RESEARCH

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Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression: A Cross-Sectional Study of Associations With Nurse-Related Characteristics Sofie Verhaeghe, PhD, RN,* Veerle Duprez, MSc, RN,* Dimitri Beeckman, PhD, RN, Joris Leys, MSc, RN, Berno Van Meijel, PhD, RN, and Ann Van Hecke, PhD, RN

SofieVerhaeghe, PhD,RN, is Professor,UniversityCentre forNursingandMidwifery,Departmentof PublicHealth, FacultyofMedicineandHealth Sciences,GhentUniversity,Ghent, BelgiumandResearcher,DepartmentofNursing,VivesUniversityCollege Leuven,Roeselare, Belgium;Veerle Duprez,MSc,RN, is PhDstudent,UniversityCentre forNursingandMidwifery,Departmentof PublicHealth, FacultyofMedicineandHealthSciences, GhentUniversity,Ghent, BelgiumandLecturer&Researcher,DepartmentofBachelor inNursing,ArteveldeUniversityCollegeGhent,Ghent, Belgium; Dimitri Beeckman, PhD,RN, is Professor,UniversityCentre forNursingandMidwifery,Departmentof PublicHealth, FacultyofMedicineandHealth Sciences,GhentUniversity,Ghent, BelgiumandResearcher,DepartmentofBachelor inNursing,ArteveldeUniversityCollegeGhent,Ghent, Belgium; Joris Leys,MSc,RN, is Lecturer&Researcher,DepartmentofBachelor inNursing,ArteveldeUniversityCollegeGhent,Ghent, Belgium;BernoVan Meijel, PhD,RN, is ProfessorofMentalHealthNursing, ResearchGroupMentalHealthNursing, InhollandUniversity ofAppliedSciences,Amsterdam, Departmentof Psychiatry,VUUniversityMedicalCenter,AmsterdamandParnassia Psychiatric Institute, TheHague, TheNetherlands; andAnnVan Hecke, PhD,RN, is Professor,UniversityCentre forNursingandMidwifery,Departmentof PublicHealth, FacultyofMedicineandHealthSciences, GhentUniversity,Ghent, BelgiumandScientific Staff,NursingScience,UniversityHospitalGhent,Ghent, Belgium.

Search terms: Attitude,patient aggression, predictor, psychiatric nursing, self-efficacy

Author contact: veerle.duprez@ugent.be,witha copy to the Editor: gpearson@uchc.edu

Conflict of Interest Statement Theauthorsdeclare that theyhaveno competing interests.

Author Contributions SV,VD, andAVHconceivedanddeveloped the designof the study. SVand JL carriedout the data collection.VD,DB, andAVHcarriedout thedataanalyses. SV,VD, JL, andBVM contributed to the interpretationof thedata. All authors contributed indrafting the manuscript, and readandapproved thefinal version.

*Bothauthors contributedequally to thiswork

First Received June6,2014; Final Revision receivedOctober25,2014;Accepted for publicationNovember13,2014.

doi: 10.1111/ppc.12097

PURPOSE: To explore mental health nurses’ attitude and self-efficacy to adult inpa- tient aggression, and to explore the association with nurse-related characteristics. DESIGN AND METHOD: Cross-sectional study in a sample of 219 mental health nurses in nine psychiatric hospitals, with stepwise linear regression analysis to detect predictive models. FINDINGS: Female and less experienced nurses were less likely to blame patients for their behavior. Gender, burnout, secondary traumatic stress, and compassion satisfaction accounted for 26.2% of the variability in mental health nurses’ self- efficacy toward aggression. PRACTICE IMPLICATIONS: There needs to be attention to professional quality of life for mental health nurses, to provide them with of self-efficacy and a positive atti- tude toward coping with aggression.

Healthcare professionals, and in particular mental health nurses, are regularly confronted with aggression (Foster, Bowers, & Nijman, 2007; Jansen, Dassen, Burgerhof, & Middel, 2006; Nijman et al., 1999; Rippon, 2000). For this study, aggression was broadly defined as “any verbal, nonver- bal or physical behaviour that was threatening (to self, others or property), or physical behaviour that actually did harm (to self, others or property)” (Morrison, 1990, p. 67). The preva-

lence of aggressive incidents in psychiatric hospitals varies considerably across countries (Bowers et al., 2011). A review by Nijman, Palmstierna, Almvik, and Stolker (2005) revealed a mean of 9.3 incidents per patient per year for adults with mental illness, with a range of 0.4–33.2 incidents per patient per year. Severity ranged from 9.2 to 11.0 points on a scale of 0–22 points, with higher scores indicating more severe aggression (Nijman et al., 2005). This variation in incidence

Perspectives in Psychiatric Care ISSN 0031-5990

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

can partly be explained by differences in defining aggression and in registration methods, different care settings, and a decreased tendency to report less threatening incidents (Bowers et al., 2011; Nijman et al., 2005). An aggression reg- istration study (n = 437) in psychiatric hospitals for adults in Belgium using the Staff Observation Aggression Scale- Revised (SOAS-R) (Nijman et al., 1999) revealed a mean of 1.71 incidents per patient per year, with an average severity score of 9.69 (SD 5.04). A small group of patients (2%) appeared to be responsible for 50% of the incidents (Verhaeghe et al., 2011).

Aggressive inpatient incidents have a multifactorial and complex nature (Abderhalden, Needham, & Dassen, 2008; Nijman et al., 1999). Occurrence of incidents, as well as their management, all reflects patient, ward, and staff variables in interaction (Abderhalden et al., 2008; Fluttert et al., 2008; Nijman et al., 1999; Nijman, de Kruyk, & Van Nieuwenhuizen, 2004).

Conceptual Framework

To gain insight into mental health nurses’ behavior toward aggressive patients, it is useful to understand the predictors of this behavior. The theory of planned behavior (TPB) provides a useful conceptual framework to accomplish this. According to the TPB, a person’s behavior is guided by his intentions, which refers to a person’s readiness to perform a given behav- ior (Fishbein & Ajzen, 2010). These intentions derive from attitudes, subjective norms, and self- efficacy (Azjen, 1988; De Vries, 1988) of the person (see Figure 1). Attitudes refer to a person’s evaluation of the behavior as more positive or nega- tive (Fishbein & Ajzen, 2010). Subjective norms encompass the influence of the judgments of others who are deemed important and the tendency to conform to that judgment (Fishbein & Ajzen, 2010). Self-efficacy or perceived behav- ioral control is the belief one has in his or her own ability to succeed in specific situations (Bandura, 1991; Fishbein &

Ajzen, 2010). Two factors of the TPB—attitudes and self- efficacy—are included in this study because they fall within the control of the individual nurse to achieve a more positive attitude toward aggressive patients or a higher level of self- efficacy, thus likely contributing to a better working alliance with improved treatment outcomes (de Leeuw, Van Meijel, Grypdonck, & Kroon, 2012).

Attitudes Toward Inpatient Aggression

Attitudes toward aggression are comprised of three perspec- tives (Abderhalden, Needham, Friedli, Poelmans, & Dassen, 2002; Bowers et al., 2011; Jansen, Middel, & Dassen, 2005; Jansen, Dassen, et al., 2006). First, aggression is perceived as a dysfunctional phenomenon that is violent, offensive, destruc- tive, intrusive, or harmful; second, aggression can also be per- ceived as a functional, instrumental, or communicative phenomenon, a feeling expressed to meet a particular need; and third, aggressive behavior can be interpreted as a normal or protective phenomenon, where aggression is an acceptable reaction to feelings of anger. The last two perspectives are highly interlinked and related to a more tolerant, permissive attitude toward aggression (Jansen, Middel, & Dassen, 2005). Research reveals that most often, mental health nurses view aggression as a harmful, offensive, and destructive behavior on the part of the patient (Finnema, Dassen, & Halfens, 2004; Jansen, Middel, Dassen, & Reijneveld, 2006; Jonker, Goossens, Steenhuis, & Oud, 2008). Few of them emphasize the positive, protective nature of aggression (Jansen, Middel, et al., 2006; Jonker et al., 2008). It is assumed that mental health nurses with more tolerant, permissive, and positive attitudes may have better clinical skills to respond to incidents of aggression. This statement is supported in different health- care domains, demonstrating the impact of positive attitudes on the quality of nursing practice, for instance, in the applica- tion of adequate pressure ulcer prevention (Beeckman, Defloor, Schoonhoven, & Vanderwee, 2011). The capacity to

Figure 1. ConceptualModel of theStudyBasedon theTheoryof PlannedBehavior

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

see aggression in a more positive perspective is reflected in the use of fewer coercive measures (Jonker et al., 2008) and con- tributes to a better working alliance with improved treatment outcomes (de Leeuw et al., 2012).

Perceived Self-Efficacy

Based on Bandura’s (1991) theory of self-efficacy, it is assumed that the perceived level of self-efficacy toward aggression will influence nurses’ actual reaction to and behav- ior toward aggressive incidents. This assumption is exten- sively supported in research on the self-management behavior of persons with chronic illness (Bonsaksen, Lerdal, & Fagermoen, 2012; Marks, Allegrante, & Lorig, 2005) and in research on nursing competencies and perceived skills (Nørgaard, Ammentorp, Ohm Kyvik, & Kofoed, 2012; Van Hecke, Grypdonck, Beele, De Bacquer, & Defloor, 2009). A mental health nurse who perceives that he/she has a low self- efficacy is more likely to see a potential violent situation as dangerous and threatening, and thus may react in a nontherapeutic way. Alternatively, perceived high self- efficacy in dealing with aggression, with the corresponding feelings of security and self-confidence, is an important con- dition for therapeutic interactions between patients and mental health nurses (Dunn, Elsom, & Cross, 2007; Lowe, Wellman, & Taylor, 2003; Martin & Daffern, 2006; Totman, Hundt, Wearn, Paul, & Johnson, 2011).

Considered within the context of the conceptual frame- work, attitudes and self-efficacy of mental health nurses toward aggressive behavior are in turn influenced by nurse- related characteristics (Azjen, 1988) (see Figure 1). Studies have provided contradictory findings about the influence of nurse-related characteristics on attitudes toward aggression. Some studies report that nurses who have had less contact with aggressive patients because of part-time schedules or fewer years of work experience, tend to have a more positive attitude toward aggressive incidents (Jansen, Dassen, et al., 2006; Jansen, Middel, et al., 2006; Palmstierna & Barredal, 2006). This is in contrast with the study by Whittington (2002), which demonstrated that tolerance for aggression is higher among more experienced nurses (more than 15 years). Furthermore, the study of Jansen, Middel, et al. (2006) revealed that female nurses agreed more than their male col- leagues that aggression is a destructive phenomenon, in con- trast to the opposite results of Palmstierna and Barredal (2006). The study by Abderhalden et al. (2002) found no rela- tionship between the perception of aggression and staff char- acteristics. These previous studies focused on identification of the appraisal and tolerance toward aggressive incidents. They did not provide information on other interesting aspects of attitudes toward aggressive incidents, such as the belief in pre- dictability of incidents, feelings of security or anxiety, feelings of competence in managing violent behavior, confidence in

dealing with aggressive incidents, and possible association with nurse-related characteristics. These aspects of attitudes can provide useful information for hospital managers and staff in evaluating and improving aggression management programs and policies.

Research on the association between mental health nurses’ perceived level of self-efficacy in managing inpatient aggres- sion and nurse-related characteristics is limited, and was conducted within a mixed population of mental health pro- fessionals, including just a small sample of mental health nurses (Lowe et al., 2003; Martin & Daffern, 2006; Totman et al., 2011).

Since aggressive incidents and verbal threats are linked with anxiety, symptoms of post-traumatic stress disorder, and symptoms of burnout (Gascon et al., 2013; Whittington, 2002), they can cause an internal value conflict (Winstanley & Whittington, 2004). This might affect nurses’ attitudes and self-efficacy toward aggressive patients and incidents. To date, it is not clear if an association exists between mental health nurses’ perceived professional quality of life and attitude or self-efficacy toward inpatient aggression. This study included perceived professional quality of life as a nurse-related characteristic.

We may conclude that studies have provided contradictory or limited findings about the influence of nurse-related char- acteristics on attitude and self-efficacy toward aggression. To eliminate this gap, this study aimed to explore mental health nurses’ attitudes and perceived self-efficacy toward inpatient aggression in adult psychiatric hospitals. The second aim was to explore the associations between attitudes and perceived self-efficacy toward aggression and nurse-related characteris- tics. The nurse-related characteristics under study are per- ceived professional quality of life, age, gender, educational degree, degree in psychiatric nursing, and length of work experience. A comprehensive exploration of mental health nurses’ attitudes and perceived self-efficacy, and their associa- tion with nurse-related characteristics, including the per- ceived professional quality of life, is important to develop tailored interventions to support mental health nurses in managing aggression.

Methods

Setting and Sample

This study focused on mental health nurses working in psy- chiatric hospitals. The selection of participants was per- formed in two phases. In phase 1, the Belgian Federal Public Service of Health Care emailed all psychiatric hospitals for adults (N = 63) in Belgium to invite them to participate in an implementation study on aggression management. Nine psy- chiatric hospitals agreed to participate. In phase 2, a purpo- sive sample of wards from the nine participating hospitals was

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

drawn. A minimum of one and maximum of three wards, where frequent incidents of aggression were reported by nursing directors, were selected from each hospital. To maxi- mize the representativeness of the sample, wards were selected for differentiation, such as type of wards (acute admission vs. chronic care wards), psychopathology (depres- sion, psychosis, or addiction care), and number of beds (ranging from small residential groups to wards with 50 beds). Psychiatric wards for forensic care were excluded. The final selection of wards was made in consultation with the nursing directors of the participating hospitals, taking into account organizational elements, such as prolonged absences of staff members, or other implementation processes that were occurring on the ward. A total of 17 wards participated. All nurses (N = 219) working on the included wards were invited to participate in the study.

Data Collection

Data were collected through self-administered question- naires completed by the nursing staff on the participating wards between November and December 2011. The question- naires consisted of the Attitude Toward Aggressive Behavior Questionnaire (ATABQ) (Collins, 1994) for measuring atti- tude, the Confidence in Coping With Patient Aggression Instrument (CCPAI) (Thackrey, 1987) for self-efficacy, the Professional Quality of Life Questionnaire (ProQoL) (Stamm, 2010) for professional quality of life, and a record of demographic data including age, gender, educational degree, education in psychiatric nursing, years of work experience in psychiatric care, and years of work experience on the ward. During a staff meeting, the research team informed the nurses of the participating wards about the purpose and procedures of the study. The nurses were asked to complete the question- naires individually during this staff meeting. Two occasions were selected to provide all nurses the opportunity to partici- pate in the study. All eligible nurses from the selected wards participated in the study.

Instruments

Attitude. Most instruments to measure attitudes toward aggression focus on the identification of the appraisal and tolerance toward aggressive incidents (Duxbury, Hahn, Needham, & Pulsford, 2008; Jansen, Dassen, et al., 2006; Whittington, 2002). This study was designed to investigate the broad range of aspects related to nurses’ attitudes toward aggression, broader than the appraisal of aggressive incidents. The ATABQ developed by Collins (1994) provided such a broad range of aspects, which are reflected in its subscales. The 12 statements on aggressive behavior of patients are divided into five subscales: patient responsibility for aggression, staff safety, predictability of incidents, competence in managing

violent behavior, and confidence of staff in dealing with aggressive incidents. Items are scored on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Scores ranged from 1 to 5 at subscale level and from 12 to 60 at scale level, with a higher score indicating a more positive attitude. The lack of reference scores and cutoff points allowed only the interpreta- tion of a mean score in relation to the mean score of another group. The ATABQ test–retest reliability is 0.97 (Collins, 1994).

Self-Efficacy. The CCPAI developed by Thackrey (1987) has the capacity to monitor perceived self-efficacy toward aggres- sion in a comprehensive and one-dimensional way. It was developed for use in mental healthcare settings (Thackrey, 1987). The instrument includes 10 statements, scored on an 11-point Likert scale, ranging from 1 (very uncomfortable) to 11 (very comfortable). Scores ranged from 10 to 110, with a higher score indicating a higher level of self-efficacy toward inpatient aggression. The CCPAI lacks cutoff scores, so a mean score can only be interpreted in relation to the mean score of another group. Previous studies with the CCPAI showed an internal consistency of α = .88 (Thackrey, 1987) and α = .92 (Allen & Tynan, 2000).

Professional Quality of Life. The ProQoL was used to measure the professional quality of life. The ProQoL assesses general job satisfaction (Stamm, 2010). It can be adapted to any pro- fession that chooses to help others (Stamm, 2010). The instrument includes 30 statements divided into three subscales: compassion satisfaction, burnout, and secondary traumatic stress (Stamm, 2010). Compassion satisfaction is referring to the pleasure one derives from being able to do his work. Burnout is referring to feelings of hopelessness and dif- ficulties in dealing with work or doing the job effectively. Sec- ondary traumatic stress is a negative feeling driven by fear and work-related trauma. The statements are scored on a 5-point Likert scale. The ProQoL has good internal consistency for its subscales: compassion satisfaction (α = .88), burnout (α = .75), and secondary traumatic stress (α = .81) (Stamm, 2010). The ProQoL was already used in research on the job satisfaction of mental health nurses (Lauvrud, Nonstad, & Palmstierna, 2009; Newell & MacNeil, 2011).

The set of instruments was translated into Dutch and French by a back-forward translation procedure with mono- lingual testing. A two-round Delphi procedure with profes- sional translators and healthcare professionals was used for the forward translation. In order to assess comprehensive- ness, the translated instruments were presented to a group of seven mental healthcare nurses and seven researchers during individual interviews. These interviews resulted in only minor changes to optimize the comprehensibility of the translated questionnaires. The professional translators con- ducted a backward translation for verification. No further

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

comments were provided. The internal consistency reliability of the translated instruments was assessed and is presented in Table 1.

Ethical Considerations

This study was approved by the Ethical Review Committee of Ghent University Hospital and by the local committees of the participating hospitals (No. B67020109275). All participants were given detailed information (written and verbal) about the study and signed an informed consent.

Data Analysis

SPSS v21 (SPSS Inc., Chicago, IL, USA) was used for all statisti- cal analyses. A significance level of .05 was used. Descriptive statistics (counts, percentages, means, and standard deviation) were calculated. The data were verified for normality of distri- bution and equality of variances. With respect to group com- parisons, independent Student’s t tests or one-way analysis of variance (ANOVA) was used. To avoid type I errors, compari- son of four groups was conducted using an adjusted alpha level of .0125. Pearson’s correlation coefficients were calculated to measure the strength of associations between the outcomes under measure (attitude and self-efficacy) and the nurse- related characteristics at scale level (age, work experience, and professional quality of life). To explore associations between nurse-related characteristics, attitudes, and perceived self- efficacy levels toward patient aggression, a forward stepwise linear regression analysis was performed. Associated factors with a significance value of less than or equal to .05 were included in the model. In the second phase, a backward regres- sion analysis was performed to verify the results of forward regression analysis. The backward regression analyses crite- rion to remove the predictor was held at F greater than or equal to .100. The models were checked for multi-collinearity.

Results

Sample Characteristics

A total of 219 nurses participated in this study. The mean age of the participants was 41.23 (SD 11.43) years and 72.6% were female. The sample consisted of 53.9% nurses with a bachelor

of science degree. A degree in psychiatric nursing was obtained by 79.4% of the participating nurses. This degree at bachelor and diploma level is obtained by following optional courses within the regular nursing curriculum. Almost 54% of the nurses had 10 or more years of work experience in psy- chiatric care, and 26.5% had worked 10 years or longer on the participating ward. An overview of the general characteristics of the sample is presented in Table 2.

Attitude Toward Inpatient Aggression

The mean score on the ATABQ was 37.36 (SD 3.79). Group comparisons for the total ATABQ score revealed no

Table 1. InternalConsistencyTranslated Questionnaires

Questionnaire Dutch version Cronbach’s α

French version Cronbach’s α

Attitude (ATABQ) .35 .52 Self-efficacy (CCPAI) .91 .90 Professional quality of life (ProQoL) .56 .52

ATABQ, Attitude Toward Aggressive Behavior Questionnaire; CCPAI, Confidence in Coping With PatientAggression Instrument; ProQoL, ProfessionalQuality of LifeQuestionnaire.

Table 2. GeneralCharacteristics of Sample

Characteristics (n = 219) N (%)

Gender Female 159 (72.6) Male 52 (23.7) Missing 8 (3.7)

Age (years) 21–30 52 (23.7) 31–40 51 (23.3) 41–50 51 (23.3) >50 63 (28.8) Missing 2 (.9)

Workexperience inpsychiatry (years) <1 18 (8.2) 1–5 41 (18.7) 6–10 42 (19.2) >10 118 (53.9) Missing 0 (.00)

Workexperienceonward (years) <1 44 (20.1) 1–5 64 (29.2) 6–10 52 (23.7) >10 58 (26.5) Missing 1 (.50)

Educational degree Diploma levela 96 (43.8) Bachelorof sciencedegree 118 (53.9) Missing 5 (2.3)

Degree inpsychiatric nursing Yes 174 (79.4) No 40 (18.3) Missing 5 (2.3)

aDiploma level is a3-yearnurse trainingeducationatqualification level 5 of theEuropeanHigher EducationArea.

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

significant differences for the nurse-related characteristics under study (see Table 3). It demonstrated only weak correla- tions with compassion satisfaction (r = .143, p < .05) and burnout (r = −.149, p < .05) (see Table 4). None of the nurse- related characteristics were retained in the regression analysis (see Table 5).

Associations with nurse-related characteristics were found at subscale level (see Tables 3 and 4). The subscale “predic- tion” revealed a mean score of 3.85 (SD .59). A weak negative correlation was found between this aspect of attitude toward patient aggression and age (r = −.178, p < .05) (see Table 4). The factor age was included in the regression analysis. The model had a predictive value of less than 10% (see Table 5).

The subscale “attribution and responsibility” revealed a mean score of 3.31 (SD .48). Group comparisons demon- strated significant differences for gender (see Table 3). Female nurses had statistically significantly higher scores on ques- tions regarding patient attribution and responsibility for aggressive incidents than male nurses (3.35 vs. 3.18, t = −2.203, df = 205, p = .029). Higher scores refer to a lower tendency to place blame and thus a more tolerant perspective on aggression. Negative correlations (see Table 4) were found between attribution and responsibility for aggressive inci- dents on the one hand, and the years of work experience in psychiatric care (r = −.166, p < .05), the years of experience on the ward (r = −.155, p < .05), and level of burnout (r = −.148, p < .05) on the other hand. The mentioned significant or cor- related factors were included in the regression analysis. The model had a predictive value of less than 10% (see Table 5).

The subscale “staff anxiety and fear of assault” revealed a mean score of 3.93 (SD .62). Higher scores refer to the belief that aggression is part of working in psychiatric care. Signifi- cant group differences were demonstrated for post-traumatic stress levels (F = 4.569, df = 2, p = .012) (see Table 3). Mental health nurses in the categories low and moderate post- traumatic stress level considered aggression more as a part of the job. This subscale revealed no significant correlations (see Table 4). None of the nurse-related characteristics were retained in the regression analysis (see Table 5).

The mean score on the subscale “need skilled intervention” was 4.18 (SD .45). Higher scores referred to a higher belief in the importance and need for training and for skills to prevent and manage aggression. Group comparisons demonstrated significant differences for degree in psychiatric nursing and borderline significance with gender (see Table 3). Nurses who did not have a degree in psychiatric nursing revealed a signifi- cantly higher need for specific training and skills to prevent and manage aggressive behavior compared to nurses with a degree in psychiatric nursing (4.36 vs. 4.14, t = 2.729, df = 211, p = .007). Male nurses reported a higher need for intervention training to prevent and manage aggression than their female colleagues (4.25 vs. 4.14, t = 1.901, df = 208, p = .059). A low positive correlation was found with compassion satisfaction

(r = .156, p < .05) (see Table 4). The mentioned significant or correlated factors were included in the regression analysis. The model had a predictive value of less than 10% (see Table 5).

The mean score on the subscale “staff confidence” was 3.76 (SD .67). Group comparisons within this subscale demon- strated significant difference for gender and compassion sat- isfaction (see Table 3). Male mental health nurses had statistically significantly higher scores on the subscale of con- fidence in the ability to deal with and having control over patients with aggression (4.00 vs. 3.68, t = 3.111, df = 101, p = .001). Mental health nurses with a high or moderate level of compassion satisfaction had a statistically significantly higher score on this subscale (F = 10.878, df = 2, p = .000). It demon- strated a positive correlation with compassion satisfaction (r = .307, p < .01) and a negative correlation with secondary traumatic stress (r = −.192, p < .01) (see Table 4). The men- tioned significant or correlated factors were included in the regression analysis. Staff confidence in dealing with aggres- sion has two predictors: gender and compassion satisfaction. These two factors explained 14.4% of the variance in staff confidence in dealing with aggressive incidents (see Table 5).

Perceived Self-Efficacy

The mean score on the CCPAI was 61.44 (SD 14.57). Group comparisons revealed statistically significant differences for gender and compassion satisfaction (see Table 6). Male nurses had a significantly higher perceived self-efficacy score than their female colleagues (71.15 (SD 12.95) vs. 58.11 (SD 13.81), t = 5.993, df = 207, p < .001). Nurses with high or moderate levels of compassion satisfaction had higher levels of perceived self-efficacy compared to their colleagues with low levels of compassion satisfaction (F = 6.259, df = 3, p = .002). A positive correlation was found between the perceived level of self- efficacy and compassion satisfaction (r = .284, p < .01) and a negative correlation with self-efficacy and secondary trau- matic stress (r = −.218, p < .01) (Table 4). The mentioned sig- nificant or correlated factors were included in the regression analysis. The regression analysis demonstrated four predictors for the perceived self-efficacy toward inpatient aggression (see Table 5). This model with gender, burnout, secondary trau- matic stress, and compassion satisfaction accounted for 26.2% of the variability in the perceived self-efficacy of mental health nurses toward aggressive incidents. Mental health nurses with lower burnout and secondary traumatic stress symptoms, with higher compassion satisfaction scores, and male mental health nurses perceived themselves as having a higher level of self-efficacy in dealing with inpatient aggression.

Discussion

This study aimed to explore mental health nurses’ attitudes and perceived self-efficacy toward inpatient aggression in

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

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3 .6 8 (. 7 4 )

W o rk ex p er ie n ce in

p sy ch ia tr y (y ea rs )

F = .5 0 2 , p

= .6 8 1

F = .5 2 7 , p

= .6 6 4

F = 2 .4 7 6 , p

= .0 6 2

F = .1 5 8 , p

= .9 2 5

F = .7 7 7 , p

= .5 0 8

F = .5 5 6 , p

= .6 4 5

<1 3 7 .8 3 (3 .2 6 )

3 .7 5 (. 5 5 )

3 .5 3 (. 3 8 )

3 .8 6 (. 7 2 )

4 .1 1 (. 4 0 )

3 .6 1 (. 7 8 )

1 –5

3 7 .1 5 (3 .9 0 )

3 .7 9 (. 7 1 )

3 .3 8 (. 4 8 )

3 .9 8 (. 6 4 )

4 .1 1 (. 5 0 )

3 .8 3 (. 6 7 )

6 –1 0

3 6 .8 3 (4 .4 7 )

3 .9 3 (. 5 8 )

3 .3 4 (. 4 8 )

3 .9 1 (. 6 3 )

4 .2 4 (. 3 8 )

3 .7 1 (. 8 4 )

>1 0

3 7 .5 5 (3 .5 8 )

3 .8 5 (. 5 6 )

3 .2 3 (. 5 0 )

3 .9 3 (. 6 0 )

4 .2 0 (. 4 6 )

3 .7 8 (. 5 9 )

W o rk ex p er ie n ce o n

w ar d (y ea rs )

F = 1 .3 6 2 , p

= .2 5 5

F = .1 7 1 , p

= .9 1 6

F = 1 .7 2 5 , p

= .1 6 3

F = 1 .2 3 9 , p

= .2 9 6

F = 1 .1 7 6 , p

= .3 2 0

F = 2 .4 0 9 , p

= .0 6 8

<1 3 7 .6 4 (3 .5 3 )

3 .8 2 (. 6 0 )

3 .3 8 (. 4 6 )

3 .8 4 (. 6 4 )

4 .1 9 (. 4 3 )

3 .6 6 (. 6 8 )

1 –5

3 6 .8 4 (3 .7 6 )

3 .8 3 (. 6 4 )

3 .3 9 (. 4 9 )

4 .0 4 (. 6 0 )

4 .1 0 (. 5 2 )

3 .8 9 (. 6 3 )

6 –1 0

3 6 .9 4 (4 .2 7 )

3 .8 9 (. 5 9 )

3 .2 6 (. 5 1 )

3 .8 5 (. 6 2 )

4 .1 7 (. 4 0 )

3 .6 0 (. 8 2 )

>1 0

3 8 .0 7 (3 .5 3 )

3 .8 4 (. 5 5 )

3 .2 3 (. 4 4 )

3 .9 2 (. 6 2 )

4 .2 5 (. 4 2 )

3 .8 3 (. 5 0 )

Ed u ca ti o n al d eg re e

in n u rs in g

t = 1 .4 2 9 , p

= .1 5 5

t = 1 .4 2 5 , p

= .1 5 6

t = 1 .2 7 8 , p

= .2 0 3

t =

−. 1 5 5 , p

= .8 8 7

t = 1 .4 6 2 , p

= .1 4 5

t = 1 .1 2 8 , p

= .2 5 0

B Sc d eg re e

3 7 .6 5 (3 .6 1 )

3 .9 1 (. 6 0 )

3 .3 4 (. 4 5 )

3 .9 2 (. 6 0 )

4 .2 2 (. 4 8 )

3 .8 1 (. 6 0 )

D ip lo m a le ve l

3 6 .9 1 (3 .9 5 )

3 .8 0 (. 5 1 )

3 .2 6 (. 5 3 )

3 .9 4 (. 6 3 )

4 .1 3 (. 4 2 )

3 .7 0 (. 7 6 )

D eg re e in p sy ch ia tr ic

n u rs in g

t =

−. 1 9 8 , p

= .8 4 3

t =

−. 7 7 8 , p

= .4 3 7

t =

−1 .3 0 3 , p

= .1 9 4

t = 1 .5 6 5 , p

= .1 1 9

t = 2 .7 2 9 , p

= .0 0 7 *

t = .0 4 1 , p

= .9 6 8

Y es

3 7 .3 9 (3 .7 8 )

3 .8 6 (. 5 8 )

3 .3 3 (. 4 9 )

3 .9 1 (. 5 7 )

4 .1 4 (. 4 6 )

3 .7 6 (. 6 4 )

N o

3 7 .2 6 (4 .0 8 )

3 .7 8 (. 5 7 )

3 .2 1 (. 5 0 )

4 .0 8 (. 7 1 )

4 .3 6 (. 4 0 )

3 .7 7 (. 8 1 )

C o m p as si o n

sa ti sf ac ti o n

F = 1 .4 4 7 , p

= .2 3 8

F = 1 .2 0 7 , p

= .3 0 2

F = 1 .6 8 6 , p

= .1 8 8

F = 1 .2 1 3 , p

= .3 0 0

F = 1 .1 7 4 , p

= .3 1 1

F = 1 0 .8 7 8 , p

= .0 0 0 *

Lo w

3 7 .0 9 (3 .5 8 )

3 .7 4 (. 6 1 )

3 .2 4 (. 4 3 )

3 .8 1 (. 6 7 )

4 .1 1 (. 4 1 )

3 .4 2 (. 7 7 )

M o d er at e

3 7 .1 2 (3 .7 6 )

3 .8 7 (. 5 6 )

3 .3 1 (. 5 1 )

3 .9 9 (. 5 6 )

4 .1 6 (. 4 7 )

3 .8 4 (. 5 8 )

H ig h

3 8 .1 3 (3 .6 7 )

3 .8 9 (. 5 8 )

3 .4 1 (. 4 5 )

3 .9 3 (. 7 4 )

4 .2 4 (. 5 1 )

3 .9 6 (. 5 9 )

B u rn o u t

F = 2 .8 9 6 , p

= .0 5 8

F = 1 .8 4 5 , p

= .1 6 1

F = 2 .7 5 7 , p

= .0 6 6

F = 1 .4 6 8 , p

= .2 3 3

F = .1 2 1 , p

= .8 8 6

F = .4 3 8 , p

= .6 4 6

Lo w

3 8 .1 6 (3 .7 3 )

3 .8 1 (. 5 5 )

3 .4 3 (. 4 3 )

3 .8 3 (. 7 1 )

4 .1 7 (. 4 9 )

3 .7 1 (. 7 9 )

M o d er at e

3 6 .9 5 (3 .4 3 )

3 .9 6 (. 5 2 )

3 .2 4 (. 5 2 )

3 .8 8 (. 5 0 )

4 .1 9 (. 4 5 )

3 .7 7 (. 5 9 )

H ig h

3 6 .4 5 (4 .7 0 )

3 .8 1 (. 5 9 )

3 .2 8 (. 5 0 )

4 .0 4 (. 7 0 )

4 .1 4 (. 5 1 )

3 .6 5 (. 7 7 )

Po st -t ra u m at ic st re ss

F = 1 .1 3 1 , p

= .3 2 5

F = .1 8 2 , p

= .8 3 4

F = .6 4 2 , p

= .5 2 7

F = 4 .5 6 9 , p

= .0 1 2 *

F = 1 .5 6 1 , p

= .2 1 3

F = 2 .5 4 2 , p

= .0 8 1

Lo w

3 7 .0 5 (4 .0 4 )

3 .9 1 (. 5 1 )

3 .3 7 (. 4 9 )

4 .0 3 (. 6 7 )

4 .2 3 (. 5 3 )

3 .8 7 (. 7 3 )

M o d er at e

3 7 .8 0 (3 .1 8 )

3 .8 4 (. 6 3 )

3 .3 3 (. 4 8 )

4 .0 2 (. 6 2 )

4 .2 1 (. 3 7 )

3 .8 3 (. 6 4 )

H ig h

3 6 .8 8 (4 .4 9 )

3 .8 5 (. 5 8 )

3 .2 6 (. 5 0 )

3 .7 3 (. 6 3 )

4 .1 0 (. 5 0 )

3 .6 1 (. 7 2 )

a P o ss ib le ra n g e: 1 2 –6 0 . b Po ss ib le ra n g e: 1 –5 . * Si g n ifi ca n t va lu es (α le ve lo f .0 5 ). * * N o t si g n ifi ca n t (a d ju st ed

α le ve lo f .0 1 2 5 ). A TA B Q , A tt it u d e To w ar d A g g re ss iv e B eh av io r Q u es ti o n n ai re ; N A , n o t ap p lic ab le .

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

adult psychiatric hospitals and to explore the association between these attitudes and perceived self-efficacy with nurse-related characteristics. The findings corroborate and extend previous findings about the influence of nurse-related characteristics on attitudes and self-efficacy toward inpatient aggression.

Attitude Toward Inpatient Aggression

The overall attitude score of this sample seems rather moder- ate. As the ATABQ is rarely used to measure mental health nurses’ attitudes toward aggressive incidents, and as there exists no cutoff point, our results cannot be compared to

earlier findings. We will discuss some of the associations or predictive models.

The results of our study demonstrated that the profes- sional quality of life had an impact on mental health nurses’ attitudes toward aggression. Mental health nurses with a higher level of compassion satisfaction, referring to the plea- sure one derives from being able to provide care, had more confidence in dealing with aggression and believed more in the importance of training. Burnout, referring to feelings of hopelessness and difficulties in dealing with or doing one’s job effectively, was linked with a more negative attribution toward aggression. This study is, to our knowledge, the first to demonstrate this association.

Table 4. Correlations

Age (years)

Work experience Professional quality of life

In psychiatry (years)

On the ward (years)

Compassion satisfaction Burnout

Secondary traumatic stress

Attitude (ATABQ) Total score .075 .012 .042 .143* −.149* −.047 Subscale—Prediction −.178* −.030 .008 .068 .068 −.025 Subscale—Patient attributionand responsibility for aggression

−.132 −.166* −.155* .121 −.148* −.056

Subscale—Staff anxiety and fearof assault .046 −.055 .005 .106 .064 −.220 Subscale—Need for skilled intervention to prevent andmanageaggression

.085 .052 .043 .156* −.027 −.133

Subscale—Staff confidence .011 −.009 .035 .307** −.052 −.192** Self-efficacy (CCPAI) Total score .080 .058 .023 .284** .052 −.218**

*Significant values (α levelof .05). **Significant values (α level of .01).ATABQ,AttitudeTowardAggressiveBehaviorQuestionnaire;CCPAI,Confidence inCopingWithPatientAggression.

Table 5. Associated Factors forAttitudeandSelf-EfficacyToward InpatientAggression (StepwiseRegressionAnalysis)

R2 p value

Modelswithperceived level of self-efficacyas variable tobepredicted Model 1—Gender .144 <.001 Model 2—Gender andcompassion satisfaction .207 <.001 Model 3—Gender, compassion satisfaction, burnout, secondary traumatic stress .262 <.001

Modelswithattitudeas variable tobepredicted Total score NA Prediction .024 .015 Model 1—Age

Patient attributionand responsibility Model 1—Experiencepsychiatry .026 .013

Staff anxiety NA Skilled interventions .019 .027 Model 1—Training .035 .011 Model 2—Training, educational degree

Staff confidence Model 1—Compassion satisfaction .104 <.001 Model 2—Gender andcompassion satisfaction .144 <.001

NA,not applicable; all predictors excluded.

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

In the current study, less experienced nurses were less likely to blame patients for their behavior and less frequently held them responsible for this behavior. They embraced a perspective in which it is more accepted that patients become violent when they feel vulnerable, helpless, or afraid (Collins, 1994). This negative association between work experience and a positive attitude toward aggression is com- parable to previous research (Abderhalden et al., 2002; Jansen, Dassen, et al., 2006; Palmstierna & Barredal, 2006). In contrast, the study of Whittington (2002) found that tol- erance for aggression is higher among more experienced nurses (more than 15 years). Our results may indicate that

more experienced nurses seem to lose a positive perspective and tolerance toward aggression. This development over time toward a tendency to place blame can be explained by the possible impact of patient aggression on nurses. The confrontation with aggression may cause emotional harm. This sample of mental health nurses showed that burnout and post-traumatic stress increased significantly for nurses employed more than 10 years. Emotionally depleted staff might find it difficult to have empathy with aggressive patient behavior, and as the study of Whittington (2002) demonstrated, burnout is associated with a more intolerant attitude.

Table 6. PerceivedLevel of Self-Efficacyof the Participants

Nurse-related characteristics

Self-efficacy (CCPAI)a

Mean (SD) Differences

Overall 61.33 (14.63) NA Gender t = 5.993, p = .000* Female 58.11 (13.81) Male 71.15 (12.95)

Age (years) F = .871, p = .457 21–30 58.54 (16.30) 31–40 62.53 (12.50) 41–50 62.22 (15.25) >50 62.19 (14.47)

Workexperience inpsychiatry (years) F = .739, p = .530 <1 57.50 (14.96) 1–5 59.80 (16.13) 6–10 61.78 (13.23) >10 62.29 (14.53)

Workexperienceonward (years) F = .803, p = .493 <1 58.80 (15.56) 1–5 62.65 (16.08) 6–10 60.47 (13.47) >10 62.57 (13.36)

Educational degree innursing t = 1.059, p = .291 BScdegree 62.35 (14.95) Diploma level 60.22 (14.21)

Degree inpsychiatric nursing t = 1.228, p = .221 Yes 60.71 (14.42) No 63.90 (15.73)

Compassion satisfaction F = 6.259, p = .002* Low 55.92 (11.73) Moderate 65.82 (15.16) High 65.69 (16.18)

Burnout F = .175, p = .839 Low 60.71 (16.09) Moderate 60.88 (14.46) High 62.38 (13.94)

Post-traumatic stress F = 2.469, p = .087 Low 63.69 (18.73) Moderate 62.30 (14.12) High 57.99 (12.66)

aPossible range: 10–110. *Significant. CCPAI, Confidence in Coping With Patient Aggression; NA, not applicable.

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

Participants reported a strong belief in training, especially for male mental health nurses, which seems to contradict the higher levels of perceived self-efficacy. Male mental health nurses more often intervene in aggression incidents than their female colleagues. This might create a stronger interest in, and thereby need for, training and competence development.

Perceived Self-Efficacy

The overall perceived level of self-efficacy was 61.44 (SD 14.57). This is comparable to Grenyer et al. (2004), who found a self-efficacy level of 62.67 (SD 19.19). Thackrey (1987) reported a self-efficacy level of 70.70 (SD not reported), which is markedly higher. The main result of this study is a four-factor model predicting about one fourth of the variability in the perceived self-efficacy of mental health nurses toward aggressive incidents. Previous research using an adapted version of the CCPAI within a group of mental health clinicians demonstrated the impact of gender on self- efficacy, whereby male mental health workers have higher self-efficacy levels than their female colleagues (Martin & Daffern, 2006). We can state that besides gender, the per- ceived professional quality of life, along with its three sub- aspects compassion satisfaction, burnout, and secondary traumatic stress, is an important nurse-related predictor for the level of self-efficacy. The generally low self-efficacy scores could have a negative effect on the perception of aggression, on professional functioning, and on task perfor- mance toward aggression.

Implications for Mental Health Nursing Practice

As the conceptual model stated, an enduring and pervasive change in behavior toward patients who behave aggressively will only be achieved by influencing mental health nurses’ attitude and self-efficacy. It should be clear that these changes in attitude, self-efficacy, and behavior cannot be achieved in a day. Change of this magnitude requires targeted investments and time. The implications for practice are situated in several areas.

First, it is important that mental health nurses understand the meaning of aggression. Mental health nurses view aggres- sion in different ways (Finnema et al., 2004; Jansen, Middel, et al., 2006; Jonker et al., 2008). As mentioned, aggression can be perceived as a dysfunctional, functional, or protective phe- nomenon. The last two perspectives reflect a more tolerant, permissive attitude toward aggression. Mental health nurses need to be aware of the possible protective and functional nature of aggression. This can increase their understanding of the nature of aggressive behavior, thus leading to a more empathetic attitude. The capacity to see aggression in a more positive way may result in a better working alliance with

improved treatment outcomes (de Leeuw et al., 2012), such as a lower use of coercive measures (Jonker et al., 2008). Knowing this and intervening appropriately can help mental health nurses learn from their experience and feel successful in their performance. This experience of success then aug- ments their perceived self-efficacy in the management of aggressive incidents.

Second, education is needed to improve attitude, self- efficacy, and performance (Beech & Leather, 2006; Needham et al., 2005). This training will enable mental health nurses to understand the multifactorial and complex nature of aggression. The training course should also provide content on and lessons in effective intervention strategies for evidence-based practice related to aggression management. As mentioned earlier, a better understanding of the meaning of aggression and identification of possible interventions will lead to a change in practice. Training alone is not sufficient.

Third, we recommend on-the-job training, which needs to be incorporated at different levels. At an individual level, mental health nurses need to be coached on their perfor- mance toward aggression. An open and nonthreatening atmosphere to perform those individual reflections must be created. The formation of attitudes is not only affected by individual characteristics but also by team dynamics (Knotter, Wissink, Moonen, Stams, & Jansen, 2013); thus, interventions at team level should consist of team discus- sions and reflection on specific incidents, actions, reactions, feelings, and thoughts toward inpatient aggression. A nurse expert in aggression management could lead this peer supervision. At the management level, mental health hospi- tals need to support and facilitate the participation in train- ing courses and on-the-job training, recruiting an expert in aggression management, and developing vision of aggres- sion management in concert with the staff. This study dem- onstrates that a higher level of professional quality of life is associated with more positive attitudes and with improved self-efficacy. A better professional quality of life, referring to positive job satisfaction, may lead to a more professional approach to manage aggressive incidents. Management needs to pay attention to the job satisfaction of their staff within the earlier mentioned open and nonthreatening atmosphere.

Fourth, it is important that nurses confront patients with their behavior. This appraisal is a learning experience for both the patient and the nurse. The nurse obtains insight into the experiences of the patient with a positive impact on his or her attitude toward aggression. An appraisal with the patient strengthens the nurse’s own competencies in dealing with aggression and thus increases the self-efficacy.

Although not a part of the present study, it will be impor- tant to identify the subjective norms, as third factor of the TPB, at team level.

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

Study Limitations

The sampling method is a limitation of this study. The researchers did not have full control over the selection of the wards within the hospitals. The nursing directors had some preferences for the participation of specific wards based upon organizational aspects. This might influence the generalizability of the results. With a response rate of 100%, it can be concluded that the participants were representative of mental health nurses for the included wards. A second limitation is the low internal consistency of the translated ATABQ scale for both the Dutch and French versions. The low internal consistency can indicate a lack of validity in the construct of attitude toward aggression as measured by the ATABQ. Results from this questionnaire must be inter- preted with caution. The translated CCPAI had good inter- nal consistency. The methodological concept of our study can only indicate associative relationships between attitude and self-efficacy on the one hand and the nurse-related characteristics on the other hand. To ensure the stability of the predictive value of the four-factor model for self- efficacy, further longitudinal research is necessary.

Conclusion

An adequate level of self-efficacy and a positive attitude toward aggression are important to decrease the severity and number of aggressive incidents and to increase staff compe- tence to intervene in a professional and therapeutic manner toward aggressive incidents. This will lead to improved quality of care, a more effective achievement of patient goals, and help nurses to be more resistant to patient aggression and the threats it poses. This study demonstrates the need for attention to professional quality of life for mental health nurses, with increased attention for more experienced nurses who may suffer from negative consequences of providing care to adults with a mental illness.

Acknowledgments

This research received a funding from Belgium Federal Public Service of Health Care. The authors would like to thank the participating hospitals, Nataly Filion, and Karen Lauwaert for their collaboration in this project.

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