JOURNAL on the Article The Effect of ACT-SMART on Nurses' Perceived Level of Confidence Toward Managing the Aggressive and

Violent Patient By Donna Cahill RN, MSN, CNS, CEN

SUMMARY of the Article

The article discussed that Aggression and violence, are healthcare problems of international proportions, it creates a significant risk for nurses and results in an unsafe work environment. Workplace aggression and violence is recognized as a major international public health problem within the healthcare community. The long-term consequences of this problem significantly affect the nursing profession and pose a major threat to the delivery of quality patient care and patient safety as stated in the article. The patient or the patients significant other in an emergency situation is stressed by the trauma that had happened to their patient, this leads to an aggressive and violent behavior which becomes non-conducive to the working atmosphere of the health care team and in extreme cases can also be a threat to their safety. The ER nurse's ability to quickly and accurately recognize, assess, and intervene with the patient or family member demonstrating behaviors that predispose them to aggression is paramount for ensuring a safe work environment. Effective communication skills provide ER nurses the ability to quickly establish trust and supports early interventions when the patients or family members are exhibiting signs of anxiety, frustration, and stress On the other hand, the article also mentioned that Escalation occurs primarily when the patients or family members do not understand the information they are given, feel that they are not being understood, or feel that their perceived emergency is being ignored. If the nurse is unprepared, unaware, and inadequately trained to recognize a patient or family member beginning to escalate, the ability to maintain a safe work environment is in jeopardy. To address this, the article presented a program called ACT-SMART, which stands for Attitudes and Communication Techniques for Scripps Mercy Aggression Reduction Training, provides nurses theory and specific communication skills which as claimed would increase the efficiency of nurses in managing certain situations. The program was designed to meet the needs of the Scripps Emergency nurse and to improve their communication skills when interacting with the difficult, manipulative, and/or aggressive patient. Another intention of the program was to decrease the perceived inappropriate use of force to restrain and detain patient's actively threatening staff ACT-SMART is an 8-hr educational training program that was developed referencing professional standards for the Emergency Nurses' Association and the American Psychiatric Nurses Association for managing the aggressive and violent persons. The ACT-SMART program was designed to emphasize the theory of interpersonal communication, crisis communication, the cycle of aggression and violence, and the legal issues associated with patient rights and physical safety measures. The specific objectives of the educational training program are to provide: (a) a discussion of professionalism and an associated exercise to reflect on how each nurse individualizes professionalism with the institution's mission statement;

(b) identification of generational and cultural issues that impact communication styles; (c) identification of strategies for improving communication among patients, family members, and other healthcare providers; (d) an examination of behavioral characteristics associated with the cycle of aggression and violence; (e) discussion regarding proper interventions for de-escalation; and (f) practice of specific evasion techniques and proper patient containment measures

Significance to Nursing Practice

Nursing is a service-oriented profession whose members typically model behaviors described as caring, compassionate, and empathetic to understand and meet the patient and family needs. Aggression and violence perpetrated by the patient diametrically opposes the ideals of the nursing profession. A secure work environment is essential for the nursing profession to ensure high-quality patient care and safety within today's healthcare environment Providing a safe work environment is high priority for healthcare organizations and may reduce the risk of future legal liability associated with workplace injuries. The consequences of the ER nurse's loss of self-confidence and discomfort with the perceived unsafe work environment have the potential to cause a decline in clinical performance and job satisfaction. The impact of decreased job satisfaction may adversely affect nursing retention and the ability of the hospital to recruit younger nurses. Workplace aggression and violence is cited frequently as the reason healthcare institutions have difficulty retaining experienced nurses. The potential for a nurse to leave the profession as a result of an unsafe work environment caused by repeated exposure to patient aggression and violence is intolerable and has significant ramifications for the professional community further aggravating the current nursing shortage. Education provides ER nurses with the theory of interpersonal and crisis communication, the cycle of aggression and violence, and the legal issues associated with patient rights and physical safety measures that promote rapid and accurate identification, assessment, and interventions for the potentially aggressive situation. Awareness of self is vital for the ER nurses to respond to situations appropriately and not impulsively. Personal self-awareness allows ER nurses to step back and be more objective and respectful with the patients and the family members and supports more positive interactions. As claimed by the article, education and training may not necessarily reduce the nurse's exposure to violence. However, the education and training does support the improved assessment skills for recognizing the anxious or distraught patient or family member and enhanced communication skills and interventions for effectively dealing with patient anxiety and fear, precursors to the escalation of aggression. Together, they have the potential to significantly reduce patient escalation, impulsive behaviors, and volatility of situations ultimately producing a safer work environment. The additional benefits that this education promotes are related to the dignity and respect provided and maintained for both the patients and family members. There is also a decline in the need for force or the associated inappropriate use of force and restraints. Success in

managing the situation supports a self-efficacy for the nurse. Feelings of success promote a change in behavior and have the potential to impact personal attitudes and morale, and provide a sense of satisfaction in meeting patient needs with care and compassion. Satisfaction with personal performance is significant for perceived job satisfaction.

Significance to Nursing Research

On the basis of the small sample size, there is a strong recommendation to continue this study and to consider replicating the study with a dedicated group of emergency nurses only. The researcher may seek an extension for gaining more data to support the current findings. A longitudinal study is suggested to validate the sustainability of perceived confidence. With future studies, it is recommended that the questionnaires be adapted and modified to support responses by general healthcare providers. Another strong recommendation is to continue to evaluate the educational program on a monthly basis and to develop a plan for obtaining a longitudinal evaluation to determine the long-term effectiveness and sustainability of the respondent's confidence. The study may also be conducted in our own setting and the results may be used to improve on the efficiency of nurses in our practice especially in dealing with aggression and violence.

Significance to Philippine Setting

As stated, the study may also be conducted in our hospitals in the Philippines. On our duties we witness several events of aggression and violence. The ACT-SMART program may also be implemented here so as to increase the efficiency of us nurses and decrease the use of force or restraints to manage such aggression and violence. Remember we our nurses, we are suppose to follow certain principles, one which I can relate is the principle of beneficence which is to do no harm, and as I have observed, restraining or the use of force to manage aggression and violence certainly inflicts harm to our clients and even hes family members.
REFERENCE:

Advanced Emergency Nursing Journal July/September 2008 Volume 30 Number 3 Pages 252 268 http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=812225