Open Journal of Nursing, 2013, 3, 426-436 OJN Published Online October 2013 (
The feelings and thoughts of mental health nurses
concerning the management of distressed and disturbed
in-patients: A comparative qualitative European study*
Vida Staniulienė1, Mary Chambers2#, Xenya Kantaris2, Raija Kontio3, Lauri Kuosmanen4, Anne Scott5,
Maria Antónia Rebelo Botelho6, Renzo Zanotti7, Maritta Välimäki8
1Faculty of Health Sciences, Klaipėda State College, Klaipeda, Lithuania
2 Faculty of Health, Social Care and Education, Kingston University and St. George’s, University of London, London, UK
3Department of Nursing Science, University of Turku and Hospital District of Helsinki and Uusimaa, Tuusula, Finland
4Department of Nursing Science, University of Turku, Turku, Finland
5Dublin City University, Dublin, Ireland
6Nursing Research and Development Unit, Escola Superior de Enfermagem de Lisboa, Coimbra, Portugal
7Department of Molecular Medicine, University of Padova, Padua, Italy
8Department of Nursing Science, University of Turku and Hospital District of Southwest Finland, Turku, Finland
Received 21 August 2013; revised 22 September 2013; accepted 19 September 2013
Copyright © 2013 Vida Staniulienė et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
High levels of distress and disturbance amongst those
experiencing acute mental illness can be a major
problem for mental health nurses. The feelings ex-
perienced by these nurses when caring for and sup-
porting disturbed and/or distressed patients along
with their concurrent thoughts are not well described
in the literature. To date, this complex issue has not
been explored within a comparative European con-
text. The objective of this qualitative study was to
explore the feelings and thoughts of mental health
nurses when supporting and caring for distressed
and/or disturbed patients in 6 European countries.
Methods: Focus groups were used to collect data
from 130 mental health nurses working in acute inpa-
tient psychiatric settings. Results: Data were analysed
using content analysis. Findings highlighted 6 broad
themes: 1) Mixed emotions: expressive and respon-
sive, 2) Procedure for caring for and supporting dis-
turbed and/or distressed patients, 3) Use of guidelines
for caring and supporting disturbed and/or distressed
patients, 4) Team and organisational support, 5) Ethi-
cal concerns: Cognitive dissonance and 6) Education
and training. Commonalities and differences were
found across all themes. Approaches to care, nurses’
role and education, clinical guidelines and/or stan-
dards vary from country to country, therefore the
care, treatment and management of distressed and/or
disturbed patients are various. As a result, mental
health nurses have different experiences, various emo-
tional quandaries concurrent with cognitive disso-
nance and different coping strategies when caring for
and supporting distressed and disturbed patients.
Conclusions: More emphasis needs to be given to the
emotional quandaries and concurrent cognitive disso-
nance experienced by mental health nurses caring for
distressed and/or disturbed inpatients in acute psy-
chiatric settings. Increased access to education and
training with particular attention to interpersonal
communication and relationship building within clini-
cal teams needs to be a priority given the experiences
described by mental health nurses.
Keywords: Acute Inpatient Psychiatric Settings;
Cognitive Dissonance; Coercive Interventions; Feelings
Mental Health Nurse; Thoughts
*Funding: This project has been funded with support from the Euro-
ean Commission’s Leonardo da Vinci programme (2006 FI-06-B-F-
PP-160701). This article reflects the views of the authors only, and the
Commission cannot be held responsible for any use of the information
contained herein.
#Corresponding author.
Mental health problems are the fastest growing burden
for healthcare internationally [1]. Globally, 450 million
people suffer from mental health problems with 1 in 4
having experiences of mental health services at some
V. Staniulienė et al. / Open Journal of Nursing 3 (2013) 426-436 427
point in their life [2]. Of the 7 key areas identified by the
WHO European Ministerial Conference on Mental Health
(2005) [3], emphasis was given to the promotion of vol-
untary admission and treatment as the basis of services
and involuntary treatment being the exception [4]. Per-
sons treated in psychiatric institutions still experience
discrimination and violations of their basic rights due to
the stigma associated with mental health problems [5].
These violations tend to be related to the use of coercive
interventions [3]. Common forms of coercion used dur-
ing inpatient treatment include seclusion and mechanical
restraints, physical holding, restricted leave and forced
psychotropic medication [6-8]. However, such coercive
interventions should only be used as a last resort/re-
sponse. Coercive interventions may be “justified” in a
crisis situation that appears to present imminent risk of
harm to the patient, staff and/or others [9] to control agi-
tated, aggressive and/or otherwise harmful behaviour
[10,11]. Persuasion to take medication may be very coer-
cive, even if physical force is not implemented [6,12].
Limitations to receiving visitors, denying patients’ “va-
cations” from the ward and restrictions in using the tele-
phone are also forms of coercion frequently seen in psy-
chiatric care [6,8].
The reported rise of patient aggression/hostility in
mental health inpatient settings has been of interest to
researchers for some time [13-16]. The topic is important
as this behaviour can be a major problem in healthcare
institutions. It has been estimated that in the UK about
70% of nurses working in psychiatric institutions have
been assaulted at least once during their career [17]. Lit-
erature has indicated that patient aggression/hostility
may be caused by nurses’ high levels of anxiety and/or
insecurity [18,19], counter-aggressiveness or a lack of
confidence in personal and professional competence [17].
The reactions and coping strategies adopted by mental
health nurses are frequently short cuts such as the use of
coercive measures or the reduction of contact with the
patient [13,19,20].
Gournay (2005) [21] identified that the nature of the
nurses’ role in acute settings has changed and has be-
come one of the most difficult areas of psychiatry. Coer-
cive practices are complex issues that are ethically chal-
lenging because they restrict an individual’s autonomy
[22,23]. There exists a discord between ethical values
and the coercive interventions used that can cause prob-
lems such as the conflict between caring for and control-
ling the patients [6,24,25]. To control and to help are
often interrelated especially in psychiatric settings. The
implementation of restrictions includes the risk of misuse
of power and perceived punishment, even if the ex-
pressed purpose is good [6,26]. Nurses may experience
negative feelings towards the distressed and/or disturbed
patients who have been involved in the use of coercion
[6,18,27] and feelings of discomfort can be produced
[28]. In acute environments, staff may not have the nec-
essary clinical skills or time to be able to manage dis-
tressed and/or disturbed patients, consequently resorting
to other methods of containment. This can generate dis-
sonance for staff as ethically and professionally they
wish to avoid using such measures but sometimes have
no option. Some nurses have expressed concerns about
the unsuccessful search for and use of alternatives to
using coercive measures [29].
The feelings and thoughts experienced by mental
health nurses when caring for and supporting ex-
tremely distressed and/or disturbed patients are not
well articulated, yet they would seem to influence the
nature and quality of care [13]. In acute clinical envi-
ronments, patient care and treatment are the responsi-
bilities of the multi-professional team. Mental health
nurses feelings and thoughts and duty of care are the
responsibilities of the whole team. It has been docu-
mented that the feelings and thoughts of a single team
member can impact upon the whole team and its in-
ternal and external dynamics [6,30].
This paper reports on one element of a European
Commissioned Leonardo da Vinci-funded Project:
ePsychNurse (F1-06-B-F-PP-160701). The project
was concerned with the continuing professional de-
velopment needs of mental health nurses regarding the
care of distressed and/or disturbed patients. Partners
from 6 European countries participated: England,
Finland, Ireland, Italy, Lithuania and Portugal. De-
scribed within the paper are the feelings and thoughts
of mental health nurses regarding the care and support
of distressed, and/or disturbed patients within acute
inpatient settings across six different countries.
2.1. Setting and Participants
The settings for the study were acute psychiatric inpa-
tient units in England, Finland, Ireland, Italy, Lithuania
and Portugal. All the units were “state-run” and were
either part of a general hospital or a larger psychiatric
hospital. Six in-patient care organisations participated in
the study. Patients within the units were a mixture of
detainees and informal admissions.
A purposive sampling frame was used [31]. Mental
health nurses who participated were identified by their
managers. The inclusion criteria for the study were being
a licensed/registered nurse, currently working in an acute
in-patient environment with at least one experience of an
aggressive event within their work setting. The partici-
pants needed to be fluent in the main national language
of their country i.e. Finnish, Lithuanian, Portuguese,
Italian or English, and be willing to participate in a focus
group discussion that would be audiotaped. All partici-
Copyright © 2013 SciRes. OPEN ACCESS
V. Staniulienė et al. / Open Journal of Nursing 3 (2013) 426-436
Copyright © 2013 SciRes.
pants were informed of the nature of the study through
written descriptive material and their informed consent
was obtained.
In total, 130 mental health nurses participated in 17
focus group interviews in the 6 countries. The number of
nurses in each focus group ranged from 6 to 11. The
characteristics of the sample are outlined in Table 1. The
majority of nurses were female, which is in line with the
general demographic data on nursing [32].The length of
participants’ working experience varied across the coun-
tries with the majority (n = 57, 69%) having worked in
nursing in general between 5 - 25 years. The mental
health nurses in 5 of the countries all completed their
basic education/articulation examination; England data is
missing, but we can report that 75% of mental health
nurses in the sample completed similar education.
2.2. Data Collection
Focus groups were chosen as the method of data collec-
tion offering the opportunity for peer support, exchange
of ideas and sharing of common values [33,34]. One of
the assumptions underpinning the use of focus groups is
that the group dynamic can assist participants to express
and clarify their views in ways that are less likely to oc-
cur in a one-to-one interview. The group environment
may offer a sense of “safety”, to those feelings anxious
for whatever reason [35]. A data collection protocol was
developed to assist with standardization across the coun-
tries to help ensure a comparable data collection process
[36]. In order to reveal mental health nurses experiences
of working with distressed, and/or disturbed patients in
the different European countries; guidance questions
were formulated based upon expert opinion and a litera-
ture review.
A pilot study was undertaken in each of the 6 countries
to test the suitability of the questions in terms of wording,
content and clinical appropriateness. The outcomes were
shared across the partner countries and minor modifica-
tions made according to country need. Each focus group
was carried out by 2 experienced interviewers. Partici-
pants were required to complete a short socio-demogra-
phic questionnaire prior to the commencement of the
focus group. Each focus group was audio-recorded and
had a duration of 1 - 2 hours. Non-verbal communication
and the interactions between participants were noted by
the interviewers.
2.3. Ethical Considerations
Approval to conduct the focus groups was obtained from
the appropriate local health authorities and/or research
and development committees in each country. Approval
from ethics committees was not required as the research
did not involve patients. All participants were assured
anonymity and confidentiality and informed they could
withdraw at any time. Formal written informed consent
was obtained from all participants.
2.4. Data Analysis
The data from each focus group were transcribed verba-
tim and content analysed using the technique outlined by
Downe-Wamboldt (1992) [37]. This involves the analy-
sis of words, phrases and categories, so that themes can
be identified. Participant anonymity and confidentiality
were maintained at all times with identifiers. The extrac-
tion process involved highlighting any phrase and/or a
sentence made by participants that referred to the feel-
ings and thoughts they experienced when caring for and
supporting distressed and/or disturbed patients.
In each country the two researchers who conducted the
focus groups independently coded the transcript data
according to the project protocol for data analysis to en-
sure homogeneity of procedure. The coded data were
then compared and contrasted for agreement and finally
reviewed by an independent researcher for verification.
Where necessary, all coded data were then translated into
It is apparent from the data that mental health nurses who
care for and support distressed and/or disturbed inpa-
tients in acute psychiatric settings experience emotional
quandaries and concurrent cognitive dissonance. Cogni-
tive dissonance is the termed coined by Festinger (1956)
Table 1. Characteristics of the sample.
Characteristic England Finland Ireland Italy Lithuania Portugal
Sample size (n) 12 22 23 33 20 20
Male/female 5/7 10/12 8/15 10/23 0/20 10/10
No. of focus groups 3 3 3 4 2 2
Age in years (majority) 31 - 40 44 (mean) 31 - 51 40 (mean)51 31 - 40
Years worked (majority range) (no in
current employment as a mental health nurse 6 - 15 (3) 16 - 25 (11)1 - 15 (16)6 - 15 (19)26 (13) 6 - 15 (8)
V. Staniulienė et al. / Open Journal of Nursing 3 (2013) 426-436 429
[38]. It is the discomfort experienced when simultane-
ously holding two or more conflicting cognitions: ideas,
beliefs, values or emotional reactions. Festinger (1985)
[38] states that in a state of dissonance, people may
sometimes feel disequilibrium like frustration, hunger,
dread, guilt, anger, embarrassment, anxiety. According to
Spencer and Myers (2006) [39] cognitive dissonance is
the distressing mental state that people feel when they
find themselves doing things that don't fit with what they
know, or having opinions that do not fit with other opin-
ions they hold.
From the analysed data the following six broad themes
were identified:
Mixed emotions: expressive and responsive
Procedures for caring for and supporting distressed
and/or disturbed patients
Use of guidelines for caring and supporting disturbed
and/or distressed patients
Team and organisational support
Ethical concerns: cognitive dissonance
Education and training.
3.1. Mixed Emotions: Expressive and Responsive
Caring for very distressed and disturbed patients evoked
strong emotions that were shared across all countries.
Fear and anxiety for their own safety, the safety of the
individual patient and others were paramount e.g. “Its
not nice—the worst part of the job Fear (Ire-
land)…“Fear, anxiety” (Finland).
Most participants highlighted fear of the unknown pa-
tient as particularly anxiety provoking e.g. “not sure how
they will react” (Italy). This fear was confounded if there
was a sense that not all team members were playing an
active role in managing the situation, “or were denying
their own fears” (Italy). Italian nurses emphasised this
more than any other group but all the other countries
with the exception of Portugal mentioned it.
Damage to the therapeutic relationship was a further
fear especially when resorting to the use of coercive in-
terventions. All groups agreed that such interventions
had the potential to negatively impact on the therapeutic
relationship but sometimes unavoidable e.g. “Nurses feel
that they have failed” (Portugal). “Harms therapeutic
relationships so try to avoid it” (England). “A conflicting
feeling in the decision to use physical restraint” (Lithua-
It was acknowledged that in most incidents any initial
damage to a relationship is generally “short lived” and
maybe more distressing for the nurse than the patient.
Some participants were of the opinion that nurses taking
control, for example using seclusion is a relief for pa-
tients as they don’t have to take responsibility for them-
selves and/or they get “quiet time” something which on
busy acute wards may otherwise be denied to them.
A feeling of fear was also generated when nurses had
to resort to the use of coercive interventions. The fear
experienced here related to physical safety of everyone
but it was also associated with the possibility that nurses
might loose control and that professional boundaries may
be crossed in the heat of the moment e.g. “Lose the
self-control in physical or verbal assault, losing the right
professional distance” (Italy) “Fear, for the revenge of
the patient after restraint, in particular the mechanical
one” (Italy), “Traumatic for everyoneFear and ap-
prehension” (Portugal).
3.2. Procedures for Caring for and Supporting
Distressed and/or Disturbed Patients
This theme centered around what happens when a dis-
turbed and/or distressed patient is admitted to the unit/
hospital or when an existing patient becomes distressed.
There was general agreement across the groups regarding
the initial steps necessary to ensure safety and good
quality care. The importance of assessing patients’ men-
tal health status together with a risk assessement were
emphasised by all groups. This would enable staff to
determine the best approach to care and some felt it im-
portant too in giving an insight into the reason why an
individual was distressed e.g. “Try to understand the
reasons for the distressed behavior of the patient” (Italy).
Throughout emphasis was given to the importance of
individual patient care with good communication and
observation… “Must always try to embrace the patient
(Portugal). Whether or not staff know the patient an on-
going assessment of his or her risk is important (Eng-
Common to all groups was the importance of using
de-escalating approaches which took a variety of forms.
Establishing a good relationship with the patient was
considered key with groups suggesting different ways of
achieving this e.g. “To co-operate with the patient as
much as possible” (Finland), “Using interpersonal rela-
tionshipEstablishing good rapport” (Ireland)…
Maintain eye contact” (Portugal). Central to the good
relationship was speaking with the person in a respectful
manner using appropriate language “with cultural sensi-
tivity” (Ireland) and … “Allowing patients time and op-
portunity to talk” (England). Staff being non-confronta-
tional and having a friendly face on the ward, someone
that the patient knows was viewed as important. The re-
lationship is the primary vehicle of care (Portugal). Be-
ing attentive and using a gentle approach were viewed as
essential by participants e.g. Care in patients own room...
Co-operation between the wards (Finland), awareness of
open space—offering patient room to move around (Ire-
land). Some nurses also affirmed the importance of the
Copyright © 2013 SciRes. OPEN ACCESS
V. Staniulienė et al. / Open Journal of Nursing 3 (2013) 426-436
ward context:
A second de-escalating approach was “use of the en-
vironment” with importance given to calmness, low sti-
mulation, support and being positive. If the atmosphere
of the ward is calm and relaxed with friendly personnel
there are less aggressive behaviours (Italy). Having
nurses visible on the ward was viewed as essential to
generating the right environment. Finnish nurses strongly
emphasised this point. Further considerations were “En-
suring a low stimulating, calm environment” (Ireland),
Familiar environment and people have a positive ef-
fect” (Lithuania). “Positive actions in the situation and
establishing a healthy environment” (Portugal). If estab-
lishing a healthy, positive environment was not immedi-
ately possible then it was considered important to re-
move the patient to somewhere quiet e.g. “Time out, in
own room or other room away from rest of ward” (Eng-
Portuguese nurses were of the view that “Talking to
the patients and the relationship are enough to solve
some situations” and Italian nurses considered … “Direct
intervention to pacify the distress pacify the patients and
calm them down” was the best approach. Constant ob-
servation was viewed as necessary by Finnish nurses and
A good coordination with services is also considered
very important to avoid restraint” (Italy).
When all attempts to de-escalate the situation failed
and as a last resort coercive interventions had to be used
a lot of anxiety and distress was expressed amongst all
participants. Some considered it a failure in terms of
their clinical skills, team working and professionalism. A
range of coercive interventions were used such as physi-
cal and mechanical restraint, seclusion and chemical re-
straint. The views expressed in the groups with regard to
physical and mechanical restraint were a fear of hurting
the patient and of restricting their freedom e.g. Scared to
harm the patient holding him or during a mechanical
restriction (Finland). Feel bad because they have the
sensation to steal the freedom of the patient (Italy).
Restrains of any form were considered as always un-
pleasant for everyone with a negative impact on rela-
tionships and aprofessional failure e.g. It is always un-
pleasant restraint the patientsBroke the relationship
Guilt was another emotion expressed by the groups. A
feeling of guilt and anxiety (Lithuania). English nurses
were of the view that physical restrain and seclusion “is
more likely to be the outcome if the patient is severely
disturbed and psychotic and kicks off without warning”.
Finnish and Irish nurses considered medication to be
preferable to other forms of restraint. All of the above
were considered negative ways of coping with the situa-
tion. However, despite the strong emotions surrounding
the use of coercive interventions some groups felt that it
would be difficult to manage without them e.g. Hard to
imagine nursing without physical restraint as a man-
agement method (England).
3.3. Use of Guidelines for Caring and Supporting
Disturbed and/or Distressed Patients
This was one theme where differences across the coun-
tries was most marked. With the exception of England
none of the countries had national guidelines regarding
how to manage distressed and disturbed patients. In the
other countries the approach was guided by the organisa-
tion, unit policy, the clinical team or individuals. For
example, Finnish nurses reported that‚ “There is no
model how to treat aggressive patient or preventive/pre-
dictive treatment modelThere are only very general
In Italy, Lithuania and Portugalitis the doctors who
prescribe the interventions to manage the patient e.g.
The doctor decides the way to manage the patient”‚
Doctor is usually called by nursing staff during the
phase of aggressiveness” (Italy)‚ “Doctor takes the deci-
sion” (Lithuania). “There are no guidelines for the man-
agement of aggressive and disturbed patients except to
restraint a p ati e nt it is necessary a doctoral prescription
(Portugal). “Different hospital wards act in different
ways in the situation” (Ireland). Italian nurses stated that
the “Line of action varies depending on the patient,
There are not specific and/or structured guidelines or
line of action”. “Usually there is a common shared me-
thod that comes from experience” (Lithuania).
3.4. Team and Organisational Support
Participants were in agreement that both team and or-
ganisational support were essential. The nature of that
support ranged from having the opportunity to discuss
issues informally with colleagues, to the organisation
ensuring adequate staffing levels and staff having access
to occupational health in the event of an untoward inci-
Discussion with colleagues was viewed as highly im-
portant within all countries, for example‚ Discussion
with colleagues...‚ “Sharing of work experiences…”
Knowledge sharing between colleagues” (Lithiania),
Teamwork, solving the problem of taking care of ag-
gressive patients” (Italy), “Its hard to switch off after an
incident” (Ireland), “Informal chats with fellow staff
members, often after an incident has occurred” (Eng-
land). “Colleagues and older staff are the main support
(Portugal). “Departmental meetings” (various problems
are discussed there) (Lithuania), “Empowering of poten-
tial…”, “to have a debate with nurses of other units to
discover othe r an d di ff erent prac t i ce s ” (Italy).
Organisational support was multifaceted with a gen-
Copyright © 2013 SciRes. OPEN ACCESS
V. Staniulienė et al. / Open Journal of Nursing 3 (2013) 426-436 431
eral consensus shared across the groups that there was a
need for increasing staff-patient ratios to ensure high
quality, respectful care and help reduce the number of
critical incidents. Increased staffing levels would allow
time for debriefing following an incident… Debriefing
with staff, thoug h only if there is an opportunity to do so,
most often there isnt any time (Eng land)… …more op-
portunities for fo rmal debriefings (England). Debriefing,
more reflection and discussion on incidentsThe medi-
cal management of patients from Doctors… (Ireland).
Having sufficient staffing levels on the wards would
enable support groups to take place on the wards… Staff
support groups on individual wards where any issue can
be raised for discussion. Adequate staffing levels to-
gether with the right staff skill mix with highly skilled
staff on duty at all times was also viewed as an organisa-
tional responsibility… More (permanent) staff on duty
More emphasis on multidisciplinary teams (England).
More skilled hospital attendantsMore support from
different services (Lithuania).
Finnish nurses stated that support and report monitor-
ing was essential to ensure nurses were enabled to pro-
mote good quality care… Support from the immediate
superior (head nurse) and nursing directorSupervi-
sion… Monitoring of reports on violence situations (Fin-
land). More support and recognition from managers
(England). Irish and Italian nurses were more vociferous
regarding the perceived lack of support from both the
organisation and clinical teams.
Occupational health support following an incident was
viewed as a further organisational responsibility. Not in-
frequently involvement in critical incidents has an emo-
tional impact on staff and access to occupational health
and the support of senior managers is vital. This point
was highlighted in particular by English and Finnish
nurses… Occupational healthcare following an incident
is important (Finland, England).
3.5. Ethical Concerns: Cognitive Dissonance
This theme highlights ethical concerns expressed by par-
ticipants regarding right to liberty and dignity, the pro-
tection of the self and others, and internal conflict. The
latter refers to the cognitive dissonance experienced by
nurses when adopting coercive measures when caring for
and supporting disturbed and distressed patients. There
were different views expressed across the country groups
with some considering coercive measures as having
positve elements. Anecessary evildone with the pa-
tientsIt can bring about a good result if it is done in
the right, properly controlled way (England). The actions
are safe and equitableThe actions are humane. Its in
the best interest of the patient (Finland).
Irish nurses were clear that coercion should be avoided
if at all possible as it was viewed as, Taking away their
dignity and their rights (Ireland). Similarly, with Portu-
guese nurses. Must always try to embrace the patient
Restraint a patient is not an ethical and deontological
behavior (Portugal).
Lithuanian nurses highlighted the dilemmas experi-
enced by nurses… The action is inhumane regarding the
patientA decisional dilemma is presented to the
nurses which involve making a choice between risking
harm to the patient, the staff and others (Lithuania).
Sometimes patients want to be secluded as it gives them
personal space (England).
3.6. Education and Training
Education and training was viewed as an organisation’s
responsibility with all participants suggesting the need
for appropriate, focused training courses aimed at how to
manage distressed and disturbed patients. For some there
was no structured training; different models were used.
There is not structured education at the hospital
Each nurse tries to make theoretical course according
need. Nurses do not have preparation, only good sense
(Italy)… Only a few nurses made theoretical courses, in
their services, concerning aggressive patients, restraints
methods and communication (Portugal). They learned by
themselves and/or supported by the nursing group or by
the psychiatristsMany nurses affirm that their educa-
tion has beentrial and errors”… continuous education
organised by the hospital has always been insufficient
regarding the management of the aggressive patient
this has been always very focused on relational aspects
or theoretical subjects (Italy).
It was considered essential that the training was tar-
geted specifically to the care of distressed patients with
more standardisation across units/hospitals with clear
instructions for actions. The theory and training is dif-
ferent to real situations on the ward (England). Poor
professional training and lack of experience create un-
certainty in the situa tion (Finland). Cant prepare for the
speed of the situationThere are a lot of decisions to be
made very quickly… (Finland).
The consensus was that training needed to be more
comprehensive and interactive… More role-play in train-
ing (England). Some participants wanted courses for
nurses only whilst others wanted multi-disciplinary
training. Italian nurses were very clear about the latter…
Education has to be structured on teamwork in any case,
multidisciplinary in character, work in team with the
doctors, in a more coordin at e d an d s y nergic w ay (Italy).
Other views on the nature of the training were the
need for more emphasis on the core skills of nursing;
need to include self-awareness and assertiveness ele-
ments to build up professional confidence, emphasis on
policies and guidelines, ward based practical training
with yearly refresher courses. Other suggested curricu-
Copyright © 2013 SciRes. OPEN ACCESS
V. Staniulienė et al. / Open Journal of Nursing 3 (2013) 426-436
lum content included how to communicate with different
patient groups; team work; how to analyse situations and
The purpose of this study was to describe the feelings
and thoughts of mental health nurses regarding the care
and support of distressed, and/or disturbed patients
within acute inpatient settings across six different coun-
tries. Given the themes that emerged from the findings, it
seems that restraining patients in whichever way causes
both emotional and cognitive issues for nurses. This
suggests a concurrent rational and intellectual analysis of
experiences rather than simple emotional responses re-
sulting from emotional quandaries.
The uniformity of the answers and shared feelings and
thoughts of anxiety and fear expressed by the mental
health nurses in the different countries suggests that
nurses have common feelings and similar states of dis-
sonance. The nurses try to be ready and open to different
management approaches, primarily founded on the the-
rapeutic relationship and its quality in the hope that it
will not be affected if difficult interventions ensue. It
could be suggested that we are close to the concept of
therapeutic pluralism [40,41] that is, the management of
the patient according to a plurality of therapeutic options
without exclusively following specific guidelines. When
caring for and supporting distressed patients the inter-
ventions must be based on respect and dignity for the
person and always involve the least restrictive options.
However, on occasion, physical restraint and/or seclusion
may be necessary to ensure both team and patient safety.
Some suppress their emotions in an effort to get through
the use of interventions like seclusion and restraint in
order to function on a daily basis. There is already litera-
ture to support this e.g. emotional distress and emotional
suppression as a defence mechanism [18,29, 42-46]. The
loss of the therapeutic relationship due to coercive inter-
ventions is indicated by Moran et al. (2009) [47]; as the
relationship is already broken down nurses continue to
use restraint and seclusion techniques and suppress their
unpleasant emotions. Furthermore, Morse (2001) [48],
states that the emotional suffering of mental health
nurses caused by a patient’s aggressive behaviour results
in their emotional withdrawal from the patient. Moran et
al. (2009) [47] conclude that the loss of relationship be-
tween nurse and patient may be caused, or at least facili-
tated, by standardised handlings and the “psychiatrisa-
tion” of the patient. Roberts (2005) [49] and Lakeman
(2004) [40] state that the quality of the therapeutic rela-
tionship is more effective than an accurate choice of in-
tervention strategies [50]. This was also conveyed by
some of the mental health nurses in this study.
Although inpatient nurses use coercive interventions,
for some it does not present ethical problems [51] as they
appear oblivious to practice issues and hold paternalistic
attitudes. For some patients seclusion maybe a positive
experience as it enables them to have a “quiet” time
away from the busy ward environment and an opportu-
nity for reflection.
Support from both peers and managers, was perceived
as very important by participant across the 6 countries.
The need for infrastructural support that comprised of
increasing the staff-patient ratio and having the correct
skill mix available was viewed as necessary, as was the
importance of smaller, safer and good quality physical
environments [52]. Managerial support that included oc-
cupational healthcare following an episode of violence or
the use of a complex intervention such as seclusion and
restrain was considered essential but not always available.
Indeed there was a fairly universal view across the coun-
tries that senior managers were not always aware or in-
terested in what took place following an incident unless
it had repercussions for them personally. The importance
of peer and team support including debriefing sessions
after an along with supervision from nursing directors
were expressed by all participants.
NICE guidelines indicate the importance of debriefing
following untoward incidents and consequently included
in individual UK Trust policies. No such guidelines exist
in the other European countries involved in the study.
There is a lack of standardisation across the countries in
terms of policies, practices and legislation regarding the
management and treatment of disturbed and/or distressed
patients. This is left to the discretion of medical staff and
senior nurses. Giving the mobility across Europe of both
patients and health care professions greater attempts at
standardisation should be considered [53].
Regarding educational needs, participants proposed
the use of practical education for all nurses at all levels
of seniority. They called for continuing education on
clinical issues using case-based clinical scenarios and
problem based learning. This form of learning can por-
tray effective interactions and support for disturbed and
distressed patients similar to that experienced by staff
working in mental health inpatient environments who
took part in an evaluation of an educational practice de-
velopment programme [54]. The participants appreciated
the knowledge and professional expertise of experienced
and older staff to educate and advise them alongside or in
addition to individual and teamwork sessions and regular,
relevant, structured education and training for all em-
ployees was deemed appropriate to encompass ethical
and legal issues. Most importantly in this training was
the contribution of patients as co-educators [54].
There is a need to research the causes of aggression
and its management from the patient’s perspective. The
outcomes of such research would give nursing staff and
Copyright © 2013 SciRes. OPEN ACCESS
V. Staniulienė et al. / Open Journal of Nursing 3 (2013) 426-436 433
management more effective tools to potentially predict
and prevent this complex and multifactorial phenomenon
[24,55]. Based on the results of this study we are able to
make suggestions for future endeavors. This paper shows
that there is still a need to increase availability of educa-
tion related to patient management and team-working/
support to foster sound internal relationships. We suggest
a two-pronged approach: 1) multi-professional education
programmes and 2) clinical supervision.
Education is key to changing attitudes and clinical
practice [53,56,57]. The Mental health nurses in the dif-
ferent countries have described fear and anxiety as
prevalent feelings experienced when caring for and sup-
porting distressed and/or disturbed patients as well as
support from peers and management. These areas should
be included in all multi-professional education organisa-
tional programmes for nurses of all levels of seniority.
The findings of this study should be taken into consid-
eration in the planning of future educational programs
and refresher courses in the updating of Mental health
nurses knowledge and skills, and their implications for
nursing practice. Such education programmes must in-
corporate the best available evidence regarding the care
and support of distressed and/or disturbed patients from
the view of mental health nurses. The core of this educa-
tion could be based on “real” patient experience/episodes
of management when patients are exhibiting aggressive
and/or hostile behaviour with shared discussion and
points of view from both professional and patient stand-
points. In the preparation of standardised clinical guide-
lines for practice, patients’ opinions (voice) should be
considered as well as ethical and legal issues; these
guidelines should be included in programmes of study
for all qualifying and post-qualifying nurses.
Clinical supervision is important in the development
of the emotional and intellectual/rational aptitude among
6 nurses [43,57] and may enable them to acknowledge,
work through and therefore manage their distressing
emotions in a safe and supportive environment [57].
Staff could engage in a process called “dissonance re-
duction” [58] which can be achieved in one of three
ways: 1) lowering the importance of one of the discor-
dant factors, 2) adding consonant elements, 3) or chang-
ing one of the dissonant factors. In addition to a profess-
sional education programme a standardised plan of cli-
nical supervision that takes into account the physical
environment of the inpatient unit and culture of the coun-
try would assist mental health nurses to pause and reflect
on the emotional and concurrent cognitive distress they
experience when caring for patients.
Managerial support in the form of being visible in
clinical areas other than when untoward episodes occur
is a further recommendation. Clinical staff need to feel
valued and “cared for” when working in such demanding
areas. The importance of adequate staffing levels is a
prerequisite for safe, effective and compassionate care,
consequently a further responsibility of senior managers.
There were a number of limitations in the study. For
example, the purposive sampling strategy, small sample
size, localisation of the focus groups in each of the 6
countries and the qualitative methodology preclude
broad generalisation of the findings. There are also spe-
cific limitations of a focus group technique, which may
have influenced the findings. For instance, Carey (1994)
[59] identifies censoring and conforming as major pit-
falls when conducting focus group interviews. These
processes occur when a person withholds or alters his/her
responses to correspond with the other group members
and/or the leader. The processes of conforming and cen-
soring may have potentially influenced the extent of
emotional and cognitive distress reported by the mental
health nurses in this study. However, there was evidence
of this distress within the data from all of the focus group
interviews and the data offers useful insights into the
feelings and thoughts experienced by mental health
nurses when caring for distressed and/or disturbed pa-
tients, which will be of interest to the wider mental
health nursing community.
Five different languages were employed in the study,
and translational and linguistic equivalence difficulties
were experienced. Healthcare systems, nurses’ education
and role, nursing guidelines and/or standards vary there-
fore the care, treatment and management of distressed
and/or disturbed patients who behave aggressively will
vary from country to country. Therefore, it is unsurpris-
ing that Mental health nurses in different countries have
different experiences and different coping strategies to
manage such patients. Direct comparisons are therefore
Despite these limitations, this study draws strength
from the inclusion of nurse participants from 6 European
countries and the comparison of yielded extensive, rich,
in-depth qualitative data about the emotional and cogni-
tive dissonance/distress experienced by these Mental
health nurses with regard to the management of dis-
tressed and/or disturbed patients. The findings are clearly
valuable for future research studies of this kind and for
the development of mental health education and practice
in all of these countries.
The findings illustrate that the management of this pa-
tient group can be a genuine emotional and cognitive dis-
tressing experience for the mental health nurses in this
study. Through tailored professional education programmes,
refresher courses, standardised international guidelines
and appropriate clinical supervision, it may be reason-
able to assume that mental health nurses may move be-
Copyright © 2013 SciRes. OPEN ACCESS
V. Staniulienė et al. / Open Journal of Nursing 3 (2013) 426-436
yond their distressing emotions and that effective and
sound nurse-patient relationships may be nurtured, so
that the need for restraint and seclusion interventions will
diminish across Europe within mental health nursing.
The authors would like to thank the nurses who participated in the
study who generously gave their time and partook in the focus group
interviews. Thanks also to Carol Hanchard and Veslemoy Guise for
their contributions to the research and Vida Staniulienė, Mary Cham-
bers, Maritta Välimäki and Raija Kontio for the first draft of this paper
and Vida Staniulienė, Mary Chambers, Anne Scott, Maria Antónia
Rebelo Botelho, Renzo Zanott, Maritta Välimäki who obtained the
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