RESEARCH

 

Discussion #1

For this week’s discussion, do the following; 

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

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

Data Collection

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

Instruments

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

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

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

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

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

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

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

Ethical Considerations

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

Data Analysis

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

Results

Sample Characteristics

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

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

Attitude Toward Inpatient Aggression

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

Table 1. InternalConsistencyTranslated
Questionnaires

Questionnaire
Dutch version
Cronbach’s α

French version
Cronbach’s α

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

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

Table 2. GeneralCharacteristics of Sample

Characteristics (n = 219) N (%)

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

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

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

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

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

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

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

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

significant differences for the nurse-related characteristics
under study (see Table 3). It demonstrated only weak correla-
tions with compassion satisfaction (r = .143, p < .05) and burnout (r = −.149, p < .05) (see Table 4). None of the nurse- related characteristics were retained in the regression analysis (see Table 5). Associations with nurse-related characteristics were found at subscale level (see Tables 3 and 4). The subscale “predic- tion” revealed a mean score of 3.85 (SD .59). A weak negative correlation was found between this aspect of attitude toward patient aggression and age (r = −.178, p < .05) (see Table 4). The factor age was included in the regression analysis. The model had a predictive value of less than 10% (see Table 5). The subscale “attribution and responsibility” revealed a mean score of 3.31 (SD .48). Group comparisons demon- strated significant differences for gender (see Table 3). Female nurses had statistically significantly higher scores on ques- tions regarding patient attribution and responsibility for aggressive incidents than male nurses (3.35 vs. 3.18, t = −2.203, df = 205, p = .029). Higher scores refer to a lower tendency to place blame and thus a more tolerant perspective on aggression. Negative correlations (see Table 4) were found between attribution and responsibility for aggressive inci- dents on the one hand, and the years of work experience in psychiatric care (r = −.166, p < .05), the years of experience on the ward (r = −.155, p < .05), and level of burnout (r = −.148, p < .05) on the other hand. The mentioned significant or cor- related factors were included in the regression analysis. The model had a predictive value of less than 10% (see Table 5). The subscale “staff anxiety and fear of assault” revealed a mean score of 3.93 (SD .62). Higher scores refer to the belief that aggression is part of working in psychiatric care. Signifi- cant group differences were demonstrated for post-traumatic stress levels (F = 4.569, df = 2, p = .012) (see Table 3). Mental health nurses in the categories low and moderate post- traumatic stress level considered aggression more as a part of the job. This subscale revealed no significant correlations (see Table 4). None of the nurse-related characteristics were retained in the regression analysis (see Table 5). The mean score on the subscale “need skilled intervention” was 4.18 (SD .45). Higher scores referred to a higher belief in the importance and need for training and for skills to prevent and manage aggression. Group comparisons demonstrated significant differences for degree in psychiatric nursing and borderline significance with gender (see Table 3). Nurses who did not have a degree in psychiatric nursing revealed a signifi- cantly higher need for specific training and skills to prevent and manage aggressive behavior compared to nurses with a degree in psychiatric nursing (4.36 vs. 4.14, t = 2.729, df = 211, p = .007). Male nurses reported a higher need for intervention training to prevent and manage aggression than their female colleagues (4.25 vs. 4.14, t = 1.901, df = 208, p = .059). A low positive correlation was found with compassion satisfaction (r = .156, p < .05) (see Table 4). The mentioned significant or correlated factors were included in the regression analysis. The model had a predictive value of less than 10% (see Table 5). The mean score on the subscale “staff confidence” was 3.76 (SD .67). Group comparisons within this subscale demon- strated significant difference for gender and compassion sat- isfaction (see Table 3). Male mental health nurses had statistically significantly higher scores on the subscale of con- fidence in the ability to deal with and having control over patients with aggression (4.00 vs. 3.68, t = 3.111, df = 101, p = .001). Mental health nurses with a high or moderate level of compassion satisfaction had a statistically significantly higher score on this subscale (F = 10.878, df = 2, p = .000). It demon- strated a positive correlation with compassion satisfaction (r = .307, p < .01) and a negative correlation with secondary traumatic stress (r = −.192, p < .01) (see Table 4). The men- tioned significant or correlated factors were included in the regression analysis. Staff confidence in dealing with aggres- sion has two predictors: gender and compassion satisfaction. These two factors explained 14.4% of the variance in staff confidence in dealing with aggressive incidents (see Table 5). Perceived Self-Efficacy The mean score on the CCPAI was 61.44 (SD 14.57). Group comparisons revealed statistically significant differences for gender and compassion satisfaction (see Table 6). Male nurses had a significantly higher perceived self-efficacy score than their female colleagues (71.15 (SD 12.95) vs. 58.11 (SD 13.81), t = 5.993, df = 207, p < .001). Nurses with high or moderate levels of compassion satisfaction had higher levels of perceived self-efficacy compared to their colleagues with low levels of compassion satisfaction (F = 6.259, df = 3, p = .002). A positive correlation was found between the perceived level of self- efficacy and compassion satisfaction (r = .284, p < .01) and a negative correlation with self-efficacy and secondary trau- matic stress (r = −.218, p < .01) (Table 4). The mentioned sig- nificant or correlated factors were included in the regression analysis. The regression analysis demonstrated four predictors for the perceived self-efficacy toward inpatient aggression (see Table 5). This model with gender, burnout, secondary trau- matic stress, and compassion satisfaction accounted for 26.2% of the variability in the perceived self-efficacy of mental health nurses toward aggressive incidents. Mental health nurses with lower burnout and secondary traumatic stress symptoms, with higher compassion satisfaction scores, and male mental health nurses perceived themselves as having a higher level of self-efficacy in dealing with inpatient aggression. Discussion This study aimed to explore mental health nurses’ attitudes and perceived self-efficacy toward inpatient aggression in 17Perspectives in Psychiatric Care 52 (2016) 12–24 © 2014 Wiley Periodicals, Inc. Mental Health Nurses’ Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression Ta b le 3 . A tt it u d es o f th e Pa rt ic ip an ts M ea su re d b y th e A TA B Q To ta ls co re a S u b sc a le S u b sc a le S u b sc a le S u b sc a le S u b sc a le P re d ic ti o n b A tt ri b u ti o n a n d re sp o n si b il it y b S ta ff a n x ie ty a n d fe a r o f a ss a u lt b N e e d sk il le d in te rv e n ti o n b S ta ff co n fi d e n ce b M e a n (S D ) D if fe re n ce M e a n (S D ) D if fe re n ce M e a n (S D ) D if fe re n ce M e a n (S D ) D if fe re n ce M e a n (S D ) D if fe re n ce M e a n (S D ) D if fe re n ce O ve ra ll 3 7 .3 6 (3 .7 9 ) N A 3 .8 5 (. 5 9 ) N A 3 .3 1 (. 4 9 ) N A 3 .9 3 (. 6 2 ) N A 4 .1 8 (. 4 5 ) N A 3 .7 6 (. 6 7 ) N A G en d er t = .8 8 3 , p = .3 8 0 t = .3 9 3 , p = .6 9 5 t = −2 .2 0 3 , p = .0 2 9 * t = 1 .6 4 3 , p = .1 0 2 t = 1 .9 0 1 , p = .0 5 9 t = 3 .1 1 1 , p = .0 0 1 * Fe m al e 3 7 .2 3 (3 .7 8 ) 3 .8 3 (. 5 4 ) 3 .3 5 (. 4 7 ) 3 .8 8 (. 6 4 ) 4 .1 4 (. 4 3 ) 3 .6 8 (. 6 6 ) M al e 3 7 .7 9 (3 .9 7 ) 3 .8 8 (. 7 2 ) 3 .1 8 (. 4 6 ) 4 .0 4 (. 5 7 ) 4 .2 5 (. 4 5 ) 4 .0 0 (. 5 6 ) A g e (y ea rs ) F = .5 8 9 , p = .6 2 0 F = 3 .3 0 1 , p = .0 2 1 * * F = 1 .4 5 9 , p = .2 2 7 F = 1 .5 6 1 , p = .2 0 0 F = .8 3 0 , p = .4 7 9 F = .9 8 4 , p = .4 0 1 2 1 –3 0 3 6 .8 8 (3 .9 2 ) 3 .9 6 (. 5 1 ) 3 .4 1 (. 4 0 ) 3 .7 9 (. 6 5 ) 4 .1 2 (. 4 3 ) 3 .7 1 (. 8 0 ) 3 1 –4 0 3 7 .1 6 (3 .0 0 ) 3 .9 5 (. 3 8 ) 3 .2 6 (. 4 6 ) 4 .0 5 (. 6 1 ) 4 .2 0 (. 4 3 ) 3 .7 8 (. 5 0 ) 4 1 –5 0 3 7 .7 6 (3 .9 6 ) 3 .8 4 (. 7 0 ) 3 .3 2 (. 6 2 ) 3 .9 4 (. 5 7 ) 4 .1 5 (. 5 1 ) 3 .8 8 (. 5 9 ) >5
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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.

References

Abderhalden, C., Needham, I., Friedli, T., Poelmans, J., & Dassen,
T. (2002). Perception of aggression among psychiatric nurses in
Switzerland. Acta Psychiatrica Scandinavica, 106(412), 110–117.

Abderhalden, C., Needham, I., & Dassen, T. (2008). Structured
risk assessment and violence in acute psychiatric wards:
Randomized controlled trial. British Journal of Psychiatry, 193,
44–50. doi:10.1192/bjp.bp.107.045534

Allen, D., & Tynan, H. (2000). Responding to aggressive behavior:
Impact of training on staff members’ knowledge and
confidence. Mental Retardation, 38(2), 97–104.

Azjen, I. (1988). Attitudes, personality and behaviour.
Buckingham, UK: Open University Press.

Bandura, A. (1991). Social cognitive theory of self-regulation.
Organizational Behavior and Human Decision Processes, 50,
248–287.

Beech, B., & Leather, P. (2006). Workplace violence in the health
care sector: A review of staff training and integration of
training evaluation models. Aggression and Violent Behavior, 11,
27–43. doi:10.1016/j.avb.2005.05.004

Beeckman, D., Defloor, T., Schoonhoven, L., & Vanderwee, K.
(2011). Knowledge and attitudes of nurses on pressure ulcer
prevention: A cross-sectional multicenter study in Belgian
hospitals. Worldviews on Evidence-based Nursing, 8(3),
166–176. doi:10.1111/j.1741-6787.2011.00217.x

Bonsaksen, T., Lerdal, A., & Fagermoen, M. S. (2012). Factors
associated with self-efficacy in persons with chronic illness.
Scandinavian Journal of Psychology, 53(4), 333–339.
doi:10.1111/j.1467-9450.2012.00959.x

Bowers, L., Stewart, D., Papadopoulos, C., Dack, C., Ross, J.,
Khanom, H., & Jeffery, D. (2011). Inpatient violence and
aggression: A literature review. Report from the Conflict and
Containment. Reduction Research Programme. Section of
Mental Health Nursing, Health Service and Population
Research, Institute of Psychiatry, Kings College London.

Collins, J. (1994). Nurses’ attitudes toward aggressive behavior,
following attendance at “The Prevention and Management of
Aggressive Behavior Programme.” Journal of Advanced Nursing,
20(1), 117–131.

de Leeuw, M., Van Meijel, B., Grypdonck, M., & Kroon, H. (2012).
The quality of the working alliance between chronic psychiatric
patients and their case managers: Process and outcomes.
Journal of Psychiatric and Mental Health Nursing, 19(1), 1–7.
doi:10.1111/j.1365-2850.2011.01741.x

De Vries, H. (1988). Self-efficacy the third factor besides attitude
and subjective norms. Health Education Research, 3(3),
273–292.

Dunn, K., Elsom, S., & Cross, W. (2007). Self-efficacy and locus of
control affect management of aggression by mental health
nurses. Issues in Mental Health Nursing, 28(2), 201–217.

Duxbury, J., Hahn, S., Needham, I., & Pulsford, D. (2008). The
management of aggression and violence attitude scale
(MAVAS): A cross-sectional comparative study. Journal of
Advanced Nursing, 62(5), 596–606.
doi:10.1111/j.1365-2648.2008.04629.x

Finnema, E., Dassen, T., & Halfens, R. (2004). Aggression in
psychiatry: A qualitative study focusing on the characterization
and perception of patient aggression by nurses working on
psychiatric wards. Journal of Advanced Nursing, 19, 1088–1095.
doi:10.1111/j.1365-2648.1994.tb01192.x

Fishbein, M., & Ajzen, I. (2010). Predicting and changing behavior:
The reasoned action approach. New York: Psychology Press
(Taylor & Francis).

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

23Perspectives in Psychiatric Care 52 (2016) 12–24
© 2014 Wiley Periodicals, Inc.

Fluttert, F., Van Meijel, B., Webster, C., Nijman, H., Bartels, A., &
Grypdonck, M. (2008). Risk management by early recognition
of warning signs in patients in forensic psychiatric care.
Archives of Psychiatric Nursing, 22(4), 208–216.
doi:10.1016/j.apnu.2007.06.012

Foster, C., Bowers, L., & Nijman, H. (2007). Aggressive behaviour
on acute psychiatric wards: Prevalence, severity and
management. Journal of Advanced Nursing, 58(2),
140–149. doi:10.1111/j.1365-2648.2007.04169.x

Gascon, S., Leiter, M. P., Pereira, J. P., Cunha, M. J., Albesa, A.,
Montero-Marin, J., & Garcia-Campayo, J. (2013). The role of
aggressions suffered by healthcare workers as predictors
of burnout. Journal of Clinical Nursing, 22(21–22),
3120–3129. doi:10.1111/j.1365-2702.2012.04255.x

Grenyer, B. F. S., Ilkiw-Lavelle, O., Biro, P., Middleby-Clemens, J.,
Comninos, A., & Coleman, M. (2004). Safer at work:
Development and evaluation of an aggression and violence
minimization program. Australian and New Zealand Journal of
Psychiatry, 38, 804–810.

Jansen, G. J., Middel, B., & Dassen, T. W. N. (2005). An
international comparative study on the reliability and validity
of the attitudes toward aggression scale. International Journal of
Nursing Studies, 42, 467–477.

Jansen, G. J., Dassen, T. W. N., Burgerhof, J. G. M., & Middel, B.
(2006). Psychiatric nurses’ attitudes toward inpatient
aggression: Preliminary report of the development of attitude
toward aggression scale (ATAS). Aggressive Behavior,
32, 44–53.

Jansen, G. J., Middel, B., Dassen, T. W. N., & Reijneveld, M. S. A.
(2006). Cross-cultural differences in psychiatric nurses’
attitudes to inpatients aggression. Archives of Psychiatric
Nursing, 20(2), 82–93.

Jonker, E. J., Goossens, P. J. J., Steenhuis, I. H. M., & Oud, N. E.
(2008). Patient aggression in clinical psychiatry: Perceptions of
mental health nurses. Journal of Psychiatric and Mental Health
Nursing, 15, 492–499. doi:10.1111/j.1365-2850.2008.01261.x

Knotter, M. H., Wissink, I. B., Moonen, X. M. H., Stams, G. J. M.,
& Jansen, G. J. (2013). Staff’s attitudes and reactions toward
aggressive behaviour of clients with intellectual disabilities: A
multilevel study. Research in Developmental Disabilities, 34(5),
1397–1407. doi:10.1016/j.ridd.2013.01.032

Lauvrud, C., Nonstad, K., & Palmstierna, T. (2009). Occurrence of
post traumatic stress symptoms and their relationship to
professional quality of life (ProQoL) in nursing staff at a
forensic psychiatric security unit: A cross-sectional study.
Health and Quality of Life Outcomes, 7(31).
doi:10.1186/1477-7525-7-31

Lowe, T., Wellman, N., & Taylor, R. (2003). Limit- setting and
decision-making in the management of aggression. Journal of
Advanced Nursing, 41(2), 154–161.

Marks, R., Allegrante, J. P., & Lorig, K. (2005). A review and
synthesis of research evidence for self-efficacy-enhancing
interventions for reducing chronic disability: Implications for
health education practice (part I). Health Promotion Practice,
6(1), 37–43. doi:10.1177/1524839904266790

Martin, T., & Daffern, M. (2006). Clinician perceptions of
personal safety and confidence to manage inpatient aggression
in a forensic psychiatric setting. Journal of Psychiatric and
Mental Health Nursing, 13, 90–99. doi:10.1111/j.1447-0349
.2006.00408.x

Morrison, E. F. (1990). Violent psychiatric inpatients in a public
hospital. Scholarly Inquiry for Nursing Practice. An International
Journal, 4, 65–82.

Needham, I., Abderhalden, C., Halfens, R. J. G., Dassen, T., Haug,
H. J., & Fischer, J. E. (2005). The effect of a training course in
aggression management on mental health nurses’ perceptions
of aggression: A cluster randomized controlled trial.
International Journal of Nursing Studies, 42, 649–655.
doi:10.1016/j.ijnurstu.2004.10.003

Newell, J. M., & MacNeil, G. A. (2011). A comparative analysis of
burnout and professional quality of life in clinical mental
health providers and health care administrators. Journal of
Workplace Behavioral Health, 26(1), 25–43.

Nijman, H., Muris, P., Merckelbach, H. L. G. J., Palmstierna, T.,
Wistedt, B., Vos, A. M., …, Allertz, W. (1999). The Staff
Observation Aggression Scale-Revised (SOAS-R). Aggressive
Behavior, 25, 197–209.

Nijman, H., de Kruyk, C., & Van Nieuwenhuizen, C. (2004).
Behavioral changes during forensic psychiatric (TBS)
treatment in the Netherlands. International Journal of Law and
Psychiatry, 27, 79–85. doi:10.1016/j.ijlp.2003.12.001

Nijman, H. L. I., Palmstierna, T., Almvik, R., & Stolker, J. J. (2005).
Fifteen years of research with the Staff Observation Aggression
Scale: A review. Acta Psychiatrica Scandinavica, 111, 12–21.
doi:10.1111/j.1600-0447.2004.00417.x

Nørgaard, B., Ammentorp, J., Ohm Kyvik, K., & Kofoed, P. E.
(2012). Communication skills training increases self-efficacy of
health care professionals. Journal of Continuing Education in
Health Professions, 32(2), 90–97. doi:10.1002/chp.21131

Palmstierna, T., & Barredal, E. (2006). Evaluation of the
perception of aggression scale (POAS)in Swedish nurses. Nordic
Journal of Psychiatry, 60(6), 447–451. doi:10.1080/
08039480601021803

Rippon, T. J. (2000). Aggression and violence in health care
professionals. Journal of Advanced Nursing, 31, 452–460.
doi:10.1046/j.1365-2648.2000.01284.x

Stamm, B. H. (2010). The concise ProQOL manual (2nd ed.).
Pocatello, ID: ProQOL.org

Thackrey, M. (1987). Clinician confidence in coping with
patient aggression: Assessment and enhancement.
Professional Psychology, Research and Practice, 18(1),
57–60.

Totman, J., Hundt, G. L., Wearn, E., Paul, M., & Johnson, S.
(2011). Factors affecting staff morale on inpatient mental
health wards in England: A qualitative investigation. BMC
Psychiatry, 11(68), 1–10. doi:10.1186/1471-244X-11-68

Van Hecke, A., Grypdonck, M., Beele, H., De Bacquer, D., &
Defloor, T. (2009). How evidence based is venous leg ulcer care?
A survey in community settings. Journal of Advanced Nursing,
65, 337–347. doi:10.1111/j.1365-2648.2008.04871.x

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

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

Verhaeghe, S., Lauwaert, K., Filion, N., Caillet, O., Gobert, M.,
Lagrange, S., . . . Leys, J. (2011). Aggression management in
psychiatry [original title: Aggressiemanagement in psychiatrie].
Federal Public Service of Health Care, Belgium.

Whittington, R. (2002). Attitudes toward patient aggression
amongst mental health nurses in the “zero tolerance” era:
Associations with burnout and length of experience. Journal of

Clinical Nursing, 11, 819–825. doi:10.1046/j.1365-2702.2002
.00659.x

Winstanley, S., & Whittington, R. (2004). Aggression toward
health care staff in a UK general hospital: Variation among
professions. Journal of Clinical Nursing, 13, 3–10.
doi:10.1111/j.1365-2702.2004.00807.x

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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

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(page number not for citation purpose)

http://creativecommons.org/licenses/by/4.0/

http://www.ijqhw.net/index.php/qhw/article/view/31330

http://dx.doi.org/10.3402/qhw.v11.31330

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.

K. Johansson et al.

2
(page number not for citation purpose)

Citation: Int J Qualitative Stud Health Well-being 2016, 11: 31330 – http://dx.doi.org/10.3402/qhw.v11.31330

http://www.ijqhw.net/index.php/qhw/article/view/31330

http://dx.doi.org/10.3402/qhw.v11.31330

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

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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

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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

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http://dx.doi.org/10.3402/qhw.v11.31330

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.

References

Adolfsson, E., Smide, B., Rosenblad, A., & Wikblad, K. (2009).

Does patient education facilitate diabetic patients’ possibi-

lities to reach national treatment targets? A national survey

in Swedish primary health care. Scandinavian Journal of

Primary Health Care, 27(2), 91�96.
Aujoulat, I., Marcolongo, R., Bonadiman, L., & Deccache, A.

(2008). Reconsidering patient empowerment in chronic illness:

A critique of models of self-efficacy and bodily control. Social

Science & Medicine, 66, 1228�1239. doi: http://dx.doi.org/10.
1016/j.socscimed.11.034

Bengtsson, J. (1998). Fenomenologiska utflykter [Phenomenological

excursions]. Göteborg: Daidalos.

Bengtsson, J. (2006). The many identities of pedagogics as a

challenge: Towards an ontology of pedagogical research as

pedagogical practice. Educational Philosophy and Theory, 38,

115�128.
Berglund, M. (2014). Learning turning points*In life with long-

term illness*Visualized with the life-world philosophy.
International Journal of Qualitative Studies on Health and

Well-being, 9, 22842, doi: http://dx.doi.org/10.3402/qhw.v9.

22842

Berglund, M., & Källerwald, S. (2012). The movement to a new

understanding: A life-world-based study about how people

learn to live with long-term illness. Journal of Nursing Care, 1,

125. doi: http://dx.doi.org/10.4172/2167-1168.1000125

Berglund, M., Westin, L., Svanström, R., & Sundler, A. J. (2012).

Suffering caused by care*Patients’ experiences from hospital
settings. International Journal of Qualitative Studies on Health

and Well-being, 7, 18688, doi: http://dx.doi.org/10.3402/qhw.

v7i0.18688

Boström, E., Isaksson, U., Lundman, B., Granheim, U. H., &

Hörnsten, Å. (2014). Interaction between diabetes spe-

cialist nurses and patients during group sessions about

self-management in type 2 diabetes. Patient Education and

Counseling, 94, 187�192. doi: http://dx.doi.org/10.1111/scs.
12092

Dahlberg, H., & Dahlberg, K. (2003). To not make definite what

is indefinite. A phenomenological analysis of perception and

its epistemological consequences in human science research.

The Humanistic Psychologist, 31(4), 34�50.
Dahlberg, K., Dahlberg, H., & Nyström, M. (2008). Reflective

lifeworld research. Lund: Studentlitteratur.

Dam, H., Horst, F., Borne, B., Ryckman, R., & Crebolder, H.

(2003). Provider-patient interaction in diabetes care: Effects

on patient self-care and outcomes. A systematic review.

Patient Education and Counseling, 51, 17�28.
Durán, A., Marı́n, P., Runkle, I., Pérez, N., Abad, R., Fernández,

M., et al. (2010). Benefits of self-monitoring blood glucose

in the management of new-onset Type 2 diabetes mellitus:

The St Carlos Study, a prospective randomized clinic-based

interventional study with parallel groups. Journal of Diabetes,

2, 203�211.
Ekebergh, M. (2007). Lifeworld-based reflection and learning: A

contribution to the reflective practice in nursing and nursing

education. Reflective Practice, 8(3), 331�343.
Friberg, F., Granum, V., & Bergh, A.-L. (2012). Nurses’ patient-

education work: Conditional factors*An integrative review.
Journal of Nursing Management, 20, 170�186.

Friberg, F., & Hansson-Scherman, M. (2005). Can a teaching

and learning perspective deepen understanding of the con-

cept of compliance? A theoretical discussion. Scandinavian

Journal of Caring Sciences, 19(3), 274�279.
Frost, J., Garside, R., Cooper, C., & Britten, N. (2014). A

qualitative synthesis of diabetes self-management strategies

Patients’ experiences of support for learning to live with diabetes

Citation: Int J Qualitative Stud Health Well-being 2016, 11: 31330 – http://dx.doi.org/10.3402/qhw.v11.31330 9
(page number not for citation purpose)

http://dx.doi.org/10.1016/j.socscimed.11.034

http://dx.doi.org/10.1016/j.socscimed.11.034

http://dx.doi.org/10.3402/qhw.v9.22842

http://dx.doi.org/10.3402/qhw.v9.22842

http://dx.doi.org/10.4172/2167-1168.1000125

http://dx.doi.org/10.3402/qhw.v7i0.18688

http://dx.doi.org/10.3402/qhw.v7i0.18688

http://dx.doi.org/10.1111/scs.12092

http://dx.doi.org/10.1111/scs.12092

http://www.ijqhw.net/index.php/qhw/article/view/31330

http://dx.doi.org/10.3402/qhw.v11.31330

for long term medical outcomes and quality of life in the UK.

BMC Health Services Research, 14(1), 348.

Gadamer, H.-G. (1989). Truth and method. New York: Crossroad

Publishing.

Gadamer, H.-G. (1996). The enigma of health: The art of healing in

a scientific age. Oxford: Blackwell.

Gadamer, H.-G. (2003). Den gåtfulla hälsan: essäer och föredrag

[Uber die Verborgenheit der Gesunheit] [The Enigma of

Health] (J. Jakobsson, Trans.). Ludvika: Dualis.

Haas, L., Maryniuk, M., Beck, J., Cox, C., Duker, P., Edwards,

L., et al. (2014). National standard for diabetes self-

management education and support. Diabetes Care, 37(1),

144�153.
Heidegger, M. (2008). Being and time. London: Harper Collins.

Hörnsten, Å., Jutterstöm, L., Audulv, Å., & Lundman, B. (2011).

A model of integration of illness and self-management in

type 2 diabetes. Journal of Nursing and Healthcare of Chronic

Illness, 3(1), 41�51. doi: http://dx.doi.org/10.1111/j.1752-
9824.2010.01078.x

Hortensius, J., Marijke, K., Wierenga, W., Kleefstra, N., Bilo, H.,

& van der Bijl, J. (2012). Perspectives of patients with type 1

or insulin-treated type 2 diabetes on self-monitoring of blood

glucose: A qualitative study. BMC Public Health, 12, 167.

Hunt, C. W. (2013). Self-care management strategies among

individuals living with type 2 diabetes mellitus: Nursing

interventions. Nursing Research and Reviews, 3(3), 99�105.
doi: http://dx.doi.org/10.4239/wjd.v6.i2.225

Hupcey, J. E. (1998). Clarifying the social support theory-

research linkage. Journal of Advanced Nursing, 27, 1231�1241.
Hupcey, J. E., & Morse, J. M. (1997). Can a professional rela-

tionship be considered social support? Nursing Outlook, 45,

270�276.
Husserl, E. (1975). Experience and judgment. Illinois: Northwestern

University Press.

Husserl, E. (1907/1989). Fenomenologins idé [The idea of

phenomenology]. Göteborg: Daidalos.

Janes, R., Titchener, J., Pere, J., Pere, R., & Senior, R. (2013).

Understanding barriers to glycaemic control from the

patient’s perspective. Journal of Primary Health Care, 5(2),

114�122.
Johansson, K., Almerud-Österberg, S., Leksell, J., & Berglund,

M. (2015). Manoeuvring between anxiety and control:

Patients’ experience of learning to live with diabetes: A

lifeworld phenomenological study. International Journal of

Qualitative Studies on Health and Well-being, 10, 27147, doi:

http://dx.doi.org/10.3402/qhw.v10.27147

Johansson, K., Ekebergh, M., & Dahlberg, K. (2009). A lifeworld

phenomenological study of the experience of falling ill with

diabetes. International Journal of Nursing Studies, 46, 197�206.
Jutterstöm, L. (2013). Illness integration, self-management and

patient-centred support in type 2 diabetes. Doctoral thesis,

Umeå University, Umeå.

Kato, N., Cui, J., & Kato, M. (2013). Structured self-monitoring

of blood glucose reduces glycated haemoglobin in insulin-

treated diabetes. Journal of Diabetes Investigation, 4(5),

450�453.
Kneck, Å., Klang, B., & Fagerberg, I. (2011). Learning to live

with illness: Experiences of persons with recent diagnoses of

diabetes mellitus. Scandinavian Journal of Caring Sciences, 25,

558�566. doi: http://dx.doi.org/10.1111/j.1471-6712.2010.
00864.x

Leksell, J., Sandberg, G., & Wikblad, K. (2006). Experiences of

an educational programme for individuals with blindness

caused by diabetes. European Diabetes Nursing, 3(2), 86�91.

Marton, F., & Ming, F. P. (2006). On some necessary con-

ditions of learning. The Journal of the Learning Science, 15(2),

193�220.
Merleau-Ponty, M. (1983). The structure of behaviour (Övers. A. L.

Fisher. Orig. titel: La Structure du Component, 1942).

Pittsburgh: Duquesne University Press.

Merleau-Ponty, M. (1995). Phenomenology of perception (Övers.

C. Smith. Orig. titel: Phénoménologie de la Perception).

(Första utgåvan 1945). London: Routledge.

Merleau-Ponty, M. (1945). Phenomenology of perception. London:

Routledge.

Norris, S., Lau, J., Smith, J., Schmid, C., & Engelgau, M. (2002).

Self-management education for adults with type 2 diabetes.

Diabetes Care, 25, 1159�1171.
Polonsky, W., Fisher, L., Schikman, C., Hinnen, D., Parkin, C.,

Jelsovsky, Z., et al. (2011). Structured self-monitoring of

blood glucose significantly reduces A1C levels in poorly

controlled noninsulin-treated type 2 diabetes. Diabetes Care,

34, 262�267.
Steinbekk, A., Rygg, L., Lisulo, L., Rise, M., & Fretheim, A.

(2012). Group based diabetes self-management education

compared to routine treatment for people with type 2

diabetes mellitus. A systematic review with meta-analysis.

BMC Health Services Research, 12, 213. doi: http://dx.doi.

org/10.1186/1472-6963-12-213

Svedbo Engström, M., Leksell, J., Johansson, U.-B., &

Gudbjörnsdottir, S. (2016). What is important for you?

A qualitative interview study of living with diabetes and

experiences of diabetes care to establish a basis for a tailored

Patient-Reported Outcome Measure for the Swedish Na-

tional Diabetes Register. BMJ Open, 6, e010249. doi: http://

dx.doi.org/10.1136/bmjopen-2015-010249

Svenaeus, F. (2011). Illness as unhomelike being-in-the-world:

Heidegger and the phenomenology of medicine. Medicine

Health Care and Philosophy, 14, 333�343. doi: http://dx.doi.
org/10.1007/s11019-010-9301-0

Swedish Council on Technology Assessment in Health Care.

(2009). Patientutbildning vid diabetes: en systematisk literature

översikt [Patient education in diabetes care: A systematic liter-

ature review]. SBU Report No. 195. Stockholm. Retrieved

August 8, 2016, from http://www.sbu.se/en/publications/

sbu-assesses/patient-education-in-managing-diabetes/

Tan, P., Chen, H.-C., Taylor, B., & Hegney, D. (2012). Experience

of hypoglycaemia and strategies used for its management

by community-dwelling adults with diabetes mellitus: A

systematic review. International Journal of Evidence-Based

Healthcare, 10, 169�180. doi: http://dx.doi.org/10.1111/j.
1744-1609.2012.00267.x

Tang, T., Funnell, M., Brown, M., & Kurlander, J. (2010).

Self-management support in ‘‘real-world’’ settings: An

empowerment-based intervention. Patient Education and

Counseling, 79(2), 178�184. doi: http://dx.doi.org/10.1016/
j.pec.2009.09.029

Toombs, K. (1993). The meaning of illness: A phenomenological

approach of the different perspective of physicians and patients.

Dordrecht: Kluwer Academic.

Wikblad, K., Leksell, J., & Smide, B. (2004). I’m the Boss’:

testing the feasibility of an evidence-based patient education

programme using problem-based learning. European Diabetes

Nursing, 1(1), 13�17.
Zoffman, V., Hörnsten, Å., Storbækken, S., Graue, M., Rassmussen,

B., Wahl, A., et al. (2016). Translating person-centered

care into practice: A comparative analysis of motivational

interviewing, illness-integration support, and guided self

determination. Patient Education and Counseling, 99, 400�407.

K. Johansson et al.

10
(page number not for citation purpose)

Citation: Int J Qualitative Stud Health Well-being 2016, 11: 31330 – http://dx.doi.org/10.3402/qhw.v11.31330

http://dx.doi.org/10.1111/j.1752-9824.2010.01078.x

http://dx.doi.org/10.1111/j.1752-9824.2010.01078.x

http://dx.doi.org/10.4239/wjd.v6.i2.225

http://dx.doi.org/10.3402/qhw.v10.27147

http://dx.doi.org/10.1111/j.1471-6712.2010.00864.x

http://dx.doi.org/10.1111/j.1471-6712.2010.00864.x

http://dx.doi.org/10.1186/1472-6963-12-213

http://dx.doi.org/10.1186/1472-6963-12-213

http://dx.doi.org/10.1136/bmjopen-2015-010249

http://dx.doi.org/10.1136/bmjopen-2015-010249

http://dx.doi.org/10.1007/s11019-010-9301-0

http://dx.doi.org/10.1007/s11019-010-9301-0

http://www.sbu.se/en/publications/sbu-assesses/patient-education-in-managing-diabetes/

http://www.sbu.se/en/publications/sbu-assesses/patient-education-in-managing-diabetes/

http://dx.doi.org/10.1111/j.1744-1609.2012.00267.x

http://dx.doi.org/10.1111/j.1744-1609.2012.00267.x

http://dx.doi.org/10.1016/j.pec.2009.09.029

http://dx.doi.org/10.1016/j.pec.2009.09.029

http://www.ijqhw.net/index.php/qhw/article/view/31330

http://dx.doi.org/10.3402/qhw.v11.31330

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StratfordUniversity School of Nursing

Syllabus Supplement

1

Course: NSG 410, Research and Evidence-Based Nursing Practice

Term: 01, 2022

Faculty: Dr. Coffin

School of Nursing Standard Course Information:

1. Understand and follow all Stratford University and School of Nursing policies and procedures
as identified in the Stratford Catalog and the School of Nursing Student Handbook.

2. Students are expected to do their own work on exams, quizzes, and individual assignments.

When an assignment or homework is completed within a group process, the faculty will clearly
indicate it.

3. All assignments have a due date and time posted, and it is the student’s responsibility to know

when the assignment is due. If the student has a problem with accessing or turning in an
assignment due to Moodle/computer/technology issues, email the instructor so the problem can
be addressed.

4. All assignments/homework must be submitted via Moodle, not via email, by the due date to

receive full credit. If there is an extenuating circumstance and the student is not able to submit
the work by the due date, the student must contact the instructor prior to the due date.

5. Unless otherwise identified by the course faculty, all assignments submitted shall be submitted

as a “final” copy. Do not submit assignments as a draft.

6. The School of Nursing requires written work to comply with the most current APA standards
and formatting and comply with the Academic Integrity standards of Stratford University.
References and citations are expected when material submitted is not the student’s original
work (i.e., definitions, evidence-based practices, interventions, lists, descriptions, etc.).
Students are encouraged to use plagiarism websites to review for plagiarism as needed. A good
resource for APA formatting is https://owl.purdue.edu

7. Students must achieve a minimum grade of 80% (B-) to pass a Nursing course. When a course
has a clinical or lab component (pass/fail), the student must pass that component to pass the
course. Students passing the theory but failing the clinical/lab will earn an overall grade of not
more than C+.

8. Course assignments and homework are identified in the table below along with the topic

outline. Detailed directions and rubrics for assignments and homework are found in the
Important Documents area of the Moodle site for the course. Students are responsible for
following the directions and meeting the requirements of the assignments, homework, and
rubric(s).

The Syllabus Supplement contains additional information to the E-Syllabus for this course. The
contents of the Syllabus Supplement are an extension of the E-Syllabus for the course, and therefore,
are viewed as part of the official contract and requirements for the course. Students are responsible for
all information in the E-syllabus, the Syllabus Supplement, and all guides, rubrics, assignment
directions, etc., posted on the Moodle site.

https://owl.purdue.edu/

Stratford University School of Nursing
Syllabus Supplement

2

9. Read your Stratford email daily. All official course communication will be done via Stratford

email and/or the course Moodle site.

10. Some Nursing courses require completion of a practice and/or proctored assessments via a
product called ATI. Specific requirements for each course are identified in a separate
document. The student is responsible for completing all ATI requirements for the course.

11. Some courses include a simulation learning activity. Guidelines and learning outcomes for

each simulation are provided to the student.

12. Tests/exams and quizzes are given on the date and at the time listed for the course.
a. Students are expected to be in their seats and ready to begin class at the appointed time.
b. Exams will be the first item of class business and will start no later than 5 minutes after

the published class start time.
c. Students who arrive to class after the exam has been distributed, and the instructor has

announced that the exam has begun may not be allowed into the classroom as this
disrupts other students.

d. The student may be allowed to take the test elsewhere provided there is a room and a
proctor available and will be expected to return to class at the time appointed to resume
class after the exam is completed.

e. Students who arrive more than 30 minutes late for class will have the option of taking
the test but within a shortened time frame as they will be expected to return to class at
the time appointed for resuming class after the exam is completed.

f. In the event a student is cognizant of a situation that will prohibit the student from
attending class (i.e., hospitalization, emergency, etc.) the student is responsible to and
must contact the instructor prior to the exam to schedule a time to take the exam.

g. Students who miss the exam due to an approved absence or documented emergency
may be required to submit evidence supporting these claims within 5 workdays of the
exam date. If the claims are verified, the students 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.

h. 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.

i. All students will bring personal items to the front of the classroom. Cell phones will be
turned off, and students may be required to place the phone on the front table during all
exams.

13. Stratford University School of Nursing uses remote proctoring software to support on-line
test security. It is a requirement for all students enrolled in any course that begins with the
prefix NSG to have the following computer support available:

a. Students are required to allow electronic or web-based monitoring for exams and / or
quizzes. It may be a requirement to turn your camera on for the proctoring period (or
use a lock down browser). Failure to permit either of these types of monitoring

Stratford University School of Nursing
Syllabus Supplement

3

modalities will result in a “0” grade for the exam. This is considered an academic
integrity violation.

b. Desktop or laptop computer (no iPads, tablets) with the ability to download Google
Chrome

c. Google Chrome: version 80 or higher
d. PC: version Windows 10 or later; Min resolution 1024 x 600
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

  • General School of Nursing Classroom Policies
  • 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/

    Stratford University School of Nursing
    Syllabus Supplement

    4

    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

    Stratford University School of Nursing
    Syllabus Supplement

    5

    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

    6

    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.

  • Other Assignments (32.5% of total grade)
  • 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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  • Quizzes (50%)
  • 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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    10

    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 )

    Stratford University School of Nursing
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  • Grading Rubrics:
  • 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%

    Stratford University School of Nursing
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    12

    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
  • 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%

    Stratford University School of Nursing
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    13

  • Literature Review Table Rubric
  • 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.

    Stratford University School of Nursing
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    15

    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.

    Stratford University School of Nursing
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    16

    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

  • Dr. Rebecca Coffin January 3, 2022
  • Faculty Signature / Date

    [Student keeps one copy/faculty files signed copy in students nursing file]

      General School of Nursing Classroom Policies
      Other Assignments (32.5% of total grade)
      Quizzes (50%)

    • No work will be accepted beyond this time, and a grade of zero will be posted. Emailed assignments will not be accepted.
    • Grading Rubrics:
      APA Assignment grading Rubric
      Literature Review Table Rubric
      Dr. Rebecca Coffin January 3, 2022

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