الفهرس 
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Abstract
Major depressive disorder (MDD), is a prevalent and severe mental illness commonly encountered in clinical settings. According to DSM-5, It involves mainly a persistently depressed mood or loss of interest in previously pleasurable activities most of the time, along with other depressive symptoms including appetite and sleep disturbance, fatigue, poor concentration, guilt feelings, suicidal ideations, which together result in psychological distress and interpersonal and occupational dysfunction.
In addition to the negative impact of depression on occupational functioning, occupational stress is also one of the most significant risk factors leading to depression, and one of the most stressful professions is psychiatric nursing as they deal with emergency situations, forced admissions and have direct confrontation with aggressive patients. Perceived aggression and depressive symptoms among psychiatric nurses have negative consequences on their mental health and productivity and may have a detrimental impact on the healthcare system with much worse impact on the standard of nursing care provided to patients.
The aim of the present work was to study perceived aggression and depressive symptoms among nurses in Maamoura Psychiatric Hospital in Alexandria. The specific objectives were to determine the prevalence of perceived aggression and depressive symptoms, identify some of their determinants and investigate the relationship between them among psychiatric nurses.
A cross sectional design was used. The study was conducted at Maamoura Psychiatric Hospital in Alexandria, affiliated to the General Secretariat of Mental Health. The target population was psychiatric nurses from both sexes working in the psychiatric wards, who were non trainees and working for not less than three months at the beginning of the research. The total sample size constituted 215 nurses, and a random sampling was used to select the nurses from all wards of the hospital.
The data collection methods and tools included:
I. A predesigned structured self-reported questionnaire (Appendix I) that was used to collect the following data from the psychiatric nurses: Socio-demographic data, work data, personal hobbies, social networks, personal history of psychological problems, family history of psychological problems, history of smoking and substance abuse, history of chronic diseases and history of interparental relationship, life stresses and familial abuse.
II. The Arabic version of Beck Depression Inventory- second edition (BDI-II, Appendix II) which is a brief self-reported questionnaire that is utilized for assessing the severity of an individual’s depression.
III. The Perception of Prevalence of Aggression Scale (POPAS, Appendix III) which is an 18-items scale on which staff can rate their experiences during the last year with different forms of aggression. The test was translated to Arabic, and its content validity was tested, as well as its reliability (Cronbach’s Alpha = 0.981).
The study revealed the following results:
Section I: characteristics of the studied sample
• The age of the nurses ranged from 22 to 59 years with a mean age of 34.29 ± 9.949 years. Sampled nurses aged from 22 to 30 years represent the highest percentage (45.1%), and only 7% were in the age group 51 to 59 years. The majority of the sampled nurses were females (88.8%), while male nurses accounted only for 11.2% of the sample.
• The majority (71.7%) of the nurses were married, followed by those who were single (22.3%), then those who were widowed and divorced (3.7% and 2.3% respectively).
• Concerning educational level, the majority of the nurses (47%) were 3 years diploma graduates, followed by those who were 5 years diploma graduates (38.1%), then nurses with bachelor’s degree represented 14%, while nurses with doctorate degree represented only 0.9%.
• Regarding monthly income, the largest proportion of the sampled nurses did not have enough monthly income (40.5%), 37.2% had enough monthly income, 20% did not have enough monthly income and were borrowing, while the least proportion had enough monthly income and was able to save (2.3%).
• As regards job title, the highest percentage of the sample (51.1%) were technical nurses, followed by (36.7%) of nurses, then 7% were nursing supervisors, and 4.7% were nursing specialists, while the least percentage was a head nursing (0.5%).
• The years of working experience of the study sample ranged from 1 to 39 years, with a mean of working experience of 13.874 ± 10.419 years. Sampled nurses with 1 to 10 years’ experience represented the highest percentage (48.8%), while those with 31 to 39 years’ experience represented the lowest percentage (6.5%).
• Most of the sampled nurses enrolled in at least 4 training courses within the prior two years of the study (38.6%), followed by those who enrolled in 2 to 3 training courses (34.9%), then those who enrolled in only one training course (22.3%), while those who did not enroll in any training courses represented only 4.2% of the study sample.
• The sampled nurses who had hobbies represented 67%. Those with no hobbies represented 33%. Among those who had any hobby, 50.8% of the sample had only one hobby, 15.3% had 2 to 3 hobbies, while only 0.9% had at least 4 hobbies. The most common hobby the sampled nurses had was listening to music (43.8%).
• Concerning social networks, most of the sampled nurses had many to moderate social networks (48.8% and 43.7% respectively), while the least percentage of them had few social networks (7.4%).
• The majority of the sampled nurses have never been smokers (93%), followed by those who were current smokers (6.1%), while those who were ex-smokers represent 0.9% of the sample.
• Concerning history of illicit substance abuse, the highest percentage of the sampled nurses reported no history of illicit substance abuse (96.3%), while only 3.7% reported substance abuse at least once in their life. Among those with a positive history of illicit substance abuse, 87.5% were abstinent, while 12.5% were still occasionally abusing illicit substances. Most of them used cannabis only (75%), and 25% of them used cannabis and alcohol.
• More than half of the studied nurses did not report any history of chronic diseases (66%), while 34% had a positive history of chronic diseases.
• History of psychological problems was present among 52.1% of the sampled nurses while 47.9% of them did not report any psychological problem within the previous year. Among those who sought psychiatric consultation, the highest percentage were diagnosed by major depression (61%), followed by generalized anxiety disorder (29.3%).
• The highest percentage of the sampled nurses had no psychiatric family history (90.2%), while only 9.8% had such history. Among them 38.1% had positive family history of depression, 23.8% had positive family history of generalized anxiety disorder, and 19.1% had positive family history of specific phobia.
• Concerning interparental relationship, the highest percentage of the sampled nurses had a good interparental relationship (39.5%), followed by an excellent interparental relationship (39.1%), a bad interparental relationship (17.2%), a fair interparental relationship (2.3%), while the lowest percentage of the sampled nurses had a very bad interparental relationship (1.9%).
• Regarding the presence of life stresses before the age of 18 years old, the highest percentage of the sampled nurses had no such history (70.7%), followed by those who reported the presence of familial violence (20%), then parental death (13%).
• According to history of familial abuse, approximately one third of the sample was physically abused (34.4%), more than one third of the sample was psychologically abused (36.7%), and a minority of the sample (3.3%) was sexually abused.
Section II: Prevalence of perceived aggression and depressive symptoms among the studied sample
• The perception of any kind of patients’ aggression within the past year was reported by the majority of psychiatric nurses as being “Never/rarely” (62.6%), followed by “Sometimes” (28.7%), and the minority of them reported perceived aggression as being “Most of the times (often/frequently)” (8.7%).
• The pattern of aggression (after adding “Sometimes” to “Most of the times”) varied from the most common (verbal aggression) (75.9%) to the least occurring (sexual assaults/rape, successful suicides and severe physical violence) (2.8%, 7% and 8.4% respectively).
• The prevalence of “Moderate/Severe” depressive symptoms among the studied nurses was 8.8%. As regards sex, the percentage of females with “Moderate/Severe” depressive symptoms was more than the double of the percentage of males (9.4% Vs 4.2% respectively).
Section III: Determinants of perceived aggression and depressive symptoms among the studied sample
Determinants of perceived aggression:
• The mean score of perceived aggression was higher among the age group 22 to 30 years than the older age group 31 to 40 years (8.30 ± 5.76 and 7.34 ± 4.46 respectively), and it was lower among age groups 41 to 50 and 51 to 59 (5.90 ± 3.93 and 5.60 ± 4.85 respectively). The difference was not statistically significant (p= 0.117). The mean score of perceived aggression was also higher in females (7.50 ± 5.21) than males (6.33 ± 4.09) and the difference was not statistically significant (p= 0.445).
• As for marital status, the mean score of perceived aggression among single nurses was higher than that among married nurses (8.50 ± 5.78 and 7.14 ± 4.99 respectively), followed by widowed nurses (6.63 ± 2.77) and divorced nurses (5.0 ± 2.55). The difference was not statistically significant (p= 0.381).
• Concerning the educational level, the mean score of perceived aggression was higher among nurses with doctorate degree (8.50 ± 0.71) than those with 5 years diploma (7.88 ± 5.69), followed by those with bachelor’s degree (7.83 ± 5.22), and the least percentage was for those with 3 years diploma (6.80 ± 4.57). The difference was not statistically significant (p= 0.624).
• As for monthly income, the mean score of perceived aggression highest among nurses with not enough monthly income and those with not enough monthly income and borrowing (7.78 ± 4.95 and 7.77 ± 6.25 respectively). The difference was not statistically significant (p= 0.469).
• As regards job title, the mean score of perceived aggression was higher among nursing supervisors (10.07±4.83), followed by technical nurses (7.73 ± 5.34), then nurses (6.71 ± 4.64), then nursing specialists (4.70 ± 4.95). The difference was statistically significant (p=0.023).
• Relating to years of experience, the less the years of experiences, the higher the mean score of perceived aggression. Those with 1 to 10 and those with 11 to 20 years of experience showed (8.28 ± 5.62 and 7.13 ± 4.49 respectively), on the other hand those with 21 to 30 and 31 to 39 years of experience reported perceived aggression of (6.22 ± 4.13 and 5.57 ± 5.11 respectively). The difference was not statistically significant (p= 0.130).
• As for number of training courses within past 2 years, the mean score of perceived aggression was higher among those with 2 -3 training courses (8.08 ± 5.05), followed by those with no training courses at all (7.67 ± 4.74), then those with 4 training courses or more (7.48 ± 4.95), and the lowest mean score was among those with one training course (6.02 ± 5.39). The difference was not statistically significant (p=0.152).
• As regards hobbies, the mean score of perceived aggression was higher among those who had hobbies (7.39 ± 5.09), than those who had no hobbies (7.34 ± 5.15). The difference was not statistically significant (p= 0.777).
• Concerning social networks, the mean score of perceived aggression was higher among nurses with moderate social networks (8.23 ± 5.10), followed by those who had few social networks (8.19 ± 4.76), then those with many social networks (6.48 ± 5.04). The difference was statistically significant (p= 0.030).
• The mean score of perceived aggression was highest among ex-smoker nurses (8.0 ± 5.66), followed by those who had never smoked (7.40 ± 5.14), then those who were current smokers (6.85 ± 4.76). The difference was not statistically significant (p=0.974).
• Concerning substance abuse, the mean score of perceived aggression was higher in nurses who have abused any drug at least once (8.13 ± 3.48) compared to 7.34 ± 5.16 among nurses who have never abused any drug. The difference was not statistically significant (p=0.353).
• The mean score of perceived aggression was found to be higher in nurses without a history of chronic diseases (7.68 ± 5.38) than those with such history (6.77 ± 4.49). The difference was not statistically significant (p=0.221). Concerning history of psychological problems, the mean score of perceived aggression was found to be higher in nurses with such history (8.28 ± 5.53) than those without (6.39 ± 4.41). The difference was statistically significant (p=0.017).
• The mean score of perceived aggression was highest among nurses who had very bad interparental relationship (11.0 ± 4.97), while those who reported an excellent interparental relationship had the lowest mean score (6.71 ± 5.29). The difference was not statistically significant (p=0.156).
• Concerning the presence of life stresses before 18 years of age, the mean score of perceived aggression was higher among nurses who suffered life stresses (8.17 ± 4.81) than those who had not suffered any life stresses (7.04 ± 5.19). The difference was not statistically significant (p=0.090).
• Concerning history of familial abuse, the mean score of perceived aggression was higher among nurses with history of physical abuse (8.14 ± 5.21) than those without (6.97 ± 5.01). The difference was not statistically significant (p=0.184). As regards history of psychological abuse, the mean score of perceived aggression was slightly higher among nurses with such history (7.63 ± 4.27) than those without (7.22 ± 5.53). The difference was not statistically significant (p=0.279). Regarding history of sexual abuse, the mean score of perceived aggression was slightly higher among nurses with such history (9.0 ± 4.20) than those without (7.32 ± 5.13). The difference was not statistically significant (p=0.328).
• Based on the findings on univariate analysis, three variables were introduced for the multivariate linear regression, and 2 variables proved to be significant predictors of perceived aggression which were; many social networks (95% CI= -2.892 – -0.169) as a protective factor from perceived aggression, and a history of psychological problems as a risk factor (95% CI= 0.381 – 3.073).
Determinants of depressive symptoms:
• Moderate/severe depressive symptoms were most observed among the age group 22 to 30 years, and was least observed among the age group 41 to 59 years (1.8%). The difference was statistically significant (p=0.048). The age group 22 to 30 years were 8.7 times more likely to suffer moderate/severe depressive symptoms than those with age group 41 to 59.
• Moderate/severe depressive symptoms were more encountered among female nurses (9.4%) than male nurses (4.2%), and the difference was not statistically significant (p=0.703).
• As for marital status, moderate/severe depressive symptoms among unmarried nurses were more than that among married nurses (16.4% and 5.8% respectively). The difference was statistically significant (p=0.014). Unmarried nurses were 3.2 times more likely to suffer moderate/severe depressive symptoms than married nurses.
• As for educational level, moderate/severe depressive symptoms with 5 years diploma represented (15.9%) among nurses, followed by those with 3 years diploma (5%), bachelor’s/doctorate degree (3.1%). The difference was statistically significant (p=0.017). Nurses with 5 years diploma were 3.6 times more likely to suffer moderate/severe depressive symptoms than those with 3 years diploma.
• Regarding monthly income, moderate/severe depressive symptoms were more seen more among nurses with insufficient monthly income and borrowing than those with insufficient monthly income and those with enough/enough and saving monthly income (16.3%, 8% and 5.9% respectively). The difference was not statistically significant (p=0.139).
• Moderate/severe depressive symptoms were more evident among technical nurses (14.5%), followed by nursing supervisors (6.7%), then nurses (2.5%). None of the heads of nursing or nursing specialists showed moderate/severe depressive symptoms (0.0%). The difference was statistically significant (p=0.042).
• Regarding years of experience, moderate/severe depressive symptoms were more evident among nurses with 1 to 10 years of experience (13.3%) than those with 11 to 20 years of experience and those with more than 20 years of experience (8.9% and 1.5% respectively). The difference was statistically significant (p=0.031). The nurses who had 1 to 10 years of experience were 9.8 times more likely to suffer depressive symptoms than nurses who had more than 20 years of experience.
• As for number of training courses within the past 2 years, moderate/severe depressive symptoms were most seen among those who did not have any training courses (33.3%), while nurses who had 4 training courses or more represented the least percentage (6%). The difference was not statistically significant (p=0.070).
• As regards hobbies, moderate/severe depressive symptoms were more evident among those who had 2 or more hobbies (14.3%), followed by those who had no hobbies (8.7%), and was least evident among those who had one hobby (7.3%). The difference was not statistically significant (p=0.448).
• As for social networks, moderate/severe depressive symptoms were more evident among nurses with few social networks (37.5%), followed by those who had moderate social networks (7.4%), then those with many social networks (5.7%). The difference was statistically significant (p<0.001). Nurses with few social networks were 9.9 times more likely to have depressive symptoms than those with many social networks.
• Moderate/severe depressive symptoms were more common among nurses who were current smokers/ex-smokers than those who had never smoked (13.5% and 8.5% respectively). The difference was not statistically significant (p=0.628).
• Relating to substance abuse moderate/severe depressive symptoms were evident among nurses who have abused any drug at least once (25%) compared to 8.2% among nurses who have never abused any drug. The difference was not statistically significant (p=0.150).
• Moderate/severe depressive symptom were found to be more in nurses with a history of chronic diseases (11%) than those without such history (7.7%). The difference was not statistically significant (p=0.432).
• Moderate/severe depressive symptoms were most common among nurses who had a very bad interparental relationship (25%), and least common among those who had excellent interparental relationship (6%). The difference was not statistically significant (p=0.124).
• Concerning the presence of life stresses before 18 years of age, moderate/severe depressive symptoms were most common among nurses who suffered parental death (17.9%), and least common among those who did not suffer any life stresses (7.2%). The difference was not statistically significant.
• Concerning history of familial abuse, moderate/severe depressive symptoms were more common among nurses with history of physical abuse (13.5%) than those without (6.4%). The difference was not statistically significant (p=0.080). As regards history of psychological abuse, moderate/severe depressive symptoms were more common among nurses with such history (12.7%) than those without (6.6%). The difference was not statistically significant (p=0.132). Regarding history of sexual abuse, moderate/severe depressive symptoms were more common among nurses with such history (14.3%) than those without (8.7%). The difference was not statistically significant (p=0.482).
• Based on the findings on univariate analysis, six variables were introduced for the binary logistic regression, and 2 variables proved to be significant predictors of depressive symptoms which were; few social networks as a risk factor (OR=9.257, 95% CI=1.991 – 43.051), and job title “nurse” as a protective factor (OR=0.107, 95% CI=0.012 – 0.924). Nurses who had few social networks were (9.3 times) more likely to suffer depressive symptoms than those who had many, and those who had the job title “nurse” were (0.1 times) as likely to suffer depressive symptoms than the others.
Section IV: Relationship between perceived aggression and depressive symptoms among the studied sample
• There was a significant weak positive correlation between female nurses perceived aggression (using POPAS scores) and depressive symptoms (using BDI-II scores), rs=0.204 and p=0.005, while the correlation between male nurses perceived aggression and depressive symptoms was a positive non-significant correlation. Also, there was a significant weak positive correlation between the total sample’s perceived aggression and depressive symptoms, rs=0.225 and p=0.001.
Based on the results of the current study, the following can be concluded:
• According to the POPAS results, perceived aggression among psychiatric nurses showed a prevalence of 8.7% as “Most of the times”, and 28.7% as “Sometimes”.
• The pattern of perceived aggression varied from the most common (verbal aggression), to the least occurring (sexual assaults/rape, successful suicides and severe physical violence).
• The prevalence of “Moderate/Severe” depressive symptoms among the studied sample was 8.8% and the percentage of female nurses was higher than males.
• On investigating different variables on univariate analysis, three variables were significantly associated with perceived aggression, namely; job title, social networks and history of psychological problems.
• Multivariate linear regression analysis revealed that two variables proved to be significant predictors of perceived aggression which were; many social networks as a protective factor for perceived aggression, and a history of psychological problems as a risk factor.
• On investigating different variables on univariate analysis, six variables were significantly associated with depressive symptoms, namely; age, educational level, job title, social status, years of experience and social networks.
• Binary logistic regression analysis revealed that two variables proved to be significant predictors of depressive symptoms which were; few social networks as a risk factor and job title “nurse” as a protective factor.
• There was a significant weak positive correlation between total psychiatric nurses perceived aggression and depressive symptoms, as well as a significant weak positive correlation between female nurses perceived aggression and depressive symptoms.
Based on the results of the current study, the following recommendations are suggested:
• There is a pressing need to increase awareness of depressive symptoms and perceived aggression among psychiatric nurses in their workplace environment, as well as their determinants, their impact and their inter-relation through psychoeducational programs directed through hospitals campaigns and medical conferences.
• Designing and implementing special healthcare systems comprehensive programs with the goal of decreasing workplace aggression from patients in psychiatric hospitals, and promoting psychiatric nurses’ mental health, through improving nurses working conditions and organizational policies, designing more specialized nurses training programs.
• Designing and implementing programs for primary prevention and management of depression among psychiatric nurses, as well as aggression among psychiatric patients.
• Further studies are needed, to study MDD, its determinants, risk factors, its protective factors, and different management approaches, as well as perceived aggression among psychiatric nurses, its determinants, preventive strategies, and its bi-directional relation with MDD.
Conclusion
In the light of the current study findings, the following can be concluded:
• According to the POPAS results, perceived aggression among psychiatric nurses showed a prevalence of 8.7% as “Most of the times”, and 28.7% as “Sometimes”. The pattern of aggression varied from the most common (verbal aggression), to the least occurring (sexual assaults/rape, successful suicides and severe physical violence).
• The prevalence of “Moderate/Severe” depressive symptoms was 8.8% among the studied sample, with a higher percentage observed in female nurses than in males.
• On investigating different variables on univariate analysis, three variables were significantly associated with perceived aggression, namely; job title, social networks and history of psychological problems.
• Multivariate linear regression analysis revealed that two variables proved to be significant predictors of perceived aggression which were; many social networks as a protective factor for perceived aggression, and a history of psychological problems as a risk factor.
• On investigating different variables on univariate analysis, six variables were significantly associated with depressive symptoms, namely; age, educational level, job title, social status, years of experience and social networks.
• Binary logistic regression analysis revealed that two variables proved to be significant predictors of depressive symptoms which were; few social networks as a risk factor and job title “nurse” as a protective factor.
• There was a significant correlation between total psychiatric nurses’ perceived aggression and depressive symptoms, as well as a significant correlation between female nurses’ perceived aggression and depressive symptoms.
Recommendations
I- For Ministry of Health and Mental Health Authorities:
• Allocating resources and funding for comprehensive mental health programs addressing depression and workplace stress among psychiatric nursing staff. These programs should encompass 3 levels of prevention; primary prevention through psychoeducational programs and promotion of supportive workplace environments with fair working conditions and policies, secondary prevention through the creation of occupational mental health services within psychiatric hospitals for the screening and early detection of depressive symptoms and burnout syndrome, and treatment of major depressive disorder and any comorbidities with reasonable costs, and tertiary prevention through continuous follow-up of depressed nurses and providing them ongoing psychosocial support for work and life stresses. Promoting nurses’ mental health will not only decrease the prevalence of depression among them, but will also decrease the prevalence of perceived aggression towards them and will improve the way they manage it.
• Integration of violence prevention and de-escalation training in healthcare education of nursing staffs. These trainings should include risk assessment, emotional intelligence, effective communication, and increase their understanding of the causes, triggers and signs of impending patients’ violence, as well as methods of self-defense and effective management of aggressive incidents.
• Designing a protocol for all mental health professionals in the comprehensive management of aggressive patients, with implementation of patients structured programs including psychosocial interventions, anger management, contingency management skills and organized activities.
• Foundation of mental health facilities respecting in their environmental designs and policies security and mental health measures for both patients and staff.
• Establishing a timeline for phased implementation of mental health programs and training initiatives for the psychiatric healthcare personnel, and monitoring the standards of working conditions and security measures in psychiatric hospitals with ongoing evaluation through feedback and statistical reports.
II- For psychiatric hospitals and nursing staff:
• Creating continuous comprehensive psychoeducational and training programs for psychiatric nurses, incorporating stress and depression prevention, and violence de-escalation strategies.
• Establishing on-site counseling services and mental health programs, addressing workplace stress, depressive symptoms, and violence prevention and developing mental health support groups among psychiatric healthcare workers. Psychiatric nurses, like their patients, should be encouraged to take advantage of available therapies.
• Creating empathetic working conditions through enhancing relationships between peer nurses, heads of nursing, psychiatrists and hospital managers, and listening with care to nurses’ complaints and reports.
• Enforcing violence prevention policies, and redesigning offices in a way that decrease isolation and having alarms that connect directly with the security officers. Providing adequate numbers of consistent nursing personnel and adequate resources according to the needs of each ward. Using less restrictive rules and improving outdoor access. Improving available space for movement, adjusting ward temperature, and limitation of noise.
• Documentation, reporting, appropriate follow-up action and effective incident management ensuring that any aggression is handled promptly, mitigating its impact on the nurse, patient, and the overall environment. A legal action must be taken once workplace aggressive incident had occurred.
III- For the researchers:
• Collaboration with healthcare institutions to ensure access to necessary resources for data gathering and ongoing impact assessment.
• Further studies with large sample size representing the psychiatric hospitals and mental health facilities should be conducted to study MDD and perceived aggression among psychiatric patients; their determinants, risk factors, protective factors, and different management approaches, as well as the correlation between them.
• Interventional approaches require more research and testing regarding their effectiveness and applicability.
• In Egypt, there is a lack of research regarding MDD among psychiatric nurses’ population, as well as perceived workplace aggression from patients towards them. Researchers have to fill this gap in order to design multifaceted interventions tailored on the Egyptian psychiatric hospitals working environments, staff and patients’ culture, and available resources.