Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Effect of Aggression Management Training on Perceived Stress Levels of Nurses Working in Mental Health Care Settings in Jordan

Rami Masa'Deh, PhD, RN; Omayma Masadeh, PhD; Samiha Jarrah, PhD, RN; Manar AlAzzam, PhD, MSN, RN; Fadwa Alhalaiqa, PhD, RN

Abstract

The current study investigated the effect of an aggression management training course on reducing perceived stress levels of nurses working in mental health care settings in Jordan. This quasi-experimental pre/post study included 83 nurses (44 male, 39 female; mean age = 33 years) who completed a sociodemographic characteristics questionnaire and the Arabic Version of the Perceived Stress Scale 10-Items Questionnaire. Participants attended 32 hours of an aggression management training course and then answered the questionnaires for a second time. Female nurses reported significantly higher stress levels than male nurses before and after the training course. Paired-samples t test showed a significant decrease in the mean total score of perceived stress of all nurses after attending the training course. The results of this study highlight the need to design and implement aggression management courses, as such training can improve nurses' mental health and perceived stress levels. [Journal of Psychosocial Nursing and Mental Health Services, 58(10), 32–38.]

Abstract

The current study investigated the effect of an aggression management training course on reducing perceived stress levels of nurses working in mental health care settings in Jordan. This quasi-experimental pre/post study included 83 nurses (44 male, 39 female; mean age = 33 years) who completed a sociodemographic characteristics questionnaire and the Arabic Version of the Perceived Stress Scale 10-Items Questionnaire. Participants attended 32 hours of an aggression management training course and then answered the questionnaires for a second time. Female nurses reported significantly higher stress levels than male nurses before and after the training course. Paired-samples t test showed a significant decrease in the mean total score of perceived stress of all nurses after attending the training course. The results of this study highlight the need to design and implement aggression management courses, as such training can improve nurses' mental health and perceived stress levels. [Journal of Psychosocial Nursing and Mental Health Services, 58(10), 32–38.]

Globally, nursing is considered one of the most stressful health care professions (Najimi et al., 2012). Mental health care settings in particular are acutely stressful and challenging, especially for nurses, as demonstrated by several studies (Masa'Deh et al., 2017; Zaki, 2016). Viegas (2015) attributed the fact that mental health nurses experience higher occupational stress than nurses working in other settings due to their provision of services to patients with behavioral and psychological problems.

A study conducted in Jordan that measured perceived stress in nurses working in various departments showed that nurses working in mental health care settings perceived the highest stress levels, followed by oncology, intensive care unit/critical care unit, and emergency department nurses, in descending order (Masa'Deh et al., 2017). Moreover, a descriptive explanatory study conducted among 119 nurses working in mental health care settings revealed that in addition to high levels of stress, nurses experienced high levels of psychiatric distress (Hasan & Tumah, 2019). A descriptive correlation design collecting data from 92 psychiatric–mental health nurses (PMHNs) in Jordan with a self-reported questionnaire also showed that these nurses reported high levels of stress (Hamdan-Mansour et al., 2011).

Nurses working in mental health care settings face many challenges due to the nature of the work environment and patient behavior; a more egregious example of this is the higher risk of being subjected to violence from service users (Itzhaki et al., 2018). In addition, nurses' perception of a high risk of violence from angry patients is a precursor of increased stress levels (Hylén et al., 2018). Pekurinen et al. (2017) conducted a study to determine and compare the prevalence of aggressive behavior from patients toward nurses, and the relationship between this behavior and the well-being of nurses in psychiatric and non-psychiatric settings. The results revealed that PMHNs reported several types of aggression more frequently compared to nurses working in medical and surgical settings. In addition to aggression and violent behavior from patients, lack of resources, insufficient training, and increased workload predict higher stress levels for PMHNs; however, violence was the leading cause of stress (Masa'Deh et al., 2018). Moreover, recent studies reported gender influences on stress levels, consistently showing that female nurses report higher levels of chronic and daily stressors than their male counterparts, and this finding applies in different departments, including mental health settings (Eisenbarth, 2019; Falavarjani & Yeh, 2019; Hasan & Tumah, 2019; Worly et al., 2019). A study using the Health Profession Stress and Coping Scale to examine gender influence on stress perception among 126 nurses found that female nurses reported higher perceived stress compared to male nurses (Caruso et al., 2017).

Several consequences of high stress levels on nurses were reported previously. On one hand, occupational stress reduced nurses' quality of life, reduced job satisfaction, increased burnout, put them at risk of secondary traumatic stress, and negatively affected the quality of care they provided to patients (Hylén et al., 2018; Itzhaki et al., 2018; Pekurinen et al., 2019). On the other hand, measures that reduced violence and aggressive behaviors were found to improve psychosocial working environment and reduce nurses' stress (Wikman, 2014).

Numerous measures have been suggested to manage stress among nurses working in mental health care settings (Shariatkhah et al., 2017; Zaki & Barakat, 2018). Farrell and Cubit (2005) compared the content of 28 aggression management programs and concluded that the majority of programs showed positive results on reducing stress levels of PMHNs. Zaki and Barakat (2018) conducted a pre/post quasi-experimental study to determine the effect of a stress management program on job-related stress among nurses working in mental health care settings in Egypt. Their findings showed a significant statistical decrease in total mean scores of the Psychiatric Nurses Job-Related Stress Scale after the introduction of a stress management program (Zaki & Barakat, 2018). Moreover, Shariatkhah et al. (2017) used cognitive-behavioral stress management to reduce job stress in 100 nurses working in several educational hospitals. Cognitive-behavioral stress management included different approaches (e.g., coping strategies, relaxation, anger management, control techniques), with results showing that the stress level among the interventional group was significantly lower than the control group (Shariatkhah et al., 2017).

To our knowledge, no interventional studies focused on aggression management in mental health nursing have been conducted in Jordan. Therefore, the current study aimed to determine the effect of an aggression management program on reducing the perceived stress levels of nurses working in mental health care settings. The following research questions were considered: (1) What is the pre-intervention mean level of perceived stress among PMHNs in Jordan? and (2) Does an aggression management course have an effect on perceived stress levels among PMHNs in Jordan?

Method

A quasi-experimental pre-/post study design was used. The study population comprised nurses working in mental health care settings in Jordan in several psychiatric–mental hospitals located in Amman (the capital city, with the largest population and highest concentration of health care services) (Jordanian Department of Statistics, 2019). Inclusion criteria were having at least a bachelor's degree in nursing; working in mental health care settings for ≥6 months; no previous exposure to aggression management training courses; and providing direct nursing care to patients with mental illness. Nurses working in administration positions, such as nursing supervisors and head nurses, were excluded because they do not have direct contact with patients.

A non-random convenience sampling technique was used. Data were collected in June 2019 and December 2019. The sample size was calculated using G power software version 3.1 (Faul et al., 2009). Assuming 80% power, an alpha level of 0.05, and medium effect size, a total of 83 PMHNs was deemed sufficient to detect statistically significant results.

Measures

Sociodemographic Characteristics. An Arabic-language sociodemographic questionnaire was developed by the research team to collect information of participants, including age, gender, educational level, weekly working hours, years of experience, marital status, and experience of aggressive behavior or violence from patients. As discussed previously and reported from previous studies, all of these variables may affect stress levels.

Arabic Version of the Perceived Stress Scale 10-Items Questionnaire (APSS10). The APSS10 is a 10-item, 5-point Likert rating scale, ranging from 0 (never) to 4 (very often). The APSS10 was used to measure perceived stress of nurses in different situations. Total scores of the APSS10 range from 0 to 40, with higher scores representing higher levels of perceived stress. Perceived stress levels were indicated by score ranges, with 0 to 13 indicating low perceived stress, 14 to 26 moderate perceived stress, and 27 to 40 high perceived stress (Cohen et al., 1983). The reliability of the APSS10 in previous studies ranged between 0.7 and 0.8 (Cohen & Janicki-Deverts, 2012).

Aggression Management Training Course

The aggression management training course was based on the LOWLINE method described by Lowry et al. (2016). This method combines techniques using words and body language that can help deescalate aggressive behavior. LOWLINE stands for the following:

  • Listen: Skilled and active listening can help in prevention of any angry outburst. PMHNs are taught how to look for non-verbal signs and listen to paraverbal communication, such as tone, inflection, and volume, as these are important to understand the reasons behind the anger reactions that are usually a response to a trigger.
  • Offer: PMHNs should be able to identify early signs of anger and should attempt to prevent an escalation of any anger response by offering choices, alternatives, and solutions when possible. Nurses should be able to communicate in a way that assures patients that their feelings are being taken seriously.
  • Wait: Nurses should not fill the void with words but wait for patients to elucidate their feelings and articulate their needs.
  • Look: Nurses are taught to maintain eye contact with patients without staring, smiling when appropriate, or maintaining a neutral expression. All of these responses were found to be helpful in de-escalating anger behavior and were culturally appropriate communication skills.
  • Incline: Nurses are taught how to incline the head to present a non-threatening posture.
  • Nod: Nurses are taught how to use a nodding technique to show continued attention and provide positive reinforcement in terms of non-verbal cues.
  • Express: Nurses are taught how to express a desire to understand or empathize.

In the current study, the research team applied the LOWLINE method in the training course provided to nurses working in psychiatric–mental health care settings. The content of the training course was discussed with three specialists in the field. Two specialists were PhDs in psychiatric–mental health nursing, and one was a psychiatric nurse. The content and methods of presenting the course to PMHNs was discussed until agreement was reached.

Nurses attended 32 hours of training over a 2-week period. The course was provided in 8 training days, each of which included 4 hours. In the first 3 days, communication skills using verbal and non-verbal techniques and the importance of respecting personal space were explained in detail. The course also included detailed information about applying active listening skills, understanding, offering solutions/alternatives, and expressing empathy, which was provided on Days 4, 5, and 6. Other techniques to deescalate aggression, such as strategies to avoid provocation, being concise, and repeating oneself, were explained to nurses on Day 7. The last day, Day 8, included review and practice of deescalating techniques. The material of the course was distributed to two members of the research team. The first researcher presented the first 3 days of the training course, and the remaining days were presented by the second researcher.

Ethics

Ethical approvals were obtained from the Institutional Review Board of the Applied Science Private University and the Jordanian Ministry of Health to collect data from governmental hospitals. Participants' rights, such as voluntary participation, privacy, confidentiality, and the right to withdraw at any time without giving a reason, were guaranteed and explained to all participating nurses. Participants were informed that all collected data were securely stored (i.e., in locked filing cabinets and password-protected computers), accessible only to the research team.

Data Collection

An invitation letter and information sheet were sent to potential participants. Researchers' contact details were provided on the information sheet for those who wanted to participate, or who had any enquiries about the study. An informed consent form was signed by those who agreed to participate. Participants completed the sociodemographic questionnaire and the APSS10 before implementation of the training program and primary analysis was performed. The course was then implemented over 2 weeks. Five months passed before the second round of data collection, with nurses who attended the course completing the APSS10 for the second time.

Data Analysis

Data were analyzed using SPSS version 25. Alpha was set as 0.05; therefore, p < 0.05 was considered significant. Descriptive statistics were used to describe the sociodemographic characteristics. A paired t test was conducted to check differences in stress levels before and after the training course.

Results

A total of 111 nurses were invited to participate in the study, of whom 97 consented. Of those, 83 nurses (44 males, 39 females) attended the training course and completed the study questionnaires, resulting in a final response rate of 86%. Most nurses were married and held a bachelor's degree in nursing. The majority of nurses reported exposure to previous aggression/violence from patients. Mean age of nurses was 33 years, with most having an approximate mean of 5 years' experience in mental health care settings (Table 1).

Sociodemographic Characteristics (N = 83)

Table 1:

Sociodemographic Characteristics (N = 83)

Independent samples t test was conducted to compare the differences in mean perceived stress at two time points by gender. Female nurses reported significantly higher stress levels than male nurses before and after the training course. At Time 1, mean stress levels of female nurses were significantly higher than those of male nurses (mean = 28.94 [SD = 4.23] vs. mean = 26.2 [SD = 3.03]; t [81] = 2.01, p < 0.001). The magnitude of the differences in the means at Time 1 (mean difference = 2.74, 95% confidence interval [CI] [0.73, 4.75]) was small (η2 = 0.05). At Time 2, mean stress levels of female nurses were significantly higher than mean stress levels of male nurses (mean = 24.19 [SD = 3.93] vs. mean = 20.23 [SD = 3.13]; t [81] = 2.01, p < 0.001). The magnitude of differences in the means at Time 2 (mean difference = 3.96, 95% CI [1.95, 5.97]) was small (η2 = 0.05) (Table 2).

Differences in Levels of Perceived Stressa According to Gender

Table 2:

Differences in Levels of Perceived Stress According to Gender

A paired-samples t test was performed to investigate the differences in perceived stress of all PMHNs before and after the training course. A significant decrease was found in the mean total score of perceived stress at Time 2 compared to Time 1 (Time 1, 27.57 [SD = 5.23]; Time 2, 22.21 [SD = 3.31]; t (82) = 3.31, p < 0.001). The magnitude of the differences in the means (mean difference = 5.36, 95% CI [2.05, 8.67]) was moderate (η2 = 0.12) (Table 3).

Differences in Levels of Perceived Stressa After the Training Course

Table 3:

Differences in Levels of Perceived Stress After the Training Course

Discussion

A quasi-experimental pre/post study with 83 nurses attending a 32-hour aggression management training course over a 2-week period was performed. Findings show that nurses working in mental health settings had high perceived stress levels. These findings are consistent with other studies conducted in Jordan, where high levels of stress among PMHNs have been reported (Hasan & Tumah, 2019). In a national study using the APSS10 to explore the perceived stress levels among 310 Jordanian nurses working in various departments, nurses working in mental health care settings experienced the highest stress levels (Masa'Deh et al., 2017). The results of the current study are also congruent with international study findings (Hylén et al., 2018; Itzhaki et al., 2018; Pekurinen et al., 2019). Our study results corroborate existing research confirming that working in mental health care settings is particularly stressful due to several factors, including working conditions, the nature of patients' disorders, lack of resources, and long work hours.

An interesting result in the current study is that female nurses had higher perceived stress levels compared to male nurses. This finding is congruent with previous studies, which reported that female nurses had higher stress levels compared to their male counterparts (Eisenbarth, 2019; Falavarjani & Yeh, 2019; Hasan & Tumah, 2019; Worly et al., 2019). This finding could be attributable to differences in stress perception being related to differences in coping mechanisms and the quality of social support between genders (Flannery et al., 2018; Mayor, 2015; Pettus-Davis et al., 2018). In addition, women and men may have different roles and responsibilities, and therefore may appraise stress differently (Lee & Jung, 2015).

The current study's results showed that perceived stress levels of nurses working in mental health settings decreased significantly after attending the aggression management training course, affirming previous findings that aggression management training courses are beneficial in addressing stress levels. For example, the results of a study conducted in Canada to assess the impact of an Omega education and training program in alleviating stress levels demonstrated the positive impact of the training program on stress scores (Guay et al., 2016). In addition, in a meta-analysis conducted by Kim (2007) to measure the effect of cognitive-behavioral job stress management, results indicated a significant improvement in stress management skills among nurses working in mental health care settings. The current study results are also in line with Pahlavanzadeh et al.'s (2016) results, which revealed a positive and enduring consequence of a stress management program on stress management behaviors of 65 nurses. Moeini et al. (2011) conducted a quasi-experimental study among 58 female nurses who underwent five sessions of a stress training program, and their results indicated that average job stress scores decreased significantly (Moeini et al., 2011).

Limitations

The current study included nurses from several hospitals in Amman, Jordan, a city with a high concentration of the national population and health care resources; thus, these results may not be generalizable to other countries or contexts. Given the role of culture in stress perception, it is suggested that future studies explore nurses in different countries and national nursing workforces.

Implications

Regardless of the limitations of the current study, the results are promising and support the design and implementation of aggression management programs for PMHNs to enhance their psychological well-being and problem-solving abilities, which ultimately affect their perceived stress levels. Research is needed to assure health care policy makers and organizations dedicate more resources and efforts into multi-faceted aggression management programs among nurses working in mental health care settings, so as to reduce the consequences that might be associated with stressful work environments. The LOWLINE method showed a positive impact on stress levels among PMHNs in the current study; therefore, nurses should be aware of these resources and be given the opportunity to enroll in such courses when possible.

Conclusion

Nurses working in mental health care settings face many challenges, including aggressive behavior of patients, which may be stressful. The results of the current study highlight the need to design and implement aggression management courses for all nurses working in mental health care settings. Such training courses can help nurses effectively manage and cope with patients demonstrating aggressive behaviors. This training may help promote good mental health among nurses, thus increasing job satisfaction and reducing burnout, absenteeism, and turnover, which could lead to improved quality of care provided in a better working environment.

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Sociodemographic Characteristics (N = 83)

Variablen (%)
Gender
  Male44 (53)
  Female39 (47)
Marital status
  Married67 (80.7)
  Single13 (15.7)
  Widowed2 (2.4)
  Divorced1 (1.2)
Educational level
  Bachelor's degree78 (94)
  Master's degree5 (6)
Faced previous violence/aggression
  Yes78 (94)
  No5 (6)
Mean (SD) (Range)
Weekly working hours30 (3.21) (23 to 40)
Age (years)33.21 (3.45) (22 to 44)
Years of experience5.11 (1.6) (0.5 to 6.5)
Total stress scorea
  Pre (Time 1)27.57 (5.23) (14 to 40)
  Post (Time 2)22.21 (3.31) (19 to 28)

Differences in Levels of Perceived Stressa According to Gender

VariableMean (SD)tp Value
Time 12.01<0.001
  Females28.94 (4.23)
  Males26.2 (3.03)
Time 22.01<0.001
  Females24.19 (3.93)
  Males20.23 (3.13)

Differences in Levels of Perceived Stressa After the Training Course

VariableMean (SD)p Value
PrePost
Total stress score27.57 (5.23)22.21 (3.31)<0.001
Authors

Dr. R. Masa'Deh is Associate Professor, and Dr. Jarrah is Dean of Nursing Faculty, School of Nursing, Applied Science Private University, Amman, Dr. O. Masadeh is Assistant Professor, Psychological and Educational Counseling, Relief International, Amman, Dr. AlAzzam is Associate Professor, Psychiatric Mental Health, Princess Salma Faculty of Nursing, Al-Albayt University, Mafraq, and Dr. Alhalaiqa is Associate Professor and Dean, School of Nursing, Philadelphia University, Amman, Jordan.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The authors are grateful to the Applied Science Private University, Amman, Jordan, for the full financial support granted to this research project.

Address correspondence to Rami Masa'Deh, PhD, RN, Associate Professor, School of Nursing, Applied Science Private University, Al Arab Street, Amman 11931, Jordan; email: r_masadeh@asu.edu.jo.

Received: April 06, 2020
Accepted: June 08, 2020
Posted Online: August 26, 2020

10.3928/02793695-20200817-03

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