Discussion #1
For this week’s discussion, do the following;
1. Choose one of the posted articles and read thoroughly.
2. Post the reference citation for the article, using APA style.
3. Identify the theoretical framework used in the article you chose (post the name of the theory and its author). Provide a brief description of the theory.
4. Discuss whether the theoretical framework is consistent with a nursing perspective.
5. Discuss whether the theoretical framework is appropriate to guide the research.
6. Describe how the authors linked the findings of the study to the theoretical framework.
Cosmic Question – Post your cosmic question related to theoretical frameworks – provide a substantial response to at least 2 of your peers’ cosmic questions.
ResearchEBP
MH Nurses_FW
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 incidence
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
© 2014 Wiley Periodicals, Inc.
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
© 2014 Wiley Periodicals, Inc.
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
.
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ve
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ll
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(3
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9
)
N
A
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5
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4
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8
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4
5
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6
(.
6
7
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N
A
G
en
d
er
t
=
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8
3
,
p
=
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8
0
t
=
.3
9
3
,
p
=
.6
9
5
t
=
−2
.2
0
3
,
p
=
.0
2
9
*
t
=
1
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4
3
,
p
=
.1
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2
t
=
1
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0
1
,
p
=
.0
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9
t
=
3
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1
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p
=
.0
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1
*
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m
al
e
3
7
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3
(3
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8
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(.
5
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3
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4
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3
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(.
6
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4
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(.
4
3
)
3
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8
(.
6
6
)
M
al
e
3
7
.7
9
(3
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)
3
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8
(.
7
2
)
3
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(.
4
6
)
4
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4
(.
5
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4
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5
(.
4
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)
4
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0
(.
5
6
)
A
g
e
(y
ea
rs
)
F
=
.5
8
9
,
p
=
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2
0
F
=
3
.3
0
1
,
p
=
.0
2
1
*
*
F
=
1
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5
9
,
p
=
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2
7
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=
1
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=
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0
F
=
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,
p
=
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9
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=
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,
p
=
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1
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1
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3
6
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8
(3
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3
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3
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(.
5
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1
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3
7
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6
(3
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3
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7
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3
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(.
6
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3
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5
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4
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5
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5
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3
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8
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5
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>5
0
3
7
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6
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6
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3
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3
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4
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3
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W
o
rk
ex
p
er
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n
ce
in
p
sy
ch
ia
tr
y
(y
ea
rs
)
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=
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2
,
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=
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8
1
F
=
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2
7
,
p
=
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6
4
F
=
2
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7
6
,
p
=
.0
6
2
F
=
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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
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3
(3
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6
)
3
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5
(.
5
5
)
3
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3
(.
3
8
)
3
.8
6
(.
7
2
)
4
.1
1
(.
4
0
)
3
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1
(.
7
8
)
1
–5
3
7
.1
5
(3
.9
0
)
3
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9
(.
7
1
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3
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8
(.
4
8
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3
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8
(.
6
4
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4
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1
(.
5
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)
3
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3
(.
6
7
)
6
–1
0
3
6
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3
(4
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7
)
3
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3
(.
5
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3
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4
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4
8
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3
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1
(.
6
3
)
4
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4
(.
3
8
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3
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1
(.
8
4
)
>1
0
3
7
.5
5
(3
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8
)
3
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5
(.
5
6
)
3
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3
(.
5
0
)
3
.9
3
(.
6
0
)
4
.2
0
(.
4
6
)
3
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8
(.
5
9
)
W
o
rk
ex
p
er
ie
n
ce
o
n
w
ar
d
(y
ea
rs
)
F
=
1
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6
2
,
p
=
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5
5
F
=
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7
1
,
p
=
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1
6
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=
1
.7
2
5
,
p
=
.1
6
3
F
=
1
.2
3
9
,
p
=
.2
9
6
F
=
1
.1
7
6
,
p
=
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2
0
F
=
2
.4
0
9
,
p
=
.0
6
8
<1
3
7
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4
(3
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3
)
3
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2
(.
6
0
)
3
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8
(.
4
6
)
3
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4
(.
6
4
)
4
.1
9
(.
4
3
)
3
.6
6
(.
6
8
)
1
–5
3
6
.8
4
(3
.7
6
)
3
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3
(.
6
4
)
3
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9
(.
4
9
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4
.0
4
(.
6
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4
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0
(.
5
2
)
3
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9
(.
6
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6
–1
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3
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(4
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7
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3
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9
(.
5
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3
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6
(.
5
1
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3
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4
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7
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4
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3
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0
(.
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0
3
8
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7
(3
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3
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3
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3
(.
4
4
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3
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2
(.
6
2
)
4
.2
5
(.
4
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3
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3
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5
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Ed
u
ca
ti
o
n
al
d
eg
re
e
in
n
u
rs
in
g
t
=
1
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2
9
,
p
=
.1
5
5
t
=
1
.4
2
5
,
p
=
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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
=
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4
5
t
=
1
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2
8
,
p
=
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5
0
B
Sc
d
eg
re
e
3
7
.6
5
(3
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1
)
3
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1
(.
6
0
)
3
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4
(.
4
5
)
3
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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
(α
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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Patients_experiences_of_support DM_FW
EMPIRICAL STUDY
Patients’ experiences of support for learning to live with
diabetes to promote health and well-being: A lifeworld
phenomenological study
KARIN JOHANSSON, PhD Student
1,2,3
, SOFIA ALMERUD ÖSTERBERG,
Associated Professor
1
, JANETH LEKSELL, Associated Professor
4,5
&
MIA BERGLUND, Associated Professor
6
1
Department of Health and Care Sciences, Faculty of Health and Life Science, Linnaeus University, Växjö, Sweden,
2
Department of Administration, Kronoberg County Council, Växjö, Sweden,
3
Primary Care, Region Kronoberg County
Council, Växjö, Sweden,
4
School of Health and Social Sciences, University Dalarna, Falun, Sweden,
5
Department of Medical
Sciences, Uppsala University, Uppsala, Sweden, and
6
School of Health and Education, University of Skövde,
Skövde, Sweden
Abstract
Learning to live with diabetes in such a way that the new conditions will be a normal and natural part of life imposes
requirements on the person living with diabetes. Previous studies have shown that there is no clear picture of what and how
the learning that would allow persons to incorporate the illness into their everyday life will be supported. The aim of this
study is to describe the phenomenon of support for learning to live with diabetes to promote health and well-being, from the
patient’s perspective. Data were collected by interviews with patients living with type 1 or type 2 diabetes. The interviews
were analysed using a reflective lifeworld approach. The results show that reflection plays a central role for patients with
diabetes in achieving a new understanding of the health process, and awareness of their own responsibility was found to be
the key factor for such a reflection. The constituents are responsibility creating curiosity and willpower, openness enabling
support, technology verifying bodily feelings, a permissive climate providing for participation and exchanging experiences
with others. The study concludes that the challenge for caregivers is to create interactions in an open learning climate that
initiates and supports reflection to promote health and well-being.
Key words: Diabetes, health, lifeworld, phenomenology, reflection, support for learning, well-being
(Accepted: 20 July 2016; Published: 17 August 2016)
Diabetes is a long-term illness that significantly
alters one’s life. The experience of learning to live
with diabetes has been shown to involve under-
standing and controlling the changing body, as well
as protecting the body from damage in both the
short and long terms. This learning has been des-
cribed in earlier studies from a lifeworld perspective
(Berglund & Källerwald, 2012; Johansson, Almerud-
Österberg, Leksell, & Berglund, 2015; Kneck, Klang,
& Fagerberg, 2011). The term ‘‘lifeworld’’ refers to
the natural attitude through which a person ap-
proaches himself/herself, other persons, and the
world (Husserl, 1907/1989). From the lifeworld
perspective, the human body is understood as a
lived body that is at the same time biologically think-
ing, feeling, and acting (Merleau-Ponty, 1945/2002).
Learning from a lifeworld perspective means an altered
understanding created through reflection and dialo-
gue that involves the whole being of his/her context
(Bengtsson, 2006; Berglund, 2014; Ekebergh, 2007).
For present purposes, learning is understood as
integrating the illness as a change in the lived body
with a new understanding of one’s self as a person
with diabetes (cf. Johansson et al., 2015). Studies in-
formed by this definition of learning have described
the importance for diabetes care of interactions that
enable sharing of patients’ personal understandings of
living with the disease (Adolfsson, Smide, Rosenblad,
& Wikblad, 2009; Boström, Isaksson, Lundman,
Graneheim, & Hörnsten, 2014; Jutterstöm, 2013;
Zoffman et al., 2016).
Correspondence: K. Johansson, Department of Health and Care Sciences, Faculty of Health and Life Science, Linnaeus University, Växjö, Region Kronoberg,
Lasarettet, SE-341 82 Ljungby, Sweden. E-mail: karin.johansson@kronoberg.se
International Journal of
Qualitative Studies
on Health and Well-being
�
# 2016 K. Johansson et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform,
and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
1
Citation: Int J Qualitative Stud Health Well-being 2016, 11: 31330 – http://dx.doi.org/10.3402/qhw.v11.31330
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Supporting patients’ learning processes and in-
corporating the illness into their lives require knowl-
edge of how patients should be educated and how
carers can satisfy their need for learning (Friberg
& Hansson-Scherman, 2005). The importance of
understanding patients’ learning processes and the
need for support has been insufficiently emphasized
in the literature. An integrative review has iden-
tified a need to clarify the nature of patient educa-
tion as the basis for developing supportive activities
(Friberg, Granum, & Bergh, 2012). One potential
problem is that patient education is often organized
according to a preplanned programme that defines
patient needs in terms of identification of carers, plac-
ing greater emphasis on the medical component of
the illness than on its existential element (Adolfsson
et al., 2009). Toombs (1993) describes the patient
perspective as illness (an internal perspective) and the
medical perspective as disease (an external perspec-
tive), which gives rise to differing expectations about
what patients need to learn and cope with. This may
also affect how health care providers think and act in
patients’ learning.
Support in living with the illness is defined as
social and professional support. Hupcey (1998) des-
cribes social support as both existential and physical,
which is experienced as complex because several
parameters are involved in producing the desired
effect. Professional support is mediated by caregivers
in their practice (Hupcey & Morse, 1997) and gen-
erally follows guidelines and policies; this support
can be emotional, but it is not the same as social
support. Although the patient is at a disadvantage
and needs to be reassured, caregivers may not nec-
essarily trust the patient. Effective support in reach-
ing treatment goals has been shown in different
ways. One way is to involve and help patients in set-
ting individual goals (Adolfsson et al., 2009), and
give opportunities for self-monitoring blood glucose
(Durán et al., 2010). Another key factor is time
with the caregiver (Norris, Lau, Smith, Schmild, &
Engelgau, 2002) and meeting nurses with knowledge
of diabetes and pedagogical training (Adolfsson
et al., 2009; Swedish Council on Technology Assess-
ment in Health Care [SBU], 2009). Timing is also
important in matching resources because support
at the wrong time or unwanted support may be nega-
tively perceived (Hupcey, 1998). Berglund, Westin,
Svanström, and Sundler (2012) found that patients
feel distrusted and mistreated when their perspective
on illness is not taken into account. This, according
to the authors, constitutes a barrier to learning.
The aim of patient education is that patients
should feel secure and develop good self-care as
well as capability, in which knowledge, motivation,
training, and support are all important elements
(Hunt, 2013). Diabetes self-management is seen
as an ongoing process of facilitating the knowledge,
skills, and ability required for diabetes self-care
(Haas et al., 2014). Berglund (2014) demonstrated
the potential to support patients’ learning using a
didactic model based on lifeworld theory, in which
the learning persons are challenged to reflect and to
personally decide how they wish to live with their
illness. Learning to live with long-term illness is an
existential issue to reduce stress and maintain and
enhance short- and longer term health and well-
being (Berglund, 2014). This focus on the patient’s
learning process raises the important question, ‘‘how
learning to live with diabetes can be promoted?’’ The
present study describes the phenomenon of support
for learning to live with diabetes to promote health
and well-being, from the patient’s perspective.
Methods
In this study, the phenomenon of support for learn-
ing to live with diabetes is explored and illumi-
nated by the reflective lifeworld research (RLR)
approach, based on phenomenological epistemology
as described by Dahlberg, Dahlberg, and Nyström
(2008).
Participants and data collection
Following Dahlberg et al. (2008), interviews were
used to explore patients’ experiences. Informants
were recruited from four care units in South Sweden
(one specialist clinic and three primary care units),
using different forms of patient education. Each
unit recruited three Swedish-speaking patients, vary-
ing in age, sex, duration of illness, and treatment.
The informants were five men and seven women
between 45 and 76 years of age, with illness duration
ranging from 2 to 46 years. Three informants had
type 1 diabetes and nine had type 2 diabetes; age of
onset varied from 13 to 74 years. Informants chose
the interview venue; five were conducted in the
home and seven were conducted in the regular care
unit. Interview duration varied between 45 and
75 min. The interviews were conducted in con-
versational form, beginning with an open question
such as ‘‘how the patient experienced falling ill and
how they learned to live with the illness?’’ Follow-up
questions (e.g., tell me more, in what way, how did you
experience it, and what has been important for your
learning) were asked to gain deeper insight into the
phenomenon.
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Data analysis
The method of analysis can be described as a
dialectical process (Dahlberg et al., 2008), beginning
with the whole, analysing its parts, and then recon-
structing the whole to understand the essence of the
phenomenon. Initial analysis of the text as a whole
then turns to a focus on its parts to identify units of
meaning: a word, a sentence, or a longer piece of text.
These meanings are scrutinized against the back-
ground of the whole before building clusters or
groups of related meanings. Following the analysis
of units of meaning and clustering in groups, the next
phase involves identifying the phenomenon’s essence.
According to Dahlberg and Dahlberg (2003), the
essence can be understood as the core aspects of a
phenomenon on an abstract level whereas the con-
stituents describe the phenomenon on a concrete
level. This can be understood as a new whole.
In this study, the analysis began by listening and
reading through the interviews to become acquainted
with their content before looking for similarities,
differences, and patterns of meaning in the verbatim
printed interviews. Questions were asked to the text
about what was said, how it was said, and what is its
likely meaning*for instance, how the informants
described the experience of learning and what sup-
ported the learning process. By observing similarities
and differences in the material, a pattern of ex-
periences and meanings emerged, transforming the
subjective lifeworld perspective expressed in the
interviews into a professional and scientific descrip-
tion, focused on the studied phenomenon.
During the course of the research, patterns changed
in character, requiring movement between the whole
and parts before finally arriving at a description of
the essence. The essential structure was further des-
cribed in terms of its five constituents. In the results
below, the essence is presented first, followed by its
constituents and quotes to illuminate the findings.
Ethical considerations
Approval for the study was granted by the Regional
Ethics Committee of Linköping (Dnr 2012/222-32).
Field officers approved the participation. Informants
were provided with oral and written information about
the aim of the study before giving written consent.
Results
Learning to live with diabetes is supported by self-
responsibility, driven by reflection on experiences,
curiosity, and a desire to understand and influence
one’s daily life and illness processes. Beginning from
responsiveness to experience-based feelings in the
lived body, reflection supports the ongoing learning
process to promote health and well-being. The tech-
nology for measuring one’s own blood glucose level
is a component of this special support, confirming the
body’s feelings and in some cases raising questions
that promote the process of reflection. Openness
enables an ability of learning support from family
and friends, as well as from professional caregivers.
Activation of reflection, participation in decision-
making, and responsibility are the cornerstones for
learning and for a supportive climate. When experi-
ences are explicitly shared with others, progress is
made, and lessons are learned from less successful
attempts. The phenomenon under study is further
enlightened by its five constituents: responsibility
creating curiosity and willpower, openness enabling
support, technology verifying bodily feelings, a per-
missive climate providing for participation and ex-
changing experiences with others.
Responsibility creating curiosity and willpower
Learning is supported by the patients’ awareness
of and willingness to take responsibility for their
own health situation, as seen in the patients’ eager-
ness to learn, their curiosity, and various forms of
knowledge seeking to improve health. Responsibility
supports learning as the patients reflect over their
experiences and use their knowledge to calculate the
risks and benefits of planned actions and to make
conscious choices. One informant described this as
follows:
Had my parents not had heart attacks, and had
I not read online that there is the risk of a heart
attack, I don’t know if I would have been so
active; I was really scared, and I still am. I know
that my erectile function works, so that is not a
concern, but the heart thing is something that is
always at the back of my mind. Had it not been
like this in my family, I don’t think I would have
been so hard on myself, I’m not sure.
Responsibility to support learning in a way that
promotes health and well-being is reflected in how
patients set their own targets for treatment of their
illness, and take responsibility for a life with the
illness and its treatment. This, in turn, is supported
by reflection of the advantages of this approach, in
terms of reduced risk of complications and of future
suffering. One informant described how his learning
was supported by his willingness and effort to
achieve blood sugar level goals like this:
When my blood sugar is at the level of a healthy
person, I feel really well, so that’s where I want
Patients’ experiences of support for learning to live with diabetes
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to be. If it is a little higher, at 6�7 and starting
to approach 7, I of course think that I will
have to make sure that it goes down a little with
an extra dose of insulin.
The pursuit to reach goals supports responsibility,
which manifests itself in creativity, and in being
critically reflective, and analytical. The goal is to find
new ways to live with the illness, replacing old habits
while maintaining the quality of life, continuing to
live by priorities that are highly valued, despite one’s
illness. This means learning to deal with this new
situation on the basis of what creates meaning.
One informant described how he still enjoys
life and manages it with responsibility as
follows: We eat delicious food. I think it’s so
good. You just have to learn to deal with it in a
sensible way. The big thing for me is cooking at
home because that gave me so much joy before
I had diabetes.
Responsibility for supporting learning in a way
that promotes health and well-being is also demon-
strated in an eagerness to understand and interpret
bodily signals, and to act on these. Knowledge of the
body’s blood sugar levels provides expanded scope
for action. As another informant reflects on what
happens with him, ‘‘I know it directly when I get too
much sugar in me and I get tired.’’ This supports
awareness that he must do something that requires
concentration to ensure that his blood sugar is at a
good level. Learning is supported by the person’s
own reflective responsibility which itself is promoted
by curiosity and desire.
Openness enabling support
Learning is also supported by openness about the
illness and the requirements that follow the treat-
ment. Openness plays an important role to get
support from family, friends, and colleagues, as well
as helping the person to reflect and find new thoughts
and a new way to live. Work relationships can be
supportive when colleagues are aware of the person’s
need for routines around breaks and meals; conver-
sely, a lack of such understanding is not supportive.
One informant described it in this way: ‘‘Before I let
them know about my diabetes, the breaks and meals
were not so regular, but now we have breaks at 8, 10
and 12, which is perfect.’’ Another informant said
that colleagues were considerate about his needs:
‘‘We schedule the meetings to 14:00 to suit’’ (his need
for regular meals).
Relatives and friends can both support and com-
plicate the routines of everyday life. Informants
described support in various ways, such as: ‘‘We
agree that we should dine at 13:00, and then get
others to say what they want, and we usually keep
4 h between meals.’’ Another informant said ‘‘My
wife does it even harder than I do.’’ Concerning the
difficulties of developing an understanding of the
need for routines, one informant said ‘‘I want to eat
at certain times, but my wife is not so firm,’’ adding:
The hardest thing is to do with my wife, she
finds it hard to resist sweets; I have to nag her
so she does not have it in view, but it is difficult,
and then I cannot resist. It is not difficult to
resist in the shop, but if it is in view at home or
I’m offered, then it is difficult.
At a superficial level, clear rules can help to
support learning ‘‘I follow the advice I got from the
diabetes nurse and got good blood sugar,’’ but
openness about how the body reacts provides support
for learning at a deeper level. Experiments showing
how food and exercise affect one’s blood sugar can
support learning if the person is open and reflects on
the results. One informant described how he tests,
observes, reflects, analyses, and reaches conclusions:
Quickly, after 2 hours, I could see what hap-
pened when I ate something. So I continued to
test, and after 3 months, I had eaten my way
through the entire range of foods. I knew that it
was ok to eat salad, as it did not show up. Then
I played around with it a bit more. Legumes
worked pretty well, and later, I mixed legumes
and salad; it was pretty okay, and I could eat my
fill. Then I searched for good salads with beans,
and just carried on.
While prescribed self-care methods can be experi-
enced as superficially supporting learning to live with
diabetes, the felt positive effects of lifestyle changes
can promote deeper learning, making it easier to
sustain those changes:
I understand that exercise is good, and I feel
it is good, it’s nice // if I have a cold or it’s
miserable weather and I don’t go out, it is as if
there is something missing // today, I have not
been out and it feels strange // I have started
something that will last, I hope.
In this way, routines and rules can help to support
a change of behaviour; through openness, the person
gets access to social support and the changed
behaviour becomes normal and natural.
Technology verifying bodily feelings
Technology that verifies knowledge and feelings in
the body can also support learning to live with
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diabetes to promote health and well-being. For in-
stance, blood glucose measurements support learn-
ing to understand the body’s signals by training
one’s sensitivity to when the level is low or high. An
informant who remembers when blood glucose
meters were introduced describes it like this: ‘‘It
was very exciting and very nice, as it enabled me to
control my illness so that I knew I was at a good
level.’’ Notes of blood sugar levels become the basis
for dialogue and reflection on readings, which pro-
motes learning about how various activities affect
blood sugar levels. An unexpected result can activate
reflection. What have I done now? What is different?
One female informant described her realization that
‘‘negative thoughts and thinking everything is bad
will not be good for your blood sugar level.’’
Technology for measuring blood sugar levels assists
understanding of the connection between food in-
take, activity, exercise, and mood or how one feels.
This technology also makes it possible to monitor
changes in blood sugar levels over time, which in itself
supports learning ‘‘great to do a check during the night
to see how blood sugar is when you are sleeping.’’
To use the technology effectively, one must have
goals to strive for; without knowledge of target values,
the patient will be unable to experience how blood
glucose measurements can support learning, and
blood glucose measurements become worthless. As
one informant described it:
I checked the blood sugar level a few times,
starting in the morning, and saw the rise when
I ate, but there were no big changes, some-
where around 5�6 and sometimes maybe 7.
Maybe I should do it once a month, but it did
not work for me anyway.
The ability to measure blood sugar levels is both
attractive and frightening, and it can create ambi-
valent feelings. For most informants, it brings a
positive feeling of safety and control, which helps to
widen the boundaries. Some informants, however,
expressed concern that the technology would take
over to a point where they would not trust their
body’s signals; one woman put it like this:
When the diabetes nurse asked me if I wanted a
blood glucose meter, I felt that I did not want a
meter. I felt that it must not take over because I
could end up pricking myself unnecessarily just
to check. Therefore, I decided to wait as long
as it works.
The same informant also said:
I do not think of the illness a lot. Sometimes,
I think that in a way it would be nice to have
the syringes so I could check and see what
I can eat. Now, it will be more like, oh, what
happened now? Why am I getting a bit dizzy?
Maybe it will be like that later, too, I just don’t
know, but somehow it still feels like it would be
more real.
Those affected cannot always connect the feeling in
their body to their blood sugar level, as bodily feelings
can be a signal of other bodily needs. Through reflec-
tion, however, the technique of measuring blood sugar,
in combination with feelings in the body and food
activities, can promote deeper learning.
In learning, to calculate the dose of insulin at meal-
time, the technology for carbohydrate counting pro-
vides additional support. A blood glucose measurement
verifies whether a dose is correct for the current
situation, and the patient will remember and use this
knowledge in similar subsequent situations. New
technologies for monitoring blood sugar levels and
dispensing medicine have made it possible to learn
how to manage the illness, minimizing its impact on
everyday life. As one informant described it:
I actually live like a healthy person, eat more
sweets than average persons do (or some
persons anyway). Actually, I think it’s not good,
but I have a good HbA1c, and I’m very careful
to check myself.
The technology supports learning by providing more
opportunities to adjust the treatment to the current
situation, which means more freedom. Reflection plays
an important role in making the patients feel safe,
giving them courage to take on the new technology and
to challenge their own understanding.
A permissive climate providing for participation
Additional support for learning is found in a per-
missive environment where health care professionals
involve the patient in designing their treatment, and
where the patient feels involved in that planning.
A female informant described it like this: ‘‘They
cannot fool me; I have to agree to it myself and then
be motivated, because I want to know what I need to
do.’’ Participation*involving the patient in making
decisions about what to do*is crucial. This partici-
pation in the caring relationship is also supported by
experiments with subsequent reflective dialogue, in
which theoretical and practical knowledge is com-
bined to increase knowledge and responsibility.
As one informant described it:
I have quite a lot of freedom and get a proposal.
We try it, adjust the dosage in a certain way,
and if it does not work, I can change units a
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little bit up and down. I think this feels pretty
good. Because there is no one else who can
solve it, I have to do it myself in order to live a
reasonably normal and simple life.
To support participation and the creativity to dare
to explore new possibilities, an open, equal, and trust-
ing relationship with the diabetes team is important.
In such a caring relationship, questioning is not
perceived as threatening but as supportive of learn-
ing. On the other hand, professional support based
on instructions and intimidation discourages learning.
One informant described unsupportive informa-
tion as ‘‘not emotional but strong facts that were
given but difficult to follow,’’ and ‘‘when I got there
and had high blood sugar levels, I was almost given
a scolding.’’ When the diabetes team professionals
hand over responsibility in keeping with the patient’s
increased knowledge, this creates a sense of security.
Knowing that one always has the option of con-
tacting the team increases self-confidence. As one
informant said:
. . . that I could call if there is anything // during
my pregnancy, I could call my doctor at any
time, night or day. In this situation, you must
have 100% backing, and it made you feel safe.
I did not need to call, it was enough to know
that I could, and that made me feel secure.
To be able to challenge their own understanding,
it was also important that the patients felt they could
trust the available health care contact person. The
informant described a different sense of security
when consulting staff with specialized knowledge of
diabetes, as compared to the health care information
service, where they felt the staff had only basic
knowledge.
A climate of trust in the caring relationship demon-
strates that some situations are more difficult to
influence. This kind of trust was illustrated in the
following terms: ‘‘The doctor agreed to a higher
blood sugar level for some time, saying it was ok; we
know what you have been through now.’’ Under-
standing supports patients to recognize the difficult
situation, talk about it, and eventually turn it into
something positive*‘‘a bit like this entire life, really.’’
A permissive climate supports the learning experi-
ence, providing knowledge and increased under-
standing that one cannot always control everything
that happens in life and so affects one’s blood sugar
level, no matter how hard you try. A permissive
climate supports learning and opens the mind to the
caring relationship, as well as to a humble approach
to life, which seems to be important in living with
diabetes.
Exchanging experiences with others
Learning is supported by sharing experiences with
others, such as professional carers, relatives, ac-
quaintances, or other persons with diabetes. Experi-
ence exchange can take place in different ways, but it
often starts a reflection process. Citing the example
of a group meeting, one informant describes it as
follows:
We sit in groups and talk, maybe with someone
next to us // hearing and sharing a lot about
practical things, what others have experienced
and how they feel, or what they are experien-
cing now. There is much to learn from each
other; we all react very differently, all of us are
individuals.
For patients with newly diagnosed diabetes, ex-
perienced patients’ stories can be an awakening that
supports the search for knowledge about the illness
and how its development can be slowed. This was
described by one informant in the following terms:
‘‘Hearing their stories was like getting a punch in
the face.’’ The exchange of experiences can also pre-
pare one for the challenges to come. In some cases,
hearing about individual variations can increase
understanding of one’s own or others’ failures and
how to overcome them. One informant describes it
like this:
For me, it has worked, but I’m a little more
humble now as to how others experience it.
They come home in the evening and are going
to cook something for the children, they should
be full and it should be done fast, so it will be
pasta. Then they cook something for themselves.
It is really hard. I changed my mind after the
course because I got to see a bit how others had
it at home; it’s not so simple, so I do not judge
as I did in the beginning.
Experiences with others can enhance understand-
ing and support learning when fears, thoughts,
and feelings are put into words. The information a
diabetes nurse tries to convey may be complemented
by the exchange of experiences within the group.
Information about insulin requirements can be daunt-
ing, but if it is described by persons using insulin
without discomfort, that fear is reduced. Another
form of support for learning is the exchange of
experiences online. One informant reported such an
exchange through an Internet chat room: ‘‘Some
guys posted their Excel sheet, and I thought that I
would do so too.’’ Accessing new channels means
that knowledge can be supported by persons far
beyond one’s own network of contacts, increasing
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the possibility of finding knowledge that meets their
personal needs.
Information presented in a way that suits an
individual’s way of assimilating new knowledge sup-
ports learning in a way that promotes health and well-
being. Some participants found support by reading
brochures, books, and the diabetes association’s
magazine, featuring research abstracts and the experi-
ences of other patients. One woman told me how she
read an article and reflected that ‘‘I have come to that
conclusion myself,’’ confirming her own insight.
Others find the Internet to be a useful source of
knowledge. As one informant described it:
On the Internet, you can search for many
things. If there’s something you have questions
about, you can just google the question*a few
words and you can see that there are many
others who have thought and written about it
before.
Learning is supported through the exchange of
experience, and the reflection over it, and how
others’ experiences can be understood in relation
to one’s own experiences. Knowledge and under-
standing increases, including the realization that
it is not always easy to live with the illness, which
creates humility about the task of learning to
live with diabetes in a way that promote health and
well-being.
Discussion
The aim of this study was to describe the phenom-
enon of support for learning to live with diabetes to
promote health and well-being, from the patient’s
perspective. This included self-responsibility, driven
by reflection on experiences, curiosity, and a desire
to understand and influence one’s daily life. This
together with openness about the illness and reflec-
tion supported by technology and a permissive cli-
mate promoted learning to live with diabetes. The
study highlights that support for learning is three-
dimensional: individual, professional, and social.
Hupcey (1998) has defined support as social and
professional. The third dimension that has been
described in this study is the importance of the
person’s own responsibility to take charge in his/her
own situation by being responsible, insightful, and
reflective. Previous studies have shown that activities
initiated and driven by patient needs can reinforce
previous knowledge and support the ability to affect
diabetes-related health, as measured by HbA1c
(Tang, Funnell, Brown, & Kurlander, 2010). There
is also evidence that patient-driven self-management
support programmes can enhance diabetes manage-
ment and self-care (Dam, Horst, Borne, Ryckman,
& Crebolder, 2003) by increasing the frequency of
healthy eating and monitoring of blood glucose
(Durán et al., 2010; Tang et al., 2010).
In addressing the research question, the RLR
approach (Dahlberg et al., 2008) was found useful
and appropriate here, as participants in the present
study were openhearted in communicating their many
experiences of support for learning to live with
diabetes. Because the aim of the study was to describe
support for learning to live with diabetes, participants
with both type 1 and type 2 diabetes have been in-
cluded in the study. This is in line with Svedbo
Engström, Leksell, Johansson, and Gudbjörnsdottir
(2016). In relation to the phenomenon of the studies
we do not believe that the type of diabetes is sig-
nificant for the results. Effort has been made to get
such a varied picture as possible of the phenomenon.
Throughout the study, the researchers sought to
maintain an open position, and preconceptions were
regularly reflected (Husserl, 1975). Bracketing these
preconceptions to achieve a scientific and reflective
position meant slowing down and remaining con-
scious of them at all times through critical question-
ing of the meanings in our results. All the authors
participated in discussions to reach a deeper sense
of the phenomenon and of the significance of the
patients’ experiences. Although KJ and JL are dia-
betic nurses, the other authors are not and have been
able to be more critically open. As the phenomen-
ological approach allows for description of the rich-
ness and varied meaning of lifeworld phenomena, the
meanings arrived at are abstractions that can ideally
be generalized (Dahlberg et al., 2008), though with
caution, as they are necessarily context-specific.
The roll of reflections in learning has previously
been described in a different context by Bengtsson
(1998), Berglund (2014), and Ekebergh (2007)
following Heidegger (2008), Gadamer (1989), and
Merleau-Ponty (1983, 1995). From a lifeworld pers-
pective, reflection is seen as a process of under-
standing which is of crucial importance for learning
(Ekebergh, 2007). The findings of the present study
confirm that support promoting reflection plays a
central role in learning among persons with diabetes.
Reflection can, according to the results, be sup-
ported by the person himself/herself, for example, by
analysing his/her actions in relation to blood glucose
values; by social support, for example, by questions
asked by relatives that start reflection; and by
professional support, for example, by a permissive
climate where the patient is allowed to reflect upon
his/her failures.
Through reflection, new understanding is created,
described by Gadamer (1989) as a horizon fusion of
new experiences with previous understanding. Reflection
Patients’ experiences of support for learning to live with diabetes
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refers to how an individual turns their attention
inward to discover the self (Bengtsson, 1998). In this
regard, it can be compared with contemplation and
consideration. Gadamer (1996) argued that by adopt-
ing this critical distance from himself, a person can
become reflectively aware of himself and his actions.
In this study, reflection is found to support learning
and, in particular, to be important for learning to
live with diabetes. Wide support for the importance
of reflection is confirmed here in the participants’
awareness of their responsibility for their own health
process. According to Hörnsten, Jutterström, Audulv,
and Lundman (2011), this emerges when the patient
integrates the illness emotionally and existentially,
learning through reflection and taking responsibility
for understanding their own body (Johansson et al.,
2015). A lived body that has been changed by illness
will not be recognized and can be described as
homeless (Gadamer, 2003; Svenaeus, 2011). Only
by learning how the body works can the sense of
insecurity and homelessness created by illness be
mastered, in what earlier studies have described as
‘‘learning turning points’’ taking responsibility for
one’s actual situation and for what can and cannot
be changed (Berglund, 2014).
The findings of the present study also show that
reflection is supported by technology that can verify
feelings and experiences relating to the body’s ex-
pression of blood sugar. This can be explained by
the variation theory described by Marton and Ming
(2006). When the patient experiments, evaluates,
and reflects on these results the result emerges as a
variation, which supports learning by enhancing the
patient’s knowledge of how the changing body reacts
and signals change. This is consistent with the results
of other studies showing that technology can be
used to supplement diabetes care, with positive im-
pacts on HbA1c, self-management behaviours, and
self-efficacy (Durán et al., 2010).
The present results highlight the need to know
targets in order to reflect, evaluate, and reach
conclusions. According to Berglund (2014), achiev-
ing objectives is important in realizing that you
have learned something. Other studies have shown
the importance of involving patients in setting their
own goals (e.g., Wikblad, Leksell, & Smide, 2004).
According to Hortensius et al. (2012), describing
the importance of balance between achieving blood
glucose targets and quality of life, blood sugar con-
trol can be both ‘‘friend’’ and ‘‘foe.’’ The present
study shows how measuring blood sugar can make
a patient feel safer, as it is sometimes difficult to in-
terpret the lived body’s signals. This is confirmed by
Tan, Chen, Taylor, and Hegney (2012), who showed
that some persons lack the necessary knowledge
to interpret body signals in identifying and self-
managing hypoglycaemia. Similarly, Kato, Cui, and
Kato (2013) showed that structured self-monitoring
of blood glucose increases knowledge of how the
lived body reacts and awareness of the connection
between food and blood sugar, leading to increased
participation in treatment change (Polonsky et al.,
2011).
The present results show that other people’s stories
can activate reflection and motivate change by
awakening understanding of what has been done,
one’s current lifestyle, and its potential future con-
sequences. The results also show that the people
around you promote reflection and accountability in
different ways, through professional or social sup-
port. A care relationship that fosters an open climate
is important for creating reflection, trust, participa-
tion, and responsibility for treatment, described as
an ‘‘inspiring’’ learning climate by Leksell, Sandberg,
and Wikblad (2006). A climate of confidence is
also important for articulation of the patient’s fears,
beliefs, and expectations (Janes, Titchener, Pere,
Pere, & Senior, 2013), which have been shown to
include fear of losing control and future complica-
tions and security with good control (Johansson
et al., 2015). In line with the present findings, Frost,
Garside, Cooper, and Britten (2014), show that
professional support that senses the patient’s level of
maturity and gradually hands over responsibility can
create a sense of safety and confidence. Through
daring to talk about the fears associated with living
with the disease in an open dialogue with the nurse
emotional barriers for learning can be reduced.
The present results also confirm that support
for learning is three-dimensional: individual, profes-
sional, and social. Relatives and friends contribute to
social support, facilitating the integration of illness
and the ability to create good habits, whereas the
illness is complicated if unsuitable habits persist. It
also became clear that other persons with diabetes
can contribute with the sense of fellowship, recog-
nition, experience sharing, and advice. Tang et al.
(2010) described how a patient-directed interven-
tion for lifelong management initiated a group
dialogue about how to prevent and treat low blood
glucose and so assisted problem solving. The results
of the present study confirm that transparency about
the illness and the exchange of experiences with
others in the same situation supports accountability
and the process of feeling ‘‘at home’’ again in the
lived body. In other words, by understanding how
one’s body reacts in different situations and what
it needs, it can be taken for granted. Again, this
aligns with earlier evidence that the new can become
the natural and regular (Johansson, Ekebergh, &
Dahlberg, 2009), developing self-confidence and a
K. Johansson et al.
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new sense of coherence in life (Aujoulat, Marcolongo,
Bonadiman, & Deccache, 2008).
The beneficial effect of group training on HbA1c is
reported by the SBU (2009), again indicating the
importance of social support. However, there is less
clarity about how group training should be designed
to promote existential learning and a sense of
‘‘home,’’ as suggested by the Steinbekk, Rygg, Lisulo,
Rise, and Fretheim (2012) study which showed that
the use of different measures of quality of life leave
us with no clear picture. It remains a challenge for
health care to promote interactions that create reflec-
tion and support responsibility, experimentation, and
the search for knowledge, encompassing both bio-
logical markers and existential learning.
Conclusion
Adopting a lifeworld perspective, the findings confirm
that reflection is important in supporting learning to
live with diabetes to promote health and well-being.
Reflection is supported by a number of factors,
including personal responsibility, transparency, tech-
nology, and exchange of experiences with others. For
caregivers, the challenge is to create interactions in an
open learning climate that will activate and promote
reflection so that knowledge and experience are
interwoven and integrated in personal learning.
For a caregiver, the challenge is to be creative and
find new ways of working that meet patient care
needs in a way that supports reflection.
For patients with diabetes, the challenge is to take
responsibility for their own learning by being open,
curious, and responsive in acquiring knowledge,
learning from others experiences, and evaluating
their own actions. To this end, patient associations,
dialogue groups, workshops, and fiction chat clubs
on the Internet can offer social support for indivi-
duals in their active efforts to learn.
Acknowledgements
We wish to thank all the informants, who by sharing
their experience of support for learning to live with
diabetes as a natural part, have made this study
possible. We also appreciate the assistance provided
by the nurses in facilitating contact between the
researchers and the participants.
Conflict of interest and funding
This project was funded by Kronoberg County
Research Center. The authors declare that there is
no conflict of interest.
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e. Mac-version: Mac OS® X 10.13 or later; Min resolution 1024 x 600
f. Internet speed: The internet speed required is 0.092 – 0.244 Mbps. Internet speed can
be tested by using w w w . sp e e dt es t . ne t
g. Microphone: Any microphone, either internal or external
h. Webcam: 320×240 VGA resolution (minimum) internal or external
1. Cell phones are a disruption to learning even in the ‘vibrate’ mode. Cell phones must be turned
off during class.
2. Laptops may be used for notetaking and desktop PowerPoint use. Wandering from the
appropriate Moodle site or ‘surfing the web’ will adversely affect the policy on use of laptops.
Students wandering from appropriate sites will be required to close and not reopen laptops for
the remainder of the course.
3. Eating is prohibited in the classroom. Beverages are permitted in non-laboratory classrooms.
4. Attendance is required by the University. Late arrival and early departures will directly affect
both the student’s understanding of the material and therefore potentially the final grade the
student earns.
5. Students arriving late for class or from breaks may be asked to remain outside the room until
the next break.
NSG 410 Student Learning Outcomes
Upon completion of this course, the student will be able to:
1. Identify the critical components of a research report.
2. Discuss appropriate use of theory and conceptual frameworks in research.
3. Develop a research / evident-based practice question in an area of interest.
4. Conduct a literature search on a specific research / practice related topic and write a literature
review.
5. Analyze methods design, sample and variable measurements, and data collection procedures in
research studies and identify the strengths / limitations and appropriateness for practice within
each study.
6. Utilize national databases to find evidence to support practice as appropriate.
http://www.speedtest.net/
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COURSE OUTLINE
Date Topic/Content Reading Activities
Week 1
Jan. 3-9, 2022
Introduction to Research and
Evidence-Based Practice
Lobiondo-Wood &
Haber,
Chapters 1 & 2
Introduction Forum
Initial Post Due: 1/5
Introduce Yourself
Practice Quiz with
Respondus
Week 1 Worksheet
Week 2
Jan. 10-16, 2022
Theory in Research
Literature Reviews
Lobiondo-Wood &
Haber,
Chapters 3, 4, & 11
Discussion Forum #1
Initial Post Due: 1/12
Responses Due: 1/
14
Quiz #1: Jan. 14
Work on PICOT
Assignment
Week 2 Worksheet
Week 3
Jan. 17-23, 2022
Qualitative Research
Appraising Qualitative
Research
Lobiondo-Wood &
Haber,
Chapters 5,6, & 7
Discussion Forum #2
Initial Post Due: 1/19
Responses Due: 1/21
Quiz #2: Jan. 21
PICOT Due: 1/22
Week 3 Worksheet
Work on APA Citations
Week 4
Jan. 24-30, 2022
Quantitative Research
• Experimental
• Quasi-Experimental
• Nonexperimental
Appraising Quantitative
Research
Lobiondo-Wood &
Haber,
Chapters 8, 9, 10, &
18
Discussion Forum #3
Initial Post Due: 1/26
Responses Due: 1/2
8
APA Citations Due: 1/2
9
Week 4 Worksheet
Week 5
Jan. 31-Feb. 6,
2022
Sampling
Legal and Ethical Issues
Lobiondo-Wood &
Haber,
Chapters 12 & 13
Discussion Forum #4
Initial Post Due: 2/2
Responses Due: 2/4
Quiz #3: Feb. 4
Work on Literature Table
Week 5 Worksheet
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Week 6
Feb. 7-13, 2022
Quantitative Research
• Data Collection
Methods
• Reliability and Validity
Lobiondo-Wood &
Haber,
Chapters 14 & 15
Discussion Forum #5
Initial Post Due: 2/9
Responses Due: 2/
11
Literature Table Due: 2/
12
Work on Literature Review
Week 7
Feb. 14-20, 2022
Quantitative Research
• Data Analysis
Lobiondo-Wood &
Haber,
Chapter 16
Discussion Forum #6
Initial Post Due: 2/16
Responses Due: 2/18
Quiz #4: Feb. 18
Work on Literature Review
Week 7 Worksheet
Week 8
Feb. 21-27, 2022
Understanding Research
Findings
Lobiondo-Wood &
Haber,
Chapter 17
Literature Review
Due: 2/26
Week 9
Feb. 28-Mar. 6,
2022
Evidence-Based Nursing
Practice
Quality Improvement
Lobiondo-Wood &
Haber,
Chapters 20 & 21
Discussion Forum #7
Initial Post Due: 3/2
Responses Due: 3/4
Quiz #5: Mar. 4
Week 9 Worksheet
Week 10
Mar. 6-13, 2022
Course Wrap-Up Discussion Forum #8
Reflection Post
Stratford University School of Nursing
Syllabus Supplement
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Readings
Students should expect to spend a minimum of two hours studying or completing assignments outside
of class for every credit hour. This course is 4.5 credit hours, so the expectation is that each student
will spend at least 9 hours at home studying and completing assignments for this course.
It is an expectation that students will read the assigned chapters of the textbook. The lecture will
enhance but not substitute for the assigned readings. Videos and interactive learning materials will also
be posted on the Moodle page to support learning of concepts. Students are expected to review posted
material.
This is an online course. It is very important that you communicate effectively with the
course instructor in person or via email. Students are expected to use their Stratford email
account when communicating with the instructor. It is best practice to read SU Email and
Moodle daily for current updates.
Assignments
Discussion Forums (17.5% of total grade): Students will participate in online forum discussions. See
rubric in Syllabus Supplement for grading. Weekly discussion items are to stimulate and engage
learning. The student will be asked to critically analyze a topic or concept discussed in class and
submit your comments on a threaded discussion board. The student will be responsible for submitting a
weekly, two-part assignment:
• Part 1: The first part will be a summary of the topic in the student’s own words (minimum of
250 words) to demonstrate understanding of the topic. The student is required to cite all sources
used in forming the post using proper APA format. Most initial posts will require a “cosmic
question” at the end of the summary. The question should be thought-provoking and related
to the week’s discussion topic. Part 1 is due on Wednesdays by 2359.
**Students will not receive credit for late posts.
• Part 2: The second part of the discussion forum aims to keep the student thinking about the big
picture. Each student is required to provide a substantive response (minimum of 150 words) to
at least two of their classmates’ posts and cosmic questions. Sources used to inform the
response should be cited using proper APA format. Part 2 is due on Fridays by 2359.
**Students will not receive credit for late posts.
Assignments must be professional in format. All work must be proofread for context, spelling, syntax,
and grammatical errors. Formatting must follow accepted academic standards to include proper APA
formatting for references and citations. References and citations are expected when material submitted
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is not the student’s original work (i.e., definitions, evidence-based practices, lists, descriptions, etc.)
and to support statements that are not general knowledge. The level of matching on the Turnitin link
should be less than 30% and the use of quotations should be kept to a minimum. A maximum of two
quotations will be accepted in any assignment.
1. PICOT/The Research Question (5%)
The student will reflect on clinical nursing practice and write a research question. The question
will be developed by using the PICOT framework (Population, Intervention, Comparison,
Outcome, Time). The student will identify a nursing clinical question as follows:
• What individual or group am I curious about? (population)
• What key intervention am I curious about? (intervention)
• What intervention will I be comparing? (comparison)
• What do I hope to accomplish, or What would happen if I did this? (outcome)
• How much time will the intervention take to achieve the desired effects? (time)
The aim of the PICOT is to discover current research and promote best practices. The PICOT
will guide the Literature Review. The PICOT must have a nursing clinical focus. A rationale
for each element of the PICOT question must be provided and supported by a credible source.
Students will be able to resubmit the PICOT assignment one time.
2. APA Citations Assignment (5%)
Select 5 primary research articles published in peer reviewed journals. Write a simple
sentence for each article to demonstrate your knowledge of formatting in-text citations using
current APA guidelines. Then provide an APA-formatted reference list for the 5 articles.
3. Literature Review Table (7.5%)
A Literature Review Table provides a succinct overview of each article. The table is especially
useful when synthesizing the information from articles, as the main elements are clearly
identified. Complete the Literature Review Table using the articles identified from your
literature search that will be used in your Literature Review.
Students will be able to resubmit the Literature Review Table assignment one time.
4. Literature Review (15%)
Each student must prepare a literature review in relation to the PICOT. This is an opportunity
to read as a scholar and develop competence in analyzing the key elements of a research article.
The student should select five primary research studies from the literature search that was
conducted – each study must have been published in a peer-reviewed journal within the last 5-8
years with at least one study published in a nursing journal. Next, analyze and appraise the
merits of each manuscript. Then, synthesize the findings to compare the studies and determine
the strength of the evidence to answer your PICOT question. Last, write a paper (6-9 pages).
See rubric to guide development of the assignment.
**No review articles of any kind are appropriate for this assignment – select only primary
research articles.**
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1. Quizzes (10% each): Students will complete five quizzes. Each quiz must be completed with
Respondus LockDown Browser on the assigned date. The student’s entire face must be
visible in the camera during the entire quiz. No hats, sunglasses, headphones/earbuds may be
worn during the quizzes – these are grounds for suspicious student activity. Following the
quiz, the instructor will review all Respondus LockDown Browser reports and footage. Any
abnormal or suspicious activity detected by Respondus LockDown Browser could result in
the student’s grade being changed to a “0.”
The quizzes are challenging, and lack of preparation puts the student at risk for failing the quiz and
possibly the course. Avoid procrastination and use resources posted on Moodle to prepare.
Exam items are selected based on course content and the level of the course in the program progression
schema. Exam questions are selected to primarily evaluate Bloom’s cognitive levels of analysis,
synthesis, and evaluation. Exam questions may be multiple choice, multiple select, or other alternate
item formats.
Students who begin the quiz late will have the option of taking the test but within a shortened period.
Students who do not score a minimum of 80% on an exam are required to meet with faculty.
Exam Make-up
In the event a student is cognizant of a situation that will prohibit them from taking an exam
(i.e., hospitalization, emergency, etc.), the student is responsible to and must contact the
instructor by email/ office phone prior to the exam to schedule a time to take the exam.
Students who miss the exam due to an approved absence or documented emergency may be
required to submit evidence supporting these claims. If the claims are verified, the student will
be allowed to make up the exam without a point penalty. Students are allowed one make-up
exam per term. The make-up must be completed within 5 workdays from the absence including
the day of absence.
Students who miss an exam due to an unexcused absence, undocumented emergency or tardiness will
receive a zero without an opportunity to the make-up exam.
Exam Item Analysis
Following each exam, and before grades are posted, each exam question is analyzed. The exam
item analysis is used to evaluate student performance as well as the validity of exam items.
Should an exam question fail analysis, the question(s) will be eliminated and only the total
number of questions answered correctly out of the total number of remaining questions will be
scored for all students. Under no circumstances can a student receive a grade more than 100%.
Late Work
Discussions/assignments must be submitted on or before the scheduled date and time. All assignments
have a due date and time posted, and it is the student’s responsibility to know when the assignment is
due. Assignments will close at the designated time.
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No work will be accepted beyond this time, and a grade of zero will be posted. Emailed
assignments will not be accepted.
Moodle provides students a 30-minute window only to make edits before discussion/assignment is
“final.” The time posted on the assignment is used to determine the submission time. Be sure to post at
least 30 minutes earlier than the discussion/assignment is due to avoid late submissions. Forums for
Moodle assignments open and close automatically based upon due times. If the student has a problem
with the Moodle page, then the student must take a screen print of the error message and include it in
an email to the helpdesk and instructor at the time it occurs. Late assignments will not be accepted,
and a grade of zero will be entered into the discussion/forum/assignment.
Grade Item Unit Percentage Percentage of Total Grade
Quizzes and Examinations 50%
Quiz 1 10
Quiz 2 10
Quiz 3 10
Quiz 4 10
Quiz 5 10
Written Assignments 32.
5%
PICOT 5
APA Assignment 5
Literature Table 7.5
Literature Review 15
Discussions 17.5%
Discussion 1 2.5
Discussion 2 2.5
Discussion 3 2.5
Discussion 4 2.5
Discussion 5 2.5
Discussion 6 2.5
Discussion 7 2.5
Discussion 8 0 – attendance
Total 100%
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Office Hours
Office hours for this class are available by appointment. Please email to arrange an appointment.
Students may wish to purchase the study guide that accompanies the textbook, as it has many exercises
that will assist them to practice the main concepts of research.
Learning Resource Center (LRC)
Each Stratford University campus has a LRC with a dedicated staff. The LRC offers computer
terminals, a physical collection developed specifically for Stratford’s programs, and access to multiple
research databases and eBooks. Students are encouraged to use the LRC resources throughout their
program to supplement classroom instruction and assigned textbooks. Please visit your campus LRC
for information about policies and procedures. The electronic resources, along with information about
LRC holdings, can be accessed through the Stratford University website.
Students are expected to use the 7th Edition of the APA Publication Manual:
American Psychological Association. (2020). Publication manual of the American Psychological
Association (7th ed.). Washington, DC: American Psychological Association. (ISBN-13: 978-
1433832161 or ISBN-10: 143383216X )
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Discussion Forums
Discussion
Forums
Item Expectation % Points Total Item
percentage
Total
percentage
Timing Initial post
Posted by the due date. 10% 15% 25%
At least 250 words.
5%
Response
post
Posted by the due date. 5% 10%
At least 150 words.
5%
Content Initial post Answer must address and be relevant
to all questions
35% 40% 65%
Readability
5%
Cosmic
Question
Must be related to the chapter under
discussion.
10% 10%
Response Must respond to two peers’ cosmic
question.
15% 15%
Citation Referencing
in in APA
7th edition
style
Must have both intext citation and a
reference list.
10% 10% 10%
Total 100%
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PICOT Rubric
PICOT Weight Present Absent
Patient/Population (add rationale with reference) Required
Intervention (add rationale with reference) Required
Comparison (add rationale with reference) Required
Outcome (add rationale with reference) Required
Timing (add rationale with reference) Optional
Total:
(100% possible)
PICOT demonstrates applicability to nursing
profession
PICOT will be returned if
not nursing-related
Submitted by deadline
No late assignments
accepted
APA Assignment grading Rubric % Total
5 in-text citations formatted using current
APA guidelines
10% for each correctly cited in-text citation 50%
Reference list of 5 articles formatted
using current APA guidelines
10% for each correctly cited reference list 50%
Grand total
100%
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Literature Review Table Rubric
Unsatisfactory
0
Partially Proficient
15
Proficient
20
Exemplary
25
Score
Articles 0-1 primary research
articles are identified
2-3 primary research
articles are identified.
4 primary
research articles
are identified.
5 primary research
articles are identified.
Articles
appropriate
to PICOT
0-1 primary research
articles appropriate to
PICOT
2-3 primary research
articles appropriate to
PICOT
4 primary research
articles appropriate to
PICOT
5 primary research
articles appropriate to
PICOT
Articles
uploaded to
Moodle
0-1 primary research
articles are included
with table
2-3 primary research
articles are included
with table
4 primary research
articles are included
with table
5 primary research
articles are included with
table
Table There are major
errors in the table
There are several
errors and/or
incomplete data
There are some
missing data and/or
errors
The table is completed
appropriately
Total /100
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Literature Review Rubric
Introduction:
• Provides rationale for
student selection of
literature
• Discussed search terms
and techniques.
• Demonstrates the need for
this research question
Clinical Question (PICOT)
• Includes the clinical
question
Appraisal of Articles:
Uses established critical appraisal
criteria to evaluate essential
components of each reviewed
study, including but not limited
to:
• Type and size of sample
• Reliability and validity of
instruments
• Methodology
• Consistency of data
collection and procedures
• Appropriate data analysis
• Results
• Identification of
limitations
Synthesis/Conclusion:
• Reflection on the analysis
and synthesis of material
• Identifies gaps and
inconsistencies
• Summarizes overall
strengths and weaknesses of
the studies reviewed
• Discuss similarities and
differences of articles
Grammar
15-10 10-5 5-0
Meets all outlined criteria
and is succinct and
sufficient. Logically
demonstrates the need for
this research question
Does not meet one of
the criteria but is well
organized, and
sufficient. Logically
demonstrates the need
for this research
question.
Does not meet two or
more of the criteria and/
or is not organized, and
sufficient. The reader
cannot conclude the “so
what”.
5 3 0
Clinical question is clearly
stated
Clinical question can
be implied but was not
clearly stated.
Clinical question was
not stated and/or were
not apparent from the
literature review.
35-25 25-15 15-0
The appraisal reflects
accurate analysis of the
essential components for
all studies
Five appropriate articles
are reviewed.
The appraisal reflects
most (lacking 2 or
more elements) of the
essential components
for one or all the
studies
Four appropriate
articles are reviewed.
The appraisal reflects
some (lacking 4 or
more elements) of the
essential components
for either study
Three or fewer
appropriate articles
are reviewed.
25-15 15-10 10-5
Meets criteria. Well
organized, follows a
logical sequence that
allows the reader to arrive
at a logical conclusion.
PICOT conclusion is
clear and well-supported
by the literature.
Does not meet 1-2 of
the criteria but is
organized, and/or
demonstrates illogical
sequencing or structure.
Conclusions relating to
PICOT are vague
and/or unsupported by
the literature.
Does not meet >2
criteria and/or is
weakly organized with
no logical sequencing
or structure.
Conclusions relating
to PICOT cannot be
made.
10-7 6-4 3-0
There are no major
grammatical errors.
There are a few
grammatical errors.
There are major
grammatical errors.
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Support and Referencing:
• See Turn-It-In
• SEE SON
INTEGRITY
STATEMENT
10-8 7-5 4-0
Incorporates the text,
course materials, and
selected readings; does not
use Wikipedia or other
non-academic resources.
There are minimal to no
errors in formatting,
referencing and style.
There are moderate
errors in APA
formatting, style, and
referencing.
Severe errors in APA
style, formatting, or
referencing. Violates
the School of Nursing
Student’s Personal
Integrity Statement
more than 2 times.
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Student Personal Integrity Statement
I, (print your name here), am provided a hard copy (or e-copy for
online courses) of the Syllabus and Syllabus Supplement in NSG 410. I am aware of:
• All due dates, including exams, assignments, and penalties associated with late work/exams,
• Attendance policies and student’s responsibilities related to attendance and student nurse dress
code,
• Policies related to classroom and clinical behavior.
I recognize that personal integrity and truth telling is essential to the professional practice of Nursing
as discussed in the School of Nursing Handbook. I have read the syllabus and agree that:
• I alone am responsible for my personal behavior and academic conduct.
• Any academic misconduct or dishonesty are grounds for course failure and may result in
probation, suspension or dismissal from the Nursing Program and Stratford University. These
include but are not limited to:
o Cheating on exams,
o Using papers written by anyone other than myself, my team or from a concurrent class
o Using papers turned in for grade during previous or current terms
o Copying work from the internet or books or articles and not giving full credit to the
authors of that work; no more than 2 sentences may be quoted or paraphrased with in-
text citation per 6 sentences.
o Falsifying documents, records or presentations,
o Claiming to have done required course work (theory or clinical) that in fact I did not do
o Providing my work (papers, exams, presentations) to another student
• I am expected to arrive at class on time, stay for the entire time allotted course
• I am expected to follow class rules outlined in the Syllabus/Syllabus Supplement. Example: No
food in classrooms
• I am expected to treat my professor and my classmates with respect even when we disagree.
I accept all policies as written and agree to follow the Syllabus/Syllabus Supplement as outlined.
Signed:
Student Signature / Date
Faculty Signature / Date
[Student keeps one copy/faculty files signed copy in students nursing file]
- General School of Nursing Classroom Policies
- No work will be accepted beyond this time, and a grade of zero will be posted. Emailed assignments will not be accepted.
Other Assignments (32.5% of total grade)
Quizzes (50%)
Grading Rubrics:
APA Assignment grading Rubric
Literature Review Table Rubric
Dr. Rebecca Coffin January 3, 2022