COPYRIGHT AND CITATION CONSIDERATIONS FOR THIS THESIS/ DISSERTATION

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1 COPYRIGHT AND CITATION CONSIDERATIONS FOR THIS THESIS/ DISSERTATION o Attribution You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. o NonCommercial You may not use the material for commercial purposes. o ShareAlike If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original. How to cite this thesis Surname, Initial(s). (2012) Title of the thesis or dissertation. PhD. (Chemistry)/ M.Sc. (Physics)/ M.A. (Philosophy)/M.Com. (Finance) etc. [Unpublished]: University of Johannesburg. Retrieved from: (Accessed: Date).

2 STRATEGIES TO FACILITATE THE PROMOTION OF THE HEALTH OF STUDENT NURSES AT A HIGHER EDUCATION INSTITUTION (HEI) IN JOHANNESBURG WHO HAS EXPERIENCED AGGRESSION By Wanda O Jacobs Thesis submitted in fulfillment of the requirement for the degree of DOCTOR CURATIONIS In COMMUNITY HEALTH NURSING In the DEPARTMENT OF NURSING SCIENCE In the Faculty of Health Science Of the UNIVERSITY OF JOHANNESBURG Supervisor: Prof M Poggenpoel Co-Supervisor: Prof CPH Myburgh 2013

3 TABLE OF CONTENTS LIST OF ANNEXURES ix LIST OF TABLES x LIST OF FIGURES LIST OF PICTURES xi xii ACKNOWLEDGEMENTS xiii SUMMARY xiv CHAPTER 1: INTRODUCTION AND OVERVIEW OF THE STUDY 1.1 Introduction and rationale Problem statement Research questions Purpose and objectives of the study Paradigmatic perspective Metatheoretical assumptions Theoretical assumptions Methodological assumptions Definitions Nursing student Aggression Health Facilitation 17

4 1.6 Research design and method Research design Research method Step 1: Concept analysis Step 2: Relationship statements Step 3: Description of the model Step 4: Description of strategies for implementation of the model Measures to ensure trustworthiness Ethical measures Significant contribution of thesis Division of chapters Conclusion 28 CHAPTER 2: RESEARCH METHODOLOGY 2.1 Introduction Purpose of the research Research design Theory-generating design Qualitative approach Explorative design Descriptive design Contextual design Reasoning strategies Analysis Synthesis 41

5 2.4.3 Inductive reasoning Deductive reasoning Research method Step 1: Concept analysis Part 1: Identification of main concepts, empirical phase Part 2: Concept definition and classification Step 2: Relationship statements Step 3: Description and evaluation of the model Step 4: Description of strategies for model implementation Measures to ensure trustworthiness Credibility Prolonged engagement Triangulation Peer evaluation Reflexivity Transferability Dense description Purposive sampling Dependability Confirmability Ethical considerations Conclusion 74 CHAPTER 3: DISCUSSION OF THE PHENOMENON OF NURSING STUDENTS EXPERIENCE OF AGGRESSION 3.1 Introduction 75

6 3.2 Exploring and describing the nursing students experience of aggression in their lives Theme 1: Nursing students experience aggression as an integral part of their life Aggression forms part of normal behaviour, of who a person is Aggression is a tool to get what you want, to punish people or make people do what you want and as a form of power Theme 2: Nursing students experience aggression as detrimental to themselves as a whole person and their interpersonal relationships Aggression experienced as impacting on themselves, as a whole person, physically, psychologically and spiritually Aggression impacts on their interpersonal relationships Conclusion 125 CHAPTER 4: IDENTIFICATION, DEFINITION AND CLASSIFICATION OF THE CENTRAL AND RELATED CONCEPTS 4.1 Introduction Identification of the main concept Defining the central concept: Facilitation of constructive self-management Facilitation Dictionary definition Subject literature definition Definition of the word facilitation Constructive 136

7 Dictionary definition Subject literature definition Definition of the word constructive Self-management Dictionary definition Subject literature definitions Definition of the word self-management Final definition of the central concept: Facilitation of constructive self-management of aggression of nursing students Definition of related concepts Assist Empower Open supportive climate Process Creative Positive Dynamic and continuous process of self-regulation Building meaningful relationships Self-awareness of one s feelings, thoughts and actions Integrated person Constructing a model case Classification of concepts Agent Recipient Context Procedure 159

8 4.7.5 Dynamics Outcome Conclusion 163 CHAPTER 5: DESCRIPTION OF A MODEL AS A FRAME OF REFERENCE FOR FACILITATING CONSTRUCTIVE SELF-MANAGEMENT OF AGGRESSION EXPERIENCED BY NURSING STUDENTS AT AN HEI 5.1 Introduction Overview of the model Purpose of the model Context of the model Assumptions of the model The nursing student (recipient) The facilitator (agent) Facilitation of constructive self-management of aggression in an open supportive climate Aggression Definitions of central and related concepts Facilitating constructive self-management of aggression Assist Empower Open supportive climate Process Positive Dynamic and continuous process of self-regulation 174

9 5.6.8 Building meaningful relationships Self-awareness of one s feelings, thoughts and actions Integrated person Relationship statements Structural description of model Red curved arrow (recipient) Yellow curved path (agent) Spiral Establishing relationships Mastering knowledge and skills Attaining knowledge and skills Process description of the model Phase 1: Establish relationships Phase 2: Mastering knowledge and skills (working phase) Phase 3: Attaining knowledge and skills (termination phase) Strategies for implementation of the model in practice Establishing relationships (relationship phase) Objective of the relationship phase Actions Mastering knowledge and skills (working phase) Objective of the working phase Actions Attaining knowledge and skills (termination phase) Objective of the termination phase Actions Evaluation of the model Clarity 216

10 Simplicity Generality Accessibility Importance Conclusion 221 CHAPTER 6: CONCLUSIONS, RECOMMENDATIONS AND LIMITATIONS OF THE RESEARCH 6.1 Introduction Conclusions of the research First objective Second objective Final objective Challenges of the research Recommendations for nursing practice, education and research Recommendations for nursing practice Recommendations for nursing education Recommendations for research Contribution of this research Closing remarks 233 Bibliography 234

11 LIST OF ANNEXURES PAGE Annexure A: Consent Letter 274 Annexure B: Ethical Clearance 277 Annexure C: Example of individual interview 278 Annexure D: Definitions 294 ix

12 LIST OF TABLES PAGE Table 3.1: Summary of themes, categories and subcategories 78 Table 3.2: Summary of themes, categories and subcategories 125 Table 4.1: Essential and related concepts for facilitation 135 Table 4.2: Essential and related concepts for constructive 138 Table 4.3: Essential and related concepts for self-management 144 Table 4.4: Final essential and related concepts of the central concept 146 x

13 LIST OF FIGURES PAGE Figure 4.1: Reasoning map 157 Figure 4.2: Procedure phases 160 Figure 5.1: Model for facilitating self-management of aggression experienced by nursing students at a tertiary education institution 166 Figure 5.2: Red curved arrow (recipient) 179 Figure 5.3: Yellow curved path (agent) 185 Figure 5.4: Spiral 187 Figure 5.5: Establishing relationships 189 Figure 5.6: Mastering knowledge and skills 191 Figure 5.7: Attaining knowledge and skills 193 xi

14 LIST OF PICTURES PAGE Picture 3.1: Road rage: Aggression displayed as common occurrence and nature of the aggressor 89 Picture 3.2: Aggression towards the weak 96 Picture 3.3: Female abuse physical scars and tears from pain 102 Picture 3.4: Verbal and physical abuse 103 Picture 3.5: Broken, sharp edges causing physical and psychological pain 106 Picture 3.6: Pain generates infliction of pain on others 108 Picture 3.7: Lashing out at anything or anybody 113 Picture 3.8: Interpersonal aggression 120 Picture 3.9: Brick wall of isolation 123 xii

15 ACKNOWLEDGEMENTS To my Saviour, Lord Almighty, for taking me through this journey, and teaching me the meaning of surrender, trust and belief! To my husband Johan, children and grandchildren, for being with and loving me. To Prof Poggenpoel, my supervisor and Prof Myburgh, my co-supervisor for your encouragement and intellectual challenges through this journey. To everybody that contributed towards this amazing journey. xiii

16 SUMMARY Aggression becomes such a part of people s daily lives that it is viewed as normal. As in the society nursing students at a higher education institution (HEI) also experience aggression in their lives. This exposure to aggression is of concern as it can be a possible obstacle in the personal and professional development and interpersonal relationships of the nursing students. The essence of this concern is that nurse educators need to gain knowledge of, insight into and awareness of the aggression experienced by nursing students to empower these students to manage aggression in their lives. The purpose of this study was to develop and describe a model as a frame of reference to facilitate the health of nursing students at an HEI in Johannesburg, South Africa, who experience aggression in their lives. The objectives of this study were as follows: To explore and describe the experience of nursing students at an HEI in Johannesburg of aggression in their lives. To generate a model from the results that will facilitate the promotion of health of the nursing students at an HEI in Johannesburg who have experienced aggression. To formulate strategies for the implementation of the model. xiv

17 The research design was theory-generative, qualitative, exploratory, descriptive and contextual in nature. Nursing students were purposefully sampled as they added to the richness of the data collected for the purpose of this research. Data was collected firstly through respondents drawing a picture and writing a self-reporting story, and secondly, through phenomenological interviews. Data analysis in this research was done by means of Tesch s method of identifying themes and categories as described by Creswell. Ethical considerations were adhere to throughout the research and consent was obtained from the nursing students participating in the research. Lincoln and Guba s method of trustworthiness was used. Two themes with categories were identified that reflected the nursing students experience of aggression in their lives. The first theme is that the nursing students experienced aggression as an integral part of their life and viewed it as a normal part of their life. The second theme is that nursing students experienced aggression as detrimental to themselves as a whole person and their interpersonal relationships. A model as a frame of reference to facilitate the health of the nursing students who have experienced aggression to self-manage aggression constructively, xv

18 was developed. The findings of this research are relevant to the world of nursing practice, nursing education and research. xvi

19 CHAPTER 1 INTRODUCTION AND OVERVIEW OF THE STUDY 1.1 INTRODUCTION AND RATIONALE Aggression and violence have become such a part of people s daily lives that aggressive behaviour is viewed as normal (Fletcher & Milton, 2007). This is evident in a statement by Pinker that because people do not engage in catburning rituals for entertainment as was done in the 16th century, they are getting kinder and gentler and therefore violence is declining. Pinker in Sabates (2011) also argues that the reason aggression has declined since the age of enlightenment is the progressive reporting of all the aggressive behaviour. It is certainly true that newspapers are full of articles reflecting aggressive behaviour towards our fellow human beings. As in the larger community of Gauteng and South Africa, the occurrence of aggression and violence also reflects in the academia of a higher education institution (HEI), and also in the education of nursing students at this HEI. Aggression, verbal and physical, puts students at academic risk (Lippert, Titsworth & Hunt, 2005). This is understandably of great concern to the academia as nursing is viewed as a caring profession (Altmiller, 2008). 1

20 The researcher is a lecturer in a nursing department at an HEI in Gauteng. The institution provides education and training to nursing students at undergraduate level, post-basic level and postgraduate level. Nursing students are educated to become professional nurses. This requires them to be exposed to the clinical work environment as well as to a theoretical work environment. During this period, the nursing students are exposed to nurse educators, educators, patients, their fellow students and their own families, each of which is a smaller society within the large society. Nursing students as a society reflect the larger society. When this smaller society reflects the larger society, the aggression in the larger society will also be reflected within this small society. The researcher as a lecturer is involved in the theoretical and clinical component of the first- to the fourth-year undergraduate nursing students. This responsibility includes lecturing and accompaniment in the clinical learning environment. Due to the researchers involvement as a lecturer with the nursing students, the students shared their experiences openly with the researcher. They relayed incidents to the researcher and fellow lecturers which relate to aggressive behaviour that they experienced. 2

21 The following scenario is a true reflection of an incident and illustrates the challenges regarding aggression: SCENARIO All three incidents involved the same male and female nursing students. A few female nursing students sat outside the residence, talking and laughing, when a male student walked past them. He thought that they were laughing at him and accused one of the girls of laughing at him. During a practical clinical training period in the hospital the same female student that was accused by the male student of laughing at him mistakenly opened the cubicle curtain, thinking that the person inside was one of her friends it was in fact the same male student. He then verbally insulted her in front of the patient. In response, she asked him to accompany her outside the cubicle, where she then insulted him and ran away. However, this incident meant that neither of them heard a patient calling for assistance. The patient that the male student had been attending to was also left unattended halfway through a procedure. 3

22 During a clinical trip for practical training the final incident between these two students took place when the students were waiting for transport to take them to the clinical training facility. The male student told her that he would teach her the hard way if she did not show him respect. She replied that respect was earned and that one could not respect someone who was rude to another. The next minute the male student hit her hard in the face and pointed his finger at her. These incidents mentioned above motivated the researcher to investigate the extent to which incidents of aggression occur. A literature search related to behaviour as described in the scenario yielded studies mostly related to violence and aggression in the workplace. Violence between workers in the workplace has been studied by Huston (2006). Other studies on violence in nursing were conducted in the United Kingdom by Lewis (2006) and Levett-Jones and Lathlean (2009); in the United States by Cooper, Walker, Winters, Williams, Askew and Robinson (2009) and Thomas and Burk (2009) and in Australia by Curtis, Bowen and Reid (2007). Other studies by Longo (2007) and a research synthesis report by Di Martino (2003) also had violence and aggression at the workplace as the focus. None of these studies however focused on the nursing student as a whole person and the possible impact of their lived experience of aggression on them as a whole person. 4

23 In South Africa Khalil (2009) published an article on levels of violence amongst nurses in public hospitals in Cape Town. No studies have been done on nursing students experience of aggression. Aggression and violence are viewed as closely related and definitions of both include biting, kicking, physical and psychological harm or injuries and verbal and non-verbal abuse (Eaton & Struthers, 2006; Renzetti, Edleson & Bergen, 2011; Schat & Kelloway, 2006). Di Martino (2003) states that in practice there is an overlap in physical and psychological violence. The behaviour as described in the scenario involving nurse-on-nurse aggression is referred to as lateral or horizontal violence. This behaviour results in psychological injury, escalating to physical harm (DelBel, 2003; Eaton & Struthers, 2006; Murray, Chermack, Walton, Winters, Booth & Blow, 2008; Sheridan-Leos, 2008; Rocker, 2010). Aggression is an act or practice of attacking without provocation, such as beginning a quarrel (Reader s Digest Oxford, 1993). The behaviour in the scenario above is the verbal insult and slap, which were directed by the male student towards the target, namely the female student. This case is a clear and definite example of aggression. 5

24 The result of this aggression is that the social relationship of these two students as classmates or as colleagues might never be the same as before and it could influence their overall health. Aggression undermines the theoretical and clinical learning environment and the result of aggression has an influence on the health of the student (Levinson, 2006; Merecz, Drabek & Moscicka, 2009; Pretorius, 2000; Quick, 1999; Varcarolis & Halter, 2009). The verbal insults incident in the ward caused both the students to be so involved in their own quarrel that they could not hear the call of a patient and therefore did not attend to the patient. The female student did not feel safe in her working environment as she had to run out of the ward to escape the male student, for fear of retaliation. The working environment is part of the outcomes of the course she had enrolled for and was a learning opportunity; learning was influenced negatively by the act of aggression (Merecz, et. al., 2009). After the slap in the face by the male student while on a clinical trip for practical training, both these students felt upset. The female student, having been physically attacked, was stunned and very unhappy. She was so frightened that she could not concentrate during her lectures and became depressed. 6

25 The outcome of harmful experiences can affect the nursing student, patient and the profession (DelBel, 2003; Huston, 2006). Emotional response or behaviour based on anger becomes less effective in solving problems in everyday life and is not good for one s own health or the health of others (Botha, 2006; Merecz, et. al., 2009). It is consequently important to determine the extent of the aggression experienced by nursing students since this influences their health as people as well as their functioning as nurses, as was evident in the scenario. It is also important to determine if they have the ability to control aggression. 1.2 PROBLEM STATEMENT In the light of the introduction and background given in 1.1, the researcher concluded that nursing students are exposed to aggressive behaviour. The scenario indicates that the exposure to aggression extends not only to their clinical environment as nursing students, but also to their lives as students in an interactive relationship with their fellow students and their personal lives. The exposure to aggression results in physical and psychological difficulties and might affect their ability to function as a whole person. The danger is that instead of caring, they become the perpetrator against the patients and others 7

26 (Longo, 2007; Stanley, Martin, Michel, Welton & Nemeth, 2007; Roche, Diers, Duffield & Catling-Paull, 2010). This can result in poor nursing care, a decrease in patient safety and care and an increase in patient dissatisfaction, errors and slow response time (DelBel, 2003; Lamontagne, 2010; Sheridan- Leos, 2008; Rosenstein & O Daniel, 2008) as was evident in the scenario. This is of concern when one considers that nursing students will eventually enter the health care profession and become caregivers to those who are vulnerable (Ferns & Meerabeau, 2007). Both the nursing students in the scenario at one stage or another became the perpetrator and the victim of aggression, and their inability to cope with aggression became evident in their reaction in each of these incidents. The scenario also highlights the personal effect aggression can have on individuals, leaving them with psychological injuries, like depression. On a personal level the effect of aggression is anxiety, exclusion and humiliation. Aggression can also affect the ability to gain competencies and achieve success (Lench, 2004; Levett-Jones & Lathlean, 2009). The result of the aggressive behaviour extends to the relationship between members in a group with the possibility of an obstacle being created in personal and professional development and interpersonal relationships (University of Johannesburg, 2010). Hofmeyr (2005) indicates that one of the greatest challenges as human beings is to cope with aggression. The need for emotional skills and knowing 8

27 how to cope with one s behaviour has been recognised as extremely important (Hofmeyr, 2005). Nurse educators need to gain knowledge of, insight into and awareness of the aggression experienced by nursing students to empower these students to manage aggression in their lives. The experience of aggression includes all the multidimensional environments in their lives. 1.3 RESEARCH QUESTIONS The following research questions were formulated for this study: What is the nursing students experience of aggression in their lives? What can be done to facilitate the health of nursing students who have experienced aggression? 1.4 PURPOSE AND OBJECTIVES OF THE STUDY The purpose of this study was to develop and describe a model as a frame of reference to facilitate the health of nursing students at an HEI in Johannesburg, South Africa, who experience aggression in their lives. 9

28 The objectives of this study were as follows: To explore and describe the experience of nursing students at an HEI in Johannesburg of aggression in their lives. To generate a model from the results that will facilitate the promotion of health of the nursing students at an HEI in Johannesburg who have experienced aggression. To formulate strategies for the implementation of the model. 1.5 PARADIGMATIC PERSPECTIVE A researcher s beliefs and assumptions about the world will be reflected in the way in which the researcher views the world. This paradigm of the researcher influences the research. It is the world view that the researcher holds which serves as a framework for conducting the research. Paradigmatic perspective involves metatheoretical, theoretical and methodological assumptions (Botma, Greeff, Mulaudzi & Wright, 2010; De Vos, Strydom, Fouche & Delport, 2011). The theory for health promotion in nursing is the point of departure that was used by the researcher (University of Johannesburg, 2010). Metatheoretical assumptions that will be discussed next involve the researcher s views about people as humans, the community, health and nursing (Botma et al., 2010). 10

29 1.5.1 Metatheoretical assumptions Within this study the individual, which is the nursing student at an HEI, is viewed holistically in interaction with the environment in an integrated manner. The nursing student is seen as a whole person with a mind, body and spirit (University of Johannesburg, 2010). The student nurse, who is part of a family, is in interaction with the environment. The external environment, according to the theory for health promotion, includes the physical, social and spiritual environment (University of Johannesburg, 2010). The nursing student functions at and interacts with the home, within the family structure and with friends, at the residence during the academic year, the HEI and the work environment. Health is a dynamic interactive process in the person s environment. The interaction of the nursing students in the various areas mentioned above reflects their relative health status within these environments and at various times. This suggests that the interaction within the various environments can contribute to or be an obstacle in the facilitation of the nursing students health. 11

30 Nurses are sensitive therapeutic professionals. Nursing as a science is an interactive process. Professional nurses function within this interactive process, and demonstrate knowledge, skills and values to facilitate health promotion through mobilising resources. Promoting the health of nursing students implies the promotion, maintenance and restoration of their health Theoretical assumptions Assumptions are statements that are taken as truths although they cannot always be tested. These assumptions are embedded in behaviour and thinking and can also be universally accepted truths, as in a value statement (Burns & Grove, 2011). The theoretical assumptions are now described based on the theory of health promotion in nursing (University of Johannesburg, 2010). The point of departure is the promotion of the health of the individual, the family, a group and the community. The focus of this study is on the nursing students experience of aggression in their lives. The complexity of their experience is intensified by their interaction with the different environments in which they function, as well as their various cultural backgrounds. Understanding their experiences of aggression in their lives will assist the nurse educator and/or community health nurse, both registered with the South African Nursing Council, with psychiatric nursing as an additional qualification, 12

31 to facilitate these nursing students through an empowering process to selfmanage aggression constructively (Botma et al., 2010) Methodological assumptions The methodological assumptions clarify the researcher s views about good science practice. The quality of the research findings relates directly to the justification of the methodology that is followed (Botma et al., 2010; Mouton & Marais, 1996). The methodological assumptions of this research are based on Botes s model (1995) for research in nursing (University of Johannesburg, 2010). The point of departure is the view that research in nursing and the science of nursing is mainly an applied science. This functional view implies the application of knowledge in practice in order to improve the practice of nursing. The researcher in this study explores and describes the nursing students experience of aggression in their lives (Botma et al., 2010). The applied nature of the research infers that all the actions to ensure trustworthiness promote the usefulness of the research findings (University of Johannesburg, 2010). 13

32 Methodological assumptions reflect the researchers opinion on what good research practice is (Botma et. al., 2010). Botes (University of Johannesburg, 2010) suggests that the methodological assumptions provide structure to the research problem, objectives and context. This in turn influences the choice regarding the appropriate research design and methods. This suggests that the research adheres to logic and justification. For the researcher to explore and describe the nursing students experience of aggression in their lives, a qualitative research design with a phenomenological approach was used. This approach requires the researcher to set aside personal experiences, called bracketing, to prevent from clouding the understanding of the nursing students experience of aggression in their lives. It was important for the researcher to remain open to the meaning of the phenomenon that those who experienced it attached to it. Through intuiting the researcher sought to understand the meaning that the nursing students attached to their experience of aggression (Botma et. al., 2010). The aim of this research was to develop a model as a frame of reference to facilitate the health of nursing students who experience aggression in their lives. This will improve the health of the nursing student and thereby improve nursing practice. 14

33 1.5.4 Definitions Nursing student In terms of section 32(1) and (2) of the Nursing Act (33 of 2005), a person undergoing education or training in nursing must apply to the Nursing Council to be registered as a learner nurse or a learner midwife, and the Nursing Council must register as a learner nurse or learner midwife any person who has complied with the prescribed conditions and who has furnished the prescribed particulars for a training programme at a nursing education institution. Universities (HEIs) are nursing education institutions as referred to in this Act. A nursing student is a university student who has not yet received a first degree. For the purpose of this study the nursing students are defined as students studying nursing in their second and third year of training, from different socio-economic environments, between the ages of 19 and 33 years of age. The age of nursing students that enrol at the university range between 19 to 33 years Aggression Aggression is behaviour that is intended to cause harm or pain, either physical or verbal (Psychiatric Nursing, 2011). Aggression, according to Mohammadi, Kahnamouei, Allahvirdiyan and Habibzadeh (2010), is defined 15

34 as causing apparent damage or using punishing behaviours to human beings or things. Baron, Byrne and Branscombe (2008) agree that aggression is an intentional infliction of harm on others. Aggressive action is any form of behaviour designed to harm or injure a living being (Shaffer, 2002). Kneisl and Trigoboff (2009) define aggressive behaviour as being directed towards getting what a person wants without consideration of others feelings. It is hostile and violent behaviour that can cause harm or injury to another human being and this behaviour can be as a result of responding to a stimuli, unmet needs and wants caused by the frustration emanating from the unmet need (Gaines & Barry, 2008; Harrington, 2006; Kneisl et al., 2004; Staub, 2003). Anger, say Kneisl and Trigoboff (2009), is the emotion, and aggression is the behaviour that arises from the emotion. Other terms that come to mind when thinking of aggression are anger, hatred, violence and hostility, to mention just a few (Larsen, 1976; Varcarolis & Halter, 2009) Health Health is a dynamic interactive process in the nursing students environment and the relative status of health is reflected by the interactions in the patient s environment (University of Johannesburg, 2010). Therefore social factors such as education, income, occupation, housing and environmental conditions can be related to health (Hattingh, Dreyer & Roos, 2006). 16

35 Facilitation Facilitation implies actions or results. It is a process of making things easier to enable something to happen in order to move forward (Collins South African Dictionary, 2007; Hattingh et al., 2006). 1.6 RESEARCH DESIGN AND METHOD Research design A research design is a blueprint for conducting a study (Burns & Grove, 2011). The chosen research design will therefore act as a roadmap, giving direction and guidance to a destination. It gives direction regarding how the research process will be conducted. The research problem determines the methods of data collection and data analysis (Babbie, 2012; Botma et al., 2010; Burns & Grove, 2011; Creswell, 2009; Maree, 2009). A theory-generating, qualitative, explorative, descriptive and contextual design was used for this study. Walker and Avant (2011) state that theory development assists the nurse in understanding the practice and provides a way of identifying and expressing key ideas about the essence of practice. The process of theory development consists of concept analysis, definitions and classifications. The character of the relationships between the concepts is investigated and the links identified, and the concepts are defined within the context of the theory (Chinn & Kramer; 2008; Dickoff, James & Wiedenbach, 17

36 1968). During this study a model was developed on a practice theory level, with a specific goal, namely facilitating the health of nursing students who have experienced aggression in their lives. A qualitative approach is regarded as one of the dominant paradigms in research, and is referred to as an interpretive methodological approach (Burns & Grove, 2011). This approach helps the researcher to gain insight into and an understanding of an unknown phenomenon. In social research a large portion of research is conducted to explore a topic or to familiarise oneself with a phenomenon. This approach was used in this study as the researcher aimed to explore and describe the nursing students experience of aggression in their lives. An exploratory design is used to gain insight into and an understanding of an unknown phenomenon (De Vos et al., 2011). This approach can be used when a researcher aims to explore a subject which in itself is relatively new (Babbie, 2012). By using an exploratory design in this study the researcher aimed to gain insight into and an understanding of the experience of aggression of nursing students at an HEI. Mouton and Marais (1996) assert that a descriptive study aims at giving an in-depth, accurate and precise description of that that is, and in this study the experience of aggression as explored is described accurately and precisely (Babbie & Mouton, 2011). A descriptive study presents a picture of a specific situation as it naturally happens (De Vos et al., 2011). 18

37 It is important that the study be placed within a context. This is important for transferability. A theory in one context might not be useful in another; therefore the context of the study should be stated clearly (De Vos et al., 2011). The research into the experience of aggression can only be understood and become meaningful if it is placed in a specific context, which is the lives of the nursing students and the lives of those around the nursing students studying at an HEI in the greater Johannesburg area (Babbie & Mouton, 2011) Research method The purpose of this research was to generate and develop a model for the facilitation of the health of nursing students who experience aggression in their lives. This research followed the method of theory generation and the following steps were taken: Concept analysis, relationship statements, description of the model and the strategies for implementation of the model (Chinn & Kramer, 2008) Step 1: Concept analysis Concept analysis is done in two parts, namely identification of the main concepts by exploring and describing the nursing students experience of aggression in their lives and then the definition and classification of the concepts. 19

38 a) Part 1: Identification of main concepts The identification of main concepts was done by means of the qualitative research method in order to explore and describe the lived experience of aggression by nursing students at an HEI in South Africa. A literature review was done to identify literature that relates to aggression and nursing students to recontextualise aggression within the nursing students context. b) Part 2: Concept definition and classification After the concept analysis and recontextualisation into the literature the central storyline was identified. The next step in theory generation was to define the central and related concepts. Chinn and Kramer (2008) state that central concepts need to be defined by existing theories, dictionary definitions, subject definitions and synonyms. The survey list of Dickoff et al. (1968) was used to determine the agent, recipient, context, terminus, procedure and dynamics of the model. 20

39 Step 2: Relationship statements Relationship statement is the investigation of the nature of relationships between concepts and the identification, if any, of links between the concepts (Chinn & Kramer, 2008). The context within which these relationships of concepts are described is the experience of aggression by nursing students at an HEI in South Africa Step 3: Description of the model A clear, detailed and complete description of the model for the facilitation of the health of nursing students at an HEI who have experienced aggression in their lives is given and evaluated according to the criteria as suggested by Chinn and Kramer (2011) Step 4: Description of strategies for implementation of the model The implementation of the model is done by describing strategies and actions. 21

40 1.7 MEASURES TO ENSURE TRUSTWORTHINESS In this research the measures to ensure trustworthiness were based on the model of Lincoln and Guba (Babbie & Mouton, 2011; Lincoln & Guba, 1985). Credibility in this research was enhanced through triangulation by using multiple data collection methods, such as drawing pictures, self-reporting narratives, interviews and field notes (refer to Chapter 2: 2.6.1). Transferability refers to whether the findings fit into a context outside the situation of study that is determined by the degree of similarity of fit between the two contexts. It is ensured by providing a dense description of the purposive sampling techniques, the research design and the findings (refer to Chapter 2: 2.6.2). Dependability was ensured by using independent coders that used a coderecode procedure. Consensus discussions were held between the researcher, independent coders as well as the researcher s supervisors to ensure consensus of themes and sub-themes (refer to Chapter 2: 2.6.3). Confirmability focused on whether the results of the research could be confirmed by another, if an audit trail could be followed to verify findings and whether the focus was on the data rather than the researcher. It was applied by using reflection and triangulation methods (refer to Chapter 2: 2.6.4). The criteria and their application to this study will be discussed in detail in Chapter 2. 22

41 1.8 ETHICAL MEASURES The word ethics comes from the Greek word ethos, meaning character (Rosenstand, 2003) and the conducting of research requires integrity and honesty, which further identify the characteristics of the researcher. Ethical research starts with identifying a topic and ends with the publication of the research (Burns & Grove, 2011). Dhai and McQuoid-Mason (2011) refer to four principles that can resolve ethical challenges troubling healthcare practitioners. The principles of autonomy, non-maleficence, beneficence and justice have to be interpreted in terms of a particular context. These standards for research were applied in this research study. Written consent of all the participants in this study was obtained to participate in the research project (see Annexure B). The participants names are not reflected in any documents that form part of the research. Should the anonymity of any participant be compromised, the records and documents will be destroyed. In-depth interviews were conducted with the consent of the participants. The participants gave separate consent for the audiotaping of the interviews. These audiotapes are locked away and only the researcher, independent 23

42 interviewer that also transcribed the interviews and study supervisors have access to these tapes. The transcription of the audiotapes is stored and locked away separately from the audiotapes and no names are indicated on the tapes and transcripts, only numbers. These audiotapes and the transcription of the tapes as well as the drawings and stories without any names will be kept until after the study has been published. The tapes as well as all the drawings, stories and transcriptions will then be destroyed two years after publication of the research. These steps will ensure that confidentiality is adhered to, which is a right of every individual to determine which and when private information is made public. All the data will be kept confidential to ensure anonymity. The principle of non-maleficence refers to avoiding harm or doing as little harm as possible. Every person has the right to be protected against psychological and physical harm. Due to the nature of the topic, namely the nursing students experience of aggression in their lives, describing or discussing their experience might have triggered traumatic events or feelings. If any participant had needed psychotherapy or any intervention during the time of data collection, it would have been provided by the researcher or fieldworker or the participant would have been referred immediately to the appropriate source with the consent of the participant. However, this was not 24

43 necessary. This is part of the researcher s professional responsibility in that it would be unethical behaviour if the researcher were to dismiss a crisis developed as part of data collection. If the researcher assessed this information as useful to the stories of the participants, it would be used as part of data with the participants consent. However, this was not necessary. This ensured that no harm came to the participants. Poor quality research is also viewed as unethical; therefore ensuring that the science is of a high standard protects the participants against harm (Dhai & McQuoid-Mason, 2011). The current research was reviewed by the Department of Nursing Science Committee, the Ethical Committee of the Faculty of Health Science as well as through various presentations to the doctoral committee to ensure the standard of the science and thus the protection of the participants. The principle of beneficence refers to doing good for others and promoting others health and interest. This principle requires the researcher to act in the best interest of the participants and to promote their welfare. The participants were informed that they could terminate their participation at any time without any harm or penalty. If participants, as the result of their participation and the nature of the topic, required intervention they will be referred, however, this was not necessary. Only participants who were willing to participate in the study gave the researcher consent in order to be part of the research study. The researcher discussed Chapter 1 of the study with the participants in order 25

44 to reveal the purpose and goal of the study. The assurance of anonymity and confidentiality was given to the participants who chose to participate in the research. Autonomy refers to a person s right to choose. Every person has the right to have their anonymity respected. This implies individual autonomous choice and decision-making by participants. Self-determination, informed consent and respect for confidentiality are entrenched within this principle. In order for the participants to make an informed decision and thus give informed consent, participants were informed of the nature of the research and their participation, and were assured of confidentiality and their anonymity in this research project. The nursing students participation was voluntary and was done during times they agreed upon to prevent interference and additional strain on them and their studies. The principle of justice requires an obligation to treat each person with what is right and proper. The research should leave the participants better off or at least not worse off. The principle of justice was dealt with by allowing the participants to relate their experiences through drawings and stories. Expressing experiences can in itself be therapeutic and can contribute to a greater body of knowledge. The student s participation was voluntary and anonymous. The researcher was also not directly involved in their teaching and could not have had any impact on their academic performance. This means that the students could not have been treated unjust or unfair should 26

45 they decided not to participate or withdrew from the research. By discussing the reasons and process of selection, recruitment, inclusion and exclusion in section a), the researcher reveals that this process was just and fair, and based on sound scientific and ethical principles. The model developed from this research will be made available for use and the intention of the researcher is to continue with the testing and implementation of this model after the study, to ensure that the community of nursing students can benefit from the contribution of the participants of this study (Dhai & McQuoid-Mason, 2011). The ethical committee of the Faculty of Health Sciences of the HEI of Johannesburg evaluated the research proposal and approved it (Annexure A). 1.9 SIGNIFICANT CONTRIBUTION OF THESIS The development of a model as a frame of reference for the facilitation of the health of nursing students who experience aggression in their lives will contribute significantly to the field of nursing. 27

46 1.10 DIVISION OF CHAPTERS Chapter 1: Chapter 2: Chapter 3: Introduction and overview of the study Research methodology Discussion of the phenomenon of the experience of aggression by nursing students Chapter 4: Identification, definition and classification of the central and related concepts Chapter 5: Description of a model as a frame of reference for facilitating constructive self-management of aggression by nursing students at an HEI Chapter 6: Conclusions, recommendations and limitations of the research 1.11 CONCLUSION In this chapter a brief background was provided leading to the research problem. An overview of the planned research was described. The research methodology will be discussed in detail in Chapter 2. 28

47 CHAPTER 2 RESEARCH METHODOLOGY 2.1 INTRODUCTION In the first chapter, the background to and rationale for this research was given. The purpose of this research was discussed. In this chapter, the research design and method will be discussed comprehensively. Felix Kaufman writes that research methodology is the theory of correct scientific decisions (Mouton & Marais, 1996). Methodology refers to the strategy of actions that governs the choice and use of both the methods and techniques that will enable outcomes. A wide variety of methods, i.e. the techniques and procedures for sampling, data collection and data analysis, can be used depending on the aims and objectives of the study and the phenomenon that needs to be investigated (Babbie & Mouton, 2011; Maree, 2009; Creswell, 2003). Research methodology therefore refers to the how of research. This means how the research is planned, structured and executed in order to reach the research goal. It is a design that is a scientifically structured method of conducting research (Botma et al., 2010; Burns & Grove, 2009; Mouton, 1996; 29

48 Mouton & Marais, 1996). The research methodology in this study is based on the four steps of theory generation as described in Chinn and Kramer (2008), Walker and Avant (2005) and Dickoff et al. (1968). Aspects regarding trustworthiness are discussed in 2.6 and ethical considerations that applied to this study were discussed in PURPOSE AND OBJECTIVES OF THE RESEARCH The purpose of this study was to develop and describe a model as a frame of reference to facilitate the health of nursing students at an HEI in Johannesburg who experience aggression in their lives. The objectives of this study were as follows: To explore and describe the experience of nursing students at an HEI in Johannesburg of aggression in their lives. To generate a model from the results that will facilitate the promotion of health of the nursing students at an HEI in Johannesburg who have experienced aggression. To formulate strategies for the implementation of the model. 30

49 2.3 RESEARCH DESIGN A research design is a blueprint for conducting a study (Burns & Grove, 2011). It is used to plan a process focusing on the end product which includes all the steps such as collection and analysis of data in a way that will achieve the anticipated outcome and ensure control over those factors that can hamper the validity of a study. The chosen research design therefore acts as a roadmap, giving direction and guidance to a destination. The research problem determines the methods of data collection and data analysis (Babbie, 2012; Botma et al., 2010; Burns & Grove, 2011; Creswell, 2009; Maree, 2009). A theory-generating, qualitative, explorative, descriptive and contextual design was used in this study. The experience of aggression of nursing students at an HEI was explored and described through qualitative methods. The findings were used to develop a model to facilitate the health of nursing students who have experienced aggression in their lives. A person s world view or life philosophy determines the choices and decisions made in a person s life. Likewise, decisions regarding research problems and research approaches will be influenced by the researcher s view of the world. It is therefore important that the researcher inform the readers about the nature of the research paradigm to prevent any ambiguity (Botma et al., 2010; Burns & Grove, 2011; Creswell, 2009; De Vos et al., 2011; Polit & Beck, 2012). The philosophy, alternatively referred to as research paradigm, is 31

50 perceived as accepted values and beliefs that direct research. The research paradigm is based on philosophical assumptions such as ontological, epistemological and methodological assumptions (Botma et al., 2010; Burns & Grove, 2011; Creswell, 2009; De Vos et al., 2011). The philosophical view of the researcher supports the postmodern constructivist and interpretive approach. Postmodernism suggests that social constructs such as language can distort reality (De Vos et al., 2011:10; Holloway & Wheeler, 2010:27). How nursing students from various backgrounds and cultures experience reality differs. The constructivist s proposition is that there is no truth out there ; truth is a synthesis of realities. The nursing students as humans are complex, and have the ability to construct and form their own experiences. The continuously changing reality of nursing students exists within the context of their real-life experience (Botma et al., 2010; Creswell, 2009; De Vos et al., 2011; Polit & Beck, 2012). The researcher believes that the nursing students construct their own reality through their own lived experience. Each nursing student constructs their truth differently as they come from different cultural and/or socio-economic environments. As human beings, nursing students are continuously trying to make sense of the world they live in. An interpretive approach proposes that the nursing students seek to understand the world they work and live in through continuously interpreting, give meaning to and trying to justify and rationalise their experience of aggression in their lives. They incessantly 32

51 construct, develop and change everyday life s interpretation of their world (Babbie & Mouton, 2011; Botma et al., 2010; Creswell, 2009; De Vos et al., 2011; Polit & Beck, 2012). Hermeneutics (Neuman, 2000) required a detailed reading and scrutiny of the written word, pictures and/or conversations by the researcher to discover the deeper embedded meaning within this conversation, written word and picture told by the nursing students in the quest to understand aggression as they experienced it in their lives (Babbie & Mouton, 2011; Botma et al., 2010; De Vos et al., 2011; Polit & Beck, 2012; Van Manen, 1990). According to Neuman (2000), hermeneutics is the subjective understanding or interpretation of human actions. The researcher sought to understand how nursing students interpret their own world. Hermeneutic phenomenology (Van Manen 1990) focuses on the understanding and meaning of the interpretation of a person s world. This interpretation is done in a specific context against the background of the external environment. According to Smith and Eatough (2007), the researcher has to make sense of the participants world through a process of interpretative activity. The researcher tries to determine how the participants make sense of their world. At the core of phenomenology is the meaning of the lived experience of humans. The nature of a phenomenon is a reflection of the nature of people as human beings, who find themselves within the context of a health care institution, who are living and making sense of their 33

52 experiences (Burns & Grove, 2009; Polit & Beck, 2012). The aim of phenomenological research is to understand the way human beings experience the world they live in. Van Manen (1990) states that to know the world means to be in the world to know what is most essential to being. The researcher searched for what it means to experience aggression as nursing students, constantly keeping in mind that social culture and traditions give meaning to the nursing students ways of experiencing aggression in their lives (Van Manen, 1990). Ontology refers to the nature of reality (Botma et al., 2010). The nature of reality (ontology) of the postmodern constructivist approach suggests that there is only a narrative truth that can be experienced only by those who live in it. This reality is subjective and can only be constructed through social and personal interpretations (Botma et al., 2010; De Vos et al., 2011). It is the researcher s position that the nursing students own reality of aggression is constructed through their own interpretation of aggression in their lives. The researcher consequently requested the nursing students to relate their stories of aggression as they experienced it in their lives. From ontology, basic assumptions about knowledge follow (Babbie & Mouton, 2011). Postmodern constructivist approach suggests that the researcher and the participants co-create understanding of the multiple representations of reality. The epistemological belief of this study was within the interpretative character of multiple constructed realities that shapes the reality of the human 34

53 being (Denzin & Lincoln, 2011). The nursing students that experience aggression in their lives construct knowledge through a process of selfconscious actions and interactions with one another and those around them, lending interpretation and meaning to their experience of aggression (Botma et al., 2010; De Vos et al., 2011; Holloway & Wheeler, 2010). Schwandt (2007) proposes that the meaning nursing students give to their life world construes their reality and can only be discovered through language. According to Polit and Beck (2012), epistemology uses the question of the relationship between the researcher and the participants: How is the inquirer related to those being researched? The assumption from a constructivist s paradigm is the close interaction between the nursing students and the researcher, and the voice and interpretation of nursing students experience of aggression is crucial for understanding aggression as the phenomenon Theory-generating design During this study a model was developed with a specific goal, namely the facilitation of the health of nursing students who experience aggression, was explored. The development of the theory on a practice level meant that the focus of the development of this theory had to be related to nursing practice and the broader scope of nursing practice (George; 2002; Walker & Avant, 2005). 35

54 According to Walker and Avant (2011), theory development assists the nurse in understanding the practice and provides a way of identifying and expressing key ideas about the essence of practice. In theory generation scientific knowledge is accrued in a precise, orderly and purposeful way (Chinn & Kramer, 2008). Constructivism, however aims at coconstruct meaning where multiple representations exist. The purpose of theory development in this study was to develop a model as a frame of reference for the practice of nursing, education and research, through coconstruction of the meaning of the multiple realities as experienced by the nursing students.. The model as a frame of reference to facilitate the health of nursing students who have experienced aggression was developed on a practice theory level (Walker & Avant, 2011). A theory on practice level impacts on the practice of nursing. Strategies have been formulated for the practice of nursing and operationalisation of the model took place within the context of the nursing practice, education of nursing students as well as future research. These strategies described for the operationalisation relate to the model developed (Walker & Avant, 2005). Chinn and Kramer (2008) explain that a theory is a creative and rigorous structuring of ideas that projects a tentative, purposeful and systematic view of phenomena. The process of theory development consists of concept analysis, definitions and classifications. The character of the relationships 36

55 between the concepts is investigated and the links identified, and the concepts are defined within the context of the theory (Chinn & Kramer, 2008; Dickoff et al., 1968). According to Dickoff et al. (1968) a model developed on a practice theory level should use a survey list of elements included in the theory. Therefore for this study a combination of the methods of Chinn and Kramer (2008), Dickoff et al. (1968) and Walker and Avant (2005) was used Qualitative approach A qualitative approach is regarded as one of the dominant paradigms in research. Qualitative research is referred to as an interpretive methodological approach (Burns & Grove, 2011). This type of research is used to explore behaviour, feelings and experiences of people and what lies at the core of their lives from the insider s perspective. The qualitative approach is used to gain insight into the meaning and understanding of people s life experiences and what gives them meaning (Babbie & Mouton, 2011; Holloway & Wheeler, 2010). Qualitative research views social phenomena holistically in the natural setting, making use of possible multiple methods that are interactive and humanistic and resulting in interpreting data (Creswell, 2009; Babbie & Mouton, 2011; Burns & Grove, 2009). Qualitative research is a systematic subjective approach. Its key feature is that the focus is on the process and the quest for understanding the phenomena in terms of a specific context. The researcher explored and described the lived experience of aggression of the 37

56 nursing students in an attempt to understand these experiences and patterns of behaviour. The researcher also attempted to understand and gain insight into the meaning and interpretation that these nursing students attached to their experiences of aggression. Data obtained in this research included narratives, pictures and words through interviews (Monette, Sullivan & De Jong, 2011). In order for the researcher to attempt to gain insight into and an understanding of the nursing students lived experience of aggression, a question, How is aggression for you in your life? was put to participants of the research Exploratory design An exploratory study is designed to increase knowledge of the field of study (Burns & Grove, 2009). An exploratory design is used to gain insight into and an understanding of a phenomenon which is unknown or which is relatively new, and in social research a large portion of research is conducted to familiarise oneself with that topic. The subject of lived experience of aggression which the researcher needed to be familiarise with is a relatively new phenomenon and has never been addressed among nursing students. In conducting a search for resources the researcher found limited literature on the topic of students experience of aggression at an HEI. The researcher could not find any study that has been done on nursing students experience of aggression, though previous research has been done on the experiences of nursing students on violence in the work environment and of learners in 38

57 secondary schools with the aim of developing psycho-educational programmes (Babbie, 2012; De Vos et al., 2011). By exploring this topic, the researcher aimed to gain insight into and an understanding of the experience of aggression of student nurses at an HEI. The results are described in detail Descriptive design As stated in Mouton and Marais (1996), a descriptive study aims at giving an accurate and precise description of that that is. The focus of descriptive research is on the how and why questions. Concepts are described and relations identified through descriptive research and this provides a picture of a situation as it naturally occurs (Babbie, 2012; Kreuger & Neuman, 2006). In this study the lived experience of aggression, as explored, and its deeper meaning are described accurately and precisely, leading to a dense description of the meaning and understanding of aggression in the lives of the nursing students (Babbie & Mouton, 2011; De Vos et al., 2011; Rubin & Babbie, 2011). A model is generated from the results of the described lived experience of nursing students of aggression. Because this model is described in the context of the nursing students within an HEI, this study can be viewed as contextual. 39

58 2.3.5 Contextual design As stated in 2.3.2, qualitative research aims to understand a phenomenon in a specific context (De Vos et al., 2011). The philosophical stance of phenomenology views a person as part of their world, with meaningful relations and practices unique to each person as the context within which that person can be understood (Botma et al., 2010). The research of the experience of aggression can only be understood and become meaningful if it is placed in a specific context, which in this case is the lives of the nursing students and of those around them at an HEI in South Africa (Babbie & Mouton, 2011). The result of the research is unique to the lives of the nursing students at an HEI and is not intended to be generalised. 2.4 REASONING STRATEGIES According to Chinn and Kramer (2011), logical thinking is part of an argument linked to reaching a logical conclusion, and reasoning is when a person is able to make sense of their thoughts, experiences and research evidence. To make sense of research evidence and to arrive at a logical assumption or conclusion, the researcher must make use of logic reasoning. Walker and Avant (2005) describe three basic approaches to theory building, namely synthesis, derivation and analysis working either inductively or deductively. During this research, the following approaches were used: 40

59 2.4.1 Analysis Through analysis the researcher can take a whole into parts in order for the parts to be understood more clearly. Through this reasoning strategy, concepts can be clarified and refined and relationships between all the parts and the whole can be examined (Walker & Avant, 2005). During this study qualitative analysis included thematical and content analysis, clarifying and refining concepts and statements with a literature review and concept relationship examination (Walker & Avant, 2005) Synthesis Synthesis, which involves interpretation and explanation, follows the analysis approach (Mouton, 1996). Walker and Avant (2005) explain that synthesis allows the combination of isolated pieces of information that are as yet theoretically unconnected. Through synthesis the data obtained from the indepth phenomenological individual interviews, field notes, drawings and selfreporting stories was organised into categories and sub-categories to identify the themes and central concepts in this research (Huberman & Miles, 2002). Statements synthesis took place during the construction of statements to indicate the manner in which two or more concepts were interrelated during the development of the model (Burns & Grove, 2009; Walker & Avant, 2005). 41

60 2.4.3 Inductive reasoning With induction, relationships can be induced by experiencing an empiric reality and reaching some conclusion. In inductive logic, particular instances are observed to be consistently part of a larger whole (Chinn & Kramer, 2008). In this study a specific phenomenon, the nursing students lived experience of aggression, was explored within a specific context of an HEI and then explained in general. Conclusions about events were drawn through reflecting, and refining and elaborating ideas into more theoretical concepts suitable for developing a model (De Vos et al., 2011) Deductive reasoning Deduction moves from the general to the specific (De Vos et al., 2011). Burns and Grove (2011) state that deductive reasoning moves from a general premise to a particular situation or conclusion. In deductive logic, according to Chinn and Kramer (2008), the premises as starting points embody two variables that can be categorized in relation to each other. Deductive reasoning was used in the description of the model based on the central concept that was derived from the field research on nursing students experience of aggression in their lives. The strategies to operationalise the model were derived from the model. 42

61 2.5 RESEARCH METHOD The purpose of this research was to generate and develop a model as a frame of reference to facilitate the health of the nursing students who experience aggression in their lives. This research followed the method of theory generation and the following steps were taken: Concept analysis, relationship statements, description of the model and the strategies for implementation of the model Step 1: Concept analysis Concept analysis is done in two parts, namely identification of the main concepts by exploring and describing the nursing students experience of aggression in their lives and then the definition and classification of the concepts. Concept analysis is a strategy that identifies a set of characteristics essential to a connotative meaning of a concept and played a significant role in theory generation. The phenomenological approach and the philosophical foundation of this study guided the concept analysis approach. The approach to concept analysis of Walker and Avant (2005) was used in this step. The procedure required exploration of the various ways in which terms are used and the identification of a set of essential characteristics that clarify the range of ideas to which those concepts may be applied (Burns, Grove & Gray, 2012; Walker & Avant, 2011). The researcher attained and constructs an accurate and true reflection for the theoretical foundation for model development. The 43

62 defining attributes is used to distinguish these concepts from similar concepts (Tofthagen & Fagerstrom, 2010; Walker & Avant, 2005). The procedure for concept analysis according to Walker and Avant (2005) included the selection of a concept, identifying the uses of all the discovered concepts and determine the defying attributes that was constructed in a model case. The uses of the concepts were discovered through perusing dictionaries, subject and related literature to determine the uses of the term. The characteristics that were most frequently associated with the concepts were identified as essential attributes. The list of essential attributes of the central concept was used in the construction of a model case. According to Walker and Avant (2011), a model case could be founded in real life. It depicts a real-life situation as an example of the main concept and contains all the critical or essential elements of the main concept. The survey list of Dickoff et. al. (1968) was used to classify the concepts and the following questions as proposed by them were asked in determining the agent, recipient, context, terminus, procedure and dynamics of the model Part 1: Identification of main concepts, empirical phase The identification of main concepts was done by means of the qualitative research method in order to explore and describe the lived experience of 44

63 aggression by nursing students at an HEI in South Africa. A literature review was done to identify literature that relates to aggression and nursing students to recontextualise aggression within the nursing students context. The researcher aimed to explore and describe the experience of aggression in the lives of nursing students studying at an HEI. Multiple data collection methods were used to explore this. a) Population and sample Kerlinger and Lee (2000) in Burns and Grove (2011) state that the population includes all elements, be it individuals, objects or substances, that meet the criteria for inclusion in a given universe. The accessible population was available to the researcher and met all the sampling criteria (Burns & Grove, 2011; Gravetter & Forzano, 2009; Mouton, 1996; Smith, 1997). The accessible population to the researcher for the purpose of this study was nursing students at an HEI in Johannesburg. Purposive sampling refers to the selection of a sample of participants by the researcher based on the purpose of the study as well as the judgement of the researcher (Babbie & Mouton, 2011). For this study the researcher ensured that specific criteria that represented the most characteristics and attributes of the population in the sample were met (Burns & Grove, 2011; De Vos et al., 2011; Polit & Beck, 2012). Nursing students were purposefully sampled as 45

64 they added to the richness of the data collected for the purpose of this research. The researcher selected those nursing students who were willing to share their experiences, and who could add to the knowledge and the understanding of aggression as they experienced it in their lives. The target population for the purpose of this study consisted of all the nursing students in the second and third year of studying towards a degree in Nursing Science at an HEI in Johannesburg. Nursing students in their second and third year have already been exposed to the clinical training environment. These nursing students were from varied backgrounds, male and female and range in age from 19 to 33 years. They worked between 12 and 20 hours a week as part of the requirements of studying towards a degree in Nursing Science at an HEI in Johannesburg. The experience of aggression can only be understood and become meaningful if it is placed in a specific context, which in this case were the lives of the nursing students and the lives of those around them. First-year students were excluded as participants for the purpose of this research, as they have very limited clinical exposure to clinical training institutions. They only start working in the clinical environment such as hospitals and clinics after May and then only for a few hours (6) a week. Fourth-year students were also excluded. During the fourth year of their training nursing students do psychiatry, which is already an exploration of the 46

65 self. The researcher did not want to add to the already full theoretical, clinical and psychological demands of this discipline on the students. In qualitative research, sample size is usually flexible. Sampling strategies, the quality of information from the participants, the scope and purpose of the study all affect the sample size (Greeff, 2005; Polit & Beck, 2012). The size of the sample also depends on data saturation. Data saturation (Pequegnat, Stover & Boyce, 2011) occurs when no new or relevant data emerges after pursuing various strategies for data collection, and redundancy has been achieved. It is when themes and categories in the data are repeated to the extent that nothing new is learned (Monette et al., 2011; Maree, 2009). The population and sampling as discussed applied to the various data collection strategies, namely the drawing of pictures and self-reporting story writing as well as the phenomenological interviews. The saturation of the data guided the researcher, as the researcher was committed to obtain a clear and indepth understanding of the nursing students experience of aggression at an HEI. b) Data collection As the researcher needed to understand the phenomenon of how nursing students experience aggression in their lives, the researcher identified different methods of data collection. The most appropriate method was firstly through drawing a picture and writing a self-reporting story, and secondly, through phenomenological interviews. It was, however, important for the 47

66 researcher to engage in bracketing in order to defer to what is known about the experience being studied and to hold back her own assumptions in order for the participants voices to be heard and understood (Creswell, 2003; Burns & Grove, 2011). The second- and third-year nursing students were invited to participate voluntarily in this research. The researcher explained the purpose of the study and what was expected of them. Measures to ensure anonymity and confidentiality were discussed with them. Informed consent was obtained from the participants and they were assured that they could withdraw at any time without penalty. Participants who might have had a need for emotional support, due to the emotional nature of the research, were encouraged to seek such support and were provided with contact details of counsellors that could assist them. i) Drawing a picture and writing a story The primary source of data collection was the drawing of a picture and writing of a self-reporting story. Because the drawer leaves an imprint of his/her inner self upon his/her drawing, as stated by Marijcke and Brown (2002) in Moolla (2007), drawing and storytelling are valuable and current ways of communication and self-expression. Visual images that represent a phenomenon can also serve in cases of people finding it difficult to say or write what they experience (Chinn & Kramer, 2008; Groves & Huber, 2003). An image can convey multiple messages, both concrete and abstract 48

67 thoughts and this image representing a thousand words are apprehended instantaneously in one single glance (Knowles & Cole, 2008) By providing the participants with the opportunity to draw, their creativity can assist in expressing their emotions such as anger and empathy and thus share their reality (Creswell, 2009). This can also allow these nursing students to become aware of what they didn t know they knew (Knowles & Cole, 2008). With the use of drawings, the researcher can see through the nursing students eyes, seeing their point of view. Hearing, seeing or feeling the details of a lived experience helps make the representation trustworthy (Knowles & Cole, 2008). According to Knowles and Cole (2008) images can be powerful tools in the various phases of research that can contribute to the credibility of the research by challenging critically and provoking new ways of interpretation and analysing these drawings. The aim of the drawings in this study was to provide the nursing students the opportunity to put their lived experience into a visual image that can be used as a aid to write the self-reporting story. Every culture has stories that are passed from generation to generation and humans thrive on stories. Through stories people relate their lives and, according to Petersen (Curtis & Eldredge, 1997), people s existence is shaped into a story; through stories, images and emotions are revealed. Stories allow the understanding of a transcendent reality, realising the extent of the meaning of being human (Peterson, 2006). The writing of a self-report story following the drawing gave the researcher a holistic description of truelife situations of the lives of the nursing students and of those around them. 49

68 Through the stories the nursing students allowed the researcher to come into their lives through images and their emotions. The data obtained from both the drawing and the self-reporting storytelling added to the richness of the data. However, certain factors influencing drawing and storytelling had to be kept in mind: - The colours used in the drawings could be influenced by the availability of the number of wax crayons, their colours and the ease with which participants could draw with them. - Drawings in themselves could be difficult to analyse or interpret. - Not all the participants may have had the ability to draw. The data was collected from the nursing students at an agreed upon time. The researcher went to an allocated venue to address the students (second and third years at separate times and venues), informing them about participation in the research. The purpose and objectives of the research were explained to the students, after which those who wished to take part each received consent forms to complete and sign. The researcher explained to the participants what was expected of them regarding the drawing of the picture and then the writing of the story. They then received coloured wax crayons and the booklet in which they could draw and write their story. Participants were requested to draw a picture illustrating How aggression is for you in your life 50

69 and then to write a story (narrative) about the picture they drew, in order to explore and describe their experiences of aggression in their lives. The participants were given about an hour to complete the drawing as well as write the story. Those who completed before the time could submit their consent forms with the completed booklet. The consent forms, drawings and stories were collected when they were completed and those who needed more time were given the opportunity to complete without pressuring them. Each booklet on both the drawing and story writing page were marked 2/08 or 3/08 to distinguish between the second- and third-year participants and to ensure anonymity and confidentiality. Before the records were copied and scanned, each was marked again from 1 to 15, depending on how many were in each year group. This was to ensure that the drawing and the story could be rematched if they were separated. Each of the pages of a booklet therefore had a number, for example 1/2/08 or 1/3/08. After the completion of all the drawings and self-reporting stories and the marking of the pages, the researcher made three copies of the stories. As a colour copy machine was not available, the researcher used a colour scanner to scan all the drawings to ensure that the colours of the drawings were preserved. 51

70 The copies were sent to the external co-coders skilled in qualitative analysis. One of these co-coders was a skilled specialist psychometrist for projective analysis and evaluation. ii) Phenomenological interviews A phenomenological interview as a method of data collection is an acceptable and applicable method in qualitative research. The purpose of using this method was to gain insight into the student nurses experience of aggression in their lives. This gave the interviewer the opportunity to probe and, after the interpretation, describe this phenomenon to its fullest (Babbie & Mouton, 2011; Burns & Grove, 2011). According to Burns and Grove (2011), the focus of the phenomenological approach is to understand the response of the whole human being within their everyday life, a life with relationships and in interaction with the environment. The philosophical orientation of the phenomenologists is that the person is viewed as a whole human, meaning phenomenologists try not to understand isolated, specific parts or behaviours, integral to the environment (Burns & Grove, 2011). The human being s existence in the world, surrounded by other human beings and its perception of the world, needs to be understood, as well as how humans perceive the world projection to the world and reflection to the self (Van der Zalm & Bergum, 2000). In the phenomenological framework, the researcher attempted to interpret and understand human beings in their everyday life, taking into consideration the interrelationship of living in the 52

71 world around us, living in a world of relationships with other people and living in an own world (De Vos et al., 2011; Morse, 1994). The nursing students experiences of aggression in their lives were explored through phenomenological interviews where the focus of the interviewer was on the phenomenon of aggression as experienced by the nursing students in their lives. Interviewing is a verbal communication between the interviewer and the participant and in this process the interviewer is presented with information. Interviewing is a flexible technique allowing the interviewer to explore the deeper meaning of the participants response in depth (Creswell, 2003; Babbie & Mouton, 2011). The interview was used as a strategy to collect verbal data from the nursing students who were asked to share their experiences of aggression in their lives with the researcher or interviewer in this research (Holloway & Freshwater, 2007). Interviewing is a form of self-reporting and the interviewer needs to assume that the information provided is accurate. It is therefore important for the interviewer to try and get the co-operation of the participants to ensure that the necessary information has been obtained. The interviewer, however, needs to be skilled and experienced, especially in formulating the questions in such a way that will ensure the information needed has been obtained without harming the participant. The interviewer also needs to be sensitive to the 53

72 communication of the participant. The independent interviewer used for these phenomenological interviews had all the above skills to conduct interviews (Creswell, 2003; Babbie & Mouton, 2011; Burns & Grove, 2011). The purpose of these interviews was to gain insight into the nursing students experience of aggression. The interviews also served to enhance credibility by triangulation and ensured data saturation. The phenomenological interviews also served to clarify themes and sub-themes that emerged from the analysis of the drawings and the narratives (Denzin & Lincoln, 2005). Nursing students in their second and third year of study were invited for an audiotaped phenomenological interview. The researcher arranged a meeting with all these nursing students. Again, the purpose and objectives of the research were explained. - An invitation to take part in data collection by means of audiotaped individual interviews on the phenomenon of their lived experience of aggression was extended to the students. - The students were informed that the researcher herself was not conducting the interviews (reasons will be discussed later). - Those who were willing to take part were given a consent form and they were requested to provide the researcher with their contact details to set up appointments for the interview. (See Annexure B.) - Although they were requested to indicate their contact details, the researcher assured them that confidentiality would be ensured by not 54

73 mentioning any names during the interviews and keeping the recordings safe and locked up, and that only the external co-coder would have access to these tapes for transcription and coding purposes (see 1.8 for a detailed discussion). These interviews were held in an office occupied for the purpose of the interviews by the skilled interviewer. The environment was quiet to prevent any disturbance during the interview and nursing students were familiar with the environment, meaning that they did not experience any discomfort and they felt safe. The participants were thus assured that their identities and information would be protected (De Vos et al., 2011). A skilled interviewer conducted the individual interviews and kept field notes. The field notes served to enhance credibility through triangulation, but also as a tool to reflect on observations during and after the interviews. A single central question was posed to the nursing students that took part in the interviews: How is aggression for you in your life? The researcher did not conduct any of the interviews. The researcher is a lecturer involved in training the first-to fourth-year nursing students and thus in an authoritative position and their involvement could have been construed as coercion. Due to this involvement with the students, the researcher was of the opinion that the trustworthiness and richness of the data as well as the ethical 55

74 considerations could be compromised had she conducted the interviews herself (Denzin & Lincoln, 2005). c) Data analysis Data analysis is a continuous process of reflection, analytical questioning, writing notes throughout the study and interpreting the greater meaning of the data in order to make sense of the text and image data (Creswell, 2009; Dahlberg, Dahlberg and Nystrom, 2008). Creswell (2009) suggests the blending of the general steps of data analysis with the specific research strategy steps and analysing from specific to general, thus engaging multiple levels of analysis. Dahlberg et al. (2008) suggest that the idea of the analysis of phenomenological research is to first understand and make sense of the text and images as a whole, and then through understanding and interpreting the parts, to search for the essence of the phenomenon to arrive at a new whole. In this research the researcher employed the methods of data analysis as described by Creswell (2009). By engaging in multiple level analysis, various stages of analysis are interrelated and thus are not always in the order presented. 56

75 Firstly, the organisation and preparation of the data comprises the transcription of interviews, optical scanning of material, preparation and organisation of the data according to the origins of collected data (Creswell, 2009). In this study, this entailed coding the collected data that is the drawings and self-reporting stories colour scanning the drawings, copying the stories and transcribing the interviews. Before the drawings were sent electronically to a specialist psychometrist for projective analysis and evaluation, they were colour scanned. The drawings and the psychometric analysis were integrated into the data analysis. Each self-reporting story, transcribed audiotape of the individual interviews and field note that was kept during the interviews was copied to provide each independent co-coder with a copy for analysis. Analysis was done by the researcher and two independent co-coders who were knowledgeable in the field of qualitative studies to ensure trustworthiness (Lincoln & Guba, 1985). Secondly, acquiring a general sense of the data requires the researcher to become familiar with the data and to reflect on its overall meaning. As the researcher and independent co-coders read through the data, they wrote notes and general thoughts about the data (Creswell, 2009). 57

76 Thirdly, detailed coding of data took place through a process of coding. This process involves taking the collected data and organising it into pieces of text before bringing meaning to the data collected (Barbour, 2008; Creswell, 2009). The researcher and independent co-coders made use of open-coding (Creswell, 2009). The drawings and the analysis of the psychometrist were integrated into the data analysis. The process of coding was done according to the following eight steps as described by Tesch in Creswell & Plano Clark (2011) used in the descriptive method of data analysis: 1. Get a sense of the whole: Each written story and transcribed interview was carefully read through individually by the researcher as well as the independent co-coders to obtain a sense of the whole. Ideas that came to mind were written down. 2. One document was selected: This could be the shortest, most interesting one or the one on top of the pile, to read through with the question what is this all about? in mind. This was done to get a sense of the underlying meaning and then comments were written about it. 3. After reading through a number of participants documents, repeating step 2 above, a list of all the topics was made. These topics were clustered together in columns, categorising them in terms of major, distinct and others. 58

77 4. The list of topics was coded with symbols, which were written next to the segments in the text that had been analysed. This was done to determine if any new categories and codes emerged. 5. Categories were developed by finding the most appropriate description for the emerged topics. Topics relating to one another were then further grouped together in an attempt to reduce the total list of categories. The major themes and sub-themes were identified in their relationships. 6. The coding for each category was finalised and alphabetised. 7. Data material for each category was assembled and preliminarily analysed. 8. Recoding of existing data took place, and categories were then refined after consensus discussions between the researcher and independent coders. After further discussion with the independent cocoders about the verification of the list of categories, the researcher referred back to the existing categories, which were then refined. Fourthly, the coding process was used to generate descriptions and themes or categories for analysis (Creswell, 2009). During this process quotes of the nursing students during interviews were indicated next to each of the themes and categories. The researcher then had a follow-up discussion with the supervisors of the research. Data was found to be saturated and a parallel was found between the findings of the naive sketches, interviews and the drawings, as evidenced by repeating themes. These identified main themes were shaped into a general description of 59

78 the phenomenon of the nursing students experience of aggression in their lives. In the fifth place, the themes and description were represented. The findings can be represented in a narrative way (Creswell, 2009). In this study, this was done in the detailed discussion of the main themes and categories, the drawings from some of the nursing students as well as quotes from the stories and transcribed interviews. Finally, data analysis requires the interpretation or meaning of the data (Creswell, 2009). Data that was analysed was recontextualised into the literature and a central storyline was identified. The raw data was provided to a person who was experienced in qualitative research to analyse the data independently of the researcher. The independent co-coders met with the researcher and they held a consensus discussion on the results of the data analysis. d) Literature review Literature in this study was consulted after data collection and analysis to prevent influencing the objectivity of the research (Botma et al., 2010). The 60

79 literature used for this study provided a theoretical context in the discussions of the themes and sub-themes. Findings from this study were compared with related studies and information in the literature, and gaps were filled in the data of this study (Burns & Grove, 2011; Creswell, 2009). The definition and classification of the central concepts were done through a thorough exploration of the literature in the library and on the internet as well as other research databases (see Annexure D). Literature in the field of nursing, medicine, sociology, psychology, education and research was explored. Information from all other relevant fields of study was also explored. The relevant literature, together with the findings, was used in the discussion and description of the nursing students experience of aggression in their lives (Chapter 3). It provides current knowledge of this phenomenon (Burns & Grove, 2011). e) Role of the researcher In qualitative research, the researcher s role is to attempt to understand the phenomenon in the real-world situation (Maree, 2009). The researcher s description of the findings embodies the engagement with and interpretation of the phenomenon, in this case namely the nursing students experience of aggression in their lives (Holloway & Freshwater, 2007). The involvement of the researcher with the participants and the field of study means that the researcher s subjectivity cannot be eliminated (Maree, 2009). However, the involvement and subjectivity of the researcher in this study 61

80 added to the understanding of the meaning of aggression within the life world of the nursing students. Due to the sensitive nature of the topic, the researcher needed to demonstrate discretion and sensitivity throughout the research process (Botma et. al., 2010). Should the nursing students experienced distress during data collection, the professional responsibility of the researcher would have been to refer the participant immediately to the appropriate source with the consent of the participant. However, this was not necessary. The researcher as the educator of the nursing students participating in the research as well as the sensitive topic of aggression posed possible ethical concerns. The researcher thus made use of a few strategies to ensure that the researchers biases, background and values did not shape interpretations during the study (Creswell, 2007). Interviews during data collection were conducted by an independent interviewer, experienced in phenomenological interviews and research. The transcribed interviews and self-reporting stories were analysed by the researcher and two independent co-coders to ensure non-bias and non-judgement by the researcher and to add to the credibility (2.6.1) of the research. Ethical clearance was obtained from the relevant structures within the university at which the research was conducted (see Annexure A). All the participants were informed about the nature of the research and the extent of 62

81 their involvement in this study. Consent from all the participants was received. Thus all the ethical measures discussed in 1.8 were adhered to Part 2: Concept definition and classification After the data analysis and recontextualisation into literature, the central storyline was identified. The next step in theory generation was to define the central and related concepts according to the explicit and implicit meaning that they portrayed (Chinn & Kramer, 2011). The researcher created meaning of the concepts by considering the three sources of experiences related to the concepts, namely the word, the concept itself and the associated feelings (Chinn & Kramer, 2008). This explains how the concepts were interpreted and used by the researcher. In this study the concepts were identified from the life experiences of aggression as portrayed by the nursing students in their stories and drawings. Central concepts need to be defined through existing theories, dictionary definitions, subject definitions and synonyms (Chinn & Kramer, 2008). The list of essential attributes of the central concept was used in the construction of a model case. According to Walker and Avant (2011), a model case could be founded in real life. It depicts a real-life situation as an example of the main concept and contains all the critical or essential elements of the main concept. The scenario described in Chapter 1 was used as the basis for this model case. 63

82 The survey list of Dickoff et. al. (1968) was used to classify the concepts and the following questions as proposed by them were asked in determining the agent, recipient, context, terminus, procedure and dynamics of the model: Agent: Who or what performs the activity? Recipient: Who or what is the recipient of the activity? Procedure: What is the guiding procedure, technique or protocol of the activity? Dynamics: What is the energy source for the activity whether chemical, physical, biological, mechanical or psychological? Framework: In what context is the activity performed? Terminus: What is the end point of the activity? Step 2: Relationship statements Relationship statement is the investigation of the nature of relationships between concepts and the identification, if any, of links among and between the concepts (Chinn & Kramer, 2008). The way in which the relationships between concepts are stated gives an indication of the theoretical purpose and the assumptions of the specific theory (Chinn & Kramer, 2011). The substance and form of the theory are provided by these relationship statements (Chinn & Kramer, 2011). In this research the purpose of this 64

83 theory was to facilitate the health of nursing students who experience aggression in their lives. According to Chinn and Kramer (2011), for the theory to become meaningful and practically applicable, the specific context must be clear. In this research the context within which these concept relationships are described is the experience of nursing students of aggression at an HEI in South Africa Step 3: Description and evaluation of the model A clear, detailed and complete description of the model for the facilitation of the health of nursing students in an HEI who experience aggression in their lives is given. The model is evaluated according to the criteria suggested by Chinn and Kramer (2011). These descriptive components are as follows and are used to give a dense description of the model: The purpose of this model: The reason for the development of this model, as well as its context and practical application, is described. The intention behind the development of this model was to facilitate the health of nursing students who experience aggression in their lives by a nurse educator experienced in facilitation skills. 65

84 The concepts of this model: These refer to the identification of the structure and relation of ideas within the model. The central and related concepts were described according to their qualitative dimensions. Definitions of the concepts: The meaning of the concepts as used in the model is described in detail to enable an understanding of them. The nature of the relationships: Links and relationships among and between concepts and statements are described, in order to give structure to the model. The structure of this model: The structure that gives form to the conceptual relationships is described in a way that the reasoning can be followed. Assumptions in this model: Assumptions are those accepted truths that are fundamental to theoretical reasoning. Those truths underlying this model and rooted in the theory for health promotion in nursing (University of Johannesburg, 2010) are described with regard to the way in which they reflect value positions or factual assumptions. In order to determine how well the model has been developed or how adequate it is in relation to its purpose, critical reflection of the theory is needed. Through critical reflection one can gain an understanding of how well 66

85 theory relates to practice, research and education activities (Chinn & Kramer, 2008). The following questions used to evaluate the model were answered by a panel of experts as well as experts in the field of theory generation: How clear is this model? This question determines how clear the model is. It reflects on the semantic clarity and consistency as well as structural clarity and consistency. How simple is this model? The simplicity or complexity of a model is evaluated according to the number of elements within each descriptive category, especially concepts and their interrelationship. How general is this model? This question refers to the breadth of scope and purpose of the model. Generality refers to the extent to which this model can possibly be applied to nursing students in other HEIs. How accessible is this model? The model is evaluated according to the extent to which the empirical phenomenon can be identified for the concepts of the model as well as the attainability of the purpose. 67

86 How important is this model? This question assesses the usefulness and applicability of this model within the practice of nursing, research and education Step 4: Description of strategies for model implementation The implementation of the model is done by providing strategies and proposing actions. The strategies for operationalising the model originated from the described model and an objective and actions of how to achieve it are written for each guideline. 2.6 MEASURES TO ENSURE TRUSTWORTHINESS It is important for researchers to conduct research scientifically and without bias. Quantitative research needs to be objective, valid and reliable, whereas qualitative research requires trustworthiness, as defined by the work of Lincoln and Guba (Babbie & Mouton, 2011; De Vos et al., 2011). All research has to be evaluated for its truth value, consistency, neutrality and applicability (Krefting, 1991; Rossouw, 2003). 68

87 In this research the measures to ensure trustworthiness were based on the model of Lincoln and Guba (Babbie & Mouton, 2011). The four criteria to ensure trustworthiness in qualitative research are as follows: Credibility The goal of credibility in qualitative research is demonstrated by conducting research in such a way as to ensure that the subject has been accurately identified and described (De Vos et al., 2011). According to Lincoln and Guba (1999), various strategies to increase credibility should be stated (Babbie & Mouton, 2011) Prolonged engagement It is important that the researcher spend sufficient time in the research setting. Prolonged engagement ensures detection of any pre-conceived ideas the researcher might have. The researcher had prolonged engagement with the raw data, refining and identifying concepts, and did an in-depth study on all the relevant concepts (Babbie & Mouton, 2011; Creswell, 2007) Triangulation Triangulation implies the involvement of more than one theory and research method in one research study. In this research the researcher made use of different methods to collect data, like drawings, self-reporting stories, 69

88 phenomenological interviews and field notes. Triangulation was also achieved by making use of external coders that transcribed and analysed data (Babbie & Mouton, 2011) Peer evaluation During peer evaluation the research is exposed to other colleagues and peers that do not have a direct interest in the research, but that have a general understanding of the nature of the study (Babbie & Mouton, 2011; Creswell, 2009). During this process of peer evaluation, revision of perceptions, insight and analysis takes place. The researcher made use of independent co-coders during analysis and had subsequent consensus discussions with the cocoders and the research supervisors to clarify categories and refine themes (Krefting, 1991). The researcher presented the research at different phases of the research process to the doctoral committee, during which time the research was discussed and interrogated. The doctoral committee consisted of experts in the study field as well as in research. The researcher also presented phases of the research at national and international forums as an opportunity for peer evaluation Reflexivity According to Creswell (2009), reflexivity is a core characteristic of qualitative research. The researcher had to reflect on how her interpretations of the findings were shaped by her background. Since the researcher could not separate herself from the research, she had to acknowledge personal values, 70

89 beliefs, culture and biases as a result of her background. The researcher was involved throughout the whole research process of the development of the model and thus reflected throughout the research process Transferability Transferability refers to whether the findings of this research are able to fit into a context outside the situation of study, as determined by the degree of similarity of fit between the two contexts (De Vos et al., 2011). Transferability relies on the dense and holistic character of a description of the qualitative research process. This was ensured by the dense description of the process, direct quotations by participants and results. The transferability of the research, however, lies with the researcher who wants to make the transfer. By giving a dense description of the theoretical framework to show how data was collected and analysed, the researcher states the theoretical parameters of the research (Babbie & Mouton, 2011; De Vos et al., 2011) Dense description A dense description of the demographics of the participants, data in context and the results with supporting direct quotations from participants and drawings in the research report allow the readers to make their own judgement on transferability (Babbie & Mouton, 2011). 71

90 Purposive sampling Purposive sampling in qualitative research serves to maximise the range of specific information in a selected context (Babbie & Mouton, 2011). The aim of this research was to explore the experience of nursing students at an HEI of aggression. The nursing students were therefore purposively selected to explore their experience of aggression in their lives Dependability Dependability implies consistency. It refers to the evidence that if the study were to be repeated within the same or similar context and with the same or similar participants, its findings would be similar (Babbie & Mouton, 2011). By ensuring a dense description of the context of the study, research methods and participants in this study complied with dependability. Peer review and triangulation also ensure dependability. Consensus discussions were held between the researcher, independent coders as well as the supervisors of the researcher to ensure consensus of themes and categories (De Vos et al., 2011). A dense description was given of the research methodology. Stepwise replication of the interviews was done by a skilled interviewer. The interviews were coded and recoded. 72

91 2.6.4 Confirmability Confirmability is focused on whether the results of the research can be confirmed by another and is applied by using reflection and triangulation methods (Babbie & Mouton, 2011). The question to be asked is whether the researcher provides evidence of collaborating findings and interpretations through an audit trail. Confirmability focuses on whether an audit trail can be followed to verify findings and whether the focus is on the data rather than the researcher (Babbie & Mouton, 2011; De Vos et al., 2011). Neutrality of data in this research was obtained through transferability and credibility of data (see and 2.6.2). An audit trail requires a traceable documentation process throughout the entire research process on all decisions and actions (De Vos et al., 2011). Through an audit trail the research can also be understood not only regarding what was discovered, but how it was discovered. The process of how the research process is understood contributes to the researcher s reflexivity and therefore enhances trustworthiness of the findings and research (De Vos et al., 2011). According to Flick (2007), the question increasingly asked is how to how to assess or evaluate what we are doing. In this research all the documentation of actions and decisions has been maintained. 73

92 2.7 ETHICAL CONSIDERATIONS See discussion on ethical principles in Chapter 1, CONCLUSION The research methodology, design and method, including the population, sample, data collection and data analysis used in the study were discussed in this chapter. The researcher justified all the elements used in the research process. Measures used to ensure the trustworthiness were discussed. Ethical principles were adhered to. In the next chapter a rich and dense description of the results from the first step, where the researcher engaged with participants, together with literature review will be discussed. 74

93 CHAPTER 3 DISCUSSION OF THE PHENOMENON OF NURSING STUDENTS EXPERIENCE OF AGGRESSION 3.1 INTRODUCTION The previous chapter described the research methodology that was followed during this research. This chapter focuses on how nursing students experience aggression in their lives. The researcher allowed nursing students to report their experience of aggression using their own creativity by drawing pictures of their experiences and writing a self-reporting story on the drawing that was done. Nursing students also had the opportunity to voice their experience of aggression during a phenomenological interview. The findings of this chapter form the basis for the development of a model to facilitate the health of nursing students who experience aggression in their lives. 75

94 3.2 EXPLORING AND DESCRIBING THE NURSING STUDENTS EXPERIENCE OF AGGRESSION IN THEIR LIVES The research of the experience of aggression can only be understood and become meaningful if it is placed in a specific context. This specific context is the lives of the nursing students studying at an HEI in Johannesburg and the lives of those around them. The participants were nursing students in their second and third year that had already been exposed to the clinical training environment. The clinical environment forms part of the context in which these students lived and worked. A total number of 50 participants drew sketches and wrote self-reporting stories. Eight of these participants were interviewed, providing depth and richness of data. These participants varied in age (ranging between 19 to 33 years), gender (male and female), race (black, coloured, asian and white), as well as background. They were in their second and third year, and had already been introduced to the clinical training environment where they worked from hours a week. Data was found to be saturated and similarity was found between the findings of the naive sketches, interviews and the drawings, as evidenced by repeating themes. 76

95 The participants that were interviewed were initially apprehensive (their own words) but then were grateful for the opportunity to voice their own experience of aggression in their lives. The interviewer observed that these nursing students found it difficult to engage in the difficult topic and to share experiences. Some of the participants stayed after the interview was completed, while some cried and others acknowledged that they were seeing professionals to help them manage their experiences. The fact that participants came from different backgrounds and were of different races and genders ensured rich data as people s experiences are influenced by their life, past and present. It seems as if the nursing students experience of aggression was mostly an intensely negative experience that might have been related to their inability to manage or cope with aggression. The central storyline was that aggression is experienced as detrimental to the nursing students themselves as a whole person and their interpersonal relationships. Nursing students reported that they lacked emotional control as well as knowledge and skills to manage aggression themselves. Therefore aggression impacted on them as a whole person, influencing their relationships. After data analysis of the drawings, self-reporting stories and phenomenological interviews, two broad themes with categories were identified that reflected the nursing students experience of aggression in their 77

96 lives. Each of these themes and categories as summarised in Table 3.1 will be discussed in detail. Verbatim quotations derived from the interviews, selfreporting stories as well as the illustrated drawings will be used to illustrate their experiences and these are supported by literature. Table 3.1 Nursing students experience of aggression THEME 1 Nursing students experience aggression as an integral part of their life Categories 1.1 Aggression forms part of normal behaviour, of who a person is 1.2 Aggression is a tool to get what you want, to punish people or make people do what you want and as a form of power THEME 2 Nursing students experience aggression as detrimental to themselves as a whole person and their interpersonal relationships Categories 2.1 Aggression impacts on themselves, as a whole person, physically, psychologically and spiritually 2.2 Aggression impacts on their interpersonal relationships The first theme is that the nursing students experienced aggression as an integral part of their life which they viewed as a normal part of their life. According to those surveyed, aggression was viewed as part of normal behaviour, of who a person is and it was experienced as acceptable to use aggression to get what a person wants, to punish people or make them do what a person wants almost to be used as a form of power. 78

97 The second theme is that nursing students experienced aggression as detrimental to themselves as a whole person and their interpersonal relationships. Aggression had a psychological, physical, as well as spiritual impact. It was experienced as impacting on interpersonal relationships not only with colleagues, friends and family, but also on their relationship with themselves (see Table 3.1) Theme 1: Nursing students experience aggression as an integral part of their life Nursing students experienced aggression as part of their lives, part of who they were, and as almost normal. Although they experienced aggression as negative, they also viewed it as a part of who people are, as normal behaviour that they were exposed to during their daily lives at all levels of the environment they interacted with Aggression forms part of normal behaviour, of who a person is Nursing students experienced aggression as negative but at the same time as inherently part of people s composition as human beings. Aggressive 79

98 behaviour to them was normal behaviour of the people they were exposed to in their daily lives. They experienced aggression between their friends, colleagues, at home, in their family environment, in their work environment and in their social lives. According to them, everybody gets angry some time. Everyone does get angry... Everybody experience aggression now and then, Aggression was not limited to expressions of anger, but also acting out aggression daily by their family, friends, colleagues and the society they lived in. This affects their interrelationships (Heppner, Kernis, Lakey, Campbell, Goldman, Davis & Cascio, 2008; Kennedy, Bolger & Shrout, 2002; Tjosvold & Fang, 2004). The nursing students experienced aggression also as part of people s lives, of who people are people s make-up as human beings. The aggression as part of human beings was also compared with aggression seen in the animal kingdom. This comparison illustrates that aggression is part of human nature. The following quotations illustrate this: Aggression to me is something that lurks within the body... 80

99 However aggression can be seen between animals, two males fighting for mating rights... some people are just aggressive, naturally This experience of the nursing students is similar to the findings of research done on aggression in dating relationships, indicating that physical and psychological aggression is considered as normal and that aggression is not a static problem as it can happen to anybody, at work and on their way to work (Brewster & Montgomery, 2005; Dharmeratnam, 2007; Heppner, et.al., 2008; James, 2010; Kennedy, et.al., 2002; Muñoz-Rivas, Gómez, O Leary,& Lozano, 2007; Straus & Ramirez, 2007). The findings of some of these studies indicate that physical aggression is usually limited to the more minor forms of aggression, such as throwing objects, kicking at something and pushing. On rare occasions physical aggression includes the use of sexual violence, weapons, beating and choking. Psychological and sexual aggression takes on the form of domination, intimidation, threats and degrading others (Eaton & Struthers, 2006; Fletcher & Milton, 2007; Fossos, Neighbours, Kaysen & Hove, 2007; Lochman, Palardy, McElroy, Phillips & Holmes, 2004; Muñoz-Rivas et al., 2007). 81

100 Anger is a powerful emotion that human beings experience when feeling threatened. However, the consequence of uncontrolled emotions is reactions, which then develop into aggressive behaviour like verbal abuse, hitting, grabbing, beating or choking the victim (Bratcher, 2007; Muñoz-Rivas et al., 2007; Murray, et. al., 2008; Teten, Miller, Bailey, Dunn & Kent, 2008; Varcarolis & Halter, 2009; Walker & Bright, 2009). The consequence of uncontrolled emotions like aggressive behaviour is experienced as extremely negative and evil. actions whereby you are evil aggression makes me think of evil Aggression is the action in which a person acts in a bad way meaning that a person demands some things that are evil to some people It seems like an evil loss of control. Ever since biblical times, it has been a believed that human nature is evil, and psychological theorists like Freud and Lorenz (Baron & Richardson, 1994) 82

101 regarded aggression as embedded in instinct. Walker and Bright (2009) conclude that if the defences that keep aggression in check are overused or underdeveloped, aggression in its early stage of evolution might be adapted and turned into pent up aggression that needs to be released (Staub, 2003). The experience of aggression as part of who one is could be explained by the understanding that aggression could also be embedded in habits of thinking. This may be due to deeply held false belief systems, which have been laid down in childhood through processes of significant events or patterns of upbringing. These belief systems maintain aggressive behaviour if it goes unchallenged. The behaviour might be learned as a coping mechanism when people feel that it is the only response they have (Bowie, 2007; Deffenbacher, 2004; Hall, 2006; Levinson, 2006; Walker & Bright, 2009). Aggression is giving expression to personal frustrations, irritations and pentup emotions. It is mostly related to anger and frustrations that cannot be articulated. This was part of the nursing students daily lives and was experienced at their work and between their family and friends. Aggressie is n gevoel van frustrasie vasgevang in woede (Aggression is a feeling of frustration trapped in anger) 83

102 ...state of extreme frustration over a situation......some people keep small frustrations bottled up in them...and then one day they just burst and attack the thing nearest to them The use of aggression as a way of expressing their frustrations was a general integrated part of the nursing students lives. Frustration is considered a central component of anger that may lead to aggression. It can be caused by the inability to achieve goals. The directed aggression from this frustration could be towards those who are getting in the way of their goals. Aggressie is vir my n manier om ontslae te raak van al my frustrasies en woede (For me aggression is a way to get rid of all my frustrations and anger or rage) Aggression is a feeling of anger leading to frustration, a boiling feeling of spilling over... Some of the participants also experienced frustration towards those who stood in their way of success, for instance the lecturer who, in their view, was responsible for whether they passed or failed. 84

103 ...experience aggression if you do not obtaining marks that one truly deserves The frustration-aggression hypothesis of Dollard, Doob, Miller, Mowrer and Sears of 1939, referred to by Moore, Shepherd, Eden and Sivarajasingam (2007), suggests that aggression is the result of standing in the way of an individual s effort to attain a goal. If, however, that goal is not important, the feeling of frustration might not be as intense as it would be in the case of a goal perceived as fundamentally important to their future goals (Kuppens & Van Mechelen, 2007; Lench, 2004; Levinson, 2006). The nursing students reported that people in their lives were aggressive towards one another and that this formed part of their social behaviour. The distinctive factor is the manner in which this aggression is managed. Everybody gets angry it is how a person handles the problem and deals or watches their own reaction as not to act violently or abusive unto other person. Aggressie is baie negatief. Verskil van man en vrou, situasie, ouderdom, ens....iets gee aanleiding tot hierdie woede...bv. Man ry 85

104 van werk af en het in die verkeer vasgesit, kom by die huis en is oortrek van die aggressie, begin op sy vrou gil en skree, soms kan dit tot fisiese aanranding of abuse lei. Dis die man se manier, alhoewel dit n swak manier is, is dit hoe hy die aggressie/situasie hanteer. (Aggression is very negative. Differs from man to woman, situation, age, etc....something leads to this anger... for example a man drives from work and gets stuck in traffic, arrives at home and is consumed by aggression, starts shouting and screaming at his wife, sometimes escalating to physical assault or abuse. This is the man s way, although a poor way, the way he manages his aggression/situation.) dis baie belangrik dat mens jou eie aggressie baie goed kan hanteer sodat dit nie negatiewe gevolge vir enigiemand het nie (it is very important to manage your own aggression to prevent it from having negative consequences for others) The management of the aggression indicates whether aggression is acceptable or not. If anger is not managed and becomes out of control, it can become destructive and problematic (Bratcher, 2007; Teten, et. al., 2008; Valentine, 2001). Sport is also a socially acceptable way of expressing aggression. It is an important and acceptable method of managing and releasing pent-up 86

105 frustrations and irritations. A certain amount of aggression within sport was felt by the participants to be healthy. Aggressie kan goed wees binne perke byvoorbeeld. op die rugby veld of wanneer mens oefen. As mens met aggressie oefen kan jy jouself harder druk as wat jy anders sou wat jou kan help met die voorbereiding van n belangrikke byeenkoms (Aggression can be good within limits like on the rugby field or when you exercise. If you feel aggression and you exercise, then you can push yourself harder than would have been the case otherwise and it can help you prepare for an important competition) It can also be expressed into socially acceptable activities such as boxing, wrestling or even basketball... Healthy aggression within sport is positive for the person that competes in various contact sports (Fletcher & Milton, 2007). The nursing students referred to the experience of acting on aggression as a general occurrence. Picture 3.1 illustrates aggression as a recurrent experience by the participant s use of the word always. Analysis of the picture and story indicates habitual aggression towards others. 87

106 ...I feel aggression on a daily basis and I perceive as being a negative feeling and don t want to feel it... As ek saam met hom op die pad was in sy BMW moes hy almal verby gaan want die idiote op die pad kan nie bestuur nie. By die verkeersligte het hy altyd oor die verkopers en pamflet uitdelers se voete probeer ry. Koerantmanne was gegooi met hulle eie koerante... (If I was with him in his BMW he had to pass everyone because the idiots on the road cannot drive. At robots he always tried to drive over the feet of the hawkers and pamphlet distributers. Newspapers were thrown at the newspaper deliverymen.) (See picture 3.1.) The tone of the story about Picture 3.1 suggests the experience as unacceptable and contempt towards the aggressor, even if it was habitual exposure to aggression. The aggressive behaviour of swearing at the newspaper seller, illustrated in Picture 3.1 may also have deeper emotional significance. Some authors (Bushman, Baumeister, Thomaes, Ryu, Begeer & West, 2009; Gomez & McLaren, 2006; Kuppens & Van Mechelen, 2007) suggest that people with a high self-esteem are more volatile than those with a low self-esteem because 88

107 those with a high self-esteem feel easily offended when challenged and that makes them more prone to violence. Picture 3.1 Road rage: Aggression displayed as common occurrence and nature of the aggressor 89

108 High self-esteem could also be a defence against low self-esteem and although they might appear to think more of themselves, they might also be extremely sensitive and threatened (Trzesniewski, Donnellan, & Moffitt, 2006). These feelings of vulnerability can be dangerous when coupled with anger and machismo (Lochman, et. al., 2004; Taylor, Davis-Kean & Malanchuk, 2007; Walker, 2005). Machismo (Walker & Bright, 2009) is a lack of believing in your own toughness to deal with anxiety and embarrassment, and then viewing yourself as weak, which results in having to show toughness through aggressive behaviour and aggressive presentation of the self. However, according to De Zulueta (2006) and Gilligan (1996), early experiences of trauma, shaming and neglect in childhood development can also cause a specific gathering of thoughts, emotions and reactions that can increase tendency to violence. Humiliation, poor self-esteem and shame are seen as core triggers of aggression (Walker & Bright, 2009). Gilligan (1996) proposes that due to the lack of self-love and self-esteem, people cannot cope with shame and that triggers aggression which restores the self. If love and/or guilt are absent, the person might act out on these aggressive impulses. Shame can have a number of foci, including feelings of failure (Blacker, Watson & Beech, 2008; Lawrence, 2006; Walker & Bright, 2009). 90

109 Aggression is a tool to get what you want, to punish people or make people do what you want and as a form of power The nursing students experienced aggression daily and realised that it could be used to make other people do what they wanted them to do. Aggression could also be used to punish other people that did not do what they want them to do and as a form of power. Using aggression as a form of power, punishment and coercing people into undesirable actions was experienced as an integral part of their lives....a behaviour in which a person want things with no choice of the next person. anger in response to not being able to get what you want or having something that you do not want Anger, victimising others......abusing others especially in terms of conflict and by threatening them... 91

110 Soms is mense aggressief om ander bang te maak... (Sometimes people are aggressive to frighten others...)...does not treat me with respect... who undermines my capability, when I am not treated fairly... In the workplace aggression might be used to intimidate employees, who might be unhappy with the working conditions (Hogh, Henriksson & Burr, 2005). This may lead to decrease productivity, interpersonal conflict and deteriorating health (Merecz, et. al., 2009). Intimidation can also be used by muggers or hijackers to make people do what they want them to do (Dharmeratnam, 2007). Violence can be used as a means to an end to punish those who might have unjustly punished or wronged them (Gilligan, 1996). An individual might have a personal meaning of insult, causing an overwhelming sense of shame. The sense of shame causes a person to avenge the wrong that was done, by punishing others (Leary, M.R., Twenge, J.M. & Quinlivan, E, 2006; Walker & Bright, 2009). In a study done at a university in Spain on aggression in dating relationships (Muñoz-Rivas et al., 2007), students admitted to threatening to break up with their partners if their partner did not comply with their wishes. 92

111 The use of aggression to make others do what they want them to do or not want them to do was experienced by the nursing students as disrespect. That in itself was experienced as a catalyst for aggression and aggressive behaviour. Does not treat me with respect who undermines my capacity, when I am not treated fairly Walker and Bright (2009) distinguish between two types of respect, namely physical and interpersonal or psychological respect. When people perceive their self-worth as challenged, aggressive behaviour can be used to protect themselves. They can fight, stand their ground and not retreat when experiencing danger or an attack or by creating fear within the attacker. This behaviour is referred to as physical respect. Physical respect differs from interpersonal respect, also called psychological respect, where a person is considered as good, which is a positive attribute. Good people are looked up to and have good interpersonal relationships with others. Interpersonal respect is the type of respect people strive towards. The aggressive person does not have the interpersonal, emotional and communication skills to ensure that type of respect. Aggression and anger are personal traits that are looked down on and can lead to disrespect and fear. Physical respect therefore does not add value to a self-image and does not have the same integrity and positive effect on self-worth as interpersonal respect. People that cannot control their aggressive behaviour feel embarrassed after an outburst 93

112 because they could not control their emotions and behaviour and that in turn enforces their feeling of poor self-worth (Antia-Otong, 2007; Kuppens & Van Mechelen, 2007; Teten, et. al., 2008; Walsh & Clarke, 2003). In studies among patients attending specialist clinics (Walker & Bright, 2009), the patients reported that although they resisted the urge to fight, they felt embarrassed for not asserting themselves. Given the opportunity later, should they be provoked, they would then resort to aggressive behaviour as provocation is a powerfull elicitor of human aggression. This assault caused feelings of relief and control (Fletcher & Milton, 2007; Giancola, Godlaski & Parrott, 2005; Walker & Bright, 2009). Nursing students indicated that aggression could be used as a form of power in order to gain power over somebody else, such as the weaker members of the community or society. These weaker members can be weaker because they are children, women or ill, reflecting physical weakness, and those who cannot defend themselves against the aggressive person. Aggression would be any forced means used to make the next person feels uncomfortable. It may be the perpetrator s way of gaining control over the victim 94

113 Aggressive people usually take it out on innocent people whom they know wouldn t be able to defend themselves... Aggression is mostly in my eyes seen to be positioned at woman as they are the weaker of the two sexes and easy targets. As in the picture, the man is aggressive towards his wife and child who have less power than him... The analysis of Picture 3.2 below, by the psychometric specialist suggests that the male figure, larger in overall size in relation to the other two figures, indicates dominance. This dominance is both physical and emotional dominance in social contact. Women are more likely to be injured because of their physically smaller stature, especially if the aggressor is male (Basow, Cahill, Phelan, Longshore & McGillicuddy-Delisi, 2007). The physical stature of women and children creates opportunities for disproportionate control with a capacity to assign rewards or punishment (Eaton & Struthers, 2006; Fast & Chen, 2009; Rosenbaum & Leisring, 2003). 95

114 Picture 3.2 Aggression towards the weak Gilbert (1998) points out that if a person is humiliated, that person is put in a powerless position. This can create feelings of being treated unjustly, that others are to blame and through humiliation a personal attack against the self is experienced. These experiences can be dealt with by projecting that feeling of humiliation onto the person that caused the humiliation through acts of aggression (Aquino, 2000; Kuppens & Van Mechelen, 2007). 96

115 Fast and Chen (2009) suggest that there is a link between self-perceived lack of competency and aggression amongst the powerful. Bandura (1997) also refers to this as perceived self-efficacy and describes it as a person s beliefs about how capable they are in organising and executing actions required in achieving a goal. Individuals in powerful positions that do not perceive themselves to be competent, in other words they think they are not capable of being influential and to interact skilfully with their environment and with others, can feel threatened. This feeling of being threatened leads to an internal state of ego defensiveness and this in turn may cause aggressive behaviour (Dunn, Elsom & Cross, 2007; Gallagher & Parrott, 2010; Guttman, 2009; Lochman, et. al., 2004; Suppiah & Rose, 2006; Taylor, et. al., 2007). The very nature of nursing with its hierarchal structure remnant of a militarian system renders an environment with opportunities for disproportionate control with a capacity to assign rewards or punishment. The vertical aggression of senior staff against junior staff within the nursing system was found by the nursing students to be an abuse of power relationships. The acceptance of this kind of aggression where the junior nurses should be submissive in order to learn skills of their profession from the senior nurses may be due to the fact that it is viewed as the culture of nursing. It can also be because within certain cultures values of respect towards the elders and people in senior positions have been instilled (Aquino, 2000; Guttman, 2009; Hogh, et. 97

116 al., 2005; Khalil, 2009; Ramírez, Fujihara, & Van Goozen, 2001; Rose, Suppiah, Uli & Othman, 2006; Rosenbaum & Leisring, 2003) Theme 2: Nursing students experience aggression as detrimental to themselves as a whole person and their interpersonal relationships Nursing students experienced aggression as detrimental to themselves on a psychological, physical, as well as spiritual level. These experiences of aggression were viewed as intense and negative, affecting also their interpersonal relationships Aggression experienced as impacting on themselves, as a whole person, physically, psychologically and spiritually The nursing students experienced aggression as negative and intense relating to the inability to manage internal and external situations and feelings, and thus impacting on the person themselves. The experience of aggression disables people, leaving them paralysed and unable to react. 98

117 Aggression to me is like a brick wall and when I am forced with aggression it feels as though I cannot get on with daily tasks of the day because there is a brick wall in my way. Intimidating aggression used by aggressors to force cooperation can cause fear. Fear can lead to panic where no physical reaction can be mastered, like the ability to speak or move. On a psychological level panic interferes with breathing and experiencing overwhelming emotions and feelings (Basow et al., 2007; Crisp & Turner, 2010; Walsh & Clarke, 2003). The internal and external situations in which the nursing students function and their current as well as pervious experiences contribute to their experience of aggression. External experiences impacting on the nursing students experience of aggression include lack of resources, poverty and the sense that lecturers did not give them the marks that they thought they deserved, as well as unequal power relations. The act of blaming others for a situation that they are not responsible for may lead to unreasonable anger and displaced aggression (Guttman, 2009; Larsen & Dehle, 2007; Reeve, 2001)....this is that makes me angry are insufficient funds to pay for my tuition fees, not having luck obtaining bursaries, segregation in the institution,... 99

118 aggression is determined by the environment you grows up in This inability to manage and control internal and external environmental influences results in feelings of frustration and irritation. This in turn leads to physical actions and psychological abuse, such as destroying somebody s self-image. Aggressie kan lei tot dood, deur iemand se lewe te neem... want kan nie aggressie aanvaar of emotioneel hanteer nie, persoon word van sy waardigheid ontneem (Aggression can lead to death, by taking somebody s life... because cannot accept aggression or manage it emotionally, deprive a person of his dignity) According to Kuppens and Van Mechelen (2007), when a person experiences interpersonal distrust, low self-esteem and low social esteem, others will be blamed if the person themselves or the circumstances caused the unpleasant event, for example lack of marks if a person has not studied and did not get the marks they thought they deserved (Gallagher & Parrot, 2010). The experience of aggression of the nursing students on the physical level was found, on the one hand, when the nursing students themselves were the aggressor and committing the acts of aggression, or on the other hand, the 100

119 victims on the receiving end of the aggressive act. Nursing students experienced aggression through physical actions, with one person physically harming another. The aggression took the form of the physical assault of people and animals by hitting, kicking, cutting or stabbing, resulting in contusions, lacerations and broken bones....soms kan dit tot fisiese aanranding of abuse lei... (sometimes it can lead to physical assault or abuse) my aggression is direct proportional to my anger when I m angry I turn to express my feeling direct and more physical like to kick somebody ass and slap him or her Physical stabbing, kicking and hitting, even killing people, was experienced as physical aggression impacting physically on people as well as other beings....and violating people and animals by beating them......fisies wees waar iemand n ander person slaan, skop of seer maak... Die doel... om merke te los blou kolle, gebroke bene, sny plekke (be physical where somebody hits, kicks or hurts another person... The aim... to leave marks bruises, broken bones, cuts) 101

120 The physical influence of aggression as experienced by the nursing students could take on many forms and was mostly focused on women and children. Verbal abuse was experienced as a form of aggression that impacts on the person on a deeper psychological way in breaking down the person s selfimage, affecting that person s life. Sexual assaults are not only a physical assault but also a major psychological assault on the victim. Picture 3.3 Female abuse - physical scars and tears from pain 102

121 In my drawing [Picture 3.3]; it is a female who suffers abuse at the hand of her husband. It could be in a form of verbal abuse; sexual abuse. That has a big effect on her life Picture 3.4 Verbal and physical abuse 103

122 The illustrated picture (Picture 3.4) emphasises aspects of the experience of aggression with a psychological impact as well as the possible poor impulse control. This is indicated by the mom figure using a physical weapon, normally associated with aggressive male behaviour. The feet pointing in opposite directions suggest possible poor impulse control. This together with the oral verbal abuse and degrading words contribute to the experience that aggression causes emotional as well as physical damage. Cultural stereotyping (Basow et. al., 2007; Leary, Twenge & Quinlivan, 2006) portraying males as the more physical aggressor and females as the more relational aggressors might influence perceptions of aggressive acts. The physical aggression from a female aggressor related to higher levels of anxiety and depression (Downs, Capshew & Rindels, 2006; Lim & Ang, 2009; Uys & Middleton, 2009). There is also the belief that females are the weaker gender and are therefore more vulnerable to physical aggression. If males aim physical aggression against females, it can cause serious harm because of the typical size and strength differences between males and females. Sexual assaults are not only a physical assault but also a major psychological assault on the victim. Sexual advances of males towards females are seen as an entitlement rather than physical assault (Flezzani & Benshoff, 2003; Thompson & Cracco, 2008). It might then also be the reason why aggression by males against females is perceived as undesirable and more damaging and why females experience aggression more negatively. Victims of aggression, however, often remain in relationships with their aggressor, which 104

123 may be because they are unwilling to recognise the damage such behaviour can cause (Basow et. al., 2007; Burton, Hafetz & Henninger, 2007). The nursing students felt that aggression was influenced by the brokenness within human beings, leading to aggressive behaviour. The people themselves have a feeling of brokenness, pain and inferiority. These feelings initiate the need to destroy other people s self-image, using nasty words, with a tone of voice and the general disrespect towards others. Die gebrokenheid is vir my die begin en die einde van aggressie. Iewers moes iets in iemand gebreek het om die aggressie te begin. Daardie gebrokenheid kom uit in aggressie en die aggressie breek weer iets of iemand anders maak seer. (For me the brokenness is the beginning and the end of aggression. Somewhere something must have broken to start the aggression. That brokenness shows in aggression and aggression breaks something else in turn or else hurts somebody else.)...i see aggression in some people as those who have been hurt and not seen to themselves on an emotional level and bottle things up. It belittles the person who is being violated. 105

124 Picture 3.5 illustrates the brokenness resulting from aggression. According to the self-reporting of the picture, the sharp edges cut and hurt those that are broken by aggression. Picture 3.5 Brokenness, sharp edges causing physical and psychological pain...when your heart is broken, feeling pain and wants to take it out on somebody. 106

125 Aggression according to me it is that emotional state that one finds himself/herself that causes him/her to act in a behaviour that is not acceptable that can cause that individual to be acting violently... Aggression is the psychological thing that leads to physical reaction. Psychological things may include failure, low self-esteem and annoyance - if the person experience the above things there is a possibility that the person will experience what we call aggression. Internal pain and hurt can result in aggression. The aggression in turn can cause pain, heartache and damage to individuals as human beings. Picture 3.6 below suggests feelings of sadness, shame or inadequacy. The position of the eyebrows and the stance of the figure in the drawing, however, indicate aggressiveness and hostility. The self-reporting story accompanying the drawing made explicit mention of those in pain causing pain in others. De Zulueta (2006) suggests that historical abuse and neglect lie at the core of many psychological problems, including aggression. De Zulueta (2006) goes on to state that when a child is the victim of abuse by the trusted adult, they do not blame the adult, but rather look for meaning and control by assuming 107

126 responsibility. The victim of the abuse concludes that they are in some ways responsible for this behaviour by being bad and therefore deserving of this abusive treatment. Picture 3.6 Pain generates infliction of pain on others: those in pain causing pain in others. 108

127 In contrast, according to Bowly s (in Gomez & McLaren, 2006) attachment theory proposes that children experiencing caring, develops the belief that the self is worthy of the love and support of others. This belief fosters a secure foundation that promotes feelings of personal control, self-efficacy and selfesteem. The quality of attachment children have with their parents influences their emotional and social development. Subsequent studies on attachment and aggression found a negative association between secure attachment and aggressive behaviour and a positive association between low self-esteem and aggression. The person consequently develops a deeply hidden negative selfbelief, which is well covered by the external appearance of arrogance. However, when they are confronted with certain social situations that awaken these negative self-beliefs, it manifests in the form of anxiety and fear. People with negative self-belief or worthlessness think they can then defeat their feelings of worthlessness through aggression (Kuppens & Van Mechelen, 2007; Matsuura, Hashimoto & Toichi, 2009; Xu, Farver & Zhang, 2009). The described experience of aggression by nursing students suggests that they were either the victims of aggression, the aggressor themselves or the observer of aggression. The student nurses described their feelings towards aggressive people with words like disrespect and disgust. They perceived aggression as negative feelings which they did not want to feel. Aggression is the psychological thing that leads to physical reaction. Psychological things may include failure, low self-esteem and 109

128 annoyance - if the person experience the above things there is a possibility that the person will experience what we call aggression....aggression can lead to physical or emotional violence against people, objects or animals. Aggression is usually always seen as negative Aggression is forceful, ugly and hateful... Aggression is hurtful During aggressive behaviour the aggressors themselves feel that they have lost self-respect and self-worth due to loss of control. for me aggression involves unnecessary violence from those who can t control their anger Victims of aggression feel hopeless and powerless and feel they lack the ability to defend themselves. They experience feelings of powerlessness and inferiority when they are humiliated and insulted either by words or assaults on them as a person. 110

129 fail to stand up against the perpetrator and this as a result crutches their self-esteem. it causes pain and heartache to destroy the self-image of a person, to humiliate a person Wanneer mens aggressief is voel jy hopeloos want jy weet nie hoe om die situasie te hanteer nie en hoe om te se hoe jy voel nie. (When you are aggressive you feel hopeless because you do not know how to handle the situation and how to say what you feel.) This description of their experience of aggression is echoed by other healthcare workers that have reported that aggression causes them to feel frustration, fear, anxiety, helplessness, depression and self-blame. Other healthcare workers have indicated that they lack the knowledge and skills in aggression management (Nau, Dassen, Needham & Halfens, 2009; Suppiah & Rose, 2006). In these experiences of the nursing students, aggression relates to the loss of emotional control and ineffective management of emotions and feelings, leading to aggressive behaviour. The aggressors had feelings and emotions 111

130 that they did not know what to do with and that had been bottled up. They tried to isolate themselves in order to manage these overwhelming feelings that threatened to explode. When they were exposed to a trigger situation and could not manage these feelings, they lost control and lashed out. Aggression was experienced as being related to stress. The victims of aggression experienced humiliation, powerlessness and inferiority. There was a feeling of frustration in and over a situation and feelings over which they had no control. Aggression builds up in your whole body and we express it through our body and mind, It needs control because it can spread like fire and consume everything! Aggression is a way of putting anger into motion, a way of expressing your anger. It can be caused by stress, emotional issues, genes, circumstances. It can be expressed by road rage, violence, abuse, murder, rape and damage to property as well as emotional damage The inability to control emotions and the frustration of not knowing what to do with the internal and external influences cause people to act out in any way they feel like and towards anything closest to them, as illustrated by Picture 3.7. The analysis of this picture suggests aggression, anger especially, by the dark slanted menacing eyes and the dark line for the mouth. This is further emphasised by the square shoulders and the red heat rays around the head. 112

131 Aggression is also experienced by being ignored. This type of aggression was experienced by the nursing students as passive aggression. Being ignored, excluded refusing company and assistance I have experienced this passive aggression in several situations, including the ward situation at work. Picture 3.7 Lashing out at anything or anybody 113

132 Aggression, according to the nursing students, resulted from insufficient emotional control. They had these feelings and emotions of anger but did not know what to do with them. The psychological impact of aggression includes nightmares, powerlessness, isolation, job dissatisfaction and depression (Hills, 2008; Laursen, Hafen, Rubin, Booth-LaForce & Rose-Krasnor, 2010; Merecz, et. al., 2009). Studies have shown that both the victims and aggressors experience behavioural problems directed internally, such as depression, anxiety, loneliness and social avoidance, as well as behaviour turned toward the social environment, such as delinquency, substance abuse, disturbing and antisocial behaviour or other forms of aggression (Chen, Miller, Grube & Waiters, 2006; Cosini & Wedding, 2008; Crisp & Turner, 2010; Haraway & Haraway, 2005; Williams, Fredland, Han, Campbell & Kub, 2009). Aggression at the workplace causes stress for nurses and that has a direct impact on their health and their job satisfaction. Nurses experiencing aggression found a conflict between the principles of caring and their negative experience of aggression. Nurses are trained and socialise towards a caring role, but it may not help them cope with their own experiences of psychological stress and distress (Dunn, et.al., 2007; Haraway & Haraway, 2005; Hills, 2008; Lench, 2004). According to the transactional theory of stress and coping (Lazarus, 2000), stressful situations and behaviour used to deal with this stressful situation have a direct effect on the physical and psychosocial health of an individual. 114

133 The impact of the experience of aggression on the spiritual level is reflected in the lack of joy and quality of life. Persoon word van sy waardigheid ontneem, wat die person numb laat,... leef nie meer nie. (Person is deprived of his dignity, which can leave the person numb... does not live anymore) The nursing students experience the actions of aggression mostly as wrong, describing them as bad and evil. They felt that aggression deprived a person of all hope and meaning to life. Vir my is aggressie n gevoel van moedeloosheid as ek nie iets omtrent n saak kan doen nie. (For me aggression is a feeling of hopelessness if I cannot do something about an issue.) Aggression impacted on the relationship of the nursing students with themselves and their God. Forgiveness is an essential aspect of a relationship with the self as well as God and both the victim and the perpetrator of aggression can be influenced by the aspect of forgiveness. Nog n aspek is vir die persoon wat die aggressie ervaar het = hoe vergewe jy die persoon wat die aggressie toegepas het? (Another 115

134 aspect for the person that has experienced the aggression = how do you forgive the person that was aggressive? ) Forgiveness within an aggressive environment, whether people were the aggressor or the victim, is necessary for the health and well-being of all involved. The individual s spirituality can also be affected by aggression (Hill & Dik, 2012). Hill and Dik (2012) assert that although forgiveness is not easy, it is a necessity for restoring spirituality that will promote a sense of closeness to humanity, nature and the Sacred. Although spirituality is highly personal and connected to forgiveness, it does not necessarily mean that one cannot exist without the other. Other research (Witfliet et al. (2001) in Orto & Power, 2007) found a relationship between forgiveness and personal control over one s own life Aggression impacts on their interpersonal relationships Interpersonal relationships are influenced by aggression. Nursing students reported that aggression impacted on their interpersonal relationships between colleagues, friends, family as well as their relationship with themselves. They said that a person s own aggression which they did not 116

135 always have control over caused internal conflict. Their own aggression was experienced as impacting on their relationship with their friends, family and colleagues. Sometimes everyone locks you out and as a result you pretend not to care even if deep down you can feel the gap Sometimes you are so tapped in there s little air for you to breath and there s no door to get out and be rescued In relationships aggression can be physical or psychological. People can be harmed through social relationships, which is much more sophisticated than physical aggression. The research done by Culotta and Goldstein (2008) found a positive correlation between physical aggression and proactive prosocial behaviour. Physical aggression might also have unacceptable consequences for the perpetrator, unlike forms of social aggression such as public humiliation, spreading rumours or gossiping and social exclusion. In relational aggression a jealous person may misinterpret social cues as threatening to a relationship and provoke behaviour, for example social manipulation, in order to get what another person has. This behaviour could be mean or nice. This social aggressive or manipulative behaviour is associated more with women than men (Basow et al., 2007; Bowie, 2007; Grekin, Sher & Larkins, 2004; Hall, 2006; Khalil, 2009). 117

136 The nursing students experienced aggression in their own home and family lives....nee wat met so n iemand (vader) assosieer ek nie want eendag n paar jaar terug het hy te goed vir sy eie familie en kinders ook geraak (no I don t associate myself with somebody like that (father) because one day a few years ago he became too good for his family and children) Aggressie bring afbreking tot verhoudings, skeure in gesinne en baie skade aan die slagoffers van menswees. (Aggression causes a breakdown in relationships, splits families and does lots of damage to the victims of being human) The aggression as illustrated in Picture 3.8 indicates the impact it has on interpersonal relationships. According to the analysis of the drawing, the absence of the ears on the male figure and the presence of ears on the female figure might suggest the unwillingness to listen to the female figure or the female might feel that she is not heard. The position of the arms and hands suggests either defensive actions or a desire for help, interpersonal contact or affection, emphasising that aggression causes damage to the 118

137 family relationships and to the people in the family themselves. This damage can lead to the breakdown and destruction of families....families can be affected to such an extent by aggression that it can affect the next generation Gomez and McLaren (2006), states that evidence suggests a link was found between family factors and aggressive behaviour. Some family issues such as marital problems, negative style of parenting and insecure child-parent relationships correlate with aggression. Poor communication of not listening or ignoring other people, influence their emotions, especially over a long period, leading to anger and aggressive behaviour. Attentiveness relates to selfconcept, sending a message that the person is not worth the attention of being communicated with (Weaver & Weaver, 2008). Self-image relates to child-parent relationships. In previous research a correlation was found between aggression and low self-esteem (Downs, Capshew & Rindels, 2006; Field, 2002; Olson & Braithwaite, 2004; Webster, Kirkpatrick, Nezlek, Smith & Paddock, 2007). According to Bowlby s attachment theory as sited in Gomez and McLaren (2006), the child-parent attachment influences the development of the self as well as the interpretation of how people act towards and around them. 119

138 Picture 3.8 Interpersonal aggression Parents who accept their children s use of aggression to achieve a goal reinforce proactive aggression, whereas those parents that use verbal abuse and physical intimidation or cruelty create an antagonistic and volatile family environment (Pickett; Iannotti, Simons-Morton, & Dostaler, 2009). When parents use harsh and unfair discipline or neglect their children, they might create a family environment where intimidating behaviour is reinforced and viewed as useful. Family members could be socialised to use aggression and 120

139 intimidating behaviour to solve conflict (McMahon & Watts, 2002; Olson & Braithwaite, 2004; Scarpa & Haden, 2006). This environment may lead to family members feelings of insecurity and can make them oversensitive to cues they might experience as threatening, leading to social conflict (Blake & Hamrin, 2007; Carter, 2002; Cowie & Jennifer, 2007; Field, 2002; Giant & Vartanian, 2003; Kennedy, et.al., 2002; Leary, et.al., 2006; Tjosvold & Fang, 2004). They may have the expectation that aggression could have a positive outcome and see that as justification to use aggression to achieve a goal. A tendency may therefore develop over time that attributes hostile intentions to confusing social interactions. This tendency and a low frustration and aggression tolerance can result in aggressive behaviour (Xu et. al., 2009). Nursing students felt that culture and race influence interactions between people. They experienced aggression between people from different races and cultures. The reasons they experienced it was perceptions. Aggression as experienced by the nursing students impacted on their relationships with their multicultural and multiracial colleagues and friends. Ek het al baie aggressie ervaar tussen rasse en ook kulture. Die aggressie dink ek vind plaas a.g.v. perceptions wat oorgedra word van geslag tot geslag. Asook mense sukkel om te aanvaar wat hulle nie verstaan nie, dus is daar misverstande wat lei tot onaangename gevoelens wat indien sterk genoeg, kan lei tot aggressie. (I have experienced lots of aggression between races and also cultures. The 121

140 aggression I think takes place because of perceptions that are passed down from generation to generation. Also people find it difficult to accept what they don t understand, resulting in misunderstanding which lead to unpleasant feelings, which if strong enough result in aggression) Culture plays a role in the experience of aggression. Seligowski and West (2009) found that in the traditional family structures in China, the husband makes all the decisions and the wife is inferior and expected to be obedient and submissive. This cultural tradition of a patriarchal system is also seen in many other countries, including India, where violence against women is condoned and women are seen as helpless. Studies done by the World Health Organisation on domestic violence all over the world indicate that women experience physical and psychological violence in their family structure. Justification for this includes gender stereotypes and religious beliefs, suggesting that women are passive victims (Ramírez, et. al. 2001; Seligowski & West, 2009). The nursing students experienced aggression caused by loss of control. They felt hopeless and powerless because of their inability to control those situations and emotions causing the aggression. The way they then reacted was to distance themselves by isolating themselves from the situation rather than to manage the situation or emotion. The nursing students stated that they then did not need their friends or colleagues, even though they 122

141 expressed anger at the situation. Picture 3.9 below illustrates the isolation of the individual. Lei tot aggressie (passief) waar ek haar en ander ignoreer en uitsluit in my lewe... (lead to aggression (passive) where I ignore her and others and lock them out of my life) Picture 3.9 Brick wall of isolation 123

142 Aggression within relationships is viewed as behaviours that manipulate in order to harm another through damage to relationships, threat of damage or both (Steinberg, Bornstein, Vandell & Rook, 2011). According to recent studies, this type of aggression within relationships has been associated with harming the physical and psychosocial health of both perpetrators and victims (Basow et al., 2007; Williams et al., 2009). The central theme from the experience of aggression as described by the nursing students relates mainly to the fact that people have feelings and emotions that they do not know what to do with. They experience hopelessness and are powerless when confronted with aggression. Aggression is mainly due to the inability to control emotions and situations, resulting in aggressive behaviour. The ability to control emotions and behaviour by initiating appropriate or inappropriate behaviour and various other actions is also referred to as self-regulation or effort control. Effort control, according to Rothbart and Bates (2006), is the ability to inhibit a dominant response and/or to activate a subdominant response, to plan, and to detect errors. People with low effort control often find it difficult to regulate their emotions and behaviour in testing situations, resulting in aggressive behaviour. This behaviour could be incompatible with society s values and might undermine social order and harmony (Deater-Deckard, Petrill & Thompson, 2007; Van Hiel, Hautman, Cornelis & de Clercq, 2007; Xu et al., 2009). 124

143 3.3 CONCLUSION This chapter focused on describing and discussing the results of the phenomenon of nursing students experience of aggression in their lives. The following main themes emerged: that aggression is experienced as an integral part of their lives and aggression is detrimental to the nursing students themselves as whole persons and their interpersonal relationships. The main findings is summarised in table 3.2: Table 3.2 Nursing students experience of aggression THEME 1 Nursing students experience aggression as an integral part of their life Categories 1.3 Aggression forms part of normal behaviour, of who a person is 1.4 Aggression is a tool to get what you want, to punish people or make people do what you want and as a form of power THEME 2 Nursing students experience aggression as detrimental to themselves as a whole person and their interpersonal relationships Categories 2.3 Aggression impacts on themselves, as a whole person, physically, psychologically and spiritually 2.4 Aggression impacts on their interpersonal relationships The conclusion from the discussion is that nursing students felt that they lacked the emotional control as well as knowledge and skills to manage 125

144 aggression themselves, and therefore aggression impacted on them as a whole person, influencing their relationships. Aggression was therefore problematic and could be detrimental to their health as a whole person. Hence it is evident that nursing students need assistance in managing aggression as they experience it in their lives. The development of a conceptual framework will be described in Chapter 4. The identification, definition and classification of the central and associated concepts as the result of the fieldwork and discussions of this chapter will follow in the next chapter. 126

145 CHAPTER 4 IDENTIFICATION, DEFINITION AND CLASSIFICATION OF THE CENTRAL AND RELATED CONCEPTS 4.1 INTRODUCTION In the previous chapter the results of the phenomenological interviews, drawings and self-reporting stories were discussed and verified by a literature review. The data analysis and results in Chapter 3 indicate that nursing students experience aggression as an integral part of their life, a part of their normal behaviour and it is used to exert power and control. Aggression has a detrimental impact on themselves and their interpersonal relationships, on a physical, psychological and spiritual level. Nursing students lack the emotional control as well as knowledge and skills to manage aggression themselves, and therefore aggression impacts on them as a whole person, influencing their relationships. Hence it is evident that they need assistance in managing aggression as they experience it in their lives. From the results in Chapter 3 it can be concluded that the impact of aggression is experienced negatively as it is destructive physically, psychologically, spiritually, intrapersonally, interpersonally as well as socially. It also became apparent that aggression is experienced as instinct, negative 127

146 due to no or insufficient emotional control and poor self-esteem, self-love, self-worth, self-awareness and self-acceptance. Aggression, according to the results in Chapter 3, can be used as a tool for power and control. Nursing students lack knowledge and skills in managing aggression and are unable to manage feelings of aggression. It is thus important that nursing students be enabled through various strategies to manage the negative impact of aggression through selfknowledge, become aware of who and what they are and ultimately accept themselves. They need to become aware of their actions and reactions. They will be empowered through knowledge and skills about themselves, people s actions and reactions, the decision-making processes, control and management of feelings and making choices and consequences of choices. The development of a conceptual framework will now be described. This theory generating process took place according to the steps discussed in chapter two. The identification, definition and classification of the central and associated concepts as the result of the fieldwork and discussions of Chapter 3 follow. 128

147 4.2 IDENTIFICATION OF THE MAIN CONCEPT It is apparent that the impact of aggression as experienced by young adult nursing students necessitates the self-management of aggression constructively, as aggression is experienced as impacting on the nursing students as a whole person. The nursing student is seen holistically and in interaction with the environment. The environment, both internal and external, includes interaction with others as well as intra-interaction (University of Johannesburg, 2010). Aggression is a combination of thinking, emotion and behaviour; therefore nursing students need to be aware of their thoughts, emotions and decisionmaking process. Thoughts can impact on emotions, which can influence decision-making and behaviour (Culotta & Goldstein, 2008; Bratcher, 2007). Although the nursing students surveyed experienced aggression as a result of insufficient emotional control and insufficient knowledge and skills to manage aggression themselves, during the decision-making process a person can still practise free will. A resourceful individual can make use of self-control strategies such as constructive self-guidance and problem-solving techniques. These self-control skills enable managing negative emotions, changing behaviour and overcoming difficulties that influence their decisions and consequent actions (Barkley, 2010; Blake & Hamrin, 2007; French, Vedhara, Kaptein & Weinman, 2010; Gaines & Barry, 2008; Groves & Huber, 2003; Liepe-Levinson, 2004; Liepe-Levinson, 2006). 129

148 It is evident that nursing students lack the knowledge and skills to selfmanage aggression constructively. Through a process of facilitation nursing students need to be empowered to master knowledge and skills to selfmanage aggression constructively. Therefore, facilitation of constructive self-management of aggression is regarded as the main concept of the proposed model and is defined next. 4.3 DEFINING THE CENTRAL CONCEPT: FACILITATION OF CONSTRUCTIVE SELF-MANAGEMENT In order to recognise the essential concepts, it will be indicated in bold and the related concepts will be underlined. In order to understand the central concept, namely, facilitation of constructive self-management of aggression, the related concepts need to be defined. The related concepts facilitation, constructive and self-management in this study need to be defined firstly using definitions from dictionaries. This will then be followed by content or subject-related explanations of their meaning (see Table 4.1, Annexure D). Other related fields where the concepts are 130

149 used are also included in the discussion to ensure meaningful description and to enhance theoretical validity Facilitation Dictionary definition (See Table 4.1, Annexure D) Facilitation, according to Wehmeier (2006), is to make an action or a process easier. Waite and Hawker (2009) define facilitation as make possible, enable, assist, help and promote which is in line with the definition in the Collins English Thesaurus (2010), namely help, promote, make easy. In the Collins English Thesaurus (2010) facilitation is referred to as further; help; forward; promote, speed up, pave the way for, make easy and the Oxford Paperback Dictionary and Thesaurus (2009) refers to facilitation as Make something possible or easier; make possible, smooth the way, enable, assist, help (along), aid, promote. Wikipedia (2010) defines facilitation as follows: Used in business and organizational settings to ensure the designing and running of successful meetings. 131

150 A person who takes on such a role is called a facilitator. Specifically: A facilitator is used in a variety of group settings, including business and other organizations to describe someone whose role it is to work with group processes to ensure meetings run well and achieve a high degree of consensus Subject literature definition (see Table 4.2, Annexure D) Facilitation is a dynamic interactive process for the promotion of health through the creation of a positive environment and mobilisation of resources, as well as the identification and bridging of obstacles in the promotion of health (University of Johannesburg, 2010). Supportive, drawing out, i.e. helping people to look at their own decisions and how to deal with them (Donald, Lazarus & Lolwana, 2002). Botha (2006) states that facilitation is about helping people engage in, manage and cope creatively with rapid changes within themselves. Facilitation is the empowerment of participants to learn. Learning takes place where the whole person, spiritual, physical and psychological, is aware and actively involved including feeling and emotion, intuition and imagining, reflection and discrimination, intention and action (Heron, 1999). The facilitator promotes an open, supportive climate for learning. The facilitator shares the responsibility and control for learning with the learner. 132

151 According to Poggenpoel (1999), facilitation refers primarily to amplifying, enabling, assisting and setting in motion the managerial processes needed for planning, maintaining and restoring professional wholeness. Facilitation is a process that will help a group increase their effectiveness through improving its process and structure and the facilitator enables the process through acquired skills (Harvey, Loftus-Hill, Rycroft-Malone, Titchen, Kitson, McCormack & Seers, 2002). In nursing facilitation is a part of the general terminology and is used widely to describe activities and processes. It is referred to as a strategy that enables the process of developing nursing practice (Simmons, 2004). According to Harvey et al. (in Dogherty, Harrison & Graham, 2010), facilitation activities occur on a continuum ranging from distinctly task-driven actions to more holistic endeavours aimed at releasing the inherent potential of individuals. Through a process of helping people to increase control over and improve their physical, mental and social health (Davies, 2010; Donald et al., 2002), in an environmental setting providing personal space that permits communication with others without threats of crowding (Corsini, 1999 in Geyser, 2004). 133

152 The facilitator provides a structure with rules, roles and gaols needed to enable the development of potential on a conscious level (van der Walt, 2003). Core values that a facilitator should have are valid information, free and informed choice and internal commitment and compassion (Schwarz, 2002). The attributes for an effective facilitator are openness, honesty, fairness, focused, consistency in actions, active listening, assertiveness, enthusiasm, accessibility and flexibility (Bensley & Brookins-Fisher, 2009). Strategies for facilitation are safety and trust, purposeful, questioning, powerful listening and dialogue, reflection and visualising, peer reflection and analysis, courage, intuition, emotional capability, change and encouragement (Bens, 2012). The term facilitator is used in psychotherapy where the role is more to help group members become aware of the feelings they hold for one another. Table 4.1 summarises the essential and related concepts of facilitation. 134

153 Definition of the word facilitation The word facilitation could therefore refer to the process to assist empowerment in an open supportive climate. Table 4.1 Essential and related concepts for facilitation Essential concepts Related concepts Enable Assist Strategies: safety and trust, purposeful, questioning, powerful listening and dialogue, reflection and visualising, peer reflection and analysis, courage, intuition, emotional capability, change and encouragement Learning Release potential Empower Process of helping to increase effectiveness Manage and cope with change Identify and bridge obstacles 135

154 Provide person space Help group to become aware of feelings Open supportive climate Professional wholeness Provides communication without threats Process of support Mobilise resources Aware and active involve Structure with rules, roles and goals Process Process of helping people to increase control over and improve their physical, mental and social health Dynamic interactive Enable development of potential on conscious level Constructive Dictionary definition (see table 4.3, Annexure D) According to the President New English Dictionary (1962), the definition of constructive is capable of constructing or creating. 136

155 Constructive, according to Waite and Hawker (2009) and the Collins English Thesaurus (2010), is having a useful and helping effect, productive, positive, practical, valuable. The Geneeskundige Woordeboek (1988) and the Groot Woordeboek (1977) both define constructive as opbouend (to build up) and samestellend (composition) Subject literature definition (see Table 4.4, Annexure D) A subject literature definition could not be found for constructive. However, constructive as used in subject literature implies a positive productive uplifting meaning. It refers to the feeling of building up, being or providing a positive rather than a negative environment. According to Johnson (2003) constructive is when you feel more energy, motivation, challenge and excitement, and the other person feels friendship, gratitude, goodwill and concern. Johnson (2003) further states that constructive is expressing feelings in an assertive, non-threatening, beneficial way. 137

156 Table 4.2 Essential and related concepts for constructive Essential concepts Creative Related concepts Valuable Useful and helpful effect Challenge To build up Positive Motivation Beneficial Definition of the word constructive Constructive can thus be defined as building up positively and creatively Self-management Dictionary definition (see Tables 4.5, 4.6 and 4.8: Annexure D) Self: Type of person you are, especially the way you normally behave, look or feel. A person s personality or character that makes them different from other people: sense of self = the feeling that they are individual people; the inner self = a person s emotional and spiritual character (Wehmeier, 2006). Having a sense of self enables people to build meaningful relationships (Corey & Corey, 2010). 138

157 A person s essential being that distinguishes them from other people. A person s particular nature or personality (Waite & Hawker, 2009). The whole person embodies dimensions of body, mind and spirit. The person functions in an integrated, interactive manner with the environment. Environment includes an internal and external environment. The internal environment consists of dimensions of body, mind and spirit. The external environment consists of physical, social and spiritual dimensions (University of Johannesburg, 2010). Management: Some literature also refers to management as control, emotional control, control of aggression or anger (Fisher, 2005; Van Leuven, 2003). Management: The act or skill of dealing with people or situations in a successful way. Manage: To be able to solve your problem, deal with a difficult situation, To keep... under control, to be able to deal with... (Wehmeier, 2006). Self-management: The term self-management could not be found in the dictionaries consulted. However, after embarking on an internet search the following definitions were found: In the field of medicine and healthcare, selfmanagement means the interventions, training, and skills by which patients 139

158 with a chronic condition, disability, or disease can effectively take care of themselves and learn how to do so (Wikipedia, 2010). Wikipedia (2010) defines self-management as follows: In business, education and psychology, self-management refers to "methods, skills, and strategies by which individuals can effectively direct their own activities toward the achievement of objectives, and includes goal setting, decision making, focusing, planning, scheduling, task tracking, self-evaluation, self-intervention, self-development, etc. Workers self-management refers to a form of workplace decision-making Subject literature definitions (see Tables 4.7 and 4.9: Annexure D) Self: The totality of all characteristic attributes conscious and unconscious, mental and physical of a person (Corsini, 1999, in Geyser, 2004). Friedman & Schustack (2006) refer to the self as the current self-concept and suggests that self can also be defined by our abilities to find purpose; make a difference, justify actions, and feel self-esteem. They suggests that the self can be defined by either the personal (described by introspection I am very creative ) or social view (described by the relation to others I am a good father ) (Friedman & Schustack, 2006). Aspects of the self, include self-awareness, self-acceptance, selfdevelopment, self-discipline, self-discovery, self-confidence, self-care, self- 140

159 analysis, self-evaluation, self-exploration, self-expression, self-help, selffulfilment, self-insight, self-love, self-management (leadership), and selfimagination (Corsini, 1999, in Geyser, 2004). Self-awareness included selfreflection and insight. Insight refers to the understanding of thoughts, feelings and behaviour (Ashley, 2007). To manage is to forecast and plan, to organize, to command, to coordinate and to control (Roussel & Swansburg, 2009). Self-management: Yeung, Fieldman and Fava (2010) propose that selfmanagement refers to methods, skills and strategies that are used to effectively guide activities to achieve set goals. It usually involves the setting of objectives, planning, scheduling and tracing of tasks, self-assessment, selfintervention and self-development. Self-management in healthcare implies that people with certain conditions receive training, acquire skills and learn interventions in order to care for themselves and to manage their conditions themselves. Self-management: Self-management is the ability to control emotions so that they do not control a person. Self-knowledge regarding emotions creates the ability to control and manage those emotions and consequent behaviour. This includes techniques assisting in regulating emotions, identifying and preventing emotional triggers and in identifying and preventing cognitive 141

160 disorders that can lead to emotional breakdowns. Self-management is when people begin to use their own awareness of feelings to manage themselves. (New Perspectives: International Conference on Patient Self- Management). Self-perception, self-knowledge and participation are paramount in self-management (Evans, Tait & Harvey, 2004). Self-management allows patients to effectively manage their health and wellbeing in a variety of situations as their lives, and needs transformation over time (Sterling, et. al. 2010). Self-management programmes provide new skills allowing people to take control over their health condition, maintain their life roles and manage negative emotions, such as fear and depression. Self management programs are based on the concept of self-efficacy or ones confidence in his or her ability to deal with health problems (Davies, 2010; Sterling, Von Esenwein, Tucker, Fricks & Druss, 2010). Efficacious self-management encompasses the ability to monitor one s condition and to effect the cognitive, behavioural and emotional responses necessary to maintain a satisfactory quality of life. Thus, a dynamic and continuous process of self-regulation is established (Barlow, Wright, 142

161 Sheasby, Turner, & Hainsworth, 2002; New Perspectives: International Conference on Patient Self-Management). Self-management enables one to resist the tyranny of emerging moods (Roussel & Swansburg, 2009). The capacity for good self-management includes emotional competencies of emotional self-control, transparency, adaptability, the drive to achieve, initiative and optimism. Emotional self-control prevents people from being hijacked by their feelings (Davies, 2010; Roussel & Swansburg, 2009). The definitions of the terms empowerment and self-care are also relevant to the definitions of self-management. Robbins, Chatterjee and Canda (2006) define empowerment as the process by which individuals and groups gain power, access to resources and control over their own lives. Funnell, Anderson, Arnold, Barr, Donnelly, Johnson, Taylor-Moon and White (1991) see empowerment as helping patients discover and develop the inherent capacity to be responsible for one s own life. An empowered patient is one who has the knowledge, skills, attitudes and self-awareness necessary to influence their own behaviour and that of others to improve the quality of their lives (Funnell et al., 1991). Self-management education is a patient empowerment strategy, the essential foundation for the empowerment approach (Funnell & Anderson, 2004). Processes are empowering if people 143

162 are able to develop skills that allow them to solve problems and make choices Cleary & Zimmerman (2004). Through self-awareness, people can accept others and themselfs to build meaningful relationships (Shadel & Thatcher, 1997). Table 4.3 is a summary of the essential and related concepts of selfmanagement. Table 4.3 Essential and related concepts for self-management Essential concepts Related concepts Dynamic and continuous process of self-regulation Control over own lives Decision-making Regulate and control emotions Problem-solving Make choices Methods, skills and strategies to direct own activities Integrated person Physical self Social self Spiritual self Health Emotional self 144

163 Building relationships meaningful Prevent and identify triggers Acts and skills in dealing with people Influence own and others behaviour Self-development Cope with Quality of life Self-evaluation Self-awareness of one s feelings, thoughts and actions Self-efficacy Gain power Transformation Self-concept Self-acceptance Self-knowledge Self-discovery Self-explore Sense of self Self-insight Definition of the word self-management It could therefore be concluded that the word self-management refers to a dynamic and continuous process of self-regulation to gain control over one s own life through self-awareness of one s feelings, thoughts and actions in order to build meaningful relationships as an integrated person. 145

164 4.4 FINAL DEFINITION OF THE CENTRAL CONCEPT: FACILITATION OF CONSTRUCTIVE SELF-MANAGEMENT OF AGGRESSION OF NURSING STUDENTS To arrive at a feasible and acceptable definition of the central concept, the above essential concepts will be refined and condensed in order to reflect the intended meaning of the central concepts (Chinn & Kramer, 1995). The essential and related concepts of the central concept, namely facilitation of constructive self-management of aggression of nursing students, are reflected in Table 4.4 below. Table 4.4 Final essential and related concepts of the central concept Essential concepts Related concepts Assist Make possible Enable Make easy Strategies: safety and trust, purposeful, questioning, powerful listening and dialogue, reflection and visualising, peer reflection and analysis, courage, intuition, emotional capability, change and encouragement 146

165 Empower Learning Release potential Process help to increase effectiveness Manage and cope with change Identify and bridge obstacles Open supportive climate Give the person space Help group to become aware of feelings Professional wholeness Provide communication without threats Process of support Mobilise resources Aware and active involve Process Structure with rules, roles and goals Process of helping people to increase control over and improve their physical, mental and social health Dynamic interactive Creative Enable development of potential on conscious level Valuable Useful and helpful effect Challenge Positive To build up Motivation Beneficial 147

166 Dynamic and continuous Control over own lives Decision-making of Regulate and control emotions Problem-solving Make choices Methods, skills and strategies to direct own activities Prevent and identify triggers meaningful relationships Acts or skills in dealing with people Influence own and others behaviour Self-development Cope with Quality of life Self-evaluation process selfregulation Building Selfawareness Self-efficacy Gain power of one s Transformation feelings, thoughts and actions Self-concept Self-acceptance Self-knowledge Self-discovery Self-explore Sense of self Self-insight 148

167 Integrated person Physical self Social self Spiritual self Health Emotional self Definition of the central concept The central concept is the facilitation of constructive self-management of aggression by nursing students. This is a dynamic and continuous process of self-regulation whereby people are assisted and empowered in an open supportive climate that is positive and creative to bring about a selfawareness of their thoughts, feelings and actions in order to build meaningful relationships as an integrated person. 4.5 DEFINITIONS OF RELATED CONCEPTS The concepts related to the central concept need to be defined according to their application in this study. 149

168 4.5.1 Assist Assist refers to the process in which the agent (nurse educator) enables the recipient (nursing student) through strategies such as safety and trust, purposefulness, questioning, powerful listening and dialogue, reflection and visualising, peer reflection and analysis, courage, intuition, emotional capability, change and encouragement Empower This is the process of helping people increase their effectiveness through learning, enabling them to manage and cope with change after they have identified and bridged obstacles in order to release their potential Open supportive climate An open supportive climate refers to giving people space through a process of support in which people are actively involved and resources are mobilised. People are helped to become aware of their feelings and thoughts and to communicate without threats to achieve professional wholeness Process Process is a dynamic interactive structure with rules, roles and goals, enabling people to develop on a conscious level. Through the process people 150

169 are enabled to increase control over and improve their physical, mental and social health Creative Creative means a challenge that will have a valuable, helping and useful effect in building people up Positive The act of being positive implies that the agent (nurse educator) motivates the recipient (nursing student), to make choices that will be of benefit to the recipients and their interpersonal relationships Dynamic and continuous process of self-regulation This refers to the process of people using methods, skills and strategies, such as problem-solving and decision-making, which direct their own activities. Through this process people aim to regulate and control their emotions, and to make appropriate choices in order to exercise control over their own lives Building meaningful relationships Building meaningful relationships implies identifying and preventing triggers in coping with aggression through self-development and self-evaluation. 151

170 Nursing students could be empowered with acts and skills in dealing with people in order to influence their own behaviour and that of others Self-awareness of one s feelings, thoughts and actions Self-awareness can be described as being critically aware and having conscious knowledge of one s self-concept or self-esteem, and gaining selfknowledge through self-exploration. Through self-discovery and selfknowledge people can access their deepest feelings and thoughts, and explore their actions as result of these feelings to gain self-insight. This is important as the nursing students need to be critically aware of their thoughts, emotions and decision-making process because thoughts can impact on emotions. These in turn can influence decision-making which influences one s actions. The aim of self-awareness in this study is to develop a constructive sense of the self. Through a constructive sense of the self, the nursing students will be able to identify and classify the emotions resulting from thoughts and the consequent actions. An internal locus of control is evidence of a healthy self-concept. Through self-awareness, self-acceptance and selfefficacy people can gain power over their feelings, thoughts and actions to transform themselves and take control of their lives Integrated person An integrated person refers to the health and interaction of the physical, emotional, social and spiritual self in order to function as a whole person that is in interaction with the internal and external environment. 152

171 4.6 CONSTRUCTING A MODEL CASE A few nursing students experienced aggression in their group during three incidents (Scenario Chapter 1). These incidents of aggression were aimed at females by a male student. The first incident took place as the girls sat outside the residence talking and laughing while a male student walked past them. He thought that they were laughing at him and accused one of them of laughing at him. The second incident took place during a practical clinical training period in the hospital when the female student mistakenly opened the cubicle curtain thinking that the person inside was one of her friends it was in fact the male student who had accused her of laughing at him. He then did not use self-control as he verbally insulted her in front of a patient. In response, she asked him to accompany her outside the cubicle, where she then insulted him and ran away, indicating that she was not able to assert herself. The final incident between these two students took place when the students were waiting for transport to take them to the clinical training facility. According to the female student, the male student told her that he would teach her the hard way if she did not show him respect. She replied that respect was earned and that one could not respect someone who was rude to others. The next minute the male student hit her hard in the face and pointed his finger at her, indicating no self-control. The female nursing student reported these incidents and a meeting with both parties were suggested by the facilitator. At this meeting both expressed their concern about the incidents, fearing they could have a detrimental impact on them. 153

172 During the meeting of each nursing student individually with the facilitator, they committed themselves to the process of facilitation. In this research facilitation is an assisting and enabling process based on establishing trust in a multicultural environment. Both of these students agreed that it was important for both of them to be actively involved in the process of communicating their feelings freely, thus creating an open supportive climate. These nursing students were assisted through communication skills in selfexploration and self-awareness and the empowerment of self-development in their self-management of aggression. The facilitator empowered these nursing students to enable them to work through the stumbling blocks in the creative and positive management of their aggression and to take responsibility for the problem-solving process. During the process the nursing students were challenged and confronted with decisions regarding their thoughts, feelings and actions. Self-awareness of feelings, thoughts and actions was created, leading to self-knowledge of their self-esteem. Self-knowledge enabled these two nursing students to access their deepest feelings, whether they were at home, in class, with their fellow students or at work. It also enabled them to use this knowledge to make choices in the management of aggression. 154

173 Both these nursing students were empowered to think and make choices to act more constructively by facilitating knowledge in assertiveness and conflict management. Through the process they were encouraged to explore their expression of feelings, thoughts and actions. This process allowed them to become an integrated person that was able to function as a whole person. They gained greater self-awareness through the process. Self-acceptance through self-knowledge was formed. They were empowered to think and act differently from the recognised feelings. The students were encouraged to explore and experiment in different ways of behaviour when confronted with aggression. During the process they reflected on their choices of behaviour, thoughts and feelings. They practised this process to allow them to realise that this way of constructively self-managing aggression was a dynamic and continuous process of self-regulation allowing them to build meaningful relationships. 4.7 CLASSIFICATION OF CONCEPTS The classification of the related concepts as described according to the six questions proposed by Dickoff et al. (1968) and described in Chapter 2 now 155

174 follows. Figure 4.1 represents the reasoning process followed derived from the six questions Agent The agents in this case performing the activities are the nurse educators. Nurse educators with facilitation skills can act as facilitators to enable the nursing students to self-manage aggression constructively. The agents have broad experience in the field of facilitation. They are critical thinkers and independent practitioners. Because the agents have worked in the education environment, lecturing and accompanying students, they have developed resources that can be called upon to assist in the process of facilitation. These resources, knowledge, experience and skills can be used by the agents to solve problems and assist in the process of facilitation of constructively self-managing aggression. 156

175 AGENT: RECEIVER: Nurse educator Student nurse as young adult PROCEDURE: Facilitation of the constructive selfmanagement of aggression DYNAMICS: Lack of emotional control Lack of skills and knowledge to manage aggression themselves Aggression has detrimental effect on intrapersonal & interpersonal relationships Aggression is detrimental to health as a whole person CONTEXT: Multidimensional environment of nursing students at a higher education institution OUTCOME: The ability to selfmanage aggression constructively as integral part of health Figure 4.1 Reasoning map 157

176 The role of the agent as a facilitator is to provide guidance and support and to mobilise resources to facilitate learning through strategies such as safety and trust, purposefulness, questioning, powerful listening and dialogue, reflection and visualising, peer reflection and analysis, courage, intuition, emotional capability, change and encouragement. Agents need to be able to effectively facilitate the recipient with guidance, empathy and professionalism. They also need to be sensitive to the needs, culture as well as the social and multidimensional environment of the recipient Recipient The recipients in this case are the nursing students at an HEI in Johannesburg. The recipients are both male and female, from various backgrounds and cultures, functioning in a multidimensional environment. These recipients are dependent on the agents. They are anxious to develop knowledge and skills which they can use to constructively self-manage the aggression they might encounter. Their self-awareness and self-control of their own thoughts and emotions that direct their behaviour have not yet been developed. 158

177 4.7.3 Context The context in which this model is applied is in a multicultural, multidimensional HEI in Johannesburg. Nursing students function in a multilevel milieu which includes their home, social, working, education and student environments. They work in the public sector, either a hospital or clinic, where they apply the theory which they learned at the HEI. The nursing students are faced with intrapersonal and interpersonal challenges between the students themselves, with colleagues, family members and friends as well as patients and lecturers. They are also faced with challenges of adapting in an environment that might be far removed from what they are accustomed to. They are expected to engage and perform on a level that requires knowledge of technology, skills on various levels and increased workload, both theoretically and clinically Procedure The procedure of this model takes place along a continuum and involves a dynamic interaction between the agent and the recipient. It is the process of facilitating constructive self-management of aggression of nursing students. The procedure consists of steps in how facilitation will take place to enable constructive self-management of aggression by nursing students. 159

178 The procedure for facilitating constructive self-management of aggression will be done over a period of one academic year. The sessions scheduled will be monthly with groups of students. The recipients move from one phase to the next with a subtle graduation. Figure 4.2 Procedure phases The phases are as follows: Relationship phase: During the relationship phase the facilitator establishes trust in a multicultural environment. The agent needs to establish rapport with the recipients by demonstrating empathy and genuineness, being consistent 160

179 and developing positive regard. The recipients should be made aware that as far as possible within a group setting confidentiality will be maintained, especially from the agent s side, but also from members in the groups (Uys & Middleton, 2009). During this phase the facilitator will give the students the opportunity to share distressing thoughts and feelings as well as incidents that they have encountered. The students will give feedback on how they felt and how they managed these incidents. They will also be able to reflect on whether the feelings, thoughts and reactions to or during the incident were appropriate and, after reflection, if they could have felt and reacted differently (Deffenbacher, 2004). Working phase: The aim of the working phase is to identify and examine selfdefeating behaviour, to test alternatives and to practise and develop skills that will enable the nursing students to manage their aggression constructively themselves. Students will also be assisted with problem-solving and decisionmaking skills for them to cope with activities they encounter during their daily living. During the working phase the facilitator facilitates nursing students in the development of: 161

180 1) a constructive self-concept; 2) an awareness of the nursing students own and other people s aggression; 3) meaningful interpersonal relationships by facilitating knowledge and skills in assertiveness, conflict management and emotional control. This will be accomplished by maintaining the relationship and gathering relevant and other data. Problem-solving skills and self-esteem can be promoted by facilitating behavioural changes and overcoming resistance behaviours, by making use of various techniques such as self-awareness exercises and role play, for example. Termination phase: A final assessment of the whole process of constructive self-management of aggression takes place during this phase. The recipients will have the opportunity to reflect on the process with regard to the feelings and reactions first experienced before the working phase and the changes in feelings, thoughts and reactions to similar incidents and feelings Dynamics The dynamics that drive this model will be the nursing students experience of aggression as an integral part of their life and as mostly intensely negative. Their lack of emotional control, knowledge and skills to manage aggression 162

181 constructively themselves affects their health as a whole person. They consequently experience aggression as detrimental to themselves as a whole person and their interpersonal relationships. They acknowledge that they are eager to learn skills and knowledge that will enable them to fulfil their role as a professional and manage their emotions and thoughts that guide their behaviour Outcome The outcome will be that the nursing students are empowered to self-manage aggression constructively as a dynamic and continuous process of selfregulation. 4.8 CONCLUSION The central concepts of a model to facilitate constructive self-management of aggression by nursing students at an HEI in Johannesburg were defined and classified in this chapter. In the next chapter the model will be densely described according to the strategies of Chinn and Kramer (1995). 163

182 CHAPTER 5 DESCRIPTION OF A MODEL AS A FRAME OF REFERENCE FOR FACILITATING CONSTRUCTIVE SELF-MANAGEMENT OF AGGRESSION EXPERIENCED BY NURSING STUDENTS AT AN HEI 5.1 INTRODUCTION In Chapter 4 the researcher started generating a tentative model as a frame of reference for facilitating self-management of aggression experienced by nursing students at a tertiary education institution through the identification, definition and classification of the central concepts. This chapter will provide a description of the actual model and its evaluation using the methods and strategies as described by Chinn and Kramer (2008) and Walker and Avant (2005). A brief overview, purpose, context and assumptions on which the model is based will firstly be discussed, followed by the definitions and relationship statements. The researcher will then describe the structure and process of the model as well as the strategies for the implementation of the model in the practice. Finally the model was evaluated by a panel of experts and the results of the evaluation will then be described. 164

183 5.2 OVERVIEW OF THE MODEL The model (Figure 5.1) gives a picture of the facilitation of self-management of aggression experienced by nursing students at an HEI in Johannesburg. The results of the study show that nursing students do not have the knowledge and skills to manage aggression they experience. The frame of reference for this model is based on the responses identified in the fieldwork. Although nursing students experience aggression as an integral part of their life, a part of their normal behaviour, they also experience it as extremely negative, detrimental to themselves and their interpersonal relationships, on a physical, psychological and spiritual level. According to their responses, they lack the emotional control, knowledge and skills to manage their aggressive feelings. Therefore aggression impacts on them as a whole person, influencing their relationships. Aggression is problematic and can be detrimental to their health. It is evident that nursing students need assistance in constructively self-managing aggression as they experience it in their lives. The facilitation process in this model is based on a therapeutic relationship between the facilitator and the nursing students, and is a planned interactive process comprising three phases. During the first phase the facilitator establishes a relationship with the nursing students, the second phase 165

184 Figure 5.1 Model for facilitating constructive self-management of aggression experienced by nursing students at a tertiary education institution 166

185 involves the facilitation of mastering knowledge and skills and the final phase comprises assessing the attainment of knowledge and skills that will ultimately enable the nursing students to manage aggression themselves. During the first phase a relationship should be established between the nursing student (recipient) and the nurse educator or community health nurse (agent). It is important that this relationship be based on mutual respect, trust and acceptance of the facilitator and the nursing students within the group as the relationship forms the foundation of the facilitation process. Throughout the research the nurse educator will be referred to as the facilitator. In the second phase, through assistance and empowerment, the facilitator can facilitate the constructive self-management of aggression experienced by nursing students. Activities will be set in motion by the facilitator together with the nursing students so that they can achieve constructive self-management of aggression. This implies the sharing of knowledge and skills that need to be mastered and helping the nursing students to move towards the purpose of the facilitation process. The facilitator assists the nursing students through various activities and interventions in self-awareness, leading to self-knowledge and self-acceptance. Once the nursing students master knowledge and techniques of understanding and accepting themselves, they can actively participate in actions and interventions. This will enable them to develop the self and an internal locus of control and to self-manage aggressive emotions constructively. Through this they will develop the ability to selfregulate aggression through a dynamic and continuous process. 167

186 The third phase reflects the end result when the nursing students have mastered knowledge and skills. The nursing students are now able to apply and utilise the knowledge and skills they have learned during the working phase. Initially in the first phase of the facilitation process the facilitator is intensely involved with the nursing students. As the nursing students gradually become more confident in mastering knowledge and skills, the facilitator s involvement gradually decreases. The nursing students develop the ability to embark on a journey of a dynamic and continuous process of self-regulation, enabling them to self-manage aggression. 5.3 PURPOSE OF THE MODEL The purpose of the model is that it will enable the nurse educator to facilitate constructive self-management of aggression experienced by nursing students. The nurse educator, i.e. the facilitator, assists the nursing students through actions and interventions, enabling them to constructively self-manage aggression on their journey to wholeness as a long-term goal. 5.4 CONTEXT OF THE MODEL Students embarking on a career in nursing receive education from an HEI. During these students education they interact not only with their family, fellow students and lecturers, but also with patients and the patients family and their community. The 168

187 HEI organises and manages their education and exposure to the various facets of their education. The context for this model is thus within an HEI in Johannesburg that offers nursing education to nursing students. Nursing students range in age from 18 to 33 years, include both male and female and are from various cultural, social and economic backgrounds. 5.5 ASSUMPTIONS OF THE MODEL The focus of this study was on the nursing student as a whole person. A nursing student is a person with a body, mind and spirit and interacts within a dynamic physical, social and spiritual environment (University of Johannesburg, 2010). This nursing student at an HEI experiences aggression as detrimental to themselves as a whole person. Aggression therefore influences their health as a human being. The assumptions on which the model is based are embedded in the theory for health promotion in nursing (University of Johannesburg, 2010). The primary assumption of this model is that it will enable the nurse educator to facilitate constructive selfmanagement of aggression experienced by nursing students. 169

188 5.5.1 The nursing student (recipient) Nursing students are registered at the South African Nursing Council as student nurses. They are currently doing a four-year nursing degree at an HEI in Johannesburg. The nursing student is seen as a whole person consisting of body, mind and spirit (internal dimension) and functions in an integrated manner with the external environment, namely the physical, spiritual and social environments. The external environment includes the interactions with their families, colleagues and fellow students, the patients, other members of the healthcare team as well as other individuals they come in contact with. Due to the nursing students experience of aggression impacting on them as a whole person and their interpersonal relationships, the assumption is that the nursing students are unable to manage aggression themselves. They are faced with aggression as well as intrapersonal and interpersonal challenges and conflicts with their families, friendships, study and work environment. These nursing students need to be empowered and enabled to develop their self-awareness, knowledge and skills to manage aggression constructively themselves. 170

189 5.5.2 The facilitator (agent) The model is based on the assumption that the facilitator is a registered nurse educator who has developed the knowledge and skills to facilitate constructive selfmanagement of aggression in nursing students. The nurse educator is also seen as a whole person consisting of body, mind and spirit in interaction with the external environment which consists of physical, spiritual and social dimensions. The nurse educator is mature and professionally experienced in working with nursing students in the educational as well as the clinical environment Facilitation of constructive self-management of aggression in an open supportive climate Facilitation is a dynamic interactive process that takes place in an open supportive learning environment in which the nursing students are enabled and empowered to manage aggression themselves. The focus of the facilitation is to enable the nursing students, through a process of self- discovery and self-knowledge, to access their feelings, thoughts, emotions as well as their actions resulting from these feelings. This is a dynamic and continuous process of self-regulation in order to build meaningful relationships as a whole person. 171

190 5.5.4 Aggression Aggression entails direct or indirect actions with the intention of inflicting harm on another human being. It also includes being the victim as well as the perpetrator of aggression. Aggression is detrimental to nursing students lives as well as their interaction with their environment, causing intrapersonal and interpersonal conflict. 5.6 DEFINITIONS OF CENTRAL AND RELATED CONCEPTS The following central and related concepts are the building blocks of this model and will first be explained before the model is further described Facilitating constructive self-management of aggression The facilitation of constructive self-management of aggression experienced by nursing students is a dynamic and continuous process of self-regulation whereby they are assisted and empowered in an open supportive climate that is positive and creative to bring about self-awareness of their thoughts, feelings and actions in order to build meaningful relationships as an integrated person. 172

191 5.6.2 Assist Assist refers to the process in which the agent (nurse educator) enables the recipient (nursing student) through strategies such as safety and trust, purposefulness, questioning, powerful listening and dialogue, reflection and visualising, peer reflection and analysis, courage, intuition, emotional capability, change and encouragement Empower This is the process of assisting nursing students in increasing their effectiveness through learning and practising, enabling them to manage and cope with change after they have identified and bridged obstacles in order to release their potential Open supportive climate An open supportive climate refers to giving people space through a process of support in which people are actively involved and resources are mobilised. People are helped to become aware of their feelings and to communicate without threats to achieve professional wholeness. 173

192 5.6.5 Process Process is a dynamic interactive structure with rules, roles and goals, enabling people to develop on a conscious level. Through the process people are enabled to increase control over and improve their physical, mental and social health Positive The act of being positive implies that the agent (nurse educator) motivates the recipient (nursing student), to make choices that will be of benefit to the recipients and their interpersonal relationships Dynamic and continuous process of self-regulation This refers to the process of people using methods, skills and strategies, such as problem-solving and decision-making, which direct their own activities. Through this process people aim to regulate and control their emotions, and to make appropriate choices in order to exercise control over their own lives. Self-regulation ensures that individuals take responsibility for behaviour. 174

193 5.6.8 Building meaningful relationships Building meaningful relationships implies identifying and preventing triggers in coping with aggression through self-development and self-evaluation. Nursing students could be empowered with acts and skills in dealing with people in order to influence their own behaviour and that of others to improve the quality of life Self-awareness of one s feelings, thoughts and actions Self-awareness can be described as being critically aware and having conscious knowledge of one s self-concept or self-esteem, and gaining self-knowledge through self-exploration. Through self-discovery and self-knowledge people can access their deepest feelings and thoughts, and explore their actions as result of these feelings to gain self-insight. This is important as the nursing students need to be critically aware of their thoughts, emotions and decision-making process because thoughts can impact on emotions. These in turn can influence decision-making which influences one s actions. The aim of self-awareness in this study is to develop a constructive sense of the self. Through a constructive sense of the self, the nursing students will be able to identify and classify the emotions resulting from thoughts and the consequent actions. An internal locus of control is evidence of a healthy selfconcept. Through self-awareness, self-acceptance and self-efficacy people can gain power over their feelings, thoughts and actions to transform themselves and take control of their lives. 175

194 Integrated person An integrated person refers to the health and interaction of the physical, emotional, social and spiritual self in order to function as a whole person that is in interaction with the internal and external environment. 5.7 RELATIONSHIP STATEMENTS The following serve as relationship statements of the model: Nursing students have the potential to self-manage aggression constructively through self-awareness of feelings, thoughts and actions, which leads to selfknowledge and self-acceptance. Nurse educators, because of their professional training, have the ability and skills to assist nursing students in becoming aware of themselves, developing self-acceptance and empowering them to think and make constructive choices. This leads them to embark on the journey of dynamic and continuous self-regulation of aggression. 176

195 The facilitator can assist and empower the nursing student to develop selfawareness and self-knowledge which will lead to self-acceptance. The process of facilitating constructive self-management of aggression begins when the facilitator and the nursing students establish a relationship. Through self-knowledge nursing students will be able to gain insight into their own feelings, thoughts and actions. This will enable them to acknowledge their own emotions and behaviour in the management of aggression. Through acceptance of the self and self-efficacy people can gain power over their feelings, thoughts and emotions to transform themselves and take control of their lives. 5.8 STRUCTURAL DESCRIPTION OF MODEL The structure and overall form of the model is described as proposed by Chinn and Kramer (2008). The model is composed of different shapes and colours that all have a significant meaning and that will be included in the description. The structure of the model is discussed and explained through the definition of the central and related concepts, the relationship statements of the concepts as well as the description of the structural forms. The model (Figure 5.1) reflects the process 177

196 and relationship of facilitating nursing students inability to self-manage aggression and transforming this to their ability to manage aggression themselves. Each of the components in the structure of the model is associated with a particular colour (Kundalini-tantra.com (n.d.); Precision Intermedia (n.d.); Princetono.com (n.d.); Sensational color.com (n.d.); whats-your-sign.com (n.d.)) and will be referred to throughout the description of the structure below. The model illustrates three aspects that together form the structure of the model. The first aspect of the model illustrated by a red arrow represents the nursing student (recipient). The second is the yellow broad curve which narrows to a point it represents the facilitator (agent). The third is the spiral helix enfolding both of the first two aspects (recipient and agent) and it illustrates the growth that takes place throughout and beyond the process of facilitation from the inability to the ability to self-manage aggression constructively. The red narrow point of the arrow overlaps with the broad base of the yellow curve, with a gradual widening of the gap between the yellow (agent) and red (recipient). The footsteps in the red arrow and yellow curve illustrate the journey through the process of facilitation from establishing a relationship, mastering skills and knowledge, assessing attainment of knowledge and skills and resulting in a dynamic and continuous process of self-regulation. At both the bottom and the end of both these two aspects, the human figurine in the triangle within the circle, surrounded by 178

197 the star-like outer circle, represents the whole person of the recipient (red) consisting of body, mind and spirit. The star-like outer circle represents the external interactions of the recipient with the community at large as being part of a family, and also a student, a worker and an agent (yellow), which are in interaction with one another in order to establish a relationship (University of Johannesburg, 2010). This whole structure lies against the background of three coloured puzzle pieces flowing into one another and representing the process of the model. The structural description of each aspect will follow: Red curved arrow (recipient) Figure 5.2 illustrates the red curved arrow representing the nursing student as the recipient. Figure 5.2 Red curved arrow (recipient) 179

198 The first part of the structure of the model is a red curved arrow, starting off narrow and ending up in a wide arrowhead. A human figurine appears at the beginning of the arrow and at the end. Black footsteps inside the arrow indicate the journey of the nursing students. The human figurine in the star-like outer structure represents the nursing students. The star-like structure housing the human figurine illustrates that the person functions in an integrated manner with the external environment, which would be the community at large. Within the external environment the person is also part of a family, the HEI and the workforce. The dark red half of the human figurine in the triangle within the circle represents the whole person consisting of body, mind and spirit (the three colours of the other half) who functions in an integrated, interactive manner with the environment (University of Johannesburg, 2010). These three dimensions are illustrated by the three points of the triangle in the circle. The head of the figurine is black. Black is associated with intelligence (Precision Intermedia (n.d.)) and the brain is associated with intelligence. The colour black therefore symbolises the mind of the nursing student. The mind includes intellectual processes that take place within the nursing students minds, the processes of making decisions that will influence choices they make as well as their emotions (University of Johannesburg, 2010). 180

199 The upper body of the figurine is in green. Green is associated with the energy on the surface of the body in the centre of the chest, and is linked to the heart (Kundalinitantra.com (n.d.); Smith (n.d.)). The green symbolises the body of the nursing student as the body cannot exist without the heart and the heart is the centre of the body. The human figurine s lower part is coloured in blue. The colour blue symbolises the spirit (Smith (n.d.)). The spirit as indicated in the theory for health promotion (2010) refers to the nursing students relationship with their God and their own conscience. Red is associated with energy, excitement and stimulation and symbolises the emotion of anger, indicating danger. Red can shock, repulse and frighten (Smith (n.d.)). The dark red filling half the human figurine symbolises anger, danger, repulsion and fear. The aggression the nursing students experience is the result of anger and frustration that they feel and do not know what to do with or how to manage it. The inability to manage this aggression affects them on a physical and emotional level. Danger is inevitable when they or others act out on their feelings of aggression, as this may cause bodily harm to the recipient of the aggressive actions. The recipient of the aggressive behaviour experiences fear, especially if the aggression is focused towards the weak person (Chapter 3) and in some cases the perpetrator as well as the recipient experience repulsion and embarrassment (Chapter 3) because of their behaviour due to their inability to control their emotions. 181

200 Each individual embraces three internal dimensions, namely body, mind (psyche) and spirit. The facilitator has developed a balance in internal dimensions as well as within their interaction with the external social dimensions. The nursing students still need to develop internal dimensions that will enable constructive self-management of aggression to cope with the challenges of aggression. Nursing students are challenged on a daily basis with negative emotions such as aggression and frustration, adaptation and changes. The challenges of adapting and developing multidimensionally within a relatively new environment and roles necessitate skills to manage the challenges they are faced with. The dark red half of the human figurine at the base of the narrow point of the red arrow is indicative of the nursing students inability to manage aggression constructively themselves. They do not yet have the ability to self-manage aggression constructively. Their inability do so influences their functioning and interaction with their internal and external environment negatively because they have feelings of rage, hopelessness and expression in abusive behaviour, it is something I have no control over (see Chapter 3). Their inability to self-manage aggression constructively therefore influences their feeling of wholeness. The narrow point of this mainly red arrow suggests this inability to self-manage aggression. The intense dark red colour signals feelings of excitement, stimulation and intensely strong emotions causing a severe reaction. The reason for this is that the nursing students sometimes have no control over and do not know how to manage their emotions (Smith (n.d.)). The dark intense red implies that the nursing 182

201 students experience aggression intensely and that the reactions of these intense feelings can result in a severe reaction since they do not have the ability to selfmanage aggression. The arrow gradually changes colour from the dark intense red narrow point of the arrow to a light fading red at the end of the arrow. This implies the passion and desire of the nursing students who are encouraged into actions of mastering skills and knowledge, resulting in a balanced whole nursing student with the ability to selfmanage aggression (Smith (n.d.)). Together with the gradual change in colour, a gradual widening of the arrow takes place, ending in a broad arrowhead. This indicates the gradual mastering of skills and knowledge. The wide end of the fading arrow suggests that the nursing students have attained the skills and knowledge enabling them to self-manage aggression. The black footsteps on the arrow mean that the nursing students are on a journey through a process that will empower them to self-manage aggression constructively. At the end of the fading arrow the human figurine in the triangle within the circle represents the whole person consisting of body, mind and spirit of the recipient (red) who functions in an integrated, interactive manner with the internal and external environment (University of Johannesburg, 2010). The star-like outer structure housing the human figurine illustrates that the person functions in an integrated manner with the external environment, which would be the community at large. 183

202 Within the external environment, the person is also part of a family, the HEI and the workforce. The colours of the human figurine change from dark red, black, green and blue to no dark red but with a black head, green upper body and blue lower body. Through their journey from inability to ability to self-manage aggression constructively, they have been empowered by a process of mastering skills and knowledge. The black head of the human figurine now implies that the nursing students have the skills and knowledge that are associated with the intellectual processes. They can now identify emotions and thoughts through the intellectual processes, making decisions that determine choices (University of Johannesburg, 2010). The whole black head, the whole green upper part and whole blue lower part of the human figurine suggest that through the journey of empowering the nursing students by the process of mastering skills and knowledge, the nursing students have restored balance and wholeness Yellow curved path (agent) Figure 5.3 illustrates the yellow curved path representing the facilitator as the agent. 184

203 The second aspect of this structure is a yellow curved path, seen below, starting off with a broad base and ending with a narrow point. Inside this path, footsteps indicate the journey of the facilitator. The yellow colour represents the agent, in this case the nurse educator and community health nurse, and symbolises optimism, energy as well as creativeness. The yellow in this model also signifies the empowerment of a person and assisting them in finding their personal strength (Smith (n.d.)). Figure 5.3 Yellow curved path (agent) The broad yellow base of the path represents the extent of facilitation and involvement with the recipient (red) in the beginning where the nursing students are unable to self-manage aggression constructively. At this stage the facilitator s 185

204 involvement through facilitation is extensive. The yellow curve path gradually narrows towards the pointed end. This is indicative of the lessening involvement as the nursing students gradually master skills and knowledge that empower them to self-manage aggression constructively. The physical proximity of the yellow path to the red arrow is also significant. The overlapping of the yellow base of the path with the narrow point of the dark intense red arrow indicates the inability of the nursing students to self-manage aggression and the extent of involvement of the agent. Through the gradual narrowing of the path to a narrow point, the path gradually moves away from the red widening arrow. This means that while the extent of the facilitator s involvement gradually decreases, the facilitator also gradually detaches from the nursing students. This happens when the nursing students gradually master skills and knowledge that enable them to selfmanage aggression constructively Spiral Figure 5.4 illustrates the spiral representing the dynamics within a continuous process of empowerment. The third aspect in the structure of the model is a spiral. This spiral, seen below, begins from a centre and moves and expands outward. This signifies growth from an 186

205 outer consciousness to the inner soul of enlightenment and intuitiveness and is mapped by the spiralling rings (Venefica (n.d.)). Figure 5.4 Spiral The spiral starts from below the point where the yellow broad base of the curved path overlaps with the dark intense red narrow point of the arrow. The spiral includes in its centre ring the human figurine in the triangle within the circle. The inclusion indicates the nursing students need for growth. The outward expanding spiral encircles both the red arrow and the yellow curved path. This signifies that both the nursing student and the facilitator are involved in the facilitation process and the growth that takes place through the journey that empowers the nursing student, enabling the self-management of aggression. 187

206 The start of the spiral with the brilliant blue symbolises dynamic, dramatic exhilaration. The nursing students are excited to be involved in the dynamic process that empowers them with skills and knowledge enabling them to self-manage aggression constructively. The gradual changes in colour starting with brilliant blue together with the widening of the spirals reflect the process of empowering as well as the growth throughout the process. The colour indigo at the end of the spiral symbolises wisdom, self-mastery and spiritual realisation as well as lesser feelings of despair. The blue is turned inward into indigo to reflect increased personal thought, insight and understanding (Smith (n.d.)). The lack of a clear but gradual change in the colour is significant as it shows that the recipient is allowed to move back and forth at their own pace throughout the process. However, with facilitation there is a gradual change in the recipients acceptance of where they are in this process of growth, allowing them to move on to explore and experience further. The open-ended spiral that fades gradually suggests that this process is a dynamic continual journey of self-regulation striving towards wholeness. The spiral represents the empowering dynamics that inherently drive nursing students. This spiral is juxtaposed against the backdrop of both the relationship development and aggression management processes that focus on moving from the inability to being able to self-manage aggression over time. 188

207 This whole structure lies against the background of three coloured puzzle pieces flowing into one another and representing the process of the model Establishing relationships Figure 5.5 illustrates the first part of the process which represents the relationship phase (establishing relationships). Figure 5.5 Establishing relationships 189

208 The first light blue puzzle piece symbolises the relationship phase. The light blue colour coincides with the start of the spiral where the brilliant blue reflects the excitement of the nursing students to be involved in this dynamic process. The blue is a colour for communication (Guida-Clark, 2011). The relationship phase is ultimately a period for the facilitator to establish a relationship with the nursing students and communication is paramount in this phase. The puzzle-like structure indicates that the relationship phase flows into the working phase. It suggests that the movement between the relationship phase and the working phase is flexible and adaptable; hence the slight gap between the two puzzle pieces Mastering knowledge and skills Figure 5.6 illustrates the second part of the process which represents the working phase (mastering knowledge and skills). The second, slightly larger light green puzzle piece represents the working phase. This phase is essentially the mastering of knowledge and skills that will enable the nursing students to be able to self-manage aggression constructively. The colour green is associated with balance, harmony and renewal (Guida-Clark, 2011). 190

209 Figure 5.6 Mastering knowledge and skills Through mastering knowledge and skills the nursing students embark on a path of balance, harmony and renewal. The skills and knowledge of self-awareness and consequent awareness of thoughts, feelings and actions assist and empower them to attain balance, harmony and renewal within themselves. 191

210 As with the relationship phase, the puzzle-like structure indicates that the working phase flows into the termination phase. It suggests that the movement between the working phase and the termination phase is flexible and adaptable; hence the slight gap between the two puzzle pieces Attaining knowledge and skills Figure 5.7 illustrates the final part of the process which represents the termination phase (attaining knowledge and skills). The final light purple puzzle piece symbolises the termination phase. This colour coincides with the end of the spiral s indigo colour, representing spiritual realisation, wisdom and insight. The light purple colour is aligned with spirituality and insight (Guida-Clark, 2011). The termination phase is the final phase and the period where the nursing students have attained knowledge and skills, enabling them the insight and wisdom to self-manage aggression constructively as a lifelong journey. The puzzle-like structure of this process indicates movement from the relationship phase through the working phase into the termination phase. 192

211 Figure 5.7 Attaining knowledge and skills The fact that the three puzzle pieces do not fit into one another but have a gap between them is meaningful, as it shows that a phase for some can take longer to 193

212 achieve and complete, and it allows the recipient to move back and forth at their own pace throughout the process. Nevertheless, with facilitation there is a gradual change in the recipients acceptance of where they are in the process of growth. This will allow them to move on to explore and experience further. 5.9 PROCESS DESCRIPTION OF THE MODEL The structure of the model has been described above and the process that is portrayed through the structure will now be explained. Empowering nursing students to constructively manage aggression themselves is a process based on three phases, namely establishing relationships, mastering knowledge and skills and attaining knowledge and skills. Through the therapeutic relationship the nursing students can undertake developmental tasks and practise healthy communication and behaviour during the three phases (Arnold & Boggs, 2007; Havenga, 2011; Kneisl & Trigoboff, 2009). The process of facilitating constructive self-management of aggression between the facilitator and the nursing students is dynamic and interactive. The facilitator manages the process, commencing once the nursing students become aware of their inability to self-manage aggression constructively, and continues throughout 194

213 their development and journey in pursuit of constructive self-management of aggression (Uys & Middleton, 2009). The separation and movement between the different phases of the process are flexible and adaptable, as indicated by the background colours and puzzle-like structure of the model Phase 1: Establishing relationships The facilitator establishes a relationship with the nursing students as a group. The group of nursing students and the facilitator are connected to one another, binding one another in a relationship through their experience of aggression which affects their health (Merriam-Webster Dictionary, 2012; Cambridge Advanced Learner s Dictionary, 2012; Compact Oxford English Dictionary, 2012). The facilitator establishes a formal relationship based on trust with the nursing students who are the experts in their lives. This trust forms the basis that will ensure a secure relationship within a multicultural environment and a process in which the nursing students are most vulnerable as they experience aggression negatively. The nursing students need to truly believe that the facilitator cares for them and empathises and shares with them, and accepts and supports them (Arnold & Boggs, 195

214 2007; Johnson, 2003; Kneisl & Trigoboff, 2009; Morrison-Valfre, 2009; Nadler, 2011). The facilitator must have certain skills and expertise which will be used in this formal relationship with the nursing students. The skills, according to Meyer (2004:36), are people and communication skills. This therapeutic relationship is a conscious relationship between the facilitator and the nursing students, taking the format of a therapeutic alliance (Kneisl & Trigoboff, 2009). According to Raskin, Rogers and Witty (2008:144), the conditions for such a therapeutic relationship are congruency, empathetic understanding and unconditional positive regard. The facilitator, in this case the nursing educator, must manage the process through the nursing students journey in pursuit of constructive self-management of aggression and therefore requires certain characteristics as a facilitator. A positive, friendly and confident facilitator creates a welcoming atmosphere where the nursing students can feel accepted. Kneisl, Wilson & Trigoboff (2004) state that the participants in the facilitation process must become aware of perceptions of the self and those of others. The facilitator s self-awareness implies that the facilitator has the ability to look within objectively, and to be aware of personal and social behaviour and the impact on others (Blom, 2006; Arnold & Boggs, 2007; Morrison- Valfre, 2009). Being aware of their own abilities and knowledge allows the facilitator to be self-confident and thus honest and humble about it. This giving of oneself in a therapeutic relationship enables the nursing students to feel safe and creates trust in the group. 196

215 This relationship is further characterised as warm, friendly with good rapport that is created by the facilitator (agent) with the nursing students (recipients) by demonstrating empathy and genuineness, being consistent and developing unconditional positive regard. Kneisl, et al. (2004) suggest that there should be a willingness to engage with one another by accepting one another without judgement. For the facilitator to establish an intimate and personal relationship with the nursing students, the facilitator must cultivate interpersonal skills such as empathy, respect, warmth and genuineness, to bind the nursing students in this relationship (Kneisl & Trigoboff, 2009; Johnson, 2006; Morrison-Valfre, 2009). The skilful facilitator needs to have knowledge of self-management of aggression, of people and interpersonal relationships, including facilitation and communication skills. In working with people the facilitator utilises the knowledge and skills to safely and effectively guide the nursing students through the process of self-discovery. The facilitator must further have secure knowledge of the culture and ethnicity of the nursing students because interpretations of their expressed thoughts and feelings are influenced by culture and vary across ethnic groups (Arnold & Boggs, 2007; Deffenbacher, 2004; Havenga, 2011; Kneisl & Trigoboff, 2009; Roussel & Swansburg, 2009). The nursing students need to be understood by the facilitator, in relation to their work in the hospital, family and external environment, including their 197

216 social environment as a student as well as their relation to their fellow students (Morrison-Valfre, 2009). The scene is set for the therapeutic relationship by creating a safe psychological environment where feelings and painful emotions can be explored. This includes a safe, quiet and physical environment ensuring privacy (Arnold & Boggs, 2007). The nursing students need to feel safe and accepted during their first contact with the facilitator while the facilitator models thoughtfulness, respect and empathy (Arnold & Boggs, 2007; Blacker, et. al., 2008). The physical environment should make the nursing students feel safe, ensure privacy and provide adequate space for movement when practising actions and interventions during the working phase. It should have enough light and ventilation as well as appropriate comfortable seating for the group of nursing students (Morrison-Valfre, 2009). The first step in establishing a relationship is to make contact with the nursing students, which is done in the therapeutic relationship. The establishing of a relationship starts during the conscious connection by the facilitator on first contact with the nursing students to assist them with their inability to manage aggression themselves as well as at the beginning of each therapeutic session (Kneisl & Trigoboff, 2009; Morrison-Valfre, 2009). The nursing students are introduced to the experienced facilitator during this phase. The facilitator (agent) interacts with the nursing students (recipients) in order to establish therapeutic relationships, where the facilitator focuses energy primarily on the nursing students and the purpose of the process (Morrison-Valfre, 2009). 198

217 At this time boundaries and limitations are established, which are maintained throughout the therapeutic relationship in order to provide structure in the relationship. Basic information such as purpose, nature and time available for the relationship is provided (Arnold & Boggs, 2007; Blom, 2006; Hamilton & Dinat, 2006; Morrison-Valfre, 2009). In this case the group of nursing students must develop a working agreement within their group. Behavioural norms such as confidentiality, mutual respect, attendance and other general and specific norms need to be contracted (Arnold & Boggs, 2007). The facilitator starts to direct the nursing students with knowledge and skills in developing the ability to self-manage aggression constructively. The process of facilitation starts with forming a relationship between the nursing students and the facilitator in an open supportive environment and the realisation of the nursing students that they do not have the ability to manage aggression constructively themselves. Creating awareness of this inability starts with self-awareness. Selfawareness provides an internal frame of reference through intrapersonal communication to relate emotionally. It also offers an external structure to explore and interpret important behavioural conjectures (Arnold & Boggs, 2007; Morrison- Valfre, 2009). In order to explore behaviour the facilitator must create within the nursing students the awareness of the components of behaviour, for example perceptions, thoughts, 199

218 emotions and actions. Behaviour must also be understood in terms of the context and settings in which this behaviour occurs (Dwivedi & Gupta, 2000; Johnson, 2003; Morrison-Valfre, 2009). The facilitator gives the nursing students the opportunity to explore and identify distressing thoughts and feelings and then explore and interpret important behaviour related to these thoughts and emotions. Through reflection on behaviour related to these thoughts and emotions, the meaning of actions and motives is scrutinised. The reflection process of examining and uncovering actions or events in human relationships can place emotions, thoughts, feelings, actions and consequences into perspective. Nursing students will also be able to reflect on whether the feelings and reactions to or during an incident were appropriate or not and whether, after reflection, they could have felt and/or reacted differently (Arnold & Boggs, 2007). This process that begins when the nursing students become aware of their inability to self-manage aggression constructively continues throughout their development on a journey in pursuit of constructive self-management of aggression. It should be kept in mind throughout the therapeutic process. To ensure the utilisation of the therapeutic process by the nursing students, the relationship should be based on the foundation of equal entitlement between them and the facilitator, commitment and acceptance (Havenga, 2011; Morrison-Valfre, 200

219 2009). Therefore the facilitator and nursing students both have shared responsibilities in learning the skills and knowledge. During this phase of the process the relationship of the facilitator and the nursing students is characterised by a dependency of the nursing students on the facilitator. The nursing students, now aware of their inability to manage aggression themselves, need the facilitator to facilitate a mutually beneficial relationship and to assist them in mastering knowledge and skills that will enable them to self-manage aggression. This is suggested in the model (Figure 5.1) by the overlapping of the red narrow point of the red arrow (representing the nursing students) and the broad base of the yellow curved path (representing the facilitator), as well as the close proximity of the two aspects in relation to each other at the beginning of the process Phase 2: Mastering knowledge and skills (working phase) At the beginning of this phase, the facilitator is intensely involved in the facilitation process with the nursing students. As the nursing students gradually attain knowledge and skills and gradually develop self-confidence in their ability to manage aggression constructively themselves, the facilitator and nursing students gradually move apart while the involvement of the facilitator gradually reduces. This is evident in the model (Figure 5.1). The red arrow representing the nursing students gradually broadens while the yellow curved path gradually narrows and the proximity of the two aspects in relation to each other gradually decreases. 201

220 Once a relationship has been established and the nursing students assess how their experience of aggression made them feel and react, the process to assist them manage aggression themselves begins. It is important to maintain the therapeutic relationship during this phase, and the importance of the relationship based on the foundation of a shared responsibility in the learning of the skills and knowledge by the facilitator and nursing students should be emphasised (Morrison-Valfre, 2009). The nursing students are thus active participants in mastering the knowledge and skills, while the facilitator assists them during this phase of the process, keeping in mind that the nursing students need for development must be met during their journey in achieving the ability to self-manage aggression constructively as a whole person. The facilitator assists the nursing students on their journey in the pursuit of constructive self-management by identifying obstacles and mobilising therapeutic interventions. Nursing students assess themselves as a whole human being. This means that because the nursing students function within the environment in an integrated and interactive manner (University of Johannesburg, 2010), their self-awareness within this extended dimension should be facilitated. Self-awareness, according to Johnson (2006), is the ability to focus attention on the self. It allows the nursing students to know and understand themselves. Emotional awareness allows a person to recognize how emotions affect performance and to use one s own values to guide decisions. By being aware of a person s own set of beliefs allows a person to find direction from within. Growing in self-awareness results in understanding why people 202

221 behave in the way they does therefore become aware of their own behavior. Identify thus also what the stimulus is and the response to the stimulus. This can be used to make effective decisions. Self-knowledge and self-understanding thus form the basis of the process of personal growth (Botha, 2006; Helfritz, Stanford, Conklin, Greve, Villemarette-Pittman & Houston, 2006). The facilitator assists and enables the nursing students in developing self-knowledge firstly through maintaining a therapeutic relationship, encouraging mutual respect, confidentiality and a safe emotional environment, and contributing to the intimate process of exploration, identification and understanding. The facilitator assists and empowers the nursing students in developing skills to identify and examine defeating behaviour, and to test alternatives. The facilitator empowers nursing students with skills to solve problems in order for them to make choices based on decisions to cope with activities they encounter during their daily living. By making use of various techniques such as self-awareness exercises and role play, nursing students can be empowered in the ability to change behaviour and overcome resistance behaviour (Gaines & Barry, 2008; Liepe-Levinson, 2004; Liepe-Levinson, 2006; Suppiah & Rose, 2006). Skills are developed and practised, empowering the nursing students to manage aggression themselves positively and creatively. 203

222 Self-awareness is a core competency to obtain self-management. The facilitator will facilitate the process of self-awareness. Emotional self-awareness can be achieved through accurate self-assessment, which requires honesty and courage to face the truth about oneself. Emotional self-assessment involves focusing on the self to gain self-knowledge and self-understanding. It requires the nursing students to become aware of and identify their thoughts, feelings and actions (Botha, 2006; Roussel & Swansburg, 2009). When the nursing students have knowledge of and understand themselves, they can acknowledge how these thoughts and feelings affect their performance. The exercise of self-awareness enables the nursing students to understand how and why they have certain thoughts and feelings in particular situations. Through selfknowledge and understanding, they can recognise and understand why they behave or react in the way they do in a particular situation. Self-awareness is important in fulfilling the need for self-affirmation and acceptance by others, and aids in building meaningful relationships. Self-knowledge and understanding forms the basis for selfdisclosure. Self-disclosure enables an individual to identify actions to be taken, improve social sensitivity and enhance the ability to present oneself appropriately resulting in improved interpersonal relations (Botha, 2006; Johnson, 2003; Roussel & Swansburg, 2009). Through a process of self-reflection the facilitator facilitates self-awareness that allows the nursing students to identify their individual strengths, weaknesses and limitations. Through this process the nursing students can acknowledge which 204

223 strengths, limitations and weaknesses need to be improved and how, and to realise what they have learnt from their own previous experiences. This will permit nursing students to recognise their own individual ability to use their own values to guide their decision-making (Botha, 2006; Nadler, 2011; Roussel & Swansburg, 2009). Self-awareness creates a constant internal monitoring system. This system reports on the person s feelings and reactions to experiences in the present. It also includes knowing and anticipating situations in which they are apt to experience feelings of stress, anger and defensiveness (Botha, 2006; Gallagher & Parrott, 2010; Nadler, 2011; Roussel & Swansburg, 2009). The capacity for good self-management is made possible through emotional selfcontrol. Emotional self-control is the prevention of being hijacked by feelings. That means that people express feelings appropriately in situations that can stimulate anger and frustration. The key to self-control is to be aware of one s own feelings and the consequent decision-making regarding actions. People are not in complete control of their physical and social environments in their daily lives. It is therefore essential for them to be in control of their thoughts, feelings and actions. Emotional control provides emotional resilience in the face of realities and situations (Barkley, 2010; Botha, 2006; Hoyle, 2010; Liepe-Levinson, 2006; Nadler, 2011; Roussel & Swansburg, 2009; Thomas, 2001; Samuel, Watkins, Bleek, & Damarell, 2006). 205

224 The facilitator facilitates self-awareness through techniques and exercises such as self-reflection, feedback in a safe environment, discussions and reflection about situations, behaviour and options. The facilitator needs to remember that the expression of feelings and emotional control vary across ethnic groups. Jordaan and Jordaan (2000) state that self-awareness enables a person to visualise what kind of person they believe themselves to be and what actions they would like to perform in future to actualise themselves. For the nursing students to be selfaware and know and understand themselves as human beings does not provide them with the skills to change. The skills for constructive self-management are built on self-awareness. For the nursing students, this means being in touch with their own self and sensing others feelings (Duval, Silvia & Lalwani, 2001; Nadler, 2011; Roussel & Swansburg, 2009) Phase 3: Attaining knowledge and skills (termination phase) The end result of mastering knowledge and skills in phase 2 should contribute to a situation where the nursing students have insight into themselves to identify and classify the emotions resulting from thoughts and then to make a decision and choices. They have gained power over their feelings, thoughts and emotions to 206

225 transform themselves and to take control of their lives and manage aggression themselves. The termination phase indicates the closure of the therapeutic relationship (Arnold & Boggs, 2007; Kneisl & Trigoboff, 2009) and should be done gradually after assessing readiness for termination (Havenga, 2011). Although the termination of a therapeutic relationship can equate to loss, the termination in itself can be significant to the nursing students experience of a sense of accomplishment, and they will be armed with skills and knowledge enabling them to manage aggression themselves. During this phase the involvement of the facilitator in the facilitation process is minimal as the nursing students have attained the ability to self-manage aggression. Through the process of mastering and attaining the knowledge and skills, the nursing students have restored balance physically, psychologically and spiritually, enabling them to function in an integrated, interactive manner with the environment. Their journey from inability to ability to self-manage aggression, empowered by a process of mastering and attaining knowledge and skills, is associated with identifying emotions and thoughts through the intellectual processes and making decisions that determine choices. This is a dynamic continual journey of self-regulation striving towards wholeness. 207

226 5.10 STRATEGIES FOR IMPLEMENTATION OF THE MODEL IN PRACTICE The following section deals with the operationalisation of the model, which facilitates constructive self-management of aggression by nursing students. The operationalisation follows the three phases of this model, namely establishing relationships, mastering knowledge and skills (working phase) and attaining knowledge and skills (termination phase). The facilitation of this process may lead to the personal growth of the nursing students journey from their inability to selfmanage aggression constructively towards their ability to do so. The following strategies are used for implementing the model in an HEI to assist nursing students in constructive self-management of aggression Establishing relationships (relationship phase) The facilitator establishes a relationship with nursing students as a group during the relationship phase. This relationship forms the foundation for the empowerment of the nursing students in an HEI in Johannesburg in their pursuit of constructive selfmanagement of aggression. 208

227 Objective of the relationship phase The objective of the relationship phase is for the facilitator (nurse educator) to establish a therapeutic relationship with the nursing students as a group in order to initiate the facilitation process Actions in establishing relationships The role of the facilitator is to facilitate the nursing students efforts in such a way that respects their values, personal resources and capacity for self-determination (Joseph, 2010). Creating and sustaining a therapeutic relationship is crucial to facilitate the process to empower nursing students to self-manage aggression constructively (Gallagher & Parrott, 2010; Newell & Gournay, 2009). According to Schwarz and Schwarz (2007), four key values a facilitator needs to internalise in establishing relationships are compassion, commitment, freedom of choice and valid information to group members. The relationship between the facilitator and nursing students can be established by the following: 209

228 The nursing students should be motivated to participate through encouragement and support from the facilitator. The facilitator respects the nursing students freedom of choice to engage in the process to facilitate the ability to self-manage aggression constructively. The nursing students also have the freedom to progress through the process at a speed that they feel comfortable with. A therapeutic environment should be created by forming a safe psychological environment where feelings and painful emotions can be explored. A supportive structure should be built within the relationship, by providing basic information such as purpose, nature and time available for the relationship. The facilitator builds a culture within this group of nursing students. The group of nursing students together with the facilitator have to develop a working agreement within the group. This includes behavioural norms such as commitment, confidentiality, mutual respect and attendance (Arnold & Boggs, 2007; Blom, 2006; Hamilton & Dinat, 2006; Schwarz & Schwarz, 2007). A relationship is established based on the foundation of equal entitlement between the nursing students and the facilitator (Havenga, 2011). The facilitator and nursing students both have shared responsibilities in learning the knowledge and skills. By creating a safe non-judgemental therapeutic environment and relationship, a desire for accurate self-assessment within the nursing students can be created. 210

229 Mastering knowledge and skills (working phase) This phase consists of assisting and empowering nursing students through the facilitation process to master knowledge and skills that will enable them to selfmanage aggression constructively. Dogherty et al. (2010) suggest that facilitation is multidimensional and needs diverse strategies. Consequently a variety of facilitation activities should be deployed to release the inherent potential of the nursing students. These activities can range from distinct task-driven actions to more holistic actions Objective of the working phase The objective of the working phase is to assist and empower the nursing students through the process of facilitation to master knowledge and skills that will enable them to self-manage aggression constructively Actions The nursing students will be assisted and empowered by the facilitator with knowledge and skills through self-awareness strategies to self-manage aggression constructively. The following self-awareness activities will empower and assist the nursing students to acquire knowledge and skills: 211

230 Identify and disclose their own strengths, weaknesses, limitations, thoughts, feelings, behaviour, impact on others, triggers and patterns (Callanan & Perri; 2006; Lawrence, 2006; Maiberger; 2009; Thomas, 2001). Johnson (2003) states that to disclose your feelings means that you have to be aware of them. According to Nadler (2011), if feelings are labelled it reduces the intensity of the feeling and it helps in the acceptance and normalisation of control. Identify their ideal behaviour and the weaknesses in targeted situations (Johnson, 2006; Jordaan & Jordaan, 2000; Roussel & Swansburg, 2009). Develop new mental skills. The brain changes physically in response to experiences and new skills can be acquired with intentional effort and with focused awareness and concentration. Being aware can help to increase choices and solutions. However, it requires mindfulness (Duval, et.al., 2001; Hughes & Miller, 2011; Lind-Kyle, 2009; Sands, 2012). Through mindfulness people can be attuned to themselves and others. Nadler (2011) explains that mindfulness means to pay attention to the here and now and not to be swept away by judgements. It requires being purposefully aware of the external and internal surroundings and internal sensations. The facilitator facilitates the development of skills for constructive self-management of aggression by engaging the nursing students in a process of experiential learning exercises, coaching and self-reflecting exercises. Mindfulness is facilitated through 212

231 exercises enhancing conscious awareness, enabling the nursing students to be brought into the moment and to centre themselves. The facilitator empowers the nursing students with knowledge and skills. As the nursing students ability to self-manage aggression constructively gradually increases by mastering the knowledge and skills, the engagement of the facilitator with the nursing students gradually decreases. This promotes independence within the nursing students, creating self-confidence in their own ability to self-manage aggression constructively Attaining knowledge and skills (termination phase) The process of facilitating the empowerment of the nursing students with knowledge and skills should result in them attaining the knowledge and skills. The nursing students will gain self-confidence through a process of personal growth and change in their own abilities to self-manage aggression constructively as a lifelong journey Objective of the termination phase During the termination phase the objective is to evaluate the attainment of the knowledge and skills and to terminate the therapeutic relationship. The nursing students now have power over their feelings, thoughts and actions to transform 213

232 themselves and to take control of their lives and manage their aggression constructively Actions During the working phase the facilitator facilitated the nursing students through a process of empowering them with knowledge and skills to enable them to selfmanage aggression. The attainment of knowledge and skills to self-manage aggression constructively needs to be evaluated. The facilitator facilitates the process of evaluation by: creating the context of self-evaluation and self-reflection regarding their experience of aggression, having attained the knowledge and skills to enable them to self-manage aggression; exploring and discussing the nursing students personal growth in the process through which they control their thoughts, feelings and actions; facilitating, through a process of self-reflection and self-evaluation, the nursing students willingness to practise new behaviour as well as their ability to present themselves appropriately in socially sensitive situations. 214

233 The termination of the process to facilitate constructive self-management of aggression will be guided by the nursing student. Closure in the relationship is reached and the nursing students have gained power over their feelings, thoughts and emotions to transform themselves and to take control of their lives and manage their aggression constructively EVALUATION OF THE MODEL This model was critically evaluated according to Chinn and Kramer s evaluation criteria (2011). A panel of 11 experts evaluated the model during a presentation by the researcher as part of the current study. The panel had an extensive and critical discussion after the presentation of the model. The experts then wrote a report of their evaluation of the model presented to them. The panel consisted of a number of people with many years experience in research and supervising students. The panel of experts included four professors. One of these had successfully supervised more than 104 PhD candidates. Another professor had supervised more than 90 PhD candidates. Three of the professors were also extensively involved in the teaching of research methodology at an HEI. All of them were also experts in qualitative and theory development methods. 215

234 The panel represented the diversity of the country. The participants were from various nursing specialities, for example critical care, psychiatric nursing, nursing education, community health nursing, as well as from other domains within HEIs. Some of the panel member s expertise included aggression and violence, as a niche area of research. Most of the participants on the panel had doctoral degrees, some were in the process of acquiring doctoral degrees and a few were novice researchers. The questions to critically reflect on a theory (Chinn & Kramer, 2011:205) covered the following areas: Clarity This question focused on the clarity and consistency of the presentation, both semantic and structural. Although the members of the panel concluded that the model was clear and easy to understand, some suggestions were made to increase clarity. Clear intended connections between concepts 216

235 Model is clear and self-explanatory Specific reference was made to the structural representation of the agent and the recipient. The agent and recipient needed to be indicated on the structure of the model. semantic clarity needs to be aligned with the structural clarity Identify the agent and recipient by indicating them on the model The researcher examined the feedback and made changes accordingly Simplicity This question focused on the number of structural components and relationships within the theory. The panel concluded that the model was simple and easy to follow. The concepts and their relationships were clear and understandable. 217

236 Model easy to follow and not to crowded The visual explanation very good easy to understand the different components and integration there off Generality This question focused on the scope of the experiences covered by the theory. The focus of the research was within an identified context. The specific context of the study was the multicultural environment of nursing students in an HEI. Through the various presentations of this research it became apparent that this could be valuable in other settings as well. The following remarks were made by the panel: this is applicable to more groups of people than just nursing students Model can be used in other context 218

237 The ability to constructively self-manage aggression as a life-long journey will influence the student as professional later in life I think that it is very valuable for nursing students can extend to all courses where there is a practical component and where students have to work together (not only students other groups of people as well) Accessibility The question focused on the extent to which concepts were grounded in empirically identifiable phenomena. The accessibility was confirmed by the following: It can be accessible to other disciplines it will be accessible and useful From the evidence of the reports of the panel it can therefore be concluded that this model s use is not just limited to the domain of nursing and nursing practice. 219

238 Importance This question focused on the extent to which the theory led to valued nursing goals in practice, research and education. The members of the panel agreed that this model was very important and made the following comments: Model is important it assist individuals with an internal locus of control and autonomy in making decisions when expose to aggression Aggression is part of life. Therefore important very useful in all areas of nursing education, clinical all fields From the evaluation of the panel as discussed, it is evident that the model complies with the criteria of Chinn and Kramer (2011). It met the criteria in that it is clear, simple, general, accessible and important. This evaluation confirms that the purpose of the research was achieved in the formulation of the model to facilitate constructive self-management of aggression experienced by nursing students as a lifelong journey. 220

239 5.12 CONCLUSION In this chapter the structure of the model to facilitate constructive self-management of aggression by nursing students at an HEI was discussed. The purpose, context of the model and the assumptions on which the model was based were described. Concepts were identified and the relationships between the concepts were explained. Strategies for the implementation of the model were outlined and the model was evaluated and the results discussed. The next chapter will contain the conclusions, recommendations and limitations of the research. 221

240 CHAPTER 6 CONCLUSIONS, RECOMMENDATIONS AND LIMITATIONS OF THE RESEARCH 6.1 INTRODUCTION In the previous chapter the model as a frame of reference for the facilitation of constructive self-management of aggression experienced by nursing students at an HEI in Johannesburg was described and evaluated. Strategies were proposed for implementation of the model in practice. In this chapter conclusions will be drawn, recommendations will be proposed and the limitations of the research will be discussed. 6.2 CONCLUSIONS OF THE RESEARCH The purpose of this study was to develop and describe a model as a frame of reference to facilitate the health of nursing students at an HEI in Johannesburg who experience aggression in their lives. In order to achieve the purpose of the research the following questions were asked: 222

241 What is the nursing students experience of aggression in their lives? What can be done to facilitate the health of nursing students who have experienced aggression in their lives? A qualitative, descriptive, contextual and theory-generating research design was used to achieve this purpose. The objectives for this research study were derived from the above questions. The manner in which the study met these objectives will now be determined. The objectives were as follows: To explore and describe the experience of nursing students at an HEI in Johannesburg of aggression in their lives. To generate a model from the results that will facilitate the health of the nursing students at an HEI in Johannesburg who have experienced aggression. To formulate strategies for the implementation of the model. 223

242 6.2.1 First objective To explore and describe the experience of nursing students at an HEI in Johannesburg of aggression in their lives The experiences of the nursing students of aggression in their lives were described in Chapter 3. The researcher allowed nursing students to report their experience of aggression by using their own creativity and drawing pictures of their experience of aggression and by writing a self-reporting story on the drawing. Nursing students also had the opportunity to voice their experience of aggression during a phenomenological interview. The researcher analysed and categorised the findings. Independent coders validated the findings, ensuring the legitimacy and truth of the findings. The data was contextualised and a literature review was done. The comprehensiveness of the literature validated the findings. It became clear that aggression is experienced as detrimental to the nursing students themselves and their interpersonal relationships as whole persons. Nursing students lacked the emotional control as well as knowledge and skills to manage aggression themselves. Consequently, aggression impacted on them as a whole person and influenced their relationships. Aggression was therefore problematic and could be detrimental to their health as a whole person. It became evident that 224

243 nursing students need assistance in the management of aggression as they experience it in their lives Second objective To generate a model from the results that will facilitate the health of the nursing students at an HEI in Johannesburg who have experienced aggression The model as a frame of reference to facilitate constructive self-management of aggression experienced by nursing students was developed on a practice theory level (Walker & Avant, 2005) and the survey list of elements according to Dickoff et al. (1968) was included in the theory. Therefore for this study a combination of the methods of Chinn and Kramer (2008), Dickoff et al. (1968) and Walker and Avant (2005) was used. The research took the following steps: Concept analysis, relationship statements, description of the model and the strategies for implementation of the model (Chinn & Kramer, 2008). A full description of the research methodology that applied to this research was offered in Chapter 2. The development of the model was described in Chapter 4. The concept of the facilitation of constructive self-management of aggression experienced by nursing 225

244 students was defined. Definitions of the central concepts and relationship statements between central and essential concepts were given. Chapter 5 provided the final model as a frame of reference to facilitate constructive self-management of aggression experienced by nursing students at an HEI in Johannesburg. This model was described in detail. A visual representation illustrated the structure of the model. The context, purpose, relationship statements and assumptions were described Final objective To formulate strategies for the implementation of the model Strategies for the implementation of the model with regard to the different objectives and actions needed to implement the model in practice were described in Chapter CHALLENGES OF THE RESEARCH The broad scope of the research in which nursing students shared their experience of aggression in their lives meant that the data was not focused on just either their experience in the work environment or their lives as students or their lives as member of a family. That being said, the point of departure of this model was that a 226

245 human being is seen holistically in interaction with the external and internal environment in an integrated manner. The normalising of aggression could have clouded the participants experiences of aggression and what they could have experienced as normal. Due to the nature of the topic, follow-up interviews with all the participants could have provided a broader understanding of their experiences of aggression. The model and strategies for the implementation of the model have not been assessed in clinical nursing practice, nursing education or in nursing research. This model can therefore be viewed as unconfirmed and evolving until it has been tested and operationalised. 6.4 RECOMMENDATIONS FOR NURSING PRACTICE, EDUCATION AND RESEARCH The development of the model to facilitate constructive self-management of aggression experienced by nursing students in South Africa has highlighted some implications for nursing practice, research as well as nursing education. Recommendations will now be presented accordingly. 227

246 6.4.1 Recommendations for nursing practice This model can be used in either a private or a public HEI that trains nursing students in South Africa. It has value in guiding the actions of facilitators, in order to facilitate constructive self-management of aggression to promote the health of nursing students in practice. It is recommended that facilitators with the necessary skills be identified from among nurse educators and that they agree to the responsibility of being a facilitator of nursing students. This will ensure that nursing students at an HEI receive the benefit of the empowerment that will enable them to self-manage aggression constructively as they experience it in their lives. The researcher believes that the implementation of the model in nursing practice can promote wholeness. The experience of aggression has a negative impact on nursing students as an integrated person in interaction with their internal and external environment. The model assists and empowers nursing students with knowledge and skills to increase their awareness of their thoughts, emotions and actions. The model can therefore be used to empower nursing students to manage aggression in their lives 228

247 with newer and more effective ways on the multidimentional levels of their interaction with their internal and external environment. The researcher also believes that this model can be of benefit to not just nursing students, but to the broader nursing, student and general community. The ability to self-manage aggression constructively can be beneficial to everybody in a community experiencing aggression. The model can therefore be of value to a much wider range of recipients. During the in-depth discussion of the model by the panel of experts, the participants highlighted and concurred that this was indeed the value of the model. The model could further be assessed in various other clinical fields such as community health nursing and in the primary health setting. The researcher believes that in a society riddled with aggression, each and every person has the potential for change. The lack of self-awareness, emotional control and the inability to self-manage aggression constructively could be contributing factors to the experience of aggression. A small group of nursing students can start to make a difference when they have the ability to self-manage aggression constructively. If they model their ability to self-manage aggression constructively through change, it could motivate others to want to achieve the same. Every small achievement is a motivation to try again. Anonomous. 229

248 6.4.2 Recommendations for nursing education This model can be utilised within nursing education to help new nurses who are commencing nursing education programmes to develop the ability to self-manage aggression constructively. Hopefully this will have a positive impact on their interpersonal relationships as students and at their clinical training facility and will promote the wholeness of the nurses. The development of the knowledge and skills should be included in the curriculum of nursing education programmes, so that nurses that graduate have the ability to selfmanage aggression in their lives constructively. They can consequently form therapeutic relationships with their patients and their colleagues, deliver holistic care, develop empathy, set boundaries and be professionally whole. The inability to self-manage aggression constructively is not just limited to nursing students. Like nursing students, they also function on multidimensional levels and experience aggression. As nurse educators and clinical tutors working with nursing students on various levels of interaction, they can thus also benefit from this model and by self-managing aggression constructively and being professionally whole. 230

249 6.4.3 Recommendations for nursing research It is recommended that further research on the current model be encouraged, so that refinement and adjustment in practice can take place. With further research the relationship statements in this model can be analysed and adjusted for implementation in various other contexts. There has been limited research undertaken in South Africa on the implementation and evaluation of self-management of aggression in nursing students and this could be further explored through research. The following research areas can be recommended regarding the research of constructive self-management of aggression and the nursing students experience of aggression and nursing within South Africa: The nursing students cultural influence on their experiences of aggression. A comparison regarding the nursing students experience of aggression within the different year groups. The development and the impact of a programme for the facilitation of constructive self-management for nursing students. 231

250 A comparison of nursing students that engaged in the process to facilitate constructive self-management of aggression and those nursing students that did not take part in the facilitation process. 6.5 ORIGINAL CONTRIBUTION OF THIS RESEARCH This model was developed to provide a frame of reference to facilitate constructive self-management of aggression experienced by nursing students at an HEI in Johannesburg. The contribution towards knowledge lies in the development and attainment of knowledge and skills to self-manage aggression constructively. The study contributes to the development of the nursing students as individuals and interpersonal relationships through self-awareness. Within nursing practice, this model provides a unique foundation for attaining new knowledge and skills to self-manage aggression as a dynamic and continuous process of self-regulation. The description and strategies to operationalise the model provide a base of understanding for those who wish to facilitate the health of nursing students who experience aggression through facilitation of constructive selfmanagement of aggression. This contributes to the health of the nursing students, brought about by self-awareness of thoughts, feelings and consequent actions to build meaningful relationships as an integral person. 232

251 6.6 CLOSING REMARKS In this study the research purpose has been achieved. Nursing students can embark on a journey of self-discovery through a process that will facilitate constructive selfmanagement of aggression. They start from a point of being unable to deal with aggression and move to a point where they attain knowledge and skills enabling them to self-manage aggression constructively as a lifelong journey. In this last chapter conclusions and recommendations have been made. The limitations of the research were explained. The facilitation of constructive self-management of aggression in nursing students is a new, important and fascinating challenge. The attainment of the knowledge and skills in the lifelong journey to self-manage aggression constructively takes time and patience and cannot be rushed. Change is difficult and needs constant practice and motivation. Human beings are always in the process of becoming, and they have the capacity for awareness and freedom and responsibility to make choices. They are always striving for identity, meaning and relationships to others (Okun, 2002). 233

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292 ANNEXURE A: Consent letter FACULTY OF HEALTH SCIENCE DEPARTMENT OF NURSING SCIENCE TEL: FAX: Dear Participant REQUEST CONSENT TO CONDUCT RESEARCH I am Wanda Jacobs, a D CUR (student) in Nursing at a tertiary institution of Johannesburg and am currently engaged in a research project entitled: Strategies to facilitate the promotion of the health of student nurses at a higher education institution (HEI) in Johannesburg who has experienced aggression. This research is conducted under the supervision of Professor M Poggenpoel (Department of Nursing Science) and co-suppervision of Professor CPH Myburgh. The objective of this study is the development of strategies to facilitate the health of nursing students experiences of aggression and are studying at a tertiary institution. The purpose of the strategies is to use the strategies to facilitate the health of nursing students who have experienced aggression and are studying at a tertiary institution. You are hereby invited to participate in the above-mentioned research. 274