c

BSC (HONS) NURSING PRACTICES DEVELOPMENT

NAME:

KHAIRUL JOHARI BIN MOHD DENIE

STUDENT REGISTRATION:

09035338

MODULE TITLE:

PRACTICAL APPLICATION OF EVIDENCE BASED PRACTICE

MODULE CODE:

PP0266

WORD COUNT:

4000 WORDS
„
 

Title of the study: Aggressive behavior 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: www.cinahl.com/ cgi- bin /refsyc?jid = 203&accno = 2009559996

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Each nurse has the experience in his career, just as I do. Refer to my experience as a male nurse in the

adult psychiatric male ward for 4 years a lot of hands on my experience, lessons and memories to me in

terms of evidence based practice (EBP) and attitude because, psychiatric male ward is different with

another wards in my hospital. My role as a nurse is to provide the best service and quality for patient and

practice evidence based practices in every action I do in nursing intervention of my patient in psychiatric

male. During my assignment, I¶II is happy to choose a topic which tends to patients with mental problems.

Therefore, I am very keen to choose the topic on ³Aggressive behavior on acute psychiatric wards;

prevalence, severity and management´ by Foster C, Bowers L & Nijman H (2007) in Journal of Advanced

Nursing 58(2), 140-149 and then this journal was accepted for publication 31 August 2006.

In addition, my rationale for choosing the topic was because most of nurses and other staff in the

psychiatric ward of the patients complained of aggressive males in psychiatric. Besides that, aggressive

behavior on acute psychiatric ward is major nursing care problem that overwhelm nursing profession at

psychiatric unit for many years. Furthermore, there are studies that say about the increase in aggressive

patients in the acute ward psychiatric. Refer to the fact (Mc George et al, 2000) the biggest improvement

is a factor that may lead to environment disruption and aggressive patients in the psychiatric ward is the

symptom severity and more like despair combined with a severe physical environment in the ward.

In fact, nursing is also an important property in the medical profession in each country which plays a role

in promoting healthy lifestyles, help someone who has problem and improve the quality of hospitals. This

assignment is intended to discuss with respect to evidence based practice related to action performed

nursing intervention care in the ward. I also will choose a practice related research journal that I do in the

ward. In addition, I will criticize research journal that has been done by the researcher and I also will bring

the other article for literature review of other work done in this field. Then, I will evaluate and look back at

practice nursing care that I did to my patients which I can improve evidence based practice. Lastly, I will
support with recommendations for my best future practice. The title of my chosen article is µAggressive

behavior on acute psychiatric wards; prevalence, severity and management¶. The purpose of the

research critique, I will do this is where I want to examine the back and look what I feel is impossible and

it is possible in the research critique I select it as well as to identify patients characteristics that may be

harmful to an aggressive staff and other patients in the ward, including patients aggressively trying to hurt

themselves and I will give the best recommendations for preventing and treating these patients

aggressively, followed by improving the quality of evidence based practice. The methodology used was

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.

In this essay I could find on the development and promotion as well, the advantages and disadvantages

of evidence based nursing intervention practice in every action I did on my patients. Then, I will clarify on

a quantitative research paper, which I take guidance from the research that I have selected. With the

critique this research we can see the extent to which strengths and weaknesses of research that

researchers have done research first and in addition, we may update new research suggests the best

idea for improving the research. I 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 evidence based practice in (AAPW).

  
  

The definition of EBP from the knowledge I have and understanding that I know throughout my nursing

care action against the person of my patients have used the evidence that has been done by researchers

in decision making for patient care. The importances of nursing research in developing EBP are

necessary to improve the quality of care to patients. In addition, the nurse is an important asset to lead
the hospital to give the best care to patients. 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 Gerrish & 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. Then, 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.

According to (Hockenberry 2006; Burns & Grove, 2007) the concept of providing high quality patient care

through EBP has been evolved. EBN process with best practice evidence and a positive clinical outcome.

This means that, by using EBP and collaboration in action nursing intervention it can prevent and reduce

unwanted items can occur in any action nursing care done and it will also reduce the pressure and give

up the attitude among the staff where to look for them in the basic practice their education to address the

problem of patients and may be one of the new technology (Sredl, 2008). Supported by told, Palfreyman

nm& 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).

EBP consist of qualitative and quantitative research, it includes traditions, assumptions, clinical expertise,

patient values, preferences and beliefs (Rush & Harr, 2001; Jacobs, 2001). In health care today is

important however, there are factor which impede adaptation of EBP. Many researchers 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).

EBP can successfully implement, if the barriers overcomes. 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. In addition, research critique is a process that should be included in the EBP, it

involves critical thinking skills, knowledge in practices nursing care Nurse must improve their practices

and also to find and critique of selected research as not all the research that there are all good, true and

accurate. It must be assessed and improved in order to improve the quality of patient care.

 

The selected research journal for review and critique in this assignment entitled µAggressive behavior in

acute psychiatric ward; prevalence, severity and management¶. The article was written by Foster C,

Bowers L and Nijman H, and was accepted for publish on 31 August 2006 as edition of Journal of

Advanced Nursing. A review of authors background demonstrates that ,Bowers L and Nijman H , posses

Doctor of Professor in Mental Health and one of them currently was an Professor of Psychiatric and

Head of Research. However, Foster C clinical Psychology in Training, Department of Psychology,

Institute of Psychiatric, London, Uk.

 

In a research journal, which I will this critique chosen this title is very appropriate to the phenomenon that

occurs in the psychiatric ward where I work. According to 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 behavior, prevalence severity and ,management in this case. Referred to the

abstract of researcher¶s journal, they clearly mention the title of article, aim of study, background, method,

findings, conclusion and lastly the keywords. 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.

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The purpose of the study is to see and review in the case of patient self- harm, the nature and prevalence

of inpatient aggressive behavior directed at staff and other patient and 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 carried out.


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Statement of the literature reviews is to provide an explanation, evaluation and clarify 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 that 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 that the frequency is 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. 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).


 
 
 

It is believed planned sample size with subject inclusion and exclusion criteria discussed. Firstly, a large

sample size used consisted of groups of two different professional back ground nurses; who are direct

patient care provider in primary health care and hospitals. Secondly, an adequate sample size used of the

SOAS. The function of SOAS is a instrument for monitoring aggressive incident in psychiatric wards.

According to (Lambert and Hill, 1994) the correlation of the SOAS total score between observes was 0.87

- 0.61, indicating fair to good agreement. Furthermore, the scale is quick to complete and there is no need

for staff to be trained to use it. Respondents completed the SOAS following each witnessed

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

behavior: 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. Respondents 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. 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.


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The overall research approach were established on a conceptual framework whereby researchers are

working and research design would influence the research process, choosing appropriate research

design is the most important stage (Gerish&Lacey, 2006). In this research, theoretical framework has

been extracted from the literature review.

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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 based on strict rule of truth, logic, laws and prediction (Burn & Growth 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 for a more effective approach is to use methods that involve the emotions and feelings. Indeed,

the qualitative and quantitative researchers are essential in a very specialist because, involving the

implementation and scientific knowledge is great. Four types of commonly used quantitative design are

descriptive study, correlation, quasi ± experimental and experimental (Burns & Grove, 2007. As according

to Siedlecki (2008), non ± experimental research includes descriptive, correlation and comparative

designs.



 

In this research journal, researchers used a questionnaire survey designed to collect data.

Questionnaires designed from the basis of published guidelines by aggressive behavior prevention and

treatment recommendations by the researchers. Survey questionnaire was designed after conducting a

pilot study. According to (Cherry & Jacob) a pilot study is feasibility, smaller case study, which is more

cost effective and able to identify strength and limitations of a planned larger scale study which is used to

determine in advance the most efficient method to conduct actual research. Questionnaires dividing into

five columns pertaining to specific aspects of aggressive behavior: 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. Respondent 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. A

representative was assigned by researchers to distribute and collect answers sheet from participants.

Questionnaires handed out in the workplace and returned during working hours to prevent participant

from referring to other resources, such as textbook and group discussions, in ± order reduce bias. So, 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. However, this cannot be

assume as I feel sometime participant might not be compliant or might be busy on that day and will not be

able to return questionnaires on the same day or even lead to providing answer which are not precise. It

is good to mention for clarify, especially for novice learner about EBP to understand better.

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The most important concern of instrument characteristics is its validity and reliability. Validity of

questions 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¶s alpha test. Accordinurns & Grove (2007), reliability

measure consistency of error in measurement technique and Cronbach¶s alpha is a commonly

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.



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In quantitative research studies, the process of analyzing data can be worrying, as it contain research

language and notion of statically test (Coughlan, Cronin & Ryan , 2007) and for nurses don¶t have good

knowledge about mathematics background, the formula can be caunting (Quint, 2000). In planned to

succeed in knowledge 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. Statically (SPSS) used to counting the statically results. SPSS is

the packaged data management by computer, which use to statically analysis data to understandable

results (Gerish & Lacey, 2006). Inferential test used by researchers to assess the difference in the index,

to measure the t-test purposes. The use of t-test was over and knowledge of the index implementation.

Variance analysis is use for (more than two group). Correlations were using the Pearson test. According

to (Quinn 2000) correlations is to measurements of which one set of measurement is related with others

and the mostly use formula are Pearson product correlation coefficient. 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.




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The finding show, the knowledge index of the guidelines according to (Robinson & Perryman 2004)

aggressive behavior can cause stress, pain, and injury to the eyes and need of prevention and treatment.

However, the effect is more verbal aggression cannot be regarded as a matter of no importance in this

context, because the patient¶s daily exposure to verbal abuse can cause emotional problems of patients. .

Reason for statements was because the treatment method was constantly changing and nurses were not

keeping themselves updated with the changes. In clinical practices some of the appropriate interventions

are still in use by the participant sample, proper communication with patient such as speak quietly with

patient so, patient are not much to think about their problems and situations. Besides, it can also use

other methods such as, medications, seclusions and restraint. Referred 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. According to (Needham et al.2004) in

the UK violence prevention training courses 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 behavior. Our findings suggest that training also needs to focus on improving methods of

communication between staff and patients, so that staffs 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.







The prevention of aggressive behavior in 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

viability. 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. Thus, the

crucial evidence based practice important in any nursing intervention we will do for the patients in the

hospital and provide a positive outcome in each of the nursing care that we do for the patients, nurses,

community and society. With the support of organizations and exposure to look for evidence of past

research is a must and needs to promote evidence based practice in nursing. They should also, have the

option of applying the best research evidence in the real world as a positive attitude in the work

environment. If all nurses to integrate in every action must be based nursing intervention made the

evidence based practice, nursing profession is held in high esteem and to improve the quality of the best

service in the hospital.

Reference


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