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THE LIVED EXPERIENCE BY PSYCHIATRIC NURSES OF AGGRESSION AMONGST COLLEAGUES by MARISA DELPORT MINOR-DISSERTATION Submitted in partial fulfilment of the requirements for the degree MAGISTER CURATIONIS In PSYCHIATRIC MENTAL HEALTH NURSING SCIENCE at the UNIVERSITY OF JOHANNESBURG SUPERVISOR: Prof. M Poggenpoel CO-SUPERVISOR: Prof. CPH Myburgh 2013 i ACKNOWLEDGEMENTS Philippians 4:13. “I can do everything through him who gives me strength”.  Thank you Heavenly Father for your knowledge and wisdom that guided me, for your power and strength that supported me and your grace that carried me throughout doing this research study.  Thank you to Prof. Marie Poggenpoel and Prof. Chris Myburgh for your patience, support and the amazing wisdom you share so respectfully. You are role models for any student.  To my loving husband, thank you for your endless support, understanding and encouragement. Your love carried me through the challenges. You are my inspiration.  Thank you to my loved ones, family and friends for believing in me. For the loved ones no longer with us, I am reassured by the belief that you would have been proud of me.  To the participants of this research study, thank you for sharing your unique experiences that contributed to the body of knowledge. My desire for the future is that your contributions to this research study would make a difference in your work environment.  To the remaining people and entities, such as Tara Hospital, the H. Moross Centre, all the research ethics committees and technical support, thank you for making this opportunity a reality. ii SUMMARY Psychiatric nursing is seen as a high-stress profession. The demands of caring for others, especially those who suffer from acute and chronic mental health impairment, can be extremely stressful (Lin, Probst & Hsu, 2010:2343). Psychiatric nurses run a high risk for being exposed to aggression in the work environment. The aggression that they experience is not only from hostile and aggressive mental health care users, but also from fellow colleagues. Aggression in the work environment has an overt negative psychological effect on the nurse (Yildirim, 2009:509; Bimenyimana, Poggenpoel, Myburgh & Van Niekerk, 2009:5). The aim of the research study was to explore and describe the lived experience of psychiatric nurses of aggression amongst colleagues in the work environment. A second aim was to formulate guidelines on assisting psychiatric nurses and their colleagues in order to facilitate their own mental health. The research design of the study is qualitative, explorative, descriptive and contextual in nature (Maphorisa, Poggenpoel & Myburgh, 2002:24). This qualitative approach created an opportunity to discover the phenomena of the lived experiences of psychiatric nurses of aggression amongst colleagues. The research study was conducted in two phases. In the first phase, data was collected by means of conducting in-depth phenomenological interviews, naïve sketches, observations and field notes until data saturation was achieved. In the second phase, guidelines, recommendations, challenges and a summary were formulated to address the lived experience of the psychiatric nurses of aggression amongst colleagues in the work environment. During data collection, the following question was asked in the in-depth phenomenological interviews and naive sketches, “What is your experience of aggression amongst colleagues in the work environment?” Tesch’s (Creswell, 2004:256) open coding method and an independent coder were used during data analysis. iii Findings indicated the following:  theme 1: the psychiatric nurse experiences aggression as subtle, passive and very harmful in a verbal and non-verbal manner;  theme 2: nurses experience a doubtful, suspicious and distrustful team environment;  theme 3: the psychiatric nurse experiences limited support when colleagues and management do not acknowledge aggression; and  theme 4: the psychiatric nurse applies coping mechanisms when he or she experiences emotional stress and aggression. The psychiatric nurses experienced a continuous process of aggression amongst colleagues. The aggression that the psychiatric nurses experience affects their ability to perform as a team, as well as the execution of their daily tasks and duties. The psychiatric nurses experience aggression, when they do not acknowledge feelings of aggression. This may occur by not talking about aggression or addressing the source of aggression. The psychiatric nurses experience limited support from their colleagues and management, whom they see as a part of the nursing team. Limited support in the work environment results in emotional distress. When the psychiatric nurses experience emotional distress, they resort to using defence mechanisms in order to cope with the emotional distress. When the psychiatric nursed do not receive effective support and guidance, they struggle to cope with the distress they experience and may use different coping mechanisms to alleviate such stress. At times destructive coping mechanisms may be used, for example passive aggressive behaviour. This behaviour contributes to continuous aggression experienced. iv OPSOMMING Psigiatriese Verpleegkunde word as 'n hoë spanning beroep gesien. Die eise wat die versorging van akute en chroniese geestelike gesondheidsorg gebruikers meebring, is baie stresvol (Lin, Probst & Hsu, 2010:2343). Psigiatriese verpleegkundiges loop 'n hoë risiko om aan aggressie in die werksomgewing blootgestel te word. Die beleefde aggressie is nie net in terme van vyandige en aggressiewe geestelike gesondheidsorg gebruikers nie, maar word kollegas onder mekaar, ondervind. Aggressie in die werksomgewing het 'n negatiewe sielkundige uitwerking op verpleegkundiges (Yildirim, 2009:509; Bimenyimana, Poggenpoel, Myburgh & Van Niekerk, 2009:5). Die doel van die navorsing was om die daaglikse ervaring van psigiatriese verpleegkundiges wat aggressie onder mekaar en in die werksomgewing ervaar, te verken and beskryf, sowel asom riglyne te formuleer om die psigiatriese verpleegkundiges en hul kollegas te help om hul geestesgesondheid te fasiliteer. Die navorsingsontwerp is kwalitatief, verkennend, beskrywend en kontekstueel van aard (Maphorisa, Poggenpoel & Myburgh, 2002:24). Hierdie kwalitatiewe benadering skep 'n geleentheid om die verskynsels van die beleefde ervarings van psigiatriese verpleegkundiges van aggressie onder kollegas na te vors. Die navorsing is in twee fases uitgedoen. In die eerste fase is data-deur middel van indiepte fenomenologiese onderhoude, naïewe sketse, waarnemings en veldnotas ingesamel totdat dataversadiging bereik is. In die tweede fase is riglyne, aanbevelings, uitdagings en ‘n opsomming geformuleer om die psigiatriese verpleegkundiges se ervaring van aggressie onder kollegas in die werksomgewing aan te spreek. Tydens data-insameling is die volgende vraag tydens die indiepte fenomenologiese onderhoude en naïewe sketse gevra, "Wat is jou ervaring van aggressie onder kollegas in die werksomgewing?" Tesch (Creswell, 2004:256) se oopkoderingmetode en 'n onafhanklike kodeerder is gebruik vir data-analise. v Die volgende temas is in die navorsing geïdentifiseer:  tema 1: die psigiatriese verpleegkundige ervaar verbale en nie-verbale aggressie as subtiel, passief en baie skadelik;  tema 2: verpleegsters ervaar 'n twyfelagtige, agterdogtige en wantrouige spanomgewing;  tema 3: die psigiatriese verpleegkundiges ervaar beperkte ondersteuning wanneer kollegas en bestuur ni aggressie erken nie;  tema 4: die psigiatriese verpleegkundiges ervaar dat hulle hanteringsmeganismes gebruik wanneer hulle emosionele stres en aggressie ervaar. 'n Deurlopende proses van aggressie word onder kollegas ervaar. Die aggressie wat die psigiatriese verpleegkundiges ervaar, beïnvloed hul vermoë om as 'n span te werk, sowel as om hul daaglikse take en pligte uit te voer. Die psigiatriese verpleegkundiges ervaar aggressie, wanneer hulle nie hul gevoelens van aggressie erken; wanneer hulle nie oor aggressie of die bron van die aggressie praat nie. Die psigiatriese verpleegkundige ervaar beperkte ondersteuning van hul kollegas en die bestuur, wat hulle as deel van die verpleegspan beskou. Beperkte ondersteuning in die werksomgewing lei tot emosionele nood. Wanneer die psigiatriese verpleegkundiges beperkte ondersteuning in die werksomgewing ervaar, lei dit tot die gebruik van verdedigingsmeganismes. Wanneer die psigiatriese verpleegkundiges beperkte ondersteuning en leiding in die werksomgewing ervaar, sukkel hulle om emosionele nood te hanteer, en end hulle verskillende hanteringsmeganismes aan. By tye word moontlike destuktiewe hanteringsmeganismes gebruik, byvoorbeeld passiewe aggressiewe gedrag. Hierdie gedrag dra dan tot die deurlopende belewing van aggressie in die werksomgewing by. vi TABLE OF CONTENT CHAPTER 1: OVERVIEW OF THE STUDY AND RATIONALE .................................. 1 1.1 INTRODUCTION .............................................................................................. 1 1.2 BACKGROUND AND RATIONALE ................................................................... 1 1.3 PROBLEM STATEMENT .................................................................................. 3 1.4 RESEARCH PURPOSE AND OBJECTIVES .................................................... 4 1.5 PARADIGMATIC PERSPECTIVE ..................................................................... 5 1.5.1 Meta-theoretical Assumptions ................................................................... 5 1.5.2 Theoretical Definition of Concepts............................................................. 7 1.5.3 Methodological Assumptions ..................................................................... 8 1.6 RESEARCH DESIGN AND METHOD ............................................................... 9 1.6.1 Phase 1 - Exploration and description of the lived experience by psychiatric nurses of aggression amongst colleagues ......................................... 9 1.6.1.1 Population and Sampling ................................................................... 9 1.6.1.2 Data collection .................................................................................. 10 1.6.1.3 Data analysis .................................................................................... 11 1.6.1.4 Literature control .............................................................................. 11 1.6.2 Phase 2 - Guidelines to assist psychiatric nurses in their work environment ....................................................................................................... 12 1.7 MEASURES TO ENSURE TRUSTWORTHINESS.......................................... 12 1.8 ETHICAL MEASURES .................................................................................... 13 1.9 DIVISION OF CHAPTERS .............................................................................. 14 1.10 CONCLUSION .............................................................................................. 14 CHAPTER 2: RESEARCH DESIGN AND METHODOLOGY .................................... 15 2.1 INTRODUCTION ............................................................................................ 15 2.2 RESEARCH DESIGN ..................................................................................... 15 2.2.1 Qualitative research ................................................................................ 15 2.2.2 Exploratory research ............................................................................... 16 2.2.3 Descriptive research ................................................................................ 17 vii 2.2.4 Contextual research ................................................................................ 18 2.3 RESEARCH METHOD ................................................................................... 18 2.3.1 Phase 1 - Exploration and Description of the Lived Experience of Psychiatric Nurses ............................................................................................. 18 2.3.1.1 Population and Sampling ................................................................. 20 2.3.1.2 Data Collection ................................................................................. 21 2.3.1.2 Data Analysis ................................................................................... 22 2.3.1.3 Literature Control ................................................................................. 24 2.3.2 Phase 2: Guidelines to assist the Psychiatric nurses to cope with the challenges of aggression amongst colleagues ................................................... 25 2.4 TRUSTWORTHINESS ................................................................................... 25 2.4.1 Credibility ................................................................................................ 25 2.4.1.1 Prolonged engagement in the field ................................................... 26 2.4.1.1 Reflective journal .............................................................................. 26 2.4.1.2 Triangulation .................................................................................... 26 2.4.1.3 Member checking ............................................................................. 26 2.4.1.4 Structural coherence ........................................................................ 27 2.4.2 Transferability .......................................................................................... 27 2.4.3 Purposive sample .................................................................................... 28 2.4.3.1 Description of results supported by direct quotations of participants 28 2.4.4 Dependability .......................................................................................... 28 2.4.4.1 Step-wise replication of the research method .................................. 28 2.4.4.2 Code – recording of data: ................................................................. 29 2.4.4.2 Dependability audit ........................................................................... 29 2.4.5 Confirmability .......................................................................................... 29 2.5 ETHICAL CONSIDERATIONS ....................................................................... 30 2.6 CONCLUSION ............................................................................................... 31 CHAPTER 3: THE LIVED EXPERIENCE BY PSYCHIATRIC NURSES OF AGGRESSION AMONGST COLLEAGUES .............................................................. 32 3.1 INTRODUCTION ............................................................................................ 32 viii