Behavioral Interventions that Treat Aggression: Employees Implementation Experiences within ...

118 Pages·2017·2.09 MB·English

Running head: BEHAVIORAL PLAN IMPLEMENTATION EXPERIENCES

Behavioral Interventions that Treat Aggression:
Employees’ Implementation Experiences within Adult Psychiatric Settings

by
Alyse C. Donovan

B.A., Loyola University Maryland, 2009
M.S., Antioch University New England, 2015

DISSERTATION

Submitted in partial fulfillment for the degree of
Psychology in the Department of Clinical Psychology
at Antioch University New England, 2017

Keene, New Hampshire
BEHAVIORAL PLAN IMPLEMENTATION EXPERIENCES ii

Department of Clinical Psychology

DISSERTATION COMMITTEE PAGE

The undersigned have examined the dissertation entitled:

BEHAVIORAL INTERVENTIONS THAT TREAT AGGRESSION:
EMPLOYEES’ IMPLEMENTATION EXPERIENCES WITHIN ADULT PSYCHIATRIC
SETTINGS

presented on June 23, 2017

by

Alyse C. Donovan
Candidate for the degree of Doctor of Psychology
and hereby certify that it is accepted*.

Dissertation Committee Chairperson:
Martha Straus, Ph.D.

Dissertation Committee members:
David Hamolsky, Psy.D.
Daniel Lambert, Ph.D.

Accepted by the

Department of Clinical Psychology Chairperson

George Trembly, Ph.D.

on June 23, 2017

* Signatures are on file with the Registrar’s Office at Antioch University New England
BEHAVIORAL PLAN IMPLEMENTATION EXPERIENCES iii
Acknowledgments
A special thank you to all of the talented individuals who choose to work within adult
inpatient psychiatric settings. Without your daily hard work and dedication to improving patient
care this project would not have been possible.
To my dissertation committee: Thank you, Dr. Hamolsky, for sparking my interest in
systems interventions. Thank you, Dr. Lambert, for your supervision and guidance on my first
behavioral plan I wrote for an inpatient setting. Thank you, Dr. Straus, for your words of
encouragement, humor, and continual support throughout this project, and my five-year graduate
school journey.
BEHAVIORAL PLAN IMPLEMENTATION EXPERIENCES iv
Table of Contents
List of Tables ................................................................................................................................. vi
Abstract ........................................................................................................................................... 1
Behavioral Interventions That Treat Aggressive Behavior: Employees Implementation
Experiences within Adult Psychiatric Settings ............................................................................... 3
Physical Aggression is a Problem in Psychiatric Inpatient Settings ........................................... 3
Aggression in Inpatient Psychiatric Settings Leads to Injury of Staff Members ........................ 3
Instances of Patient Aggression Predict Negative Staff Work Performance .............................. 5
Patient Demographics and Diagnosis Predict Aggressive Behavior .......................................... 5
Hospital Environment and Treatment Factors Predict Aggressive Acts .................................... 6
Behavioral Theory Conceptualizes the Function of Aggression ................................................ 9
Behavioral Interventions are Effective at Reducing Aggression in Inpatient Settings ............. 10
Behavioral Plans Only Work When Implemented Correctly ................................................... 12
Components of Implementation for Evidence-Based Practices ................................................ 13
The Transition from Evidence-Based Practice to Treatment Program is Complex .................. 16
Statement of Purpose ................................................................................................................ 18
Research Questions ................................................................................................................... 18
Method .......................................................................................................................................... 18
Study Design ............................................................................................................................. 18
Methodology: Interpretive Phenomenological Analysis .......................................................... 19
Sampling and Recruitment ........................................................................................................ 20
Measures ................................................................................................................................... 21
Procedures ................................................................................................................................. 23
Issues of Trustworthiness .......................................................................................................... 26
Data Analysis ............................................................................................................................ 28
Results ........................................................................................................................................... 30
Demographic Data .................................................................................................................... 30
Employees’ Roles in Implementation of Behavioral Interventions .......................................... 30
Current Training Within the Treatment Program ..................................................................... 34
Process for Development of Behavioral Interventions ............................................................. 35
Process to Monitor Staff Members’ Behavioral Plan Implementation Skill Level .................. 36
Current Facilitators of Behavioral Plan Implementation .......................................................... 37
Current Barriers to Behavioral Plan Implementation ............................................................... 40
Employees’ Motivations to Continue Behavioral Plan Implementation .................................. 42
Employees’ Emotional Experiences During Behavioral Plan Implementation ........................ 44
Employee Recommendations to Improve Behavioral Plan Implementation ............................ 46
Discussion ..................................................................................................................................... 54
Dependability and Reliability ................................................................................................... 55
Transferability ........................................................................................................................... 56
Limitations ................................................................................................................................ 58
Behavioral Plan Implementation Needs Assessment ................................................................ 59
Previous Training and Attitudes Toward Behavioral Plan Implementation ............................. 63
Areas for Further Investigation ................................................................................................. 64
Researcher Biases Emerged During Data Collection ............................................................... 65
BEHAVIORAL PLAN IMPLEMENTATION EXPERIENCES v
Conclusion .................................................................................................................................... 68
References ..................................................................................................................................... 74
Appendix A: Demographic Form ................................................................................................. 79
Appendix B: Recruitment Letter ................................................................................................... 80
Appendix C: Semi-structured Interview Outline .......................................................................... 81
Appendix D: Informed Consent Document .................................................................................. 82
Appendix E: Data Collection Permission Letter ........................................................................... 84
BEHAVIORAL PLAN IMPLEMENTATION EXPERIENCES vi
List of Tables
Appendix F: Data Table ................................................................................................................ 85
BEHAVIORAL PLAN IMPLEMENTATION EXPERIENCES 1
Abstract
When adults hospitalized within inpatient psychiatric settings engage in aggressive behavior, it
can have detrimental psychological and physical effects on not only other patients, but on
hospital employees. Several adult psychiatric inpatient facilities have successfully reduced rates
of patient aggression through the implementation of behavioral interventions. While there is
much research on factors that lead to successful implementation of evidence based interventions,
the literature had not yet explored the subjective experience of employees who are asked to
implement behavioral plans in adult psychiatric settings. This study utilized Interpretive
Phenomenological Analysis to gain an understanding of employees’ perceptions of barriers and
facilitators to implementation of behavioral plans that target patient aggression. Participants were
employees within maximum and intermediate security units within a forensic state psychiatric
hospital. The results express the behavioral plan implementation needs for the studied treatment
program. These needs include: (a) an increase in communication between all disciplines involved
with behavioral plan implementation; (b) an increase in the number of floor staff members and
consistent unit assignments; (c) more direct involvement from behavioral technicians; (d) more
nurses trained on behavioral interventions, (e) an increase in direct involvement of authors of
behavioral plans and behavioral technicians with floor staff members and patients; (f) designated
time for staff to complete various implementation tasks; (g) required behavioral theory
competency standards for case managers before behavioral plan authorship is allowed; (h)
continued trainings on behavioral theory and practice for all staff; (i) a formal data collections
system to measure patient behaviors over time; and (j) a formal data collection system to
determine staff fidelity to behavioral plan implementation.
Keywords: adult psychiatric inpatient, aggression, behavior plans, behavioral interventions
BEHAVIORAL PLAN IMPLEMENTATION EXPERIENCES 2
This dissertation is available in open access at AURA: Antioch University Repository and
Archive, http://aura.antioch.edu/ and OhioLINK ETD Center, https://edt.ohiolink.edu
BEHAVIORAL PLAN IMPLEMENTATION EXPERIENCES 3
Behavioral Interventions That Treat Aggressive Behavior:
Employees’ Implementation Experiences within Adult Psychiatric Settings
Risk of physical injury from patient aggression is a significant problem for individuals
who work within psychiatric inpatient settings. While there are evidence-based behavioral
treatments for aggressive behavior, these treatments are not always implemented as intended.
This dissertation is a qualitative study that sought to understand the successes and struggles
psychiatric hospital employees have when implementing behavioral plans with patients who
have aggressive behavior.
Physical Aggression is a Problem in Psychiatric Inpatient Settings
A meta analysis of adult inpatient aggression research published between 1960 and 2009
found that 16.92% of United States psychiatric patients engaged in some form of aggressive act
within one month of admittance to a psychiatric hospital (Bowers et al., 2011). Physical
aggression is defined as any act that is intended to cause another person physical pain (Anderson
& Bushman, 2002). The most common types of physical aggression reported in psychiatric
inpatient settings include: “biting, kicking, hitting, scratching, grabbing, pinching, spitting, or
pulling hair” (Jansen, Dassen, & Groot Jebbink, 2005). Aggression can be further classified as
hostile or instrumental. Hostile aggression is “impulsive, thoughtless (i.e., unplanned), driven by
anger, having the ultimate motive of harming the target, and occur[s] as a reaction to some
perceived provocation” (Anderson & Bushman, 2002, p. 29). Conversely, instrumental
aggression is proactive and premeditative, with the perpetrator hoping to accomplish a goal other
than harming the victim through their aggressive action (Anderson & Bushman, 2002).
Aggression in Inpatient Psychiatric Settings Leads to Injury of Staff Members
The job-related violent crime rate for psychiatrists and mental health professionals is
BEHAVIORAL PLAN IMPLEMENTATION EXPERIENCES 4
more than five times the rate for all other occupations, with 68.2 incidents reported per 1000
workers per year (Friedman, 2006). For mental health custodial workers, the incident rate is even
higher, with 69.0 per 1000 workers experiencing a job-related violent crime per year (Friedman,
2006). Of those employees that required time away from work in 2014 due to an occupational
injury or illness, 52% of psychiatric aids, 46% of psychiatric technicians, and 75% psychiatrists
cited being physically injured by mental health care patient as the source of their injury (U.S.
Department of Labor, 2015).
In a similar vein, Privitera, Weisman, Cerulli, Tu, and Groman (2005) surveyed
employees of a psychiatric hospital and found that 34% of clinicians and 8% of non-clinicians
had experienced assaults from patients. Staff that had close and frequent contact with patients,
including nurses, physicians, and advanced practice nurses, were the staff members most likely
to be assaulted by patients (Privitera et al., 2005), with one in four psychiatric nurses being
injured by assaultive patients each year (Quanbeck, 2006). This research also highlighted the
concern that surveyed employees greatly under-reported aggressive incidents to hospital
administration; in fact, employees only filed incident reports for 50% of aggressive incidents
experienced. Therefore, it is likely psychiatric hospitals may have inaccurate records of how
many assaults by patients actually occur on a daily basis (Privitera et al., 2005). Possible reasons
for nursing staff underreporting assaultive patient behaviors included: expectations that
experiencing patient aggression was part of the job; the employee did not sustain a serious
injury; beliefs that patients did not intend to cause harm; belief that filing a report is too hard or
time consuming; belief that administration would not take action based upon a filed report; and
lack of procedures requiring reporting of aggressive incidents (Snyder & Chen, 2007).