Hostile behaviour by mental health care users (MHCUs) is prevalent in forensic units in South Africa, and this causes service providers distress and burnout. Psychiatric nurses (PNs) find it difficult to render quality care to MHCUs who are threatening them and also challenging their authority in a forensic unit. Forensic mental health care practitioners may be challenged to engage authentically with MHCUs who constitute a risk to their personal safety or who have committed acts the practitioner finds morally disturbing. There is a need to facilitate the mental health of PNs in a forensic unit to manage hostile behaviour constructively.
The objective of this article is to describe the process that was followed in developing, implementing and evaluating a model that could be used as a framework of reference to facilitate the mental health of PNs in a forensic unit to manage hostile behaviour constructively.
A theory-generative, qualitative, exploratory descriptive and contextual study design was used to develop the model. The steps of the process entailed the identification of the central concept, the definition of the central concept and other essential criteria and the classification of the central and related concepts. The model was then described and evaluated.
The central concept was identified as the ‘facilitation of empowerment of PNs to manage hostility in a constructive manner’, defined, classified and then described and evaluated.
The model as framework of reference could assist PNs in managing hostility in a forensic unit constructively.
The overall purpose of forensic care is to promote the quality of life of mental health care users (MHCUs) and enable their re-entry to a safe and healthy life in the community (Jeon, Gang & Oh
Psychiatric nurses in a forensic unit at a psychiatric institution faced challenges to their mental health. These PNs experienced hostile behaviour from MHCUs, resulting in fear, disempowerment and emotional distress (Tema
By developing a model to facilitate the mental health of PNs, they will be assisted to manage the hostile behaviour by MHCUs in a constructive manner.
The purpose of the research study was to describe, implement and evaluate a model that can be used as a framework of reference for the advanced psychiatric nurse (APN) to facilitate the mental health of PNs in a forensic unit to manage hostile behaviour constructively.
The research study objectives were to:
derive central concepts to be utilised in a model to facilitate the mental health of PNs in a forensic unit to manage hostile behaviour constructively;
describe relationships between these concepts;
describe a model as a framework of reference for an APN;
implement and evaluate the model.
The key concepts model, facilitation, mental health, manage, constructively and hostility were defined.
A model is a symbolic representation of an empiric experience in the form of words, pictorial or graphic diagrams, mathematic notations or physical material (Chinn & Kramer
Facilitation is defined as a dynamic interactive process through the creation of a positive environment and mobilisation of resources, as well as the identification and bridging of obstacles in the promotion of health (University of Johannesburg
Mental health is a dynamic interactive process that reflects harmonious interaction of the internal and external environments of the PN, as well as mobilisation of resources, to promote mental health as part of holistic health and well-being (University of Johannesburg
To manage is to carry out the task of ensuring that a number of activities are performed in such a way that a defined objective is achieved. To manage is to succeed in doing something difficult (Longman South African School Dictionary
Constructively means being useful or helpful, serving to build or improve (Oxford South African Concise Dictionary
Hostile behaviour is behaviour characterised by verbal abuse, threatening and aggressive behaviour, uncooperativeness and behaviours that have been defined as undesirable or in violation of established limits (Schultz & Videbeck
A theory-generative, qualitative, exploratory, descriptive and contextual design was utilised to develop and implement the model (Austin, Goble & Kelecevic
The four steps of model development were followed (Chinn & Kramer
Trustworthiness was observed throughout the study by using Guba’s model of trustworthiness criteria (Lincoln & Guba
In this study, ethical conduct was ensured by following ethical standards as set out by Dhai and McQuoid-Mason (
In this study, concept analysis was performed by exploring the PNs’ experience of hostility in a forensic unit by MHCUs. This was carried out in two phases, namely identification and definition of the central concept and the classification of concepts (Chinn & Kramer
In the researchers’ previous study of the PNs’ experience of hostile behaviour by MHCUs in a forensic unit (Tema
Identification of central concept based on the results of field study on psychiatric nurses’ experiences of hostile behaviour by mental health care users in a forensic unit.
Themes | Identified central concepts |
---|---|
Experienced lack of constructive nurse–patient relationships | Facilitation of empowerment of PNs |
Experienced fear related to threats from MHCUs | |
Disempowerment associated with lack of knowledge and support by management | |
Experienced emotional distress, resulting in the use of coping mechanisms |
PN, psychiatric nurses; MHCU, mental health care users.
The concept ‘facilitation of empowerment was defined as a dynamic interactive process between the APN and PNs, making it possible for PNs in a forensic unit to have authority, by providing them support to help them to be competent in managing the hostility of MHCHs in a forensic unit in a constructive manner’. Competency by PNs in managing hostility in a constructive manner results in empowered PNs, which enhances the mental health of PNs.
The concepts were classified as follows:
The agent is the person who facilitates empowerment. In this study, the agent is the APN who enables the disempowered PNs in a forensic unit to manage hostility in a constructive manner.
The recipient is the person or persons who benefit from the facilitation of empowerment process. In this study, the recipients are the PNs who work in a forensic unit at this specific psychiatric institution and participate in the empowerment process.
The context is the environment in which the empowerment of PNs is facilitated. In this study, the context is a forensic unit, a special unit in a psychiatric institution that caters for MHCUs who had committed offences owing to their mental illness and were found not to be fit to stand trial.
The dynamics in the model entail PNs experiencing hostility by MHCUs in a forensic unit, leading to distress, feeling of incompetency, marginalisation, hopelessness, culminating in disempowerment.
The procedure is the process of facilitating the empowerment of PNs by the APN, enabling them to obtain authority, providing them with support, to be competent in managing hostility in a constructive manner. The process comprised three phases: the relationship-building phase, the working phase and the termination phase. Through the process, the APN makes it possible for the PNs to move from feeling disempowered to feeling empowered.
Terminus is the empowered PNs who manage hostility in a constructive manner (see
Thinking map for conceptual framework.
Survey list | Description |
---|---|
Agent | Advanced psychiatric nurse |
Recipient | Psychiatric nurses |
Dynamics | Lack of constructive nurse–patient relationships, fear related to threats from MHCUs, disempowerment associated with lack of knowledge and support by management, and emotional distress resulting in the use of coping mechanisms |
Procedure | Facilitation of empowerment of psychiatric nurses: obtaining authority, support and competence |
Context | Forensic unit in a psychiatric institution |
Outcome | Empowered psychiatric nurses to manage hostile behaviour of MHCUs constructively |
MHCU, mental health care users.
In this study, the relationship statements were formulated as follows:
The facilitation process is initiated by the APN who engages the PNs in the forensic unit in a dynamic interactive process, thereby building a trusting relationship. The APN shows respect for the PNs as important persons with spirit, mind and body, to make it possible for them to express their feelings.
The APN enables the PNs to obtain authority, by giving them support, to make decisions independently with regard to managing hostility in a constructive manner. Psychiatric nurses are assisted to look at alternative ways of becoming competent in managing hostility in a constructive manner.
Competency by PNs in managing hostility in a constructive manner results in empowered PNs.
The description of the structure of the model is based on the following: theoretical definitions, relationship statements, purpose of the model, assumptions of the model and the process description. The theoretical definitions and the relationship statements have been discussed in the paragraphs above.
The purpose of the model is to provide a frame of reference that can be used by the APN to facilitate the empowerment of PNs in a forensic unit to manage hostility by MHCUs in a constructive manner.
In this study, the assumptions of the model were adapted from the Theory of Health Promotion in Nursing of the Department of Nursing (University of Johannesburg
The APN and PNs are seen holistically in integrated, harmoniously interaction with individuals in the forensic unit (Tema
Both have internal environments that consist of body, mind and spirit. Three aspects are interrelated and interdependent, working as a system. The ultimate outcome of the facilitation of empowerment of PNs, that is, competency, will lead to the physical, mental and spiritual well-being of the PN (Tema
The PN has an external environment that consists of physical aspect, such as the home or church, that provide comfort; social aspect, that is, colleagues, family and friends; and a spiritual aspect that entails divine connection with God (Tema
Psychiatric nursing is an interactive dynamic process, whereby an APN facilitates the promotion of mental health of PNs. In this interactive process, there is a trusting relationship and mutual involvement between both parties in the facilitation of empowerment of the PNs (Tema
The APN uses himself or herself in a therapeutic manner, conveying sensitivity as he or she applies his or her knowledge, wide range of skills and values to facilitate the empowerment of the PNs, which results in the promotion of their mental health (Tema
The promotion of mental health implicates mobilisation of resources by the APN, in facilitating the empowerment of PNs (Tema
Mental health is a dynamic, interactive process in PNs’ environment, the forensic unit (Tema
The relative mental health of PNs is reflected by their interaction in the forensic unit, where they are able to manage hostility by MHCUs in a constructive manner, which is the ultimate goal (Tema
The structure of the model is depicted in
A model to facilitate the empowerment of psychiatric nurses to constructively manage hostility by mental health care users in a forensic unit.
Phase 1 is the relationship-building phase and it has two aspects, that is, dynamic interactive process and making it possible. The dynamic interactive process serves as a foundation on which the APN lays the three phases of empowerment and also as a vehicle for the facilitation of the empowerment process. The APN conveys an attitude of acceptance that is essential in creating a warm and safe environment to allay PNs’ fears. The APN explains his or her role and the roles of the PNs, to work collaboratively. Making possible is the second aspect of the relationship-building phase, and in this session the focus is on assessment and identification of challenges. The APN engages the PNs in brainstorming to explore their purpose, objectives and expectations. The PNs make a commitment to participate actively in the empowerment process. James (
The working phase entails three aspects: PNs having authority, providing support and helping them to be competent. The APN makes it possible for the PNs to have control over their situations, by encouraging them to exercise their rights to independence in making decisions and being responsible and accountable for the outcomes of the decisions in managing hostility in a constructive manner. The APN as a resource person applies his or her specialised knowledge, wide range of skills and attitude to provide emotional and informational support to the PNs and bring about change to their lives. Through the provision of support by the APN, the PNs in a forensic unit become confident and encouraged to implement what they have acquired in a real practical situation (see earlier in article results of step 1 defining and classifying central concepts as well as
The APN helps the PNs to be competent by encouraging them to master and internalise significant skills and qualities that will make it possible for them to use themselves as the therapeutic tool in the interactive-intervention process with the MHCUs in a forensic unit. Competencies that the PNs are facilitated to master are constructive self-concept, emotional control, effective communication skills, interpersonal skills, assertiveness skills and problem-solving skills.
Constructive self-concepts and identities are the central orientational devices with which PNs navigate and negotiate their everyday lives (Lofland et al.
Myburgh, Poggepoel and Du Plessis (
Effective communication plays a vital role in the management of aggression (Bimenyimana et al.
Healthy interpersonal relationships can be attained by mastering interpersonal skills, which entails constructive communication, listening and responding and addressing interpersonal conflict (Naicker, Myburgh & Poggenpoel
Assertiveness is defined as the ability to have self-confidence about what you want and being able to communicate effectively about it (Perry
Problem-solving is focused on trying to solve immediate problems, which is viewed as a gap between ‘what is’ and ‘what should be’. Problem-solving and decision-making require critical thinking, which is a high-level cognitive process (Yoder-Wise
In the termination phase, the measure for successful termination will be the extent to which the PNs have achieved the set objectives. Both the APN and PNs assess whether the PNs have been empowered through obtaining authority and competency in managing hostility by MHCUs in a forensic unit constructively. Psychiatric nurses are engaged in self-assessment and are encouraged to continue with self-assessment even after the termination phase, to maintain their level of competency.
The evaluation of the model, by a panel of model development experts, was based on the criteria for model evaluation, as described in Chinn and Kramer (
The implementation of the model and also the evaluation of the implementation of the model have not been published yet.
The findings of the study encouraged the researcher to make recommendations for psychiatric nursing practice, nursing education and nursing research. It has become apparent from the results of the study that participants benefitted from implementing the model in a forensic unit. The model could be used in all health settings where PNs encounter hostility by MHCUs. The nurse managers could also use the model to help subordinates who often display hostile behaviour towards them and co-workers. The model could benefit the families of MHCUs in the forensic unit, as well as the community and the society at large. In nursing education, the model could be integrated into the curriculum for the basic 4-year comprehensive nursing degree and diplomas in psychiatric nursing programmes. Lecturers could use the model when managing students who display hostility towards them and fellow students. It is recommended that further research be carried out by applying the model in different contexts.
The model serves as a solid foundation on which psychiatric students will be grounded during their training, which will enable them to be competent in managing hostile behaviour in a forensic unit. The model will help policymakers to formulate a policy regarding the managements of hostile behaviour by MHCUs in a forensic unit, as well as the policy to promote the mental health of PNs in a forensic unit. A mentally healthy PN will have a positive impact on the MHCUs, co-workers, the families of MHCUs and the community at large, and this will promote the integration of MHCUs into their families and community.
In concluding this study, the researcher is of the opinion that the main purpose of the research has been achieved, that is, to describe, implement and evaluate a model as a frame of reference to facilitate the mental health of PNs in a forensic unit to constructively manage hostile behaviour by MHCUs. All steps of model development have been fully described, as well as the ethical consideration and trustworthiness. The PNs’ experiences on the implementation and evaluation will be discussed in a future article.
The authors acknowledge Leatitia Romero for language editing and University of Johannesburg for financial support for research.
The authors declare that they have no financial or personal relationships that may have improperly influenced them in writing this article.
T.T. conducted the research for the thesis and wrote the draft manuscript. M.P., the supervisor, continuously corrected the manuscript until it was accepted for publication. C.M., the co-supervisor, corrected the draft manuscript.
The research was supported by the Faculty of Health Sciences of the University of Johannesburg awarding grants to the researcher.