The purpose of the research study was to develop, describe and evaluate a model that can be used as a framework of reference for the advanced Psychiatric Nurse Practitioner (PNP) to assist PNs in the effective management of aggression from the patients.

The research study objectives were the following:

to derive from the researcher’s Masters’ research central concepts to be utilised in the model, to define and classify them;

After key concepts analysis, the central concept was identified as the ‘effective self-management of aggression’. The key concepts model, facilitation, effective, self-management and aggression were defined.

Chinn and Kramer (2011:157) define a model as a symbolic representation of an empirical experience in the form of words, pictorial or graphic diagrams, mathematical notations or physical material. In this research study, a model structure was developed as a framework of reference and illustrated what the advanced PN practitioner was to do in facilitating the effective self-management of aggression experienced by PNs.

The concept of facilitation is understood as a dynamic interactive process for the promotion of mental health through the creation of a positive environment and mobilisation of resources as well as the identification and bridging of obstacle in the promotion of mental health (University of Johannesburg 2012:7). In this research study, facilitation was defined as a dynamic interactive process through which the advanced PNP guides and provides assistance to the PNs in making easier the effective self-management of aggression.

According to Wehmeier, McIntosh and Turnbull (2005:469), effective means producing the result that is wanted or intended. In this research study, effective referred to the use of operative alternative means by PNs aimed at producing the intended result, which is their self-management of aggression.

One of The Oxford Advanced Learner’s Dictionary’s (Hornby 2010:902) definitions of ‘management’ is, that it is the ‘act or skill of dealing with people or situations in a successful way’. The researcher was convinced that to manage other people, one should start with self or self-management. In this research study, ‘self-management’ was defined for the PNs as the ability to regulate their emotions so that they can take responsibility for, and can implement actions for, needed change resulting in taking control of their lives and self-managing aggression effectively.

Franz et al. (2010:1), Irwin (2006:309), and Ketelsen et al. (2007:92) define aggression as a behaviour characterised by anger; hostile thoughts, words and actions towards others that manifests in speech, tone of voice, body language, outward expression of anger or rage; and threatening, actual or physical. In this research study, aggression meant ‘any act or omission that resulted in physical, psychological, emotional, or spiritual discomfort’. It entails verbal, non-verbal or physical expressions such as swearing, hostile looks, threats, indecency, inappropriate touch, consciously withholding information regarding one’s health, intentional non-cooperation, embarrassing someone and ultimately using physical force. The extreme expression of aggression that results in physical harm, such as in beating or injuring someone, was described, in the research study, as ‘violence’.

A psychiatric institution is defined as a mental healthcare facility where care, treatment and rehabilitation are provided in accordance with the rules and regulations of the Department of Health as stipulated in the Mental Health Care Amendment Act 12 of 2014 (Government Gazette, no 37693). In this research study, a psychiatric institution referred to is a third-level referral hospital where adults and adolescents, male or female, general or forensic patients are referred for care, treatment and rehabilitation because of their being unmanageable in other healthcare facilities.

It is also important to note that in the concept of advanced PNP, a PN is referred to as a person with a post-basic qualification and having both theoretical and clinical competencies in the management of aggressive incidents.

Concept analysis took place in two phases. In phase one, the central concept was identified, and in phase two, the identified concept were defined and classified.

Phase one: Identification of the central concept

The central concepts were identified through the field works that were conducted.

Phase two: Definition and classification of concepts

Concepts were defined using hard copies, online dictionaries and subject-specific literature. Concepts were given meaning, or the meaning they represented was expressed, and linguist representations of the concepts were expressed in empiric reality (Chinn & Kramer 2011:165).

The survey list of Dickoff, James and Wiedenbach (1968:434–450) was utilised to classify the following concepts and comprised the agent, the recipient, the procedure, the dynamic, the context and the outcome as discussed below.

The identified and defined concepts in step one were put into interrelated statements (Chinn & Kramer 2008:246–248, 2011:180).

The description of the model was based on the six components suggested by Chinn and Kramer (2008:235–248). These components are purpose, concepts, definitions, relationships, structure and assumptions (Chinn & Kramer 1995:106–123). The model’s structure and process were described. After providing a description of the model on structural and process aspects, the guidelines for the implementation of the model were provided.

The evaluation of the model used the Chinn and Kramer (2008:235–248) evaluation criteria of clarity, simplicity, generality, accessibility and importance of the model. The model was evaluated throughout by three experts: two professors and one Ph.D. holder, who are the supervisor and co-supervisors. The model was also evaluated during the annual research forum organised by the University of Johannesburg. On all these occasions, the model was found to comply with the above criteria for model development.

The structure of the model is discussed following the sub-headings: purpose of the model, assumptions of the model, relationship statements and the process description. The theoretical definitions of the central concept and the relationship statements have been described previously.

The purpose of the model was to provide a frame of reference for the advanced PN practitioner for the facilitation of effective self-management of aggression experienced by PNs working in a psychiatric institution.

The assumptions of this model are embedded in the Theory for Health Promotion in Nursing (University of Johannesburg 2012:4–14). Assumptions were also inspired by another source: the Cognitive Behaviour theory (Blenkiron 2010:1–276). These assumptions are set out below.

PNs and the advanced PNP are seen wholistically; embody dimensions of body, mind and spirit; and function in an integrated manner with the environment (University of Johannesburg 2012:4).

The environment includes an internal and external environment. The internal environment consists of dimensions of body, mind and spirit. The external environment consists of physical, social and spiritual dimensions (University of Johannesburg 2012:5).

Psychiatric nursing is an interactive process for the facilitation and the promotion of mental health (University of Johannesburg 2012:5). This process is not a linear one. It requires patience, commitment, material and spiritual resources, and a clear vision in a safer workplace environment.

PNs mobilise resources by identifying and bridging the obstacles in the promotion of health (University of Johannesburg 2012:7). The identification of obstacles entails assessing the environment (both internal and external) for what it really is and strategising on how to solve the identified problems in it with the available resources. The bridging of obstacles comprises self-assessment for the strengths and weaknesses, the resources (human and materiel) required for an effective and lasting solution (University of Johannesburg 2012:7). The resources in the PNs environment are centred on the use of the self as the main actor or the scene of effective self-management of aggression.

Mental health is a dynamic interactive process in the PNs environment (University of Johannesburg 2012:5). For the PNs to feel at ease while caring for the people with mental illnesses, they must perceive the environment as safe and welcoming allowing them to maximise their potentials in fulfilling their core of duty in caring for the mentally ill patients entrusted to them. The role of the advanced PNP is to lead the way on the road which the PNs have less travelled but need to take for growth and development. PNs are allowed to work on and modify their perception about the environment in order to modify it. Blenkiron (2010:1) argues that the problem is not so much the events in one’s life, but the way in which the person interprets and acts upon them.

The facilitation of effective self-management of aggression experienced by PNs promotes their mental health when they manage to take control of the workplace environment. This facilitation requires knowledge, skills, goodwill, commitment and time from both the PNs and the advanced PNP on one side and the availability of resources and support from the nursing management on the other side.

The advanced PNP is a sensitive therapeutic professional (University of Johannesburg 2012:4) who demonstrates knowledge, skills, attitude and values in facilitating the effective self-management of aggression experienced by PNs from the patients. To achieve this, the advanced PNP must be flexible and understanding, bearing in mind that some PNs may be resistant or even hostile to change if they have come to believe that no change is possible or that the process for change may be painful compared to the situation they are in at present (McCormack & McCance 2006:476).

The workplace environment has a positive or negative impact on PNs depending on how they perceive and interact with it. Working positively on how PNs perceive workplace aggression and instilling in them hope will have a positive effect on how they self-manage this aggression effectively and will promote the mental health of the PNs and improve the quality of care rendered to the patients. Clarke (2009:843) believes that hope is the foundation of recovery from mental health problems.

As displayed in Figure 1, the model structure is framed in red as an indication of potential danger the workplace environment of the PN is embedded in. It consists of three phases that are composed of steps. Each step is a building stone towards the model implementation.

The relationship phase enables both the researcher and the PNs to establish a working relation for a common purpose. It consists of three steps: (1) building trust; (2) understanding aggression; and (3) imparting hope and belief. The building of trust allows the PNs to lay down their fears and exchange information (Johnson 2003:99), coming to an understanding why the assistance is needed and how it will be achieved so that the proposed ideas can inspire confidence (Corey, Corey & Corey 2010:140). The first task in implementing any kind of change in health sector is to understand the logic of things as they are presently (Petersen et al. 2010:49). Hope is defined as the belief that change is possible (Corey et al. 2010:252). Truly speaking, hope cannot be instilled in someone. However, when suffering alone, individuals may not realise that their feelings and experiences are relatively common ones (Forsyth 2014:555–556). In sharing experiences, PNs may realise that problems have solutions and that they have the ability to improve (Robbins & Hunsaker 2012:156).

In the working phase, the identified challenges are put to the test by implementing the strategised alternatives. Corey et al. (2010:228) argue that the working phase is characterised by the commitment of members to explore significant challenges. The working phase consists of four steps that represent the four areas where challenges were mostly coming from. These areas are the facilitation of self-awareness; the facilitation of communication skills; the facilitation of stress management; and the facilitation of conflict management.

Sturm et al. (2014:659) argue that for self-awareness to successfully develop, individuals must have not only an understanding of themselves but also an understanding of and appreciation for others’ perceptions of them. The process of self-awareness entails the ability to imagine a future that is better than the past, evaluate alternatives, identify problems and a yearning to progress towards an ideal (Ashley & Reiter-Palmon 2012:1). Self-awareness also entails the change of mindset, belief, perception and attitude because how people feel about themselves has a profound effect on day-to-day functioning (Gitterman & Shulman 2005:18).

Communication plays a vital role in the management of aggression enabling both the PN and the patient to interpret both verbal and non-verbal messages correctly. Hargie and Dickson (2004:43) believe that often non-verbal communication proves decisive in conveying information and making judgements about others.

Job stress is defined as a situation wherein job-related factors interact with a worker to change his or her psychological or physiological condition such that the person is forced to deviate from normal functioning (Weinberg, Sutherland & Cooper 2010:56). Deviating from normal functioning may prove to be counter-productive in the PNs’ attempts to manage patient’s aggression. In managing aggressive incidents, one of these three ways is suggested: identifying and eliminating or minimising stressful situations, teaching the individual to cope with stress or helping those individuals who have become victims of exposure to stress (Weinberg et al. 2010:156). The skills that are needed in stress management are becoming aware of negative symptoms, determining the sources of stress and doing something constructive to cope with stress (Hunsaker 2005:130).

De Dreu and Gelfland (2008:6) define conflict as a process that begins when an individual or group perceives differences and opposition between itself and another individual or group about interests and resources, beliefs, values or practices that matter to them. Although conflict is an inevitable part of life and that it is prevalent among registered nurses working in the healthcare environment (Whitworth 2008:921), in conflict situations, individuals tend to develop an inflated view of their own cooperativeness and their counterpart’s hostility (De Dreu & Gelfand 2008:16). Therefore, avoiding unnecessary conflict, reducing the effect of destructive conflict, finding a solution and using any effective methods to control the direction of the conflict may help in resolving conflicts (Zhang et al. 2014:370).

During the termination phase, the researcher and PNs evaluate whether the intended results have been achieved. The PNs strive now to keep the gained experience while the researcher progressively withdraws from the facilitation process. Maintenance can be understood as a time of perpetual adjustment so that one prevents a falling back into older habits, but rather integrates the new self and the new behaviour into one’s daily living (Cormier, Nurius & Osborn 2013:280–281).

The evaluation of the model was based on the criteria of clarity, simplicity, generality, accessibility and importance of the model (Chinn & Kramer 2011:196–204) as discussed below.

Clarity: Chinn and Kramer (2011:198) argue that in determining how clear a theory is, one should consider the following: semantic clarity, semantic consistency, structural clarity and structural consistency, that is, understanding the intended theoretical meaning of the concepts and the intended connections between concepts within the theory and the whole of the theory. The concepts were found to be meaningful, helpful and consistent. The concepts also provided a structural map that was comprehensible that was supported by logic arguments. However, some suggestions were made with regard to the order of the steps in the structure and the use of different colours. These suggestions were taken into consideration and modifications were made as suggested until all parties were satisfied.

Simplicity: While evaluating the model for its simplicity, the focus was on the number of elements within each descriptive category, particularly the concepts and their interrelationships (Chinn & Kramer 2011:201). The model was found to be simple.

Generality: The generality of a model refers to its breadth of scope and purpose (Chinn & Kramer 2011:202). The model was found to be general and that it could be applied to the PNs experiencing patients’ aggression or to all nurses working with patients.

Accessibility: Addresses the extent to which empirical indicators for the concepts can be identified and to what extent the purposes of the model can be attained (Chinn & Kramer 2011:203). The concepts of model were found to be accessible, grounded and applicable to mental health nursing.

Importance of the model: In nursing, the importance of the theory is closely tied to the idea of its clinical significance or practical value (Chinn & Kramer 2011:204). The evaluators stated that the model had a potential to influence nursing actions, that it could be an avenue to address a really serious challenge in interacting with challenged patients and that the model could guide nursing practice for nurses to have structured debriefing sessions to prevent secondary trauma, or as a frame of reference.