PROFORMA FOR REGESTRATION OF SUBJECT FORDISSERTATION
Ms.LEEMOL P.K
I YEAR M. Sc. NURSING
PSYCHIATRIC NURSING
YEAR 2016 -2017
DHARWAD INSTITUTE OF MENTAL HEALTH AND NEUROSCIENCES (DIMHANS)
DHARWAD
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / MS. LEEMOL P.KM. Sc. NURSING FIRST YEAR
DHARWAD INSTITUTE OF MENTAL HEALTH AND NEUROSCIENCES, DHARWAD.
2 / NAME OF THE INSTITUTION / DHARWAD INSTITUTE OF MENTAL HEALTH AND NEUROSCIENCES, DHARWAD.
3 / COURSE OF STUDY AND SUBJECT / M.Sc. NURSING
MENTAL HEALTH NURSING
4 / DATE OF ADMISSION TO THE COURSE / 13/10/2016
5 / TITLE OF THE TOPIC :
“AN OBSERVATIONAL STUDY TO ASSESS THE AGGRESSIVE BEHAVIOR AMONG PERSONS WITH MENTAL ILLNESS AT EMERGENCY WARD OF DIMHANS DHARWAD”.
1
6 / BRIEF RESUME OF THE INTENDED WORK6.1. INTRODUCTION:
Aggressive behavior of psychiatric inpatients threatens the safety and wellbeing of both patients and caregivers.1 These incidence often threatens the safety of patients and staff and may result in the use of coercive measures such as seclusion or restraints.2
The correlation between psychiatric disorder and aggressive behavior have always been a subject of debate and two questions about which it seems to be particularly difficult to reach agreement are whether psychiatric patients are more likely to be aggressive or whether diagnosis predict aggressive behavior.3
Aggression of psychiatric patients represents a serious threat to the safety of both patients and staff members.1 Apart from the physical and psychological consequences, patient violence has considerable financial implication.4
Aggressive behavior by psychiatric patients is a serious issue in clinical practice and adequate management of such behavior is required with careful evaluation of factors causing the aggression.5
Numerous surveys of psychiatric inpatients, outpatients, homeless and mentally ill persons, and emergency room patients have found that a large proportion of persons in treatment for mental health problems have at some time been victims of violent physical abuse.6
Patients who are violent are not a homogenous group, and their violence reflects various biologic, psychodynamic, and social factors. Most researchers and clinicians agree that a combination of factors plays a role in violence and aggression, although there are differing opinions regarding the importance of individual factors7.
Review of literature says that several factors are emerged as significantly related to aggression and violence in inpatient psychiatric wards. One of the most consistent findings was that patients who were aggressive had a diagnosis of schizophrenia, mania, psychosis. In addition to that past history of aggression and admission as an involuntary patient. Also there are some evidence that staff experience and training contributed to reducing aggression in inpatient psychiatric units.8
6.2.NEED FOR THE STUDY:
Aggressive behavior of psychiatric inpatients cause severe complication during treatment, nurses as the largest occupational group within hospital, have the highest risk of being assaulted among personal in medical institution.9
The problem of violence and aggressive behavior among patient with psychiatric disorder has centralized the attention of research. Although differences in methods, designs and setting make it difficult to compare results from studies carried out in differentcountries.10
There is a general agreement among clinicians and research that aggression and violence on inpatient psychiatric units place health care workers at significant risk for injury. Therefore, it is important for nursing staff to understand the factors associated with aggression and violence on inpatient units.8
Aggressive behavior has become of increasing concern in the practice of psychiatry. A large number of patients are often admitted to emergency departments.11 This type of patients implies specific challenges for the diagnosis and treatment of psychiatric disorders and their violent presentations, as the mental health provider is asked to identify potentially dangerous individuals to reduce the risk.12
Most of the patients with stable mental illness do not present an increased risk of violence.13 Some of the literature shows that rates of aggressive behavior among mentally ill patients peak at time of admission to hospital, and they remain high for a period after discharge when many patients still experience active psychiatric symptoms.14
Although there is a significant body of research on the subject of aggression and violence on inpatient psychiatric ward. The question of which factors are associated with increased risk for assaulting others remains illusive. There is a critical need for well designed nursing research that takes into account the complexity of the problem of aggression in inpatient psychiatric units. Thus helps in synthesis of the best available evidence upon which nurses might confidently ground their practices.8
Although previous studies have focused on aggressive episodes and its characteristics, but very few studies has conducted on factors influencing aggressive behavior, consequences of aggressive behavior and measures used to control that behavior among mentally ill patients and none of the study conducted in Indian psychiatric wards to assess the factors influencing aggressive behavior among mentally ill patients.
6.3 REVIEW OF LITERATURE
Review of Literature refers to an extensive, exhaustive and systematic
examination of publications relevant to the study. It makes investigator familiar with the
existing studies and providing information, which helps to support the hypothesis under
the study and critically analyze the structure and content of research report.15Literature relevant to present study is mentioned under following headings.
Studies related to incidence of aggressive behavior
Studies related to factors influencing aggressive behavior
Studies related to incidence ofaggressive behavior.
An observational study was conducted in Mysore Medical College and Research Institute to evaluate the prevalence of aggressive behavior and coercive measures on anacute Indian psychiatric ward for 30 days using Staff Observation Aggression Scale Revised (SOAS-R) Indian, and found 229 violent incidents was seen among 63% of patients admitted in acute wards and among that 27% were managed by intravenousinjections, and 35% of incidents were provoked by the relatives, 56% of relatives were the target of the incidents, 35% of incidence were managed by relatives, 14% of other patients relatives were involved in the incidence. Most of the patients were physically restrained.Study concluded that relatives are commonly triggers and victims of aggressions on the investigated acute Indian psychiatric wards.16
A study investigated the aggressive behavior of all mentally ill patients within a whole psychiatric hospital Bielefeld, over a 1-year period to assess the prevalence and characteristics of aggressive episodes and index inpatients, and to identify predictors of patients at risk by a multivariate approach in German psychiatric hospital using Staff Observation of Aggression Scale to assess aggressive behavior. Characteristics of index inpatients were compared with those of non-index inpatients. Logistic regression analysis was applied to identify risk factors. A total of 171 out of 2210 admitted patients (7.7%) exhibited 441 aggressive incidents (1.7 incidents per bed per year). Logistic regression analyses revealed as major risk factors of aggression: diagnoses (organic brain syndromes OR = 3.6, schizophrenia OR = 2.9), poor psychosocial living conditions (OR = 2.2), and critical behavior leading to involuntary admission (OR = 3.3). Study concluded that predictors of aggressive behavior can be useful to identify inpatients at risk. Nevertheless, additional situational determinants have to be recognized. Training for professionals should include preventive and de-escalating strategies to reduce the incidence of aggressive behavior in psychiatric hospitals. The application of de-escalating interventions prior to admission might be effective in preventing aggressive behavior during inpatient treatment especially for patients with severe mental disorders.9
Studies related to factors influencing aggressive behavior.
A cross-sectional descriptive study was conducted to examine the characteristics of aggressive incidents by ward type, for 6 months using the Staff Observation Aggression Scale- Revised, Japanese version in 30 wards across 20 Japanese psychiatric hospitals among 3 types of wards: emergency, acute and standard wards. On analyzing 443 incidents reported, results showed significant differences in SOAS- R responses by ward type. In acute psychiatric wards, staff requiring patients to take medication was the most common provocation, and verbal aggression was the most commonly used means. In emergency psychiatric wards, victims felt threatened. In standard wards, both the target and provocation of aggression were most commonly other patients, victims reported experiencing physical pain, and seclusion was applied to stop their behavior. These findings suggest that ward environment was an important factor influencing aggressive behavior.5
The systematic literature review was conducted on violence on inpatient psychiatric units, to identify the significant factors associated with violence and aggression on inpatient psychiatric units. The databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Psyc INFO, and Medline were searched using the key words aggression and/or violence. Studies including the review were those that were published between 1992 and 2002, conducted on inpatient psychiatric units, 27 articles were reviewed. The findings were organized into the following categories patient-related variables, staff-related variables, unit-related variables, interactional variables, and studies related to prediction of aggression and violence. The findings indicate that (a)much of the available evidence supports the experienced clinician’s knowledge of who is at risk for becoming aggressive on inpatient psychiatric units ;(b)among factors shown to be related to violence, some can be modified and others cannot ;and (c)there is a critical need for well-designed nursing research that takes into account the complexity of the problem of aggression and violence on inpatient psychiatric units.8
A prospective observational study was conducted on demographic, clinical characteristics and treatment of aggressive patients admitted to acute behavioral unit of St Luke’s university community general hospital Bethlehem, for 17 months data was collected during the admission and then weekly and within 24 hrs of discharge using MOAS and found the result asYounger males with a history of previous psychiatric admissions and violence who presented with severe agitation symptoms were more at risk for aggressive behavior during hospitalization.Bipolar disorder, psychotic symptoms, and substance use significantly contributed to aggression.Patients significantly improved with inpatient treatment; aggressive patients most often experienced a significant reduction in symptoms of paranoia.17
A study was conducted to investigate factors affecting assessment of severity of aggression as provided by ward nurses, using the Japanese-language version of Staff Observation Aggression Scale-Revised (SOAS-R). Nurses who observed 326 aggressive incidents involving psychiatric inpatients at five mental health facilities for 8 months in Japan provided their assessments of the incident severity both on the established rating scale, the SOAS-R, and on a visual analogue scale (VAS), a one item scale to indicate overall aggression severity.Study concluded that consumer and nursecharacteristics appeared to influences the overall judgments of severity of aggressive incidents, which may be connected to decisions about the use of coercive measures, such as seclusion/ restraint or forced medication.18
Systematic reviews on aggression in psychiatric wards havebeen done. By searching in the Pub med, Embase and PsychInfo databases for English, Italian, French or German language papers published between 1 January 1990 and 31 March 2010 using the key words "aggress*" (aggression or aggressive) "violen*" (violence or violent) and "in-patient" or "psychiatric wards", and the inclusion criterion of an adult population (excluding all studies of selected samples such as a specific psychiatric diagnosis other than psychosis, adolescents or the elderly, men/women only, personality disorders and mental retardation). The variables that were most frequently associated with aggression or violence in the 66 identified studies of unselected psychiatric populations were the existence of previous episodes, the presence of impulsiveness/hostility, a longer period of hospitalization, non-voluntary admission, and aggressor and victim of the same gender; weaker evidence indicated alcohol/drugmisuse, a diagnosis of psychosis, a younger age and the risk of suicide. Alcohol/drug misuse, hostility, paranoid thoughts and acute psychosis were the factors most frequently involved in 12 studies of psychotic patients. Harmony among staff (a good working climate) seems to be more useful in preventing aggression than some of the other strategies used in psychiatric wards, such as the presence of male nurses.19
A study was conducted to determine violence risk factors in acute psychiatric inpatients. The study was conducted in a locked, short-term psychiatric inpatient unit and involved 374 patients consecutively admitted in a 1-year period. Socio-demographic and clinical data were obtained through a review of the medical records and patient interviews. Psychiatric symptoms at admission were assessed using the Brief Psychiatric Rating Scale (BPRS). Psychiatric diagnosis was formulated using the Structured Clinical Interview for DSM-IV. Past aggressive behavior was evaluated by interviewing patients, caregivers or other collateral informants. Aggressive behaviors in the ward were assessed using the Overt Aggression Scale. Patients who perpetrated verbal and against-object aggression or physical aggression in the month before admission were compared to non-aggressive patients, moreover, aggressive behavior during hospitalization and persistence of physical violence after admission were evaluated. Violent behavior in the month before admission was associated with male sex, substance abuse and positive symptoms. The most significant risk factor for physical violence was a past history of physically aggressive behavior. The persistent physical assaultiveness before and during hospitalization was related to higher BPRS total scores and to more severe thought disturbances. Higher levels of hostility-suspiciousness BPRS scores predicted a change for the worse in violent behavior, from verbal to physical. Study concluded thata comprehensive evaluation of the history of past aggressive behavior and psychopathological variables has important implications for the prediction of violence in psychiatric settings. 20
A study was conducted to examine the relationship between ward occupancy level and staff-to-patient ratio and incidents of aggressive behavior, both physical and verbal, on an acute inpatient unit in rural New Zealand. Data was collected from the ward's log of adverse incidents and the ward census over a 12-month period. Among 381 admissions, 58 incidents were recorded, 25 incidents of verbal aggression and 33 incidents of physical violence. The average occupancy level when an incident occurred was 77%, compared with 69% when no incidents occurred. The average ward occupancy were 80% when verbal incidents occurred and it was 70% when physical incidents occurred, there was no association was found between violence and staff-to-patient ratio. Incidents were significantly more likely to occur during the afternoon shifts (3 p.m. to 11 p.m.).Study concluded that crowding was found to be significantly associated with aggressive incidents, and in particular with verbal aggression.21
6.4 PROBLEM STATEMENT :
“AN OBSERVATIONAL STUDY OF AGGRESSIVE BEHAVIOR AMONG PERSONS WITH MENTAL ILLNESS AT EMERGENCY WARD OF DIMHANS DHARWAD”.
6.5 OBJECTIVES :
1.To observe incidence of aggressive behavior among persons with mental illness.
2.To assess provocative factors, consequences, and measures used to stop aggressive behavior among persons with mental illness.
3.To assess patient, staff and ward related aggressive behavior variables.
4.To find out the association between level of aggression with selected demographic and clinical characteristics of persons with mental illness.
6.6 OPERATIONAL DEFINITIONS :
Aggressive behavior :
It refers to a behavior that causes physical and or emotional harm to others. It may range from verbal abuse to physical abuse. It can also involve harming personal or public property. In the present study aggressive behavior is assessed by Staff Observation Aggression Scale-Revised(SOAS-R) and Modified Overt Aggression Scale(MOAS).
Person with mental illness :
A person who have disturbance in thinking, emotions, and or behavior resulting in an in ability to cope with life’s ordinary demand and routines. In the present study persons with mental illness refers to those who are diagnosed with mental illness (as per the ICD-10) and admitted in emergency psychiatric ward DIMHANS, Dharwad.
6.7 Assumptionsof the study:
- Aggression is more commonly seen among individuals with mental illness.
- Various factor influence aggressive behavior among individuals with mental illness.
H1– Incidence of aggressive behavior will be more among persons with mental illness.
H2 – There will be significant relationship between level of aggression with patient related variables.
H3 – There will be significant relationship between level of aggression with staff related variables.
H4 – There will be significant relationship between levels of aggression with ward related variables.
6.9Delimitation of study:
Study is limited to mentally ill patient who are admitted in emergency psychiatric ward.
7. MATERIALS AND METHODS :
7.1 SOURCE OF DATA
Data will be collected through observation from mentally ill patients who are admitted in a emergency psychiatric wards at DIMHANS,Dharwad.
7.1.1Research approach.
Quantitative research.
7.1.2Research Design.
Descriptive research design will be used for this study. (Observational study)
7.1.3 Setting
The study will be conducted atemergencyward of DIMHANS, Dharwad, Karnataka. Dharwad Institute of Mental Health and Neurosciences, is a 212 bedded state government mental hospital. It is a tertiary care hospital located in north Karnataka of southern India. The emergency department houses 20 beds, 10 each for male and female patients. Wards are managed by psychiatrist and nursing staff.
7.1.4 Accessible population:
Patients who are admitted at DIMHANS, Dharwad
7.2 METHODS OF COLLECTING DATA
7.2.1 Sample:
Mentally ill patients who are admitted inemergency psychiatricwards of DIMHANS, Dharwad.
7.2.2 Sampling techniqueSample size:
All the patients who are admitted in emergency ward during data collection period (5 to 6 months)
7.2.4 Criteria for selection of samples :
Inclusion criteria:
- Patients who are diagnosed under various mental illnesses according to ICD-10 F-category.
- Age between 18-60years old
- Who are willing to participate