University of Ghana http://ugspace.ug.edu.gh l~IVERSITY OF GHANA SCHO()L OF PUBLIC HEALTH COLLEGE OF IIEALTII SCIEseEs AGGRESSIOS AND VIOLENCE IN MENTAL HEALTH INPATIENT UNITS: A CASE STl'DY AT THE ACCRA I~SY('IIIA l 'RIC HOSPITAl. TIII~ 1))~"""KTATIf)N Sl H'-1ITTt:O TOTHE (;SIVERSITY OF GIIANA,l.I-:GON IN PARTIAl.. n;1.nu~n;/'IIT Of Tilt: IU:Ql llltt:MENT FOR THE AWARD OF THE MASTER OF Pt:HU( ' IIt:AlTiI I>I-:C;Ht:t MAY,20t9. University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereb) declare that apan rrom specific rererenCd .... hieh have bcten acknowledled this Resewch Proposaiis my O"IoTlworitput logether / ,.1111 ~~.-- (Student) 21" MAY. 2019 Dr. Abdallab Ibnbim (Supervisor) University of Ghana http://ugspace.ug.edu.gh DECLARATION I herdl)declarcthatapanfrom specific references which have been acknowledgcdthisResateh PropoYI is my own work pUI together ~---- Si8Jl8lure Date AngdllAoo. •• H. .M lD Adjri-Supoeg 2!1'MA\',20t9 Si~ o.te Dr. Abda.a.b Ibrahim CSupen-isor) University of Ghana http://ugspace.ug.edu.gh DEDICATION This thesis is ded.iate'd 10 the Almighty God for- bcinS the 5OUtt:e of my Stmlgth throughout this IWUIW. 10 my nusbmd Mr. JoseptI 8 . Nsi.ah for his II'ernmdous suppor1 and encoungemena and 10 my cntire family. I also dedicate it to all health ..... orkers working In psychialric units in Ghana. University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGMENT First Md foremoSi I thank the depIttment of Health Policy Planning and Management I mo thMk my dear )ectureD of School of Public Health, especially my able. ded~ and rMticuious SUpnviSOf Dr. Ibrahim Abdallah. all of whom conaibuled immensely and in various W8ystowardsachicvln,thislJ'Ulsucccss May God bless youaJl University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS ....•••.• _.ii DECLARATION ..... . .. ......... iii DEDiCATION ........................... .. ........ i" ACKNOWLEDGME:"'iT ............... . UST or TABLES ........... LIST OF FIGURES ........... .. .. .......... .. UST Ot· ABHH.1:VIATIONS ..................... .. •. ........ :.:ii ABSTRACT ........... .. CHAPTER ONE ........ IIHRODl'CTION. 1.1 Backgroundof1heaudy ...... 1.2Statemenloftheproblem . 1.3 Research questions ........ 1."SilP'ific.ance of the study .. .. 1 SObjecti\lesofthestudy .. .. 1.5.1 Genna\obje!>ion and violence in Psychiatric Hospitals .... ~._ I 2.4 'The effect of aggression and violence on ~ inpatient huhh workers 8t the Psychiatric Hospital .... .. ............... ................... 11 University of Ghana http://ugspace.ug.edu.gh 2.5 Hospital Management's response to aggression and violence at the Psychiatric Hospital. 12 ...................... 15 CHAPTER THREE ................................... 15 3.llntroduction ......... . .. ..... 15 3.2Studydcsign 3.3Studyarea ...... 3.4SNdypopulatK>n. .. . 16 ............... 16 3.6DcscripiionofVarlables: ... . ............. 16 3.7 Sample and sampling techniques ...................... 17 3.8 SWdy tool ......................... 17 3.9Qualitytonb"ol.... .. .... ... ...................... 17 3.10 Data collection staae ... . ...• 18 3.11 Data entry and proce.s.img .... . ...................... 18 3.12Dau.analysis ... 3.13 Ethicalconsiderationlissues .. 3.14 Dcscription OfiUbjccu invol .... ed in the study ... 3.15 Potential riskslbenefits compensation .... 3.16 Privacy/confidenliaJily 3.17Compensacion ....... ··· ...................... 20 3.IS O ... .wr.geand usage 3.19Wrineninfonnedconsenl .... . ..................... 20 3.20 Connictofintcrest ................ 20 3.21 Proposal and funding information .... . ....... ............. 20 3.22limitalions .. ····················.· .......••••..... 21 University of Ghana http://ugspace.ug.edu.gh ..•..••••• _ •• 22 CHAPTER FOL'R ..• .. .... 22 RESuLTS. .... . .... 22 4.llnlroduction ... .. .. 22 4.2 Demographic lbta oftbe respondent ........... . 4.3 11lc prevalence of awession and violence at Accra Psychiatric Hospitai... ......... . 4.4 Productivity(Worlc. output) of inpatient heaJthworkcrs ..•.....••..... 4.SThe prevakncc of aggrasion and violence at the Accra Psychiatric: Hospital ........ .. 4.6 The effect of aggression and violence on the work output of inpatient health workers at Accra Ps)chWric Hospital (Using Percentages and Frequencies}. ... ..•... 29 4.7 The Effect of Agression and Violence on the produ.ctivity Inpatient Health Workers at Accra PlychiaaIW Hospital (UsinaBinary Logistic Regression)aX . ....... .. .......... 30 4.7.1 Aggreuion Re:1I1Cd F.cton that Influence the Produ.ctivity of Inp.tient Health Workers at Accl"1l Psychiacric: HospitaJ (APH) ....... .. 4.7.2 Logistic Repuion (Agaression Related F.ctor.; and In~tient He.lth Workers Produc:tivify at Accra PsychiaIric Hospital (APH)) .. 4.7.J Violence Rc:latcd FactonThaI IntluencetheProductivityoflnpt.tientHealth Worker sal Accra Psydl.~c Hospital tAPH) 4.7.4 LogiJtics R.qre:uion (VioLent RclalCd faclOrS and Productivity oflnpatient Workers al AccraPsychilltricHospi. .I } ..... 4 •• Hospital manaaement's response to awession and violence 5.IThc prevaJenceofaggrcuion and violence 8l Accra Psychiatric HospitaJ .... 5.2Theeffectof~5Ionandvio~ontheworkoutputofinpmienthcalthworkersat ~I"1IPsyebialricHospital. ... 5.JHospilalmanaaC'ment'src:sponseto.ggres.slooandviotcncc .... . ...... 4) CONCLUSION AND RECOMMENDATION_._. __ •_ _. .. University of Ghana http://ugspace.ug.edu.gh 6.2Coocluston ... 6.3 Recommendlition .... .. .......• 5 REFt~RENC.:S ... _ ..•. __ ..... APPENDICES_. ...... . . .... . 50 APPENDIX 2: ... .. ... 55 University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 4.1: Demography ....... 22 Table 4.2: Form ofaggrnsion and frequencyof occurrence 3t Ihe hC'lspital . ... 24 Tabk 4.3: Experience of violen! behavior Tablt4 .4 Work output of inpalient health workers ....... 26 TabJe4.S Agressiooand violcnccbeh.vior .... ............... 29 Table 4.6 PerunuSC Distribution ofProduclivicy by Characteristics of Respoodent.s (n =110) . 31 Tablo4.7 ~gistic Regreuton (Aggrnston Rel8kd Factors and Inp.tient Worken Productivity) 34 Table 4 .8 Percentage Distribution of ProdUClivil)' by Characlcristin of Respondents (Violent Behaviour) .. . Table 4.9 LosiSlic Regression (Violent Related Factor and Productivity of Inpatient Health WOfUn) .... Table 10 HOipibll mMllgemenl's l"ll:SpOnJeto'ggrcuionand violcncc .... .. .. .............. 39 University of Ghana http://ugspace.ug.edu.gh Fipe J: Conceptual framework indiatina the: effect of aggression and viokncc on the wock outpuIofinpetiallheaJthworkcn ... University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONs Ac:aa Psychiatric Hospital Vioknce and Aggression of Patients Scale University of Ghana http://ugspace.ug.edu.gh ABSTRACT BlICkgrooad:lbeincidenceofaggressionandviolencetowardsheaJthcareworkersappeartobc an everyday issue (Spencer et: al.. 2010). This is because. with patients who are mentally ill, there is always a cause for aggression and violence due to a combination of factors such as inlen!.e mc:ntaI distress and pcrsonality. physical environment and behaviour and attitudes of heal lhc:~ workers. ')')w study sought to achieve three objectives at the Accra Psychiatric Hospital: to examine the prevalence of aggression and violence. assessed the effect of aggression and violence on the output of inpatient health workers, as well as assessed the bospital's management re:sponse to aggreuion and violence Metllods: The slUdy adopted a quantitative approach. Purposive sampling method was used in selectinalOOhealthcareworkers.Similarly,thestudyreviewedhospitalrecorosonviolenceand aggression for the period 2012 to 2016. The dependent variable for the study was level of work output while asgr~~ion .d violence was the independent variables. Stata 15.1 was used 10 processthedala .. ~ellasadeloCripliveandinferentialstatislicsintheanalysis. Resulbl aad CODclvsio.: 1lIe mulls of the study revealed that cases of aggression and violence were prevalent, especially in male patients than in female patients. On the effect ofaggrc:ssi on and Vtolencc on work output. inpatient healLhworkers identified experiences of being binen, 5bou&edtt.kieked.hit and pushed by patients, and these subsequently led to anxiety,depression and extra workloads or duty after work. It wu also ccvaled thai inpatient health workers who Iwdbcenshoutedat.werelikelytobepnxfuc:tivcthanthosewhohadeverbeenshoutedtt. This was the same cue as inpatients that had never experienced violence. They were more likely \0 be productive than those who cw.perienced violence. The hospital's management response \0 University of Ghana http://ugspace.ug.edu.gh *ilJUSion and vwlence by patients was Uwouch !he use of medication. IC'Chasion and negotiMion. Given lhese poinl.s. it mIIy be said that issues of aggression and violencc towards inpatient heal th workcn were ine"itabk at the A«ra Psychiatric Hospital. The study recommended that mental Malth institutions should employ more inpatients health workers to relteve the overburdening of alrt:adyexistini inpaticnt heahh workers ratio University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODl'CTION 1.1 Bacqrouador,bcstudy Every day.1lI'OUftd the wood. heahhcare workers put in a lot of work to provide optimal care for palientswilhintheirhcahhc.-efllCilitiesand legisilliveframework. Even50,healthcarcwo rkers an: the main WgdS of vtolence and aggression from patients (Spencer, Stone & McMillan, 2010). Precdcly, around theworlcl, inlheheahhcarcsCClor, one in two healthcare workers isa Wad of acts of aggTe»Kln and violence, and nurses are three timc~ vulnerable 10 acts of agrcuion and violence than other hcalthcve worker group (International Labor Organiution. 2002). In dcfininB agreSiioolDdvio1encc:. Di Manino (2000) observes that there is no generally accepted defmition due to the varying perceptions of what constitutes violent and agrcssive bcMv1cMn in other cultures and socia] bKkgrounds. In other wotdJ. in some cultures and JOCictie:a, the limils between acceptabk: and unacceptable a~gre~sive and violent behaviOUR can be vapc. Nonctbclesa. Oi Martino (2000) definn a8ll'nsion as the intent to cause hann. In olherwordl,aggressionismoreorlessaf«lingofhostilebehaviouforathreal ot attack, while YioIcnce is ac:n.Ily the usc of physical force injure or abuse another. from Iheperspective of mental health units. the inddencc of agrc:ssion and violence towards healthcare workers appear to be an everyday issue (Sprncer d aI., 2010). This is because, with patients who are mentally ill. theft is always a cause for aaares.sioo and violence due: to a combmation of intrins.ic and cxcrinsic: fKT.or.; (lWwoocI. 2017). Some examples of the intrimic reclOrl include physical University of Ghana http://ugspace.ug.edu.gh sympcoms or intense mental distress and personality, whi le some of the extrinsic factors include IIIliwde and behaviour of heallhcare workers and other pcopie, physical envirorunent of the health facility and restrictions with respect to the movement and actions of the patients in the healthfacility(Harwood,20J7). Various studies hive identified violence and aggression as a primary huard in the work cnvironmentformen&al health care practitioners (Whittington & Richter,2006; lozzinoetaJ• • 201S; Inoue. Tsukano. Muraoka, Kaneko &Okamura 2006; McCann, Baird &Muir-Coc:lnne 2014}. A study done by 0wftI. Tarantello, Jones &Tennant (1998) in Sydney. Austnlia which was primarily aimed ac predicting aggressive and vioient behlvior... revelled an eight-leve lscale ofviolern and Iggrt'$sivecascs recorded by staff within a period of seven-month. Thus using the sca&e. amoDI 1,2'9 violent cases 58% was iCriOUS. A prospective data from three aduh acute psychiatric W1its in a general hospital and two units ina primary psychiatric hospital on violent cases was used. Similarly MKidleby-Clements (2009) conducted a study which was aimed It examining the link between health professional anitudes and subsequent aggression by mental health inpaeienls. "The study basically explored patient views on how staff manages aggre·ssion. 'Ibe oU(C{)me of the study disclosed that patients reported that the interpersonal facwr sofmental health staff wac impoI\ant contributor to their aggression. Similarly, high stafT rigidity was Imked .... ithlll" tolerance for pattern aggression. In Ghana, the stigma towards people with mental disorder is usually due to deep-rooted (can about agm,sion and vto&ence (Drew et al.. 2011). For this reason. using the Accra Psyehiatric Hospital 8$ a cue study, this study examined the impact of aggression and vtolence 00 pcrfonnanceatlhementaJhealthinpaticntuniL University of Ghana http://ugspace.ug.edu.gh 1.2StalemHlloft"eproblnl In mco&aJ health units, particularly detained patients with symptoms of severe mental illness and personality issues especially in psychiab'ic intensive care, aggression and violencc are ve rymuch common (Antonysamy, 201l). Even though vioknce and aggression are common. inpU;ent health workers. especially nurws working in mental health in~ticnt WlilS should not deny it as an unavoidable part oftheic roles (Spencer. Stone & McMillan. 2010). This does not mean thai detained patic:nu with symp&oms of mental illness are dangerous. Instead. adequate management. more precisely the knoVlJedge and skill in managing violent and aggrc5sive behlviourot potentially violent and aggressive patients may in fact help them get well and bencr.and lcuenthenced for rcstrictions whil51 carin, for the patients (Stone. 2009). But that is not Clltirdy the case. In the last few years It the ACCT8 PsychUitric Hospital, nurses have embarked on a ~everal demonstrations to draw attention to the issue of lICk of medication (Accra Psy.:hiatric Hospital. 2014). The issue of lack of essential medication such as tranquilizers to ~ and glm aggreuive and violenl bebaviounofpalienlS always put the nurses at risk in the health facility. This situation. along with the issue of poor quality and quantity of feeding pelicnts compound the already diffiCult working conditions of nurses at the hospital. This ncceuitales a need to wtdertake this research to rand out about the prevalence of auression and violence at the Accra Psychiatric Hospital. the effect of agreuion and violence on the productivity of inpatienl htalth workers.t the facility (Accra Psychiatric Hospital), u well u the rn.anasanent response to acts of 8sgre5sion _ violence at the health facility (Accra PsychWric Hospital) University of Ghana http://ugspace.ug.edu.gh 1.3 Researcbquestioos I. WhrIt is the prevaknceofaggres.sion and violence at Accra Psychiatric Hospital? Ii. What is the effect of aggression and violence on productivityofinpalient heallh workers atAccraPsychiabicllospital? III. How is management re!iponse to aggrnsion.oo violence at Accra Psychiltric Hospital? 1.4Significanceoftbeshdy The ltUdy wdl highlight the ~valence. effect and how to manage the dynamics of aggression and viok!nu IU mental health facility and Hospital Authority response at the Accra Psychiatric Hospital. Thus. the findings of the study will help individuals, health workers and patients, and heatth institutions to be acquainted with the dynamics of aggression and v iolence in psychiatric im~icntunits.Thesludywillfurthcr.ddlOtheaJreadyexistin8Iitetaluteonthistopicandalso !lefVe IS. refcrmc:e or baseline data for other students and researchers who wish to funher research on this topic orodler stmilar ones. loS Ohjectives oftbe study l.S.lGe.eralobjedive To examine the dynamics of aggression and violence al the Accra Psychiatric Hospital (APH) 1.5.2Specificobjectfto.oft~eshldy Toassessthepreva1mceofaggressionandviolenceatAccraPsychiatricliospital To determine the ef'fect ofaggrnsion and violence on produttivityofinpatientheaJth worken81 1ccra Psyehiatric Hospital. To IbSoeU Hospi1al manqemenfs response to aggression and viotcnc:e al Accra Psychiatric Hospilal. University of Ghana http://ugspace.ug.edu.gh 1.6CoDceptuaIFn..ft¥"ork AC(M'If;(pCUlI framework. is all IIssetconsistin, o(a wide range ofthought$ 8S well as pen:eption ~ reviewed from related studies and presenled in anOlher subject of study (Retehcl & Ramey. [987). The illustration below therefore inlCfJ'fCts lhe: magnitude or effect of tile independent \,unforlheperiod2012to2016suchasassaullinthefonnofbcingbeacen. billat.kickcdlndpushcd,insulcedanddu'ealcnedverbally. 3.8Shdytool The main instruments used fot the lbIdy was a questionnaire and a data extraction sheet. The quettionna;recontainedleCtions1hal:focuscdonthebiodacaofthcrespondentsandsectionsthai deakwichlhe5CCOftdIndlhirdobjective-softhestudy. The record from the hospital was used to achieve the lirsc objectivc of the study 1.' Quatity ooDtrol Prior 10 adminille:rinl the questionnaire• • tc:IC8t'Ch as!oislllnl with basic knowledge in the SCUlly as weU. a dIU eMry clerk WH engaged and b'ained. On • rqular bbi". the rescateh ..i stlalb also be monitored and supervised. On a daily baait before data entry. all completed da&a was validated or authorized. Also. only completed questionnaires were used. Prior to runninadlc -.lysis. the data set was clemed after the daIa entry process. The ensuing questions focused on thclpeCirlCobjectiv~ University of Ghana http://ugspace.ug.edu.gh 3.IOOalecolled_ stale Daily visits were made 10 the itUdy site by principal investigalOr 10 make sure lhat there is strict adherence 10 the research guidelines, Thereafter. the researcher infonned the selected rnpondenlS (health workers) about the scudy details, This was to give the respondents an idea of whalloexpttlfromtbestudy.lnansweringthequeslionnaire,therespondentswereaskedtotick or answer appropriately in • list ofpm:Jecennincd questions. At the end oftbc data collection procaa.tberespondenlswcrethankedwill betbanked for tbeir time 3.n o.be.try.ad proceuiag 11Ic compkted questionnaires were coded within 24 hours. Data was entem::l and cross checked for enon twice by usin, Microsoft Excel 2013 and then imported into Stata 15.1 which wr; used 10 procen lhedata J,12lbtaa.alylis 1be qucsllOM&ires were coded and keyed inlOthe database of the Stata 15.1 for processina. AISO,daIa_Jyw wasdoneusingthedescriPliveslatislicsofpercentagcsandfrequencits,and inferential statistic of logl~lic regression. The results were then presented in tables and eraphs • • 'Of the ltudy. low morale, absmleeism, lalenns to workltardy were coded as dependent variable which was mc1Isurc as high productivity or tow productivity. Similarly, imults by patients, verbal threalsandphysicaJllllck werec:odedasindependcnt variables, University of Ghana http://ugspace.ug.edu.gh 3.U Etllical coasideratioo/issues GII.oa Heallb Senices Etllical Approval Prior to Ihe begiMing oftbe study. ethical approval was sought from the Ghana H~lth Service Ethical R.cv~Commiuee of the Research and Development Division. Approvalr~shldyarea Penniuion and approvaJ was soupt from the hospigl administration before data wu coll«1Cd. J.14Deaeriptlooorsubjectsinolvedin the study The SlUd)' populations ""ere clients who visit the health facilities for trc.tment (lnpMic:nts and 3.15P. .t ialrilkslbeDefits~pensatioo 80th the study population and the society stand 10 benefit from the study. Study population will have knowledge of quality of health care at the hospital. Also examining the dynamk.s of agrnston and violcn« in menlal health im~ticnt units can be used as a platform for sensitizing policymakcrsandopinioo LeAdeB. Subscquenlly, programs can be instituted to promOle good hcahh,educationonthc prevalence, impact and Hospillli managements' response to aggression andvioacnce an mcnu.1 hcalth imp.lient units. This can hclpreducc Ihl! prcvalenccof ..g reuion and violence to menW health impatient unilS, and mental illness gcnenl1y. Results of the study cx.amiDina the dynamics of aggression and violence in mmtal hcahh im~imt units will help makc: infonncd decisionsaboul the health ofpatienti and improve upon care rcndercd to thcm.u well • teduc:m, vtolence and aggression towards health care workers. This research poses miIiaum poI1mIiaI risk to the study populMion or society in the sense that some questions may bcUllCOmfortablc fortbe participants. University of Ghana http://ugspace.ug.edu.gh J.16Privacy/coolideotiality The questiomaires were given to the respondents on a one on one basis. The processing of the d.u.and..tysiswill bc done as one unit to ensure lhat no questionnaire rcsultcan bctraccd\o8 pu1icular rapondcnL The name of the participants does not appear in final report. J .11 COI8pusatioo No compcn~ll()n was given lO cltenlS for participating in Ihili research. Their inputs were however recogniud mel appreciated J.IIOatastoralcaodllsage Quntionnaireswcre ooded and kept under lock and key in a cupboard , and the key was kept by the principal invesligalor_DatacoUectcdwascoded and enlerc:d within 24 hou rsofcollection, ....t saved under a pau",ord known to only the principal invcsligator. Soft. copy of data was I&oRd on a C[)'ROM and extcmaJ hard drive as well . All data collected will be kept by the principal in\'ciliplOr for 3-4 yean lO allow for publtc:Ation of research, after whk:h queslionnairc:swillbedcstroycd. J.19 Written iorormed CODseot Writ&cn informed consent was sought from study participants before data collected from them. Panicipacion wu abIolutely voluntary. Respondents wen: given the opportunity to stop their paMK::ipationintheswdyanytimethcyarctircdorwanttooplOU\ofthestudy. J.20ConRictofloterest IIlCft is no COIlfJict of interest associated with this "'urk !>inl.:c it is soicly for academic purpose. J.2J Propoeal uti r.N~ .rOrmadoD This research is sclf-fmanced by me University of Ghana http://ugspace.ug.edu.gh The review of the hospital records has its limitation as it is diffieuh to ascertain if the mfonnaiionwurecordedlppropriMely. University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR This chapter presenLs the results oflhe study. The dernognphic: results are firstpresentro roUowed by rnulLs to the speeific objeclives of the stucly. 4.1 Delnogrwphicdatao(lhe respoadeat Frequency Pe~ent.ge(%) Ale .zo.29yean. 3O-J9years 50.0 4O-49)ears 2.7 50-60ycars 0.0 100.0 s;;--.- ~ Female 81.8 Educational level Catif-. 14.5 Diploma University of Ghana http://ugspace.ug.edu.gh Advanced Diploma 0.0 Degree 29.1 Total Religion Christian TraditionalisllSpirin..list 100.0 Forhowlonghaveyoubeenpracticiog l-4yesrs S-9yan 1(t.14)'C1l'S IS-19years 0.0 20 yanmd abo\te As Ihown in Table 4.1. 55 (50.00/e) of the respondents were 30 to 39)'UJ'S old, whils152 (47.3%) werc 20 to 29 years and 3 (2.7%) were 40 to 49 yearsokl. Most 90 (81.8%)ofthc: respondents were females and 20(18.2%) were mates. Addilionally. a linle more than half 62 (56.4%) of the respondents had diplom... Also. 32 (29.1%) bad degree and 16 (14.5%) hMI oertiftcMe. Majority. 98(89.0%) of the respondents Wert Christians and 12 (10.9%) were Moslems (Islam). University of Ghana http://ugspace.ug.edu.gh Finalty.m0il67(60."'o)ofthempondentsstatedlhatlhey havebccnpracticing forlt04 YCaI'S. Whilst. J4 (30.9%) practiccd for 5 to 9 years and 9 (S.2%) prac1iced for 10to 14 years. 4.3 The preuleace of aggression and violence lilt A«ra Psychialric Hospilal Table 4.2: Form ofagcression and frequency ofCK:currence at Ibehospi lal .---~po~ N PercealorCase! 19 9.0% 18.6% 59 57.8% 2) 11.0% 22.5% 41.4% 85.3% 10.5% 21.6% 100.0% 20S.9% Table 4.2 shows multiple response on the fonn of aKfP"Cssion that occurs frequently al the hospiaaI. As lnd~ in Table 3, 81 (41.4%) of the respondents Klcntified shouting as a fonn of aagrcssion. this is followed by S9 (28.1%) hinin&. 23 (11.0%) kick ing. 22 (10.5%) pushing and bd"119('.0%~ Tabk4.JE.J.perieMeofviolcntbellavior FI"ftJ.cacy Percentale ~syounperience\'io&e.tbehaViollrattlteb~~'.!!·"!L1= =~-==(~%:;:I= = 91 12.7 No 19 17.3 Total 110 100.0 How rrequeDt doyo-;-experi·ence violent bebavlO·:::u'c:c.':-:;'.::-e-....!.!.!!- ~~-- ~ Frequently 25.5 ~ 68 Ram, 14 12.7 Total 110 100.0 Han you ever beea _ ...D y ".rused ill any w.y by a University of Ghana http://ugspace.ug.edu.gh V~inlbftore 20 18.2 No 90 81.8 Toeal 110 100.0 ~tiea'.pl!1sic!l!l'..a"ack~beforeatthehospit.1 Yes 46 41.8 ~ M = Total 110 100.0 At indicated m Table 4.3, most 91 (82.70~) of the respondents stated th:Jt they experienced yiolc:nt behavioural the hospital and 19(17.3%) they don' t. Most 68161 . ~o) of the respondents stated that they .omctimes eXlXricnce violcnt be"'viours III the: ho.."Ital, wbilS128 (25.5%) Slated frequendy and 14 (12.7%) said that they raely do. Addilton.lly. mcJIt 90 (81.80/.) ofthc: rnpondenu said that they had not becn sexually haraMCd A little more than t..lf 64 (S8.J-/e) ofthc rnpundenlS swed that a pallcnt had not attacked them ~)'i~.It) In !he pail at the hospital and 46 (41 8°~) ~M:I they had l"H:en o.nnckc:d in thc p&~ University of Ghana http://ugspace.ug.edu.gh 4." ProdHfivity (Work output) of inpatient bealtlll workers Table 4.4 Workoutputofinpatien. llealth workers Frequency Percents,e (%) Do you reoor1 10 work early y" 97 88.2 No 13 11.8 Tota. 110 100-0 ArevfHI.bleto.enyo.rsetgoabatwork Yes 80 72.7 No 30 27.3 110.0 ~"'•'!•!!, !LyI o-.,.-, -,., .-.-.- .d o-.p."". ".'" ,,"d =due to aKgressiop and violence attbebpsDital y" J3 30.0 No 77 70.0 Total 110 100.0 Have you ever relt aDIious due to a2gression and violence at ~~bosPi"l ~---.----75---68-.2--- No 35 31.8 -~~~.Y~~~"~"':!•i•L o:""'!!!!:!d~,tyii:ia!l!;n,~,w~o!i.!'k=====~II=O= ~IOO~.O== 13 11.8 No 97 88.2 Tolal 110 100.0 How OrteD do you absentvourselrrrom work Oft," 0 0.0 Very often 0 0.0 .....y 73 66.4 Not. all 37 33.6 Total 110 100.0 As shown in Table 4.4, most 97 (88.2%) of the rnpondents stated dw they reported to work e.rtyandI3(lI.B%)saidno Most 10 (72.7) of the respondents said lhey were able 10 meet thcir Kt goals at worklnd 30 (27.3) stated thatthcywere not University of Ghana http://ugspace.ug.edu.gh AdditionaUy, 77 (70.0%) of the respondents Slated that they were not depre5sed due 10 aa.reWon Mnd violence at the hospilal and 33 (30.0%) slated yes. Also,most75(68.2~)oftherespondentssaidtbeyfeltanxiousduetoaggressionandviolenceat the hospil&l and 35 (31 .8%) saKI disagreed. Oul ofll0 (IOOJ)I'4) of the respondents. 97(88.2%) said that they had been takenex.tra duty afterworkandI3(II.So/.)sa.tedno. Finally, when respondents were asked on how often the)' had absenled themselves from work, 73 (66.4%)statedrarelyand37(33.6~o)statednotatall . 4.STbeprevalenceofaggressiOllandvioieocea.tbeAa:raPsychiatrictiospi.al This scctton anaIyges the prevalence of aggression and violence at the Accra Psychiatric Hospital uSlna rcconts from the hospilal from a period often yean. The report covers the male and female .... ard bctwcen 2008 and 201S, A total of 294 cases of aggression andviolcnce were recorded at the Accra PsychiMric Ilospiial. Oul of the total 294 cases. 156 were male staff and 138 were female_fT. The re:port reveakd that thcre was prevalence ofag,sression and violence at the Accra Psychialric Hospital. The aggression and violence recorded included the use of abusive words including tbrab, physical assaults on nurses as well as fellow patients like rape. beating ofnursn or fellowpatientsaswell~theuseofobjectstoanacknursesandpllticnts. From the report it was revealtd that in 2008. only two Ca.$CS were recorded in the male ward whcras no case was recorded in lhe fcnl&le ward. In the year 2009, nine casc:s were recordcd in bulb Cbe male and female ward. ConseqUCDlly the year 2010 saw 18 cases in the male ward and University of Ghana http://ugspace.ug.edu.gh 16cascs mthefcrnak ward.1nthe ye.20II. 13 cases wertrecMded in the mile ward and II in the femak ward. The year 2012 saw one Cast in the male ward and 14 C&KS in tM female ward whucas in the year 2013. nine cases \'/ere rttorded in the male ward and five casei were rc:cordedi"lhefemaleward . ln2014.14cascs~rttordedinthemalewardandl)casesjn cbe fanale ward. Funhmnore. 2015 hid 29 cases in the male ward and 20 cases in the female WInI. ConscqumtJY. in thc year 2016,22 cases were recorded in the male ward and 16 cases wert recorded in Che female ward. For the year 2017. 35 cases were recorded in the male ward and 26 cases in the female ward whereas in the )'ur 2018, four cases were record~ in the male WIrd .rid eight cues were recorded in the female ward. Based on the repon the total number of cates in the mak ward rccOf'd from 2008 10 201 8 was 1S6 tases were in the female ward thelOUl The n:pon funher revealed the highest incidents of violence and aures5ion reported by the 00sr· .... , wu in the year 2017 with 35 cases in the male ward and 26 cases in the female ward. Oa the ocher hend. \he k>wC'Sl incident was in the year 2008 with only two t"ases in the male ward and no case m:orded in the female ward. University of Ghana http://ugspace.ug.edu.gh ••6 The dln::t of acgres.siOD and vio~Dce OD tbe work OUlp.t of i.patient bealtb workers at Acua Psychiatric Hospit.al (l'sing Pereeatages aDd Frequencies). Table 4.5 Aa:gression and violucebebvior Doyo.ueerinceauressivebebaviorattbeboseita' Ves 16 110 ~:JOfteD do roe experience agcressioe bdlavior ~t the h~~1 --~2~7--~2~45'---- Frequently 58.2 Sometimes IW% 63.7% HllbyAPa'iC'AI 1.363 0.243 Y" 43.M'. 56.4% No 32.4% 67.60/. Kicked By • .,.fint, 1.364 0.243 v. 25.0% 75.0% 38.9% 61.1% University of Ghana http://ugspace.ug.edu.gh 11.9590.001 ShCMIted AI By A 29.3% 70.7% 72.2% 1.100 0.294 Source: (Fitld Oata.201S) Thetab5e p~entsthe Percentage diSlr'ibulion of productivity bychnracterislicl' (Aggression Related) of the respondenu. Among the respondaus who agreed they expc:ric:m:cd aggressive bd\avKlur 81 the hospital , most (69.1%) are highly productive whilst OO.9Yo) have low productivity. Also. most (68.8%) of the respondents who has ne ver experienced aggreSiive bcl-wlviour II the hospilal have low productivity whils t (31.3%) have high productivity. This rdaaionship is stMiItically signiflC&lll at 5% significance level with a P·value of 0 .004 Also, Most (63.00/.) of the respondents who frequentl y experienced aggressive behaviour were hipl) productive whilst (37.0%) have low productivity. Most (64.1%) of the respondents who ~imccxperiencc:daggressivebehaviourhavehighproductivilywhilst(35.9%)tt.veJow productivity. Furthermore, moll (63.6%) of the respondcnts who rarely experienced ag8fnsion behaviour equally have high productivity whilst (36.4%) have low productivity. This relationship isnocSlatisticallysignifacant. In additton. amana the respondents wbp bave ever been bitten by II patient, most (62.5%) have hip productivity whila (37.5%) have low productivity. Also, most (63.7%) of the rnpondcnts University of Ghana http://ugspace.ug.edu.gh who had never been binen by. p8lient have high productivity whilst (36.3%) have low productivity. This relalionship is not statiitieaJly signilicant. Fu:rthmnore, a liuk more Ulan half (56.40/.) of Ule- tnpondenlS who had ever been hit by a paeie-ne have high productivity whilst (43.6%) hive- low productivity. Also, most ( 67.6%) of the- rcspondcnb who had never been hit by. ~tient have high productivity whilst (32.4"-0) have low produccivity. ThiJrelalionshipisnotstatisticallysignificant Also, most (75.0%) of the respondents who had ever been kicked by a patient have high productivity whilst (25.0%) have low productivity. In addition. Most (61.1%) of ehe respondents who had never been kicked by a patient have- high produceivity whilst (38.9%) have low productivity. Thisrtlalionshipisnotstatistieallysignificant Abo, most (70.7%) of the respondents who ever been shouted at by a patient have high productivity whilst (29.3%) have low producti\lit)·. In addition. most (72.2%) of the respondents who had never been shou~ at by I patient have low productivity whilsc (27.8%) hIVe high pruducti\lit) . This relationship U statistically signilicant at 5% signilicance level wi thap.vllue Finally. M~ (70.00/.) of the respondenu. had ever been pushed by a patient hIVe high produccivity whilst (30.0~) have low productivity. Also, most (60.0%) of the respondents who h.d never been pushed a patient have high productivity whilst (40.~/o) are have low Pl"Oductivity.Thisn:lationshipisnOlslatisticallysignificant University of Ghana http://ugspace.ug.edu.gh •. 7.2 Lo&h:tk Rq:rft.!ioa (AggJU!lioD Rel8ted factors and Inpatient Hcall" Workers ProchKriYity at Accn Psycbilltric: Hospital (APH» TaWe4.7 ~isric: Recressioe (~aressioD Welated Factors and Inpatient Workers Low Productivity Versus High Productivi!! Odds Ratio 95·/. p- CJ value Variabla UDDer ~:«OrAnrft.!l\'C' V" 1.00 No 4.02 0.957 16.894 0.058 Fl"flqlleDIorEIperienceor AUnuioD Frequently Somse control. and any time they were 10 anend to a mental health patient. the memory of ever been iboulCdatortbe fear of being shouted wouldbeprovokedandthiscouldserM>uslyatT~t dleirproductivityanddle vice vena istnaeforthose who had never experienced shouting • that is, they would have control and work effectively and efficiently which would increase their productivity. This wu similar to the study conducted by Spencer et aI., (2010), which identified fear as one of the many aftermaths of the acts of aggression and violence towards health care AIIo. the study revealed that nurses or inpstient health workers who nevcr experienced vio&ence of any form an: mure likely to be productive than those who has ever experienced violence. This University of Ghana http://ugspace.ug.edu.gh may be ti a I"HU1t of the: ~t that vicHenot in nature impedes growth and development and productivilyti well. lbat is when the health workerexperiencevioience it can have a physical hann on them or it can have an emotion depreuion on them, in whkh ever way it would affect their productivity. Simll., mults were obtained by Lanna e1 al (2016) who conducted a study ontheerrecuofviolc.nceontheperformanceofn~sandcontludedthatnursesbecome cynicaJ on dcaling with violence from patient and nurses' wellbeing could be afTe<:tedand this could make nuning compliceted. 5.3I105pitlll mau#cmcnt's raponse to aglras"* aMI violence On the fC')ponr.e to ag~"ive and violent behaviours by patients, most (57.3%) of the mpondenb Indicaled \hat it was not effective though several response measures, including mcdtcation, scclusionand nesociation withpatknls were highlighted. In summary, though the hospital used seetusion. medication and neJOti.lion with patknt.'> as ways of managing Jlggr'C'Ssiontnd violence. they were notefTective. The resuits are similar to the study conducted by McCMn (2014) on the attitudes of clinical staff towards the cau$CS and management of agaresmn in acute old aaepsychiatry inpatient surroundings, Findings fromt hestudyreveatcd rnedicacion. ~latlon with patients and seclusion as the management response to ag&f'Cuion and violence by patlcntl. University of Ghana http://ugspace.ug.edu.gh cHAPTER SIX CONCIXSION AND RECOMMENDATION 6.IIDtroduC1ion This ehapter concludes the study and as well as make retommendation for policy makers and '.2COKlnioD The study aimed at exwnining the prevalence of agaression and violence at Acero Psychiatric: Hospital; Ihe effect of aggres.!>ion and vaoknce on the work output of inpatienl health workers at Acga Psychiabie Hospital; 115 well as the management response to apression and violence at Accnhyc:htMricHoipital From the study, cases of aggression and violence are prevalent in male patients than in female pldtcnts. On the effect of agrenion and violence on Yoorl< output, inpatient health worken MSmliflCd expcricnces acts ofaSgrnsion and violence in the form ofbcing bitten. shouted at. kiekcd, hit and pushcd by patients, and thcscsubscquentlyleadtoanxiety,depressionand extra woridoads or cIury after work. It was also revealed lhat inpalient health workers who had neYi:r beeashouledare more: likely to be productive than those who had ever been shouted at, also pIliaaI wbo bMI never experienced violence were more likely to be productive than lhose who had evcr expc:rienccd vioLenl;e. howcver,thc inpalicnt hrcalth workers indic.ate that the prevalenee oflqft:5Sion8lld violence by paUc:nlS do not have any signiflUlrt effcct on their ability to report 10 'Wd ~Iy. achieve set goal5 al work or being abient from work. University of Ghana http://ugspace.ug.edu.gh With respect 10 the manl&Cfflenf response 10 .ggres)ion and violence by pt.tlents. the inpatient hcalth\loorker" idenlify agr« to the use of three measures., includingmcdicmion, seclusion and flCllotialion. lIowever, they (inpatient health workers) indicate lhal these measures are not I "The results reveak:d that inpatient heallh workers are burdened with work duties due to agrcmon and violence by pMief'lls. To this end. the study suggests health institutions should bring in nev. tools. and employ more inpattenu health workers to relieve the overburdeningofalreadyexisling inpatienlhealth workers. 2. From thc sbIdy, ltwas revealed that inpatient health workers experienced several forms of aggression and violence by patients such as biting. shouting, kicking. hinina and pushing ..d to some extent !ohouting It the inpatients health worker and other violent acti'o'itiesaffa:t their productivity to reduce the prevllmc:c ofthnc physical attaeks and aurcuift behavioun and \0 increate the productivity of inpatient health workers. the stud) recommends that. health institution should organize de-escalation training pr'OII"MtS for the inpalimt health worken. fbe training should focus more on competent inaeractionsrnpectin.pltienu'penpectivessochaslistening.distractin.andre-focusina the patient on wmething prn.ili'o'e. u!'>ing humour, givin, choices and -.el1ing limits, 3, 1nellUdyrecommendsthatfuturestudieiishouldincludernoreinpllienthcallhwork~, • well. other hospitals to help make a better generalisation of the study fandi.nas. University of Ghana http://ugspace.ug.edu.gh REFERENCES Accra Psycm.lric Hospital. (2014). TIw Plight of lite P!»'chiatrlc Nur-se. Retrieved from https:lJaccrapsychiatrichospital.orgtpagesJpostsIthe-plighl-cf-a-psychjauic-nurse-20.php Allen. J. J .• &: Anckrson, C. A. (2015). AggrwJSion and violence: definitions aNi d'sllltClions. Rca1evcd July 25. 2017, from: http://public.psych.iU1ate.eduicaalabstractsJ20IS- 2019l17AA2.pdf Aimvik. R.o Rasmussen, K., & Woods, P. (2006). Challenging behaviour in the eklerly- monitoring violent incidents. International Journal a/Geriatric PsychiDiry. 21(4). 368- Antonysamy. A. (201l). How can we reduce violence and aggre. . !>Isive in residc;nlial care sctlings. JoWItQ[ of PsycltiIJlrIC and Mental Health NurSing. 2011 . 18(2):97-104. SchaNon. A .• Zeh. A., WendeleT. D .• Peters. C .• Wohlert, C., Harling, M . &Nienhius, A. (2012). Frequency tmd comequelfC8S of violence aNI aggression towards employees in the German healtheare and wt>lfare system: a eros.r~ectiona( study. Accessed July 24, 2017, (rom: hnp:llbmjopen.bmj.comfconlentJ2J5/eOOI420 Spmcer. S .• Stone. T .• & McMillan, M. (2010). Violence and aggressIon 'n menial heo/iit ityNllw/'llllllits: an evoIlIJQJion of aggres.!lan minimisation progratfU. RelTieved August 1. 2017. from : joumaJs.sf'u.ca/hnrhlindex.phplhnehlarticleiviewFilel70161 Swnc. T.E. (2009). Swearing ' impact on nurses and impliCQIlons for thera~ulic practice Unpublished PhD lhesis ptC"SCtIted to the University of Newcastle. Australia. Whiuinston. R., & Ridller, D. (2006). From the individual to the interpersonal: environment and inta-action in Ihe escalalion of violence in menial health seuings In: Richter, D., &. Whittington, R. VlOknce In ,.nlQJ heallh ulling3: Cm4e3, cunsequenc~s, manORement. New York : Springer. I.lntra T. Anuila M, Komio R, Adams C, E &Vlllimiki M.,(2016). Violent events, ward climate and ideu (or violence prevention among nurses in psychiatric wards: a focus group study. 'nlerntllW:Hto/ JoIITItDJ ofM ental Health Systems 10, 27 OIuponaT, Vin: I, Ishol8 A &AkereJe E.,(2017). Aggres.skln rate in acute inpatient psychiatric ;~:PP~~t7~f substance abuse and psychosis. MOJ Addiction Medicine &: Therapy University of Ghana http://ugspace.ug.edu.gh Owen C. T&I'1IfltcUo C. Jooes M &: Tennant c.. (NO). Violence and aggression in psychiatric units. Retrie ... cdfrom https:lIPS.PSYchi8tryonlin~ .orgIdoilIO.11761PS.49.lI.l452 APPENDlCI-:S QUESTIONNAIRE l."astudentfromtheUniversityofGhatlaundertakingaresearchpwjeclinPartiaJ Fulfillment or the Requirements for a Masters Degree in Public. Plnse you are assured wt information Biven for this project will remain confidential and will be used only for academic purposes. ln~eyourdKIieebYlickingappropriale)yandfeeifreeloeommcntwhcTenecessary. QOI QUESTION I All' a)20-29)caf')IJ AGE I b)30-39)'earsIJ C) 40-49 years I I d)50-6()y. .... 11 2s.. a) Malel) GENDER b) Female[] 3 EdueaUonaluve) .) Cenir. .... [ I EDUCA b) Diploma II c) AdvanocdDiplomal1 d) De_II '-- University of Ghana http://ugspace.ug.edu.gh e) Otber(Plcasespec:ify) ....... ········ REUG 4 Religion a) Christian() b)bIam[1 e) Tr.ditionalisliSpiritualistll d)Other[1 J-4yeanll lENPRACT S Forhowktng 0) .... vcyoubcal b) S-9yearsll e) 1O-14yeanll d) J5-J9yean I I e) 20yearsormore() Sec1ioD B: A&grasioa and "iolent behaviour 6. Doyouexpmence 0) Yesl I auressionbcbaviourat b) No II tbchMpital'? 7.~oftendoyou a) Frequcntl)'[} OFTABH b) Sometimesll o)RaroJy II University of Ghana http://ugspace.ug.edu.gh form of a) Biting () FORMAGR 8. What aggInSionoccurs b) Hitting II trequently .. the c)K.icking[] hospital? (Tic/cmore Ih.,. Oll~ Ifp Msible) d)Shouting[J c)Pushins I) 9. Have you ever been a) Yes() bitten bya patient b) No( I before? 10 Haveyouc'9'crbeenhil a) VesT 1 HBNT by a patient before? b) No( J II Have you ever been a) Y"I J HYEBK kickcd by a patient b) No I J 12 Have you ever been .) Yes! J w.outcd at by a patient b) Nol) 1) Have you ever been .) y.,1 J HBPB pushcdby a patienl b) Nol ) bcf"",? ~ University of Ghana http://ugspace.ug.edu.gh IS How~do)'OU HFDVB .) Frcquenll y {] expcric:nctrioicnt behaviours al the b) Sometimes I J hospital? c) Rarely () 16 Haveyoucverbten a) Yes [ ] HSHP sexually Mnsscd in ."ywaybyaJMIient b) No ( ) before? 17 Has a patient physically a) Yesl ) HPPAB anacked you before at """". ....I ? b) No I I SKlfu_C: work CMltPIiC oflnpatieot health wor-kcrs. ~ QUESTION . A-N-SWE-'R--- CODE r - II Do you report to iI) Ycs( J worlc.carJf' b) No (1 I Ale youllb&e to meet .) Yesl I AYBMG )'0\1 5ct goalsal b) No {J 20 Havcyounerbeen a) Yes I 1 HYEBD ~du,to b)No(1 """""ond 21 HaveyouevcrfeJt a) Yes( I HYEAV 8AAioulducto b) No II aqn:ss.,nand violenu at the hospital? University of Ghana http://ugspace.ug.edu.gh 22 Doyoutakeoncxtnl a) Ycs(] DYTED duty after ""OI"k? b) No ( ] 23 Howoftmdoyou c) Often HODAW absent yourself from d) Veryoftcn e)R.arely o Not aI all Section D: Itospital manag«:men"s response til a~g,,('ssiun aad ,,~.ce ~ESTlDN I a) Ves[ I 24 ~;:-=I)'1O ~ond b) No[ J violcnc:ebchaviourm ~S~~;;-t -+~a)~Y~"~[-J- - -----+=--='"'---" rcsortto mcdication ,1=0 m_anage aggrenion b) No J J andvioltenhcc e 26Do~USoe a) Vcs(] KCIusion as a form of rnanaa:inlaareuton b) No [1 ~~:::thC I h~wl? 27 00 m. ... ..,ent I a) Yes [ J nqocioIcwdh ~ ... fonnofl b) No [ J n-.gina agness ion and.,iolcntbeha.,iour atlhchosoital? 21 Whatother s Plcase&tale .... . ... areu.sedto respond to agrasicmand viokwbeha¥iourby ~_ ... the University of Ghana http://ugspace.ug.edu.gh ThonJcyou APPENDrx2: P'urpoworlhestudy I am AngdaAdomaa Hanson Adjei·Sarpong of University of Ghana Public Health School. This qutsttol\Nlire is foc- a survey to 8~quire data for my MPH research on th~ topic: "Aggression And Viok:nc~ In Mental Health Inpatient Units : A Case Study At The Accra Psychiatric Hospital" The study has been approved by the Ethical Review Committee of Ghana Health Scntce.informalion obtained would be us«l for purely academic purposes and treated with absolu1.tconrtdcntiality. PlebClickasappropriate I'hank you for your time. Priuql CHfidNliality Abo 10 ensure anonymity lind confidentiality. respondent~ will not be required 10 write DatliStorageandUule Thequesc~usedbythestudywjllbeunderthecareoftheprincjpaJinvesligator.Thehard copy will be coded into the data base of statistical software, The hard eopy of the data will be under lock whiles lhc 10ft copy will be saved on • computer under a password known only to the ~investigator.AbaCkuPortheSOftcOPywillalSObekePtonapendrive'ndkeptUIl