Abstract

Introduction: Violence and aggression in the state mental health inpatient units is an aggressive epidemic affecting health care workers on a global scale. Objectives: The objectives of the study were to describe and explore the experience of nursing students regarding violence and aggression in state mental health inpatient units, to find out the contributing factors of aggression and violence in the state mental health inpatient unit and the consequences of violence and aggression towards student nurses. Methodology: A Qualitative descriptive design was employed, using semi-structured interviews to collect data till saturated at ten respondents. Data was analyzed using the thematic analysis method. Results: Four themes and ten subthemes emerged from the study. The population included eight females and two male students. Findings: indicated that most of the students experienced verbal aggression and a few students experienced physical aggression. The aggression and violence were inflicted more by patients and less by patient’s relatives. Conclusion: It can be concluded that nurses in the state psychiatric inpatient unit experienced more verbal aggression in the form of name calling, which included using derogatory or offensive terms, threats, yelling and shouting compared to physical violence.

Keywords: Experience; Nursing students; Aggression; Violence; State mental health inpatient unit

Key points: Violence and aggression in the state mental health inpatient units is an aggressive epidemic affecting health care workers on a global scale.

Introduction

Aggression and violence in mental health setting is a serious Occupational and public health concern [1]. Country case studies reports stated that the percentage of workplace violence (WPV) in mental health in patient department has reached more than 75% in some countries (Martino, 2002 as cited in Al- Omari ,2019). Aggression and violence are alarming issues that impact all health care workers, including nurses in health care settings [2]. Additionally, World Health Organization (2022) [3] further reported that, between 8 and 38% of nurses in mental health inpatient units suffered from health-care violence and aggression at some point of their career compared to other workplaces. Violence and aggression in the state mental health inpatient units is an aggressive epidemic affecting health care workers on a global scale [4]. According to the World Health Organization (2013) [5], country case studies report state that the percentage of aggression and violence in psychiatric inpatient units has reached more than 75% in some countries (Di Martino, 2002, as cited in Al-Omari., 2019). Violence and aggression are alarming issues which impact all health care workers, including nurses and nursing students in health care settings (Whelan, 2008, as cited in Al-Omari., 2019). In South Africa, a study on the experience of psychiatric nurses done at a selected public mental hospital in Limpopo on 71 nurses and the study reported that 93.5% of the respondents experienced aggression and violence in the form of physical, psychological and verbal. The perpetrators are the patients and sometimes the relatives of the patients [6]. In Namibia there are no recent studies conducted on the experiences of aggression and violence towards nurses or nursing students in the state mental health inpatients unit. Looking at this statistic it is evidenced that, violence and aggression is common among health care workers working in state mental inpatient units, particularly among nurses which can lead to serious diverse negative consequences among the nurses or patients/patient families. This high prevalence of violence and aggression towards nurses in mental health facilities would finally become a public health threat. There for it is important to use the evidence generated to formulate strategic plans, raising awareness, frequent incident reporting, proper training in early identification of violence and aggression, most especially to nursing students in nursing schools and colleges, which might help in decreasing workplace violence and aggression towards health care professional [7].

Objectives

The objectives of this study were to describe and explore the fourth-year students experience regarding violence and aggression in state mental health inpatient units, to find out the contributing factors of aggression and violence in the state mental health inpatient unit, and to find out the consequences of violence and aggression towards student nurses.

Methods

This study employed a qualitative descriptive explorative design. This method was employed as it allowed the researcher to ask questions that cannot be easily put into numbers to understand the experience of the fourth-year nursing students regarding violence and aggression in state mental health inpatient unit in-depth. The accessible population in this study was the 88, 4th year nursing students at the University. The population was determined by data saturation at ten respondents. Criteria for this study included all the fourth-year nursing students who have been allocated to the mental health inpatient unit for two weeks and more in September 2023 using probability sampling.

Data collection

Data was collected by the researcher through semi-structured face to face individual interviews using an interview guide. The interviews were conducted in English, and this helped the researcher in obtaining in-depth understanding of the topic under study. The interview lasted approximately 7 to 10 minutes. The researcher started off with the main question and continued with probing questions to keep the semi-structured interview on track. The researcher tape recorded the interview and took field notes during clinical placements. The interviews took place in a closed room to maintain privacy. The data collection process lasted for two weeks (from the 28th August to 04th September). Data was analyzed using thematic analysis.

Findings

The respondents comprised of eight female and two male fourth year nursing students at the University, Khomas region. The researcher explored the experience nursing students regarding aggression and violence in state mental health inpatient units the number of respondents who were involved in the interviews are summarized below in table 1. Data saturated at ten respondents, four themes and eleven sub themes emerged as indicated in table 2 above.

Themes and sub themes

Experience of aggression and violence

Most respondents indicated experiencing verbal aggression and less respondents experienced physical violent behavior. Most of the aggression and violent incidents towards the participants were from patients and less incidents from the patient’s relatives.

Physical violent behavior

Less respondents indicated experiencing physical violence. This was shown by the below quotes. “On my second week of mental placement, I was working at Male B. It was Friday and sport day. So we do various sport activities with patients. So I was playing soccer with this patient, all of a sudden the patient started kicking me and hitting me with a soccer ball. It was so hurting so much “(P03).

Verbal aggression

More than a half of respondents indicated experiencing verbal aggression at the hands of the patients and less from patients’ relatives. The below quotes from participants are eminent. “One day, at ward C, which is a female ward at Windhoek Central mental hospital, it was early in the morning and the nurse in charge instructed me and other students to work in the courtyard where the patients are in, so we go do vital signs. As I was doing this patient’s blood pressure, the patient asked whether her BP readings are within normal ranges, and I said they are normal. The patient disagreed with me and started calling me names, threating me, like expressing threat to harm me and shouting at me. “(P01).

Contributing factors to aggression and violence

More incidents of aggression and violence towards the respondents were due to patient factors. Less incidents of aggression and violence towards the respondents were due to environmental factors in mental health inpatient units.

Patient factors

Most respondents indicated that most of the violent incidents in mental health inpatient units is due to patient factors. The below quotes are evident. “This patient was diagnosed with Schizophrenia “(P01). “The patient that I was doing a daily assessment on is diagnosed with bipolar disorder “(P02).

Environmental factors contributing to violence and aggression from patients

Less respondents reported that they experienced aggression and violence due to environmental factors.

“Apart from the patient’s mental disorder, which is schizophrenia and drug abuse, this patient was also complaining of their rooms being dirty, so I think this dirty rooms can also be the reasons why the patient got angry “(P05). Management of victims of aggression and violence from patients and relatives. Some patients received counselling after the incident of aggression and violence, some wrote incident reports for documentation purposes and in some of the incidents the respondents indicated that there were no actions taken.

Counselling

Some of the respondents received counselling services as a means of psychological and emotional support. This respondent further emphasized the importance of counselling after an incident of aggression and violence below. “After the nurse in charge saw what happened, he could see I was really disturbed, because that was my second week at mental, the nurse came to talk to me in private room. He tried counselling me. His words really made a profound impact. I was feeling a little bit relieved after that. This also helped me manage the anger and disappointments that I was feeling “(P01).

Incident report writing

Some of the respondents reported being told to write incident reports after an incident of aggression and violence by their superiors. “After the patient kicked me and hit me with a ball, the senior registered nurse suggested that I write and incident report. So yeah, I wrote the incident report. In the incident report, I explained thoroughly what happened and the minor injury that I sustained and the details of the physical violent from the patient. I think for me, write an incident report is very crucial because it helps maintain the of the incident for not only for administrative purposes “(P03).

Consequences of aggression and violence incidents

Most of the respondents indicated that the incidents of violence and aggression from the patients and the patient’s relatives have consequences. Some respondents indicated that, the incidents cause poor nurse –patient relationship. Some respondents indicated that the incidents caused poor patient care, and some participants indicated that the incidents of aggression and violence instilled fear and anxiety.

Poor nurse -patient relationship

Some respondents had a poor nurse –patient relationships following incidents of aggression and violence in mental health inpatient unit as evidence by the below quotes. “That incident caused me to be distant, from that, I promised myself not to communicate nicely and engage with the patients anymore, I promised myself that I will not even answer back when they are saying anything, because I just didn’t want the same insults and threats to happen to me. All this affected my relationship with patients, because as much as I know this patients’ needs me more than anything, I was also scared to engage with them. “(P02).

Poor patient care

Some respondents indicated that, patient care following incidents of aggression and violence became poor. “After that day, I was always scared to go in the courtyard to do vital signs. And I was also scared to talk to the patients. And this affected my nursing care to the patients. Because I know it’s my responsibility to make sure that, their vital signs are done, all the medication is given at the correct time, but despite all that, I was very scared. “(P01).

Job dissatisfaction

Some of the participants below indicated that they experienced job dissatisfaction after the incidents of aggression and violence at mental health inpatient wards. “That day one of the patient family shouted at me, from that I just felt like I did something wrong, I felt like maybe I the way I explained to them was inappropriate, and I always felt like I don’t have what it takes to be a final year student, it has been. tough form me. I just felt like maybe mental hospital was not for me. “(P04).

Discussions of findings

Demographic data

Demographic information provided data regarding research participants and is necessary for the determination of whether the individuals in a particular study are a representative sample of the target population for generalization purposes [8]. Gender composition, the researcher interviewed 20% males and 80 % female participants. The reason for a high number of female nurses might be that nursing is still regarded as a profession for women. Dill, (2023) [9] confirmed that, nursing is labelled as a female career, thus many females flock to this profession because of their inherent capacity to care for another human being. Nurses are often seen as caring, compassionate, patient, and understanding. And nursing thrives on a woman’s instinct to nurture. Secondly, the age of the participants formed part of the demographical characteristics. For this characteristic, the results indicated that all the participants who were part of the study are between the age range of 22 and 28 years.

Discussion of themes

The researcher discussed four themes. The theme one is the experience of nursing students regarding aggression and violence, and this entailed physical aggression and verbal aggression. In theme two the researcher discussed the contributing factors to aggression and violence under two themes which is the patient factors and environmental factors. In theme three the researcher discussed the management of victims of aggression and violence. This theme is discussed entailed the counselling of victims, writing of incident reports and no action. Theme four discussed the consequences of aggression and violence, this theme entailed results on poor nurse-patient relationships, poor patient care, job dissatisfaction, emotional distress and burnout.

Experience of aggression and violence

Experience of physical aggression and violence was reported by few respondents. Respondents reported experiencing the most serious forms of physical aggression and violence in form of kicking and hitting with objects. Most participants reported experiencing verbal aggression at the hands of patients and less of patient’s relatives. Verbal aggression was inflicted in forms of threats, shouting and using foul languages. The study findings on physical aggression and violence is in accordance with results of a cross-sectional study done in one of the state psychiatric hospitals in Benin Nigeria on experience of aggression and violence among nurses working in the mental health inpatient units. This study pointed out that, physical aggression was the least common among all the other reported types of aggression and violence. Physical violence and aggression involved causing harm to the nurses by mental patients through actions such as kicking, punching or hitting (James et al., 2019). Additionally, the findings on verbal aggression is in accordance with study done In South Africa on the experience of psychiatric nurses at a selected public mental hospital in Limpopo on 71 nurses and the study reported that 93.5% of the respondents experienced aggression and violence in the form of verbal. The perpetrators are the patients and sometimes the relatives of the patients [6].

Contributing factors to aggression and violence

Most of the respondents reported that the violent and aggressive incidents were due to patient factors. The patient’s factors included the patient’s mental conditions such schizophrenia, bipolar conditions, substance abuse. The respondents further reported that, the patient’s mental conditions make mental inpatient departments prone to aggression and violence incidents. Few respondents reported that, few incidents of aggression and violence in mental health inpatient wards happen because of the environmental factors. The environmental factors identified by the respondents as causes of aggressive and violent incidents are such as, the dirty and overcrowded patients’ rooms. The findings on patients’ factors is in line with what [10], reported that the mean average of mental health inpatient staff reporting having been exposed to violence and aggression due to patient’s mental conditions seemed to be high which was 60 %. Weltens et al., (2019) had the same sentiments and reported that, numerous environmental factors have been examined, such as the perceived (absence of) privacy for patients, personal space and freedom to move around, restrictions placed upon patients, inconsistent following of the rules, feeling unsafe, noise on the ward and the feeling of physical confinement. The locked doors of a closed ward may be perceived by the patient as being controlled.

Management of victims of aggression and violence from patients and relatives

In this study, 40% of the respondents reported receiving counselling services after an aggressive and violent incident. Another 40% of the participants reported of writing incident reports after the incidents in mental inpatient wards. 20% of responded reported that, there were no actions taken following the incidents of aggression and violence in the mental inpatient wards. On counselling services, the results of this study are in accordance with the study done on the experience of nurses in mental health departments in Turkey by (Eker et al., 2019) [11]. This study highlighted that some of the post-aggression and violence proceeding, or action were in the form of counselling to the victims. Counselling sessions after an aggressive or violent incident is very crucial as it help student nurses to deal with challenging and emotionally demanding situation in psychiatric inpatient departments [12]. The findings regarding writing of reports after an aggressive or violent incident in mental health inpatient unit, is in line with a study that was done on the prevalence and consequences of aggression and violence towards nursing staff working in state mental inpatient wards in Germany that reported that, incidents of aggression and violence were systematically documented by the institution by means of incident report writing. The response from 55% of the respondents. 85% of employees reported the attack: in 94.6% of cases to a superior and in 9% to the accident insurer [13].

Consequences of aggression and violence incidents

All respondents indicated that incidents of violence and aggression from the patients and the patient’s relatives caused negative consequences. A few of the respondents reported that they had poor nurse - patient relationships following incidents of aggression and violence in mental health inpatient units. Respondents further reported that the patients care following incidents of aggression and violence became poor, because of fear that the same incidents will happen. More respondents reported that they experienced fear and burnout after incidents of aggression and violence in state mental inpatient units. The findings on poor patient relationship, Aljohani et al., (2021) [14], similarly highlighted that violence and aggression in psychiatric inpatient wards significantly hampers nursing professionals. Constant fear and anxiety dramatically decrease the quality of nursing care. In addition, incidents of violence and aggression negatively affect the therapeutic relationship between nurse and patient. Violence results in humiliation and guilt, which negatively affects the psyche of a nurse. In the long run, this phenomenon causes burnout, decreased job satisfaction, and reduced attraction to the nursing profession.

Furthermore, Aljohani et al., (2021) [14], noted that, aggression and violence in psychiatric departments creates a toxic environment for nurses and patients which can hinder effective communication between nurses and patients. This affects nursing care to patients because, the nurses will be fearful, anxious and stressed to provide emotional support. This result is in accordance with the results of the current study. The findings of this study regarding job dissatisfaction is comparable to the findings by Mulaudzi et al., (2020) [15] which revealed that nurses were experiencing burnout because of aggression and violence incidents affects their passion for the profession. Nurses may develop attitude towards patients, which compromises quality nursing care (Hylén et al., 2019) [16]. This was confirmed in a study by Hiebert et al., (2021) [17], where participants reported that they were reluctant to work with patients with a history of violence; some were considering leaving their job altogether and with overall job dissatisfaction [18].

Conclusion

The objective is intended to explore and describe the fourthyear nursing students’ experiences regarding violence and aggression in mental inpatient units. The results indicated that most of the respondents experienced verbal aggression, and a few respondents experienced physical aggression and violence. The aggression and violence were inflicted more by patients and less by patient’s relatives. The respondents further indicated that, the patient’s mental illness made mental inpatients wards prone to violence and aggression. On this note, the respondents reported that, mental illness causes impairment in communication, and this also cause aggression and violence towards nurses. Another factor that was reported as a cause of aggression and violence is the environmental factors, regarding this the participants indicated that unhygienic rooms or wards is the one of the observed environmental causes. The respondents indicated experiencing poor nurse –patient relationships, poor patient care, job dissatisfaction, emotional distress and burnout. Findings added revealed that nurses experience complex challenges in acute psychiatric wards as they are always faced with aggressive and unpredictable patient behavior.

Ethical considerations

Ethical clearance was obtained from the School of Nursing and Public Heath SoNEC 18/2023. As this study was conducted on human beings, the researcher adhered to the following ethical fundamental principles required to guide researchers to comply with research ethics: Respect for a person, Beneficence, Nonmaleficence and Justice.

Author contribution

Joseph Galukeni Kadhila was responsible for supervision, analysis, drafting, editing and writing up of the manuscript University of Namibia, Beata Naghenda was responsible for drafting of the manuscript and data collection, University of Namibia.

Data availability

Data may be available on request from the corresponding author Mr Joseph Galukeni Kadhila, jkadhila@unam.na. (University of Namibia).

Acknowledgement

We would like to thank all nursing students that avail themselves to take part in our study from the University of Namibia, Khomas region Namibia..

Data availability

Data available on request from the authors.

References

1. Lu L, Lok KI, Zhang L, Hu A, Ungvari GS, Bressington DT, et al. (2019) Prevalence of verbal and physical workplace violence against nurses in psychiatric hospitals in China. Archives of psychiatric nursing 33(5): 68-72.
2. Al-Omari H, Khait AA, Al-Modallal H, Al-Awabdeh E, Hamaideh S (2019) Workplace violence against nurses working in psychiatric hospitals in Jordan. Archives of psychiatric nursing 33(5): 58-62.
3. World Health Organization (2022) Prevalence of Aggression and Violence in Psychiatric Services.
4. Welten, I, Bak M, Verhagen S, Vandenberk E, Domen P, van Amelsvoort T, et al.(2021) Aggression on the psychiatric ward: prevalence and risk factors. A systematic review of the literature. PloS one 16(10): e0258346.
5. World Health Organization (2013) Workplace Violence and Harassment.
6. Njaka S, Edeogu OC, Oko CC, Goni MD, Nkadi N (2020) Work place violence (WPV) against healthcare workers in Africa: A systematic review. Heliyon 6(9): e04800.
7. Moges S, Belete T, Mekonen T, Menberu M (2021) Lifetime relapse and its associated factors among people with schizophrenia spectrum disorders who are on follow up at Comprehensive Specialized Hospitals in Amhara region, Ethiopia: a cross-sectional study. International Journal of Mental Health Systems 15(1): 42.
8. Lee M, Schuele C (2020) Demographics. In Neil J. Salkind (Ed.).
9. Dill K (2023) Nursing A Female Career.
10. Civilotti C, Berlanda S, Iozzino L (2021) Hospital-based healthcare workers victims of workplace violence in Italy: a scoping review. International journal of environmental research and public health 18(11): 5860.
11. Eker HH, Özder A, Tokaç M, Topçu I, Tabu A (2019) Aggression and violence towards health care providers, and effects thereof. Archives of psychiatry and psychotherapy 4: 19-29.
12. Maddineshat M, Hashemi M, Besharati R, Gholami S, Ghavidel F (2019) The effectiveness of clinical teaching of mental health courses in nursing using clinical supervision and Kirkpatrick’s model. Electronic physician 10(1): 6265.
13. Schablon A, Wendeler D, Kozak A, Nienhaus A, Steinke S (2019) Prevalence and consequences of aggression and violence towards nursing and care staff in Germany—A survey. International journal of environmental research and public health 15(6): 1274.
14. Aljohani B, J Burkholder, QK Tran, - Chen, K Beisenova, A Pourmand (2021) "Workplace violence in the emergency department: a systematic review and meta-analysis." Public health 196: 186-197.
15. Mulaudzi NP, Mashau NS, Akinsola HA, Murwira TS (2020) Working conditions in a mental health institution: An exploratory study of professional nurses in Limpopo province, South Africa. curationis 43(1): 1-8.
16. Hylén U, Engström I, Engström K, Pelto-Piri V, Anderzen-Carlsson A (2019) Providing good care in the shadow of violence–an interview study with nursing staff and ward managers in psychiatric inpatient care in Sweden. Issues in mental health nursing 40(2): 148-157.
17. Hiebert BJ, Care WD, Udod SA, Waddell CM (2022) Psychiatric nurses lived experiences of workplace violence in acute care psychiatric units in Western Canada. Issues in mental health nursing 43(2): 146-153.
18. Encyclopedia of Research Design. (pp. 347-348). Thousand Oaks, CA: SAGE Publications, Inc.