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Walden University

ScholarWorks

Walden Di##e"$a$in# and Dc$"al S$%die#

2015

Communication Skills of Novice PsychiatricNurses with Aggressive Psychiatric Patients

Rose MossWalden University

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Walden University

College of Health Sciences

This is to certify that the doctoral study by

Rose Moss

has been found to be complete and satisfactory in all respects,

and that any and all revisions required bythe revie committee have been made!

Revie Committee

"r! #llison Terry, Committee Chairperson, Health Services $aculty

"r! Sophia %ron, Committee Member, Health Services $aculty

"r! &ileen $oles, University Revieer, Health Services $aculty

Chief #cademic 'fficer&ric Riedel, (h!"!

Walden University

)*+


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#bstract

Communication S-ills of .ovice (sychiatric .urses ith #ggressive (sychiatric (atients

by

Rose /! Moss

MS, University of Hartford, +001

(ro2ect Submitted in (artial $ulfillment

of the Requirements for the "egree of

"octor of .ursing (ractice

Walden University

March )*+


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#bstract

The transition from novice nurse to a competent psychiatric staff nurse is often associated

ith ma2or communication challenges, primarily hen caring for aggressive patients!

3uided by (eplau4s theory, this quantitative study assessed the communication s-ills of

novice psychiatric nurses 5 N 6 )7 ho or-ed )8 months or less in the state psychiatric

hospital ith aggressive psychiatric patients! #dditionally, certain demographic data such

as gender, age range, level of education, and length of time or-ing ere analy9ed to

determine their impact on communication s-ills! The survey consisted of )* questions

hich assessed demographic data, communications s-ills, and hospital:based orientation!

%ased on #.';#, novice nurses did not differ on hospital:based orientation based on

gender, age, level of education, or length of time or-ing! .ovice nurses4 communication

s-ills did not differ by gender, age or level of education< hoever, novice psychiatric

nurses ho had or-ed +0:)8 months had stronger communication s-ills than those

or-ing less time ith aggressive patients 5 F 6 1!0, p = *!**7! # communication s-ills

class during hospital orientation to prepare novice nurses to communicate effectively

ith aggressive patient as recommended to nursing leadership and staff! #

communication s-ills class held during hospital orientation could enhance the nurse:

patient relationship, cultivate a safer and secure milieu, and improve patient outcomes!

The findings have implications for positive social change for staff development to

improve the hospital orientation for novice psychiatric nurses to become better equipped

as effective communicators ith aggressive psychiatric patients!


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Communication S-ills of .ovice (sychiatric .urses ith #ggressive (sychiatric (atients

by

Rose /! Moss

MS, University of Hartford, +001

(ro2ect Submitted in (artial $ulfillment

of the Requirements for the "egree of

"octor of .ursing (ractice

Walden University

March )*+


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"edication

This ".( (ro2ect Study is dedicated to my daughters Tyra /! Moss and

>acqueline Moss:Royale for their support and encouragement to achieve this goal!


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#c-noledgments

? ould li-e to especially than- "r! #llison Terry, my ".( Committee Chair at

Walden University for her consistent encouragement and support as she has helped me

reach this point in my academic career! ? ould also than- to faculty members at

Walden University, "r! Sophia %ron and "r! &ileen $oles for their support and

illingness to serve on my ".( Committee! ? than- my preceptor, Meari #very, #(R.,

"irector of Staff "evelopment ho assisted me in achieving this goal as ell as the

.urse &@ecutive Committee at Connecticut ;alley Hospital! ? also than- (atricia 'liver

ho assisted ith the statistical analysis! ?n addition, my colleagues Aarin Ciance, ".(

and >ames /a$eir, ".( provided their continuous and unconditional support and

encouragement during this entire 2ourney! My cousin %etty %urrus has consistently

provided the spiritual support along the ay!


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i

Table of Contents

/ist of Tables !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! iv

/ist of $igures !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!v

Section +B ?ntroduction to the Study !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+

%ac-ground of the (roblem !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+

(roblem Statement !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

(urpose Statement !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

(ro2ect 'b2ectives !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1

(ro2ect Duestion !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1

Significance of the (ro2ect !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!E

Significance to (ractice!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!F

?mplication for Social Change in (ractice !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!0

"efinition of Terms!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+*

#ssumptions !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+)

/imitations !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+)

Summary !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+)

Section )B Revie of /iterature and Theoretical $rameor- !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+8

?ntroduction !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+8

Specific /iterature !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+

3eneral /iterature !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)+

Theoretical $rameor- !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)8

(eplau4s Theory !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! )8


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ii

Summary !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! )1

Section B Methodology !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)F

?ntroduction !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)F

(ro2ect "esignGMethods !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)F

(opulation and Sampling !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)0

"ata Collection 5?nstrument and (rotection of Human Sub2ects7 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!*

"ata #nalysis !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)

(ro2ect &valuation (lan !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Summary !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!8

Section 8B $indings, "iscussion, and ?mplications !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1

$indings!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1

"iscussion of $indings !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!8

?mplications !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!88

(ro2ect Strengths and /imitations !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!81

Recommendation for Remediation of /imitations !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!8E

#nalysis of Self !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!8E

Summary !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!80

Section B Scholarly (roduct !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+

References !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!F8

#ppendi@ #B Communication S-ills of the .ovice (sychiatric .urse Survey !!!!!!!!!!!!!!!!!0*

#ppendi@ %B Communication ith (atients ith cancerB # 3ree- Study !!!!!!!!!!!!!!!!!!!!!!!!!08

#ppendi@ CB 'ffice of the Commissioner /etter of #pproval !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!0E


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iii

Curriculum ;itae !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!0F


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iv

/ist of Tables

Table +! Hospital:based s-ills and communication s-ills!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!E

Table )! "emographics of hospital:based and communication s-ills!!!!!!!!!!!!!!!!!!!!!!!!!!!!F

Table ! #nalysis of variance!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!8*


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v

/ist of $igures

$igure +! #verage scores on hospital:based orientation and communication s-ills!!!!!1


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+

Section +B ?ntroduction to the Study

Background of the Problem

The transition of ne nurse graduates from registered nurse 5R.7 into

professional practice is a vital and critical development period 5%enner, +0F)7! Most

initial psychiatric or behavioral health e@periences of ne nurse graduates occur in their

clinical rotation ithin nursing programs! Aramer 5+0E87 described the transition as a

Ireality shoc-J 5e!g!, feeling overhelmed, angry, depressed, and inadequate despite the

preparation for practice during nursing school 5as cited in Martin K Wilson, )*++, p! )+7!

$actors associated ith transitioning from ne nurse graduate to professional nurse are

inadequate clinical preparation, lac- of confidence in various s-ills, conflict issues,

unrealistic e@pectations of self and staff, mi@ed feelings about responsibilities, role stress,

lac- of support from staff, and burnout 5>eell, )*+< Morro, )**07! Similarly, the

transition from a medical:surgical nurse to a psychiatric nurse is considered a ma2or

change and is often involves significant stressors and challenges!

#ccording to "uchscher 5)**F7, the transitional process can determine the

difference beteen a successful career and abandonment of a profession due to a high

level of stress and burnout! #d2usting to a ne role, here communication is the core of

managing the care of psychiatric patients can be challenging and can create an

unpredictable setting that may be difficult for the novice psychiatric nurse to handle! $or

the purpose of this paper, the term novice psychiatric nurse refers to ne nurse graduates

ho are ne to psychiatric nursing and nurses ho have e@perience in another specialty

in nursing 5e!g!, medical:surgical7 but lac- e@perience in the psychiatric setting!


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)

?npatient psychiatric units have been considered an e@tremely stressful

environment for direct care staff or-ing ith patients ith aggressive and unpredictable

behaviors 5Ward, )*+7! ?npatient psychiatric units consist of a number of patients ho

suffer from various types of mental illnesses! ?t can be difficult for the nurse to maintain

effective communication ith such patients! This has been difficult to manage even for

the e@perienced psychiatric nurse! ?n order for effective communication to occur, the

nurse:patient interaction and therapeutic engagement must be established first ith the

aggressive patient!

The primary function of nursing, hich has been considered a dynamic and

rearding 2ob, is ta-ing care of patients! To properly care for them, appropriate

communication is essential! #lthough patient:centered communication is the -ey that aids

in the development of a positive nurse:patient relationship, nurses have been considered

poor communicators ith patients suffering from various mental illnesses, hether

novice or e@perienced 5Sharac, McCrone, Sabes:$iguera, Csip-e, Wood, K Wy-es,

)*+*7!

Maintaining effective communication beteen the psychiatric nurse and

psychiatric patients has been considered the main core of care in mental health 5(eplau,

+0), +00E7! The importance of communicating therapeutically ith patients has been the

cornerstone in nursing practice! (sychiatric hospitals attempt to maintain a safe

environment for the patients and direct care staff on the units 5>ones, .olan, %oers,

Simpson, Whittington, Hac-ney, K %hui, )*+*7! #ggressive patients ho cause conflict

on the unit ma-es providing care a serious challenge for all frontline nurses


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Problem Statement

Communication is the -ey factor in providing and managing the care of patients

ith mental illness, especially patients ho display aggressive behavior! (eplau 5+00E7

stated that the nurse:patient relationship is the core of mental health nursing and that the

behaviors of both nurse and patient interacting together play a significant role in the

quality of patient care and its outcome! #lthough communication is the foundation of the

nurse:patient relationship, psychiatric nurses have been critici9ed for their lac- of

interaction and therapeutic engagement ith patients 5Sharac et al!, )*+*

(sychiatric units, hether acute or long:term, that e@perience high levels of

conflict or unpredictable behaviors from psychiatric patients have shon increases in

physical and psychological in2uries ith staff 5#nderson K West, )*++7! (sychiatric

patients4 aggressive behavior has generated high acuity levels causing an unsafe milieu!

#ggression by psychiatric patients represents a serious threat to the safety and security of

both patients and staff 5>ones et al!, )*+*< Ward, )*+7! Wor- pressure, poor

communication s-ills, stress, and time constraints have all contributed to psychiatric

patients4 conflict behaviors 5Currid, )**0< Ward, )*+7! #ccording to Ward 5)*+7, the

ma2ority of R.s or-ing in an inpatient psychiatric unit have e@perienced aggressive or

violent behavior by patients at least once in their career! $or novice nurses ho have

e@perienced various levels of aggressive behavior from patients ithin their first year of

practice resulted in high levels of stress, including significant cost to the organi9ation and

2ob attrition 5/ampe, Stratton, K Welsh, )*++< (ar-er, 3iles, /antry, K McMillan, )*+87!


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8

The nurse4s attitude toards psychiatric patients has a significant effect on the

type of communication that occurs beteen them 5Weight K Aendal, )*+7! .ovice

psychiatric nurses find they lac- competence and confidence and that this is perceived by

patients ith mental illness as negative behavior ?n a study of >ordanian nurses conducted

by Hamdan:Mansour and Wardam 5)**07, 1*L of >ordanian nurses e@hibited negative

attitudes toards patients ith mental illness! Hamdan:Mansour and Wardam 5)**07

emphasi9ed that establishing and maintaining appropriate communication can be

e@tremely difficult, especially hen nurses perceive mentally ill persons to be

Idangerous, immature, dirty, cold hearted, harmful, and pessimisticJ 5p! E*7!

#lthough patient:related aggressive acts toard the staff on inpatient units had

declined from >uly )*+) to >une )*+8 at a large state psychiatric hospital in southern

.e &ngland, these acts seemed to have had an effect on the nurse:patient interaction,

particularly ith novice psychiatric nurses! #t this hospital, novice nurses do not receive

a revie of basic communication s-ills during hospital orientation! The ability to

approach aggressive psychiatric patients and communicate effectively ith has been

observed by nursing staff to be a difficult tas- for novice psychiatric nurses! #s a result, ?

conducted a survey of novice psychiatric nurses hich revealed their perceptions of their

communication s-ills! #n educational module on enhancing communication s-ills for

novice psychiatric nurses as recommended to be used during future hospital orientation

ith novice nurses! ?t ould provide the necessary communication s-ills to facilitate the

nurse:patient relationship ith the psychiatric patient, especially the aggressive patient!


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Purpose Statement

Some obstacles that impeded nurses from communicating ith psychiatric

patients ere as follosB fear of 5a7 hat to say, 5b7 ma-ing the situation orse by

ac-noledging the patient4s behavior, and 5c7 as-ing the patient about their suicidal

thoughts or feelings of anger! (atients ho struggled ith depression or hallucinations

ere often loo-ing for someone to tal- to about their thoughts and ho they ere feeling!

.urses ho ere not equipped in communicating ith psychiatric patients impeded the

nurse:patient relationship! The frontline staff4s poor communication affected the safety of

patient and staff< the staff and patient relationship< and patient and staff satisfaction

5%oles, .!, Mac-intosh, K Torn )**+< $leischer, %erg, immermann, WNste, K

%ehrens, >! )**07! "eveloping a relationship involved communication! The relationship

and communication concepts ere clearly connected!

Some psychiatric patients on an acute inpatient or long:term psychiatric unit ho

are diagnosed ith ma2or depressive disorder, psychotic disorder, or a personality

disorder may e@perience severe psychosis, may be severely depressed, may e@press

suicidal or thoughts of self:in2ury and display aggressive behavior! These patients need to

be maintained in a safe environment! Many novice psychiatric nurses feel that their

ability to communicate ith, assess, and treat such patients appropriately are inadequate!

This creates tension in providing care and hinders the development of the nurse:patient

relationship!

The purpose of this needs assessment pro2ect as to conduct a survey ith novice

psychiatric nurses to determine their communication s-ills! in the folloing areasB


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1

confidence level in their communication s-ills as a novice psychiatric nurse< -noledge

about mental illness before being hired< communication s-ills ith psychiatric patients<

use of communication s-ills during hospital and unit orientations< feelings about

interacting ith aggressive patient< the nurse:patient relationship< and communication

ith nursing staff! The result of the survey led to the recommendation of an educational

module on enhancing communication s-ills during hospital orientation for novice nurses

to facilitate the nurse:patient interaction and relationship ith psychiatric patients on

inpatient psychiatric units!

Project Objectives

This pro2ect as developed to achieve the folloing ob2ectivesB

• To survey the communication s-ills of novice psychiatric nurses ithin the

nurse:patient relationship

• To provide staff development and nursing leadership ith insight into novice

psychiatric nurses4 use of communication techniques ith psychiatric patients

• To recommend an educational program on communication s-ills to facilitate

the interactions of novice psychiatric nurses ith aggressive psychiatric

patients on inpatient units

Project Question

.e nurse graduates and nurses ho transitioned from another nursing specialty,

such as medical surgical nursing, into the psychiatric setting, received the same hospital

orientation at this state hospital! The pro2ect question as as follosB #re the

communication s-ills of ne nurse graduates or nurses ith no prior psychiatric


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E

e@perience satisfactory to interact ith aggressive psychiatric patients on inpatient

psychiatric unitsO

Significance of the Project

The translation of evidence into practice represented a poerful tool and an

e@ample of ho change efforts improved nurse:patient relationships, patient outcomes,

nursing practice, and strengthened health care delivery 5White K "udley:%ron, )*+)7!

Therefore, effective communication is essential for the delivery of quality care for all

patients! (sychiatric nurses have been critici9ed for their lac- of communication,

interaction and therapeutic engagement ith patients 5Sharac et al!, )*+*7! .urses4

attitude toards psychiatric patients has a significant effect on the type of communication

that occurs beteen the nurse and patient 5Weight K Aendal, )*+7! Studies have shon

that the nurse4s approach to the patient, comprehension of the nurse:patient relationship

and the behaviors displayed beteen both play a significant role on the quality and

outcome of patient care as ell as the safety and security on the unit 5>ones et al!, )*+*<

Ward, )*+7 $indings suggest that a class on communication s-ills and techniques for

nurses caring for psychiatric patients has improved the nurse:patient relationship and

resulted in better patient outcomes 5#- et al!, )*++7!

To understand the communication s-ills of the novice psychiatric, a survey as

needed to determine the perceptions of novice psychiatric nurses ho care for aggressive

psychiatric patients! $indings from the survey revealed that although novice psychiatric

nurses perceived their communication s-ills to be satisfactory, their ritten comments

ere about a need to integrate communication classes during the hospital orientation that


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F

ould equip them to appropriately interact and engage in effective communication ith

their patients at the start of their or-ing period! &stablishing a communication s-ills

class ould change staff development hospital orientation curriculum for novice nurses!

?n turn, a class ould provide better prepared novice nurses to manage aggressive

patients on the units that ould result in positive patient outcomes on safer and secure

units!

Significance to Practice

&ffective communication, a fundamental component in nursing, is considered an

essential requirement in the nurse:patient relationship in hich the patient is the focal

point in the relationship! Within the frameor- of that relationship, nurses help patients

develop s-ills that can help them cope ith their problems! The combination of hat is

contributed beteen the nurse and the patient has more impact on the relationship! .urses

have to balance the safety and security of all patients ith improving or maintaining the

mental status of each patient!

.urses need to build a caring and trustful relationship to enables patients to feel

more secure and to help them open up and share their true feelings! The nurse:patient

relationship should be based on honesty and respect! Studies have shon that nurses in a

psychiatric setting and thus or- in a fearful setting, value trust and effective

communication hen developing a therapeutic relationship ith their patients 5>acob K

Holmes, )*++< Ward, )*+7! &ffective communication training has the potential to

facilitate the nurse:patient relationship that can result in a significant impact on nursing


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0

practice particularly in the manner of approach, communication s-ills, empathy, and

reduction in undesirable events 5#- et al!, )*++< %oles et al!, )**+7!

Implication for Social Change in Practice

.egative attitudes and biases toards people ith mental illness e@ist in the

general population 5Hansson et al!, )*++7! Hoever, among mental health professionals,

the current approach toards mentally ill patients, studies have shon a prevalence of

negative attitudes that focus on stereotypes and social distance 5Hansson et al!, )*++7!

This has resulted to have a profound negative social impact in hich the patient4s

attitudes ere overall the same as mental health professionals 5Hamdan:Mansour K

Wardam, )**07! Mental health professionals4 attitudes about mental ill patients can

impede communication and therefore have implications on the patient4s treatment!

.urses4 attitudes and beliefs about patients ith mental illness have been shon to

influence the ay patients are treated and spo-en to on an inpatient psychiatric unit!

.ovice or even e@perienced psychiatric nurses ho possess negative attitudes have the

potential to develop poor communication s-ills hich affect the quality of care, patient

outcomes, and loer patient satisfaction!

Current practice on inpatient psychiatric units has been associated ith

overcroded and chaotic environments< high stimulus atmosphere that contributes to

escalating behaviors< conflict over patient4s course of treatment< length of time it ta-es to

act on patient4s concerns and needs< a lac- of contact and emotional engagement ith

patients< insensitivity to patient4s cultural and belief system< and an apathetic attitude

toards patients in general 5%2or-dahl, (almstierna, K Hansebo, )*+*7!


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+*

?n order for psychiatric patients to receive quality nursing care, it is imperative

that psychiatric nurses use effective communication to establish and maintain the nurse:

patient relationship! This as difficult for nurses at this state hospital ho or- ith

patients ith aggressive or unpredictable behaviors! Wor-ing ith difficult patients

required interventions that ould affect safety for both the patient and staff! The

aggressive behavior 5or behavior that created chaos on the unit7 as seen as no e@cuse for

poor nurse:patient communication 5>acob K Holmes, )*++7! #s mentioned earlier, it is

the quality of the communication that determines hether the relationship moves in a

positive or negative direction! ?mplications for positive social change for staff

development to improve hospital orientation and for novice psychiatric nurses to become

more -noledgeable and better equipped as effective communicators ith aggressive

psychiatric patients!

Definition of Terms

Aggressive behavior is any verbal or nonverbal, actual or attempted, conscious or

unconscious, forceful means of harm or abuse of another person or ob2ect 5Halter, )*+8,

p! 1E)7!

Communication skills or therapeutic communication techniques are verbal or

nonverbal techniques that encourage e@ploration of feelings, foster understanding of

behavioral motivation and are non2udgmental, discourage defensiveness, and promote

trust 5Tonsend, )*++, p! ++07!


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++

Effective communication is essential to practice and is shaped by open:ended

questions, listening, empathy, and assertiveness! ?t is clear in content and requires an

e@change of ideas and common understanding beteen people 5Halter, )*+8, p! ++7!

Mental or psychiatric illnesses refer to mental disorders ith definable diagnosis

and are manifested in significant dysfunction in developmental, biological, or

psychological disturbances in mental functioning 5Halter, )*+8, p! )7!

Novice psychiatric nurses are graduate 5beginner7 nurses or advanced 5e@pert7

nurses transitioning from one specialty area in nursing into psychiatric nursing 5%enner,

+0F)7!

Nurse patient interaction is the process in hich a nurse and a client e@change or

share information, verbally or nonverbally! ?t is fundamental to communication and is an

essential component of the nursing assessment 5Halter, )*+8, p! +)7!

Nurse-patient relationship consists of a therapeutic relationship beteen a nurse

and a client built on a series of nurse:patient interactions! The nurse:patient relationship

is central to patient satisfaction 5Halter, )*+8, p! +7!

Peplau’s theory focuses on the interpersonal processes and therapeutic

relationship that develops beteen the nurse and client 5(eplau, +0), +00E7! ?t includes

three -ey phases, the orientation, or-ing 5hich combines identification and

e@ploitation7, and resolution!

Psychiatric nurses provide ongoing assessment on the condition of the patient

both mentally and physically 5Tonsend, )*++, p! +1+7!


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+)

ssumptions

Members on the healthcare team desire optimal patient outcomes and are

concerned about the aggressive behavior of psychiatric patients on the inpatient units!

#lthough novice psychiatric nurses receive training on non:violent prevention

intervention program during hospital orientation, patient aggressive behavior remains

significant on the inpatient units! #n assumption of this pro2ect is that communication

s-ills revieed ith novice psychiatric nurses during hospital orientation ould better

prepare them to interact ith aggressive psychiatric patients resulting in improved nurse:

patient relationship and positive patient outcomes!

!imitations

The limitations in this pro2ect ere minimal! The survey as conducted ith

only) out of ) novice psychiatric nurses or-ing in a large state hospital in central

Connecticut ithin the past )8 months! The small sample si9e limited the overall

generali9ability of the findings to the greater population of private and public psychiatric

hospital!

Summar"

.ovice psychiatric nurses are minimally trained in managing aggressive

psychiatric patients! They are challenged by the limited time and resources afforded their

hospital and unit:based orientation! Since communication is the -ey to the nurse:patient

interaction and relationship and to the cornerstone of nursing practice, it is essential for

novice psychiatric nurses to be ell equipped to manage patients ith aggressive or

unpredictable behaviors ithin the conte@t of the inpatient psychiatric setting! The


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+

primary purpose of this pro2ect as by ay of a survey, to conduct a needs assessment of

the communication s-ills of novice psychiatric nurses! The results of the survey led to the

recommendation of an educational module on communication s-ills that could be

integrated into the orientation for ne nurse graduates! The nurse:patient interaction and

nurse:patient relationship impacts patient behavior, patient outcomes, and patient

satisfaction!

?n Section ), a comprehensive literature revie as conducted that demonstrated

the evidence available to support the needs assessment survey of novice psychiatric

nurses4 communication s-ills ith psychiatric patients!


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+8

Section )B Revie of the /iterature and Theoretical $rameor-

Introduction

This section includes specific and general evidence retrieved from a literature

search! ?n addition, a theoretical frameor-, (eplau4s theory on interpersonal relations is

described! The theory acted as a guide in this ".( pro2ect!

(sychiatric hospitals or- hard to maintain a safe environment for patients, direct

care staff, and au@iliary staff! The novice psychiatric nurse ho is ad2usting to a ne role

here communication constitutes the core of managing the care of psychiatric patients

has proven to be challenging in an unpredictable and chaotic setting! (roviding such care

is difficult even for e@perienced psychiatric nurses 5>ones, .olan, %oers, Simpson,

Whittington, Hac-ney, K %hui, )*+*7! The nurse:patient interaction must be established

and maintained for effective communication to occur ith aggressive patients!

The literature search used to electronic databases, the Cumulative ?nde@ to

.ursing and #llied Health /iterature 5C?.#H/7 and M&"/?.&! %oth ere searched for

literature published ithin the past years! Aey search terms used to identify articles

included the folloingB novice psychiatric nurses ne! nurse gra"uate psychiatric

nurses aggressive behavior nurse-patient interaction nurse-patient relationship

transitioning nurse an" communication skills#

?n the literature search, it as quite difficult to find articles published ithin the

last years on novice nurses4 interaction and care of psychiatric patients! #lso scarce

ere articles addressing the novice nurse or-ing in the behavioral health field or

e@perienced nurses transitioning from another specialty into psychiatric nursing! What ?


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+

did find ere many older articles from +00 to )** that e@amined nurses4 attitudes,

e@periences, and managing the care of the aggressive psychiatric patient! These articles

ere primarily on emergency departments, general medical:surgical units, inpatient units,

and forensic settings!

# total of * articles ere identified, appro@imately + ere selected for the

literature revie! The specific literature pertained to communication s-ills of nurses or

nursing students ithin the psychiatric setting hile the general literature as related to

nurses4 communication s-ills ithin the general hospital or community setting!

Specific !iterature

Simulation is a method to enhance training in the psychiatric setting and is being

used in many nursing programs! Webster 5)*+7 stated Iithout effective communication

and continuous assessment ith reflection of onePs on communication techniques, the

student is unable to elicit patient values and collaborate ith the patient to plan and

provide quality careJ 5p! 1817! Webster 5)*+7 described a simulation activity that used

the Duality and Safety &ducation for .urses 5DS&.7 competency of patient:centered

care to improve therapeutic communication s-ills in the psychiatric setting! .ursing

students ere video:taped for +:)* minutes interacting ith actors portraying to have

various types of mental illness! The students identified communication techniques used

and evaluated their strengths and areas for improvement! $eedbac- and debriefing

regarding -noledge, s-ills, and attitudes ere provided by faculty because the use of

therapeutic communication s-ills has alays been essential in providing quality patient:

centered care!


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+1

%ilgin 5)**07 described an evaluation of the nurse4s interpersonal styles and the

influence it has on the behavior of psychiatric patients! The nurse4s interpersonal style

has been a precursor of aggression and violence on inpatient units! Continuous incidents

of aggression interrupted the quality of the therapeutic milieu! .urses4 interpersonal

styles and perceptions triggered conflicts ith psychiatric patients! The descriptive study

e@amined the relationship of the nurse4s interpersonal relationship styles and the assaults

by psychiatric patients! The study consisted of +1) psychiatric full:time nurses in a

hospital in ?stanbul! The participants ere given the ?nterpersonal Style ?nventory related

to interpersonal involvement< conte@t of sociali9ation< conte@t of autonomy< conte@t of

self:control< and conte@t of stability! The findings of the study deciphered that the nurses4

interpersonal style increased their li-elihood of being a victim of assault 5%ilgin, )**07!

.urses ho ere aare of their environment had the ability to predict patient4s

aggressive behavior before it escalated and ere able to prevent or manage the patient

more effectively 5%ilgin, )**07!

Steart and %oers 5)*+7 conducted a study on verbally aggressive behavior of

patients on inpatient psychiatric units! The authors used a Ibroad definition, ranging from

ma-ing loud noises to threats of harmJ 5p! )E7! The )) adult psychiatric inpatients in

the first ) ee-s of their current admission ere selected by nursing staff from +

hospitals in the /ondon area! The (atient:Staff Conflict Chec-list 5(CC7 used to collect

data counted the conflict 5behaviors7 and containment 5time out, sho of force, restraints7

of the patient on each shift!


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+E

"uring data collection the patient4s medical and nursing records ere evaluated to

complete the (CC! The final results shoed there ere +,1 of verbal aggression from

)1 patients during the ):ee- study period! The categories of verbal aggression

included abusive language, shouting, threats, racism, anger, and unspecified verbal

aggression 5Steart K %oers, )*+7! The most frequent type of verbal aggression as

abusive language! The most targeted group for verbal aggression as nursing staff! There

as a higher incident of verbal aggression ith patients ith a history of violent

behavior!

%2or-dahl, (almstierna, and Hansebo 5)*+*7 conducted a qualitative study on the

nurse4s approach hen caring for the psychiatric patients in the acute psychiatric setting!

The participants included in the study ere nineteen staff members ho consisted of ten

registered nurses and nine nursing assistants! #ll of the participants in the study ere

referred to as nurses and the median or- e@periences ere +8 years! The taped

intervies lasted no more than F* minutes and the participants ere encouraged to

provide e@amples of situations that occurred on the units!

The data revealed to approaches nurses use in caring for acute psychiatric

patientsB the ballet dancer and the bulldo9er! The ballet dancer approach communicated

caring, compassion, empathy, trust, and closeness toards each patient! The bulldo9er

approach as aligned ith safety, security, control, and setting limits to prevent chaos on

the unit! The nurses attempted to use the bulldo9er approach ith sensitivity regarding

the patient e@perience to -eep the unit safe and secure!


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+F

Ward 5)*+7 e@plored the nurse:patient relationship, violence, and aggression in

acute inpatient psychiatric units! The researcher described ho physical, emotional, and

psychological aggression ere e@pected on psychiatric units and the manner in hich it

as managed had become of main concern for psychiatric nurses! # feminist frameor-

guided the study to get a female4s perspective on violence, aggression, and nursing

practice! ?ntervies and focus groups ere conducted ith + participants that e@pressed

violence as a part of the 2ob as it as e@pected hen or-ing ith psychiatric patients!

The participants identified or-place stressors contributed to the interference of

the nurse:patient interaction! Those stressors ereB Iunsupported involuntary admissions,

limited or-place design, poor staffing s-ill mi@, comple@ patient diagnoses, and

ine@perienced staff or-ing beyond their scope of practiceJ 5Ward, )*+, p! )F7! The

environment being unpredictable and challenging heightened the emotional state for both

the nurse and the patient! The participants agreed that additional training and education

on communication s-ills as a ay to reduce the ris- of violence on psychiatric units!

%oers, %rennan, Winship, and Theodoridou 5)*+*7 described the results of a

study regarding e@perienced nurses in their interactions ith patients ho e@hibited acute

mental illness! The behaviors of these patients ere challenging and perple@ing! The

perceptual disturbances, the delusions and hallucinations, made it difficult for the nurse:

patient interaction to occur! Studies have shon that not much of the nurses4 time

appro@imately FQ)+L as directed in interacting ith patients 5%oers et al!, )*+*, p!

)87!


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+0

The authors continued to note that guidance on ho to interact ith patients in an

active psychotic state, ithdran, agitated and aggressive ere inadequate! %y means of

snoballing, the nurses from three /ondon mental health national health system ere

identified by their nursing leadership! The )F nurses ere intervieed and analysis

discovered seven themes 5%oers et al!, )*+*7B 5a7 moral foundation 5notice the patient

and be genuine7< 5b7 interactions 5careful observation and choose the right nurse to

interact7< 5c7 being ith the patient 5focus on the patient and not the symptoms7< 5d7

nonverbal communication 5tone of voice, caring and quiet7< 5e7 emotional regulation

5nurses need to regulate their on responses7< 5f7 getting things done 5ma-ing

suggestions, being fle@ible, giving positive feedbac-7< and 5g7 tal-ing about symptoms

5listening, accepting and respecting patient4s e@periences7! Therefore, better

communication beteen the nurse and the patient reduced aggression and violence, social

isolation for patients ho ere a ris- for suicide, and improved patient outcomes and

increased patient satisfaction!

%oles, Mac-intosh, and Torn 5)**+7 evaluated an education training program in

solution:focused, brief therapy 5S$%T7! The S$%T, a ne therapy, as utili9ed as a

frameor- in communication s-ills training for nurses! %oles et al 5)**+7 described

S$%T as Iboth a system of communication and a set of assumptions about ho best to

motivate individuals to change, adapt and grois briefculturally congruent ith

nursing practicereduces many of the emotional stresses and constraints that currently

inhibit communicationJ 5p! 807! The e@ploratory study consisted of si@teen R.s from

various clinical settings ho attended a 8:day training program for F ee-s 5%oles et


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)*

al!, )**+7! The design involved quantitative and qualitative components! Duantitative

data 5using pre:and post:training scales7 and qualitative data 5using a focus group si@

months after the training7 ere collected! The findings of quantitative data shoed

significant changes in the nurse4s practice after the training! The qualitative data revealed

changes in practice for nurses that centered on re2ecting the problem:oriented approach

and reduction of their feelings regarding inadequacy and emotional stress! The S$%T as

regarded as relevant and useful as a training tool to assist nurses ith their

communication s-ills since it as proven Iharmonious ith nursing values of

empoerment, increased patient responsibility and participation in careJ 5%oles et al!,

)**+, p! 7!

#- et al! 5)*++7 study consisted of +1 emergency department 5&"7 nurses ho

attended a communication s-ills training! The training addressed the folloing areas onB

nurses4 current level of communication s-ills and empathy< level of communication s-ills

and empathy after training< affect the program had on patient satisfaction< and the number

of undesirable events beteen nurses and patients and patients4 complaints before and

after the program! The program as assessed using a communication s-ills scale,

empathy scale, and patient satisfaction survey! The results shoed communication s-ills

training improved &" nurses4 communication and empathy s-ills ith psychiatric

patients and an increase in patient satisfaction and reduction of the undesirable events and

complaints during nurse:patient interactions 5#- et al!, )*++7!


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)+

#eneral !iterature

Happ et al! 5)*++7 e@amined the ability of critical care nurses to communicate and

interact ith non:spea-ing critically ill patients by means of various methods and

assistive techniques in the medical intensive care and cardiovascular:thoracic units! Ten

R.s, from each unit ere randomly chosen and * patients, + from each unit in hich

three non:spea-ing patients 5due to oral endotracheal tube or tracheostomy7 ere

assigned to each nurse! "ata as obtained in a :minute video recording sessions of

nurse:patient interaction for ) consecutive days! The data collector used field notes to

describe conditions that occurred during the care of non:spea-ing patients and ho

riting pads and communication boards ere used to communicate ith such patients

5Happ et al!, )*++, p! e)7!

%esides computing descriptive statistics, the data analysis measured

communication interactions in frequency, initiation, success, quality, ease of

communication, and patient4s ability to communicate by ay of head nod, facial gestures!

Communication boards or assistive devices ere not observed in this study! The results

of the study suggested the areas critical care nurses4 needed to improve regarding

assistive communication access, communication materials, and communication about

pain and other symptoms 5Happ et al!, )*++7!

(ich, Ha9elton, Sundin, and Aable 5)*+*7 conducted a literature revie on

patient:related violence against nurses, particularly emergency department 5&"7 nurses!

#n e@tensive search on C?.#H/, Medline, and 'vid from +00F to )**F as performed!

#lthough the focus as on &" nurses, other relevant information such as in mental health


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))

ere also included hich totaled references! The &" as identified as the highest:ris-

areas for aggression and violence in a healthcare facility! With the high percentages of

aggression and violence, many nurses have become desensiti9ed of this behavior as this

type of patient behavior has become commonplace and accepted as a part of the 2ob!

The article described physical and psychological in2uries that resulted from

violence impacted nurses regarding significant implications on the quality of patient care!

Safety measures such as personal alarms, loc-ed doors, security, cameras, and 9ero

tolerance approach had not been advocated by many health care services as these

prevention and control measures had the potential to impede the nurse:patient interaction

5(ich et al!, )*+*7! The authors concluded that relying on early assessment s-ills from &"

nurses have identified the ris- of patient violent behavior before it escalates! (olicy:

ma-ers, administrators, and sta-eholders have a responsibility to prioriti9e patient:related

violence for preventative action!

$leischer, %erg, immermann, WNste, and %ehrens 5)**07 conducted a systemic

literature revie to define and describe the concept of the nurse:patient communication

and interaction! # total of 0E citations ere found hich -ey points ere e@tracted and

synopsi9ed according to categories for revie! The results of the literature shoed that

although there as an undefined relationship beteen communication and interaction the

to ords are used interchangeably or synonymously!

$leischer et al! 5)**07 stated Ithe main intention of communication and

interaction in the health setting is to influence the patient4s health status or state of ell:

beingJ 5p! 07! Communication is categori9ed as verbal and nonverbal and it4s the


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)

behavior of the interaction beteen the nurse and the patient that gives meaning to hat

has been conveyed! The authors concluded that the nurse and the patient4s roles in

communication and interaction hich is a shared process needed to be ta-en into

consideration and not be ignored!

Martin and Wilson 5)*++7 conducted a qualitative phenomenological study ith a

purposive convenient sample of seven nely licensed R.s ho had been or-ing for

one year on various medical:surgical units including specialty units! &ach nurse

completed a to ee- transitional program to ease the transition from student nurse to

professional nurse! The program consisted of but not limited to communication s-ills,

delegation, conflict resolution, time management, and the importance of self:care! The

intervies ere audio:taped and the data ere analy9ed using the Colai99i4s 5+0EF7

seven step process! The to themes that emerged ereB adapting to the culture of nursing

and development of their professional responsibilities 5Martin K Wilson, )*++7! The

nurse:patient interaction or relationship as not mentioned in this study! The emphasis

as on collegial relationships beteen nurse:nurse and nurse:doctor and the challenges it

presents during the process of acculturation!

(atterson, Curtis, and Reid 5)**F7 used the phenomenological method to study

the s-ills, -noledge, and attitudes e@pected of nely graduated mental health nurses in

an inpatient setting! The purposive sampling of eight registered nurses participated in

individual semi:structured intervies! The four themes that emerged ere

communication, safety, self:aareness, and treatment! $ourteen competencies ere


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)8

identified ithin the four themes! ?n this study, communication as the most important

issue for ne graduate nurses 5(atterson et al!, )**F, 8+17!

Theoretical $rame%ork

Peplau&s Theor"

&ffective communication has the potential to promote positive change, better

patient outcomes, patient and staff satisfaction and provide a safer environment! (eplau4s

5+0), +00E7 middle range theory ?nterpersonal Relations focused on the nurse:patient

relationship through effective communication as utili9ed to guide this pro2ect! The

process of communication has been described as respectful, empathetic, trustorthy, and

acceptable 5(eplau, +00E7! (eplau4s theory as an appropriate theoretical frameor- for

this pro2ect because effective communication has been a primary ay to prevent or

reduce aggressive patient behavior! Senn 5)*+7 noted that the interpersonal relations4

theory had been idely tested and evidence:based practice had evolved through

qualitative and quantitative research 5p! 87!

'riginally, the theory as described in four phasesB orientation, identification,

e@ploitation and resolution! Since then the four phases have been revised to three -ey

phasesB orientation, or-ing 5hich combines identification and e@ploitation7, and

resolution! Within this theory, the nurse ta-es on many roles 5i!e!, stranger, resource

person, counselor, leader, surrogate, and teacher7!

The orientation phase, the initial step beteen the nurse and the patient e@plains

the roles, defines the problem, and collaborates a plan beteen the nurse and patient! ?t is

during the orientation phase that the nurse4s behavior denotes a pattern of being receptive


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)

and interested in the patient4s concerns and medicalGpsychiatric problems 5(eplau, +00E7!

$or e@ample, hen the nurse observes the patient displaying signs of aggressive

behavior, the nurse4s approach to the patient is to establish trust, define the problem, and

both mutually agree on a plan to remedy the situation!

The or-ing phase contains to phases 5identification and e@ploitation7! Much of

the relationship is performed during this phase! (atient set goals< see-s and dras help<

meet needs< gains -noledge about their illness< acquires available resources< fosters

personal strength< and begins to function in an independent role! The nurse provides

information and assistance to patients hile recogni9ing and sustaining the focus on the

or- hich patients must do in their on interests! The poer shifts from the nurse to

the patient as the patient becomes more independent! This all occurs during the

identification and e@ploitation phases 5(eplau, +00E7! $or e@ample, nurses attempt to

assist the patient to set goals on changing aggressive behavior by providing alternatives

from personal preferences on file or as-ing the patient hat usually or-s to reduce the

aggression! When the patient ma-es a decision to change aggressive behavior and

proceeds to change behavior on the information provided by the nurse, the poer has

shifted and the patient functions independently!

Resolution or final phase is the completion of the relationship beteen the nurse

and patient since the patient4s needs have been met and the patient moves forard to

discharge 5(eplau, +00E7! "ue to long:term and chronic conditions of many patients ith

mental illness, the last phase of the relationship may continue for months, years or until

death of the patient! $or e@ample, hen the patient4s aggressive behavior becomes non:


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)1

aggressive and maintained, this phase of the nurse:patient relationship has been resolved

only on the issue of aggressive behavior to non:aggressive behavior but the remainder of

the relationship continues until the patient is discharged from the hospital or at death!

The care of patients cannot proceed effectively toard outcomes that are

beneficial until the relationship has been achieved! ?n each phase of (eplau4s theory,

observation, listening, trust, compassion, empathy and being non:2udgmental are -ey

components that equip the novice psychiatric nurse to interact ith both aggressive and

non:aggressive psychiatric patients on inpatient psychiatric units!

Summar"

%ased on the literature revie, current articles that addressed the novice nurse

or-ing in the behavioral health field or nurses transitioning into psychiatric nursing

from another specialty ere scarce! The search produced many articles that e@amined

nurses4 attitudes, e@periences, and communication in managing the care and treatment of

the aggressive and non:aggressive psychiatric patient that focused on emergency

departments, general medical:surgical units, inpatient settings, forensic units, and

community settings, but they ere more than years! Many of the studies emphasi9ed

the importance of training and educating nurses on the use of communication s-ills in

their interaction ith aggressive or non:aggressive psychiatric patients because

communication facilitates the nurse:patient relationship!

?n many of the studies, communication the foundation in nursing and the -ey

component in mental health nursing as most important for ne graduate nurses! There

has been a plethora of research on the interaction and communication ith health


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)E

professionals and patients but the disconnection beteen communication and interaction

as evident and still e@ist today! This disconnection has resulted in patient related

violence and unsafe environments for staff! #lthough studies have concurred that

education and training ere the most effective ay to prevent patient related violence

toards nurses on inpatient units, Wassell 5)**07 noted other studies sho no difference

in patient related violence after educating and training staff on using appropriate

communication s-ills! Wassell 5)**07 suggested that more research as needed to

identify the important parts of a training program or patient management protocol to

protect healthcare or-ers from patient violence!

The ne@t section of the paper includes the pro2ect design, methodology, data

analysis and pro2ect evaluation plan are described!


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)F

Section B Methodology

Introduction

The purpose of this pro2ect as to conduct a survey ith novice psychiatric

nurses on their communication s-ills ith aggressive psychiatric patients! This section

includes the pro2ect design, the method, the target population and sample si9e, the tool

used to collect data, data analysis, and the pro2ect evaluation plan!

Project Design'(ethods

The approach used for this pro2ect as quantitative! #ccording to Terry 5)*+7,

quantitative research deals ith patterns that are distinctive or unique to a target

population! The design used for this pro2ect as descriptive! %urns and 3rove

5)**07e@plained that a descriptive design Imay be used to develop theory, identify

problems ith current practice, 2ustify current practice, ma-e 2udgments, or determine

hat others in similar situations are doingJ 5p! )E7! This as a pro2ect that used a

survey!to get the perceptions of novice psychiatric nurses4 communication s-ills in

dealing ith aggressive psychiatric patients! This approach as useful in that the survey

identified a problem ith the current practice of hospital orientation curriculum! .ovice

psychiatric nurses felt the current practice of hospital orientation lac-ed revie on

communication s-ills in regards to dealing ith aggressive patients!

This approach as appropriate becauseB

• the structured survey primarily focused on forced:choice

• the surveys ere distributed quic-ly

• the gathering data as done in relatively short period of time


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)0

• the pro2ect had to be completed ithin the time frame of the ".( program

• there as no manipulation of any groups or statistical controls

• there ere no measurements for cause and effect

• there as limited contact ith the participants in the distribution and

collection of the surveys

The question that guided the pro2ect study asB #re the communication s-ills of

ne nurse graduates or nurses ith no prior psychiatric e@perience satisfactory to interact

ith aggressive psychiatric patients on inpatient psychiatric unitsO

Population and Sampling

# purposive sample of novice psychiatric nurses as used in this study! %urns

and 3rove 5)**07 stated that this type of sampling also -non as 2udgmental or selective

sampling targets a particular group of individuals ith similar interest! Therefore, the

primary goal of the purposive sampling as to concentrate on specific characteristics of

novice psychiatric nurses to facilitate ansers to the pro2ect question! The sample si9e

as based on the number of ne nurse graduates and nurses ho transitioned from

another specialty in nursing and as hired during >une )*+) to >une )*+8! The target

sample included ) novice psychiatric nurses employed at a large state psychiatric

hospital in southern .e &ngland ith appro@imately 1** beds and +1** employees! #

total of ) surveys ere distributed! Tenty:five surveys 5EFL7 that ere returned met

all inclusive criteria!

The inclusion criteria consisted of ne nurse graduates< nurses transitioning from

another nursing specialty 5e!g!, medical:surgical, home care, s-illed nursing setting7 to


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*

psychiatric nursing< nurses or-ing as a psychiatric nurse for )8 months or less< and are

R.s, full:time, part:time, per diem, durational< and employees ho had or-ed as /(.s,

mental health or-ers, or forensic treatment specialist before becoming R.s! &@clusion

criteria included R.s ho had or-ed in psychiatric nursing for more than )8 months or

ho had or-ed as a psychiatric nurse in the past!

This pro2ect as approved by Walden University ?nstitutional Revie %oard,

approval number *0:++:+8:*EFF, the "epartment of Mental Health and #ddiction

Services 5"MH#S7 'ffice of the Commissioner 5see #ppendi@ C7, and Connecticut

;alley Hospital 5C;H7 Research Committee!

Data Collection

? used the instrument of 3eorga-i, Aalaidopoulou, /iarma-opoulou, and

Mysta-idou 5)**)7, a )*:item questionnaire that has validity and reliability that e@amined

nurses4 truthful communication ith cancer patients 5see #ppendi@ %7 as a guide in

designing this study4s )* questions survey 5see #ppendi@ #7! ? found the questions in

3eorga-i et al!, survey on communication provided guidance in formulating questions for

this pro2ect survey! Three attempts ere made by means of to emails and a letter sent

by ay of postal service to inform the corresponding author Ayria-i Mysta-idou, (h",

M", in #thens, 3reece that their tool 5see #ppendi@ %7 as used only as a guide to

develop this pro2ect4s survey questions, but no response as ever received!

#ccording to %urns and 3rove 5)**07 Ithe survey is used to describe a data

collection technique in hich the researcher uses questionnaires 5collected by mail or in

person7 or personal intervies to gather data about an identified populationJ 5p! )87!


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+

The survey 5see #ppendi@ #7 consisted of ) parts! The first section consisted of novice

psychiatric nurses demographic data such as gender, age range, level of education, and

length of time employed at the psychiatric hospital! ?n the second part, the nurses ere

as-ed to evaluate their communication s-ills in dealing ith aggressive and non:

aggressive psychiatric patients hich covered their confidence and competent level as a

psychiatric nurse< -noledge about mental illness before being hired< thoughts on

hospital and unit:based orientation< vies about interacting ith aggressive patient<

assessment s-ills on psychiatric patients< and the support of nurse preceptors!

To maintain anonymity, any identifying information such as name, race, ethnicity,

birthdate, shift hours, assigned divisions, units, buildings or title status 5e!g!, full:time,

part:time, durational, staff nurse, head nurse, nurse supervisor, nurse manager, or per

diem7 ere not listed on the survey! The instructions on the survey ere clear about

informing the participants not to print or sign their name on any items 5i!e!, survey and

the self:addressed postage paid envelope7 returning to the researcher and that completion

of the survey implied informed consent and participation in the study!

# folder ith the names and assigned units of novice psychiatric nurses hired

during the period of )8 months 5>une )*+) Q >une )*+87 as provided by the director of

staff development! The invitation to participate letter, survey, and postage:paid, self:

addressed envelope ere placed in an envelope, addressed and sealed by me alone and

sent out through the hospital4s internal mailing system to each novice psychiatric nurse

ho fit the inclusive criteria!


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)

#fter +* business days, ? sent an email to each participant as a reminder to

complete the survey! Within * business days of distributing ) surveys, )E surveys

5F8L7 ere returned, ) surveys ere eliminated! Tenty:five surveys 5EFL7 met all

inclusive criteria and ere used in this study!

Data nal"sis

"ata analysis began * days from the survey disbursement using / Stat )*+8

softare! The data analysis presented the descriptive statistics and the percentages of the

categorical variables using a 8:point /i-ert scale! 'riginally, the survey contained a :

point /i-ert scale as follosB + 5 strongly agree7, ) 5agree7, 5"isagree7, 8 5 strongly

"isagree7, and 5unsure7! The ansers of +1 questions by ) nurses sa only unsure!

#s it is difficult to ran- unsure4 these choices ere removed for the purpose of

averaging the /i-ert scale! This gave a 8:point /i-ert scale from +Q8 ith strongly agree

given a 8 and strongly disagree given a +! There ere four questions that ere as-ed in

the negatives and they ere reversed coded so that a high score indicated a positive

position on all the questions! The numbers ere then averaged by individual and by

questions!

The survey consisted of )* questions, of hich 8 assessed participants4 gender,

age range, level of education, and length of time or-ing in the hospital to determine

their impact on communication s-ills! The +1 remaining questions on communications

s-ills emerged to ma2or themes, 1 questions related to hospital:based orientation and +*

questions related to novice psychiatric nurses4 communication s-ills or-ing ith

aggressive on inpatient psychiatric units! Since the questions measured different and


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distinct constructsB one specifically about the hospital orientation and one about the

nurses communication s-ills, ? decided to analy9e the questions in to groups!

The t tests ere conducted on the binary variables< gender and level of education,

and to #.';#s ere run on the age range and the length of time at the hospital! The

higher the score the more agreement there as ith the statement indicating a positive

vie! The questions that had more to do ith the specific hospital and unit:based

orientation received the loest scores hile novice psychiatric nurses4 perceptions of

their communication s-ills ith psychiatric patients ere higher!

Project )valuation Plan

Summative evaluations are outcome focused and are conducted at specific

intervals of a program or after the completion of a program 5Aettner, Moroney, K Martin,

)*+7! The summative evaluation as used at the completion of the data analysis in this

pro2ect! The evaluation provided significant information that as most helpful for the

hospital4s staff development! %ased on the ritten comments on the surveys from the

novice psychiatric nurses, an educational module on communication s-ills as developed

to be integrated into the hospital orientation program! The novice psychiatric nurses

rote in the comment section of the survey that they needed less time in the hospital

classroom and more time in the unit orientation! ? felt that it ould be beneficial for this

psychiatric hospital to have a revie class on communication s-ills for all ne nurse

graduates! # revie of communication s-ills has the potential to enhance the nurse

patient relationship and better patient outcomes! Studies have shon that nurses improve

in their interaction ith patients in the psychiatric setting hen they have engaged in a


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8

simulation on communication or communication s-ills training 5#- et al, )*++< %oles et

al, )**+< Webster, )*+7!

Summar"

The section included the pro2ect design, method, target population, sample

si9e, the tools used to collect data, analy9ed data, and the pro2ect evaluation plan! The

quantitative approach, non:e@perimental descriptive design received a purposive sample

of ) novice psychiatric nurses that as based on ne nurse graduates hired at the state

psychiatric facility during >une )*+) to >une )*+8! ? developed a survey of )* questions

on novice psychiatric nurses4 communication s-ills ith psychiatric patients hich as

guided from the questionnaire on nurses4 truthful communication ith patients ith

cancer by 3eorga-i et al 5)**)7! This needs assessment pro2ect as completed ith a

summative evaluation based on responses and ritten comments from the surveys

received from novice psychiatric nurses!

The purpose of the study as to survey novice psychiatric nurses4 communication

s-ills in dealing ith aggressive patients! The goal of the pro2ect as to provide insight to

staff development and nursing leadership of novice psychiatric nurses communication

s-ills since the pro2ect question asB Are the communication skills of ne! nurse

gra"uates or nurses !ith no prior psychiatric e$perience satisfactory to interact !ith

aggressive psychiatric patients on inpatient psychiatric units% #lthough the results

shoed that these nurses communication s-ills to be satisfactory especially hen they

had or-ed for a longer period of time in the hospital, evidence:based studies have

shon that nurses can enhance the nurse:patient relationship in the psychiatric setting


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hen they have attended communication s-ills training 5#- et al!, )*++< %oles et al!,

)**+< Webster, )*+7! Therefore, an educational module as recommended that should

focus on various aspects of the psychiatric nurse regarding communication s-ills, the

nurse:patient interaction and relationship and interventions and management of

aggressive behavior ith psychiatric patient on inpatient units!

The ne@t section describes the results, discussions, and implications of the study!


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1

Section 8B $indings, "iscussion, and ?mplications

$indings

The purpose of this needs:assessment pro2ect as to conduct a survey to

determine the communication s-ills of novice psychiatric nurses4 communication s-ills

hen dealing ith aggressive psychiatric patients in the inpatient psychiatric setting

during their employment at the state psychiatric hospital! The survey as made up of )*

questions, 8 of hich questions focused on demographics, 1 of hich as-ed about

specific aspects of the hospital and unit:based orientation, and +* of hich concentrated

on communication s-ills of novice psychiatric nurses hen or-ing ith aggressive and

psychiatric patients on inpatient psychiatric units!

The findings, discussion, and implications of this pro2ect ere based on the

responses to the surveys! When all questions ere averaged, the scores ranged from )!

to !1, ith a mean score of !* 5see $igure +7!

Figure #verage scores on hospital:based orientation and communication s-ills


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E

The novice psychiatric nurses gave themselves the highest scores for atching

patients4 body language hen tal-ing to them! Their loest scores ere given to

questions regarding hospital orientation!

The difference in average scores beteen 5a7 the questions that ere hospital

based and those that ere 5b7 based on the communication s-illsP of novice psychiatric

nurses is stri-ing! ?t leads to the suspicion that these to different groups of questions

measured very different constructs! ?n fact, a correlation test confirmed that suspicion

5p =!***+, R

)

6 !*E07 5see Table +7!

Table +

'ospital-base" skills an" communication skills

Type of Duestion MeanStandard

"eviation(

;alue

Hospital %ased )!180 *!8 =!***+

Communication

S-ills !)+1 *!F+RB

;ariablesHospital

%asedCommunication

S-ills

Hospital %ased + *!*E0

Communication

S-ills *!*E0 +

3iven this finding, it as decided that additional analysis should be run and that

the scores should be separated into to groups! Duestions , 1, F, 0, +F, +0 dealt ith the

hospital:based orientation hereas Duestions E, +*, ++, +), +, +8, +, +1, +E, )* dealt

ith communication s-ills!


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F

Separate t tests ere run to compare the scores of hospital:based questions of

males versus females, and then the type of degree shoed no statistical significance!

Similarly #.';#s ran beteen testing the influence of the variables age range and

length of time in the hospital shoed no statistical significance! ?n other ords, the

hospital:based scores did not appear to be affected by the nurses gender, age range, level

of education, or length of time in the hospital! There as a slight difference in the

communication s-ills questions as gender, age range and level of education did not sho

significant difference in score but the length of time in the hospital did sho a

statistically significant difference in scores!

The variable, the length of time at the hospital consisted of three levelsB = +)

months< +)Q+F months< and +0Q)8 months! This demonstrated variability in the mean and

in fact the difference as statistically significant p = *!** 5see Table )7! The $ score

1!FF as statistically significant 5see Table 7! This shoed that the length of time spent

in the hospital e@plained about F!L of the movement in the dependent variable,

average communication s-ills scores! # similar but not as strong relationship can be seen

ith all scores but none hen the hospital:based orientation scores ere tested ith

length of time or-ing in the hospital, there as no relationship!

Table )

(emographics on hospital-base" an" communication skillsMeasure ;ariables . Mean p

value

#ll scores 3ender

$emaleMale

)+8

)!00!*F

*!8


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0

"egree

#"%"

#ge) or under

)1:8* yrs!8+: yrs!1 K older

Time in hospital

= +) mo+):+F mo+0:)8 mo

+EF

)

+8F+

F1

++

!*8F)!0)1

)!010

)!08E!*E

!81E

)!FE)!F+F!)+

*!8+

*!810

*!*+0

Hospital:%ased

Duestions

3ender

$emale )+ )!18) *!0EMale 8 )!1+

"egree#" +E )!10F *!8)E

%" F )!81

#ge) or under ) )!1+E *!0*8)1:8* yrs! +8 )!18F

8+: yrs! F )!1+E1 K older +

Time in Hospital= +) mo F )!)+ *!E0

+):+F mo 1 )!1+0:)8 mo ++ )!E)

CommunicationS-ills Duestions 3ender

$emale )+ !+ *!)++Male 8 !+08

"egree

#" +E !) *!+%" F !+F


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8*

#ge

) or under ) !+ *!)FF)1:8* yrs! +8 !++1

8+: yrs! F !F1 K older + !EEF

/ength of timein Hospital

= +) mo F !*FF *!**+):+F mo 1 )!0E+0:)8 mo ++ !8E

Table

Analysis of variance

Source "$ Sum ofsquares

Meansquares

$ (r $

Model ) +!0 *!10E 1!FF *!**

&rror )) )!))0 *!+*+Corrected Total )8 !1)VVVVVVVVVVVVVVVVVVVVVVVVVVVV

Compute" against mo"el

)*Mean +),

?n the last section of the survey, novice psychiatric nurses ere as-ed to rite

comments on hat their areas of concern regarding communication ith the psychiatric

patient< and ho the hospital and unit:based orientation could be improved for future

novice psychiatric nurses! The comments ere as follosB

• Communication from R. to non:licensed staff is very difficult in

psychiatric terminology! 5( )7

• $ormal training on communication s-ills, techniques and psych

assessment should be available to novice nursing staff! 5( 7


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8+

• ? do not have concerns regarding communication ith psychiatric patients!

5( 87

• Time on the unit and in treatment plan revies 5T(Rs7 ould be helpful

before classroom revie of T(Rs! T(R documentation as confusing in

classroom before seeing or revieing it in an actual T(R meeting! Too

much classroom time spent before introduction to unit! ?nformation

overload in classroom orientation! 5( 07

•

? did not have a contact person during my orientation! ? believe all ne

graduate nurses should have a preceptor during the orientation process< not

2ust float around and follo different nurses! ?t is important to have some

consistency during this period of learning and groing! Many nurses

aren4t alays comfortable giving feedbac-! ? thin- ? ould have benefited

from having one nurse to orient ith! 5( +)7

• Spending too much time in classroom! Unit:based orientation could be

more organi9ed! (rogress of orientee should be monitored more closely!

5( +7

• My concern is more about preparing the novice nurse for dealing ith

hostile unlicensed staff ho thin- they are here to ma-e all of the

decisions! .ovice nurses should be prepared to properly communicate

ith these same people that challenge every decision the nurse ma-es:thus

leading to constant frustration! 5( +E7


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8)

• Staff 2ust assumes that a ne hire should already -no hat to do! The

preceptor had a negative attitude, did not li-e to teach, and isolated the

ne hire! 'rientation should start by pretending the ne hire has never

had psychiatric training before and remember hat it as li-e to be ne!

5( ))7

• ? believe that staff that are ne to this type of client need more training in

ho to tal- ith clients that are dually diagnosedho to deal ith them

hen they are escalated, and ho not to argue ith clients! While e are

given some info on de:escalation, there can alays be more training

during orientation ith dealing +B+ regarding ho to engage conversation

ith psychiatric patients! 5( )7

• .e nurses should be given hand:outs on behaviors and signs to loo- for,

ould help, along ith vocabulary to use in charting! 5( )F7

• The areas of concerns for me as not getting adequate time in orientation

to learn about patients, and the level of aggressive behavior that can be

portrayed, and allo ne nurses to orient as long as they need to ensure

that they can be able to treat the patients effectively! 5( )7

The to issues that surfaced from the comments from the novice psychiatric

nurses ere their concerns on the lac- of -noing ho to communicate ith their

patients or hat to observe regarding patients4 behaviors and classroom overload in the

hospital:based orientation! The participants e@pressed the need to provide training on

communication s-ills at the beginning of their or-ing period, to equip them to care for


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8

the patient but also prepare them to communicate ith staff! The participants also made

comments on the need to reduce the time spent in classroom orientation and use some of

that time on the units!

?n summary, the time spent or-ing in the psychiatric hospital seemed to be the

most important factor influencing novice psychiatric nurses4s communication s-ills ith

aggressive psychiatric patients! The more e@perience in the hospital the greater the

communications s-ills!

Discussion of $indings

The purpose of this needs assessment pro2ect as to conduct a survey to

determine novice psychiatric nurses communication s-ills ith aggressive psychiatric

patients in the inpatient psychiatric setting during their employment at the state

psychiatric hospital! This study shoed that communication s-ills of novice psychiatric

nurses ho had more time or-ing in the psychiatric setting, primarily +0:)8 months, to

be satisfactory ith aggressive patients! Communication s-ills received higher scores

compared to the hospital:based orientation questions!

The best predictor of novice psychiatric nurses4 communication s-ills ith

aggressive patients as the length of time or-ing in the hospital! .urses ho or-ed

+0:)8 months scored higher in their communication s-ills hich implied that they ere

more confident and competent in the nurse:patient relationship compared to those nurses

ho or-ed less than +0 months at the hospital! The longer nurses or-ed in the

psychiatric setting, the more e@perienced they became in their assessment of patient4s

behavior, approach to patients, and more s-illful ith aggressive psychiatric patients! ?n


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88

nursing programs, there still remains an inadequacy for nursing students to develop

communication s-ills ith psychiatric patients! Therefore, the need for novice psychiatric

nurses to attend training or a revie class on communication s-ills during hospital

orientation ill most li-ely enhance their communication, increase the time spent

interacting ith psychiatric patients, improve the nurse:patient relationship, and maintain

a safe environment for staff and patients on the inpatient units!

Implications

The implications of communication s-ills of novice psychiatric nurses on

practice, for future research, and social change are described in this section! $or years,

nurses4 communication s-ills have been critici9ed for not being compassionate, caring or

empathetic! ?t is critical that novice nurses have the ability to s-illfully interact ith

patients in any setting but most important ith aggressive psychiatric patients in the

psychiatric hospital! ?ncreasing novice nurses4 -noledge and aareness on their

communication s-ills as it relates to the inpatient setting has the potential to reflect on

ho these nurses interact ith people ith mental illness outside of their safety 9one,

such as in the community!

The results of the surveys have provided data that the length of time or-ing in a

psychiatric setting is the best indicator in understanding communication s-ills of novice

psychiatric nurses ith aggressive psychiatric patients! More time or-ing ill improve

the novice nurses4 communication s-ills ith aggressive psychiatric patients and that ill

increase the nurse:patient relationship< promote better patient outcomes< and most li-ely

have a positive economic impact on the healthcare delivery system as it can affect the


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8

costs in reducing patient in2uries, novice psychiatric nurse turnover and or-er4s

compensation!

The novice psychiatric nurses in this study described a need for training during

hospital orientation that ould better prepare them to deal ith hostile and aggressive

psychiatric patients! .urses ho come right out of nursing school into the psychiatric

setting bring ith them a miniscule amount of communication s-ills ith psychiatric

patients! # communication s-ills class ould equip the novice psychiatric nurse to

become more proficient and effective in dealing ith aggressive and non:aggressive

psychiatric patients! The safety of novice psychiatric nurses hen

novice psychia

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