Introduction
Ineffective management of life stressors and the incapability of handling aggression represent a complex problem that requires a profound analysis and a well-developed strategy for a behavioral change. Aggressive outbursts toward other patients or staff members because of life stressors’ impact are a common issue in numerous psychiatric settings (Kaunomaki et al., 2017). By utilizing a combination of the Theory of Modeling and Role-Modeling (MRM) and Non-Coercive Intervention (NCI) to address the instances of aggressive and violent behaviors in patients, one will transform the role of a nurse into the one of an educator and emotional support, thus helping patients deal with stressors.
The problem of violent behaviors is very common in patients suffering from mental health issues. Emotional concerns, among which aggression takes an important place along with the feeling of shame and social isolation, pertain to the high levels of stigma by which mental health issues are characterized (Belete, 2017; Abdelghaffar, Ouali, Jomli, Zgueb, & Nacef, 2018). Specifically, patients may display self- and hetero-aggressive tendencies after experiencing a mental trauma and becoming mentally disturbed and developing issues such as PTSD, depression, or bipolar disorder (Baranowski & Pawlowski, 2017). Therefore, further tools for restraining patients with aggressive tendencies and preventing them from causing harm to themselves and others are needed.
For this purpose, the use of MRM and NCI should be incorporated into the treatment framework. Bickle, Haw, Stewart, and Stubbs (2011) assert that non-coercive treatments have a vastly positive effect on patients displaying aggression and violence. Mielau et al. (2016) also stress the ethical aspects of NCI as a tool for managing mechanical restraint since the latter poses a particularly important obstacle to effective treatment. The importance of restructuring the roles of nurses as the method of managing aggression levels in patients also deserves to be mentioned among intervention tools (Kalagi, Otte, Vollmann, Juckel, & Gather, 2018). Therefore, an all-embracive analysis of MRM and NCI as the methods of handling patient aggression toward staff members and other patients is needed.
Literature Search
An in-depth search for relevant sources was performed in order to explore the problem of managing aggressive behaviors and violence in patients with the help of MRM and INC. To locate peer-reviewed articles with high relevance and credibility levels, Google Scholar and CINAHL were used. Specifically, the databases of the National Center of Biotechnology Information (NCBI) were utilized to identify the articles that encapsulated the principles of MRM and INC, displaying their effects in the clinical setting. The search process was limited to the instances of aggression or violence among adult patients with mental health disorders. Thus, ten articles were identified.
The concept of coercive interventions as the method of handling aggressive outbursts among mental health patients was used as a search item to locate the articles by Georgieva, Mulder, and Whittington (2012), Kaunomaki et al. (2017), Bickel et al. (2011), and Baranowski and Pawlowski (2017). The phenomenon of MRM, in turn, was used as the search term to identify the study by Kalagi et al. (2018). The papers by Cowman, Bjorkdahl, Clarke, Gethin, and Maguire (2017) and Fugger et al. (2016) were identified when searching for the responses that patients may provide when being administered MRM and INC, as well as the methods of addressing these responses adequately to promote faster recovery.
The tools for verbal management of violent behaviors among patients with mental health concerns were explored by Richmond et al. (2012), Mavandadi, Bieling, and Madsen (2016) and Price, Baker, Bee, and Lovell (2015) in their initial and follow-up studies (Price, Baker, Bee, & Lovell, 2018). Finally, Vieta et al. (2017) and Mielau et al. (2016) provide a set of guidelines for efficient provision of MRM and INC.
Historical Evaluation of Theory
The Theory of Modeling and Role-Modeling was created by Erickson, Tomlin, and Swayne (Alligood, 2014). Initially, the framework served as a broad approach toward managing patients’ needs based on the idea of patient uniqueness and the necessity to adopt an evidence-based and case-specific approach to each concern (Alligood, 2014).
When evaluating the scope of the theoretical framework in question, it is reasonable to mention that the MRM theory used to be seen as a mid-range one, yet further studies on its effects and application in the clinical setting have shown that it warrants the title of a grand theory (Alligood, 2014). The proposed theoretical framework allows reevaluating the role of a nurse in the process of managing a patient’s needs and administering the required treatment to the target population.
Specifically, MRM posits that the process of treatment should encompass the physical, psychological, and behavioral aspects of recovery, thus implying a change in patients’ behaviors and attitudes (Alligood, 2014). Therefore, while being first introduced as a mid-range theoretical approach, MRM has developed the potential to be viewed as a grand theory. In retrospect, the theoretical approaches that may have influenced the development of MRM include Orem’s Theory of Self-Care deficit and Watson’s idea of nursing being a combination of science and art (Alligood, 2014).
The NCI framework, in turn, is based on the premise of utilitarianism as an ethical approach in nursing, which suggests that the necessity to maximize the probability of a positive outcome in patients (Alligood, 2014). As a result, coercion, which can be seen as the direct opposite of the principle of patient autonomy, can be adopted to prevent the further deterioration of a patient’s condition. When combined with a broader concept of MRM, NCI helps to develop a theoretical framework for addressing the instances of aggressive behaviors in patients with mental health issues.
Therefore, historically, the MRM framework was designed as a generalized framework that was supposed to be applied on a global level and serve as the platform for minor theories used in the clinical setting. However, after being shaped and acquiring the elements of other mid-range theories such as Orem’s and Wrights’ frameworks, the MRM framework gained the status of a mid-range theoretical approach that could be applied to cater to the demands of a specific population.
The identified evolution of MRM can be seen as crucial when considering its effects on the management of issues associated with mental health and patients’ consent. Indeed, after the integration of the concepts of patient education, the focus on self and the use of patient-nurse communication as the pathway to care enhancement, the MRM theory has acquired the characteristics that allowed it to assist patients in handling life stressors.
Conceptual, Theoretical, and Methodological Research Issues
Since the MRM theory represents an intersection of a grand and a mid-range theory, it helps to determine the role of a nurse in managing the problem of patient behavior, in general, and the levels of aggression among patients with mental health concerns, in particular, on several levels. For instance, when introducing the perspective of a broader scope, MRM allows embracing the idea of addressing behaviors in patients on a personal level and considering patient-specific information when shaping an intervention (Belete, 2017).
Particularly, the foundational idea of the MRM framework posits that a nurse should encourage patients’ agency and independence are to be acknowledged and taken into consideration when shaping the process of therapy and choosing the appropriate treatment. Therefore, the conceptual aspects of the MRM theoretical framework include the ideas of a nurse accepting the role of an educator and building the relationships based on trust with a patient.
The conceptual aspect of the MRM framework is closely interconnected with its theoretical elements. Specifically, the MRM approach suggests that several principles associated with controlling the recovery process should be incorporated into the framework for managing patients’ needs. Specifically, the concept of self-esteem as the basis or the management of patients’ health issues should be mentioned among the cornerstone constituents of the MRM theory. The specified item allows making an intervention patient-centered and addressing the specific problems that a customer may have when acknowledging the presence of a health issue and accepting the proposed treatment.
The concept of self-esteem is especially important in handling the cases involving mental disorders in adult patients. Because of extraordinarily high levels of social stigma associated with the specified concerns, patients are often very reluctant to admit that they have a mental health problem. As a result of a prolonged state of denial, a patient will progress from the early onset of a mental issue development to a more advanced stage that is much more difficult to address.
The problem aggravates when dealing with the needs of patients displaying aggressive behaviors since they may inflict significant harm to other patients and healthcare staff members unknowingly. Consequently, a nurse must foster the development of self-esteem in a patient, becoming the support system for the latter (Kaunomaki et al., 2017). Therefore, the application of the tools that ensure safety from social prejudices for patients is critical in the described scenario to prevent the incidences of aggression and violence in the vulnerable groups.
Similarly, the issue of trust as an integral element of the MRM framework. The specified constituent of the theory allows a nurse to build a strong rapport with a patient in order to convince the latter to accept the suggested treatment (Kalagi et al., 2018). Cowman et al. (2017) address the issue of nurse-patient relationships and the significance of cooperation and trust in them, thus pointing to the fact that MRM should be utilized as the tool for enhancing NCI and assisting patients with aggression problems in acknowledging their problem.
Finally, the focus on a positive attitude throughout the treatment process can be seen as the third element of the MRM approach. In NCI, the specified aspect of maintaining the treatment process consistent and uninhibited is essential since it also allows a patient to recognize their autonomy and use it to accept the proposed treatment. Particularly, the element of MRM mentioned above helps to build the setting in which a patient is willing to cooperate. As a result, the use of physical restraints in handling the cases of patients with mental disorders can be avoided successfully, which is essential since the specified experiences can be extraordinarily traumatic (Belete, 2017).
The theoretical issues raised in the MRM theory incorporate the principle of self-care, the concept of patient education, and the idea of transpersonal relationships between a nurse and a patient. The specified concepts are borrowed from the two principal theories that presumably constitute the essence of the MRM framework, which are Orem’s and Watson’s theories. Particularly, the focus on a patient and their needs, especially the necessity to recognize the urgency of treatment and the gravity of a refusal from it are taken directly from Orem’s idea of self-care and patient education as the pathway to it. The specified theoretical elements contribute to the successful management of the issues associated with patients’ unwillingness to follow the prescribed therapy and treatment process. As a result, the use of NCI becomes a possibility,
Finally, methodological issues associated with the application of the MRM theory should be addressed. According to the studies performed by Haw et al. (2011), the proper representation of the target population remains a challenge due to the use of the convenience sampling strategy. Indeed, the application of convenience sampling affects the accuracy of research outcomes to a significant degree and often implies the underrepresentation of specific groups in a study (Baranowski & Pawlowski, 2017).
While the identified concern can be addressed by conducting follow-up research and stratifying the selected population into several groups based on specific characteristics such as age and gender, the problem remains unresolved (Haw et al., 2011). The specified methodological concern needs to be managed in order to increase the accuracy of research outcomes and design a uniform approach toward managing the needs of mental health patients. NCI is an intervention aimed at encouraging patient agency and enhancing their ability to address life stressors.
Another methodological concern that needs to be addressed includes the limitations of a grand nursing theory as a whole. According to the existing interpretation of a middle-range nursing theory, it is expected to address a certain health issue on a patient-specific level, which does not imply a generalized approach. Thus, the use of a middle-range theory can assist only in handling the problems of a very specific group. However, the specified methodological issue can be resolved partially be appealing to the nature of MRM, which incorporates the elements of a grand and a middle-range theory since it was initially designed as the former. Therefore, in theory, MRM can be shaped and adjusted to serve the needs of other vulnerable groups.
Summary of State of Sciences
As the review of the existing studies shows, the problem of managing life stressors in patients with mental health issues remains topical and requires immediate management. Introducing the principles of MRM and NCI to the cases in which patients display high rates of aggression and violence is essential since it allows establishing a stronger control over the problem (Bickel et al., 2011). Therefore, the current state of research regarding the issue of violence management in mental health patients and the change in a nurse’s role in it requires further analysis.
Taking patients’ emotional issues into account when facing the possibility of them failing to develop skills for managing life stressors is a critical step in therapy that informs a change in the role of a nurse. Particularly, studies display the need for a nurse to become the support system and the source of knowledge for a patient. Particularly, studies indicate that it is critical for a nurse to accept the roles of an educator and a counselor when assisting them to manage stressors that lead to aggression and violent behaviors (Fugger et al., 2016).
As stressed above, because of the denial that a number of patients with mental health issues acquire, it is critical to design the setting in which patients can recognize their health issues and start a constructive dialogue with a nurse (Maguire, 2017). Building trust as one of the critical aspects of the MRM framework is needed to introduce the target population to the idea of self-management of their anger issue and, thus, develop the opportunities for them to control their outbursts of rage. Therefore, the proposed theory implies that a nurse should include the role of an educator and the provider of support for a patient with aggression issue and violent behavior to the one of a care provider. As a result, a shift in patients’ perceptions of their agency and effects that they have on their behaviors will be observed.
Therefore, the application of MRM and NCI as the method of assisting patients with aggression problems and difficulties controlling their violence is critical. By including the identified theory and its core principles into the contemporary mental health care setting, one will create the environment in which patients will be eager to change. Studies show that the application of NCI and the use of the MRM framework as the platform for the proposed change leads to a tremendous shift in patients’ understanding of their behavioral problems (Maguire, 2017).
Heron lies the importance of refusing from coercive treatment as the method of addressing patients’ attitude toward stressors. Instead of helping the vulnerable groups to recognize the problem, coercive therapy multiplies the impact of stress on patients’ well-being. Therefore, it is the role of a nurse to introduce the principles of patient independence and patient education into the modern mental health care setting.
References
Abdelghaffar, W., Ouali, U., Jomli, R., Zgueb, Y., & Nacef, F. (2018). Posttraumatic stress disorder in first-episode psychosis: Prevalence and related factors. Clinical Schizophrenia & Related Psychoses, 12(3), 105-112. Web.
Alligood, M. R. (2014). Nursing theorists and their work (8th ed.). Greenville, NC: Elsevier.
Baranowski, P. & Pawlowski, T. (2017). How patients’ characteristics influence the use of coercive measures. Indian Journal of Psychiatry, 59(4), 429-434. Web.
Belete, H. (2017). Use of physical restraints among patients with bipolar disorder in Ethiopian Mental Specialized Hospital, outpatient department: Cross-sectional study. International Journal of Bipolar Disorders, 5(1), 17-25. Web.
Bickle, A., Haw, C., Stewart, I., & Stubbs, J. (2011). Coercive treatments in forensic psychiatry: A study of patients’ experiences and preferences. Journal of Forensic Psychiatry & Psychology, 22(4), 564-585.
Cowman, S., Bjorkdahl, A., Clarke, E., Gethin, G., & Maguire, J. (2017). A descriptive survey study of violence management and priorities among psychiatric staff in mental health services, across seventeen European countries. BMC Health Services Research, 17(1), 59.
Fugger, G., Gleiss, A., Baldinger, P., Strnad, A., Kasper, S., & Frey, R. (2016). Psychiatric patients’ perception of physical restraint. Acta Psychiatrica Scandinavica, 133(3), 221-231. Web.
Georgieva, I., Mulder, C. L., & Whittington, R. (2012). Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions. BMC Psychiatry, 12, 54. Web.
Kalagi, J., Otte, I., Vollmann, J., Juckel, G., & Gather, J. (2018). Requirements for the implementation of open door policies in acute psychiatry from a mental health professionals’ and patients’ view: A qualitative interview study. BMC Psychiatry, 18(1), 304-314. Web.
Kaunomaki, J., Jokela, M., Kontio, R., Laiho, T., Sailas, E., & Lindberg, N. (2017). Interventions following a high violence risk assessment score: A naturalistic study on a Finnish psychiatric admission ward. BMC Health Services Research, 17(1), 26-33. Web.
Mavandadi, V., Bieling, P. J., & Madsen, V. (2016). Effective ingredients of verbal de‐escalation: Validating an English modified version of the ‘de‐escalating aggressive behavior scale’. Journal of Psychiatric and Mental Health Nursing, 23(7), 357-368.
Price, O., Baker, J., Bee, P., & Lovell, K. (2015). Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. The British Journal of Psychiatry, 206(6), 447-455.
Price, O., Baker, J., Bee, P., & Lovell, K. (2018). The support-control continuum: An investigation of staff perspectives on factors influencing the success or failure of de-escalation techniques for the management of violence and aggression in mental health settings. International Journal of Nursing Studies, 77, 197-206.
Richmond, J., Berlin, J., Fishkind, A., Holloman, G., Zeller, S., Wilson, M., … Ng, A. (2012). Verbal De-escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, 13(1), 17-25.
Vieta, E., Garriga, M., Cardete, L., Bernardo, M., Lombrana, M., Bianch, J., … & Martinez-Aran, A. (2017). Protocol for the management of psychiatric patients with psychomotor agitation. BMC Psychiatry, 17, 1-11.