User workplace violence toward nurses can be found in nearly every domain of nursing. Research shows that mental health nurses are among the highest victims of violence perpetrated by patients averaging a risk rate of 22% higher than other specialties (Llor-Esteban, Sánchez-Muñoz, Ruiz-Hernández, & Jiménez-Barbero, 2017). Mental health nurses working in inpatient psychiatric units are at a unique risk for suffering violence related to their patient population’s diagnosis, common comorbidities, and mental instability. This violence is not limited to physical assault but also includes aggressive behavior, verbal abuse, sexual harassment, and threats (Llor-Esteban et al., 2017). A thorough integrative literature review was executed to find the most beneficial violence screening tool for use in an inpatient psychiatric setting.
It is reported that one in five patients admitted to an inpatient psychiatric unit will carry out an act of aggression or violent behavior (Lozzino, Ferrari, Large, Nielssen, & de Girolamo, 2015). Research has shown several risk factors that can lead to aggressive behavior including; male gender, diagnosis of schizophrenia, substance use, history of violence, marital status, and inability to effectively cope with situational crises (Baby, Glue, & Carlyle, 2014; d’Ettorre & Pellicani, 2017; Lozzino et al., 2015).
Workplace violence may not only cause physical harm to the nurse but can also have a negative effect on their psychological well-being, and the quality of care they provide. After exposure to workplace violence nurses could become angry, have increased stress levels and anxiety, show symptoms of post-traumatic stress disorder, shame, guilt, and decreased job satisfaction (d’Ettorre & Pellicani, 2017). When left unaddressed these symptoms can produce nurses with poor coping skills, which has been found to lead to substance abuse, absenteeism, diminished quality of care related to resentment and burnout (Bimenyimana, Poggenpoel, Myburgh, & van Niekerk, 2009).
Statement of Problem
Nurses should have the ability to provide quality care to their patients in a safe, healthy environment. However, related to the large percentage of violence towards nurses from patients, the work environment has become increasingly less safe. This is especially true in mental health settings where the patient population can be more impulsive and aggressive. This integrative review proposes to investigate several different violence screening tools that could predict violence in patients. By predicting violence with a proven tool, rather than using clinical judgment alone, the staff could preemptively put interventions in place and improve the violent environment that nurses are currently practicing in.
Purpose of Project
While it is helpful for nurses to be aware of risk factors, best practice would be to use a screening tool that can effectively predict violent behavior rather than clinical judgment alone. Current literature identifies several violence screening tools that could be appropriate for use with patients in a mental health inpatient setting. The purposes of this integrative review are to; a.) appraise the current research and identify various violence screening tools, b.) discover which violence screening tool is valid, reliable, and has sufficient evidence to support its use and c.) make recommendations for incorporating the chosen tool. The tool will help nurses predict aggressive behavior, initiate interventions and modify their plan of care accordingly.
Significance of the Project
The broad impact of this project was to improve the nurse’s ability to predict violent behaviors. Being aware of possible impending violence can lead to early interventions and increased safety for staff. This project will provide a comprehensive review and understanding of violence screening tools which could change or advance practice (Ahmed, Andrist, Davis, & Fuller, 2013). A DNP can use this research and implement it in practice in order to improve the practice of nursing and patient outcomes.
Which violence screening tools are most effective and user-friendly in predicting violent behavior in adult inpatient mental health consumers?
This literature search was conducted using search terms including ‘mental health’, ‘nurs*’, ‘violence’, and ‘inpatient’ and were used in various combinations. The databases used were the Cumulative Index to Nursing and Allied Health Literature (CINAHL) complete and Pub Med. The analysis was limited to peer-reviewed scholarly articles published in English between 2012-2017. Once an adequate amount of literature was acquired, the research was examined.
A level one evidence research article used a systematic review and meta-analysis to estimate the prevalence of violence in psychiatric acute inpatient hospital and to determine risk factors for aggressive behavior (Lozzino et al., 2015). The authors reviewed studies published between January 1995 and December 2014 that reported violent behavior in psychiatric units, that totaled 35 studies and 23.972 inpatients (Lozzino et al., 2015). The outcome of this systematic review found that one in five patients admitted to a mental health inpatient unit commit an act of violence during their stay (Lozzino et al., 2015). Factors that increased the risk of violence found across the 35 studies included male gender, involuntary hospitalization, alcohol use, substance use, and history of violence (Lozzino et al., 2015). When determining the effectiveness of a screening tool, these risk factors should be considered.
Two additional research articles focused on the negative effects of exposure of violence on the mental health nurse’s well-being (Baby et al., 2014; Itzhaki et al., 2015). Mental health nurses are found to face the highest risk for violent attacks by patients when compared to other specialties (Itzhaki et al., 2015). The result of this violence is disturbing and can cause serious psychological harm that affects not only the nurses work abilities but also their personal lives. Life satisfaction related to satisfaction with health, family, leisure, and feelings of self-worth were found to decrease significantly when associated with job stress and verbal and physical violence (Itzhaki et al., 2015). Work-related outcomes include fear, anxiety, distress, post-traumatic stress disorder, resentment and decreased job satisfaction, and inability to provide quality care (Baby et al., 2014).
The last article included in this literature review concentrated on identifying patients at risk of inpatient violence (Meehan, de Alwis, & Stedman, 2017). Based on current literature, nurses generally use their clinical judgment to determine if a patient is at risk for future episodes of violence (Meehan et al., 2017). However, new evidence is showing that validated structured violence screening tools are more precise than using clinical judgment alone (Meehan et al., 2017). The benefit of using a reliable, evidence-based screening tool is that it allows nurses to implement early de-escalation techniques and improve their plan of care related to risk management and patient care (Meehan et al., 2017).