Dismissing De-Escalation Techniques as an Intervention to Manage Verbal Aggression Within Mental Health Care Settings: Attitudes of Psychiatric Hospital-Based Nigerian Mental Health Nurses
The risk of violence within mental health care settings is high. Although literature does indicate certain mental illness symptoms, and or labels, as associated with increased risk for violence there is no definitive causative factor. Interrelated environmental factors directly influence verbal aggression and risk of violence. Specifically, lack of, or inadequate, mental health care legislation and policy, and practitioner attitudes, knowledge and skills are noted as core influential factors. The purpose of this study was to present de-escalation techniques, as an intervention, and describe the response of psychiatric hospital-based Nigerian mental health nurses. A qualitative approach using content analysis of audio recorded pre- and post-intervention focus group discussions was adopted. The intervention â€“ one oral and visual presentation of de-escalation techniques â€“ bisected focus group discussions. The objective for the pre-intervention focus group was to facilitate participantsâ€™ descriptions of current experiences and practices towards verbal aggression and violence management in order to inform and contextualise the intervention, specifically the relevant application of information within the intervention. The objective of the post-intervention focus group discussion was to describe participantsâ€™ responses to the intervention. Purposive sampling of nurses at unit or ward manager level yielded eight participants who attended both focus groups and the intervention. Results indicate that participants felt betrayed by all role players within the mental health care service system, were disappointed that de-escalation techniques were considered evidence-based practice, and hopeless about their introduction. Participantsâ€™ fears for their safety are suggested to have informed a more militant approach to the management of aggression, an approach perceived by participants to strengthen nursesâ€™ control over their own and patientsâ€™ physical and emotional welfare. A review of Nigerian mental health legislation to set the context for human rights of both nurses and mental health care patients is recommended. In addition, a need exists for further research utilising a participatory action research approach. Such an approach will allow the participants to reflect, develop self-awareness, understand and respond to a specific context.
Arnold, E.C. & Boggs, K.U. 2015. Interpersonal relationships: Professional communication skills for nurses. 7th edition. Missouri, U.S.A: Elsevier Health Sciences. ISBN 978-0-323-24281-3
Bader, S., Evans, S.E. & Welsh, E. 2014. Aggression among psychiatric inpatients: The relationship between time, place, victims, and severity ratings. Journal of the American Psychiatric Nurses Association, 20(3):179â€“186.
BjÃ¶rkdahl, A., Hansebo, G., & Palmstierna, T. 2013. The influence of staff training on the violence prevention and management climate in psychiatric inpatient units. Journal of Psychiatric and Mental Health Nursing, 20(5):396-404. https://doi.org/10.1111/j.1365-2850.2012.01930.x
Bowers, L. 2014. A model of de-escalation. Mental Health Practice, 17(9):36â€“37. https://doi.org/10.7748/mhp.17.9.36.e924
Chukwujekwu, D.C. & Stanley, P.C. 2011. Prevalence and correlates of aggression among psychiatric in-patients at Jos University Teaching Hospital. Nigerian Journal of Clinical Practice, 14(2):163â€“167.
Drew, N., Funk, M., Tang, S., Lamichhane, J., ChÃ¡vez, E., Katontoka, S., Pathare, S., Lewis, O., Gostin, L. & Saraceno, B. 2011. Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis. The Lancet, 378(9803):1664â€“1675.
Elo, S. & KyngÃ¤s, H. 2008. The qualitative content analysis process. Journal of Advanced Nursing, 62(1):107â€“115. https://doi.org/10.1111/j.1365-2648.2007.04569.x
Gallo, K.P. & Barlow, D.H., 2012. Factors involved in clinician adoption and non -adoption of evidenceâ€based interventions in mental health. Clinical Psychology: Science and Practice, 19(1):93â€“106.
Hallett, N. & Dickens, G.L. 2015. Deâ€escalation: A survey of clinical staff in a secure mental health inpatient service. International Journal of Mental Health Nursing, 24(4):324â€“333.
Itzhaki, M., Peles-Bortz, A., Kostistky, H., Barnoy, D., Filshtinsky, V. & Bluvstein, I. 2015. Exposure of mental health nurses to violence associated with job stress, life satisfaction, staff resilience, and post-traumatic growth. International Journal of Mental Health Nursing, 24(5):403â€“412.
Jack-Ide, I.O., Uys, L.R. & Middleton, L.E. 2012. A comparative study of mental health services in two African countries: South Africa and Nigeria. International Journal of Nursing and Midwifery, 4(4):50â€“57.
James, B.O., Isa, E.W. & Oud, N. 2011. Patient aggression in psychiatric services: The experience of a sample of nurses at two psychiatric facilities in Nigeria. African Journal of Psychiatry, 14(2):130â€“133.
Loewenstein, K. & McManus, M. 2014. 'Don't Tell Me to Calm Down!': De-escalation of the agitated patient in a hospital setting. In Gallo, K & Smith, L.G (eds,), Building a culture of patient safety through simulation, an interprofessional learning model, 171-186. New York: Springer Publishing Company. ISBN: 978-0-8261-6007-5.
Mc Andrew, S., Chambers, M., Nolan, F., Thomas, B. and Watts, P. 2014. Measuring the evidence: Reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient wards. International Journal of Mental Health Nursing, 23(3):212â€“220. https://doi.org/10.1111/inm.12044
Mitchell, A., Ahmed, A. & Szabo, C. 2014. Workplace violence among nurses, why are we still discussing this? Literature review. Journal of Nursing Education and Practice, 4(4):147â€“150. https://doi.org/10.5430/jnep.v4n4p147
Nelson, R. 2014. Tackling violence against health-care workers. The Lancet, 383(9926): 1373â€“1374. https://doi.org/10.1016/S0140-6736(14)60658-9
Nestor, P.G. 2014. Mental disorder and aggression: Personality dimensions and clinical features. American Journal of Psychiatry, 59(12):1973â€“1978.
Papadopoulos, C., Ross, J., Stewart, D., Dack, C., James, K. & Bowers, L. 2012. The antecedents of violence and aggression within psychiatric in-patient settings. Acta Psychiatrica Scandinavica, 125(6):425â€“439.
Pompeii, L., Dement, J., Schoenfisch, A., Lavery, A., Souder, M., Smith, C. & Lipscomb, H. 2013. Perpetrator, worker and workplace characteristics associated with patient and visitor perpetrated violence (Type II) on hospital workers: A review of the literature and existing occupational injury data. Journal of Safety Research, 44:57â€“64.
Price, E., Baker, J., Bee, P. & Lovell, K. 2015. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. The British Journal of Psychiatry, 206(6):447â€“455. https://doi.org/10.1192/bjp.bp.114.144576
Richmond, J.S., Berlin, J.S., Fishkind, A.B., Holloman, G.H., Zeller, S.L., Wilson, M. P. & Ng, A.T. 2012. Verbal de-escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, 13(1):17â€“25. https://doi.org/10.5811/westjem.2011.9.6864
Ukpong, D.I., Owoeye, O., Udofia, O., Abasiubong, F. & Ukpong, S. 2011. Violence against mental health staff: A survey in a Nigerian psychiatric hospital. The Psychiatrist, 35(2):46â€“49. https://doi.org/10.1192/pb.bp.110.030098
Westbrook, A.H. 2011. Mental health legislation and involuntary commitment in Nigeria: A call for reform. Washington University Global Studies Law Review, 10(2):397â€“418.
World Health Organization. 2012. WHO quality rights tool kit: Assessing and improving quality and human rights in mental health and social care facilities. World health organization, Geneva. Retrieved from http://apps.who.int/iris/bitstream/10665/70927/3/9789241548410_eng.pdf (Accessed 05 November 2013).
World Health Organization. 2013. Mental health action plan 2013â€“2020. World Health Organization. Retrieved from http://www.who.int/mental_health/publications/action_plan/en/ (Accessed 15 October 2015).
Yoshizawa, K., Sugawara, N., Yasui-Furukori, N., Danjo, K., Furukori, H., Sato, Y., Tomita, T., Fujii, A., Nakagam, T., Sasaki, M. and Nakamura, K. 2016. Relationship between occupational stress and depression among psychiatric nurses in Japan. Archives of Environmental and Occupational Health, 71(1):10â€“15. https://doi.org/10.1080/19338244.2014.927345