Lessons learned from the trenches about violence.
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Humans↗
Biomedical subjects
E F Morrison
Publications and source records attributed to E F Morrison.
A nurse-led, unit-based program to reduce restraint use in acute care.
Although the effectiveness of restraints is not proven, the dangers of restraints are clear. Many advocate for the reduction of restraint use in tertiary care settings. The Joint Commission on the Accreditation of Healthcare Organizations is setting the standard by insisting that hospital administrations create a culture that emphasizes restraint reduction. Despite the importance of this task, very little is available in the literature to direct or guide this effort. The purpose of this article is to describe a unit-based Restraint Reduction Program that was successful on a neurology/neurosurgery unit.
Academic Medical Centers↗
Managing the care of complex, difficult patients in the medical-surgical setting.
The increasing medical, psychological, and social complexity of hospitalized patients is a serious concern. Most staff nurses are inadequately prepared to deal with the complexity of these patient's issues. The difficult patient is described as having a medical condition requiring hospitalization and who also exhibits problems such as pain, substance abuse, and issues such as anger, manipulation, or noncompliance which are difficult and challenging behaviors. An overview of the most troublesome patients seen in the inpatient setting today and some clinical direction on how to best manage these patients are presented.
Adaptation, Psychological↗
The culture of caregiving and aggression in psychiatric settings.
Organizational culture was used as a general framework for a causal modeling study examining the relationships of work environment with staff beliefs about caregiving and aggression. Specifically, staff who perceived the organization as emphasizing control at the expense of growth and relationship issues would be more controlling in their approach to patients and perceive more aggression. A sample of 162 nursing staff participated from three hospitals. The results indicated that 10% of Aggression was predicted by two model variables indicating control. During exploratory model testing however, age, sex, socioeconomic status and satisfaction with the hospital were all predictive of a controlling belief about caretaking or aggression.
Adult↗
Managing violence without coercion.
Managing violence has become a priority for nurses working in health care settings (AAN Expert Panel, 1993; Editorial, 1992; Lipscomb & Love, 1992). Although psychiatric nurses have a long history of dealing with and managing violent situations, very little attention has been given to a critical analysis of our traditional methods of managing violence. The purpose of this paper is: (a) to present an interactional theory of aggression and violence that argues for the coercive nature of violence in persons with a mental illness (Morrison, 1990b, 1992b, 1993b), and (b) to propose a different approach to managing violent situations that emphasizes negotiation and collaboration, rather than control. Vignettes of violent situations provided by a clinical nurse specialist are used to highlight the presence of this coercive interactional style in patients, as well as to critically examine interventions for managing violence. It is hoped that an honest examination will assist nurses to re-evaluate current practices for managing potentially difficult situations.
Adult↗
The evolution of a concept: aggression and violence in psychiatric settings.
In a series of studies examining aggression and violence by persons with a mental illness, a coercive interactional style emerged as an important predictive variable in hospital settings. This interactive style addresses one issue noted in the literature, the relative effect of personal versus environmental variables, by describing how violent individuals interact with their environment in purposeful ways. The findings from three specific studies are summarized to describe how this interactive style was identified, quantified and documented as a predictor of aggression and violence. It is hoped that this synthesis of research findings will facilitate the application of research to practice settings.
Aggression↗
A comparison of perceptions of aggression and violence by psychiatric nurses.
The current study was designed to obtain an initial understanding of the questions, "How consistent are the perceptions of psychiatric nurses regarding the seriousness of violent behavior" and "Are their perceptions consistent with those of nurses who do not have extensive psychiatric experience?". An exploratory study was conducted using items to measure Violence to Self, Others (Verbal and Physical) and Property. The items were formatted using Thurstone's method of paired comparisons and judgments regarding the seriousness of each type of violent behavior for the categories of doing grievous harm to self, others or property. Final weights were obtained using procedures outlined by Thurstone (1959) (The Measurement of Values. University of Chicago Press, Chicago). The sample included doctoral students in nursing (n = 35) and psychiatric nurses (n = 34) currently working in the inpatient psychiatric setting. The most noteworthy finding was the extent of disagreement within the psychiatric nurse group regarding the seriousness of the behaviors.
Adult↗
The measurement of aggression and violence in hospitalized psychiatric patients.
Aggression and violence are significant clinical problems in psychiatric inpatient units. However, research exploring violent behavior is limited by the lack of an adequate research scale. This paper reports on the development and testing of the Violence Scale (VS), a behavioral rating scale which measures aggressive and violent behavior towards self, others and property. The VS has been tested in two studies of psychiatric inpatients (N = 162) and (N = 42). Tests of reliability included internal consistency, item analysis and stability. Tests of validity included content and construct validity. The psychometric results were evaluated through the application of standard statistical criteria [Carmines, E. G. and Zeller, R. A. (1979). Reliability and Validity Assessment. Sage University Press, Beverly Hills, CA; Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika 16, 197-333; Nunnally J. (1978). Psychometric Theory, McGraw-Hill, New York]. Coefficient alpha was 0.91 (study 1) and 0.68 (study 2) and stability was r = 0.79 (study 1). The items met most of the established criteria for item analysis and internal consistency. In factor analysis, the items met the criteria for loading onto the three predicted factors (others, self and property). Results of predictive model testing indicated that three of the four predicted relationships were supported. Initial testing indicates the scale is moderately stable, is internally consistent, and has evidence of initial limited construct validity.
Adult↗
Toward a better understanding of violence in psychiatric settings: debunking the myths.
Because of the risk of dealing with violent patients on a daily basis, psychiatric clinicians must keep abreast of new developments in the field and after their practice accordingly. However, belief in outdated theories results in the continuation of some traditional practices that are minimally effective for decreasing violence. Five myths about violence are identified and alternatives offered to clinicians interested in changing their approach. The five myths are: (1) the violent person is out of control, (2) the use of a punching bag decreases violence, (3) staff doing a good job means controlling patients, (4) unconscious staff conflicts result in aggression and violence by patients, and (5) the fearful clinician is most often assaulted.
Aggression↗
Control or negotiation: a health care challenge.
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Humans↗
A coercive interactional style as an antecedent to aggression in psychiatric patients.
As with society at large, violence in psychiatric settings is a serious clinical problem. Despite a great deal of attention, however, very little is currently known about the underlying theory or interventions to reduce aggression and violence in hospital settings. In this study, some psychiatric patients were viewed as having a general, aggressive, interactional style, motivated by the traits of Intimidation and Interpersonal Control, which when combined were labeled Coercion. A causal model in which violence and aggression were hypothesized to be predicted by a coercive interpersonal style and negatively predicted by an accommodating interpersonal style was tested. These interpersonal styles were proposed to mediate antecedent variables, that is, history of violence, psychiatric diagnoses, and length of hospitalization. Data were collected in two hospitals on psychiatric patients (N = 156) and analyzed using multiple regression techniques. The results of theoretical model testing suggested that 60% of the variance in Aggression was explained by four model variables: (a) Intimidation and Interpersonal Control (Coercion) (beta = .44), (b) Length of Hospitalization (beta = .26), (c) History of Violence (beta = .27), and (d) Bipolar Affective Syndrome (beta = .21). The implications for clinical care are discussed.
Adolescent↗
A hierarchy of aggressive and violent behaviors among psychiatric inpatients.
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Adult↗
Victimization in prison: implications for the mentally ill inmate and for health professionals.
Despite the focus on the increasing number of mentally ill in prisons and jails, very little actually is known about the psychological effects of prison on this high-risk group. A qualitative study was conducted to explore the inmate subculture and its effect on a person who is mentally ill. Interviews were conducted with 13 subjects who were both inmates and staff members in a forensic halfway house. The results suggest that the victimization that is a way of life within the prison system poses particular problems for mentally ill inmates, whose lack of social and economic resources, dependence, and need for attention make them particularly vulnerable. The implications of victimization of the mentally ill for health care professionals working in prisons also are discussed.
Adaptation, Psychological↗
The QUALCARE Scale: developing an instrument to measure quality of home care.
In previous research, the theoretical and methodological problems associated with operationalizing elder abuse have been multiple. The QUALCARE Scale was developed in response to the documented problems. The scale is an observational rating scale designed to quantify the quality of family caregiving to home-dwelling elders in six areas: physical, medical management, psychosocial, environmental, human rights and financial. The scale is a 53 item scale in a Likert type format. The QUALCARE Scale is completed by professional nurses after a nursing assessment of the degree to which the caregiver meets the needs of the elder in the six dimensions. The nursing assessment involves both observations and verbal data gathering. In this paper, the development of the scale and the methodological issues associated with scale development are discussed.
Aged↗
The QUALCARE Scale: testing of a measurement instrument for clinical practice.
This article continues the discussion of the theoretical and methodological issues associated with the use of measurement instruments in nursing such as the QUALCARE Scale. The QUALCARE Scale is an observational rating scale designed to quantify the quality of family caregiving to home-dwelling elders in six areas: physical, medical management, psychosocial, environmental, human rights and financial. This manuscript continues the discussion by reporting the psychometric properties of the scale. The QUALCARE Scale was tested in a descriptive correlational study with 249 caregiver-elder dyads. The results supported evidence of interrater reliability, internal consistency, and criterion and construct validity. Three issues in the use of measurement instruments in clinical practice are discussed: (i) quantification versus qualification, (ii) clinical relevance and (iii) the establishment of rating standards.
Aged↗
The development and use of observational measurement scales.
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Bias↗
The tradition of toughness: a study of nonprofessional nursing care in psychiatric settings.
Violence is a significant problem in psychiatric settings; however, nursing research that identifies organizational influences related to violent patient behavior is rare. This paper reports on an exploratory study conducted on the psychiatric units of a metropolitan public hospital. The key concept generated by the data was the "tradition of toughness." Within this psychiatric setting, "control" of patient behavior was emphasized resulting in norms and roles that operationalized the theory. The norms were (a) "The need for physical restraint" and (b) "It's not you we don't trust." The nursing role was labelled "enforcing" and included the strategies of (a) "Policing," (b) "Supermanning," and (c) "Putting on a show."
Female↗
Nursing adaptation evaluation: a method for evaluating nursing care.
The Nursing Adaptation Evaluation method (NSGAE) is presented as a means by which psychiatric nurses can explicate and articulate their practice by, among other strategies, evaluating the effectiveness of nursing care. Having a method for evaluating patient improvement facilitates the evaluation of nursing care and, ultimately, contributes to an expansion of our theoretical base.
Adaptation, Psychological↗