Aggression Toward Psychiatric Nurses and It`s Relation With Patient`s Satisfaction About Quality of Care

Sayed, Amany Galal; Sayid, Nadia Ebraheem; Mohamed, Amany Anter

doi:10.21608/msnj.2019.187784

Aggression Toward Psychiatric Nurses and It`s Relation With Patient`s Satisfaction About Quality of Care

Document Type : Original articles

Authors

¹ Bsc of Nursing, Minia psychiatric hospital

² Assistant Professor, Psychiatric and Mental Health Nursing Department, Faculty of Nursing – Assiut University

³ Lectuererof Psychiatric and Mental Health Nursing, Faculty of Nursing - Minia University

10.21608/msnj.2019.187784

Abstract

This study aimed to assess the relationship between aggression toward psychiatric nurses and patient satisfaction about the quality of care. Design: Adescriptive correlational design was used in this study. Settings: Minia Hospital for Psychiatric Health and Addiction Treatment. Participants: a convenience sample of (100) psychiatric inpatients hospitalized during the study duration. All nurses working (on duty) in the psychiatric wards (2018), their total number was(54). Methods: tools used in this study werePerception of Prevalence of Aggression Scale POPAS questionnaire, Impact of Patient Aggression on Careers Scale, while patients completed Rome Opinion Questionnaire for Psychiatric Wards’ (ROQ-PW) to measure their satisfaction about the quality of care. Results: Verbal abuse was the highest form of aggression(74%), Whilesexual assault was at the least level(2.3%).Around half ofnurses reportedhigh impact of aggression.Relation impairment between patients and nurses was the most effect of aggression on nurses(51%). The lowest level of satisfaction was in the area of staff professionalism (10.4±2.3). Conclusions: there wasa highly Significant negative correlation between aggression toward psychiatric nurses and satisfaction about the quality of care (p=.003), and ahighly positive correlation between aggression toward psychiatric nurses and the total impact of aggression on health careier (p=.000).Recommendation: provide continouse training program onhow to deal with aggressive patient, increase security, video monitoring, and creating workplace violence prevention committees.

Highlights

AmanyGalalSayed¹, Nadia EbraheemSayid², AmanyAnter Mohamed ³

1 - Bsc of Nursing, Minia psychiatric hospital

2-Assistant Professor, Psychiatric and Mental Health Nursing Department, Faculty of Nursing – Assiut University

3- Lectuererof Psychiatric and Mental Health Nursing, Faculty of Nursing - Minia University

Keywords

Full Text

Introduction

International concern about violence and aggression in work place is increasing day after day because it is a major and serious worldwide public health problem that touching health services personnel (1). In Egypt about 250,000 nurses working in health services and thousands of nursing students graduate each year and join the medical field in order to introduce help and support to patients (2), but the conflicting idea is that a patient would want to harm a nurse or allied professional who are trying to help(3). Hospital workers have been found to have the greatest rates of non-fatal work place assault injuries when comparing with other workers from different jobs that result from aggressive acts by patients (4). Among hospital workers, the risk of aggression from patients is greatest toward nurses, mental health professionals and security staff (5). In psychiatric settings a dilemma arises from concerning aggression from psychiatric patient is a part of nurses work or being aggression should be stopped(6).

Nurses are more likely to have more interaction, involved in aggressive incidents with patients, and facing of all types of trauma, suffering, and life threatening events than other health care providers,that known to put them at greatest risk of aggression than others in the health care profession(7). Aggression in work place is a pressing concern for nurses in all settings and for psychiatric nurses in particular(8).

Aggression from patients even physical or non-physical has negative implications for employees health and safety and quality of patient care(9).Additionally to health problems from physical injury, worker responses to violence may negatively impact the work environment by creating fearfulness, low morale and productivity, absenteeism, and increase turnover(10). Not only aggression and violence harmful to the person and the organization, it is also very expensive, in one recent year, over two million Americans reported being physically attacked at work resulting in $13.5 million in medical costs alone, there are also some international data regarding costs that are troubling (11).

The Joint Commission issued an alert regarding rude and disruptive behavior in health care settings .The Joint Commission states that intimidating and disruptive behavior can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes,and increased the cost of care (12). Safety and quality of patient`s care is dependent on more professional environments. Safety and quality of care requires teamwork, communication, and collaborative work environment. To ensure quality and to promote culture safety, health care organizations must address the problem of behavior that threaten the performance of health care team(13).

Significance of study

Inpatient aggression is a pressing concern for nurses in all settings and for psychiatric nurses in particular. When compared to other industries, the rate of aggression is the highest among hospital workers, 8.3 per 10,000 workers vs. 2 per 10,000 workers, and among this group nurses are the most ‘at risk’(14) . As much as 70% of abuse toward nurses may be unreported(15). This is because of the complexities that arise, in part, from a health care culture resistance to the impression that health care providers are at risk for patient-related aggression combined with complacency that aggression "is part of our job" (16) .

Psychiatric nurses commonly reported the effects of exposure to occupational aggression to be associated with reduced productivity, decreased job satisfaction, burn-out, increased use of sick days(17). Where health care workers report high stress and dissatisfaction in their work, emotional exhaustion, depersonalization and inefficacy ,the patients also report a reduced level of care and autonomy and satisfaction when the relationship deteriorates.Low quality of patient`s care may lead to low satisfaction, low compliance with treatment and little cooperation with staff (18) .

Aim of the study

This study aimed to assess prevalence of aggression toward psychiatric nurses and its relation to patients`satisfaction about quality of care.

Research questions:

What are the nurses’ perceptions of the prevalence of aggression in Minia psychiatric hospital?
Is there a relationship between aggression toward psychiatric nurses and patient satisfaction about quality of care?

Research Design:

A descriptive correlational design was utilized to achieve the aim of the present study.

Setting:

This study was conducted at El. Minia Hospital for mental health and addiction treatment. It is a governmental hospital is affiliated to the ageneral syndicate for psychiatric health which is affiliated to the ministry of health (MOH). It serves all districts of Minia governorate. The hospital consists of inpatient departments (psychiatric wards, addiction ward) and outpatient clinics (children and adolescent clinic, psychiatric clinic, neurologic clinic); the capacity of the hospital is 53 (33 beds for psychiatric patients and 20 beds for addiction patients) and hiring 250 employees and 60 of them are nursing staff.

Sample:

The subjects of this study consisted of a convenience sample of (100) psychiatric inpatients from thosehospitalized during the study duration.Also, all nurses was working (on duty) in psychiatric wards (2018), their total number was (54) nurses.

Exclusion criteria :

For psychiatric patients:Mental retarded patients, Addiction patients.
For nurses: Nurses with experience less than one year.

Tools for Data Collection:

The following tools were used for collecting data in this study.

Tool I:Staff`s questionnaire:

Part 1: personal data sheetto obtain variables such as age, gender, education, ward, position, and duration of experience in mental health nursing.

Part 2:The Perception of Prevalence of Aggression Scale (POPAS):

It was developedbyOud, (2001).This questionnaire has been developed to assist individuals in identifying the frequency with which they have been confronted with aggressive or violent behavior during the last year in the course of their professional work as a health care worker in psychiatry. There are in total 17 questions. The POPAS rates experience with 16 types of aggressive behavior .For each form of aggressive behavior surveyed, a definition and examples were provided on the POPAS. It is rated on a 5-point Likert scale as 1= never, 2= occasionally, 3= sometimes, 4 = often, and 5 = frequently. The scoring system was categorized as follows:17:39 low prevalence, 40:61 moderate prevalence ,62:85 high prevalence(19).

Part (3): Impact of Patient Aggression on Careers Scale (IMPACS):

It was developed by Neehdam, (2010), to measure negative consequences of patient aggression on nurses. It consists of 10 items included in three domains impairment of the relationship between patients and nurse (items 1,2,3,4,) , adverse moral feelings (items 5,6,7,8,), adverse feeling to external sources(items 9,10)respectively. It was rated on five points Likert scale (1=never, 2=rarely, 3=sometimes, 4=often and 5=always). The scoring system was categorized as follows:10: 23 low impact, 24:35 moderate impact, 36:50 high impact(20)

Tool II: Patient Questionnaire

Part (1): personal datasheetto obtain personal data of the patients: such as patient's age, gender, residence, education and job.
Part (2): clinical data sheet to obtain medical history: diagnosis, the number of admission, duration of illness and experience of violent behavior, ward.

Part (3): Rome Opinion Questionnaire for Psychiatric Wards’ (ROQ-PW):

It was designed to measure patients` satisfaction and opinion about the quality of care given to them, it includes only 10 items on three domains professionalism of staff (items 1,2,3,4,10), availability of information (items 5,6,7,) ,and physical environment (items 8,9)respectively.It was rated on a 5-point Liker scale, with higher numbers indicating greater satisfaction. It is rated on a (1) ‘not very’; (2) ‘mildly’; (3) ‘sufficiently’; (4) ‘very, with some exceptions’; and (5) ‘very, with no complaints’. (21)The scoring system was categorized as follows:10: 23 low satisfaction, 24:35 moderate satisfaction, 36:50 high satisfaction.

Tools	Cronbach's alpha
POPAS	0.90
IMPACS	0.77
ROQ-PW	0.85

Reliability

The tools were designed in its final format and tested for reliability by using, cronbach`s alpha coefficient test ,

Validity

Study tool were reviewed by five experts in the field of this study atCairo university ,Asiut university, and AienShams university to examine the content validity. Modifications were done according to the panel`s judgment on the clarity of sentences, appropriateness of content. Based on experts comments and recommendations of study supervisors minor changes had been made in the questionnaire.

Pilot study

The pilot study was conducted on 10% of the sample(10)Patients, and (6)nurses to investigate and ensure the feasibility, objectivity, applicability, clarity and adequacy of the study tools and to estimate the timeneeded for filling the tool .The pilot study sample was included because no modification donein the study tools.

Procedure:

To fulfill the aim of the study an official permission was obtained from the director of the health and population directorate and the director of Minia hospital for mental health and addiction treatment. In order to conduct the study, the aim of the study was explained by the investigator to the subjects to get their approval prior starting their participation in the study.

In April 2018, the investigator submitted the questionnaire to the nurses and asked them to fill them out, enfold and cover them with provided wrapper, and return them to the head nurse within one week.

The patient`s sample data collected throughstructured interview conducted in the patient`s roomafter ten days of admission;The researcher assured the voluntary participation and confidentiality to each patient who agreed to participate.Measures were taken to protect patient's ethical rights. After explaining the purpose of the interview and getting agreement of the patient to participate in the research, the questionnairewas read, explained to the patient and the responses were recorded by the investigator for eliminating the systematic error. Data were collected by using a socio-demographic data sheet ,Rome Opinion Questionnaire for Psychiatric Wards’ (ROQ-PW). The researcher collected data through three sessions in the week ,each session take form 10:20 minutes according to the patient`s condition.Data collection was conducted over a six months’ period extending from April,2018 to October,2018.

Ethical Considerations:

A written initial approval was obtained from the research ethical committee of the Faculty of Nursing, Minia University. Written informed consent was obtained from each participating patient and oral consent from nursing staff after explaining the nature and purposes of the study. Each assessment sheet was coded and participant`s name was notappearing on the sheets for the purpose of privacy and confidentiality. The study sampleswere assured that there is no risk to study subjects during application of the research.The participant was assured that they can withdraw at any time from the current study without any effect on their treatment and care or their working condition.

Statistical Analysis:

The collected data were coded, categorized, tabulated, and analyzed using the Statistical Package for the Social Science (SPSS 20.0). Data were presented using descriptive statistics in the form of percentages, frequency, mean and standard deviation. In order to study the possible association between aggression reported by staff and perceived satisfaction about the quality of care by patients, it was necessary to connect the data sets from the POPAS and quality of care questionnaires. Hospital department was the one variable that was the same in both questionnaires, and thus provided the link between the two data setsInferential statistical tests of significance, such as T.test, Pearson correlation, and linear regression analysis were used to identify group differences and the relations among the study variables

Results:

Table 1: distribution of personal data of nursing staff (n= 54).

Personal data	No.		%
Gender
Males	23		42.6
Females	31		57.4
Age
20:30	19		35.2%
31:40	22		40.7%
41:50	8		14.8%
>50	5		9.3%
Mean age	33.5± 5.4 years
Education
Secondary (diploma)	36		66.7%
Technical institute	10		18.5%
Baclurate	8		14.8%
Ward
Free males	21		38.9%
Economic males	19		35.2%
Females	14		25.9%
Training
Yes		5	9.3%
No		49	90.7%
Experience
1:5 years		14	25.9%
6:10 years		17	31.5%
11:20 years		19	35.2%
21:30 years		4	7.4%
Mean of experience years		12.8± 4.7 years
Total		54

Table (1): showed that, the majority of the studied sample was females 57%, while 43% were males.40.7% of the studied sample wasinthe age group of 31 to40 years with mean age 33.5± 5.4 years. 66.7% of the nurses had secondary (diploma) degree of education , 38.9% of themwere working in the free male ward, and 35.2% of them had 11:20 years' experience with mean experience years 12.8± 4.7 years.

Table (2): Distribution of perception of prevalence of aggression scale among nurses: (n=54)

Perception of aggression scale	Never		occasionally Sometimes \		Often \ frequently
Perception of aggression scale	No.	%	No.	%	No.	%
Verbal aggression	3	5.6%	11	20.3%	40	74.1%
Threatening verbal aggression	6	11.1%	18	33.3%	30	55.6%
Humiliating aggressive behavior	5	9.3%	18	33.3%	31	57.4%
Proactive aggressive behavior	2	3.7%	23	42.6%	29	53.7%
Passive aggressive behavior	5	9.3%	15	27.6%	34	63.1%
Aggressive splitting behavior	4	7.4%	23	42.6%	27	50%
Threatening physical aggression	5	9.3%	24	44.4%	25	46.3 %
Destructive aggressive behavior	5	9.3%	27	50%	22	40.7%
Mild physical violence	6	11.1%	26	48.2%	22	40.7%
Sever physical violence	14	26%	21	38.8%	19	35.2%
Mild violence against self	8	14.8%	20	37%	26	48.2%
Sever violence against self	14	26%	20	37%	20	37%
Suicide attempts	10	18.5%	27	50%	17	31.5%
Successful suicides	24	44.4%	25	46.3%	5	9.3%
Sexual intimidation	26	48.1%	25	46.3%	3	5.6%
Attempted Sexual assault	52	96.3%	2	3.7%	0	0%
Sick leave	33	61.1%	18	33.3%	3	5.6%
Total	54

Table (2): revealedthat ,Verbal aggression was the highest form of aggression 74.1%, followed by non- physical forms of aggression which include Passive aggressive behavior ,humiliating aggressive behavior ,threatening verbal aggression ,proactive aggressive behavior, aggressive splitting behavior, 63.1%, 57.4%, 55.6 ,53.7%, 50% respectively. While the sexual intimidation and assault was the lowest 3.7%. Also,about 61% of nurses who was facing aggression did not take sick leave after aggressive incidents.

Table (3): Distribution of Impact of Aggression on Carrer Scale among nurses (no=54).

Variable	Never		rarely \ Some times			Often \ always
Variable	NO	%	NO		%	NO	%
Impairment of relationship between patients and carrer
I avoid contact with this patient	2	3.7%		13	24.2%	39			72.1%
I feel insecure at work	0	0%		21	38.9%	33			61.1%
I experience a disturbance in the relation with the patient	3	5.6%		20	37.1%	31			57.3%
I feel insecure in working with the patient	3	5.6%		16	29.4%	35			65.0%
Adverse moral emotions
I have a guilty consciences toward the patient	6	11.1%		21	38.9%	27		50%
I feel sorry for the patient	2	3.7%		21	38.9%	31		57.4%
I have feeling of being failure	13	24.2%		25	46.2%	16		29.6%
I feel a shamed of my work	12	22.2%		25	46.2%	17		31.6%
Adverse feeling to external sources
I have feeling of anger toward the clinic I am working in	5	9.3%		26	48.2%	23		42.5%
I feel that I am having to deal with societies problems	1	1.8%		18	33.4%	35		65.0%
Total	54

Table (3): showed that the highest impact of aggression came in the item of nurses avoid contact with this patient (73.1%),followed by feel insecure in the workplace(61.1%), or in working with patients (63%), dealing with societies problems (63.1%), while feeling of being afailure or ashamed of work came in the lowest level of impact (29.6%),(30.5%) .

Figure (1): distribution of levels of impact of aggression on carrer scale among nurses (no=54)

Figure (1) demonstrated that, (57%) of nurses perceived high impact of aggression, but only (11%) of them perceived low impact of aggression.

Table (4):distribution of personal and medical data of study sample (patients) (n=100)

Personal an medical data	No	%
Gender
Males	81	81%
Females	19	19%
Age
20:30	47	47%
31:40	23	23%
41:50	30	30%
Mean age 33.5± 5.8
Duration of illness
1:5	29	29%
6:10	42	42%
11:20	20	20%
20:30	9	9%
Diagnosis
Schizophrenia	57	57%
Depression	13	13%
Mania	7	7%
Others	23	23%
Times of Admission
Firsttime	23	23%
2:5 times	57	57%
More than five times	20	20%
Aggression
Yes	65	65%
No	35	35%
Total	100

Note: other diagnosis included borderline personality disorder, obsessive compulsive disorder

Table (4): illustrated that, majority of the studied sample were males(81%), where females were only (19%). 47% of the studied sample (patients) werein age group 20:30 years with mean age 33.5± 5. 42% of them were suffering from psychiatric disease from 6:10 years, 57%of them were diagnosed with schizophrenia, and 57% of them were admitted to hospital for 2:5 times.Also 65% of the studied sample experienced aggression acts toward staff.

Table (5):distribution of Rome Opinion Questionnaire for Psychiatric Wards’ (ROQ-PW) amongpatients (n=100)

ROQ-PW	Not at all		Not very\ sufficiently			Very with some exception\ very with no exception
	NO	%	NO	%		NO		%
Staff Professionalism
Suitability of care	29	29%	51		51%		20		20%
Staff availability	23	23%	71		71%		6		6%
Staff kindness and politeness	47	47%	48		48%		5		5%
Dealing with agitated patients	57	57%	43		43%		0		0%
Psychological group activities	10	10%	67		67%		23		23%
Information availability
Information about a health condition	0	0%	85		85%		15		15%
Information about drugs	0	0%	79		79%		21		21%
Information about care after discharge	1	1%	72		72%		27		27%
Physical environment
Physical environment	0	0%	43		43%		27		57%
Recreational activities	0	0%	61		61%		39		39%
Total	100

Table (5) showed that, the lowest area of satisfaction was dealing with agitated patients (57%), followed by staff kindness and politeness 47% .While 85%of studied sample represented sufficient satisfaction about information delivered to them , and 57% of them represent high satisfaction about the physical environment.

Table (6): distribution of Rome Opinion Questionnaire for Psychiatric Wards`s domains(n=100).

ROQ-PWdomains	Total score	Mean	S.D
Staff Professionalism	25	10.4	±2.3
Information availability	15	9.2	±3.1
Physical environment	10	6.8	±2.8

Table (6) showedthat ,the lowest domain of patient satisfaction was staff Professionalism (M=10.4±2.3), but the highest domain of satisfaction was Physical environment (M=6.8±2.8)

Figure (2): distribution of levels of Rome Opinion Questionnaire for Psychiatric wards' (n=100).

Figure (2) illustrated that, 57% of the studied sample represented moderate satisfaction about the quality of care and only 22% of them represented high satisfaction.

Table (7): Correlation between total POPAS and total QOC-PW and total IMPACS.

Total POPAS	Total IMPACS		Total QOC-PW
	R.	P.	R.	P.
	.932**	.003	-.921*	.022

** Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed).

Table(7) revealed that, there was a significant negative correlation between total POPAS and total QOC-PW, and positive correlation between total POPAS and total IMPACS.

Discussion:

Concerningpersonal data of the 1st studied sample (nurses), the present study revealed that, more than half of the studied sample werefemales(Fig 1). This result might be due togender inequality in the nursing profession as it was for many decades taken as female's profession, Also it could be attributed to in equality in numbers of nursing student at the first place in nursing schools, and may be it isn’t the best paid job especially in governmental places. This result was in the same tone with (22) who found that, efforts to promote gender equality in workplaces of all kinds may be widespread, but the number of men in nursing remains stubbornly low.

The present study revealed that, over the third of the study sample worked on the free male ward. This finding might be related to that it is the biggest word with regard to bed's number.

Regarding different types of aggression, the present study revealed that, verbal aggression was the highest form of aggressive acts faced by psychiatric nurses(table2). This might be due to that, verbal aggression appears to be almost uncritical and more a consequence of contact time than any pre-selection. This result was in agreement with (23)who reported that, there may be something about the nature of the nurse–patient interaction, which contributes to increased experiences of verbal aggression. In this context (24)represented that, the annual incidence of verbal assaults 70%. Similarly (25) reported that, 60% of the confrontations with aggression is verbal aggression. Also (26)reported that, Verbal aggression was the commonest type of aggression.

As for sexual harassment and rape, the present study revealed that, they were at the lowest rate (table2). This might be related to our religious and culture which criminate this actions. This finding compatible to the findings of(24)whofound that,the annual incidence about 25% of nurses report sexual harassment.

Concerning day off after facing aggressive acts, the current study revealed that,around two thirds of the studied sample didn’t take days off as aresult of aggression (table2). This might beattributed to that, nurses and their mangers seeing aggression as a-part of psychiatric nurses' profession. This result was congruent with (27)who reported that, only 5% of the subjects had called out sick following an aggressive incident.

Regarding to the impact of aggression on health among nurses,the present study revealed that, around fifty of the studied samplesuffered high impact of aggression (figure 4). This result was supported by(18)who reported that, about half of his study sample suffered high impact of aggression including physical ,psychological ,emotional, and cognitive effects. Similarly (28) who reported that, two thirds of the employees felt under high levels of stress as a result of the incidents .

The present study appointed that, around half of the sample experienced impairment in relation with patients in the form of (disturbance of therapeutic relation, avoidance of aggressive patient, feel insecure with working with patients ,and feel insecure at the work place) (figure 3). Also, around three quarters of the sample represented avoidance of patients after the aggressive incident (table 3). This avoidance of contact with the patients , impairment of relationship between nurse and patient were the most obvious reactions of nurses after patient`s aggressive acts and might be related to fear from an aggressive patient or fear of permanent side effects of the assault and by its turn produce impairment of their relation.

The previous finding was consistent with (29) who reported that, avoidance of aggressive patient was the most common reaction of nurses. In the same line (30) reported that impairment of the nurse-patient relationship after aggressive acts by the patients was the most serious problem.

In addition the present study revealed that, two thirds of the studied sample presented the feeling of insecure at work place (table 3).This might be due to the administration`sreaction after aggressive incidents as they saw aggression as a part of nurse`s job and didn’t treat nurse as a victim of assault.This finding was supported by (31)who revealed that, after aggressive actsnurses' perceptions of their job competency and security or satisfaction with the workplace may be affected. Also, (6) reported that, many assault victims feel insecure at work.

In addition, the current study illustrated that,around two thirds of studied sample feelinsecur in working with the aggressive patients(table9). This might be related to psychiatric nurses look to mental patients as impulsive and can`t control his actions. This finding was partially supported by (32)who signify that, 25% of psychiatric nurses felt that their life had been threatened in aggressive incidents. Similarly (4)found that , insecurity and fear might be relatedto being at the mercy of the perpetrator.

Also,approximately half of the studied sample reported guilty consciences and sorry toward the patient (table3). This feeling of sorry or guilty consciousness might be related to inability to handling the situation in a more appropriate way. In this respect,(33) found that, many of the staff members felt guilty after dealing with aggressive patients . Also(34) who reported that, guilt or self-blame or shame were also a prominent reaction to aggression reported in a majority of the studies.

In addition, the present study revealed that, two thirds of the studied sample represented the feeling of insecure at work place (table 9).This might be due to the administration reaction after aggressive incidents as they see aggression as a part of nurse`s job and didn’t treat the nurse as a victim of assault.This finding was supported by (31)who revealed that, after aggressive actsnurses' perceptions of their job competency and security at or satisfaction with the workplace may be affected. Also, (6) reported that, many assault victims feel insecure at work

As regard to the patient`s personal data, the current study demonstrated that, Majority of the studied sample (patients)were males where females were only (19%) (fig.5). This might be interpreted by males being at higher level of responsibility and life stress which may put them at higher prevalence to psychiatric disorders or simply that the sample taken from two males ward against one female ward. This finding was in contrast with (35) who found that, mental disorder prevalence is higher in women than men (19.0%, 12.9%) respectively.

Moreover, the present study revealed that, around half of the studied sample (patients) was in the age group 20-30 years (table 4). Also, around one third of themduration of their illness was6:10 years(table 4). And half of them were diagnosed with schizophrenia(table 4). This mightdue to that schizophrenia is the most prevalent psychiatric disorder. This finding was supported by (36)who reported that,across studies that use household-based survey samples, clinical diagnostic interviews, and medical records, estimates of high prevalence of schizophrenia and related psychotic disorders in Egypt .

The present study found that, more than two thirds of the studied sample represented aggressive acts toward nurses (table 4). This might be due to the psychiatric patients complain from,impulsivity, hyperactivity, hallucination and delusions which effect on patient and his behaviors.This finding was congruent with (17) who stated that, (57%) of aggressors were usually patients at psychiatric clinic.

Concerning patient satisfaction about quality of care,The present study illustrated that, over all patient`s level of satisfaction about the quality of care was moderate (fig. 2).This result wasconsistent with (37) who found that, consumers were asked to rate their overall satisfaction by marking a number from 1 to 10 (where 1 = very bad and 10 = excellent). A mean score of 6.8 resulted.This finding was in disagreement with (38) who signified that, high proportion of patients were dis-satisfied with quality of care

Moreover, results of the present study demonstrated that, most of the studied sample were quiet satisfied about meeting their request when asking for help(table 5). This might be due to the number of the nursing staff to represent help as needed . This finding was supported by(39)who revealed that, Patient satisfaction was highest in the area of receiving help when needed ,60% reported that admission was good, and 76% of the patients felt that staff were caring and showed sympathy in acceptable manner.In the same line (40)presented that, respondents reported moderate satisfaction with time available to be with other patients, and their degree of comfort talking to staffas needed. The previous finding wasincongruent with (37)who reported that,the treating team dealt in-promptly with concerns and requests was rated bad at 80% disagreement.

Regarding, dealing with agitated patients , the current study illustrated that, dealing with agitated patient being at the lowest satisfaction area in the patient`s care (table 5) .This might be due to that the patients seeing the nurses dealing with excessive force, and in an unprofessional manner with agitated patients. In the same context (37)revealed that, most dissatisfaction areas were restrictions and compulsory care. Also (39)repoted that, patients showed low satisfaction in the area of restrictions on movement, with 47% evaluating restrictions as negative or very negative. Similarly (41) who represent that, patients demonstrated lack of patient’s dignity while dealing with aggression.

Regarding the physical environment, the current study revealed that, the physical environmentincluded cleanliness, food, sound level, companion patients,the comfort and esthetics of the places. The environment and recreational services (Table 5) represented the highest satisfaction items. This might be related to presence of suitable rooms, good ventilation, proper bathrooms, good light, sanitary food, clean clothes, and numerous entertaining events. These findingswere in consistent with (42) who represented that, all items included in physical environment and recreational activities attracted 75% of patient`s satisfaction.The current findings were in contrast with (43) who revealed that, physical environment need to more improvement in areas of single bedrooms, a maximum of two patients per room and aspecial room for eating, clean clothes, aclean bed and tasty food were considered to be tokens and recreational activities need to be more attractive .

Concerning the relation between the study variables, The current study revealed that, there were high positive significant correlation between facing aggression and it`s impact on nurses(table 7) especially on areas of impairment of relation between patient and nurses and adverse moral feelings this can interpreted by excessive facing of different types of aggression that put nurse in dilemma between dealing with aggression as a-part of their job or refuse it as humiliating to their dignity so, they resort to stay away from aggressive patients and at the same time feeling of guilt about this. This result was supported by(44) who defined seven categories of consequences of workplace aggression: (1) physical, (2) psychological, (3) emotional, (4) work functioning, (5) relationship with patients/quality of care, (6) social/general, and (7) financial. Also, (45) found that, the health care professionals who had been exposed to physical and verbal violence reportedahigher percentage of anxiety, emotional exhaustion, depersonalization and burnout syndrome compared with those who had not been subjected to any aggression.

The present study revealed that, there was a highly significant negative correlation between aggression toward psychiatric nurses and patient`s satisfaction about qualityof care(table 7) .As mentioned before facing aggression by nurses made them more deniable to patients, tending to dealing improperly, feeling that this patient the only treatment to him is being in isolation. This result was supported by (38) who reported that, there was a highly statistically significant negative correlation between patient satisfaction about quality of care and facing of aggression. Similarly (31) who signified that, Patient`s aggression and assault can lead to real or perceived impairments in professional performance, leading nurses to doubt the quality of their work. Also (46) reported that, of those who had experienced aggression, over two-thirdsindicated that it frequently or occasionally contributed totheir potential to make errors, or to affect their productivity, decreased job performance and headache andtheir patients represent lower level of satisfaction .

Conclusion

Based on the present study, the result could be concluded that, Nurses working in psychiatric settings experience high levels of aggression at work, especially verbal aggression, where sexual abuse came at the lowest level. The serious effects of aggression toward nurses appearin the area of nurse`s performance and relation with patients.There was a positive association between aggression toward psychiatric nurses and impact of aggression on nurses. There was a negative association between aggression toward psychiatric nurses and patient satisfaction about the quality of care.

Recommendations:

Based on the previous findings of the present study, the following recommendations are suggested:

For clinical implication:
- Continuous training program about how to deal with anaggressive patientwichshould be designed and conducted to improve the nurse's awareness of the problems.
- Increased security, video monitoring, and safe nursing areas were important safety measures.
- Creating workplace violence prevention committees are seen as vital.
- Tertiary prevention recommendations suggested by the respondents included the option of taking legal action once workplace violence had occurred and offering adequate followup care and necessary treatment after the violent event.
- For further research:
  - Further studies are necessary using alarge probability sample for generalization of the result
  - Repeating this study with involving physicians, social workers, and all staff involved in patient care.

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