Inpatient aggression and work stress: comparing civil and forensic psychiatric nursing

In their daily work, psychiatric nurses are subjected to patient-perpetrated verbal and physical aggression. They manage a high level of work stress. As compared to their colleagues working in civil settings, forensic psychiatric nurses may experience different rates of patient aggression and work stress. Such experiences have implications for the mental health and productivity of nursing staff. In inpatient settings, homicide by a patient is a rare event. Representing the most severe form of patient aggression, patient homicide may be expected to have significant effects on the psychological well-being of psychiatric nurses. The present cross-sectional study comprised two separate phases. The broad aims of the first phase were to explore and compare the psychological well-being of civil and forensic hospital-based psychiatric nurses and to uncover factors contributing to and buffering against the development of posttraumatic stress reactions and general distress. Owing to the occurrence of a double patient homicide in a forensic psychiatric hospital where this study was underway, the study was expanded to include a second phase. The broad aims of the second phase were to evaluate the effects of patient homicide, on posttraumatic stress reactions and general distress in forensic psychiatric nurses, both working across the entire hospital and working on the unit where the patient homicide occurred. In the first phase, a battery of self-report measures was administered to 97 forensic psychiatric nurses in a forensic psychiatric hospital and 99 civil psychiatric nurses across three civil hospitals. In the second phase of the study, a slightly modified questionnaire was re-administered to 107 forensic nurses from the same forensic psychiatric hospital, five months after the occurrence of patient homicide. Multiple regression analyses indicated that while working in a civil setting is a risk factor for reporting higher levels of work stress, civil and forensic nurses experience similar psychological well-being and demonstrate comparable coping strategies and attitudes. As a group, 14-17% of civil and forensic nurses met diagnostic criteria for posttraumatic stress disorder (PTSD), and 36% scored above the threshold for psychiatric caseness. A tentative model of the development of posttraumatic stress reactions and general distress was developed, illustrating that frequency of aggression and level of work stress have direct effects on both posttraumatic stress reactions and general distress. The moderating roles of coping strategies, attitude to personality disorder and attitude towards patient aggression were also highlighted in the model. Following the occurrence of patient homicide, forensic nurses in general demonstrated resilience, not displaying increased (or decreased) symptoms of posttraumatic stress or general distress. In comparison, there were trends for higher proportions of nurses working on the unit where the homicide occurred to meet criteria for PTSD and to score above the threshold for psychiatric caseness after the patient homicide, as compared to before the homicide. The present study affirms that psychiatric nursing is a challenging and stressful occupation and highlights risk factors for poor psychological well-being in mental health nurses. Limitations of the study, implications for employers and individual nurses, and directions for future research are discussed