Merly Theresia Mammachan

EFFECTIVENESS OF SELF-INSTRUCTIONAL MODULE ON
KNOWLEDGE REGARDING MANAGEMENT OF
PSYCHIATRIC EMERGENCIES AMONG 2nd YEAR P. C. B. Sc.
NURSING STUDENTS OF A SELECTED COLLEGE OF
NURSING AT MANGALORE
By
MERLY THERESIA MAMMACHAN
Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka
In partial fulfilment
of the requirements for the degree of
Master of Science
in
PSYCHIATRIC NURSING
Under the guidance of

Mr. Rajarathinam.P, M. Sc. (N)
Asst. Professor
Department of Psychiatric Nursing
Athena College of Nursing
Mangalore
2012
DECLARATION BY THE CANDIDATE
I, Merly Theresia Mammachan that this dissertation/thesis titled
“Effectiveness of self-instructional module on knowledge regarding Management
of Psychiatric Emergencies among 2nd year P. C. B. Sc. nursing students of a
selected college of nursing at Mangalore” is a bonafide and genuine research work
carried out by me under the guidance of Mr. Rajarathinam. P, M.Sc. (N), Assistant
Professor, Department of Psychiatric Nursing, Athena College of Nursing,
Mangalore.
Date: 8.2.2012
Place: Mangalore Merly Theresia Mammachan
ii
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation titled “Effectiveness of self-
instructional module on knowledge regarding Management of Psychiatric
Emergencies among 2nd year P. C. B. Sc. nursing students of a selected college of
nursing at Mangalore” is a bonafide research work done by Merly Theresia
Mammachan in partial fulfilment of the requirement for the degree of Master of
Science in Nursing.
Mr. Rajarathinam. P
Date: 8.2.2012 Asst. Professor
Place: Mangalore Department of psychiatric nursing
Athena College of nursing
iii
ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE
INSTITUTION
This is to certify that the dissertation titled “Effectiveness of self-
nursing at Mangalore” is a bonafide research work done by Merly Theresia
Mammachan under the guidance of Mr Rajarathinam.P, M.Sc. (N), Asst.
Professor, Department of Psychiatric Nursing, Athena College of Nursing,
Mangalore.
Seal & signature of the HOD Seal & signature of the Principal
Dr.(Sr) Alphonsa Ancheril Sr. Ann Rose D’Almeida

Professor & HOD Principal
Dept. of psychiatric Nursing Athena College of Nursing
Date: 8.2.2012 Date: 8.2.2012

Place: Mangalore Place: Mangalore
iv
COPYRIGHT
Declaration by the Candidate
I hereby declare that the Rajiv Gandhi University of Health Science,

Karnataka shall have the rights to preserve, use and disseminate this
dissertation/thesis in print or electronic format for academic/research purpose.
Date: 8.2.2012
Place: Mangalore Merly Theresia Mammachan
© Rajiv Gandhi University of Health Sciences, Karnataka
v
ACKNOWLEDGEMENT
With all my heart I will say to the Lord, “There is no one like you. You protect the
weak from the strong, the poor from the oppressor” [Psalm 35]
With immense joy and gratitude I raise my heart in praise and thanks giving to
God Almighty for his manifold graces and blessings showered on me all through this
study.
It is my pleasure and privilege to give sincere thanks to all those who have
contributed to the successful completion of this endeavour.
I express my deep sense of gratitude to my Guide, Mr. Rajarathinam.P
Assistant Professor, Department of Psychiatric Nursing, Athena College of
Nursing for his expert guidance, valuable suggestions, constant encouragement and
illuminating guidance to make the work a successful learning experience. His
tremendous support and timely help served as source of inspiration to explore.
I express my sincere thanks to Dr (Sr) Alphonsa Ancheril, Professor, HOD,
Department of Psychiatric nursing, Athena College of Nursing for her constant
guidance, scrutinizing skills and support that kept me in track. She has made a sincere
effort in moulding the investigator’s raw thinking by providing valuable suggestions
and making this project a fruitful and successful learning experience.
Extensive sense of gratitude is due to Sr. Ann Rose D’Almeida, Principal,
Athena College of Nursing. Her tremendous support and timely help served as source
of inspiration to explore. Her positive strokes have helped to shape the study in many
ways.
vi
It is my privilege to express my sincere gratitude to Mr. R. S Shettian,
Chairman and Mrs. Asha Shettian, Secretary for giving me an opportunity to
undertake the course at Athena Institute of Health Sciences, Mangalore.
I express my sincere thanks and appreciation to Mrs. Sonia Lobo, lecturer
Department of Psychiatric Nursing, Athena College of nursing Mangalore for the
love, constant support and timely assistance rendered for the fruitful completion of
this study.
I express my sincere thanks to the participants who formed the core and basis
of this study for their whole hearted co-operation in participating in this study.
I am grateful to Principal and staff members of Athena College of Nursing
and City College of Nursing for granting me permission to conduct the study and for
the support throughout the study.
I acknowledge with sense of gratitude to Mr. Suresh, Statistician for his
approachable nature, immense help, and direction in the statistical analysis needed for
the study.
Thanks to the library staff of Father Muller Medical College Mangalore, and
Athena college of Nursing, Mangalore for providing help with library facilities.
Grateful acknowledgements to all the experts who validated the tool and self
instructional module, for their judgment and constructive criticism
My Sincere thanks to Mr. Roshan and Miss Sheethal. M. Raj for the effort
taken to prepare the manuscript.
vii
Thanks to 18th batch B.Sc (N) students of P. G. College of Nursing. Bhilai,
for their constant prayer and support.
Special thanks to all my classmates, friends and the members of Athena
institution especially Ms. Bency Baby Thakarapallil, for their co-operation and
assistance in making this study a pleasant learning experience.
My wholehearted thanks to my parents Mr. T. Mammachan &
Mrs. Annamma Mammachan, and my sister Ms. Merin Sara Mammachan for
their constant prayers and support. They have made this endeavour possible through
their love, patience and concern.
My sincere thanks and gratitude to all those who directly or indirectly helped
me in the successful completion of this thesis and to make this learning experience a
memorable one.
Date: 08-02-12
Place: Mangalore Ms. Merly Theresia Mammachan
viii
LIST OF ABBREVIATIONS
χ2: Chi-Square
P.C.B.Sc.: Post Certificate Bachelor of Science
r: Reliability
RGUHS: Rajiv Gandhi University of Health Sciences
SD: Standard Déviation
SIM: Self Instructional Module
WHO: World Health Organisation.
ix
ABSTRACT
Background and objectives
A psychiatric emergency is an acute disturbance of behavior, thought or mood
of a patient which if untreated may lead to harm, either to the individual or to others
in the environment. Emergency psychiatry is the clinical application of psychiatry in
emergency settings. Conditions requiring psychiatric intervention may include
attempted suicide, severe depression, aggressive behavior, epilepsy or other rapid
changes in behavior. The demand for emergency psychiatric services has endured a
rapid growth throughout the world Since 1960s. Psychiatric emergency services are
rendered by professionals in the field of medicine, nursing, psychology and social
work. The actual number of psychiatric emergencies has also increased significantly,
especially in psychiatric emergency service settings located in urban areas.
Aim
The aim of this study is to assess the effectiveness of self-instructional module
(SIM) on management of psychiatric emergencies.
Objectives of the study
The objectives of the study are to:
1. Assess the knowledge level of 2nd year P. C. B. Sc. nursing students regarding
the management of psychiatric emergencies as measured by structured
knowledge questionnaire.
x
2. Evaluate the effectiveness of self-instructional module on management of
psychiatric emergencies in terms of gain in mean post-test knowledge score of
2nd year P.C. B. Sc. nursing students.
3. Find out association between the mean pre-test knowledge score of 2nd year
P.C. B. Sc. nursing students regarding management of psychiatric emergencies
and selected socio demographic variables (age, sex, years of work experience,
area of experience).
Methods
A pre experimental one group pre-test – post-test design was used for the
study. The sample consisted of 48 subjects selected by convenient sampling
technique. A structured knowledge questionnaire was used to collect the data. After
the pre-test a SIM was administered to the subjects and on the seventh day post – test
was conducted with the same knowledge questionnaire. The collected data was
analyzed by using descriptive and inferential statistics.
Result
The mean post test knowledge scores obtained by subjects (28.22) was higher
than the mean pre - test score (15.55). In the pre-test only 25% had good knowledge
score and no one had excellent knowledge score, whereas in the post-test 83.3% had
excellent knowledge score. Paired ‘t’ test was done to find out the significant
difference between mean pre-test and mean post-test knowledge score was found
highly significant (t47 = 20.33, p<0.001). There was no significant association
between student nurses knowledge regarding management of psychiatric emergencies
xi
and selected socio demographic variables (age, sex, years of work experience, area of
experience) at 0.05 level of significance.
Interpretation and conclusion
Finding of the study showed that the knowledge scores of student nurses were
very poor before the introduction of SIM. The SIM facilitated them to increase their
knowledge regarding management of psychiatric emergencies which was evident in
post test knowledge scores. Hence SIM was an effective strategy for providing
information and to improve knowledge of student nurses.
Keywords
Knowledge; effectiveness; self-instructional module; psychiatric emergencies;
2nd year P. C. B. Sc. nursing students.
xii
TABLE OF CONTENTS
Chapter
No. Title Page No.
1. Introduction 1-5
2. Objectives 6-13
3. Review of literature 14-28
4. Methodology 29-45
5. Results 46-57
6. Discussion 58-62
7. Conclusion 63-67
8. Summary 68-70
9. Bibliography 71-77
10. Annexure 78-136
xiii
LIST OF TABLES
Table
No. Title Page No.
1. Frequency and percentage distribution of samples according to 48

demographic characteristics
2. Grading of pre-test and post-test knowledge scores of subject 51
3. Area-wise mean percentage of pre-test and post-test knowledge 52

scores and mean percentage gain
4. Significant difference between the mean pre-test and post-test 54

knowledge score
5. Area-wise paired‘t’ test showing significant difference between 55

the mean pre-test and post-test knowledge scores regarding
management of psychiatric emergencies
6. Association between mean pre-test knowledge scores and 56

selected variables
xiv
LIST OF FIGURES
Fig.
No. Title Page No.
1. Conceptual frame work based on general system theory (Ludwig 12

Von Bertalanffy 1968)
2. Schematic representation of study design 30
3. Schematic representation of different phases of study 31
4. Bar diagram showing the distribution of sample according to 49

their age
5. Pie diagram showing the distribution of sample according to 49

their sex
6. Cylindrical diagram showing the distribution of samples 50

according to their total years of experience
7. Cylindrical diagram showing the distribution of samples 50

according to their area of experience
8. Bar diagram showing the pre-test and post-test knowledge level 51

of the subjects
9. Bar diagram showing area-wise pre-test and post-test knowledge 52

scores of student nurses
xv
LIST OF ANNEXURES
Annexure
No. Title Page No.
1. Letter requesting permission to conduct pre-testing and 78

reliability and pilot study
2. Letter requesting permission to conduct the main study 79
3. Letter requesting for expert opinion to establish content 80

validity of the research tool and SIM
4. Content Validation Certificate 81
5. Acceptance form for tool validation 82
6. Criteria checklist for validation of the tool 83
7. Blueprint of Structured Knowledge Questionnaire 85
8. Consent form 86
9. Tool 87
10. Key answer for knowledge questionnaire 93
11. Grading of knowledge 94
12. Acceptance form for SIM 95
13. Content validation certificate (SIM) 96
14. Criteria check list for evaluation of SIM 97
15. Self instructional module 99
16. List of Validators 130
17. Master data sheet- Pre-test 132
18. Master data sheet- Post-test 134
19. Statistical formulas 136
xvi
1. INTRODUCTION
Background of the study
Emergencies may be classified as major, where there is a danger to life
either of the patient or to others in his environment or minor where there is no
threat to life but causes severe incapacitation. Emergency psychiatry is the
clinical application of psychiatry in emergency settings. Conditions requiring
psychiatric intervention may include attempted suicide, severe depression,
aggressive behaviour, epilepsy or other rapid changes in behaviour. The demand
for emergency psychiatric services has endured a rapid growth throughout the
world Since 1960s. The actual number of psychiatric emergencies has also
increased significantly, especially in psychiatric emergency service settings
located in urban areas.1

A psychiatric emergency is an acute disturbance of behaviour, thought or
mood of a patient which if untreated may lead to harm, either to the individual
or to others in the environment. Thus the definition of a psychiatric emergency
differs from other medical emergencies in that the danger of harm to the society
is also taken into account.1
Psychiatric disorders are common in medical inpatient and outpatient
populations. As with all medical problems, a good history, including a collateral
history from relatives and friends, physical and mental status examination, and
appropriate laboratory tests help establish a preliminary diagnosis and
treatment plan. Of all patients who commit suicide, 70% have a major
depressive disorder. Patients who are at great risk have minimal supports, a
history of previous suicide attempts, a plan with high lethality, hopelessness,
1
psychosis, paranoia, and/or command self-destructive hallucinations. Other
psychiatric emergencies include psychotic and violent patients. Patients who are
agitated or psychotic need rapid tranquilization with an intramuscular
neuroleptic every half hour to 1 hour until the agitation and combativeness are
under control. Psychiatric emergency condition is common and the patient needs
proper care and treatment.2
An article on Management of the psychiatric emergency issued by
University of Pittsburgh School of Nursing provides concrete, practical
information designed to increase the knowledge base of the health care provider
who works with psychiatric emergencies. Numerous treatment aspects are
addressed, including assessment of psychiatric emergencies and intervention
principles. The article emphasizes need for specialized emergency care. The
article includes a discussion of frequently used psychiatric emergency
medications and their effects and side effects and legal issues integral to
psychiatric emergency care also included confidentiality and involuntary
commitment, are addressed.3

A study on the triage of psychiatric patients in the hospital emergency
department: a comparison between emergency department nurses and
psychiatric nurse consultants was done in Australia. The triage process has been
found to be less effective for patients presenting with mental health related
problems. The findings showed that all presentations to the ED for psychiatric
problems (n = 137) were triaged using the mental health guidelines over a 3-
month period. The same presentations were triaged by psychiatric nurse
consultants employed in the ED and the results compared. These findings suggest
that mental health education for emergency nurses is necessary if the guidelines
2
are to be used effectively and improve outcomes for patients presenting with
psychiatric problems.4
Psychiatric emergency services are rendered by professionals in the field
of medicine, nursing, psychology and social work. Professionals working in
psychiatric emergency service setting are usually under a high risk of violence
due to mental state of their patients. So thorough knowledge regarding
management of psychiatric emergency is needed for proper care and service.
Need for the study
An emergency is defined as an unforeseen combination of circumstances
which call for an immediate action. A psychiatric emergency is a disturbance in
thought, mood and action which cause sudden distress to the individual and or
sudden disability, thus requiring immediate management. This has become a
challenging field in the face of rise in incidence of violence, rape, abuse,
addiction, and murder in the society.1
In the last decade emergency departments have seen a dramatic rise in
the presentation for mental health-related issues. In 2007, 3.2% of the
presentations were mental health-related issues. This is over 1,90,000
presentations. The emergency department is well suited for people with mental
illness to be attended, related to its 24 hours 7 days a week accessibility. It is
estimated that 75% of mental healthcare is provided in the physical care sector,
with limited access to specialist support.5

The major psychiatric emergencies are suicide, aggressive behaviour,
depression and epilepsy. Suicide has become an important public health concern
worldwide. It is currently one of the most important causes of death in Asia,
3
Europe and North America. In India, according to the National Crime Bureau,
14 lakh suicides takes places every hour and more than 1,25,017 persons die by
suicide in our country. In the last decade, the suicide rate has increased from 7.9
to 10.8 per 1,00,000 populations. Research findings in both western and local
studies show that as many as 30% to 70% of those who died by suicide had
consulted a doctor within one month prior to their death. So health team
members play a very important role in suicide prevention and intervention6
A study related to aggressive behaviour showed that nurses were most
commonly targeted and involved in 57.1% of incidents. The most frequent
provocation of the aggression was the patient being denied something such as
leave from the ward (29.5% of incidents).The most frequent means used by the
patient was verbal aggression (60% of incidents) and verbal intervention were
used most frequently to manage the aggressive behaviour (43.7%).7
A study was conducted to determine the severity and relationship of
depression, hopelessness, and suicide intent in individuals attempting suicide in
an emergency department in north India. The finding showed that
organophosphorous consumption and drug overdose was the most common
method (75%) to attempt suicide. Psychiatric illness was present in 57% cases,
depression being most common in 37.5% cases.8
A study conducted in Taiwan showed that there were significantly higher
levels of state anxiety among psychiatric nurses when patients exhibited verbal
and physical aggression rather than just physical aggression. An important
outcome of this study was the added understanding of cognitive appraisal trait
anxiety and attitude that influence the management of psychiatric emergencies.9
4
Psychiatric emergency conditions are increasing and need immediate
management and care. Health personnel should have adequate knowledge to
provide emergency care. Nurses are the people who work with the patients 24
hours a day and 7 days a week. Student nurses are the future staff nurses. If they
are provided with sufficient knowledge regarding the management of psychiatric
emergencies, they will be able to provide immediate care and minimise
complications. The investigator, from her own experience, review of literature,
and discussion with experts realised that psychiatric emergency is increasing
more and more, and nurses are not well prepared to meet these emergencies.
Therefore, the investigator felt the need to assess the knowledge of students
regarding psychiatric emergencies and to provide a self-instructional module to
improve their knowledge.

Statement of the problem
Effectiveness of self-instructional module on knowledge regarding
Management of Psychiatric Emergencies among 2nd year P. C. B. Sc. nursing
students of a selected college of nursing at Mangalore.
Summary
This chapter has dealt with the introduction, need for the study and
statement of the problem. The following chapter deals with the objectives of the
study, which would provide direction for carrying out this study.
5
2. OBJECTIVES
This chapter deals with main objectives of the study, concepts involved
and conceptual frame work on which the study is based.
Statement of the problem
Effectiveness of self-instructional module (SIM) on knowledge regarding
Management of Psychiatric Emergencies among 2nd year P. C. B. Sc. nursing
1. Assess the knowledge level of 2nd year P. C. B. Sc. nursing students
regarding management of psychiatric emergencies as measured by
structured knowledge questionnaire.
psychiatric emergencies in terms of gain in mean post-test knowledge
score of 2nd year P. C. B. Sc. nursing students.
3. Find out association between the mean pre-test knowledge score of 2nd
year P.C. B. Sc. nursing students regarding management of psychiatric
emergencies and selected socio demographic variables (age, sex, years of
work experience and area of experience).
6
Operational definitions
Knowledge: The correct responses of student nurses regarding the management
of psychiatric emergencies as measured by a structured knowledge
questionnaire.
Effectiveness: The extent to which the self-instructional module has achieved the
desired effect as elicited by the difference in mean post-test knowledge score and
mean pre-test knowledge score.
Self-instructional module: It is a self-learning guide in English prepared by the
investigator for 2nd year P. C. B.Sc. nursing students, which deals with different
types of psychiatric emergencies and their management.
Psychiatric emergencies: It refers to psychiatric conditions which are acute in
nature leading to threat to oneself or threat to others like suicide, aggressive
behaviour, severe depression, and epilepsy.
2nd year P. C. B.Sc. nursing students: It refers to male or female individuals, who
are studying 2nd year Post Certificate B.Sc. Nursing course in a private nursing
college of Mangalore.
Variables under study
Independent variable: In this study, it is self-instructional module regarding
management of psychiatric emergencies.
Dependent variable: In this study, it is knowledge of 2nd year P. C. B. Sc. nursing
students regarding management of psychiatric emergencies.
7
Extraneous variable: In this study, it is age, sex, total years of work experience
and area of experience.
Assumptions
• Students studying in 2nd year P. C. B. Sc. nursing will have some
knowledge regarding management of psychiatric emergencies.
• Self-instructional module is an accepted strategy of teaching.
Hypotheses
All hypotheses will be tested at 0.05 level of significance.
H1 : The mean post-test knowledge score of 2nd year P. C. B. Sc. nursing
students regarding management of psychiatric emergencies will be
significantly higher than their mean pre-test knowledge score.
H2 : There will be significant association between the mean pre-test knowledge
score of 2nd year P. C. B. Sc. nursing students regarding management of
psychiatric emergencies and selected socio-demographic variables (age,
sex, years of work experience and area of experience).
Conceptual framework for the study
Conceptual framework presents a broad, general explanation of the
relationship between the concepts of the research study, based on an existing
theory. Conceptual framework deals with abstract that are assembled by virtue
of their relevance to common theme. A conceptual framework states functional
relationships between events and is not limited to statistical relationship.10
8
This study is intended to evaluate the effectiveness of self instructional
module on management of psychiatric emergencies among 2nd year P. C. B. Sc.
nursing students in a selected college of nursing at Mangalore.
The conceptual framework of the present study is based on general
system theory with input, process, output and feedback. This theory was
introduced by Ludwig Von Bertalnffy (1968).11
According to system theory, a system is a group of elements that interact
with one another in order to achieve the goal. An individual is a system because
he/she receives energy and information as input from the environment and
releases them to the environment. The inputs when processed provided an output
and continue to be so, as long as the input, process, output and feedback keep
interacting. If these are changes in any of the parts, there will be change in all the
parts. Feedback from within the system or from the environment provides
information, which help the system to determine whether it meet its goal.11
In this study this concepts are explained as follows
Input
It is the process by which system receives information, energy or matter
from the environment for a system to work well; input should contribute to
achieve the purposes of the system.
In this study it refers to student nurse selected socio demographic data
(age, sex, total years of work experience and area of experience) and self
instructional module, on management of psychiatric emergencies, which may
influence the knowledge of 2nd year P. C. B. Sc. nursing students.
9
Process
It refers to action needed to accomplish the derived task. To achieve the
derived output, that is to evaluate the effectiveness of the self instructional
module on management of psychiatric emergencies.
1. Assess knowledge of 2nd year P. C. B. Sc. nursing students regarding
management of psychiatric emergencies with the help of knowledge
questionnaire.
2. Administration of validated SIM on management of psychiatric
emergencies.
3. Self learning.
4. Administration of post-test using same questionnaire.
Output
It refers to the product of process. After processing the input, the system
releases the energy and information to the environment as output.
In the present study, evaluation of the effectiveness of self instructional
module on management of psychiatric emergencies is output that may also be
regarded as the product of the process. This is achieved through a comparison
between pre and post knowledge score of the objects.
Feedback
It is process that provides information about the system output and its
feedback on input.
10
Accordingly the higher knowledge score obtained by 2nd year P. C. B. Sc.
nursing students in the post-test indicate that the self instructional module was
effective in increasing the knowledge score of 2nd year P. C. B. Sc. nursing
students regarding management of psychiatric emergencies. If there is no gain in
knowledge score then the process has been repeated.
Environment
The individual environment is the fixed constraints that may influence the
effectiveness of self instructional module. In the present study the environment
may be considered as the hospital and the teaching college.
Diagrammatic representation of conceptual framework of study is
represented in Figure 1.
11
ENVIRONMENT
PROCESS
INPUT OUTPUT
¾ Preparation of the tool,

structured knowledge
questionnaire and STP
Gain in
LEARNER’S ¾ Administration of knowledge
BACKGROUND structured knowledge
questionnaire (Pre-test-O1). score
• Age ¾ Administration of SIM Post-test
knowledge
• Sex Ï In general score
Ï Suicide
• Total years of work Ï Aggression
experience Ï Severe Depression
Ï Epilepsy No gain in
• Area of exposure > Administration of structured
knowledge
knowledge questionnaire
score
FEEDBACK
Under study Not Under study
Figure 1: Conceptual framework for evaluating the effectiveness of SIM regarding management of psychiatric emergencies based on
System Theory (by Ludwig Von Bertalanffy 1968).
12
Delimitations
1. This study will be delimited to 2nd year P. C. B. Sc. nursing students of a
selected college of nursing in Mangalore.
2. Generalisation is not possible due to small sample size.
Scope of the study
1. The findings would reveal existing knowledge of 2nd year P. C. B. Sc.
nursing students regarding management of psychiatric emergencies.
2. Self instructional module will help to improve knowledge of 2nd year
P.C.B. Sc. nursing students regarding management of psychiatric
emergencies.
Summary
This chapter has dealt with the objectives of the study, assumption,
hypothesis, conceptual framework, delimitation and scope of the study. The next
chapter synthesizes the extensive review of literature done to form a basis for
this study.
13
3. REVIEW OF LITERATURE
A review of literature is an essential activity of scientific research
projects. It involves systematic identification, location, scrutiny and summary of
written materials that contains information on the research problem.47
The literature was reviewed by using MEDLINE, YAHOO search engine,
GOOGLE search engine and PUBMED search apart from research and non
research literature from journals and books.
Review of literature helps to relate the findings of one to another with a
view to develop a comprehensive body of scientific knowledge in a professional
discipline from which valid and pertinent theories may be developed. The
required literature is grouped under following headings:
1. Incidence and prevalence of Psychiatric emergencies.
2. Risk Factors of psychiatric emergencies in hospital.
3. Knowledge regarding psychiatric emergencies management.
4. Role of nurse in psychiatric emergencies.
5. Effectiveness of SIM.
Incidence and prevalence of Psychiatric emergencies
A population-based epidemiologic study was conducted to determine
behavioural emergency in India. The study was aimed to evaluate the occurrence
of acute behavioural problems as an emergency attended by emergency
management service in the state of Gujarat and Andhra Pradesh. Keyword
14
analysis of records was carried out. A total of 40,541 cases of behavioural
emergencies were recorded, in which the male-female ratio was 1.3:1. Suicidal
attempts, whether in the form of poisoning (60.5%) or otherwise (30.7%), were
the most common emergency, followed by acute psychiatric causes (4%) and
alcohol intoxication (3%). Victims were male (p=0.02), having a low
socioeconomic condition (p<0.02) and older (p<0.001). The study suggested that
acute psychiatric emergency which forms about 9% of all emergency; require
the emerging role of emergency psychiatric services.12
A study was done on determinants of emergency room visits for
psychological reasons for a four month period in an Indian General Hospital.
Psychiatric emergencies constituted only 2% of all emergency visits. Males
outnumbered females in a ratio of 2:1. Self-referrals constituted 77% of the
samples; 21 % of patients were brought by police. Two-thirds of the patients
were brought owing to the severity of their clinical condition and the rest, one-
third, for medico-legal and social reasons. Approximately 80% of the patients
sought consultation within one month of the onset of illness episode. First episode
of mental illness was within last one year of the emergency room visit in 60%
patients. Past history of hospitalization for mental illness was obtained only in
10% of cases. The pattern suggested that there was no misuse of emergency
services by psychiatric patients although 20% of the patients presented with
social problems only which required social rather than psychiatric intervention.13
A study was conducted to determine whether an index for measuring
quality of care for psychiatric emergency is reliable and valid. The study used
primary data collected over a 12-month period from two urban hospitals in the
15
North East. Data were collected on 2,231 randomly selected emergency
psychiatric patients treated in the emergency departments of the two hospitals.
The study showed that a subjective model can be used to develop a reliable and
valid index for measuring quality of care, with potential for practical application
in management of health services.14
A study was conducted to describe the psychiatric emergency research
collaboration in eight emergency departments. 50 samples were randomly
selected emergency psychiatric patients. Majority (71%) of the subjects had
some form of laboratory test performed, 53% had urine toxicity screening and
41% had blood alcohol level drawn. Agitation was present in 52% with 25%
receiving a medication to reduce agitation and 6% being physically restrained.
The study suggested that a common standard for documenting, abstracting and
reporting on the nature and management of psychiatric emergencies is feasible
across a wide range of healthcare institutions.15
A study was done on Violence and aggression in psychiatric units in
Sydney. It was aimed to done the frequency and types of these behaviours in
acute psychiatric inpatient settings were examined, and potential interactions
between staffing and patient mix and rates of the behaviours were explored.
Data was collected using a ranking scale and staff reports. Results showed that a
total of 1,289 violent incidents were recorded over a seven-month period. Based
on the scale, 58 percent of the incidents were serious. Seventy-eight percent were
directed toward nursing staff. Complex relationships between staffing, patient
mix, and violence were found. The study concluded that violent incidents in
16
psychiatric settings are a frequent and serious problem and staff needed proper
training to manage it.16
A study was done to assess the characteristics, management and outcomes
of people identified with mental health issues in an emergency department in
Australia. Data were collected from the emergency department's electronic
records system for two months. Total Mental health patients were 290. Over half
were male; mean age 37.4 years; 49% were in triage category, 45% arrived by
ambulance; 39 % were overdosed/intoxicated and 55% received one or more
diagnostic investigations. The findings showed that psychiatric emergency cases
need immediate management and care. 17
A study was done to assess the Prevalence of depression and cognitive
impairment in older adult emergency medical services patients in USA. Samples
were 1,342 older adults (age ≥60 years) presenting to an academic medical center
ED. Data were collected by using interview schedule. The results shows that
fifteen percent of EMS patients had moderate or greater depression, as
compared with 14% of patients arriving via other modes (p = 0.52). Thirteen
percent of the EMS patients had cognitive impairment, as compared with 8% of
those arriving via other modes (p < 0.01).18
A study was done on prevalence of major depressive disorder among
emergency department patients in Latin-American countries. Data were
collected using criteria interview and a questionnaire screen including the center
for Epidemiological Studies Depression Scale. Prevalence of MDD ranges from
23.0 to 35.0%. The estimates are based on a total of 1,835 patients aged 18 years
and over, with response rates of 83.0%.Multivariate analysis identified a lower
17
level of education, smoking, and self-reported anxiety, chronic fatigue, and back
problems to be independently associated with MDD. The data suggest that the
prevalence of MDD is elevated among emergency department patients in Latin
American countries.19
18
Risk Factors of psychiatric emergencies in hospital
A study was done in Taiwan to assess the Risk factors for aggressive
behaviour among psychiatric inpatients. Samples were 111 new psychiatric
inpatients in Taiwan. Data was collected by nursing staff using the Overt
Aggression Scale (OAS) during the patients' hospitalization. On average,
aggressive patients were hospitalized longer than non-aggressive patients. After
duration of hospitalization was controlled for, it was found that patients with an
earlier onset of illness were more likely to be aggressive than other patients.20
A study was done to assess patients with mood disorders admitted for a
suicide attempt to an emergency. The aim of the study was to assess risk factors
associated with suicidal behaviour in adult patients suffering from major mood
disorders (MD) and admitted to a hospital emergency department (ED).Samples
were 283 adult patients with MDs admitted to an ED between 2006-2007. The
study reported that MD patients were almost 2 times more likely to have been
admitted for a suicide attempt (odds ratio =1,97;p< 0,01) than patients without
MDs. MD patients admitted for a suicide attempt were more than 3 times more
likely to report suicidal ideation at the psychiatric interview (OR=3,26 ; p< 0,01),
than non attempter MD patients. The study suggested that Suicide behaviour is
one of the major reasons of use of EDs in MDs, and suicide risk is still high in the
next hours after suicide attempt and admission in the ED.21
A study was done to assess profile of risk factors associated with suicide
attempts in Orissa, India. It was aimed to study the risk factors associated with
suicide attempts in Orissa. Cross-sectional study design was used. 149 suicide
attempters were participated. Data were collected using Rating scale, results
19
shows that more number of attempters had a family history of psychiatric illness
and suicide, childhood trauma, medical consultation within one month, had
experienced stressful life events and had expressed suicidal ideas. Suicide
potential was high in almost half the cases. More than 80% of all attempters had
psychiatric disorder; however, only 31.5% had treatment. Major physical illness,
family and marital conflicts, financial problems, and failure in examinations
were more frequent life events.22
A Case Control study was done to assess risk factors associated with
attempted Suicide among people living in and around Pondicherry. One hundred
and thirty-seven attempted suicide patients were participated. The strength of
association with the risk of attempt was calculated using odds ratio with 95%
confidence interval. Odds ratios for the factors identified to be significantly
associated with increased risk of suicide attempt were 15.82 for unemployment,
3.02 for lack of formal education, 3.95 for the presence of stressful life events in
the last six months, 3.12 for suffering from physical disorders and 6.78 for
suffering from idiopathic pain. Significant association was not revealed in
respect to marital status, type of family, early parental losses, family history of
suicide and presence of psychiatric morbidity.23

A study was done on Factors affecting psychiatric inpatient
hospitalization from a psychiatric emergency service in USA. Data were collected
from 1,305 admission cases in PES. Results showed that Clinical severity was a
consistent predictor of hospitalization. However, age, gender, race/ethnicity,
homelessness, employment and Alcohol and drug use status were all significant
related to hospitalization. The study concluded that Individual and community
20
factors that affect use of psychiatric emergency services merit additional focused
attention.24
A study was done to compare the prevalence and co morbidity patterns of
psychiatric disorders in subjects making medically serious suicide attempts in
New Zealand. 302 suicidal attempters were examined for the study. Data was
collected using semi structured interview. Results showed that 90.1% had a
mental disorder at the time of the suicidal attempt. Mental disorder include
mood disorders (33.4); substance use disorders (2.6); conduct disorder or
antisocial personality disorder (3.7); and non affective psychosis (16.8).the study
conclude that risk of a suicide attempt increased with increasing psychiatric
morbidity.25
Knowledge regarding psychiatric emergencies
A study was conducted to evaluate the skill training on risk management
training initiative in 3 mental health services in the north west of England, UK.
The training was delivered during a 6 month period in 2002. A pre-test/post-test
design was used for the study. Data was collected from 458 staff nurses.
Qualitative interview were conducted with a purposive sample of 16 participants
to explore the impact on clinical practice. From before training to immediate
post-training, all changes in the attitude were in the direction of improvement,
with statistically significance reduction in score on 10 of the 14 items. From
before training to 4 months, there were changes in the direction of improvement
in 11 of 14 items. Skill was completed by 71% subjects before and immediately
after training and 25% subject before and 4 months after training.26
A study was done to assess Nursing students' experiences in managing
patient aggression in Germany. Samples were twelve nursing students. Data
21
were collected using semi-structured interviews and evaluated by qualitative
content analysis. Results showed that managing patient aggression is a general
challenge for nursing students. This study suggested that nursing students need
preparation and training in handling patient aggression and acquire knowledge
about aggression, awareness of contributing problems, self-confidence in dealing
with aggressive patients.27
A study was done on Organization and function of academic psychiatric
emergency services in USA. Survey method with questionnaire as a tool was
used. The response rate was 91% (n=51) and 92% of PES sites were open 24 h a
day, 7 days a week, and 94% had an attending psychiatrist present at least 8 h
daily. Mean (SD) length of stay in the PES was 9.0 (11.3) hours. The PES
facilities were effective at referring patients to aftercare, and 51% of PES sites
provided follow-up care. The findings highlight the importance of adequate
medical training for PES staffs, the need for improved aftercare programming,
and better access to substance abuse treatment for discharged patients.28
A study was done to determine the effects of a communication skills
training program on emergency nurses and patient satisfaction in turkey.
Sixteen emergency nurses attended a 6-week psycho education program that was
intended to improve their communication skills. The effects of the program were
assessed using rating scales and patient satisfaction survey. Findings showed that
the mean communication skill score (177.8±20) increased to 198.8±15 after
training (p=0.001). The patient satisfaction survey of 429 patients demonstrated
increased scores on confidence in the nurses (76.4±11.2 to 84.6±8.3; p=0.01).
"Communication Skills Training" can improve emergency nurses'
22
communication and empathy skills with a corresponding increase in patient
satisfaction.29
A study was done on evaluate the efficacy of a suicide education
programme for second-year student nurses in Taiwan in 2008. It was aimed to
investigate the learning outcomes of a suicide Education programme. A quasi-
experiment research design was used. The total sample group (n = 174)
comprised second-year student nurses. 95 students were randomly selected to an
experimental group who attended a four-hour suicidal education programme
and 79 comprised a control group who did not attend the programme. All
participants were given a questionnaire before and after the programme. Results
demonstrated that the experimental group had higher scores than the control
group. Thus study showed that suicide education programme raised student
nurses' awareness about the phenomenon of suicide and promoted positive
caring attitudes towards people who attempt suicide.30
A study was conducted to determine the extent of training in clinical
psychiatry that is provided and/or required by emergency medicine (EM)
residency training programs and paediatric emergency medicine (PEM)
subspecialty residency training programs. Results show that there was a 76%
response rate among EM programs, and 76% of the respondents reported no
formal training in the management of acute psychiatric emergencies. Few (24%)
training programs provide formal psychiatric training for their EM residents,
and even fewer (< 3%) provide such training for their PEM fellows.31
A study was done to evaluate the knowledge, attitude and perception of
medical students prior to and after a training course about epilepsy in Brazil.
23
Questionnaires were completed by 185 medical students, before and after
epilepsy training. Comparison of the knowledge scores prior to (mean=53.9,
standard deviation=11.4) and after the course (mean=63.8, standard
deviation=11.9) showed that students had improved knowledge after the course
(t-test=5.6, p<0.001). The study concluded that training course on epilepsy for
medical students can promote improvement in the knowledge, attitudes and
perception regarding epilepsy.32
A study was done to evaluate the knowledge of epilepsy in primary care
system health professionals prior to and after an educational intervention in
Brazil. After pre-test with a questionnaire educational interventions were
delivered to 631 subjects who include health professionals and community
leaders. Post-test done after 6 months. The findings showed that knowledge score
prior to (mean=22.3, standard deviation=12.5) and after (mean=36.6, standard
deviation=12.5) the intervention showed that health professionals had improved
knowledge after the training (t-test=12.4, p<0.001). Training courses can
promote increased knowledge in a cost effective way in the primary care
setting.33
Role of nurse in psychiatric emergencies
A study on nursing care to patients with co morbidity clinical and
psychiatric in hospital emergency service was done in 2009, in the emergency
service of a general hospital in Brazil. It aims to investigate how nurses take care
of patients with clinical and psychiatric co-morbidity. Six nurses, seven nursing
technicians and 14 nursing assistants participated. Data obtained through semi-
structured interviews. The study revealed that nursing care of patients with
24
clinical and psychiatric co morbidity does not have any specificity, with emphasis
on basic care, physical and chemical restraint. This study suggest that it is
necessary to establish local training in mental health and make nurses aware of
the care needs of this clientele.34
A study was done to an evaluation of staff training in psychological
techniques for the management of patient aggression. In this longitudinal Study
47 nurses attending a training day to learn strategies for coping with violent
psychiatric patients were compared with 108 non-attending control group
subjects. After implementation of the training and wards sending a majority of
staff to the training experienced a particularly significant reduction in assaults.
The study shows that 1-day training package for staffs was effective for the
management of patient aggression.35
A study was done on an exploratory investigation into the nursing
management of aggression in acute psychiatric settings in Australia. The overall
aim of this study was to explore the clinical management of patients identified as
potentially aggressive in psychiatric inpatient settings. A multi method approach
was used to collect the data. This included surveys, focus groups, and a file audit.
Samples were selected randomly. The findings indicated that 88% of nurses who
participated in the survey were assaulted and indicated the need for risk
assessment, team management and review. The study suggested support
structures, formal preceptoring and supervisory arrangements and post incident
supports were suggested as part of an overall strategy to support nurses working
in acute inpatient settings.36
25
A study was done to assess the attitudes of emergency staff toward
attempted suicide patients: a comparative study before and after establishment
of a psychiatric consultation service. It was aimed to compare the attitudes of
emergency room staff in a general hospital toward patients who had attempted
suicide before and after establishment of a psychiatric consultation service.
Attitudes were measured on the Understanding Suicidal Patients Scale. Sample
size was 100. The study showed that providing a psychiatric consultation service
did not significantly affect attitudes among general hospital emergency room
staff toward attempted suicide patients during its first year of operation, but in
general, the emergency room staffs were content with the opportunity for
psychiatric consultation.37
A study was done on mental health liaison nursing in the emergency
department: on-site expertise and enhanced coordination of care in Australia. It
was aimed To evaluate the Mental Health Liaison Nurse (MHLN) service based
in the emergency department (ED).Data were gathered through survey Data
obtained from the Emergency Department Information System (EDIS)
demonstrates that the Mental Health Nurse Practitioner (MHNP) is able to see a
majority of patients at, or close to, the point of triage. These findings are
reinforced by ED staffs who rate highly the readily available access to mental
health assessment and enhanced coordination of care. This study suggests that
the MHLN role has significant benefit for patients presenting to the ED by
reducing waiting times, streamlining transition through the department and
improving follow-up.38
26
A study was done on the impact of inpatient suicide on psychiatric nurses
and their need for support in Japan. It was aimed to examine post-suicide stress
in nurses and the availability of suicide-related mental health care services and
education. Samples were 531 psychiatric nurses. Data was collected using self-
reported questionnaire. The findings show that the rate of nurses who had
encountered patient suicide was 55.0%. The proportion of respondents at a high
risk post-traumatic stress disorder (PTSD) was 13.7% and 15.8% of respondents
indicated that they had access to post-suicide mental health care programmes.
The survey also revealed 26.4% nurses attending in-hospital seminars on suicide
prevention or mental health care for nurses. The study concluded that it is
essential to provide systematic post-suicide mental health care programmes for
nurses who exposed to inpatient suicide.39
A study was done to explore the effectiveness of the mental health nurse
practitioner role in the emergency department in Australia. Discursive paper
was used to collect data. The study finding showed that the introduction of the
mental health nurse practitioner role in the emergency department leads to
increased staff competence and confidence in interacting with those presenting
with mental health issues. The mental health nurse practitioner role also
addresses the serious problem of stigma associated with those with a mental
health issue.40
A comparative study was done between emergency department nurses
and psychiatric nurse consultants based on triage of psychiatric patients in the
hospital emergency department in Australia. All presentations to the ED for
psychiatric problems (n = 137) were triaged using the mental health guidelines
27
over a 3-month period. The same presentations were triaged by psychiatric nurse
consultants employed in the ED and the results compared. The results indicate a
high level of difference in the triage ranking by the two groups of nurses. These
findings suggest that mental health education for emergency nurses is necessary
if the guidelines are to be used effectively and improve outcomes for patients
presenting with psychiatric problems.41
Effectiveness of SIM
A study was conducted to determine the effectiveness of self-instructional
module on the management of violent patients among nursing personnel in a
selected psychiatric hospital in Karnataka. Pre experimental one group pre-test
post-test design was used. Purposive sampling technique was used to select a
sample of 30 nursing personnel. Results showed that the total mean percentage
of the post-test knowledge score 84.24% with mean±sd of 27.8±1.7 is higher than
mean percentage of pre-test knowledge score 62.64% with mean±sd of
20.67±3.14. The significance of difference between the pre-test and post-test
knowledge scores was statistically tested using paired ‘t’ test and was found to be
very highly significant (t=11.66, p < 0.05).42
A study conducted to determine the effectiveness of SIM on management
of violent patient among nursing students, in selected nursing school, in Udupi.
Pre experimental one group pre-test post-test was used. The result showed that
the mean percentage in the post-test was 82.40% which was significantly higher
than the pre-test knowledge score of 34.86%. A very highly significant difference
(t=22.62, P<0.05) was found between pre and post-test knowledge score. Thus the
study concluded that self instructional module was effective in improving the
28
knowledge of nursing students regarding management of psychiatric
emergencies.43
A study was done to evaluate the benefits of the psychiatric emergency
service (PES) model, in comparison to the model of the psychiatric consultant to
the emergency department. A retrospective chart review of 100 involuntary PES
patients and 100 involuntary patients of the two groups were compared. After
establishment of the psychiatric emergency service, there were improvements in
the following categories: timely rendering of psychiatric emergency care (330 vs.
639 min, P<.01), completion of mental status exam (95% vs. 49%, P<.01), safety
in the form of seclusion (6% vs. 15%, P<.05). The study concluded that PES is a
multidisciplinary system that can be beneficial to psychiatric emergency patients
by providing timely rendering of care, improving access to care, and ensuring
safety and better assessment.44
A study was done to examine whether a specific educational effort
reduces emergency department violence in the short term and quantify the
amount of violence in the ED in Canada. Cross-sectional prospective surveys
were done after the Prevention and Management of Aggressive behaviour
Program. The numbers of reported violent interactions at the same intervals
were 49, 19, and 46 and 0.79 respectively. The number of reported interactions
involving verbal violence at the same intervals was 154, 58, and 69 and 0.47
respectively. The study conclusion that Violent events are frequent in the ED.
Education programs may reduce the number of events at least temporarily but
do not clearly reduce violence in the long term.45
29
A study was done to determine the effectiveness of Self Directed Learning
in improving learning outcomes in health professionals. The study analyzed 59
studies that enrolled 8011 learners. Twenty-five studies (42%) were randomized.
The overall methodological quality of the studies was moderate. Compared with
traditional teaching methods, SDL was associated with a moderate increase in
the knowledge domain (SMD 0.45, 95% CI 0.23–0.67), a trivial and non-
statistically significant increase in the skills domain (SMD 0.05, 95% CI − 0.05 to
0.22), and a non-significant increase in the attitudes domain (SMD 0.39, 95% CI
− 0.03 to 0.81). The study concluded that SDL in health professionals education
resulted moderate improvement in the knowledge domain compared with
traditional teaching methods and may be as effective in the skills and attitudes
domains.46
30
4. METHODOLOGY
Research methodology is a way to solve the research problem
systematically. It may be understood as a science of studying how research is
done scientifically. The scope of research methodology is wider than that of
research. It not only about the research methods but also consider the logic
behind the method used in the context of the research study. It explains why a
particular method or technique is used or not used in the study. Thus, research
results are capable of being evaluated either by the researcher herself or by
others.47
The present study was aimed at evaluating the effectiveness of self-
nursing at Mangalore.
Research approach
An evaluatory research approach was used to find out the effectiveness of
self-instructional module on knowledge regarding Management of Psychiatric
Emergencies among 2nd year P. C. B. Sc. nursing students
Research design
A researchers overall plan for obtaining answers to the research questions
for testing the research hypothesis is referred to as the research design.48
The function of the research design is to provide for the collection of
relevant evidence with minimal expenditure of effort, time and money. It
31
provides an explicit blueprint of how research activities will be carried out as a
guide for the investigator.
The research design used in this is pre experimental one group pre-test
post-test design is represented schematically in Figure 2.
Group Pre-test Intervention Post-test
I O1 X1 O2
Figure 2: Schematic representation of study design
Group: 2nd year P. C. B. Sc. nursing students of a selected college of nursing at
Mangalore.
O1 : Administration of structured knowledge questionnaire for assessing
the pre-test knowledge level of student nurses regarding management
of psychiatric emergencies.
X1 : Administration of SIM
O2 : Administration of structured knowledge questionnaire for assessing
post-test knowledge level of student nurses after administration of
SIM.
The study was conducted in 3 phases and it is schematically represented
in Figure 3.
32
Phase I Phase II Phase III
Preparation of structured knowledge Administratio

SAMPLING questionnaire and SIM Pre-test (O1) n of SIM (X) Post-test (O2) Data analysis
• Group-2nd year P. C. B. • Review of literature Pre-test to Administration Post-test to • Level of

Sc. nursing students of a assess the of prepared assess the pre-test and
• Discussion with experts
selected college of knowledge SIM to the knowledge post-test
nursing in Mangalore. • Preparation of blue print level of student nurses level of student scores.
student nurses after the pre- nurses on
• Sampling technique- • Preparation of structured knowledge • Analysis
by a test. seventh day by
Convenient sampling questionnaire and
structured the same
technique. interpretatio
• Preparation of SIM knowledge structured
n of data.
• Sample size-50 questionnaire. knowledge
• Content validity
questionnaire • Testing of
• Pre –testing hypothesis.
• Reliability of the tool • Interpretati
on of the
• Pilot study
findings.
Figure 3: Schematic Representation of different phases of Study Design
33
In phase I, preparation of structured knowledge questionnaire and SIM was
done. These were prepared after doing the review of literature, and the tool was
sent for content validity to 10 experts. Pre-testing and reliability was checked.
SIM was prepared and content validity was done by 10 experts.
In phase II
1. Pre-test
2. SIM administration
3. Post-test
Pre-test was done on the first day and the SIM also was given on the same
day. Post-test was conducted on the 7th day.
In the phase III, analysis of the collected data was done using descriptive and
inferential statistics.
Variables under study
A concept which can take on different quantitative values is called a
variable.47 Three types of variable were identified in the study.
Dependent variable
If one variable depends upon or is a consequence of other variable, it is
termed as dependent variable. 47
In this study, it is level of knowledge of 2nd year P. C. B. Sc. nursing
students regarding management of psychiatric emergencies.
34
Independent variable
A variable that is antecedent to the dependent variable is termed as
independent variable. 47
In this study, it is self-instructional module regarding management of
psychiatric emergencies.
Extraneous variable
Independent variable that are not related to the purpose of the study, may
affect the dependent variable, are termed as extraneous variables. 47
In this study, it is age, sex, total years of work experience and area of
experience.
Settings of the study
Research setting is the most specific place where the data collection
occurs, where the population or the portion of that is being is located, and where
the study is carried out.47
The investigator selected Athena College of nursing, Mangalore as per
convenience. This Institution has the following nursing courses like - GNM, B.
Sc.,
P. C. B. Sc. and M. Sc nursing and it has total strength of students around 615
students. The annual intake of P. C. B. Sc. Nursing students is 50. The College of
nursing is attached to a multi-specialty Hospital with modern technology and 24
hours causality service. It is a 200 bedded private hospital, which is situated in
the heart of Mangalore city.
35
Population
Population is the total number of people who meet the criteria that the
researcher has established for a study from whom subjects will be selected and to
whom the findings will be generalized.47
Population for the present study consisted of 2nd year P. C. B. Sc. nursing
students.
Sample
A sample is a small portion of population selected for observation and
analysis. 47
Sample consists of a subset of population selected to participate in a
research study. Sample for this study consisted of 50 students studying 2nd year
P. C. B. Sc. nursing in Athena College of Nursing at Mangalore.
Sampling technique
Sampling refers to the process of selecting a portion of the population to
represent entire population. 47
Convenient sampling technique was used in this study. Investigator
selected all 2nd year P. C. B. Sc. nursing students studying in Athena College of
Nursing at Mangalore.
36
Inclusion criteria for sampling
Student nurses who are:
• Studying in 2nd year P. C. B. Sc. nursing in Athena College of Nursing in
Mangalore.
• Available during data collection
• Willing to participate in the study.
Exclusion Criteria for sampling
Student nurses who are not
• available during data collection
• Willing to participate in the study.
Data collection
Data collection tool
Tool is the device that an investigator uses to collect data. The tool in a
research should, as far as possible, be a vehicle that would be best obtained for
drawing conclusions, which are pertinent to the data.48
In this study, the data collection instruments are:
1. Demographic proforma
2. A structured knowledge questionnaire
37
Development of the tool
The following steps were adopted for the development of the tool:
• Review of literature.
• Discussion with experts in the field of psychiatric nursing, psychiatry and
psychology.
• Development of blueprint.
• Construction of a knowledge questionnaire and self instructional module.
• Content validity and modification as per suggestion.
• Pre-testing and establishing reliability.
• Preparation of the final tool.
Preparation of blueprint
A blueprint was prepared prior to the construction of structured
knowledge questionnaire. It depicted the distribution of items according to the
content areas. It included three domains knowledge, comprehension, and
application. It had 17 knowledge items (45.94%), 16 comprehension items
(43.25%) and 4 application items (10.81%). The structured knowledge
questionnaire consisted of 4 content areas, that were general information
regarding psychiatric emergencies-4 items (10.82%), suicide-7 items (18.92%),
aggressive behaviour-10 items (27.03%), severe depression-5 items (13.51%), and
epilepsy-11 items (29.72%). The knowledge questionnaire consists of 37 items
38
and demographic proforma had 4 items
(Annexure 7).
Testing of the tool
Criteria rating scale for validation of the tool was developed. Tool
consisted of demographic proforma and structured knowledge questionnaire.
Criteria rating scale had agree, disagree and suggestion for experts regarding
accuracy, relevancy and appropriation of the content. (Annexure 6)
Content validity
Content validity refers to the degree to which an instrument measures
what is supposed to measure. 47
To ensure content validity, the structured knowledge questionnaire and
demographic proforma along with problem statement, objectives, hypothesis,
operational definition, blueprint, criteria checklist, answer keys, letter seeking
suggestions and acceptance form were submitted to 10 experts in the field of
psychiatric nursing and psychiatry (annexure 16). The experts were requested to
give their opinion regarding accuracy, relevancy and appropriateness of the
content against the criterion rating scale, which had column for “agree”,
“disagree”, “remarks” and “suggestion”.
Tool 1: Demographic proforma
Initial tool had 4 items and all the items retained after validation with
modification of 2 items. Two items had 100% agreement and 2 items got 80%
39
agreement, some modifications were made on the demographic variables based
on the experts’ suggestions.
40
Tool 2: Knowledge questionnaire:
Initial tool had 37 items. Among those, 12 items had 100% agreement, 14
items had 90% agreement, 8 had 80% agreement and 3 had 60% agreement.
Three items were deleted as per expert’s suggestions. The remaining 34 items
after making necessary modifications were retained as such.
The final tool consisted of demographic proforma with 4 items and
knowledge questionnaire with 34 items. (Annexure 9)
Pre-testing of the tool
The pre-test helps the researcher to determine if respondents can
understand the items and if directions are clear.
On 6th July 2011, the tool was pre-tested by administering structured
knowledge questionnaire to 10 samples of 2nd year P. C. B. Sc. nursing students
of a college of nursing after getting permission from the concerned authority and
the participants. The purpose was to determine the clarity of items, presence of
ambiguous items, and the time required to complete the questionnaire and to
identify the difficulty in understanding the items. The time taken by students to
complete the tool was approximately 30 minutes. All the items were clearly
understood and the responses were found to be appropriate. No modifications in
the items were made.
Reliability of the tool
41
Reliability of the research instrument is defined as the extent to which the
instrument yields the same result on repeated measures. It is then concerned
with consistency, accuracy, precision, stability, equivalence and homogeneity.47
The final tool was tested for reliability by administering it to 6 samples of
2nd P. C. B. Sc. nursing students of City College of nursing, Shaktinagar,
Mangalore. The subjects completed the questionnaire within 30 minutes. All the
subjects found no difficulty in understanding the test items. The reliability of the
tool was established using split half technique, which measures the coefficient of
internal consistency. The reliability was tested by using Karl Pearson’s product
moment cor relation formula. Spearman’s Brown Prophecy formula was used to
find out the reliability of the full test. The reliability of the tool was found to be
0.94, which indicated that the tool was reliable. No modifications of the tool were
made. (Annexure 1)
Description of the final tool
The final tool comprised of 2 parts
Part 1: Demographic proforma
It consisted of 4 items namely age, sex, total years of work experience and
area of exposure.
Part 2: Structured knowledge questionnaire
Structured knowledge questionnaire consisted of 34 questions covering 5
aspects on management of psychiatric emergencies. The areas included general
information regarding management of psychiatric emergencies, suicide,
42
aggressive behaviour, severe depression and epilepsy. The items were of
multiple-choice type with 4 options and one correct answer. Each correct
response car ried a weight age of one score. Thus the maximum score was 34 and
the minimum score was zero. The questions were prepared in English.
The score were categorized arbitrarily as follows:
Level of knowledge Score Percentage
Poor 0-11 < 35
Average 12-17 36 -50
Good 18-26 51 -79
Excellent 27-34 >80
Development of self instructional module
One of the objectives of the study was to prepare a self instructional
module (SIM) SIM was prepared based on:
• Literature review
• Discussion with experts
• Investigator’s own experience
The steps involved in SIM development were:
• Preparation of first draft of SIM
• Modifications as per the suggestions from guide
• Development of criteria checklist
43
• Content validation of SIM
• Preparation of final draft of SIM
The SIM was developed according to the objectives of the study. The
investigator prepared overall plan of SIM, which covered all areas dealt in the
questionnaire (Annexure 15).
Content validity of SIM
The draft of the SIM along with the problem statement, objectives, and
operational definition was submitted to 10 experts in the field of psychiatry and
psychiatry nursing. The validators were requested to give their opinions and
suggestions about the content, relevancy, appropriateness and usefulness of the
SIM. There was no major correction and 100% agreement was there with regard
to relevancy, appropriateness and selection of content area of SIM. The experts
were the same people who validated the tool (Annexure 16). SIM covered the
following areas
1. Introduction.
2. General information on psychiatric emergencies
• What is psychiatric emergencies
• what are characteristics of psychiatric emergencies
• what are the objectives of psychiatric emergencies
• what are the management priorities of psychiatric emergencies
44
• explain the management strategies of psychiatric emergencies
3. Suicide
• what is suicide
• what are the management of suicide
4. Severe Depression
• what is severe depression
• what are the management of depression
5. Aggression
• what is aggression
• what are the management of aggression
6. Epilepsy
• what is epilepsy
• what are the management of epilepsy
Pilot study
A pilot study is the whole study operation in miniature. It reveals to the
investigator about the feasibility, weakness, and practicability of carrying out the
main study. It also helps to confirm the duration and familiarize with
administration and scoring of the tools.48
45
A preliminary run of the main study was conducted from 6th July 2011to
13th July 2011 in a different population with similar characteristics as population
under study. It was conducted in City College of nursing, Shaktinagar
Mangalore. This was made in view of avoiding contamination of study
population. After obtaining written permission from the head of the institution,
the tool was administered to 10 students (4 male and 6 female). (Annexure 1)
Proper explanation about study was given to the respondents. After obtaining
their consent, the tool was administered. The respondents were assured of the
confidentiality of their identity. It was conducted in a similar way as final data
collection. The average time taken to complete the pre-test was 30 minutes. After
the pre-test, the self instructional module regarding management of psychiatric
emergencies was administered. After seven days post-test was conducted using
the same tool to assess the effectiveness of the self instructional module. The
study was found feasible and practicable. No modifications were made in the tool
after the pilot study. Data analysis was done using descriptive and inferential
statistics. No problems were faced during the pilot study. The investigator then
proceeded for the main study.
Problems faced during data collection
The investigator did not face any problem during data collection
Data collection method
In order to conduct the research study in Athena College of nursing,
Mangalore written permission obtained from the Principal of Athena College of
nursing, Mangalore. The data collection date, time, and place were confirmed
after discussion with the Principal. Class room was arranged and permission was
46
secured from the coordinator (Annexure 2). The data was collected on 25 – 07 –
2011. On the day of data collection investigator met the subject at 2 pm in
Athena College of nursing; sample was selected by using convenient sampling
technique. The sample size was 48 as two students were absent. The purpose of
the study was explained and informed consent was obtained from the students
prior to the administration of structured knowledge questionnaire to ensure
their co-operation and prompt answers. Confidentiality was assured to all the
subjects. The pre-test was conducted from 2.00 - 2.30 pm. Then SIM was given.
Information was given regarding the post-test and the date and time was
confirmed for the post-test on 1 – 08 – 2011.
The post-test was conducted after seven days by using the same
structured knowledge questionnaire on 1 – 08 – 2011 at 10 am. All respondents
cooperated well with the investigator during the data collection period. The data
collection process was terminated after thanking the respondents for their
cooperation and prompt response. The collected data was compiled for data
analysis.
Problems faced during data collection
The investigator did not face any problem during data collection.
Plan for data analysis
In order to achieve the stated objectives of the study, the data obtained
from the subject were coded numerically and tabulated. After tabulation and
coding data was entered into a spread sheet. The collected data will be analyzed
using descriptive and inferential statistics.
47
The various categories for analyzing the numerical data based on the
objectives of study are given below
Section 1: Demographic variables will be analyzed using frequency and
percentage.
Section 2: Paired ‘t’ test will be used to find out the effectiveness of SIM
regarding management of psychiatric emergencies.
Section 3: Association between demographic variables and mean pre-test
knowledge score will be calculated using chi- square test.
For testing the hypothesis the level of significance will be kept at 0.05.
Summary
This chapter dealt with the research approach, setting of the study,
variables, population, sample and sampling technique, criteria for the
development of tool, testing of the tool, pilot study, data collection process, and
plan for data analysis. The next chapter deals with the findings of the study.
48
5. RESULTS
This chapter deals with the analysis and interpretation of data collected
from 48 samples of 2nd year P. C. B. Sc. nursing students through a structured
knowledge questionnaire scheduled to assess their knowledge and to determine
the effectiveness of SIM on management of psychiatric emergencies.
Analysis is the process of organizing and synthesizing the data in such a
way that research question can be answered and hypothesis is tested. The
purpose of the analysis is to reduce the data to an intelligible and interpretable
form so that the relation of research problem can be studied and tested.
In this study the data were categorized and analyzed based on the
objective of the study using descriptive and inferential statistics.
Objectives of the Study
regarding management of psychiatric emergencies as measured by
score of 2nd year P. C. B. Sc. nursing students.
3. Find out the association between the mean pre-test knowledge score of 2nd
year P. C. B. Sc. nursing students regarding management of psychiatric
49
emergencies and selected socio demographic variables (age, sex, years of
work experience and area of work experience).
Organization of findings
The data is analyzed and presented under the following headings.
Section I: Sample characteristics
Section II: Effectiveness of SIM on management of psychiatric emergencies.
a. Level of pre and post-test knowledge score regarding management of
b. Area-wise analysis of pre-test and post-test knowledge scores regarding
Section III: Testing of hypothesis.
a. Paired ‘t’ test to test the significant difference between the mean
difference of pre-test and post-test knowledge score
b. Association between the mean pre-test knowledge scores and
demographic variables.
Section I: Sample characteristics
This section deals with the description of sample characteristics in terms
of frequency and percentage.
50
Table 1: Frequency and percentage distribution of samples according to
demographic characteristics
N = 48
Variables Frequency Percentage
1. Age in years
a. 21-30 38 79.17
b. 31-40 9 18.75
c. 41-50 1 2.08
2. Sex
a. Male 1 2.08
b. Female 47 97.92
3. Total years of work experience
a. 1 year 22 45.84
b. 2-5 years 21 43.75
c. 5-10 years 5 10.41
d. Above 10 years - -
4. Area of work experience
a. Psychiatric ward 1 2.08
b. General ward 21 43.75
c. other 26 54.17
51
Figure 4: Distribution of samples according to their age
Distribution of sample according to their age shows that 79.17% of
sample belongs to the age group of 21-30 years, 18.75% belongs to 31-40 years
and 2.08% were 41-50 years. (Table 1, Figure 4).
Figure 5: Distribution of samples according to their sex
Distribution of samples according to sex wise shows that most of them
(98%) were female, when compared to male (2%). (Table 1, Figure 5).
52
Figure 6: Distribution of sample according to their total years of experience
Data presented in Table 1 and figure 6 shows that of the sample 45.8%
had 1 year experience and 43.75% had 2-5 years of experience. Only 10.41% had
5-10 years of experience.(Table 1,Figure 6).
Figure 7: Distribution of samples according to their area of experience
Data presented in Table 1 and Figure 7 shows that 43.75% of sample had
experience in general ward, 54.17% had experience in other speciality area and
2.08% had experience in psychiatric ward (Table 1, Figure 7).
53
Section II: Effectiveness of SIM in terms of gain in knowledge scores
a. Level of pre and post-test knowledge score regarding management of

Table 2: Grading of pre-test and post-test knowledge scores of subjects
N = 48
Pre-test Post-test
Grading of Score
knowledge (%) Frequency Percentage Frequency Percentage
Poor (0-11) < 35 1 2.08 - -
Average (12-17) 36 -50 35 72.92 -
Good (18-24) 50 -80 12 25.00 8 16.70
Excellent (25-34) 80 -100 - - 40 83.30
Total 48 100.00 48 100.00

Maximum score=34
Figure 8: Bar diagram showing the pre-test and post-test knowledge level of the
subjects
Level of pre and post-test knowledge score shows that, in pre-test 72.92%
had average knowledge score, 2.08% had poor knowledge and 25% had good
54
knowledge score. In post-test majority of sample (83.3%) had excellent
knowledge score and remaining 16.7% had good knowledge score. (Table 2,
Figure 8).
b. Area-wise mean percentage and mean gain of pre-test and post-test

knowledge scores regarding management of psychiatric emergencies
Table 3; Area-wise mean percentage of pre-test and post-test knowledge scores

and mean percentage gain
N= 48
Knowledge Score
Pre-test Post-test
Max Difference
Area Score Mean SD % Mean SD % in Mean%
In General 4 2.08 1.03 52 3.37 .665 84.3 32.3
Suicide 5 2.50 .912 50 4.12 .927 82.5 32.5
Aggression 10 4.25 1.75 42.5 8.39 1.45 83.9 41.4
Severe 4 1.85 .93 46.3 3.35 .946 83.8 37.5

Depression
Epilepsy 11 4.81 1.43 43.7 9.10 1.37 82.7 39.0
overall 34 18.9 2.38 55 29.1 3.54 85.5 30.5
55
Figure 9: Diagram showing area-wise pre-test and post-test knowledge scores of
student nurses
Area wise analysis of knowledge score of 2nd year P. C. B. Sc. nursing
students regarding management of psychiatric emergencies shows that in pre-
test highest mean percentage was 52% in the area of Psychiatric emergencies in
general aspects with mean score of 2.08 ± 1.03 and lowest was 42.5% with mean
score of 4.25±1.75 in the area of aggressive behaviour whereas in post-test mean
percentage was around 84% with mean score of 3.37±.66,8.39±1.45 and
3.35±.946 in the areas of general aspects, Aggression and Severe depression and
around 82% with mean score of 4.12±.92 and 9.10± 1.37 in the area of Suicide
and Epilepsy. Hence highest mean difference 41.4% was found in aggression and
lowest 32% was found in general aspects and suicide. (Table 3, Figure 9)
Section III: Testing of hypothesis.
a. Paired ‘t’ test to test the significant difference between the mean pre-test
and post-test knowledge score
In order to find out the significance of difference between the mean pre-
test and post-test knowledge scores a paired ‘t’ test was computed and the data is
presented in Table 4.
To test the statistical difference a null hypothesis was stated.
H01 : There will be no significant difference between the mean pre-test and
post-test knowledge score of 2nd year P. C. B. Sc. nursing students
regarding management of psychiatric emergencies at 0.05 levels.
56
Table 4: Significant difference between the mean pre-test and post-test mean
knowledge score
N=48
Knowledge Mean SD
test score Mean of ‘t’
diff diff SE value Inference
Pre-test 15.50
12.70 4.33 0.625 20.33 Significant
Post-test 28.22
Maximum score=34, t47=1.96, P < 0.05
Paired ‘t’ test to test the significant difference between the mean
percentage of pre-test and post-test knowledge score shows that the mean post-
test knowledge scores (28.2) is higher than the mean pre-test knowledge scores
(15.5). The calculated ‘t’ value is (20.33) is higher than the table value (t47=1.96).
It indicated high significance. The finding shows that SIM was highly effective in
improving the knowledge of students (p<0.001). Hence the null hypothesis is
rejected and research hypothesis was accepted. (Table 4)
Area-wise ‘t’ test value showing significant difference between the pre-test and
post-test knowledge scores regarding management of psychiatric emergencies
In order to find out significance of difference between the pre-test and
post-test knowledge scores of different areas a paired ‘t’ test was computed and
the data is presented in Table 5.
H02 : There will be no significant difference between the area wise mean pre-
test knowledge score and mean post-test knowledge score.
57
Table 5: Area-wise paired‘t’ test showing significant difference between the pre-
test and post-test knowledge scores on management of psychiatric emergencies
N=48
Mean Mean SD
Area score diff of diff SE ‘t’ value Inference
In general 4 1.291 1.12 0.168 7.670 Significant
Suicide 5 1.625 1.20 0.173 9.390 Significant
Aggression 10 4.140 2.04 0.290 14.040 Significant
Severe depression 4 1.500 1.11 0.160 9.370 Significant
Epilepsy 11 4.290 2.09 0.300 14.150 Significant
It is evident from table 5 that SIM was effective in improving the
knowledge in all the areas regarding management of psychiatric emergencies.
The obtained ‘t’ value is greater than the table value (1.96) in all the areas and
the statistical significance is p<0.001 level. Therefore the null hypothesis is
rejected and research hypothesis is accepted. (Table 5)
b. Association between the mean pre-test knowledge scores and selected

variables.
H02 : There will be no significant association between the mean pre-test
knowledge score of 2nd year P. C. B. Sc. nursing students regarding
management of psychiatric emergencies and selected socio-demographic
variables (age and years of work experience).
58
Table 6: Association between mean pre-test knowledge scores and selected
variables
N=48
Knowledge score
Variable ≤ mean > mean χ2 Inference
1. Age
a. Below 30 30 8 Not
0.673
Significant
b. Above 30 6 4
2. Sex
a. Male 1 0 Not
0.340
b. Female 35 12 Significant
a. 1 year 18 4 Not
0.447
b. >1 year 18 8 Significant
4. Area of experience
a. General 16 5 Not
0.028
Significant
b. Others 20 7
Association between mean pre-test knowledge scores with selected
variables shows that there was no significant association between mean pre-test
knowledge score and selected demographic variables such as age, sex, total year
of work experience and area of exposure. Hence the null hypothesis (H02) was
accepted and research hypothesis was rejected. (Table 6)
59
Summary
This chapter has dealt with the results of data analyzed using both
descriptive and inferential statistics. The analysis was car ried out on basis of
objectives and hypothesis of the study. The effectiveness of the SIM was
identified by using frequency and percentage. The paired ‘t’ test was used to find
out the significant difference between pre-test and post-test knowledge scores
and the association between pre-test knowledge scores and selected variable was
calculated by using Chi-square test.
60
6. DISCUSSION
This chapter deals with the major findings of the study and discussed
them in relation to similar studies conducted by other researchers. The study
determines the effectiveness of SIM on knowledge regarding management of
psychiatric emergencies. The findings of the study are discussed with reference
to the objective and hypothesis stated in chapter two along with findings from
other studies.
The findings of the present study are discussed under the following
headings:
Section I: Demographic variables.
Section II: Pre and post-test knowledge score of student nurses regarding
Section III: Effectiveness of SIM in term of gain in post-test knowledge score.
Section IV: Association between mean pre-test knowledge score and selected
demographic variables.
Major findings of the study
Section I: Demographic variables.
The frequency and percentage distribution of sample showed that
majority (79.17%) of sample belonged to the age group 21-30 years. Majority
(97.92%) of the samples were female and 45.84% had 1 year experience. Almost
61
half (54.17%) of the samples had experience in specialty area and only 2.08%
had worked in psychiatric ward.
The present study is supported by the findings of other studies. A study
conducted in Taiwan showed that 61.1% samples belonged to the age group of
20-29 years, 28.3% were in the age group of 30-39 years. Majority of the samples
(93.3%) were females and 97.2% had experience in psychiatric area.9
Another study conducted in Karnataka showed that majority (80%) of
the respondents were aged 21-30 years, followed by 31-40 years (13.33%) and
least percentage of the subjects (6.67%) were aged 41-50 years and all samples
were females. Majority (80%) of the subjects had worked with violent patients.
All the subjects had worked in the psychiatric ward for 1 – 5 years.42
Section II: Pre and post-test knowledge score regarding management of

psychiatric emergencies
The present study finding showed that in the pre-test most (72.92%) of
the sample had average knowledge score regarding management of psychiatric
emergencies. The mean pre-test knowledge score was 15.5. In the post-test most
of the subjects (83.3%) had excellent knowledge score. The mean post-test
knowledge score was 28.22.
The findings of the present study are supported by other studies where in
researcher have found that nurses had inadequate knowledge regarding
62
A study was done in Brazil to evaluate the knowledge of medical students
about epilepsy and the findings showed that mean pre-test knowledge score was
53.9±11.4 and mean post-test knowledge score was 63.8±11.9.32
Another study conducted in Karnataka to assess the knowledge of nurses
regarding management of violent patient showed that the total mean percentage
of the post-test knowledge score was 84.24% with mean±sd of 27.8±1.7 and total
mean percentage of pre-test knowledge score was 62.64% with mean±sd of
20.67±3.14.42
Section III: Effectiveness of SIM in terms of gain in post-test knowledge score.
The findings of the present study showed that SIM was effective in
improving the knowledge of student nurses regarding management of
psychiatric emergencies. The mean post-test knowledge scores (28.22) was higher
than mean pre-test knowledge score (15.5).The mean percentage of post-test
knowledge score was (83.02%) higher than the mean percentage of pre-test
knowledge score (45.58%). The findings were statistically significant at 0.001
level (t48= 1.96, t=20.05). This shows that SIM was highly effective in improving
the knowledge of student nurses regarding management of psychiatric
emergencies.
Similar findings were reported by other researchers as well.
This finding was supported by a pre experimental study conducted in
Udupi to find out the Effectiveness of SIM on the management of violent patients
among nursing students , where in a very highly significant difference (t=22.62,
P< 0.05) was found between pre and post-test knowledge score. 43
63
A study was conducted in Karnataka to assess the effectiveness of self-
instructional module on the management of violent patients among nursing
personnel. The findings showed that the total mean percentage of the post-test
knowledge score 84.24% with mean±sd of 27.8±1.7 was higher than mean
percentage of pre-test knowledge score 62.64% with mean±sd of 20.67±3.14. The
significance of difference between the pre-test and post-test knowledge scores
was statistically tested using paired ‘t’ test and was found to be very highly
significant (t=11.66, p < 0.05).42
Section IV: Association between the mean pre-test knowledge score of 2nd year
P. C. B. Sc. nursing students and selected demographic variables.
Association between the mean pre-test knowledge score and selected
demographic variables showed that:
1. There was no significant association between the mean pre-test knowledge
scores and age (χ2 =0.673 at 0.05 level of significance).
score and sex (χ2 =0.340 at 0.05 level of significance).
scores and total years of work experience (χ2 =0.447 at 0.05 level of
significance).
scores and area of work experience. (χ2 =0.028 at 0.05 level of
significance).
The findings of present study are supported by other studies
64
A study conducted in Taiwan to assess the nurses’ anxiety and cognition
in managing psychiatric patients’ aggression showed that there was no
significant association of mean knowledge score with selected variables like age
and sex.9
A study conducted in England to evaluate the training programme for
managing people at risk of suicide showed that there was no significant
association of mean knowledge score with selected variables like age, sex and
number of years in profession.49
Based on the findings of the present study it could be concluded that
student nurses need to improve their knowledge regarding management of
psychiatric emergencies. SIM is an effective and accepted teaching strategy.
Summary
This chapter discussed the significant findings of the study in relation to
other studies. Earlier studies conducted by other researchers also showed that
SIM is helped in increasing knowledge of the participants. The next chapter
deals with the conclusions drawn based on the findings of the present study.
65
7. CONCLUSION
This chapter deals with the important conclusions drawn based on the
findings of study and their nursing implications.
Assessment of the knowledge level regarding management of psychiatric
emergencies, preparing a self instructional module and thereby improve the
knowledge level of 2nd year P. C. B. Sc. nursing students regarding management
of psychiatric emergencies the main concept of this study.
Based on the findings of the study the following conclusions were drawn:
Most of the student nurses (35%) had an average knowledge (40– 59%)
before the administration of the SIM. But after the administration of the SIM
there was increase in their knowledge as it is evident from the post-test
knowledge score where most of them (83.3%) gained excellent score (80 – 100%).
After the administration of the SIM, the post-test knowledge score
showed that there was an increase in the knowledge regarding management of
psychiatric emergencies. (Pre-test mean score 15.5 and post-test mean score
28.22).
A significant difference in pre-test and post-test mean knowledge score
was notes (t = 20.33, p<0.001). The finding shows that SIM was useful in
improving the knowledge regarding management of psychiatric emergencies
An increased knowledge can bring about changes in practice and thus in
turn will provide proper care to the patient and protection to self.
66
Nursing implications
The findings of the present study have shown that student nurses lacked
knowledge regarding management of psychiatric emergencies. The study also
proved that SIM was an effective method in improving the knowledge of student
nurses. The implications of this study are discussed under the following
headings: nursing education, nursing practice, nursing administration and
nursing research. The dissemination of knowledge takes place when the research
findings are made use in the following field.
Nursing education
The study also gives priority for preparing SIM emphasis should be done
on psychiatric emergencies while imparting knowledge to the students. Since
most of the psychiatric emergencies are treated in emergency department all the
nurses should be aware how to treat such emergencies.
The SIM can be used as a mode of imparting information to the students
and the educators. Every student nurse should be encouraged to learn more
about management of psychiatric emergencies. The skill will also be developed
by practicing it.
Nursing practice
With the responsibility for improving patient care to identify the legal
implications of care and increasing accountability towards patient care, the
student nurses need to be given adequate knowledge regarding care of
psychiatric emergency patients. A systematic and continuous assessment of
patient can be done to recognize the signs of emergency condition and its causes.
67
Psychiatric emergency patients can be found in almost all settings, not just in
psychiatry wards. Thus the area needs to be given due importance as it may save
lives and help in giving comprehensive care to the patients. Frequent in-service
education programmes can be conducted to keep nurses up-to-date with the
latest changes taking place in the area of management and this knowledge can be
used to train the newly recruited staff nurses.
Nursing administration
Nursing administrators should take initiative in creating plan and policies
for conducting awareness programmes. They should plan for manpower, money,
material, methods and time to conduct successful educational programs. Health
administration should make the education department aware about emergency
condition and its management and assign staff for conducting the structured
teaching programme in hospitals and also in the community. This study also
implies on the appropriate teaching and learning materials to be prepared and
made available for nurses regarding management of psychiatric emergencies.
Nursing research
The emphasis on research and clinical studies should be focused on
improving the quality of nursing care. The present study is only on the initial
investigation in the area of improving knowledge of student nurses regarding
management of psychiatric emergencies. There is a need for extended and
intensive research in the areas of practice, attitude and belief of student nurses
regarding management of psychiatric emergencies, provision given by the
institution, economical and psychological support given by the nurse
administrators and institution administrators.
68
Nurse researchers should be aware of the healthcare system and status of
nursing profession. The ability to identify the complimentary roles and areas of
role overlap with the nurses will empower them to acknowledge, accept, and
practice their role with less ambiguity and frustration. More and more studies
should be done in the school, college and communities.
Limitations
1. The sample was chosen from only one institution. This restricts the
generalisablity of the results.
2. Convenient sampling technique was used to select the sample.
3. Study did not assess the clinical practice on management of psychiatric
emergencies.
4. Study was limited to a small number of student nurses (48).
5. All the aspect of psychiatric emergencies was not included in the study.
Suggestions
Health teaching units could organize planned teaching programme
Recommendations
On the basis of study findings, the following recommendations are made
for further study:
1. A study could be conducted on a larger sample; thereby the findings can
be generalized.
69
2. An exploratory study could be conducted to identify the knowledge and
practice of student nurses regarding management of psychiatric
emergencies.
3. An experimental study could be undertaken by having a control group.
4. A follow-up study could be carried out to find the effectiveness of SIM in
terms of retention of knowledge.
5. A comparative study could be carried to find out knowledge of student
nurses and staff nurses who work in psychiatric wards.
Summary
The overall experience of conducting this study was a satisfying one as
there was good cooperation from student and college authorities. The
respondents were satisfied and happy with the information they received. The
study was a new learning experience for the investigator. The result of the
present study showed that there is a great need for the student nurses to update
their knowledge regarding management of psychiatric emergency. The study
revealed that SIM could be used as an effective teaching strategy.
70
8. SUMMARY
This chapter deals with the summary of the study, its discussion and
conclusions drawn, implications, suggestions and recommendations for the
nursing service and for the field of nursing research.
regarding the management of psychiatric emergencies as measured by
score of 2nd year P.C. B. Sc. nursing students.
3. Find out association between the mean pre-test knowledge score of 2nd
year P.C. B. Sc. nursing students regarding management of psychiatric
emergencies and selected socio demographic variables (age, sex, total
years of work experience and area of experience).
The study attempted to examine the following hypotheses at 0.05 levels of
significance.
H1 : The mean post-test knowledge score of 2nd year P. C. B. Sc. nursing
students regarding management of psychiatric emergencies will be
significantly higher than their mean pre-test knowledge score at 0.05 level
of significance.
71
H2 : There will be significant association between the mean pre-test knowledge
score of 2nd year P. C. B. Sc. nursing students regarding management of
psychiatric emergencies and selected socio-demographic variables (age,
sex, total years of work experience and area of work experience)
The study assumed that:
• Students studying in 2nd year P. C. B. Sc. nursing will have some
knowledge regarding management of psychiatric emergencies.
• Self-instructional module is an accepted strategy of teaching
The key variables under the study were:
• Self-instructional module regarding management of psychiatric
emergencies, as independent variable.
• Knowledge of 2nd year P. C. B. Sc. nursing students regarding
management of psychiatric emergencies, as dependent variable.
Conceptual frame work of this study was based on general systems theory
with input, process, output, and feedback, first introduced by Ludwig Von
Bertalanffy (1968).
A pre experimental one group pre-test post-test design with evaluatory
approach was adopted to determine the effectiveness of the SIM in terms of gain
in mean post-test knowledge score. Convenient sampling technique was used to
select 48 samples from Athena College of nursing, Mangalore. The following
tools were used to collect the data:
Tool I: Demographic proforma which contained four items.
72
Tool II: Structured knowledge questionnaire to assess the level of knowledge
The steps involved in the development of instrument were preparation of
blueprint, content validity, pre-testing and testing of reliability. The coefficient of
the internal consistency was calculated by split half technique. The reliability of
the tool was 0.94, which indicates that the tool was reliable. Pilot study was
conducted on 10 samples of 2nd year P. C. B. Sc. nursing students of City College
of Nursing Shaktinagar, Mangalore from 6-7-2011 to 13-7-2011 to find out the
feasibility of the study. No modification was found necessary.
The main study was conducted on 48 samples of 2nd year P. C. B. Sc.
nursing students of Athena College of nursing, Mangalore from 25-7-2011 to 1-8-
2011. The obtained data was analyzed and interpreted based on the objectives
and hypotheses of the study. The frequency and percentage were used to analyze
the sample characteristics; frequency percentage, mean, standard deviation and
paired ‘t’ test were used to determine the effectiveness of SIM. The association
between pre-test knowledge score and selected demographic variable were
determined by Chi square test.
Findings of the study proved that SIM was effective in improving the
knowledge of 2nd year P. C. B. Sc. nursing students regarding management of
The present study, in short, gave the researcher a new experience, a
chance to widen the knowledge and a venue to interact with student nurses. The
direction from the guide, various experts and cooperation of student nurses
played a major role in successful completion of the study.
73
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in India; a population based epidemiological study. Social Psychiatry
2010 May; 45(5):589-93.
13. Adityanjee. Determinants of emergency room visits for psychological
problems in a general hospital. Journal of Social Psychiatry 1988 Mar;34:25-
30.
14. Gustafan DH, Sainfort F, Johnson SW. Measuring quality of care in
psychiatric emergencies: construction and evaluation of Bayesian index.
Health Survey Research 1993 Jun; 28(2):131-58.
15. Bourdeax ED, Allen MH, Classen C. The psychiatric emergency research
collaboration-01: methods and results. General Hospital Psychiatry 2009
Nov-Dec; 31(16):503-4.
16. Owen C, Tarantello C, Jones M, Tennant C. Violence and aggression in
psychiatric units. Psychiatric Service. 1998 Nov;49(11):1452-7.
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17. Shafiei T, Gaynor N, Farrell G. The characteristics, management and
outcomes of people identified with mental health issues in an emergency
department, Melbourne, Australia. Journal of Psychiatry Mental Health
Nurse 2011 Feb;18(1):9-16.
18. Shah MN, Jones CM. Prevalence of depression and cognitive impairment
in older adult emergency medical services patients. Prehosp Emerg Care
2011 Jan;15(1):4-11.
19. Castilla-Puentes RC, Secin R.A. multicenter study of major depressive
disorder among emergency department patients in Latin-American
countries. Depression Anxiety 2008;25(12):199-204.
20. Chang JC, Lee CS .Risk factors for aggressive behaviour among
psychiatric inpatients. Psychiatr Serv 2004 Nov;55(11):1305-7.
21. Pompili M, Innamorati M. Patients with mood disorders admitted for a
suicide attempt to an emergency ward. Neuropsychiatry 2010;24(1):56-63.
22. Nilamadhab Kar. Profile of risk factors associated with suicide attempts:
A study from Orissa, India Indian J Psychiatry 2010 Jan-Mar;52(1):48–
56.
23. Srivastava MK. Sahoo RN. Risk factors associated with attempted
suicide: a case control study. Indian J Psychiatry 2004 Jan-Mar;46(1):33–
8.
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24. Unick GJ, Kessell E .Factors affecting psychiatric inpatient
hospitalization from a psychiatric. [on line]. Available from:
URL:http://www.pubmed.com.[accessed 10.8.2011].
25. Beautrais AL, Joyce PR. Prevalence and comorbidity of mental disorders
in persons making serious suicide attempts: a case-control study. [online].
Available from: URL:http://www.pubmed.com. [accessed 10.8.2011].
26. Gask L, Dixon C, Morris R. Evaluating skill training for managing people
at risk of suicide. Journal of Advanced Nursing 2005 Nov;739-50.
27. Nau J, Dassen T, Halfens R, Needham I. Nursing students' experiences in
managing patient aggression. Nurse Education Today. 2007
Nov;27(8):933-46.
28. Currier GW, Allen M. Organization and function of academic psychiatric
emergency services. [online]. Available from:
URL:http://www.pubmed.com. [accessed 21.7.2011].
29. Cinar O, Sutcigil L. Communication skills training for emergency nurses.
[online]. Available from: URL:http://www.pubmed.com. [accessed
18.7.2011].
30. Sun FK, Long A, Huang XY, Chiang CY. A quasi-experimental
investigation into the efficacy of a suicide education programme for
second-year student nurses in Taiwan. Journal of Clinical Nursing 2011
Mar;20(5-6):837-46.
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31. Santucci KA, Sather J, Baker M.D. Emergency medicine training
programs' educational requirements in the management of psychiatric
emergencies: current perspective. Paediatric Emergency Care. 2003
Jun;19(3):154-6.
32. Noronha AL, Fernandes PT. Training medical students to improve the
management of people with epilepsy. [on line]. Available from:
33. Fernandez, Noronha AL. Training the trainers and disseminating
information: a strategy to educate health professionals on epilepsy.
[online]. Available from: URL:http://www.pubmed.com. [accessed
21.7.2011].
34. Paes MR, Maftum MA, Mantovani Mde F. Nursing care to patients with
comorbidity clinical and psychiatric in hospital emergency service. Rev
Gaucha Enferm 2010 Jun;31(2):277-84.
35. Whittington R, Wykes T. Evaluation of staff training in psychological
techniques for the management of patient aggression. Journal of Clinical
Nurse. 1996 Jul;5(4):257-61.
36. Delaney J, Cleary M, Jordan R, Horsfall J. An exploratory investigation
into the nursing management of aggression in acute psychiatric settings in
Australia. Journal of Psychiatry Mental Health Nursing 2001
Feb;8(1):77-84.
37. Suokas J, Suominen K, Lönnqvist .attitudes of emergency staff toward
attempted suicide patients: a comparative study before and after
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establishment of a psychiatric consultation service Journal Crisis
2009;30(3):161-5.
38. Royal Prince Alfred Hospital, Sydney, New South Wales. Mental health
liaison nursing in the emergency department: on-site expertise and
enhanced coordination of care in Emergency Department. Australia.
Journal of Advance Nursing 2004 Dec-2005 Feb;22(2):25-31.
39. Takahashi C, Chida F, Nakamura H, K. The impact of inpatient suicide
on psychiatric nurses and their need for support. [online]. Available
40. Nicholls D, Gaynor N, Shafiei T. Mental health nursing in emergency
departments: the case for a nurse practitioner role. Journal of Clinical
Nursing. 2011 Feb;20(3-4):530-6.
41. Happell B. The triage of psychiatric patients in the hospital emergency
psychiatric nurse consultants [online]. Available from:
42. Fernandes PV. Effectiveness of self-instructional module on the
management of violent patients among nursing personnel in a selected
Psychiatric hospital, Karnataka. Unpublished M. Sc. (N) thesis submitted
to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.
43. Paul R. Effectiveness of SIM on the management of violent patients
among nursing students in selected schools of NSS at Udupi. Unpublished
M. Sc. (N) thesis submitted to MAHE, Manipal; 2000.
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44. Woo BKP, Chan VT, Ghobrial N, Sevilla CC. Comparison of two models
for delivery of services in psychiatric emergencies. [online]. Available
45. Fernandes CMB, Raboud JM. The effect of an education program on
violence in the emergency department. Emergency Medicine 2002
Jan;39:47-55.
46. Murad MH. Effectiveness of self-directed learning in health professions
education: a systematic review. Medical Education 2010;44:1057–68.
47. Polit DF, Hungler BP. Nursing Research principles and methods. 6th ed.
Philadelphia: J. B. Lippincot; 1999.
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Annexure 1
Letter requesting permission to conduct pre-testing and reliability and pilot
study
81
Annexure 2
Letter requesting permission to conduct the main study
82
Annexure 3
Letter requesting for expert opinion to establish content validity
of the research tool and self-instructional module
From,
Ms.Merly Theresia Mammachan
Falnir Road, Mangalore
To,
Subject: Request for expert opinion and suggestions to establish content

validity of the research tool and self-instructional module
Respected sir/madam/sister,
I, Ms.Merly Theresia Mammachan, M. Sc. Nursing (psy) student of Athena

College of Nursing, Mangalore, have selected the following topic for my
dissertation to be submitted to Rajiv Gandhi University of Health Sciences as a
partial fulfilment for the requirement for award of Masters of Science in
Nursing.
Topic: Effectiveness of self-instructional module on knowledge regarding

management of psychiatric emergencies among 2nd year P.C.B.Sc. nursing
students of a selected college of nursing at Mangalore
I hereby enclose the following:
• Objectives of the study and operational definitions.

• Structured knowledge questionnaire and blueprint on Management of
Psychiatric Emergencies
• Answer key
• self-instructional module with the criteria checklist
I request you to go through the items and give your valuable suggestions
and opinions to establish the content validity of the tool and self-instructional
module. Kindly suggest modifications additions, if any, in the remark column.
Thanking You,
Yours sincerely
Ms. Merly Theresia

Mammachan
Place: Mangalore
Date:
83
Annexure 4
Content Validation Certificate
I hereby certify that I have validated the tool of Miss. Merly Theresia
Mammachan, M. Sc Nursing student, Athena College of Nursing who is
undertaking the following study:
Effectiveness of self-instructional module on knowledge regarding
management of psychiatric emergencies among 2nd year P.C.B.Sc. nursing
Place: Signature of the expert
Date: Designation and address
84
Annexure 5
Acceptance form for tool validation
Name: -----------------------------------------
Designation: -----------------------------------------
Name of the institution -----------------------------------------
Statement of acceptance / non acceptance to validate the tool.

Topic: “Effectiveness of self-instructional module on knowledge regarding
management of Psychiatric Emergencies among 2nd year P.C.B.Sc. nursing
Signature of the expert
Designation and address

Place:
Date:
85
Annexure 6
Criteria checklist for validation of the tool
Instructions: please review the items in the tool and give your suggestions
regarding accuracy, relevance and appropriateness of the content. Kindly place a
tick mark ( 9 ) in the appropriate column. If there are any suggestions or
comments please mention in the remarks column.
Q. No Agree Disagree Remarks
Base line proforma
Structured knowledge questionnaire.
10
11
12
13
14
15
86
Q. No Agree Disagree Remarks
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
Any other suggestions
87
Annexure 7
Blueprint of Structured knowledge questionnaire
Sl. Compre- Weighta

No. Content Knowledge hension Application Total ge
1 Psychiatric 1, 4 2 3 4 10.82
emergencies
2 Suicide 5, 6, 7, 8 9, 11 10 7 18.92
3 Aggressive 12, 13, 14, 16, 17, 18, 20 10 27.03

behaviour 15, 19 21
4 Severe 23 22, 24, 25, 5 13.51

depression 26
5 Epilepsy 27, 28, 29, 30, 31, 32, 37 11 29.72

34, 33 35, 36
Total 17 16 4 37
Weightage 45.94 43.25 10.81 100.00
88
Annexure 8
Consent form
Dear participant,
I, Ms.Merly Theresia Mammachan, am the M. Sc. Nursing student of

Athena College of Nursing. As part of my cur riculum, I am conducting a study
titled “Effectiveness of self-instructional module on knowledge regarding
Management of Psychiatric Emergencies among 2nd year P.C.B.Sc. nursing
students of a selected college of nursing at Mangalore’’
In this regard, I would like to ask you a few questions. Kindly answer the
questions without any hesitation. The information provided by you will be kept
confidential and used only for the purpose of the study.
Thanking you,
Ms. Merly Theresia Mammachan
I am willing to participate in the study
____________________________
Signature of the participant
89
Annexure 9
Tool
Knowledge questionnaire to assess the knowledge regarding the management of
Instruction: Kindly read the following questions. Select and put [√] mark which
one you feel more appropriate and respond to each question. Your answer will
be kept confidential.
Part I: Demographic proforma
1. Age in years:
a. 21-30 [ ]
b. 30-40 [ ]
c. 40-50 [ ]
2. Sex:
a. Male [ ]
b. Female [ ]

a. 1 year [ ]
b. 2-5 years [ ]
c. 5-10 years [ ]
d. Above 10 years [ ]
4. Area of work experience

a. Psychiatric ward [ ]
b. General ward [ ]
c. Other [ ]
Part II: - Knowledge questionnaire
1. Which is the correct answer for Psychiatric emergencies?

a. An acute disturbance of thought ,affect and psychomotor activity
leading to threat to others [ ]
b. An acute disturbance of thought and affect leading to threat to
oneself, or others [ ]
c. An acute disturbance of thought ,affect and psychomotor
activity leading to threat to oneself, or others [ ]
d. An acute disturbance of behaviour leading to threat to oneself,
or others [ ]
90
2. Which of the following area have the possibility to occur psychiatric
emergency condition?
a. Community area [ ]
b. Medical wards [ ]
c. Psychiatric OPD and wards [ ]
d. All of the above [ ]
3. Which of the following immediate assessment should be done in a
psychiatric emergency condition?
a. Patient environment [ ]
b. Patient behaviour [ ]
c. Availability of staff [ ]
d. Availability of medication [ ]
4. Which of the following are considered as priority in the management of

psychiatric emergencies?
a. Safety of patient and people [ ]
b. Safety of the property [ ]
c. Diagnosis of patient [ ]
5. Which of the following act is called suicide?

a. Act of human being intentionally causing his or her own death [
]
b. Act of human being intentionally causing others death [ ]
c. Act of human being intentionally causing destruction of property [ ]
d. Act of human being helping others to end their life [ ]
6. Which of the following age group is suicidal peak for men and women?
a. Before 45 and before 55 [ ]
b. After 45 and after 55 [ ]
c. Before 30 and before 50 [ ]
d. After 30 and after 50 [ ]
7. Which condition has highest risk factor of suicide?

a. Phobia [ ]
b. Severe Depression [ ]
c. Schizophrenia [ ]
d. OCD [ ]
8. Which of the following is the most important clinical decision to be made

for patient with suicidal ideation?
a. Keep in restraints [ ]
b. Administer sedatives [ ]
c. Hospitalise the client [ ]
91
d. Ignore the client [ ]
9. Which one is the most important key aspect to prevent suicide?

a. Constant surveillance [ ]
b. Diversion therapy [ ]
c. Visit to religious place [ ]
d. Yoga and meditation [ ]
10. Which of the following term is called as a behaviour that aims at inflicting
pain or injury on object or persons?
a. Anger [ ]
b. Depression [ ]
c. Aggression [ ]
d. Mania [ ]
11. Which part of the brain is involved in aggression?

a. Hypothalamus [ ]
b. Medulla oblongata [ ]
c. Cerebrum [ ]
d. Cerebellum [ ]
12. Which hormone level increases in case of aggression?

a. Growth hormone [ ]
b. Estrogen [ ]
c. Testosterone [ ]
d. Aldosterone [ ]
13. Which hormone level is low in case of aggression?

a. Norepinephrine [ ]
b. Dopamine [ ]
c. Serotonin [ ]
d. Adrenaline [ ]
14. Which drugs to be administered to a violent patient?

a. Diazepam + lorazepam [ ]
b. Diazepam + haloperidol [ ]
c. Clozapine + haloperidol [ ]
d. Atropine + lorazepam [ ]
15. How many hours after inj haloperidol can be repeated, if symptoms of
aggression are not controlled?
a. ½ hour [ ]
b. 1 hour [ ]
c. 1 ½ hour [ ]
d. 2 hour [ ]
92
93
16. In which of the following conditions inj haloperidol cannot be repeated?
a. Depression [ ]
b. Mania [ ]
c. Schizophrenia [ ]
d. Seizure disorder [ ]
17. What is the main use of Restraints?

a. Restrict the freedom of movement of patient [ ]
b. Isolate the patient [ ]
c. Punish the patient [ ]
d. Reinforce the patient [ ]
18. How often a nurse should observe client in restraints?

a. Every 15 minutes [ ]
b. Stay with the client [ ]
c. Every 1 hour [ ]
d. No need for observation [ ]
19. What distance is to be maintained when nurse facing an aggressive

patient?
a. 5 feet distance [ ]
b. More than 5 feet distance [ ]
c. 3 feet distance [ ]
d. No distance [ ]
20. Which criteria symptom is more important to diagnose severe

depression?
a. Elevated mood [ ]
b. Retardation of movement [ ]
c. Suicidal tendencies [ ]
d. Retardation of speech [ ]
21. Which is the first choice of drug to treat depression?

a. Lithium [ ]
b. Imipramine [ ]
c. Diazepam [ ]
d. Phelezine [ ]
22. Which therapy is used to change the negative thought associated with
severe depression?
a. Cognitive behaviour therapy [ ]
b. Behaviour therapy [ ]
c. Psychoanalytic therapy [ ]
d. Group therapy [ ]
94
23. How many ECT’s are required for treating severe depression?
a. 2-4 [ ]
b. 6-8 [ ]
c. 10-15 [ ]
d. more than 15 [ ]
24. Which of the following is called Episode of abnormal, motor, sensory,

autonomic and psychic activity?
a. Epilepsy [ ]
b. Seizure [ ]
c. Akinesia [ ]
d. Extrapyramidal symptoms [ ]
25. Which of the following is correct for Pseudo seizure?

a. Convulsion with loss of consciousness [ ]
b. Purposive convulsive movements [ ]
c. Convulsion occur during sleep [ ]
d. Grand mal seizures [ ]
26. Which of the following are characteristics of a true seizure?

a. Convulsion with loss of consciousness [ ]
b. Talking or screaming throughout the seizure [ ]
c. Convulsion occurring in safe place [ ]
27. How many unprovoked seizures are required for the diagnosis of
epilepsy?
a. 5 [ ]
b. 4 [ ]
c. 3 [ ]
d. 2 [ ]
28. Which disorder is associated with temporal lobe epilepsy?

a. Medical disorder [ ]
b. Physiological disorder [ ]
c. Psychological disorder [ ]
d. Genetic disorder [ ]
29. Which epilepsy causes aggressive and violent behaviour?

a. frontal lobe [ ]
b. parietal lobe [ ]
c. temporal lobe [ ]
d. occipital lobe [ ]
95
30. Which test is used to monitor electrical brain activity?
a. MRI [ ]
b. EEG [ ]
c. Telemetry [ ]
d. CT scan [ ]
31. What is the use of SPECT? ( Single photon emission computed

tomography)
a. To asses cerebral blood flow [ ]
b. Classify the type of seizure [ ]
c. Detect cerebro vascular abnormalities [ ]
d. To probe the action of single brain cell [ ]
32. Which medication is used in first step during the management of

epilepsy?
a. lorazepam [ ]
b. phenytoin [ ]
c. phenobarbitol [ ]
d. midazolam [ ]
33. Which medication is used in second step during the management of

epilepsy?
a. Perinorm [ ]
b. Phenargan [ ]
c. Phenytoin [ ]
d. Lithium [ ]
34. Which is the most appropriate position for a person during seizure?
a. Side lying position [ ]
b. Supine position [ ]
c. Fowlers position [ ]
d. Prone position [ ]
96
Annexure 10
Key answer for knowledge questionnaire
1. C 10. C 19. C 28. C
2. D 11. A 20. C 29. C
3. B 12. C 21. B 30. B
4. D 13. C 22. A 31. A
5. A 14. B 23. B 32. A
6. B 15. A 24. A 33. C
7. B 16. D 25. C 34. A
8. C 17. A 26. A
9. A 18. A 27. D
97
Annexure 11
Grading of knowledge
Level of knowledge Score Percentage
Poor 0-11 < 35%
Average 12-17 36 -50%
Good 18-26 51 -79%
Excellent 27-34 >80%
98
Annexure 12
Acceptance form for self instructional module
Name: -----------------------------------------
Designation: -----------------------------------------
Name of the college: -----------------------------------------
Statement of acceptance/non acceptance to validate the self instructional module
Topic: “.Effectiveness of self-instructional module on knowledge regarding

Place:
Date: Signature
99
Annexure 13
Content validation certificate (self instructional module)
I hereby certify that I have validated the content of SIM regarding
management of psychiatric emergencies done by Ms Merly Theresia
Mammachan, MSc Nursing student, Athena College of Nursing who is
undertaking the following study.
Topic: Effectiveness of self-instructional module on knowledge regarding

Signature of the expert
Designation and address
Place:
Date:
100
Annexure 14
Criteria Checklist for evaluating self-instructional module on knowledge
regarding Management of Psychiatric Emergencies
Instructions
Kindly go through the criteria listed below which has been formulated for
evaluating the self-instructional module regarding management of Psychiatric
Emergencies. Please read each statement carefully and place a tick mark (9) in the
appropriate column, which expresses your opinion about the module. Please give
your suggestions in the column for ‘Remarks’.
Remarks
Sl. and
No. Criteria Agree Disagree suggestions
1. Formulation of Objectives
The module has
1.1 General objectives.
1.2 Specific objectives in terms of
learner’s behavioural outcomes.
2. Selection of Content
2.1 Psychiatric Emergencies
2.2 Suicide
2.3 Aggression
2.4 Severe Depression
2.5 Epilepsy
3. Organization an presentation
3.1 Module has introduction and table of
contents
3.2 Each unit plan includes the following
aspects
3.3 Unit Objectives
3.4 Content
3.5 Exercise
3.6 Glossary has given meanings of
different terminologies
4. Languages
4.1 Simple and easy to understand
4.2 Explain the technical terms when
needed
101
Remarks
Sl. and
No. Criteria Agree Disagree suggestions
5. Feasibility
5.1 P. C. B. Sc. nursing students would be
able to comprehend the module
through self leaning
5.2 The module is interesting to read.
Signature of Validator
102
PREPARED BY: MS. MERLY THERESIA MAMMACHAN
M. Sc. NURSING STUDENT
ATHENA COLLEGE OF NURSING
103
Instruction for using module
Application of module
The module is designed as a tool for basic education on management of

psychiatric emergencies for 2nd year P. C. B. Sc. nursing students. The module is
designed as a self instructional material to provide the self learning for the
2ndyear P. C. B. Sc. nursing students. Each part of the module is sequentially
arranged, each one builds the knowledge as described in the previous part.
Structure of the module
Module is divided in to five parts and each part has two sections
Section I
• Specific learning goal
• Description of the content
Section II
• Points to be remembered
• Questions and answers
104
Use of the module
The module consists of self instructional materials designed for the

learners to achieve the pre specified objectives. The learners can study at the
home without description and can study alone without any assistance. The
matter is presented in simple language and it is organized in logical sequence.
Each part of this module is having specific areas of learning and review
questions to check your progress.
A glossary of terms is provided to help you

understand the medical terms. The references are
provided to help you to study further and to clarify your
doubts.
You need to read and understand the specific

learning goal given in the beginning of each part. In order to achieve these
learning goals you need to read each part. If you find it difficult to understand
any part of the learning package, read it again. Then answer questions given at
the end of each part and check your answer given at the end of the module. If
you have not answered all the questions correctly, read the content again, answer
correctly and then proceed to the next part.
105
General objectives
On completion of the module the student will be able to understand
1. What is psychiatric emergencies
2. what are characteristics of psychiatric

emergencies
3. what are the objectives of psychiatric

emergencies
4. what are the management priorities of

5. explain the management strategies of psychiatric emergencies
6. what is suicide
7. what are the management of suicide
8. what is severe depression
9. what are the management of depression
10. what is aggression
11. what are the management of aggression
12. what is epilepsy
13. what are the management of epilepsy
106
PART I
Section I
Psychiatric emergencies
Specific learning goal
After studying this module, you will be able to:
• understand the meaning of psychiatric emergencies
• explain the characteristics of psychiatric emergencies
• describe the objectives of psychiatric emergencies
• list down the management priorities of psychiatric emergencies
• discuss the management strategies of psychiatric emergencies
DEFINITION
A psychiatric emergency is an acute

disturbance of behaviour, thought or mood of
a patient which if untreated may lead to
harm, either to the individual or to others in
the environment.
Emergencies may be classified as

• Major- where there is a danger to life either of the patient or to others in
his environment
• Minor- where there is no threat to life but causes severe incapacitation.
Psychiatric emergency may arise anywhere- in the

psychiatric OPD or wards, medical wards or in the
community.
107
Psychiatric emergency has risen due to several
social factors like growing menace of substance abuse,
criminal behaviour and violence.
CHARACTERISTICS
• Any condition or situation making the patient
and relatives to seek immediate treatment.
• Disharmony between subject and environment
(and there is danger to patient /society/property)
• Sudden disorganization in person so that he cannot cope with day to day
obligation such as personnel, social occupational etc
OBJECTIVES
1. To safeguard the life of patient.
2. To bring down the anxiety of family member.
3. To enhance emotional security of others in the environment.
MANAGEMENT PRIORITIES
• First priority- to ensure the safety of patient, the people around him and
the property
Two assessments in first priority are:

1. Immediate assessment;
patient behaviour
2. Further assessment; the
physical environment safety
• Availability of trained
personnel
• A search for drug and weapon abused
• Verbal and non verbal expression of behaviour
• Second priority – the formulation of tentative diagnosis of a condition.

This is done by Psychiatric history, mental status examination, Physical
examination, Laboratory tests.
108
Section 2
2.1 Points to be remembered:
You have completed part-1 of this module. In this part you have read
about:
• A psychiatric emergency is an acute disturbance.
• Emergencies may be classified as Major and minor.
• A psychiatric emergency is a condition seeks immediate treatment and

due to Disharmony and Sudden disorganization.
• First management priority is to ensure the safety of patient, the people
around him and the property and second priority is the formulation of
tentative diagnosis of a condition.
• Psychotherapeutic measures and psychopharmacological agents are the
management strategies for psychiatric emergencies
2.2 Fill in the blanks with appropriate answer:
1. ________ is an acute disturbance of behaviour, thought or mood.

2. Emergencies are classified into ________ and ________.
3. Psychiatric emergency seek ________ treatment
2.3 True or false:
1. Psychiatric emergency arise only in psychiatric OPD or wards (T/F)
2. Psychiatric emergency may cause danger to patient /society/property

(T/F)
3. Formulation of diagnosis is the first management priority of psychiatric

emergency. (T/F)
109
110
PART II
SUICIDE
Section I
• understand the meaning of suicide
• discuss the epidemiology of suicide
• list down the aetiology of suicide
• explain the management of suicide
• discuss the prevention of suicide
Introduction
Suicide is among the ten leading causes of

death in most countries around the world. Suicide
is not a diagnosis or a disorder; it is behaviour.
Suicide occurs in all age groups, social classes and
cultures. Suicide is derived from Latin word Sui
means” self”, and caedere means “to kill”.
Definition
Suicide is the act of killing oneself voluntarily.
Suicide is used to denote self planned and

deliberate termination of one’s life.
Epidemiology
According to WHO suicide rates have

increased by 60% worldwide in last 50 years.
More than a million people die from suicide each
111
year all over the world. With one suicidal death every 40 sec and an attempt
every 3 sec, its global mortality rate is 16 per 1, 00,000 as per WHO figures. The
suicide rate in India is reported as 10.83 per 1, 00,000. Kerala (29 per 1, 00,000)
Karnataka (21 per 1, 00,000) had the highest rate of suicide.
Marital Status- The suicide rate for single persons is twice that of mar ried
persons. Divorced, separated, or widowed persons have rates four to five times
greater than those of the married.
• Sex- men have greater risk of

completed suicide Age –male above 40
• Suicide is three times more Female above 55
common in men than in women

• Women have higher rate of attempted
suicide.
Socioeconomic status- Individuals in the very highest and lowest social
classes has higher suicide rates than those in the middle classes.
AETIOLOGY
1. Genetic Predisposition
• Twin study have shown a much higher
concordance rate for monozygotic twins
than for dizygotic twins
• The genotypic variations in the gene for

tryptophan hydroxylase, indicates
significant association to suicidality.
• Adoptive studies shows that suicidal behaviour occurs more

frequently in the biological
relatives of adoptees who commit
suicide than in adoptive relatives
2. Central serotonin level: Low level or

deficiency of serotonin is associated with
suicidal risk.
112
3. Physical and psychiatric disorder
4. Sociological factors
Management of suicidal patient
General Issues
First and important clinical decision to be made for patient with suicidal
ideation is to hospitalise the clients. Depending on the intensity of the suicidal
risk the patient may treated as an inpatient or outpatient.
On admission:
• Assess risk
• Assess any physical injuries and toxic state
• Physical examination and psychiatric
examination
• Remove object which might be used as means of
suicide
PSYCHIATRIC INPATIENT MANAGEMENT
Management in a psychiatric ward gives staff

time to interview suitable informants, and for
psychotropic medications to be administered and for
their beneficial effects or side effects to be closely
monitored.
PSYCHOTHERAPY
Psychotherapy in its various modalities (individual, group, family or

marital) can be commenced when the patient is able to hold a conversation and is
able to describe his/her problems, feelings and thoughts in a coherent manner.
MEDICATIONS
113
• Antidepressant medications may take between one to two weeks or more
to take effect.
• Tricyclic antidepressant medications are

unsafe in over dosage in view of their
potential for cardio toxicity and
arrhythmias, which could prove fatal.
• Antipsychotic medications should be used

when psychotic symptoms are associated
with depression.
• Mood stabilisers such as lithium carbonate, carbamazepine and sodium

valproate, are often prescribed but might prove dangerous when ingested
in over dosage.
• Sedation is important in an agitated patient and a short course of

benzodiazepines such as diazepam, lorazepam, alprazolam or
bromazepam, maybe used.
ELECTROCONVULSIVE THERAPY
Electroconvulsive therapy is safe and

effective in the treatment of depression,
especially where suicide risk is high or when
the patient refuses to eat or drink.
NURSING MEASURES
• Remove sharp objects such as knives, scissors, and mirror from the
client’s possession and assess.
• Remove toxic substance such as drugs and alcohol.
• Remove the clothing that could be used for self destruction such as sarees,
dupattas, and neck ties.
• Do not allow the client to put bolts in the door and toilets.
114
• Make a written schedule for him every day.
• In daily schedule, don’t forget to schedule at least two 30 minutes periods

for activities such as listening to musical instrument, meditating, doing
relaxation exercises, doing needle work, reading a book or magazine,
gardening, playing games etc.
Suicide Prevention
Constant surveillance is the most important key aspect to prevent suicide
World suicide prevention

day-10th September
SECTION 2
2.1 Points to be remembered
You have completed part II of this module, in this part you have read
• Suicide is the act of killing oneself voluntarily.
• Age, sex, marital status, genetics, neuro chemical factors are factors
influencing suicide
• Antidepressants, antipsychotics, mood stabiliser, ECT, psychotherapy are

main management of suicidal patient
• Constant surveillance is the most important key aspect to prevent suicide
2.2 Fill in the blanks with appropriate answer
• _______ is the act of killing oneself voluntarily.
• _________ Medications should be used when psychotic symptoms are

associated with depression.
• World Suicide Prevention Day is ______
2.3 True or false
115
♣ Women have higher rate of attempted suicide.(T/F)
♣ Low level or deficiency of serotonin is associated with suicidal risk. (T/F)
♣ Allow the suicidal patient to put bolts in the door and toilets.(T/F)
116
PART III
AGGRESSION
Section I
After studying this part, you will be able to;
• understand the meaning of aggression
• list down the aetiology of aggression
• discuss the clinical features of aggression
• explain the management of aggression
DEFINITION
Aggression is a behaviour intended

to threaten or injure the victim’s security
or self esteem. It is a response that aims at
inflicting pain or injury on object or
persons.
Aetiology
1. Psychological
• Organic brain disorder
• Mental retardation
• Learning disability
• Severe emotional deprivation
• Over rejection in childhood
• Exposure to violence in formative years
2. Socio cultural
• Poverty and inability to have basic necessity of life
• Disruption of marriages
• Production of single parent families
117
• Unemployment
• Difficulty in maintaining interpersonal ties, family structure and
social control
3. Biological:
• 3 areas of brain believed to be
involved in aggression
i. Limbic system
ii. Frontal lobe
iii. Hypothalamus
• Low serotonin level, high dopamine, nor epinephrine, acetyl
choline, high testosterone level
1. Psychiatric disorder- schizophrenia, mania, depression, organic brain disorder
2. Alcohol abuse
3. Stress
Some disorders associated with aggression
ORGANIC NON ORGANIC CONDITION
CONDITION
SEIZURE DISORDER PSYCHOTIC NON PSYCHOTIC
Brain injury Schizophrenia Anti social
personality
Infection of brain Delusional disorder Substance abuse
Neoplasma of brain Mania Situational crisis
Delirium stress
Drug intoxication
Withdrawal state
118
CLINICAL FEATURES
Prodormal symptoms
That is characterized by anxiety and tension, verbal abuse
and profanity and increased hyperactivity.
119
MANAGEMENT
1. Observe the client for escalation of anger.
2. When these behaviours are observed, first ensure that sufficient staffs are
available to help with a potentially violent situation.
3. Technically for dealing with aggression
• Talking down
• Present a calm appearance
• Speak softly
• Speak in a non provocative and non judgmental manner.
• Stand 3 feet away from the patient
4. Medication
• Diazepam 5- 10 mg IV slowly (or lorazepam 1-2 mg IV slowly)
with haloperidol 2-10 mg IV/IM.
• Haloperidol may be repeated after 30 min if symptoms are not
controlled. Haloperidol avoided in patient with potential seizure
disorder.
5. Call for resistance
• Remove self and other client from immediately
• Call other team members
• Show of strength is the best method to deescalate a patient
• Client may agree to take medicine if not agree then
6. Restraints or seclusion
• Restraints – it is method used to
restrict the freedom of movement or
normal access to one’s body, material
or equipment
2 types
i. Physical restraints- any manual
method, physical or mechanical
device used to restrict the freedom of movement.
ii. Chemical – medication used to restrict the movement of the
patient
Main protocols for patient in restraints are
120
− Physician reissues a new order for restraints every 4 hour
for adult and every 1-2 hours for adolescents.
− Observe the client in restraints every 15 minutes
− Ensure that circulation to extremities is not compromised.
• Seclusion – it is the method in
which putting the patient alone
in a room from which the person
is physically prevented from
leaving.
7. Observation and documentation
• Observe the client every 15
minutes in restraints
• Check vitals
• Assess the client with needs related to nutrition with hydration and
elimination
• Change position
• Document all observations
SECTION 2
You have completed part III of this module, in this part you have read
• Aggression is a behaviour intended to threaten or injure the victim’s
security or self esteem.
• Psychological, Socio cultural, Biological, Psychiatric disorder, Alcohol
abuse, Stress are the causative factors of aggression
• Prodormal symptoms are the main symptoms of aggressive behavior
• Assessment, examination, control of aggression, medication, restraints,
and seclusion are the main management of aggression
• _________ is a response that aims at inflicting pain or injury on object or

persons.
121
• _________ characterized by anxiety and tension, verbal abuse and
profanity and increased hyperactivity.
• _________ restrain is the method in which medication used to restrict the
movement of the patient
• _________ is the method in which putting the patient alone in a room
• Physician reissues a new order for restraints every _________ hour for
adults
2.3 True or false
Show of strength is the best method to deescalate a patient(T/F)
Speak loudly while dealing with aggressive patient. (T/F)
Haloperidol avoided in patient with potential seizure disorder. (T/F)
122
PART IV
SEVERE DEPRESSION
Section I
After studying this part, you will be able to:
• Explain the meaning of depression

• List the aetiology of depression
• Understand the clinical manifestation
of depression
• Describe the assessment of depression
• Discuss the management of depression
DEPRESSION
This disorder is characterized by depressed mood or loss of interest or

pleasure in usual activities. Evidence of impaired social and occupational
functioning has existed for at least 2 weeks.
AETIOLOGY
1. Genetic theories
• First degree relative of depressive

disorder is 25%
• The concordance rate in unipolar

disorder for monozygotic twins is
46% and for dizygotic twins is 20%.
2. Biochemical theories
• Decrease in nor epinephrine and

serotonin cause depression
123
• Catecholamine low in depression
3. Neuro endocrine theories
• Elevated serum cortisol
• Diminished thyroid stimulating

hormone
• Melatonin is a methylated indole

secreated from pineal gland and
decrease nocturnal melatonin secretion in depression.
4. Psychosocial theories
• Life event and environmental stress
• Premorbid personality
5. Psychoanalytic theory: It was developed by freud in 1957. According to

this theory of depression focused on three major area
• Hostility turned inward or anger against self.
• Due to major loss
• Ongoing dynamic conflict with in self
CLINICAL MANIFESTATION
• Depressed mood
• Loss of interest
• Anxiety
• Insomnia
• Suicidal thought
• Guilt
• Somatic symptoms
− General loss of energy
124
− Quickly become tired
− Vague feeling of aches in muscles
− Complains of headache
• Psycho motor retardation
• Agitation – state of restlessness
• Panic attack
• Uncommon symptoms-paranoid ideas, obsession thoughts, compulsive

rituals. Suicidal tendency is the important criteria symptom to diagnose
severe depression.
ASSESSMENT
• History taking
• Physical examination
• Mental status examination
• Dexa methasone suppression test
It is a biologic marker used for distinguish individual with depression and

post traumatic stress disorder. In this test check the circulating amount of
cortisol. Increased cortisol level means depression and decreased cortisol level
means post traumatic stress disorder
• Rating scales
The beck depression inventory and zung rating scales are self report
measures used to assess the presence of depression and severity of depression.
MANAGEMENT
3 Main phases of management
• Acute phase- goal is to eliminate the symptoms
• Continuous phase- goal is to prevent relapse and promote recovery
125
• Maintenance phase- goal is to prevent recurrence
1. Somatic treatment
First drug of choice-
• Antidepressant imipramine 75-150 mg
for 2 weeks
The other antidepressants are
i. Selective serotonin reuptake inhibitors e.g. fluoxamine
ii. Tricyclic antidepressant e.g. imipramine
iii. Mono amine oxidase inhibitors e.g. phenalazine
iv. Serotonin norepinephrine reuptake inhibitors e.g.

venlafaxine, duloxetine
2. Electro convulsive therapy
• Safe, economic, no absolute contraindication
• Usually 6-8 ECT are needed
• Antidepressant are used along with ECT
• Used for patient with severe depression with somatic delusion and
suicidal idea
3. Anti psychotics are important in the treatment of delusional depression
4. Psychosocial treatment
Cognitive behavior therapy- aims at correcting the

depressive negative cognition
Interpersonal therapy- attempted to recognize and explore
interpersonal stressors.
126
SECTION 2

You have completed part IV of this module, in this part you have read:
• Depression is a disorder is characterized by depressed mood or loss of

interest or pleasure in usual activities
• Genetic theories, Biochemical theories, neuro endocrine theories,

psychosocial theories, psychoanalytic theory are the etiological factors
for depression
• Depressed mood, Loss of interest, Anxiety, Insomnia, Suicidal thought are

the clinical features of depression.
• History taking, Physical examination, mental status examination, dexa

methasone suppression test, rating scales are the measures used to assess
the aggression
• Antidepressant, ECT, antipsychotics, psychosocial treatment are the

main management of depression
1. Decrease in nor epinephrine and serotonin cause ________

2. Psychoanalytic theory was developed in the year ________
3. ________ Scales are used to assess the presence of depression and severity
of depression.
4. ________ is the treatment used for patient with severe depression with
somatic delusion and suicidal idea
5. ________ test is used to check the circulating

amount of cortisol.
2.3 True or false
Φ Antidepressants should not used along with

ECT. (T/F)
Φ Nocturnal melatonin secretion is decreased in depression. (T/F)
127
Φ Anti psychotics are used in the treatment of delusional depression. (T/F)
128
PART-V
EPILEPSY
Section I
• explain the meaning of epilepsy

• discuss the prevalence of epilepsy
• understand the clinical manifestation of epilepsy
• describe the diagnostic measures of epilepsy
• discuss the management of depression
EPILEPSY
• Seizures are episode of abnormal motor, sensory, autonomic or psychic

activity.
• Epilepsy is a group of syndromes characterized by unprovoked recur ring

seizure; hence at least two unprovoked seizures are required for the
diagnosis of epilepsy.
PREVALENCE
Epidemological studies from

developed countries have revealed that
epilepsy occurs at a prevalence rate of
approximately 5/1000 population and
the incidence rate of 50/1, 00,000/ year.
About 10% of all epileptic have

some psychological problems and half
of them need psychiatric care.
129
Temporal lobe epilepsy is particularly associated with psychological
disorder.
In children high
percentage is associated with
high brain damage and
associated learning problems.
Seizures are divided into
1. Simple partial seizures
2. Complex partial seizures
3. Generalized partial seizures
1. Simple partial seizure: It is seizure with elementary symptoms, generally

no impairment of consciousness. The symptoms are only a finger or hand
may shake, mouth may jerk uncomfortably. The patient may talk
unintelligibly, may be dizzy may experience unusual or unpleasant sights,
sound odors or tastes but without loss of consciousness.
2. Complex partial seizure: It is seizure with complex symptoms, generally

with impairment of consciousness. In this patient either remains
motionless or moves automatically but inappropriately excessive emotion
of fear, anger, elation or irritability
3. Generalized seizure: It is grand mal seizures involve both hemisphere of

brain. Intense rigidity of the entire body may occur. The tongue is often
chewed and the patient is incontinent of urine and feces. After 1 to 2
minutes the convulsive movements begin to subside; the patient relaxes
and lies in deep coma.
130
Pseudo seizure is characterized by purposive convulsive
movements, 20-800 seconds, partial amnesia, never occur
during sleep, and occur in safe places.
Features that help to differentiate psychogenic seizure from epileptic

convulsion include
1. Asymmetrical thrashing movement of the limbs and side to side head

movement rather than bilaterally symmetrical tonic clonic movement.
2. Pelvic thrusting
3. Lack of stereotypic pattern with repeated events.
4. Talking or screaming throughout the seizure
5. Very long duration
6. Bilateral involvement with impairment of consciousness.
7. Sudden return to consciousness following prolonged generalized seizure
ASSESSMENT AND DIAGNOSTIC FINDINGS
• History taken
− To seek evidence of pre existing

injury
− Questioned about illness or

head injuries that may have
affected the brain.
• Physical and neurological examination
• Diagnostic examinations include

biochemical, hematologic and
serotologic studies.
131
• MRI is used to detect structure lesions
such as focal abnormalities, cerebro
vascular abnormalities, and cerebral
degenerative changes.
• EEG assists in classifying the type of

seizures
• Micro electrodes –depth electrodes inserted deep in brain to probe the

action of single brain cells.
• Telemetry is used to monitor electrical brain activity while the patient

purses his or her normal activity
• SPECT (single photon emission computed tomography) is an additional

tool that is sometime used to
identify the epileptiogenic
zone so that area in the brain
giving rise to seizures can be
removed surgically. It may be
helpful to measure cerebral blood flow in clients undergoing surgery for
epilepsy
MEDICAL MANAGEMENT
The main management is
1. Object should be moved out of the way so that the client doesn’t strike his
or her head or extremities.
132
2. Any tight clothing around the person’s neck is loosened.
3. Put a pillow or folded blanket under the affected person’s head.
4. Do not attempt to open the airway once the tonic phase has ceased.
133
SIDE LYING POSITION is given to the patient during seizure.
MEDICATION
1st step -Lorazepam IV 0.1 mg/kg @ 2mg/min

Seizure ↓ continuing
nd
2 step- IV Phenytoin 20mg/kg@ 50 mg/ mt
rd
3 step-additional 5-10 mg of phenytoin
th
4 step-IV phenobarbitol 20 mg/kg@ 50-75 mg/mt
th
5 step- additional 5-10 mg/kg Phenobarbital IV
th
6 step-anaesthesia with midazolam or propofol
134
SECTION 2
You have completed part V of this module, in this part you have read
• Epilepsy is a group of syndromes characterized by unprovoked recur ring

seizure
• Simple partial seizures, Complex partial seizures, generalized partial

seizures are the main classification of seizures
• History, Physical and neurological examination, MRI, EEG Micro

electrodes, Telemetry, SPECT are the diagnostic measures used in
epilepsy
• Phenytoins, Lorazepam,Phenobarbital are the medication used in case of

epilepsy
1. ________ are episode of abnormal motor, sensory, autonomic or psychic

activity.
2. ________ is seizure with elementary symptoms, generally no impairment

of consciousness
3. ________ is used to monitor electrical brain activity.
2.3 True or false
Φ Generalized seizure is grand mal seizures involve both hemisphere of

brain.(T/F)
Φ EEG assists in classifying the type of seizures. (T/F)
Φ Prone position is given to the patient during seizure. (T/F)
135
Conclusion
As in other branch of medicine, emergency arise in psychiatric also. This

need immediate attention because of the potential threat to the lives of the people
or others. Emergencies, which are life threatening, are preferably routed to a
setting where facilities to meet such situation are available. Such facilities
include, in addition to those of investigation, medication and cross consultation
in allied medical specialties, adequate staff and if need be, facilities to physically
restrain the patient.
ANSWERS
Part 1:
2.2 Fill in the blanks
1. Psychiatric emergencies
2. Major and Minor
3. Immediate
2.3 True or false
1. False
2. True
3. False
Part 2:
1. suicide
2. antipsychotics
3. 10th September
2.3 True or false
1. True
2. True
3. False
Part 3:
1. Aggression
2. Prodormal symptoms
3. Chemical
4. Seclusion
5. 15 minutes
136
137
2.3 True or false
1. True
2. False
3. True
Part 4:
1. Depression
2. 1957
3. Rating
4. ECT
5. Dexa methasone test
2.3 True or false
1. False
2. True
3. True
Part 5
1. Seizures
2. Simple partial
3. telemetry
2.3 True or false
1. True
2. True
3. False
138
Bibliography
1. Kapoor B. Textbook Of Psychiatry Nursing 1 Edition. Delhi Kumar

Publishers; 2006.
2. Kaplan H I.Sadok.B.J.
Synopsis Of Psychiatry-
Behavioural Science Or
Clinical Psychiatry. 9 Edition.
Hong Kong; William and
Willisons Publishers; 1998.
3. Bhatia M.S. Essentials Of
Psychiatry.4 Edition.
Newdelhi; CBS
Publishers;2004.
4. Townsand C Mary. Psychiatric
Mental Health Nursing.4 Edition. Philadelphia, F. A Davis Company;
2003.
5. Niraj Ahuja. A Short Text Book Of Psychiatry. 5 Edition. Newdelhi,
Jaypee Brothers; 2004.
6. Stuart G W. Principles And Practice Of Psychiatry. 1 Edition Noida;
Mosby Publishers; 2001.
7. Namboodri V M D. Text Book Of Psychiatry. 2 Edition New Delhi;

Elseivier India P V T Ltd; 2005.
8. http://www.pubmed.com
139
Annexure 16
List of experts who validated the tool and SIM
Psychiatric Medicine
1. Dr. Shafekh. A. T.
Associate professor
Department of psychiatry
Father Muller Medical College.
Psychiatric Nursing
2. Dr. Sr. Alphonsa Ancheril,

P. G. Co-ordinator
Mangalore.
3. Mrs. Irene Veigas

Principal
Sahyadri College of nursing
Mangalore.
4. Dr. Christopher Sudhaker

Dean
Manipal College of nursing
Mangalore.
5. Mrs. Thereza Mathias

Professor and HOD
Laxmi Memorial College of nursing
Mangalore.
6. Mr. N. Balasubramaniam
Professor and HOD
Shree Devi College of nursing
Mangalore.
7. Mrs. Nalini M.
Associate Professor and HOD
Nite Usha Institute of Nursing Sciences
NITE University.
8. Mr. Shivakumar J.
Associate Professor
Laxmi Memorial College of nursing
Mangalore.
140
9. Mr. Jestine Jose
Associate Professor and HOD
Indira College of nursing
Mangalore.
10. Mrs. Krupa P.

Assistant Professor and HOD
K. Pandyrajah Ballal College of nursing
Mangalore.
141
Annexure 17
Master data sheet - Pre-test
Demographic
data Knowledge questionnaire
1 2 3 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34
1 a b b c 1 1 0 0 1 1 1 1 1 1 1 1 0 1 0 0 1 1 0 1 1 0 1 0 1 1 1 0 1 1 0 0 1 1
2 a b a b 1 1 1 0 1 0 1 0 0 1 1 0 1 0 0 1 1 1 1 0 1 1 1 0 1 0 0 1 0 0 0 1 1 1
3 b b b b 1 1 1 0 1 0 0 1 0 1 1 0 1 1 0 1 1 1 1 0 0 1 1 1 1 1 0 0 0 0 0 1 1 1
4 a b b b 0 0 0 0 1 0 1 0 0 0 1 1 0 1 1 0 1 1 1 1 0 1 0 0 1 1 0 0 1 1 1 0 0 1
5 b b c b 1 1 0 0 1 0 1 0 0 0 1 1 0 1 1 0 1 1 0 1 0 1 0 1 1 0 0 0 1 1 1 0 0 1
6 a b a c 1 1 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 1 0 0 0 0 1 0 0 1
7 a b a b 0 0 0 0 1 0 0 0 0 1 1 0 0 1 1 0 1 0 0 1 0 0 0 0 1 1 0 0 0 0 1 0 0 1
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9 b b c c 0 0 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 0 1 1 0 1 0 1 1 0 0 1 1 0 0 1 1
10 c b c b 0 0 1 0 1 1 1 0 0 0 1 0 0 1 0 1 1 1 0 0 0 0 0 1 1 1 0 0 1 1 0 0 1 1
11 b b c c 0 1 0 1 1 1 1 0 1 0 1 0 0 1 0 0 0 0 0 0 1 0 1 1 0 0 0 0 1 1 0 0 1 1
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27 a b b c 1 1 0 0 1 1 1 0 0 1 1 0 0 0 1 1 1 1 0 1 1 0 0 0 1 1 0 0 1 1 0 1 1 1
142
Demographic
data Knowledge questionnaire
1 2 3 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34
28 a b b b 0 1 0 0 1 0 1 1 1 1 1 0 1 1 0 1 1 1 0 1 1 0 1 0 0 1 0 0 1 1 0 0 1 1
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32 a b a b 0 1 1 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 1 0 0 1 0 1 1 0 1 1 1 0 0 0 1
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38 a b a b 1 1 0 0 1 0 0 1 0 1 1 0 0 1 0 0 1 1 0 1 0 0 0 0 0 1 0 1 0 1 0 0 1 0
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40 a b a b 1 1 0 1 1 0 0 1 0 0 1 1 1 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1 0 0 1 0
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Annexure 18
Master data sheet- Post-test

Knowledge questionnaire
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34
1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 0 1 1 1 1 1 0 1 1 1 1 1 0 1 1 1 0 1 1
2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 1 1 1 0 1 1 1 1
3 1 1 1 0 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 1 1 1
4 0 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 1 1 1 1 1 1
5 1 1 1 0 1 1 1 1 0 1 1 1 0 1 1 1 1 1 0 1 1 1 1 1 1 1 0 0 1 1 1 0 1 1
6 1 1 1 1 1 0 1 0 1 1 1 1 0 1 1 0 1 1 1 1 0 1 0 1 1 1 1 1 1 1 1 1 1 1
7 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
8 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 0 0 1 1
9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 0 1 1 1 1 1 1 1 0 1 1
10 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 0 0 1 0 1 1 1 1 0 1 1 0 0 1 1
11 0 1 0 1 1 1 1 0 1 1 1 0 0 1 1 0 0 0 0 0 1 1 1 1 1 0 1 0 1 1 1 0 1 1
12 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 0 1 0 1 1 1 0 0 1 0 1 1 0 1 1 1
13 1 0 1 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 0 1 1 1 1
14 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 0 1
15 0 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 1 1 1 0 1 1 1
16 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
17 0 1 0 0 1 1 1 0 1 1 1 1 1 0 0 0 1 1 0 0 1 1 0 1 1 1 0 1 1 1 1 1 1 1
18 1 1 1 1 1 1 0 0 0 1 1 1 1 0 0 1 1 1 0 1 1 0 0 1 0 1 0 1 1 1 1 1 1 1
19 1 0 1 1 1 1 0 0 1 1 1 1 0 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 1
20 1 1 1 0 1 0 0 1 0 1 1 1 1 1 1 1 1 0 0 1 1 0 0 1 1 1 0 0 1 1 0 1 1 1
21 1 1 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1
22 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0
23 1 1 1 1 1 1 1 1 0 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1
24 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 1 0 1
25 1 1 1 0 1 0 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1
26 1 1 1 1 1 0 1 0 1 1 1 1 1 1 1 1 1 1 0 1 1 0 1 0 1 1 0 1 1 1 1 1 1 1
27 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 1 1 1
28 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 1 1 0 0 1 1
144
Knowledge questionnaire
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34
29 1 1 0 1 1 0 1 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0
30 0 1 1 1 1 1 1 1 0 0 1 1 1 0 0 0 1 1 0 1 0 0 1 0 1 1 0 0 1 1 0 0 1 1
31 0 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 0 1 1 1 1 1 1 1 0 1 1
32 0 1 1 1 1 1 0 1 1 0 1 1 1 1 1 1 1 1 0 1 1 1 1 0 1 1 0 1 1 1 1 1 1 1
33 1 1 1 1 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 1 1 1 1 1 1
34 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1
35 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 0
36 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 1
37 1 1 1 0 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1
38 1 1 0 0 1 1 0 1 0 0 1 1 1 1 0 0 1 1 0 1 1 1 1 1 0 1 0 1 0 1 1 1 1 0
39 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 1 1 1 1 1 0 1 0 0
40 1 1 0 1 1 1 0 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 0 0 1 0 0 1 0
41 1 1 1 0 1 1 1 0 0 0 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
42 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1
43 1 1 1 1 1 1 1 1 1 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1
44 1 1 0 1 0 1 1 1 1 0 1 0 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 0 1 1 1 1 1 1
45 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1
46 1 1 0 1 1 1 0 0 1 1 1 1 1 1 0 0 0 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
47 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1
48 1 1 1 1 1 1 1 1 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1
145
Annexure 19
Statistical Formulas
1. Karl Pearson’s Correlation Coefficient
Σxy − (Σx)(Σy )
r=
[nΣx 2
][
− ( Σ x ) 2 nΣy 2 − ( Σy ) 2 ]
2. Spearman Brown Prophecy Formula
2r
r 1=
1+ r
3. Paired ‘t’ test
t=
d
d=
∑d σd =
∑(d − d ) 2
σd 2 n n
n
4. Chi-square test with 2 X 2 contingency table
N (ad − bc) 2
χ2=
(a + b)(c + d )(a + c)(b + d )
5. Chi-square test with 4 X 2 contingency table
2
(∑ Oi − Ei ) 2
χ=
Ei
6. Chi-square test with Yates correction
N[| ad − bc | −( N / 2]2
χ2=
(a + b)(c + d )(a + c)(b + d )
146
PREPARED BY: MS. MERLY THERESIA MAMMACHAN
M. Sc. NURSING STUDENT
ATHENA COLLEGE OF NURSING
1
Instruction for using module
Application of module
The module is designed as a tool for basic education on management of

psychiatric emergencies for 2nd year P. C. B. Sc. nursing students. The module is
designed as a self instructional material to provide the self learning for the 2ndyear P.
C. B. Sc. nursing students. Each part of the module is sequentially arranged, each one
builds the knowledge as described in the previous part.
Structure of the module
Module is divided in to five parts and each part has two sections
Section I
• Specific learning goal
• Description of the content
Section II
• Points to be remembered
• Questions and answers
2
Use of the module
The module consists of self instructional materials designed for the learners to
achieve the pre specified objectives. The learners can study at the home without
description and can study alone without any assistance. The matter is presented in
simple language and it is organized in logical sequence.
Each part of this module is having specific areas of learning and review
questions to check your progress.
A glossary of terms is provided to help you

understand the medical terms. The references are provided to
help you to study further and to clarify your doubts.
You need to read and understand the specific

learning goal given in the beginning of each part. In order to
achieve these learning goals you need to read each part. If you find it difficult to
understand any part of the learning package, read it again. Then answer questions
given at the end of each part and check your answer given at the end of the module. If
you have not answered all the questions correctly, read the content again, answer
correctly and then proceed to the next part.
3
General objectives
On completion of the module the student will be able to understand
1. What is psychiatric emergencies
2. what are characteristics of psychiatric

emergencies
3. what are the objectives of psychiatric

emergencies
4. what are the management priorities of

5. explain the management strategies of psychiatric emergencies
6. what is suicide
7. what are the management of suicide
8. what is severe depression
9. what are the management of depression
10. what is aggression
11. what are the management of aggression
12. what is epilepsy
13. what are the management of epilepsy
4
PART I
Section I
Psychiatric emergencies
• understand the meaning of psychiatric emergencies
• explain the characteristics of psychiatric emergencies
• describe the objectives of psychiatric emergencies
• list down the management priorities of psychiatric emergencies
• discuss the management strategies of psychiatric emergencies
DEFINITION
A psychiatric emergency is an acute

disturbance of behaviour, thought or mood of a
patient which if untreated may lead to harm,
either to the individual or to others in the
environment.
Emergencies may be classified as

• Major- where there is a danger to life either of the patient or to others in his
environment
• Minor- where there is no threat to life but causes severe incapacitation.
Psychiatric emergency may arise anywhere- in the

psychiatric OPD or wards, medical wards or in the
community.
5
Psychiatric emergency has risen due to several
social factors like growing menace of substance abuse,
criminal behaviour and violence.
CHARACTERISTICS
• Any condition or situation making the patient and
relatives to seek immediate treatment.
• Disharmony between subject and environment
(and there is danger to patient /society/property)
• Sudden disorganization in person so that he cannot cope with day to day
obligation such as personnel, social occupational etc
OBJECTIVES
1. To safeguard the life of patient.
2. To bring down the anxiety of family member.
3. To enhance emotional security of others in the environment.
MANAGEMENT PRIORITIES
• First priority- to ensure the safety of patient, the people around him and the
property
Two assessments in first priority are:

1. Immediate assessment; patient
behaviour
2. Further assessment; the physical
environment safety
• Availability of trained
personnel
• A search for drug and weapon abused
• Verbal and non verbal expression of behaviour
• Second priority – the formulation of tentative diagnosis of a condition. This is

done by Psychiatric history, mental status examination, Physical examination,
Laboratory tests.
6
Section 2
2.1 Points to be remembered:
You have completed part-1 of this module. In this part you have read about:
• A psychiatric emergency is an acute disturbance.
• Emergencies may be classified as Major and minor.
• A psychiatric emergency is a condition seeks immediate treatment and due to

Disharmony and Sudden disorganization.
• First management priority is to ensure the safety of patient, the people around
him and the property and second priority is the formulation of tentative
diagnosis of a condition.
• Psychotherapeutic measures and psychopharmacological agents are the
management strategies for psychiatric emergencies
2.2 Fill in the blanks with appropriate answer:
1. ________ is an acute disturbance of behaviour, thought or mood.

2. Emergencies are classified into ________ and ________.
3. Psychiatric emergency seek ________ treatment
2.3 True or false:
1. Psychiatric emergency arise only in psychiatric OPD or wards (T/F)
2. Psychiatric emergency may cause danger to patient /society/property (T/F)
3. Formulation of diagnosis is the first management priority of psychiatric

emergency. (T/F)
7
PART II
SUICIDE
Section I
• understand the meaning of suicide
• discuss the epidemiology of suicide
• list down the aetiology of suicide
• explain the management of suicide
• discuss the prevention of suicide
Introduction
Suicide is among the ten leading causes of

death in most countries around the world. Suicide is
not a diagnosis or a disorder; it is behaviour. Suicide
occurs in all age groups, social classes and cultures.
Suicide is derived from Latin word Sui means” self”,
and caedere means “to kill”.
Definition
Suicide is the act of killing oneself voluntarily.
Suicide is used to denote self planned and deliberate

termination of one’s life.
Epidemiology
According to WHO suicide rates have

increased by 60% worldwide in last 50 years. More
than a million people die from suicide each year all
8
over the world. With one suicidal death every 40 sec and an attempt every 3 sec, its
global mortality rate is 16 per 1, 00,000 as per WHO figures. The suicide rate in India
is reported as 10.83 per 1, 00,000. Kerala (29 per 1, 00,000) Karnataka (21 per 1,
00,000) had the highest rate of suicide.
Marital Status- The suicide rate for single persons is twice that of married persons.
Divorced, separated, or widowed persons have rates four to five times greater than
those of the married.
• Sex- men have greater risk of completed

suicide Age –male above 40
• Suicide is three times more Female above 55

common in men than in women
• Women have higher rate of attempted suicide.
Socioeconomic status- Individuals in the very highest and lowest social classes
has higher suicide rates than those in the middle classes.
AETIOLOGY
1. Genetic Predisposition
• Twin study have shown a much higher
concordance rate for monozygotic twins than
for dizygotic twins
• The genotypic variations in the gene for

tryptophan hydroxylase, indicates significant
association to suicidality.
• Adoptive studies shows that suicidal

behaviour occurs more frequently in the biological relatives of
adoptees who commit suicide than in
adoptive relatives
2. Central serotonin level: Low level or

deficiency of serotonin is associated with
suicidal risk.
3. Physical and psychiatric disorder
9
4. Sociological factors
Management of suicidal patient
General Issues
First and important clinical decision to be made for patient with suicidal
ideation is to hospitalise the clients. Depending on the intensity of the suicidal risk the
patient may treated as an inpatient or outpatient.
On admission:
• Assess risk
• Assess any physical injuries and toxic state
• Physical examination and psychiatric examination
• Remove object which might be used as means of
suicide
• Safe ward environment
PSYCHIATRIC INPATIENT MANAGEMENT
Management in a psychiatric ward gives staff time

to interview suitable informants, and for psychotropic
medications to be administered and for their beneficial
effects or side effects to be closely monitored.
PSYCHOTHERAPY
Psychotherapy in its various modalities (individual, group, family or marital)

can be commenced when the patient is able to hold a conversation and is able to
describe his/her problems, feelings and thoughts in a coherent manner.
MEDICATIONS
• Antidepressant medications may take between one to two weeks or more to

take effect.
10
• Tricyclic antidepressant medications are unsafe in over dosage in view of their
potential for cardio toxicity and arrhythmias, which could prove fatal.
• Antipsychotic medications should be used

when psychotic symptoms are associated with
depression.
• Mood stabilisers such as lithium carbonate,

carbamazepine and sodium valproate, are often
prescribed but might prove dangerous when
ingested in over dosage.
• Sedation is important in an agitated patient and a short course of

benzodiazepines such as diazepam, lorazepam, alprazolam or bromazepam,
maybe used.
ELECTROCONVULSIVE THERAPY
Electroconvulsive therapy is safe and

effective in the treatment of depression,
especially where suicide risk is high or when
the patient refuses to eat or drink.
NURSING MEASURES
• Remove sharp objects such as knives, scissors, and mirror from the client’s
possession and assess.
• Remove toxic substance such as drugs and alcohol.
• Remove the clothing that could be used for self destruction such as sarees,
dupattas, and neck ties.
• Do not allow the client to put bolts in the door and toilets.
• Make a written schedule for him every day.
• In daily schedule, don’t forget to schedule at least two 30 minutes periods for
activities such as listening to musical instrument, meditating, doing relaxation
11
exercises, doing needle work, reading a book or magazine, gardening, playing
games etc.
Suicide Prevention
Constant surveillance is the most important key aspect to prevent suicide
World suicide prevention

day-10th September
SECTION 2
You have completed part II of this module, in this part you have read
• Suicide is the act of killing oneself voluntarily.
• Age, sex, marital status, genetics, neuro chemical factors are factors
influencing suicide
• Antidepressants, antipsychotics, mood stabiliser, ECT, psychotherapy are

main management of suicidal patient
• Constant surveillance is the most important key aspect to prevent suicide
• _______ is the act of killing oneself voluntarily.
• _________ Medications should be used when psychotic symptoms are

associated with depression.
• World Suicide Prevention Day is ______
2.3 True or false
♣ Women have higher rate of attempted suicide.(T/F)

♣ Low level or deficiency of serotonin is associated with suicidal risk. (T/F)
♣ Allow the suicidal patient to put bolts in the door and toilets.(T/F)
12
PART III
AGGRESSION
Section I
After studying this part, you will be able to;
• understand the meaning of aggression
• list down the aetiology of aggression
• discuss the clinical features of aggression
• explain the management of aggression
DEFINITION
Aggression is a behaviour intended to

threaten or injure the victim’s security or self
esteem. It is a response that aims at inflicting
pain or injury on object or persons.
Aetiology
1. Psychological
• Organic brain disorder
• Mental retardation
• Learning disability
• Severe emotional deprivation
• Over rejection in childhood
• Exposure to violence in formative years
2. Socio cultural
• Poverty and inability to have basic necessity of life
• Disruption of marriages
• Production of single parent families
• Unemployment
13
• Difficulty in maintaining interpersonal ties, family structure and social
control
3. Biological:
• 3 areas of brain believed to be
involved in aggression
i. Limbic system
ii. Frontal lobe
iii. Hypothalamus
• Low serotonin level, high dopamine,
nor epinephrine, acetyl choline, high testosterone level
1. Psychiatric disorder- schizophrenia, mania, depression, organic brain disorder
2. Alcohol abuse
3. Stress
Some disorders associated with aggression
ORGANIC CONDITION NON ORGANIC CONDITION
Seizure disorder PSYCHOTIC NON PSYCHOTIC
Brain injury Schizophrenia Anti social personality
Infection of brain Delusional disorder Substance abuse
Neoplasma of brain Mania Situational crisis
Delirium stress
Drug intoxication
Withdrawal state
CLINICAL FEATURES
Prodormal symptoms
That is characterized by anxiety and tension, verbal abuse
and profanity and increased hyperactivity.
14
MANAGEMENT
1. Observe the client for escalation of anger.
2. When these behaviours are observed, first ensure that sufficient staffs are
available to help with a potentially violent situation.
3. Technically for dealing with aggression
• Talking down
• Present a calm appearance
• Speak softly
• Speak in a non provocative and non judgmental manner.
• Stand 3 feet away from the patient
4. Medication
• Diazepam 5- 10 mg IV slowly (or lorazepam 1-2 mg IV slowly) with
haloperidol 2-10 mg IV/IM.
• Haloperidol may be repeated after 30 min if symptoms are not
controlled. Haloperidol avoided in patient with potential seizure
disorder.
5. Call for resistance
• Remove self and other client from immediately
• Call other team members
• Show of strength is the best method to deescalate a patient
• Client may agree to take medicine if not agree then
6. Restraints or seclusion
• Restraints – it is method used to restrict
the freedom of movement or normal
access to one’s body, material or
equipment
2 types
i. Physical restraints- any manual
method, physical or mechanical
device used to restrict the freedom of movement.
ii. Chemical – medication used to restrict the movement of the
patient
Main protocols for patient in restraints are
15
− Physician reissues a new order for restraints every 4 hour for
adult and every 1-2 hours for adolescents.
− Observe the client in restraints every 15 minutes
− Ensure that circulation to extremities is not compromised.
• Seclusion – it is the method in
which putting the patient alone in a
room from which the person is
physically prevented from leaving.
7. Observation and documentation
• Observe the client every 15
minutes in restraints
• Check vitals
• Assess the client with needs related to nutrition with hydration and
elimination
• Change position
• Document all observations
SECTION 2
You have completed part III of this module, in this part you have read
• Aggression is a behaviour intended to threaten or injure the victim’s security
or self esteem.
• Psychological, Socio cultural, Biological, Psychiatric disorder, Alcohol abuse,
Stress are the causative factors of aggression
• Prodormal symptoms are the main symptoms of aggressive behavior
• Assessment, examination, control of aggression, medication, restraints, and
seclusion are the main management of aggression
• _________ is a response that aims at inflicting pain or injury on object or

persons.
• _________ characterized by anxiety and tension, verbal abuse and profanity
and increased hyperactivity.
16
• _________ restrain is the method in which medication used to restrict the
movement of the patient
• _________ is the method in which putting the patient alone in a room
• Physician reissues a new order for restraints every _________ hour for adults
2.3 True or false
Show of strength is the best method to deescalate a patient(T/F)
Speak loudly while dealing with aggressive patient. (T/F)
Haloperidol avoided in patient with potential seizure disorder. (T/F)
17
PART IV
SEVERE DEPRESSION
Section I
• Explain the meaning of depression

• List the aetiology of depression
• Understand the clinical manifestation of
depression
• Describe the assessment of depression
• Discuss the management of depression
DEPRESSION
This disorder is characterized by depressed mood or loss of interest or pleasure

in usual activities. Evidence of impaired social and occupational functioning has
existed for at least 2 weeks.
AETIOLOGY
1. Genetic theories
• First degree relative of depressive

disorder is 25%
• The concordance rate in unipolar

disorder for monozygotic twins is
46% and for dizygotic twins is 20%.
2. Biochemical theories
• Decrease in nor epinephrine and

serotonin cause depression
18
• Catecholamine low in depression
3. Neuro endocrine theories
• Elevated serum cortisol
• Diminished thyroid stimulating

hormone
• Melatonin is a methylated indole

secreated from pineal gland and
decrease nocturnal melatonin secretion in depression.
4. Psychosocial theories
• Life event and environmental stress
• Premorbid personality
5. Psychoanalytic theory: It was developed by freud in 1957. According to this

theory of depression focused on three major area
• Hostility turned inward or anger against self.
• Due to major loss
• Ongoing dynamic conflict with in self
• Depressed mood
• Loss of interest
• Anxiety
• Insomnia
• Suicidal thought
• Guilt
• Somatic symptoms
− General loss of energy
19
− Quickly become tired
− Vague feeling of aches in muscles
− Complains of headache
• Psycho motor retardation
• Agitation – state of restlessness
• Panic attack
• Uncommon symptoms-paranoid ideas, obsession thoughts, compulsive rituals.

Suicidal tendency is the important criteria symptom to diagnose severe
depression.
ASSESSMENT
• History taking
• Physical examination
• Mental status examination
• Dexa methasone suppression test
It is a biologic marker used for distinguish individual with depression and post
traumatic stress disorder. In this test check the circulating amount of cortisol.
Increased cortisol level means depression and decreased cortisol level means post
traumatic stress disorder
• Rating scales
The beck depression inventory and zung rating scales are self report measures
used to assess the presence of depression and severity of depression.
MANAGEMENT
3 Main phases of management
• Acute phase- goal is to eliminate the symptoms
• Continuous phase- goal is to prevent relapse and promote recovery
20
• Maintenance phase- goal is to prevent recurrence
1. Somatic treatment
First drug of choice-
• Antidepressant imipramine 75-150 mg
for 2 weeks
The other antidepressants are
i. Selective serotonin reuptake inhibitors e.g. fluoxamine
ii. Tricyclic antidepressant e.g. imipramine
iii. Mono amine oxidase inhibitors e.g. phenalazine
iv. Serotonin norepinephrine reuptake inhibitors e.g. venlafaxine,

duloxetine
2. Electro convulsive therapy
• Safe, economic, no absolute contraindication
• Usually 6-8 ECT are needed
• Antidepressant are used along with ECT
• Used for patient with severe depression with somatic delusion and
suicidal idea
3. Anti psychotics are important in the treatment of delusional depression
4. Psychosocial treatment
Cognitive behavior therapy- aims at correcting the

depressive negative cognition
Interpersonal therapy- attempted to recognize and explore
interpersonal stressors.
behavior with depression
21
SECTION 2

You have completed part IV of this module, in this part you have read:
• Depression is a disorder is characterized by depressed mood or loss of interest

or pleasure in usual activities
• Genetic theories, Biochemical theories, neuro endocrine theories, psychosocial

theories, psychoanalytic theory are the etiological factors for depression
• Depressed mood, Loss of interest, Anxiety, Insomnia, Suicidal thought are the
clinical features of depression.
• History taking, Physical examination, mental status examination, dexa

methasone suppression test, rating scales are the measures used to assess the
aggression
• Antidepressant, ECT, antipsychotics, psychosocial treatment are the main

management of depression
1. Decrease in nor epinephrine and serotonin cause ________

2. Psychoanalytic theory was developed in the year ________
3. ________ Scales are used to assess the presence of depression and severity of
depression.
4. ________ is the treatment used for patient with severe depression with
somatic delusion and suicidal idea
5. ________ test is used to check the circulating amount of cortisol.
2.3 True or false
Φ Antidepressants should not used along with ECT.

(T/F)
Φ Nocturnal melatonin secretion is decreased in

depression. (T/F)
Φ Anti psychotics are used in the treatment of delusional depression. (T/F)
22
PART-V
EPILEPSY
Section I
• explain the meaning of epilepsy

• discuss the prevalence of epilepsy
• understand the clinical manifestation of epilepsy
• describe the diagnostic measures of epilepsy
• discuss the management of depression
EPILEPSY
• Seizures are episode of abnormal motor, sensory, autonomic or psychic

activity.
• Epilepsy is a group of syndromes characterized by unprovoked recurring

seizure; hence at least two unprovoked seizures are required for the diagnosis
of epilepsy.
PREVALENCE
Epidemological studies from

developed countries have revealed that
epilepsy occurs at a prevalence rate of
approximately 5/1000 population and the
incidence rate of 50/1, 00,000/ year.
About 10% of all epileptic have

some psychological problems and half of
them need psychiatric care.
Temporal lobe epilepsy is particularly associated with psychological disorder.
23
In children high percentage is associated with high brain damage and
associated learning problems.
Seizures are divided into
1. Simple partial seizures
2. Complex partial seizures
3. Generalized partial seizures
1. Simple partial seizure: It

is seizure with elementary
symptoms, generally no
impairment of consciousness. The symptoms are only a finger or hand may
shake, mouth may jerk uncomfortably. The patient may talk unintelligibly,
may be dizzy may experience unusual or unpleasant sights, sound odors or
tastes but without loss of consciousness.
2. Complex partial seizure: It is seizure with complex symptoms, generally

with impairment of consciousness. In this patient either remains motionless or
moves automatically but inappropriately excessive emotion of fear, anger,
elation or irritability
3. Generalized seizure: It is grand mal seizures involve both hemisphere of

brain. Intense rigidity of the entire body may occur. The tongue is often
chewed and the patient is incontinent of urine and feces. After 1 to 2 minutes
the convulsive movements begin to subside; the patient relaxes and lies in
deep coma.
Pseudo seizure is characterized by purposive convulsive

movements, 20-800 seconds, partial amnesia, never occur
during sleep, and occur in safe places.
24
Features that help to differentiate psychogenic seizure from epileptic
convulsion include
1. Asymmetrical thrashing movement of the limbs and side to side head

movement rather than bilaterally symmetrical tonic clonic movement.
2. Pelvic thrusting
3. Lack of stereotypic pattern with repeated events.
4. Talking or screaming throughout the seizure
5. Very long duration
6. Bilateral involvement with impairment of consciousness.
7. Sudden return to consciousness following prolonged generalized seizure
ASSESSMENT AND DIAGNOSTIC FINDINGS
• History taken
− To seek evidence of pre existing injury
− Questioned about illness or head injuries that may have affected the
brain.
• Physical and neurological examination
• Diagnostic examinations include biochemical, hematologic and serotologic

studies.
• MRI is used to detect structure lesions

such as focal abnormalities, cerebro
vascular abnormalities, and cerebral
degenerative changes.
• EEG assists in classifying the type of

seizures
25
• Micro electrodes –depth electrodes
inserted deep in brain to probe the action
of single brain cells.
• Telemetry is used to monitor electrical

brain activity while the patient purses his
or her normal activity
• SPECT ( single photon emission computed tomography) is an additional tool

that is sometime used to
identify the epileptiogenic zone
so that area in the brain giving
rise to seizures can be removed
surgically. It may be helpful to
measure cerebral blood flow in clients undergoing surgery for epilepsy
MEDICAL MANAGEMENT
The main management is
1. Object should be moved out of the way so that the client doesn’t strike his or
her head or extremities.
2. Any tight clothing around the person’s neck is loosened.
3. Put a pillow or folded blanket under the affected person’s head.
4. Do not attempt to open the airway once the tonic phase has ceased.
26
SIDE LYING POSITION is given to the patient during seizure.
MEDICATION
1st step -Lorazepam IV 0.1 mg/kg @ 2mg/min

nd
2 step- IV Phenytoin 20mg/kg@ 50 mg/ mt
rd
3 step-additional 5-10 mg of phenytoin
th
4 step-IV phenobarbitol 20 mg/kg@ 50-75 mg/mt
th
5 step- additional 5-10 mg/kg Phenobarbital IV
th
6 step-anaesthesia with midazolam or propofol
27
SECTION 2
You have completed part V of this module, in this part you have read
• Epilepsy is a group of syndromes characterized by unprovoked recurring

seizure
• Simple partial seizures, Complex partial seizures, generalized partial seizures

are the main classification of seizures
• History, Physical and neurological examination, MRI, EEG Micro electrodes,

Telemetry, SPECT are the diagnostic measures used in epilepsy
• phenytoins, lorazepam,phenobarbital are the medication used in case of

epilepsy
1. ________ are episode of abnormal motor, sensory, autonomic or psychic

activity.
2. ________ is seizure with elementary symptoms, generally no impairment of

consciousness
3. ________ is used to monitor electrical brain activity.
2.3 True or false
Φ Generalized seizure is grand mal seizures involve both hemisphere of

brain.(T/F)
Φ EEG assists in classifying the type of seizures. (T/F)
Φ Prone position is given to the patient during seizure. (T/F)
28
Conclusion
As in other branch of medicine, emergency arise in psychiatric also. This need

immediate attention because of the potential threat to the lives of the people or others.
Emergencies, which are life threatening, are preferably routed to a setting where
facilities to meet such situation are available. Such facilities include, in addition to
those of investigation, medication and cross consultation in allied medical specialties,
adequate staff and if need be, facilities to physically restrain the patient.
ANSWERS
Part 1:
1. Psychiatric emergencies
2. Major and Minor
3. Immediate
2.3 True or false
1. False
2. True
3. False
Part 2:
1. suicide
2. antipsychotics
3. 10th September
2.3 True or false
1. True
2. True
3. False
Part 3:
1. Aggression
2. Prodormal symptoms
3. Chemical
4. Seclusion
5. 15 minutes
29
2.3 True or false
1. True
2. False
3. True
Part 4:
1. Depression
2. 1957
3. Rating
4. ECT
5. Dexa methasone test
2.3 True or false
1. False
2. True
3. True
Part 5
1. Seizures
2. Simple partial
3. telemetry
2.3 True or false
1. True
2. True
3. False
30
Bibliography
1. Kapoor B. Textbook Of Psychiatry Nursing 1 Edition. Delhi Kumar

Publishers; 2006.
2. Kaplan H I.Sadok.B.J. Synopsis
Of Psychiatry- Behavioural
Science Or Clinical Psychiatry. 9
Edition. Hong Kong; William
and Willisons Publishers; 1998.
3. Bhatia M.S. Essentials Of
Psychiatry.4 Edition. Newdelhi;
CBS Publishers;2004.
4. Townsand C Mary. Psychiatric
Mental Health Nursing.4
Edition. Philadelphia, F. A Davis
Company; 2003.
5. Niraj Ahuja. A Short Text Book Of Psychiatry. 5 Edition. Newdelhi, Jaypee
Brothers; 2004.
6. Stuart G W. Principles And Practice Of Psychiatry. 1 Edition Noida; Mosby
Publishers; 2001.
7. Namboodri V M D. Text Book Of Psychiatry. 2 Edition New Delhi; Elseivier

India P V T Ltd; 2005.
8. http://www.pubmed.com
31
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EFFECTIVENESS OF SELF-INSTRUCTIONAL MODULE ON

KNOWLEDGE REGARDING MANAGEMENT OF

PSYCHIATRIC EMERGENCIES AMONG 2nd YEAR P. C. B. Sc.

NURSING STUDENTS OF A SELECTED COLLEGE OF

MERLY THERESIA MAMMACHAN

Dissertation submitted to the

Under the guidance of

DECLARATION BY THE CANDIDATE

I, Merly Theresia Mammachan that this dissertation/thesis titled

“Effectiveness of self-instructional module on knowledge regarding Management

of Psychiatric Emergencies among 2nd year P. C. B. Sc. nursing students of a

selected college of nursing at Mangalore” is a bonafide and genuine research work

Professor, Department of Psychiatric Nursing, Athena College of Nursing,

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation titled “Effectiveness of self-

instructional module on knowledge regarding Management of Psychiatric

Emergencies among 2nd year P. C. B. Sc. nursing students of a selected college of

nursing at Mangalore” is a bonafide research work done by Merly Theresia

Mammachan in partial fulfilment of the requirement for the degree of Master of

This is to certify that the dissertation titled “Effectiveness of self-

instructional module on knowledge regarding Management of Psychiatric

Emergencies among 2nd year P. C. B. Sc. nursing students of a selected college of

nursing at Mangalore” is a bonafide research work done by Merly Theresia

Mammachan under the guidance of Mr Rajarathinam.P, M.Sc. (N), Asst.

Professor, Department of Psychiatric Nursing, Athena College of Nursing,

Dr.(Sr) Alphonsa Ancheril Sr. Ann Rose D’Almeida

Date: 8.2.2012 Date: 8.2.2012

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health Science,

© Rajiv Gandhi University of Health Sciences, Karnataka

contributed to the successful completion of this endeavour.

I express my deep sense of gratitude to my Guide, Mr. Rajarathinam.P

Assistant Professor, Department of Psychiatric Nursing, Athena College of

illuminating guidance to make the work a successful learning experience. His

tremendous support and timely help served as source of inspiration to explore.

I express my sincere thanks to Dr (Sr) Alphonsa Ancheril, Professor, HOD,

Department of Psychiatric nursing, Athena College of Nursing for her constant

effort in moulding the investigator’s raw thinking by providing valuable suggestions

and making this project a fruitful and successful learning experience.

Extensive sense of gratitude is due to Sr. Ann Rose D’Almeida, Principal,

Chairman and Mrs. Asha Shettian, Secretary for giving me an opportunity to

undertake the course at Athena Institute of Health Sciences, Mangalore.

I express my sincere thanks and appreciation to Mrs. Sonia Lobo, lecturer

Department of Psychiatric Nursing, Athena College of nursing Mangalore for the

I am grateful to Principal and staff members of Athena College of Nursing

the support throughout the study.

I acknowledge with sense of gratitude to Mr. Suresh, Statistician for his

instructional module, for their judgment and constructive criticism

taken to prepare the manuscript.

for their constant prayer and support.

Special thanks to all my classmates, friends and the members of Athena

assistance in making this study a pleasant learning experience.

My wholehearted thanks to my parents Mr. T. Mammachan &

their love, patience and concern.

Place: Mangalore Ms. Merly Theresia Mammachan

P.C.B.Sc.: Post Certificate Bachelor of Science

RGUHS: Rajiv Gandhi University of Health Sciences

SD: Standard Déviation

SIM: Self Instructional Module

WHO: World Health Organisation.

Background and objectives

A psychiatric emergency is an acute disturbance of behavior, thought or mood

in the environment. Emergency psychiatry is the clinical application of psychiatry in