the lived experience by psychiatric nurses of aggression amongst colleagues
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Surname, Initial(s). (2012) Title of the thesis or dissertation. PhD. (Chemistry)/ M.Sc. (Physics)/ M.A. (Philosophy)/M.Com. (Finance) etc. [Unpublished]: University of Johannesburg. Retrieved from: https://ujdigispace.uj.ac.za (Accessed: Date).
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
ii
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.
iii
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.
iv
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.
v
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.
vi
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.
vii
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
viii
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
ix
3.2 DESCRIPTION OF THE SAMPLE .................................................................. 32
3.3 DESCRIPTION OF THE ENVIRONMENT IN WHICH THE RESEARCH WAS
CONDUCTED ........................................................................................................ 33
3.4 DATA ANALYSIS OF INTERVIEWS ............................................................... 33
3.4.1 Central story line ..................................................................................... 33
3.4.1.1 Theme 1: The psychiatric nurse experience aggression as subtle,
passive and very harmful in a verbal and non-verbal manner ........................ 36
3.4.1.2 Theme 2: Nurses experience a doubtful, suspicious and distrustful
team environment ........................................................................................... 40
3.4.1.3 Theme 3: The psychiatric nurses experience limited support when
aggression is not acknowledged by colleagues and management ................. 42
3.4.1.4 Theme 4: Psychiatric nurses experience using coping mechanisms
when emotional stress and aggression is experience .................................... 47
3.5 THE RESEARCHER’S PERSONAL FIELD NOTES, OBSERVATION FIELD
NOTES, METHODOLOGICAL FIELD NOTES AND THEORETICAL FIELD NOTES
51
3.6 DISCUSSION OF THE RESULTS .................................................................. 52
3.7 CONCLUSION ............................................................................................... 55
CHAPTER 4: OVERVIEW, GUIDELINES, RECOMMENDATIONS, CHALLENGES
AND CONCLUSIONS ............................................................................................... 56
4.1 INTRODUCTION ............................................................................................ 56
4.2 GUIDELINES .................................................................................................. 56
4.2.1 Guideline 1: Facilitating the management of aggression experienced
amongst colleagues ........................................................................................... 58
4.2.2 Guideline 2: Facilitating teamwork, in a trusting and caring work
environment ....................................................................................................... 60
4.2.3 Guideline 3: Addressing factors contributing to aggression experienced in
the work environment ......................................................................................... 61
4.2.4 Guideline 4: Strategies to cope effectively when aggression is
experienced ....................................................................................................... 62
x
4.3 CONCLUSION OF RESEARCH ..................................................................... 63
4.3.1 RESEARCH DESIGN AND METHOD ..................................................... 65
4.3.1.1 Phase 1: Exploration and Description of the Lived Experience by
Psychiatric Nurses of aggression amongst colleagues .................................. 65
4.2.1.2 Phase 2: Guidelines to Assist the Psychiatric Nurses to cope with the
challenges of aggression amongst colleagues ............................................... 66
4.4 RECOMMENDATIONS AND FUTURE RESEARCH ...................................... 67
4.5 CHALLENGES ............................................................................................... 68
4.6 SUMMARY ..................................................................................................... 69
4.7 CONCLUSION ............................................................................................... 71
REFERENCES .......................................................................................................... 73
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REFERENCE LIST
APPENDIX A: ETHICAL CLEARANCES .................................................................. 80
APPENDIX B: REQUEST FOR CONSENT TO CONDUCT RESEARCH ................. 85
APPENDIX C: PARTICIPANT’S INFORMATION SHEET ......................................... 88
APPENDIX D: INTERVIEW....................................................................................... 92
APPENDIX E: NAIVE SKETCH .............................................................................. 111
TABLE LIST
TABLE 3.1 – THE LIVED EXPERIENCE BY PSYCHIATRIC NURSES OF
AGGRESSION AMONGST COLLEAGUES .............................................................. 34
TABLE 4.1 - THE GUIDELINES AND RECOMMENDATIONS FORMULATED FOR
THE PSYCHIATRIC NURSE EXPERIENCING AGGRESSION AMONGST
COLLEAGUES .......................................................................................................... 55
FIGURE LIST
FIGURE 3.1 - SUMMARY OF THE FINDINGS OF THE LIVED EXPERIENCE OF
THE PSYCHIATRIC NURSE .................................................................................... 57
FIGURE 4.2 - FINDINGS OF THE LIVED EXPERIENCE OF THE PSYCHIATRIC
NURSE ..................................................................................................................... 71
1
CHAPTER 1: OVERVIEW OF THE STUDY AND RATIONALE
1.1 INTRODUCTION
In this chapter, the background and rationale of the research study, as well as the
conceptual and operational definitions of aggression, are discussed. In addition it
mainly describes the purpose and objectives of the research study, as well as the
research design and ethical principles. At the end of the chapter, the chapters of the
research study are listed and an informative summary is made.
1.2 BACKGROUND AND RATIONALE
Psychiatric professional nurses have daily interaction with their clients, their clients’
families and their colleagues. Through daily interaction with their environment,
psychiatric nurses form different types of relationships. In a typical working day, the
psychiatric nurses are in constant interaction with their working environment (Bilgin,
2009:257). During these interactions the psychiatric nurses have the opportunity to
improve on their interpersonal skills.
Bilgin (2009:257) studied the interpersonal skills of nurses in the work environment
and stated that nurses are more likely to feel that their rights are ignored while the
rights of patients are established and protected. According to Lin, Probst and Hsu
(2010:2343), research has identified nursing as high a stress profession. Nurses
cope daily with extreme physical and psychological demands inherent in providing
care to acute and chronic populations. The demands of caring for others can be
extremely stressful on the psychiatric nurse (Van Rhyn & Gostsana, 2004:18).
2
According to Van Rhyn and Gostsana (2004:19), most studies done on stress
experienced in a psychiatric setting focused on registered professional nurses, with
findings indicating that psychiatric nurses are exposed to various stressors that are
common to other areas of nursing. Typical examples of these various stressors are
staffing levels, overwork and administrative duties. In addition they face unique
challenges in their day-to-day work that reflect in their interaction with a particular
client group. Working with shortages of staff, in an inadequate physical working
environment, under hierarchical pressure with regard to colleagues, co-workers or
medical staff, as well as being victims of interpersonal violence, are an indicator of a
stressful work environment (Bilgin, 2009:257).
Various studies have been done on violence in the work environment. Yildirim
(2009:505) states that nurses are at a high risk of being exposed to violence in the
work environment. According to Yildirim (2009:509), violence in the form of fellow
colleagues’ bullying, as well as exposure e to aggression and hostility from their
clients who they care for in psychiatric hospitals (Bimenyimana, Poggenpoel,
Myburgh & Van Niekerk, 2009:5), are all indications of the harsh realities with which
psychiatric nurses have to deal on a day-to-day basis. Furthermore, both Yildirim
(2009:505) and Bimenyimana, et al (2009:5) indicate that violence of this type
ultimately has an overt negative psychological effect on the nurses. The study will
only be conducted amongst psychiatric nurses in their work environment and not
amongst psychiatric nurses and their clients.
Kaplan and Sadock (2003:150) define aggressive behaviour as the intent to cause
another person harm. They further explain that many behaviours are aggressive,
even though they do not involve direct physical injury. Examples of this behaviour are
verbal aggression, coercion, intimidation and social ostracism of others. The
importance and effects of these behaviours in day-to-day living should not be
underestimated. Aggressive behaviour could have harmful psychological
3
consequences and can affect the recipients’ self-esteem, social status and
happiness.
Passive aggressive behaviour is a manifestation of passive or reactive expression of
underlying aggression. This behaviour is characterised by covert obstructionism,
procrastination, stubbornness and inefficiency (Kaplan & Sadock, 2003:150). It can
manifest itself by means of learned helplessness, resentment, bad temper, deliberate
failure to accomplish requested tasks, chronic late coming, forgetting things and fear
of competition (Wetzler,1992:36). According to Wetzler (1992:36), passive
aggressive behaviour is passive, sometimes obstructionist resistance to following
through with expectations in interpersonal or occupational situations. Passive
aggression is a pervasive pattern of negative attitudes and resistance in interpersonal
or occupational situations.
According to the Theory for Health Promotion in Nursing (University of
Johannesburg, 2006:4), “The person is seen holistically in interaction with the
environment”. Psychiatric nurses daily interact with their working environment, as
discussed in Yildirim (2009:505) and Bimenyimana, et al (2009:5). The psychiatric
nurses experience violence and aggression from not only their colleagues, but from
their clients, which have negative psychological effects. Therefore, violence,
aggression and specifically passive aggressive behaviours have, in this case, an
overt negative effect on the psychiatric nurse who presents as a wholistic person with
mind, body and spiritual dimensions.
1.3 PROBLEM STATEMENT
Violence and aggression in psychiatric hospitals have been widely researched
internationally and nationally (Bilgin, 2009:257; Bimenyimana, et al, 2009:5). Kaplan
and Sadock (2003:150) define aggression as the intent to cause harm to another
person. They further explain that many behaviours are aggressive, even though they
4
do not involve physical injury. Examples of these behaviours are verbal aggression,
coercion, intimidation and social ostracism of others.
The importance and effect of these behaviours in day-to-day living should not be
underestimated. The assumption is made that it could have severely harmful
psychological consequences in the long-term and that it can thus affect the
participants’ self-esteem, social status and happiness. Bowers (Bilgin, 2009:253)
states that staff’s positive attitudes could have an effect on their clients. Bilgin
(2009:253) explains the importance of nursing staff’s roles and attitudes in the
interaction with the psychiatric environment, which should ultimately strive to create a
therapeutic milieu. This implies that the psychiatric nurse’s interpersonal skills play an
extremely important role in the creation of such an ideal milieu in the work
environment.
The researcher works as a psychiatric professional nurse in an academic psychiatric
hospital in the Gauteng region. While working in a psychiatric unit, the researcher
observed that at times colleagues display behaviours such as constant late coming,
refusal and/or delaying of participation in tasks and, at times, ignoring one another.
The following research questions guide this research:
what is the lived experience of the psychiatric nurses with aggression amongst
colleagues in the work environment; and
what can be done to assist psychiatric nurses in their work environment and
manage aggression to facilitate their own mental health?
1.4 RESEARCH PURPOSE AND OBJECTIVES
The overall purpose of the study is to explore and describe the lived experience of
the psychiatric nurses of aggression amongst colleagues in the work environment
and to formulate guidelines on assisting psychiatric nurses in managing their
aggression in order to facilitate their own mental health.
5
The objectives of the study are to
1. explore and describe the psychiatric nurse’s lived experience of aggression
when in interaction with fellow colleagues, and
2. formulate guidelines on assisting the psychiatric nurses in managing their
aggression and to facilitate their mental health.
1.5 PARADIGMATIC PERSPECTIVE
Babbie and Mouton (2011:645) define paradigm as “a model or framework for
observation and understanding, which shapes both what people see and how people
understand it”. Paradigm is thus a world view underlying the theories and
methodology of a scientific subject. Paradigm implies a commitment to a collection of
convictions that are meta-theoretical, theoretical and methodological by nature. The
Theory for Health Promotion in the Nursing Department of Nursing Science
(University of Johannesburg, 2006:9) will be applied to this research study. This
implies a wholistic approach of the psychiatric nurse - body, mind and spirit - with
maximum use of resources, striving for the respect of his or her rights and his or her
place in human society.
In the paragraph that follow, the meta-theoretical, theoretical and methodological
assumptions of the study is discussed.
1.5.1 Meta-theoretical Assumptions
An assumption, as described by Burns and Grove (2005:728), is a statement not
considered or found to be true, although the statement have not been tested.
6
Assumptions influence the logic of the study, and their recognition leads to more
rigorous study development. The Theory for Health Promotion in Nursing of the
Nursing Department of Nursing Science’s (University of Johannesburg, 2006:6)
wholistic view of the human being leads to the concepts discussed in the paragraphs
that follow.
The whole person embodies dimensions of body, mind and spirit. In this research
study, the person is any professional nurse who is registered with the South African
Nursing Council, working in an academic psychiatric hospital and who is in interaction
with other professionals.
Body: the body includes all anatomical structures and physiological reactions
to an aggressive environment (University of Johannesburg, 2006:6).
Mind: the mind is associated with the capacity and intuition of a person to
think logically, understand and make associations. Analysis and judgement,
both of which the psychiatric nurse is capable of doing (University of
Johannesburg, 2006:6).
Spirit refers to the psychiatric nurse who reflects his or her relationship with
his or her god. The spirit consists of two interrelated components, namely
morality or ethics and relationship, in this case, with God. In this research
study, the spiritual also includes the psychiatric nurse’s perception of the
values of others that they interact with, the convictions and ethics that guide
and direct his or her work and the motivation that drives him or her (University
of Johannesburg, 2006:6).
The environment comprises an internal and external environment. The internal
environment consists of the dimensions of the body, mind and spirit, while the
external environment is physical, social and spiritual (University of Johannesburg,
7
2006:6). The external environment represents the physical structures of the
institution, the professional and social interactions amongst the nurse and other
health care workers, as well as the clients and the ethics and core values that
motivate the individual to believe in the values of people who suffer from mental
illnesses.
Psychiatric Nursing: psychiatric nursing is the interactive process in which
the psychiatric nurse is a sensitive, therapeutic professional who facilitates the
care, treatment and rehabilitation of the clients by means of the mobilisation of
resources (University of Johannesburg, 2006:4).
Mental Health: this is a state of being in which a person is simultaneously
successful at working, loving and resolving conflicts by coping and adjusting to
the recurrent stresses of everyday living (Uys & Middleton, 2010:16).
1.5.2 Theoretical Definition of Concepts
In order to avoid bias, the researcher enters the field with an open mind; bracketing
(Burns & Grove, 2005:729) is implemented when the researcher treats the
participants’ experiences without any unfairness or preconceived ideas. The findings
are contextualised by literature control.
The conceptual definitions of the terms used in the research study are now
discussed.
Lived experience: in phenomenological research, lived experience refers to
describing the meaning of a concept or a phenomenon experienced by
psychiatric nurses. The focus is on describing what all participants have in
common as they experience a phenomenon (Creswell,1994:51).
8
Psychiatric nurse: in this study, a psychiatric nurse refers to a registered
psychiatric nurse. The psychiatric nurse is registered at South African Nursing
Council (Bimenyimana, et al, 2009:6).
Aggression: aggression is defined as the intent to cause harm to another
person, but it is further explained that many behaviours are aggressive even
though they do not involve physical injury. These behaviours include verbal
aggression coercion, intimidation, managerial styles that have harmful
psychological effects on others and ostracism of others. These behaviours
have a negative effect on other people’s self-esteem, social status and
happiness (Kaplan & Sadock, 2003:150).
Colleagues: In this research, colleagues refer to the psychiatric nurses
working in a specific specialised unit in a public psychiatric hospital in
Gauteng.
1.5.3 Methodological Assumptions
The methodological assumptions reflect the researcher’s views of the nature and
structure of the science in the discipline. The assumptions are stated in terms of the
objectives and method of the research and the criteria for validity. Measures to
ensure trustworthiness (Creswell, 2009:196) will be discussed in detail in the chapter
2, in order that the findings may be supported by two principles of science, namely
logic and justification.
Logic is a science that involves valid ways of relating ideas to promote understanding
(Burns & Grove, 2005:741). Logic is used in order to determine truth or to explain and
predict a phenomena. Justify is to demonstrate or prove to be just, right or valid.
9
1.6 RESEARCH DESIGN AND METHOD
A research design is the “blueprint for conducting a study that maximises control over
factors which could interfere with the validity of findings” (Burns & Grove, 2005:734).
The research design of the study is qualitative, exploratory, descriptive and
contextual in nature (Maphorisa, Poggenpoel & Myburgh, 2002:24). This qualitative
approach creates an opportunity to discover the phenomena of the lived experiences
of psychiatric nurses of aggression amongst colleagues. The intention for exploring
this phenomena is to gain an understanding of the lived experiences of psychiatric
nurses. Burns and Grove (2005:55) state that the purpose of the phenomenological
research approach is to describe experiences as they are lived. The aim is to capture
the psychiatric nurses’ lived experiences of aggression amongst colleagues. The
terms exploratory, descriptive and contextual will be described in more detail in
following chapter 2.
The research is conducted in two phases. In phase 1 the lived experience by
psychiatric nurses of aggression amongst colleagues is explored and describe. In
phase 2 guidelines are formulated on assisting psychiatric nurses in coping with the
challenges of aggression amongst colleagues.
1.6.1 Phase 1 - Exploration and description of the lived experience by
psychiatric nurses of aggression amongst colleagues
A phenomenological approach (Creswell, 2007:59) will be followed in phase 1. The
population and sampling, data collection, data analysis and literature control will be
discussed in phase 1.
1.6.1.1 Population and Sampling
10
A population is the entire group of individuals who meet the sample criteria for
inclusion in a research study for which information is desired (Burns and Grove,
2005:746). The accessible population for this study are all the psychiatric nursing
staff registered with the South African nursing council and currently employed in an
academic psychiatric hospital in Gauteng.
Participants for this study would be individual psychiatric nursing staff members who
can identify signs of aggressive behaviour in the work environment when interacting
with colleagues. The researcher decided on a purposeful sampling method.
According to Burns and Grove (2005:352), a purposive sample involves the
researcher’s conscious selection of certain participants to be included in the study.
Furthermore, the sample consists of prospective participants who are likely to provide
information about the phenomenon under investigation.
1.6.1.2 Data collection
Data for the research study is collected by means of in-depth phenomenological
interviews and naive sketches (Giorgi, 1985:21). Interviews can reveal the discourses
and language, verbal and non-verbal, that people use to construct their lived realities
(Lee & Stanko, 2003:200). The researcher’s intention is to gain clarity into the
participants’ lived experiences with aggression amongst colleagues. The following
question will be asked in the in-depth phenomenological interviews and naive
sketches, “What is your experience of aggression amongst colleagues in the
work environment?” All interviews will be recorded and all naive sketches taken for
coding and further analyses. Field notes will be taken based on observations during
the interviews. All participants’ permission to use an audio-recorder will be requested.
The audio-recordings will be kept under lock and key in the researcher’s office and
only the researcher and supervisors will have access to these audio-recordings. The
recordings will be destroyed two years after publication of the research. Interviews
will be conducted until data saturation occurs, after which they will then be
11
transcribed verbatim (Streubert & Carpenter, 2011:122). The researcher would use
communication skills such as probing, clarifying, reflecting on the context, bracketing,
minimal response and summarising (Burns & Grove, 2005:542).
1.6.1.3 Data analysis
Tesch’s open coding method, which comprises eight steps of data analysis (Creswell,
2009:155), will be employed to develop themes and categories. Direct quotes will be
used from transcriptions of the in-depth phenomenological interviews. Field notes, as
well as the naive descriptions, will be analysed in order to identify different topics and
create themes and categories (Wilson, 1989:380). The focus in the data analysis will
be on psychiatric nurses’ lived experience of aggression amongst colleagues. An
independent coder will be used to code the information gathered and discuss
identified themes with the researcher until consensus is reached.
1.6.1.4 Literature control
Literature provides a framework within which to establish the importance of the study,
as well as a benchmark for comparing the results of the study to other findings
(Creswell, 1994:21). During this process, the researcher will demonstrate the
usefulness of the findings compared to what is already known on the subject. This is
done as there is no local theory with which to compare findings. The researcher will
attempt to show the implications of the findings in relation with the psychiatric nurses’
professional and personal development, as well as the academic psychiatric hospital
in which these psychiatric nurses work. This will constitute the basis of the
formulation of guidelines on managing this aggression in the work environment.
12
1.6.2 Phase 2 - Guidelines to assist psychiatric nurses in their work
environment
Guidelines to assist psychiatric nurses in their work environment will be derived from
the results of phase 1.
1.7 MEASURES TO ENSURE TRUSTWORTHINESS
The method of establishing trustworthiness was adopted from Lincoln and Guba
(Krefting, 1991:156), who identify credibility, transferability, dependability and
confirmability as strategies to ensure trustworthiness.
To ensure credibility, the researcher would prolong the engagement with participants,
to the point of data saturation. The information gathered from the participants will be
checked with the participants during and after data collection. All in-depth
phenomenological interviews will be recorded and transcribed. Participants will be
asked to write a naive sketch contributing to data saturation (Krefting, 1991:164-166).
Transferability will be ensured by giving a description of the demographic information
of the participants, as well as a dense description of data, supported by direct
quotations from participants (Krefting, 1991:166-167).
Dependability will be achieved by means of a dense description of the research
methodology used in this research. All interview materials, transcripts,
documentation, findings, interpretations and recommendations will be kept available
and accessible to the supervisors, and any other researcher, for the purpose of
conducting an audit trail at a later date (Krefting, 1991:167-168).
An audit trail of the verbatim descriptions, themes and categories will ensure
confirmability. The researcher will provide a description of the research methodology,
and purposeful sampling will be used (Krefting, 1991:168-169).
13
Chapter 2 will discuss trustworthiness will in depth.
1.8 ETHICAL MEASURES
The study involved human participants and as such their rights will be protected.
Therefore ethical principles were and will be adhered to. The four ethical principles,
namely autonomy, non-maleficence, beneficence and justice, will be applied to this
study. Each principle is binding, unless it clashes with an equal or stronger obligation
(Dhai & McQuoid-Mason, 2011:3).
All suitable participants will be given a fair opportunity to choose to participate. The
participants will be assured of their rights to self-determination. The researcher will
inform the prospective participants about the proposed study (see appendix C),
enabling the participants to determine whether they want to participate in the study or
not. Obtaining the participants’ informed consent is essential. The necessary
informed consent will be obtained by means of a letter (see appendix B) that will
explain the goals of the prospective study to the participants (Burns & Grove,
2005:181-190).
The participants will be assured of their rights to privacy; their personal information
will be kept private and be destroyed two years after the completion of the study. The
participants name will not be mentioned during or after the interviews or during
transcription and coding. All information received will be treated professionally and
with respect. Keeping all data that was collected confidential, will assure the
participants of their privacy. The researcher will be guarantee confidentiality on her
part.
14
Data will be collected by means of in-depth phenomenological interviews and naive
sketches, and consent will be obtained for the use of an audio-recorder. All
participants would have the choice to opt out of the interview at any stage, or refuse
to answer specific questions, should they wish to do so. Participants will be
requested to provide permission to record the interviews. Recordings will be kept
under lock and key, with only the researcher and supervisors having access to it.
Recordings will be destroyed two years after publication of the research. Participants
will not be identified in the research report. No compensation will be paid to any of
the participants for participating in the study (Burns & Grove, 2005:181-190). No
harm is anticipated during the course of the research. The participants will benefit by
verbalising their lived experiences (Dhai & McQuoid-Mason, 2011:3).
1.9 DIVISION OF CHAPTERS
This research study is divided in to four chapters.
Chapter 1 comprises the overview of the research study. Chapter 2 discusses the
research design and method. Continuing to chapter 3, the lived experience by
psychiatric nurses of aggression amongst colleagues will be presented by means of
the research study findings. In the final chapter, chapter 4, guidelines on and
recommendations for the research study will be presented and discussed.
1.10 CONCLUSION
This chapter broadly discussed the overview of the research study, focusing on
background and rational of the research question and objectives. In addition, the
research design and method were briefly outlined and ethical considerations
mentioned. In chapter 2, the researcher will focus in detail on the research design
and method that will be used in this research study.
15
CHAPTER 2: RESEARCH DESIGN AND METHODOLOGY
2.1 INTRODUCTION
In chapter 2, the researcher elaborates on the research design and method of study.
Burns and Grove (2005:736) explain that a research design is the blueprint for
conducting a study that increases the control over factors including the validity of the
research findings. To explore and describe the lived experience by psychiatric nurses
of aggression amongst colleagues, the researcher intends to use a qualitative,
phenomenological design. The researcher is to observe the psychiatric nurses in
their natural setting, attempting to clarify their experiences of aggression amongst
colleagues.
2.2 RESEARCH DESIGN
The research design is qualitative, exploratory, descriptive and contextual in nature
(Maphorisa, Poggenpoel & Myburgh, 2002:24).
2.2.1 Qualitative research
In this research study, the researcher seeks to inquire into and identify the essence
of human experience about a phenomenon as described by a participant (Creswell,
2009:233). The focus will be on how the individuals in a group view and understand
the world and how they make sense out of their experiences (Maree, 2010:50). This
qualitative approach creates an opportunity to discover the phenomena of the lived
experiences by psychiatric nurses of aggression amongst colleagues. Edmonds and
Kennedy (2013:112) explain that a qualitative method represents a form of data
16
collection and analysis with the focus on understanding an emphasis on meaning.
Qualitative research is considered emerging and non-experimental.
Babbie and Mouton (2011:53) define qualitative research as “social research
according to which research takes its departure point as the insider’s perspective on
social action”. Qualitative research consists of a set of interpretive, material practice
that makes the world visible and transforms it. Thus qualitative research studies the
phenomena in their natural setting, attempting to make sense or interpret phenomena
in terms of the meanings people attach to them.
Qualitative research involves closer attention to the interpretive nature of inquiry.
According to Creswell (2007:39), qualitative research is characterised by the
following: a researcher should give a wholistic view of social phenomena by
identifying the complex interaction of factors in psychiatric nurses’ interaction with
their colleagues in the work environment.
The qualitative research process is emergent, meaning that the initial plan for
research cannot be prescribed and that the phases may change. The researcher
should keep focus during the entire process of qualitative research on learning the
meanings that the psychiatric nurses hold about the aggression they experience
amongst colleagues (Creswell, 2007:39). The goal of phase 1 is to seek a deeper
significant and meaningful structure of the lived experience of aggression amongst
nursing colleagues (Tappan, 2011:387).
2.2.2 Exploratory research
Exploratory research is most commonly conducted to explore a topic or provide a
fundamental familiarity with the studied phenomena. This approach is more likely
used when the researcher examines a new or relatively new subject. Exploratory
research is done to satisfy the researcher’s curiosity and desire for better
17
understanding (Babbie & Mouton, 2007:88). An exploratory approach is applied to
examine the possibility of a study for further exploration. This approach is used to
develop new hypotheses about existing phenomena (Babbie & Mouton, 2011:80).
In this research, the researcher intends to use in-depth interviews during which the
personal experiences of the psychiatric nurses are recorded and later transcribed
and analysed. In this research study, the researcher aspires to use communication
skills in the form of open-ended questions, clarification and the skill of listening so
that the participants can share their lived experiences of aggression amongst
colleagues. This study will be done to create an understanding of aggression
amongst psychiatric nurses, to formulate guidelines and to improve the psychiatric
nurses’ working conditions. Data obtained will be compared to other research studies
done elsewhere and as a result contributes to the body of knowledge in research.
2.2.3 Descriptive research
Descriptive research is designed to describe the situation and occasion in detail. This
kind of design is used when very little is known about the research question (Babbie
& Mouton, 2007:89). The researcher observes and then describes the phenomenon
that was observed. The researcher typically continues to examine why the observed
phenomena exist and their possible impact on their environment (Babbie & Mouton,
2011:80).
The researcher describes the process that is followed in collecting and analysing
data and findings. This is first-hand information with regard to the lived experience by
the psychiatric nurse of aggression amongst colleagues. Additional research done in
future could uncover findings developing the theory on psychiatric nurses’ lived
experience of aggression amongst colleagues, thus building towards the future body
of knowledge in social research.
18
2.2.4 Contextual research
Qualitative research seeks to understand occasions, actions and practices on order
to place the phenomenon in context. The aim is to explore and describe the
phenomenon in the concrete, natural context in which it occurs. If the researcher
understands the phenomenon against the background of the whole context, and how
such a context confirms the meaning of the phenomenon concerned, then only can
the researcher truly claim to understand the event (Babbie & Mouton, 2011:272).
One psychiatric nurse’s lived experience of aggression amongst colleagues can be
different from another psychiatric nurse’s experience, and can be understood by the
individual’s subjective description of the lived experience. In this research study, the
researcher respects and acknowledges the individuals’ experiences and the meaning
that they attach to their lived experiences of aggression amongst colleagues.
2.3 RESEARCH METHOD
The research study is conducted in two phases. In phase 1 (2.3.1), the lived
experiences by psychiatric nurses of aggression amongst colleagues are explored
and described in order to assist nurses in coping with aggression in their working
environment. In phase 2 (2.3.2) guidelines are formulated from the results evident in
phase 1. Thus the results of phase 1 are used to formulate guidelines on assisting
nurses in coping with the challenges of aggression amongst colleagues.
2.3.1 Phase 1 - Exploration and Description of the Lived Experience of
Psychiatric Nurses
Burns and Grove (2005:55) state that the purpose of the phenomenological research
approach is to describe experiences as they are lived. Babbie and Mouton (2011:28)
19
emphasise that all beings are engaged in the process of making sense of their world
by continuously interpreting, creating and giving meaning to all actions. Edmonds and
Kennedy (2013:136) add that a phenomenological approach is the description of an
individual’s immediate experience. Creswell (2007:60) explains that a
phenomenological approach should place the emphasis on understanding several
individuals’ shared experiences of a phenomenon, with the importance placed on
understanding these experiences. This approach will support the development of a
deeper understanding of the phenomenon. The aim of this research is to capture the
lived experience by psychiatric nurses of aggression amongst colleagues.
Marshall and Rossman (1999:46) stresses the importance that the researcher
should, as far as possible, try to see things through the eyes of the participants that
they interview. In attempting to put aside the researcher’s own values, prejudices and
preferences by doing this, he or she refrains from working from his or her “own frame
of reference”. Creswell (2007:61) emphasised the participant’s view of the
phenomenon. Researchers must bracket out as much as possible of their own
experiences. Bracketing is a way of indicating scientific rigour in the
phenomenological approach. Bracketing is the technique of suspending or putting
aside what is known about an experience under studied (Burns & Grove, 2005:729).
This technique is used in order to avoid being pre-judgemental. The aim is to put the
researcher’s experience aside in order not to interfere through either data collection
or data analysis; therefore the bracketing method is used.
A phenomenological approach has systematic steps, in data analytical procedure and
guidelines for assembling textual and structural descriptions (Creswell, 2007:60).
Inductive reasoning is used when little or no information is known about a specific
phenomenon. Thus in an inductive argument, supportive data provides gradual
support after an exploratory and descriptive design has been followed (Babbie &
Mouton, 2011:643).
20
2.3.1.1 Population and Sampling
The outline on population and the sampling method is as set out below.
a) Population
A population includes all the units of analysis, meaning the participants of
a population (Babbie & Mouton, 2011:79).The population for this study is psychiatric
nursing staff registered with the South African Nursing Council. The targeted
population for the study consists of the psychiatric nursing staff. The accessible
population for the study is psychiatric nursing staff who is currently employed in an
academic psychiatric hospital in Gauteng.
b) Sampling method
Sampling is a procedure according to which the population are chosen to form part of
the research study (Sullivan, 2009:457). Sampling involves the selection of people,
events, behaviours or other elements that are needed to conduct a study. Silverman
(2010:139) adds that the purpose of sampling is typically to study a model that forms
part of an exact defined population in order to make assumptions about the whole
population. The sampling method is the process of selecting a group of people to be
studied (Burns & Grove, 2005:341-346). In this study, the researcher decided on a
purposive sampling method. Purposive sampling is when the researcher selects
participants who represent the sample that will provide the information needed to
address the research question (Sullivan, 2009:457).
The criteria for sampling are as follows: participants are individual professional
nurses who are currently working in the academic psychiatric hospital where the
research is conducted, and who have been working there uninterruptedly for a
minimum period of 24 months. The psychiatric nurses need a minimum amount of
21
experience in an academic psychiatric hospital in order to give a valid account of their
experiences and to be familiar with the environment in which they work. They must
be willing to participate by sharing their experiences freely. They must also sign a
consent form to be interviewed and audio-recorded, thus giving permission to
conduct an interview. They must be able to speak English or Afrikaans. Only
psychiatric nurses are to be interviewed about their lived experiences of aggression
amongst colleagues and not members of a multi-professional team. In this research,
the lived experience of aggression will be explored and described in the context of
psychiatric nurses amongst colleagues.
2.3.1.2 Data Collection
Data collection is a method applied to answer the research questions (Maxwell,
1996:74). The researcher has an open mind when entering the participants’ world
and builds a trusting relationship with them before conducting the interviews. The
researcher should at all times bear the concepts of confidentiality, respect and
privacy of the participants in mind. A room suitable for interviewing and recording is
arranged in order that the sound of the recording is clear to allow effective
transcription.
Data for the research study would be collected by means of in-depth
phenomenological interviews. Curtis and Curtis (2011:29) explain that in-depth
interviews are a way of gathering data from one person at a time. Access to data will
only occur if there is mutual respect amongst researcher and participant (Streubert &
Carpenter, 2011:36). Interviews can reveal the discussion and language, verbal and
non-verbal, which people use to construct their lived realities (Lee & Stanko,
2003:25). The participant is asked to write a naive sketch about his or her experience
in order to accumulate a truthful reflection of their lived experiences.
22
The researcher’s intention is to gain clarity with regard to the participant’s lived
experience of aggression amongst psychiatric nurses. The following question will be
asked during the in-depth phenomenological interviews and naive sketches, “What
is your experience of aggression amongst colleagues in the work
environment?” All interviews will be audio-recorded and all naive sketches put
forward for coding and further analyses. Field notes are taken based on observation
during the interviews. According to Creswell (2009:186), the researcher should keep
field notes of his or her observations. Observations will include verbal and non-verbal
clues such as metaphors, changes in tone and facial expressions. These
observations are included in the data for data analysis. Permission to use a recorder
will be requested from all participants. Interviews will be conducted until data
saturation has occurred, after which it will be transcribed verbatim (Streubert &
Carpenter, 2011:122). The researcher will use communicating skills such as probing,
clarifying, reflecting the context, bracketing, minimal response and summarising
when conducting the interviews (Burns & Grove, 2005:253).
2.3.1.2 Data Analysis
The process of data analysis involves making sense of the data collected. It involves
preparing the data for analysis and conducting different analyses. Moving deeper and
deeper into understanding the data and, in the end, interpreting the overall meaning
of the data (Creswell, 2009:190). The steps applied to data analysis are generally
similar, building on data from the research question. In data analysis, the researcher
goes through the data and highlights significant statements, sentences or quotes that
provide an understanding of how the psychiatric nurse experience aggression
amongst colleagues. Thereafter the researcher develops clusters of meaning from
these significant statements into themes (Creswell, 2007:61).
Tesch’s (Creswell, 2009:186) open coding method that comprises eight steps of data
analysis will be employed as a guide in developing themes and categories. Direct
23
quotes will be extracted from the transcriptions of the in-depth phenomenological
audio-recorded interviews. There field notes, as well as the naive sketches, will be
analysed to identify different topics and create categories (Wilson, 1989:380).
Tesch’s (Creswell, 2009:192) open coding method is applied by following the steps
below.
- Step 1: the researcher listens to the audio-recorded interviews several times
and read the naive sketches attentively. The researcher then jots down ideas
as they come to mind and compares them to the his or her notes on the non-
verbal expressions of the interviewee.
- Step 2: the researcher picks one recorded interview in an attempt to
understand what the interviewee said, summarising the underlying message.
- Step 3: the researcher groups the topics according to the themes and sub-
themes in order to obtain an overall picture that comprises different parts.
- Step 4: at this stage, the topics listed above are abbreviated, placed into
codes, compared and contrasted in order to ensure that no theme is left out.
Coding represents the operations by which data is broken down,
conceptualised and put back together in new ways.
- Steps 5 and 6: the researcher uses appropriate vocabulary and the most
descriptive wording in order to shorten and condense categories. A final
decision is made regarding each category, and codes are alphabetically
placed.
24
- Steps 7 and 8: the data material belonging to the same category is
assembled in one group. Preliminary analysis is preformed and, if necessary,
existing data is recorded.
An independent coder will be employed to code the gathered information and to
discuss the identified themes with the researcher.
2.3.1.3 Literature Control
Literature provides a framework in which to establish the importance of the study, as
well as a benchmark for comparing the results of the study to other findings
(Creswell, 1994:21). The researcher will demonstrate the usefulness of the findings
compared to what is already known elsewhere, as there is no local theory to which
findings can be compared. A literature control is necessary as a scientific method to
validate the results obtained, in order that the results of the research may be
compared to other research projects previously done. This is done in order to identify
similarities, differences and the unique contribution of the research (Bimenyimana, et
al, 2009:24).
In this study, the researcher will explain the implications of the findings relating to the
psychiatric nurses, their personal development and to the hospital in which they
nurses work. In this work environment, the psychiatric nurses interact with their
colleagues and management on a daily basis. This will contribute to the formulation
of guidelines on and recommendations for managing aggression experienced by the
psychiatric nurses in the work environment.
25
2.3.2 Phase 2: Guidelines to assist the Psychiatric nurses to cope with the
challenges of aggression amongst colleagues
The results of phase 1 will be used to derive guidelines on assisting nurses in coping
with the challenges of aggression amongst colleagues.
2.4 TRUSTWORTHINESS
Trustworthiness refers to the acquirement of knowledge and understanding of the
true nature, essence, meaning, attributes and characteristics of the phenomenon
(Leiniger, 1985:68). Guba’s strategies ensure trustworthiness in qualitative research
(Lincoln & Guba, 1985:290-327).
The strategies of trustworthiness in this research study include credibility,
dependability, confirmability and transferability (Krefting, 1991:156), as explained
below.
2.4.1 Credibility
According to Guba and Lincoln (Greener, 2011:105), a qualitative inquiry is used in a
research method that involves prolonged engagement, and which is emerged in the
field. Holloway and Wheeler (2010:303) explain that credibility is when the
participants recognise the meaning that they themselves attach to a situation or
condition, as well as their true findings in their own social context.
The researcher’s findings indicate a compatibility with the perception of the nurses
under study. Implementing the credibility strategy, research should be conducted in
such a manner that the probability of the findings found will be credible (Krefting,
1991:296). The researcher’s attention focused on the points described in the
paragraphs that follow.
26
2.4.1.1 Prolonged engagement in the field
According to Krefting (1991:302), the researcher should spend enough time with
participants on site and explain the process of data collection to them in detail. All the
participants’ questions were answered and expectations were clarified. The
researcher also explained the goals and objectives of the research in order to allow
the participants to understand their role in this research study.
2.4.1.1 Reflective journal
The researcher uses a journal in which his or her experiences during the interviews,
be it the use of metaphors, non-verbal cues, postures or the feelings of the
researcher while interviewing are jotted down as part of the data.
2.4.1.2 Triangulation
In order to increase the credibility of this research study, the researcher used various
sources and methods (Krefting, 1991:305). The process of data collection involves
interviews and naive sketches, as well as the observation of participants during
interviews. The data analysis was done by means of co-coding, where the researcher
and independent coder reach consensus regarding the research findings.
2.4.1.3 Member checking
At the end of data collection and data analysis, before communicating the findings,
the researcher met the participants individually and shared with them the summary of
what emerged during the data analysis in order to confirm and validate what was
27
identified. The participants were given an opportunity to add or retract information
that might have been mistreated or omitted.
2.4.1.4 Structural coherence
Guba (Krefting, 1991:220) explains that credibility in any research is supported by
establishing structural coherence. That is, ensuring no unexplained inconsistencies
between data and the participants’ interpretation (Guba, 1981). Data in this research
study focused on psychiatric nurses’ experience of aggression amongst colleagues.
A variety of phenomena are sought after in qualitative research; this is done to
ensure credibility, and not consistency, when describing and understanding data
correctly. Structural coherence is also influenced by the method in accordance with
which data forms a logical and holistic picture (Krefting, 1991:220).
2.4.2 Transferability
Babbie and Mouton (2011:277) state that transferability in qualitative research refers
to the extent to which the following aspect can be applied to a different context or
with other participants. All observations made are defined by the specific context in
which it occurs. Qualitative research is an attempt to understand phenomena in a
particular context. For these reasons, concept transferability is used rather than
generalisation. Transferability relays to those who wish to apply it to the receiving
context.
Shenton (2004:69) suggests that the presentation of certain phenomena in certain
groups may be unique, but it is also an example of a broader group and, as a result
of this unique viewpoint of transferability, the smaller grouped experience should not
be rejected. If prospective researchers believe their circumstances to be similar to
that described in this study, they may relate the findings to their own work, hence
sufficient contextual information about fieldwork is provided to enable the reader to
relate better.
28
2.4.3 Purposive sample
Purposive sampling was chosen as a means to find participants who provided much
needed research information. The criteria were set and the researcher intended to
welcome everyone who met the criteria until saturation was reached.
2.4.3.1 Description of results supported by direct quotations of
participants
The researcher analysed the data independent from an independent coder, after
which a consensus discussion was held with regard to the findings of the research
study, the verbatim quotations from interviews and naive sketches. This will be
presented in chapter 3.
2.4.4 Dependability
Dependability refers to the provision of evidence by means of findings. If the study
were to be repeated with the same or similar participants in the same or similar
context, its findings would be similar (Babbie & Mouton, 2011:278). Shenton
(2004:71) stresses that the steps in the study should be reported in detail, enabling a
prospective researcher to repeat the work, even if it is not necessarily to gain the
same results.
2.4.4.1 Step-wise replication of the research method
Throughout this research study, the researcher described the steps taken and
supports them with references to literature. Steps to be taken in this research study
will be explained later in this chapter.
29
2.4.4.2 Code – recording of data:
Raw material, such as audio-recorded interviews, naive sketches and the comments
of the independent coder, were kept in a safe place under lock and key as proof of
this research study. It will remain under lock an key for two years after publication of
research and then destroyed.
2.4.4.2 Dependability audit
In addition to using an independent coder during data analysis, this research study is
still to be submitted and evaluated by the research supervisor and co-supervisor,
after which the research study will be submitted for further tests of trustworthiness.
2.4.5 Confirmability
Confirmability refers to the degree to which findings are the product and focus of the
inquiry and not of the biases of the researcher (Babbie & Mouton, 2011:278).
Holloway and Wheeler (2010:303) explain confirmability as objectivity in research. It
should be possible to trace the source of the research data.
The researcher remained faithful to academic and ethical requirements in conducting
this research. Therefore the outcome of this study is the original work of the
researcher. The researcher kept field notes, observations and memos, as was
previously mentioned. In order to comply with these requirements and to guarantee
the findings, conclusions and recommendations that are supported by all data will be
compared to the investigator’s interpretation and the actual evidence.
30
2.5 ETHICAL CONSIDERATIONS
Ethical issues must be considered in all research studies. A research study needs to
be done by applying principles that protect participants in the research from harm or
risk (Holloway & Wheeler, 2010:53). Autonomy, non-maleficence, beneficence and
justice are the four ethical principles that will be applied to this research study. Each
principle is binding unless it clashes with an equal or stronger obligation (Dhai &
McQuoid-Mason, 2011:3).
The participants were given the option to use their right of autonomy, volunteering
their informed consent and participation. All participants should be self-governing
individuals with decision-making capacity. All participants should possess adequate
information regarding the research in order to give consent or decline participation
(Streubert & Carpenter, 2011:62). Obtaining a participant’s informed consent is
essential. The necessary informed consent was obtained by means of a letter (see
appendixes B and C) that explains the goals of the prospective study to the
participants (Burns & Grove, 2005:181). Permission was requested from participants
to audio-record interviews. The audio-recordings will be kept under lock and key.
Only the researcher and supervisors will have access to the recordings. The
recordings will be destroyed two years after publication of the research.
The participants were assured the right to privacy by keeping their personal
information private and destroying it after the study has been completed. The
participants’ names were neither mentioned during or after an interview, nor during
transcription and coding. All information received was treated professionally with
respect to confidentiality and privacy. By keeping all data collected and confidential,
the participants were assured of the right to confidentiality. The researcher
guaranteed confidentiality on her part.
31
Every participant had the choice to exit the interview at any stage or refuse to answer
a specific question, should they wish to do so. The participants could not be assured
complete autonomy, as the nature of data collecting inhibits this due to the interaction
between the researcher and participants. Participants will not be identified in the
research report. Giving each participant a code name insures anonymity in the text.
No compensation was paid to any of the participants for partaking in the study (Burns
& Grove, 2005:190). No harm was foreseen with regard to the research project;
however, should re-enactment of any aggression experienced provoke a crisis, such
a participant would be referred to professional (Dhai & McQuoid-Mason, 2011:3). The
participants will benefit from the promotion of their interests and mental health in the
work environment.
2.6 CONCLUSION
In this chapter the research design and concepts such as Exploratory, descriptive
and contextual research were discussed. The processes of data collection and data
analysis were described in depth, and measures to ensure were discussed. In the
next chapter, the findings of research study will be explored and shared. Starting with
the process that was followed, the description of the themes and categories
supported by recorded quotes and literature control.
32
CHAPTER 3: THE LIVED EXPERIENCE BY PSYCHIATRIC NURSES OF
AGGRESSION AMONGST COLLEAGUES
3.1 INTRODUCTION
Chapter 2 addressed the research methodology. In chapter 3, the findings of the
research are presented and discussed according to the data obtained from in-depth
phenomenological interviews, field notes taken during interviews and naive sketches
done by the participants. Triangulation was ensured by conducting eight interviews,
taking field notes and naive sketches done. Data saturation occurred with all the data
collected.
In the interviews, as with the naive sketches, one central question was asked, “What
is your experience of aggression amongst colleagues in the work
environment?” Themes and categories emerged from discussions about the data
obtained during the analysis of the data. The researcher and independent coder
analysed the data and reached consensus regarding the themes and categories.
Analysis was done according to Tesch’s open coding method that involves eight
steps of data analysis (Creswell, 2009:192).
3.2 DESCRIPTION OF THE SAMPLE
A total of eight registered psychiatric nurses volunteered to participate in the
research. The reregistered psychiatric nurses consisted of two males and six
females, ranging from ages 24 to 59. One of the interviews was an auto-
ethnographical interview during which the researcher shared her own experience with
an interviewer. The participants had to meet the sample criteria of being psychiatric
nursing staff and registered with the South African Nursing Council, with two or more
years’ experience in the same hospital. The entire group of participants in the
33
research study worked in either an open, semi-closed or a specialised psychiatric unit
in the hospital.
3.3 DESCRIPTION OF THE ENVIRONMENT IN WHICH THE
RESEARCH WAS CONDUCTED
All interviews were conducted on the hospital premises, in a private room or office
space with a door that can close in order to protect privacy and to maintain
confidentiality. Most interviews were conducted in the comfort of the participants’ own
ward where they were working at the time of the interviews. Seven of the eight
interviews were conducted in English and one was conducted in Afrikaans.
3.4 DATA ANALYSIS OF INTERVIEWS
3.4.1 Central story line
The psychiatric nurse experiences aggression as subtle, passive and harmful,
manifesting in a verbal and non-verbal manner. Nurses experience their team
environment as doubtful, suspicious and distrustful, which leads to questioning
themselves, their colleagues and their career as psychiatric registered nurses
working in a psychiatric hospital.
The psychiatric nurses experience management as giving limited support, which
appears to contribute to the distress and demoralisation of the nurses. The
psychiatric nurses experience management as not acknowledging the aggression
they experience. The psychiatric nurses experience limited support in the work
environment. Table 3.1 lists the themes and categories as obtained from the data
collected from the psychiatric nurses and their experience of aggression amongst
colleagues.
34
Table 3.1 – The lived experience by psychiatric nurses of aggression amongst
colleagues
The lived experience by psychiatric nurses of aggression amongst colleagues
THEME CATEGORY
Theme 1
The psychiatric nurses experience
aggression as subtle, passive and
very harmful in a verbal and non-
verbal manner
Experience of verbal aggression
Psychiatric nurses experience gossiping as
aggression:
Hostility and backbiting
Snide remarks and comments are made
Psychiatric nurses experience aggression as a
language barrier:
Language and cultural differences are abused
Psychiatric nurses experience judging as
aggression
Experience of non-verbal aggression
Psychiatric nurses experience ignoring as
aggression
Psychiatric nurses experience negative body
language and staring looks as aggression
Theme 2
Nurses experience their team
environment as doubtful, suspicious
Psychiatric nurses question themselves
Treat the “self” shabbily
35
and distrustful
Feel incompetent
Psychiatric nurses question colleagues
Do not trust each other
Do not care for each other
Feel insecure and intimidated
No teamwork
Psychiatric nurses question their career
Lose passion for the job
Feel demotivated and demoralised
Theme 3
The psychiatric nurses experience
limited support when colleagues
and management do not
acknowledge aggression
Psychiatric nurses experience being
unsupported in the work environment as
aggression
Lack of or no support
Psychiatric nurses experience
management as reprimanding
Constant threats of disciplinary actions
A lot of judgement
Lack of resources in the work environment
No recognition for their work
Unfair assignment of duties
Limited support
Theme 4
Psychiatric nurses experience that
they use coping mechanisms when
they experience emotional stress
Psychiatric nurses experience emotional
stressors as a result of aggression in the
work environment
36
and aggression
Emotional stress
Frustration
Disappointment and mistrust
Resentment
Psychiatric nurses experience aggression
and cope by means of applying defence
mechanisms
Suppression
Projection of anger
Withdrawal
Psychiatric nurses experience aggression
and cope by means of passive aggression
Absence at work
Unproductiveness at work
Revenge
3.4.1.1 Theme 1: The psychiatric nurse experience aggression as subtle,
passive and very harmful in a verbal and non-verbal manner
The psychiatric nurses explained in the interviews that their experience of aggression
affected them deeply and negatively, especially amongst colleagues in the work
environment. Psychiatric nurses, as participants, experience aggression in different
forms. The participants reported that aggression manifested in a verbal and a non-
verbal form at times. As the data emerged, it appeared as if the participants
experienced aggression amongst colleges in a subtle, passive and very harmful
manner.
37
“I have witnessed a lot of passive aggression and underlying hostility amongst
colleagues”.
Various studies done internationally and nationally focused on the violence and
aggression of professional nurses in their work environment (Yildirim, 2009:505;
Bimenyimana, et al, 2009:5). Yildirim (2009:506) states that nurses run a high risk of
being exposed to violence in the work environment. The bullying amongst psychiatric
nurses focuses more on nurses in their work environment and the negative
implications of this form of aggression (Yildirim, 2009:504; Sa & Fleming, 2008:411).
During the interviews, the psychiatric nurses explained that their experiences of
aggression manifested in a verbal form, such as when colleagues gossip and make
side remarks or make inappropriate comments in the work environment. The
psychiatric nurses explained that this is a harmful and disrespecting experience for
them.
“... gossiping perhaps in another language ...”
“It’s like talking behind each other’s back and it’s like being negative towards
them ...”
Antoniazzi (2011:746) states in a study of respect as experienced by registered
nurses that violence and aggression is becoming more acceptable in many work
environments. Findings revealed that communication is a key factor in conveying
respect, including what is and what is not communicated, as well as how
communication takes place amongst colleagues. Yildirim (2009:506) explains that
verbal aggression is the most common type of violence amongst health care
personnel; this form of aggression includes shouting, reprimanding and belittling.
Gossiping has a devastating effect on the work environment (Antoniazzi, 2011:753).
38
Psychiatric nurses experience language abuse and cultural differences as
aggression. These differences often result in a harmful feeling of isolation and being
ignored. This may also lead to participants being suspicious of their colleagues,
which in turn affects the team negatively.
“They do it to kind of provoke me ... they sometimes do it to rat against me ...”
“... blocking me out of conversations”.
“Who I work with, their first language is not my first language ... they tend to
converse in their first language ...”
Research reports that education and socialisation at different levels exhibit different
values and perceptions of professional identity. This has been observed to create
conflict amongst nurses when they enter the workforce (Pearson, Porritt, Doran,
Vincent, Craig, Tucker & Long, 2006:225). In multicultural teams, increased levels of
relationship conflict were found. The diversity was related to both process and
delegation conflict and affected the communication outcomes (Jager & Raich,
2011:234).
In addition, psychiatric nurses describe their experiences of aggression manifested in
a non-verbal manner. Participants described the non-verbal behaviour as being
passive aggressive.
“I felt a lot of passive aggression in a new ward I was allocated to. Staff
members would sit with their back to me, and blocking me out of
conversations ...”
Timmins and McCabe (2005:66a) state that even though nurses have the necessary
skill to manage conflict in the work environment, they may avoid retribution by
39
avoiding conflict and playing a passive role. Lewis (2002:110) adds that not just
verbal, but also non-verbal, aggression manifests in the work environment. The
researcher continues to explain that this appears in an overt and covert manner and
can result in psychological and emotional distress. The perpetrators of work
environment harassment include managers as supervisors and colleagues (Lewis,
2002:110-111).
The participants described that their colleagues ignore and judge this aggressive
behaviour in the work environment, resulting in being treated unprofessionally. This
leads to feelings of apprehension about working in a team, which leads to
participants who would rather work in isolation. Participants verbalised that body
language and staring looks can communicate aggression to them.
“... cold shoulder, not speaking to you, passive aggression ...”
“... say something or with their body language ...”
“... passive aggressive looks ... look at you in a way, but people really do look”
“... it’s just this pushing away, not including ... feel unwelcome ... feel not a part
of the team ...”
Warnock (2008:84) states that forms of unprofessional behaviour may be as subtle
as unintended disrespect, judgement of peers, breaches of confidentiality and
dishonesty in the disclosure of adverse events. Yildirim (2009:505) lists the following:
isolation and being excluded as an effect of bulling in the work environment. Lewis, et
al (2002:110) explain that non-verbal aggression manifests in the work environment
as glaring, ridicule, isolation, being excluded as well as withholding of support and
information.
40
3.4.1.2 Theme 2: Nurses experience a doubtful, suspicious and distrustful
team environment
The psychiatric nurses experience their team environment as doubtful, suspicious
and distrustful when they are confronted with aggression. The environment becomes
so toxic that it creates a paranoid team environment. This toxic and paranoid
environment results in the psychiatric nurses questioning themselves. This
consequently affects the psychiatric nurses’ treating of themselves without respect
and in a poor manner. This has an appalling effect on the psychiatric nurses not
enjoying their work, and it influences service delivery to clients. The psychiatric
nurses verbalised how ineffectual they feel in this seemingly paranoid environment. It
resulted in the psychiatric nurse having a poor self-esteem and decreased
confidence, which in turn affect the quality of their work output.
“... you burn out, you feel unwell you feel not cared for ...”
“... neglecting ourselves ...”
“... it was hard to function effectively”
“... lowered self-esteem ...”
Lewis (2002:111) states that most people would like to deal with negative treatment
in the work environment in an indirect manner, thus ignoring the behaviour as well as
avoiding the perpetrator or discussing the issue directly. The researcher explains that
as a result of aggression in the work environment, the following feelings manifest:
self-blame, shame, self-deprecation, insecurity, inadequacy and a lack of self-
confidence (Lewis, et al., 2002:114). Antoniazzi (2011:747) emphasises that
aggression results in a lack of motivation, loss of confidence and reduced self-
esteem, depression, anger, anxiety, absenteeism and irritability. Lin, Probst and Hsu
41
(2010:2342) add that job stress would be positively correlated with depression. Thus
stress experiences in the work environment can affect the psychiatric nurses’ mental
health.
Because of the aggression, the psychiatric nurses experience their team environment
as doubtful, suspicious and distrustful, and therefore question their colleagues. The
consequences of questioning their colleagues are that they do not trust each other
and do not care for each other in the work environment. The feelings of not being
cared for result in the psychiatric nurses questioning themselves, thus leaving them
feeling insecure, which leads to easy intimidation by each other. This has an effect
on team work and contributes to the quality of care in the work environment.
“... It is more of a neglect of each other and colleagues ...”
“It does not feel like a team ...”
“... duty room became ‘hot’ ...”
“... not part of a team ...”
Happell, Martin and Pinikahana (2003:39) recognise that the work pertaining to
nursing is often stressful and that stress has been identified as one of the reasons for
nurses failing to function at an optimum level of effectiveness. Stress and work
environment conflict have a significant effect on the nurses. As a result they may
experience physiological, psychological and social challenges, thus affecting the
individual nurse’s self-esteem and self-confidence. Yildirim (2009:505) further
explains that individuals who are exposed to work environment conflict become
unable to do their work because of the damage inflicted on them.
42
Bilgin (2009:257) explains that conflict in the work environment not only affects
service delivery, but the caring role of nurses as well. The ward’s culture, insufficient
teamwork, a lack of support from administrators and no conflict-prevention training
add to the detriment of these nurses. Pearson, et al (2006:225) add that nurses are
unwilling to take responsibility for their own actions.
With a lack of trust in the interaction between psychiatric nurses in the nursing team,
the nurses begin questioning their career on a daily basis. Their experience of
aggression makes them feel frustrated and challenged. Anger and resentment
contribute to the psychiatric nurses loosing passion for their daily duties - not wanting
to go to work or finding excuses to be absent. Lacking motivation they become
demoralised and seek other more fulfilling career opportunities.
“... seeking greener pastures”
“... you harbour resentment, you lose your passion, you resent coming to
work”
Bullying, violence, damaging effects, harassment and conflicts are some of the words
used in various researches to describe aggression in the work environment.
Aggression affects the individuals not just at physical, but also emotional level. These
affects bring into question their job satisfaction, work performance, motivation and
productivity (Yildirim, 2009:504; Lewis, et al; 2002:109; Bilgin, 2009:252). Dormann
and Zapf (2001:483) maintain that The indicated job dissatisfaction is closely related
to absenteeism, fluctuation, organisational inefficiency and counterproductive
behaviour.
3.4.1.3 Theme 3: The psychiatric nurses experience limited support when
aggression is not acknowledged by colleagues and management
43
Psychiatric nurses experience limited support in the work environment apparently
because of aggression being present. The most evident experiences of aggression
are associated with limited or no support, by not acknowledging each other, avoiding
each others feelings and difficult circumstances. The psychiatric nurses verbalised
that they do not feel supported by their colleagues and/or the management that they
work with everyday. In this research study, the psychiatric nurses interviewed see
management as their colleagues in the work environment.
“... not a lot of support ...”
“... we don’t support each other ...”
“... how they don’t support ... and if you like to support there is something
wrong with you ...”
Bilgin (2009:252) lists occupational and emotional stressors relating to nurses in the
work environment and points out that little emotional and/or administrative support
contributes to the nurses’ stressors. This can negatively affect the nurses by
influencing their well-being. Currid (2009:42) confirms that a lack of support in the
work environment is a source of stress. Nursing staff mostly feel unsupported by
managers.
Funakoshi, Miyamoto and Kayama (2007:231) state that in order for psychiatric
nurses to feel some emotional support, they need to disclose their concerns openly
amongst colleagues. This support is essential and helps the psychiatric nurses to not
feel isolated, but as a result feel more supported. Antoniazzi (2011:745) states that it
is important to have strong supportive collegial relationships. The relationships that
they have with their colleagues have a direct impact on how they experience their
work environment. Currid (2009:42) continues to explain that support can be offered
44
in various forms, and states that clinical supervision is a resource of support in the
work environment.
The psychiatric nurses reported that their experience of no support from
management contributes to feelings of being judged in the work environment.
According to the psychiatric nurses, aggression manifests itself in management’s
continuous reprimands and constant threats of disciplinary actions and performance
appraisals. The psychiatric nurses constantly expressed that their experience of
management not recognising their work makes them feel despondent towards the
work environment.
“... a lot of emphasis on discipline ...”
“... bombarded with performance appraisal P.M.D ...”
“... management also doesn’t lead by example ...”
“... management are neglectful of us, they are not interested, they’re ignorant
...”
Admi and Mashe-Eilon (2010:152) state that managers have the traditional role of
assisting all staff members in their workload as well as at an interpersonal level.
Andrews and Wan (2009:340) note that nurse managers can play a significant role in
controlling the effects of both work stress and aggression in the work environment.
Funakoshi, et al (2007:228) emphasise that it is the managers’ role to provide the
nurses with the source of primary support. In their findings they state that nurses who
experienced their managers as unsupportive had higher psychological distress and
were emotional exhausted.
45
Psychiatric nurses want to work in an environment where they are able to develop
supportive and respectful relationships with their managers and co-workers
(Antoniazzi, 2011:748). The researcher found that when respect is present and
nurses feel respected, they are happier and more positive and experience the
environment as warm and friendly. Respect in the work environment includes respect
for a person as an individual and for his or her culture. When nurses are respected, it
manifests in more effective communication and acknowledgement (Antoniazzi,
2011:753). Pearson, et al (2006:224) found in their review that many nurses seek
recognition in the nursing profession.
Bowler (2011:450) explains that punishment or punitive behaviour by management is
seen as abusive supervision. Abusive supervision is defined as follows:
“subordinates perceive that their supervision is consistently engaging in hostile or
aggressive verbal and nonverbal behaviour”. This type of behaviour will have a
negative impact on the nurses. The nurses would be more likely to outwardly resist
managers; it also brings about deviant behaviour. In addition the nurses will
experience emotional distress that results in more work- or family-related conflict
(Bowler, et al, 2011:451). Bowler (2011:249) adds that performance management is
the manager’s responsibility, and a critical step in this process is determining the
cause of a subordinate’s behaviour. Yildirim (2009:509) states that nursing staff who
experience a negative relationship or unconstructive communication with their
managers and colleagues, tend to decrease their motivation and performance.
Further contributing to distress, the psychiatric nurses experience pressure, a lack of
resources and unfair assignment of duties. The participants related the lack of
resources in the work environment to a shortage of staff, a lack of equipment and a
lack of in-service training. Psychiatric nursing staff noted that one of the factors
contributing to aggression in the working environment is the unfair assignment of
duties or rotation of nursing staff to other wards without consulting or informing them
46
prior to rotation. A large number of nursing staff cope with conflict by finding a new
place of employment, which in turn results in an increase in staff turnover.
“... shortage of staff ...”
“... rotate the duties ...”
“... aggression due to incompetent toward some procedures ...”
“... not included in decisions and your whole life is basically changing is
aggressive ...”
Bowler, et al (2011:428) found that managers who fail to praise success and who
hold subordinates accountable for negative outcomes for which they are not
accountable, are harmful to nursing staff. Currid (2009:42) states that nursing staff
mostly feel unsupported by managers. Support can be afforded by offering clinical
supervision, listing, training and education. However, Currid further explains that a
lack of recourses is frequently seen as limited support, due to the addition of excess
workload, which in turn contributes to the nurses’ stressors.
Antoniazzi (2011:745-756) found that in a working environment with dysfunctional
nurse-to-nurse relationships, the lack of respect is evident. This is more prominent
when the environment has budgetary constraints, increased workloads, increase of
personal expectations and constant changes. Antoniazzi believes that this results in
increased job stress, decreased job satisfaction and increased sick time to the
degree of nurses leaving the profession. This in itself adds to the lack of personnel as
resources, and results in a high turnover of personnel in the nursing profession.
47
3.4.1.4 Theme 4: Psychiatric nurses experience using coping
mechanisms when emotional stress and aggression is experience
Psychiatric nurses experience emotional stress as a result of aggression in the work
environment, and use different coping mechanisms to survive in this environment.
When the psychiatric nurses experience emotional stress, they feel overwhelmed and
burnt out. The emotional stress in the work environment leads to various factors
affecting the individual. One of the emotional stressors of the psychiatric nurse is
frustration, which can lead to aggression in the work environment.
“... emotionally get to someone ...”
“... you can cause enough emotional damage ...”
“... I am stressed ...”
“... You burnout ... I am not a machine …”
“... needs of staff not being met ... emotional needs ...”
Nursing is recognised as a very difficult occupation in which stress may be highly
prevalent (Lin et al, 2010:2343). McGibbon, Peter and Gallop (2010:1354) define
stress as the nurse experiencing unpleasant emotions such as anger, fear,
uncertainty, frustration, anxiety, lack of concentration and diminished efficiency.
Burnout, according to Sherring and Knight (2009:1234), occurs when stress is
experienced over a prolonged period. Research indicates that stress and burnout are
directly related to conflict and aggression in the work environment (Coffey &
Coleman, 2001:397). Stress affects the health and well-being of the nurses (Andrews
& Wan, 2009:340) .
48
According to Hannigan, Coyle, Fothergill and Burnard (2000:127), emotional
stressors are described as emotional exhaustion and occur as a result of feeling
emotionally overextended by one’s work. The researchers explain that this may lead
to work responsibilities overwhelming nurses.
The psychiatric nurses experience disappointment when aggression is present in the
work environment, which leads to mistrust and damages effective teamwork in the
work environment. Aggression ultimately leads to resentment in the work
environment. When the nurses experience constant negative stress and
overwhelming emotions, the team starts feeling demoralised and tension builds up,
allowing aggression to evolve.
“... don’t seem to care ... everyone for himself ...”
“... can’t see each other’s struggles ...”
“... no one has time ...”
“... constant demoralisation ... can cause tension ... resentment and
aggression ...”
“... there is ... resentment ... trying to improve the circumstances ...
superficiality ...”
Sa and Flemming (2008:412) explain that exposure to stress can lead to any form of
conflict, violence and aggression at work that have a negative impact on individuals,
organisation and the society as a whole. Aggression is a major source of inequality,
discrimination and stigmatisation in the work environment.
49
Antoniazzi (2011:745) states that nurses’ relationships with their colleagues have a
direct impact on how they experience their work environment. The researcher found
dysfunctional nurse-to-nurse relationships in the work environment and notes that a
lack of respect being shown amongst nurses. The researcher adds that nurses
mostly experience aggression from other nurses, which makes them feel more
powerless and affects their emotional well-being (Antoniazzi, 2011:747).
When the psychiatric nurses experience overwhelming emotional stress and
aggression in the work environment, they find a means of coping with their feelings.
The psychiatric nurses manage and cope with aggression by means of defence
mechanisms. The most general defence mechanism is suppression - not wanting to
manage conflict or aggression in the work environment. The psychiatric nurses
project anger and aggression when they experience aggression in the work
environment. Withdrawal, isolation, suppression, projection and passive
aggressiveness are defence mechanisms found to be used by various psychiatric
nurses when they are overwhelmed and experience emotional stress and
aggression.
“I don’t address it ...”
“... displace the anger ...”
“... ek bly meeste van die tyd uit hulle pad …”
(“... I stay away from them most of the time...”)
Currid (2009:41) explains that when nurses are overwhelmed by work demands,
stressors like aggressions can threaten their ability to cope. Lin, et al (2010:2343)
define coping as “constantly changing cognitive and behavioural efforts to manage
specific internal and external demands that are appraised as exceeding the
50
resources of the person”. Coping is categorised as active coping and avoidant coping
in order to manage conflict and stressful events.
Isolation is when the nurses separate themselves from the aggression they
experience in order to cope with it. Suppression is a mature defence mechanism
where a nurse consciously postpones attention to a stressor or impulse to conflict by
avoiding it. Projection is an unconscious means of dealing with aggression by
attributing them to others (Kaplan & Sadock, 2003:207-208).
Psychiatric nurses experience that aggression in the work environment tends to be
overwhelming and cope by means of passive aggressive behaviour. The passive
aggressive behaviour noted is that psychiatric nurses tend to be absent from work,
with or without excuse, resulting in high absenteeism. They are unproductive at work,
not delegating duties or not appointing themselves for any duties. At times the
professional nurses take revenge on each other with the intend to punish or cause
harm.
“... don’t want to come to work …”
“... you become unproductive …”
“… not performing delegating duties …”
“… you do things with an attitude …”;
“… you make statements ... a way of getting them …”
Andrews and Wan (2008:343) explain that when nursing staff experience stressors in
the work environment as unchangeable, it becomes threatening to them and they use
emotional responses such as anger and avoidance as a coping strategy. Lewis
51
(2002:111) reports that more passive and non-fatal forms of aggression are
manifested in the work environment. The researcher explains that passive
aggression in the work environment is seen as spreading rumours and not providing
information or necessary support. Cottrell (2001:157) states that stress and
aggression in the work environment compromise factors such as a lack of
productivity due to staff conflicts, recruitment and retention challenges, burnout,
absenteeism, litigation and rapid staff turnover.
3.5 THE RESEARCHER’S PERSONAL FIELD NOTES,
OBSERVATION FIELD NOTES, METHODOLOGICAL FIELD NOTES AND
THEORETICAL FIELD NOTES
While immersed in the process of obtaining data, the researcher observed and
experienced the phenomena of passive aggression, not only evident in the interaction
with other staff members, but also at a personal level. In the researcher’s interaction
with staff members while approaching possible participants to voluntarily participate
in the research study, she noted that certain psychiatric nurses appeared to be
ignoring her request to participate in the study. The psychiatric nurses would avoid
eye contact when she approached them and speak to each other in their vernacular
language.
In a particular scenario, one of the operational managers agreed to give the
researcher feedback at a prearranged time, but did not manage to do so. The
researcher’s personal experience while immersed in reviewing the literature was that
it is a lengthy process, and she experienced feelings of apprehension. Due to these
feelings she lost focus and felt disconnected and distant. At times she did not want to
engage in the research process and seemed to avoid the topic.
It was clear to the researcher that the psychiatric nurses experience aggression and
passive aggression on a daily basis. It seemed as if the interaction amongst
52
psychiatric nurses was of a disrespectful and destructive nature. In addition, she
experienced disrespect while obtaining data during the research. The psychiatric
nurses’ style of coping with the aggression amongst colleagues differed, and
aggression was managed more often than not in an ineffective manner. It seemed as
if the researcher experienced passive aggressiveness while engaging in the research
by procrastinating.
All the interviews of this research were conducted while the psychiatric nurses
worked in the same Psychiatric Hospital. The interviews were conducted in the wards
where the participants worked, with one exception. The interviews were conducted in
a venue that was easy for the participants to access and they would have time to
participate in the research. It was neutral ground; they could talk openly, freely and in
confidence. The researcher also experienced the empathy and respect of the nurses
for including them in her research. This at times posed a challenge, as their
colleagues knew when and who was interviewed. All interviews conducted were
private and the rooms and offices doors could close but not lock. During two of the
interviews with the psychiatric nurses interruptions occurred, but the researcher could
continue with the interviews. The participants verbalised their confidence to do the
interviews before the commencement of each interview.
3.6 DISCUSSION OF THE RESULTS
The intention of this study was to explore and describe the lived experience of the
psychiatric nurses of aggression amongst colleagues in the work environment. From
the findings of the research study on the lived experience of psychiatric nurses, it is
evident that the psychiatric nurses experience aggression amongst colleagues. Most
psychiatric nurses shared the experience of aggression. The findings indicated that
aggression was indeed present in the work environment.
53
The psychiatric nurses reported that different types of aggression are present in their
work environment, namely verbal and non-verbal aggression. Verbal aggression was
visible in the forms of gossiping, backbiting, side remarks made to each other, the
abuse of language barriers and cultural differences. The nurses denied direct or
physical aggression in their work environment and only reported that in selective
cases they have the urge to react at a physical level. All the psychiatric nurses
emphasised the experience of non-verbal aggression in the work environment. Non-
verbal aggression manifested in the psychiatric nurses’ reports of feeling ignored and
judged by their colleagues. They experienced glaring looks and having backs turned
on them as in aggressive body language.
The aggression that psychiatric nurses’ experience affects the nurses at various
levels. The research findings indicated that the psychiatric nurses themselves are
affected by aggression in the work environment. As individuals, their self-worth and
self-esteem were affected, blaming themselves for the aggression they experienced
as well as for feeling incompetent to perform their duties. The psychiatric nurses
questioned the colleagues and found that there was no teamwork amongst them. The
experience of aggression became passive and the psychiatric nurses reported a
doubtful, suspicious and distrustful team environment. Ultimately, the experience of
aggression made the psychiatric nurses question their career, loosing their passion
for their jobs and left them demotivated and demoralised.
In all the interviews conducted with the psychiatric nurses, they reported on the
evident lack of support in the work environment. They described the lack of support
as colleagues or management not acknowledging aggression. The psychiatric nurses
experienced that management reprimanded them by constantly reporting the nurses
and assigning duties unfairly. Threats of disciplinary action against the psychiatric
nurses are a common occurrence. In addition, no recognition would be shown for the
nurses’ hard work.
54
The psychiatric nurses’ experience of aggression in the above forms resulted in
emotional distress, leaving them with feelings of frustration disappointment, mistrust
and resentment. The experience of emotional distress resulted in the psychiatric
nurses using defence mechanisms. Defence mechanisms differ from mature
defences such as suppression to neurotic defences as withdrawal and isolation, to
narcissistic defences such as projection of anger and to immature defences such as
passive aggressive behaviour (Kaplan & Sadock, 2003:207-208). Ultimately the
passive manner in which the psychiatric nurses manage aggression is similar to how
they experience aggression amongst colleagues in the work environment. Figure 3.1
illustrates the process in accordance with which psychiatric nurses experience
aggression in the work environment amongst colleagues.
In summary, the process by which psychiatric nurses experience aggression in the
work environment amongst colleagues is seen as a continuous process. When the
psychiatric nurses experience aggression, it affects themselves, their ability to
perform as a team as well as their daily tasks and duties. When aggression is not
acknowledged by not talking about aggression or addressing the source of
aggression, the psychiatric nurses experience limited support from their colleagues
and management who they see as a part of the nursing team. The 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. Different defence mechanisms may be used. If the
psychiatric nurses do not have effective support and guidance in the work
environment, they would not know how to cope with the distress they experience. At
times destructive coping mechanisms may be used, for example passive aggressive
behaviour. This behaviour then once more contributes to the aggression experienced
in the work environment.
55
Figure 3.1 - Summary of the findings of the lived experience of the psychiatric
nurse
3.7 CONCLUSION
Chapter 3 discussed the lived experiences of the psychiatric nurses of aggression
amongst colleagues. The findings of the research study were explored and revealed.
These accounts of experiences were supported by means of quotes and literature
control.
Chapter 4 will give an overview of the study, along with guidelines, recommendations
and challenges that emerged from the research study. Thus findings will be
presented on the lived experiences by the psychiatric nurse of aggression amongst
colleagues in the work environment.
56
CHAPTER 4: OVERVIEW, GUIDELINES, RECOMMENDATIONS, CHALLENGES
AND CONCLUSIONS
4.1 INTRODUCTION
Chapter 4 will provide an overview of the study by recounting the background, the
problem statement and the aim of the research study. Thereafter guidelines and
recommendations for the psychiatric nurses and their colleagues will be presented.
The guidelines and recommendations will be made to aid the psychiatric nurses
when aggression is experience amongst colleagues in the work environment. The
discussions will continue with challenges experienced in the study.
4.2 GUIDELINES
It is clear from the research findings in chapter 3 that the psychiatric nurses’ work
environment are in dire need of effective interventions. The psychiatric nurses
experience aggression when in interaction with their colleagues and management.
Effective coping strategies are not necessarily in place in their work environment.
The guidelines and recommendations formulated in this research study will only
provide the psychiatric nurses, their colleagues and nurses in management with
which they interact with on a daily basis with possible suggestions. Suggestions and
recommendations will be made to nursing practice and future research; there is more
to know about the phenomena of aggression in the work environment amongst
colleagues.
The guidelines and recommendations are applicable when the psychiatric nurses are
in interaction with colleagues and nursing managers. When interviewing the
57
psychiatric nurses in-depth, the psychiatric nurses were able to voice their needs in
their own work environment and made recommendations regarding their colleagues
and management. Table 4.1 presents the guidelines and recommendations that were
formulated based on the findings of this research study.
Table 4.1 - The guidelines and recommendations formulated for the psychiatric
nurse experiencing aggression amongst colleagues
THEME GUIDELINES
Theme 1
The psychiatric nurses experience
aggression as subtle, passive and
very harmful in a verbal and non-
verbal manner
Guideline 1
Facilitating the management of aggression
experienced amongst colleagues
An open communication system
Active listening
Conflict resolutions method
Self-awareness
Theme 2
Nurses experience a doubtful,
suspicious and distrustful team
environment
Guideline 2
Facilitating teamwork, a trusting and caring
work environment
Acceptance and support amongst colleagues
Teambuilding activities
Mutual respect from colleagues
Interpersonal skills development
Theme 3
The psychiatric nurses experience
limited support when aggression is
not acknowledged by colleagues
and management
Guideline 3
Addressing factors contributing to
aggression experienced in the work
environment
Interest and support from management
Mutual respect from management
Recognition and acknowledgment in the work
58
environment
Management should be transparent
Theme 4
Psychiatric nurses use coping
mechanisms when they experience
emotional stress and aggression
Guideline 4
Strategies to cope effectively experiencing
aggression
Regular opportunities for debriefing
Assertiveness training
Anger control
Stress management
4.2.1 Guideline 1: Facilitating the management of aggression experienced
amongst colleagues
The psychiatric nurses experience aggression as subtle, passive and very harmful in
both a verbal and non-verbal manner. The experience of aggression in the work
environment can be more effectively managed if psychiatric nurses were able to
communicate openly. Communication is a vital aspect in every part of the psychiatric
nurses’ day. Communication forms part of their ability to perform their daily duties.
Therefore more effective communication skills need to be put in practice in the work
environment in order to alleviate miscommunication and misinterpretation.
According to Antoniazzi’s findings (2011:753), effective communication entails active
listening to colleagues by giving them full one’s attention and creating opportunities
for ongoing dialogue. When engaging in reflective discussions, providing validation,
making eye contact and speaking with a caring tone of voice not only better verbal
communication, but are also more effective with regard to non-verbal communication.
If the psychiatric nurses are able to communicate openly in an effective manner, it
assists these psychiatric nurses in managing conflict in the work environment. Altun
and Argon (2011:729), note that a conflict management education programme should
59
be compiled for nurses. Managers should be educated about the reasons causing the
conflict experienced amongst the psychiatric nurses and about strategies to resolve
these conflicts. Vivar (2006:201) describes five common methods of managing
conflict, namely competitive, avoidance, accommodation, compromise and
collaboration. There is no appropriate or inappropriate strategy to deal with conflict.
Time availability, context, culture and type of personality should always be taken into
account when attempting to resolve conflict.
According to Edmund (2010:43), differences amongst colleagues in the work
environment that result from aggression are not stagnant. To a certain extent it
develops over time. Aggression and conflict resolution must match the conflict
dynamics. Edmund (2010:43) states that most aggression experienced in groups
contains both subjective and objective components. Subjective factors, such as
seemingly unmet needs or threats, are key influencing factors. This is followed by
powerful and influenced identity elements such as race, gender and culture.
Objective factors, such as limited resources and direct aggression, can be minor
contributors to conflict dynamics. Therefore effective conflict resolution focuses on
the group members’ subjective meanings in terms of issues, communication, emotion
and identities.
The researcher noted that in order to achieve an effective conflict resolution, an
assessment should be made about what type of conflict strategy should be used. To
effectively assess the conflict, both parties should be aware of the source of conflict
or the unresolved problem. According to Kneisl, WiIson and Trigoboff (2004:7), self-
awareness is how well individuals know themselves and whether they can develop
the ability to be sensitive. Additionally the authors state that the effective efforts to
relate to and communicate with others depend on how well people know themselves.
Thus self-awareness in the work environment is essential for addressing aggression
amongst colleagues in the work environment.
60
4.2.2 Guideline 2: Facilitating teamwork, in a trusting and caring work
environment
The psychiatric nurses experience a doubtful, suspicious and distrustful team
environment. The psychiatric nurses explained that they need their colleagues to
alleviate aggression in the work environment by focusing on teamwork. In explaining
teamwork, they stated that they need to have support amongst themselves and to
accept each other as individuals. In order for psychiatric nurses to feel supported,
they should be able to disclose their concerns openly amongst colleges. This support
is essential and helps the psychiatric nurse to not feel alone, but more supported
(Funakoshi, Miyamoto & Kayama, 2006:231). Gunusen and Ustun (2010:485) add
that emotional exhaustion levels can be decreased by means of interpersonal
interventions.
The researcher recommends that the psychiatric nurses, in order to manage the
aggression in their work environment effectively amongst colleagues, they must
create an awareness of teamwork. Tyler and Parker (2010:43) state that teamwork is
associated with positive attitudes amongst colleagues. Additionally the researchers’
findings revealed that positive attitudes contributed to effective teamwork amongst
colleagues, extending to all other nursing units and shifts. According to Amos, Hu
and Herrick (2005:11), it is the manager’s responsibility to plan, coordinate and
convey a vision that inspires teamwork. It is important for the nurse manager to
understand the principles of group dynamics in order to apply them to team building.
Helping staff to develop interpersonal skills is essential to building a unified team.
In order for teamwork to be effective, the psychiatric nurses need an open
communication system. Conveying respect comes into question and the psychiatric
nurses reported that passive aggression was viewed as the lack of respect conveyed
or communicated in the work environment. Antoniazzi (2011:752) states that respect
61
is the willingness to acknowledge, accept and value the uniqueness of another
person and oneself.
The researcher emphasised that open communication and supportive interpersonal
relationships were linked with positive attitudes towards the work environment. This
could possibly result in job satisfaction, improved job performance and an increase in
retention of psychiatric nurses (Amos, Hu & Herrick, 2005:16). With regard to
interpersonal skills development, Kidd and Finlayson (2010:21) add that nursing as a
profession and as a workforce cannot overcome its collective distress unless the
individual aspects are also addressed.
4.2.3 Guideline 3: Addressing factors contributing to aggression experienced
in the work environment
The psychiatric nurses experience limited support when their colleagues and
management do not acknowledge aggression. The psychiatric nurses explained that
they need more support in the work environment in order to address aggression
effectively. The psychiatric nurses view this support as management taking an
interest in them as a sign of being cared for. Funakoshi, et al (2007:228) emphasises
that it is the manager’s role to provide the nurses with the source of primary support.
He states that nurses experience their managers as unsupportive, having higher
psychological distress and being emotionally exhausted.
The psychiatric nurses said that having mutual respect is a basic requirement for
management in the work environment. Psychiatric nurses want to work in an
environment where they are able to develop supportive and respectful relationships
with their managers and co-workers (Antoniazzi, 2011:748). Antoniazzi (2011:748)
states that when respect is present and nurses feel respected, they are happier and
more positive and the environment is warm and friendly. Respect in the work
environment includes respect for another person as an individual and his or her
62
culture. When nurses are acknowledged and respected, a manifestation of effective
communication is established (Antoniazzi, 2011:753).
Yildirim (2009:509) adds that when nursing staff experience negative relationships or
communication with their managers and colleagues, their motivation decreases and
their performance is hampered. The psychiatric nurses said they wanted fair
recognition in their work environment. Pearson, et al (2006:224) add that in their
review many nurses sought recognition in the nursing profession. By recognising and
acknowledging the psychiatric nurses for work they have done in the work
environment, the harbouring of passive aggressive thoughts, feelings and/or actions
could possibly be defused. The psychiatric nurses stated that transparency is one of
the needs that management has to employ in order to alleviate aggression. The
psychiatric nurses explained that they do not want management to discriminate
against them. And they not only want their work respected, but also need to be
acknowledged individuals.
4.2.4 Guideline 4: Strategies to cope effectively when aggression is
experienced
Psychiatric nurses use coping mechanisms when they experience emotional stress
and aggression. These psychiatric nurses will benefit from teachings on the use of
effective coping techniques and methods. The researcher questions the psychiatric
nurses’ ability to use the skills they obtained during their training as students, as most
of them are overwhelmed and exhausted. Even though the psychiatric nurses teach
their clients skills, the psychiatric nurses are not able to use the skills themselves.
Currid (2009:42) supports this statement and found that nurses do not use the
therapeutic interventions they have been trained to use.
When psychiatric nurses experience aggression in the work environment, they feel
overwhelmed and therefore verbalise that they need to be afforded the opportunities
63
to debrief and talk about their experiences and feelings. Currid (2009:42) adds that
support in the work environment can be offered in various forms, for example clinical
supervision, listening, training and education. Additional skills can be used in the
psychiatric nurses’ work environment, such as assertiveness training, anger control
and stress management.
Assertiveness is a learned behaviour and it consists of expressing your own desires
and thoughts or taking care of yourself, but not at the expense of others (Kneisl, et al,
2004:352). Assertiveness can be a valuable skill in the work environment if the
psychiatric nurses can express themselves respectfully in a non-threatening manner.
Timmins and McCabe (2005:42b) support the recommendations and state that
assertiveness is closely related to uncaring behaviour in the work environment.
Anger control skills and stress management can be valuable to nursing staff when
provoked in any way or form by other psychiatric nurses. This can assist the
psychiatric nurses in creating awareness and thinking about their own process of
action and how to react. Currid (2009:45) recommends that support groups for
nurses be established as an inexpensive way for nurses to deal with their difficult
environment.
4.3 CONCLUSION OF RESEARCH
The psychiatric nurses are in constant interaction with their environments and their
work environment (Bilgin, 2009:257). The Theory for Health Promotion in Nursing
(University of Johannesburg, 2006:6) states that, “the person is seen holistically in
interacting with the environment in an integrated manner”. Psychiatric nurses interact
daily in their environments as well as in their work environment.
Aggression in psychiatric hospitals has been widely researched internationally and
nationally. Both Yildirim (2009:505) and Bimenyimana, et al (2009:5) indicate that
64
aggression ultimately has an overt negative psychological effect on nurses and what
the psychiatric nurses experience. Aggression could have harmful psychological
consequence and can affect the psychiatric nurses’ self-esteem, social status and
happiness. Passive aggressive behaviour is a manifestation of passive or reactive
expression of underlying aggression (Kaplan et al, 2003:105). Therefore, violence,
aggression and specifically passive aggressive behaviours, have a harmful effect on
the psychiatric nurse who is a holistic person with mind, body and spiritual
dimensions (University of Johannesburg, 2006:6).
The importance and effect of aggressive behaviours in day-to-day living should not
be underestimated. Bowers (Bilgin, 2009:253) states that the positive attitudes of
staff could have an effect on their patients. Bilgin (2009:253) explains the importance
of the nursing staff’s roles and attitudes in the interaction with the psychiatric
environment, which should ultimately strive to create a therapeutic milieu. This
implies that the psychiatric nurses’ interpersonal skills play an extremely important
role in the creation of such an ideal milieu in the work environment.
The researcher works as a psychiatric professional nurse in an academic psychiatric
hospital in the Gauteng region. The researcher made certain observations while
working in a psychiatric unit that indicated challenges in the behaviour of psychiatric
nurses and their interaction with their colleagues.
The following research question was posed:
“What is your experience of aggression amongst colleagues in the work
environment?”
The objective of the study was to
- explore and describe the psychiatric nurses’ lived experience of aggression
when in interaction with fellow colleagues, and
- formulate guidelines on assisting the psychiatric nurses in their working
environment.
65
4.3.1 RESEARCH DESIGN AND METHOD
The aim of this research was to capture the lived experience by psychiatric nurses of
aggression amongst colleagues. A qualitative phenomenological approach was used.
This approach created an opportunity for the researcher to discover the phenomena
of the lived experiences by psychiatric nurses of aggression amongst colleagues
(Creswell, 2009:233). The study is thus qualitative, exploratory, descriptive and
contextual in nature (Maphorisa, Poggenpoel & Myburgh, 2002:24). Data was
collected by means of conducting in-depth phenomenological interviews and asking
participant to write naive sketches about their experience.
Trustworthiness refers to the acquiring of knowledge and understanding of the true
nature, essence, meanings, attributes and characteristics of the phenomenon
(Leiniger, 1985:68). To ensure trustworthiness, the following was adopted: credibility,
dependability, confirmability and transferability (Krefting, 1991:156). In this study, the
researcher used all the means possible to select information-rich participants, to
collect data objectively and to analyse the data with known scientific methods. An
independent coder was used to increase the credibility of the findings, while
determining the short-comings of the research process.
4.3.1.1 Phase 1: Exploration and Description of the Lived Experience by
Psychiatric Nurses of aggression amongst colleagues
In phase 1 of this research study, the lived experiences by psychiatric nurses of
aggression amongst colleagues were explored and described. While analysing the
research data, four main themes emerge and were identified. The themes were
identified after the data has been analysed. The first theme found in the data was that
psychiatric nurses experienced aggression as subtle, passive and very harmful in
both a verbal and non-verbal manner. The first theme thus indicates that the
66
psychiatric nurses experience aggression in the work environment amongst
colleagues.
The second theme discussed is that nurses experience a doubtful, suspicious and
distrustful team environment. This theme indicates that teamwork and the rendering
of services are affected by the aggression that the psychiatric nurses experience in
the work environment.
The third theme listed is that psychiatric nurses’ experience limited support when
colleagues and management do not acknowledge aggression. The psychiatric nurses
were able to name the needs and expectations of the colleagues and of
management. The last and fourth theme explored is the psychiatric nurses’
experience of using coping mechanisms when they experience emotional stress and
aggression. The psychiatric nurses explained different ways by means of which they
manage stress and aggression in the work environment. At times this would result in
using destructive coping mechanisms, for example passive aggression, only adding
to the aggression experienced in the work environment.
4.2.1.2 Phase 2: Guidelines to Assist the Psychiatric Nurses to cope with
the challenges of aggression amongst colleagues
The results of phase 1 are used to formulate guidelines on assisting nurses in coping
with the challenges of aggression. The following guidelines and recommendations
were formulated for the psychiatric nurses, their colleagues and management. The
first guideline issued was to facilitate management in managing any aggression
experienced amongst colleagues. This manner of facilitation will therefore also equip
psychiatric nurses to cope better with aggression in the work environment. The
second guideline issued was the facilitation of teamwork by creating a trusting and
caring work environment. The researcher believes that when teamwork is facilitated,
the services rendered will improve.
67
The third guideline derived from the findings is to address factors that contribute to
the aggression experienced in the work environment. The findings of this research
study indicate that when someone is ignored or not acknowledged, it is experienced
as a form of aggression. The fourth and last guideline issued is to formulate
strategies to effectively cope with experiences of aggression. The findings indicate
that the psychiatric nurses use different strategies and means to cope with
aggression in the work place; at times coping mechanisms can be destructive in
nature.
4.4 RECOMMENDATIONS AND FUTURE RESEARCH
The researcher formulated guidelines and recommendations for the psychiatric
nurses when they experience aggression in their work environment. In nursing
practice, the objective of the nursing staff and management is to render optimum
care to all their clients. It should be noted, however, that the availability of resources
contributes to the restrictions in terms of client care. Currid (2009:42) adds that
support can be offered in the work environment; however, resources are not always
available.
In order for psychiatric nurses to be able to optimally attend to the care of their
clients, the mental health of the psychiatric nurse should be attended to as well. The
mental health of the psychiatric nurses should be management’s priority. Thus
nursing management is required to provide the psychiatric nursing staff with effective
and sufficient support by availing the resources necessary to attend to the mental
health of psychiatric nurses. The researcher acknowledges that nursing managers
are also exposed to aggression in the work environment, and suggests that they also
be exposed to the necessary skills needed in order to render effective support in the
work environment. Future research can possibly explore the lived experiences of
aggression by nursing management in the work environment.
68
Happell, et al (2003:40) describe job satisfaction Happellas an emotional state that
depends on the interaction of individuals, their colleagues’ characteristics, values and
expectations in the work environment. Job dissatisfaction frequently contributes to
the stress and burnout experienced in the work environment. Antoniazzi (2011:746)
adds that increased stress leads to job dissatisfaction, increasing the absenteeism of
nursing staff in the work environment, thus increasing the pressures on nursing staff
and resources in the work environment. Therefore psychiatric nurses’ needs for
effective support in the work environment should be met in order to address possible
job satisfaction, absenteeism and staff retention. Further research could be done on
the effect of support experienced by psychiatric nurses in the work environment.
The researcher recommends that future research should develop a programme that
would effectively address the needs of the psychiatric nurses in their work
environment. The researcher acknowledges that there is currently an employee
health and wellness programme in place. However, the researcher recommends that
this programme be revised and developed specifically to assist psychiatric nurses in
their work environment on a daily basis. This equipped them with the necessary skills
to not only render the essential care to their clients, but also in their interaction with
colleagues and nursing management. Such a programme will support and assist the
psychiatric nurses when aggression is experienced in the work environment.
4.5 CHALLENGES
The research study provides insight into the lived experiences of aggression by
psychiatric nurses amongst colleagues. This research study has its challenges. The
site at which the research was conducted is an academic psychiatric hospital in
Gauteng, with open, semi-closed and specialised psychiatric units. The research is
unique in that there has not been any research done in this facility into the
experience of aggression by psychiatric nurses amongst colleagues or related topics.
69
Hence this posed a challenge, as limited literature and theories were available to
compare the findings to. The research study was contextual of nature and the
findings were contextualised to the hospital at which the research was conducted.
The quality of the data audio-recordings was poor due to unforeseen external
interferences on the recorder; even so transcribing was possible. The psychiatric
nurses’ naive sketches supported the data collection process, although some of the
participants’ hand writing was unrecognisable. Most of the interviews were conducted
in English, although it was not the participant’s first language. This language barrier
posed a challenge, as most participants had to express their experiences in their
second language.
The interviews were conducted on the hospital premises, in a private room or office
space with a door that can close for privacy, in order to maintain confidentiality. Most
interviews were conducted in the comfort of the participants’ own ward where they
were working at the time of the interviews. This also posed a challenge, as most of
the psychiatric nurses’ colleagues were aware of who was participating, even though
the content of what was said was kept confidential, in accordance with ethical
principles.
4.6 SUMMARY
The purpose of the study was to explore and describe the lived experience of the
psychiatric nurses of aggression amongst colleagues in the work environment. From
the findings of the research study on the lived experience of psychiatric nurses it is
evident that the psychiatric nurses experience aggression amongst colleagues.
During in-depth interviews, the psychiatric nurses verbalised that they not only
experience aggression amongst colleagues, but from nursing management as well
“... management are neglectful of us, they are not interested, they’re ignorant ...”. The
70
psychiatric nurses reported that various forms of aggression occur and that they
experience aggression in a suspicious, paranoid and hostile team environment.
Although the psychiatric nurses denied any direct physical aggression, they reported
that the experience of aggression affected them at emotional and psychological
levels. Not only did they experience distress, but they also showed signs of
decreased levels of self-worth and self-esteem, thus lacking assertiveness skills in
the work environment. This affected their performance in the work environment and
decreased their job satisfaction. Not only did the psychiatric nurses question
themselves, but they also started to question their colleagues, management and their
careers. Feelings of not being motivated and decreased levels of passion pointed to
signs of burnout.
Contributing to the psychiatric nurses’ experience of aggression was the feeling that
their colleagues and management did not support them. The psychiatric nurses
experienced management as reprimanding, constantly reporting them, threatening
the psychiatric nurses with disciplinary action, not recognising their work and
assigning duties unfairly. The psychiatric nurses’ experience of aggression resulted in
emotional distress, leaving them with feelings of frustration, disappointment, mistrust
and resentment.
The experience of emotional distress resulted in the psychiatric nurses using
defences mechanisms. At times the psychiatric nurses managed the experience of
aggression in a passive manner. The manner in which they experienced aggression
amongst colleagues in the work environment, is similar to how they cope with
aggression in the work environment. In summary, figure 4.1 illustrates the process of
how psychiatric nurses experience aggression in the work environment amongst
colleagues.
71
Figure 4.2 - Findings of the lived experience of the psychiatric nurse
4.7 CONCLUSION
This chapter supplied an overview of the study by recounting the background, the
problem statement and the aim of the research study. Guidelines and
recommendations were formulated to assist the psychiatric nurses when aggression
72
is experience amongst colleagues in the work environment. The guidelines and
recommendations for the psychiatric nurses, their colleagues and management were
presented. Recommendations were made with regard to nursing practice and future
research. The discussions were followed by presenting the challenges found in the
research study. Thereafter the chapter was concluded by a brief summary and
illustration of the research study.
73
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APPENDIX A: ETHICAL CLEARANCES
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84
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APPENDIX B: REQUEST FOR CONSENT TO CONDUCT RESEARCH
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CONSENT FORM TO PARTICIPATE IN THE RESEARCHER STUDY
I (Name in full) ___________________________________________________ have
read and understand the consent in the request letter to participate in the research
study on “THE LIVED EXPERIENCE BY PSYCHIATRIC NURSES OF
AGGRESSION AMONGST COLLEAGUES”.
Further on I confirm that I give the permission freely, knowing that the information
given to the researcher will be treated confidentially and anonymously even though
the University of Johannesburg will make the final result of the research study public
to the academic world.
I also know that at any time I may withdraw my consent participation without any
penalty. I have had enough time to ask questions and the answers have been
satisfactory. I also consent for audio taping of the interview, and analysing of
narrative sketches.
PARTICIPANT:
Name:_________________________Signature:______________Date:________
RESEARCHER:
Name:_________________________Signature:______________Date:________
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CONSENT FORM FOR PERMISSION TO AUDIO-TAPE INTERVIEW
I (Name in full) ___________________________________________________ have
read and understand the consent in the request letter to participate in the research
study on “THE LIVED EXPERIENCE BY PSYCHIATRIC NURSES OF
AGGRESSION AMONGST COLLEAGUES”.
I confirm that I understand that I have the opportunity to ask questions regarding the
research study and information regarding audio-taping, privacy, confidentiality, and
anonymity.
I herby give my permission that the interview with me can be audio taped.
PARTICIPANT:
Name:___________________________Signature:______________Date:________
RESEARCHER:
Name:___________________________Signature:______________Date:________
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APPENDIX C: PARTICIPANT’S INFORMATION SHEET
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UNIVERSITY OF JOHANNESBURG
FACULTY OF HEALTH SCIENCES
DEPARTMENT OF NURSING SCIENCE
15 April 2011
The Prospective participant
REQUEST TO CONDUCT RESEARCH
Dear Sir/Madam,
My name is Marisa Delport. I am a professional nurse and I am currently registered
with the University of Johannesburg for the Masters Degree in advanced Psychiatric
Nursing. In order to fulfil all the requirements for a master’s degree, I am currently
doing a research project to which I would like to invite you to participate.
Your contribution, as participants, will be highly appreciated and will make a
difference. The title of the research project is “THE LIVED EXPERIENCE BY
PSYCHIATRIC NURSES OF AGGRESSION AMONGST COLLEAGUES” the study
will be done under supervision and guidance of professor M Poggenpoel and C P H
Myburgh, at the University of Johannesburg.
The objectives of this study are:
Explore and describe the psychiatric nurse lived experience of aggression amongst
colleagues.
To formulate guidelines to assist psychiatric nurses and to facilitate their mental
health.
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After obtaining your permission, a phenomenological interview will be conducted for
45-60 minutes, whereby you will describe you experience of aggression between
colleagues. Only one open- ended question will be asked during the interview: “How
is aggression for you between psychiatric nurses in this ward?” I request your
permission to audiotape this interview. The audiotapes will be kept under lock and
key, only I and my supervisors will have access to the audiotapes. The audiotapes
will be destroyed two years after publication of the research. In addition you would
be asked to write a naive sketch of your experiences of aggression between
colleagues.
Arrangements will be made with you once the permission has been granted by you,
as to the place where the interview will be conducted (at a convenient to you).
Research findings will be made available to you on request. Participation in this
study is voluntary and that even during the course of the interview you can terminate
the interview without any harm. You will not be paid for participating in this study.
In order to protect your identity, you will:
Freely sign an informed consent before the beginning of the interviews
No name will be mentioned during interview or after, during transcription and
decoding;
All information received will be treated professionally with respect to confidentiality
and privacy;
In the research project no harm is foreseen, however should the reliving the
experience of aggression provoke a crisis, referral to professional help is planned;
You may decide to withdraw from the study at any time without fear of penalty.
The results of the study will be made known to you and a copy will be made available
to the nursing management of the institution where participants can obtain a copy.
Should you have any queries please contact me at:
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Postal address:
Marisa Delport
P.O. Box 6793
Cresta,
2118
Phone: 0828621881 (from 17:00 to 20:00 only)
E: mail to [email protected]
Yours faithfully
MARISA DELPORT
M CUR PSTCHIATRIC MENTAL HEALTH NUSING STUDENT
PROFESSOR MARIE POGGENPOEL, RN., PHD
SUPERVISOR
PROFESSOR CHRIS MYBURGH, BSC HONNS, M COMM, DED, HED
CO-SUPERVISOR
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APPENDIX D: INTERVIEW
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Interview 8
Key: R = Researcher P = Participant
R: I would like to ask you about your experience of aggression between colleagues
in the workplace?
P: I would say, I’ve definitely experienced aggression in the workplace and that it
became or is very real to me and that, um...the aggression, at times, is subtle, but
harmful, and what I mean by that is, I experience aggression, not so much physically,
but I experience aggression as receiving threats in the workplace, especially if things
in the duty-room became ‘hot’. ‘Hot’ meaning that there were lots of issues going
around and lots of issues being dealt with.
R: Do you mean verbal aggression?
P: Ver..yes I‘ve experienced verbal aggression....in the form of threats and
argumentative and um...somehow I want to say manipulative as well. Um...
commentary, um...
R: How are...What do you mean by manipulative? Could you expand on that?
P: Manuiputlive...manipulative in the way that people will say something that makes
you feel guilty and then you do it anyway; and that can be for anything in um....
because patients or example um...off-duties, they can make you feel guilty for not
working the right hours or the hours they set out or...um....
R: When you say manipulative; what was the reason for them to be manipulative....
to make you feel uncomfortable? What would be the reason?
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P: I would, I would assume that the...they would do it out of their own gain. They
want to turn the situation to better themselves.
R: And what would be the result of that?
P: Frustration, frustration, a lot of frustration.
R: You said um...I’m not quite clear what you were saying. You said, “Made you feel
they had an intention of making you feel that and”..and then you felt that or actually
acted out that. I wasn’t quite clear what you were saying. You said the intention of
making you feel a certain way and then it did happen.
P: It’s just...it comes down to; they want to turn things in their favour and it makes
you feel like....guilty, and then you realise that they are manipulating and why you
feeling guilty and then you have feelings towards them because they inflict this upon
you and it’s not your stuff.
R: So how do they do that? How do they make you feel guilty? What is it they do that
makes you feel guilty?
P: It’s the things they say, could be comments.
R: Comments you say about er... about your work? About your appearance, about
what you say, about...? What would it be about?
P: About....I won’t say it’s something specific towards me, they would always be
more broad, non specific, but it’s like....
R: It’s hidden is it?
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P: Yes.
R: You feel guilty because you feel there’s a hidden meaning underneath it?
Although it’s not obvious that it’s pointed at you, because it’s general. But you P:
...take it personally or you think there is a personal issue there, which makes you feel
uncomfortable?
P: Ja, it’s how they’re not able to be direct or straight or come...forthcoming with
what the situation might be. And all of that leads to some kind of build up of
aggression, ‘cos you feel like they’ve done something against you if they try to move
or manipulate things in their way, they are doing wrong against you, so you or I am
building up feelings of guilt, regret, frustration and the more it builds up the more
....you cannot stop it from.... being expressed in another way and that usually
happens by ignoring him, or making some commentary back on whatever situation it
would...would be at that point, you know, and reach (interrupted).
R: So, if I could summarise from what I’m hearing you say. You’re saying they make
a broad comment and you feel that’s almost like a underhand comment. They’re not
being overt with you, not being open with you. They’re going round it and it makes
you feel guilty, makes you feel you’ve done something, whether you have or not.....
P: hm hm! (agreement).
R: ....And that frustration and that indirect comment makes you feel angry and
frustrated and the way you deal with it is to...just ignore them or act in a way that
maybe you wouldn’t normally act as a way of dealing with it.
P: Hmm! Mm. You go home feeling very exhausted because so many things going on
around, that’s so, in my opinion, unnecessary.
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R: Hm.
P: And you feel drained and ...
R: So it’s not always the work, but the interaction of what’s happening in the ward
that makes you feel so exhausted and drained, but the under....undercurrent that
you’re aware of.
P: And sometimes when an...another scenario, if you are overworked and you are
exhausted and the work is so intense that when they do certain things, it adds up to
it. When I’m speaking about certain things, I’m referring to when my Black colleagues
would speak in their own language en exclude me in conversations and I’ve got no
idea what’s going on around me, and um... they all laughing and pointing and
eh...you know it’s probably they don’t speak about you and sometimes they do, but
the thing is you don’t know and you wonder and all of that ideas and feelings going
around. That frustration just increases it. When you are exhausted and tired, you
don’t have the tolerance to deal with that.
R: Hmm. So there is that uncertainty of really knowing what they’re saying, causes
other stress.
P: Especially if you don’t agree on something. It’s not like talking to you, being
upfront again, being specific. “Let’s speak about it, let’s share ideas around it”. They
just accept it, acknowledge and then.... go on...on their own mission.
R: So are you saying that if you speak about something, they don’t make a
comment? And it’s just not commented on and things just keep going on so you’re
not sure whether they...there’s an agreement or not? Is that what you’re saying?
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P: They...they...they will come to agreement, but there will always be further
discussions, and it makes me concerned about, “What is that discussion all about”?
And sometimes I just feel angry with them.
R: I’m not clear what you’re saying. Um... there’s discussion and then there’s an
agreement, but then there seems to be not an agreement because it keeps
continuing.
P: Ye...they continue in their own language.
R: Are they continuing in your own language, so is there an agree..(interrupted).
P: We had a discussion. We came to sort of agreement and they will keep on
discussing it in their own language without me being a....or that’s my assumption. I
assume, but sometimes you can hear what they are talking about; every second word
or every pointing or their body lang..... maybe it’s just assumptions, but sometimes it
feels like they got teeny with it and they’re not leaving the subject. So the
feelings....doesn’t really go away or be dealt with because there’s always this
uncertainty, you know.
R: So it’s not really been resolved. You think it’s been resolved and then you hear
them continue talking, so you know in a way it’s not resolved, because you can’t join
in. It makes you think, “What are they talking about”?
P: Mm!
R: It’s very, it makes you feel very uncomfortable.
P: Exactly! And sometimes I just feel angry with them.
R: Hmm.
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P: I do; and because there’s no open space or real space to share one’s frustration
and anger, even if the frustration is about your colleagues, or even if the frustration is
about your patients or your working environment. There’s no open space to share
those feelings of anger and frustration and you can’t be overtly um...angly...angry.
You can’t be openly so and you...its unprofessional and un....not like me as a person
to be verbally attacking and that’s my opinion seems sometimes um...impulsive to be
verbally attacking, but then you still sitting with this feeling. You’ve no outlet for them
and then you just can’t help it but to suppress it and then it manifests in other ways,
like you are.... turning your back on them, and you don’t wanna talk to them when
they are having a conversation or you just don’t want to interact in that stage or um...
R: So it feels that when (ahem). It feels like maybe when you feel uncomfortable’
threatened because you’re not sure what’s being said. Things haven’t been correctly
evolved. Evolving later on, it becomes almost like a protection for yourself, so it
becomes a defence it...You don’t actually engage with them because it’s...its too
difficult, too challenging and that might be again misinterpreted as not in a way that
you don’t want them to interpret it. But that’s the only way at that moment you feel
you can deal with it, or you don’t feel you want to be engaged with them. You turn
away because...
P: When you are angry and frustrated you don’t feel like engaging with anyone. It’s
even difficult engaging with patients or doing what you need to do, when you have
anger; angry feelings.
R: So you say it stops you being functional?
P: To a point. When you do things, you do with some kind of attitude.
R: Hmm.
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P: “I’m busy now, I, You know”? “Can’t talk right now”.
R: So you’re expressing things in a way that you don’t really want to, but its just your
own anger and frustration. It actually leads you to behave in that...those ways, which
you don’t want to really, but it’s just a way of coping with what’s going on?
P: It’s like....in your attitudes change. You, like all of a sudden you ....not your normal
self, meaning you’ve got an attitude, you make snappy comments, um...you...and to
ease things off and to not make it that obvious, you make jokes about it, so this.... it’s
almost ends up to be a circus.
R: Mmm!
P: And then you just go home and then, you just somewhere you need to relieve
these unresolved issues, and because there’s no real space to deal with it.
R: Hmm. Facing this unresolved in the workplace and then you go home and there’s
no place for you there to resolve it or no place in the workplace to resolve it.
P: No place in the workplace.
R: It sounds like you would like that.
P: I think it would be quite helpful if there’s a safe space for one to express; a non-
judgemental space. Because some days you would feel angry about everything and
then you don’t want to express it to people because you might just hurt their feelings
and you don’t want to express it to superiors, because they might just pass
judgement onto you and there’s....categorised you as a very... P: ...irritable person
and meanwhile there’s just something that can be shared and dealt with and
mentored.
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R: Hmm. So it seems like you’re coming up with some ideas. You said it’s not safe to
express with your colleagues and the management; it’s not safe, but you’re saying
that it would be nice for some sort of mentorship.
P: I believe so. And don’t get me wrong, a lot of people try really hard. Your direct
managers, they really try really hard in times to resolve something when it’s there. I
must give them that, but it’s only at the point they intervene when it’s gotten out of
hand, or it’s so ridiculous....or sometimes it’s...they’ve got frustrations and it just
comes down to you and you have to interact with them and...and they are frustrated
and they’ve got managers as well, and so it just boils down from the top to the bottom
and the people in higher positions, they take out their frustrations on someone below
them and subordinates if I can say that, and they take out frustration on someone
below them and then the people at the bottom doesn’t really have somewhere to go
with their frustration and anger. Soos...soos...
R: Top down thing.
P: Yes.
R: Top down. Seems like you can see what’s happening.
P: I do think so, or and that’s just my opinion. Um...that I can acknowledge as much
as I’m struggling in the workplace. They can also be struggling and they have also,
they also have their frustrations. So somehow I would like to see a point where
everyone res....within are or feels safe enough to deal with their frustrations. In lots of
things we sees um...also snappy comments and not well P: ...thought through
decisions and impulsive decisions and um...from management I also see....
R: (Something drops) (Whispers) Sorry! Okay!
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P: I also see....some immaturity, but now I sound judging and I don’t wanna judge
them, because I want to acknowledge that they also in difficult positions and my
experience, it seems, immature. Um...and somehow I think that so...you, the staff
members leads by example and that’s where its also frustrating to see that there’s a
whole chain of people not being supported, and support, I mean, non-judgemental,
safe environment, because some people give support or they think they give support
and it can be very punitive and that punitiveness can lead to more frustrations and
more ‘not dealing with it’.
R: So you’re saying that, um, the results is results of the situation often results, is
dealt in a punitive way, which actually escalates the feelings to be even worse?
P: Exactly!.And everyone say because we are psychiatric nurses, we can deal with
emotions and we have...know what a coping skill is, and sometimes even though you
know these things, that the environment is not safe enough, or does not feel safe
enough to implement the skills, the knowledge you have.
R: Hmm. So does that make you feel very frustrated, because you have the
knowledge and the skills. You’re trained to do it, but you can’t implement them
because; the unsafe place that you...you feel that you feel that you’re in, you can’t be
therapeutic in the way you’d like to be. How does that make you feel?
P: It upsets me. It...it frustrates me, but it saddens me as well. It...it’s very sad to
think about that of... I can teach people how to cope and I’ve got knowledge to use
coping skills, but it’s not okay for me or safe for me to use that and it’s sad. It’s sad. It
makes me feel not wanting to come to work.
R: Hmm.
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P: It makes me drag my feet. It makes me think twice whether or no... the patient
care I’m giving or sometimes I can’t help it, but I like to be late for work.
R: Hmm.
P: Sometimes I’m really late for work.
R: Hmm.
P: And people is understanding and I appreciate that, but I know if I have a safe
outlet that I would not express my frustration, maybe unconsciously in these
manners.
R: You say you demotivated, but people do understand?
P: Yes it’s....I am demotivated. And people acknowledge in a certain way the
demotivation, but that’s where it stays. There are minimal interventions for motivation.
Um...minimal interventions for upliftment of moral, and if there is occasions where the
staff, or nursing staff, or hospital staff comes together. I feel like it’s done with such
lightness, or it’s not taken up seriously although we come together to have fun. I don’t
sense a lot of respect, even though you can take it and make of it what you need to. I
would just like to see more thought through efforts, so I can acknowledge that they
making an effort, but it’s not thought through, it’s not really support like, for instance,
we had a ‘culture day’ and everyone dress up in their culture and it was these
extremely loud music and everyone dance and it was fun to a certain degree, but
and..and it could relax and relate to people in a different manner and you weren’t in a
stressful, duty room environment, but your thoughts were in the duty room, “ Sjoe!
P: ...When are they ending, because I need to go back to patients”? It’s not time
allocated for you to relax, it’s time allocated to make fun, but it’s not addressing the
issues.
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R: Hmm. You are acknowledging that they are creating some atmosphere, er...in
terms of providing some sort of interaction with the other staff members in a psoitive
way, but the real deep, down issues are being sidelined, not really looked at in the
appropriate way that you think they should be addressed. It is creating fun, but it’s not
addressing the issues.
P: That’s it!
R: You seem sad.
P: It is sad. I...I do feel sad. I feel ....sad, because I would like to think of me...of
being a passionate psychiatric nurse, enjoying what I do, appreciating my colleagues.
But sometimes, the small things that could be resolved so easily, is not resolved and
it comes to, there’s a whole cycle of unresolved feelings just piling up and become
unresolved issues, and issues not dealt with correctly becomes just painful feelings
and it changes your behaviour and how you react towards others and how you treat
someone else. They become f...hurt and their hurt just pile up and then there’s this
unresolved cycle of feelings emotions and the thing is we work every day with other
people’s, our patients’ feelings and issues. We work with that. We have no space to
go to and say. “Let’s deal with it, let’s leave it here, let’s think it through and let’s see
how we can help then”. We don’t ....we deal with theirs, but we don’t deal with our
own.
R: Seems like you’ve identified the needs. Do....do you know how it could be
resolved? You looking at ways that you would think might be helpful for you.
P: Ha no I’ve mentioned earlier in mentorship, which I think would be great, but that
would be....that should be done by executive management and how, where their
passion lies. Also depends on how it would be effective and then if you are able to
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support your fellow colleague, then you also feel like you make a difference and you
can take your knowledge and you can have environment where you can practise that.
But, in the same sense, in this hospital it’s not always safe to deal with your feelings
or to address issues and I don’t see, unless you are very creative, how to convince
the colleagues or nurses of this hospital to participate in that, because there’s, I feel,
management is not trustworthy in that sense.
R: You’re talking a lot about safety. The felt sense of um...trust and safety seems to
be coming up all the time in your conversation?
P: I don’t trust the people who need to provide a safe environment, emotional safe
environment.
R: You’ve obviously thought a lot about this. Have you thought about how that safety
could, like trust and safety that you need you need to talk about, could be.... If you
were given the position of creating trust and safety, what would you do?
P: Look, I think trust and safety need to come from....it’s for individuals, by individual.
So even if it’s just one individual who can make change of the thinking pattern of the
way the hospital staff is thinking, or is indi...individuals, more than one, that can take
that task. It should be very strong individual with a passion for the staff, and I think
that there currently, there’s... I don’t see a lot of passion for staff members.
R: Hm.
P: I don’t see a lot of care, understanding and maybe some motivation here and
there, but care, not a lot of. So I would do that. I’m doubting me as a person would do
it, but if I am in such a position, I would say that it’s a great responsibility. I would
need to take up a lot of responsibility and I would need to have respect for that
position and it would er...be very respectful approach, and I think um...as there is a
105
lot of experiences of aggression in the workplace, that, even though it’s very hard and
tight and aggressive, passive or verbally or however, that there must be a more
softer, caring approach to that.
R: Is there any other form of aggression or any other experience of aggression that
you’ve experienced between colleagues while you’ve been working? You spoke
about feeling frustrated and underhand issues of people talking about things after
you’ve discussed it. Is...is there any other examples you want to share, that come to
your mind?
P: I’ve mentioned the late coming as the snappy comments as aggression, the
sarcastic comments is aggressive. I said late coming, um....
R: Anything’s you’ve observed?
P: Undermining us, undermining of opinion, undermining of position or rank if that can
be acknowledged.
R: And when you disres...are you talking about disrespect or.....?
P: I...in the end that is disrespectful.
R: You talked about verbal aggression or passive aggressiveness. Is there any other
form of aggression you’ve observed?
P: I must say I’ve never experienced some physical aggression, where someone
wanted to hit me or....but I must say that sometimes it felt like he wanted to physically
attack someone and if anything that shows the intensity of the aggression that is
experienced in the duty room.
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R: So even if it wasn’t...doesn’t have...you didn’t see actual phy...physical
aggression, you felt the intensity of it as if it was so?
P: Yeah, definitely! I can recall once or maybe twice that I really feel like, “Please
get out of my way before I do something that I’ll regret later”.
R: So did you feel that coming to...to you, and that made you want to react to that in
the same form? Is that what you’re saying?
P: Mm mm! Exactly!
R: Hmm. Mmm,. so we mentioned, you mentioned quite a lot of things like
demotivation, coming late, not wanting to interact, feeling that intensity. Um...has it
affected you in any other way, physically or emotionally?
P: I think the anger and not dealing with the uh...feelings ends up to be more
stressful and the stress affects you, and physically as well. Sometimes it’s not just
that you are so demotivated at work, but you feel so physically tired and unwell. So, I
think it manifests if you can’t deal with it and in a civil, verbal manner and safe space,
it manifests on a physical level. If you....headaches, tiredness, exhaustion and also
emotionally it’s...it...someone’s...s... I want to make a statement and say, “It steals
your passion”.....
R: Mm.
P: ...”It steals your passion”.
R: Seems like you’re one of the team. Do you feel one when...when you’re
experiencing that lack of passion, it’s infectious like other...other staff members also
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begin to feel the same as you, or is it just something you’ve experienced yourself or
are you aware that other people are experiencing what you’re exp.... what you’re
talking about?
P: Right now I’m speaking for myself, but if I think about my experience in the
workplace, then I see depassionalised person now, if there’s such a word. They are
also demotivated. It’s like....
R: Are you aware that what you’re going through, you have a sense that maybe
other people are experiencing what you are going through? There’s this feeling of
that....
P: I believe so....yes.
R: Any one of two incidences you have mentioned a couple at the beginning stand
out in your mind, that’s really sticking out right now of what you’ve been talking
about?
P: There’s a few incidences ‘n a few flashing through, ‘n that, when I speak about
that, and especially in my previous ward where I worked, that someone made a
comment towards me and personal attack and I almost felt like, “I need to leave this
room, otherwise I’m gonna attack you physically”.
R: Hmm.
P: So intense it became.
R: Hm.
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P: And that we were always scold for, “Why you late”? And everyone was late, not
just me. Some were more later than....they more delayed, so it’s just.... What I
experienced, I just na....not only saw in my behaviour, I saw in the people around me
as well.
R: Hm, so it’s not... you didn’t feel alone in that experience. You were aware that
other people experience.... Would you say that’s a result of the work you were doing
or a result of the stress that the other staff members are going through or, or that a
combination both or none of those things?
P: I would definitely say it was a combination, because the work environment is so
stressful. You deal with such hectic patients that somehow that’s gonna overflow
within the dynamic of the staff, but it’s that continuous overflow and not dealing with
it, adds to the frustrations of staff, which just make.... it’s like a ticking time bomb.
R: Hmm.
P: It’s not helpful, it’s not safe.
R: Hm.
P: It’s not safe.
R: Now you’ve moved to another department that you been...It sounds like, are you
still experiencing similar situations, or are they different forms of aggression that
you’ve experienced or...?
P: Quite surprisingly, it was different. It was very different in the sense of, um...where
in the previous ward saw things dealt or swept under the carpet. Here at some
occasion it was more directly, and I felt the manager, at times, would not choose
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sides, that he would be very diplomatic. He try and acknowledge and respect and I...I
saw that as being helpful, but it’s not like there is no underlying, passive behaviour
going on, but I feel like it’s more manageable. And that back as soon as there are
hectic or stressful work or patients in that environment, the more things comes up.
R: So it’s like a trigger.
P: Ja.
R: Mm. Is there anything else you’d like to share about your experience of
aggression? Seems like you’ve had different...you’ve had different wards, but you’ve
still experienced it, maybe differently um...but it has been there in both ...both
situations.
P: Lastly, it’s just, I feel like there can..there can be done more. There can be given
more support to staff. They can be more acknowledged, more respected, and I feel
like the staff deserves more trust.
R: Who...who needs to do that for the staff? Each other?
P: People in the supervising role.
R: And the management?
P: Number one...
R: Supervisors?
P: ...and number two for each other. I really think all staff deserve a safe, emotionally
safe environment, because they have such a challenging work, tasks.
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R: So how would you envision that? Would you envision having a time to unload or
someone to run a group or be part of in-service training or ....?
P: I think all of those options can be explored and are implemented and that...that
there’s not just one channel of dealing with stuff. And stuff meaning emotions,
frustration, situation issues, but that there’s more than one channel to be able to deal
with these things and I think it should be compulsory for all staff because some staff
will just take their feelings and just avoid, ignore, suppress, which in the end leads to
all of those aggression, frustrations all over again.
R: So we got like one minute more. Is there anything more before we close that
you...you feel that you‘ve covered everything that you want to speak about?
P: I think I’ve um...expressed that. There is frustrations and that there is a need...a
need to support colleagues in the workplace.
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APPENDIX E: NAIVE SKETCH
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