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Building resilience in nursing students: Coping with aggression and violence at work

Hopkins, Martin (2015) Building resilience in nursing students: Coping with aggression and violence at work. PhD thesis, Murdoch University.

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Background: Nursing students are at significant risk of aggression and violence in clinical settings, however, the prevalence and the impact of these on this vulnerable group remains unclear. Nursing students’ experiences of aggression and violence and their ability to develop resilience to these adverse events requires further study.

Aims: This study set out to identify the prevalence and characteristics of workplace aggression and violence experienced by nursing students enrolled in one university’s Bachelor of Nursing program. Another primary aim of the study was to aid students in the development of coping skills to manage aggression and violence encountered in the workplace through the delivery of focused education strategies informed by a positive psychology approach.

Methodology: A quasi-experimental design, using a mixed method repeated measures survey, was used to collect quantitative and qualitative data about personal experiences of aggression and violence from second and third year nursing students, in addition to their responses to two specially designed education interventions. Data were collected using Likert Scale and closed and open ended survey questions, the Resilience Scale, Attitude Towards Aggression (ATAS) Scale and the International Positive Affect Negative Affect Short Form (IPANAS-SF) Scale, at three different time points: baseline, immediately post intervention and post clinical practicum. A cinemeducation and a standard education intervention were designed to increase resilience and positivity in students when facing aggression and violence. Students’ resilience, positivity and attitudes towards aggression and violence were investigated and compared in response to exposure to the interventions.

The response rate at baseline was 87.5% (n=97) for the second year students and 60% (n=56) for the third year nursing students, however, there was significant attrition over time with large differences in the response rate at individual time points. Parametric and non-parametric tests were conducted to analyse the data. All p values lower than .05 were considered significant. Qualitative data regarding nursing students’ feelings and perceptions as a result of exposure to aggression and violence were examined using content analysis.

Results: Participants were mainly female with no children and aged 17 to 54 years. Almost 40% of all participants at baseline felt at risk of experiencing physical aggression in the clinical environment with 30% reporting they had actually experienced it. Non-physical aggression was even more prevalent with approximately 60% of students having personal experiences and nearly two thirds reporting they felt at risk.

A mixed ANOVA was used to examine the effectiveness of the two education interventions on student’s resilience in participants who completed surveys at all three time points. The cinemeducation group (n=9) had mean resilience scores of 12.67, 16.06 and 10.72 at baseline, post intervention and post clinical practicum respectively, compared to the standard education group (n=11) scores of 14.59, 23.68 and 8.82 respectively. There was no statistically significant interaction between the education and time on students’ resilience scores F(2,13) – 2.655, p=.84, partial n 2 .129. However, there was a statistically significant difference in resilience at different time points in this group as a whole (n=20) F(2,40) – 11.990, p<.0005, partial n 2 .400 with a statistically significant mean increase of 6.24 from baseline to post clinical practicum but a statistically significant mean decrease of 10.10 from post intervention to post clinical practicum.

The second year nursing students’ attitude towards aggression was analysed across five domains: communicative, offensive, protective, destructive and intrusive. A Wilcoxon signed rank test indicated that a significant change in attitude occurred over time, with students viewing aggressive incidents as having less personal destructive impact at post clinical practicum compared to baseline T = 22.5, z = -3.13 (corrected for ties) n – Ties = 20, p = .002, two tailed. This effect can be considered “large”, r = .70. No significant changes in the other domains were observed.

The IPANAS-SF provided information of the students’ overall perception of aggression related to specific clinical scenarios as well as their feelings about their last personal experience of aggression and violence. The only statistically significant change observed from baseline to post clinical practicum was an overall increase in the students’ negative affect in relation to the last aggressive incident (p = .046). Neither education intervention received by the second year nursing students had a statistically significant effect on either their attitudes or positivity towards aggression. However, the qualitative data identified more positive feedback for the cinemeducation intervention and the students receiving this intervention reported they were able to relate the information to real life situations and apply the knowledge obtained in their clinical practice.

Results from a follow up analysis of a third year cohort (n=71) provided similar results to those obtained from the baseline third year students, however, they had a statistically significant higher range of scores (p= 008 - .031) in the ATAS, compared to the third year baseline students, with only a “small” effect, range r = .19 - .24. The third year follow up group of nursing students level of resilience (Mean Rank = 69.35, n = 71) was significantly higher compared to the third year nursing students baseline scores (Mean Rank = 53.32, n = 53), U = 2,368, z = 2.459, p = .0.14, two tailed, although this effect was also small, r = .22.

The qualitative findings from the study for all the students combined identified two main themes from the data collected. The first theme that arose was ‘overpowered and controlled by personal experience of aggression and violence’ and captured the negative effect of aggression and violence on nursing students. This indicates that aggression and violence in the clinical setting is perceived by this sample of students as having a significant personal impact. Interestingly, some of the students described developing their personal coping mechanisms for dealing with the events and the aftermath of aggression and violence, which was evidenced in the second main theme ‘developing attributes of resilience’. The themes arising from the nursing students’ qualitative data support their reported negative experience of aggression and violence and the existence of individual qualities and skills within the student group that help to build personal resilience in the sample group.

Conclusion and recommendations: The sample of nursing students involved in this study experience, and perceive themselves to be at risk of, considerable physical and non-physical aggression and violence in the workplace, resulting in feelings of uncertainty, distress and anxiety. It is clear that clinical workplace settings need to continue to develop safe work environments. At the same time educational institutions can assist students in developing personal skills to help them cope with aggressive situations in clinical practice. It is recommended that aggression management education be integrated into undergraduate nursing curriculum specifically aimed at nursing students and effective strategies to enhance and improve nursing students’ resilience and positivity when dealing with the aftermath of aggressive and violent incidents in the clinical environment are developed.

Item Type: Thesis (PhD)
Murdoch Affiliation(s): School of Health Professions
Supervisor(s): Morrison, Paul and Fetherston, Catherine
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