. The short time frame between the trainingcourse and the follow up measurement or non-responsiveness of the measurement instruments may explain this finding. r 2004 Elsevier Ltd. All rights reserved. Keywords:  Aggression; Attitude; Perception of aggression; Psychiatric nurses; Training in aggression management; Violence 1. Introduction Patient aggression in mental health settings is wellrecognised as a major problem (Arnetz and Arnetz,2000; Whittington and Wykes, 1994) and is according to some authors (Hansen, 1996) on the increase. Rates of patient aggression in psychiatric settings range from 0.07(Richter, 1998; Steinert et al., 1991) to 0.25 aggressive incidents per bed and year (Cooper and Mendonca,1989). According to a single centre study conducted atthe Psychiatric University Clinic in Zurich 10% of newlyadmitted patients were aggressive (Geser, 1999). Injuriesmay reach as many as 16 injuries per 100 staff (Carmeland Hunter, 1989). Because nurses provide a 24-h careservice they take the brunt of such aggression (Vander-slott, 1998). This considerable source of stress onnurses may even lead to considering leaving thenursing profession (Arnetz et al., 1998; Ito et al., 2001). Thus dealing with aggressive or violent patientsand coping with the sequelae thereof is a majorchallenge for nurses. ARTICLE IN PRESS$-see front matter r 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.ijnurstu.2004.10.003  Corresponding author. Tel.: +41719121369. E-mail address: (I. Needham).  Patient aggression may be mediated by variousinfluencing factors such as ward crowding (Nijmanand Rector, 1999; Palmstierna et al., 1991), or ward culture (Morrison, 1998, 1990), or interactional style of the personnel (Blair, 1991; Whittington and Wykes, 1994). Training courses in aggression management havebeen suggested as appropriate ways to equip personnelto deal with patient aggression in mental health settings(Cahill, 1991). Such training courses have lead tochanges in variables like a reduction of the use of seclusion (Morales and Duphorne, 1995; Ramirez et al., 1981), staff confidence (McGowan et al., 1999; Turnbull et al., 1990), knowledge on topics concerning themanagement of aggression (Calabro et al., 2002; Rice et al., 1985), or nurses attitudes on aggression (Beech,1999; Calabro et al., 2002). Nurses’ attitudes towards patient aggression may belinked to actual behavioural performance (Collins, 1994;Whittington and Higgins, 2002) in dealing with aggres-sive patients. Some studies have demonstrated thatattitudes toward patient aggression such as a ‘‘traditionof toughness’’ (Morrison, 1990) or staff’s views regard-ing the genesis of aggression (Duxbury, 2002) influencetheir interactional style. These studies support theposition that on viewing aggression as positive beha-viour in certain circumstances (e.g. the enhancement of assertiveness, the capacity to accomplish one’s goals)one is inclined to react to aggression in a morepermissive fashion (Whittington, 2002). A trainingcourse tested by Collins demonstrated the capacity toincrease nurses’ comprehension for patients’ aggressivebehaviour immediately after the training course but notat follow up after 6 months (Collins, 1994). In the samestudy a greater proportion of nurses disagreed thatpatients ‘‘threaten staff to get their own way’’ after thetraining. In spite of the small sample ( n ¼ 22) this studyshows that educational measures may lead to attitudechange. For these reasons investigations into attitudinalchange following courses in aggression management arenecessary (Collins, 1994).Dealing with aggressive incidents involving patientsoften leaves carers with adverse feelings such as guilt orself-blame (Gates et al., 1999; Hauck, 1993; Murray and Snyder, 1991; O’Connell et al., 2000; Ryan and Poster, 1989), compassion with the aggressor (Arnetz andArnetz, 2001; Murray and Snyder, 1991), avoiding the perpetrator (Adams and Whittington, 1995; Chambers, 1998; Richter, 1999), or the perception of an impaired relationship (Arnetz and Arnetz, 2001; Chambers, 1998; Gates et al., 1999; Levin et al., 1998). Carers may also feel insecure in dealing with the patients (Bin Abdullahet al., 2000; Fry et al., 2002; Hauck, 1993; O’Connell et al., 2000; Poster, 1996), or have doubts regarding their professional competency (Bin Abdullah et al., 2000;Flannery et al., 1995; Hauck, 1993; Lanza et al., 1991), or even develop feelings of being a failure (Hauck, 1993).Sometimes nurses may become angry towards thehospital they are working in (Chambers, 1998; Hauck, 1993; Lanza et al., 1991) and even ask themselves if  they are working in the right profession (Bin Abdullahet al., 2000; Hauck, 1993; Lanza et al., 1991; O’Connell et al., 2000).Given the capacity of such trainings to influenceattitude towards patient aggression we devised this studyto investigate the effects of a training course beingoffered currently in Switzerland. We hypothesised that atraining course in the management of aggressivebehaviour (the independent variable) will lead to (a) amore positive perception of aggression, (b) to highertolerance towards patient aggression, and (c) a reductionof adverse feelings on dealing with aggressive patients of nurses working in psychiatric acute in-patient settings(Fig. 1). 2. Method  2.1. Design This multi-centre randomised control trial (Fig. 2)was designed to test the effectivity of a trainingprogramme in aggression management to influencenurses’ perception of and attitude on patient aggression.All 87 acute psychiatric wards in the German speakingpart of Switzerland were invited to participate inthe study. The six wards recruited for this studyagreed to waiting list randomisation. Three wardswere randomly allocated to the intervention groupand the remaining three to the control group. Thecontrol group received the training after completionof this study.  2.2. Sample All 114 nurses working on the six participating wardswere invited to participate in the study. Participantscompleted the questionnaire before the intervention (thetraining course in aggression management) and a secondtime after 3 months. The characteristics of the partici-pating nurses are demonstrated in Table 1. ARTICLE IN PRESS IV DVs Training course Perception of aggression Adverse feelings Fig. 1. Research model. I. Needham et al. / International Journal of Nursing Studies 42 (2005) 649–655 650   2.3. Intervention The training program in the management of aggres-sion developed by Nico Oud (Oud, 1997) consisted of 20lessons each lasting 50min administered on 5 consecutivedays. The course aimed to provide knowledge, capabil-ities and techniques to the students. The following areaswere treated: Types and causes of aggression, the genesisof aggression, reflection on one’s own aggressivecomponents, theory on the various stages of aggressiveincidents, behaviour during aggressive situations, typesof conflict management, communication and interaction,post aggression procedures, workplace safety, preventionof aggression, breakaway techniques, and role play. Thestandardised intervention was administered to completenursing teams of wards by experienced psychiatric nurseswho had previously completed an educational measureto train the teams. The teachers played no part in therandomisation process, the study design, data collectionand analysis or other study activities.  2.4. Instruments The nurses completed a questionnaire containing of socio-biographic items (age, gender, and years of professional experience) and questions on their experi-ences of aggression (frequency of experiences of verbaland physical aggression and of threat).  2.5. Perception of aggression To ascertain the perception of aggression the shortversion of the Perception of Aggression Scale (POAS-S)was employed (Needham et al., 2004). This scale isderived from the ‘‘Perception of Aggression Scale’’(Jansen et al., 1997). It shows a two factor solution— aggression as ‘‘functional, comprehensible’’ and as‘‘dysfunctional, undesirable’’ behaviour. The shortened12 item version has demonstrated similar psychometricproperties to the full instrument (Needham et al., 2004).Possible scores range from 6 to 30 points with highscores indicating high agreement to the factors (aggres-sion as ‘‘functional, comprehensible’’ and ‘‘dysfunc-tional, undesirable’’ behaviour).  2.6. Tolerance measure The ‘‘Tolerance Scale’’ (Whittington, 2002) uses 12items of the ‘‘Perception of Aggression Scale’’ (Jansen etal., 1997) representing neutral, non-condemnatory orpositive statements concerning patient aggression. Thisinstrument has been employed in a cross sectional surveyon of predominantly mental health nurses in the UnitedKingdom. To our knowledge it has not been used tomonitor change in conjunction with an interventiondesigned to influence attitude. Possible scores rangefrom 12 to 60 points with high scores indicating hightolerance towards patient aggression.  2.7. IMPACS  The ‘‘Impact of Patient Aggression on Carers Scale’’(IMPACS) is an instrument designed to measure adversefeelings of carers in handling incidents involvingaggressive patients (Needham et al., submitted). Thethree factors—’’impairment of relationship between ARTICLE IN PRESS Eligible wards (n = 6) Randomi-sationNurses in interventionwards (n = 30) Pre-test Training course Post- Test Nurses in controlwards (n = 28) Pre- test Post- Test t1 t1 + 90 days Fig. 2. Study design.Table 1Demographic characteristics of the groupsVariable Control Intervention  P  Gender (females, males) 14, 14 18, 12 0.444 a Mean age (SD) 39.21 (8.7) 36.47 (8.7) 0.288 b Nursing experience in years (SD) 12.62 (7.9) 9.85 (8.5) 0.423 a Nursing experience in psychiatry in years (SD) 11.83 (7.6) 7.48 (6.8) 0.598 a Career prevalence of attack (SD) 6.93 (8.2) 3.03 (2.6) 0.480 aa Pearson’s  w 2 test. b Mann–Whitney  U   test. I. Needham et al. / International Journal of Nursing Studies 42 (2005) 649–655  651  patient and carer’’, ‘‘adverse moral emotions’’, and‘‘adverse feelings to external sources’’—demonstratesatisfactory internal validity with Cronbach’s alphas of 0.78, 0.69 and 0.60, respectively. The possible scoresrange from 4 to 20 points on the first two and from 2 to20 on the third factor.  2.8. Data analysis Chi-Square and Mann–Whitney tests and indepen-dent samples  t -tests were conducted to test the compar-ability of the two groups at baseline. A repeatedmeasures design (univariate analysis of variance of thetwo measurements) was used to monitor change betweenbaseline and follow up measurements conducted 3months after the intervention.The outcome variables were the perception of aggres-sion, tolerance towards patient aggression, and adverseemotions in dealing with aggressive patients. In all casesthe items were aggregated into the dimensions or factorsof the employed scales. A two-way type I errorprobability of less than 0.05 was considered to indicatestatistical significance. All data were analysed using theSPSS 12 software. 3. Results 3.1. Demographics Fifty-eight nurses completed the questionnaires (30 inthe intervention and 28 in the control group) renderingan overall response rate of 51%. No significantdifferences were found between the groups regardinggender, age, nursing experience, experience in psychia-try, and the career prevalence of attack (Table 1). 3.2. Testing of group differences at baseline All comparisons of the means of the variables of thecontrol and intervention groups were non-significant(positive perception of aggression ¼ 0.679, negativeperception of aggression ¼ 0.315, the tolerancescale ¼ 0.498, ‘‘impairment of relationship betweenpatient and carer’’ ¼ 0.469, ‘‘adverse moralemotions’’ ¼ 0.055, ‘‘adverse feelings to externalsources’’ ¼ 0.731). 3.3. Post-intervention effects No statistically significant differences of the meanswere found between the intervention and control groupson the positive perception of aggression, the negativeperception of aggression, the tolerance scale, the‘‘impairment of relationship between patient and carer’’,‘‘adverse moral emotions’’, and ‘‘adverse feelings toexternal sources’’ (Table 2). The only trend towardschange was on the mean of the item ‘‘impairment of relationship between patient and carer’’. The mean fellslightly in the intervention group (from 8.0 to 7.6 points)but rose slightly in the control group (from 7.6 to 8.0points). However, with a  P   of 0.233 this result is well outof the range of statistical significance. 3.4. Discussion In this study we tested the hypotheses that a trainingcourse in aggression management would positively ARTICLE IN PRESS Table 2Pre- and post-scores on all variablesItem Group Pre-score a Post-score a P  b Perception of aggression (POAS-S) ‘‘positive’’ Control 16.7 (3.5) 16.3 (2.9) 0.912Intervention 17.1 (4.2) 16.8 (3.7)Perception of aggression (POAS-S) ‘‘negative’’ Control 17.0 (4.0) 18.5 (4.0) 0.315Intervention 17.3 (3.7) 17.7 (4.2)Tolerance scale Control 34.5 (6.3) 32.4 (5.4) 0.614Intervention 35.7 (7.2) 34.5 (6.6)IMPACS: ‘‘Impairment of relationship between patient and carer’’ Control 7.6 (2.3) 8.0 (2.0) 0.233Intervention 8.0 (2.0) 7.6 (1.7)IMPACS: ‘‘Adverse moral emotions’’ Control 6.8 (1.6) 7.7 (2.2) 0.281Intervention 7.7 (2.1) 8.0 (1.6)IMPACS: ‘‘Adverse feelings to external sources’’ Control 4.6 (1.7) 4.5 (1.3) 0.953Intervention 4.5 (1.4) 4.7 (1.3) a Mean (SD). b Test of within-subjects contrasts using the repeated measures design. I. Needham et al. / International Journal of Nursing Studies 42 (2005) 649–655 652
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