Introduction

This purpose of this paper is to critically appraise a research article titled ‘ Aggressive
behavior on acute psychiatric wards: prevalence, severity and management ’ by Choloe
Foster, Len Bowers & Nijman (2007). This article was published in the Journal of
advanced Nursing 58(2), 140 – 149. Accepted for publication 31 August 2006.

The reason why this research article is chosen is because aggressive behavior on
acute psychiatric ward are major nursing care problem that overwhelm nursing
profession at psychiatric unit for many years. Duxbury (2002) aggressive behavior
poses a threat to the physical and psychological health of psychiatric nursing staff, the
fear that result from working in a climate of potential danger can also have a damaging
impact on patient care. It is more prevalent than Dementia, Alzheimer disease, and
many other condition that receive considerably more attention. Especially to patient
diagnose as schizophrenia and bipolar but, it also happened for patient that diagnosed
with depression and others mental health problem. In Adult Acute Psychiatric Ward
(AAPW), in the one of the large hospital in Malaysia, where I have practiced my nursing
profession for the past four years, aggressive behavior among the patient is one of the
major problem where nurses must cope up in measuring patient quality care.
Consequently, many mental health professionals fears that aggression within inpatient
psychiatric service is increasing (Wells & Bowers 2002). Aggression and violent are
unfortunate but ever present and growing future of health service work environment
(Badger & Mullan 2004). Besides, to investigate the nature and prevalence of inpatient
aggressive behavior directed at staff and other patients and, in the case of patient self-
harm, the method used by nursing staff to manage this.

Hence, in this essay, I will explore about develop and encourage, advantage and
disadvantage EBP in my clinical practices, I will critique a quantitative research paper;
utilized research critique tools from Coughan, Cronin & Ryan, (2007) because it
approaches research process questions more systematically. By critique a research
paper, the strengths and weakness of study can be appraised, and it is useful to
develop research skills for the new researcher (Nieswiadomy, 1993).Finally yet
importantly to integrate research findings in aggression behavior prevalence, severity
and its management in my clinical area, evaluate strategy for developing and
implementing EBP in (AAPW).

Evidence Based Practice

The important of nursing research in developing EBP had been driven by the need to
provide quality of care within current economy constraint (Flemming, 2007).
Furthermore as nurses’ accountable to provide excellent patients care, EBP thus
became vital which will enhance practice in (APW) . Research is essential in a practice
profession like nursing . It is necessary to systematical study; to improve current
practice, and develop new empirical knowledge that can be synthesize into evidence,
therefore can apply it to achieve effectiveness clinical practice (Burns & Grove, 2007).
According to Gerish & Lacey (2006), by implementing EBP, we aims to providing most
appropriate care in a correct manner at most expedient time, therefore optimize patient
care, in a cost effective ways. Health care organizations are influence by changes in the
environment; it needs to be responsive and flexible, with an increasing growth of
technology and research in health care (Gerish &Lacey, 2006). The concept of
providing high quality patient care through EBP has been evolved (Hockenberry 2006;
Burns & Grove, 2007) . EBN processes has established best evidence practices and
positive clinical outcomes. This means, by using EBP and incorporating it into nursing
care plans will avoid undesirable repetitious action in practice and decrease expensive
alternative outcomes associate with poor patient’s management, it also will eliminate
stress and frustration for staffs attempt to reinvent the wheel in applying their basic
education to patient problem and new technology (Sredl, 2008). Supported by tod,
Palfreyman & Burke, (2004) EBP necessitate nurses to change culture and move away
from traditional practices to clinical inquiry practice in – order for nursing profession to
progress. As stated by Hamer & Collinson, (2005) the process of EBP is to find
evidence, appraising and applying in health care management and practices. The
results of the research process can form a foundation as guidelines to implement policy
and protocol ( Burns & Grove, 2007).

For effective decision, making further consideration must involve provision of

professional expertise, clinical evidence, economic and consumer perspective (Leach,
2006). Therefore, the essential of having a knowledge acquired from tradition, authority,
borrowing, trial and error, experiences, role modeling, reasoning and intuition cannot be
undermine in nursing practice. By incorporate latest research in evidence-based finding
not only help to achieve effective patient outcomes but also empower for nurses for
decision making in today health care system (Burns & Grove, 2007).

EBP consist of two main approaches, qualitative and quantitative research, it includes,
east and west therapies, traditions, assumptions, patient advocacy, clinical expertise,
patient values, preferences and beliefs (Rush & Harr, 2001; Jacobs, 2001).

EBP in health care today is important. However, there are factor, which impede
adaptation of EBP. Many researchers have highlighted the barriers in implementing
EBP to novice practitioner, they have difficulty in analyzing research papers and the
terminology is like a new language to them, it’s more scientific in term, concept, method,
critique and finding, are confusing, ( Coughlan, Cronin & Ryan, 2007; Valente, 2003).
Beside others, include lack of confidence to evaluate research, limited interest, limited
access, power to change practice based on research finding, time and organizational
constrains (Brancato, 2006).

EBP can successfully implement, if the barriers overcomes. In APW, the practice
among practitioners will remain the same, without and understanding of important of
EBP. Therefore, support and motivationfrom the organization is important beside self –
awareness of the needed to professionally development. As stated by Sredl (2008), we
as nurses the need to move forward from an old practice of thought where nurses are
call doctors handmaidens to contemporary nurses who are at forefront of the shift.
Nurses must continuous improve their knowledge, skill and competence.

Nurse must be able to integrate research in their practice and able to understand the
research process. We also need to evaluate and critique research finding because not
every piece of evidence is good quality, it must be evaluate and appraise (Gerish &
Lacey, 2006). Critiquing research is a essential process toward EBP, it involves critical
thinking skill, appraise and apply knowledge of evidence in practice ( Burns & Grove,
2007). However single evidence from one study, may not give the best evidence in
practice, it is best to review research evidence from several research studies through a
systemic review (Gerish & Lacey , 2006).

Practitioner who are likely to apply EBP in their decision – making are those, open –
minded, inquisitive and with systemic characteristic (Hamer & Collinson, 2005 ).
Research awareness programs should be including in nurse education program. Nurses
should understand the important of research development, it is after all is to improve
patient care and enhance profession development ( Gerish & Lacey , 2006

Research Paper

Title of The Study: Aggressive behaviour on acute psychiatric wards: prevalence,

severity and management.

Authors : Chloe Foster BSc MSc Clinical Psychologist in Training, Department of

Psychology, Institute of Psychiatric, London , UK.

Len Bowers PhD RMN Professor of psychiatric Nursing and Head of Research, City
university, St Bartholomew’s School of Nursing and Midwifery, department of Mental
Health and Learning Disability, London , Uk

Henk Nijman Phd Professor of Mental Health, City University St Bartholomew’s School
of Nursing and Midwifery, department of Mental Health and Learning Disability,
London , Uk

Journal: Journal of Advanced Nursing 58(2), 140-149

Available at:
CRITIQUE:

Authors:

The authors are nurses, some with research degree and PhD qualification. They are
working in Department Of Mental Health at City University and Institute of Psychiatry at
London UK . Their professional statuses seem appropriate in performing such research.
However a research paper need to be appraised based on its reability and validity and
not by researchers qualification only ( Coughlan, Cronin &Ryan, 2007 ).

Title:

The title describes the study clearly and concisely. Nieswiadomy (1993) stated the title
should be brief and less than fifteen words if possible, it should contains words that
describe the study, where this title about aggressive bahaviour, prevalence severity and
management in this case.

Since the study was conducted in the UK alone, the journal title would suggest to be
read as aggressive on acute psychiatric behavior in the UK, Prevalence, severity and
management. And it is appropriate to reflect the real situation of Europe at the
surroundings. My experience as a nurse in a mental hospital found that the rate of
aggressive behavior among Asian patients is much lower than those mentioned in this
journal. But the rate of self harm patients is rather high, and verbal aggression towards
hospital staff is almost the same as those mentioned in this journal.

ABSTRACT:

The purpose of the study is to investigate the nature and prevalence of inpatient
aggressive behaviour directed at staff and other patients and, in the case of patient self-
harm, the methods used by nursing staff to manage this. According to Nieswiadomy
(1993), a good abstract should be written in about one to two hundreds words and
enable reader to have brief idea of what is going to be discussed in this research and
create an interest for reader to read on. The insight of studies presented, it include
background explanation about the reason the studies carrie out. Methods: Nursing staff
on five acute inpatient wards in one hospital in the United Kingdom collected data on
aggressive incidents using the Staff Observation Aggression Scale – Revised during a
10 month period from June 2001 to April 2002.

Purpose Of The Study and Literature Review:

Literature reviews is to provide an explanation and evaluation of evidence on the topic

study it assist in developing question and data collection method of the research topics
(Burns & Grove 2007). Researchers provide background of the current knowledge of
studied problem, about worldwide aggressive behavior is the major problem in mental
health care. They also stress on available guidelines in many countries for aggressive
behavior aggressive behavior in acute psychiatric ward including Australia and Canada.
Highlight in literature review the contents and evaluation statement of other researchers’
studies in several developed countries like United Stated and Europe, about nurses’
knowledge of prevalence, severity and management.

These findings may not accurately reflect overall mental patients around the world. This
is because we are born in places where the background is also different with different,
such as race, religious, and cultural. Attitudes and behavior people who live in the city
would not be the same with people who live in rural areas. And it is closely related to
human behavior. Asia those who are less likely physically gentle rather than the African
or Arabian descent who looks tough and sturdy and large physically. Thus this study
should be conducted in all the continents to represent diversity ethnic communities.

Referring to the results of a study conducted by researchers, shows the percentage

frequency Aggressive behavior in psychiatric wards of the highest frequency of verbal
aggression aggressive patients and the percentage is 60%. However, this statement
may be disputed by researchers in the statement where he said the decision to use
verbal aggression is the highest percentage. Because, referring to my experience of
four years I worked in acute psychiatric ward in my hospital, I found the most frequent
outcome for the victim was threatened.

Meanwhile, according to the researcher the percentage frequency Aggressive behavior

in psychiatric wards was the most lowers aggressive patients using provocation to
justify leaving ward. I found it accurate and correct and I agree. Because, referring to
my experience of four years I worked in acute psychiatric ward in my hospital, I support
this statement where he said the decision to use provocation as an excuse to leave the
ward is the lowest percentage .

Literature used and need to be wide – ranging for reader to aware the problem study
and use most relevent source that has direct approach on the problem studies (burns &
grove, 2007). Beside also stated, what is known and unknown about the problem
studies. Quality of content and source well presented the references range from years
1996 to 2004, (Burn& Grove,2007).

Therefore, the resources are current as the research critiqued accepted for published in
2007. Literature sources are from primary sources, it mean the description of studies
are written by original authors, alternatively secondary resources refer to quote of
content from primary sources this could cause misinterpretations of source and induce
bias (Nieswiadomy).

Sample and sample size

Sample size determination is important; a large sample size is needed in quantitative

studies to detect diferences between group, ( Winsett & Cashion, 2007; Siedlecki,
2008). It is believed planned sample size with subject inclusion and exclusion criteria
discussed. Firstly, a large sample used consisted of groups of Registered Nurses and
healthcare assistants on five wards in one hospital in East London participated to
reduce bias in sampling.

Secondly, an adequate sample size were trained in the use of the SOAS- The
Staff Observation Aggression Scale (SOAS) is an instrument for monitoring
aggressive incidents in psychiatric wards. It was first presented by
 Palmstierna and Wistedt [1987]. The interobserver reliability of the scale
was found to be satisfactory [Palmstierna and Wistedt, 1987]. In a later
study [Nijman et al., 1997a], staff members were asked to record aggression
on the SOAS independently. The correlation of the SOAS total scores
between observers was 0.87 and the kappa was 0.61, indicating fair to good
agreement [Lambert and Hill, 1994]. Furthermore, the scale is quick to
complete and there is no need for staff to be trained to use it

Respondents completed the SOAS-R (Nijman et al. 1999) following

each witnessed aggressive incident. Aggression was defined as any
verbal, non-verbal or physical behaviour that was threatening to the self,
others or property, or physical behaviour that actually harmed self,
others or property.

The SOAS-R consists of five columns pertaining to specific aspects of

aggressive behaviour: the provocation; means used by the patient in the
aggressive incident; target of the aggression including the patient’s
self; consequences for the victim; and measures used to stop the
aggression. Respond- ents are asked to put one or more ticks in each column,
and to give the time and date of the aggressive incident and the
patient’s initials. The SOAS-R also provides a severity score for the
incident. The total severity score of the SOAS-R can vary from 0 (least
severe form of aggression) to 22 points (most severe form of aggression).
In a review of studies using the SOAS-R published since 1987, Nijman
et al. (2005a,
2005b) concluded that severity scores appeared to be stable across studies,
with the mean lying at around 10 points. The exception was one British
study, in which a mean severity of
13Æ0 was reported (Van Gestel 2002).
 Involvement of ethical committee in research is important to ensure
protection of human right of subject, to protect from harm , fairness,
confidentiality, anonymity. It includes informed consent, provides clear
information to participants about their right to withdraw from studies
(Cherry & Jacobs, 2007) and data obtained according to Siedleck (2008) will
be locked securely for six to seven years. Research Commission of the
University of Jaen gave approval to the studies. Participant was voluntary
and anonymity guarantee. The research objective been stated in each
question and consent given by participant on returning of survey
questionnaire.

Theoretical Framework

The overall research approach were established on a conceptual framework

whereby researchers are working and research design would influance the
research process, choosing appropriate research design is the most important
stage (Gerish&Lacey, 2006). In this research , theoratical framework has been
extracted from the literature review.

Methodology

This is quantitative research paper. Quantitative research methodologies include formal,objective

and systemic process; numeric data obtain to evaluate information. It is philosophical origin
called logical positivism, which basedon strict rules of truth, logic, laws and prediction (Burn &
Grove, 2007). Truth is absolute for researchers in quantitative research, to find the truth,
researchers has to be objective. A single reality defined by tedious measurement, no values,
feelings and perception can be included in measurement of reality. It is conducted to examine
theory by describing variables, cost and effect relationships and establish relationship variables
(Burn & Grove, 2007).

Qualitative research is subjective, more on understanding human experiences and situation to

develop theories, human experience are difficult to quantify hence qualitative approach are more
effective method of research involve emotion (Burns & Grove, 2007).

Both quantitative and qualitative research need researcher expertise, involve rigor
implementation and scientific knowledge generated (Burns & Grove, 2007).

Four types of commonly used quantitative design are non – experimental study, descriptive study
and correlation, quasi – experimental and experimental (Burns & Grove, 2007).Research designs
used in this report are non – experimental quantitative designs. As according to Siedlecki (2008),
non – experimental research includes descriptive, correlation and comparative designs. As such,
this appropriate designs used by these authors.

Data collection

In this report, researchers used a questionnaire survey designed to collect data. Registered
Nurses and healthcare assistants on five wards in one hospital in East London
participated. All wards approached agreed to take part in the study and 56 staff
were trained in the use of the SOAS-R. Four of the five were mixed sex wards serving a
defined geographical locality and the fifth was a smaller women-only ward. The wards
were not specialized by diagnosis and all provided short stays foracutely ill patients of
working age.

The psychiatric unit in which these wards are located is situated in the grounds of a larger
general hospital. The mean rate of admissions is approximately three per ward per
week, with approximately half of patients admitted being male, under 35 years of age
and with a psychotic disorder. The wards had 18 beds and were staffed by a
combination of qualified psychiatric nurses (approximately 75%) and unqualified
healthcare assistants. In whole-time equivalent terms there was one staff member to one bed.
Wards typically operated with all beds occupied. All staff were trained by an approved
trainer in the prevention and management of aggression, the training consisting of a 5-
day course followed by annual updates.

Respondents completed the SOAS-R (Nijman et al. 1999) following each witnessed
aggressive incident. Aggression was defined as any verbal, non-verbal or physical
behaviour that was threatening to the self, others or property, or physical behaviour
that actually harmed self, others or property. The SOAS-R consists of five columns
pertaining to specific aspects of aggressive behaviour: the provocation; means used by the
patient in the aggressive incident; target of the aggression including the patient’s
self; consequences for the victim; and measures used to stop the aggression. Respond-
ents are asked to put one or more ticks in each column, and to give the time and date of
the aggressive incident and the patient’s initials.

The SOAS-R also provides a severity score for the incident. The total severity score of the
SOAS-R can vary from 0 (least severe form of aggression) to 22 points (most severe form
of aggression). In a review of studies using the SOAS-R published since 1987, Nijman et
al. (2005a 2005b) concluded that severity scores appeared to be stable across studies, with
the mean lying at around 10 points. The exception was one British study, in which a mean
severity of 13Æ0 was reported (Van Gestel 2002). A researcher visited the wards each
week to check on completion of the scales. The SOAS-R forms were collected by a
researcher at regular intervals and checked against official records in an attempt to
minimize missing data and ensure that there was no duplication of reporting. Approval
for the study was obtained from the Local research Ethics Committee. Staff were
informed of the details of the study, that they were free to withdraw at any time and that
information given about the individual ward on which the incident took place, staff
member completing the form or patient involved would be kept confidential and would
not be identified in reports. Written consent was obtained from nursing staff on the
wards.

Instrument design / Validity and reliability

The most important concern of instrument characteristics is its validity and reliability.
Validity ofquestions obtained after a pilot study done on questionnaire, to refine and
removes misleading questionnaires. Three experts in (GNEAUPP) consulted to assessed
validity questionnaire and reliability was assessed by using Cronbach’salpha test.
According to burns & Grove (2007), reliability measure consistency of error in
measurement technique and Cronbach’s alpha is acommonly used measurement.
Correlated coefficient is a term used to express reliability, perfect reliability is 1.00 and
0.00 is no reliability, with minimum accepted value of 0.08 to develop well develop
measurement tools. In this studies the alpha = 0.92 which is near to one to judge near
perfect reliability of instrument.

Data analysis – statistic analyze

In quantitative research studies, the process of analyzing data can be worrying, as it contain
research language and notion of statiscal test (Coughlan, Cronin & Ryan , 2007) and for nurses
don’t have good mathematics background, the formula can be daunting (Quint, 2000). In order to
succeed in understanding statistic analysis it is essential to have mathematics background,
critical thinking skill and proper teaching strategic on research process ( Robinson, 2001).

The researchers used both descriptive and inferential statistic test. Statiscal package for the social
sciences (SPSS) used to calculate the statiscal results. SPSS is computerized data management
packages, which use to statiscal analysis data to understandable results ( Gerish & Lacey, 2006).
Inferential test used by researcher to assess differences in the index, measured by mean of t-test.
T-test pair used to assess knowledge and implementation index among groups. Varience analysis
is use for (more tha two group). Correlations were using the Pearson test. Correlations is to
measurements of which one set of measurement is related with others and the mostly use
formula are Pearson product correlation coefficient (Quinn.2000). Descriptive test use by
researchers in this study to describe variable in this samples, result is shows in percentage.

The probability of the results obtained by chance is name P-value in statistic analysis. In
quantitative study a lowest level of probability is P<0.05, mean less than 5% result getting by
chance (Burns&Grove, 2007). P<0.001 reported in this research, with this statistic significant
difference achieved.

The findings of the studies were explain in texts, presented in table and percentage it is
appropriate and provide easy interpretation of the result.

Discussion/Recomendation
The findings show, the knowledge index of the guidelines physically aggressive behavior can
cause pain, visible injury and the need of treatment. However the effects of verbal aggression are
not to be underestimated, as daily exposure to swearing, threats and verbal abuse can cause
lasting emotional damage to nursing staff (Robinson & Perryman 2004). Reason for statements
was because the treatment method was constantly changing and nurses were not keeping
themselves updated with the changes. In clinical practice some of the appropriate intervention
are still in use by the participant sample, such as calmly talking them away from the
situations,medications, seclusions and restraint. Alty and Mason (1994) suggest that containment
methods such as restraint and seclusion maybe used as a sanction against rule breakers and to
ensure compliaent and conformity to ward or hospital rule and guidelines.

Refered to studied i very agreed with the journal researchers that other recommended
intervention such as previous evidence has shown that staff and patients has very different
perceptions about the use of containment measures and their function, and this may result from
a lack of communication between them. Violence prevention training courses in the UK are
aimed at avoiding eruptions of patient aggression, minimizing the risk of injury, reducing the
need for harsh coercive measure and helping patients control their behaviour (Needham et
al.2004). Our findings suggest that training also needs to focus on improving methods of
communication between staff and patients, so that staff are able to identify adequately the
provoking factors of aggression, recognize the importance of interpersonal factors in provoking
such incidents, and thereby reduce the occurrence of aggression on psychiatric wards.

Conclusion

The prevention of aggressive behavior on acute psychiatric wards is a great clinical impotency
therefore a growing knowledge about the effectiveness of managing them correctly with latest
research finding is fundamental of it. As professional nurse integrate, EBP in practice is
becoming very important to meet the challenge rising from high expectation of patients and
today health care demand to provide high quality care.

In acute psychiatric wards, not many nurses are aware of the important of EBP, they are either
too busy with work, not motivated or not interested. The hospital internet provides free
accessible database and website for employees to access information but not many are aware of
such informative resource avaibility. Management plays a crucial part here to communicate with
employees and relay information available.

As a professional nurse, we are accountable to update our practice based on evidence, it enables
us to be patient advocates in providing quality care based on EBP. EBP courses should be teach
at all level in nursing and to encourage diploma level graduate nurses in Malaysia to
professionally self- development, to obtain Bachelor science degree courses. This will result in
understanding the importance of evidence based practice nursing, it values and outcomes of
implications in nursing practices.