Ready, Aim Fire! Mental Health Nurses Under Siege in Acute Inpatient Facilities

Issues in Mental Health Nursing, 34:281–287, 2013Copyright © 2013 Informa Healthcare USA, Inc.ISSN: 0161-2840 print / 1096-4673 onlineDOI: 10.3109/01612840.2012.742603

Ready, Aim Fire! Mental Health Nurses Under Siege inAcute Inpatient Facilities

Louise Ward, PhDSchool of Nursing and Midwifery, La Trobe University, Melbourne

It has been clearly acknowledged and well-documented thatphysical, emotional, and psychological violence is a central themeand an expected workplace hazard for registered nurses working inacute inpatient mental health care facilities. Limited research, how-ever, has focused on how registered nurses have been able to copewithin this environment and adequately protect themselves fromharm. A critical feminist research project recently explored thelived experience of 13 Australian, female, registered nurses work-ing in a busy metropolitan acute inpatient mental health care facil-ity. “Fear” was exposed as the precursor to violence and aggression,both “fear as experienced by the nurse” and “fear as experienced bythe patient.” The participants reported experiencing a sense of fearwhen they could not accurately or confidently anticipate a patientresponse or reaction. They identified this relationship with fear asbeing “part of the job” and part of the unpredictable nature ofcaring for people experiencing complex distortions in thinking andbehavior. The participants believed, however, that additional work-place pressures complicated the therapeutic environment, resultingin a distraction from patient care and observation. This distractioncould lead to nurse-patient miscommunication and the potentialfor violence. This article discusses a major theme to emerge fromthis study, “Better the devil you know!” The theme highlights howmental health nurses cope with violence and why they choose tocontinue working in this complex care environment.

Acute inpatient mental health care facilities have longbeen considered stressful, with registered nurses workingon the frontline dealing with this sometimes aggressive andunpredictable environment (Carlsson, Dahlberg, & Drew, 2000;Crowe & Carlyle, 2003; Leifer, 2004; Mullen, 2009; Ward,2011). These environments, however, are considered essentialin the provision of assessment and short-term intensive man-agement of the mentally unwell. Inpatient treatment supports acontinuum of care for people who are unable to be managed ad-equately in the community setting (Delaney & Johnson, 2012).

Over the past two decades there has been a major shift fromhospital care to community treatment, resulting in patients pre-senting to inpatient facilities at a later stage of their illness

Address correspondence to Dr. Louise Ward, School of Nursingand Midwifery, La Trobe University, Melbouorne, 3086, Victoria, Aus-tralia.

progression. It is, thus, more likely the patient will require in-voluntary admission and be less accepting of treatment. Thereare also an increasing number of patients being scheduled forcare who suffer with dual diagnosis, drug and alcohol depen-dency, and complex challenging mental health concerns. Mullen(2009) states that as a result of these increasing demands onmental health services “the focus for care is on the containmentof difficult behaviour and the management of those consideredto be ‘at high risk of harm”’ (p. 83). This complex patient mixis considered the most stressful aspect of mental health nursing(Jenkins & Elliott, 2004; Pompili et al., 2006) and the mostchallenging element to providing and maintaining a safe envi-ronment free from violence and aggression (Finfgeld-Connett,2009; Maguire & Ryan, 2007; Oei, Foong, & Casey, 2006).Therefore the growing dilemma of how to care for these pa-tients, as well as how to manage them, continues to divide theprofession (Cleary, 2004; Stuhlmiller, 2003).

Workplace violence continues to be a leading source of stressand personal injury for staff and patients within acute inpatientfacilities (Carlsson, Dahlberg, & Drew, 2000; Hamaideh,Tuvesson, Eklund, & Wann-Hansson, 2012; Johnson, 2010;Woods, Ashley, Kayto, & Heusdens, 2008). Workplace violenceis defined as an incident that results in physical, psychological,and emotional injury (Duncan, Hyndman, Estabrooks, &Hesketh, 2001) with significant cost to the individual and theorganization (Johnson, 2010; Meehan, Fjeldsoe, Stedman, &Duraiappah, 2006). It is considered an occupational hazardin nursing (Edwards & Burnard, 2003; Winstanley & White,2003; Wolfe, 2006), and simply managing this phenomenonhas become a priority for mental health nurses worldwide(McGuire & Ryan, 2007; Nolan et al., 1999).

Research reports that between 75% and 100% of registerednurses working in inpatient mental health care have experiencedviolence perpetrated by patients at least once in their career(Maguire & Ryan, 2007; New South Wales Nurses Association[NSWNA], 2007). It has been reported that inexperienced nursessuffer greater levels of violence and an increased prevalence ofaggressive behaviour by patients in their first year of practice,resulting in increased levels of stress and poor retention rates(Jenkins & Elliott, 2004; McKenna et al., 2004).

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Evidence suggests that the increased level of violence andthe growing number of assaults on registered nurses who workin acute inpatient mental health care facilities potentially di-rects nursing practice toward a more restrictive and defensiveapproach to care (Foster, 2001; Happell et al., 2012; Lowe,Wellman, & Taylor, 2003). Restrictive interventions, such asseclusion and restraint, may be considered useful in preventinginjury at the time of the incident, however recent studies indi-cate greater consequences are experienced by both patient andnurse as a result (Happell et al., 2012; National Mental HealthConsumer and Carer Forum [NMHCCF], 2010; Stubbs et al.,2009). Seclusion and restraint have serious drawbacks but, inacute mental health care, few alternative management strate-gies are available (Hickie, 2010). Seclusion and restraint areconsidered detrimental to the therapeutic relationship betweenconsumer and registered nurse (Happell et al., 2012; NMHCCF,2010).

The purpose of this study was to investigate nursing prac-tices in acute inpatient mental health care environments and toexplore the nurse-patient relationship, violence, and aggression.We sought to better understand professionals’ ways of copingwithin an environment that is considered to be so challenging.

METHODThis study adopted a critical feminist framework placing

women (gender) as central to the research process. The re-searcher chose a feminist perspective as she supports the beliefthat women and nurses have been oppressed and continue tobe marginalized within the nursing profession (Fletcher, 2006;Rose & Glass, 2008; Skillings, 1992; Taylor, 2006; Ward, 2011).

Additionally, psychiatry and mental health care, coupled withthe medical model, has long been the domain of men. This do-main has been an overbearing force impacting on health caredecisions, the nursing role, and patient outcome and recovery(Hutchinson, Wilkes, Vickers, & Jackson, 2008). In light ofthis, the researcher sought a women’s perspective on violence,aggression, and the practice of nursing within an acute mentalhealth care facility. Feminist principles guided the study andacknowledged the individual experiences of the women partic-ipants. A critique of practice, highlighting gender related issueand power imbalance, was also undertaken, linking subjectivitywith knowledge production (Ramazanoglu, 2002).

Ethical ConsiderationsFollowing approval from the University and the Area Health

Service, an information sheet was placed in the inpatient mentalhealth care facility communication book and the ward’s dailydiary. Women registered nurses interested in the study wereprovided with an information sheet and an opportunity to meetwith the researcher to discuss the study further. Thirteen womenchose to participate in the research project. The women wereall registered nurses; they had, however, varying degrees ofexperience working at many different hospitals across Australia.

All of the participants had been working in an inpatient mentalhealth care facility for at least ten years. Pseudonyms wereused to protect the identity of the participants, maintaining aconfidential and ethical research process (Ward, 2011).

As the researcher is also a mental health nurse, attentionto the insider/outsider researcher/participant role relationshipwas reflected upon and consistently considered to prevent apower imbalance (Ward, 2011). As a critical feminist project,it was essential to ensure the research participants felt safe andable to speak out and reflect on their experiences and, throughconsciousness raising, avail an opportunity for empowermentand transformative change.

This study adopted two specific research methods: individualinterviews and focus groups. These methods were used to pro-vide the participants with an opportunity to share their storiesand be heard in confidence. Each participant was individuallyinterviewed, and all participants attended both focus groups. Theinterviews were carried out at an off-campus location selectedby each participant. Each interview lasted approximately twohours and was audiotaped with consent. The researcher tran-scribed the audiotaped recordings, and all data collected wasstored in a locked filing cabinet (Ward, 2011).

The first focus group was held before the individual inter-views, and the second focus group was held after all of theparticipants had been interviewed. The focus groups also wereaudiotaped, and the researcher took notes. Both focus groupslasted approximately three hours. The first focus group wasunstructured so that discussion could flow across a variety ofthemes and concepts; the second was semi-structured, raisingissues that had emerged from the individual interviews. Re-discussing particular themes, such as issues of power, authority,discourse, and social justice in mental health care, supportedconsciousness raising and praxis as the participants expressedinterest in change. Again, all data were transcribed by the re-searcher and stored securely (Ward, 2011).

The first semi-structured interview question was: “Why didyou choose a career in mental health nursing?” The secondquestion was: “Why did you choose to stay?” The followingquestions related to violence were then asked throughout thecourse of the interview: “To what extent does violence impactupon your workplace? Can you give examples?” If a participantanswered “yes” to this question and continued to speak aboutviolence, then the following question was asked, “How haveyou been able to cope? How do you feel the risk of violencecould be reduced?”

Data AnalysisThematic analysis was used to analyse the data. This process

involved reading and re-reading the transcripts and identifyingthemes (Rennie, 2000). Patterns and similarities in the wordsand phrases used by participants in the first focus group andin the individual interviews were identified and significantstatements were extracted and organised into clusters (Ward,

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2011). The thematic clusters were then compared to theoriginal transcripts and discussed with the participants in thesecond focus group for accuracy and reliability. As Kellehear(1993) believed, this process enabled the researcher to “checkback” (p. 38) with the respondents about the themes thatmight have emerged from the narrative. The focus group datawas also extracted and coded, linking any further patternsof thought, feelings, and behavior. In keeping with criticalfeminist research, the practice of reflexivity through journalingand painting was used when analyzing the data. Observationson body language, gestures, eye contact, and tone of voicewere recorded, as were the researcher’s feelings and thoughtson the process and on participant disclosure. These reflectionscontributed to refining and clarifying the emerging themes.

FINDINGSThe 13 research participants believed that violence was “a

part of the job” and was an expected workplace hazard for mentalhealth nurses. They were critically aware that caring for peo-ple who experience complex distortions in thinking and behav-ior could be unpredictable and, at times, dangerous. The nurseparticipants also believed, however, that additional workplacestressors, such as unsupported involuntary admissions, limitedworkspace design, poor staffing skill mix, complex patient di-agnoses, and inexperienced staff working beyond their scope ofpractice, contributed to workplace pressure and a chaotic andfractious environment. This environment then exposed both thenurse and the patient to a heightened emotional state (auto-nomic arousal) where feelings of stress, fear, and uncertaintyemerged. This increased pressure, resulting in an unpredictableand potentially “volatile cauldron” and a situation where the par-ticipants felt a “fear of the unexpected.” The chaos hindered thenurses’ ability to accurately and confidently anticipate the pa-tient’s response or reaction. For the purpose of our focus groupdiscussion, when fear was being referred to we decided on thefollowing agreed definition:

Fear is a negative emotion induced by a perceived threat that causesanimals to move quickly away from the location of the perceivedthreat, and sometimes hide. It is a basic survival mechanism, occur-ring in response to a specific stimulus such as pain or the threat ofdanger. (Wikipedia, 2009)

Better the Devil You Know!As the nurse participants shared their experience in indi-

vidual interviews and collectively at the focus groups a majortheme emerged: “Better the devil you know.” This theme cap-tured the participants’ comprehensive understanding of mentalillness and the acknowledgment of violence as a potential threatwhen working as a mental health nurse. It also revealed theway in which fear and violence in mental health nursing wasconstrued as a private event and discussed only with those expe-riencing similar situations. Speaking out about violence seemedto depend on the situational context and people present. The

13 women all felt this was related to gender. They felt that, aswomen, they dealt with issues privately to protect those aroundthem. In this instance they were referring to their colleagues andpatients.

All 13 participants had made a conscious choice to remain inthe profession despite violence being a workplace hazard. The“devil they knew” was the workplace and their experiences asregistered nurses working in mental health care. One participantsaid:

There is comfort in what you know . . . violence is a part of the job.Patients get scared and they act on that fear. We get scared too, fear ofthe unexpected. I wouldn’t want to particularly leave my colleagueshere as we have a lot of trust in each other and that is somethingyou build on over time. I have always said, “It’s better the devil youknow!”

The 13 participants supported this sense of belonging andloyalty to the group and they all accepted violence as “a partof the job” and precipitated by fear. The participants had allworked in acute inpatient mental health for over ten years andthey all expressed a strong desire to continue to care for peo-ple with mental health problems, despite the risk of injury orinsult. The participants acknowledged the problems associatedwith their workplace but were acutely aware that other inpatientfacilities internationally were experiencing the same problems.One participant said:

I have thought about leaving this job . . . but I value my relationshipswith colleagues and my role as a nurse too dearly to go. I don’t thinkmental health nursing is any different anywhere else. The problembeing, you are detaining people who don’t want to be detained!

The participants were able to identify and articulate theirfeelings of fear and anxiety in maintaining the nurse-patientrelationship. They were conscious that the patient may lackinsight into his or her need for admission and illness status.

The additional workplace stressors, such as unsupportedinvoluntary admissions, inadequate workspace design, poorstaffing skill mix, and complex patient diagnoses with drug- andalcohol-related presentations, contributed to workplace pressureand manifestations of further fear and uncertainty. The follow-ing reference to noise and a busy workspace describes a state ofchaos and increasing pressure. One participant reported:

You just get used to the whole thing . . . people yelling, phonesringing, observation room windows being hit when the patients don’tfeel they have our attention or they want to get out. Mad people lostin their own mind . . . nursing staff raising their voices . . . it’s justconstant. There’s no room for us all. I feel, at times, I’m a target andit’s ready, aim, fire! I am either on the attack or on the defensive,however I am always conscious of the possibilities of violence.

Another participant comments on the physical environmentstating:

Sometimes it can be all you think about when things are bad. Theaggression and violence, the lack of resource, bad space, the angrystaff and the unhappy patients; you wonder if anything is working asit should? Sometimes when there has been a lot of abuse and anger

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at work I leave feeling so exhausted, and I just want to shower andget clean. I just want to scrub the day off my skin. It’s all over you,people’s pain.

Another participant referred to the poor staff mix within thefacility. A power imbalance between senior and junior nursingstaff was identified by 11 of the participants as a contributingfactor to poor communication and ineffective teamwork:

There can be tension on the unit between nurses, between doctorsand nurses and nurse and management . . . the environment is just sosmall and the personalities so large. Some nurses are more skilledthen others. It is difficult working in a mismanaged team.

There was also a sense of isolation described. A sense of“doing it” alone:

Mental health nursing is about taking what society doesn’t want tosee or can’t deal with and putting it behind a door. Locking it awayso that people don’t have to see it!

A cramped workspace, coupled with a feeling that mentalhealth nursing is in itself being “locked away,” silenced thenurse participants (n = 12) and prevented them from “speakingout” prior to the research. They learnt to manage the chaos andthe potential for violence themselves.

One participant stated:

Violence is a part of the culture. I personally hate anger and abuse. Iworked out quickly that it wasn’t personal . . . but you can still feeldown after a shift . . . Listening to a patient’s distress, fear, and angerabout being locked up in a unit is vital to their safety and recovery.I’ve seen so many nurses freak because of a patient’s fear and anger.The patient ends up being secluded and punished for his or her ownexpression. It makes you wonder who’s crazy!

As the participants noted (n = 13) that nurses can experience“fear of the unexpected.” It was confirmed by the participants(n = 13) that seclusion and restraint was, at times, used as a con-sequence to prevent violence when ward pressure has escalated.The pathway of care then resulted in a custodial managementstyle. All the participants considered violence as negatively im-pacting on their workplace. They believed it was important toensure the environment remained calm and could be used thera-peutically. High levels of ward pressure were believed to hindercare and patient treatment:

I believe that violence on the unit and the aggression from patientscomes from fear. The patient’s frightened about where they are andwhat’s happening to them. The nurse is frightened about the patientnot knowing how they are going to react. As a nurse you have towork with what you’ve got, reduce the stress as much as you can,and avoid being misunderstood.

Another participant spoke about a patient experiencing psy-chosis and how attention to space, communication style, andpresentation had to be considered:

They [the patients] come in and they are in an acute state of unwell-ness and they are virtually left in our care. It can be quite frighteningfor them. If I see this, I try to work one-on-one with the person. Not

overpower them. Violence comes from nurses not reading the cues.They’re either inexperienced or uninterested.

The participants (n = 13) felt that effective communicationbetween nurse and patient was essential in order to preventviolence. Ongoing assessment skill also was considered neces-sary when interacting with patients. The complicated treatmentof patients suffering drug and alcohol issues was consideredstressful. This complex patient presentation was seen against abackdrop of an inpatient facility running at maximum capacity.

Violence is a large part of mental health nursing. Patients can befearful, there’s terror, hallucinations, their beliefs, and we have tosometimes hold them down to give them medications and it can beawful for everyone. You need to acknowledge it, so you know howto deal with it. If I am frightened about how a patient may react, thenI plan accordingly. I communicate differently.

The nurse and patient were reported to “fear the unexpected.”The participants (n = 13) agreed that anticipating violence ora violent reaction was extremely frightening. They experiencedsadness, anxiety, loss of control, and nervousness about impend-ing danger. They also expressed a sense of regret that the situa-tion had escalated. They could all, however, identify strategies tomanage the situation and support their professional well-being.

If there is “agro” on the ward you see that in the nurses too, which isalmost the fight or flight thing, gearing yourself up so you are readyon one level and you can find yourself getting more hyper-vigilant.I try to stay aware of my stress levels and talk with my colleagues todebrief.

The nurse participants (n = 13) believed they coped withviolence in the workplace because they knew why it existed.They could identify fear in themselves and in the patient. Theyfelt that talking or debriefing with their colleagues allowed foran opportunity to de-stress, unwind, and review their practice.

You can have times when you are being abused constantly. Recentlyat work there was extreme violence between a staff member and apatient and I kept getting pulled into it. I had to take time off just tonurture myself.

DISCUSSIONThis study explored the experiences and practices of 13

mental health nurses working within an acute inpatient mentalhealth care facility. The study revealed many stressors within theenvironment, such as unsupported involuntary admissions, inad-equate workspace design, poor staffing skill mix, and complexpatient diagnoses with drug- and alcohol-related presentations.Unique to this research, however, the nurse participants linkedworkplace stressors to increased workplace pressure. This pres-sure resulted in a heightened emotional state where feelings of“fear” were experienced between nurse and patient. “Fear of theunexpected” was considered the precipitating factor to violence.The participants (n = 13) accepted the potential for violenceas “part of their job.” They were critically aware that caring forpeople experiencing mental illness and complex distortions in

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thinking and behavior could be dangerous. As supported by re-search, a strong association has been established linking thoughtdisorders and impaired thinking to violent behaviour duringinpatient treatment (Duxbury et al., 2004; Steinert, Wolfe, &Gebhardt, 2000). The participants in the study (n = 13) workedwith this knowledge to keep themselves safe. The findingsalso concur with research carried out by Duxbury (2002) thatsuggested external factors within the workplace contributenegatively to the nurse patient relationship and violence:

Patients perceived environmental conditions and poor communica-tion to be a significant precursor of aggressive behaviour. Nurses,in comparison, viewed the patients’ mental illnesses to be the mainreason for aggression, although the negative impact of the inpatientenvironment was recognized. From interview responses, it was evi-dent that both sets of respondents were dissatisfied with a restrictiveand under-resourced provision that leads to interpersonal tensions.(Duxbury, 2005, p. 469)

A recent study undertaken by Tuvesson, Eklund, and Wann-Hannson (2011) investigated nursing in acute mental healthfacilities and concurred with the findings of the present study,identifying the impact of environmental factors on nursing staffand the staff’s ability to act in concordance with their ethicalbeliefs and cope with the complex inpatient workspace.

The contradictive nature of nursing in psychiatric in-patientcare—the will to do good and the demands for effectiveness—hasbeen found to create stress, and staff that work in psychiatric carehave described that they experience feelings of inadequacy and atroubled conscience. (Tuvesson et al., 2011, p. 208)

The participants also identified managing the violence in iso-lation and feeling responsible for the escalation of events lead-ing up to the incident. This is further supported by Woods et al.(2008), confirming the most significant issue related to violenceand aggression within inpatient facilities is the underreportingof incidents due to the following: the differing definitions ofviolence, the frequency of violence, the cumbersome reportingsystems, the lack of change or action taken following previouslyreported incidents, and a fear of being blamed for the incidentitself.

A study undertaken by Cutcliffe (1999) highlighted that tra-ditionally nurses “keep a lid on things” (p. 114), which supportsthe current study and the sense of isolation and inadequacy ex-pressed by the participants. This may be the reason why How-erton Child and Mentes (2010) found violent incidents to beunderreported.

The participants from the present study introduced copingmechanisms used to reduce stress and, more importantly, de-scribed a sense of acceptance that violence was always going tobe a potential workplace hazard. This acceptance allowed themto work with this knowledge and keep themselves safe. A studyundertaken by Mitchell and Hastings (2001) found that staffworking in inpatient care used a variety of coping methods, suchas adaptive strategies, denial, and disengagement. Disengage-ment was thought to indicate emotional exhaustion. Individual

coping mechanisms were linked directly to psychological well-being (Hastings, 1995). Therefore, gaining greater insight intothe coping strategies of women registered nurses working inacute mental health care could assist health care organisationsdesign more appropriate inpatient facilities based on nursingknowledge and experience.

Participants felt that patients admitted involuntarily presentedwith a higher risk of violent and aggressive behaviour as the pa-tient was being detained and could be fearful of the process. Theparticipants believed that managing admission, and this crucialpoint of patient engagement, was essential to developing a rap-port and an effective therapeutic relationship. The research find-ings however support concerns that seclusion and restraint arethe most frequently used consequence of violence. The partici-pants were worried that due to workplace environmental issues,mental health nursing was moving to a more custodial model ofcare (Happell et al., 2012; NMHCCF, 2010). The 13 participantsin this study opposed seclusion and restraint and preferred toprevent incidents through the use of effective communicationand appropriate care. This correlates with the research by Hap-pell et al. (2012), which suggests that nurses feel unsuccessfuland inadequate in their care if custodial practices need to beintroduced.

Acknowledging fear as a precipitating factor to violence mayassist nurses working within these environments to move awayfrom restrictive and defensive care strategies, reducing the useof seclusion and restraint. There has been a number of compre-hensive research and workplace interventions aimed to reduceviolence and aggression within the acute inpatient mental healthcare facility, and a number of theories have been developed toexplain the causes of violence and aggression. Finfgeld-Connett(2009) performed a meta-analysis on 15 qualitative studies andfound that inflexible and disengaged nursing resulted in non-therapeutic outcomes (i.e., aggression/violence), whereas au-thentic engagement resulted in positive therapeutic outcome.Authentic engagement could be perceived from this study as anhonest and transparent acceptance that both nurse and patientare vulnerable in the workplace. Through open communication,violence could be avoided and, through strategic managementof this environment, a therapeutic space could be maintained.

Other studies indicate that violence toward staff occurs whenunreasonable patient requests are denied (McGuire & Ryan,2007; Rigby & Burrows, 2003). Daffern, Mayer, and Mar-tin (2006) undertook research within an acute forensic mentalhealth unit and attest that nursing practice might contribute topatient aggression and the occurrence of violent incident. Rocheand Duffield (2007) identified the relationship stating that “vio-lence and threats of violence have been identified as particularlystressful to nurses working in mental health with workplace vi-olence having a direct impact on their retention” (p. 97). Thecurrent study refutes this, as the nurses acknowledged the riskof violence they faced as mental health nurses but were still ac-tively engaged in remaining in the profession and in their placeof work.

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Numerous zero tolerance strategies have been implementedacross mental health care services to address violence and ag-gression in the workplace. Zero tolerance has however beencriticized for attributing violence and the responsibility of man-aging violence directly to the patient. This one-sided phenom-ena of blame could potentially lead some staff to discount theirability to reduce the risk of violence through appropriate andconsidered nursing care. Zero tolerance expectations may lead todisinterested or disengaged clinicians (National Health ServiceExecutive, 1999). Subsequently, disinterested or disengaged at-titudes may promote negative nurse-patient interaction and thishas been identified as an antecedent to non-therapeutic relation-ships (Duxbury, 2002). The participants of the current studywere extremely protective of the patient and offered no blametoward them. They acknowledged that mental illness impactson behavior, and they clearly associated patient fear with thepotential risk of violent reaction. A zero tolerance strategy wasnot perceived as practical or supportive.

LimitationsThe limitations of this study are that there were only 13

women participants engaged in the research project and it wasconducted in one acute mental health care facility. Expandingthe study to community mental health care would provide fur-ther insight into the way in which women mental health nursesmanage violence in the workplace. Additionally an explorationof the patient experience is a future project goal.

CONCLUSIONThe purpose of this study was to investigate nursing prac-

tices in acute inpatient mental health care environments andto explore the nurse-patient relationship, violence, and aggres-sion. The investigation sought to better understand profession-als’ ways of coping within an environment considered chal-lenging. The participants linked workplace stressors, such asunsupported involuntary admissions, inadequate workspace de-sign, poor staffing skill mix, complex patient diagnoses, anddrug- and alcohol-related presentations, to increased workplacepressure. This pressure resulted in a heightened emotional state(autonomic arousal) where feelings of fear were experienced be-tween nurse and patient. Fear of the unexpected was consideredthe precipitating factor to violence.

The women participants of the study report on a range ofexperience working within an acute inpatient facility. The envi-ronment was viewed as unpredictable and challenging. Violenceis considered a workplace hazard, multi-factorial, and unique toeach individual situation. Acknowledging fear as a precipitat-ing factor to violence allowed the mental health nurses to beconscious of behavioural cues and escalating patient anxiety.Acknowledging fear as a precipitating factor to violence alsoprompted participants to question the organizational manage-ment of the workplace. Through focus group discussion andconsciousness raising the women were able to reflect on prac-

tice and seek change. Health care organisations need to take re-sponsibility for the additional workplace issues impacting on theparticipants and on their role as mental health nurses. There is aneed for improved workplace design and better management ofstaffing skill mix. Mental health care facility management mustreview admission policies to ensure complex patient diagnoseswith drug- and alcohol-related presentations are adequately sup-ported in the most appropriate environment receiving the mostappropriate treatment.

There is a need for mental health nurses to constantly engagewith each other, review practice and build professional strengthfrom their skills, knowledge and expertise. From a feministperspective, praxis should drive the future vision of inpatientfacility care and mental health nurses must lead the decisionmaking on workplace design and patient care. The participantsbelieved that acknowledging violence in mental health nursingmade room for further education and training on communicationstyles and patient care, reducing the risk of violence and the useof seclusion and restraint.

Declaration of interest: The author reports no conflicts ofinterest. The author alone is responsible for the content andwriting of the paper.

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