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Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

12 Perspectives in Psychiatric Care 52 (2016) 12–24
© 2014 Wiley Periodicals, Inc.

Mental Health Nurses’ Attitudes and

Perceived Self-Efficacy

Toward Inpatient Aggression: A Cross-Sectional Study of
Associations With Nurse-Related Characteristics
Sofie Verhaeghe, PhD, RN,* Veerle Duprez, MSc, RN,* Dimitri Beeckman, PhD, RN, Joris Leys, MSc, RN,
Berno Van Meijel, PhD, RN, and Ann Van Hecke, PhD, RN

SofieVerhaeghe, PhD,RN, is Professor,UniversityCentre forNursingandMidwifery,Departmentof PublicHealth, FacultyofMedicineandHealth
Sciences,GhentUniversity,Ghent, BelgiumandResearcher,DepartmentofNursing,VivesUniversityCollege Leuven,Roeselare, Belgium;Veerle
Duprez,MSc,RN, is PhDstudent,UniversityCentre forNursingandMidwifery,Departmentof PublicHealth, FacultyofMedicineandHealthSciences,
GhentUniversity,Ghent, BelgiumandLecturer&Researcher,DepartmentofBachelor inNursing,ArteveldeUniversityCollegeGhent,Ghent, Belgium;
Dimitri Beeckman, PhD,RN, is Professor,UniversityCentre forNursingandMidwifery,Departmentof PublicHealth, FacultyofMedicineandHealth
Sciences,GhentUniversity,Ghent, BelgiumandResearcher,DepartmentofBachelor inNursing,ArteveldeUniversityCollegeGhent,Ghent, Belgium;
Joris Leys,MSc,RN, is Lecturer&Researcher,DepartmentofBachelor inNursing,ArteveldeUniversityCollegeGhent,Ghent, Belgium;BernoVan
Meijel, PhD,RN, is ProfessorofMentalHealthNursing, ResearchGroupMentalHealthNursing, InhollandUniversity ofAppliedSciences,Amsterdam,
Departmentof Psychiatry,VUUniversityMedicalCenter,AmsterdamandParnassia Psychiatric Institute, TheHague, TheNetherlands; andAnnVan
Hecke, PhD,RN, is Professor,UniversityCentre forNursingandMidwifery,Departmentof PublicHealth, FacultyofMedicineandHealthSciences,
GhentUniversity,Ghent, BelgiumandScientific Staff,NursingScience,UniversityHospitalGhent,Ghent, Belgium.

Search terms:
Attitude,patient aggression, predictor,
psychiatric nursing, self-efficacy

Author contact:
veerle.duprez@ugent.be,witha copy to the
Editor: gpearson@uchc.edu

Conflict of Interest Statement
Theauthorsdeclare that theyhaveno
competing interests.

Author Contributions
SV,VD, andAVHconceivedanddeveloped the
designof the study. SVand JL carriedout the
data collection.VD,DB, andAVHcarriedout
thedataanalyses. SV,VD, JL, andBVM
contributed to the interpretationof thedata.
All authors contributed indrafting the
manuscript, and readandapproved thefinal
version.

*Bothauthors contributedequally to thiswork

First Received June6,2014; Final Revision
receivedOctober25,2014;Accepted for
publicationNovember13,2014.

doi: 10.1111/ppc.12097

PURPOSE: To explore mental health nurses’ attitude and self-efficacy to adult inpa-
tient aggression, and to explore the association with nurse-related characteristics.
DESIGN AND METHOD: Cross-sectional study in a sample of 219 mental health
nurses in nine psychiatric hospitals, with stepwise linear regression analysis to detect
predictive models.
FINDINGS: Female and less experienced nurses were less likely to blame patients
for their behavior. Gender, burnout, secondary traumatic stress, and compassion
satisfaction accounted for 26.2% of the variability in mental health nurses’ self-
efficacy toward aggression.
PRACTICE IMPLICATIONS: There needs to be attention to professional quality of
life for mental health nurses, to provide them with of self-efficacy and a positive atti-
tude toward coping with aggression.

Healthcare professionals, and in particular mental health
nurses, are regularly confronted with aggression (Foster,
Bowers, & Nijman, 2007; Jansen, Dassen, Burgerhof, &
Middel, 2006; Nijman et al., 1999; Rippon, 2000). For this
study, aggression was broadly defined as “any verbal, nonver-
bal or physical behaviour that was threatening (to self, others
or property), or physical behaviour that actually did harm (to
self, others or property)” (Morrison, 1990, p. 67). The preva-

lence of aggressive incidents in psychiatric hospitals varies
considerably across countries (Bowers et al., 2011). A review
by Nijman, Palmstierna, Almvik, and Stolker (2005) revealed
a mean of 9.3 incidents per patient per year for adults with
mental illness, with a range of 0.4–33.2 incidents per patient
per year. Severity ranged from 9.2 to 11.0 points on a scale of
0–22 points, with higher scores indicating more severe
aggression (Nijman et al., 2005). This variation in inciden

ce

Perspectives in Psychiatric Care ISSN 0031-5990

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

can partly be explained by differences in defining aggression
and in registration methods, different care settings, and a
decreased tendency to report less threatening incidents
(Bowers et al., 2011; Nijman et al., 2005). An aggression reg-
istration study (n = 437) in psychiatric hospitals for adults in
Belgium using the Staff Observation Aggression Scale-
Revised (SOAS-R) (Nijman et al., 1999) revealed a mean of
1.71 incidents per patient per year, with an average severity
score of 9.69 (SD 5.04). A small group of patients (2%)
appeared to be responsible for 50% of the incidents
(Verhaeghe et al., 2011).

Aggressive inpatient incidents have a multifactorial and
complex nature (Abderhalden, Needham, & Dassen, 2008;
Nijman et al., 1999). Occurrence of incidents, as well as their
management, all reflects patient, ward, and staff variables in
interaction (Abderhalden et al., 2008; Fluttert et al., 2008;
Nijman et al., 1999; Nijman, de Kruyk, & Van
Nieuwenhuizen, 2004).

Conceptual Framework

To gain insight into mental health nurses’ behavior toward
aggressive patients, it is useful to understand the predictors of
this behavior. The theory of planned behavior (TPB) provides
a useful conceptual framework to accomplish this. According
to the TPB, a person’s behavior is guided by his intentions,
which refers to a person’s readiness to perform a given behav-
ior (Fishbein & Ajzen, 2010). These intentions derive from
attitudes, subjective norms, and self- efficacy (Azjen, 1988; De
Vries, 1988) of the person (see Figure 1). Attitudes refer to a
person’s evaluation of the behavior as more positive or nega-
tive (Fishbein & Ajzen, 2010). Subjective norms encompass
the influence of the judgments of others who are deemed
important and the tendency to conform to that judgment
(Fishbein & Ajzen, 2010). Self-efficacy or perceived behav-
ioral control is the belief one has in his or her own ability to
succeed in specific situations (Bandura, 1991; Fishbein &

Ajzen, 2010). Two factors of the TPB—attitudes and self-
efficacy—are included in this study because they fall within
the control of the individual nurse to achieve a more positive
attitude toward aggressive patients or a higher level of self-
efficacy, thus likely contributing to a better working alliance
with improved treatment outcomes (de Leeuw, Van Meijel,
Grypdonck, & Kroon, 2012).

Attitudes Toward Inpatient Aggression

Attitudes toward aggression are comprised of three perspec-
tives (Abderhalden, Needham, Friedli, Poelmans, & Dassen,
2002; Bowers et al., 2011; Jansen, Middel, & Dassen, 2005;
Jansen, Dassen, et al., 2006). First, aggression is perceived as a
dysfunctional phenomenon that is violent, offensive, destruc-
tive, intrusive, or harmful; second, aggression can also be per-
ceived as a functional, instrumental, or communicative
phenomenon, a feeling expressed to meet a particular need;
and third, aggressive behavior can be interpreted as a normal
or protective phenomenon, where aggression is an acceptable
reaction to feelings of anger. The last two perspectives are
highly interlinked and related to a more tolerant, permissive
attitude toward aggression (Jansen, Middel, & Dassen, 2005).
Research reveals that most often, mental health nurses view
aggression as a harmful, offensive, and destructive behavior
on the part of the patient (Finnema, Dassen, & Halfens, 2004;
Jansen, Middel, Dassen, & Reijneveld, 2006; Jonker,
Goossens, Steenhuis, & Oud, 2008). Few of them emphasize
the positive, protective nature of aggression (Jansen, Middel,
et al., 2006; Jonker et al., 2008). It is assumed that mental
health nurses with more tolerant, permissive, and positive
attitudes may have better clinical skills to respond to incidents
of aggression. This statement is supported in different health-
care domains, demonstrating the impact of positive attitudes
on the quality of nursing practice, for instance, in the applica-
tion of adequate pressure ulcer prevention (Beeckman,
Defloor, Schoonhoven, & Vanderwee, 2011). The capacity to

Figure 1. ConceptualModel of theStudyBasedon theTheoryof PlannedBehavior

13Perspectives in Psychiatric Care 52 (2016) 12–24
© 2014 Wiley Periodicals, Inc.

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

see aggression in a more positive perspective is reflected in the
use of fewer coercive measures (Jonker et al., 2008) and con-
tributes to a better working alliance with improved treatment
outcomes (de Leeuw et al., 2012).

Perceived Self-Efficacy

Based on Bandura’s (1991) theory of self-efficacy, it is
assumed that the perceived level of self-efficacy toward
aggression will influence nurses’ actual reaction to and behav-
ior toward aggressive incidents. This assumption is exten-
sively supported in research on the self-management
behavior of persons with chronic illness (Bonsaksen, Lerdal,
& Fagermoen, 2012; Marks, Allegrante, & Lorig, 2005) and in
research on nursing competencies and perceived skills
(Nørgaard, Ammentorp, Ohm Kyvik, & Kofoed, 2012; Van
Hecke, Grypdonck, Beele, De Bacquer, & Defloor, 2009). A
mental health nurse who perceives that he/she has a low self-
efficacy is more likely to see a potential violent situation as
dangerous and threatening, and thus may react in a
nontherapeutic way. Alternatively, perceived high self-
efficacy in dealing with aggression, with the corresponding
feelings of security and self-confidence, is an important con-
dition for therapeutic interactions between patients and
mental health nurses (Dunn, Elsom, & Cross, 2007; Lowe,
Wellman, & Taylor, 2003; Martin & Daffern, 2006; Totman,
Hundt, Wearn, Paul, & Johnson, 2011).

Considered within the context of the conceptual frame-
work, attitudes and self-efficacy of mental health nurses
toward aggressive behavior are in turn influenced by nurse-
related characteristics (Azjen, 1988) (see Figure 1). Studies
have provided contradictory findings about the influence of
nurse-related characteristics on attitudes toward aggression.
Some studies report that nurses who have had less contact
with aggressive patients because of part-time schedules or
fewer years of work experience, tend to have a more positive
attitude toward aggressive incidents (Jansen, Dassen, et al.,
2006; Jansen, Middel, et al., 2006; Palmstierna & Barredal,
2006). This is in contrast with the study by Whittington
(2002), which demonstrated that tolerance for aggression is
higher among more experienced nurses (more than 15 years).
Furthermore, the study of Jansen, Middel, et al. (2006)
revealed that female nurses agreed more than their male col-
leagues that aggression is a destructive phenomenon, in con-
trast to the opposite results of Palmstierna and Barredal
(2006). The study by Abderhalden et al. (2002) found no rela-
tionship between the perception of aggression and staff char-
acteristics. These previous studies focused on identification of
the appraisal and tolerance toward aggressive incidents. They
did not provide information on other interesting aspects of
attitudes toward aggressive incidents, such as the belief in pre-
dictability of incidents, feelings of security or anxiety, feelings
of competence in managing violent behavior, confidence in

dealing with aggressive incidents, and possible association
with nurse-related characteristics. These aspects of attitudes
can provide useful information for hospital managers and
staff in evaluating and improving aggression management
programs and policies.

Research on the association between mental health nurses’
perceived level of self-efficacy in managing inpatient aggres-
sion and nurse-related characteristics is limited, and was
conducted within a mixed population of mental health pro-
fessionals, including just a small sample of mental health
nurses (Lowe et al., 2003; Martin & Daffern, 2006; Totman
et al., 2011).

Since aggressive incidents and verbal threats are linked with
anxiety, symptoms of post-traumatic stress disorder, and
symptoms of burnout (Gascon et al., 2013; Whittington,
2002), they can cause an internal value conflict (Winstanley &
Whittington, 2004). This might affect nurses’ attitudes and
self-efficacy toward aggressive patients and incidents. To date,
it is not clear if an association exists between mental health
nurses’ perceived professional quality of life and attitude or
self-efficacy toward inpatient aggression. This study included
perceived professional quality of life as a nurse-related
characteristic.

We may conclude that studies have provided contradictory
or limited findings about the influence of nurse-related char-
acteristics on attitude and self-efficacy toward aggression. To
eliminate this gap, this study aimed to explore mental health
nurses’ attitudes and perceived self-efficacy toward inpatient
aggression in adult psychiatric hospitals. The second aim was
to explore the associations between attitudes and perceived
self-efficacy toward aggression and nurse-related characteris-
tics. The nurse-related characteristics under study are per-
ceived professional quality of life, age, gender, educational
degree, degree in psychiatric nursing, and length of work
experience. A comprehensive exploration of mental health
nurses’ attitudes and perceived self-efficacy, and their associa-
tion with nurse-related characteristics, including the per-
ceived professional quality of life, is important to develop
tailored interventions to support mental health nurses in
managing aggression.

Methods

Setting and Sample

This study focused on mental health nurses working in psy-
chiatric hospitals. The selection of participants was per-
formed in two phases. In phase 1, the Belgian Federal Public
Service of Health Care emailed all psychiatric hospitals for
adults (N = 63) in Belgium to invite them to participate in an
implementation study on aggression management. Nine psy-
chiatric hospitals agreed to participate. In phase 2, a purpo-
sive sample of wards from the nine participating hospitals was

14 Perspectives in Psychiatric Care 52 (2016) 12–24
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Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

drawn. A minimum of one and maximum of three wards,
where frequent incidents of aggression were reported by
nursing directors, were selected from each hospital. To maxi-
mize the representativeness of the sample, wards were
selected for differentiation, such as type of wards (acute
admission vs. chronic care wards), psychopathology (depres-
sion, psychosis, or addiction care), and number of beds
(ranging from small residential groups to wards with 50
beds). Psychiatric wards for forensic care were excluded. The
final selection of wards was made in consultation with the
nursing directors of the participating hospitals, taking into
account organizational elements, such as prolonged absences
of staff members, or other implementation processes that
were occurring on the ward. A total of 17 wards participated.
All nurses (N = 219) working on the included wards were
invited to participate in the study.

Data Collection

Data were collected through self-administered question-
naires completed by the nursing staff on the participating
wards between November and December 2011. The question-
naires consisted of the Attitude Toward Aggressive Behavior
Questionnaire (ATABQ) (Collins, 1994) for measuring atti-
tude, the Confidence in Coping With Patient Aggression
Instrument (CCPAI) (Thackrey, 1987) for self-efficacy, the
Professional Quality of Life Questionnaire (ProQoL)
(Stamm, 2010) for professional quality of life, and a record of
demographic data including age, gender, educational degree,
education in psychiatric nursing, years of work experience in
psychiatric care, and years of work experience on the ward.
During a staff meeting, the research team informed the nurses
of the participating wards about the purpose and procedures
of the study. The nurses were asked to complete the question-
naires individually during this staff meeting. Two occasions
were selected to provide all nurses the opportunity to partici-
pate in the study. All eligible nurses from the selected wards
participated in the study.

Instruments

Attitude. Most instruments to measure attitudes toward
aggression focus on the identification of the appraisal and
tolerance toward aggressive incidents (Duxbury, Hahn,
Needham, & Pulsford, 2008; Jansen, Dassen, et al., 2006;
Whittington, 2002). This study was designed to investigate the
broad range of aspects related to nurses’ attitudes toward
aggression, broader than the appraisal of aggressive incidents.
The ATABQ developed by Collins (1994) provided such a
broad range of aspects, which are reflected in its subscales. The
12 statements on aggressive behavior of patients are divided
into five subscales: patient responsibility for aggression, staff
safety, predictability of incidents, competence in managing

violent behavior, and confidence of staff in dealing with
aggressive incidents. Items are scored on a 5-point Likert scale
from 1 (strongly disagree) to 5 (strongly agree). Scores ranged
from 1 to 5 at subscale level and from 12 to 60 at scale level, with
a higher score indicating a more positive attitude. The lack of
reference scores and cutoff points allowed only the interpreta-
tion of a mean score in relation to the mean score of another
group. The ATABQ test–retest reliability is 0.97 (Collins,
1994).

Self-Efficacy. The CCPAI developed by Thackrey (1987) has
the capacity to monitor perceived self-efficacy toward aggres-
sion in a comprehensive and one-dimensional way. It was
developed for use in mental healthcare settings (Thackrey,
1987). The instrument includes 10 statements, scored on an
11-point Likert scale, ranging from 1 (very uncomfortable) to
11 (very comfortable). Scores ranged from 10 to 110, with a
higher score indicating a higher level of self-efficacy toward
inpatient aggression. The CCPAI lacks cutoff scores, so a
mean score can only be interpreted in relation to the mean
score of another group. Previous studies with the CCPAI
showed an internal consistency of α = .88 (Thackrey, 1987)
and α = .92 (Allen & Tynan, 2000).

Professional Quality of Life. The ProQoL was used to measure
the professional quality of life. The ProQoL assesses general
job satisfaction (Stamm, 2010). It can be adapted to any pro-
fession that chooses to help others (Stamm, 2010). The
instrument includes 30 statements divided into three
subscales: compassion satisfaction, burnout, and secondary
traumatic stress (Stamm, 2010). Compassion satisfaction is
referring to the pleasure one derives from being able to do his
work. Burnout is referring to feelings of hopelessness and dif-
ficulties in dealing with work or doing the job effectively. Sec-
ondary traumatic stress is a negative feeling driven by fear and
work-related trauma. The statements are scored on a 5-point
Likert scale. The ProQoL has good internal consistency for its
subscales: compassion satisfaction (α = .88), burnout
(α = .75), and secondary traumatic stress (α = .81) (Stamm,
2010). The ProQoL was already used in research on the job
satisfaction of mental health nurses (Lauvrud, Nonstad, &
Palmstierna, 2009; Newell & MacNeil, 2011).

The set of instruments was translated into Dutch and
French by a back-forward translation procedure with mono-
lingual testing. A two-round Delphi procedure with profes-
sional translators and healthcare professionals was used for
the forward translation. In order to assess comprehensive-
ness, the translated instruments were presented to a group of
seven mental healthcare nurses and seven researchers during
individual interviews. These interviews resulted in only
minor changes to optimize the comprehensibility of the
translated questionnaires. The professional translators con-
ducted a backward translation for verification. No further

15Perspectives in Psychiatric Care 52 (2016) 12–24
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Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

comments were provided. The internal consistency reliability
of the translated instruments was assessed and is presented in
Table 1.

Ethical Considerations

This study was approved by the Ethical Review Committee of
Ghent University Hospital and by the local committees of the
participating hospitals (No. B67020109275). All participants
were given detailed information (written and verbal) about
the study and signed an informed consent.

Data Analysis

SPSS v21 (SPSS Inc., Chicago, IL, USA) was used for all statisti-
cal analyses. A significance level of .05 was used. Descriptive
statistics (counts, percentages, means, and standard deviation)
were calculated. The data were verified for normality of distri-
bution and equality of variances. With respect to group com-
parisons, independent Student’s t tests or one-way analysis of
variance (ANOVA) was used. To avoid type I errors, compari-
son of four groups was conducted using an adjusted alpha level
of .0125. Pearson’s correlation coefficients were calculated to
measure the strength of associations between the outcomes
under measure (attitude and self-efficacy) and the nurse-
related characteristics at scale level (age, work experience, and
professional quality of life). To explore associations between
nurse-related characteristics, attitudes, and perceived self-
efficacy levels toward patient aggression, a forward stepwise
linear regression analysis was performed. Associated factors
with a significance value of less than or equal to .05 were
included in the model. In the second phase, a backward regres-
sion analysis was performed to verify the results of forward
regression analysis. The backward regression analyses crite-
rion to remove the predictor was held at F greater than or equal
to .100. The models were checked for multi-collinearity.

Results

Sample Characteristics

A total of 219 nurses participated in this study. The mean age
of the participants was 41.23 (SD 11.43) years and 72.6% were
female. The sample consisted of 53.9% nurses with a bachelor

of science degree. A degree in psychiatric nursing was
obtained by 79.4% of the participating nurses. This degree at
bachelor and diploma level is obtained by following optional
courses within the regular nursing curriculum. Almost 54%
of the nurses had 10 or more years of work experience in psy-
chiatric care, and 26.5% had worked 10 years or longer on the
participating ward. An overview of the general characteristics
of the sample is presented in Table 2.

Attitude Toward Inpatient Aggression

The mean score on the ATABQ was 37.36 (SD 3.79). Group
comparisons for the total ATABQ score revealed no

Table 1. InternalConsistencyTranslated
Questionnaires

Questionnaire
Dutch version
Cronbach’s α

French version
Cronbach’s α

Attitude (ATABQ) .35 .52
Self-efficacy (CCPAI) .91 .90
Professional quality of life (ProQoL) .56 .52

ATABQ, Attitude Toward Aggressive Behavior Questionnaire; CCPAI, Confidence in Coping With
PatientAggression Instrument; ProQoL, ProfessionalQuality of LifeQuestionnaire.

Table 2. GeneralCharacteristics of Sample

Characteristics (n = 219) N (%)

Gender
Female 159 (72.6)
Male 52 (23.7)
Missing 8 (3.7)

Age (years)
21–30 52 (23.7)
31–40 51 (23.3)
41–50 51 (23.3)
>50 63 (28.8)
Missing 2 (.9)

Workexperience inpsychiatry (years)
<1 18 (8.2) 1–5 41 (18.7) 6–10 42 (19.2) >10 118 (53.9)
Missing 0 (.00)

Workexperienceonward (years)
<1 44 (20.1) 1–5 64 (29.2) 6–10 52 (23.7) >10 58 (26.5)
Missing 1 (.50)

Educational degree
Diploma levela 96 (43.8)
Bachelorof sciencedegree 118 (53.9)
Missing 5 (2.3)

Degree inpsychiatric nursing
Yes 174 (79.4)
No 40 (18.3)
Missing 5 (2.3)

aDiploma level is a3-yearnurse trainingeducationatqualification level 5
of theEuropeanHigher EducationArea.

16 Perspectives in Psychiatric Care 52 (2016) 12–24
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Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

significant differences for the nurse-related characteristics
under study (see Table 3). It demonstrated only weak correla-
tions with compassion satisfaction (r = .143, p < .05) and burnout (r = −.149, p < .05) (see Table 4). None of the nurse- related characteristics were retained in the regression analysis (see Table 5).

Associations with nurse-related characteristics were found
at subscale level (see Tables 3 and 4). The subscale “predic-
tion” revealed a mean score of 3.85 (SD .59). A weak negative
correlation was found between this aspect of attitude toward
patient aggression and age (r = −.178, p < .05) (see Table 4). The factor age was included in the regression analysis. The model had a predictive value of less than 10% (see Table 5).

The subscale “attribution and responsibility” revealed a
mean score of 3.31 (SD .48). Group comparisons demon-
strated significant differences for gender (see Table 3). Female
nurses had statistically significantly higher scores on ques-
tions regarding patient attribution and responsibility for
aggressive incidents than male nurses (3.35 vs. 3.18,
t = −2.203, df = 205, p = .029). Higher scores refer to a lower
tendency to place blame and thus a more tolerant perspective
on aggression. Negative correlations (see Table 4) were found
between attribution and responsibility for aggressive inci-
dents on the one hand, and the years of work experience in
psychiatric care (r = −.166, p < .05), the years of experience on the ward (r = −.155, p < .05), and level of burnout (r = −.148, p < .05) on the other hand. The mentioned significant or cor- related factors were included in the regression analysis. The model had a predictive value of less than 10% (see Table 5).

The subscale “staff anxiety and fear of assault” revealed a
mean score of 3.93 (SD .62). Higher scores refer to the belief
that aggression is part of working in psychiatric care. Signifi-
cant group differences were demonstrated for post-traumatic
stress levels (F = 4.569, df = 2, p = .012) (see Table 3). Mental
health nurses in the categories low and moderate post-
traumatic stress level considered aggression more as a part of
the job. This subscale revealed no significant correlations (see
Table 4). None of the nurse-related characteristics were
retained in the regression analysis (see Table 5).

The mean score on the subscale “need skilled intervention”
was 4.18 (SD .45). Higher scores referred to a higher belief in
the importance and need for training and for skills to prevent
and manage aggression. Group comparisons demonstrated
significant differences for degree in psychiatric nursing and
borderline significance with gender (see Table 3). Nurses who
did not have a degree in psychiatric nursing revealed a signifi-
cantly higher need for specific training and skills to prevent
and manage aggressive behavior compared to nurses with a
degree in psychiatric nursing (4.36 vs. 4.14, t = 2.729, df = 211,
p = .007). Male nurses reported a higher need for intervention
training to prevent and manage aggression than their female
colleagues (4.25 vs. 4.14, t = 1.901, df = 208, p = .059). A low
positive correlation was found with compassion satisfaction

(r = .156, p < .05) (see Table 4). The mentioned significant or correlated factors were included in the regression analysis. The model had a predictive value of less than 10% (see Table 5).

The mean score on the subscale “staff confidence” was 3.76
(SD .67). Group comparisons within this subscale demon-
strated significant difference for gender and compassion sat-
isfaction (see Table 3). Male mental health nurses had
statistically significantly higher scores on the subscale of con-
fidence in the ability to deal with and having control over
patients with aggression (4.00 vs. 3.68, t = 3.111, df = 101, p =
.001). Mental health nurses with a high or moderate level of
compassion satisfaction had a statistically significantly higher
score on this subscale (F = 10.878, df = 2, p = .000). It demon-
strated a positive correlation with compassion satisfaction
(r = .307, p < .01) and a negative correlation with secondary traumatic stress (r = −.192, p < .01) (see Table 4). The men- tioned significant or correlated factors were included in the regression analysis. Staff confidence in dealing with aggres- sion has two predictors: gender and compassion satisfaction. These two factors explained 14.4% of the variance in staff confidence in dealing with aggressive incidents (see Table 5).

Perceived Self-Efficacy

The mean score on the CCPAI was 61.44 (SD 14.57). Group
comparisons revealed statistically significant differences for
gender and compassion satisfaction (see Table 6). Male nurses
had a significantly higher perceived self-efficacy score than
their female colleagues (71.15 (SD 12.95) vs. 58.11 (SD 13.81),
t = 5.993, df = 207, p < .001). Nurses with high or moderate levels of compassion satisfaction had higher levels of perceived self-efficacy compared to their colleagues with low levels of compassion satisfaction (F = 6.259, df = 3, p = .002). A positive correlation was found between the perceived level of self- efficacy and compassion satisfaction (r = .284, p < .01) and a negative correlation with self-efficacy and secondary trau- matic stress (r = −.218, p < .01) (Table 4). The mentioned sig- nificant or correlated factors were included in the regression analysis. The regression analysis demonstrated four predictors for the perceived self-efficacy toward inpatient aggression (see Table 5). This model with gender, burnout, secondary trau- matic stress, and compassion satisfaction accounted for 26.2% of the variability in the perceived self-efficacy of mental health nurses toward aggressive incidents. Mental health nurses with lower burnout and secondary traumatic stress symptoms, with higher compassion satisfaction scores, and male mental health nurses perceived themselves as having a higher level of self-efficacy in dealing with inpatient aggression.

Discussion

This study aimed to explore mental health nurses’ attitudes
and perceived self-efficacy toward inpatient aggression in

17Perspectives in Psychiatric Care 52 (2016) 12–24
© 2014 Wiley Periodicals, Inc.

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

Ta
b

le
3
.

A
tt

it
u
d
es

o
f

th
e
Pa
rt
ic
ip
an
ts
M
ea
su
re
d
b
y
th
e
A
TA
B
Q

To
ta

ls
co

re
a

S
u

b
sc

a
le

S
u
b
sc
a
le
S
u
b
sc
a
le
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b
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a
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b
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a
le

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re

d
ic

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o

n
b

A
tt

ri
b

u
ti

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a
n

d
re

sp
o

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b
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it

y
b

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ta

ff
a
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ie

ty
a
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d
fe

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r

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a
ss

a
u

lt
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d

sk
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le

d
in

te
rv

e
n

ti
o
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b
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ta

ff
co

n
fi

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ce
b

M

e
a
n

(S
D

)
D

if
fe

re
n

ce
M

e
a
n
(S
D
)
D
if
fe
re
n
ce
M
e
a
n
(S
D
)
D
if
fe
re
n
ce
M
e
a
n
(S
D
)
D
if
fe
re
n
ce
M
e
a
n
(S
D
)
D
if
fe
re
n
ce
M
e
a
n
(S
D
)
D
if
fe
re
n
ce

O
ve
ra
ll

3
7
.3
6
(3
.7
9
)

N
A

3
.8
5
(.
5
9
)

N
A

3
.3
1
(.
4
9
)

N
A

3
.9
3
(.
6
2
)

N
A

4
.1
8
(.
4
5
)

N
A

3
.7
6
(.
6
7
)

N
A

G
en
d
er

t
=

.8
8
3
,
p

=
.3
8
0

t
=
.3
9
3
,
p

=
.6
9
5

t
=

−2
.2
0
3
,
p

=
.0
2
9
*

t
=
1
.6
4
3
,
p

=
.1
0
2

t
=
1
.9
0
1
,
p

=
.0
5
9

t
=
3
.1
1
1
,
p

=
.0
0
1
*

Fe
m
al
e

3
7
.2
3
(3
.7
8
)

3
.8
3
(.
5
4
)

3
.3
5
(.
4
7
)

3
.8
8
(.
6
4
)

4
.1
4
(.
4
3
)

3
.6
8
(.
6
6
)

M
al
e

3
7
.7
9
(3
.9
7
)

3
.8
8
(.
7
2
)

3
.1
8
(.
4
6
)

4
.0
4
(.
5
7
)

4
.2
5
(.
4
5
)

4
.0
0
(.
5
6
)

A
g
e
(y
ea
rs
)

F
=
.5
8
9
,
p

=
.6
2
0

F
=
3
.3
0
1
,
p

=
.0
2
1
*
*

F
=
1
.4
5
9
,
p

=
.2
2
7

F
=
1
.5
6
1
,
p

=
.2
0
0

F
=
.8
3
0
,
p

=
.4
7
9

F
=
.9
8
4
,
p

=
.4
0
1

2
1
–3
0

3
6
.8
8
(3
.9
2
)

3
.9
6
(.
5
1
)

3
.4
1
(.
4
0
)

3
.7
9
(.
6
5
)

4
.1
2
(.
4
3
)

3
.7
1
(.
8
0
)

3
1
–4
0

3
7
.1
6
(3
.0
0
)

3
.9
5
(.
3
8
)

3
.2
6
(.
4
6
)

4
.0
5
(.
6
1
)

4
.2
0
(.
4
3
)

3
.7
8
(.
5
0
)

4

1
–5

0

3
7
.7
6
(3
.9
6
)

3
.8
4
(.
7
0
)

3
.3
2
(.
6
2
)

3
.9
4
(.
5
7
)

4
.1
5
(.
5
1
)

3
.8
8
(.
5
9
)

>5
0

3
7
.6
0
(4
.1
8
)

3
.6
6
(.
6
7
)

3
.2
3
(.
4
5
)

3
.9
2
(.
6
2
)

4
.2
4
(.
4
4
)

3
.6
8
(.
7
4
)

W
o
rk
ex
p
er
ie
n
ce
in

p
sy
ch
ia
tr
y
(y
ea
rs
)

F
=
.5
0
2
,
p

=
.6
8
1

F

=
.5
2
7

,
p

=
.6
6
4

F
=
2
.4
7
6
,
p

=
.0
6
2

F
=
.1
5
8
,
p

=
.9
2
5

F
=
.7
7
7
,
p

=
.5
0
8

F
=
.5
5
6
,
p

=
.6
4
5

<1 3 7 .8 3 (3 .2 6 )

3
.7
5
(.
5
5
)

3
.5
3
(.
3
8
)

3
.8
6
(.
7
2
)

4
.1
1
(.
4
0
)

3
.6
1
(.
7
8
)

1
–5

3
7
.1
5
(3
.9
0
)

3
.7
9
(.
7
1
)

3
.3
8
(.
4
8
)

3
.9
8
(.
6
4
)

4
.1
1
(.
5
0
)

3
.8
3
(.
6
7
)

6
–1
0

3
6
.8
3
(4
.4
7
)

3
.9
3
(.
5
8
)

3
.3
4
(.
4
8
)

3
.9
1
(.
6
3
)

4
.2
4
(.
3
8
)

3
.7
1
(.
8
4
)

>1
0

3
7
.5
5
(3
.5
8
)

3
.8
5
(.
5
6
)

3
.2
3
(.
5
0
)

3
.9
3
(.
6
0
)

4
.2
0
(.
4
6
)

3
.7
8
(.
5
9
)

W
o
rk
ex
p
er
ie
n
ce
o
n

w
ar
d
(y
ea
rs
)

F
=
1
.3
6
2
,
p

=
.2
5
5

F
=
.1
7
1
,
p

=
.9
1
6

F
=
1
.7
2
5
,
p

=
.1
6
3

F
=
1
.2
3
9
,
p

=
.2
9
6

F
=
1
.1
7
6
,
p

=
.3
2
0

F
=
2
.4
0
9
,
p

=
.0
6
8

<1 3 7 .6 4 (3 .5 3 )

3
.8
2
(.
6
0
)

3
.3
8
(.
4
6
)

3
.8
4
(.
6
4
)

4
.1
9
(.
4
3
)

3
.6
6
(.
6
8
)

1
–5

3
6
.8
4
(3
.7
6
)

3
.8
3
(.
6
4
)

3
.3
9
(.
4
9
)

4
.0
4
(.
6
0
)

4
.1
0
(.
5
2
)

3
.8
9
(.
6
3
)

6
–1
0

3
6
.9
4
(4
.2
7
)

3
.8
9
(.
5
9
)

3
.2
6
(.
5
1
)

3
.8
5
(.
6
2
)

4
.1
7
(.
4
0
)

3
.6
0
(.
8
2
)

>1
0

3
8
.0
7
(3
.5
3
)

3
.8
4
(.
5
5
)

3
.2
3
(.
4
4
)

3
.9
2
(.
6
2
)

4
.2
5
(.
4
2
)

3
.8
3
(.
5
0
)

Ed
u
ca
ti
o
n
al
d
eg
re
e

in

n
u
rs
in
g

t
=
1
.4
2
9
,
p

=
.1
5
5

t
=
1
.4
2
5
,
p

=
.1
5
6

t
=
1
.2
7
8
,
p

=
.2
0
3

t
=

−.
1
5
5
,
p

=
.8
8
7

t
=
1
.4
6
2
,
p

=
.1
4
5

t
=
1
.1
2
8
,
p

=
.2
5
0

B
Sc
d
eg
re
e

3
7
.6
5
(3
.6
1
)

3
.9
1
(.
6
0
)

3
.3
4
(.
4
5
)

3
.9
2
(.
6
0
)

4
.2
2
(.
4
8
)

3
.8
1
(.
6
0
)

D
ip
lo
m
a
le
ve
l

3
6
.9
1
(3
.9
5
)

3
.8
0
(.
5
1
)

3
.2
6
(.
5
3
)

3
.9
4
(.
6
3
)

4
.1
3
(.
4
2
)

3
.7
0
(.
7
6
)

D
eg
re
e
in
p
sy
ch
ia
tr
ic

n
u
rs
in
g
t
=

−.
1
9
8
,
p

=
.8
4
3

t
=

−.
7
7
8
,
p

=
.4
3
7

t
=

−1
.3
0
3
,
p

=
.1
9
4

t
=
1
.5
6
5
,
p

=
.1
1
9

t
=
2
.7
2
9
,
p

=
.0
0
7
*

t
=
.0
4
1
,
p

=
.9
6
8

Y
es

3
7
.3
9
(3
.7
8
)

3
.8
6
(.
5
8
)

3
.3
3
(.
4
9
)

3
.9
1
(.
5
7
)

4
.1
4
(.
4
6
)

3
.7
6
(.
6
4
)

N
o

3
7
.2
6
(4
.0
8
)

3
.7
8
(.
5
7
)

3
.2
1
(.
5
0
)

4
.0
8
(.
7
1
)

4
.3
6
(.
4
0
)

3
.7
7
(.
8
1
)

C
o
m
p
as
si
o
n

sa
ti
sf
ac
ti
o
n

F
=
1
.4
4
7
,
p

=
.2
3
8

F
=
1
.2
0
7
,
p

=
.3
0
2

F
=
1
.6
8
6
,
p

=
.1
8
8

F
=
1
.2
1
3
,
p

=
.3
0
0

F
=
1
.1
7
4
,
p

=
.3
1
1

F
=
1
0
.8
7
8
,
p

=
.0
0
0
*

Lo
w

3
7
.0
9
(3
.5
8
)

3
.7
4
(.
6
1
)

3
.2
4
(.
4
3
)

3
.8
1
(.
6
7
)

4
.1
1
(.
4
1
)

3
.4
2
(.
7
7
)

M
o
d
er
at
e

3
7
.1
2
(3
.7
6
)

3
.8
7
(.
5
6
)

3
.3
1
(.
5
1
)

3
.9
9
(.
5
6
)

4
.1
6
(.
4
7
)

3
.8
4
(.
5
8
)

H
ig
h

3
8
.1
3
(3
.6
7
)

3
.8
9
(.
5
8
)

3
.4
1
(.
4
5
)

3
.9
3
(.
7
4
)

4
.2
4
(.
5
1
)

3
.9
6
(.
5
9
)

B
u
rn
o
u
t

F
=
2
.8
9
6
,
p

=
.0
5
8

F
=
1
.8
4
5
,
p

=
.1
6
1

F
=
2
.7
5
7
,
p

=
.0
6
6

F
=
1
.4
6
8
,
p

=
.2
3
3

F
=
.1
2
1
,
p

=
.8
8
6

F
=
.4
3
8
,
p

=
.6
4
6

Lo
w

3
8
.1
6
(3
.7
3
)

3
.8
1
(.
5
5
)

3
.4
3
(.
4
3
)

3
.8
3
(.
7
1
)

4
.1
7
(.
4
9
)

3
.7
1
(.
7
9
)

M
o
d
er
at
e

3
6
.9
5
(3
.4
3
)

3
.9
6
(.
5
2
)

3
.2
4
(.
5
2
)

3
.8
8
(.
5
0
)

4
.1
9
(.
4
5
)

3
.7
7
(.
5
9
)

H
ig
h

3
6
.4
5
(4
.7
0
)

3
.8
1
(.
5
9
)

3
.2
8
(.
5
0
)

4
.0
4
(.
7
0
)

4
.1
4
(.
5
1
)

3
.6
5
(.
7
7
)

Po
st
-t
ra
u
m
at
ic
st
re
ss

F
=
1
.1
3
1
,
p

=
.3
2
5

F
=
.1
8
2
,
p

=
.8
3
4

F
=
.6
4
2
,
p

=
.5
2
7

F
=
4
.5
6
9
,
p

=
.0
1
2
*

F
=
1
.5
6
1
,
p

=
.2
1
3

F
=
2
.5
4
2
,
p

=
.0
8
1

Lo
w

3
7
.0
5
(4
.0
4
)

3
.9
1
(.
5
1
)

3
.3
7
(.
4
9
)

4
.0
3
(.
6
7
)

4
.2
3
(.
5
3
)

3
.8
7
(.
7
3
)

M
o
d
er
at
e

3
7
.8
0
(3
.1
8
)

3
.8
4
(.
6
3
)

3
.3
3
(.
4
8
)

4
.0
2
(.
6
2
)

4
.2
1
(.
3
7
)

3
.8
3
(.
6
4
)
H
ig
h

3
6
.8
8
(4
.4
9
)

3
.8
5
(.
5
8
)

3
.2
6
(.
5
0
)

3
.7
3
(.
6
3
)

4
.1
0
(.
5
0
)

3
.6
1
(.
7
2
)

a P
o
ss
ib
le
ra
n
g
e:
1
2
–6
0
.
b
Po
ss
ib
le
ra
n
g
e:
1
–5
.
*
Si
g
n
ifi
ca
n
t
va
lu
es

le
ve
lo
f
.0
5
).
*
*
N
o
t
si
g
n
ifi
ca
n
t
(a
d
ju
st
ed

α
le
ve
lo
f
.0
1
2
5
).
A
TA
B
Q
,
A
tt
it
u
d
e
To
w
ar
d
A
g
g
re
ss
iv
e
B
eh
av
io
r
Q
u
es
ti
o
n
n
ai
re
;
N
A
,
n
o
t
ap
p
lic
ab
le
.

18 Perspectives in Psychiatric Care 52 (2016) 12–24
© 2014 Wiley Periodicals, Inc.

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

adult psychiatric hospitals and to explore the association
between these attitudes and perceived self-efficacy with
nurse-related characteristics. The findings corroborate and
extend previous findings about the influence of nurse-related
characteristics on attitudes and self-efficacy toward inpatient
aggression.

Attitude Toward Inpatient Aggression

The overall attitude score of this sample seems rather moder-
ate. As the ATABQ is rarely used to measure mental health
nurses’ attitudes toward aggressive incidents, and as there
exists no cutoff point, our results cannot be compared to

earlier findings. We will discuss some of the associations or
predictive models.

The results of our study demonstrated that the profes-
sional quality of life had an impact on mental health nurses’
attitudes toward aggression. Mental health nurses with a
higher level of compassion satisfaction, referring to the plea-
sure one derives from being able to provide care, had more
confidence in dealing with aggression and believed more in
the importance of training. Burnout, referring to feelings of
hopelessness and difficulties in dealing with or doing one’s
job effectively, was linked with a more negative attribution
toward aggression. This study is, to our knowledge, the first
to demonstrate this association.

Table 4. Correlations

Age
(years)

Work experience Professional quality of life

In psychiatry
(years)

On the
ward (years)

Compassion
satisfaction Burnout

Secondary
traumatic stress

Attitude (ATABQ)
Total score .075 .012 .042 .143* −.149* −.047
Subscale—Prediction −.178* −.030 .008 .068 .068 −.025
Subscale—Patient attributionand responsibility
for aggression

−.132 −.166* −.155* .121 −.148* −.056

Subscale—Staff anxiety and fearof assault .046 −.055 .005 .106 .064 −.220
Subscale—Need for skilled intervention to
prevent andmanageaggression

.085 .052 .043 .156* −.027 −.133

Subscale—Staff confidence .011 −.009 .035 .307** −.052 −.192**
Self-efficacy (CCPAI)
Total score .080 .058 .023 .284** .052 −.218**

*Significant values (α levelof .05). **Significant values (α level of .01).ATABQ,AttitudeTowardAggressiveBehaviorQuestionnaire;CCPAI,Confidence
inCopingWithPatientAggression.

Table 5. Associated Factors forAttitudeandSelf-EfficacyToward InpatientAggression (StepwiseRegressionAnalysis)

R2 p value

Modelswithperceived level of self-efficacyas variable tobepredicted
Model 1—Gender .144 <.001 Model 2—Gender andcompassion satisfaction .207 <.001 Model 3—Gender, compassion satisfaction, burnout, secondary traumatic stress .262 <.001

Modelswithattitudeas variable tobepredicted
Total score NA
Prediction .024 .015
Model 1—Age

Patient attributionand responsibility
Model 1—Experiencepsychiatry .026 .013

Staff anxiety NA
Skilled interventions .019 .027
Model 1—Training .035 .011
Model 2—Training, educational degree

Staff confidence
Model 1—Compassion satisfaction .104 <.001 Model 2—Gender andcompassion satisfaction .144 <.001

NA,not applicable; all predictors excluded.

19Perspectives in Psychiatric Care 52 (2016) 12–24
© 2014 Wiley Periodicals, Inc.

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

20 Perspectives in Psychiatric Care 52 (2016) 12–24
© 2014 Wiley Periodicals, Inc.

In the current study, less experienced nurses were less
likely to blame patients for their behavior and less frequently
held them responsible for this behavior. They embraced a
perspective in which it is more accepted that patients
become violent when they feel vulnerable, helpless, or afraid
(Collins, 1994). This negative association between work
experience and a positive attitude toward aggression is com-
parable to previous research (Abderhalden et al., 2002;
Jansen, Dassen, et al., 2006; Palmstierna & Barredal, 2006).
In contrast, the study of Whittington (2002) found that tol-
erance for aggression is higher among more experienced
nurses (more than 15 years). Our results may indicate that

more experienced nurses seem to lose a positive perspective
and tolerance toward aggression. This development over
time toward a tendency to place blame can be explained by
the possible impact of patient aggression on nurses. The
confrontation with aggression may cause emotional harm.
This sample of mental health nurses showed that burnout
and post-traumatic stress increased significantly for nurses
employed more than 10 years. Emotionally depleted staff
might find it difficult to have empathy with aggressive
patient behavior, and as the study of Whittington (2002)
demonstrated, burnout is associated with a more intolerant
attitude.

Table 6. PerceivedLevel of Self-Efficacyof the
Participants

Nurse-related characteristics

Self-efficacy (CCPAI)a

Mean (SD) Differences

Overall 61.33 (14.63) NA
Gender t = 5.993, p = .000*
Female 58.11 (13.81)
Male 71.15 (12.95)

Age (years) F = .871, p = .457
21–30 58.54 (16.30)
31–40 62.53 (12.50)
41–50 62.22 (15.25)
>50 62.19 (14.47)

Workexperience inpsychiatry (years) F = .739, p = .530
<1 57.50 (14.96) 1–5 59.80 (16.13) 6–10 61.78 (13.23) >10 62.29 (14.53)

Workexperienceonward (years) F = .803, p = .493
<1 58.80 (15.56) 1–5 62.65 (16.08) 6–10 60.47 (13.47) >10 62.57 (13.36)

Educational degree innursing t = 1.059, p = .291
BScdegree 62.35 (14.95)
Diploma level 60.22 (14.21)

Degree inpsychiatric nursing t = 1.228, p = .221
Yes 60.71 (14.42)
No 63.90 (15.73)

Compassion satisfaction F = 6.259, p = .002*
Low 55.92 (11.73)
Moderate 65.82 (15.16)
High 65.69 (16.18)

Burnout F = .175, p = .839
Low 60.71 (16.09)
Moderate 60.88 (14.46)
High 62.38 (13.94)

Post-traumatic stress F = 2.469, p = .087
Low 63.69 (18.73)
Moderate 62.30 (14.12)
High 57.99 (12.66)

aPossible range: 10–110. *Significant. CCPAI, Confidence in Coping With Patient Aggression; NA,
not applicable.

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

21Perspectives in Psychiatric Care 52 (2016) 12–24
© 2014 Wiley Periodicals, Inc.

Participants reported a strong belief in training, especially
for male mental health nurses, which seems to contradict
the higher levels of perceived self-efficacy. Male mental
health nurses more often intervene in aggression incidents
than their female colleagues. This might create a stronger
interest in, and thereby need for, training and competence
development.

Perceived Self-Efficacy

The overall perceived level of self-efficacy was 61.44 (SD
14.57). This is comparable to Grenyer et al. (2004), who
found a self-efficacy level of 62.67 (SD 19.19). Thackrey
(1987) reported a self-efficacy level of 70.70 (SD not
reported), which is markedly higher. The main result of this
study is a four-factor model predicting about one fourth of
the variability in the perceived self-efficacy of mental health
nurses toward aggressive incidents. Previous research using
an adapted version of the CCPAI within a group of mental
health clinicians demonstrated the impact of gender on self-
efficacy, whereby male mental health workers have higher
self-efficacy levels than their female colleagues (Martin &
Daffern, 2006). We can state that besides gender, the per-
ceived professional quality of life, along with its three sub-
aspects compassion satisfaction, burnout, and secondary
traumatic stress, is an important nurse-related predictor for
the level of self-efficacy. The generally low self-efficacy
scores could have a negative effect on the perception of
aggression, on professional functioning, and on task perfor-
mance toward aggression.

Implications for Mental Health Nursing Practice

As the conceptual model stated, an enduring and pervasive
change in behavior toward patients who behave aggressively
will only be achieved by influencing mental health nurses’
attitude and self-efficacy. It should be clear that these changes
in attitude, self-efficacy, and behavior cannot be achieved in a
day. Change of this magnitude requires targeted investments
and time. The implications for practice are situated in several
areas.

First, it is important that mental health nurses understand
the meaning of aggression. Mental health nurses view aggres-
sion in different ways (Finnema et al., 2004; Jansen, Middel,
et al., 2006; Jonker et al., 2008). As mentioned, aggression can
be perceived as a dysfunctional, functional, or protective phe-
nomenon. The last two perspectives reflect a more tolerant,
permissive attitude toward aggression. Mental health nurses
need to be aware of the possible protective and functional
nature of aggression. This can increase their understanding of
the nature of aggressive behavior, thus leading to a more
empathetic attitude. The capacity to see aggression in a more
positive way may result in a better working alliance with

improved treatment outcomes (de Leeuw et al., 2012), such as
a lower use of coercive measures (Jonker et al., 2008).
Knowing this and intervening appropriately can help mental
health nurses learn from their experience and feel successful
in their performance. This experience of success then aug-
ments their perceived self-efficacy in the management of
aggressive incidents.

Second, education is needed to improve attitude, self-
efficacy, and performance (Beech & Leather, 2006; Needham
et al., 2005). This training will enable mental health nurses
to understand the multifactorial and complex nature of
aggression. The training course should also provide content
on and lessons in effective intervention strategies for
evidence-based practice related to aggression management.
As mentioned earlier, a better understanding of the meaning
of aggression and identification of possible interventions
will lead to a change in practice. Training alone is not
sufficient.

Third, we recommend on-the-job training, which needs
to be incorporated at different levels. At an individual level,
mental health nurses need to be coached on their perfor-
mance toward aggression. An open and nonthreatening
atmosphere to perform those individual reflections must be
created. The formation of attitudes is not only affected by
individual characteristics but also by team dynamics
(Knotter, Wissink, Moonen, Stams, & Jansen, 2013); thus,
interventions at team level should consist of team discus-
sions and reflection on specific incidents, actions, reactions,
feelings, and thoughts toward inpatient aggression. A nurse
expert in aggression management could lead this peer
supervision. At the management level, mental health hospi-
tals need to support and facilitate the participation in train-
ing courses and on-the-job training, recruiting an expert in
aggression management, and developing vision of aggres-
sion management in concert with the staff. This study dem-
onstrates that a higher level of professional quality of life is
associated with more positive attitudes and with improved
self-efficacy. A better professional quality of life, referring to
positive job satisfaction, may lead to a more professional
approach to manage aggressive incidents. Management
needs to pay attention to the job satisfaction of their staff
within the earlier mentioned open and nonthreatening
atmosphere.

Fourth, it is important that nurses confront patients with
their behavior. This appraisal is a learning experience for both
the patient and the nurse. The nurse obtains insight into the
experiences of the patient with a positive impact on his or her
attitude toward aggression. An appraisal with the patient
strengthens the nurse’s own competencies in dealing with
aggression and thus increases the self-efficacy.

Although not a part of the present study, it will be impor-
tant to identify the subjective norms, as third factor of the
TPB, at team level.

Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression

22 Perspectives in Psychiatric Care 52 (2016) 12–24
© 2014 Wiley Periodicals, Inc.

Study Limitations

The sampling method is a limitation of this study. The
researchers did not have full control over the selection of the
wards within the hospitals. The nursing directors had some
preferences for the participation of specific wards based
upon organizational aspects. This might influence the
generalizability of the results. With a response rate of 100%,
it can be concluded that the participants were representative
of mental health nurses for the included wards. A second
limitation is the low internal consistency of the translated
ATABQ scale for both the Dutch and French versions. The
low internal consistency can indicate a lack of validity in
the construct of attitude toward aggression as measured by
the ATABQ. Results from this questionnaire must be inter-
preted with caution. The translated CCPAI had good inter-
nal consistency. The methodological concept of our study
can only indicate associative relationships between attitude
and self-efficacy on the one hand and the nurse-related
characteristics on the other hand. To ensure the stability of
the predictive value of the four-factor model for self-
efficacy, further longitudinal research is necessary.

Conclusion

An adequate level of self-efficacy and a positive attitude
toward aggression are important to decrease the severity and
number of aggressive incidents and to increase staff compe-
tence to intervene in a professional and therapeutic manner
toward aggressive incidents. This will lead to improved
quality of care, a more effective achievement of patient goals,
and help nurses to be more resistant to patient aggression and
the threats it poses. This study demonstrates the need for
attention to professional quality of life for mental health
nurses, with increased attention for more experienced nurses
who may suffer from negative consequences of providing care
to adults with a mental illness.

Acknowledgments

This research received a funding from Belgium Federal Public
Service of Health Care. The authors would like to thank the
participating hospitals, Nataly Filion, and Karen Lauwaert for
their collaboration in this project.

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