Violence Against Nurses In Psychiatric Health And Social Care Essay

Violence Against Nurses In Psychiatric Health And Social Care Essay Violence is currently prevalent in every sphere of social life. Nowadays, health care personnel are facing more harsh behaviours than ever before, here in Jordan. The rising rate of violence in health care settings has become a major problem for nurses. Nurses are at considerable risk of occupational (work-related) violence. Working primarily in psychiatric departments resulted in an increased risk for both physical assault and non-physical violence (Nachreiner, et al., 2007). Psychiatric health care providers have high rates of work place violence victimization, but yet little is known about the strategies used by them and their facilities to manage, reduce, and prevent violence (Peek-Asa, et al, 2009). Their presence in stressful situations such as incidents (violent incidents), suicide attempts, waiting to visit a doctor, or transfer of patients to another ward or another hospital exposes them to more abuse or harsh behaviour from patients, families, relatives and friends than oth er hospital staff (Kwak et al., 2006). The motivation of this paper stemmed from a recently news in the media reporting the increased incidents of violence and aggression faced by nurses in Jordanian hospitals. The media news prompted the author to reflect on current knowledge and understanding of these events in both in Jordan and around the world to make recommendations for managing reducing, and prevention of these events in the future. Recommendations for future research in this area were addressed also. Recommendations for future research will enable nurses to deepen their understanding of violence and aggression in psychiatric settings which in turn will lead to improved strategies, policy and practice leading to increased safety for nurses and patients. This paper was intended to be a commentary paper on the phenomena of violence in psychiatric settings; however, to comment on this phenomenon an extensive literature review was conducted and will be presented also. The paper design compared the violence with the cr ime. The perpetrator of this crime is the psychiatric or mentally ill patient, while the victim is the psychiatric/mental health nurse. The scene where the crime occurred is the psychiatric setting. The Aim This paper aims to provide a general understanding of the whole picture of violence against nurses in psychiatric settings. In order to achieve that, this paper addressed the following topics: (1) Recent epidemiology of episodes of violence in psychiatric words, (2) Defining violence and related concepts, types, and forms, (3) The perpetrator, (4) The victim, (5) Prevention of violent incidents, (6) Assessment of violence, (7) Management of violent episodes. Methods The following databases were searched: EBSCO host service databases (Academic Search complete, Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus), MEDLINE, Psychology and Behaviours Sciences Collection). These databases were searched for English language papers published between 1 January 2006 and 1 April 2011 using the key words violen* (violence or violent) and in-patient or psychiatric words or psychiatric settings. Limiters were used in each database to include and exclude certain studies. The search was limited to full text articles, available references articles , articles published between 1 January 2006 and 1 April 2011 in scholarly (peer reviewed) journals. Special limiters for Academic Search Complete were periodical publications, English language articles, and articles with PDF full text. Special limiters for CINAHL Plus were articles with available abstract, English language articles, research articles only, articles that considered humans only as research subjects, articles with at least one nurse author, studies conducted in inpatient settings only, and articles with PDF full text. Special limiters for MEDLINE were: articles with abstract available, English language articles, articles that considered humans only as research subjects, articles published in nursing Journals only. Only PDF full text articles were searched in psychology and Behavioural Sciences Collection. After completing search, 197 studies resulted. Most of them were included in this paper. However, some were not included because they did not respond to the objects of this paper. Some of studies in references lists of the resultant articles were also reviewed and included for epidemiological purposes even they are older than five years. Some of them were also used for critically reviewing the updated studies (à ¢Ãƒ ¢Ã¢â€š ¬Ã‚ °Ã‚ ¥5 years). Definitions Violence in the workplace can take various forms ranging from abusive language, threats, physical assaults, and even homicide (Wassell, 2009). There are many different definitions of violence. This section will define and differentiate between violence forms and forms. The world Health Organization (WHO) define violence as: The intentional use of physical force or power, threatened or actual, against oneself another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevlopment, or deprivation (WHO, 2005, p.5). Work-related violence is any activity or event occurred in the work environment involve the international use of physical or emotional abuse against an employee, resulting in negative physical and emotional consequences (Nachreiner, et al., 2007). A less restrictive definition was the definition of Baron and Neuman; they define workplace violence as direct attacks which occur in the work place itself or within an organization (Baron Neumann, 1998). Physical assault is hitting, slapping, kicking, pushing, grabbing, sexually assaulted, or any type of physical contact aimed to injury or harm (Nachreiner et al.). A threat occurred when someone used words, gestures, or actions for freighting another one without attempting harm or injury (Nachreiner et al.). Sexual harassment occurred when one is a subject for any type of unwanted sexual behaviour (words or actions). (Nachreiner et al.). Verbal abuse is calling another person -must be associated with the name- with unfavourable words for the purpose of hurting emotionally injuring. Jenkins (1996) believes that even threat of physical violence is considered physical violence (Jenkins, 1996). WHO determined three types of violent acts: physical, sexual, and psychological (WHO, 2005, p.6). Violence and aggression are two interrelated concepts extensively studied in nursing literature. Although, they are not the same, nursi ng literature widely used them interchangeably. In this paper, violence and aggression will be used interchangeably. Epidemiology The risk of being subjected to violence among health staff is 16 times higher than in other occupational groups in the service sector (Kingma, 2001). There is an escalating alarming trend of all forms and types of violence towards nurses in health care settings (Whelan, 2008). Nurses are at the highest rates of nonfatal workplace assault and violent victimization in all health care settings (Lanza, Zeiaa, Rierdan, 2006). There is a considerable difference in the prevalence and incidence of episodes of violence in mental health settings, depending on the countries in which the studies were carried out. A survey of 4.826 nurses conducted by the American Nurses Association, 17% reported that they have been physically assaulted, and 57% reported that they had been abused in the last year (Peek-Asa, et al., 2009). Also, only 20% reported that they felt safe in their current work environments. Psychiatric nurses are the highest subjects of violent victimization rates of all types of nurse s (Islam, Edla, Mujuru, Doyle, Ducatman, 2003). In an analysis of the results of the Assaulted Staff Action Programme (ASAP) that persists for 15 years; 1.123 mental health nurses (69.58%) were victims of violence by patients. They were the subjects of physical (85.32%), sexual (1.18%), nonverbal intimidation (1.67%), and (6.01%) assaults. 46.34% of injures were soft tissue bruises, 10.16% were head and back injuries, 5.76% were bone/tendon/ligament injures, 12.39% were open wounds, scratches, or spitting incidents, 1.8% were abdominal wounds, and 18.65% were psychological fright. 36.69% were mild injures, 31.52% were moderate, and 14.13% serious and intense (Flannery, Farley, Rego, Walker, 2007). A survey in psychiatric institutions in Switzerland reported that 70% percent of nurses reported being physically attacked at least once in their career (Needham, et al., 2004). A multiregional study of nursing staff members from acute psychiatric settings showed that 76% of the particip ants reported that they were assaulted at least once (Peek-Asa, et al., 2009). In a study in Iran, verbal abuse was experienced by 87.4% of nurses during a 6-month period, and physical violence by 27.6% during the same period of time (Shogi, Sanjari, Shirazi, Heidari, Salemi, Mirzabeigi, 2008). The most frequent and most severe forms of verbal abuse reported were judging and criticizing, accusing and blaming, and abusive anger (Kisa, 2008). In one Arabic study, a national cross sectional survey was conducted in Kuwait to document the prevalence and determinants of violence against nurses in healthcare facilities. 48% of nurses experienced verbal violence; and 7% only experienced physical harm over the previous six months (Adib, Al-Shatti, Kamal, El-Gerges, Al-Raqem, 2002). Another Arabic study in Bahrain, Hamadeh and colleagues found the average assault rate on nurses is 4.4%. (Hamadeh, Al Alaiwat, Al Ansari, 2003). No similar studies were conducted in Jordan. However, this high results may be an emergent indicator of the escalating trend in Jordan and other Arabic countries because of their similar Arabic culture to Kuwait and Bahrain. Epidemiological studies were recommended to conduct to determine the incidence and prevalence of this phenomenon in Jordanian health care settings and especially in mental ones. Despite the high prevalence of violence acts toward nurses, only 20% of violent incidents are reported by nurses. This is due to staff being accustomed to violence; peer pressure not to report; differential reporting based on gender of the victim, fear of blame; excessive paper work; and incomplete or invalid information on reports completed by persons not witness to the event (Crilly, Chaboyer, Creedy, 2004). This problem should also be addressed in future studies to investigate its causes and to solve it. The Victim Nurses are usually the subjects of violence victimization. However, Other mental health care professionals such as physicians and physiotherapists are also at a considerable of violent acts (Stubbs Dickens, 2009). This paper addressed nurses only as subjects of victimization from psychiatric and mentally ill patients. Psychiatric patients assaults on nurses victims are a worldwide occupational problem. There is remarkable consistency in victim characteristics over time (Flannery, Juliano, Cronin, Walker, 2006). Men nurses were exposed to more abuse than women (Shagi, et al., 2008). However, there is an inconsistent finding in the literature identifying whether males or females are more violence-prone (Camerino, Estryn-Behar, Conway, Der Heijden, Hasselhorn, 2008). The risk of experiencing abuse was higher in nurses with more job experience or who worked more hours (Shagi et al.). On the other hand, a longitudinal cohort study showed that younger nurses with less job experiences are at increased risk violence (Camerino et al., 2008). However, exposure to violence was not significantly associated with age, gender, duration of employment in nurses working in child and adolescent psychiatric units (Dean, Gibbon, McDermott, Davidson, Scott, 2010). Having a lower job title (air or practical nurse), b eing in closer contact with patients, having special personality traits, using drug or alcohol, reporting extreme fatigue , may lead to higher risks for aggression and harassment at the workplace (Cooper Swanson, 2002). Nachreiner et al, agree with Copper Swanson on that LPNs an increased risk for both physical assault and non-physical violence compared to RNs (Nachreiner et al, 2007). Violent incidents are often related to the low awareness of nurses about the adequate therapeutic communication skills in dealing with patients (Cooper Swanson, 2002). Perceptions attitudes of nurses on patients violent incidents in psychiatric settings are extensively studied in the literature. Psychiatric nurses attitudes are different across countries (Jansen, Middel, Dassen, Reijneveld, 2006). According to some nurses violence is perceived as dysfunctional/undesirable. Whereas in others, violence is perceived as a functional comprehensible phenomenon (Abderhalden et al., 2002). 97% of participants believed that dealing with aggressive behaviour was a part of work in mental health inpatient unit (Dean, Gibbon, McDermott, Davidson, Scott, 2010). In the same study, 69.7% of participants believed that the current level of physical aggression in the ward was unacceptable, whereas only 12% report that it was acceptable, and the others reported feelings of uncertainty (Dean et al, 2010). They rationalize that by recognize that staff with more positive attitudes exhibited lower state anxiety. There are negative attitudes of nursing students to violen t incidents, and these attitudes are deteriorated over time (Bowers, Alexander, Simpson, Ryan, Carr-Walker, 2007). The perception of aggression scale (POAS) is a newly developed attitude inventory assessing nurses attitude toward aggressive patients (Palmstierna Barredal, 2006). Consequences of violent incidents on nurses were also extensively investigated in the literature. Responses to violence encompassed three major categories relating to physical emotional and professional impact (Dean, et al., 2010). They found that physical injuries divided to: direct injuries from the violent incidents, injuries while implementing restrictive interventions, and physical symptoms such as headache and muscle tension (Dean, et al.). Major physical injuries were on the head, the trunk, the upper and lower extremities (Langsrud, Linakker, Morken, 2007). Ongoing mental fatigue, stress, shock, helplessness, anger, vulnerability, feelings of being emotionally drained, anxious, impaired sleep and concentration were all emotional responses of nurses as a result of being violent (Dean, et al.). Nurses also respond with the following emotions and behaviours: frustration, despair, hopelessness, substance abuse, absenteeism, retaliation and the development of I do not care attitu de (Bimenyimana, Poggenpoel, Myburgh, Niekerk, 2009). The results of verbal abuse or violence by patients, often result in a severe psychological impact in nurses (Inoue, Tsukano, Muraoka, Kaneko, and Okamara, 2006). The most common emotional reaction to violence was anger, followed by shame, humiliation and frustration (Kisa, 2008). The Perpetrator Violence is common among individuals entering mental substance abuse words. Episodes of violence on psychiatric wards have been extensively studied, with one of the main aims being to identify who is more likely to be violent during hospitalization. However, it is difficult to determine that, because violence is a complex behaviour links with a variety of biological, psychopathological, and social factors. 15-years study concludes that older male patients with schizophrenia and younger personality-disordered patients are high-risk assailants (Flannery, Juliano, Cronin Walker, 2006). Antisocial personality disorder poses a great risk for violence among women than men (Yang Coid, 2007). Anxiety disorders and any personality disorder are more severe among violent women; alcohol dependence and hazardous drinking are more severe among violent men (Yang Coid). In a recent literature, Cornaggia and colleagues found that the psychiatric diagnosis most frequently associated with aggressive behaviour is paranoid schizophrenia. As patients with paranoid schizophrenia retain sufficient ability to plan and commit acts of violence related to their delusions (Cornaggia, Beghi, Pavone, Barale, 2011). Higher levels of hostility-suspiciousness predict the worsening of the pattern of violence (Amore et al., 2008). Persecutory delusions appear to increase risk of violence in some patients; co-occurren ce of persecutory delusions and emotional distress may increase the risk of violence (Bjorkly, 2006). Lower social class of origin, offending behaviour in the parental generation loss of the father, a new partnership of the remaining parent, growing up in blended families promoted the development of offending behaviour in general (Stompe, et al., 2006). Past history of violence toward others, substance abuse disorders are risk factors for future violence (Flannery, Julliano, Cronin, Walker). Past history remains the most consistent and stable predictor of future violence (Amore et al., 2008). Dual diagnosed patients with substance abuse disorders and bipolar sample have more violent acts (Grunebaum, et al., 2006). Black and minority ethnic are more often perceived as potentially violent to others (Vinkers, Vries, Van Baars, Mulder, 2009). Internalizing symptoms and affective reactivity contributed to aggression severity more than impulsivity and demographics (Kolko, Baumann, Buks tein, Brown, 2007). Even the month of birth of patients is considered a risk factor of violent behaviour (Cailhol, et al., 2009). Repeatedly violent patients had a higher length of residency, a higher number of previous violent behaviours (Grassi, et al., 2006). A past history of head injury with loss of consciousness was more frequent among persistently physically aggressive patients (Amore, et al., 2007). Assessment Many studies also discussed high risk children in the literature. Aggression appears associated with a wide variety of commonly psychiatric disorders in children (Connor McLaughlin, 2006). Children of bipolar parents are at high risk of hostility, aggression, violence (Farchione, et al., 2007). Adolescent conduct disorder patients are more likelihood to be violent (Ilomak, Viilo, Hakko, Marttunen, Makkikyro, Rasanen, 2006). Children with learning disabilities who had a comorbid psychiatry diagnoses reported a significantly higher amount of peer victimization than children without a cormobid psychiatric disease (Baumeister, Sterch, Geffken, 2007). Many other results showed results opposed to what known. Foley and colleagues found that violence at presentation with first-episode psychosis is not associated with duration of untreated psychosis (Foley, Browne, Clarke, Kinsella, Larkin, O`Callagham, 2007). No substantial evidence support the relation between insight and violence risk (Bjorkly, 2006). The Scene The scene of violence victimization against the psychiatric nurses by psychiatric and mentally ill patients is the psychiatric settings. The structure of the setting can provoke the manifestation of violence (Steffgen, 2008). Also, environmental design have been demonstrated to deter violence (Wassell, 2009). Inadequate staffing levels and lack of opportunities for clients to participate in therapy may provoke violence behaviour (Sturrock, 2010). The role of uncertainty concerning job stability represent a casual factor Also, lack of job security may cause violent behaviour The absence of social support and co-workers increases the risk of nurses in this setting to physical and verbal violence (Steffgen). The occurrence of workplace violence may cause damage to both the individual and the institutions. Organizations may face increased absenteeism, sick leave, property damage, decreased performance and productivity, security costs, litigation, workers compensation, and increasing turn over rates (Jackson, Clare, Mannix, 2002). Prevention Previous nursing literature suggested a number of strategies that can be considered by nurses to prevent violence. There is limited research on effective interventions to prevent patient violence (Kling, Yassi, Smailes, Lovato, Koehoorn, 2010). However, failing to accept and implement preventive measures in psychiatric settings has an impact to reduce violence in these settings (Wassell, 2009). Improved reporting may be of big benefit of reducing physical violence (Nolan Citrome, 2007). This may be occur by early recognition and intervention of potentially occurring violent incidents in the future. After conducting the Violence Prevention Community Meeting (VPCM), a significant decrease in patients violence were found across day, evening and night shift for pre-treatment vs. treatment and pre-treatment vs. post treatment comparisons. VPCM is a semi-structured protocol for the purpose of violence prevention (Lanza, Rierdan, Forester, Zeiss, 2009). Early recognition has strong practical implications for psychiatric nurses by helping them to assist patients with the detection of early warning signs. Early recognition is pay special attention to the early social and interpersonal factors that may deteriorate the patient behaviour to violent one (Fluttert, Meijel, Webster, Nijman, Bartels, Grypdonck, 2008). Steffgen identified many preventative measures of workplace violence such as: measures concerning the physical environment, measures concerning the management of the organizations and the behaviours of the members in the organizations, policies, counselling and training measures (Steffgen, 2008). A 6-module program have been shown to be effective in reducing and preventing violent incidents in a 6-months evaluation period. The 6 modules were about violence risk assessment, theoretical models of violence, assertive training, ethical legal issues of violence management (Anderson, 2006). Dubin et al identified six gold recommendations to prevent violence incidents in psychiatric emergencies. Firstly, all newly admitted patients should be assessed for risk of violence; those who have risk factors should be continually assessed. Second, nurses should avoid evaluating and/or treating patients at risk for violence alone or in an isolated office. Third, nurses must remember that patients violence is a response to feelings of helplessness, passivity, and perceived or actual humiliation; therefore nurses should avoid becoming verbally or physically towards them. Fourth, nurses are supposed to use non-coercive methods such as de-escalation to prevent escalation of patients aggression. Fifth, limit setting should always offer the patient two options with one option being the preferred option. Sixth, an armed patient should not be threatened and the clinician should respond in a non-threatening manner offering help and understanding. Finally, evaluation of environment safety s hould occur periodically and changes should be implemented that will enhance safety (Dubin, Julius, Novitsky, William, 2009). Assessment The first step in mental nursing process and one of the most important duties in psychiatric settings is assessment. Psychiatric nurses are faced with a great number of situations in which risk assessment are needed. Risk assessment is a process concerned with a variety of issues à ¢Ãƒ ¢Ã¢â‚¬Å¡Ã‚ ¬risk for what, when, where, and to whom-not just the were Prediction of future violence (Haggard-Grann, 2007). Predicting violence has been compared to forecasting the weather. Like a good weather forecaster, the nurse does not state with certainty that an event will occur. Instead, he/she estimates the likelihood that a future event will occur. Like weather forecasting, predictions of future violence will not always be correct (Scott Resnick, 2006). Three major types of violence risk assessment are extensively reviewed in the literature. The three types are: (1) Clinical violence risk assessment, (2) Structural risk assessment tools, (3) Functional assessment. The number of risk assessment instruments has increased in the recent years (Haggard-Grann). Risk assessment tools should include situational aspects, behavioural patterns, and predicted events or stressors (Haggard-Grann). The first step when determining which instrument to use for a specific risk assessment is to determine the purpose and context for which the instrument is needed (Haggard-Grann). Decision should be made regarding whether the assessment is for the first time (to separate the highly risk patients from others) or for continuous ongoing assessment (Haggard-Grann). If adopted in clinical practice with a professional way, these instruments will indeed aid in the assessment and early recognition of violent incidents. However, they are inescapable part in the clinical practice in psychiatric settings. (Haggard-Grann). Awareness of the limits and abilities of such instruments is required. Lurigio and Harris underscored the importance of performing more accurate assessment tools that can for example determine the upcoming type of violence, or the likelihood of weapons use (Lurigio Harris, 2009). A risk assessment tool mainly contains two types of factors: static and dynamic. Dynamic factors are of a great importance in a decision context whereas static factors are at less importance. Dynamic factors should be assessed regularly in a structured time schedule (ex. every 1 hr). (Haggard-Grann). Static variables are based on intrapersonal factors (ex., personal biological characteristics) that served as risks factors for a patient to be potentially violent in the future. (Haggad-Grann). Many violent risk assessment tools were developed for the aim to assess the violent incidents in psychiatric settings. Sexual Aggression scale is an effective assessment tool to record systematically the occurrence of sexually aggressive behaviours for patients who reside in psychiatric hospitals. (Jones, Sheitman, Hazelrigg, Camel, Williams, Paesler, 2007). It is a brief scale consists of 4 sub scales with a brief description of them. The Alert System is a system includes a risk assessment form used by nursing staff to assess patients upon admission to the psychiatric setting in order to identify these at an increased risk of violence (Kling, et al ., 2010). If identified as at risk for violence, a flag is placed on the patients chart and wristband to contain staff of a patients potential for violence (Kling et al). The warning is intended to allow workers to take precautions to prevent violent incidents in flagged patients. These precautions may include: wearing a personal alarm, being near a security personals, not having sharp objects in the patients room, and not entering the patients room alone (Kling et al). Study results indicate that the Alert System is effective in identifying potentially violent patients. However, the ultimate goal of implementing the Alert System is to reduce the risk of violent incidents (Kling et al). Risk for in-patient violence in acute psychiatric intensive unit can be a high degree be predicted by nurses using the Broset violence checklist (Bjorkdahl, Olsson, Palmstierna, 2006). The BVC is a method to predict risk for violence from patients within the coming 24 hrs in acute psychiatric inpatient settings (Bjorkdahl, Olsson, Palmstierna). BVC is used to assess the patient three times daily: in the morning, noon, and night shifts (Bjorkdahl, Olsson, Palmstierna). The BVC assess absence or presence of six behaviours: confusion, boisterousness, irritability, verbally, threatening, physically threatening and attacking object (Bjorkdahl, Olsson, Palmstierna). The HCR-20 is a structured professional checklist designed for the assessment of risk future violence in patients with violent history / or a major mental disorder or personality disorders. (De Vogel De Ruter, 2006). The HCR-20 consists of 20 items, divided into three subscales: historical scale, clinical scale, and risk management scale. The predictive validity of the HCR-20 was good (De Vogel De Ruiter). The Forensic Early Warning Signs of Aggression Inventory (FESA) was developed to assist nurses and patients in identifying and monitoring early warning signs of aggression in forensic patients (Fluttert, Meijel, Leeuwen, Bjorkly, Nijman, Grypdonck, 2011). The Maudsley Violence Questionnaire contains 56-items measure a number of cognition (including: beliefs, rules, distortions and attributions) that are related to violence (Warnock-Parkes, Gudjonsson, Walker, 2007). The Psychopathy Checklist (PCL) is a clinical rating scale designed to measure psychopathic attributes in mentally ill patients, Patients who score higher have higher rates of violent recidivism (Scott Resnick, 2006). The PCL uses a semi-structured interview, case-history information, and specific criteria to rate each of 20 items on a three- point scale (0, 1, 2). (Scott Resnick). Total scores (ranging from 0 to 40) reflect an estimate of the degree to which the patient matches psychopathy (Scott Resnick). The Violence Risk Appraisal Guide (VRAG) is a risk assessment instrument of 12 items. It is probably the most well-known assessment instrument aimed to assess dangerousness in high-risk mentally ill patients. It is used to appraise the violence risk in psychiatric and other health settings (Scott Resnick, 2006). It is constructed by taking variables known to predict violent behaviour among men with mental disorders who have records of previous violent behaviour then summarizing the variables into one scheme (Haggard-Grann, 2007). Interactive Classification Tree is a recent tool for assessing the violence risk of patients discharged from psychiatric facilities (Scott Resnick, 2006). This tool utilizes a sequence of questions related to risk factors for potential violence (Scott Resnick). According to the answers, another related question is posed, until the pt is classified into a category of high or low risk of future violence (Scott Resnick). Structured risk assessment tools have inherent limitation when used alone. Criticisms of instruments include the following: they provide only approximations of risks; their use is not generalizable beyond the studied populations: they are rigid, and they fail to inform violence prevention risk management (Scott Resnick, 2006). Functional assessment approaches seek to clarify the factors responsible for the development, expression and maintenance of problem behaviours. This is achieved through assessment of the behaviour of interest, the individuals predisposing characteristics, and the antecedent events, considered important for the initiation of the behaviour, and the consequences of the behaviour, which maintain and direct its developmental course (Daffern, Howells, Ogloff, 2007). They identify 9 common functions of violent behaviour in psychiatric settings in the literature: demand avoidance, to force compliance, to express anger, to reduce tension, to obtain tangibles, social distance reduction (attention seeking), to enhance status or social approval, compliance with instruction, to observe suffering (Daffern, Howells, Ogloff). Functional assessment have many implications for the prediction and prevention of inpatient violence and for the treatment of violent patients. The distinction of functional assessment approaches and structured assessment tools is that the first emphasize the correct classification of the form of a particular behaviour and the other one emphasize the purpose of the behaviour (Daffern, Howells, Ogloff). The clinical risk assessment method is the oldest method of violence risk assessment. It is the classical method of expecting, predicting, and assessing of risk. This means that the nurse gathers the information that he or she believes to be useful and on the basis of that information makes a judgment of the risk (Haggad-Grann, 2007). Unfortunately, this method cannot predict future violence with high accuracy. The accuracy of a

Buddha :: essays research papers

Buddha There are many Buddha’s in the world. The story by Ashvaghosha called The Life of Buddha talks about the original Buddha, and how he came to be. Sculptures and pictures of Buddha always have the same features. From the Art Institute in Chicago comes a sculpture of Buddha from China. These two things have a lot in common. The parts of the body in the sculptures depict certain things about a Buddha’s life and the way Buddhism spread though Asia influenced the arts depicting Buddha.   Ã‚  Ã‚  Ã‚  Ã‚  Most works of art involving Buddha have features that are almost always there. Whenever a person sees Buddha, he always has most of the ten qualities or powers of a Buddha, described in Story of the Life of Buddha Shakyamuni. However there are thirty-two major characteristics and eight minor, among them is the eight-spoked lines on the soles and palms. The spot between Buddha’s eyebrows, sometimes calls the third eye or wisdom bump, is a mark of wisdom. The nose has a specific length like the ears have their own characteristics. The enlightenment-elevation on the top of the head, describe by old texts as emerging from the head of a saint, symbolize Buddha’s enlightenment and is a visible symbol of the â€Å"spiritual generative power that strives toward heaven and passes into the immaterial sphere.† (Buddhist Art: Perfect Proportions of a Buddha, Para. 3). The Yoga position stemming from the pre-Buddhist tradition in India hides the lower half of Buddha’s body, but show the divine meditating with the utmost concentration, soles visible. The image of Buddha expresses serenity and proportional beauty. These Measurements are laid out in the canon of Buddhist art, which corresponds to ideal physical proportions; each span has a twelve-finger breadth and has 9 breadths. If there is a background behind Buddha it usually depicts a halo around his head. For example, the Buddha in Buddhism: a Brief Introduction on page thirty-eight exhibits a fiery halo. The Buddha statue from the Art Institute is sitting in the lotus position, have the wisdom bump, and the hair is knotted on the top of the head. Also the Buddha would have had long ear lobes if they were not broken off. The long ear lobes seem to be a symbol of his wealth and that the fact that they are now longer filled shows that he renounced wealth. At the end of the story the Prince did just the he renounced his wealth and became Buddha.

Ethical Decision making by School Principals Essay

Principals are faced with the challenge of managing schools and there is need for them to be ethical, respectful, inspiring, creative and knowledgeable about methods of instruction and the culture of the school and curriculum. These principals are also faced with the challenge of knowing and identifying areas of support that is able to enhance the school’s mission and also manage the areas that impede the achievement of a stated mission of the school. Since the needs of students are ever changing, they should also be in a position to make both smaller and larger adjustments that could be beneficial to the school and easily manageable by the organization in the management of these decisions. (Sousa, 2003, pp. 195-198). A decision is termed as ethical when it is able to bring about positive results and does not harm other people or the third party. These decisions are able to bring forth respect, trust, fairness and caring, responsibility and demonstrate good citizenship. When a decision accomplishes the needs of people together with their purposes, it is then termed as an effective decision. Ethically sound decisions are mostly advanced by two critical aspects namely discernment and discipline. For a decision to poses the aspect of discernment, it requires judgment and knowledge. The strength of character on the other hand, makes up a good decision and this takes moral change and the will power to be able to do what needs to be done (Hoy & Tarter 2004, pp. 56-60). Ethical decision making calls for good leadership from principals. Leadership may be described as the authority or ability of an individual or individuals to lead others towards the achievement of a goal. It involves directing and influencing others towards the accomplishment of the stated common objectives and involves responsibility and accountability for the group. There are various leadership styles that are used today in many organizations and institutions. The autocratic type of leaders apply unilateralist while dominating their team-members in order to achieve a particular objective. However, this method often results to resistance from the team- members, as this style generally requires constant pressure and a lot of direction to get things done. On the other hand, this style could be more effective in urgent situations requiring urgent action (Schiminke, 1998, pp. 107-110). In the Laissez-Faire leadership, little control is exercised by managers over their groups. This allows the team-members to sort out their duties and obligations but the manager is not in any way involved with them. This style of leadership however is ineffective at certain circumstances since the team is left floundering with limited motivation and direction. Laissez- faire is effective in cases whereby a manager leads a team that is highly skilled and motivated and these people have in the past produced excellent work. The Democratic leader on other hand often uses participation and the groups’ teamwork towards attaining a collaborative decision. This style focuses on communication between the leader and the team and hence a positive climate for achieving results is created. The leaders consult their teams before making a decision while still in control of the team. These leaders allow the team to make decisions on how certain duties will be carried out and by whom (Schiminke, 1998, pp. 107-110). In addition, a good democratic leader is one who approves participation by team members and delegation of duties or tasks is done wisely. This kind of a leader values the points put forward from them and also encourages any group discussion. He also empowers the team through motivation. On leadership styles include a coercive leader, authoritative. Leader, affiliative leader, pace setting and a coaching leader. A coercive leader demands obedience, which should be instantaneous and applies initiative, achievement and self-control. In times of crisis or company turn around, this style is considered to be more effective but it mostly creates a negative climate for the performance in an organization. The authoritative leader on the other hand is considered to be one of the most effective as this leader inspires employees to follow a vision, facilitate change and creates a strong organizational climate that results in positive performance. The affiliative leadership values people, their emotions and their needs and relies on friendship and trust to promote flexibility, innovation and risk taking. A pacesetting leader can create a negative climate because of the high standards he or she sets. This style works best in attaining quick results from highly motivated individuals who value achievement and take the initiative. Lastly, the coaching leader builds a positive climate by developing skills that will foster long-term success. This type of leader also delegates responsibly, and is skillful in issuing assignments that are quite challenging. Leadership entails organizing people in a bid to achieve the stated goals of the group. It is therefore essential that leaders should posses certain basic qualities that will enable them to be effective leaders in whatever situation or task they undertake (Guy, 1990 pp. 105-107). Leaders should display a good work ethic that will enable other employees to emulate. A good work ethic includes: being on time, being organized giving praise to employees, being well prepared for meetings and having good communication within the venture that will go a long way towards achieving emotional and financial success. Therefore a leader should set an example with an ethical set of values for other managers and employees. For a leader to be effective, he/she should be willing to constantly learn at the same time integrate the knowledge they have acquired through learning into their leadership style. They must also develop skills that will promote them into being good leaders. Another quality of a good leader is that they should constantly keep up with the current trends in leadership and be aware that the leadership styles are constantly changing. In other words these leaders should be open to change. A good leader should also be able to mobilize people and acquire their trust in the process. Good leaders should also have the ability to communicate effectively with their subordinates communication is an essential aspect since it involves both listening and sending messages or telling others what needs to be done. Moral leaders are in a position to produce good moral leadership. They mostly apply restraint and power in their leadership. They are willing to accept any results without imposing control on other people. This is stewardship. It enables leaders to accept their faults which are human instead of shielding themselves under their authority and status. Ethics can be described as the codes of conduct that guide on how one should behave regarding moral duties and virtues. These moral principles guide a person in determining what is wrong or right. Morality by principals can be termed as personal ethics. This is because personal ethics reflect the expectations of people of all works in the society. Ethics has got two aspects: the ability to determine right from wrong, propriety from impropriety and good from evil. The second perspective concerns the commitment to perform an action that is proper, right and good. The principles of personal ethics include: trustworthiness and honesty, concern for the well being of others preventing harm refusing to take unfair advantage, respect for the autonomy of others and basic justice. Ethics as displayed by principals in schools or any other leaders could be classified as under written and unwritten codes of ethics: codes of ethics are the efforts which are systematic in nature and are used in defining the right conduct. They also provide guidance and help in the installation of confidence in various aspects of life from the government and all organizations. The main guidance is reflected in the decision making process especially where values seem to conflict. Written codes of ethics can be made known by an organization, professional or jurisdiction. On the other hand unwritten codes that exist and that help us in our lives are more effective than the written ones. Un written codes of ethics include rules such as honesty, security, loyalty among others. These unwritten codes of ethics mostly arise from family and cultural tradition and can also be found in workplace. These written and unwritten codes of ethics mostly arise from family and cultural tradition and can also be found in workplace. These written and unwritten codes of ethics are found in the society and they help one in establishing their personal belief system. Ethical behaviors should be a part and parcel of an individual’s daily routine (Murphy & McMurty, 2000. pp. 110-115). I believe that Principals need to make strategic decisions since society and environment are dynamic and this provides them with a means that is strategic in nature that could enable them consider the external environment by focusing on the strength of the school organization, reducing weaknesses in school and also identify all the available opportunities that could put the school at a better position to be able to gain a competitive advantage. School principals are able to make an ethically defensible decision when the decision is well thought considering all the formal possible angels meaning that everybody takes part in decision making. In addition, ethically sound decisions in corporate all the possible solutions regarding the positive and negative outcomes of the decision. The decisions made by school principles need to involve a consultative process, team or group process or delegated duties to the staff members. This will help principals to come up with an ethically sound decision that will have a positive impact to all the members of the society which includes the students. Today, school leaders are the people who are accountable ethically, legally and morally for any decisions that they make in schools. Dempster and Parry (1999) note that the schools pressure mainly arise from four sources that is pressure of involving non-educationalists in the decision making in schools; changes in the growth of knowledge and applying the new advanced technology in learning processes; increased social problems such as suicide, violence and unemployment. This means that school leaders are constantly faced with ethical dilemmas while making decisions in schools hence resulting in conflicting ethical principles. Therefore how ethics/morals impact on decision-making is profound as this could easily change the way society operates. Foster (1986) also notes that it is the actions by the officials of the school that will strongly determine personal codes of ethics and values (Shapiro, 2000, pp. 120-125). On the ethical decision making by principals in schools, Denig and Quinn (2001) proposed a philosophical model with two moral principles namely; care and justice. They argue that most of the decisions that are made by school leaders, are mainly based on formalism which is policy and law and this is aimed at bringing about the greatest good to all (utilitarianism). In other words, this approach clearly views decision making as a rational approach that involves the use of universal principles. The decision maker performs what is right that could result in good deeds to all rather than individualism hence equity becomes the desirable outcome. They also point out that it is only through making decisions by collaborative means that these leaders can be able to analyze the dilemmas and get prepared to encompass the principle of working together with the school system and this eventually results in making decisions that are ethical (Sousa, 2003, pp. 195-198). Greenfield (19991) on the other hand argues that school leaders experience distinct sets of demands concerning ethics. He notes that schools being moral institutions are designed to bring for the social norms and other principles. They should be able to make decisions that are morally acceptable. He further notes that although schools are charged with the responsibility of creating moral values and making moral decisions by dedicating themselves to promote the well-being of their students, it is surprising that the same students have virtually no right to express themselves to what goes on in their schools and it is for these reasons that the conduct of these school leaders need to be moral (Kowalski, 2001, pp. 5-98). Robert Starratt (1991) also talks of equality in social arrangement benefits by arguing that today’s social arrangement results to unequal benefits among people. He argues that school principles should not only behave ethically but also be responsible individuals. Lastly, Green field argues that the authority of the principal is moral and teachers should be convinced that the decisions make by the principal reflects all the values that they support (Nutt, 2002, pp. 50-54). Kidder (1995) defines an ethical dilemma as the responsibilities that people face in making choices between two rights cherished values that conflict are the principle cause of dilemmas. For instance a principal is bound to be faced with a dilemma if at all he/she cherishes both the teacher and student and the teacher decides to enact a policy that will result in low expectations. Some philosophers and thinkers have come up with a number of guidelines that could help to solve these dilemmas faced by school leaders. They argue that leaders should be able and willing to act along the set standards of ethics. They could also address and also should be caring and conscious reflection whenever they lead other people (Nutt, 2002, pp. 50-54). School leaders could also form ethics committees to help them solve ethical dilemmas as these committees could prove helpful in raising the awareness concerning ethical issues, advising educators and also in the formulation of codes of ethics. A quality decision that is made by a school principal will depend on a number of factors made, extent to which others are able to generate a quality solution, how the problem is structured and the degree of commitment. Moreover, decisions made in schools require a lot of staff decision and support. School principals also need to understand the culture of their schools while attempting to make any decisions as this will establish whether the decision made is appropriate for the school. Therefore, these head teachers need to analyze and comprehend any relevant and comprehend any relevant information presented to them together with data. They also need to gather and measure evidence, issue judgments and finally make the necessary decisions. Creativity is essential as these will help in solving any anticipating problems hence development of opportunities for the school. Finally, school principals should be in a position to demonstrate quality judgment. This will enable them to know how and when they need to make any decisions among others. Decisions made by school principals could be autocratic, consultative, Group or Delegated decisions. An autocratic decision is that which the school principal makes it himself / herself by use of the available information or gathered from other groups or people. This therefore requires these school leaders to make appropriate and quick decisions when expected to do them at a particular point in time consultation on the other hand means that a problem has to be shared amongst individuals in order to obtain collective views or ideas but the school principal has to make the final decision afterwards.

The Twelve Tables Essay - 1457 Words

The Twelve Tables were the first laws ever written down and shown to the public in Ancient Rome. The Twelve Tables were displayed in the Roman Forum or marketplace. The Twelve Tables were also the earliest surviving writings of Ancient Rome. When the founding fathers started to draw up the Constitution, they looked at Rome, and were inspired by The Twelve Tables to write the first laws of the United States. The Twelve Tables were not just the first written down laws in Ancient Rome. The Twelve Tables were used as a basis of future law throughout the world. Rome was changing. The people of Rome were changing. The citizens of Rome were getting tired of being ruled by others. They wanted to rule themselves. So after years of fighting†¦show more content†¦Caesar then went to Rome and declared himself Emperor just as Sulla did before him. As the Republic of Rome transitioned into an Empire, The Twelve Tables stood the test of time. As the empire began to fall, The Twelve Tables were spared. In the Middle Ages, Rome’s Twelve Tables were fairly similar to the laws of the time. In 1787, when the Constitution of the United States was being written, James Madison as well as the Constitution drafters looked to R ome as a model for their new government. Both of the set of laws underline a person’s individual rights. However, something was missing. Fresh in the minds of the new American citizens were violations of individual rights during the colonial and revolutionary periods. Several states made their ratification of the 1787 Philadelphia Constitution contingent on adding a Bill of Rights. This would more explicitly, outline individual freedoms of a person The First Congress of the United States, therefore, on September 25, 1789, proposed twelve amendments. The founding fathers dipped into the Roman past another time. The Twelve Tables clearly affected and motivated the writers of The Constitution to copy the laws of the Romans. 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