Culturally safe management of aggression and violence in 
mental health care institutions 
- 'NWU I 
\ueRAI! . 
LIBRARY 
I 
/_ !'!l.t'.f-1:,{ENG CAMPUS 
CALL NO., 
2019 -07- 1 5 
ACC.NO. , 
Theresa M. Bock 
Student number: 24630497 
A thesis submitted to North-West University in fulfilment of the requirements for 
Doctor of Philosophy in Nursing at the Mafikeng Campus of the North-West 
University 
Promoter: Professor A.J. Pienaar 
December 2015 
DECLARATION 
By submitting this research assignment electronically, I declare that the entirety of the work 
contained therein is my own, original work, that I am the authorship owner thereof and that 
I have not previously in its entirety or in part submitted it for obtaining any qualification. 
Date December 2015 
Signature 
Theresa M. Bock 
DEDICATION 
To-the- memory of cilL the, H. ea.lih,, CcurE1/ u~~ I ha>vE1/ n.uv.s-ed,, 
OVeY the-pcv,;t 3 0 yeav}: 
The potency of a lifelong initiative 
This research project is a sub-project of the Seboka research Team. The African academic 
is firstly the child of mother Africa and secondly the creator of knowledge in the primary 
context of Africa and secondarily in the global sphere. The configuration of an African 
scholar's identity necessarily entails accepting a bundle of responsibilities shaped by 
mother Africa's potent imperatives. Etymologically defined, 'Seboka' denotes a 'group,' a 
'team,' a 'community' and a phenomenal 'coming together' of sorts. The term of necessity 
subsumes one's ephemeral individuality under the value-generating ethos of 
'communitarian' solidarity. A signifier of the shared benefits of synergy, the Seboka emblem 
- depicting a pride of lions on a mission under the supreme guidance of collective vision - is 
a celebration of the invaluable wealth of sharing and reciprocal engagement which lies at 
the heart of Africa's philosophy. As such, the Sebeka concept was born out of respect for 
the imperatives of mother Africa, whose breast has availed the milk of human kindness 
moulding the African children into a team of valiant warriors in legitimate defence of their 
priceless heritage. 
The Sebeka logo summons to memory the telling axiom, 'A lion that goes on a hunt by 
itself, without co-existing in a pride, will always fail to catch even a limping deer.' In the 
same communitarian spirit, Seboka uses the claypot as a key emblem, symbolising sharing 
and communal solidarity. The Seboka team perceptively unpacks this definitive element of 
African life and essence, the profound Ubuntu philosophy, potently encapsulated in the 
dictum 'I am, because we are,' hence placing community and group care above the focus 
of the self. This Seboka team is a rich confluence of various tributaries, but the Community 
is their first consideration. 
The hallmark of Seboka's invaluable research output has been the endeavour to strike 
signature partnerships with the community, the very custodians of the forests, mountains 
and rivers which are the abode of nature's healing essence and strength. Quite 
enlightening is the Khoi-chiefs statement made recently in an open platform, 'The veld is 
our chemist' (Kok V, 2013). The wisdom enshrined in this statement is a telling testimony of 
how conventional medical practice has always tapped into the resourcefulness of medicinal 
plants and other curative phenomena in Africa's rich forests. Notwithstanding the research 
on medicinal plants, the Sebeka team predominantly re-engineer the broader practices of 
the African child 
Seboka Greeting 
The activities of the Seboka project is predominantly funded by the National 
Research Foundation (RSA); The Department of Science and technology (RSA) and 
the North-West University (Mafikeng Campus) 
ACKNOWLEDGEMENTS 
I would like to acknowledge Elize for giving me the endless support and motivation when I 
was overwhelmed, you kept the household during my many hours away from home and 
even while I was "absent" whilst in the house but so preoccupied with my own thoughts. 
My dad Arthur and his wife Marie, thank you for collecting me at the airport at all hours of 
the night and giving me a home away from Cape Town. Eitel and Kim, Arthur and Suzy (my 
siblings and their spouses) thank you very much for all the moral support. 
To the Research team, whom I consider to be my extended family; my sincere thanks. 
When my motivation lacked, you helped me along. 
This research journey was like many other researchers experienced before. I would have 
given in to ups and downs, but I want to give gratitude to my Heavenly Father for pulling 
me through serious illness whilst undertaking this journey. If it was not for the will of God, 
this would not have been. 
My employer, thank you for granting me study leave to complete this task. 
Evalo and Leon Van Wijk my sincere thanks for always assisting with advise and the 
access to databases and research articles, your assistance is worth more than gold. 
Prof. Pienaar, I want to single you out as you showed the necessary confidence in my 
ability and project. We survived some serious tribulations, but like the logo of our Research 
team says, 
"a Solitary lion is incapable of even catching a limping deer." 
The pride came through after all! 
Kea le boha ntate! 
ABSTRACT t.fWu-, 
~ lj'rj 
(Key words: Cultural safety; aggression; violence; mental health care facilities.) --
Aggression and violence in Health Care is common course in mental health care facilities . 
Literature informs that staff finds it difficult to managing aggression and violence. This is 
exacerbated in the South African context where we deal with diverse cultures despite the 
fact that the majority of our mental health care users rely heavily on care from their own 
indigenous healers according to their Indigenous Knowledge System. This adherence to a 
Western Based Knowledge System often makes care not culturally safe or appropriate. 
Most of the research done in this regard focusses on pure management of aggression and 
violence and the effect of training programmes in the European context. This research 
project, however explored the methods used by indigenous healers and combining that 
knowledge and practices with additional training in cultural sensitivity and awareness, to 
determine the effect of a treatment interventions which includes inter alia with 
understanding the phenomenon of aggression and violence, de-escalation techniques, safe 
restraint and dignified break away techniques. The research objectives addressed aspects 
such as Indigenous Knowledge and skills, attitudes of staff with regards to the 
management of aggression and violence, cultural sensitivity of staff, refinement of a 
training programme on the management of aggression and violence to include skills and 
knowledge used by indigenous healers which is applicable to the management of 
aggression and violence and determining the effect of the training programme on the 
above. 
An exploratory sequential mixed method was followed, with a qualitative phase which used 
makgotla as novel data collection method, the information generated during this data 
analysis was utilised to augment current literature and refine an existing training 
programme. The indigenous healers used in this study were from the same geographical 
area where the participants in the experimental groups are employed, as they would be 
dealing with mental health care users from the same cultural group their respective mental 
health care institutions would serve. 
The quantitative phase consisted of a pretest and posttest after a training programme (the 
refined training course). The researcher primarily made use of purposive sampling, based 
on findings in the literature study and, thereafter, proceeded to perform randomised cluster 
sampling. In the latter, the researcher randomly selected which hospitals will fall into which 
experimental group. Participants completed the MAVAS (management of aggression and 
violence attitude scale) and the lntercultural sensitivity questionnaires for both the pretest 
and the posttest, after the administration of the training programme. Questionnaires for the 
posttest were administered after the presentation of different parts of the training 
programme in the different mental health care institutions, these pretests and posttest 
results were compared both within the groups and between the experimental groups. 
Descriptive statistics were used to describe the demography of the participants and 
inferential statistics were used to determine the effect of the training programme. 
The findings revealed that the experimental group constituted of participants with the least 
amount of experience in mental health care had the most significant attitudinal change with 
regards to the management of aggression and violence. All the experimental groups 
showed a significantly improved understanding of how the environment in the mental health 
care facility can contribute to mental health care user related violence and aggression and 
that improved communications between mental health care providers and mental health 
care users can contribute to a decrease in aggression and violence. 
The most remarkable result was however the group who only received training on cultural 
sensitivity and awareness had the most significant change in attitude in the management of 
aggression and violence. This experimental group was coincidentally the least experienced 
in mental health care. Therefore it can be concluded training programme which included 
cultural sensitivity and awareness showed the most significant effect on the attitudes 
towards the management of aggression and violence and the youngest least experienced 
group were more influenced by the training. 
These findings have implications for nursing curricula in foundational programmes with 
reference to cultural sensitivity and awareness and the management of mental health care 
user related aggression and violence. Mental health care facilities and management must 
be made aware of the benefit of such a training programme when orientating the neophyte 
to the services and also for continuous professional development of permanent employees 
to improve their ability to deal with aggression and violence and to render cultural safe 
care. The community can also benefit from this research through equipping them with the 
skills to deal with aggression and to avoid harmful practices as identified during the 
makgotla. 
Finally this study suggests avenues for further research , namely determining the perception 
of mental health care users with reference to whether they render the care received to be 
culturally sensitive and appropriate, exploration of the culturally safe mental health care 
environment and research focused on "unlearning" destructive attitudes in mental health 
care providers. 
Table of Contents 
Declaration ...... .. ........ ..... ................ ..... .. ... .. .... ..... ....... .......... ....... .. ... ... ...... .. .......... .. .. .. .. ii 
Acknowledgements .. .... ....... .... ..... ... .... .... ............. ...... .. .. ... .. ............ .. ........ .. .. ....... .... ... .. v 
Abstract ........................ ... .. ... ... .... .. .. ... ... ...... .... ........... .... .... .... .. .. ....... ......... ....... .. ... .. .. .. vi 
CHAPTER 1 .... ...... ..... ...... ... ... .. .. ........ .. .. .. ..... ........ .. .... .... ........ .... .. ... ..... .... .... .............. .. ........ ..... 1 
OVERVIEW OF THE RESEARCH .... .. .... ... ....... .. .... .......... .. ... ......... ....... ...... ... .......... ... .... ....... ... 1 
1.1 TITLE ... .. ........... ....... .. ... ..... .... ...... ... ... ............. .. ........ .... .... ...... ................. .... .. .. ..... ... 1 
1.2 INTRODUCTION AND RATIONALE FOR THE RESEARCH ..... .. .. .. ... .. ........... .... .... 1 
1.3 BRIEF LITERATURE REVIEW .. ..... ...... ... ... .. .. .. ... ....... ... ......... ... ..... ....... ...... .... .. ...... 3 
1.4 CONTEXT ... ... .. .. ........ ..... .. .. .... ...... ....... .... ........ .... ..... .... .. ..... ........ ... ......... ........ ... .. ... 5 
1.5 PROBLEM STATEMENT ...... .... ..... ........ ...... ........ ... ........ .... ... ... ... ... .. .... .. .... .... .. ..... .. 6 
1.6 AIMS AND OBJECTIVES OF THE RESEARCH .. .. ..... ... .. .. .. ... .... ........ .. ... ............ ... . 7 
1.6.1 Central theoretical argument .. ............ ... ... .... ... ...... ... .. .... .... .. ....... .... ......... ........ .... ... . 7 
1.6.2 Hypothesis .... .. ...... .. ........... .. .... .... ..... .... .... ....... ...... ..... .... ....... ... ...... .. .. ..... ...... ...... .. .. 8 
1.7 RESEARCHER'S ASSUMPTIONS ... .. ..... ...... ....... ... ..... .. ... ..... .... ...... ... ...... .... .. .... ... . 8 
1.8 PHILOSOPHICAL GROUNDING OF THIS RESEARCH ... ..... .... .... .. ...... ... .... ..... .... .. 8 
1.9 THEORETICAL ASSUMPTIONS ... .. ......... .. ... ...... ... ..... .......... ............ .. ... .. .. ...... .. ..... 9 
1.9.1 Cultural awareness and sensitivity ... ... .. ..... .... ..... ... .... .. .. .. ........ ... ..... ... ... .. .:  ...... .... ... . 9 
1.9.2 Cultural safety .... .. ... ... ...... .. ....... ......... .. .. .... .... .. ...... ..... ...... ...... .. ..... ....... ... .......... .... 10 
1.10 METHODOLOGICAL ASSUMPTIONS ........ ....... .. ...... ....... .... ... ....... ... .... ..... .. .. ..... .. 10 
1.11 RESEARCH DESIGN AND RESEARCH METHOD .... ......... ... ... ... .... .... ... .. .. .... ...... 11 
1.11.1 Overview of the research design and research method ..... .. .. ...... .... ...... .......... ... .... 12 
1.12 STUDY OUTLAY .... ....... .. .. .. ... .. ...... ..... ... .... ... ... .. ............. .. ... ........ ... ........ .. ..... ... ... .. 13 
1.13 CONCLUSION .... ....... ....... .. ... .. .... .. .. .... .... .. ..... .... .... ... .... .. .... ........ .. .. .... .. ....... .... .... . 13 
CHAPTER 2 ...... ..... ...... ........ ...... ..... .. ...... ... ........ .. .. .... ...... ..... .. ... ...... ...... .... ...... ........... .... ... .... .. 14 
LITERATURE STUDY .. .......... ... .............. .... .... .. .. ... ....... .... .. .. ... ..... ..... .. .. ... .. ....... ....... ...... ... .... .. 14 
2.1 INTRODUCTION ........ ........ ...... ... ..... .. ... ....... .. ... ..... ... ....... .... ...... ...... ........ .... .. ....... . 14 
2.2 AFRICAN INDIGENOUS KNOWLEDGE SYSTEMS (AIKS) AND WESTERN-
BASED KNOWLEDGE SYSTEMS (WBKS) ..... .... ................. .......... ...... ... ........ ... ... 14 
2.2.1 Introducing the status quo with regards to cultural differences as evident in 
health care institutions ..... .. ... ...... .... ... ... .. ..... ..... ....... .... .... .... ... .... .. ...... ...... ..... ... ...... 15 
2.2.2 Broad overview of African Indigenous Knowledge Systems (AIKS) ... ... .... .... ... .... .. . 16 
2.2.3 Broad overview of WBKS ... ....... .. ........ .... .... ..... ..... ..... ... ....... ... .. .. .... .. ....... .. ... ..... .... 18 
2.2.4 When two opposing world views meet.. ...... .. .... ..... ...... ... .... ......... .. ...... ..... ..... .. .... ... 19 
2.2.5 WBKS versus IKS ... .. .... ... ... .... ... ............. ........ .. ... .... ... ... ... .. ... .. .. .. .... .. .... ...... ... ... .. .. 21 
2.2.6 Attitudes of Western-based health care practitioners towards AIKS .... ..... ....... .. ... .. 23 
2.2.7 Attitudes of indigenous healers towards the WBKS ..... ..................... ........ ........... ... 27 
2.2.8 Resistance to share Al KS .... ........... ..... .............. ............... .... ... .. ......... .. ................. 28 
2.2.9 Legalisation of indigenous health practices .... ..... .. .. ... .......... .. ................. ..... ......... . 28 
2.2.10 Movement towards co-existence of Al KS and WBKS ................ .... .. ............ ......... .. 30 
2.3 PERCEPTIONS OF MENTAL ILLNESS ................ ...... ... ........ ... ...... ......... ..... ........ . 31 
2.3.1 Mental illness explained within the AIKS .... ... ............... .... ...... .................. .. ........ .... 31 
2.3.2 Treatment of mental illness within AIKS ... ....... .. .......... .. .. .. .... ... ... ... ......... ..... .... ... ... 33 
2.3.3 Mental Illness explained within the WBKS ..... .... ..... ..... ......... ... ................. ..... ......... 36 
2.3.4 Treatment of mental illness within the WBKS/Allopathic view ... ... ........... ... ....... .... .. 38 
2.4 AGGRESSION ASSOCIATED WITH MENTAL ILLNESS ..... .. ... ..... ....... .... ............ 39 
2.4.1 The view of aggression associated with mental illness from a WBKS 
perspective ......... ................. ... ......... ..... ..... ..... .. .... .... .... ...... .. ... ... ............................ 40 
2.4.1.1 Management of mental illness related aggression and violence within the 
Western-based scientific knowledge/bio-medical system ....................................... 42 
2.4.2 AIKS view of aggression associated with mental illness ....... ... ....... .......... ... ........... 43 
2.4.2.1 Management of mental illness related aggression and violence within the AIKS .... 43 
2.5 CULTURAL SAFETY AND CULTURAL SENSITIVITY ...... .. ....... .... .. ........... .. ......... 45 
2.6 TRAINING IN THE MANAGEMENT OF VIOLENCE AND AGGRESSION .......... .. . 47 
2.6.1 Content of the curriculum for training packages in the management of 
aggression and violence .......... ..... .. ... ....... ..... .. ...... .. .. ... .... .... .. ..... ............ .............. . 48 
2.7 CONCLUSION .. ................................. .................. .. ... ............................................. 50 
CHAPTER 3 ... ......... .... ............ .......... .... .... ....... ........ ........................ ......... ...... ......................... 52 
RESEARCH DESIGN AND METHODOLOGY ...... ...................... ... .. .. ...... .................. .. ............ 52 
3.1 INTRODUCTION ......... ..... ... ... ... ..... .... .... .... .. .... ........ .. ... .. ... .... ..... ............. ... ........... 52 
3.2 METHODOLOGY ....... .. .......... ... ... ..... .... ... ... .... ... ... .. .... .... ....... .................. ... .. ......... 52 
3.2.1 Research approach and design ......... .. .... ... ..... .. .... ... .. ..... .... ........ ............. ... ........... 52 
3.2.2 Overview of the research design and methodology ................ .... ... ........... .. .. ......... . 53 
3.2.2.1 Qualitative phase ..... ... ......... ........ ..... ....... ........................................ .. .............. ..... . 53 
3.2.2.1.1 Adaptation of the MAVAS questionnaire ...... .. .......... ... .......... ....... .. .. ............ .. ......... 55 
3.2.2.2 Quantitative phase of the research ... ....... ........ ...... ... ... ... .......... ........ ....... .. .. ... ..... ... 55 
3.3 THE QUALITATIVE PHASE OF THIS RESEARCH PROJECT .............. .. ..... ... ...... 55 
3.3.1 Population and sampling ............. ......... .... ............. ..................... ... ............ ... ......... . 56 
3.3.2 Consent. .. .... ...... ......... ...... ........................... ......... ... .................................. .. ........... 56 
3.3.3 Rigour during the qualitative phase of this research ............................................. .. 57 
3.3.3.1 Trustworthiness/credibility, validity and confirmability .......... ... .. ..... ............. .. .......... 57 
3.4 QUANTITATIVE PHASE OF THIS RESEARCH ............ .... ........ ....... ........... .. ......... 59 
3.4.1 Population and sampling ......... ........................... .... .................... .. ........................ .. 59 
3.4.1 .1 Selection of the hospitals and experimental groups to take part in the study .......... 60 
3.4.2 Inclusion and exclusion criteria ............ ........ .... ......... .... ..... ....... .................. ... .. ... .. .. 64 
3.4.3 Rigor during the quantitative component of this research ................................... .... 64 
3.4.3.1 Validity/legitimacy ................ ... .. ....... ..... ................. ................................................. 64 
3.4.3.2 Reliability .............. ... ............ ...... ... ... ............... .. ........ .. ........... ......... ......... ... ............ 65 
3.4.4 Control during the research project .. ... ... .. ... .................... ..... ... ... ..... ........ .... ....... .... 65 
3.4.4.1 Prevention of cross-contamination ........ ... ............ ......... ... ..... ............................ ... .. 65 
3.4.4.2 Control over extraneous variables ........ .... .................... .... .. .. .... ...... ...... ..... ....... ..... . 66 
3.5 ETHICAL AND MORAL CONSIDERATIONS ............ .. .. ...................... ...... ............. 67 
3.5.1 Risks, benefits, and ethical considerations .......... ....... .. ..... ..................................... 67 
3.5.2 Risks .... .... ..... .. ... .............. ......... ........ ........... ... .. ............... ...... .. .............................. 67 
3.5.3 Benefits ..................... ... ................. ..... ................................. .................... ............... 67 
3.5.4 Ethical considerations ......... ... .... .... ..... .. .................................. .. ............................. 67 
3.5.4.1 Anonymity ............. .......................................... ............................... .... ........ ............ 68 
3.5.4.2 Confidentiality ................ ............... ...... ....... ............ .. ........ ................ ....... ............... 68 
3.5.5 Informed consent ... ... ........ ......... ... ...... ...... ... .. .. ........ ....... ... ......... ............ ........... .... 68 
3.5.6 Ethical considerations pertaining to conduct of the researcher ........... ... ................ . 69 
3.5.7 Cognitive justice as ethical principle .... ..... ............ ... .... .. ......................................... 69 
3.6 CONCLUSION .............................. .. ............ ... ........ .. .......................................... .... 70 
CHAPTER 4 ............... .. ................. ................. .. .......... .. .................... .. ...................................... 71 
QUALITATIVE PHASE: RESULTS, DATA ANALYSIS, INTERPRETATION AND 
DISCUSSION ... ............................ .... ......................................... ... ..... .......... ....... ... ................. .. 71 
4.1 INTRODUCTION ...... ..... ................. ...... ......... ..... .. ............................... .. ................. 71 
4.2 PURPOSE ........ ........... .... ... .......... .... ... ..... ...... ..... .... ...... ... .... ..... ........................... . 71 
4.3 DESCRIPTION OF THE POPULATIONS ............................................................... 71 
4.4 DATA COLLECTION .............................. .. ................ ... ... .. ...... ...... ......... .. .. ............ . 72 
4.4.1 Negotiations for the Lekgotla in a rural village in Lesotho .................. ........ ........ .. ... 72 
4.4.2 Context of the Lekgotla in the rural Basotho village ........... ............ ......................... 73 
4.5 DATA ANALYSIS ............... ...... .. ...................... ... ..... .... .................................... .... .. 73 
4.6 THEMES, CATEGORIES AND CONCEPTS ...... ... ...................................... ........... 75 
4.7 PRESENTATION OF FINDINGS OF THE LEKGOTLA WITH THE BASOTHO ...... 75 
4.7.1 Theme 1: Comprehension and conceptualisation of mental illness 
according to indigenous knowledge .................................. ..... .... ... .......................... 75 
4.7.1.1 Categories .......... .... .............. ... ... ..... ....... ................................. ....... ......... .. ......... .... 76 
4.7.2 Theme 2: Identifying aggression ..... .. ............ .. ....................................................... 78 
4.7.2.1 Categories .............. ............ .. .... .. ..... .. ........ .... ........... ... ................... ..... .... ........ ..... .. 79 
4.7.3 Theme 3: Recognising the causes of aggression .......................... ... ...... ............. ... 80 
4.7.3.1 Categories .. ........ .. ... .... ..... .................................. .. ...................... .. ...... ........... ..... ... . 80 
4.7.4 Theme 4: Predictors of aggression ............ .. ....... ................................... .. .. ........ ..... 81 
4.7.5 Theme 5: Indigenous techniques in the management of aggression ....... ... ...... .... .. 81 
4.7.5.1 Categories .... ............. ..... ... .. .. ....... ........ ............... ........ ... ........ ..... ..... ... .. ..... ............ 81 
4.7.6 Theme 6: Diminishing destructive methods of dealing with aggression and 
violence ..... .. ........ ..... ........ ..... .. ............... .... ..... .... ... ..... ... ... ..... ........ .......... ... .... ... .... 84 
4.7.6.1 Categories .. ......... ..... ... ..... .... ... ................ .. ...... .... .... ....... ..... .... ....... .......... ... ....... .... 84 
4.8 NEGOTIATIONS FOR THE LEKGOTLA IN A KHO/SANVILLAGE. ......... ....... ..... .. 85 
4.8.1 Context of the /ekgotla in a Khoisan village .. ...... ...... .. ..... .. ... .... ....... ........ .. ............. 86 
4.9 PRESENTATION OF FINDINGS OF THE LEKGOTLA IN THE KHOISAN 
VILLAGE .... ........ ..... ..... .......... ... .. .. ....... ... ...... ..... ... ... .... ..... ...... .... ... .......... .. ... ... .... .. 86 
4.9.1 Theme 1: Comprehension and conceptualisation of mental illness 
according to indigenous knowledge .. .... ... ........ .... ...... .. ... ...... .... ... ... ... ...... .... .......... . 86 
4.9.1.1 Categories .. .... ............. ... .... ...................... .. .. ....... ..... ... ............ .... ... .......... .... ...... .... 87 
4.9.2 Theme 2: Identifying aggression .. ...... .... ... .......... ... ... ..... · .~-!.--Nwu······'"' ·······8 8 
4.9.2.1 Categories ........ : ··.· · ....... ....... ............. ........... .... ...... •· •· •l .JB RARY/ ·· ·· ·· 89 
4.9.3 Theme 3. Recognising the causes of aggression ........ .... .... .. ..... .. .. ....... :-:-:-:-:-.. .· . ...... .. 90 
4.9.3.1 Categories: ...... .... .... .... .. .. ........ ... ......... ... .. ... .. .. ...... .... ... ... ...... ......... ..... ...... ........... .. 91 
4.9.4 Theme 4: Predictors of aggression ....... .. .. .... .... ........ ... .. ... .... ... .. ................. ....... ... .. 91 
4.9.5 Theme 5: Indigenous techniques in the management of aggression ....... .. ............. 92 
4.9.5.1 Categories .. ..... .......... .... ........... ..... ..................... ....... .. ..... ... .... .... ... ...... .... .. ... ......... 92 
4.9.6 Theme 6: Diminishing destructive methods of dealing with aggression and 
violence .... ....... ...... ...... .. ... ......... ... ... .. ... .... ..... ... ........ ... ... ......... ... .. .......... .. ....... ....... 93 
4.9.6.1 Categories ........ ... ... ..... .... ... .... .. ...... ........ ..... .......... ........ ......... .. ........ ... .... ... ...... ...... 93 
4.10 CONVERGENCE BE1WEEN THE BASOTHO AND KHOISAN DATA . .......... ....... . 95 
4.10.1 Comprehension and conceptualisation of mental illness according to 
indigenous knowledge ..... ... .. ..... ........ .... ... .... ..... .. .. .. ...... .... ..... .. ...... ........ .... ...... ...... 95 
4.10.2 Causes and management of mental illness according to indigenous 
knowledge ............... ... ... ...... .............. .......... .. ...... .. .. ....... ... .... ... .............................. 96 
4.10.3 Identification of aggression ... .. ......... .... ..... ...... .... .......... ...... ..... ............... ................ 96 
4.10.3.1 Causes of aggression ............ .. ... ... ...... .. ... ... ...... .. .... .... ... ........ .................. .............. 96 
4.10.4 Management of aggression according to indigenous knowledge .... ... .... .... ............. 97 
4.10.4.1 Verbal management of aggression ..... ... .. ... ........................ .. .............. .. ..... .. ......... .. 98 
4.10.4.2 Physical management of aggression ... ... .... ............. .... ..... ........... .. ..... .. ..... .. ... ....... . 98 
4.10.4.3 Do not intervene if no intervention is necessary ... ... ... ...... ... .... ...... .. ......... ... ... .. ...... 98 
4.10.4.4 Medicinal component ..... .......... ...... ...... .... .. ...... ... .... ... ..... ... .... ..... ..... ........ .... ......... . 99 
4.11 CONCLUSION ... ........ ..... .. .......... ..... .... .... ... .... .. ...... ..... ......... ..... ...... ........ ... ........... 99 
CHAPTER 5 ..... ... ........ .......... ....... .... ....... .. ..... ... .. .... .. ... .. ... ...... ..... .. .. ....... ..... ...................... .... 102 
QUANTITATIVE PHASE: RESULTS, DATA ANALYSIS, INTERPRETATION AND 
DISCUSSION .... .. ... ....... .. ... .. .. .. .... ....... ........ .. .... ............ .... .. ............. ... .. .. ... .. ............. ..... ........ 102 
5.1 INTRODUCTION ..... ... ..... .... .. .......... ..... ............ .......... ............ ..... ..... .. .... ...... ........ 102 
5.2 TRAINING PROGRAMME (TREATMENT) PHASE OF THE RESEARCH 
PROJECT ....... .. ..... ... ...... ............... ........ .. ......... ........... ......... ... .... ..... ... ........ ... ... .. 102 
5.2.1 Administration of the mavas and the cultural awareness and sensitivity 
questionnaires and training programme (treatment) .................. .. ... ..... ....... ........ .. 103 
5.2.2 Context of the training programme .. ........................ .. ................. .. ............. .. ......... 105 
5.2.3 Development of the curriculum for the training programme ....................... .. ......... 105 
5.2.4 Nature of the training programme/curriculum ............ .... ........ ... ...... ......... ...... ....... 106 
5.2.4.1 Step one (1 ): Consideration of situational factors such as instructional 
challenges of the course, and expectations from the learner and how the course 
will fit into the larger curricular context ........................... .. ...... .. .............. .......... ..... 106 
5.2.4.2 Step two (2): Learning goals. What do you want the learner to learn that would 
stay with them for years? ..... .. ....................... ....................................... .. ... ........... 107 
5.2.4.3 Step three (3): Feedback and Assessment procedures. What will the students 
have to do to demonstrate that they have achieved the goals of the training 
course? ...... .... .... .. .. .. ... .. .......... .. ................. .............. ........ ......... ....... ............ .... .... 108 
5.2.4.4 Step four (4) Teaching and learning activities. How would you involve the 
students? ........ ........ ... .......... ....... .. .............. ........................... ._ .. .. ...... .... .......... ... .. 108 
5.2.4.5 Step five (5): Make sure the key components are all integrated ........ .. ... ...... .. ... ... 109 
5.3 PRESENTATION AND ANALYSIS OF THE DATA .. ..... ... ... ...... .. .............. ... ........ 109 
5.4 RESULTS OF THE DATA .... ......... .... .. .... .................. ... .... ....... ...... ........... .... ........ 110 
5.4.1 Demography of the respondents ..................... ... ............. ......... .. .... .................... .. 11 O 
5.4.1.1 Gender of the participants ... .... .. .......... ............. ..... ... .......... ........... .. ..................... 110 
5.4.1.2 Training received in the management of aggression and violence .......... ... ..... ...... 111 
5.4.1.3 Years of experience in the different groups .................................. ... ..................... 112 
5.5 RESPONSES ON THE MAVAS QUESIONNAIRE ... ........ .................... ....... ......... 113 
5.5.1 Rationale for the pre-test and the post-test. ... ................... .... .............. ........ ... ....... 114 
5.5.2 Discussion of the results on the MAVAS questionnaire ....................... .. ............... 114 
5.5.2.1 Question one (1). Patients are aggressive because of the environment they are 
in .. ... .... ..... ........ ......... ..................... ... ... .... .. .. ............. .. ....... .. ......... ....................... 115 
5.5.2.2 Question two (2). Other people make patients aggressive or violent ...... .... ......... . 116 
5.5.1.3 Question three (3). Patients commonly become aggressive because staff does 
not listen to them .... ...... ....... ... ........ .... ........ .......................................................... 117 
5.5.2.4 Question four (4). It is difficult to prevent patients from becoming violent or 
aggressive ..... ......... .... ......... .. .. ..... ................................ .... ............. .. ................... .. 118 
5.5.2.5 Question five (5). Patients are aggressive because of the environment they are 
in ... ...... ... ...... ........ ........ ........................... .. ....... .. ......... ......... ...... ................ ... ...... . 119 
5.5.2.6 Question six (6). Poor communications between staff and patients lead to 
patient aggression ......... ..... .... .................. ....... .. .... ... ............ .. ....... ............ ........... 120 
5.5.2.7 Question seven (7). There appears to be types of patients who frequently 
become aggressive towards staff ... .... .... .. .. .. .. ............... ... ...... ... ............. .... .. ... ..... 121 
5.5.2.8 Question eight (8). Different approaches to suit different cultural groups are 
used on this ward to manage patient aggression and violence ................ ....... .... .. 122 
5.5.2.9 Question nine (9). Patients who are aggressive towards staff should try to 
control their feelings ........ .. .... ....... .... ....... ..... ... ... .... .... .... ..... ... .... ... ..... .............. .... 123 
5.5.2.10 Question 10. When a patient is violent, seclusion is one of the most effective 
approaches to use ...... .... ..... .... ... .... .. ...... ..... ... .... .. .. .... ......... .. ........... ......... ........... 124 
5.5.2.11 Question 11 . Patients who are violent are often physically restrained to 
administer sedation .... ...... .. ... .... ... ........... ...... .. ....... .... .. ..... ....... .... .......... ...... ........ 125 
5.5.2.12 Question 12. The practice of secluding violent patients should be discontinued ... 126 
5.5.2.13 Question 13. Medication is a valuable approach for treating aggressive and 
violent behaviour ......... ... .......... ... ..... .... .... .............. .... .. ..... .... ... .... .......... .. .......... .. 127 
5.5.2.14 Question 14. Aggressive patients will calm down automatically if left alone .. ........ 128 
5.5.2.15 Question 15. The use of negotiation could be used more effectively when 
managing aggression and violence .. .... .... .... ...... .. ..... .... ....... .. .. .... ............... ......... 129 
5.5.2.16 Question 16. Restrictive care environments can contribute towards patient 
aggression and violence .... ... .... ... ....... ........ ........ ........ ... .... .... ... .... ........................ 130 
5.5.2.17 Question 17. Expression of aggression does not always require staff 
intervention .... ........... ............ ......... ... ............. .. ........ .. ..... .......... .... ....... ...... .......... 131 
5.5.2.18 Question 18. Physical restraint is sometimes used more than necessary ..... .... .... 132 
5.5.2.19 Question 19. Alternatives to the use of containment and sedation to manage 
violence could be used more frequently .... ....... ... ... .... ..... ..... .... .. .. ... ............... ...... 133 
5.5.2.20 Question 20. Improved one to one relationships between staff and patients can 
reduce the incidence of patient aggression and violence ...... .. ... .. ........ .. .... ... ........ 134 
5.5.2.21 Question 21. Patient aggression could be handled more effectively on this ward . 135 
5.5.2.22 Question 22. Prescribed medication can in some instances lead to patient 
aggression and violence .. .. ............ ...... .. ... ........ .... ...... ....... ...... ... .. .. ...... ..... .... ... .... 136 
5.5.2.23 Question 23. It is largely situations that contribute towards the expression of 
aggression by patients .... .. ............ ....... ... ..... .. ..... ...... ...... ........ ... ............... .... .. ..... 137 
5.5.2.24 Question 24. Seclusion is sometimes used more than necessary .................... .. .. 138 
5.5.2.26 Question 26.The use of de-escalation is successful in preventing violence ..... ... .. 140 
5.5.2.27 Question 27. If the physical environment were different, patients would be less 
aggressive ....... ....... ......... .......... .... ... ........ ... ............. ...... ........ .... ........... ... ........... . 141 
5.5.3 ANALYSIS OF THE INTER CULTURAL SENSITIVITY AND AWARENESS 
QUESTIONNAIRE .. .. .. ................ ... ..... ........... .. ......... .. ... ... ....... .. .... .. ............... ..... 148 
5.5.3.1 I enjoy interacting with people from different cultures ....... ....... ....... ... ..... ... ... ....... . 149 
5.5.3.2 I think people from other cultures are narrow-minded ... ...... .... ... ....... .... .. .... ..... ... .. 150 
5.5.3.3 I am pretty sure of myself in interacting with people from different cultures ......... . 151 
5.5.3.4 I find it very difficult to talk in front of people from different cultures .. ... ..... .. ....... ... 152 
5.5.3.5 I always know what to say when interacting with people from different cultures ... 153 
5.5.3.7 I don't like to be with people from different cultures ..... ..... ... ... .. ...... .. ... ....... ......... . 155 
5.5.3.8 I respect the values of people from different cultures ... .. ..... .. .... ........ .... .. ... .. ... ...... 156 
5.5.3.9 I get upset easily when interacting with people from different cultures .. ... ...... ... ... . 157 
5.5.3.10 I feel confident when interacting with people from different cultures ............ .... .... . 158 
5.5.3.11 I tend to wait before forming an impression of culturally-distinct counterparts ...... 159 
5.5.3.12 I often get discouraged when I am with people from different cultures .... .. ... .. ... ... . 160 
5.5.3.13 I am open-minded to people from different cultures .... .. .. .. ... ..... ....... .. ..... ..... ........ . 161 
5.5.3.14 I am very observant when interacting with people from different cultures .... ... .... .. 162 
5.5.3.15 I often feel useless when I am interacting with people from different cultures .... ... 163 
5.5.3.16 I respect the ways people from different cultures behave .. ...... ..... ......... .... .......... . 164 
5.5.3.17 I try to obtain as much information as I can when interacting with people from 
different cultures ... ..... ...... ..... .. .. ... ... ... ... .... ... .......... ....... .............. .......... ... .... ..... .... 165 
5.5.3.18 I would not accept the opinions of people from different cultures ...... ... ... .... ..... ... .. 166 
5.5.3.19 I am sensitive to my culturally-distinct counterpart's subtle meanings during our 
interaction ...... .... ... ... ..... .... ... ..... ..... .... .... .... ... ....... .. ... ..... ...... ... ...... ... ...... ... .. .. ... .... 167 
5.5.3.20 I think my culture is better than other cultures ...... ........... ..... .... .............. ... .... ....... 168 
5.5.3.21 I often give positive responses to my culturally-different counterpart during our 
interaction ... ...... .... .. ....... .. ..... ....... ... ...... ... .. .. ..... ...... ..... ... .. ..... ..... ...... ......... ..... ..... 169 
5.5.3.22 I avoid those situations where I will have to deal with culturally distinct persons ... 170 
5.5.3.23 I often show my culturally-distinct counterpart my understanding through verbal 
or nonverbal cues ... ...... .... ..... ..... .... .. .. .... ......... .. ..... ....... ... ....... ..... ... ....... .. ...... ... ... 171 
5.5.3.24 I have a feeling of enjoyment toward differences between my culturally-distinct 
counterpart and me .. ... ... ... ....... .... ... ... ............ ....... ...... ..... .. ........... ... .... ...... .... ... ... 172 
5.6 DISCUSSION OF THE RES UL TS .... ..... ..... .... .. .. ....... ... ...... .. .... .. .. ....... ... ..... ... ...... 178 
5.6.1 MAVAS questionnaire .... ..... ...... .... ..... .... ... .. .. .... .... .. .. ... .... .. ..... ... ..... .. .... ... .. ... .... ... 178 
5.6.1.1 Internal causes of aggression and violence ... .... ... ... ..... ... .... .. ... .. .. ... ...... .... ..... .. .... 178 
5.6.1.2 External causes of aggression . .... ..... .... ... ... .. ...... .. ..... .... ........ ... ....... ........... ... ..... . 181 
5.6.1.3 Situational causes of aggression ... .. .... ... .. ............ ... ..... ....... .... .... .... .. ... ............. ... 183 
5.6.1.4 Management of aggression and violence .. ........... .... ....... .... ..... .. ..... ....... .... ......... . 186 
5.6.1.5 Concluding remarks .. .... .... ... .... .. ... ...... .. ..... ..... .... .... .... .. ..... ..... ... ... .. .. .... ... .... .... .... 191 
5.6.2 Inter cultural sensitivity and awareness questionnaire .. ..... ....... ........ .... ..... .. ... ..... . 192 
5.6.2.1 I enjoy interacting with people from different cultures .... .. ....... ...... .. .... .. ..... ... .... .... 192 
5.6.2.2 I think people from other cultures are narrow-minded ... ..... ..... ....... ..... ....... ... ... .. ... 192 
5.6.2.3 I am pretty sure of myself in interacting with people from different cultures .. ....... . 193 
5.6.2.4 I find it very hard to talk in front of people from different cultures .. ........ ... .... ......... 193 
5.6.2.5 I always know what to say when interacting with people from different cultures ... 193 
5.6.2.6 I can be as sociable as I want to be when interacting with people from different 
cultures ........... .. .. ...................... .... ... ... ...... ....... ...... ... ..... .. ..... .... .. ... ....... ............... 194 
5.6.2.7 I don't like to be with people from different cultures .... ... .. ... ... .. ................ ............. 194 
5.6.2.8 I respect the values of people from different cultures .. ... .. ... .. .. ..... ... ... .. .... .. ......... .. 194 
5.6.2.9 I get upset easily when interacting with people from different cultures ..... ......... .... 195 
5.6.2.10 I feel confident when interacting with people from different cultures ...... ... .. ........ .. 195 
5.6.2.11 I tend to wait before forming an impression of culturally-distinct counterparts .... .. 195 
5.6.2.12 I often get discouraged when I am with people from different cultures ..... ...... .... ... 195 
5.6.2.13 I am open-minded to people from different cultures ............ .. ....................... ......... 196 
5.6.2.14 I am very observant when interacting with people from different cultures ... ... ....... 196 
5.6.2.15 I often feel useless when interacting with people from different cultures .. ......... .... 196 
5.6.2.16 I respect the ways people from different cultures behave .... ..... ... ......... ........ ........ 196 
5.6.2.17 I try to obtain as much information as I can when interacting with people from 
different cultures ....... .... ....... .... ... ........... ..... ........ ............ .... .... ... ... ....... ... ........ ..... . 197 
5.6.2.18 I would not accept the opinions of people from different cultures ................... ... .. .. 197 
5.6.2.19 I am sensitive to my culturally-distinct counterpart's subtle meanings during our 
interaction ...... ..... ..... ....... ......... ... ................ .... ....... ............... .. ... ... ....................... 197 
5.6.2.20 I think my culture is better than other cultures .. .... ... ... .... .. ..... ..... ...... ..... ......... .. .... 198 
5.6.2.21 I often give positive responses to my culturally-different counterpart during our 
interaction ...... ........ ... ............... .... ..... .. .............. ......................... .... ..... ... ...... ........ 198 
5.6.2.22 I avoid those situations where I will have to deal with culturally-distinct persons .. 198 
5.6.2.23 I often show my culturally-distinct counterpart my understanding through verbal 
or nonverbal cues ...... .. .. .... ... .... .. ... .. ....... .... .. ... ... ..... ... ... ... ..... ................... .. .......... 198 
5.6.2.24 I have a feeling of enjoyment towards differences between my culturally-distinct 
counterpart and me ... ..... ........... ... .... ..... ........................... .. .. .. .... ... ............... ..... ... 199 
5.6.1.25 Concluding remarks .. ...... .... .... .. ... ....... ... ..... ...................... ....... ........... ................. 199 
5.7  CONCLUSION ......... ..... ... ......... .... .. ........... .... ......... .... .... .......... .. .. ...... .. ....... ... .... . 199 
CHAPTER 6 ..... .... ......................... ...... ....... ....... ...... ..... ..... ........ ... ... .. .......... .......... ................. 200 
CONCLUSION AND RECOMMENDATIONS ........ ....... ..... ........ ..... .. .............. .. ..... ....... ...... .. .. 200 
6.1 INTRODUCTION ....... .. ............. .... ... ............... ............... ..... ....... ..... ..... ... .... .......... 200 
6.2 CONCLUSIONS FROM THE OUTCOMES ...... ..... ... ...... .... .......... ............... ...... ... 201 
6.1.1 What are the attitudes of Mental Health Care Practitioners towards the 
management of aggression and violence? ..... ........ ..... ... ............ .. ........... ..... ... ..... 201 
6.1.2 An exploration of African Indigenous Knowledge Systems used to manage 
mental health care user related aggression .... .... ....................... ............. .............. 201 
6.1.3 The establishment of base-line data on the level of cultural sensitivity and 
awareness of mental health care practitioners ... ... ... .... .. .. .... .... .. .. ..... ...... ... ... ....... . 201 
6.1.4 Discussion of the efficacy of a training programme/ intervention (treatment) ........ 202 
6.1.4.1 Understanding regarding the internal causes of aggression and violence ..... ....... 203 
6.1.4.2 Understanding of the situational causes of aggression and violence ...... ... .... .... ... 204 
6.2 RECOMMENDATIONS .. ........... .... ........ .. ..... .... .... ............ ..... .. ................ ... ..... ..... 204 
6.2.1 Suggestions for mental health care facilities ... ...... ....... ...... .. ... .... ................. ......... 204 
6.2.2 Suggestions for nursing curricula .. ..... ... ....... ......................... ..... .... ............ ........ .. 205 
6.2.3 Suggestions for the content of training programme for MHCU .... ...... ...... .... ....... .. . 205 
6.2.4 Suggestions for the community .... .................... ...... ...... ... .... .... ....... ....... ... ........ .... 206 
6.3 RECOMMENDATIONS FOR FURTHER STUDIES ...... ...... .... ..... ............ .. .... ...... 207 
6.4 STUDY LIMITATIONS ... .. ...... ... ....... .. .. .. ........... .... ...... .. ... ........... ......... .............. ... 207 
6.5 SUMMARY ............ .......... ..... ..... ... ........ .... .... .... .... ..... ... ... ........ ..... .... ....... ... ... .. ..... 208 
LIST OF REFERENCES .... .... .. .... .. ... .... .. .... ... .. ....... ........ ..... ............. .... .... ... ................ ........ .. 210 
List of figures, tables and illustrations 
PAGE 
Figure 1.1 Schematic design of the research project ..................... ........ ......... .. 12 
Figure 2.1 Concept map of the training programme for culturally safe the 
management of aggression and violence ..  . . . . . ..  . ..  . . . . . ..  ..  . . . . . . ..  ..  . ..  . . . . . . 49 
Figure 3.1 Schematic representation of the research methodology . . . . . . . ..  . . . ..  . . . . 53 
Photo 3.1 marked cups used to place the folded papers marked with the 
names of the hospitals, the treatment and the numbers of the 
experimental groups ........ ....... ....... ... ... ..... .. ... .. .. ....... ...... ..... ............ 61 
Photo 3.2 Folded papers in the appropriately marked cups ...... .... ................ .. . 62 
Photo 3.3 Randomised selection of treatment and groups... ... .......... .. ............. 62 
Table 3.1 Table representing randomised selection .... ....... ... .. ... ... ... .. .. .. ......... 63 
Figure 4.1 SIP-DD Concept map of proposed training programme for the 
management of aggression and violence ......... ...... .. .. ....... ........ .... . . 
101 
Figure 5.1 Fink's taxonomy of significant learning ............... .. .... ............. .......... 107 
Table 5.1 Gender of participants ............ ....... ... ... ..... ..... ... ...... ......................... 110 
Table 5.2 Table of training received ................................................................ 111 
Table 5.3 Years of experience with student population included . . . . . . . . . . . . . . . . . . . . . 112 
Graph 5.1 Graphic representations of the years of experience for the total 
group of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  ..  ..  . . . . . . ..  . . . 113 
Graph 5.2 Representation of the different occupational classes who took part 
in the research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  ..  . . . . . . . . . . . . . . . . . . . . . . . . . ..  ..  . . . . . . . . . . . 113 
Graph 5.3 Patients are aggressive because of the environment they are in .. ... 115 
Graph 5.4 Other people make patients aggressive or violent. ...... ..... .. ...... .... ... 116 
Graph 5.5 Patients commonly becomes aggressive because staff does not 
listen to them ....... .. ................... ................ ... ........... .. ........... .... ........ 11 7 
Graph 5.6 It is difficult to prevent patients from becoming violent r aggressive . 118 
Graph 5.7 Patients are aggressive because of the environment they are in ..... 119 
Graph 5.8 Poor communications between staff and patients lead to patient 
aggression . . . . . . . . . . . . . . ..  ..  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  . . . . . . . . . . ..  . . . 120 
Graph 5.9 There appears to be types of patients who frequently become 
aggressive towards staff...................... ... .... .. .. ........ ... ....... .. ..... ... ..... 121 
Graph 5.10 Different approaches to suit different cultural groups are used on 
this ward to manage patient aggression and violence . . . . . . . . . . . . . . . . . . . . . 122 
Graph 5.11 Patients who are aggressive should try and control their feelings ... . 123 
Graph 5.12 When a patient is violent, seclusion is one of the most effective 
approaches to use. ........... ... .... .... .. ... .. .......... ...... ........ .. .............. ... .. 124 
Graph 5.13 Patients who are violent are often physically restrained to 
administer sedation . . . . . . . ..  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  . . . . . . . . . . . . . . . . . . . . . . . 125 
Graph 5.14 The practice of secluding violent patients should be discontinued ... 126 
Graph 5.15 Medication is a valuable approach for treating aggressive and 
violent behaviour .... ........... ..... ......... ...... .... ...... ..... ......... .. ......... ...... . 127 
Graph 5.16 Aggressive patients will calm down automatically if left alone 128 
Graph 5.17 The use of negotiation could be used more effectively when 
managing aggression and violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  . . . . . . . . . . . . . 129 
Graph 5.18 Restrictive care environments can contribute towards patient 
aggression and violence ... ...... ..... .... ... .. ........... ..... .... .... ... .. .. ............ 130 
Graph 5.19 Expressions of aggression do not always require staff intervention . 131 
Graph 5.20 Physical restraint is sometimes used more than necessary .. ..... .. .... 132 
Graph 5.21 Alternatives to the use of containment and sedation to manage 
patient violence could be used more frequently. ... .. ..... .... ...... ..... ... .. 133 
Graph 5.22 Improved one to one relationships between staff and patients can 
reduce the incidence of patient aggression and violence .... .......... ... 134 
Graph 5.23 Patient aggression could be handled more effectively on this ward . 135 
Graph 5.24 Prescribed medications can in some instances lead to patient 
aggression and violence ........ ...... ........ .. ..... ... .... ...... .. ... ... ...... ... ..... .. 136 
Graph 5.25 It is largely situations that contribute towards the expression of 
aggression by patients. .. ... ... ...... .... ....... ......... ...... ....... ... .... ... ... ... .. ... 137 
Graph 5.26 Seclusion is sometimes used more than necessary . . . . . . . . . . . ..  . . . . . . . . . . . 138 
Graph 5.27 Prescribed medication should be used more frequently to help 
patients who are aggressive and violent ... .. .... .... ...... ... ........ ....... .. ... 139 
Graph 5.28 The use of de-escalation is successful in preventing violence 140 
Graph 5.29 If the physical environment were different, patients would be less 
aggressive .... .......... ...... .. .... ... ...... ..... ............. .. ... .... ......... .. ........ ...... 141 
Graph 5.30 Overall graph for Gauteng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  . . . . . . . . . . 143 
Graph 5.31 Overall graph for North West... ... .... ... ..... ..... ..... .... ...... ... ...... .. .... ...... 145 
Graph 5.32 Overall graph for Western Cape. ...... .. .. .... ......... ...... ......... .. ... ... .. ..... 147 
Graph 5.33 I enjoy interacting with people from different cultures . . . . . . . . . . . . . . . . . . . . . . 149 
Graph 5.34 I think people from other cultures is narrow-minded . . . . . . . . . . . . . . ..  . . . . . . . . 150 
Graph 5.35 I am pretty sure of myself in interacting with people from different 
cultures. .............. .. .......... .... ....... ..... ............ ....... ..... ...... ... ........ .... .. . 151 
Graph 5.36 I find it very difficult to talk in front of people from different cultures . 152 
Graph 5.37 I always know what to say when interacting with people from 
different cultures .............................. ........ ... ..................................... 153 
Graph 5.38 I can be as sociable as I want to be when interacting with people 
from different cultures ... .................. ............. .... ....... .. ..... .... .............. 154 
Graph 5.39 I don't like to be with people from different cultures . . ........... .... .. ...... 155 
Graph 5.40 I respect the values of people from different cultures ...... ....... .......... 156 
Graph 5.41 I get upset easily when interacting with people from different 
cultures ...... .... ...... ...... .. ................ .... ...... ..... ..... ........ .. ... ........ ... ... .... 157 
Graph 5.42 I feel confident when interacting with people from different cultures 158 
Graph 5.43 I tend to wait before forming an impression of culturally-distinct 
counterparts . . . . ..  . . . . . . . . . . ..  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 
Graph 5.44 I often get discouraged when I am with people from different 
cultures . . . . . . . . . ..  ..  ..  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 
Graph 5.45 I am open minded to people from different cultures .... ............. ....... . 161 
Graph 5.46 I am very observant when interacting with people from different 
cultures . . . . . . . . . . . ..  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 
Graph 5.47 I often feel useless when interacting with people from different 
cultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 
Graph 5.48 I respect the way people from different cultures behave ....... .... ... .... 164 
Graph 5.49 I try to obtain as much information as I can when interacting with 
people from different cultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  . . . . . . . . . . . . . . . 165 
Graph 5.50 I would not accept the opinions of people from different cultures ..... 166 
Graph 5.51 I am sensitive to my culturally-distinct counterpart's subtle 
meanings during our interaction . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 167 
Graph 5.52 I think my culture is better than other cultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  . . 168 
Graph 5.53 I often give positive responses to my culturally-different counterpart 
during our interaction........... .. ................................. ......................... 169 
Graph 5.54 I avoid those situations where I have to deal with culturally-distinct 
persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  . . . . . . . . ..  . . . . . ..  . . . . . . . . . . . . ..  . . . . . . . . ..  . . ..  . . . ..  . . . . . . . . . . 170 
Graph 5.55 I often show my culturally-distinct counterpart my understanding 
through verbal or non-verbal queues ............. .... ...................... ........ 171 
Graph 5.56 I have a feeling of enjoyment towards differences between my 
culturally-distinct counterpart and me . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  . . . . . 172 
Graph 5.57 Overall graphs for Gauteng . . . . . . . . . . . . . . . . . . . . . . . ..  . . . . . . . . . . . . . . . . . . ..  . . . . . . . . . . . . . . . . 173 
Graph 5.58 Overall graphs for North West .. ..... .. ............... ............. ........ .. .......... 175 
Graph 5.59 Overall graphs for Western Cape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  ..  . . . . . . . . . . . . . . . 177 
LIST OF ANNEXURES 
PAGE 
ANNEXURE 1 TRANSCRIPT OF THE MAKGOTLA ......................... .. ............ 228 
ANNEXURE 2 CURRICULUM FOR THE CULTURAL SAFE MANAGEMENT 
OF AGGRESSION AND VIOLENCE .... ... .......... .. . ...... .. ......... .. 253 
ANNEXURE 3 PERMISSION TO USE THE MAVAS QUESTIONNAIRE. ....... 271 
ANNEXURE 4 QUESTIONNAIRE ON THE MANAGEMENT OF MENTAL 
HEAL TH CARE USER RELATED AGGRESSION ...... .... .. .... ... 273 
ANNEXURE 5 INTERCULT URAL SENSITIVITY SCALE ............ ... ...... ... ....... . 277 
ANNEXURE 6 PARTICIPANT INFORMATION LEAFLET .. ..................... ........ 279 
ANNEXURE 7 ETHICAL CLEARANCE FOR STUDY FROM NWU .... ... . .. ....... 282 
ANNEXURE 8 PERMISSION FROM THE RESPECTIVE HEAL TH CARE 
INSTITUTIONS AND PROVINCES....... ........ ...... .. ............ ....... 283 
ANNEXURE 9 INTERCODER PROTOCOL AND LETTER OF AUTHENTICITY 295 
ANNEXURE 10 CONFIRMATION LETTER FROM STATISTICIAN .... .... .... .. .. .. 297 
ANNEXURE 11 CONFIRMATION LETTER FROM LANGUAGE EDITOR ....... . 298 
List of abbreviations 
AIKS African Indigenous Knowledge Systems 
DSM5 Diagnostic and Statistic Manual 5 
IKS Indigenous Knowledge System 
MAVAS Management of Aggression and Violence Scale 
WBKS Western Based Knowledge Systems 
MHCU Mental Health Care User 
Definitions 
Concept Conceptual definition Researcher's operational definition 
Aggression The Penguin Dictionary of Psychology (1995:18) describes aggression as Emotional, psychological reaction used to 
"a desire to produce fear or flight in others". Aggression is a motivation to create fear or to intimidate others. Aggression 
harm another individual (Geen & Donnerstein, 1998:Loc.105) and Farlex must not be confused with violence, because 
Partner Medical Dictionary© Farlex(2012).Bock (2013: 105) supports the violence is the behavioral component. 
definition of aggression as mentioned in (Uys & Middleton, 2013:255) 
where aggression is uttered threats as opposed to physical harm. 
Attitude Attitude was defined in 1860 by Herbert Spencer and Alexander Bain as Attitude is therefore an intangible, 
referenced by Cacioppo et al. (1994:261) and was used to explain an persistent/bold stance towards something; 
internal state of readiness for action which includes affect. In further such as an idea or a phenomenon. 
elaboration the researcher concurred with the following definition of 
attitude being "a general enduring evaluative perception of a stimulus or 
set of stimuli" (Cacioppo et al., 1994:261 and Lakkaraju & Speed, 
2010:76). 
Cultural Health care providers understand there are cultural differences to Noticing one culture differs from the next and 
awareness overcome between them and their patients (Tjale & de Villiers, 2004:24) the ability to identify these differences, without 
and Hogg. A person becomes aware of the existence of cultural doing anything about these differences. 
differences between groups and can stand back to reflect upon those 
cultural differences 
Culturally The online dictionary defines culturally acceptable to be a behavior Culturally acceptable is anything accepted as 
acceptable accepted by the majority of a culture, McIntyre (2016: 1996) agrees with normal for a particular culture. 
xxiii 
Concept Conceptual definition Researcher's operational definition 
this definition. 
Cultural safety Cultural safety was defined by Ramsden as cited in Tjale and De Villiers Rendering care that the MHCU observes as 
(2004:24) , to be the ability to evaluate a persons' own cultural mind-set safe. 
and recognise, respect and nurture the culture of another person. For the 
purpose of this research project the researcher concurs with the definition 
of Ramsden and Spoonley (1994:163), namely that cultural safety means 
the nurse is open minded and flexible in her attitude towards other 
cultures. The researcher will include Leininger's definition of Culture-
congruent care as augmentation of the definition by Ramsden wherein 
Leininger refers to culture-congruent care as service which fits in with the 
beliefs and way of life of the client. Cultural safety is "recognising the 
position of another culture in society" as stipulated by Polascheck 
(1998:452) 
Cultural "The nurse understands and respects the legitimacy of cultural A person considers how their behavior may 
sensitivity differences and reflects on the impact of their own cultural beliefs and affect another culture 
values on the therapeutic relationship" (Tjale & de Villiers, 2004:25). 
According to Sublette and Trappler (200: 133) and Portalla and Chen 
(2010:21) cultural sensitivity is the affective aspect which represents the 
ability of a person to appreciate the differences of another culture and to 
also respect it. Fritz et al. (2002: 167) continues to explain that cultural 
sensitivity includes cultural awareness and self-awareness. 
Mental Health Hospital or facility approved in terms of the Mental Health Care Act (17 Of A hospital or care facility accredited to provide 
Care 2002) to provide health care and rehabilitation services to mental health mental health care. 
xxiv 
Concept Conceptual definition Researcher's operational definition 
Institution care user 
Violence Uys and Middleton (2013:255) reports violence to be; the infliction of The physical/behavioral component of 
physical injury to self, or others. Moreover, the Collins Pocket English aggression. 
Thesaurus (2012:601) defines violence as follows: "Use of brute force or 
rough handling of another person or property." Kaliski (2006: 118), 
confirms that there are various forms of violence and that violence is 
associated with posing a danger to others 
XXV 
CHAPTER 1 
OVERVIEW OF THE RESEARCH 
1.1 TITLE 
Culturally safe management of aggression and violence in mental health care facil ities 
(Key words: Cultural safety; aggression; violence; mental health care facilities.) 
1.2 INTRODUCTION AND RATIONALE FOR THE RESEARCH 
As a Mental Health Care Practitioner, the researcher witnessed many incidents of mental health 
care user related violence and aggression. The researcher also experienced situations where 
she doubted the practice of secluding a person who is deemed aggressive to be the best option 
to manage the MHCU. The researcher acknowledges self-perceived difficulty in establishing a 
therapeutic relationship with persons who could not converse in English or Afrikaans (the 
Mother tongue of the researcher) . The use of an interpreter often left the researcher with the 
impression that there is better rapport between the interpreter and the mental health care user 
than with the rest of the therapeutic team. The interpreter would refrain from translating back 
what the MHCU said as they deem it to be non-sensical. Often this left the researcher in a 
position where she felt as though she does not understand the patient's perception about his 
situation, and some of the cultural practices seemed to be alien as is reflected upon in the 
following paragraph. 
Through the literature, the researcher established that amongst some cultural groups there is a 
practice where some people will consume small amounts of Jeyes Fluid ® (a powerful 
disinfectant containing amongst things tar acids) to rid themselves of what is considered 
possession by an evil spirit. Due to Jeyes Fluid ® being a toxic irritant with the inducement of 
vomiting being contra-indicated, this practice is frowned upon in medical circles, despite being 
used by western medicine during the 1870's to treat conditions such as scarlet fever. 
Subsequently, due to the toxicity of Jeyes Fluid ®, substances such as these are confiscated 
upon admission of the patient to the psychiatric hospitals as it is deemed to be contraband. It is, 
however, common course that routine searches for possible contraband and confiscation 
thereof are part of hospital policy. However, this often results in aggressive reactions by MHCU. 
Unfortunately, practices such as ingestion of and often bathing in Jeyes Fluid forms part of the 
IKS of some cultures. 
Therefore, the researcher is of the belief that due to a lack of understanding of the perspective 
of persons from a culture different to that of the mental health care provider, the therapeutic 
relationship is compromised as the mental health care user is forced to adapt to a WBKS in 
terms of the "way things are done here". 
One particular incident which springs to mind is when the researcher witnessed an extremely 
anxious mental health care user in his bewilderment grabbing a bottle of mineral turpentine and 
attempting to take a sip out of the bottle. Obviously the researcher grabbed the bottle away from 
him before he could actually swallow it; the highly flammable turpentine which spilled over him 
was promptly cleaned off by the researcher. During a follow-up debriefing interview, the 
researcher established that he (the mental health care user) believed that as turpentine is used 
to strip away paint and clean objects; the ingestion of this turpentine would have stripped away 
the evil spirit which he believed possessed him. 
Aggression and violence are accepted as the "norm" in psychiatry. Health care providers are 
constantly faced with violence and aggression, as concluded in several studies (Needham, 
2004:2; Chen eta!. , 2005:141 ; Lewis-Lanza eta!., 2006:71 ; Bock, 2013:105). 
The researcher, through a study (Bock, 2010:55), confirmed that the majority of mental health 
care practitioners experience difficulty in the management of aggression and violence in mental 
health care users, and had not received training to capacitate them. This perception by the 
researcher, of aggression and violence being difficult to manage, is confirmed through a study 
by Mavundla (2000: 1575), wherein he observed that staff found it difficult to deal with 
aggression and that psychiatric patients are difficult to manage. 
Complicating the situation within the South African context is the fact that South Africa is a 
country with 11 official languages nestled in their own cultures (Joyce, 2009:7), and within this 
multi-cultural context each culture has their perspectives around mental illness and the 
treatment thereof. In an attempt to develop an understanding of the status quo in South Africa, 
the researcher consulted literature and noted that there are two opposing knowledge systems in 
South Africa, namely the Indigenous Knowledge System (IKS) and the Western based 
knowledge system (WBKS). These two systems each have their own vantage points in terms of 
illness and disease, which perspectives the researcher will elaborate in the following section. 
1.3 BRIEF LITERATURE REVIEW 
African Indigenous Knowledge Systems (AIKS) is deemed to be a collection of knowledge, skills 
and practices within a specific frame of reference and a specific geographical area, which 
allows people to make sense of; and live and survive in their environment (Naidoo, 1985:2; 
Quiroz, 1994:12; Okpako, 1999:482; Viljoen & Van der Walt, 2003:15; Raphesu, 2010:3). 
Almost contrary to this definition, the Western-based knowledge health care system is based on 
scientific measurement and scientific reasoning whereas the Indigenous Health Knowledge 
System is based on understanding referred to as magico-religious perspective (Tjale & de 
Villiers, 2004:4). Within this AIKS, the term African Primal Health care coined by Dr Mbulawa in 
2012 as cited by Taaka et. al. (2013:128) refers to the health care rendered in this knowledge 
system, unique to the African community. This African Primal Health care is more than mere 
magico-religion as assumed by Tjale and De Villiers (2004:4) , because it in essence refers to 
the continent "Mother Africa" who provides all components to allow for health of her "children," 
the African community. 
The different views of health care systems are defined to be pluralistic and reported to exist 
parallel to one another. Based on this report, and estimation by authors such as Robertson et 
al. (2001 :87) and Abba (2011) - that as much as 70% of South Africans use traditional healers 
as primary health care providers - it is important that this source of health care provision be 
recognised within the current health care system as it has stood the test of time 
The recognition of the indigenous healing practices used by indigenous healers has led to a 
quest to legalise the IKS practices to ensure safety to the user. As such, the Traditional Health 
Practitioners Act (22 of 2007) was promulgated to regulate the profession. Through this 
Traditional Health Practitioners Act (22 of 2007) the practices, training and registration of these 
health providers are regulated (Janse van Rensburg, 2009: 157). 
Both Indigenous knowledge Systems and WBKS have their unique conviction regarding the 
phenomenon and causes of mental illness. Possible causes of mental illness within IKS are 
reportedly through supernatural causes, witchcraft, breaking of taboos, especially in cases 
where a disease is of a chronic nature as pointed out by Tjale and De Villiers (2004:147-149). 
These causes are linked with the frame of reference and often cultural norms of the person 
attempting to explain mental illness (Kabir et al. , 2004:2; Teferra Shibre, 2012:1). The 
diametrically opposite view of mental illness within WBKS is explained by means of a scientific 
approach. Teferra and Shibre (2012:1) also notice that WBKS focuses more on biological, 
genetic and social causes for mental illness as opposed to Indigenous Knowledge Systems 
which focusses on supernatural and religious factors as influential in the cause of mental illness. 
The phenomenon of mental illness is explained through a plethora of signs and symptoms as 
depicted in the Diagnostic and Statistic Manual 5, established through research (Robertson et 
al. , 2001 :9). The DSM 5 allows for what is deemed reliable diagnosis and is objective in 
establishing differential diagnoses. There are definite medical, genetic, social and psychological 
causes for mental illness (Robertson et al. , 2001 : 16). Robertson et al. (2001 : 16) continue to 
explain the phenomenon of mental illness from a bio-psychosocial model with an emphasis on 
an allopathic explanation. 
In view of these different causes for mental illness, the logical deduction is that treatment of 
mental illness will differ between IKS and WBKS's. 
Several authors touched on the topic of how mental illness is treated in the different Indigenous 
Knowledge Systems; a commonality is that the treatment is directly related to what is 
considered to be the ethiology of the disease (Mzimkulu et al. , 2006:425; Shankar et al., 
2006:230). Similarly, in WBKS's the allopathic treatment of mental illness commences with a 
diagnosis of the illness by means of a Mental Status Examination, where all the signs and 
symptoms of the illness are confirmed (Robertson et al., 2001 :39-50). Thereafter, psychotropics 
or allopathic medicine are administered to treat the symptoms identified (Robertson et al. , 
2001 :417). 
Due to a link between mental illness and aggression, it is necessary to explore both the IKS and 
WBKS's perceptions of this mental illness related aggression and the subsequent proposed 
treatment strategies as both IKS and WBKS have methods which they feel is best, and perhaps 
safest to deal with this aggression and violence. 
Aggression was cited to be the most common feature associated with the presence of a 
confirmed mental illness in a study performed by Kabir, et al. (2004:3). Several authors are in 
agreement that extreme forms of behaviour such as violence might be indicative of an 
underlying mental illness (Shankar et al., 2006:231 ; Ewhirudjakpor, 2009:24; Sorsdahl et al., 
2010:286). In terms of the WBKS, the phenomenon of aggression in persons with recognised 
mental illness has been well researched and accordingly documented by numerous 
researchers. This has allowed mental health care providers to make certain predictions with 
regards to the clientele more prone to aggression and violence. Koen et al. (2003:254) proved a 
link between substance abuse and violence in male mental healthcare users with 
schizophrenia, as supported by similar findings by Milton et al. (2001 :439) and McDougall 
(2000:98) , who noted the presence of severe psychosis and conduct disorders in adolescence 
who exhibit aggression. 
In South Africa the Mental Health Care Act (17 of 2002) makes allowance for a person who is 
mentally ill and a danger to himself, other persons or their property; to be admitted to a hospital 
for observation. Furthermore, if the person resists treatment and is not prepared to undergo any 
form of treatment, the Mental Health Care Act (17 of 2002) informs practitioners that such a 
person can be forced to undergo treatment involuntarily. 
As observed and reported by the researcher, mental health care users in WBKS are often 
secluded in single rooms and sedated with psychotropics when aggressive. Similarly, within 
IKS, it was revealed that some of the indigenous healers managed aggression associated with 
mental illness by physical means such as tying the person up with ropes and occasionally 
chains, to prevent harm or injury to others (Sorsdahl et al., 2010:286). The pharmacological 
management of aggression revolved around the use of "muti''. "Umuti" stems from the isiZulu 
language and literally means "medicine" (Labuschagne, 2004:192). This can be in the form of a 
liquid, ointment or powder. This medicine, "muti" can be administered to the patient via different 
routes and applications such as sniffing , drinking, inhalation of vapours when burned, topical 
application in incisions made by the indigenous healer and baths with "muti" in it. The 
administration of "muti" is only one part of the treatment regimen and it is further followed up 
with rituals to complete the healing process (Sorsdahl et al. 2010:287). 
1.4 CONTEXT 
As a mental health care practitioner, the researcher has witnessed numerous incidents of 
violence and aggression as associated with mental illness. The researcher observed both 
effective and less effective attempts to deal with the management of aggression and violence. 
Difficulty in the management of aggression and violence was particularly exacerbated during 
dealings with MHCU's from a culture vastly different from that of the health care provider and 
more so if the MHCU's could not converse in English or Afrikaans. This observation led the 
researcher to deduce that it is possible that a lack of understanding and appreciation of cultural 
differences might affect the ability to therapeutically deal with aggression as encountered in 
mental health care users from diverse cultures. 
It is noteworthy that the researcher has experienced several incidents where MHCU's who 
became aggressive were treated by means of what is referred to as traditional psychiatric 
methods to contain this aggression and violence. Such traditional methods, as referred to by 
Duxbury (2002:325), include the use of mechanical restraint and seclusion in a single room. 
The researcher is of the belief that there is no valid "one cure fits all" regime to manage mental 
health care user related violence, considering that people differ in terms of their culture and 
knowledge system, and any degree of insensitivity and indifference to these cultural differences 
leads to unsafe care. 
1.5 PROBLEM STATEMENT 
Health care practitioners find it difficult to manage aggression and violence. Adding to this 
problem is the cultural diversity of mental health care users, especially in a country such as 
South Africa with its 11 different official languages. Mental health care practitioners are trained 
to use what Duxbury (2002:325) refers to as traditional western based methods in the 
management of aggression and violence. Due to the cultural diversity of mental health care 
users, the methods used by mental health care practitioners do not acknowledge the multi-
cultural sphere within which care is to be rendered. 
In light of the previous discussions, the researcher is in agreement with the finding of Breidlid 
(2009:142), who warns that the exclusion of IKS will hinder the development of a scientific 
understanding of natural phenomena, including natural methods of delivering culturally-
competent health care. Therefore, the researcher promotes the inclusion of IKS in the education 
and training of health care providers. Ignoring IKS will ignore the cultural, beliefs and spirituality 
of a MHCU. 
From the problem statement, a question arises: 
Could a training programme which includes cultural safety and awareness training, with 
a focus on the management of aggression, within a multi-cultural context; effect 
attitudinal changes in the cultural awareness, sensitivity, and safety with reference to 
the attitudes of mental health care practitioners, towards the management of 
aggression and violence? 
To answer this broad question, the following exploratory research questions needed to 
be addressed: 
• What are the attitudes of mental health care practitioners towards the management of 
aggression and violence? 
• How culturally safe and aware are mental health care practitioners? 
• How effective is a proposed training programme on management of aggression and 
violence, in combination with cultural sensitivity and awareness, to bring about attitudinal 
changes in Mental Health Care Practitioners? 
1.6 AIMS AND OBJECTIVES OF THE RESEARCH 
The aim of this research is to establish whether a training programme (which includes training in 
cultural sensitivity and awareness) aimed at capacitating mental health care practitioners to 
manage aggression and violence, within a multicultural context would affect attitudinal changes 
in the cultural sensitivity and awareness and changes in attitudes towards the management of 
aggression and violence of MHCU. 
Further objectives in this study include the following: 
• An exploration of African Indigenous Knowledge Systems used to manage mental health 
care user related aggression. The data generated through makgotla is found in chapter 4 
and incorporated into training programme as presented in Annexure 2 and discussed in 
section 6.1.2. 
• The establishment of base-line data on the level of cultural awareness and sensitivity of 
mental health care practitioners. Baseline data was established during 201 0 (Bock & 
Pienaar 2013) and during 2015 for this study. 
• An assessment of the attitudes of mental health care providers towards the management 
of aggression and violence and cultural sensitivity and awareness A discussion of the 
observed attitudes is concluded in section 6.1.1 in chapter 6. 
• The implementation of a training programme that will capacitate mental health care 
practitioners to manage aggression and violence in a culturally diverse sphere. See 
section 6.2.2. 
• To influence nursing curricula to include IKS with regards to the management of MHCU 
related violence. This recommendation is explained in section 6.2.3. 
With the aims and objectives of this research in mind, the researcher subsequently developed 
the central theoretical argument and hypothesis for this research. 
1.6.1 Central theoretical argument 
The conduct of makgotla (focusing on how aggression and violence in persons known to be 
mentally ill is managed), with indigenous healers will augment current knowledge in terms of 
how aggression is being managed within an African IKS, and will further guide the content for a 
curriculum/training programme for the culturally safe management of aggression and violence. 
1.6.2 Hypothesis 
The researcher proposed a complex non-directional hypothesis, namely: "Implementation of a 
training programme in the management of aggression and violence with a focus on cultural 
sensitivity, awareness and cultural safety, will lead to a change in attitude towards the 
management of aggression and violence in mental health care practitioners". 
1.7 RESEARCHER'S ASSUMPTIONS 
A philosophical stance is explained to be a philosophical view held by a group or persons, and 
forms an integral part of conceptual models; one example of such a model would be Madeleine 
Leininger's theory of cultural care, diversity and universality (Burns & Grove, 2011 :229; George, 
2002:497) and lrihapeti Ramsden's Cultural safety theory (Ramsden, 2000). Noting the 
existence of such assumptions the researcher's assumptions that training could impact on 
attitudes towards the management of aggression and violence and cultural safety and 
awareness, were tested during the quasi experimental phase of this research. The researcher 
will elaborate on these assumptions further in this chapter. 
1.8 PHILOSOPHICAL GROUNDING OF THIS RESEARCH 
The researcher is in agreement with Leininger who describes human beings to be capable of 
caring and being concerned about the needs of others (George, 2002:494). This statement by 
Leininger is supported by Pienaar (2013: 10) where he explains the concept of Ubuntu, where 
one only becomes through the group or others. The researcher hence deems this care to be 
focussed on the need of others and a person getting better through care by others. In Africa 
especially, the full spectrum of care includes spiritual care, which cardinal dimension is ignored 
in Western care. Because the African is characteristically a deep spiritual being, his health 
seeking behaviour includes the spiritual dimension (Pienaar, 2013:1). This emphasises the 
urgent need for cultural awareness and sensitivity in mental health care practitioners in order to 
render culturally safe care. 
Care and health are universal concepts to all cultures; however the method of rendering care 
and the application of IKS in the rendering of care is not universal, as emphasised by Leininger 
(George, 2002:492). In Africa the care rendered within AIKS refers to Primal Care which was in 
existence since time immemorial , long before the existence of WBKS (Taaka et al. 2013:128). 
WBKS challenges th is concept, as will be elaborated on during the literature review. 
The researcher therefore assumes that one can only truly care for another person if you have 
an understanding of the perspective and the culture of such a person. This assumption is 
supported by Fulcher (2002:702) where the author indicates that the only person who could 
inform the nurse that care is culturally safe is the recipient of the care. Therefore the "makgotla" 
will inform the researcher on culturally safe and acceptable care; this knowledge could influence 
the training programme. 
1.9 THEORETICAL ASSUMPTIONS 
1.9.1 Cultural awareness and sensitivity 
Cultural awareness refers more to the cognitive reaction or functioning in a person where he or 
she becomes aware of the differences in the cultural norms and values of different groups 
(Hardy & Laszoffy 1995: 227; Tjale & De Villiers, 2004:37; Leppert & Howard, 2011 : 1) . Being 
culturally aware does not imply that one is culturally sensitive. It merely indicates a beginning to 
perform duties ritualistically appropriate without the presence of the emotional and spiritual 
component appropriate to the "other" culture (Koptie, 2009:31 ). 
Cultural sensitivity in addition is described as being aware of cultural differences between 
people, respecting those differences and noticing and accepting that the perceptions of people 
will differ from one's own perception . Additionally, it implies that a person will refrain from 
making a value judgement on another person's cultural perception, and will adapt their own 
skills to become more sensitive towards others. Therefore, cultural sensitivity implies the 
affective functioning or reaction in a person. (Hardy & Laszoffy, 1995:227; Seibert, et al. 
2002:143; Tjale & De Villiers, 2004:27, 38; Leppert & Howard, 2011:3). Koptie (2009:31) 
elaborates further and states that in cultural sensitivity, the nurse is aware of her own culture 
and she is aware that she brings her own culture into the nurse-patient relationship and that her 
own culture will impact on the cultures of others. 
The above-mentioned description of cultural sensitivity leaves the researcher with the 
impression that this cultural sensitivity in the individual is observable or measurable on a 
continuum. This motivated the researcher to further explore this through the use of a cultural 
sensitivity scale as designed by Chen and Starosta (2000) . 
It is unknown how culturally aware and sensitive mental health care practitioners in psychiatric 
hospitals in Southern Africa are in the execution of their duties. 
1.9.2 Cultural safety 
It is generally assumed that health care users can have input in their own treatment. The Mental 
Health Care Act (17 of 2002) also advocates for the right of the patient. Ramsden and Spoonley 
(1994: 164) refer to this as cultural safety. Contrary to the quest for cultural safety, the 
researcher has experienced that the patient admitted as involuntary have very limited input into 
his treatment plan, if any. Ramsden and Spoonley (1994: 165) reiterate this quest for cultural 
safety through pointing out the effect that culture has on the effectiveness of health care. 
Therefore, the sunrise model of Leininger and a combination of Ramsden 's cultural safety 
models is applicable to this research project and the researcher will apply and use these 
proposed models in combination with the information collected during the makgotla with the 
indigenous healers, to influence training programmes aimed at improving the ability of mental 
health care practitioners to manage aggression and violence in a multi-cultural milieu. 
1.10 METHODOLOGICAL ASSUMPTIONS 
This research project being an exploratory sequential mixed methodology is anchored in both 
the post-positivist and interpretivist paradigm due to the sequential qualitative and quantitative 
phases of this research. 
The interpretivist paradigm is observed where the researcher interviewed indigenous healers in 
order to get an understanding of how they manage violence and aggression in mentally ill 
persons. The researcher used this information obtained during the qualitative phase of the 
research to adapt a training programme on the management of aggression and violence to 
include AIKS with regards to the management of aggression and violence. The Phenomenon 
under investigation are indigenous healers in their own social reality and according to Loiselle 
and Profetto-McGrath (2011: 1179) this encompasses trying to understand how the healers 
manage aggression and violence in their own environment with the aim of describing this 
phenomenon after analysis, roots the qualitative phase of this research solidly in the 
interpretivist paradigm. 
Creswell (2014:7) explains Post-positivism clearly as being "deterministic", where any cause will 
have an effect. This maxim correlates with the assumption of the researcher that "treatment" 
(the proposed training programme for the culturally safe management of aggression and 
violence) will have an effect on the attitudes of mental health care users towards the 
management of aggression and violence in a culturally safe manner. 
The post-positivist framework is further identifiable through the researcher's quasi-experimental 
design (Andrew & Halcomb, 2009:122). In the event where the researcher attempts to control 
variables and conditions, and to investigate cause and effect, the study falls within the 
perspective of positivism as stipulated by Henning et al. (2011 : 17). Within the post positivist 
research the aim is to understand the underlying causes of a natural phenomenon as per 
Loiselle and Profetto-McGrath (2011 :10). This assumption by the post positvism and post-post 
positivism underpins the aim of what the researcher wishes to accomplish, namely researching 
the cause and effect and attempting to obtain objectivity whilst recognising the impossibility of 
total objectivity (Loiselle & Profetto-McGrath, 2011 :11 ). The post positivism has been very 
prominent in nursing research according to Loiselle and Profetto-McGrath (2011 : 10). Hence, in 
this research project the researcher attempted to explore attitudes and investigated the effect of 
a treatment through a cross-sectional design with treatment partitioning (Burns & Grove, 
2011 :284). As this research project is not aimed at generalising to a general population, this 
proposed research project which is a mixed methodology falls within the perspective of post-
positivism (Maree, 2007:65) , as opposed to the positivism which seeks to establish 
generalisability. 
1.11 RESEARCH DESIGN AND RESEARCH METHOD 
A mixed methodology design is more than a mere combination of qualitative and quantitative 
data in a single study. It requires integration of data at some point (Creswell , 2012: 14, Polit & 
Beck, 2012:603; Andrew & Halcomb, 2009:3). With this mixed methodological approach, the 
researcher was able to explore the knowledge of indigenous healers and the IKS used to 
manage mental health care user related violence, augmented current literature and tested the 
implementation of a training programme aimed at the management of aggression and violence 
in a culturally safe manner. 
MIXED METHODOLOGY I 
EXPLORATORY SQUENTIAL DESIGN 
Phase 1 
Qualitative interpretivist 
Phase 2 
Quantitative Post-positivist 
Figure 1.1 : Schematic design of the research project (designed by TM Bock) 
1.11.1 Overview of the research design and research method 
The qualitative phase of the research consisted of makgotla with indigenous healers. 
Information obtained during this phase was used to adapt the structured MAVAS questionnaire 
to include components of IKS. The makgotla will be further explained in Chapter (3) three of this 
thesis. 
The aim of the qualitative component was to describe how indigenous healers treat aggression 
and violence in mentally ill persons, focusing on why they propose the specific form of treatment 
and how effective they consider this treatment to be. Henning et al. (2011 :3) recommend a 
qualitative approach to investigate "how and why" a phenomenon takes place. Social reality is 
explained by Henning et al. (.2011: 13) to be an attempt at understanding from the perspective of 
the role players, hence the decision to conduct makgotla with indigenous healers. 
The quantitative phase of this research project consisted of the utilisation and application of the 
adapted MAVAS questionnaire and the Inter Cultural Sensitivity Scale in the form of a pre- and 
post-test to determine changes in attitudes towards the management of aggression and 
violence and cultural sensitivity in the subjects chosen for the study after the administration of a 
training programme aimed at the management of aggression and violence in a culturally safe 
manner. 
In Chapter (3) three the researcher will elaborate further on the processes which were followed 
during this research. 
1.12 STUDY OUTLAY 
Chapter 1: Overview of the research 
Chapter 2: Literature review 
Chapter 3: Research methodology 
Chapter 4: Qualitative phase of this research and the discussion of the findings 
Chapter 5: Quantitative phase of this research and the discussion of the findings. 
Chapter 6: Recommendations and conclusion of the research 
1.13 CONCLUSION 
The WHO (2004) encourages a utilisation of skill mix to deal with staffing problems in mental 
health care. The researcher as previously stated recognises the role of Indigenous healers in 
the mental health care of 70% of South Africans. This is echoed in Pienaar (2013:151), who 
explains that unique primal health care practices have outlived the Western health care 
practices and continue to dominate in rural areas. 
Therefore the researcher feels these skills could possibly be utilised in the rendition of health 
care to the diverse population of South Africa. Not only can these skills be used, but cross-
pollination should take place between WBKS and AIKS as this would encourage the provision of 
culturally safe care. 
The lack of scientifically generated evidence depicting staff's attitudes of the management of 
mental healthcare user related violence and aggression and cultural sensitivity in the four 
psychiatric hospitals chosen for this study necessitated further investigation to collect data to 
evaluate the current status of the management of aggression in a culturally safe manner and to 
test if the proposed training programme has an effect on the aforementioned attitudes. 
In subsequent chapters, the researcher will discuss the findings from the literature review, the 
research methodology followed during this study, the research outcomes, the training 
programme curriculum designed and final conclusions made. 
CHAPTER 2 
LITERATURE STUDY 
2.1 INTRODUCTION 
This literature review chapter will further discuss the literature consulted by the researcher in 
search of the conceptualisation of topics such as aggression and violence, IKS and attitudes of 
staff. The literature review will also elaborate on the attitudes of staff and indigenous healers 
towards mental health care and aggression as sometimes found in mental illnesses. 
Through consultation of the literature, the management of aggression and violence associated 
with mental illness will be investigated. A comparison will be made between the perceptions of 
the above-mentioned within the AIKS and Western based medicine also known as Allopathic or 
Western biomedicine system (Andrews & Boyle, 2003:282). 
This chapter continues to provide an overview of AIKS and the WBKS to create an 
understanding of the two concepts. The researcher elaborates further on the attitudes of health 
care practitioners in the WBKS towards Al KS and vice versa, in order to establish whether the 
two opposing knowledge systems are both acknowledged in terms of the provision of care to 
MHCU. The different perceptions of mental illness and the management of mental illness are 
explored with reference to the way in which the two opposing world views deal with mental 
illness. 
Through a comparison the researcher additionally explored the tolerance of the opposing 
knowledge systems to each other and how it is utilised in the Southern African countries. The 
aim of this approach is to provide the reader with an overview of the differences between the 
knowledge systems and how these differences impact on the quality of care MHCU still receive 
today. 
2.2 AFRICAN INDIGENOUS KNOWLEDGE SYSTEMS {AIKS) AND WESTERN-
BASED KNOWLEDGE SYSTEMS (WBKS) 
"He who speculates from the shore about the ocean shall know only its 
surface, but he who would know its depths must be willing to Plunge into it." 
Anonymous 
One can only truly understand a culture different from their own if they are prepared to delve 
into the culture in order to understand the perspective of the said culture (Naidoo, 1985: 1) . 
2.2.1 Introducing the status quo with regards to cultural differences as evident in 
health care institutions 
Each cultural group has its own cultural norms, beliefs and traditions. These traditions include 
health care practices, building styles, clothes, dietary beliefs, the existence of a higher spiritual 
being responsible for the creation of all life on earth and beliefs about causative factors 
(Andrews and Boyle, 2003:274; Helman, 2001 :2; Tjale & De Villiers, 2004:161). Giddy 
(2012: 19) reported some cultures which believe that there are incidences where an evil external 
force accidentally gains power over humans and this can cause illness or death, these beliefs 
are frowned upon by WBKS. 
In terms of the co-existence of the Western Based Knowledge Systems (WBKS), the researcher 
has experienced situations where the culture and knowledge systems of MHCU are not always 
recognised or where staff are insensitive towards a culture. One such example is during 
celebration of Christmas. The wards in the hospital where the researcher used to work are 
decorated very festively with Christmas trees; gifts are given to MHCU on Christmas morning, 
regardless of the cultural and religious beliefs of the person. However, the researcher noticed 
that Chanukah, a Jewish festivity which coincides with Christmas, is ignored. Similarly, other 
religious celebrations such as Eid for the Muslim patients and Diwali for the Hindu patients, 
went by without an acknowledgement by the staff. 
The researcher assumes that through acknowledgement of these beliefs, the mental health care 
practitioners might contribute to a positive mental health care user experience, and hence begin 
to provide culturally safe care. 
Attempts geared at collaboration between WBKS and AIKS are further explored and the 
researcher elaborates on the intended professionalisation of indigenous healers. 
In conclusion, the similarities and differences between the two diametrically opposed knowledge 
systems will be illustrated; with a further exploration of the current training provided to assist 
mental health care providers to manage the aggression and violence associated with mental 
illness in a culturally safe manner. The researcher will continue to elaborate on how cultural 
awareness and sensitivity is addressed as part of the proposed curriculum. 
In order to facilitate further discussions, it is necessary to provide an overview of AIKS as 
described in this work. 
2.2.2 Broad overview of African Indigenous Knowledge Systems (AIKS) 
South-Africa, a country on the most Southern tip of the African continent, has eleven (11) official 
languages, each of which is nestled in its own culture (Joyce, 2009:7). It is common course that 
along with the different cultures come unique perceptions of the world and practices by which 
the members of the different cultures make sense of their environment and lived experiences. 
An explanation of Indigenous Knowledge Systems (IKS) can be found in a definition by Quiroz 
(1994:14) wherein he defines (IKS) to be the totality of the knowledge and skills of a group of 
people, which knowledge and skills make it possible for them to live in and off their specific 
geographical area. Raphesu (2010:3) elaborates further through citing Quiroz (1994), 
expanding the definition to indicate that each new generation adapts this knowledge to suit 
changes in their environment. This definition is supported by Maila and Loubser (2003:276) and 
Ngomane and Mulaudzi (2010:30), who reiterate that it is inherited knowledge, customs used to 
advance themselves and it is quite unique to each culture. IKS is sometimes referred to as 
Traditional African Medicine (TAM) when treatment of illness is discussed (Okpako, 1999:482). 
Okpako (1999:482) continues further and refers to IKS as the more than mere medicine, 
referring broadly to the: "accumulated experience of ancient Africans". 
Therefore, based on the findings of the authors cited above, the researcher establishes that 
African Indigenous Knowledge Systems (AIKS) is a collection of knowledge, skills and practices 
within a specific frame of reference and a specific geographical area, which allows people to 
make sense of; and live and survive in , their environment on the African continent. AIKS is thus 
not a static phenomenon but evolves as people evolve, and this flexibility allows people to adapt 
to changes. 
This AIKS is deeply embedded in the culture of all people and forms part of their worldview 
(Maila & Loubser, 2003:276; Higgs, 2010:2414). Both the metaphysical aspects as well as the 
technology, social , economic and philosophical learning and educational systems should be a 
part of the definition of AIKS, as stated in a study done by Hoppers and Makhale-Mahlangu 
(1998) in Breidlid (2009:141). 
The AIKS is sometimes explained to be based on understanding from a magico-religious 
perspective (Tjale & De Villiers, 2004:4; Holland, 2001 :3). This magico-religious perspective is 
explained by Tjale and De Villiers (2004:4) through a holistic explanatory model. This model 
refers to the body being in harmony with the physical world, social world and other people. 
Illness would stem from disharmony between these afore-mentioned systems. How the person 
would interpret the illness will depend on their unique cultural beliefs and knowledge systems. 
Because many Africans believe and are one with their ancestors, they would often find the 
cause of illness through reference to this world of contact with the Ancestors. WBKS would refer 
to this form of belief as being magico-religious (Edwards et al., 1983:213). 
The magico-religious perspective becomes more evident where Indigenous healing systems 
include the practice of the indigenous healers' use of spiritual forces to determine "the cause of 
ill health and misfortune" (Ensink et al. , 1999:26; Shankar, Saravanan & Jacob, 2006:222). A 
further definition of indigenous healing explains indigenous healing to be, "the sum total of 
knowledge, skills, and practices based on the theories, beliefs and experiences indigenous to 
different cultures that are used to maintain health , as well as to prevent, diagnose, improve, or 
treat physical healing and mental illness" (WHO, 2002). 
In elaboration on the concept of the magico-religious perspective, notably one category of 
healers within AIKS is referred to as diviners, who are reported to possess the ability to "divine 
the cause of illness and misfortune". Divining the cause of illness refers to the practice where 
the diviner enters into a state of trance in order to communicate with the ancestors who will then 
indicate the cause of illness. (Joyce, 2009:47). 
In further explanation, diviners reportedly have power over life and death and can use this 
power for either good or evil purposes, as alluded to in a study by Ngubane (1977) in Ensink et 
al. (1999:25). 
Equally important is to note that religious healing systems are commonly found in the Eastern 
African regions and developed under the influences of Islam and Christianity (Teuton, Dowrick 
& Bentall , 2007: 1267). 
These religious influences of WBKS on AIKS can be traced back to the 1820's during the British 
settlers' occupation of the Cape and the subsequent spread throughout South Africa, in its wake 
establishing numerous missionary stations. The Anglicisation of Southern Africa soon spread 
throughout the rest of the African continent, with the Christian religion being preached in order 
to "convert and save Africans" (Joyce, 2009:21 ). 
This spread of religion through Africa is one of the examples where two opposing forces , 
namely religion and AIKS, met and "something new" was created . 
Through the meeting of these two forces, that is the exposure of religion to AIKS, a new form of 
healing emanated, manifesting through the birth of a new type of healer known as the prophet. 
This prophet, according to Pienaar and Manaka-Mkwanazi in Uys and Middleton (2013:136), 
prays through known ancestors to the "unknown god" who would then give guidance towards 
the healing process. Notably, the difference between the prophet and the diviner is that the 
prophet does not make use of the throwing of bones or the use of medication but rather relies 
on the use of "holy water" and readings from the Bible (Uys & Middleton, 2013: 136). In the 
context of this research, the prophet is therefore a practitioner who bases healing on the Holy 
Scriptures and the diviner in contrast is a person who not only seeks answers from the 
Ancestors but also uses medication of an indigenous nature in the treatment of a health seeker. 
This opinion of Uys and Middleton (2013: 136) is also noted by Mzimkulu and Simbayi 
(2006:420), who refer to the establishment of an independent African church that broke away 
from the western oriented missionary churches. It was within this African church that the 
prophet started practicing. 
Subsequently, in contrasting WBKS and AIKS, the researcher notes that in terms of AIKS, the 
African world view looks at the essence and existence of man not from knowledge based on 
scientific reasoning but from direct experience and the transfer of this experience to the 
community and family. 
Thus, in conclusion, the sum total of AIKS is more than a mere magico-religious belief system. 
Instead, it is a holistic view of life, with knowledge generated through the lived experience of the 
cultural group and the transfer of this knowledge from generation to generation through verbal 
communication. Maila and Loubser (2003:277) refer to this AIKS as to be "user-derived and not 
scientifically derived." It however complements modern day innovations as seen in WBKS. The 
WBKS will be described in the next section in order to introduce the reader to the opposite 
system. 
2.2.3 Broad overview of WBKS 
The WBKS prides itself on being rational (Tjale & De Villiers, 2004:3). Rationality implies 
exactness, relying only on true observations (Rosnow & Rosenthal, 1999:3). Within the WBKS, 
there is no place for mysticism, and there are definite causes and effects. Knowledge is gained 
according to scientific measurement and proof under strict control (Henning, 2004:3). This 
knowledge system is also described as "exact thinking and correct thinking" (De Vos et al., 
2009:3). 
WBKS are generally endorsed by most governments and organisations such as the World 
Health Organisation (Teuton et al., 2007:1261). WBKS see disease as a biological reaction and 
the intervention should be medicine aimed at killing the bacteria and virus, as well as to 
suppress the symptoms associated with the illness (Tjale & De Villiers 2004:84; Andrews and 
Boyle, 2003:85). In the context of this research, WBKS is deemed to be knowledge generated 
through scientifically researched evidence. However the two opposing world views inevitably 
had to meet. 
2.2.4 When two opposing world views meet 
"When two powers meet one will rub off on the other and after the experience 
neither of the two parties will be the same. " 
(Mumford & Anjum, 2011). 
Reflecting on the statement in the text box above, the researcher will endeavor to explain how 
the words of Mumford and Anjum (2011) above, echoe the findings of Higgs (2008:446) and 
Joyce (2009: 13), where they indicate that through the colonial influence, the African people's 
world view was ignored and Africa was forced into an "inverted image of the Western 
Eurocentric identity". The researcher will continue to argue, through quoting research, how the 
African world view due to the tenacity of culture managed to survive the influence from WBKS 
and added in the creation of "something new''. 
African countries, through their many diverse cultures, share a commonality; namely the 
influence of the Western-based knowledge on the African continent. Despite the influences of 
the WBKS, Africa has proven to be a continent where the diverse cultures possess tenacity and 
resilience, hence westernisation has not changed deep-seated cultural beliefs (lzugbara & 
Undieb, 2008:165). The AIKS have survived the influence of the WBKS. The contact between 
AIKS and WBKS has not occurred without conflict. 
Conflict between WBKS and AIKS is observed through the example of the management of 
witchcraft-related killings, a practice that is acceptable in some African cultures and taboo in 
Western cultures. 
The attitude of WBKS is further portrayed in the way in which witchcraft in AIKS and the 
dealings with alleged witches within traditional tribal councils is frowned upon. For scientifically-
based knowledge systems, there is no belief in supernatural or magico religious beliefs as 
supposedly found in AIKS. 
Hund (2003:10) reported that within AIKS, if a person was deemed to be a witch, a tribal court 
was held and witches found guilty were executed. South African courts were not equipped to 
deal with allegations of witchcraft and this led to the promulgation of the South African 
Suppression of Witchcraft Act, No. 3 of 1957, subsequently amended by Act 50 of 1970. This 
act now allows for persons accused of witchcraft to pursue an action of defamation of character 
against the accuser (Hund, 2003: 10). 
Similarly, even within the "rational" WBKS there are certain groups who share some belief in 
unscientific supernatural and magico-religious beliefs. This gives rise to conflicting opinions 
amongst groups who share the same WBKS. One such example can be found in the practice of 
Satanism and demonic possession and Christianity and the exorcism of demons. 
Because Satanism is practiced in a covert form and therefore surrounded with mysticism, 
Langone ( 1990: 101) found that media publication spurts on the exploration and experimentation 
with this form of belief system and it tickles the interest of especially adolescents. The 
researcher is of the opinion that Satanism is a form of magico-religious belief system as it is 
reported by Langone (1990: 102) that participation in satanic rituals, where members allegedly 
drink human blood, forms pacts with Satan and will subsequently possess more power. Miller et 
al. (1999:211) made a similar observation with regards to cult members who believed 
participation in such rituals will provide them with a longer life, increased health and power over 
others. This magico religious thinking is further evident through ideas of reference and odd 
beliefs as is manifested through the behaviour of the members of a cult (Miller et al., 1999:212). 
Wheeler, Wood and Hatch (1988:547) echoe this finding of other authors and continues to point 
out that the satanic rituals not only intrigues adolescents but leaves them with the belief that 
there is power in the rituals and that there is personal, religious and sexual gratification in 
attending such rituals. This belief of sexual gratification is confirmed in the writings of LaVey 
(1969:87) (the father of Satanism) wherein it is stated " ... The purest form of carnal existence 
reposes in the bodies of animals and human children who have not grown old enough to deny 
themselves their natural desires ... ". 
Society is quite unaccepting of the practice of Satanism, not so much the worshipping of Satan 
but rather the rites involved, such as alleged human sacrifices which is considered to be crime 
against humanity and therefore punishable under penal law. Satanism, as practiced religion and 
the modern church of Satan, was established on Walpurgisnacht, (A witches' Sabbath) 30 April 
1966 when Anton LaVey proclaimed himself to be the high priest of the church of Satan. 
(Langone, 1990: 123), La Vey continued and wrote the Satanic Bible in 1969, (Langone, 
1990: 124). Satanism is filled with mysticism such as the symbols, seances, meetings and black 
weddings, even human and animal sacrifices, use of drugs and attendance of sexual orgies 
(Wheeler et al., 1988:545). 
Therefore, the researcher is of the opinion that WBKS are used as a departure point to define 
concepts not indigenous to what is deemed the norm from the Western perspective, and 
subsequently places value judgment on practices from a WBKS perspective, yet within WBKS 
there are also sub cultures such as the practitioners of Satanism which is also not understood 
within the WBKS. This leads to condemnation of practices which do not form part of what 
WBKS deems to be the norm with the researcher observing this as a form of ethnocentrism 
whereby "different practices" are condemned, and "own" practices are accepted to be the only 
truth. 
To conclude, Ralushai in his summary report on witchcraft violence in South Africa (cited by 
Hund, 2003: 125), confirmed that despite early missionaries' "condemnation of indigenous 
healers" the practice have continued to survive; this confirms the tenacity of cultural practices 
and includes the tenacity of sub-cultures such as Satanism. The researcher concludes that the 
two opposing forces are still in existence and are continually shaping one another. 
2.2.5 WBKS versus IKS 
The researcher is of the belief that Africa as a developing continent does not differ much from 
the rest of the world. As seen in the literature, countries such as Australia, Nieu Zealand and the 
United States of America to name but a few, are all in the position where there is more than one 
health care perspective and knowledge system running alongside one another. Tjale and De 
Villiers (2004:2) and Berg (2003: 195), echoes this observation when pointing out that in South 
Africa we have the WBKS and AIKS running parallel with one-another, which will influence the 
health care system. 
In order to understand the role of the different knowledge systems, it is essential to explore both 
and their role within the South African context. The "rationally focused" WBKS is often a barrier 
to understanding the AIKS (Hund, 2003:33). 
The WBKS is based on scientific measurement and scientific reasoning, whereas the coinciding 
different views of health care systems are defined to be pluralistic (Teuton et al., 2007:126). 
Even though the AIKS and the health care rendered within this system is seen as lay care and 
therefore not viewed as professional, all cultures in one way or another depend on this form of 
care due to the often inaccessibility of Western-based care to people in rural areas, hence they 
primarily seek the help of the indigenous healer (Atindanbila & Thompson 2011 :459). Leininger, 
as quoted by Tjale and De Villiers (2004: 152), identified four types of lay care used by all 
cultures and further elaborates that this type of care arises from experience and common 
sense. The types of lay care identified are care given by family members, social networks, self-
help groups and self-medication. 
The researcher, like most South Africans, has directly experienced health care rendered by her 
mother, care which is based on the family's knowledge system which also forms part of the IKS. 
One such example is the consumption of heated red wine during a bout of measles. Within this 
knowledge system of the family, there is a belief that the consumption of the red wine would 
expedite a breakout of the rash associated with measles and therefore prevent complications 
associated with measles. This is one example of a practice that has not been medically tested 
at the time, but is an example of knowledge passed down within the different generations of the 
researcher's family. 
In Africa, there are distinctly different healing systems and views around mental health . These 
can be divided into indigenous, religious and allopathic views of healing systems (Ensink & 
Robertson, 1999:24; Okpako, 1999:482). Sorsdahl et al. (2010:284) note that the option of more 
than one healing system allows for the preferences of the population as to which system they 
want to utilise. The option of more than one healing system acknowledges the existence of 
more than one view of illness and the seeking of health care based on the view of individual 
people (Beckerleg , 1994:299). Ovuga, Boardman and Oluka (1999:276) submit that it is 
beneficial to have different healing systems running alongside one another as it allows the 
health care user the freedom to seek alternatives should they be dissatisfied with one or the 
other system. These aforementioned views differentiated from one another through their 
individual definitions will inevitably lead to different treatment and management strategies. 
According to Yen and Wilbraham (2003b:564), the AIKS differs from the WBKS in that it 
attempts to focus on why a phenomenon happens as opposed to how it happens. The "how it 
happens" is based on scientific reasoning as found in the WBKS. 
Noteworthy is how WBKS refers to the use of indigenous practices and AIKS as "alternative 
medicine" when this practice is sought over the Western-based medicine. Where Western-
based medicine is used in conjunction with alternative treatment, this is referred to as 
"complimentary medicine" (Andrews & Boyle, 2003:85; Janse van Rensburg, 2009:158) . This 
reference leads the researcher to deduce that through the terms used above, namely the use of 
complementary medicine, there is evidence of a readiness to include these types of practices. 
Therefore the stage is set for collaboration between the two opposing knowledge systems. 
Regardless of the set stage, the two opposing world views have their different opinions of one-
another. 
2.2.6 Attitudes of Western-based health care practitioners towards AIKS 
Culture is important to every person as it defines a person and allows one to make sense of the 
world. Therefore culture is shared by a group of persons and allows for standardisation of what 
the specific group believes. It further sets boundaries for those who are included in the same 
group (Tjale & De Villiers, 2004:66). 
Due to the fact that people with different cultures have different values, it often so happens that 
people with one culture cannot associate with practices and beliefs of another culture outside 
their own. They then would deem their own sets of beliefs superior to that of another culture. 
This is referred to as ethnocentrism (Tjale & De Villiers, 2004:45; Andrews & Boyle, 2003:7). 
Ethnocentrism hinders consideration and acceptance of other cultures. In a situation such as 
the nurse-patient relationship, where the nurse has a lack of understanding of the culture of the 
patient, this situation can lead to conflict and feelings of inferiority in the patient. Yen and 
Wilbraham (2003b:564) point out that historically the psychological and psychiatric institutions 
made assumptions on what is referred to as the "primitive African personality" and attempted to 
manage mental illness from a Western knowledge based perspective, therefore adding to the 
ethnocentrism as stated by the authors above. 
WBKS has attempted to understand AIKS. However, in the attempt to explain AIKS, the WBKS 
has unfortunately added to the creation of confusion through loose referrals and the 
synonymous use of terms such as reported in a study by Hund (2003). Hund (2003: 12-15), 
reported the findings of academic writers where they refer to "sangomas" as witchdoctors, 
adding to the impression amongst the layperson that a "sangoma" does witchcraft. 
Similarly, authors such as Berg (2003:196) have noted that within WBKS indigenous healers 
are often referred to as witchdoctors and that this term is loosely generalised to different 
cultures. This generalisation often leads to confusion, as for example in the Xhosa culture the 
"isangoma" acts as a spiritual medium between the client and the ancestors and the "inyanga' is 
a diviner and herbalist focused on prescribing medicines and cures. However, in the Venda and 
Tsonga cultures, both the sangoma and herbalist are referred to as "inyanga". Noteworthy is 
that all "sangomas' are herbal ists and diviners, yet not all diviners are "sangomas". The 
differentiation lies in the length of training and if a person received a calling "twaza" to become a 
sangoma (Mzimkulu & Simbayi, 2006:420). Yet Berg (2003:196) informs that within WBKS all of 
these healers are loosely referred to as "witchdoctors" I even though there are clear dismo -\ 
between the different functions of the different types of healers in AIKS. \ NR ARY J 
-LIB -
In the current curriculum of health care, the western and allopathic worldviews are inculcated 
into practitioners during training . This adds to the difficulty that health care providers experience 
in accepting that indigenous healers should be included as part of the health care system (Tjale 
& De Villiers, 2004:4). Thus it might be difficult for nurses to understand and value AIKS in the 
WBKS because they might feel superior with regards to knowledge in their area of expertise. 
Teuton et al. , (2007:1268) and Yen and Wilbraham, (2003a:550) observe that staff generally 
feel that psychotic disorders fall within an area of specialisation and are ideally the domain of 
qualified psychiatric staff. As such, the staff reportedly felt more at comfort with indigenous and 
religious healers dealing with non-psychotic disorders. This bias is demonstrated in staff 
reporting that the indigenous and religious healers are not skilled enough to deal with psychosis 
and might misdiagnose psychopathology that should be assisted by WBKS (Teuton et al. , 
2007:1268-1270; Yen & Wilbraham, 2003a:552, 557). 
Contrary to this statement, Berg (2003: 196) celebrates indigenous healers to be skilled 
psychotherapists who underwent years of rigorous training and subsequently have the 
necessary approval of the Ancestors. Additionally (Yen & Wilbraham, 2003a:550) confirm the 
hesitance of staff to refer to indigenous healers through reporting a finding in their study where 
the decision for the multi-disciplinary team to allow consultation with an indigenous healer is not 
made by professionals but rather it is "patient- or family driven". 
Teuton et al. (2007:1268-1270) further explain that the bias does not end with statements such 
as reported above but continues to include judgments where nursing staff assumed that 
indigenous healers were secretly administering neuroleptics to patients to boost their statistics 
of "curing" patients. The nurses continued to report that they think indigenous healers use "mutl' 
consisting of human flesh . Muti is a Zulu word meaning medicine (Labuschagne, 2004:192). 
This "mutl' is then given to unsuspecting patients. The nurses elaborated further in alluding to 
the fact that the indigenous healers instill fear in patients through informing them that they have 
provoked the anger of the Ancestors, hence ensuring that patients come for follow up visits 
where rituals are performed to appease the Ancestors. All of the above would ensure that the 
indigenous healers generate financial income from the unsuspecting patients. 
In elaboration on muti consisting of human flesh, it is noted that: 
Traditionally the chief of a cultural group was allowed to sanction a "medicine murder" if it was 
for the benefit of the community or when a new chief was installed. In the case of Gadiwe v The 
State (2007), the report was that the life and energy of the victim will be transferred into the 
person using the muti containing human flesh. The allegation made above is supported by 
Roelofse (2012: 1) who sites (Prinsloo & Du Plessis, 1989:621 ; Ralushai , Masingi, Madiba & 
Van den Heever, 1995). These medicine murders are reportedly not committed by strangers but 
rather a family member or acquaintance of the victim (Labuschagne, 2004: 193). Muti is reported 
to be harvested from live victims and the area harvested can be directly linked to the needs of 
the sangoma 's customer. In example, Labuschagne (2004:193) reports that the harvesting of 
hands supposedly brings wealth to the person who will make use of the muti. The lnyanga and 
sangoma never took part in this ritual killing . This practice is in direct contrast with Western 
Based knowledge and therefore the supplier of this type of muti is punishable by law in South 
Africa (Hund, 2003:90). The perception of the nursing staff that the treatment of psychosis 
should occur within health care in the WBKS only, as reported by Teuton et al. (2007:1268); and 
Yen and Wilbraham (2003a:550), leaves the researcher with the impression that an underlying 
motive for statements such as these might stem from ignorance or possibly feelings of being 
threatened by the utilisation of AIKS as opposed to the WBKS which the nurses are more 
acquainted with. This type of judgment leads to a disregard of the role of indigenous practices 
and an attitude of rejection. 
WBKS through claims by scientists adds to the discouragement of the use of indigenous 
medicine by claiming that the dosages used are imprecise and the safety of all plant remedies 
have not been tested (Okpaka, 1999:483). This perception of WBKS is echoed in a study where 
Abbe (2011 ) reports that indigenous medicine and treatment is dismissed as unsafe practices. 
In contradiction with the statement by Okpaka (1999) , Breidlid (2009:142) opposes what he 
refers to as a "lack of respect" for AIKS by western scientists through portrayal of the assumed 
superiority of the western epistemology. Attitudes such as these will prevent the necessary 
sustainability of AIKS, frustrating their endeavour to meet human development needs. 
The researcher concurs with the statement of Breidlid (2009:142) and notices that regardless of 
tests being done on treatment within the AIKS in order to dispute the use thereof, there are 
benefits to the use of AIKS. AIKS must have its deserved place in the health care system, as 
will be explained in the following section. 
In addition to treatment of ailments through rituals and administration of indigenous medicine, a 
study by Okpako (1999:483) addressed the impact of the placebo effect of traditional African 
medicine. In the course of this study, it was proven that the therapeutic intervention such as the 
rituals accompanying the use of indigenous medicines contributes significantly to the relief of 
illness, hence the reference to the placebo effect of the traditional African medicine. The 
placebo effect of AIKS is further demonstrated by Holland (2001 : 13) who submits that about 
40% of illness may possibly have a psychological cause and that the success rate of the 
traditional healer lies in the AIKS form of healing that focuses more on the spiritual wellbeing of 
the patient. 
This reference to the placebo effect is not always made as a positive remark, as observed in the 
experience of the researcher. As the researcher has noted, there are incidents where patients 
are injected with normal saline for pain control and when the normal saline solution alleviates 
the pain, health care providers will record this as malingering behaviour on the side of the 
patient, without a clear understanding of the placebo effect. Conversely, the attention of the 
health care provider is of far greater benefit to the health care user than the mere administration 
of medication. 
Okpako (1999:483) and Holland (2001 :20) echoed this notion, elaboring that due to the close 
nature of the relationship between the indigenous healer and his client, as well as the close ties 
between them, the placebo effect is much more pronounced than is the case in the relationship 
between the western practitioner and his client. 
The placebo effect stems from a deep seated belief in the power of the treatment (Becker, 
1974:108). South African born actress Antoinette Pienaar, a white South African woman who is 
undergoing an apprenticeship under a renowned Khoisan herbalist "Oom Johannes," also 
emphasises the importance of a person's belief in the efficacy of any herbal medicine. A person 
who does not believe in the efficacy cannot expect healing to take place (Pienaar, 2008:36). 
"Oom" (uncle) Johannes reportedly tells a patient, "Go, take the herbs and believe" (Pienaar, 
2008:37). 
Over and above the reported placebo effect, an interview with Mutwa, a sangoma as referred to 
in Hund (2003: 154 }, revealed that the sangoma reports that communication will be on the level 
of a patient, and the sangoma will also never divulge his personal opinion to a patient even if 
the patient feels he was bewitched and the sangoma reportedly knows this is not the case. 
Therefore, the perception created is that AIKS might be more flexible than WBKS due to the 
acceptance of more than just biological causes for illness. 
As early as 1961, the opposing views of AIKS and WBKS were evident. Tjale and De Villiers 
(2004:5) cite Szasz who postulated that traditional medicine might possibly be superior to 
western medicine as indigenous healers know their clients on a more personal level as opposed 
to the medical doctor in the westernised medical model. 
2.2.7 Attitudes of indigenous healers towards the WBKS 
To understand the attitudes of indigenous healers toward the WBKS a perceptive consideration 
of the two opposing worldviews is essential. 
Teuton et al. (2007:1267) reported that the indigenous healers in the study indicated that a 
client could be treated by both the indigenous healers and western medical personnel. 
Beckerleg (1994:303) echoes this and refers to this practice as medical pluralism. It was noted 
that Swahili people studied by Beckerleg sought the medical advice and intervention of both 
Western medicine and a "sharif (a type of indigenous healer in Kenya who consulted the Quran 
to try and find a diagnosis) . In support of the authors cited above, Ensink et al. (1999:29) also 
reported the practice of multi-pluralism in isiXhosa speaking patients in Cape Town, who 
consulted diviners, faith healers and herbalists simultaneously, in attempts to find a cure for 
mental illness. Within AIKS, some forms of illness can occur naturally. Uys and Middleton 
(2013: 132) report that this illness is referred to as "umkuhlane" and further inform that 
indigenous people readily seek the help of practitioners within the WBKS for the treatment of 
this type of illness. This leads the researcher to deduce that the indigenous healers and 
indigenous people are more tolerant to opposing views when compared to practitioners within 
the WBKSI bio-medical perspective. Indigenous healers who took part in a study by Sorsdahl et 
al. (2010:287) reported that they are aware that often western medical practitioners do not 
agree with their methods of treatment, and this may be due to some of the "mutl' recipes used 
and the ingredients in it. One such recipe shared, allegedly cures a condition known as 
"amafufunyanci' which is a form of bewitchment. The recipe contains the following ingredients: 
"1 teaspoon of Methylated spirit, ½ teaspoon of Benzine ®, a few pieces of the " lndonya" (a 
traditional herb), 1 teaspoon of vinegar and½ teaspoon of a herb called "umdlebe". This mixture 
is then administered in the form of an elixir. According to Sorsdahl et al. (2010:287) the 
indigenous healers reported that western medicine is not in agreement with this treatment 
because it contains Benzine. 
Hund (2003:154) reported on an interview with a "sangomci' named Mutwa, that African people 
are very wary of "white people" because white people do not believe in the culture of the African 
people. The sangoma reported that this disbelief of white people with regards to the culture of 
African people can negatively influence the soul of the African person. African people are more 
sensitive to the soul than white people (Hund, 2003:154). These differences between the two 
systems have led to mistrust between the two opposing world views. 
2.2.8 Resistance to share AIKS 
Although both the WBKS and IKS can learn from each other, divergent opinions and 
experiences are noted. 
Sorsdahl et al. (2010:287) reported that the indigenous healers are very resistant to share 
secrets of the trade and recipes for "mutl' with any person other than an initiate undergoing 
training , considering that the practices are deemed to be the intellectual property of the 
traditional healer and the initiates only. The researcher observed the same during data 
collection as will be noted in Chapter (4) four. 
This hesitation by indigenous healers to share their knowledge is echoed in a statement by 
Doubell (2010) during a power point presentation, where he advocates that the rights of 
indigenous healers should be protected against exploitation by commercial players. This quest 
for protection is also reflected in the Intellectual Property Rights from Public Financed Research 
Act (51 of 2008), wherein the act regulates benefit sharing in the commercialisation of 
indigenous knowledge and practices (South Africa, 2008). 
The Khoisan chief, Adam Kok the 5th , during a conversation in a Khoisan village in 2012, 
referred to the previous utilisation of the knowledge of the hoodia plant by Western-based 
scientists. The scientists reportedly made financial gain out of the marketing of hoodia for 
medicinal purposes. The commercialisation of hoodia was done without recognising that this is 
indigenous knowledge. None of the financial yield was ploughed back into the already 
impoverished Khoisan community whose intellectual property was used. This exploitation of 
intellectual property strengthens the perception that indigenous knowledge is only 
acknowledged if money is to be made out of it (Quiroz, 1994, Kok, 2012, Raphesu, 2010). 
2.2.9 Legalisation of indigenous health practices 
Acknowledgement of AIKS and its role in South Africa has been researched and attempts have 
been made to form collaborations between AIKS and WBKS. This collaboration included 
legitimisation of AIKS practices (Yen & Wilbraham, 2003a:543). Sillitoe (2000:4) and Chivaura, 
as cited by Ncube (2006:219), warn that the WBKS cannot be used to "interpret and categorise" 
the AIKS as this will encourage a person to view AIKS as filled with myths and superstitions. 
The recognition of the indigenous healing practices used by indigenous healers has led to a 
quest to professionalise the AIKS practices to ensure safety to the user. Therefore the 
Traditional Health Practitioners Act (35 of 2004) was promulgated to regulate the profession. 
Through this act the practices, training and registration of these health care providers are 
regulated (Janse van Rensburg , 2009:157; South Africa, 2004). Any person in terms of this act 
who practices as a "Traditional Medical Practitioner" but who is not registered in terms of this act 
is guilty of a criminal offence and can be fined up to R2 000,00 or 2 years imprisonment (Hund, 
2003:109). 
The establishment of a professional regulating body for professionals gives recognition to their 
practices. It can therefore be accepted that this recognises Indigenous healing practices as part 
of the health delivery system in South Africa. Through the promulgation of the Traditional 
Health Practitioners Act (35 of 2004) , more health care options are available to South Africans 
and each person can make use of health care services according to their own preferences 
(Sorsdahl et al. , 2010:285; South Africa, 2004). 
Unfortunately, ignorance often leads to a breakdown of collaborative efforts. Ignorance is 
demonstrated in a study by Yen and Wilbraham (2003a:547), when the multidisciplinary team 
entered into discussion with indigenous healers by providing them with vignettes of a patient 
with a mental illness that was difficult to diagnose. Ignorance, though not intentional, became 
evident through a lack of understanding of the complexity of diagnostics through rituals. The 
indigenous healers cannot perform divination rituals on a "paper person". This knowledge 
pertaining to diagnostics within AIKS lacked in the multi-disciplinary team who invited the 
indigenous healer to take part in the diagnostic formulation and discussion of the patient. 
Further examples of ignorance are evident in a study where Hund (2003:35) reports that 
ignorance of AIKS and imperialism by WBKS led to the enactment of the Witchcraft 
Suppression Act No 3 of 1957 amended by Act 50 of 1970) and that this caused an increase in 
witchcraft violence. Therefore the Ralushai Commission Report recommended the repeal of the 
act and in addition recommends rehabilitation of the legitimate role of the sangoma. The 
sangomas in terms of this report should be brought under state control. This alludes to the 
recognition of the role of the sangoma and their healing practices. 
Robertson (2006:87), Abbo (2011) and Pienaar (2013: 151) report that about 70% of South 
Africans use indigenous healers as primary health care providers, therefore the legitimate role 
of the Indigenous Healer must be recognised in order for the gap between the two opposing 
treatment models to be bridged as this will encourage the rendering of culturally safe care to all. 
(Berg 2003: 196). 
For this to happen, closer collaboration between Western-oriented care and primal care based 
on IKS is necessary. 
2.2.1 O Movement towards co-existence of AIKS and WBKS 
Higgs and Higgs (2001 :9) propose that one can change your perception of others and how you 
relate to the world, leading to the creation of something "more beautiful and better than we had 
before". Therefore, the caution is for one not to attempt to understand AIKS from a WBKS 
perspective (Sillitoe, 2000:4). Instead, one would rather attempt to understand the perception of 
others and other cultures from within their unique frame of reference, as opposed to trying to fit 
different cultures into one's own world view. The Western worldview and influence in Africa is 
being challenged , and recognition is given to the African world view by means of an African 
philosophy. This gives a deserved recognition to the AIKS through what Higgs (2008:499) refers 
to as the "African Renaissance". This renewal is focused on the expansion and inclusion of the 
African World view in education (Higgs, 2008:499, 450-455; Ndofirepi, 2011 :248). 
Higgs (2008:447) points out that some of the Western cultures have since started realising that 
AIKS, though not seen as scientific reasoning, has much to offer and might possibly assist the 
scientific community to understand natural phenomena. In addition, it might also prove to be 
essential for sustainability, hence the support of the quest of O'Donoghue, Masuku, Janse van 
Rensburg and Ward (1999) as quoted by Maila and Loubser (2003:276) to have AIKS included 
in education and health curricula. Abbo (2011) strongly recommends that curricula in medical 
schools must include AIKS as a deeper knowledge will allow more open discussions between 
western and indigenous health practitioners, thereby increasing cultural competence. The quest 
to include AIKS in educational curricula is echoed in recommendations in a chapter titled "Notes 
on African Witchcraft" by Chavunduka in a book edited by Hund, wherein he proposes that 
teaching of African traditional medicine should be introduced into educational institutions (Hund, 
2003: 142). Additionally, Berg (2003: 195) reminds one of the urgency to become acquainted 
with other world views as ignorance can have disastrous consequences for effective health care 
provision. Noteworthy is that Indigenous Knowledge Systems still exist despite the introduction 
of the "superior" WBKS. There have been attempts made to ensure that both practices run 
concurrently and become more interfaced with one-another (Janse van Rensburg, 2009: 157). 
Perceptions of health and illness are thus influenced by the specific knowledge system of the 
person or cultural group we are dealing with, and this especially influences perceptions about 
mental illness. 
2.3 PERCEPTIONS OF MENTAL ILLNESS 
Mental illness in most cultures is associated with disability (Shankar, Saravanan & Jacob, 
2006:221). Additionally, mental illness was historically viewed as people being "mad, fools or 
possessed" (Andrews & Boyle, 2003:272). In order to understand the concept of mental illness, 
it is necessary to explore the phenomenon and management within the perspective of the 
culture a person is dealing with . 
2.3.1 Mental illness explained within the AIKS 
The topic of mental illness within the AIKS has not been broadly investigated. However, 
Shankar et al. (2006:221), Teuton et al. (2007:1260) and Ovuga (1999:276) assert that the 
concept mental illness is defined within the frame of reference of the person requested to define 
it. In conjunction with a personal frame of reference, conceptualisation of the concepts with 
regards to what constitutes mental illness is also based on the cultural system of beliefs of a 
specific group of people (Kabir et al. , 2004:2; Hund, 2003:33). 
All studies consulted pointed out that the recognition of a condition such as mental illness was 
based on the observation of the behaviour of the person who is deemed "mentally ill" (Kabir et 
al., 2004:4; Shankar et al. , 2006:225; Sorsdahl et al., 2010:286). Within the AIKS, symptoms of 
mental illness furthermore include eccentric behaviour, wandering aimlessly and talkative 
behaviour (Kabir et al. , 2004:3). 
Possible causes of mental illness include supernatural causes, witchcraft, breaking of taboos, 
especially in cases where a disease is of a chronic nature as pointed out by Tjale and De 
Villiers (2004:147-149). Joyce (2003:48) also informs that any illness that cannot be diagnosed 
and healed within the western knowledge based system is deemed to be a "calling from the 
ancestors". The cause of mental illness due to intervention by a traditional healer is mentioned 
by Holland (2001 : 13), wherein the author indicates that he traditional healer reportedly 
possesses the power to inflict mental illness on an individual. This sheds light on an 
understanding of mental illness and illness per se as attributable to factors external to the 
person as cited by Baumann (2007:44) . A study in a village in Nigeria , however, had 
respondents identifying alcohol and street drugs included as potential causes of mental illness 
(Kabir et al. , 2004:3). This finding was corroborated in a study by Abbe (2011 }, where alcohol 
was specifically linked to the presence of mania. Hence the statement can be made that mental 
illness within AIKS is not a natural occurrence, but is rather caused by some sort of interference 
(Janse van Rensburg, 2009:159). 
Directly in contrast with the African world view is the perception of the WBKS, where reportedly 
Africans are labelled as having an external locus of control because they are deemed to be 
unwilling to accept responsibility for their own misfortune (Abbo, 2011). 
The supernatural origin of mental illness is also cited by Sankar et al. (2006:225), who identified 
the Indian term "saivinal' which translates to black magic, as a cause of mental illness in Indian 
people. The term "saivinal' also relates to possession by dead people in the Indian folklore 
(Sankar et al. , 2006:255), or a "Jihn" in Swahili folklore (Beckerleg, 1993:310). Ensink and 
Robertson (1999:24) quote Farrand (1984) who notes that indigenous people will rely on the 
treatment of indigenous healers if they experience the cause of an illness to be due to 
bewitchment or other supernatural causes. 
In elaboration of the supernatural causes of mental illness, the isiZulu culture believes that 
witches or "Abathakathl' are responsible and that bewitchment is done my means of "throwing" 
illness. Such symptoms of the "throwing of illness" are mental disturbances (Crawford & 
Lipsedge, 2004:133-134). Witches in the Zulu culture are considered to be men because men 
are physically stronger than women. However, not all mental disturbances are referred to as 
bewitchment. Crawford and Lipsedge (2004: 136) explain that if a person is called to become a 
diviner, he or she will be psychologically affected through a condition known as "Ukuhlanya". 
This condition is reportedly brought on by the Ancestors calling a person to become a diviner. 
Similarly, in the isiXhosa culture a person who receives the calling to become a diviner 
"ukutwasa" may show symptoms of psychiatric illness (Ensink & Robertson , 1999; Ensink & 
Robertson, 1999:26). 
Additionally, Mzimkulu and Simbayi (2006:418) identify spirits called "ngozl' as the causative 
factor in psychotic illness; these spirits are the spirits of a person(s) who was killed by the 
patient or his Ancestors. 
Even though the role of the ancestors in the Zulu culture is to watch over the people and their 
well-being , the ancestors will withdraw themselves if a person has displeased them. The Zulu 
culture believes that unseen spirits reside in all people and when the ancestors are displeased 
with a person, other people may use these spirits against the person in whom they reside. 
Witches have secret knowledge to use these spirits (Hund, 2003:64). Innocent acts such as 
stepping over dangerous tracks as laid down by witches or potentially being poisoned with soil 
and ants from graves can cause mental illness in a person. Furthermore, a witch can send evil 
in the form of the "Lightning bird", "tokoloshe" or a "river snake" to an unsuspecting person, who 
will then fall ill with a mental illness (Ensink & Robertson, 1999:34). 
Within the AIKS the indigenous healer can differentiate between mental illness and what is 
deemed to be a calling to become a diviner. This is done by examining the symptoms which the 
client presents to the diviner. Mental illness is seemingly more severe and the symptoms would 
interfere with the normal functioning of the client. The symptoms will include erratic and bizarre 
behaviour, which would include a deficit in self-care which is absent in the event of II twaza" or a 
calling to become a Diviner (Mzimkulu et al., 2006:424). 
The ancestors, as reported by Holland (2001: 186), can bring about illness and even death. 
However, this is done to induce good behaviour and therefore it is seen as some social 
regulator, and the ancestors evidently have a parental role in society. 
Regardless of the cause and perception of mental illness, the phenomenon is well described in 
both perspectives (the WBKS perspective will be discussed in section 2.3.3). There are, 
however, different opinions as to whether the WBKS's management of mental illness is 
culturally appropriate, hence the appeal to negotiate with indigenous healers to form a more 
culturally grounded understanding of the patient's problem. This is because a problem might not 
be understood by the Westernised knowledge system in the same way as done by traditional 
practitioners (Yen & Wilbraham, 2003a:544-545). I NWU I 
2.3.2 Treatment of mental illness within AIKS LIBRARY_! 
Several authors touched on the topic of how mental illness is treated in the different AIKS . A 
commonality is that the treatment is directly related to what is considered to be the etiology of 
the disease (Mzimkulu et al. , 2004:425; Sankar et al. , 2006:230). 
The indigenous healers rely on guidance by Ancestors to treat mental illness. Such treatments 
attempt to correct imbalances or appease the Ancestors where taboos have been broken. The 
treatment consists of holistic care to both the client and the family, whereby a person is 
cleansed through the administration of herbs that will induce vomiting . Combined with this, the 
indigenous healers will perform rituals such as singing and dancing at the client's home to 
exorcise evil spirits. Mzimkulu et al., (2006:246) note that the rituals are often accompanied by 
the consumption of alcohol and slaughtering of a goat. Additionally, the healer or his wife would 
bath the afflicted person in 11 muti'' as the final step in the cleansing ritual. One of the drugs used 
in the treatment of psychosis was identified by Prince 1960 to be Rauwolfia vomitoria as cited in 
Abba (2011 .). The Collins Paperback English Dictionary (2004: 1075) defines II mutl' to be 11a 
form of informal South African medicine, usually herbal." The word is derived from the isiZulu 
word 11 umuthi," which means tree. Herbs are used by means of ingestion, sniffing, smoking, 
steam inhalations or enemas (Mzimkulu & Simbayib, 2006:425). 
Within the AIKS, it is not uncommon to find practitioners who specialise in certain illnesses. 
Some healers tend to specialise in the management of mental confusion which includes specific 
symptoms such as unprovoked aggression, repeated running away from home and inexplicable 
behaviour. This specialisation stems from previous success in the same types of behaviour 
(Crawford & Lipsedge, 2004: 138). In the Southern Sotho culture, the "Lethue/a" who is usually a 
female, specialises in the treatment of mental illness (Hund, 2003:79). 
At a conference of the World Council for Psychotherapy, Berg (2003: 195) refers to a statement 
by Madu, Baguma and Pritz (1999) wherein the authors refer to the positive effect that rituals 
have on the mental health of individuals. Rituals reportedly allow the individual to re-establish 
links with the Ancestors because disconnectedness adds to suffering in the individual (Berg, 
2003:202). Berg (2003:202) continues to inform that because of family participation in rituals, 
the link between the patient and family will necessarily also be re-established. This emphasises 
the importance of spirituality to the African person. 
AIKS practices that revolve around religious themes also consider mental illness to be a form of 
spirit or demonic possession and suggest that such illness could be treated by spiritual methods 
(Edwards et al. , 1983:215; Crawford & Lipsedge, 2004:139; Sankar 2006:230) as is evident in 
the following examples. 
The Southern Sotho "Lethuela" uses hypnosis and exorcism to treat mental illness. Similarly, 
the Tsonga people believe in magic. In the event of mental illness against the background of a 
long term illness, they feel it is due to "baloyi," a form of bewitchment. The Northern Sotho 
culture uses the services of a "Se/oadl' who is a gender blind person - neither male nor female. 
This "Se/oadl' takes on the role of "Ngaka," who acts as a spiritual medium and healer. The 
Swazi culture makes use of a "Sangom;i' who could be either male or female to diagnose 
illness and use the "Nyanga" who makes homemade medicine to treat mental illness (Joyce, 
2009:79, 89, 99, 108). Most of the Ngu tribes, as found in South Africa, believe in the 
involvement of bewitchment in the phenomenon of mental illness (Joyce, 2009:13). The 
existence of possession by demons is also supported in the Holy Bible where it is reported that 
Jesus cast out many evil spirits (Bible, 1984). Various subcultures within Westernised cultures 
include groups of people who believe in the existence of demonic possession as cause of 
mental illness, as Pfeifer (1994:247) notes. Demonic possession is usually treated by means of 
exorcism; this treatment is a common practice in the Roman Catholic- and Charismatic 
churches (Pfeifer, 1994:247). Notably, researchers warn against the potential damage caused 
by performing exorcisms where a patient has formally been diagnosed with a psychiatric illness. 
Allen (s.a.), Crawford and Lipsedge (2004:139) and Khatab and Mousel (1998:99) reported 
incidents where people died during the performance of exorcisms. 
The rites that are performed during an exorcism involve prayers, commands, fumigation, 
burning of herbs and sprinkling of holy water (Bancroft, 1998; Sankar et al., 2006:230). 
Exorcisms and their effect are medicalised by authors, who compare them to certain 
psychological interventions such as "abreaction" therapy. During this therapy, the allegedly 
possessed person is excited into an emotional frenzy during which he displays an exaggerated 
state of the emotions he is suffering from, such as exaggerated anger and fear. During this 
intense display and emotional effort, the possessed person becomes so tired that he collapses 
from mere exertion. After the collapse, the person feels relief and calm and is often left with a 
feeling that he is relieved from the demon that possessed him (Bancroft, 1988). 
Belief in possession does not only exist in the AIKS associated with African cultures. It also 
stems from faiths such as Christianity, Judaism, Hinduism and Voodoo-ism (Bancroft, 1998). As 
much as some people believe in the existence of demonic possession, the researcher (during 
her career as a psychiatric nurse practitioner) has experienced that staff in general share the 
sentiments of authors such as Henderson (1982: 129) who strongly indicates that there is no 
such thing as spirit or demonic possession, but that the sufferer is merely "possessed" by intra-
psychic conflicts from earlier life. 
Contrary with beliefs such as disregarding the existence of demonic possession, therapists 
within WBKS do acknowledge the existence of Satan worshipping and the negative effect these 
practices will have on the mental health care user and mental health care provider (Wheeler et 
a/. , 1988: 549). In elaboration, Wheeler et al. (1988:549) advise that Satanism thrives on fear 
and therefore when dealing with a mental health care user involved in Satanism, the mental 
health care provider should not display any signs of fear. Wheeler et al. (1988:549) further 
explain that it is usually rebellious adolescents who get involved in Satanism and display 
magico-religious thinking. They resist any form of authority and will therefore necessarily display 
difficulty in establishing rapport with the mental health care provider. 
Faith healers who "cure" through prayer and the laying on of hands have received such special 
powers through a higher "power'' by means of divine intervention (Barret, s.a.). Faith healers are 
included in the category of indigenous healers. They occasionally practice exorcism if they 
deem illness to be due to a form of possession (Naidoo, 1985:3). 
In AIKS, if mental illness is not due to bewitchment, the sangoma will use the hallucination and 
delusion of the patient to move him towards sanity. The sangoma will play along with the 
hallucination and will interact with the hallucination and chase it away or command it to leave 
until such time as the patient reports that the hallucination is gone (Hund,2003: 156). In the 
event of phobias, the person will be invited to a sacrificial rite and the skin of the animal that is 
sacrificed will be shaped into a pillow. The patient will be requested to lie face down on the 
pillow and he will be held down in this position by strong men. The sangoma will then place the 
object of the phobia on the patient's back. The patient in this position will have difficulty in 
breathing and will , in order to prevent suffocation , give in to the presence of the object of his 
phobia in order to be able to breathe normally. This succumbing and acceptance of the object of 
the phobia is deemed to be a cure of the phobia , according to Hund (2003:157). 
Further to the treatment of mental illness through different indigenous healers , families within 
AIKS reported that they would willingly look after their family members who suffer from mental 
illness (Ohaeri & Fido, 2001 :494). This is confirmed by Paul and Pienaar (2013:38) . The 
researcher assumes that this is an attempt to keep mentally ill persons as part of the family unit 
and the community. 
2.3.3 Mental Illness explained within the WBKS. 
"Pains of the mind can only be cured by the mind. " Victor Hugo Francisco Makumbuy, 
as quoted by Dr Peter Becker (Becker, 1974:114) 
Mental illness has been surrounded with mysticism in all cultures. 
During the middle ages, there was a general belief that mental illness was due to demonic 
possession (Robertson et al., 2001 :1). The era of the Modern Scientific psychiatry started 
during the French Revolution under the guidance of Phillipe Pinel who started with empirical 
observation and recording of cases (Robertson et al., 2001 :3). This revolution caused a shift in 
the perception of Westerners, who began to appreciate that there is more to Mental Illness than 
demonic possession. Mental illness is now defined as maladaptive behavioral patterns that 
interfere with a person's ability to function normally in relationships, in his/her occupation and it 
causes the person discomfort (Baumann, 2007:561 ). The Mental Health Care Act (17 of 2002) 
further defines mental illness to be "a positive diagnosis of a mental health related illness in 
terms of accepted diagnostic criteria made by a mental health practitioner authorised to make 
such a diagnosis." (South Africa, 2002). 
Mental illness is further explained through a plethora of signs and symptoms as depicted in the 
Diagnostic and Statistical Manual IV (DSM IV) established through research (Robertson et al., 
2001 :9). The DSM IV, recently upgraded and adapted to the 5th edition (DSM-5), allows for 
reliable diagnosis and is very objective in establishing differential diagnoses. There are definite 
medical , genetic, social and psychological causes for mental illness, and the phenomenon is 
explained from a bio-psycho-social model, with the emphasis based on an allopathic point of 
departure (Robertson et al. , 2001 : 16). 
Allopathic medicine is defined to be the "system of medical practice which treats disease by the 
use of remedies which produce effects different from those produced by the disease under 
treatment. Medical doctors practice allopathic medicine." (Medical Glossary, 2005). The term 
allopathy was coined by C.F.S. Hahnemann in 1842, where he determined that allopathic 
medicine treats disease with drugs that will result in producing the same symptoms as one 
would expect in a healthy individual. 
The researcher noted through literature that regardless of the scientific knowledge whereby a 
diagnosis and etiology of psychiatric illness is made within the WBKS, and the evidence that 
there are definite physiological causes for such mental illness which creates an empathetic 
understanding of mental illness, severe prejudice still exists even in the health care fraternity. 
This prejudice towards mentally ill persons from members of the health care fraternity is 
demonstrated in studies such as those undertaken by Ogunsemi , Odusan and Olatawura 
(2008: 150), wherein it is reported that the medical students who took part in the survey would 
not want psychiatrically ill persons to stay next to them, nor would they want a family member to 
marry them. The view of Ogunsemi et al. (2008: 150) is shared by Ewhirudjakpor (2009:22) who 
identified that medical practitioners, regardless of their medical background, still had deep-
seated beliefs about mental illness that are contrary to scientific knowledge. Contrary to 
scientifically-based knowledge, it was identified in a study that some health care providers 
identified curses and witchcraft to be a cause of mental illness (Ewhirudjakpor, 2009:22). 
The researcher has observed that some practitioners within the WBKS notoriously frown upon 
perceptions of religious healers, believing that hallucinations and the "hearing of voices" might 
be caused by demonic possession and factors other than the allopathic theories on the cause of 
conditions such as schizophrenia. Statements such as these mentioned above are often 
ridiculed and made out to be "old wives tales". This experience of the researcher is echoed 
through the quotation of Rose (1997) in Barret (s.a.) : "After nearly twenty years of work, I have 
yet to find one 'miracle cure' ; and without that (or, alternatively, massive statistics which others 
must provide) I cannot be convinced of the efficacy of what is commonly termed faith healing". 
This type of prejudice within the medical fraternity might prevent referral to indigenous healers 
as part of the multi-disciplinary team, regardless of the belief system of the client. 
Notably, the majority of health care providers are quite intolerant to the belief in spiritual healing 
and as reported by Barret (s.a.), a medical doctor claims that numerous scientists have "de-
bunked" allegations of spiritual healing. Allegations such as this are made out to be an illusion 
of Christian Science, whereby illness stems from faulty beliefs and that prayer works through 
replacing faulty beliefs or "bad thoughts with good ones" Barret (s.a.). These beliefs still 
influence the way in which mental illness is treated. 
2.3.4 Treatment of mental illness within the WBKS/Allopathic view 
Regardless of the statistics claiming that four fifths of the world population reside in non-
Western countries, the reality is that psychiatric resources are mainly localised in industrial 
societies, making psychiatric services mainly part of WBKS ( Andrews & Boyle, 2003:277). 
Allopathic treatment of mental illness commences with a diagnosis of the illness by means of 
Mental Status Examination, where all the signs and symptoms of the illness are confirmed. This 
Mental Status Examination includes a detailed history taking and corroboration or verification of 
information given by the patient with a family member (Robertson et al., 2001 :39-50). 
Psychotropics or allopathic medicine were first discovered during the early 1950's (Robertson et 
al. , 2001 :417). Prior to the administration of these psychotropics, patients often had to undergo 
cruel treatments such as lobotomies, leucotomies, and electro convulsive therapy, without the 
comfort of anaesthesia and occasionally, insulin comas were also induced (Robertson et al., 
2001 :445-446). 
Hospitalisation has since moved away from custodial care to the implementation of community 
mental health centres where community health groups have also been established. The aim of 
mental health has moved from hospitalisation in specialist hospitals to a more community-based 
service (Robertson et al. , 2001 :418). However, the mentally ill person is still contained in a 
hospital setting , depending on the degree of distress the person suffers . Yen and Wilbraham 
(2003a:554) report that this containment is not to remove a person from society but to provide a 
safe area for the patient, where they will feel secure. The researcher doubts whether this will be 
the case in the event of incarceration, especially if the care givers do not understand the 
patient's world view and belief system, and do not share the sentiment of the patient with 
regards to his/her perceived cause of the illness. Yen and Wilbraham (2003a:555) confirm this 
suspicion of the researcher in stating that the patient being nursed by predominantly "white" 
English speaking practitioners will add to a difficulty in the different parties' understanding of 
one-another, resulting in an escalation of the level of distress the patient experiences. 
Such an example of increased levels of distress is observed in mental health institutions where 
health care users are not allowed to keep any personal possessions with them. The Zulu people 
customarily wear bangles made from goat skin after sacrificial rituals. Uys and Middleton 
(2013: 135) assert that these bangles remind the person wearing them of the bond between 
them and the ancestors, providing an assurance of recovery from illness. 
When the mental health care provider lacks an understanding of such connotations and forcibly 
remove such bangles, this raises the anxiety level in the mental health care user because the 
mental health care user perceives this as a taboo. This is how ignorance becomes 
counterproductive in a therapeutic relationship between the mental health care user and the 
mental health care provider. 
Robertson et al. (2001 :425,426) advocate for the development of a culturally competent system 
of care that will provide care to all cultures. Unfortunately, this support does not obscure the fact 
that allopathic health care providers are not always in support of the inclusion of indigenous 
healers as part of the team. An area that needs special attention is how the aggression 
associated with mental illness is dealt with . 
2.4 AGGRESSION ASSOCIATED WITH MENTAL ILLNESS 
The phenomenon of aggression in psychiatry has been well researched and documented by 
several researchers (Needham, 2004:2; Lewis-Lanza et al., 2006:71 ; Chen, Hwu & Williams 
2005:71 ). The researcher noted that several authors use the word violence and aggression 
interchangeably, an opinion also reflected in the work of Irwin (2006:309) and Lucas and 
Stevenson (2006: 195). 
The Collins English Paperback Dictionary (2004:31) defines aggression as "an attack or harmful 
action , or any offensive activity that stems from a hostile or obstructive mental attitude". More 
clarification, however, lies in the following definition declaring aggression to be "a desire to 
produce fear or flight in others" Penguin Dictionary of Psychology (1995: 18). Most authors 
agree that aggression is used as a term to depict acts such as threats, the use of profanities or 
raising the tone and volume of voice to others, without resorting to a behavioral action where 
there is an intention to do physical harm to a person or the property of anoth_er person (Uys & 
Middleton, 2013:255; Mason & Chandley, 1999:6). 
Noteworthy is Owen et al. (1998:1458) who pointed out that a person using aggression might do 
this in order to act as a warning that violence might follow on aggression if not managed 
correctly. Aggression comes in different forms which range between different extremes from 
verbal aggression through physical aggression. Mason and Chandley (1999:60) indicate that 
the louder the person's voice becomes, the higher the potential for violence. Verbal aggression 
can therefore be seen as a warning of imminent violence. Verbal aggression should not be seen 
as harmless as llkiw-Lavelle and Grenyer (2003:90) pointed out, considering that constant 
exposure to verbal aggression and the emotional effect suffered can equate to one episode of 
physical violence. 
Aggression is not only observed in institutions where mentally ill persons are cared for. It is a 
social phenomenon that affects all aspects of society and it is transferred to institutions through 
MHCU who reflect the values of society (Levin, Hewitt & Misner, 1998:249). 
2.4.1 The view of aggression associated with mental illness from a WBKS 
perspective 
Aggression and violence in hospitals and the psychiatric milieu is deemed to be the norm, as 
opposed to a rare occurrence. This statement has been proven by numerous authors (James, 
Isa & Oud, 2011 :130; Oostrom & Van Mierlo, 2008:320; Needham, 2004:2; Chen et. al. , 
2005: 141 ). Nurses are the backbone of any health institution, due to the much higher ratio of 
nurses per patient compared to the ratio of other health care practitioners. Due to the number of 
nurses per patient and the nature of the job description, namely direct health care to the health 
care user, nurses will definitely be more exposed to mental health care user-related violence 
when compared to the other categories of health care providers (Aquilina, 1991 :200; Binder & 
McNiel, 1994:545; Carmel & McNiel, 1989:46; Bj0rkly, 1999:62; Hahn, Needham, Abderhalden, 
Duxbury & Halfens, 2006: 197). During a previous study where the researcher determined the 
attitudes of mental health care practitioners towards the management of aggression and 
violence, the findings corresponded with the report by James et al. (2011: 133), namely that the 
nurses view aggression as negative (Bock, 2010:99) this necessitates empowering the nurse to 
deal with management of aggression and violence. 
The incidences of mental health care user-related violence have necessitated numerous 
research projects, hence the phenomenon of aggression in persons with recognised mental 
illness has been well researched and documented by different researchers. 
This has allowed mental health care providers, of whom the nurse forms an integral part, to 
make certain predictions with regards to the clientele more likely prone to aggression and 
violence. Koen (2003:254) proved a link between substance abuse and violence in male mental 
healthcare users with schizophrenia, as supported by similar findings by Milton et al. 
(2001 :439). Similarly it is common course that aggression is related to other mental illnesses 
such as psychosis and manic episodes. 
The nurse has a vital role to play in the management of aggression and violence and Irwin 
(2006:311) advises that the nurses are the "most significant variable in all prevention 
strategies". Risk assessments used to predict the potential for violence in the patient might 
hamper the nurse-patient relationship, where the nurses who perceive the patient as a potential 
threat might be influenced against the patient and this in turn may complicate treatment, 
management strategies, and the quality of care. This creates a juxtaposition where behaviour 
that must be countered is actually caused. 
Through numerous studies, it is evident that the factors that precipitate and contribute to 
aggression include confined areas, overcrowding, high temperatures, low staffing levels, 
seclusion and the use of restraints (Soliman & Reza, 2001 :77-79; Duxbury, 2002:331-333; 
Duxbury & Whittington, 2005:470; lgnelzi, Stinson, Raia, Osinowo, Ostrowski & Schwirian, 
2007:453; Geen & Donnerstein 1998:Loc1987) . Sublette and Trappler (2000:132) reported in a 
study with Jewish patients that not allowing practices within the Judaism, such as reading the 
Tanakh and Talmud and performing ritual prayers, increased the anxiety of the patient, and as 
known; raised anxiety levels may contribute to the incidence of aggression. Through a blanket 
application of ward rules such as withholding religious material from a person who is deemed 
"religiose" (Penguin Dictionary of Psychology, 1995:659), the AIKS of the specific patient is 
ignored and, therefore, the relationship between the practitioner and the patient becomes non-
therapeutic. In addition to this reality, the existence of counter transference is also reported, 
where therapists and health care providers attempt to "enlighten" patients to different religious 
views (Sublette & Trappler, 2000: 130). The above mentioned attitudes from staff and 
authoritarian interaction styles, refusing requests and unreasonable demands, are examples 
that not only allude to ignoring the knowledge system of a mental health care user but also 
typical examples of causes of aggression in mental health care facilities (Lucas & Stevenson, 
2006:199). 
Shockingly, the opposite has been reported where the nursing staff is implicated to be the 
aggressor as opposed to being the care giver to the person suffering from a mental illness. 
(Lucas & Stevenson, 2005:197). The extent of aggression patients suffered, as proven in a 
study by Lucas and Stevenson (2005) , varied from verbal abuse, physical assault to reported 
sexual abuse. 
Knowledge of the nature of aggression and strategies implemented thus far have not 
succeeded in preventing aggression . The researcher will elaborate in the next section on the 
management of aggression in the WBKS and how it exacerbates an already complicated 
problem. 
2.4. 1. 1 Management of mental illness related aggression and violence within the 
Western-based scientific knowledgelbio-medical system 
In South Africa, the Mental Health Care Act (17 of 2002) makes allowance for a person who is 
mentally ill and a danger to himself, other persons or their property, to be admitted to a hospital 
for observation. Furthermore, if the person resists treatment and is not prepared to undergo any 
form of treatment, the same act informs practitioners that such a person can be forced to 
undergo treatment as an involuntary person. This implies that the person deemed a danger to 
himself or others can be admitted to an institution against his wishes (South Africa, 2002). 
Therefore aggression in a person suffering from a mental illness is considered seriously, where 
intervention must be implemented. In addition , sanctions such as the use of seclusion, 
involuntary hospitalisation and closed-ward systems are imposed on the patients in any event of 
aggression , as experienced by the researcher. It is clearly noted that numerous studies were 
conducted with regards to the management of aggression and violence and a commonality 
amongst the findings was that if a person was deemed a threat to him/herself or the safety of 
others, such behaviour is managed through single seclusion, prescribing medicine or increasing 
the dosage and even the use of restraints (Canatsey, Bermudez & Roper, 1994: 13; Fisher 
1994: 1589; Duxbury, 2002:325). 
Methods such as seclusion and the use of restraints are seen as the "trad itional methods" 
whereby aggression is managed. These "traditional methods" are deemed to do more harm 
than good, and they have been implicated to exacerbate the problem of aggression, as opposed 
to effectively managing it (Duxbury, 2002:325; Canatsey, Bermudez & Roper, 1994:13; llkiw-
Lavelle & Grenyer, 2003:392; Fisher, 1994:1589). Hahn et al. (2006:198) partially agrees with 
this statement but continues to refer to a study by Duxbury (1999), wherein it is evident that 
nurses treat aggression by means of the biomedical model which indicates an exclusion of 
AIKS. 
Opposed to the European countries that use restraints as part of managing violent and 
aggressive MHCU's, the South African hospitals do not use restraints to manage aggression in 
the majority of mental health care institutions. In mental health care, as reported in section 2.4.1 
of this study, the management of aggression and violence is primarily the function of the nurse, 
due to the nature of her job description and scope of practice. In view of this statement, it is 
therefore within the scope of the nurse to perform risk assessments for the propensity of 
aggression, as well as to receive the patient on admission, perform assessments and ensure 
that the environment in the ward is safe. The nurse must also observe for signs of aggression 
and implement the necessary interventions to curb such problems (Mc Hugh & Wain, 1995:23). 
Adding to complications in the management of aggression, Bock (2010:101) identified a 
difference amongst staff as to what constitutes aggression. It was identified that the methods 
and application of techniques to deal with aggression is not applied consistently, thus causing 
confusion in patients with a resultant increase in dissatisfaction with regards to treatment 
regimes. This situation perpetuates a perception that some staff members are more lenient with 
regards to the application of ward rules and implementation of methods to deal with aggression 
and violence such as the use of seclusion, than others. This will necessarily add to an already 
complicated treatment regime. 
2.4.2 AIKS view of aggression associated with mental illness 
Aggression was cited to be the most common feature associated with mental illness in a study 
performed by Kabir et al. (2004:3). Several authors are in agreement that extreme forms of 
behaviour such as violence might be indicative of an underlying mental illness (Shankar et al., 
2006:231 , Ewhirudjakpor 2009: 24; Sorsdahl et al. , 2010:286). 
Additionally, aggression has been cited as a symptom of a mental illness and might be due to 
disconnectedness with ancestral spirits (Degonada & Scheidegger, 2009). This aggression in 
mental illness has also been identified as associated with " twaza" or a calling to become a 
traditional healer, until such time as the person accepts the calling, the aggression, social 
isolation and bizarre behaviour will persist, according to Atindanbila and Thompson (2011 :458). 
2.4.2. 1 Management of mental illness related aggression and violence within the 
A/KS 
A survey amongst indigenous healers in Mpumalanga revealed that some of the indigenous 
healers managed aggression associated with mental illness by physical means, such as tying 
the person up with ropes and occasionally chains, to prevent harm or injury to others (Sorsdahl 
et al., 2010:286). 
The pharmacological management of aggression revolved around the use of "mutl'. This "muti,'' 
that is the combination of different herbs and some unknown substances (sometimes even 
human flesh as noted in section 2.2.6), can be administered to the patient via different routes 
and applications such as sniffing, drinking, inhalation of vapours when burned, topical 
application in incisions made by the indigenous healer and baths with "mutl' in it. The 
administration of "mutl' is only one part of the treatment regimen and it is further followed up 
with rituals to complete the healing process (Degonada & Scheidegger, 2009; Okpako 
1999:482). 
In addition to the treatment, the afflicted person is also encouraged to stay in the home of the 
traditional healer where the traditional healer would ensure compliance with the prescribed 
treatment. This practice is done because due to the nature of the relationship between the 
healer and the client and due to the smaller communities within the AIKS in the rural areas, the 
mentally ill person and the healer are often known to one-another (Sankar et al., 2006:226). 
Noteworthy at this stage, is that during the sixth century within WBKS, when the belief in 
demonic possession of the mentally ill was rife, the mentally ill were cared for in monasteries 
operated by the church. Later, during the twelfth century, mentally ill persons were cared for in 
the houses of very religious people, all in an attempt to include them in family life (Koenig & 
Larson 2001 :68). This observation leads the researcher to note some similarities between AIKS 
and WBKS, which will be elaborated on in the conclusion of this chapter. 
In continuation, the theoretical assumptions that Traditional African Medicine (TAM) 
practitioners make about the origins of an illness are consistent with their methods of treatment 
of the illness (Okpako 1999:482), therefore: 
The treatment of severe mental illness with associated aggression within the AIKS is very 
difficult and complicated and the treatment is almost coercive and occasionally so severe that it 
has led to injury of the patients (Ensink et al., 1999:25). 
Clients who are very aggressive are often tied down, beaten into submission and some have 
even been the victims of sexual assaults in order to contain them. The severe treatment stems 
from reports that these violent clients are a severe challenge to both the family and the 
indigenous healer (Mdluli & Msomi 1989:15). 
Contrary to the ensuing thought, not all aggressive clients are abused by indigenous healers, as 
some healers reportedly calm the client down by talking to them and burning herbs that relax 
and calm the client (Mzimkulu et al. , 2006:425). During a lekgotla negotiated and held in 
Lesotho during November 2012, and attended by the researcher, the indigenous healers from 
the district reported the existence of aggression as associated with mental illness. However, the 
most effective way in dealing with this aggression, as reported by the indigenous healers was 
to: 
• Immediately untie a person, if the person is brought to them tied up by the family. 
• Talk to the person in a neutral and calm way. 
• Attempt to understand the cause of the aggression. 
2.5 CULTURAL SAFETY AND CULTURAL SENSITIVITY 
As a psychiatric nurse, the researcher witnessed the forced removal of "medicine against evil" 
from an Indian lady admitted at an acute psychiatric unit. The health care user carried a small 
pouch attached to a string around her neck, and because the staff and ward rules do not allow 
any mental health care user to wear any ornate decorations in the ward, she was asked to 
surrender the item for safe keeping. The client resisted and attempted to explain that she is 
wearing it for protection. The staff did not acknowledge this explanation and continued to 
remove the pouch forcefully. The client reacted aggressively in an attempt to keep this pouch 
with her. The mental health care user was eventually sedated and placed in seclusion because 
of "aggressive behaviour". Retrospectively, after a study of the literature, the researcher is 
horrified by her own ignorance at the time of the above incident. A question that the researcher 
poses to herself is, "What harm could have come from allowing this particular patient to keep 
this small pouch in her possession? 
Furthermore, would it have been possible to keep this pouch on a shorter string around the arm 
as opposed to a longer one around the neck which poses a danger to commit suicide through 
hanging? This potential action would have fitted in with Leininger's theory of cultural care as it 
would have been the concept of culture care accommodation, catering for negotiation in action 
(Leininger, 1991 :42; and Tjale and De Villiers, 2004:23) . . 
Did the forceful removal cause the patient more emotional damage? 
The pioneer of cultural safety in New Zealand , lrihapeti Ramsden, is quoted by Fulcher 
(2002:690) and she answers this question by stating that if the cultural needs of a person are 
not met, it causes emotional damage, which is seen as culturally unsafe practice. 
Fulcher (2002:702) echoes Ramsden 's call for cultural safety and concurs that it is important to 
know how connected a person is to his/her cultural traditions in order for care givers to provide 
culturally safe care, as " ... cultural safety gives meaning to the aspects of caring" (Fulcher, 
2002:701 ). This cultural safety theory of Ramsden fits in very well with the cultural care theory 
of Leininger, and allows for the care provider to "come into the health care/cl ient relationship 
"recogn ising themselves as bearers of their own culture and to understand how that culture 
impacts on other people ( Ramsden & Spoonley, 1994:164) and (Richardson, 2010:1) . 
. Andrews and Boyle (2003:6) explain Leininger's Sunrise model and shed light on what the 
Westernised worldview should strive towards, namely to preserve, accommodate and repattern 
the care given so that it will become culturally congruent. Keep all the good practices and 
reshape the potentially dangerous practices. Would the staff involved in the incident in the 
example above have had enough information on different cultures and what are safe practices, 
then the whole situation would most probably have been dealt with differently? 
The example above also serves to prove that the staff involved reasoned from a WBKS 
perspective and ignored the IKS of the client involved. 
In further elaboration, Leininger (1967:33) warns that ignoring cultural differences seriously 
interferes with the nurse's ability to help the patient. What the nurse might see as resistance 
from the patient can be traced to the difference in the cultural backgrounds of the nurse and the 
patient (Leininger, 1967:33) . 
The researcher is also in agreement with the findings of Koenig and Larson (2002:74) , where 
they recommend that supporting spiritual beliefs of a mental health care user ensures comfort 
for the patient and will reduce the stress they experience significantly. The authors continue to 
explain that in the event of beliefs being bizarre , it is necessary to determine if these beliefs are 
due to psychosis or part of the religious culture of the patient (Koenig & Larson 2001 :74). Even 
though the authors Koenig and Larson (2001 :74) point out that it is difficult to ascertain if the 
beliefs are valid, the researcher is of the opinion that the necessary information is obta inable 
through collecting co-lateral information from the family of the mental health care user. The 
researcher strongly feels that through researching the beliefs and customs of MHCU, one can 
truly create an accurate understanding of the MHCU and his frame of reference in order to 
provide holistic care. 
The researcher is therefore of the opinion that all nurses should become culturally sensitive and 
aware of the different backgrounds of their patients in order to render safe and congruent care 
to all health care users. 
2.6 TRAINING IN THE MANAGEMENT OF VIOLENCE AND AGGRESSION 
Breidlid (2009:142) warns that the exclusion of AIKS will hinder the development of a scientific 
understanding of a natural phenomenon, hence championing the inclusion of AIKS in education. 
The researcher is in agreement with the previous author and is of the opinion that AIKS must be 
included in training programmes that prepare health care providers in the management of 
aggression and violence. Hahn et al. (2006: 197) quoted Needham (2002), who has pointed out 
that there is a lack of systematic staff training in risk assessment and the management of 
aggression. The researcher concurs with the literature, where it is proposed that staff should 
receive training that allows for the implementation of more preventative methods such as 
communication, and de-escalation techniques (Hahn et al., 2006:198; James et al., 2011 ;133). 
Numerous strategies and policies have been implemented to assist health care providers to 
deal with patient-related aggression, such as policy CG029 in the National Health Service 
Litigation Authority (NHSLA), which formulated risk management standards as an approach to 
educate health care providers in the therapeutic management of aggression (McHugh & Wain, 
s.a.). It was initiated in East London in the United Kingdom. This policy focuses on predictors of 
violence, talk down techniques, safe restraining , de-briefing and the writing of post incident 
reports . The policy includes guidelines on talk down techniques. However, as with most policies, 
it provides general guidelines that do not include additional management strategies that 
associate with Indigenous Knowledge Systems. Instead, the guidelines focus on management 
from within a WBKS. 
The literature indicates that training programmes may bring about attitudinal changes in health 
care workers with regards to an improvement in the ability to deal with aggression and a 
decrease in anxiety levels (Patterson, Turnbull & Aitken, 1992, Collins, 1994:31 , Grube, 
2001 :307, Beech and Leather, 2006:28 and Hahn et al., 2006:198). The opposite has been 
detected in a few studies with no tacit proof of attitudinal change (Collins, 1994, Needham, 
Abderhalden, Halfens, Dassen, Haugh & Fischer, 2005; Hahn et al., 2006:200) . 
Notably, a study conducted in Scotland showed that staff felt they benefited by a training 
session that reduced anxiety and increased their confidence and physical skills to deal with 
aggression (Bell & Waclawski, 2002) . A concern that manifested after the training was that staff 
reported a significantly higher incidence of aggression and physical injuries (Bell & Waclawski, 
2002) . The researchers continue to explain this phenomenon as a possibility that staff might 
engage in more physical incidents due to their newly acquired skills . However, this is not based 
on researched evidence. 
Regardless of training programmes, the researcher is of the opinion that due to the fallible 
nature of humans, mistakes are bound to happen in terms of the talk down and de-escalation 
techniques employed. The researcher therefore implemented a training programme in the 
Western Cape, a province in South Africa, which included amongst de-escalation and talk down 
techniques also dignified break away and safe restraining techniques. The initiative behind 
dignified break away techniques is based on the finding that it is not always possible to prevent 
situations where staff will be assaulted by violent patients. Furthermore, the researcher noted 
that staff sometimes fall back on previous methods of managing aggression, forfeiting newly 
acquired skills. This leads to staff failing to de-escalate aggression, which imminently leads to 
violent behaviour on the side of the mental health care user. With the implementation of 
dignified break away techniques, the staff can break free from a violent mental health care user 
without injury to themselves or the patient. The researcher could not find any training packages 
which included cultural awareness, sensitivity and cultural safety as part of the management of 
aggression and violence during the literature search. 
2.6.1 Content of the curriculum for training packages in the management of 
aggression and violence 
The literature consulted indicates that the majority of current training packages include: 
• Definitions of aggression and violence 
• Nature and prevalence of aggression 
• Theories on aggression 
Nursing interventions such as prediction of violence, communication, breakaway techniques, 
boundary setting, post incident care, ward security and ethics of aggression 
management.(Duxbury 2002:335; Duxbury & Whittington, 2005:476; Hahn et al., 2006:203; 
James eta/., 2011:454; Bock, 2010:104). 
However, In order to provide training packages to equip health care providers with the skills to 
deal with the management of aggression and violence, the researcher is of the firm belief that it 
is imperative that the training course acknowledge cultural differences in order to render care 
that is culturally safe. The rapport between the mental health care user and mental health care 
provider will only really become fully effective if the mental health care provider has an in-depth 
understanding of the multitude of different cultural identities he or she has to deal with on a daily 
basis. Andrews et al. (2003:5) warns that cultural conflicts may emanate due to the use of 
techniques which are not always culturally acceptable. The knowledge of different cultural 
practices will therefore influence the efficacy of care rendered. Dr Madeleine Leininger identified 
similarities and differences between cultures as early as 1950 and advocated for the 
acknowledgement of the preservation of good cultural practices, acknowledgement and 
accommodation of safe practices and the re-patterning of unsafe practices. (Andrews & Boyle, 
2003:6; Tjale, 2004:21-23). 
A proposed training package should therefore contain the following components as portrayed in 
figure 2.1. The following schematic representation is proposed for use by a person when they 
manage aggression and violence. 
Figure 2.1: SIP-DD Concept map of proposed training programme for the culturally safe 
management of aggression and violence (designed by TM Bock) 
The full curriculum for the training programme can be found as annexure three of this thesis. 
The aim of the training programme (primarily designed based on the findings of the study (Bock, 
2010) wherein the researcher identified that mental health nurses could not identify the cause, 
predict aggression or perform talk down techniques) is to: 
• Sensitise the learner to cultural awareness, sensitivity and culturally safe care. 
• Make the learner aware of their own levels of cultural awareness, sensitivity and 
culturally safe care. 
• Encourage the implementation and maintenance of safe cultural practices to allow for a 
better mental health care user experience in the mental health care institution. 
• Acquaint the learner with the concepts and definition of violence and aggression. 
• Educate the learner regarding the different causes of aggression and violence. 
• Equip the learner with the knowledge on how their individual management styles will 
influence aggression and violence. 
• Increase the ability of the learner to predict aggression and violence in MHCU. 
• Enhance the ability of the learner to perform appropriate talk down techniques. 
• Equip the learner with the basic skills in dignified break away techniques. 
• Encourage the use of safe restraining techniques when talk down techniques prove 
inefficient. 
• Equip the learner with the necessary skills to deal with specialised groups such as 
adolescent, geriatric patients and the client with a neuro-developmental disorder. 
2. 7 CONCLUSION 
There are two apparently opposing views with regards to the management of aggression and 
violence. Despite some medical practitioners' intolerance of the Indigenous Knowledge 
Systems, there are many similarities with regards to the management of aggression and 
violence. 
In both AIKS and WBKS, mentally ill people in general have an unfavorable public image (Kabir 
et al. , 2004:5), and it should be noted that the cultural conception of mental illness will 
necessarily influence the way the health care user and the community perceive Western-based 
treatment (Farrand, 1984 cited by Ensink et a/.1999:24) 
The mentally-ill aggressive person is removed from the environment that influences him to be 
more aggressive. The aggressor is physically or mechanically restrained to prevent further 
injury to self or others or the property of others. This treatment happens in both the AIKS and 
WBKS. 
People are engaged on a therapeutic level, be it through psychotherapy or the use of rituals. 
They receive "pharmacological" intervention, albeit psychotropics or "muti''. Both the WBKS and 
the AIKS prescribe treatment and require compliance with treatment. Even though the 
prescriptions might differ in the two mentioned systems, there are set reg imens and both 
systems lay claims to being able to either cure or induce some type of remission where the 
health care user remains symptom free. Both systems are used to prevent further harm to self 
or others. 
At face value, it seems as though both systems appear to benefit both the patient and society. 
However, the two systems are not yet fully integrated and therefore the patient might be forced 
to use the WBKS where his cultural beliefs are not always considered. 
In addition to the above literature, it is implied that a pluralistic approach might not always be 
the best option, as Degonada and Scheidegger (2009) reported in their findings. The latter 
indicated that the outcome of treatment in some patients was worse when they had to be sent to 
a medical doctor in addition to seeing the indigenous healer. It seems as though treatment with 
an indigenous healer only provided the best results for certain patients. 
From the literature consulted , it is clear that there is a gap in courses aimed at managing 
aggression and violence. There is apparently a skills gap in terms of equipping health care 
providers with the necessary information around AIKS and the management of aggression. The 
current training courses all focus on a Westernised approach. This approach might not be 
effective in the Southern African context which is characterised by many diverse cultures. 
CHAPTER 3 
RESEARCH DESIGN AND METHODOLOGY 
3.1 INTRODUCTION 
This chapter describes the methodology followed during this study. It also elaborates on the 
aims of this study and how the researcher decided on the instruments to be employed. The 
procedures that were used during data collection, as well as sample selection and the ethical 
considerations during the research process are described. A discussion of the data analysis 
methods that were utilised concludes this chapter. 
3.2 METHODOLOGY 
3.2.1 Research approach and design 
The researcher used a mixed methodology design. This design encompasses more than a 
mere combination of qualitative and quantitative data in a single design (Davies, 2007:25; Polit 
& Beck, 2012:603). It requires integration of data at some point in the design (Andrew & 
Halcomb, 2009:3, Creswell & Plano Clark, 2011 :Loe 264; Polit & Beck, 2012:603; Creswell , 
2014: 14 ). Davies (2007: 11) cautions that a mixed method research should only be undertaken 
when a person has enough time to do this type of research. With this exploratory mixed method 
design, the researcher had two distinct phases of data collection (Creswell , 2012:226). This 
approach enabled the researcher to explore the knowledge of indigenous healers and the IKS 
used in the management of mental health care user related violence? 
The information obtained during the qualitative phase augmented the existing literature and 
guided the researcher to adapt the training programme designed during 2010 as a 
recommendation from her previous research, for the management of aggression and violence to 
include components of cultural awareness and safety, while also adapting the existing 
Management of aggression and violence attitude scale (MAVAS) to suit the situation in South 
Africa. Therefore the proposed integration of data, which is characteristic of mixed method 
research, took place during the refinement of a training programme and adaptation of the 
MAVAS questionnaire. The training programme was used during the subsequent quantitative 
phase of this research. 
This assumption of the researcher is confirmed by Polit and Beck (2012:605) who propose the 
utilisation of mixed method research especially for the purpose of instrumentation in preparation 
of a quantitative research project. 
The researcher will continue with an in-depth explanation of the processes followed during the 
subsequent qualitative and quantitative phases of this sequential exploratory research in 
sections 3.3, 3.4 and 3.5 of this research thesis. 
MIXED METHODOLOGY 
EXPLORATORY SQUENTIAL DESIGN 
Phase 1 
Qualitative interpretivist 
Phase 2 
Quantitative Post-positivist 
Figure 3.1: Schematic representation of the methodology (designed by TM Bock) 
3.2.2 Overview of the research design and methodology 
3.2.2. 1 Qualitative phase 
The qualitative phase of the research consisted of makgotla (plural for lekgotla) with indigenous 
healers. Information obtained during this phase was used to adapt the structured MAVAS 
questionnaire and refine the training programme as referred to in section 3.2.1 to include 
components of IKS. 
Lekgotla (singular) is not a very common method of collecting data; it has proven to be an 
extremely valuable method of collecting qualitative data, especially when dealing with 
knowledge within the AIKS. The makgotla has been compared with focus groups, yet this is an 
erroneous perception as the makgotla have a very distinctive method and process to be 
followed, which is very well described by Pienaar (2004:25). During makgotla the researcher 
does not take actively part in questioning Pienaar (2013:73 describes it well that during 
makgotla the researcher sits and "listen respectfully". Similarly there is a set protocol for the 
attendees of the /ekgotla to follow, the researcher observed that the elders speak first followed 
by the younger male and the females addressed the lekgotla last. All attendees could offer their 
opinion and the validation of inputs occurred after the lekgotla when the members approached 
the researcher. 
Makgotla are arranged through the chief in the community. In this instance, the chief of a 
Khoisan community and the chief of the Basotho indigenous healers were the appropriate 
persons to approach in terms of the negotiations. 
The process, as described by Pienaar (2004:25), was followed when the researcher 
approached the chief of the Khoisan community in a village in the Northern Cape, as well as the 
Chief Basotho Indigenous Healer. 
The researcher explained the purpose of the research to both chiefs during the respective 
makgotla. 
Once the makgotla was negotiated, the Chief of the particular community and the Chief of the 
indigenous healers called together the local indigenous healers. At this platform, the Head of 
the indigenous healers posed the researcher's questions to the attendees: "How do you 
manage aggression and violence in people who are mentally ill in your community?", and "How 
effective is this management of aggression and violence?" 
In the Northern Cape, the chief of the Khoisan community called the community and the 
gheiga 's together and similarly introduced the question. 
As seen in the subsequent paragraph, the nature of these questions lends itself to qualitative 
research. 
Henning, Van Rensburg and Smith (2011 :3) as well as Polit and Beck (2012:607) recommend a 
qualitative approach to investigate "how and why" a phenomenon takes place. Social reality is 
explained by Henning et al. (2011 : 13) to be an attempt at understanding from the perspective of 
the role players, hence the decision to conduct makgotla with indigenous healers in order to 
understand how they manage aggression as associated with mental illness. 
3.2.2 . 1. 1 Adaptation of the MA VAS questionnaire 
The researcher only had to make a slight semantical adaptation to the questionnaire, namely 
question 11 , the word 'physical ' was added to 'restraint' as it is not general practice in South 
Africa to restrain a person mechanically by means of cuffs and braces. The rest of the MAVAS 
questionnaire was kept as is, since it had previously proven to be well accepted by participants 
in the previous study conducted by Bock (2010) in four psychiatric hospitals in a province in 
South Africa. 
The body of knowledge gained through makgotla was used in the development of the 
conceptual model and content for the training programme, as will be elaborated on in Chapter 
(3) three. 
3.2.2.2 Quantitative phase of the research 
The quantitative phase of this research project consisted of the utilisation and application of the 
adapted MAVAS questionnaire (annexure five in this study) and the lntercultural Sensitivity 
Scale (as found in annexure six). This was all in the form of a pre- and post-test to determine 
attitudes towards the management of aggression and violence as well as culture sensitivity. 
The researcher used a pre- and post-test to determine if there were any attitudinal changes in 
the participants in this study. 
The post-test was conducted after the administration of different components of the treatment to 
different groups of participants in this research. During this quasi experimental phase, the 
researcher attempted to control variables through the administration of the questionnaires 
during different stages in the training course to the different groups. The researcher will 
elaborate on this in the following section. 
3.3 THE QUALITATIVE PHASE OF THIS RESEARCH PROJECT 
As referred to in section 2.2.2.1 the aim of the qualitative component was to augment existing 
literature, to obtain information indigenous to the community under focus in the study. 
Thereafter, this information was included in a training programme geared towards culturally safe 
management of aggression and violence as designed by the researcher. 
3.3.1 Population and sampling 
The researcher approached and interviewed Basotho Indigenous healers and a Khoisan village, 
bearing in mind that there is very little information available in terms of how the Khoisan and 
Basotho manage violence and aggression in relation to mental illness. 
In comparison, existing literature elaborates on cultures such as the Xhosa, Zulu and other 
cultures from Southern Africa through studies by Mufamadi (2001), Sorsdahl et al. (2011), 
Ukpong et al. (2011 ), Teferra and Shibre, (2012), to mention but a few. There is limited 
information available on how it is dealt with by the Basotho and the Khoisan . 
The researcher made use of purposive sampling , where the researcher sampled the population 
which would most benefit this study. The latter is described by Polit and Beck (2012:517) as 
well as Burns and Grove (2011 :313), who refer to this form of sampling as judgmental sampling. 
This selective sampling method opted for by the researcher stemmed from an in-depth literature 
review, revealing that limited knowledge is available on the IKS management of aggression and 
violence as associated with mental illness within the Basotho and Khoisan cultures. 
This insight gained justifies why the researcher made use of purposive sampling for identifying 
the participants in the qualitative phase of this research. De Vos et al. (2009:202), as well as 
Babbie and Mouton (2003: 166) explain the legitimacy of this sampling method if the researcher 
has a specific aim in mind and has knowledge of the population required for the study. 
3.3.2 Consent 
The researcher negotiated the makgotla with the Chief and informed the Chief about the value 
of the input of the Indigenous healers, considering that their input would help in adapting a 
questionnaire to suit the Southern African context. Focus was on the ultimate goal of generating 
a training programme aimed at enhancing cultural sensitivity and awareness, whilst promoting 
culturally congruent care to mentally ill persons within a specific cultural context. Without such 
negotiation, the first level of consent to collect data would have been unsuccessful. 
Consent was catered for in the following ways: Amongst the Basotho healers, after the village 
Chief was satisfied with the explanation, he called the head of the indigenous healers and 
explained the nature of the research to him. Thereafter, the head of the indigenous healers 
called upon indigenous healers in the community to a lekgotla, where the research questions 
were posed by the head of the indigenous healers to the participants in the lekgotla. In addition 
to this explanation, the researcher also provided the chief with the written ethical approval 
granted by the HREC of the North West University (NWU) - (see annexure seven). 
In the Khoisan village, the Chief called the community together in the community hall where the 
key question of the researcher was posed to the community members who took part in the 
/ekgotla. The researcher also provided the chief with a copy of the ethical clearance from NWU. 
During the makgotla with the Basotho healers and the Khoisan village, the researcher explicitly 
sought verbal permission to record the proceedings by means of a digital audio recording and, 
where appropriate, video recording. The researcher guaranteed the attendees that they need 
not offer their names and that their names will not be made known. The researcher also 
explained that the recordings will be in safe keeping and not be made public. The researcher 
explained that the recordings will be transcribed on paper. The chief asked for a copy of the 
audio recording. This was provided to the chief during the validation of the data collected. With 
the necessary consent given, the chief of the Khoisan village granted permission for video 
recording of the /ekgotla. 
3.3.3 Rigour during the qualitative phase of this research 
During the qualitative phase, the researcher strived to obtain rigour by means of validating the 
data collected (Rolfe, 2006:307).This will be further elaborated on in the following section 
3.3.3. 1 Trustworthiness/credibility, validity and confirmability 
Trustworthy/credibility 
Polit and Beck (2012:584) describe Lincoln and Guba's framework for the development of 
trustworthiness of a qualitative study, which framework includes the concepts of credibility, 
dependability, confirmability and transferability. This model suited the study undertaken by the 
researcher and the concepts were addressed in this study as follows: 
Credibility, as used in the Lincoln and Guba framework, refers to the confidence in the truth of 
the data. This alludes to carrying out a study so that the believability of the research will be 
enhanced (Polit & Beck, 2012:585). 
Trustworthiness was further established through makgotla with indigenous healers, which the 
researcher recorded and transcribed verbatim to a word document. This data also included 
narrative descriptions of the settings of the makgotla and the behaviours and body language of 
the participants as suggested by Burns and Grove (2012:94). 
The lekgotla in the Khoisan village was done in Afrikaans, a language indigenous to the area, 
and the mother tongue of the researcher. The use of this process of asking participants about 
the findings as final validation fits in with the phenomenological analysis of data described by 
Colaizzi (1978) as cited by Polit and Beck (2012:566), a model adopted by the researcher too. 
This process used will be described more comprehensively in Chapter (4) four of this thesis. 
It is worth noting, however, that the lekgotla with the Basotho healers was conducted in 
Sesotho, the language of the Basotho indigenous healers. The researcher audio-recorded the 
lekgotla with the Basotho healers. The audio recording was presented to a Mosotho colleague 
of the researcher, who holds a master's degree in nursing. He translated the recordings 
verbally, whilst the researcher typed the translation to a word document. This colleague also 
attended the lekgotla and assisted the researcher with interpretation during validation of the 
findings of the makgotla, especially with the few indigenous healers in attendance who could not 
converse in English . The transcribed documents and audio recording were subsequently 
presented to a postgrad master's degree student who is multilingual and fluent in Afrikaans, 
English and seSotho. The postgrad student in return translated the English back to seSotho, 
then the researcher and a colleague compared the documents to see if it was still an accurate 
reflection of the original content. Ultimately, the documents proved to be accurate and credible. 
The researcher additionally sat down with individual members of the /ekgotla to confirm what 
they said during the /ekgotla . This helped to confirm the data which was collected , and allowed 
for further clarification to ensure the validity of the collected data (Creswell , 2012:201 ). In 
research circles, it is also known as member checking. This member checking and back 
translation of the transcripts helped ensure the dependability of the data collected in terms of 
the Lincoln and Guba framework (Polit & Beck, 2012:585). 
The member check as described above also served the purpose of triangulation of data as 
described by Polit and Beck (2012:431) wherein they explain that returning to the population to 
validate the data serves as time triangulation , a process which they deem similar to a test and 
re-test situation in quantitative research. 
In order to add further validity to the research, the researcher provided substantial description of 
the research setting , observations made in terms of non-verbal communication and group 
dynamics during the makgotla, as can be seen in annexure one of this work. 
After the completion of the both the makgotla with the Basotho healers and the Khoisan village, 
the researcher was approached by individual indigenous healers and community members who, 
during a one-to-one informal conversation, added to what was discussed during the different 
makgotla. This approach from the indigenous healers was additional evidence of the trust 
relationship that was established during the negotiations for the lekgotla. 
Confirmability 
According to Klepper and Knobloch (2010:323), confirmability focuses on the characteristics of 
the data. The confirmability and objectivity or, as referred to by Polit and Beck (2012:722) , the 
neutrality of this data was enhanced through the researcher presenting all available raw data to 
a colleague, Dr E Van Wijk, who has a PhD in nursing. The latter is well-experienced in 
qualitative research . Dr Van Wijk participated as an independent coder. This process 
determined that the independent coder and the researcher identified the same codes and 
categories. The confirmability was further enhanced through validating the findings with the 
community where it was collected . 
Transferability 
The aim of this research was to give an informed description of how the indigenous healers 
manage aggression and violence. The researcher made sure not to transfer this information to 
another setting, but rather to include positive practices in a new training programme focused on 
managing aggression and violence in a culturally safe manner. 
3.4 QUANTITATIVE PHASE OF THIS RESEARCH 
The researcher deployed a mixed method research design with a sequential exploratory 
approach. When the research begins with a qualitative phase followed by a quantitative phase, 
it is an exploratory sequential approach (Creswell , 2014:225). During the quantitative phase, the 
researcher followed a quasi-experimental design with three experimental groups and one 
control group. 
3.4.1 Population and sampling 
The researcher made use of different levels of sampling for the different stages in the 
quantitative component of this research. 
The researcher primarily made use of purposive sampling, based on findings in the literature 
study and, thereafter, proceeded to perform randomised cluster sampling. In the latter, the 
researcher randomly selected which hospitals will fall into which experimental group. 
The population for this quantitative component of the research constituted of all categories of 
staff working in the acute admission units of mental health care institutions in South Africa. 
The researcher initially opted to exclude the Western Cape psychiatric hospitals from this study 
as the researcher previously conducted research in these four psychiatric hospitals to 
investigate the attitudes of staff towards the management of aggression and violence. After 
further investigations and numerous requests from the Provincial Government of the Western 
Cape inviting the researcher to come and present training in the rural areas in the Western 
Cape and facilities with 72-hour admission units as described by the Mental Health Care Act (17 
of 2002), the researcher and her supervisor decided to include the aforementioned facil ities in 
the Western Cape. The researcher took this action of not including the four psychiatric hospitals 
in the Western Cape in an attempt to prevent a type I and type II error in the research project, 
as she had previously conducted research there and had a roll out of a training programme 
based on findings of her previous study. In the latter, indications were that less than 20% of the 
staff in the acute admission units of the four psychiatric hospitals in the Western Cape had 
received training in the management of aggression and violence. 
Further to this, there was also a poor response from several provinces when approached for the 
necessary permission to conduct the research there. 
3.4. 1. 1 Selection of the hospitals and experimental groups to take part in the 
study 
After the researcher obtained the necessary ethical clearance from NWU to conduct the study, 
the researcher approached the Departments of Health in Gauteng, Freestate, North West 
Province, Northern Cape, and the Western Cape. Thereafter, the researcher selected all 
Psychiatric Hospitals with acute admission units in the respective provinces. Finally, the 
researcher included all the hospitals that provided the necessary permission to conduct this 
research project there. 
As previously stated, it was quite a task to obtain permission and some hospitals did not provide 
the necessary permission regardless of permission granted by the National Health Research 
Councils of the different provinces. Ultimately, the researcher secured permission in four 
different hospitals, one in each of the provinces who positively responded to the request, 
namely Gauteng, Northern Cape, North West Province and Western Cape. These provinces are 
the primary provinces where the participants who took part in the qualitative phase of this 
research come from geographically, and where the members would be referred to in the event 
of a mental Illness. The researcher thereafter continued to randomly select the different 
hospitals for allocation to the different experimental groups. This process will be described in 
the following paragraphs. 
Purposive sampling , as an example of the non-probability sampling method, is acceptable if the 
researcher is well acquainted with the particular population to be used in the research according 
to Babbie and Mouton (2003: 166), or in the event where the persons fit the criteria of what is to 
be researched, according to Henning (2004:71 ). 
The researcher, as part of the quasi-experimental design of this research, attempted 
randomisation within the non-probability sample as a second level of sampling. The researcher 
randomly selected hospitals for each of the experimental groups. The aim for this randomisation 
was to allow any of the four hospitals an equal opportunity to be selected to receive the 
treatment as described in the table. 
The researcher wrote down the names of the three mental health care institutions with acute 
admission units who granted the researcher the necessary permission to conduct her research 
there. The numbers two, three and four were also written down on papers, as were three 
different treatments decided upon to be given to the three different experimental groups. The 
Information mentioned above was written on equal size 5 cm by 5 cm papers, folded in four, 
placed in equal sized cups marked group, hospital and treatment, as can be seen in the photo 
below. 
Photo 3.1: Marked cups used to place the folded papers marked with the names of the hospitals, the 
treatment and the numbers of the experimental groups (photo by TM Bock) 
The researcher then proceeded to place all the marked papers in the appropriate cups as is 
evident in the photo below. 
Photo 3.2: Folded papers in the appropriately marked cups (photo by TM Bock) 
After the abovementioned procedure, the researcher asked a friend to select one folded piece 
of paper from each of the cups marked hospital, group and treatment and to paste the three 
selected underneath one-another on a wall. The researcher's friend proceeded until there were 
no more folded papers left in any of the cups. 
On the wall, there was now a randomly selected group with a number, hospital and treatment 
partitioning reflected through this randomised process followed. This selection can be seen in 
the picture below. 
2 3 
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fik"'"- ~ 
lftAlt ·~ iteM.-A_., 
~ft. ,aTC,MirfT 
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Photo 3.3: Randomised selection of treatment and groups (photo by TM Bock) 
Below is a representation of the randomised selection of the different experimental groups, in 
table format. 
Table 3.1: Table representing randomised selection 
Group 
1 2 3 4 
Number 
Treatment Control group/no Management of Management of Management of 
treatment .Will aggression aggression aggression 
be given the understanding understanding understanding 
literature to read aggression and aggression and theories aggression and theories 
theories on on aggression on aggression 
aggression Break away techniques Break away techniques 
Breakaway Safe restraining Safe restraining 
techniques Cultural safety Cultural safety 
Safe restraining De-escalation techniques De-escalation 
Cultural safety techniques 
De-escalation 
techniques 
Mental A psychiatric A hospital with a 72 A Psychiatric hospital in A Psychiatric hospital in 
health care hospital in the hour facility in the the Gauteng Province the North West Province 
Northern Cape rural areas of the 
institution 
Western cape 
Instrument MAVASand MAVAS and MAVAS and lntercultural MAVAS and lntercultural 
used lntercultural lntercultural Sensitivity Scale Sensitivity Scale 
Sensitivity Scale Sensitivity Scale 
Pre- and Yes, the posttest Yes the post test Yes the course Yes the course 
post-test requested via e- conducted upon interrupted after interrupted after 
mailed copies completion of the presentation of cultural presentation of cultural 
back to the whole training sensitivity, and sensitivity and the post 
researcher course Management of test conducted, 
aggression thereafter the rest of the 
understanding course was presented in 
aggression and theories full 
on aggression 
the post test conducted, 
thereafter the rest of the 
course presented in full 
The admission units of the hospitals chosen for the study and all the staff involved in the multi-
disciplinary team were all invited to voluntarily participate in the research project. The 
researcher opted to include all of the mental health care practitioners working in acute 
admission units of a particular hospital. The researcher approached the CEO's and the nurse 
managers of the different hospitals and made appointments where she would come and present 
the training course. The managers arranged for staff to come and attend the course. 
3.4.2 Inclusion and exclusion criteria 
In the event where a province did not have a mental health care institution, th is province was 
excluded from the research , such as the Southern Cape. 
The four psychiatric hospitals in the Western Cape were excluded from the study as the 
researcher previously explained. 
Additionally, any mental health care institutions without acute admission units were also 
excluded from the study. The rationale for this decision can be found in the literature which 
informs us that aggression incidents by MHCU are more rife in acute admission units as 
opposed to long term psychiatric units where MHCU are no longer in the acute phase of a 
mental illness. 
All the hospitals included in the study based on the criteria mentioned in the previous paragraph 
were included in the study for the purpose of random selection. 
From these hospitals, the appropriate sample of all the staff in the acute admission units was 
used. This included all the members of the multi-disciplinary team, who through the nature of 
their work had direct contact with MHCU. The personnel, in terms of the Mental Health Care Act 
(17 of 2002) , included all categories of nurses, psychiatrists, medical officers, cl inical assistants 
undergoing training in psychiatry, psychologists, occupational therapists and social workers. 
The researcher included the security personnel in the ward , following reports in the literature 
and by the staff in the admission units, that the security personnel assist the staff in the physical 
restraint and physical containment of the aggressive mental health care user. 
3.4.3 Rigor during the quantitative component of this research 
3.4.3. 1 Validity/legitimacy 
The MAVAS questionnaire has well been assessed as a valid instrument. 
The researcher in a study (2011) piloted the MAVAS questionnaire after having adapted 
Question 11 to suit the situation in Southern Africa. The question was rephrased to read 
"Patients who are violent are often physically restrained when administering medication ." It 
previously read, "Patients who are violent are often restrained for their own safety. " During the 
Pilot test in 2011 , it was concluded that this semantic change made no difference to the content 
and the understanding of the questionnaire. As South Africa still does not make use of restraint 
for any purpose other than administering medication, the researcher opted to use the adapted 
MAVAS questionnaire for this study also. 
The MAVAS questionnaire, having been tested by Duxbury during 2003, has proven to be both 
reliable and valid . Bock (2010:39) reported the findings of Duxbury (2003) , wherein it was 
established the after factor analysis and determination of four themes set a tan eigenvalue of 
1.8, whilst the overall factor analysis was favourable as each theme loaded at a reported 0.8 
and above. 
These values make this instrument credible. After a test-re-test situation on the same group, 
the scores were compared by means of a Pearson's r correlation coefficient , and the results 
were a rel iable coefficient of 0.89. Based on the above, the researcher feels confident that the 
MAVAS instrument would be the ideal instrument to use in the test-re-test situation after the 
administration of different treatments. 
Similarly the lntercultural sensitivity scale designed by Chen and Starost (2000), has been 
proven to be valid and reliable by Fritz et al. (2002: 168) through testing it by means of factor 
analysis and testing the tool against seven (7) other scales for concurrent valid ity which proven 
satisfactory. 
3.4.3.2 Reliability 
The researcher established the reliabil ity and internal consistency of the adapted questionnaire, 
as outlined in section 3.4.3.1 . Therefore, the researcher decided not to repeat this pilot again. 
3.4.4 Control during the research project 
3.4.4. 1 Prevention of cross-contamination 
As the researcher had quasi experimental design with a control group and three experimental 
groups with three different treatments, it was necessary to prevent cross contamination between 
groups. Therefore, the researcher randomly selected different groups from different provinces to 
prevent th is type of cross contamination where one group could influence another group's 
responses during either the pre or post-test (Babbie & Mouton, 2003:230). The post-test 
administered to the control group was used to determine whether exposure to the measure 
instruments possibly had an influence on the attitudes and cultural sensitivity and awareness of 
the respondents. 
3.4.4.2 Control over extraneous variables 
Any research project, according to Bums and Grove (2012:177), will have unexpected variables 
interfering with the research and relationships between the variables which may cause an 
interference in terms of the causal relationships between the variables. In essence, control 
therefore implies that the researcher will attempt to ensure that all influences on the dependent 
variables will be held constant in an attempt to prevent any form of contamination of the findings 
(Polit & Beck, 2012: 177). 
Some variables cannot be controlled and are referred to as confounding variables (Bums & 
Grove, 2012:177). Possible confounding variables in this study would be the level of education 
of the participants, as well as their years of service. However, due to a test-re-test situation, 
these variables are not controlled as the aim of the research is to see if there are changes in 
attitudes towards the management of aggression and violence and cultural sensitivity. These 
variables should not play a role because, regardless of age, years of service or level of 
education, the aim is not to test the participants but to determine the effect of the treatment. 
In an attempt to control some of these variables, the researcher conducted the research at the 
participants' places of employment to stay in their natural environment and prevent influences 
from being in a different milieu or what Bums and Grove (2012: 177) refer to as environmental 
variables. 
The researcher had questionnaires delivered to respondents' places of employment and had 
the questionnaires collected a week later, in an attempt to prevent the Pygmalion and 
Hawthorne effects, whereby respondents are influenced by the presence of the researcher 
(Babbie & Mouton 2003: 221 ; Rosnow & Rosenthal, 1999:3, 19). Unfortunately, due to the 10% 
response rate in the control group, the researcher sacrificed the Hawthorne effect and 
administered the pre and the post test on the same day to ensure a better response rate. This 
will be elaborated on in Chapter five. 
The researcher, after experiencing the poor response rate in the control group, ensured that the 
time span between the pre- and post-test was exactly the same for all groups. As Rosnow and 
Rosenthal (1999: 186) report, it is important to allow all groups in the research design equal time 
for the treatment to take effect. 
3.5 ETHICAL AND MORAL CONSIDERATIONS 
3.5.1 Risks, benefits, and ethical considerations 
In terms of the Helsinki declaration which was adopted in 1964 and subsequently revised up to 
the latest revision of 2004 (Burns & Grove, 2012: 105), this research was conducted to generate 
knowledge and influence training programs for mental health care providers to enhance their 
ability to manage aggression and violence therapeutically, and to incorporate Indigenous 
Knowledge Systems in the individualised health care user package of care. 
3.5.2 Risks 
The researcher foresaw no risk to any of the participants in the study, but made her contact 
details available to all participants in the event that a need arose to discuss any concerns. 
There was the possibility that on completion of the questionnaires, the participant might have 
experienced flashbacks of previous mental health care user related violence, where the 
participant might have been either present or a victim . In such an event, the participant may 
contact the researcher, whereby the researcher will formally refer the participant to the 
Government Employees Assistance Service for necessary counseling . 
3.5.3 Benefits 
The outcomes of this research project provided information beneficial to the participants , with 
secondary benefits such as an improvement in the ability to manage aggression and violence. 
This is advantageous to both mental health care providers and MHCU. 
3.5.4 Ethical considerations 
The researcher submitted this proposal to the Health research and Ethics Committee of North 
West University for the necessary ethical clearance. On receipt of ethical clearance , the 
researcher submitted a copy of the proposal and proof of ethical clearance to the Western Cape 
Government Department of Health, Gauteng Government Department of Health, KwaZulu-Natal 
Government Department of Health, Northern Cape Government Department of Health, Eastern 
Cape Government Department of Health, as well as the Orange Freestate Government 
department of Health. The researcher registered the research on the National Health Research 
Database of South Africa. Upon approval by the different provinces, the researcher secured 
permission from the respective hospitals where the research was conducted. 
Over and above the ethical considerations, the researcher also applied moral principles such as 
referencing the works of others, giving a true reflection of the data collected and reporting 
objectively, as is pointed out by authors such as Burns and Grove (2012: 103). 
The researcher adhered to the following ethical considerations for her nontherapeutic research 
project and for the protection of all participants' rights : 
3.5.4. 1 Anonymity 
The researcher maintained anonymity of participants through the administration of structured 
questionnaires, where no participant was required to affix their name. As much as possible, the 
researcher asked participants to sign informed consent to take part in this research project. 
Anonymity was ensured as the questionnaires and the consent forms were returned in different 
boxes in order to prevent the researcher from making any possible links between 
questionnaires and consent forms. 
The researcher ensured anonymity of the institutions where the research was conducted. 
However for the purpose of distinguishing between the control and experimental groups, the 
researcher used different coloured questionnaires for the purpose of data capturing. All the 
same, anonymity was maintained as described in the previous paragraph. 
3.5.4.2 Confidentiality 
The researcher maintained confidentiality by not making public the names of the institutions 
involved in the research project. Furthermore, the researcher handled all documents received 
confidentially and it is still kept locked away at the researcher's residence. Additionally , the 
researcher kept confidential any information shared privately by respondents. 
3.5.5 Informed consent 
All participants in this research were informed about the aims of this research project, namely to 
establish baseline data in terms of their attitudes towards the management of aggression and 
violence, their perception of cultural sensitivity and awareness and the effects of a training 
programme on their ability to manage aggression and violence within a culturally sensitive 
context. 
The rights of the research Pi:lrticipants were spelled out in the consent form prior to participation 
in the research project. All participants were informed that their participation was entirely 
voluntary and that they could withdraw from the study at any time without being disadvantaged 
in any manner. The value of the contribution is also spelt out in the information leaflet attached 
to the consent form. 
Notably, the researcher asked participants to submit their consent forms in a separate box 
provided. However, where the researcher noted more questionnaires than consent forms, the 
completed questionnaires were deemed as consent given. 
3.5.6 Ethical considerations pertaining to conduct of the researcher 
The researcher will publish the findings of the research project. The researcher accurately and 
objectively presents the findings of the research, and references all sources used. 
The proposed training programme was presented to the College of medicine in Rondebosh 
Cape Town and they awarded CPD points for the Health Professional Council Members to 
attend this course. 
Additionally, as the participants during the qualitative phase of this research are from 
marginalised communities and have indigenous knowledge, the researcher committed to not 
make known privileged information which came to her knowledge during the /ekgotla, especially 
in terms of the use of indigenous medicines which are not common knowledge. For the 
intellectual property of these marginalised communities, the principle of cognitive justice will be 
elaborated on as part of this consideration by the researcher. 
3.5.7 Cognitive justice as ethical principle 
Due to the experience of the Khoisan community in terms of the exploitation of their indigenous 
knowledge, the researcher will at all times refer and acknowledge the knowledge and practices 
which belong to the Khoisan and the Basotho. Shiv Visvanathan (1999) coined the term and 
advocated the equality of "knowers," in this case the Basotho and Khoisan . Therefore the 
researcher, with the permission of these groups, will formally acknowledge all of their 
knowledge referred to in the management of aggression and violence. 
3.6 CONCLUSION 
This research project was a very labour-intensive process as is expected with a mixed method 
research project. It came with an unexpected amount of obstacles in terms of obtaining the 
necessary permission to collect data and getting access to the different hospitals. The 
researcher will discuss the collection of the data and the analysis thereof in depth in chapter 
four and five . The information will be dealt with in separate chapters, even though they are 
linked and part of a continuum. 
CHAPTER4 
QUALITATIVE PHASE: RESULTS, DATA ANALYSIS, INTERPRETATION 
AND DISCUSSION 
4.1 INTRODUCTION 
Chapter (4) four focuses on the qualitative phase of this sequential exploratory design. This chapter 
will describe the methodology and the findings upon analysis of the data. This provides the 
perceptive context for the development of the curriculum to facilitate cultural safe management of 
aggression and violence. After discussing the findings from the two makgotla, the researcher will 
proceed with a convergence. 
During this study, the researcher used makgotla to collect qualitative data in order to augment 
existing literature in terms of the way in which Indigenous healers and the community manages 
aggression and violence as associated with mental illness. 
4.2 PURPOSE 
The information collected during the qualitative phase was incorporated into a curriculum for a 
training package aimed at changing the attitudes of MHCU towards the management of aggression 
and violence. 
This chapter will further elaborate on the data collection method followed, the analysis of the data 
and the themes, categories and concepts identified during data analysis, as well as the context 
during which the data collection took place. 
4.3 DESCRIPTION OF THE POPULATIONS 
The researcher conducted makgotla in a rural village with the Basotho Indigenous Healers and a 
Khoisan village (Northern Cape, South Africa). The makgotla constituted of indigenous healers and 
community members in both the Basotho village and the Khoisan village. The /ekgotla with the 
Basotho comprised of 12 Research team members and 54 Indigenous healers and community 
71 
members. In the Khoisan village, there were 5 (five) research team members (all involved in IKS 
research) , amongst which was the researcher and 35 community members. 
The sample was selected through purposive sampling. The researcher opted for purposive 
sampling as the information needed for the research question to be answered clearly lies within the 
exclusive knowledge of the Indigenous Healers and the indigenous community members. 
Notably, the indigenous healers had no western medical or psychological training in the 
management of aggression and violence, yet they have to manage these conditions. Their current 
knowledge in terms of the management of aggression and violence relies deeply on common sense 
and knowledge that was transferred to them during their initiation as Indigenous healers, as is 
evident in the following extract from the transcript of the /ekgotla with the Basotho healers. 
Additionally, the healers also rely heavily on intuition. 
"Somebody that knows what it is to be an indigenous healer and those tremendous initiations of the 
traditional healer (ngaka ya sitso- doctor of culture) ; they will know how to deal with mad people." 
4.4 DAT A COLLECTION 
During this study, the researcher made use of lekgotla to collect data. Lekgotla is comprehensively 
described in Chapter (3) three. 
4.4.1 Negotiations for the Lekgotla in a rural village in Lesotho 
The Lekgotla was negotiated in terms of the standard protocol, whereby the researchers negotiated 
with the different Chiefs and informed said chiefs of the intent and nature of the lekgotla. The Chiefs 
called upon the Head of the Basotho indigenous healers, who in turn called all the indigenous 
healers in the community together for the intended lekgotla. The researchers attended as quiet 
observers and the Chief of the Indigenous healers was coached regarding the aim of the questions 
and he was subsequently requested to chair the lekgotla. The chief and members of the /ekgotla 
were assured that anonymity would be ensured and that there is no need to share information 
deemed to be sacred. 
During the negotiations, the three researchers discussed the aims of the lekgotla with the Chief 
Indigenous Healer, namely to answer their respective questions. 
72 
For the purpose of this research the researcher posed the following question: 
"How do you manage violence and aggression in a mentally ill person?" 
4.4.2 Context of the Lekgotla in the rural Basotho village. 
A rural Basotho village was used as gathering place for the lekgotla. It is a quaint, neat little village 
with several huts and the community centre where the /ekgotla took place. 
The Chief Indigenous Healer welcomed everybody present and posed the questions to the lekgotla. 
Apart from the 12 members of the Research team, there were 30 Indigenous healers who attended 
the /ekgotla. A /ekgotla is open for any member of the community to attend and all members have 
equal input into the question posed. The researcher observed that there were male and female 
Indigenous Healers present. The male indigenous healers were the first persons to respond to the 
questions, and the elders replied first. After the youngest male responded, the female indigenous 
healers would take their turn, also in ranking of the elders first. The observation of the researcher is 
that everything is dealt with in a respectful manner and that all inputs were welcomed. The 
Indigenous Healers were all dressed in Traditional clothing with different goatskin headbands and 
head coverings made out of beads. During a one-on-one conversation, the indigenous healers said 
that those wearing the goatskin head gear received their calling to become an indigenous healer 
during a dream and those who were wearing the beads received their calling via a vision while they 
were awake. 
The Chief of the Basotho Indigenous Healers opened the proceedings by welcoming all present, 
and explaining the nature of the questions to be addressed. 
The negotiations and context of the data collected in the Khoisan village is discussed in section 4.8 
and will be concluded in section 4.1O  with the convergence of the data collected in the makgotla. 
4.5 DAT A ANALYSIS 
The data which was collected by means of audio recording and video recordings were transcribed 
verbatim by the researcher herself. The data in seSotho was translated from seSotho into English 
by the researcher's colleague who is a bilingual Mosotho man with a Master's degree in nursing. 
The English transcript was then given to another colleague, a qualified teacher who translated it 
73 
back to seSotho to validate the translation . The transcripts in Annexure Three are verbatim reports 
and translations of the makgotla. The researcher did a manual coding of the data as opposed to the 
use of a computer programme, the reason being that the researcher wanted to immerse herself in 
the data. 
The phenomenological analysis technique used for the data analysis was described by Coliazzi 
(1978) as cited by Polit and Beck (2012:566) and the researcher observed that this method fits the 
procedure of lekgotla extremely well, as validation of the data is a crucial part of the conclusion of 
any lekgotla. This method consists of seven steps, but the distinguishing characteristic of the use of 
this method lies in the seventh phase, during which the researcher validates the findings with the 
participants in the research project. 
During the steps of the Colaizzi method, the researcher proceeded as follows: 
• Phase 1 
The researcher read through all the transcripts and field notes made whilst listening to the 
recording of the /ekgotla to get an overall perception of the material. 
• Phase 2 
The researcher highlighted all significant statements in the text as can be seen in annexure 2. 
• Phase 3 
The meaning of each statement was formulated in a code in a column next to the statement. 
• Phase 4 
Discrepancies were coded as differences and all codes were validated as a reflection of what was 
said. 
• Phase 5 
Results were integrated into a description of categories and sub categories. 
74 
• Phase 6 
Themes were discussed and examples provided to validate the information through the verbatim 
text. 
• Phase 7 
The preliminary findings were presented to participants during a validation session. 
A discussion of the themes, categories and concepts will follow. 
4.6 THEMES, CATEGORIES AND CONCEPTS 
All the transcribed data was then read and re-read along with the video and audio recordings. This 
data was then coded and emerging categories, concepts and themes were identified. After this 
process, the researcher gave a copy of the transcripts to Dr. E Van Wijk who acted as an 
independent coder. When compared, it was clear that the researcher and Dr. Van Wijk both 
identified similar concepts and themes. Our method was thematic content analysis to develop 
themes and categories. These themes and categories were then eventually used to develop a 
conceptual framework for the course developed as treatment during the quantitative part of this 
research. 
4.7 PRESENTATION OF FINDINGS OF THE LEKGOTLA WITH THE BASOTHO 
The data analysis resulted in the identification of six core themes, namely mental illness, 
aggression and the management of aggression according to indigenous knowledge and health 
practices. Several categories were identified with themes. 
4. 7.1 Theme 1: Comprehension and conceptualisation of mental illness according 
to indigenous knowledge 
Amongst the Basotho healers, mental illness is explained by Female Healer no. 3 to be: 
"Mahlanya, (Confused/mad ones) , they are not thinking straight. " 
75 
An elder amongst the Basotho healers explained that madness must have something to do with 
nerves because the medicine helps. 
"There is medicine burnt when he comes into the house, it will make him drowsy and then when 
he is mad it is not madness; it is the nerves, and when the medicine makes him drowsy, th is 
calms down the nerve break, and he will be soft, calm and sleep." 
4. 7. 1. 1 Categories • • ~ I • 
I NWU _I LJBRAll_YJ 
• Causes of mental illness 
The Basotho healers deem mental illness to be caused by numerous factors inclusive of unknown 
causes, intra psychic pain, problems, lack of support systems and even environmental causes. 
Female Healer 3 referred to unknown causes as: "People coming from the caves." 
Male Healer 1 posed the following cause: "Some of the mad people must be removed from the 
place where they are because they are mad because of the surroundings they find themselves 
in." 
Female healer 2: " ... no family at al l. Maybe th is is the problem that caused him to this state 
(sic)." 
Furthermore, they emphasised that often mental illness is misdiagnosed in a person , as captured in 
the following words of Male Healer Number 1: 
"Some of the mad people are just mad and just want someone to sit and talk with them 
then the madness is gone." 
• Management of mental illness 
The treatment of mental illness is linked to the identified cause of the Mental illness as highlighted 
by Male Healer number 2: 
"As for me, th is type of sick person, (sic) the way I treat them depends on what caused the 
madness." 
76 
There are no set protocols for the management of mental illness. This statement is corroborated by 
a claim by Male Healer 3, as is evident in the following : 
"Let me say to you, it differs according to the indigenous healers." 
The Basotho Healers felt that a real Healer will be able to manage the mentally ill person . This is 
evident in the statement of Female Healer 3: 
"Somebody that knows what it is to be an indigenous healer and those tremendous initiations of 
the trad itional healer; they will know how to deal with mad people." 
The one attendee to the /ekgotla laid claims to the ability to cure mental illness, as seen in the 
words of Female Healer no. 3: 
"I don't just work with people (Sic) sick; I even cure mad people (Mahlanya), really mad ones; 
even if they are from a Mental hospital." 
An important aspect in the management of Mental Illness is considered to be family involvement, as 
mental illness is often caused by a lack of a support system. The Chief healer explains the 
importance of family involvement, especially in the event of mental illness being of a chronic nature. 
"If he continues to be mad.-~ this person starts from here being helped but again we must make 
sure he understands and family understands the situation he is in." 
The family involvement in the management of mental illness is echoed by all the healers through 
either clapping of the hands, nods of agreement and even echoing statements such as the 
following : 
Male healer 2: "I will talk to the family to explain what has happened. "He will not talk; I will talk 
to the family. " 
Female healer 2: "This man with no family, I will ask who he works with. Maybe th is is why he 
became so ill. " 
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The use of indigenous medicines is an important component in the treatment of Mental Illness. 
"When th is man comes here, he will find medicine burned as he is coming through. Others will 
find they must sniff here is medicine burning." Male Healer 2 confirmed. "I will touch him with 
medicine in my hand." "He will step over the medicine." Male Healer 1, "Some will need 
medicine to drink; some will need medicine to bath for cleansing ." 
Although Psychiatric Hospitals play an important rol~ in the management of Mental !llness, the 
Chief Mosotho Healer judges these hospitals to be non-therapeutic in appearance, as is evident 
through his following statement. 
"I have seen that there are huge walls around the hospital for mad people . When you are a 
visitor there, it looks as though you are in prison." 
4.7.2 Theme 2: Identifying aggression 
The Basotho Healers recognise aggression, and that it could potentially be lethal, but they place 
great value on separating the aggression or behaviour from the person. The healers went as far as 
stating that not all mentally ill people are necessarily violent. 
Female healer 2 pointed this out beautifully in saying: 
"Do not look at what they are doing . Bring back their mind so that it can come back from what 
he is doing." 
Furthermore, this approach where the indigenous healer fits the treatment to a specific client 
confirms the researcher's belief of no val id "one cure, suits all" regime to manage mental health 
care user related violence, because people differ in terms of their culture and knowledge system. 
This is evident through the following quotation by a Mosotho Indigenous healer: 
There are mad people who are very mad and they take some stuff orally . Others need to smoke 
something. Some of the mad just need medicine for cleansing. They use this when bathing and 
that will help them out of the state they are in. It all depends on how madness got onto this 
person. " 
The healers also emphasised that one must not just accept that all people with a mental illness are 
prone to aggression. 
78 
4.7.2.1 Categories 
• Mental status 
The Basotho Indigenous Healers distinguished between the emotions and physical behaviour in a 
person diagnosed with aggression. 
"The mind of the person is aggressive, not he himself' 
• Emotions 
It is imperative that the indigenous healer be in control of their own emotions as it may rub off onto 
the patient and aggravate the patient. 
Female healer 2: "At this point if he wants to hit you do not take a stick to hit them back. The only 
thing I do is to be calm and show no sign of violence." 
• Behaviour 
As the behaviour of the mentally ill person might be inappropriate or disinhibited, it is crucial for the 
healer to remain in control of the situation. 
Female healer 2:"Most of the time when they come they ask can I kiss this women? As a 
female healer you do not allow this to happen to you. " 
• Common misinterpretation of behaviour 
The indigenous healers who took part in the /ekgotla pointed out that not all mad people are 
aggressive. Furthermore, human reaction such as distress has been reportedly misconstrued to be 
aggression, when in actual fact it was a normal human reaction . This was elaborated on by the 
Chief Healer in the /ekgotla: 
" ... this man who was jumping was coming from another house where he was dumped by his 
girlfriend. People thought he was mad and started calling ambulances. They captured him and said 
he must be taken to the hospital. " 
79 
4.7.3 Theme 3: Recognising the causes of aggression 
4.7.3.1 Categories 
• Manage the cause of the aggression 
The participants in the lekgotla were all in agreement that the way in which the aggressive person 
is approached will have an effect on their aggressive state. The approach must be neutral and the 
person managing the aggressive patient needs to stay calm and show and in understanding of the 
patient's situation. Through showing an understanding and not trying to communicate immediately, 
the patient will often calm down. The calmness of the intervener will rub off onto the aggressive 
person. 
• Hospitals may not be the most appropriate way to manage aggression associated with the 
mentally ill 
The indigenous healers described psychiatric hospitals as non-therapeutic because even whilst 
visiting them, the hospitals looked more like prisons than what their perception of a hospital would 
be. They are part of the environmental causes of aggression, hence the advice that if this is the 
situation then these causes could be remedied through removing a person from those conditions. 
Ch ief Healer: "In Gauteng, I have seen that there are huge walls around the hospital for 
mad people. When you are a visitor there it looks as though you are in prison." 
Male healer No 1: "Some must be removed from the place where they are because they 
are mad because of surroundings they find themselves in". 
These beliefs of the indigenous healers is echoed by researchers within the WBKS as seen 
through the work of (Soliman & Reza, 2001 :77-79, Duxbury, 2002:331-333; Duxbury & 
Whittington, 2005:470; lgnelzi et al., 2007:453) , where they confirm that confined areas, 
overcrowding , high temperatures, low staffing levels, seclusion and the use of restraints 
precipitate aggressive behaviour. 
The behaviour of people can lead a person to become aggressive, and this is well noticed by 
the Basotho Indigenous healers. 
80 
4.7.4 Theme 4: Predictors of aggression 
The indigenous healers were very clear about identifying the symptoms of aggression and what the 
possible causes were. Causes were linked with mental illness, and absence of a support system. 
There was no offer at all to possible predictors of aggression, or to preempt aggression. This may 
stem from the African perspective about time, as explained by Beyaraza who is cited by Smith 
(2001 ); the African is living in the here and now because the future must still come and he will deal 
with the future once it has arrived. For the African, the concept of time is two-dimensional , namely 
the past and the here and now. 
4.7.5 Theme 5: Indigenous techniques in the management of aggression 
The healers described the dangers associated with aggression and the Chief Indigenous Healer 
emphasised that the aggressive person is capable of killing a healer, hence it is important that they 
must be approached in a calm manner. 
4.7.5.1 Categories 
• Verbal component 
Verbal skills are used in a calm manner, as explained by female healer no. 1 
"To get them there you need to "gekisa" (beg) them, to be calm. It is very important that with 
these people you be calm when you approach them because in their mind they are already 
aggressive. If you come with aggression, you will aggravate them. " 
Female healer 3: "I will ask him what he sees and what he hears." 
A theme which grew out of initiating the verbal management of aggression is the building of rapport 
and making the person feel welcome. This is accomplished through inviting a person into the yard 
or house of the indigenous healer to come and sit down to talk and even the offering of a beverage, 
as derived from the following statements. 
Female healer 3: "I give this man a sacred hand and he sits down. I would take a mug and give 
him water and say. 'Sit here my love', and immediately the person become calm and sit down. I 
befriend them." 
81 
Female healer 4: "When they are calm I tell them to sit down; then give them my hand." 
• Physical component 
The Basotho healers disclosed to the researcher that if the aggressive person becomes 
aggressive, it is better not to react physically. The Mosotho healer informed as follows: 
"At his point if he wants to hit you do not take a stick to hit them back (sic): I do not agree with 
this treatment you will make him mad worse (sic)." 
Female Healer 3: "Even after violent, when I give them a hand of mercy protection they become 
calm because I am calm." 
One of the physical strategies proposed by the indigenous healers, in an attempt to gain control 
over the aggressive person, is to get that person to sit down. This is accomplished through 
extending an invite to make the person feel welcome. 
Female Healer 2 expressed the importance of getting the aggressive person to calm down 
through the following : "Make sure you get them to sit down so that you can talk to this person, 
this is corroborated by Female Healer no 3 who similarly invites the person to sit down in a 
sacred place and then to talk to this person in a calm manner." 
All of the Healers are in agreement that if a mental health care user is brought to them and this 
patient is tied up, it is important to build rapport, gain their trust and have them untied. Untying them 
will make them feel welcome, and thus become more co-operative. 
Female Healer 3: "When they come in my yard tied up I say 'Untie him'. I go to them and give 
them a hand of mercy protection and a hand that calms them down." 
Female healer 2: "When he comes to my house I untie him." 
• Do not intervene when no intervention is necessary 
The Basotho healers are convinced that it is not always necessary to intervene. In some instances, 
you just need to remove the cause of the disturbing behaviour and merely engage in a conversation 
with a person. 
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Male Healer no.1 "Some of the mad people are just mad and just want someone to sit and talk 
with then the madness is gone." 
• Medicinal component 
The Healers admitted to treating aggression and violence as associated with mental illness through 
administering different medicines. The decision around the type of medicines used is based on 
Knowledge acquired during training and initiation into becoming an indigenous healer. It also relies 
heavily on spirituality, as can be seen in the responses of Female healer 2 and 3. 
"These medicinal plants (sic) are there and there are medicines we use even though they are 
different. I will give only these I believe would help. " "Somebody that knows what it is to be an 
indigenous healer and those tremendous initiations of the traditional healer; they will know how 
to deal with the mad people. 
"Not on all mad people you will give something to smoke or drink" 
The healers pointed out different routes of administering medicines, such as: 
Female healer 1: " .... go through the smoke ... " 
Chief healer: ... Medicines are burnt. .. " 
Male healer 1: "some takes stuff orally others smoke stuff ... " 
Male healer 1: "Some of the mad just need medicine for cleansing. They use th is when bathing, 
that will help them out of the state they are in ." 
Male healer 2: " ... I will go to the gate and have medicine in my hand; I do not touch them with 
the medicine in my hand, but will throw the medicine on the ground and get him to step over the 
medicine." "When he is inside my house I will touch him with the medicine in my hand. " 
All of the healers who joined in the lekgotla agreed that medicine is not administered while a person 
is acutely aggressive, nor are all forms of aggression treated with medication, as is evident in the 
following statements: 
83 
Female healer 4: "No I do not give medicine when he is violent; I only give medicine when 
everything has calmed down." 
It is evident through the transcript that there are differences in the treatment of aggression and the 
treatment of mental illness. Acute aggression is managed through giving medicine to calm a person 
down and mental illness is only managed once the person is calm. No consent is required to 
administer sedation, but consent and understanding are required to treat mental illness. The 
literature informs us that lmphepho is used as a sacred medicine which helps calm a person down 
(Africa Mystics, 2015) . The literature confirms that this medicine is smoked or vapourised as 
alluded to by the Basotho healers. 
Older male healer: "When a man comes here he will find medicine burnt as he is coming 
through. Others will find medicine they must sniff ... it will make him drowsy when he is mad." 
"Th is person starts here from being helped but again we must make sure he and his family 
understands the situation he is in." 
4.7.6 Theme 6: Diminishing destructive methods of dealing with aggression and 
violence 
The Indigenous healers referred to practices which they find unacceptable, namely restraint, 
bondage and physical beatings, to the extent where a mentally ill person would become so tired 
that they pass out. 
4.7.6.1 Categories 
• Verbal component 
Communication and understanding are very important aspects in the management of mental illness 
and aggression in the Basotho community. The use of communication skills is reported to be the 
entry point into the management of aggression. Female Healer no1 indicated that it is crucial that 
the healers stay calm when dealing with the aggressive person. Remaining calm makes it easier to 
calm the aggressive person down as evident in the following statement. 
84 
Female healer no 1: "Yes yes you as a person must be above this person .. . do not be violent be 
calm when working with them, they are sick. To get them there, (calm) you have to gekisa (beg) 
them, to be calm. You need to approach them calm because in their mind they are already 
aggressive. If you come in with aggression you aggravate what is in their mind." 
• Physical component 
The indigenous healers reported an old seSotho proverb which states, 
"The back of a mad person is corrected by smacking them." 
are too tired to fight anymore. They will then be given medicine to make them sleep and after they 
wake up the treatment of the mental illness will commence. 
4.8 NEGOTIATIONS FOR THE LEKGOTLA IN A KHO/SANVILLAGE 
Negotiations for the Lekgotla took place in the humble residence of the chief and his wife. Upon 
arrival at the Chief's house, the researcher enjoyed the view of the hills and the soccer field on 
which a few goats were grazing. The researcher were awaiting the arrival of the Chief, as he was 
down at the community centre making sure everything is ready for the research team. While waiting 
for Chief, the researcher sat on the stoop and had a conversation with the Chief's wife. 
When the Chief arrived, the researcher were invited into the Chief's house, a welcome cool relieve 
from the humid heat outside. After introductions and being offered some cool drink, the researchers 
and Chief discussed the aims of the lekgotla, and what the researcher endeavoured to discuss with 
the community. The researcher gave out the topic, the management of aggression and violence in 
the community and the methods the community uses when a person with a mental illness becomes 
aggressive and violent. 
The Chief agreed to lead all proceedings which took place in the Khoisan village Community 
centre, and gave the necessary permission for the lekgotla to be captured via video recording as 
well as still photos. The Chief requested that the material be made available to him and that the 
material captured be used for the purpose Qf the research only and not for commercial purposes. 
The researchers agreed to this request. 
85 
4.8.1 Context of the lekgotla in a Khoisan village 
The specific Khoisan village where the lekgotla was conducted is quiet and humble. When the 
researcher arrived, goats were running across the veld , whilst the ants were scurrying on the 
ground. One could hear a cock crowing and announcing the imminent rain rolling along with the 
thunder clouds in the distance. At the house of one of the elders , a big pot of food was bubbling 
over an open fire, spilling the appetising aroma of chicken stew. Ladies were busy kneading dough 
for "rooster brood" (a type of bread in the form of a bun, which will be baked over the warm coals) , 
and the whole of the community was in preparation for the feast to be held after the lekgotla. 
The /ekgotla only commenced after the researchers negotiated the proceedings with the Chief of 
the Khoisan. 
4.9 PRESENTATION OF FINDINGS OF THE LEKGOTLA IN THE KHO/SANVILLAGE 
4.9.1 Theme 1: Comprehension and conceptualisation of mental illness according 
to indigenous knowledge 
As conceptualised in the indigenous Khoisan community, mental illness is a condition that affects 
the brain of a person. 
"Their heads are not working to well"/ 
Mental illness is diagnosed through observation of the behaviour of a person, as their behaviour will 
often be contrary to the norm for the community. An example may be through a display of 
inappropriate and often sexually disinhibited behaviour as described by some of the ladies during 
the lekgotla. 
'This child cannot speak but he comes with a five rand coin to the women and shows that he 
wants to have sex with them." 
"She will all of a sudden dress flamboyantly in very high heels and go visit the "English" church , 
and then during the sermon she would develop the "loop siekte" (wandering illness) get up from 
the pew and walk out of church mid-sermon." 
86 
Mental illness is observed through the eyes of the community to fluctuate between bouts of compos 
mentis and illness. This point towards the identification of mental illness going into periods of 
remission. 
4.9.1.1 Categories 
• Causes of mental illness 
The Khoisan community identified that there might be an evil cause for aggression and this will be 
dealt with on a spiritual level. The elder referred to this as quoted. 
Male Elder: "A restless spirit inside the person." 
Mental illness is further identified as an illness of the brain. 
Chief: "Their heads are not working so well. " 
The community has experienced cases where some of the mentally ill persons to use their mental 
illness to their own benefit as alluded to by a member. 
Member1 : "The community has experienced some of the psychiatric patients to be "aspris" 
because their behaviour is often a means to an end. One day they cannot do anything for 
themselves, the next minute they know how to work with money." 
"Today he is o.k. and tomorrow he is mad." 
• Management of mental illness 
The community in general is very tolerant of the mentally ill and tries to accommodate them in the 
community. However, if the mental illness causes a severe disturbance, they prefer to have the 
person hospitalised. 
Member 7: "if you do not pull yourself together they will take you with the ambulance to 
Bloemfontein of Weseinde." (Bloemfontein refers to the Freestate Psychiatric Complex in 
Bloemfontein, the capital of the Freestate province and Weseinde being a psychiatric hospital in 
the Northern Cape.) 
87 
Member 7: "You see that ch ild there ... we do not really know how to deal with him, except to talk 
to him calmly and calm him down when he gets so upset." 
It is also interesting to note that the Khoisan community members felt that mental illness might be 
under the control of the patient; an understanding reflected in the following statement. 
Member 7: " ... pull yourself together ... " 
In situations where the cause of mental illness is deemed to be due to a restless or evil spirit , the 
management revolved around a spiritual nature as responded by the Elder male: 
Male Elder: "Spiritually you need to invite God into you to counteract the upset spirit in the other 
person. You must ask God for guidance." 
Mental illness and the mentally ill are accepted as part of the community, therefore the community 
members reach out to the mentally ill to provide assistance where needed. 
Members of the lekgotla in the Khoisan village reported that they often reach out to help the 
mentally ill. The Indigenous Healers confirmed this and emphasised the importance of reaching out 
to the mentally ill as one of the causes of Mental Illness is identified as lack of a support system. 
The Khoisan community identified the use of indigenous medicines as an important aspect of the 
treatment of Mental Illness. They also consider Psychiatric Hospitals to play an important role in the 
management of Mental illness. 
4.9.2 Theme 2: Identifying aggression 
Aggression is diagnosed through observation of the behaviour of the aggressive person, and it 
became apparent during the Lekgotla that aggression is definitely associated more with mental 
illness. 
Chief: " ... those people who do not have all their faculties, we know that in general they are 
more or less always aggressive and that they want to make and break things." 
Where there is no evidence of mental illness, the community referred to this person as getting on 
his high horse for nothing. 
88 
Chief: " ... this person gets on his high horse for nothing and get upset for no reason. They get 
into the boxing rink quickly." 
The Chief advised that during this Lekgotla we should not discuss the increase of aggression due 
to drug abuse in the community 
Member 2: "From my side ... I know with me I have a man who is not always well and can get 
upset. " 
The nature of aggression has been described as to be unpredictable by different attendees to the 
lekgotla, as is evident in the following : 
Chief: "The person who would sit and then all of a sudden feel he must punish someone for no 
apparent reason ." 
Member 5: " ... You will th ink he goes th is way but then he goes that way." 
4.9.2.1 Categories 
• Mental status 
The Khoisan community did not elaborate much on the mental status of the aggressive person. 
However, the Chief alluded to the increase of hard core drug abuse in the community and that this 
has increased in incidences of aggression and a sub judice court case where murder was as a 
result of aggression and drug abuse. 
• Emotions 
The Khoisan Community agreed that it is extremely important to maintain control over your own 
emotions when dealing with the aggressive person. 
Member 3: "When the mad person is so angry, you stay calm . It does not help to become 
angry." 
Member 7: "When he is very very (sic) you need to be very very humble and calm, and talk to 
him with respect. " 
89 
Member 6: " ... the way in which you speak to a person who is a bit high. If you speak with 
calmness and in good spirit and tone of voice this will bring the person down." 
Member 5: "lf a person goes up the stream ... stay calm and do not speak because you will give 
him power." 
Member 2: 'This person with aggression you must speak in a calm voice this is the key. Do not 
backchat and do this with calmness." 
• Behaviour IL INBRWAUl! YJ  
The mentally ill person is deemed to be more prone to violence. 
Chief: "We have people like that in the community who "lost" it. Do you work the same way to 
calm him down as the others?" 
Member 1: "You work with him in a different manner because there is a restless spirit in him." 
Member 1: "The ladies seem to manage the men. They do something because they can get 
injured (sic). What is it they do? They seem to be able to manage the men." 
• Common misinterpretation of behaviour 
There was an open declaration that aggression often stems from misinterpretation of behaviour. 
This was explicitly stated by one of the attendees: 
Member 7: "The child knows what he wants but he cannot speak, I take him to the shop to pick out 
what he needs. The shop owner does not want him there because he is says the child steals 
because he is mad. This makes the child aggressive. " 
4.9.3 Theme 3: Recognising the causes of aggression 
Causes of aggression in the Khoisan community have been linked with mental illness and 
substance abuse. 
90 
Member 8: "They sometimes get so angry because they hear voices talking to them or they get 
angry because of some inner pain which can only be healed by God." 
The behaviour of other people can lead a person to become aggressive. This is one of the 
observations made by the Khoisan community and was thus captured: 
Member 9: "See that child there is one of the mad people, he is without a mother and a father 
and his younger brother takes his pension money, this makes him aggressive. I have witnessed 
people pouring water over him or throwing stones at him and this makes him more aggressive. " 
4.9.3. 1 Categories: 
• Manage the cause of the aggression. 
The Khoisan community differentiated between mental illness, restless spirit possession and 
substance abuse as potential causes of aggression. They only referred to spiritual management of 
aggression, where there is a restless spirit involved. 
Member 1: "You ask God how you must react. Spiritually you must invite God into yourself to 
counteract the upset spirit in the other man. You ask God for guidance and which words you 
must use. Nothing is impossible with God the evil spirit is compelled to listen to the voice of 
God." 
• Hospitals may not be the most appropriate way to manage aggression associated with the 
mentally ill 
The Khoisan recognised the importance of mental hospitals, and even threatened some of the 
community members with hospitalisation when they become unruly. 
4.9.4 Theme 4: Predictors of aggression 
The Khoisan community deems aggression to be somewhat unpredictable in nature, as pointed out 
by the Chief. 
"Now aggression is when a person gets on his high horse for noth ing and get upset for no 
reason ..."  
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4.9.5 Theme 5: Indigenous techniques in the management of aggression 
The Khoisan community elaborated on the management of aggression and referred to a practice 
called "Xarrare" (this process is normally used to praise or calm down-e.g. you 'xarrare' a baby-
singing lullabies and rocking or praise a person to make them feel important in an adult manner). 
This practice is very specific to the Khoisan. They continued and alluded that the Khoisan women 
who are more vulnerable compared to the aggressive men are on the contrary quite efficient in the 
use of xarrare to calm down the aggressive male through the use of this very indigenous technique 
which will be elaborated on in the following section. 
4.9.5. 1 Categories 
• Verbal component 
The whole of the Khoisan community was in agreement that in order to manage aggression, it is 
very important to stay calm. This was echoed in many different ways as captured in the following 
extracts: 
Member 3: "I have witnessed when the mad person is so angry and you stay calm it does not 
help to argue, just sit down and whistle softly until he is calm." 
Member 2: "This person with aggression. You must speak in a calm voice. This is the key." 
Member 5: "If a person goes up the stream, stay calm and do not speak because if you do you 
give him power." 
Member 6: "When I get upset he has such a beautiful personality he would just say, 'Oh my 
sweetheart.' And then I calm down." (Example of xararre) 
• Physical component 
The Khoisan community informed the researcher that if a person becomes aggressive, it is better 
not to react physically. 
92 
Member 7: "Gently hold him tell him to calm down (Showing how she holds a person, and rock 
them gently in a swaying motion; to calm them down.) You will then feel his body become calm." 
(Example of xararre) 
• Do not intervene when no intervention is necessary 
The Khoisan pointed out that often it is useful to use diversionary techniques and to have no other 
form of intervention, as this would assist a person to calm down. 
Member 2: "Rather send a person like that to go fetch water." 
• Medicinal component 
The members of the community reported during the validation afterwards that they administer 
medication when a person has calmed down. This medicine is part of the calming down technique. 
Member 8: "If you haven 't got medicine to calm them down you can give them sugar water, 
duwweltjiestamphout or grashout to drink. This will help them calm down." 
4.9.6 Theme 6: Diminishing destructive methods of dealing with aggression and 
violence 
The Khoisan mentioned some ineffective techniques sometimes used, such as threatening the 
aggressive person, beating him or throwing water over them when they are aggressive. They say 
they do this because they do not always know how to deal with the aggressive person. They have, 
however, noted that these techniques make the aggressive person more aggressive. 
4.9.6.1 Categories 
• Verbal component 
It is evident that some members of the Khoisan community use coercion to manage aggression as 
is explicitly stated by one of the members: 
93 
Member 7: "If you do not pull yourself together they will take you with the ambulance to 
Bloemfontein. You must calm down or you will be taken to Mental hospital in Northern Cape. 
You act as though you are mad but you are not really mad ." 
Because some people view mental health to be under the control of the person they, often tell them 
to pull themselves together, or they would use verbal threats to coerce them into controlling 
themselves. The Khoisan communities identified this as being ineffective and often resulting in 
power struggles between the aggressor and the rest of the community. 
Threats to have a person admitted to a psychiatric hospital are equally ineffective and often evoke 
more aggression in the aggressor. 
The geigas in the Khoisan community and Basotho healers pointed out that when verbally 
managing aggression, timing is also a factor to be taken into consideration. Verbal techniques are 
ineffective when a person is still very belligerent. 
• Physical component 
The indigenous healers reported an old seSotho proverb which states, 
"The back of a mad person is corrected by smacking them." 
One of the elders in the Khoisan community reported that sometimes aggression is managed 
through beating up a mad person. 
"Jy fok horn op!"(Loosely translated "You give him a beating .") 
During the validation after the lekgotla, one of the members described some additional destructive 
techniques which seem to aggravate the aggression. 
Member 9: "I have witnessed people pouring water over the mad person who is so angry, but 
does not always work; sometimes it makes them more aggressive." 
Noteworthy is that both communities reported these physical beatings to be not effective at all as 
they increase aggression. 
94 
Both communities reported that the aggressive person must be ready to accept physical contact by 
the person managing their aggression. The Khoisan community referred to this as "Xarrare", a form 
of embrace and pacifying a person like you would rock a baby. The Basotho healers referred to the 
use of a "hand of mercy". When touching the aggressive person , you yourself need to be calm. 
Both communities rejected the use of restraints. The Basotho Healers advise on the need to "Untie 
a person." "The person will become calm if I am calm ." 
4.10 CONVERGENCE BETWEEN THE BASOTHO AND KHOISAN DATA 
4.10.1 Comprehension and conceptualisation of mental illness according to 
indigenous knowledge 
Mental illness is diagnosed through regarding the behaviour of a person, as their behaviour will 
often be contrary to the norm for the community, such as through a display of inappropriate and 
often sexually disinhibited behaviour. This observation by the community and indigenous healers is 
in line with the DSM-5 definition which points out that "Mental disorders are usually associated with 
significant distress or disability in social , occupational, or other important activities. " (DSM-5, 
20:2013). 
Mental illness is observed through the eyes of the community to fluctuate between bouts of compos 
mentis and illness. This points towards the identification of mental illness going into periods of 
remission. These references by the Indigenous Healers, as found in the transcript Annexure 2, 
confirm the findings of Kabir et al. (2004:4); Shankar et al. (2006:225) and Sorsdahl et al. 
(2010:286) wherein the authors pointed out that the recognition of a condition such as mental 
illness was based on the observation of the behaviour of the person who is deemed "mentally ill". 
Kabir et al. (2004:3) further confirms what IKS identified as symptoms of mental illness such traits 
as eccentric behaviour, wandering aimlessly and talkative behaviour (Kabir et al. , 2004:3). 
Both the Basotho and Khoisan identified that: "a mad person does not think straight". 
Some causes of mental illness are not known for the indigenous healers. This is especially true if 
the patient brought to them is not familiar or a member of the community or village where the healer 
practices. 
95 
4.10.2 Causes and management of mental illness according to indigenous 
knowledge 
Both cultural groups made a link between the cause and the management of mental illness. 
Depending on the cause, the management will be adapted accordingly, as explored in a study by 
Mufamadi (2001 :92). In the latter's study, the indigenous healers also reflected on the distinction of 
the different causes as determined by the symptoms the person presents. Where the cause is 
deemed to be of a spiritual nature or internal pain, it is dealt with in a spiritual manner. Sometimes 
the cause might be unknown and you deal with this mental illness in a very individualistic manner. 
Mufamadi (2001 :88) explains this well through her observation that the traditional healer's view of 
the disease is so much more in line with the patient's view; hence the success rate in curing the 
disease is ultimately so much higher. In further elaboration, the traditional healer will treat both the 
invading ghost and the symptoms of the illness, catering also for the associate psychosocial 
problems of the illness. 
4.10.3 Identification of aggression 
Neither cultural group attempted to predict aggression. Both groups, however, had specific criteria 
by which they defined and identified aggression. 
4.10.3.1 Causes ofa ggression 
Within the Indigenous Knowledge System, the causes of aggression have been linked to mental 
illness, the use of substances, environments and often some degrees of unpredictability. 
Even though both the Khoisan and the Basotho made a link between mental illness and 
aggression, the Basotho indicated that not all mentally ill persons are prone to aggression . 
However, there are definite situations which would invariably add to incidences of aggression, such 
as the behaviour of other persons and even the mere appearance of hospitals which look like 
prisons. Jansen et al. (2003:84) reported similar findings and also linked the use of restraints with 
an increase in aggression. The Basotho feel it is important to remove a person from the situation 
which makes him feel aggressive. These different observed causes as identified by the indigenous 
healers correlate well with findings of Jansen et al. (2006:82) , where the authors elaborate on how 
the attitudes of staff or persons towards a mentally-ill person will influence the behaviour of the 
96 
client. Similarly, Roos (2005:53) reported that taking care of difficult patients will influence the 
behaviour of the nurse negatively. 
This observation by the Indigenous healers is reiterated by researchers within the WBKS as seen 
through the work of (Soliman & Reza, 2001 :77-79; Duxbury, 2002:331-333; Duxbury & Whittington, 
2005:470; lgnelzi et al., 2007:453), where they confirm that confined areas, overcrowding, high 
temperatures, low staffing levels, seclusion and the use of restraints precipitate aggressive 
behaviour. 
4.10.4 Management of aggression according to indigenous knowledge 
Divination of the individual causes of aggression and mental illness is done by either the throwing 
of bones or observation of the patient, which is similarly described by Mufamadi (2001 :93) 
The subsequent treatment and medicine is also divined. It is very individually and culturally based 
and no set protocols are followed as is evident in WBKSs through a reference by Duxbury 
(2002:325), where the author points out that violent and aggressive persons are sedated and 
restrained. 
As observed by the researcher, there seems to be one difference between Western Based 
Medicine and Indigenous Knowledge Systems, and that is the individuation of treatment within the 
Indigenous Knowledge Systems as opposed to the prescription of protocols as often seen in 
Western Medicine. 
The Basotho healers, contrary to the Khoisan community, reported that they are well equipped to 
deal with aggression due to the nature of the training they underwent when they became "Ngaka" 
(Indigenous Healers). Berg (2003:196) echoes this self-awareness of the indigenous healers 
through reporting that the rigorous training of the indigenous healers made them skilled 
psychotherapists. 
Unfortunately, the flip side of the coin also holds as both the Basotho and the Khoisan reported that 
there are incidences where destructive methods are used to manage aggression . They are 
convinced that these methods add to the aggression , and are destructive in nature. 
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4. 10.4.1 Verbal management of aggression 
The calmness in the voice, when communicating with a person who is aggressive, was noted by 
both the Basotho and the Khoisan. A theme that emerged from both groups is to make the 
aggressor feel comfortable, through inviting them to sit down and not necessarily communicating 
but just having a calm presence. 
Verbal management for both cultures included a form of debriefing which relied on the correct 
timing , which is when the aggressor is calm. There would be negotiations and consultation about 
the causes and the effect of the aggressive behaviour. 
The role of a mediator, in this case the Indigenous healer, is very important as they would also talk 
to the family and involve them, explaining to the family what is happening with the patient. This 
family involvement is also noted in the study by Mufamadi (2001 :95) , which confirms the 
importance of the African principle of family involvement and Ubuntu. Not only will this involve the 
family. It will help strengthen the family bond and foster re-integration of the affected member with 
his family. 
4.10.4.2 Physical management of aggression 
Both the Khoisan and the Basotho prefer not to react physically towards aggression and to not 
make use of restraints. However, if the person is a bit calmer, physical contact will become more 
bearable to the aggressor. The decrease of the use of restraints is also recommended by Hopton 
(1995:115) who recommends the use of therapeutic intervention strategies. The physical contact 
would revolve around making a person feel welcome and invited. However, on the odd occasion 
where the person is physically aggressive, it might be necessary to bring the person physically 
under control in order to administer medication. 
4.10.4.3 Do not intervene if no intervention is necessary. 
Both the Khoisan and Basotho informed that often no interaction is necessary other than removal of 
the cause of the aggression (albeit a person or situation). 
98 
4.10.4.4 Medicinal component 
The use of medication plays a role in the Khoisan and the Basotho community. Both groups prefer 
to offer the medication to a person when they are a bit calmer. The Basotho have reported on the 
administration of medication as emergency management even against the wishes of the person . 
Reportedly, they sometimes have to fight a client in order to get him to step over medication to calm 
him down. 
This practice is familiar as the researcher has experienced within Western Based Knowledge and 
practice that MHCU who are out of control often are restrained and medication would be 
administered against their wishes in order for them to be sedated to assist them to gain control over 
themselves and their emotions. 
The difference, however, remains that in WBKS there are set protocols for the administration of 
sedation and the only time these set protocols are deviated from is in instances where there is a 
known allergy or previous adverse reactions to any of the set medications. 
As opposed to the Khoisan, the Basotho felt that the sharing of the medication used during these 
practices is privileged information. 
4.11 CONCLUSION 
The analysis of the data collected during the makgotla provided insightful considerations. The 
researcher noted that the practices have more in common with WBKS than expected . Leininger has 
identified seven cultural and social structural dimensions that influence a person's perception of 
health, illness and care. These Leininger referred to as universals as they occur in all cultures 
(George, 2002:491 ; Tjale & De Villiers , 2004:22). Similar to the theory of Leininger, the researcher 
identified more commonalities than differences between the management of aggression within the 
IKS and WBKS. 
Both IKS and WBKS have identified causes for aggression, and these include mental illness and 
neurological problems. Within both IKS and WBKS, there is administration of some form of 
psychotherapy, ritual and family involvement. Medication plays a significant role in the management 
99 
of aggression associated with mental illness. The causes of aggression will determine the 
management in both the IKS and WBKS. 
Although there are good strategies in the management of aggression and violence, there are 
reported destructive techniques such as shouting or the beating of clients and patients, in the 
management of aggression and violence in both IKS and WBKS. This potentially exists due to a 
lack of training and information about aggression and mental illness and a lack of understanding 
the perspective of the MHCU. Unfortunately, there remains friction between Western Based 
Treatment and Indigenous Knowledge System practices, as Western Based Medicine focuses on 
the physical and materialistic causes of illness, whereas Indigenous Medicine focuses on the 
spiritual origin of the illness, as observed by Richter (2003: 12). 
The proposed conceptual model, as represented below, includes the components which should 
form part of a training course in the culturally safe management of aggression and violence. As is 
evident in the transcripts and analysis of the data, the Basotho and Khoisan go through a similar 
process when dealing with aggression and violence as seen in mental illness. This includes an 
understanding of self, being sensitive to another person's culture, identifying the manifestation of 
aggression, determining the possible causes of aggression and dealing with aggression according 
to the cause. Both the Basotho and the Khoisan are clear that the cause of aggression must be 
removed if the behaviour is to be resolved . Chapter six (6) will focus on the recommendations and 
an in-depth explanation as to how the conceptual map was implemented. 
100 
Figure 4.1 : SIP-DD Concept map of proposed training programme for the management of aggression and 
violence (designed by TM Bock) 
The following chapter will focus on the analysis of the quantitative data collected pre and post the 
administration of treatment compartments, based on a training package inclusive of knowledge 
shared by the Basotho and Khoisan healers and the literature availed to the participants in the 
respective hospitals described in Chapter (3) three. 
101 
I ·Nwu -CHAPTER 5 llBRAf!YJ 
QUANTITATIVE PHASE: RESULTS, DATA ANALYSIS, INTERPRETATION 
AND DISCUSSION 
5.1 INTRODUCTION 
This study is an exploratory sequential research with a qualitative phase consisting of makgotla. 
The data generated was used to refine a training programme, which was presented as part of a 
pre- and post-test. The study endeavoured to determine whether a training programme focused on 
culturally safe management of aggression and violence which includes training in cultural safety 
and awareness will influence the attitudes of mental health care providers in the management of 
aggression in MHCU. 
The previous chapter (chapter four) focused on the results, data analysis, interpretation and 
discussion of the findings of the qualitative phase. The present chapter focuses on the results, data 
analysis, interpretation and discussion of the quantitative phase. 
This quantitative phase of the exploratory sequential mixed method project entailed a pre- and a 
post-test used to determine if the training programme (treatment) influenced the attitudes of 
respondents towards the management of aggression and violence. This pre- and post-test was 
administered to all groups, even the control group, as it is possible that the questionnaires used 
might influence the attitudes of respondents towards the management of aggression and violence. 
For this research, the researcher used a non-directional hypothesis, namely: "The administration of 
a training programme will effect attitudinal changes towards the management of aggression and 
violence in respondents". 
5.2 TRAINING PROGRAMME (TREATMENT) PHASE OF THE RESEARCH 
PROJECT 
The training programme (treatment) in this quasi-experimental design required the presentation of a 
course to manage aggression and violence. This training programme was developed after a 
consultation of relevant literature and the inclusion of the indigenous knowledge obtained during the 
qualitative phase of this research project, as will be elaborated on in section 5.2.3. 
102 
The researcher used the Management of Aggression and Violence Attitude Scale (MAVAS), and 
the Cultural Sensitivity and Awareness Scale in the pre- and post-test. The timing of when to 
administer the post-test was randomly selected and is described in the next section. A different 
sequence of the training programme (treatment) was presented in four different provinces in an 
attempt to prevent cross contamination of respondents which would have been likely if the 
researcher used different wards within one hospital or even possibly different hospitals within one 
province. The allocation of the groups and training programme (treatment) for this non-equivalent 
group design was selected as described in Chapter three, and is elaborated on in the following 
section. 
5.2.1 Administration of the mavas and the cultural awareness and sensitivity 
questionnaires and training programme (treatment) 
The administration of the training programme (treatment) was randomly selected, as described in 
chapter three, section 3.4.1 .1. 
The researcher administered the post-test at different intervals for the different experimental 
groups. 
Group one (1) (Northern Cape) : This group was given the pre-test which they completed; thereafter 
they received the literature to read at leisure and were requested to return the post-test to the 
researcher via e-mail. The CEO of the institution reassured the researcher that the three staff 
members who did not have access to e-mail could send their questionnaires back via his e-mail. 
Unfortunately only one (1) respondent answered the post-test; hence the data collected in the 
Northern Cape is disregarded. 
The researcher felt morally compelled to expose all participants to the total training programme 
(treatment) as it focuses on cultural sensitivity, predictors of violence and safe break away 
techniques; hence the researcher assumes this to be beneficial to all participants. Therefore, with 
this in mind, the researcher interrupted the training programme at different intervals for the 
respective hospitals in order to do the post-test and provide the total training programme. 
This moral obligation further compelled the researcher to also provide the control group with all of 
the course material to read at leisure after she received the post-test from them via e-mail a week 
later as agreed upon. 
103 
Group two (2) (Western Cape): The group was also given the consent form as well as both the pre-
and post-test when they arrived for the training programme. The Post-test for all experimental 
groups was marked with a red sticker and a number which corresponded with the pre-test 
questionnaire to allow the researcher to differentiate between the pre- and post-test when capturing 
the data. The training programme (treatment) for group two entailed: 
• Management of aggression, understanding aggression and theories on aggression 
• Break away techniques 
• Safe restraining 
• De-escalation techniques 
• Cultural safety 
After the completion of the total training programme, the participants were given an opportunity to 
complete the post-test and place it in a sealed box provided by the researcher. 
Group three (3) (Gauteng), received training in the following sequence: 
• Management of aggression, understanding aggression and theories on aggression 
• Cultural safety 
• Break away techniques 
• Safe restraining 
• De-escalation techniques 
The researcher administered the post-test for group three (3) directly after the presentation of 
management of aggression, understanding aggression, theories on aggression and cultural safety. 
The participants completed the questionnaires and placed it in the sealed mailbox provided . 
Thereafter, the rest of the training programme followed. Noteworthy in Gauteng a reported 
n14=82% of respondents have received training in the management of aggression and violence. 
Group four (4) (North West Province): The training programme for this group commenced with 
Cultural safety and awareness and then the post-test was administered. Similarly, the respondents 
had to place the post-test in the sealed box as per the other provinces. After the completion of this 
post-test the respondents received the rest of the training programme. 
104 
• Cultural safety 
• Management of aggression , understanding aggression and theories on aggression 
• Break away techniques 
• Safe restraining 
• De-escalation techniques 
5.2.2 Context of the training programme 
Data was only collected in those provinces and hospitals that responded and consented to the 
researcher's application to conduct the research project there. 
Evident from the correspondence in Annexure seven (7), the hospitals made it clear that it is 
difficult to release any staff to attend the proposed training as there are severe staff shortages. 
Furthermore, it was emphasised that the participation is voluntary. The researcher was dependent 
on the support of the Nurse Mangers and Chief Executive Officers at the respective hospitals to 
release staff for the proposed interventions. 
The participants in this research were staff working in the acute-, sub-acute-, admission-, forensic 
admission and adolescent units of the respective hospitals. The population included all members of 
the multidisciplinary team namely all categories of nursing staff such as auxiliary nurses, enrolled 
nurses, registered nurses, registered psychiatric nurses, advanced psychiatric nurse practitioners, 
operational managers, occupational therapists, occupational therapist assistants, speech 
therapists, medical officers and registrars in some provinces. The homogeneity of these groups lies 
in them all being members of the multidisciplinary team working in acute psychiatric units. 
Those hospitals who consented to the research and the training programme provided the 
researcher with a venue for presentation of the training. The researcher provided all training 
material, and the equipment such as the laptop and data projector. In addition to training materials , 
the researcher provided refreshments such as coffee, tea and biscuits during the allocated tea and 
lunch breaks. 
5.2.3 Development of the curriculum for the training programme 
As stated, the researcher already developed the foundational curriculum and followed the 
guidelines as set out by Arend Carl to identify gaps in the existing curriculum and then proceeded 
105 
to refine the curriculum (Carl , 1995:40). During 2010, the researcher obtained baseline data 
through a previous study and identified the gaps through comparing the responses of participants 
to the ideal responses on the MAVAS questionnaire. This baseline data was augmented through a 
literature review and it became the basis of the foundational programme. The data obtained during 
the qualitative component of this exploratory sequential research was then added to this 
foundational programme. The result is a combination of professional, western-based knowledge 
and indigenous knowledge from the community, to form a curriculum which includes "common 
knowledge" and cultural sensitivity and awareness in the management of mental health care user 
related violence. This approach to curriculum development is referred to as the academic approach 
by Carl (1995:39, 47) . 
The convergence of data took place during the development of the refined curriculum available in 
Annexure 2, and the adaptation made to the MAVAS questionnaire to suit the practices used in the 
provision of mental health care here in South Africa. 
5.2.4 Nature of the training programme/curriculum 
The researcher integrated Fink's taxonomy of significant learning when she designed the outcomes 
for the curriculum and training programme. The researcher deems this taxonomy by Fink to be the 
quintessential taxonomy to be utilised in the training programme for the management of aggression 
and violence. 
The development of any training course that promotes significant learning consists of five steps as 
identified by Fink (2003:5). These steps, according to Fink (2003:5), are explained in the next 
section with further explanation as to how it was applied to the training programme (treatment) as 
designed by the researcher. 
The researcher applied these steps to the training course as explained in section 5.2.3.1 to 5.2.3.5. 
5.2.4.1 Step one (1): Consideration of situational factors such as instructional 
challenges of the course, and expectations from the learner and how the 
course will fit into the larger curricular context 
As advised by Fink (2003: 1) the researcher, after the lekgotla, combined the information from the 
makgotla and used the nature of the questions on the MAVAS questionnaire along with current 
106 
literature available and formulated outcomes for the curriculum. Thus the curriculum is based on 
the important learning goals identified during the above mentioned engagement results obtained 
from the study conducted by the researcher in 2010, (Bock, 2010). 
5.2.4.2 Step two (2): Learning goals. What do you want the learner to learn that 
would stay with them for years? 
• Understand the phenomenon of aggression as part of the Foundational knowledge identified 
through the application of Fink's taxonomy (Fink, 2003:9) . 
• Apply the newly acquired knowledge to effectively manage aggression and violence, 
through critical thinking. 
• Integrate knowledge about aggression to identify and eliminate causative factors. 
• Understand self and other human beings as alluded to in the Human Dimension aspect of 
Fink's taxonomy, (Fink, 2003:8) . 
• Show caring towards the client through being culturally aware and safe. 
Figure 5.1: Fink's taxonomy of significant learning 
107 
5.2.4.3 Step three (3): Feedback and Assessment procedures. What will the 
students have to do to demonstrate that they have achieved the goals of the 
training course? 
In terms of Fink's taxonomy of significant learning, the researcher set up the following 
outcomes for this course: 
• On completion of this training package, the learner will be able to diagnose the early signs 
of mental health care user related aggression before it escalates into violence. 
• The learner will be able to identify potential causes of aggression. 
• The learner will be aware of their own perception of the management of aggression and 
violence. 
• The learner will be able to deal with a mental health care user in a culturally aware and 
sensitive manner, 
• The learner will be able to de-escalate aggression to a manageable level. 
• The learner will be able to apply break away techniques which will allow them to break free 
from holds without injuring themselves or the mental health care user. 
• The learner will be able to safely restrain MHCU where such methods are indicated. 
The feedback from the learners was obtained through evaluating their responses on the MAVAS 
and Intra Cultural Sensitivity Scale, this provided further insights in terms of where the training 
programme should be tweaked. Furthermore, it conforms with Fink's assumption that change in a 
learner is an indicator of learning which took place (Fink, 2003:3) . This form of assessment is 
forward looking assessment according to Fink (2003:14), a form of assessment where the teacher 
anticipates situations where the learner will require the knowledge and paints scenarios as close to 
real life as possible where she expects the learner to solve the problem. This is exactly the format 
the researcher used when she presented the training programme to the different experimental 
groups. 
5.2.4.4 Step four (4) Teaching and learning activities. How would you involve the 
students? 
Learners were involved through sharing experiences and they were requested to make 
recommendations pertaining to scenarios sketched by the course presenter, as explained in the 
108 
previous section. The use of the language skills during de-escalation of aggression was managed 
through role play. 
During the presentation of the dignified break away techniques and safe restraint, it required the 
active physical participation of the learner and learners had to physically demonstrate the ability 
and competence to apply the skill taught. 
5.2.4.5 Step five (5): Make sure the key components are all integrated 
The researcher attempted to integrate all levels of the course as the participants were from vastly 
different levels of education and had different pre-knowledge. The researcher constantly evaluated 
the pre knowledge and encouraged discussion and self-reflection in all participants. 
Further, integration focused on catering for cultural awareness and sensitivity into all components 
of the course. 
5.3 PRESENTATION AND ANALYSIS OF THE DATA 
Burns and Grove (2011 :372) highlight the process followed for data analysis, elaborating on how 
data will be prepared for the analysis, description of the sample and the reliability of the 
measurements used. The hypothesis as well as questions that the research project wishes to 
answer guide the researcher and the statistician as to which statistical methods to use. 
The two questionnaires in this project, namely the MAVAS questionnaire and the lntercultural 
sensitivity questionnaire, both collect ordinal quantitative data. This raw data was then captured on 
a Microsoft Excel spreadsheet and the researcher computed central tendency (the mean, mode, 
median). Brink (1987:56) advises that the mode and the median should be the calculation of choice 
when dealing with ordinal data. 
Descriptive statistics was used to describe the demographic data and these are represented in 
tables, cone and bar diagrams. The captured raw data was submitted to a registered statistician, 
llja de Boer, who used the SAS Version 9 data analysis software. 
The relationship between responses, within the experimental group and between experimental 
groups, was calculated by means of the t-test because there is an intervention involved in three 
109 
independent samples (Burns & Grove, 2011 :404) . Two tailed tests of significance were computed 
due to the non-directional hypothesis (N1) set by the researcher. The non-directional hypothesis set 
by the researcher indicates that a significance level of 0.05 scores will be higher or lower than 95% 
of the population. Burns and Grove (2011 :380) elaborate and state that in such a case, a= 2, 5% of 
the extreme statistical values will be in two tails of the extremes and would not be statistically 
significant. At this significance level of 0.05, p<0.05 will represent statistical significance. Therefore 
this level of significance means there is a 5% probability of error, or that the researcher is 95% 
confident of the findings. 
5.4 RES UL TS OF THE DAT A 
This section of the chapter presents the data generated during data collection for both the pre-tests 
and post-tests of all three experimental groups. It contains the descriptive statistics, the 
questionnaires and research objectives. 
5.4.1 Demography of the respondents 
5.4. 1. 1 Gender of the participants 
Table 5.1: Gender of participants 
North West Province Northern Cape Western Cape Gauteng 
Frequency Percentage Frequency Percentage Frequency Percentage Frequency Percentage 
Gender 
(1' {%} (1' (%} (1' (%} (1' (%} 
Male 53 32 4 33 11 46 5 29 
Female 115 68 8 67 13 54 12 71 
Total n=68 100 n=12 100 n=24 100 n=17 100 
68% female and 32% male for North West, 67% female and 33% male for Northern Cape, 54% 
female and 46% male for the Western Cape and 71 % female and 29% male for the Gauteng 
experimental group is representative of the target population due to nursing being predominantly a 
female dominated profession in South Africa. 
The only variable the researcher attempted to control was the type of ward where the respondents 
worked. The homogeneity of the respondents was mainly a result of being part of the 
110 
multidisciplinary team working with acutely ill MHCU in the acute admission units as per the Mental 
Health Care Act (17 of 2002). 
5.4. 1.2 Training received in the management of aggression and violence 
Table 5.2: Table of training received. 
North West Province Northern Cape Western Cape Gauteng 
Training Frequency Percentage Frequency Percentage Frequency Percentage Frequency Percentage 
received (1' (%) (1' (%) (1' (%) (1' (%) 
Yes 17 10 4 33 6 25 14 82 
No 152 90 8 67 18 75 3 18 
Total n=169 100 n=12 100 n=24 100 n=17 100 
The previous table (5.2) reflects the total population of N 222, with a reported 18.5% of the overall 
respondents reportedly having received training in the management of aggression and violence . 
The opposite holds, namely that the majority of 81 .5% respondents had never received any form of 
training in the management of aggression and violence in MHCU. The different experimental 
groups reflect this overall percentage very closely with North West reporting 90% of respondents 
not having undergone training. The Western Cape is a close second at 75% followed by the 
Northern Cape with 67%. Gauteng is the exception to the rule and 82% of respondents indicated 
that they had received training in the management of aggression and violence. A similar 
observation with reference to gender in nursing was made by Bock (2010) during a previous 
baseline study conducted in the Western Cape. 
111 
5.4. 1.3 Years of experience in the different groups 
Table 5.3: Years of experience with student population included 
North West Province Northern Cape Western Cape Gauteng 
Years of Frequency Percentage Frequency Percentage Frequency Percentage Frequency Percentage 
expe- (~ (%} (~ (%} (~ (%} (~ (%} 
rience 
<1 year 151 91 1 9 17 71 0 0 
1-5 years 10 6 3 27 5 21 3 19 
6-10 1 1 2 18 0 0 2 12.5 
years 
11-15 2 1 0 0 2 8 2 12.5 
years 
16-20 0 0 0 0 0 0 2 12.5 
years 
21-25 1 1 1 9 0 0 5 31 
years 
26-30 1 1 2 18 0 0 2 12.5 
years 
>30 0 0 2 18 0 0 0 
Total 166 100 11 100 24 100 16 100 
The participants in this research project, as reflected in the table above, are spread across the table 
which is divided in categories of 5 years. 97% of participants in North West had between one and 
five years of experience, whilst there was a similar observation of 92% of participants for the 
Western Cape. The Northern Cape reported the highest level of years of experience in the one (1) 
to 10 year group namely 45% of respondents. 
Not all of the participants completed this questionnaire. Three (3) respondents in North West, 1 in 
the Northern Cape and 1 in Gauteng did not answer this question. The following cone shaped 
histogram shows the distribution of the years of experience of all the participants in the different 
experimental groups. 
The cone shaped histogram below makes it visible that the majority of the respondents for the total 
population had between one (1) and five (5) years of experience as mental health care providers 
employed in acute admission units of mental health care facilities, as described and set out in the 
Mental Health Care Act (17 of 2002). 
112 
18 
16 
14 ■ North West Province (students 
12 excluded) 
10 ■ Northern Cape 
8 
6 ■ Western Cape 
4 
■ Gauteng 
2 
0 
<1 1-5 6-10 11-15 16-20 21-25 26-30 >30 
year years years years years years years 
Graph 5.1: Graphic representations of the years of experience for the total group of respondents 
8 
7 
6 
5 
4 
I 
3 ■ Gauteng 
2 
l I I ■ Northern Cape 
1 1 l II l rn 1 i l 1 ti ■ Western Cape 
0 
~...  (l) (l) (l) (l) (l) u ... ... 
' J l 
... ... ... ... ... > f- C +" +" +" 
... ... 
V, V, V, V, V, ·.::: (l) +" ro C 0 V, V, (l) (l) ■ North West (l) +" OD ·.::: 0 ro +" 'i: u 'o.. 
+" OD 
:::I :::I :::I :::I :::I ... 
z z z re re :::I 
:g +" u +" ro 
C C ..c. C u C .!!! 0 re 
re 0 
".C.. ... C  (l) +" "C "C u u ro (l) ..c. V, 0 V, :.c (l) C. re 
re 
~ .>..  C 
Vl u u ..c. 
re ~ .(.l.)  ·.::: > E V, (l) <I: > +" E 
(l) +" 
V, .!!! e 
+" 
(l) re a.. +" f- V, 
+" ni f- 0 a.. 
..c. ~ 
u V, 
V, "C C 
E V, C ·oo ..c. 0 (l) ·.::: V, u (l) 0 LU ... > u ·.;::; (l) u0  <I: (l) V, C a.. re r..o.  C. V, 
> (l) 
"C C. 
<I: 0 
Graph 5.2: Representation of the different occupational classes who took part in the research 
5.5 RESPONSES ON THE MAVAS QUESIONNAIRE 
These sections will present data with regards to what the attitudes of mental health care providers 
are towards the management of aggression and violence during a posttest and if the treatment 
intervention had any effect on the attitudes of mental health care providers. 
113 
The respondents were instructed to use the response keys as set out in the MAVAS questionnaire 
to determine their agreement or disagreement using a (✓) with each of the 27 statements in the 
MAVAS questionnaire. The response keys were as follows: 
• Strongly agree 
• Agree 
• Disagree 
• Strongly disagree 
5.5.1 Rationale for the pre-test and the post-test 
The aim of the post-test was to address the null hypothesis (H.) namely, to determine if the 
treatment administered had an effect on the participants. The null hypothesis (H.) for this test 
stated, 'The training programme will have no effect on the participants in this research ." The non-
directional hypothesis stated that the training programme will have an effect. The administration of 
three different training programmes (treatment) was compared: 
5.5.2 Discussion of the results on the MA VAS questionnaire 
The MAVAS questionnaire consists of 27 questions as stated in section 5.5. All questions were 
answered by the respondents in the project, and the results will be discussed question by question. 
The researcher discarded the questionnaires where respondents only completed the pre-test. In 
North West, 11 participants only completed the pre-test and submitted empty post-test. The 
researcher discarded this data as it would have skewed the results of the post-test. 
As stated, the results for the Northern Cape who were the randomly selected control group was 
also discarded as only one respondent completed the post-test. The computed results for each 
question will be represented by a bar diagram and table , then an interpretation of the results will 
follow. This chapter will conclude with a summary of the findings. 
The analysis of the findings in the MAVAS questionnaire will be further discussed in section 5.6. 
114 
5.5.2.1 Question one (1). Patients are aggressive because of the environment 
they are in 
t-Test Paired Two_Sample for Means a 0.05 
GAUTENG 
PREQl POSTQl dill 95%C onfidence lntmal 
82.4% Mean 2.0S8823S3 l.8823S294 0.176 --O.m 0.630 
Variance 0.43382353 0.485294ll 
Observations 17 17 
Pearson Correlation 0.1522389 
Hypothesized tiAe:an Difference 
df 16 
tStat 0.824 
,PIT<=t) one-tai l 0.211 
Stroot,, aeree/aeree Strong!ydisagree/dsagn,e TC ritical one-tail 1.746 
:1GAUTING 765" 82.4" 23.5!1 17.6!1 cannot Reject Null Hypothesis because p >0 .05 (Means are the same) 
PIT<=t) two-tail 0.422 
TC ritical Two-tail 2.UO 
cannot Reject_ _ Nu l_l_Hyl'_Ot_hesis because p >0.05 (Means are the same) 
t-Test: Paired Two Sample for Means a 0.05 
NORTHWEST 
94.5% PREQl POSTQl dill 95%C onfidence Interval 
Mean 2.076923(1! l .<I06S9341 0.670 0.476 0.864 
Varianc-e ----- 0.58=98 0.48840049 
Observations 91 91 
Pearson Correlation 0.19062234 
Hypothesized Mean Difference 
df 90 
5.5% 
tStat 6.864 
Post-test PIT<=t) one-tail 0.CXXJ 
Stront,, agn,e/agre, Strongydisagree/<lsa@re• TC ritical one-tail 1.662 
- ■ NORTli W!ST 73.6% 945!i 26.4" 5.5" Reject Nu ll Hypothesis because p <0 .05 (Means are Different) 
Pl~ =t) two-tail 0.CXXJ 
TC ritical Two-tail 1.987 
Reject Null_ Hypothesis_because p <0 .05 (Means are Different) 
t-T~st: Paired Two Sample for Means a 0.05 
WESTERN CAPE 
PREQl POSTQl dill 95%C onfidence Interval 
83.3% 
Mean 2.41666667 1.58333333 0.833 0.090 1.577 
Variance 1.73188<!06 0.94927536 
S4.2% Observations 24 24 
Pearson Correlation -0.16389413 
Hypothesize~ Me_a~-~~~!ence 0 
df 23 
tStat 2.318 
PIT<=t) one-tai l 0.015 
:>rt-test Post-test TC ritical one-tail 1.714 
Stron~ agree/agree Stronjj-1d.agrtt/clsagree 
I Reject Null Hypothesis because p <0 .05 (Means are Different) . I W£STIRN CAPE ◄s-8% 83.3" 54 .2~ 16.7!1 
PIT <=t) two-tail 0.030 
TC ritical Two-tail 2.069 
Reject Null Hypothe_sis_beca_use p < 0.05 (Means are Different) 
Graph 5.3: Patients are aggressive because of the environment they are in 
Questions for both the pre-test and the post-test were answered by all respondents , namely 
Gauteng n=17, North West n=91 , and Western Cape n=24. 
During both the pre-tests, the majority of the respondents show agreement with this statement. 
115 
5.5.2.2 Question two (2). Other people make patients aggressive or violent 
t-Test: Paired Two Sample for Means a 0.05 
GAUTENG 
PREQ1 POSTQ1 dill 95%C onfidence Interval 
88,2" 
Mean 188235294 -0.118 -0.S9S 0.3S9 
Variance 0.610294U 0.37S 
Observati ons 17 17 
Pearson Corre lation 0.lll4S6 
Hy~thesized Mean Differe~ce 0 
17.6% df 16 
11.8% tStat -0.523 
P(T<=t) one-tail 0.304 
Pft·l,ll P<>5Ml'st TC ritical one-tai l 1746 
S.00g!-,'(f5>trt(/dsa,,tt cannot Reject Nul l Hypothesis because p >0.05 (t.Aeans are the same) 
I GAlll'ENG P(T<"1) two-Uli l . O.ra! 
TC ritical Two-tail 2.UO 
Cannot Reject Null Hypothesis because p > 0.05 (t.Aeans are the same) 
t-Test: Paired ~~_oSample for Means 0.05 
NORTHWEST a 
89.0% 92.3% PREQ1 POSTQ1 dill 95%C onfidence Interval 
Mean 182417582 153846154 0.286 0.WI 0.470 
Variance 0.S9J964S9 0.4957265 
Observations 91 91 
Pearson Correlation 0.27950244 
11.0% 7.7% 
Hypot~~sized Mean Differ~-~~ 
Post-test P"-tr.st Pail-test df 90 
Stronl',' ag,u/asret SlronW.Vdkagret/dsagrre tStat 3.078 
; ■ NORTHWEST 11.o;.; 7.7" P(T<"1) one-tail 0.001 
TCritic.al one-tail 1.662 
Reject Nul l Hypothesis because p < 0.05_(Means are Different) _ 
P(T<"1) two-tail 0.003 
TC riti cal Two-tail 1987 
Reject Null Hypothesis because p < O.DS (Means are Differe nt) 
a 0.05 
WESTERN CAPE 
PREQ1 POSTQ1 dill 95% Confidence Interval 
79.2% M-ean- ------ -- 2-.2Cfil3333 170833333 0.500 0.DSI 0.949 
Variance 
~8.3% 130253623 llnl014S 
Observations 24 24 
41.7% 
Pearson Corre lation 0.54394792 
20.8% ~Jhesized ~an Oiffere~~ 0 
df 23 
t Stat 2.304 
P" ·t:est ?C6t-~st Prt-~st Post-test P(T<"1) one-ta!'_ 0.015 
StrOfl~ ag~'1agree Stronglydls.agree/du gree T Critical one-tail 1714 
~•-W_'B_TIRN_C_AP~E __SB_. 31_' _~  __79_ .2_,._ ___4_ 1.7_,._ i. __ 20.8" ..... Reject Null Hypothesis be~se p <0.05 (~ans ar~ fferent) 
P(T<ot) two-tail 0.031 
TC ritical Two-tail 
Reject Null Hyp_~.!-~~-~is be~~.se p <O.~ J~ _ans are Different) 
Graph 5.4: Other people make patients aggressive or violent 
In both the pre-test and the post-test all experimental groups show agreement with this statement. 
It is worth noting that there is a significant statistical difference in the North West and the Western 
Cape experimental groups in terms of the pre-test and the post-test results. This effectively implies 
that the training programme had an effect on their attitudes towards the role others play in making a 
patient aggressive. 
116 
5.5.1.3 Question three (3). Patients commonly become aggressive because staff 
does not listen to them 
t-Test: Paired Two Sample for fv'leans Cl 0.05 
GAUTENG 
88.2% PREQ3 POSTQJ diff 95% Confidence Inte rval 
Mean 2.47058824 1-88235294 0.588 0.222 0.954 
64.7% 
Variance 0.51470588 0.36029412 
Observations 17 17 
35.3% 
Pearson Correlation ..... 0.42686736 
11.8% Hypothesized Mean Difference 0 
df 16 
Pn!-~si: T Post•test PosMrst tStat 3.405 
Stron~ Ag~e/agree Stroo§Ydlsa,grte/dugru P(T<=t) one -tail 0.002 
■GAUTENG ! 64 .7" 88.2" 35.3~ ll.89' T Critical one-tail 1.746 
Rel~ct ~ull Hy~~.!.~.~si~_~ecaus_~-~-~-0.05 (ME:_~~-~-~_re Different) 
P{T<=t) two-tail 0.004 
T Critical Two-tail 2.120 
Reject Null Hypothesis because p <0.05 (Means are Different) 
Cl 0.05 
NORTH WEST 
91-1% PREQ3 POSTQ3 diff 95% Confidence Interval 
Mean . 2-16483516 1-51648352 0.648 0.417 0.879 
Variance 0.69474969 0.58583639 
Observations 91 91 
Pearson Correlation 0.03923445 
·-·· ~ ...... --
Hypothesized t.Aean Difference 
8.9% 
di 90 
i Post-test tStat 5.576 
Stror.ty ag~c/iljree Stronflydisagrtt/ds.agrr:e. P(T<-t) one-tail 0.000 
: ■ NORTHWEST 65.6% 91.l~ T Critical one-tail 1.662 
Reject Null Hypothesis because p < 0.05 (Mea~s are Different) 
P(T<-t) two-tail 0.000 
T Critical Two•tail 1.987 
Reject Null Hypothesis because p < a.OS (Mea~s are Different) 
t·Test: Pa ired Two Sample for Means 0.05 
WESTERN CAPE 
PREQ3 POSTQ3 ditt 95" Confidence Interval 
83.3% 
Mean 2.29166667 1.54166667 0.750 0.314 1.186 
Variance 1.08514493 0.7807971 
54.2% ,_ Observations 24 24 Pearson Correlation 0.43495089 Hypothesized Mean Difference 0 df 23 16.7% tStat 3.560 
P(T<=t) one•tail 0.001 
Prt--ttst ?osMtst P~~st j Post-test T Critical one•tail 1.714 
Suoo~ acree/agree Strongiydis.agree/clsaeree Reject Null Hypot_~-~~is beause p < 0.05 (Mean~_are Different_) 
■ Y.'ESTERN CAPE 54.2~ 833" 45.8" 16.79' P(!._~~l t".'-10--ta~ ------·--- . . ..... ·-'-- _ 0.002 
T Critical Two-tail 2.069 
Reject Null Hypothesis beause p < 0.05 (Means are Different) 
Graph 5.5: Patients commonly becomes aggressive because staff does not listen to them 
All three experimental groups showed an overwhelming initial agreement with this statement, with 
percentages of agreement varying from 64.7% for Gauteng, 65.6% for the North West and 54.2% 
for the Western Cape. The Posttest results with reference to agreement with the statement were as 
follows: 88.2% for Gauteng, 91 .1%  for the North West and 83.3% for the Western Cape. It is 
observed that Gauteng, which only received training in cultural sensitivity and awareness and 
theories around aggression, showed a statistically significant change in attitude as did the Western 
Cape, who received the total training package. Inexplicably the North West group also showed a 
117 
statistically significant change in attitude even though they only received training in cultural safety 
and awareness. It is not clear if the completion of the MAVAS questionnaire might have played a 
role . The researcher will discuss this group's responses on the cultural safety and awareness 
questionnaire, in section 5.6. 
5.5.2.4 Question four (4). It is difficult to prevent patients from becoming violent or 
aggressive 
t-Test: Paired Two Sample for Means 
GAUTENG a 0.05 
PREQ4 POSTQ4 diff 95% Confidence lntmal 
Mean 1.41176471 1.47058814 -0.059 -0.443 0.316 
52.9% 52.9% Variance 0.6323S294 0.38970588 
Observations 17 17 
Pearson Correlation 0.46657707 
Hypothesized Me_a_n D(fference 
df 16 
Stroo~ agree/agrH Stronglydisagree/disagree 
tScat -0.314 
47.1% 52.9% 
P(T<=t) one-tail 0.375 
TC ri tical one-tail 1.746 
cannot Reject_Null_ _ liypothesis because p >O JJ_S (Means are the same) 
P(T<=t) two-tail 0.750 
TC ri tical Two-tail 1.llO 
cannot Reject Null Hypothesis because p >0 .05 (Means are the same) 
NORTH WEST t-Test: Paired~ Sample for Means a 0.05 
PREQ4 POSTQ,4 diff 95% Confidence Interval 
68.1% Mean 1.67032967 1.868131B7 ·0.198 ·0.456 0.060 
Variance 0.9345S433 0.84!XJ841S 
Observations 91 91 
Pearson Corre lation 0.13775409 
Hypothesized_M ean Difference 
df _j __9 0 
Stronlv agree/agree Stronglydtu1gree/dsae:ree tStat ·1.511 
■ NORTHWEST 39.6" 31.9" 60.49' 68 .1% 
P(T<=t) one:tai_l __ 0.066 
TCritical one-tail 1.661 
cannot Re ject Null Hypothesis because p >0.05(Means are the sam•I 
P(T<=t) two-tail . 0.131 
TCritical Two-cail 1987 
cann_ot Reject Nullliypothesis because p >0.OS(Me_ans a_re the sam•I 
t-Test : Paired Two Sample for Means a 0.05 
WESTERN CAPE 
PREQ,4 POSTQ,4 diff 95% Confidence Interval 
Mean 1.115 2.29166667 -0.167 -0.5S4 0.120 
66.7" 
Vari ance 0.89673913 143297101 
Observations 14 14 
Pearson Corre lation 0.65681698 
Hypothesized Mean Difference 
df 13 
tScat -0.891 
P(T<=t) one-cail 0.191 
Stroolv agt!;e/agree 
. ■ WESTERN CAP£ 66.7" 54.2" 33.3';,i, 45.8" T Critical one-tail 1714 
cannot Reject N~II _Hypothesis because p >o _. OSJ_Means are the same) 
P(T<=t}t wo-cai~ _ 0.382 
TC ritical Two-tail 1.069 
cannot Reject Nul l Hypothesis because p >0.05 (Means are the same} 
Graph 5.6: It is difficult to prevent patients from becoming violent or aggressive 
118 
I~ INBRWAUll YJ  
All three experimental groups showed varied responses with the Gauteng and Western Cape 
group. Almost half the respondents found it difficult to prevent aggression. North West, however, 
did not agree with the statement that it is difficult to prevent aggression and violence. 
5.5.2.5 Question five (5). Patients are aggressive because of the environment they 
are in 
t-Test: PairedTw~p~e for Means_ _ (l 0.05 
GAUTENG 
82.4% PREQS P057QS dill 95% Confidence lnteNal 
76.5% 
Mean l .05882353 188235294 0.176 -0.2n 0.630 
Varianct 0.68382353 0.485294U 
Observations 17 17 
17.6% Pearson Correlation 0.33824581 
Hypothesized Mean Difference 
df 16 
Post·t6t 
tStat 0.824 
Strong!ydtsasree/dngiu 
P(T<=t) one-tail 0.211 
■ GAIJTENG 76.55' 82.4" 235'6 17.6'-
T Critical one-tail 1746 
c.annot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail 0.422_ _ 
T Critical Two-tail 2.UO 
cannot Reject Nul l Hypothesis because p >0.05 (Means are the same) 
(l 0.05 
NORTHWEST 
PREQS POSTQS dill 95" Confidence Interva l 
Mean 2.53846154 2.42BS7143 0.110 -0.115 0.335 
54.9% Varianct 0.94017094 0.89206349 53.8% 
Observations 91 91 
Pearson Correlati on 0.36397994 
Hypothesized Mean Difference 
df 90 
tStat 0.971 
Strongiyd5agrtt/ clsagree P(T<=t) one-tall 0.167 
■ NORTHWEST 46.2% 45.l"- T Critical one-tail 1662 
.ea~not Reject ..~ ~!·'·-~~-othesis becaus~p- ~ 0.?5 (Mea~.! ~-'~¥th e same I 
P(T<=t) two-tail ___ _ 0.334 
T Critical Two-tail 1987 
Cannot Reject Null Hypothesis because p > 0.05 (~ans are the same) 
t-Test: Paired Two Sample for Means 0.05 
WESTERN CAPE 
PREQS P057Q5 diff 95% Confidence Interval 
Mean 2.29166667 0.292 -0.182 0.765 
70.8% Variance l.lTI10145 0.7826087 
Observations 24 24 
Pearson Correlation 0.36316n 
Hypothesized ~~-~--~~f~rence 
df 23 
tStat 1273 
P(T<=t) one-tail 0.108 
T Critical one-tail 1.714 
Strongfyd!Slgret./cisagret Cannot Reject Null Hypothesis because p > 0.05 (~ans are the same) 
• WESTERN CAPE 41.7" 29.2% P(T<=t) two-tail 0.216 
T Critical Two-tail 2.1169 
Cannot Reject Nu~_l_ _ !:f)'pothesis because .P. >0.05 (Means are the same) 
Graph 5. 7: Patients are aggressive because of the environment they are in 
All respondents answered this question. As can be seen, the post shows that Gauteng increased 
agreement after training from 76.5% to 82.4%, North West from 53.8% to 54.9% and the Western 
Cape from 58.3% to 70.8%. 
119 
5.5.2.6 Question six (6). Poor communications between staff and patients lead to 
patient aggression 
t· Test: Paired Two Sample for Means CI 0.05 
GAUTENG 
88.2% PREQ6 POSTQ6 diff 95% Confidence Interval 
Mean 2.05882353 176470588 0.294 -0.179 0.76 
Variance 0.43382353 0.69117647 
Observations 17 17 
Pearson Corre lation 0.25513U6 
11.8% 
.t!YP.~-~~~-~-i~~-~--~ -~~--~(~~~~nce 0 
df 16 
P<m-test 
t5tat 1.319 
Strontt agree/aaree 
' ■ GAIJTENG 76.5!< 88.2% 23.5!1 11.8!,\ P(T<=t) one-tail 0.103 
T Critical one-tail 1.746 
Cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(k1) two-tail 0.206 
T Critical Two-tail 2.U0 
Cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
NORTHWEST CI 0.05 
95.6% 
81.3% PREQ6 POSTQ6 diff 95% Confidence Interval 
Mean 1.82417582 1.40659341 0.418 0.216 0.6 
Variance 0.83540904 0.46617817 
Observations 91 91 
Pearson Corre lation 0.29387351 
Hypothesized Mean Difference 0 
?re-test df 90 
!Stat 4.UO 
............................... 
'. ■ NORTH WEST _P(T<=t) one-tail __ __ 0.000 
T Critical one-tail 1.662 
Reject Null Hypothesis because p <0 .05 (Meansare Diffe rent) 
P(T<=t) two-tail 0.000 
TC ritical Two-tail 1.987 
Reject Null Hypothesis because p <0 .05 (Means are Different) 
!-Test: Paired Two Sample for Means CI 0.05 
WESTERN CAPE 
91.7% 
PREQ6 POSTQ6 diff 95% Confidence Interval • 
Mean 
----- 1.91666667 1.5 0.417 0.005 
Variance ---- 1.03623188 0.43478261 
Observations 24 24 
Pearson Corre lation 0.38865017 
--20.8%- Hypothesized Mean Difference 0 8.3% df 23 tStat 2.095 Prt-kst Post-tr.st P(T<=t) one-tail 0.024 Strong!ydi!iagrte/ciugree 
T Critical one-tail 
79.2,. 1.714 j ■ WESTERN CAPE 91.7'6 
Reject Nul l Hypothesis because p <0 .05 (Means are Different) 
P(T<=t) two-tail 0.D47 
T Critical Two-tail 2.069 
_Reject Nul l Hypothesis because p < 0.05 (Means are Different) 
Graph 5.8: Poor communications between staff and patients lead to patient aggression 
With reference to the diagram, it is notable that in all three groups the majority of the respondents 
agreed with the statement. 
120 
5.5.2. 7 Question seven (7). There appears to be types of patients who frequently 
become aggressive towards staff 
t-Test: Paired Two Sample for Means 0.05 
GAUTENG a 
88.2'6 82.4% PREQ7 POSTQ7 diff 9S%C onfidence Interval 
Mean I. 70588235 2.11764706 -0.4U -0.730 -0.094 
Variance 0.47058824 0.48S294U 
Observations 17 17 
17.6% 
11.8% Pearson Correlation 0.600l7102 
Hypothesized Mean Difference 0 
Pr'f'-test Post-test di 16 
Siron~ agru/agr« Stroogydisagrtt/dsasrte !Stat -2.746 
; ■GAi/TENG . 88.2" 82.4" 11.8!1 17.6!< 
P(T<"1) one-tail 0.007 
TC ritical one-tail 1746 
Reject Nul l Hypothes is because p <0 .05 (Means are Different) 
P(T<:t) two-tail 0.014 
TC ritical Two-tail 2.120 
Reject Null Hypothesis_because p <0 .05 (Means are Different) 
NORTHWEST 0.05 
84.6'6 89.0% PREQ7 POSTQ7 diff 95% Confidence Interval 
Mean 1.92307692 174725275 0.176 ·0.0U 0.364 
Variance 0.605U821 0.54652015 
Observations 91 91 
15.4% Pearson Correlation 0.29427444 11.0% 
Hypothesized Mean Difference 0 
Prt-test di 90 
~---+-----StrONy' 1gree/agrtt Stroogtydiugree/di~e tStat I.Sf,() 
' a NORTH WES( 84.69' 89~ 15.4% 11.0% P(T<ot) one-tail_. . 0.033 
TC ritical one-tail 1662 
Reject Null Hypothesis because p <0 .05 (Means are Different) 
P(T <"1) two-tail 0.066, 
TC ritical Two-tail 1.987 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
t-Test: Paired Two_Sample for Means a 0.05 
WESTERN CAPE 
PREQ7 POSTQ7 diff 95%C onfidence Interval 
75.0% Mean 2.08333333 195833333 o.us -0.422 0.672 
Variance 1.55797101 O.S634058 
Observations 24 24 
Pearson Correlation 0.23590134 
Hypothesized Mean Difference 0 
df 23 
tStat 0.473 
Pre -test Post-test Prt-test Post-test 
P(T<"1) one-ta_il .. 0.320 
Strongtydls~t/c:is.18~e 
l ■ wmERNCAPE TC ritical one-tail 1714 34.89' 25.ll!i 
cannot Reject Nul!_HvP.~.t~esis because p > ~05-("1eans are the same) 
P(T<:t) two-tail 0.641 
TC ritical Two-tail 2.069 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
Graph 5.9: There appears to be types of patients who frequently become aggressive towards staff 
All respondents answered this question. Gauteng was the only group which showed a decrease in 
agreement with the statement in the post-test, namely a decrease from 88.2% to 82.4%, North 
West and Western Cape showed an increased agreement, namely 84.6% to 89% for North West 
and 65.2% to 89.0%. 
121 
5.5.2.8 Question eight (8). Different approaches to suit different cultural groups are 
used on this ward to manage patient aggression and violence 
I-Test: Paired Two Sample for Means a 0.05 GAUTENG 
PREQB POSTQB dill 95% Confidence Interval 
Mean 2.58823S19 2.3S294118 0.235 -0.054 0.524 
58.8% 
52.9% 
47.1% Variance 0.63235194 0.61764Jai 41.2% 
Observations 17 17 
Pearson Correlation 0.74711053 
Hypothesized Mean Difference 
Posf-test Pre-test Post-tt.st 
I di 16 
Stron~ agru /agree Stro!lWYdisagrtt/dsagree 
tStat 1.725 
■ GAIJTENG 47.196 58.8% 
P(T<=t) one-tail_ _ _ 0.052 
TC ritical one-tail 1.746 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) ,. 
P(T<:t) two-tail 0.104 
TC ritical Two-tail 2.120 
cannot Reject Null Hypothesis because p >0 .05 (Meansare the same) 
t-Test: Pa ired Two Sample for Means 
NORTHWEST a 0.05 
PREQB POSTQB dill 95% Confidence Interval 
Mean 2.7S824176 2.1978022 0.560 0.336 0.785 
63.7% 61.5% 
Variance 0.91868132 0.98266178 
Observations 91 91 
Pearson Correlation 0.39002309 
Hypothesized~~~ Difference 0 
di 90 
Stronly agrn/11Bree !Stat 4.963 
a NORTHWEST 38.59' 63.7" P(T<_:t) one-tail . O.CXXl 
TC ritical one-tail 1.662 
Reject Null Hypothesis becau~ <0 .05 (Me_~ • Different) 
P(T<:t) two-tail O.CXXl 
TC ritical Two-tail 1.987 
Reject Null Hypoth~_sis because p < 0.05 (Means are Different) 
t-Test: Paired Two Sample for M_ea_ns_ __  a 
WESTERN CAPE ---- 0.05 
PREQB POSTQB diff 9S% Confidence Interval 
75.0% Mean 2.125 1.875 0.250 -0. 267 0.7 67 
65.2% Variance 133152174 0.98369565 
Observations 24 24 
Pearson Correlation 0.35615491 
~pothesized ~~-~.P(ff.~rence 0 
df 23 
tStat lCXXl 
Pre-test 
-~(T<:t) one-taH __  0.164 
Stronly 1g1u/agree 
TC ri tical one-tail 1.714 
■ WESTERN CAPE 65.2!; 
ca_nnot Reje!'I ~~l~pot_~_esis becaus~--~-' 0.05 (Means are_t_~~ same) 
~IT <"1) two-tail_ ___ . 0.328 
TC ritical Two-tail 2.069 
Graph 5.10: Different approaches to suit different cultural groups are used on this ward to manage patient 
aggression and violence 
The majority of the respondents agreed that they use different approaches on the ward. 
122 
5.5.2.9 Question nine (9). Patients who are aggressive towards staff should try to 
control their feelings 
GAUTENG I-Test: Paired Two Sample for Means Cl 0.05 
PREQ9 POSTQ9 diff 95%C onfidence Interval 
70.6% 64.7% Mean l .05882353 l .35294118 -0.294 -0.691 0.103 
Varianc, 0.55882353 0.49264706 
-, --35-.3% ~-~n V V Pearson Correlation 0.43442769 Hyp~~.~.~~·i·~~-~-~a-~--~-i~erence 0 Post-test Fre-test j PosHtst M 
Stronly agru /agree Stronglydisagrtt/dsagree ------------.----U 
■ GAUTENG 70.616 64.7!4 29.◄% 35,3;. t St at --------..----- ".'.:?2!.,. ___ -
P(T<=t) one-tail 0.068 
TC ritical one-tail 1.746 
1?nnot R:ject Null Hypothesis because p >0 .05(~ .ans ~re_the sanie) ~------e-----, 
P(T<=t)two-tail ........ o,1:36. __- --'------------'----, 
TC ritical Two-tai l 2.UO 
cannot Reject Null Hypothesis because p >0 .05 (Means are the same) 
NORTH WEST t-Test: Pai red Two Sample for tv1eans Cl 0.05 
PREQ9 POSTQ9 diff 95%C onfidence Interval 
76.9% 
Mean 2.0769231)! 2.l20879U -0.044 -0.265 0.178 
Variance 0.6940170') 0.61855922 
Observations 91 91 
'~23.1% T.24.-2% Pearson Corre lation 0.13827519 Hypothesized Mean Difference 0 Pre-tr,st Post-~st df 90 
Sb'~ ag~e/agree . Stroogtyd'iwgree/tka5ree tStat -0.394 
■ NORTH VJEST j 76.9'! 75.8'1 23.1% 24.2% P(T: =tl_c,~-tail 0.347 
TC ritical one-tail 1.662 
cannot Reject Null Hypothesis because p >0.05 (Meansare the same) 
.!'..(T<=t) two-tail 0.694 
TC ritical Two-tail 1.987 
cannot Reject Null Hypothesis because p >0.05 (Means are the '""'.el .. 
t•Test : Paired Two Sample for Means 
WESTERN CAPE Cl 
0.05 
PREQ9 POSTQ9 diff 95%C onfidenc, Interval 
70.8% Mean 1875' lUS -0.250 -0.561 o.~1 
Variance 0.72282609. 0.46195652 
Observations 24 24 
Pearson Correlation 0.55490256 
29.2% 
20.8% Hypothesized Mean Difference 0 
df 23. 
~-~ tStat -1.661 ' Pre-tr st Post.tr-st Pre-trst Post-tffi P(T<=t) one-tail 0.055 
Stronly agrte/ag1ee Stton'G'rdisag,tt/dsagree 
TC ritical one-tail 1714 
• WESTERN CAPE 79.216 70.816 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail 0.110. 
TC ritica l Two-tail l069· 
cannot Reject Null Hypothesis because p >0 .05 (Means are the same) 
Graph 5.11 : Patients who are aggressive should try and control their feelings 
All respondents answered all questions. The majority of respondents were in agreement with this 
statement, that 70.6% for Gauteng, 76.9% for North West and 79.2% respondents felt that patients 
who are aggressive towards staff should try and control their feelings. This will be discussed in 
section.5.6.1.1 
123 
5.5.2.10 Question 10. When a patient is violent, seclusion is one of the most 
effective approaches to use 
I-Test: Paired Two Sample for Means 
GAUTENG a 0.05 
PREQ10 POSTQ10 diff 95%C onfidence lnteNal 
64.7% 70.6% Mean 2.11764706 0.118 -0.191 0.42 
Variance 0.860294U 0.62S 
Observations 17 17 
Pearson Correlation 0.767!U47 
Hypothesized Mean Difference 0 
df 16 
SlfoNt' ag1u / 1grtt !Stat O.ID! 
· ■ GAIJfENG 64.7" 70.69' 
P(T<at) one-tai l. ... 0.21S 
TC ritical one-tail 
cannot Reject Null Hypothesis because p >0.05 [Means are the same) 
P(T<at) two-tai l 0.431 
TC ritical Two-tai l 2.120 
cannot Reject Null Hypothesis because p >0.05 [Means are the same) 
NORTHWEST I-Test: Paire_dT"'o SalTlple for Means a 0.05 
.PREQlO POSTQlO diff 95% Confidence lnt<Nal 
73.3% Mean 198901099 2.1m230n -0.780 -1022 -0.538 
Variance 0.8332.!U3 102393162 
Observations 91 91 
Pearson Correlation 0.27390049 
Hypothesized Me~if!_erence ..... -
df 90 
Strontt agree/agree Strootfd&lgree/<ISQtee !Stat -6.403 
: a NORTH WEST [ 73.39' 36..3~ 26.,,. 63.,,. 
P(T<at) one-tail 0.IXX) 
TC ritical one-tail 1662 
Reject Null Hypothesisllecause p <0 .05 [Means are Different) 
P(T<at) two-tail_ O.IXXl 
TC ritical Two-tail 1987 
Reject Null Hyp_ol~!~i-~lle_c:ause p <0 .05 (~~~s are_DiUerent) 
t-Test: Paired Two Sample for Means a 0.05 
WESTERN CAPE 
PREQlO POSTQlO diff 95" Confidence lnt<Nal 
70.8% Mean 2.l li 2.2003333 -0.IID -0.434 0.267 ···•· ·•· 
Va ri ance 0.983f/J565 112862319 
Observations 24 24 
Pearson Correlation 0.67569174 
Hypothesized __ Mean Oifference 
df 23 
!Stat -0.492 
P(T<at) one-tai l 0.314 
Stront,, agree-/agr~ Strongtydisagru/<isagrre 
, ■ W£STIRN CA?E 70.B!i 58.3!i 29 .2!i I 41.11< TC ritical one-tail 1.714 
cannot Reje~_Nul_lliy~othesis because p >O:~'-~ -~~s are the same) 
P(T<at)two-ta_il ___ 0.627 
TC ritical Two-tail 2.0f/J 
cannot Reject Nul l Hypothesis because p >0.05 (Meansare the same) 
Graph 5.12: When a patient is violent, seclusion is one of the most effective approaches to use 
All respondents answered this question and it is observed that the majority of the respondents held 
firm beliefs that this is one of the most effective methods to use. 
124 
5.5.2.11 Question 11. Patients who are violent are often physically restrained to 
administer sedation 
t-Test: Paired Two Sample for Means 0,05 
GAUTENG 
94.1% 
PREQll P05TQ11 diff 95%C onfidence Interval 
70.6% 
t.'ean _2.05881353 176470588 0.294 -0.179 0.767 
Variance 0.55882353 0.31617647 
Observations 17 17 
Pearson Correlation 0.03498557 
HY.P~!~-~-~.i.~.:-~--~ -a~ _Di_!!.~~:_n~_e___ _ 
df 16 
Stron!P'fdisagree/disagrtt 
tStat 
j ■ GAUITNG 70.6* 94.1'Jli ----
P{T<=t)one-tail 0.103 
TC ritic.al one-tail 1.746 
Cannot _Re_ject Null tfypothesisbecause p >0 .05 {t.'eans are_the same) 
_P{_,:~_"1) two-tail 0.206 
TC ritic.a l Two-tail 2.120 
Cannot Reject Nul l Hypothesis because p >0 .05 {tie ans are the same) 
t-Test: Paired Two Sample for Means 
NORTH WEST a 0.05 
78.0% 81.1% 
PREQll POSTQll diff 95%C onfi dence Interval 
t.'ean !.~1099 1.92307692 0.066 -0.162 0.294 
Variance 0.81098901 0.69401709 
Observations 91 91 
18.9% Pearson Correlation 0.2062054S 
Hypothesized t.'ean Difference 
T Post -test df 9D 
Stronly agree/agree Strontydis.agree/disa~r tStat O.S7S 
j ■ HORTH WEST 78.ll% 81.1'6 22.0% 18.9% P{T<=t) one-tail 0,283 
TCriticalone-tail !,f,62 
_c:a_nnot Reject Nul l Hypo_t_h~si_s because p >0.05 {tie ans are the same')-- --~ 
~{T<_"l)!vJo:tail O.S67 
TCritical Two-tail 1.987 
Cannot Reject Null Hypothesis because p >0.05 (t.'eans are the same) 
t:Tes_t:Paired Two Sample for Means 0.05 
WESTERN CAPE a -~-------
87.5% PREQll P05TQ11 diff 95%C onfidence Interval 
t.'ean 2.04166667 16666=6667+-__0._ 37_5, 0.838 
Variance 134601449 0.84057971 
Observations 24 24 
Pearson Corr-elat-ion ---------0.4-631-500-! 
Hypothesized tJ.ean Difference 
12.5% 
df 
tStat 
Post-rest 
Stront,, agre e/agree Strongtydisagrtt/dsagree P{T<=t) o~e-tail 0.054 
1■  WESTERN CAPE 66.7¥.i 87.59' 33.3'6 12.5% TC ritical one•tail 1.714 
Cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail 0.107 
TC ritic.al Two-tail 2.069 
Cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
Graph 5.13: Patients who are violent are often physically restrained to administer sedation 
All three groups agreed that they agree with this statement in both the pre-test and post-test. 
125 
5.5.2.12 Question 12. The practice of secluding violent patients should be 
discontinued 
t-Test: Paired Two Sample for Means 
GAUTENG a 0.05 
88.2% 82 .4% PREQll POSTQll diff 95% Confidence Interval 
Mean 3.29411765 3.17647059 0.118 -0.191 0.426 
Variance 0.47058824 0.52941176 
Observations 17 17 
17.6% Pearson Correlation 0.64081552 
Hypothesized Mean Difference 0 
T Poi; t- lest Post-test df 16 
Stronly agrte/aa,te Sttooflydisaa,tt/dsagrt e t5tat 0.808 
■ GAUTENG 11.8" 17.6" 88.2% 82.4" 
P(T<=t) one-tail 0.215 
TC ritical one-tail 1.746 
cannot Reject Null Hypothesis because p >0.05 (Means are the sa me) 
P(T<=t) two-tail 0.431 
TC ritical Two-tail 2.120 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
NORTHWEST t-Test: -~•ired Two Sample for ~ans a 0.05 
PREQll POSTQll diff 95% Confidence Interval 
Mean 2.81318681 2.25274725 0.560 0.288 0.833 
Vari ance 0.97582418 1.05763126 
Observations 91 91 
Pearson Corre lation 0.15636533 
Hypothesized Mean Difference 0 
PrMrst Post-test Prt·test Pos; t-~ I df 90 
StrOffit 1gree/agree Stroogtydl:sagree/ clsagtte tStat 4.11!2 
. a NORTHWEST 69.2" 38.5% P(T<=t) one-tail ... O.IXXJ 
TC ritical one-tail 1662 
Reject Null Hypothesis because p <0.05 (Means are Different) 
P(T<=t) two-tail O.IXXJ 
TC ritical Two-tail 1987 
Re ject Null Hypothesis because p <0 .05 (Means are Different) 
t-Test: Paired _Tw_o -~ _mple for Means a 0.05 
WESTERN CAPE 
PREQll POSTQll diff 95%C onfi dence Interval , 
Mean 2.875 2. 79166667 0.083 -0.526 0.692' 
66.7% 66.7% 
Va ri ance 107ai5217 112862319 
Observations 24 24 
33.3% 33.3% Pearson Corre lation 0.05438463 
Hypothe si zed Mean Difference 
df 23 
tStat 0.283 
Pre-Ust Post-tut 
P(T<=t) one-tail 0.390 
Stronlv agtte/asree Stronglydl\agrtt/dlff8ree 
TC ritia l one-tail 
. • WESTERNC APE 33.31, 33.3'i 1714 66.791: 66.7" 
cannot Reje ct_N~ll __ liypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail .. -~780 
TC ritical Two-tail 2.069 
cannot Reject Null Hypothe sis because p >0 .05 (Means are the same) 
Graph 5.14: The practice of secluding violent patients should be discontinued 
The question of whether seclusion must be discontinued was met with disagreement by a majority 
in Gauteng, North West and the Western Cape. Interestingly, the North West shows a decrease in 
disagreement on the post-test, which will be discussed in section 5.6.1.4. 
126 
5.5.2.13 Question 13. Medication is a valuable approach for treating aggressive and 
violent behaviour 
t-Test: Paired Two Sample for Means 
GAUTENG a 0.05 
88.2% 88.2% 
PREQ13 POSTQ13 diff 95%C onfidence Interval 
Mean 1.94117647 194117647 0.!Dl -0.182 0.182 
Variance 0.3Cll823S3 O.Ja!82JSJ 
Observations 17 17 
11.8% 11.8% Pearson Correlation 0.7976~ 
Hypothesized Mean Difference 
Pml•ll!SI df 16 
Stronglydisa,gree/ i:ISl1~e 
l ■ GAIIT[NG tStat 0.!Dl 11.s;; 1 11-"" 
P(T<=t) one-tai l 0.500 
TCritical one-tail 1.746 
cannot Reject Null Hypothesis because p >0.05 !Means are the same) 
P(T <=I) two-tail l!Dl 
TCriticalTwo-tail 2.120 
_cannot Reject Null Hyp~thesis because?>._0:llS If.leans are the same) 
NORTHWEST a 0.05 
PREQ13 POSTQ13 diff 95% Confidence Interval 
71.4% Mean 2.0l296703 2.16483S16 -0.!l2 -0.lll O.CM;7 
Variance 0.7 65SfiTT7 0. 76141636 
Observations 91 91 
Pearson Correlation 0.40028934 
Hypothesized Mean Difference 
df 'iKl 
Stronglydisagrtt/dsagrre tStat -13IS 
■ NORTHWEST 71.4" 63.79' 28.6'6 36.~ P(T<=tl one-tail 0.0'J6 
TCritical one-tail 1.662 
cannot Reject Null Hypothesis because p >0.05 (Meansare the same) 
P(T<=t) two-tail _ 0.19~ --
TCriticalTwo-tail 1987 
cannot Reject Null Hypothesis because p >0 .05 (Means are the same) 
WESTERN CAPE I-Test: Paired Two_~mple for Me•~---···· . 
a 0.05 
87.5% PREQ13 POSTQ13 diff 95%C onfidence Interval 
Mean 1.833JJ33J 1Eif>666667 0.167 --0.130 0.463 
Variance 1.01449275 O.Eif>666667 
Observations 24 24 
Pearson Correlation 0.722Slroi 
Hypothesized Me_an Difference 0 
12.5% 
df 23 
tStat 1.163 
Pmt-test 
P(T<=t) one-tail 0.UJ! 
Stroo!y •s~e/agtee Stroogt·,.disae;ree/dsasree 
: ■ W[Sl[RN CAPE 75.0% 87.5'6 25.0% 125% TC ritical one-tail 1.714 
cannot Reject N.~ll_~l'JX)thesis becaus~_P> ,_0.05 (Means are the same) 
,P:!Ltwo-~ _om_ 
TC ritical Two-tail 2.CM;9 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
Graph 5.15: Medication is a valuable approach for treating aggressive and violent behaviour 
On the whole, all three (3) experimental groups agreed that medicines are a valuable approach to 
managing behaviour. 
127 
5.5.2.14 Question 14. Aggressive patients will calm down automatically if left alone 
t-Test: Paired Two Sample for "'ans (1 0.05 
GAUTENG 
76.5% PREQ14 POSTQ14 diff 95% Confi dence Interval 
"'an 2.823Sl941 2.58823S29 0.235 -0.152 0.622 
Vari ance 0.S2941176 0.8823Sl94 
Observations 17 17 
Pearson Correlation 0.61860151 
Hypothesized "'an Differen':._ _ 
df 16 
!Stat 1.289 
P(T<=t) one:tail 0.108 
TC ritical one-tail 1.746 
Cannot Reject Null Hypothesis because p >0 .05 (""ans are the same) 
P(T<=tl two-tail _ 0.216 
TC ritical Two-tail 2.120 
cannot Reject Null Hypothesis because p >0.05 ("'ans are the same) 
NORTHWEST t-Test: Paired Two Sainplefor "'ans (1 0.05 
PREQ14 POS7Q14 diff 95% Confi dence Interval 
"'an 2.53846154 2.24175824 0.297 0.034 0.559 61.5% 
Variance 0.89S7265 0.9!ll68132 
Observations 91 91 
Pearson Correlation O.U43706S 
Hypothesized "'an Difference 0 
·-· -- ···-· 
df 90 
5tron~ ~ , /agree tStat 2.24S 
j ■ NORTH W[ST 50.0'4 61 5 '-
P(T<=t_)~ne:~ il 0.014 
TC ritical one-tail 1.662 
Reject Null Hypothesis because p <0.05 ("'ans are Different) 
P(T<=t) two-tail 0.027 
TC riticalTwo-tail 1987 
Reject Null Hypothesis because p <0.05 ("'ans are Different) 
t·Test: Paired Two Sample for Means a 0.05 
WESTERN CAPE 
PREQ14 POSTQ14 dill 95% Confidence Interval 
66.7% 62.5% V"a''" 
2.91666667 2.625 0.292 -0.165 0.749 
ri ance 0.94927536 0. 76630435 
Observations 24 24 
37.5% 
33.3% Pearson Correlation 0.31860709 
Hypothesized Mean Differena 0 
df ~--23 
!Stat 1.320 
..... ,.. ·r ... ,. ... , P(T<=t}o ne-tail 
·- ..... 0.100 ·--
Stronglydlsagttt./ds.agru TCritical one-tail 1.714 
j ■ \.YESTERNC APE 33.3* 37 .S'Jo: 66.7.. 62 .5. . 
Cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t} two-tail 0.200 
TCriticalTwo-tail 2.069 
Graph 5.16: Aggressive patients will calm down automatically if left alone 
All respondents answered this question and across all three groups there were overwhelming 
disagreements with this statement. Notably, after the training programme there were changes in 
attitudes observed, with Gauteng registering decreasing disagreement from 76.5% to 52.9%, North 
West from 50% to 38.5% and Western Cape 66.7% to 62.5%. 
128 
5.5.2.15 Question 15. The use of negotiation could be used more effectively when 
managing aggression and violence 
t-Test: Paired Two Sample for Means 
GAUTENG a 0.05 
88.2% 88.2% 
PREQJ5 POSTQJ5 diff 95% Confidence Interval 
Mean 164705882 164705882 0.!XXl -0.257 0.257 
Varianc.e 0.492647a; 0.492647ai 
Observations 17 17 
11.8% 11.8% Pearson Correlation 0.74626866 
Hypothesized Mean Difference 0 
Prt-te.st llosl-ttlt df 16 
StrooV(disagree/cisag,ee 
!Stat 0.!XXl 
■ GAIJTENG 88.2'1 88.2" U.8" 11.8% 
Pl:T.<=t) one-t~il 0.500 
T Critical one-tail 1.746 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail l .!XXl 
TCritical Two-tail 2.U0 
cannot Reject Null Hypothesis because p >0 .05 (Means are the same) 
_t-Test: Paired Two Sample for Means 
NORTH WEST 0.05 
91.2% PREQJ5 POSTQJ5 diff 95%C onfidence Interval 
Mean 1.92307692 1.65934066 0.264 0.054 0.474 
Variance 0. 76068376 0.49377289 
Observations 91 91 
Pearson Correlation 0.1924S426 
8.8% 
Hypothesized Mean Difference 0 
Post-tie.st Pre -test Posl-test df 90 
Stron~ agree/agre-e StrOflllydisagrtt/ dsagru tStat 2.493 
l • NORTH WEST 81.39' 91.2" 18.71' 8.8% P(!~=t)one-t_~i l__ __ _ 0.007 
TCritical one-tail 1.662 
Reject Nul l Hypothesis because p <0 .05 (Means are Different) 
P(T<=t) two-tai l 0.015 
TC ritical Two-tail 1.987 
Reject Nul l Hypothesis because p <0 .05 (Means are Different) 
t-Test: Paired Two Sample for Means a 0.05 
WESTERN CAPE 
83.3% PREQJ5 POSTQJ5 diff 95%C onfidence Interval , 
Mean 1.91666667 2 ·O.CBJ -0.653 0.486 
Varianc.e 0.94927536 U913043S 
Observations 24 24 
Pearson Correlation 0.22699497 
Hypothesized_Mean Difference 
df 23 
tStat -0.303 
P(T<=t) one-tail 0.382 
TCriticalone-tail 1.714 
[ ■ WESTERN CAPE 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail 0.765 
TCriticalTwo-tail 2.069 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
Graph 5.17: The use of negotiation could b~ used more effectively when managing aggression and violence 
There was consensus in all groups as all respondents agreed with this statement. 
129 
5.5.2.16 Question 16. Restrictive care environments can contribute towards patient 
aggression and violence 
Hest Paired Two Sample for Means a 0.05 
GAUTENG 
82.4% PREQ16 POSTQ16 diff 95" Confidence Inte rval 
Mean 2 1!1764~ -0.118 --0.519 0.lB4 
Variance O.l7S 0.61029412 
Observations 17 17 
23.5% 
17.6" Pearson Corre lation 0.3919368 
,111111111, Hypothesized Mean Differenc.e 
Pmt~st · df 16 
StrOfl~ •B~e/agr« Strongfydisqrt:-e/clsagree t Stat --0.621 
■ GAUTE>IG 17.6% 2.3.5:1. P(k--tjone-tail o.m 
TC ritical one-tail 1746 
C.nnot Reject Null Hypothesis because p >0.05 {f.'eans are the same) 
P(T<"l) two-tail 0.S4l 
TCritical Two-tai l 1120 
C.nnot Reject ~ul_l Hypothesis because P? 0.05_{!1.e_ans are the same) 
a o.os 
NORTH WEST 
95.6% 
85.7% PREQ16 POSTQ16 diff 95" Confidence Interval 
Mean 1.83516484 15(,()43956 0.275 0.057 0.491 
Variance 0.6058fa!I 0.38241758 
Observations 91 91 
Pearson Correlation -0.10603101 
14.3% 
4.4% Hypothesi_zed Mean Difference 
Pre-tut Pre-tut Post-ttst df 90 
; 
Stron¥ aeree/agree Stron;ydisagree/li~gl!!t tStat 1.510 
; ■ NORTHWEST SS.7% 95.6. . 14.3% 4.4" P(T<"l) one-tail 0.007 
TC ritical one-tai l 1662 
Re ject Null Hyp_"!hesis because p <0.05 {Means ~re Different) 
P(T<"l) two-tail.. 0.014 
TC ritical Two-tail 1.987 
Reject Null Hypothesis because p <O.t:6 !Means are Different) 
t-Test: Paire-d Two- Sample for Means a 0.05 WESTERN CAPE -------,--
91.7% PREQ16 POSTQ16 diff 95" Confidenr.e Interval 
Mean ---------~-2-.125- 1.5 0.625 0.161 1.088 
Variance 0.89673913 O.lmi9565 
Observations 24 14 
Pearson Correlation 0.10597146 
Hypothesiz~.d -~an. .~ ff~renr.e 
8.3% df 13 
tStat 1.794 
Pa-test Post-test Pre-te.st Post-test P(T<"l) one-tail 0.005 
Stroogtydisagret/ dsagree TC ritical one-tail 1.714 
l ■ WESTIRNCAPE 66.).. 9L7" 33.3" s.:is; 
Re ject Null Hypothesis because p <0.05 {Means are Different) 
P(T<"l) two-tail........ 0.010 
TCriticalTwo-tail 
Reject Null Hypothesis because p <0 .05 (Means are Different) 
Graph 5.18: Restrictive care environments can contribute towards patient aggression and violence 
All respondents answered this question and the majority of the respondents agreed with this 
statement, that is 82.4% for Gauteng, 85.7% for North West and 66.7% for Western Cape. 
130 
IJ .JNB\fN!AIfT!Y7J  
5.5.2.17 Question 17. Expression of aggression does not always require staff 
intervention 
GAUTENG .t-Test: Paired ~wo Sample for Means a 0.05 
82.4% 
76.5% PREQ17 POSTQ17 diff 95% Confidence Interval 
Mean 3.05882353 0.059 -0.227 0.345 
Variance 0.43382353 0.5 
Observations 17 17 
17.6% Pearson Corre lation 0.67097829 
Hypothesized Mean Diffe rence 
Pre:--trst T Post -test .df 16 
Stron!v aeru/agree Sttonglydisagreejdsagree t5tat 0.436 
j ■ GAIJTENG 17.63- 23.5% 82 .4% 76.5% 
0.334 
1.746 
cannot Reject Nul l Hypothesis because p >0.05 (Means are ~he same) 
P(T<=t) two-tail _ _,__ _o_ .6-6-8+ ___, __ _______  
TCritical Two-tail 2.120· 
Cannot Reject Nul l Hypothesis because p >0.05 (Means are the same} 
NORTH WEST t-Test: Paired Two Sample for Means a _ 0.05 
PREQ17 POSTQll diff 95%C onfidence Interval , 
80.2% 
Mean _ 3.13186813 l.74lli275 0.385 0.143 0.627 
60.4% 
Varianc-e --------~0-.604-6398- 0-.946-5201-5 ---
39.6% 
- -- Observations 91° 91 19.8% -Pe-ars-on- Co-rre-lat-ion- -----,---_- 0.-132+6705-8, --,----..;-- ----------· Hypothesized Mean _Difference o_ Pre-test i PosMest T Post-test ~ ~ Stronty agree/agrtt Stronglydisagrtt/dsag~e t b __________ ,_ 3.fil 
i ■ NORTHWEST 19.89' 39.6% ~ (T<=t) one-tail 0.001 
·r Critical one-tail 1.662, 
Reject Nul l Hypothesis because p <0 .05 (Means are Different) 
P(T<=t) two-tail 0.002 
T Critical Two-tail 1.987 
Reject Nul l Hypothesis because p <0.05 (Means are Different) 
t•Test: Paired Two Sample for ~ans a 0.05 
WESTERN CAPE 
PREQ17 POSTQll diff 95%C onfidence Interval = 
Mean 2.45833333; 2.29166667 0.167, -0.386 0.119· 
58.3% Variance l.1286B19, 0.65036B2 
Observations 24 24 
Pearson Correlation - --0.0401756--
Hypothesized tv\ean Differen~ - ____ 0 
~ B 
tStat 0.624 
'P(T<=t) one-tail 0.269 
i :r Critical one-tail 1714 ■ WESTERN CAPE 
cannot Reject Null Hypothesis bec,use p > 0.05 (Means are-th_e_sa_m_e)~---.------....; 
'p(T<=t) two-tail 0.539 
TC ritical Two-tail 
.Cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
Graph 5.19: Expressions of aggression do not always require staff intervention 
The majority of respondents did not agree with the statement and felt that patient aggression 
requires staff attention. In Gauteng, 82.4% of respondents did not agree with this statement, Whilst 
in North West 80.2% and in the Western Cape 45.8% did not agree with his statement. 
131 
5.5.2.18 Question 18. Physical restraint is sometimes used more than necessary 
GAUTENG a 0.05 
PREQJB POSTQlB diff 95% Confidence Interval 
64.7% Mean 2.70S88235 2.4U7647! 0.294 -0.059 
58.8% 0.647 
Variance 0.72058824 0.38235294 
Observations 17 17 
Pearson Correlation 0.6023567 
Hyp~_~hesized Mean Dlffere_~_ce 0 
df 16 
Strongfydf!iagrtt/dsagrre \Stat 1.768 
■ GAtJTENG 58.8% 
.P(T<=t) one-tail 0.048 
;r Critical one-tail 1.746 
,Reject Null Hypothesis because p <0.05 (Meansare Diffe rent) 
P(T<=t) two-tai l 0.096 
TC riticalTwo-tail 2.120 
:eann~t Reject NuU_Hypothesis because p >0 .05 (t.1eans are the same) 
NORTH WEST t-Test: Paired Two Sample forMeans_ ______a  __o ~-- __ -----'----; 
PREQlB POSTQJB diff 95%C onfidence Interval 
80.0% 
Mean 1.95604396 1879U088 0.072 -0.150 0.JOJ 
·variance 0.84249084 0.81855921 
·observations 91 91 
Pearson Correla-tion -------0-.287-8863-9 -
Hypothesized Mean Difference 0 
Pre-test Post-test Pre- lf:st Post-tr:st df 90 
Strontt agru /agree Stronglydisat!;rtt/dwgree \Stat 0.675 
j ■ NORTH WEST 73.6~ 80.°'6 26.4~ 20.0% P(T<=t) one-tai l 0.251 
TC ritical one-tai l 1.662 
_Cannot Reject Nul l Hypothesis because p >0.05 (Me_an_s.. a r~_the same) 
~(T<=t) two-tail 0.502 
TCritical Two-tail 1.987 
Cannot Reject N_u ll Hypo~sis because p >~(t.1eans are the same) 
t-Test: Paired Two Sample for Means a 0.05 WESTERN CAPE 
PREQ18 POSTQJB diff 95% Confidence Interval 
70.8% Mean 2.29166667 2.08JJJ333 -0.257 0.674 
Variance 0.5634058 10-362-3188- ----
Observations 24 24 
37.5% Pearson Corre lation 0.25!32035 
29.2% 
HxP.~!~-~-~~.~-~~--~ -~~--~(~-~-~_ence 0 
df 23 
...... \Stat 0.926 ~ 
P(ks) one-tail 0.182 
Stron~ agree/agree Strong!ydisagrtt/dlsagre.? 
37.5'6 29 .296 TC ritical one-tail ■ WE51£RN CAPE 1.714 62.5% 70.8% 
;Cannot Reject Nul l Hypothesis because p >0.05 (Means are the same) 
.P(T<=t) two-tail 0.364 
·rcritical Two-tail 2.069 
Cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
Graph 5.20: Physical restraint is sometimes used more than necessary 
All the respondents agreed with this statement and there is an increase in agreement with this 
statement observable in the post-test. In Gauteng, agreement increased from 41.2% to 64.7%, as 
in North West it increased from 73,6% to 80% and the Western Cape from 62.5% to 70.8% 
132 
5.5.2.19 Question 19. Alternatives to the use of containment and sedation to 
manage violence could be used more frequently 
t-Te_st: Paired Two Sample for Means 
GAUTENG a 0.05 
82.4% 
76.5% PREQ19 P05TQ19 diff 95%C onfidence Interval 
Mean 2.0588BS3 2.235294ll -0.176 -0.630 o.m 
Variance- --- 0.55882353 0.19117647 ---····- --
Observations 
17.6% 23.5% 
17 17 
Pearson Correlation -0.04499213 
Hypothesized Mean Difference 
Post-ttst 
df 16 
S!rOfl&fydisagrtt/cisagriee 
tStat ------- -0.824 17.69' 23.S" 
P(T<"l)~n_e·_tai_l ___  0.211 
TC ritical one-tail 1.746 
cannot Reject Null Hypothesis because p >_~l:5 (Mea~ are the same) 
P(T<"l)two-tai l 0.422 
TC ritical Two-tail 2.UO 
cannot Reject Null Hypothesis because p >0.05 (Meansare the same) 
t-Test: Paired Two Sample for Means 
NORTHWEST a 0.05 
PREQl9 P05TQ19 diff 95%C onfidence Interval 
64.8% 64 .8% Mean 2.14285714 2.1978022 -0.055 -0.273 0.163 
Variance 0.8ll69841 0.69377289 
35.2% 35.2% Observations 91 91 
Pearson Correlation 0.27269413 
Hypo~~e~!-~~-~--~ -~-~--~-~er~-~~e 
Pre-ttst Post-test P"•te st df 90 
i 
Stront,, a,greie/agree Stronglydlsagrtt/<isa&ree !Stat -0.500 
■ NORTH WEST 64.81' 64.8" P(T<"l) one-tail O.lO'J 
TC ri tical one-tail 1662 
cannot Reject Nu ll Hypothesis because p >0 .05 (Means are the same) 
P(T<"l) two-tail 0.618 
TCri tical Two-tail 1.987 
cannot __~ eject Null Hypothesis be~se p >0 .05 (Means are the same) 
t-Test: Paired Two Sample for Means a 0.05 
WESTERN CAPE 
PREQ19 P05TQ19 diff 95%C onfidence Interval 
75.0% Mean 2.25 2.lli ·0.393 0.643 
Variance 0.7173913 1.07065217 
Observations 24 24 
33.3% Pearson Correlation 0.16lll75 
·25.0% ·1 Hypothesi~e~ __M ean D_i_~:renct df 23 tStat 0.499 Strool\' P(T<:t) one-tail ag1u/q rtt. PreS-t!rro~n fn'dUgree/ dsagree i 0.311 
I • WfS!ER,S CA?f 66.7'1 7S.O!I 33.3Ji. 25..DK TCritical one-tail 1.714 
cannot Re je.ctNuUfly~the.sis beouse p >0 .1~ (Means are the same) 
P(T<"l) tw~·tail 0.622 
TC ritica l Two-tail 2.069 
cannot Reject Null Hypothesis because p >0 .05 (Means are the same) 
Graph 5.21 : Alternatives to the use of containment and sedation to manage patient violence could be used 
more frequently 
This question was answered by all respondents and it met with an overwhelming majority agreeing 
with this submission during both the pre-test and the post-test. Gauteng is the only group which 
showed a very slight decrease in agreement with the statement during the post-test. 
133 
5.5.2.20 Question 20. Improved one to one relationships between staff and patients 
can reduce the incidence ofp atient aggression and violence 
_t-_Te_s_t: _Pa_ir_ed_T_w_o_Sa_m~p_le_fo_r_M_ea_ns_ _____a_  __o. os_ _____- s_ __  
GAUTENG 
94.1% 94.1% 
PRfQlO POSTQ20 diff 95% Confidence Interval 
Mean 1.58823529 1.58823529 0.000 -0.257_ 0.257 
Variance 0.63235294 0.63235294 
Observations ------17 17 
Pearson Correlation 0.80232558 
5.9% 5.9% Hypo~esi_zed_~~~ Difference 
T T M U Post•lPtt Pos.t•!Mt 
Stronly aa~e/agre-e Stronglydisagrte/dsagree tStat 0.000 
l ■ GAUTENG 94.l~ 94 .1% 5.9% 5.9'6 P(T_<_=t~) o_n_e_-ta_il_ _________0 .500 
TCritical one-tai l 1746 
Cannot Reject Null Hyp~thesis because p > 0.05 (Means are the same} 
_P(T<=t) two-tai l LCXX>_.. .. 
T Critical Two-tail 2.120 
t-Test: Paired Two Sample for Means 0.05 
NORTH WEST " -------s---
95.6% 98.9% 
PRfQlO POSTQ20 diff 95% Confidence Interval 
Mean 1.38461538 1.23076923 0.154 0.008 0.299 
Variance 0.41709402 0.24615385 
Observations 91 91 
Pearson Correlation 0.2747458 
4.4% Hypothesized Mean Difference 
df 90 
PrHest Post-~t 
Stron~ ag~e/agrtt t5tat 2.103 
■ NORTH WEST 95.6!! 98.9" P(T<=t) one-tai!._ 0.019 
T Critical one-tail 1662 
Reject Null Hypothesis because_ _ e<  0.05 (Means are Different). ... 
P(T<=t) two-tail 0.038 
TC ritical Two-tail 1987 
Reject_NuUHypothesis because p < 0.05 (Means are Different) 
t-Test: Paired Two Sample for Mean_, ______a  0.05 
WESTERN CAPE 
87.5% PRfQlO POSTQ20 diff 95%C onfidence Interval 83.3% 
Mean 175 1.58333333 0.167 
Variance . 106521739 103623188 
Observations 24 24 
Pearson Correlation 0.14484136 
.~P~!~esized Mean Difference 0 
16.7% 12.5% df 
tStat 0.609 
~-test Pon-test Pre-test Post-~t P(T<=t) one-tail 0.274 
Stron>( ~ru/~rtt StronF(disagre@/dsagru T Critical one-tail 1714 
I• W £STERN CAP£ 83.3;. 87.55' 16.7% 12.S!I cannot Reject Null Hypothesis because p > 0.05 (Me.ans are the same) 
_P(T<=t) two-tail 0.548 
T Critical Two-tail 2.069 
cannot Reject Null Hypothesis because p > O.°?JMeans are the same) 
Graph 5.22: Improved one to one relationships between staff and patients can reduce the incidence of 
patient aggression and violence 
All experimental groups showed an overwhelming agreement with this statement and the post test 
for North West and Western Cape shows a 4% increase in agreement. 
134 
5.5.2.21 Question 21. Patient aggression could be handled more effectively on this 
ward 
t-Test: Paired Two Sample for Means 
GAUTENG a 0.05 
100.0% 100.0% 
PREQ2l POSTQ2l diff 95% Confidence Interval 
Mean 1.76470588 1.58823S29 0.176 -0.09S 0. 
Variance 0.19117647 0.2573S294 
Observations 17 17 
Pearson Corre lation 0.38122129 
0.0% 0 .0% Hypot~esized Mean Difference 0 
?osHPSl df 16 
Stroogtydisaptt/dsagru !Stat 1.376 
l ■ GAUTENG , 100.°" I 100.°" o.o;; I 0.0!6 P(T<=t) one-tail 0.094 
TCritica l one-tail 1.746 
cannot Reject Nul l Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail 0.188 
T Critica l Two-tail 2.120 
0.05 
NORTH WEST t-Test: Paired Two Sample for Means ----~- _ a 
93.3% 93.4% PREQ2l POSTQ21 diff 95% Confidence Interval 
Mean 1. 78021978 !.S274lli3 0.253 0.108 0.39 
Variance 0.46227106 0.42979243 
Observations 91 91 
Pearson Corre lation 0.46239253 
6.7% 6.6% Hypothesized Mean Difference 
T df 90 Prt-~st ?ost-ttst Prt- lrst 
Stronlrr agret/"lfee S"""81y<fbagrtt/magree tStat 3.481 
■ NORTHWEST 93.~ 93.4'6 6.N P(T<=t) one-tail 0.000 
T Critical one-tail 1.662 
Rej:~-~~!I Hypot~:~.(~. becaus:__e_~:05 (Mea~~--!~e Different) 
P(T<=t) two-tail 0.001 
T Critical Two-tail 1.987 
Reject Nu ll Hypothesis because p <0.05 (Means are Different) 
a 0.0S 
WESTERN CAPE 
PREQ21 POSTQ2l diff 95% Confidence Interval 
79.2% Mean 2 1.91666667 0.083 -0.309 0.47 
Variance 0.60869S6S 0.86231884 
Observations 24 24 
Pearson Corre lation 0.42008403 
Hypothesized Wiea~.Eiffe rence 0 
df 23 
tStat 0.440 
P(T<=t) one-tail 0.332 
TCritical one-tail 1.714 
I■  WESTERN CAPE cannot Reject Nul l Hypothesis because p >0.05 {Wieans are the same) 
P(T<=t) two-tail 0.664 
TCritica l Two-tall 2.069 
Cannot Reject ~.U~.1.~pothesis ~!::-1.::'.se p >~:~ .{_~ans are the same} 
Graph 5.23: Patient aggression could be handled more effectively on th is ward 
There was a 100% agreement with this statement by Gauteng in both the pre-test and the post-test. 
North West had a 93.3% agreement in the pre-test and a 93.4% agreement in the post-test. 
Western Cape had a 70.8% agreement in the pre-test and a 79.2% agreement with the statement 
on the post-test. 
135 
5.5.2.22 Question 22. Prescribed medication can in some instances lead to patient 
aggression and violence 
t-Test: Paired Two Sample for Means a 0.05 
GAUTENG 
PREQ22 POSTQ22 diff 95% Confidence Interval 
,.,.an 2.41176471 2.58823529 ·0.176 ·0.S92 0.23 
58.8% 
52.9% 
47.1% Variance 1.00735294 0.63235294 
41.2% 
Observations . 17 17 
Pearson Corre lation 0.6llli596 
Hypothesized Mean Difference o, 
T Post-teit di 16 
Strong!yc!isagrtt/dsagree !Stat ·0.899 
: ■ GAUT'ENG 58.87'- 47.1" 41.1" 52.9" P(T<=t) one-tail 0.191 
T Critical one-tail 1.746 
cannot Reject Null Hypothesis because p > 0.05 {Means are the same) 
P(T<=t) two-tail 0.382 
TC ritical Two-tail 2.120 
a 0.05 
NORTHWEST 
PREQ22 POSTQ22 diff 95% Confidence Interval 
75.8% ,.,.an 2.274lli27 2.02197802 0.253 0.036 0. 
61.5% 
Variance 0.82368742 0.84395604 
38.5% Observations 91 91 
·-24.2% ·Pe arson Correlation 0.35249345 Hypothesized Mean Difference 0 di 90 Pre-test Post-test P~-test ! Pu.Mffi f Stton;.i ,grte/agru StronfYd"'g,..Jci»g,,e t Stat 2.320 i • NC>ftTH W£ST 61.S" 75.8% 38.5" 24.2" P(T<=t) one-ta il 0.011 
T Critical one-tail 1.662 
Reject Nu ll Hypothesis because p < 0.05 (Means are Different) 
P(T<=t) two-tail 0.023 
T Critical Two-tail 1.987 
t-Test: Paired Two Sample for Means a 0.05 
WESTERN CAPE 
PREQ22 POSTQ22 diff 95% Confidence Interval 
79.2% 
,.,.an ----------2.29166667 1-916-666-67 ---0.375 ---0.-245 --0.99 
Variance 0.82427536 1.03623188 
Observations 24 24 
Pearson Corre lation -0.16073488 
!iYPOthesized Mean Difference 0 
di 23 
!Stat 1.251 
P(T<=t) one-tail 0.112 
T Cri tica l one-tail 1.714 
■ 'A'ESITRN CAPE 
cannot Reject Null Hypothesis because p >0.05 (""'ans are the same) 
P(T<=t) two-tail 0.224 
T Critica l Two-tail 2.069 
cannot Reject Null_ Hypothesis because p >0.05 (""'ans are the same) 
Graph 5.24: Prescribed medications can in some instances lead to patient aggression and violence 
All experimental groups showed a majority agreement with this statement which increased after the 
training programmes, with Gauteng being the exception to the rule. 
136 
5.5.2.23 Question 23. It is largely situations that contribute towards the expression 
of aggression by patients 
t-Test: Paired Two Sample for Means a 0.05 
GAUTENG 
88.2% PREQ23 POSTQ23 diff 
Mean 1.88235294 2. 23S29412 -0.3S3 
Variance 0.36029412 0.S6617647 
29.4% Observations 17 17 
Pearson Correlation 0.203S0103 
Hypothesi2ed Mean Diffe rence o 
df 16 
!Stat -1.689 
■ GAIITTNG 88.2" 70.6% P(T<=tLone-tail 0.05S 
TC ritica l one-tail 1.746 
Cann.~!. . ~eje~ ..~ ~!.(.. ~ pot.~!~.~ becaus:.P..? o.. ~  I~.ans are th~ same) 
P(T<=t) ~ o-tail O.lll 
T Critica l Two-tall 2.120 
Cannot Reject Null Hypothesis because p >0 .05 (Means are the same) 
t-Test: Paired Two Sample for Means a 0.05 
NORTH WEST 
87.9% 91.2% PREQ23 POSTQ23 diff 95% Confidence lnterva 
Mean 1. 73626374 1.69230769 0.044 ·0.131 0.2 
Variance 0.48522589 0.48205128 
·•· ··•···· 
Observations 91 91 
Pearson Correlation 0.26685324 
12.1% 8.8% Hypo~~.~siz~d ~~.~~ Diffe r~-~~ - 0 
df 90 
Pre-te st PosMest Pre-test :· Po5t.(est t Stat 0.498 
Stron¥ agree/agree Stron~ydisagre,/ clso!fee P(T<=t)~ne-tail 0.310 
■ NORTH WEST 87.9!6 91.2" 12.1!6 8.85; 
T Critical one-tail 1.662 
Can.~~.!. . ~e jMt ~~~_( __H ypothe~-~~ b~ca~s~ __e .?.~-~ (~ans are the Jame) 
P(T<=t) two-tail 0.620 
T Critical Two-tail 1.987 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
t-~est:.Paired.Two Sample for Means a 0.05 
WESTERN CAPE 
PREQ23 P05TQ23 diff 95% Confidence lnterv 
79.2% Mean 2.16666667 l .87S 0.292 -0.111 o. s 
62.5% Variance 0.57971014 o.n282609 
Observations 24 24 
37.5% Pearson Correlation o.30224n2 
Hypothesized~ Difference o 
20.8% 
df 23 
_111111, !Stat 1.497 
~ -~st Post-trst Prt-te st Post-test P(T<=t) one-ta_il_ 0.074 _____ .....,._ 
Stro,W agree/agree s.,..,.,disaom/dsaoree T Cri t ica l one-tail 1.714 
I•W ESTERN CAP€ I 625 " 79.29' 37.59' 20.8" cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(T<=t)_two-ta~--- 0.148 
T Critica l Two-tail 2.069 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
Graph 5.25: It is largely situations that contribute towards the expression of aggression by patients 
All three experimental groups agreed with this statement in both the pre-test and the post-test and 
the null hypothesis (Ho) could not be rejected for any of the three experimental groups. Therefore , it 
is evident that the training programme had no statistically significant impact on any of the 
experimental groups. 
137 
5.5.2.24 Question 24. Seclusion is sometimes used more than necessary 
t-Test: Paired Two Sample .!~r Mean~_ a 0.05 
GAUTENG 
PREQ24 POSTQ24 dill 95% Confidence lnterva 
Mean 2.52941176 2.58823529 -0.059 -0.484 0. 
52.9% 52.9% 
47.1% 47.1% Variance . 0.51470588 0. 75735294 
Observations 17 17 
Pearson Correlation 0.4710775 
Hypothesized Mean Difference 0 
df 16 
!Stat -0.293 
! ■ GNJTENG '. P(T<=t) one-tail 0.387 
TCritical one--tail- -------~- 1.746 
_cannot _Reject Nu_ll Hy~_oth_':~S because p > 0.IJS(Mea~_s are the same) 
,_P(T<=t) ~?·tail___ o.m 
TCritical Two-tail 2.120 
t-Test: Paired Two Sample for Means a 0.05 
NORTHWEST 
86.8% -PREQ24 POSTQ24 dill 95% Confidence lnterva 
Mean 1.93406593 1.62637363 0.308 0.107 0. 
Variance 0.81782662 0.59218559 
Observations 91 91 
Pearson Correlation 0.34739355 
13.2% ..;,.. 
Hypoth~ zed t.Aean Diffe~ ce 0 
Post-test df 90 
Stronlv agree/agree Stronldvdis,gree/d.sag.ree t5tat 3.049 ..;.. 
■ NORTliWEST 71! .0!I 86.8" 22 .0I< 13.2!1 P(T<=t) one-tail 0.002 
T Critical one-tail 1.662 
Reject Nu ll Hypothesis because p < 0.05 (Means are Different)_ ___  
P(T<=tl_!wo-tail . 0.003 
TCritical Two-tail 1.987 
t-Test: Pa ired Two Sample for Means a 0.05 
WESTERN CAPE 
PREQ24 POSTQ24 dill 95% Confidence lnterva 
Mean 2.125 2.25 -0.125 -0.612 0.36 
66.7% 66.7% Variance . 0.89673913 1.23913043 
Observations 24 24 
Pearson Correlation 0.38152441 
33.3% 33.3% 
Hypoth~.~.(~ed ~ -a•~--~ifference 0 
df 23 
!Stat -0.531 
I Ptt·test T PosMest Pre-test P06t-test P(T<=t) ?ne-tail 0.300 Stronlv agree/agree StronsfY'disag,ee/clwe~e T Critica l one•tail 1.714 
: • WESTERN CAPE I 66.7!1 66.7!1 33.391 I l l.391 cannot Reject Null Hypothesis becaus~ p > 0.05 (~ean_s are the_s ame) 
_P(T<=t) 111:'~·tail 0.601 
T Critica l Two•tail 2.069 
Graph 5.26: Seclusion is sometimes used more than necessary 
The majority of all respondents agreed with this statement. All respondents answered this question. 
138 
5.5.2.25 Question 25. Prescribed medication should be used more frequently to help 
patients who are aggressive and violent 
t-Test: ~~~~~ Two Sample to: _~ans a 0.05 
GAUTENG 
88.2% 88.2% PREQ25 POSTQ25 diff 95% Confidence Interval 
Mean 1.82352941 ·0.176 -0.379 0.02 
Variance 0.65441176 o.s 
Observations 17 17 
11.8% 11.8% Pearson Corre lation 0.87409664 
Hypothesi2ed Mean Difference 0 
Pre-tut Pmt-l!est df 16 
Stron~ ~e/agrtt Stronglydlsagrtt/du g~e !Stat -1.8S2 
f ■ GAUITNG 88.2" 88.2" 11-8'1 1 11"" P(T <:t) one-tail 0.041 
T Critical one-tail 1.746 -l----
Reject N~!I Hypothesis because p <O .~J.~ans are Differe_nt) 
P(T<:t) two-tail 0.083 
T Critical Two-tail 2.UO 
cannot_R~ct N~j!_liypothe_s_~_~cause P.~.-~:.05.!~."."~.are the same) 
t-Test: Pai red Two Sample for Means a 0.05 
NORTHWEST 
PREQ25 POSTQ25 diff 95% Confidence Interval 
68.1% Mean 2.10989011 l21978022 -0.110 ·0.333 0.1 
57.1% Variance 0.8989011 0.81782662 
Observations 91 91 
Pea"on Corre lation 0.33437024 
.Hyp othesized Mean Difference ··- --·· 0 ~ 
tStat ·0.980 
j ■ NORrnWEST 68.15' 57.1% 31.9" 42..9" P(T <:t) one-tai l 0.16S 
T Critical one-tail 1662 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<:t) two-tail 0.330 
T Critica l Two-tail 1.987 
Cannot Rej~ Null ~pothesis because p > 0.05 (Means are the same) 
t-Test: Paired Two Sample for Means a 0.05 
WESTERN CAPE 
PREQ25 POSTQ25 diff 95% Confidence Interval 
70.8% 75.0% ,;M,;=e•n:___ ___________2 083333_33_ 19.!..~---· 0.167 
Variance o.86231884 o. ns36232 
Obse-r-v-a-t-i-ons- --·- -- --- 24 24 . ----
Pearson Correlation 0.16837912 
Hypothesized Mean Difference 0 
df 23 
!Stat 0.700 
-~(T <=t) ~ne_:tall . 0.246 
!itronf'i 1gru/agree T Critical one-tail 1.714 
; • \.YESTERN CAPE 70A 751>9' 29.2i£ 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(T<=t) two-tail 0.491 
T Critical Two-tail 2.069 
Graph 5.27: Prescribed medication should be used more frequently to help patients who are aggressive and 
\ violent 
All three experimental groups agreed with this statement in both the pre-test and the post-test and 
the null hypothesis (Ho) could not be rejected for any of the three experimental groups. Therefore , it 
is evident that the training programme had no statistically significant impact on any of the 
experimental groups. 
139 
5.5.2.26 Question 26. The use of de-escalation is successful in preventing violence 
t-Test: Paired Two Sample for Means a 0.05 
GAUTENG 
88.2% 82.4% PREQ26 POSTQ26 dill 95% Confidence Interval 
Mean 1.94117647 1.94117647, 0.CXXl -0.406 o. 
Variance 0.30882353 0.68382353 
Observations 17 17 
17.6'¼ 
11.8% Pearson Correlation 0.4CXXl128 
' 
Hypothesized Mean Differenc:e o 
P~-test ?ost-~st ?osMtit df 16 
___, ...__ __str_ oo_~_'8c."--•l_as~re_e ___ __. ___s_• o_o,~;,dls_ag..r .e_ e/_cl_wg~"-' ' ----< t Stat 0.CXXl 
L■_GA_UIT_NG 88c .__ __ ·2_1< _- '-__8_ 2·4_"_ _- -'-__11_ ·•-" --~--'-7·6_"_--' P(T<=t) one-ta il 0.500 
T Critica l one-tail 1.746 
Cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail 1.CXXl 
TC ritical Two-tail 2.120 
cannot Reject Null Hypothesis because p > 0.05 (Wieans are the same) 
a 0.05 
NORTH WEST 
PREQ26 POSTQ26 dill 95% Confidence Interval 
75.8% Mean 2.13186813 1.96703297 0.165 -0.068 0.39 
Variance 0.62686203 0.6989011 
Observations 91 91 
Pearson Corre lation o.057CXXln 
':'Y?othe~ e~ rve.ean Differe~ 0 
df 
I ----- ~---~---'-------
Stron).,- agree/agree Strongiydisagre~disagree t Stat 1406 
r■---Nc=OATHccW--°cE-ST+---6-2..-,.--.;.--'--7-5.-l!,-. -+---3-7.l-l-!. -"-----';------'-2-, .-2. -. -----, P!T<:t) on~ ta il 0.082 
T Critica l one-tail 1.662 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(T<=t) two-tail 0.163 
T Critica l Two-tail 1.987 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
t-Test: Paired Two Sample for Means a 0.05 
WESTERN CAPE 
PREQ26 POSTQ26 dill 95% Confidence Interval 
83.3% 
75.0% Mean 1.83333333 1.875 -0.042 -o.464 o. 
Variance 0.49275362 0.80978261 
Observations 24 24 
-- t-
Pearson Corre lation . 0.24090237 
25.0% ~thesi~ed ~~n Di!fere~~- o 
23 
1_1_1:1:1..1.1.1 1-11_-111_ .  df t Stat ·0.204 ·r ·.Pos!-be,1 · Pre-ti-st i Post-test I P(T<:t) one-tail 0.420 
Stront, a~t/agret liD'onPfdisagret/dsa,g:tt I T Critical one-tail 1.714 
[ ■ WESTERN CAP£ &3.3!1 ! 7S.O!I 16.7'6 2S.0'6 cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(T<=t) two-tail 0.840 
T Critical Two-tail 2.069 
Graph 5.28: The use of de-escalation is successful in preventing violence 
All three experimental groups agreed with this statement in both the pretest and the posttest and 
the null hypothesis (Ho) could not be rejected for any of the three experimental groups. Therefore, it 
is evident that the training programme had no statistically significant impact on any of the 
experimental groups. 
140 
\ J.. INBRWAUfl Y1  
5.5.2.27 Question 27. If the physical environment were different, patients would be 
less aggressive 
t-Test: Pa ired Two Sample for Means a 0.05 
GAUTENG 
88.2% PREQ17 POSTQ17 diff 95% Confi dence Interval 
Mean 2.17647059 2.058823S3 0.118 -0.191 0.42 
Variance 0.65441176 0.68382353 
29.4% Observations 17 17 
Pearson Correlation 0.73094579 
~ Hypothesized Mean Difference 0 
Post -test T Pre-tut j PosMMt 7 di 16 
Stroni.., agree/agree Suooglydisa,gree/ d sagree tStat 0.808 
: ■ GAIJTENG 70.61' 88.2" P(T<=t) one-tail 0.215 
T Critical one-tail 1.746 
C.nno!._R eject Null Hypothesis because !': 0.0S (Means are the same) 
P(T<=t) two-tail 0.431 --
T Critical Two-tail 2.120 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
NORTH WEST t-Te~!=P aired Two Sample ~ -Mean~ a 
0.05 
91.2% PREQ17 POSTQ27 dill 95% Confidence Interval 
70.3% Mean 2.05494505 1.69230769 0.363 0.151 0.57 
Variance 0.7 1916972 0.59316239 
Observations 91 91 
Pearson Corre-lati-on --- 0.213304U 8.8% 
Hypothesi zed Mean Difference 0 
l>rt-(Ut Pos:MHt Pre~st PO§M~~t di 90 
Stror\¥ agrte/agret Stroogtydiiagrtt/dwgrte tStat 3.402 
!o  NORTH WEST 703 " 1 9L2" 29.7!, 8.8" P(T<=t)~ e-tai_l _ 0.000 
TC ritica l one-tail 1.662 
Reject Nu ll Hypothesis because p <0.05 (Means are Different) 
P(T <=t) two-tail 0.001 
TC ritica l Two-tail 1.987 
Reject Nu ll Hypothesis because p <0.05 (Means are Different) 
t-Test: Paired Two Sample for Means_ __. .__ _a  ___o_. 05_ ______+ ----1 
WESTERN CAPE 
PREQ27 POSTQ27 diff 95% Confidence Interval 
75.0% Mean 1.95833333 1.91666667 0.042 -0.361 0.44 
Variance 0.5634058 0.86231884 
Observations 24 24 
Pearson Corre lation 0.36906654 
-25.0-% -25-.0% -Hypothesized Mean Difference 0 di 23 t5tat 0.214 Pre-tr:st j Post-test P(T <=t) one-tail 0.416 Stronly agree/agree Strof'@lydisagrtt/dYSrt!e TCritical one-tail 1.714 
l ■ WESITRN CAPE 75.0'li 75.0'li 25.0'li 25.0'li Can~~~ Reje:': ..~ -~-~!. . l:iVPDthe~!.~ becaus~_P.?' 0.05 (M_:ans are the ~me) 
P(T<=t) two-tail _________ .•. 0.833 
T Critical Two-tail 2.069 
Cannot Reject N~II Hypothesis because p >0.05 (Means are the same) 
Graph 5.29: If the physical environment were different, patients would be less aggressive 
All three experimental groups strongly agree with this statement, and this agreement increased 
after training programmes. For Gauteng, we observe an increase from 70.6% to 88.2%, whilst 
North West registers an increase from 70.3 % to 91 .2% with the Western Cape having the exact 
pre- and post-test agreement at 75. 
141 
The following three (3) graphs display the overall view of mean scores pre- and post-test per 
statement compared to the expected mean. It makes a visual representation of how the treatment 
intervention impacted on the respondents. 
142 
GA..UTENG 
e phys ical environment vv e re different, paclents \Nou l d be less aggressive. 1.00 
u se of de--esc.a l at:lon I s .successfu l In preventing viole n ce 1.00 
::rlbe d medle&tfon s hould be u se d rnore freq....,ent:ly to help patients vvh o are 1 .00 1 . a2 
.!iSSfve and violent: . 
1s lor" is sometimes used more chan necessary. 1 .00 
rgely s ituation s t hac contribute tovvard s the express i on of aggress i o n by patients. 1 .00 
~rib d medication can In some lnst:ances l ead to patlen,t asgresslon and vlo l e n c ce. 1 .00 
nt: aggress i on could b e handled mor""e e ffectiv e ly on thi s vvard . 1.00 
oved one co one re l atle>n s hlp s betv,,,een s taff and p 1:Jent:s can reduce th e :1..00 
e n ce of patient: agg,·esslon and v lolenoe . 
natives to the use o fc.ont:efnmen·t: and seda·t:10,-... to manage pat:lent: violence cou ld 1.00 
>e d more frequen tly . 
l e.a l restraint: i .s son-.et:lmes use d more t:h n necessary . ;1..00 
ess lo.-.s o f aggression do not a lvvays reqL1lre s taff fn,:erv ntlon. 
i-f c tlve ca re environments ca n contribute tovvarcls patient ags;resslo n and vio l e nce. 1.00 .:1.2 
.1 se of negotlal:lon could be u se d more e ffectively vvhen managins aggression and 
es.s lve patient s -vvlll ca lm dovvn utomat:lco lly If l e ft a l one. 4- .00 
l ca t:lon I s a va l uable app,roa c h for tr- e arlns asgresslve and vio l ent: behaviour-. 
pr-act ic-e of secluding violent patlent:s sho...,ld be dlsce>n't:li-.u e d. 7 4-.00 
! nl:s vvho are viol e nt are o ft: e ,--.. phys ic.ally ,·est •·a1r-,,ed 1:0 admlnlscer sedation. u 
,-,, a pat:lenl: I s vlolent:. secl..., s lon I s o n e of the mos t effecclve approac h es t o u se. 1 .00 
? nt: s who are aasres s lve t:ow&r-ds staff s hould try to con cr-o l their feellns; s:. 1 .00 
rent: approaches to s uit: d i fferent: c ultural gr-oups are u sed on this vvard to manage 1 .00 
e a ppear to be types of pa1::lent:s who fr-equently beco m e aag ,·esslve towards st:aff. 1 .00 
· c.o mmunlcat:lon bee.ween staff and pat:len·t-s l eads to patient aga ,·-ess lon. 1 .00 
= ncs are aggr essive bec.a use they a..-e Ill. 
:ilffl c ult t:o prevent: pal:.lent:s from becoming violent: or- aggressive. 4 .00 
~ nt s commonly b eco m e assresslv.a bee.a u se s ~eff does not llst:en to them . o 
_,.__ Pre - test 
!' r- people make pati e nts aagresslve or- vio l ent: . 00 
---- Post- tes t 
!!!l nt s are as.e:ressive be u se of the envif•onment t h e y ar-e In. E:00 ~ Jdeal score after intervention 
s ~ .-onalv d ls,&.-cc 
D Overall graph for Gauteng 
143 
In the Gauteng experimental group where the respondents had training on theories of aggression 
and cultural sensitivity prior to the post-test, it shows that there is an improved agreement with the 
statements around accepting that patients could be treated more effectively, that poor 
communication and staff not listening to patients contribute to patient related aggression. An 
interesting manifestation is that during the post-test, the respondents more readily agreed with the 
statement that patients are often restrained to administer medication. 
144 
NC>RTH VVEST 
e phy.s l c ol e nviro nme nt: w ere different. patlen.t:s wou l d be less aggressive. 
u se o r de--e~ca l atlon I s s u ~essrul In pre-ven,ti..-.B vio l e n ce 
rlbed n -..ecf i c 11:1 0 ..--. s l "lould be u se d rYlo r e f'.-equ e n.t:: l y t: e> t-, e lp patients wh o are 2.22 
,s:s lve and V' i o l e nt . 
s l on I s so m .e t:lmes u se d more th n n ecessary. 
11rge ly s ltuatlo,"ls thnc:cont:rlbut:e cowards t:1,e exp ,·es.s l o •--i of agaresslon by pat:l e n ts. 
:rlbecf m edic t:l o .--. c an Ir"\ some Ins tances l ea d to put:le r"lt: aag ,· e.s.s l o n and vio l e n ce. 
nt: eoasre,s :s l o n could b e h and l e d mo r e e f'fective l y e> n this word. 
o v e d o n e to o n e r e leot:l o n shlp:s b e twee n :st& ff e nd p &t: l e nt:s c an r ed u ce the 
e n ce of patient agsres s l o n and vlo l e n 
not:lvos to th e u se of conta i nme nt: and sedot:lon t o m noae patient: v i o l e n ce cou l d 2.19 
.eel ,,-,ore freq u e nt l y. 
l c.a l restraint I s somecimcs u se d m o re th.l!ln necessary. 
,ss l ol"'IS o f aggres.siol"'I do n oc a l vvavs r e quire s c.aff lnte r-vent i o r. . 1 . 00 2. 
•Jc tlv e c or-e envl r- o nme .-. 11: s co n c.ont.r-lbute t o vv rds pot:lent e:sr-es s lon and vl o l e n c.e. ".1.. . 00 
• &e of' n egot l ,;.-.; lon c ou l d b e u sed m or-e e ffectiv e l y vvh e n • ..,.... naglng aggress i o n a nd 
l c.a tlon I s o vo l uab l e approach f or t r eat::l n g aggres.sive e n d v l o l e nll: behaviour. 
:. r oct:l c:.e of sec l uding v l o l e nll: pat:.len1:.s s h o uld be dlsco n c lnu d . 4.00 
•nt: s vvho ore vlo l e n ·t. r e o f'ten phy.s l co ll y re .stro l n e d to admlnlscer sedati o n . 
patie nt I s vio l ent. secl u s i on I s o n e of' "t:h e m os t: e f'fec:t l v e approach es to u se. :LOO 
=n't::,; vv l "IO ar·e a e;gresslve t:.ovvards s t:. a f C .s l "loul d t:.ry co co n t;.-o l their fee li ngs.. 1 . 00 
rent: approach es to s uit cl l f'fere n't: c ult: u r I gro ups are u .secl o n t h i s ward t o manose 1 .00 
e appear to b- types o f pl;'lt:le r"l t:S vv l "I O freq1..1ent l y be o me aggr-ess lve 11: o vvorc:l s st::af'f. 1 .00 
communic ation b e tween s taff a nd pa t i ent s l eads to patient 1:1ggre.ssion . 1 . 00 
u "lts er-e agg r essive be-cause they 1:1re ill. 
: llffl cu l t t o prevent: patients from bee.om.Ing vlo lent: o ,. aggressive. 4 . 00 
t nt s. comm.only b ecome as.a.,.esslve b eca u se st:af-f' d oes n ot l i sten t:.o th e m. -:o 
~ Pre-·t::.est 
,,. people make pat i e nt s aggress i ve o ,. v l o l e nt . .oo 
------ Post- test 
g,gres s lve becau se o f the environment: they are In. r . O<l.40 ~ I d ea l score a ft e r int:e rv-ention 
I Overall graph for North W est 
145 
The experimental group from the North West Province included Psychiatric Nursing students in 
their third and fourth years of training. The North West experimental group had training only in 
cultural sensitivity and awareness prior to the posttest. This observation is quite interesting because 
it seems as though the either cultural sensitivity questionnaire or the MAVAS questionnaire played 
a role in their attitudes. 
146 
VV E STERN CAPE 
e physical enviro nme nt were different. patient s w o uld be l es.s aggressive. 1 .00 
us of de-esc e l at:lon I s s u ccess1-ul In preven ting v l o l e.-.ce 1 .00 
rlbed medl t:lon s h o uld be used more freq u e ntly t:o h e lp p tl e n t:s who are 1 .00 
:sslve and vio l ent:. 
s lon I s somet: ln,es u sed m o re than n ecessa r-v . 1 .00 
,orge l v s ituat i o n s that: cont: r l but:e towards th e ex.press l o n o f ag.g r ess l on by patients. 1 .00 
:rlbed medlcat:lor1 ca n In some Ins tan ces l e ad to patient asgresslor, ar11d vio l e n ce. 1.00 
n.t agg r ession c c n ..d d be h nd l ed m ore effec tively on this word. 1.00 
oved o n e to o n e r e lat:lonshlps betvveen staff and pati e nts ca n r ed u ce the 1 .00 
ence o f patient: agg.-esslon and vlo l ence. 
n atives to th e u .se o f con t a i nme nt: a nd .sedation to manage pacle nt: v i o l e n ce could 1.00 
~e d ,,-.ore freq u e ntly. 
lca l restraint: Is $Ome t:lmes u sed more t:han n ecessa ry . 1.00 
! ss lons o f aggression do not:. alvvays require st:o ff intervent i o n . 1.00 
·l c t:lve ca re environments can contribute tovva ,·ds patient aggression and viol e n ce. 1 .00 
, se of' 1,egot l at l on c.ould be use d more effec.tlve ly vvhen managing aggression and 
e ssl v e paclent:s vvlll ca lm dovvn a uto m a ti ca lly If l e f't: a l o n e . 4-.00 
le tlon I s a v a luable approach f or treatJng aggressive and vio l ent b e h vlour. 8 3 
1ractlce o f secluding viol ent pa t i e n ts shoul d be discontinued. .79 4.00 
n ts vvh o are v i olent are often physic.ally r estra ined t.o administer sede t:.f o n . 
n a p at i e nt: I s vfolent, sec l u sion Is o n e o f the m ost eff ct:lve approacl es t:o u s e . 1 .00 
nts wh o a r e agg r essive t:.ovvards staff s h o uld t.ry to cont.re l t:.heh· feelings . 1.00 
re,,t app r·oach es to s uit d l ffe,·e nt c ultural g,·oups are u se d o n thi s vva,· d t:o manage 1.00 1 3 
e appea r to be types o f patients vvh o fre qu.=,nt ly become aggressive t: o vvard s .s taff. 1 .00 
comm unlc.a tl o n betvveen s taff and p atients l eads top tl e ntagg..-esslon . 1.00 
,nts a r e aggr,essh,e b eca u se they are Ill. 2.29 
liffi c uh: to p.-event patients from b ecoming v i o l e nt o r aggressive. 4 .00 
,nts commonly become ggr esslve because staff does n o t listen t o t h e m. . o 2 . 29 
r pe o p l e n,oke patient:.s s.sresslve or- vio l e nt . .00 ------ Pr e - te.st 
__._. Post- test 
,nts ar-e aggressive b ecause of the env i ronme nt they are In. r .00 2.41 ~ Idea l s o r e after intervention 
Olsare• S t:ronalvclisar<e-e 
i Overall graph for Western Cape 
147 
The experimental group from the Western Cape underwent the total training programme before the 
post-test. When looking at the results from the Western Cape, there is a more observable change 
in attitudes on certain of the responses on the MAVAS questionnaire. With specific reference to the 
pre-test and the post-test scores, more respondents were in agreement with the involvement of the 
environment and poor communication as possible causes for mental health care user related 
violence. 
Both Gauteng and the Western Cape experimental groups more readily admitted to the use of 
physical restraint to administer medication. This response is not visible in the North West 
experimental group and the researcher attributes this to the level of experience in psychiatric 
nursing, where 97% of the respondents had between one (1) and five (5) years of experience in the 
field . 
These observations are noted whilst observing the within group responses when looking at the one 
tailed posttest result. In the between group responses with the two tailed results , these differences 
are balanced out. Therefore, within a group a result may show statistical significance , whilst 
between groups it does not show statistical significance. 
5.5.3 ANALYSIS OF THE INTER CULTURAL SENSITIVITY AND AWARENESS 
QUESTIONNAIRE 
The lntercultural sensitivity questionnaire was the second questionnaire added to address the 
efficacy of combining cultural sensitivity and awareness as part of the training programme in the 
culturally safe management of aggression and violence. The following sections will deal with the 
findings on the questionnaire and a similar question by question approach will be followed as with 
the discussion in the MAVAS questionnaire. The lntercultural sensitivity questionnaire consists of 
24 questions with a five (5) point Likert scale rating whereas one (1) reflects strong disagreement, 
two (2) indicates disagreement, three (3) is neutral/uncertainty, four (4) indicates agreement and 
five (5) reflects strong agreement with the statements. 
The researcher proposed a non-directional hypothesis (N1), namely that a training programme will 
have an effect on the attitudes of respondents with regards to cultural sensitivity and awareness. 
This effect will be tested by means of a pre-test and a post-test, where the lntercultural sensitivity 
scale will be used to test for any possible changes in the respondents with regards to their 
responses on the 24 questions in this questionnaire. 
The following section will analyse the findings on each of the 24 questions. 
148 
5.5.3.1 I enjoy interacting with people from different cultures 
GAVTENG a 0.05 
88" 88" PREQl POSTQl diff 95% Confidence lnterva 
Mean 4.17647059 4 0.176 -0.095 a. 
Variance 1.02941176 1.5 
Observations 17 17 
Pearson Correlation 0.90534U9 
Hypothesized "-"ean Difference a 
12" df 16 
6" 6% 
!Stat 1.376 
P!l!-est Pcl.t-ti1 ~ -le.it PC&;.-,; Prl! -test Jlcs:·tir P(T<=!)_~e_:!ail 0.094 
____ Strar:~_asuftgrtt ·_·-_- ·--fCfUT,A-A-l --°" -~-~-- C-ff-ll,•-H /d-~ ··--·: T Critical one-tail 1.746 
, ■ GAiJllNG ~ ~ ~ ~ ~ ~ 
can no~ Reject Null Hypo~~esis because .e.>  ~-OS (Means ar~.!~ same) 
P(T<=t) two-tail 0.188 
T Critical Two-tail 2.U0 
cannot Reject Null Hypothesis because p >0.05 (Wieans are the same) 
NORTHWEST t·Test: Paired Two Sample for Means a a.as 
PREQl POSTQl diff 95% Confidence lnterva 
96" Mean 4.14285714 4.49450549 -0.352 -0.661 -0. 
Variance 1. 7015873. __0 .67496947 
Observations 91 91 
Pearson Correlation 0.07849936 
Hypothesized Mean o;fference a 
df 90 
t Stat ·2.257 
_13"_ 3" P(T<=t) one-tail 0.013 2" Pre41!st ...1 ",.   .... I....L... _ ---_----- .. T Critical one-tail 1.662 Reject Null Hypothesis because p < 0.05 (Means are Different) 
a NOlm4~'£ST j ""''""-85% 96" P(T<=t) two-tail 0.026 "' "' "" "' T Crttical Two-tail 1.987 
Reject Null Hypothesis because p < 0.05 (Means are Different) 
WESTERN CAPE t-Test: Paired Two Sample for Means a a.as 
83" 
PREQl POSTQl diff 95% Confidence lnterva 
Mean 3.54166667 4.20833333 ·0.667 -1.345 a.a 
Variance 1.99818841 1.38949275 
Observations 24 24 
Pearson Correlation 0.24244846 
Hypothesized Mean Diff.~rence a 
df 23 
.... .. 1" 
!Stat · 2.033 
P(T<=t) one-ta ll 0.027 
T Critical one-tail 1.714 
• WESTERN CAPE Reject Null Hypothesis because p < 0.OS_(Means are Differ!~9 
P(T~L_l:"?•tall 0.054 
T Crttical Two-tail 2.069 
cannot Reject Null Hypothesis because p > a.OS (Means are the same) 
Graph 5.33: I enjoy interacting with people from different cultures 
The three experimental groups all agreed with this statement and the percentages were quite high , 
namely 88% agreement for Gauteng, *5% agreement in the pre-test and 96% agreement in the 
post-test for North West, Western Cape showed 63% agreement in the pre-test and 83% 
agreement in the post-test. 
149 
5.5.3.2 I think people from other cultures are narrow-minded 
GAl/TENG t•Test : Paired Two Sample for Means a 0.05 
76% PREQ2 POSTQ2 diff 95% Confide nce Interval 
Mean 2.29411765 0.294 -0.059 0.64 
Variance l .34S58824 
Observations 17 17 
Pearson Corre lation 0.80819319 
24% Hypothesized Mean Difference 0 
_I 12" 12% di 16 !Stat 1.768 .,...., , P•a;t-~t  •?l\t·IUt St-or-ft  """- ,,,, .... P(T<=t) one-tail 0.048 ,.,,i tt,r,f.,f, . -,--,.,-,. -N-'11T-l<AI-. ,-.,,. ---"-'"''="f'ii-~•H~ T Cri tical one-tail 1.746 
"" Reject Null Hypothesis because p < 0.05 (Means are Diffe rent) 
P(T<=t) two-ta il 0.096 
TCritical Two-ta il 2.120 
cannot Reject Null _Hypoth_e_sis because p > 0.0S (Means are the same) 
NORTHWEST t-Test: Paired Two Sample for Means a 0.05 
66% 
PREQ2 POSTQ2 diff 95% Confi dence Interval 
S6" Mean 2.43956044 2.28571429 0.154 -0.111 0.4 
Variance l .S157S092 1.45079365 
Observations 91 91 
Pearson Correlation 0.4S384605 
Hypothesized rv'ean Difference 0 
23% 
di 90 
_Li ,i .i . tStat 1.153 P(T <=t) one-tail 0.126 TCri tlca l one-·t'.a:ci'1- _____  1.662 
~-lrR. Pau~t P1t;-ttsl Par.-tit P~-lt5l Polt·tnt 
cannot Reje~ Null_H ypothesis because p > 0.05 (Means are the same) 
Str~tJ"ffh!lrtt N'ElJTMi Str0n9Yd.ug~~:il(lrH 
23% 1IS P(T_<_=t) tw_?·tail 0.252 
T Critical Two-ta il 1.987 
cannot Reject Null ~~othesis because p >0.05 (Wieans are the same) 
WEmRNCAPE t-Test: Paired Two Sample for Means a 0.05 
PREQ2 POSTQ2 diff 9S% Confidence Interval 
67% Mean 2.20833333 1.91666667 0.292 -0.182 0.7 
Variance 1.12862319 1.2971014S 
Observations 24 24 
Pearson Correlation 0.48212021 
Hypothesi zed Mean Difference 0 
i _a__i_JL.J . di 23 tStat 1.273 
~tl!S ftc&t-mt ~~it "51-fl$t ?f£42st Po'1-4nt P(T<=t) one-tail 0.108 
Str0f'"1cfwptf~ T Cri t ical one-tail 1.714 
• WEmlNW< 111< .. "" .,,. Cannot Rej ect Null Hypothesis because p > 0.05 (Means are the same) 
P(T<=t) two-tail 0.216 
T Cri t ica l Two-tail 2.069 
Cannot Reject Null ~p-~-~-~-~-s!_~_because p > 0.05 (Means are the same ) 
Graph 5.34: I think people from other cultures is narrow-minded 
All three experimental groups with an overwhelming majority were in disagreement with this 
statement in both the pretest and Posttest. For all of the experimental groups, the means were 
similar. 
150 
5.5.3.3 I am pretty sure of myself in interacting with people from different cultures 
GAl/TENG t-Test: Paired Two Sample for Means a 0.05 
82" PREQ3 P05TQ3 diff 95% Confidence lnterva 
Mean 3.58823529 4.05882353 ·0.471 -1.154 0.21 
Variance 2.25735294 0.683823S3 
Observations 17 17 
Pearson Correlation 0.47345567 
Hypothesized tv\ean Difference 0 
di 16 
________ ! Stat , -1.461 
Pmt-tit P(T<=t) one-tail 0.082 
N!l/HW. T Critical one-tail 1.746 
!• GAilJ11NG ~ ~ 24% 6'li 
cannot Reject Null Hypothesis because p >0.05 (Wteans are the same) 
P(T<=t) two-tail 0.163 
T Critical Two-ta il 2.120 
cannot Reject Null Hypothesis because p > 0.05 (Wieans are the same) 
NORTHWEST t-Test: Paired Two Sample for Means a 0.05 
80% PREQ3 POSTQ3 diff 
Mean 3.92307692 4.06593407 -0.143 
Variance 1.31623932 0.88449328 
,9_~servations'------ 91 91 
Pearson Correlation 0.17981474 
Hypothesized Mean Difference 0 
di 90 
!Stat · l.012 
_P(T <=t) one-tail 0.157 
T Critical one-tail 1.662 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(T <=t) two-tail 0.314 
a NO«TliWfST 
T Critical Two-tail 1.987 
WESTERN CAPE t-Test: Pa ired Two Sample for Means a 0.05 
~ 
PREQ3 POSTQ3 diff 95% Confidence lnterva 
Mean 3.375 3.58333333 -0.208 -0.736 0.3 
Variance 1.375 1.29710145 
Observations 24 24 
Pearson Correlation 0.41509168 
Hypothesized tJiean Difference 0 
di 23 
tStat -0.816 
P(T<=t) one-tail 0.211 
T Critical one-tail 1.714 
• wrnuNCA?E Cannot Reject Null Hypot.hesi s because p >0.0S (~~ns are t he same) 
P(T<=t) two-tall 0.423 
T Critical Two-tail 2.069 
~nnot Reject Null Hyp~!~~~.is because p > a.OS (~~~-s .3:~e t he same) 
Graph 5.35: I am pretty sure of myself in interacting with people from different cultures 
All respondents agreed with this statement and in the post test there was an observed increased 
agreement, namely Gauteng improved from 65% to 82%, North West from 7 4% to 80% and 
Western Cape from 50% to 67%. 
151 
5.5.3.4 I find it very difficult to talk in front ofp eople from different cultures 
GAUTENG '~-~Test: Paired Two Samp~_: for tv1eans a 0.05 
76% PREQ4 POSTQ4 diff 95% Confidence Interval 
,Wiean 2.23S29412 2.29411765 -0.0S9 -0.TI6 0. 
Variance l.31617647 1.47058824 
Observations 17 17 
Pearson Correlation 0.39638732 
24% 24% ·Hypothesized Wean Difference 0 
_1i_ __6"_' _ df 16 - °"°- t Stat -0.187 
~-tHl i Posl·lest Pff-~Jt PosMest ~l!§l Pmt-9:St P(T<=t) one-tail 0.427 
•-- _ ----~ atJ«-efasrH NHITRAl St"OJWY" diWIIH ,hf!Alftt 
j 'J69', T Critical one-tail 1.746 ■ GAUTEHG - 2•• 26 6'!i- 0. 711!: ...,... 
cannot Rej~-~ Null Hyp?thesis because_E_> 0.05 (~-~~s are the same) 
P(T<=t) _two:tail 0.854 
T Critical Two-tail 2.120 
cannot Reject Null Hypothesis because p > 0.OS (~-~~• are the same) 
NORTHWEST ·t-Test: Pai red Two Sample for Means a 0.05 
59" PREQ4 POSTQ4 diff 95% Confidence Interval 
'Mean 2.47252747 2.48351648 -0.011 -o.2n o. 
Variance l .58534799 l.474lli27 
Observations 91 91 
'. Pearson Correlation 0.48838882 
29" 29" 
Hypothesized Mean Difference 0 
J_J__ df 90 13% 12'11 ·tstat ·0.084 P(T<=t) one-tail 0.467 
PfT--llelt Pm1-1nt ,,,...,. T Critic.al one-tail 1.662 Pmt.-st- ··;···· ~-trst 
NH/lMI. 5c--Ollfjy clsatru/ di.Slgrff ;cannot Rej ~ Null Hyp_~ _hesis b_':_C!'~~~..E "._!).OS (~~•_a.re the •~.":'el S!J'OfWy qrNl..-tt ■ NOITI-IWE'ST ,.,,. ""' ""' mi ""' ~[!_<=t) two-tail 0.933 T Critical Two-tail 1987 
WESTERN CAPE t-Test: Paired Two Sample for ~ans a 0.05 
PREQ4 POSTQ4 diff 9S% Confidence Interval 
Mean 2.625 2.75 -0.125 -o.m 0.42 
Variance l.37S 1.23913043 
-Observat ions 24 24 
Pearson Correlation 0.3S807233 
~ pothesized Mean Di~~rence 0 
:df 23 
!Stat -0.473 
_P_(T<=t) one-tail 0.320 
T Critical one-tail 1.714 
■ WE5T£RNCA?E ~ ~ 1,,. 259' ~ -46,1, 
cannot Rej.".c:t Null Hypot_h_e_sis because_p > 0.0S (M<!ans are the same) 
P(T <=t) two_:,t.!i_l 0.641 
T Critical Two-tail 2.069 
·cannot Reject Nu ll Hypothesis because p > 0.0S (Means are the same) 
Graph 5.36: I find it very difficult to talk in front of people from different cultures 
All respondents answered this question and the majority disagreed with it. Gauteng and North West 
seemed to have shown increased agreement with this statement from 71 % to 76% for Gauteng and 
a marginal 1%  increase in agreement for North West; Western Cape to the contrary showed a 
decrease from 58% to 46%. 
152 
5.5.3.5 I always know what to say when interacting with people from different 
cultures 
GAUTING t-Test: Paired Two Sample for tileans a 0.05 
47" 
PREQS POSTQS diff 95% Confidence Interval 
Mean 3.23S29412 3.47058824 ·0.235 ·0.766 0.296 
Variance 1.31617647 0. 76470588 
Observations 17 17 
Pearson Correlation 0.50571508 
H.','.pothesized tilean Difference 
di 16 
t Stat -0.940 
-~ ~--'" ?mt-tit P(T <=t) one-tail 0.181 ~d516!H /li~ T Criti cal one-tail 1.746 35,o "" 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(T <=t) two-tail 0.361 
T Critical Two-tail 2.U0 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
NORTHWEST ~~: Paired_Iwo Sample fo~Means a 0.05 
PREQS POSTQS diff 95% Confidence Interval 
Mean 3.23076923 3.30769231 -0.077 -0.353 0.199 
Variance 1.2017094 1.37094017 
38% 
Observat ions 91 91 
Pearson Correlation 0.31629969 
__ llj~t Hypothesized Mean Difference 0 di 90 !Stat ·0.553 P(T <=t) one-tail 0.291 TC ritical one-tail 1.662 
Prt-li!R f-on-t!U ~-11!.SS: l Pmt--15 Pn!.-5: Pm?~ ~~at Reject Null Hypothesis because ~ 0.05 (Me.~~re the same) 
.S,f,r.a ntfy •P~tt/« NMMI. ~ dwg.-et/~tt _P(T<=t) two:tai_l O.S82 ■ NOl!THW£51 "" mi T Critical Two-tail 1.987 
cannot Reject Null Hypothesis because p > a.OS (Means are the same) 
WEmRN CAPE a 0.05 
PREQS POSTQS diff 95% Confidence Inte rval 
Mean 3.37S 2.95833333 0.417 ·0.031 0.864 
38% Variance 1.11413043 l.cm514493 
_Lil_Li Observations 24 24 Pearson Correlation 0.4893341 7 .~~.othesized Mean Differen.~ 0 di 23 tStat 1.926 
Pit!•• ~t-lKL Prt-tr!l Fost'il:St ~- }1;15Htst P(T <=t) one-tail 0.033 
~-r.e/lflff ,.,. filEUTRAl s:tOr\f'rd.~ T Critical one-tail 1.714 •\\'BlHt-.CAPl ""' ""' Reject Nu ll Hypothesis because p < 0.05 (Means are Different) 
P(T< =t) two-tail 0.067 
T Critical Two-tail 2.069 
Graph 5.37: I always know what to say when interacting with people from different cultures 
All respondents answered this question and it seems as though almost ½ of the respondents in 
each of the experimental groups reported uncertainty on this particular question. 
153 
IJ ,.INBWRAUl! Y]  
5.5.3.6 I can be as sociable as I want to be when interacting with people from different cultures 
GAlJTENG a 0.05 
82!1 
PREQ6 POSTQ6 diff 95% Confidence Interval 
Mean 3.94117647 3.8823.5294 0.0S9 -0.470 0. 
Variance 0.933823S3 0. 73S29412 
Observations 17 17 
Pearson Correlation 0.3682S29S 
Hypothesized Mean Difference 0 
df 16 
tStat 0.236 
P(T<=t) one-tail 0.408 
T Critical one-tail 1.746 
• GMJlU<G 
cannot Reject Null Hypo~sis because p >1!:_05 (Means are the same) 
P(T<=t) two-tail 0.817 
T Critical Two-tail 2.120 
_cannot Reject Null liyp_ot_h~sis because p > _ll:_IJS (Means are the same) 
NORTHWEST t-Test: Paired Two Sample for Means a 0.05 
PREQ6 POSTQ6 diff 95% Confidence Interval 
Mean 3.00439S6 3. 78021978 ·0.176 -0.440 0. 
Variance 1.33064713 1.04004884 
Observations 91 91 
Pearson Correlation 0.3219S826 
Hypothesized Mean Difference 0 
df 90 
tStat ·1.321 
P(T<=t) one-tail 0.09S 
T Critical one-tail 1.662 
,canno~.-~eject Null HvP<?.!~esis because P.~.~:_05 (Means _are the same) 
; • NO«™WBT ,P_(T<=tl_!"."o·tail 0.190 
T Cri tical Two-tail 1.987 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
WESTE RN CAPE t-Test: Paired Two Sample for Means a 0.05 
46% 
42% PREQ6 POSTQ6 diff 95% Confidence Inte rval 
Mean ----- --3.16666667 3.16666667 0.IXXJ -0.623 0.6 
Variance l.27S36232 1.1884058 
25% ,9bservati~~ __ -·--·--·~· __ _ 24 24 
J_Pe arson Correlation o.11m04 Hypothesized ~an Difference 0 df 23 !Stat 0.IXXJ 
:-··P <t:-W;st . PaiMH t P~ -te,t Past-et P(T<=t) one-tail O.S00 
~ ,aret.'ag:"ee HruTllA/. StorW)'~e/diaittt T Critical one-tail 1.714 
. ■ WESTEJINCAP'E 4R 421' 
canno~.-~.~j~ct Null Hypot~-~~.(s because p > a.as {Means are the same) 
P(T<=t) two-tail l .lXXJ 
T Critical Two-tail 2.069 
~nno!.~.eject Null Hypo~~e~is ~ecause p >g:.QS (Means are th~ same) 
Graph 5.38: I can be as sociable as I want to be when interacting with people from different cu ltures 
The pre and post-tests did not differ significantly for any of the three experimental groups. As a 
matter of fact, in all three groups the majority of the respondents agreed with the statement. 
Remarkably, the Western Cape had lower agreement responses with this statement in comparison 
with the other two experimental groups and during the post-test, there was a slight decrease in the 
agreement response during the post-test in comparison with the pre-test, namely a decrease from 
46% to 42%. 
154 
5.5.3.7 I don't like to be with people from different cultures 
GAUTENG t-Test: Paired Two Sample for tv'eans a 0.05 
94" 
PREQ7 POSTQ7 diff 95% Confidence Interval 
llflean -1•.7-0•5¥8•8-23-5~ -1.9-411-7647 -0.235 -0.996 0.52 
Variance 0.97058824 0.93382353 
Observations 17 17 
Pearson Correlation -0.15060ill 
Hypothesized Mean Difference 0 
df 16 
!Slat -0.655 
,,,. NRJTR,1i. ■ GAl/TING "" '"' ... -94'9· -"-
_!'(T<=t) one-tail 0.261 
.. T Critical one-tail 1.746 ., Cannot Reject Null Hypothesis because p > 0.05 (tJieans are the same) 
P(T <=t) two: tail 0.522 
T Critical Two-tail 2.120 
Cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
NORlHWEST t-Test: Pair~~ Two Sam~_I~--~~~-Means a 0.05 
91" 90% PREQ7 POSTQ7 diff 95% Confidence Interval 
llflean 1.61538462 1.75824176 -0.143 -0.386 0.10 
Variance 0.86153846 1.07423687 
Observations 91 91 
Pearson Correlation 0.29496118 
Hypothesized Mean Difference 0 
df 90 
!Stat -1.165 
11% 9% P(T<=t) one-tail O.U4 
11' 1" -- T Critical one-tail 1.662 Pff•IHt: Pml-ti1 """"'" cannot Reject Null Hypothesis because p >0.05 (llfleans are the same) .S..lr of-.v ..f f/i#./.t.t  NEUl!W s,,.,,.;,d- _P(_!~=t) two-tail 0.247 ■ filCIRTH-.UT "' "' "'" ""' TCritical Two-tail 1.987 
Cannot Reject Nul l Hypothesis because p >0.05 (Means are the same) 
t-Test: Paired Two Sample for Means 
WESTERN CAPE a 0.05 
75" 
PREQ7 POSTQ7 diff 95% Confidence Interval 
llflean -2.45-833-333- 2-.16-666-667 0.292 -0.373 0.9 
Variance 1.5634058 1.53623188 
Observations 24 24 
Pearson Correlation 0.20105974 
Hypothesized Mean Difference 0 
df 23 
tStat 0.908 
P(T<=t) one-tail 0.187 
T Critical one-tail 1.714 
.~nnot Rej~-~ Null HvP.?..t_~.~sis becau.~-~..  ~? 0.05 (~.~-~-~--are the same) 
P(T <=t) two-tail 0.373 
T Critical Two-tail 2.069 
Graph 5.39: I don't like to be with people from different cultures 
All three experimental groups disagreed with this statement and during the post-test, only Gauteng 
showed an ever so small decrease in disagreement with the statement, namely a decrease from 
92% to 82%. 
155 
5.5.3.8 I respect the values ofp eople from different cultures 
GAUTENG t-Test: Pa ired Two Sample for Means a 0.05 
IOOil PREQB POSTQB diff 95% Confidence Interval 
Mean 3.94117647 4.41176471 -0.471 -1.286 0.34 
Variance 2.18382353 0.25735294 
Observations 17 17 
Pearson Correlation -0.04904082 
Hypothesized Mean Difference 0 
df 16 
O'll !Stat -1.224 
- P~st Post-test P(T<=t) one-tail 0.119 ---------· Str~ dSljlff./di,qrtt ............ T Cri tical one-tail 1.746 (5 0t 2ft mi cannot Reject Nul l Hypothesis because p >0.05 {Wieans are the same) 
P(T<=t) two-~il 0.239 
T Critical Two-tail 2.U0 
Cannot Reject Null Hypothesis because p >0.05 !Means are the same) 
NORTHWEST t-Test: Paired Two Sample for Means a 0.05 
87" PREQB POSTQB diff 95% Confidence Interval 
Mean 4.16483516 4.34065934 -0.176 -0.473 o.u 
Variance 1.58363858 0.89377289 
Observations 91 91 
Pearson Correlation 0.18576036 
. Hypothesi zed Wean Difference 0 df 90 !Stat -1.176 13% 7" _;. _P(T<=t) one-tail 0.121 -- --------- ____ __ T Cri tical one-tall 1.662 ,,.-¥. •-, Post-Int ..,,. .1 ut · PmMPst PR-tut PosC·YSt ,~nnot Rej ect Null Hypot~esis because p > 0.05 (Means are the same) 
Stronrf•·t~~M N('JTAA.. StrOO,V d511rce/dugrtt 
P(T<=t) two-ta ll 0.243 
a NO,tTHWEST '-"' "' 
T Cri t ical Two-ta il 1.987 
WESTERN CAPE t-Test: Paired Two Sample for ~ans a 0.05 
PREQB POSTQB diff 95% Confidence Inte rval 
Mean 3. 79166667 4.33333333 -0.542 -1.084 0.00 
Variance 1.30253623 0.92753623 
Observations 24 24 
Pearson Correlation 0.26370633 
Hypothesized ~an Difference 0 
df 23 
t Stat -2.066 
P(T<=t) one-tail 0.025 
T Cri t ic.al one-tail 1.714 
Reject Null Hypothesis because p < 0.05 (Means are Different) 
P(T<=t) two-ta ll 0.050 
T Cri t ic.a l Two-ta il 2.069 
Graph 5.40: I respect the values of people from different cultures 
All the three experimental groups agreed strongly with this statement, with a slight increase in 
agreement observed in the post-test score 
156 
5.5.3.9 I get upset easily when interacting with people from different cultures 
GAUTENG ,~-Test: Paired Two Sample for Means a a.as 
94% 
881' PREQ9 POSTQ9 diff 95% Confidence Interval 
.Mean 1.76470588 1.76470588 0.000 -0.481 0.48 
Variance 0.94117647 0.31617647 
Observations 17 17 
Pearson Correla-ti-on- ~-,~-- 0.35045651 
:Hypothesized Mean Difference a 
12% ·df 16 
61' 
°" -0% !Stat 0.000 ....... Post-11!:Sl - ... ,. .... ,,, .... PQa.Mrs1 P(T<=t) one-tail a.soc SfOfWr~~/a,JN ... S-trondv.~"" "" ...f t T Critical one-tail 1.746 cannot Reject Null HvP,~t~-~-~~.s.~~cause p > 0.05 (_~~~s .~!e the same) 
P(T<=t) two-tail 1.000 
T Critical Two-tail 2.120 
NORTHWEST t-Test: Paired Two Sample for Means a a.as 
86% 
82" 
PREQ9 POSTQ9 diff 95% Confidence Interval 
Mean 1. 76923077 1.86813187 -0.099 -0.335 a. 
Variance 0.97948718 1.02686203 
Observations 91 91 
Pearson Corre lation 0.3S708S93 
,Hypothesized Mean Difference a 
df 90 
tStat -0.831 
81' 9" 7" 9" P(T<=t) one-tail 0.204 
r-·!!-~-!!-,······!!····-·~·--!!---r···· -----, T Cri tical one-tail 1.662 Pre~st 
cannot Reject ~_ull Hy~ot_~es is because p > 0.05..l_~a~!. are the same) 
sercw.., IIJH/16fff NWTAAI. 
• NORTHWEST . .... 62!i P(T<=t) two-ta il 0.4a! "" "' "' "' T Critical Two-tail 1.987 
_cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
WESTERN CAPE t-Test: Paired Two Sample for Pv'eans a a.as 
75" 
71% PREQ9 POSTQ9 diff 95% Confidence Interval 
Mean 2.04166667 0.042 -0.398 a. 
'Variance l .08S14493 1.13043478 
Observations 24 24 
Pearson Correlation 0.Sl03274 
Hypothesized Mean [?iff~rence a 
17" 
--•13" 8" 
df 23 
---- ■ ---■---- tStat 0.196 Pll•• Pa6t-tHt P~·te.• ltost.-rst ~~it j Pou-Cl:11 _P_(T<=t) one-ta il 0.423 
Slt"qy19"H/tg:ee NEViRM. 5tr"Of9y ciY11u/diiqrtt T Critical one-tail 1.714 
• Wt:ST£RN U.PE •cannot Reject Null Hypothesis because p >0.05 (~ans are the same) 
,P(T<=t) two-tall 0.846 
T Critical Two-tail 2.069 
Cannot Reject Null Hv~?.!.~.~~is because p >0.05 (~-~~~. are the same) 
Graph 5.41 : I get upset easily when interacting with people from different cultures 
All the three experimental groups disagreed with this statement and the training programme did not 
persuade them otherwise. Because all the means are more or less similar, the null hypothesis (No) 
cannot be rejected. 
157 
5.5.3.10 I feel confident when interacting with people from different cultures 
GAUTING t-Test: Paired Two Sample for Means a 0.05 
PREQ10 POSTQ10 diff 95% Confidence Interval 
Mean 3.94117647 3.823S2941 0.118 -0.323 0.55 
Variance 0.30882353 0. 77941176 
Observations 17 17 
Pearson Correlation 0.35969439 
Hypothesized Wtean Difference 0 
df 16 
tStat 0.566 
Pft--lESI Pm.flt PR-tt!!il Pml,1!\.1 P(T<=t) one-tail 0.290 
-== c---'-"-""·' y~,,.~ SC'orfh diS4glH / disi,rtt T Critical one-tail 1.746 
■ G.IUTENG ~ 161' "' ll" cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
_P(T<=t) two-ta_il . 0.579 
T Critical Two-tail 2.UO 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
NORTH WEST t-Test: Paired Two Sampl~Jor Means a 0.05 
PREQ10 POSTQ10 diff 95% Confidence Interval 
Mean 3.65934066 3.93406593 -0.275 -0.554 0. 
Variance 1.38266178 0.9956044 
Observations 91 91 
Pearson Correlation 0.24S80nl 
Hyp~thesized Mean Difference 0 
df 90 
19'1 
IS% t Stat -1.953 
P(T <=I) one-tail_ _ 0.027 
- ----■-~-•- T Critical one-tail 1.662 Poll-ces.t Pfe-ctst fQt'"1t:St Reject Null Hypothesis because p <O.OS(Means are Different) .... ,.,. ,.,. NflJTJW. ,.,,. Stroorf cls,srnldis,fC1ee P(T<"_I) two-ta_il____ 0.054 L'-" 
TCritical Two-tail 1.987 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
WESTERN CAPE t-Test: Paired Two Sample for Means a 0.05 
PREQ10 POSTQ10 diff 95% Confidence Interval 
Mean 3.41666667 3.45833333 -0.042 -0.658 0.57 
Variance 1.55797101 1.12862319 
Observations 24 24 
Pearson Correlation 0.21039115 
Hypothesized Mean Difference 0 
df 23 
tStat -0.140 
P(T<=t) one-tail 0.445 
T Critica l one-tail 1.714 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(T<=t) two-tail 0.890 
T Critical Two-tail 2.069 
Graph 5.42: I feel confident when interacting with people from different cultures 
This question was met by agreement by all three experimental groups. It is observed that the pre 
and post-test agreement with this statement decrease in Gauteng from 82% to 76%, in the North 
West it increased by 10% and an 8% increased agreement is observed for the Western Cape. 
158 
5.5.3.11 I tend to wait before forming an impression of culturally-distinct 
counterparts 
0.05 
GAlITTNG t-Test: Paired Two Sample for Means a 
S!l'JI PREQ11 POSTQll diff 95% Confidence Interval 
Mean 3.52941176 3.47058824 0.059 -0.404 0.52 
Variance 0.63970588 1.13970588 
Observations 17 17 
Pearson Correlation 0.5683534 
12%_118%_  _Hypothesi_~_ed Mean Ditt:.~:nce df 16 
!Stat 0.270 
P(T<=t) one-tail 0.395 
T Critical one-tail 1.746 
■ GAUTING 
cannot Reject Nu ll Hypothesis because p > O.OS (Means are the same) 
P(T<=t) two-tail 0.791 
TCritical Two-tail 2.U0 
NORTHWEST 0.05 
641' 
59'JI PREQ1l POSTQ11 diff 95% Confidence Interval 
Mean 3.57142857 3.63736264 -0.066 -0.294 0.16 
Variance 0.91428571 0.98925519 
Observations 91 91 
Pearson Correlation 0.3TI19384 
141' Hypothesized fv1ean Difference 0 
df 90 
_______ / L141' L !Stat -0.575 P(T<=t) one-tail . 0.283 
T Critical one-tail 1.662 
~51 Pml-lffl Pre4est PDA-"51 ~ -tst Pw"-mt Cannot Re.!_~ct Null Hyp~t_hesis because p > 0.05 (~-~-~s are the same) 
S~qU/ff!Jtt H[l.lTP.i!t ~~"- P(T <=t) two-tail 0.567 
■ NORTHw'CST j 
T Critical Two-tail 1.987 
Cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
WESTERN CAPE t-Test: Paired Two Sample for Me~ a 0.05 
581' 57" PREQ1l POSTQ1l diff 95% Confidence Interval 
Mean 3.41666667 3. lli 0.292 -0.349 0.93 
Variance 1.47101449 1.67934783 
Observations 24 24 
Pearson Correlation 0.26971058 
Hypothesized Mean Dif!!!ence 0 
df 23 
tStat 0.942 
P(T<=t) one-tail 0.178 
T Critical one-tail 1.714 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(T<=t) l\llo~tail 0.356 
T Critical Two-tail 2.069 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
Graph 5.43: I tend to wait before forming an impression of culturally-distinct counterparts 
All the three experimental groups remained consistent in their pre- and post-test reporting of this 
statement. 
159 
5.5.3.12 I often get discouraged when I am with people from different cultures 
t-Test: Pai~ed Two Sampl_e for Pv\eans a 0.05 
GAllTENG 
88% PREQ12 POSTQ12 diff 95% Confidence Interval 
Mean 2.35294118 1.82352941 0.529 -0.129 1. 
Variance 1.49264706 0.65441176 
Observations 17 17 
Pearson Correlation -- 0-.2ff5-6-6-7•0· 57 
Hypothesized Mean Difference 0 
df 16 
tStat 1.705 
.f'(T <=t) one-tail 0.054 
T Critical one-tail 1.746 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(T<=t) two-tail 0.108, 
T Cri tical Two-tail 2.120 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
NOIITHWEST t-Test: Paired Two Sample for Means a 0.05 
8ll0 
PREQ12 POSTQ12 diff 95% Confidence Interval 
71% 
Mean 1.92307692 2.21978022 -0.297 -0.603 0.01 
Variance 1.18290598 1.37338217 
Observations 91 91 
·Pearson Correlation 0.15288968 
Hypothes~d "'1ean Difference 0 
I°" df 90 •~-----•13"  --9" '!Stat -1.923 - P(T<=t) one-tail 0.029 "-1. ....t  PtY1'• ,-;..,. T Critical one-tail 1.662 "" Reject Nul l Hypothesis because p <0.05 (Means are Different) 
P(T<=t) two-ta il 0.058 
T Critical Two-tail 1.987 
_cannot Reject Null HyfJoth_esis because ~? g:05 (~ans are the same) 
WESITRN CAPE t-Test: Paired Two Sample for Means _ a 0.05 
71" PREQ12 POSTQ12 diff 95% Confidence Interval 
Mean 2.16666667 26fHH,fi/ -0.500 -1097 0.09 
48" Variance 0.57971014 24057971 
Observations 24 24 
35% 
........ 1. Pearson Corr!: lation 0.41724859 Hypothesized Mean Difference 0 df 23 -~" t Stat -1.732 ......... P(T<=t) one-tail 0.048 So-on;.,d~r.idls,.J.g ,t.e e T Critical one-tail 1.714 
Reject Null Hypothesis because p < 0.05 {fv\eans are Different) 
P(T<=t) two-tail 0.097 
T Critical Two-tail 2.069 
cannot Reject Null Hypothesis because p >0.05 (~ans are the same) 
Graph 5.44: I often get discouraged when I am with people from different cultures 
Disagreement with this question is observed in all three experimental groups. Gauteng shows an 
increased disagreement in the post-test, namely from 71 % to 88%. There were significant statistical 
changes observed for North West and the Western Cape, which will be elaborated on in section 
5.6.2.12. 
160 
5.5.3.13 I am open-minded to people from different cultures 
GAUTENG t-Test: Paired Two Sample for fv\eans a 0.05 
88% 88% PREQ13 POSTQ13 dill 95% Confidence Interval 
Mean 3.94117647 3.8823S294 0.059 -0.633 0.750 
Variance 0.80882353 0. 73529412 
Observations 17 17 
Pearson Correlation -0.17162327 
Hypothesized Mean Di!!.~!.ence 0 
df 16 
61' 6% 6% 6% 
tStat 0.180 
...-....• ttl.-..,_ -...-.... .-....., , ?l!--11!1' ?ol.t·lts.t . P(T<=t) one-tail 0.430 ... NEl/11'.N. --.-. -----. T Critical one-tail 1.746 ''"""'-~ ..." ' i • GAl.m·HG [ ""' ""' "' Cannot Reject Null Hypothesis because p >0.05 (Wieans are the same) 
P(T<=t) two-tail 0.859 
T Critia,I Two-tail 2.120 
cannot Reject Null Hypothesis because p >0.05 {Means are the same) 
NORTHWEST 0.05 
81% PREQ13 POSTQ13 dill 95% Confidence Interval 
Mean 3.79120879 3.98901099 -0.198 -0.502 0.107 
Variance 1.5003663 1.05543346 
Observations 91 91 
Pearson Correlation 0.16591977 
Hypothesized Mean Difference 0 
df 90 
141' tStat ·1.290 
P(T <=t) one-tail 0.100 
T Critical one-tail l .f,62 
Can~~t __~ eject Null HvP'?.!~es!s because p -~ -OS (fv'leans are !~e same) 
P(T<=t)two-tail ---~- 0.200 
14% 7S 
T Critia,I Two-tai l 1.987 
Cannot Reject Null Hypothesis because p >0.05 (fv'leans are the same) 
WESlIRN CAPE t-Test: Paired Two Sample for Means a 0.05 
PREQ13 POSTQ13 dill 95% Confidence Interval 
67" Mean 3.79lf,6f,67 4.04lf,6f,67 -0.250 -0.736 0.236 
Variance l.04l f,6f,67 1.34601449 
J Observations 24 24 Pearson Correlation 0.4482696 Hypothesized ~an Di!.!_~_~ence 0 df 23 !Stat -1.064 
~•ll Jut-IN Plit-lut '°5l•lftt Pil!-trlt ~ ·'"' P(T <=t) one-tail 0.149 
______s c~~-t~tl"-'"--;.---N-MU_. _ ___s ~~-1~ ---~ T Critical one-tail 1.714 
■ WESTEA,-.un · &NI ~ 2W l.3% "' .. cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail 0.299 
T Critia,I Two-tall 2.069 
Cann~!_Reject Null Hyp~!~~~is because p -~-0.05 jMeans are~~ same) 
Graph 5.45: I am open minded to people from different cultures 
This question, similar to question 14, indicates that the null hypothesis cannot be rejected and that 
the training programme had no influence on the respondents. 
161 
5.5.3. 14 I am very observant when interacting with people from different cultures 
a 0.05 GAlllING 
PREQ14 POSTQ14 diff 95% Confidence Interval 
Mean 3.82352941 3.88235294 -0.059 -0.921 0.803 
Variance 0.90441176 0.98529412 
Observations 17 17 
Pearson Correlation -0.4868274S 
Hypothesized tllean Difference a 
18% 
• df 16 °" tStat -0.145 Pie--1.f!ll Pmt·V'St Pre-le.SI. Pas.t-tesl: ?lot·lrst Post..-st P(T <=t) one-tail 0.443 
-•cGcN=JTEN~G - c.~,c,~.•e~eJ -,;r..e NEUTAAI. 
StrO!Wfd\ac,."ff~tt_ ___ _ 
,. TCritical one-tail 
'"' '"' :!Bl! "" ----
1.746 
_c;,nn~_~eject Null Hypothesis because p >_0.0S (Means are.!_he same) 
~IT~:() two-tail 0887~ 
T Critical Two-tail 2.120 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
NORTH Wm t-Test: Paired Two Sample for Means a 0.05 
79" 79" PREQ14 POSTQ14 diff 95% Confidence Interval 
Mean 4 4.04395(,()4 -0.044 -0.325 0.237 
Variance 1.31111111 1.17582418 
Observations 91 91 
Pearson Correlatio-n --- 0.26846508 
Hypothesized Mean Difference a 
df 90 
tStat -0.311 
•9% ~-•10% --- •12% ~•11% -··1 P(T <=t) one-tail 0.378 TCritical one-tail 1.662 Pfe•tHl Pol1~t ?f~·ttst ?ml-tsl cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
N£\/TML St,~ ~ /1fitagtee 
""' P(T<=t) two-tail 0.757 "' T Critical Two-tail 1.987 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
WffiERNCAl'E t-Test: Paired Two Sample for Means a a.as 
71% PREQ14 POSTQ14 diff 95% Confidence Interval 
Mean ------- 3.625 3.29166667 0.333 -0.333 1.000 
Variance -------1.02717391 2.30253623 
Observations 24 24 
Pearson Correlation 0.27211199 
Hypothesized Mean Difference a 
df 23 
!Stat 1.034 
P(T<=t) one-tail 0.156 
T Critical one-tail 1.714 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail 0.312 
TC ritical Two-tail 2.069 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
Graph 5.46: I am very observant when interacting with people from different cultures 
Respondents in all three experimental groups agreed with being observant when interacting with 
people from other cultures, even though the Western Cape group shows a reconsideration of the 
response during the post-test. This minimal difference from 71 % down to 58% is of no statistical 
significance, albeit an interesting observation. 
162 
5.5.3.15 I often feel useless when I am interacting with people from different 
cultures 
GAUTENG t-Test: Paired Two Sample for Means a 0.05 
82% 
76% PREQ15 POSTQ15 diff 95% Confidence Interval 
Mean 2.11764706 2.17647059 -0.059 -0.647 0.529 
Variance 1.36029412 1.02941176 
Observations 17 17 
Pearson Correlation 0.45670678 
-- Hypothesized Mean Difference 0 18% di 16 ----- ---- tStat -0.2U .....R  ....... ""1-1,<1 .,, ..,a ,.., ..... P(T <:t) one-ta il 0.417 NEUTIW. T Critical one-tail 1.746 c•.._GN_JTEN~G.- -- ---·-~--=-"''-~-' ~-°'-"--'----'-6-!1--'- !:2:."c'c . ~-- cannot Reject Null Hypothesis bec,use p >0.05 (Means are the same) 
P(T <:t) two-ta il 0.835 
T Cri tic,! Two-tail 2.U0 
NORTHWEST a 0.05 
PREQ15 POSTQ15 diff 95% Confidence Interval 
Mean 1.8021978 2.03296703 -0.231 -0.540 0.078 
Variance 1.24932845 1.45445665 
Observations _____  91 91 
-Pearso-n Corre-lation 0.18623037 
.~poth·~·~·ized ~-~·~ Di~.~-~-~-~-~e 0 
di 90 
18" __ _ !Stat -1.484 ~-!!--1----~--- -..... ... ----~ P(T <:t) one-ta il 0.071 ~ ~ TCritica l one-tail 1.662 cannot Reject Null Hypothesis bec,use p > 0.05 (Means are the same) 
NEVTJI.M. 
P(T<:t) two-ta il 0.141 
■ NORTI-iWBT "' "' "" ""' TCritic,I Two-tail 1.987 
_cannot Reject Nu_ll Hypoth~si_s be_c:ause p > o,.~ (Means are th:_same) 
WEillRN CAPE a 0.05 
7 1% PREQ15 POSTQ15 diff 95% Confidence Interva l 
Mean 2.33333333 2.lli 0.208 -0.274 0.690 
Variance 1.01449275 l.24456522 
Observations 24 24 
Pearson Correlation 0.42562933 
Hypothesized tv'ean Diffe rence 0 
di 23 
tStat 0.894 
,P(T<:t) one-tail 0.190 
T Critical one-tail 1.714 
_c:annot~eject N.~ 11 Hypot~:sis ~ec:a?_~e p > 0.05 (Mea_ns are the same) 
P(T<:t) two-tail 0.380 
T Critical Two-tail 2.069 
cannot Reject Null Hypothesis bec,use p >0.05 (Means are the same) 
Graph 5.47: I often feel useless when interacting with people from different cultures 
All respondents showed similar disagreement with this statement during the pre-test and the post-
test. Gauteng and North West reported a slight decrease in the reported disagreement with the 
statement during the post-test, namely for Gauteng the scores from pre-test to post-test decreased 
from 82% to 76% and for North West, it decreased from 85% to 78%. 
163 
5.5.3.16 I respect the ways people from different cultures behave 
t-Test : Paired Two Sample fo r ~ans 0.05 
GAUTENG 
PREQ16 POSTQ16 diff 95% Confide nce Interval 
Mean 4.11764706 4.2941176S -0.176 -0.630 a.in 
Variance 0. 735294U 0.22058824 
Observations 17 17 
Pearson Correlation a.2 190890.2 
Hypothesized Mean Difference a 
df 16 
-6% t Stat -0.824 0% - P(T <=t) one-tail . 0.211 PnMHt PasJ:--l!St ~51 Pt$!-4et T Critical one-tail 1.746 .,,. ,,. St.:■=NG """' "" .". ~lfsag1H /dislfrtt 1111 ,can~~ Rej~ Null Hypothesis because p >0.05 (~R~_ns are t!!_e same) P(T<=t) two-tail 0.422 
T Critical Two-tail 2.120 
t-Test: Paired Two ~~~pie for ~ans a 0.05 
NORTHWEST 
PREQ16 POSTQ16 diff 95% Confidence Interval 
Mean 3.9U08791 4.l3IB6813 -0.220 -0.485 0.045 
Varianc-e ----------- 1.39218559 0.9Ei019536 
Observations 91 91 
Pearson Correlation 0.31766222 
_Hypothesized tv'iean Difference a 
···--· r-
df 90 
18" tStat -1.648 
P(T<=t) one-tail 0.051 
T Critical one-tail 
----- 1.662 
,-· ~~.st A:&t-481 .Pt■!~s-t ---Po-'1-t•tlt - ~•-est ----P.m:t....w- cannot Reject Nul l Hypothesis because p > 0.05 (rv1eans are the same) '""'"•"- N£UTil,t,t s~ clsipre.lmilfPtt ,P(T<=t) two-tail ·- ·-t 0.103 
1.987 
t-Test: Paired Two Sample for Means 
WEmRN CAPE a 0.05 
831' 
PREQ16 POSTQ16 diff 95% Confidence Interval 
Mean 3.54166667 4.lli -0.583 -1.179 0.013 
Variance 1.3894927S 1.07065217 
_l .~bservations 24 24 Pearson Corre lation 0.19160U3 Hypothesized Mean Difference a -+ di 23 tStat -2.024 
P(!:'=t) one-tail 0.027 
T Critical one•tail 1.714 
""' "" ""' '"' "" ... Reject Nul l~y~Jh~-~!.~.. ~ .~.~.~~ p ~-O~J Means ~~~ Different) 
P(T<=t) two-tail 0.055 
T Critical Two•tail 
Cannot Reject Null Hypothesis because p >0.0S (Means are the same ) 
Graph 5.48: I respect the way people from different cultures behave 
There is strong agreement with this statement in all experimental groups . Gauteng registered 
increased agreement from 82% to 100%, North West increased from 70% to 81 % and Western 
Cape from 58% to 83%. 
164 
5.5.3.17 I try to obtain as much information as I can when interacting with people 
from different cultures 
GAlJTlNG t-Test: Paired Two Sample for Means a 0.05 
PREQ17 P05TQ17 diff 95% Confidence Interval 
Mean 4.29411765 4.17647059 0.118 ·0.482 0.717 
Variance 0.59558824 0.90441176 
Observations 17 17 
Pearson Correlation 0.09517624 
Hy~~!~esize~- Mean Difference 0 
df 16 
6% 61' 
()!I !Stat 0.416 
........ ......... ..°..".. . --..-.. ....-. ---Plt--le-ll: ·-"·-'-~-- - P(T<=t) one-tail 0.342 .S...t i~.,.;•t1.1..  NMMl TCritical one-tail 1.746 • GtimING / ~ "' "" "' "' cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
P(T<=t) two-tail 0.683 
T Critical Two-ta il 2.120 
NORTHWEST a 0.05 
87" PREQ17 P05TQ17 diff 95% Confidence Inte rval 
Mean 4.2~79121 4.21978022 -0.011 -0.248 0.226 
Variance 0.8781~ 0.86227106 
Observations 91 91 
Pearson Corr-ela-tion ---·------0.25313246 
Hypothesized Mean_D ifference __________  0 
di 90 
- !Stat ·0.092 Sll 8" 8% 8" P(T<=t) one-tail 0.463 ........ ....... T Critical one-tail 1.662 Pmt-el -· ......... - .. cannot Reject Null Hypoth_esis because p > 0.05 (Means are the same) ~ ..t t/ flgfff NfO'!llAl ~&wipn/dltairtt oNOIITHwrn .,. ""' "' "" P(T<=t) two-tail 0.927 TC ritical Two-tail 1.987 
cannot Reject Null Hypothesis because p > 0.0S (Means are the same) 
WESTERN CAPE t-Test: Paired Two Sample for Means a 0.05 
71!1 
67" PREQ17 P05TQ17 diff 95% Confidence Interval 
Mean 3.58333333 3.875 -0.292 -0.882 0.299 
Variance l .2971014S 2.11413043 
Observations 24 24 
Pearson Correlation 0.43977862 
21% Hyp~_thesized ~an Difference 0 
di 23 
....... _..,,. __ i---~i t Stat Pl't ·leSI: -- ,,.._,,. _L ·l.022 ......... P(T<=t) one-tail 0.159 .~,,.. t.l/,C:ft NMMl SO<q!y- T Critical one-tail 1.714 • 'MSITRN CAP£ "" lN ... "" 21" cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
_P(T<=t) two-tail 0.3_1_7 ____  
T Critical Two-ta il 2.069 
can.not Rej~ct-~u ll Hypothesis because_p  > 0.05 (Means are_t~e same) 
Graph 5.49: I try to obtain as much information as I can when interacting with people from different cultures 
The majority of respondents agreed with this statement and this agreement stayed more or less 
consistent throughout. 
165 
5.5.3. 18 I would not accept the opinions ofp eople from different cultures 
a a.as 
GAl/TtNG 
88% PREQlB POSTQlB dill 95% Confidence Interval 
71% Mean 2.0S882353 1.82352941 0.235 -0.355 0. 
Variance 1.43382353 0.65441176 
Observations 17 17 
-~~ I.. ~  ~ Pearson Correlation 0.39851713 Hypothesized Mean Difference. a di 16 tStat 0.846 
. Pr!•R Polt-«st Pfttest ' Pot!--Vit S~ IHtt ,---PM'05t·'iN t P(T<=t) one-J~. ... 0.205 rn; ... T Critical one-tail 1.746 ■ GAIJTL'4(: "' ~nnot Reject Null Hypothesis because p > 0.05 (Means are the sa"'.".L ___- r---,------1 
P(T <=t) two-tail 0.410 
T Critical Two-tail 2.U0 
cannot Reject Null Hy_p~thesis because p >0.05 (Means are the same) 
NORTHWEST t:_!~ Paired Two Sample for tv\eans a a.as 
76" PREQlB POSTQlB dill 95% Confidence Interval 
74% 
Mean 2 2.05494505 -0.055 -0.416 0. 
Variance l .5lllllll 1.6969475 
Observation-s ----- 91 91 
Pearson Correlation 0.06244787 
Hypothesized Mean D!!!,erence a 
di 90 
17" 15% !Stat -0.302 
11% 
I I -7% P(T<=t) one-tail 0.382 ......... ... .... - ....... T Critical one-tai l 1.662 P,.-H ?Gl.1.-S.t Pol.t •lt\l cannot Reject Null Hypothesis because p >0.05 (Mean~ re the same) ~lfltt/lirtt ■PiORTMWBi "" 15'< "' U5 '",. .". ""'"·-·~- P(T <=t) two-tail a.7 63 T Critical Two-tail 1.987 
cannot Rej."_cl N_ull Hypothesis because p >.~.OS (M.<".~ns are the same) 
WESTERN CAPE t-Test: Paired Two Sample for tv\eans a a.as 
75% 
PREQlB POSTQlB dill 95% Confidence Interval 
Mean 2.US 2.20833333 -0.083 -0.705 0.5 
Variance 1.24456522 1.73731884 
Observations ----- 24 24 
Pearson Correlation o.2mo100 
Hypothesized Mean Differe nce a 
df 23 
t Stat -o.2n 
P(T <=t) one-tail 0.392 
T Critical one-tail 1.714 
• WESTERN CAPf • 
Cannot Reject~ Hypothesis becau~e p >0.05 (Mea~~are the same !.__ 
P(T<=t) two•t~il__ ... ···············---- 0.784 
T Critical Two-tail 2.069 
Cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
Graph 5.50: I would not accept the opinions of people from different cultures 
A minority of respondents actually admitted that they do not accept the opinions of other people 
from different cultures, and after the training programme, these opinions changed as follows: 
Gauteng in the pretest 12% which decreased to 6% for the posttest, North West 17% which 
decreased to 15% and Western Cape 13% actually increased to 17%. 
166 
\ NWU ] 
'LIBRAflY 
5.5.3.19 I am sensitive to my culturally-distinct counterpart's subtle meanings 
during our interaction 
0.05 
GAUTENG t-Test: Paired Two Sample for Means a 
53il PREQ19 POSTQ19 diff 95% Confidence Interval 
4711 
I ,..  Mean 3.11764706 3.35294118 -0.235 -0.974 0.504 411' Variance 1.48529412 1.24264706 Observations 17 17 24% Pearson Correlation 0.243553 Hypothesized Mean Difference 0 
12% 
-· --- II ~--_J 
df 16 
tStat -0.675 
........ ?~1Ht '°" .... ' P(T<"I) one-tail 0.255 
.S,,1. r°""'~e/113rtt ""'""' Stroniv~/disagrtt ,m, TC ritical one-ta il 1.746 ■ G,1,i.JllNG "" UM "'' 24% cannot Reject~II Hypothesis beC3use p > 0.05 (Means are the!~eL ____ ,_  
_P (T<"l)two-tai l __ ---·--- ___ ~ O.SO!l 
T Critical Two-tail 2.120 
cannot Reject Nu(I H.vpoth~~ becaus~ p _> 0.05 (Wtea~ are the same) 
NORTH WEST a a.as 
56" PREQ19 POSTQ19 diff 95% Confidence Interval : 
Mean 3.12087912 3.48351648 -0.363 -o.rn -o.053. 
43" Variance 1.68522589 1.319169n- ---
Observations 91 91 
33" 
18% Pearson Correlation
25" --- --------0-.2659004 
I l_i Hypothesized Mean Difference 0 J df 90 tStat -2.326 P(T <"!) one-tail 0.011 ,,.,.,... -· ....... T Critical one-tail 1.662 Prt-t,t ""'""" Prt,teS:: ~.-«r..,-~ Reject Null Hypothesis _beC3use p < 0.05 (Means are Diffe rent) NEUTRAl Str°'¥\'dsag,wC~ 
■ HORTH WEST . ,.,. "" "" ""' "" 17~ P(T<"l) two-tail 0.022 T Critical Two-tail 1.987 
Reject Null Hypothesis because p <0.05 (Means are Different) 
WESTERN CAPE t·Test: Paired Two Sample for Means . ---;---- a 0.05 
38" 
PREQ19 POSTQ19 diff 95% Confidence Interval · 
Mean 3.04166667 3 0.042 -0.668 o.7 S1 
-----············1· 
Variance 1.34601449 l.4782f,()87 
Observations 24 24 
Pearson Correlation 0 
Hypothesized tv1ean Difference 0 
df 23 
! Stat 0.121 
,P(T<=t)o_ne_-t_ai_l ___  0.452 
T Critic.al one-tail 1.714 
-----
..~ ~~~! ..~ .~!:~ .~.~.~!. . ~e~!~~~.(~ b.: .~ .~~~ ..P . > 0.05 jMeans are the -~~-~!.L 
P(T<"I) two-tail 0.904 
T Critic.al Two-tail 2.069 
cannot Reject Null Hypothesis because p > 0.05 (Wieans are the same) 
Graph 5.51 : I am sensitive to my culturally-distinct counterpart's subtle meanings during our interaction 
Similar to the observation in question 5, almost ½ of the respondents in each of the experimental 
groups reported uncertainty on this particular question. 
167 
5.5.3.20 I think my culture is better than other cultures 
GAl/TENG t-Test : P~!red Two Samp~~_!?r Means a 0.05 
PREQ20 POSTQ20 diff 95% Confidence Interval 
Mean 2.11764706 2.058823S3 0.059 -0.679 0.79 
Variance l.23S29412 1.183823S3 
Observations 17 17 
Pearson Correlation 0.14896989 
Hypothesized Mean Difference 0 
df 16 
!Stat 0.169 
P(!<;t) one-tail 0.434 
T Cri tical one-tail 1.746 
~ 
cannot_.~eject Null,_.Hypothesis because~.::".~.:.~ (_~ans are the same) 
P(T<;t) two-tail 0.868 
T Critical Two-tail 2.120 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
NORTH WEST t-Test: Paired Two Sample for Means a 0.05 
81% PREQ20 POSTQ20 diff 95% Confidence Interval 
Mean 1.86813187 1.85714286 0.011 -0.327 0.34 
Variance 1.53797314 1.59047619 
Observations 91 91 
Pearson Correlation 0.15832376 
Hypothesized Mean Differ1:_nce 0 
df 90 
11% 15" 11% tStat 0.065 
P(T<;t) one-tail 0.474 
---• T Critical one-tail 1.662 ~-•  1t- Po-stt1t- .l- -P■Jt.-trtt  _<=.ann~ -~~ Null Hypothesis because p >0.05 (Means are the ~ e) 
St'onfY 119'H /111fff . NEUTUL ... 75" 8l!i P(T<;t) two-tail .. 0.949 
T Critical Two-tail 1.987 
Ca_nnot ~eject Null Hyp_othe~is because p > 0.05 (Means are the same) 
WEffiRN CAPE t-Test: Paired Two Sample for Means a 0.05 
58% PREQ20 POSTQ20 diff 95% Confidence Interval 
Mean 2.29166667 2.25 0.042 ·0.415 0.4 
Variance 1.43297101 1.58695652 
Observations 24 24 
25% Pearson Correlation 0.61267461 
11% 
17% 17% Hypoth~ i!ed Mean Di!fe_~~nce 0 
I.,._,, ,, ___ I . I df 23 !Stat 0.189 ......... ,,..., Past~1 ..,..,. P(T<;t) one-tail 0.426 
Sa:,nsv.-u /agree NEUTRAL T Critica l one-tail 1.714 
■ W15TONWE "" "'' "" 110< """''" ""-- Cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<;t) two-tail 0.852 
T Critical Two-tail 2.069 
Cannot Reject Null Hypo_thesis because p >00_()5_1 Means are the_ _s a_rne) 
Graph 5.52: I think my culture is better than other cultures 
All three experimental groups showed disagreement with this statement and after the training 
programme, this disagreement grew as follows: From 76% to 82% for Gauteng, 75% to 81 % for 
North West and an increase from 58% to 63% for the Western Cape. 
168 
5.5.3.21 I often give positive responses to my culturally-different counterpart 
during our interaction 
GALJTtNG t-Test: Paired Two Sample for Pv\eans a 0.05 
8l% 82" 
PREQll POSTQll diff 95% Confidence Interval 
,.M ean 3.94117647 3.82352941 0.118 -0.359 0.595 
Variance 1.05882353 0. 77941176 
'l-~ -~~-~-~ -~~~-~ns_ ___  17_ 17 
Pearson Correlation 0.53825425 
tHypothesized Mean Di!!_erence o' 
18ll. 
_di 16 
'. !Stat 0.523 
: ~-lest j i.".(T<=tLone_:!~ ____ _ 0.304 
Stroot, a,:e!/i!ftt 
~TCritical one-tail 1.746 
a GA.ITTNG j 82,. ~ "" "" !-f~-~-~-~~-.~~je~. . Null Hypothesis because p > O.~?.J~~~-~--~:..i!.~-~--~~m.e) ____ ~---,-~-
l~(!~=t)t_wo-tail o f,08 
TCritical Two-tail 2.120· 
;cannot Reject Null Hypothesis because p >O.~ (Means are_the same) 
NORTHWEST r ~Test: Paired Two Sample for Pv\eans a 0.05 
67ll 
PREQll POSTQll diff 95% Confidence Interval 
1.Mean 3.6043956 3.64835165 -0.044 -0.371 0.283 
;Variance 1.53064713 1.4971917 
'~ ~at,.o ns_ _ 91_ 91-+----+----~--.... 
on Correlation 0.18599409 
0 
22" 
90-S-···· 
-0.267 
0.395 
lTCritical one-tail 1.662 
tcannot Reject Null Hypothesis because p >0.05 (Means are the same) 
I r 
■ HORIB'lt'EST 63% 67S n• ",. P(T<=t) two-tail 0.790 "" 
'T Critical Two-tail 1.987 
IC.,~notRejec:t~u!l_fiypothesis because p >0.05 (Means are the same).~---~ .L 
WESTERN CAPE i!:}est: Paired Two Sample for Wieans a 0.05 
- 71% PREQ21 POSTQll diff 95% Confidence Interval ;Mean 3.58333333, 3.79166667, -0.208 -0.831 0.414 ~Variance . 1.21014493 1.5634058 
Observations 24 24 
!Pearson Correlation . 0.2186323i 
iHvpothesized f\liean Difference 
ldf 23 
' 
. cannot Reject Null 1-fypothesis because p >O._~ (we..~."~~_ re}he same) 
:P(T<=t) two-tail 0.496· 
1TCritical Two-tail 2.069 
Graph 5.53: I often give positive responses to my culturally-different counterpart during our interaction 
All three experimental groups had the same responses for both the pre-test and the post-test and 
these responses did not change after the administration of the pre-test. Notably, these are the 
expected norms for the responses on this particular statement, one which a person would not wish 
to change through a training programme. 
169 
5.5.3.22 I avoid those situations where I will have to deal with culturally distinct 
persons 
GAl/TENG ,t-Test: Paired Two Sample for ~ans a 0.05 
71l! 
PREQ22 POSTQll diff 95% Confidence Interval 
59" Mean 2.47058824 2.47058824 O.CXXl ·O.7 92 0.7 92 
Variance 1.51470588 1.38970588 
Observations 17 17 
29% 1 Pearson Correlation 0.18244753 Hypothesized fv\ean Difference a ·•~-test- . df 16 tStat a.cm Fast-RX P1e-te~ Port-tnt -----------,P1 ! < = t) one-tail 0.500 Sttoo,fy-ap;t/agttt Stron,h tlwgrtt/diYrgftt 
• G,\i.!Tl:NG \ 2ft 29'6 T Critical one-tail ----- 1.746 
,Canno! Reject N~ Hyp_othesis ~-•cause p >0.05 (Means are the same) 
P(T<=t) two-ta il UXXJ 
TCritical Two-tail 2.UO 
Cannot Reject Null Hypot_hesis because p >0.05 (Means are the same) 
NORTHWEST t-Test: Paired !~o Sa n:ipl.e fo!, Pv'ieans 0.05 
PREQ22 POSTQll diff 95% Confidence Interval 
Mean 2.53846154 2.61538462 -a.on -0.389 0.23S 
Variance 1.7 8461538 1.66153846 
Observations 91 91 
Pearson Correlation 0.34744388 
Hypothesized Mean Difference a 
df 90 
!Stat ·0.489 
P(T<=t) one-ta il 0.313 
TCritical one-tail 1.662 
Cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
■ NORTHWEST ) . P(T<=t) two-tail 0.626 
T Critical Two-tai l 1.987 
Cannot Reject Nu ll Hypothesis because p > 0.05 (Means are the same) 
WESTERN CAPE 0.05 
63" PREQll POSTQll diff 95% Confidence Interval . 
Mean 2.41666667 2.41666667 O.CXXl ·0.693 0.693 
Variance 1.2971014S 1. 73ll!8406 
Observations 24 24 
Pearson Correlation 0.11119938 
~ poth~i_z~M ean_D_iff_e_re_n_ce_ ___  --- a- 
df 23 
!Stat O.CXXl 
P(T<=t)_one-tail .. o.soo,. ... 
0
""'""" T Critical one-tail 1.714 a wtSTtitNr.AX ' 215 25~ ""' "" Cannot Reject Null Hypothesis because p >0.05 (Wieans are the same) 
P(T<=t) two-tail l .CXXl 
T Critical Two-tail 2.069 
Cannot Reject Nul l Hypothesis because p > a.OS (Means are the same) 
Graph 5.54: I avoid those situations where I have to deal with culturally-distinct persons 
There is overall disagreement with this statement. In Gauteng , there was a slight decrease in 
disagreement from 71 % to 59%, North West stayed consistent and the Western Cape increased 
disagreement from 50% to 63%. 
170 
5.5.3.23 I often show my culturally-distinct counterpart my understanding through 
verbal or non verbal cues 
GAi/TING t-Test: PairedTw_2 Sampl~_for Me~ a 0.05 
82" 
PREQ23 POSTQ23 difl 95% Confidence Interval 
Mean 3.8823S294 3.88235294 0.CXXJ -0.364 0.364 
Variance 0.61029412 0.48529412 
Observations 17 17 
Pea~on Correlation ___ ~-- 0.54719738 
Hypothesized Me_an_D_if_le_r_en_c_e ____  0 
df 16 
!Stat 0.CXXJ 
,P(T<=t) one-tail 0.S00 
········•+ 
,.T C ritical one-tail 1.746 • GNJIDIG 
cannot R~ject Null Hy~oth~s_is_beca~se p > 0.0S (Means are the same) 
,P(T <=t) tw?:~!1 UXXJ 
T Critical Two-tail 2.120 
cannot Reject_Nu)I_H yP.°.th~s_is _b.~cause p > 0.05 (Means are the same) 
NORTHWEST t-Test: Paired Two Sample_for Means a 0.05 
66'6 
PREQ23 POSTQ23 difl 95% Confidence Interval 
Mean 3.50549451 3.63736264 -0.132 -0.430 0.166 
Variance 1.56385836 l .4114n41 
Observations 91 91 
Pearson Correlation 0.31171899 
Hypothesized Mean Difference 0 
df 90 
14% 
!Stat -0.879 
_L P(T <=t) one-tail 0.191 T Critical one-tail 1.662 
Psot-tst 1'<5t-R:S I 
cannot Reject Null Hypot~~~is be~u_se p ~ 0.05 (Means ~re the same) 
Stroo;,, Nglff/drwgrtt 
■ NOIITHWEST j .... ..,. P!T<=t) two-tail _____ 0.382 
T Critical Two-tail 1.987 
_cannot Reject Null_Hypothesis because pl o.OS (Means are the same) 
wtmRNCAPE a 0.05 
PREQ23 POSTQ23 difl 95% Confidence Interval 
Mean ·-3-.41-6·66·6·67- -3.20-833-333. --0-.20-8 ~--0.-450 0.867 
Variance 1.38405797 1.91123188 
Observations 24 24 
Pearson Correlation 0.26509653 
Hypothesized Mean Diff~ren'= 0 
df 23 
tStat 0.654 
P(T<=t) one-tail 0.260 
T Critical one-tail 1.714 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail 0.519 
T Critical Two-tail 2.069 
cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
Graph 5.55: I often show my culturally-distinct counterpart my understanding th rough verbal 
or non-verbal cues 
The reported responses for both the pre-test and the post-test were one of overwhelming 
agreement across all three experimental groups. 
171 
5.5.3.24 I have a feeling of enjoyment toward differences between my culturally-
distinct counterpart and me 
t-Test; Paired Two Sample for Means a 0.05 
GAUTENG 
PREQ24 POSTQ24 diff 95% Confiden e 
88% 
Mean 3.823S2941 4.058823S3 -0.235 -0.622 
76% Variance 0. 77941176 0.30882353 
Observations 17 17 
Pearson Correlation O.S320479S 
Hypothesized Mean Difference 0 
df 16 
t Stat -1.289 
P(T<=t) one-tail OJ.a! 
12% 12% 12% 
T Critical one-tail 1. 746 
·------~cannot Rej~ N~ Hypothesis bec.,us~ >0.05 (Means are t~e s~e) 
Pre-test- r-Pasr-test·--· Pre-test Post-ll!st · Pre-test Post- P(T<=t) two-tail 0.216 
Strongty a_gree/agree NEl/TRAL Strongly disog.,e/disagi TCritical Two-tail 2.120 
~■ GA-!ITE-NG- --76-ll -~--88%- -~-1-1%- ~--12-% -~--U%- - ---(JI) Cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
NORTH WEST _!-Test: Paired Two Sample for M_e;_a_ns'---~ a 0.05 
72" PREQ24 POSTQ24 diff 95%Confiden 
Mean 3.86813187 3. 76923077 0.099 -0.241 
Variance 1.44908425 1.49059829 
Observations 91 91 
Pearson Correlation ------. O.OC324664-4 ---· 
~pothesized Wean Difference 0 
21" df 90 _i I __i _ _i___ __ t Stat O.S78 P(T<=t) one-tail 0.282 
T Critic.al one-tail 1.662 
~II ftc5t-tit Plot·R\t ~Mt.st ! ~-tell Pmt-trst 
cannot Reject Null Hypothesis becau.s_e?~ 0.05 (Means are th_e_ _ sa_111e)_ 
St:~ agrt:daptt NWTTW ~ort,r clug:uJdh,afJtt 
a NOATHWESTj "" .... m, P(T~"1) two-tail O.S65 
T Critic.,I Two-tail 1.987 
cannotR,ejectN.ul_l..f:tvPothesis be"'".'•P.>. 0.05 (Means are _t_h_e ~111e) 
WESTERN CAPE t•Test : Paired Two Sample for ~ans a 0.05 
PREQ24 POSTQ24 diff 9S% Confiden 
Mean 3.2003333 3.37S -0.167 -0.910 
42" 
-Var-ianc-e ---------- 1.47644928 1.80978261 
J 0 bs  e rvations 24 24 Pearson Correlation 0.05652084 Hypothesized fv'ean Difference 0 di 23 t Stat -0.464 
~--st ?ost~ P(T<=t) one-tail 0.324 
StrOOfY .,~. ..f t TCritic.,I one-tail 1. 714 
• V,'[ST£RN 01£ '"' cannot Reject Null Hypothesis because p >0.05 (Means are the same) 
P(T<=t) two-tail 0.647 
TCritical Two•tail 2.069 
cannot Reject Null Hypothesis because p > 0.05 (Means are the same) 
Graph 5.56: I have a feeling of enjoyment towards differences between my culturally-distinct 
counterpart and me 
The respondents across the board agreed with this statement. Upon the training programme, 
Gauteng shows increased agreement from 76% to 82%, as Western Cape follows suit with an 
increased agreement from 50% to 58%. 
172 
GAUTENG 
feellns o f enjoyment towords dlffere-nc.es b e tween my cvlturall v-- 3 .82 4 .06 S.00 
counte rpart. and rn e . 
Jhow n.,v c u11,..,· • lly - dlsU,.,ct: c.oun l.erpart: mv unders,;andlns 3.BB 3.BB 
, verba l o r nonverbol cues. 
1 .00 
those s i tuation• \Nhera I wil l have to deoL wlt.h c.u lturolly- dls tln c.t. peraons. 2 .47 
give positive rtu 11:,o n ses t·o my cu lt·urallv-dlfferent counten:u11rt: . 82 3 . 94 A S.00 
=>ur lnter.,,.c, Inn 
1 . 00 
TOy c u ltur • Is b,elter then Ot"her c ulTure.s. 2 . 06 2. 12 
-.s it Ive to my c u lturolly- dlstln c. t c.ounteroa.-1·.s. subtle ,..,.,,i,uu,intr• .35 5.00 
:Jour lnt" e roc.rlon . 
1 .00 
:1...82 2 .06 
o blaln •"' ,-r,u c.h In f o , .-n ... 110 ,. ,;,.,. I Cbn ...,h.,,n ln tera c th•g wit.I, 
from d ,ffere ,,l c ullu,·••· 4 . 18 
4 .12 
.t the waya peopl e f ron'\ dl t"teren t c ultu.-es beh.ave . 
1 .00 
'ee l ,.u:e t ess when 1ntorac tln9 ...... 1th p eople from dlffe.-ent c uh:ur Zl.1 
r y obse ,·vont when 1nt:e r e.:-1:lng ....,,.,rh people f.-om dU t ... .-cnt c u lu.~•·us. 3. 5.00 
3.88 
en- rnlnded to peopl e fro,-n dlr-t'erent c::-ultures . --======~~:-::--~I 5 .00 1 ~ S.00 
=, w•lt before forming •n Impress i o n of culturelly - dlst:lnc t. counterp•rt.,_ 
3.47 
__.,__ Pre- test 
nfld ... ,,t ....,,. ,, ,..,... lnt,..,ac llns -,llh p""ople frorn dlfte.-enl o;ultu • e "'- 1 . 00 3.82 ~ Posr- tesr 
~ l d@al s ore fter Intervention 
~et easily when ln t ern ctlng with people f.-om different c ulture•. :1..7 
1.00 
1: the vc,,lue s or people fr o m d lffe,,en t cu ltu.-es. 3.94 A. 5 . 00 
1 .00 
Ike to be wi th pe, o p l .., fro ,...,, dl1'l e r t0nt: c ult:ure,a. 1 .94 
• n• •oclable • ., I wont to be wh .. n lnt .. rect l ng with peopl e fron-. dlffer•nt. 3 . 94 S.00 
• know ....,hot to • •v ....,he n lnterac:1clng with p eople fro m dlHeren l c ultures . S.00 
1 .00 
.,,.. , y hn , d to l u lk In 1, ontof p.., o pl,e f rom d;ffe.-ent cultu.-••· 2 . 24 9 
, tty s ure o f ,....,.,..,.,.,r In ln t ar•c:-ting with people fro m dlff e .-e,-.t c uhu,·••· 4 .05 S .00 
1 .00 
,eop l e f rom olher e ult:urea are nnrrow- mlnded . 00 . 29 
nt.eroc:1:lne; ,.,..,1,h people fro m dlffc.-ent c ultu r es. A S.00 
4 .00 4 . 17 
0 . 00 1.00 2 .00 3 . 00 4 . 00 5.00 6.00 
Overall graphs for Gauteng 
173 
The graph for Gauteng shows no attitudinal changes between the pre-test and the post-test 
responses after the training programme with regards to sensitivity towards other cultures. All 
questions followed the curve of the ideal responses as depicted in green on the graph above. 
174 
NORTH VVEST 
.,. feellns o f' e nJo yn-.en c towards dlff'erenc:4S,i, bst\Neen my c u l tura lly~ S.00 
t: counterpa.-c end m e. 
• h o w my c u lcu,.& lly - d l ,. tln c t count.e rpbrt ,-.-.y under "tar, dlng 3.64 S.00 
:h v erba l or n o ,..,ve ,-ba l c ues;. 
1 .00 
thOsft s ltubtlono>....., h e r e I \NIii have to deal wit h e u h .ura ll y - d l a;. Une l:per,.ons.. 2.5 4 
~-:;:, ~~: ::~~c::·~ s.po n ses to my c ult.ural ly - dlffe rent. count:erpart_ 3 . 60 
1 . 00 
rn y c ulture 1.., belle• t. h an o ll-.e ,· c.u ltur6s. 1 . B S 87 
,nslclve t o my c.u l t u re ll y - dr.!ltinct c.ounterpa , t "s a:ubt.lo m e 8n l,-.gs 3. 4 8 S.00 
o u r Ince, 8 C t:l o n . 
1 .00 
:t n o t .-ccept che o pinions o f p eop l e fr·om d ifferen t: c ulcu re:i;. 2 . 0 5 2.00 
obta in PS mu c h l nformat.lon i>S I c "'n wh,a,n lntere c t.lng wHh S .00 
, fro m dlH"ere nt c ultures. 
c t t.h e ways p eop l e fro m d ifferent: c vlt.u.-es b e h nvo. 3.91 S.00 
1 . 00 
feel us C'!O l es.s w h e n lnterac ltln,;c w i th peopl e fro m d l f'fe ,·e nl c ulLLU "ft:lll. 
•ry o bse rvent w hen ln t e ro c tl ng with peopl e f"ro m differe nt c ultures . .00 S.00 
:,en- rn l nded to peo 1> l e f", om diffe rent c ulture s . 
3.79 S.00 
get d l scoureged when I i01Y> with peo p l e f'ro ,..,... different c u l tures. 1 . 92 . 22 S.00 
1 .00 
to wait before f orming a ,-. 1,...-. p r esslon o f c ulture l ly- dlstlnc t counterparts. 
__.._ Pre-t es t 
o nflde nt vvhen lnterecclng with p eop l e fr o m d iffe r e nt c u l t u res . 1 . 00 3.93 ~ Po s -t - test 
--,,a,:- Ide a l score a fte r· intervention 
:>set ees l l y w h en ln1er.o c t l ne wit h p eo p l o:- fr o n-. diffe r e nt· c ulture•. .l. . 77 
1 . 00 
c t lhe vulue :1: o f peo ple f r-on, dlf"Te r ,;,,nt c ult:ure.,;; . 4 . :1. 4 3 4 .._ 5.00 
1.00 
li ke t o be wit h p eop l e from d iffe r ent c ult:ure.~ . ..,... l. . 76 
,e as soc l ab l e as I want t o b~ when lnt:o ra c t l nK wi th p eop l e fro m diffe rent 3.60 S .00 
,,. know .,,.,h.,,t t o """Y .,,., h •n I n t eracting w ith p eople fr o m dlf1"orent c ulture ... 1S .00 
1 .00 
: very h 1t1rd to talk In f ·ront of people fr o m diTferent c u l tures. 2.47 
·e t tv 5 ure o f myliae lf 1,-. 1o-.tere c t1ns wh: h peop l e f rom diffe, e nt c ultu, e,o. 3.92 4 .06 S.00 
1 .00 
peopl e f rom o the r c ultures ure nurrow-n,onded. 2.2 8 2. 44 
i,-.tcruc:tlng .,.,1th p eopl e f r o ,...-. diflc , en t .::ultures. 5.00 
4 . 4 9 
0 .00 :t.00 2.00 3.00 4 .00 S.00 6.00 
l Overall graphs for North West 
175 
From this graph, it is evident that the treatment intervention had very limited impact on the North 
West experimental group. There seems to be a very slight change in the reported feelings of 
competence when dealing with persons from another culture, but it is statistically insignificant. 
176 
\NESTERN CAPE 
, feeH,, s o f enj o yment: to....,&rd s d i f'fe renc e-" b e tween rny c u l tu,-a lly- 3.37 
: count e rpart: and n,c. 
~ h o "" my c.u l tu ,·e lly--d lt.-t.lnc l coun t e r p .. ,,: n,y under• uond l ng S . 00 
-, v erba l o , n o n vc ,· bo l u e• . 
1 .00 
2.4 2 
give p0$ l t l ve r e,. p o n s e t. tc o rny c u l t uro ll y - dl fferent c.o u nte r perl 3 . 7 9 3 . SB S . 00 
o ur 1i, 1.er• c 1. l o n 
1 . 00 
Tly c u l 1:ure I s b e 1. t e r th a n o t h e r c u l t ures. 
r"IS lt:lve t.o m y c ulturoll y - dls tln c t: counterp•rt·s s ubtl e m e en l n&s 3.00 S.00 
:;,u, l n 1.e r .. c tlo n . 
1. .00 
n o 1: a ccept the opin i o n s of i:,,e o ple f r o m diU •erent c ultures . 
o bt..,ln &Iii muc h l n f o.-n-.bt:l o n - s I c..a,o n ...., ,-. .., ,... lnt:era c tl ne whh S .00 
f'r o m d lffe ,·ent c u hu r es . 
: t the ""•V• p eop l e t r o m dl tt e r e n t c u l t:ures be h ave . 4 . 1 3 S.00 
1.00 
fee l u5e l e•11o wh e n l n t .sra c tlng ""Ith p eop l e to o ,-r, dl l f e ,·ent c u l tu , cs . 2 . 3 3 
ry ob 1>u r va, nt w h <l! n h '> t e r8C1 Ins w il h p e op l e fro m d l ff.., r e nL c ul t ur•"· S . 0 0 
a n - minde d 1 0 p<ttop l .,, rro m d l ff...,,.,, t c u lt u,es . 
3.79 S .00 
,1 ,e,t. d l scou ,·•s•d wh•n I •m w ith p e o 1, l e fro m d l ffa r e ,,t c ul l ur••· S.00 
1 . 00 
:> wait befo re f o rmin g en l mpre.sslo n of cu l t u ral l y - distinct c o u n\.ef'parts. 
- Pre- t e s t 
,nflde nt. wh e n ln1 e r..,, c.t.ln1;1 \Nl t h pa o p l e f r o ,-n diffe r e n t c u l tures . '.1. .00 ~ Post- test 
~ I d e a l s co ,· e afte r l nte rv e nt.i o n 
1 .00 
. t· t:h e va l u e ,: o f pe o p l e f ro ,-n d l f fe , en t: c u l 'l.u,es. 4 S . 0 0 
1 .00 
l k c, to be wit h p<t'lo p l o:, f r o nl dl f f erent: c u l t:uf'@S . 2 . 46 
, a s socl pb l e us I ..... a n t: t o b e w h en l nte r a c tln9 w ith p eop l e f r o ,,.. d iffere nt S . 0 0 
~ kn O \N ...., h at t o • •Y when i nteract lns. with p ... o pla f'ro m differe nt c u l toure s.. S.00 
1 . 00 
ve ,·v ha ,·d to 1:a l k In f , o n t o t p e op l e fro m dl ffere ,, 1: c u lt u ,·e -' -
,tty s ure o f myself I n l n te r o c t lns w l1 h p eop l e f .-o ,,... dlffere nL e u lt ur•s. 5.00 
1. .00 
,oople fr o ,,... oth er c u l 1 u res. r.ore n .. r r ow- 1-nl n d e d . 2.2 1 
nr e r e c tln9 w l l:h p eop l e fro m d i ffere nt c ulcure s . ...._ 5.00 
U . 00 1 . 00 2 .00 3 .00 4 .00 5 .00 6 . 00 
Overall graphs for Western Cape 
177 
The Western Cape showed a statistically significant change in attitude after the training 
programme, with reference to showing respect to other cultures and knowing what to say to 
persons from another culture. The Western Cape, during the post-test, admitted more readily that 
they do not always wait before they form an opinion about persons from another culture. 
5.6 DISCUSSION OF THE RESULTS 
This section will discuss the findings and relate it to the literature review. The synthesis and 
clarification of the findings will be according to the research objectives. 
5.6.1 MAVAS questionnaire 
The MAVAS questionnaire has certain themes identified with the different questions, and these 
themes are internal causes of aggression and violence, External causes of aggression and 
violence, Situational causes of aggression and violence and management of aggression and 
violence. The treatment administered to the respondents as training programme incorporated all of 
these themes in the curriculum as set out in section 5.2.4.3. The researcher performed the pretest 
prior to the treatment, with the post-test administered after the treatment in order to see if there is 
an attitudinal change in respondents with regards to these themes on the MAVAS questionnaire. 
After the perusal and analysis of the responses, the following conclusions are made. 
5.6. 1. 1 Internal causes of aggression and violence 
Questions (4) four, (5) five, (7) seven, (9) nine, 14 and 17 relate to the internal causes of 
aggression, i.e. causes within the patient. 
• Question four: It is difficult to prevent patients from becoming violent or aggressive 
Notably, at least 52.9% of the respondents reported that it is difficult to prevent patients from 
becoming aggressive. In the post-test after the training programme, this percentage 
decreased to 47.1%, the p-value being (p=0.750) . As such, p>0.05 shows that the training 
programme had no significant statistical effect on the Gauteng group. North West 
experimental group had a low indication of 39, 6% agreement with the statement and it 
decreased to 31 .9%. The (p=1.987) also appears statistically insignificant, with a similar 
178 
finding for Western Cape, namely (p=0.382). Therefore, the training programme did not affect 
any significant statistical changes in the attitudes towards this statement. 
Observably, the attitudes within all three groups remained stable, regardless of whether the 
training was done or not. Therefore, the null hypothesis (Ho) is accepted and the training 
programme made no change in the attitudes of the respondents with reference to their 
perceived difficulty in the prevention of violence and aggression. 
• Question five: Patients are aggressive because they are ill 
All respondents were in agreement with the statement that patients are aggressive because 
of their illness. Albeit statistically insignificant, it is noted however that scores for all 
experimental groups did change with regards to the percentage of who agrees with this 
statement during the post-test. The differences are as follows : Gauteng 76.5% to 82.4%, 
North West 53.8% to 54.9% and Western Cape from 58.3% to 70.8%. The expected ideal 
response for this question also points towards agreement with this statement. 
The majority of the respondents were in agreement with this statement and subsequently, 
because this is an accurate perception of the respondents , the training did not change their 
attitudes, thus the null hypothesis (Ho) is accepted. Therefore, it can be stated that the 
training programme had no effect on the respondents. All probability values exceeding 0.05 
namely Gauteng (p=0.422), North West (p=0.334) and Western Cape (p=0.216) lead the 
researcher to accept the null hypothesis (No), indicating a statistically insignificant relationship 
between the training programme and the attitudes in the post-test. The strong agreement with 
this statement corresponds well with findings wherein Duxbury and Whittington (2005:474) 
reported that nurses clearly see mental illness as a good indicator of aggression and 
violence, 
• Question seven: There appear to be types of patients who frequently become 
aggressive towards staff 
All the respondents were in overwhelming agreement with this statement based on the one 
tail t-test; Gauteng was the only group which showed a statistical insignificant change 
between the groups on the posttest Gauteng (p=0.014) leads to a rejection of the null 
hypothesis (No) ,. An interesting phenomenon on this question is that within the groups when 
179 
computing the one-tailed test, both North West and Western Cape showed a statistically 
significant change. The probability values for this test are reflected as follows, for North West 
(p=0.066) and for Western Cape (p=0.641). Because p>0.05, it is stated that the null 
hypothesis (No) cannot be rejected and the training made I significant statistical difference. 
• Question nine (9): Patients who are aggressive towards staff should try to control their 
feelings 
With the probability values for the three experimental groups reportedly being Gauteng (p 
=0.136), North West (p =0.694) and Western Cape (p=0.110) none of the three experimental 
groups showed any statistically significant changes in attitudes in this question. Therefore, 
the null hypothesis (Ho) could not be rejected for this response; hence the training programme 
had no significant statistical effect on the three groups. 
It, however, remains observable that agreement with this statement did decrease between 
the pre-test, administration of treatment and the post-test, Gauteng showed a decrease in 
agreement from 70.6% to 64.7%, North West from 76.9% to75.8% and Western Cape 79.2% 
to 70.8%. 
• Question 14: Aggressive patients will calm down automatically if left alone 
The majority of respondents disagreed with the statement that respondents will automatically 
calm down if left alone. The North West province showed a statistically significant change in 
attitude. However, it is remarkable that they did not receive the training programme which 
dealt with aggression or the management of aggression. They only received training in 
cultural awareness and sensitivity. This group, in terms of demographics, is also the youngest 
group in comparison with the other groups. 
The training programme only affected the attitudes of the North West experimental group. 
However, for the Western Cape and the Gauteng groups, the null hypothesis (Ho) could not 
be rejected. Upon closer inspection, it is however evident that for both Gauteng and the 
Western Cape, the post-test showed minimal higher agreement with the statement. After the 
training programme for Gauteng, the agreement in the Post-test increased to 47.1% from the 
initial 23.5% in the pre-test. Similarly, the Western Cape response increased to 37.5% in the 
post-test after an initial 33.3% agreement in the pre-test. The p values being p>0.05 for 
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Gauteng (p=0.216) and Western Cape (p=0.200) show no relationship between the training 
programme and the attitudes in the post-test of Gauteng and Western Cape. 
This is observation in contrast with the perception of the indigenous healers in section 
4.7.3.1, where they recommend that the calmness of the mental health care provider should 
rub off on the aggressive person and that it is not always necessary to intervene. The 
aggression can be easily managed if the cause is removed. 
• Question 17: Expressions of aggression do not always require staff intervention 
Question 17 was met with an overwhelming response rate indicating disagreement with this 
statement. 
The post-test showed a slight decline in disagreement with the statement, namely Gauteng 
now reported 76.5% disagreement as opposed to the 82.4% disagreement before the 
training . North West dropped from 80.2% down to 60.4% and at a p<0.05, namely (p =0.002), 
this is the only group which shows a significant relationship between the training programme 
and the post-test scores. Disagreement in the post-test in the Western Cape dropped from 
45.8% to 41.7%, and shows no statistical significance as (p =0.539). Therefore, it can be 
deduced that only the North West experimental group showed a significant difference in 
response after the treatment. 
The posttest also showed that the treatment intervention could not persuade the respondents 
otherwise. This attitude proves to be very tenacious in comparison with the North West 
experimental group, where their conviction of disagreement changed from 80% during the 
pretest to lower to 60.4% during the posttest even though they only received training in 
cultural sensitivity and awareness. The outcomes of the qualitative research in chapter four 
(4) section 4.10.4.3 show that the indigenous healers, both the Khoisan and Basotho, 
informed that often no interaction is necessary. Mccann et al. (2014:2) and Brodaty et al. 
(2007) reported similar conflicting feelings in staff as to when intervention is necessary. 
5.6.1.2 External causes of aggression. 
This theme is observed in questions 1, 16 and 27. 
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• Question one (1) Patients are aggressive because of the environment they are in 
The statement in question one (1) refers to the environment being a cause of patient related 
violence. As observable in graph and table 5.3, Gauteng showed no statistically significant 
change in their attitudes towards this question p>0.05 at (p=0.422) the probability level 
exceeding the set p level indicating a statistical insignificant relationship between the training 
programme and the post-test results . This might possibly be explained by the fact that 
Gauteng reported that 82% of their respondents had training in the management of 
aggression and violence. 
North West and Western Cape, on the other hand, showed a significant change in attitude 
towards this question, with North West showing a significant increased agreement between 
post and pre-test from 73.6% to 94.5%. Even though they only received training in cultural 
sensitivity and awareness, the Western Cape experimental group on the other hand 
underwent the total training programme and showed an increased response of agreement 
from 45.8% during the pre-test to 83.3% during the post-test. For the North West group, the p 
value is (p=0.000) which indicates a statistical significant difference in scores for the pre-test 
and the post-test. Similarly, the Western Cape who received the total training programme had 
a post-test p value of (p=0.030), also showing a statistically significant difference. 
Therefore, the null hypothesis (Ho) is accepted for Gauteng but rejected for the North West 
and the Western Cape, the conclusion being that the training programme had a statistically 
significant effect on the North West and the Western Cape, and had a positive attitudinal 
change. 
This finding echoes what was observed by Duxbury and Whittington (2005:474) , where both 
staff and patients recognise the role of the environment in adding to mental health care user 
related violence and aggression. 
• Question 16: Restrictive care environments can contribute towards patient aggression 
and violence 
All of the respondents recognised how the restrictive care environments can contribute 
towards patient related aggression and violence, and the training programme brought about a 
statistically significant change in attitude in the Western Cape (p=0.010) and the North West 
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(p=0.014) experimental groups, indicating that the null hypothesis can be rejected. Gauteng, 
who previously had training, maintained their positive agreement with his statement. Western 
Cape showed the highest post-test agreement with this statement, namely an increase from 
66.7 % to 91 .5%. North West did not show such a large margin of growth, which is to be 
expected if it is considered that they were not exposed to the training programme. It is 
uncertain what might have affected such an attitudinal change in the absence of the training 
course. 
This observation of agreement is consistent with a finding by Duxbury and Whittington 
(2005:474), whereby they reported that staff and patients both identified the environment as a 
contributing factor in the manifestation of aggression and violence. 
• Question 27: If the physical environment were different, patients would be less 
aggressive 
Similar observations were made with reference to the responses of the North West group to a 
question of changes in the physical environment, where they only received training on cultural 
sensitivity and awareness, yet they are the only group who showed a significant difference in 
response in the post-test (p=0.001). Gauteng showed increased agreement with the 
statement, namely an agreement rate of 70.6% in the pre-test and an increase to 88.2% in 
the post-test, although they received training in theories around aggression. This proves that 
re-confirmation of prior knowledge may result in attitudinal changes. 
5.6. 1.3 Situational causes of aggression 
Situational causes are reported in questions two (2), three (3), six(6), 15, 20 and 23, where there is 
reference to communication between staff and patients, actions of people, relationships and 
situations which might all contribute to patient related aggression. 
• Question two (2) Other people make patients aggressive or violent 
Question two (2) specifically refers to people causing aggression in patients. Even though 
Gauteng showed an insignificant decrease in agreement with this statement from 88.2% to 
82.4% (the cause of which is uncertain) , the majority still agrees with other persons 
contributing and causing aggression. North West and the Western Cape showed a change in 
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NWU l 
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attitude towards this statement and increased agreement with this s' tatement after the training 
programme and subsequently. The null hypothesis (Ho) cannot be rejected for Gauteng, due 
to the probabil ity for Gauteng being (p=1 .608) thus p>0.05. 
The contrary is noted for both North West and Western Cape, the respective probability 
values being (p=0 .003 and p=0.031) p<0.05. Therefore , it can be inferred there is a 
statistically significant relationship in the training for North West and Western Cape in the 
post-test attitudes. 
This kind of agreement, especially when referring to the word "other'' in the statement , is part 
of what is referred to as the attributional theory (Duxbury & Whittington, 2005:470), where it 
takes the responsibility away from the nurse and attributes it towards either the patient or the 
situation. The researcher, therefore, assumes that being equipped with knowledge and also 
the strong presence of attributing responsibility elsewhere makes it easier for respondents to 
agree with this statement. 
• Question three (3) Patients commonly become aggressive because staff does not 
listen to them. 
All three groups showed a statistically significant increased agreement with the statement in 
question three (3) which states that patients become aggressive because staff do not listen to 
them. This response is very important as it shows that the training programme made staff 
more aware of the importance of communication between them and the mental health care 
user and how poor communication leads to patient aggression , as is seen in question six (6) 
The statistical significant observation is observed in the probability value for the respective 
experimental groups, namely, Gauteng (p=0.004), North West (p=0.000) and Western Cape 
(p=0.002) The null hypothesis is rejected because p<0.05 and therefore the training 
programme is deemed to have had a significant influence on attitudes. 
• Question six (6) Poor communication between staff and patients leads to patient 
aggression 
The three experimental groups all strongly agreed with this statement in the pre-test. During 
the post-test, it is observed that the perception increased in Gauteng from 76.5% to 88.2%, 
but due to the p-value being p>0.05, the training programme made no statistically significant 
184 
difference in Gauteng. The two other experimental groups on the other hand show a 
statistically significant relationship between the post-test and the training programme, as the 
p<0.05 in the North West and Western Cape. The values are (p=0.000) for North West and 
(p=0.047) for the Western Cape. The null hypothesis (Ho) is therefore rejected and it is 
deduced that the training made a statistically significant difference in North West and the 
Western Cape. For Gauteng, the null hypothesis (H.) is accepted and the training made no 
difference there. 
• Question 15: The use of negotiation could be used more effectively when managing 
aggression and violence 
Although all respondents agreed with this statement and it is not expected to sway attitudes 
and opinions in any other direction, it is noted that there is a statistically significant difference 
in the North West experimental group in terms of their post-test p-value, with (p=0.015) 
showing that the training programme impacted on their response to show an even higher 
agreement from an initial 81 .3% to 91.2%. 
The Gauteng response remained exactly constant. However, there was a slight decline in the 
post-test agreement observed for the Western Cape. With p=0.765 there is no relationship 
between this observation and the training programme. This observation, however, remains 
unexplained. Therefore, based on the observed p-values for both Gauteng and Western 
Cape p>0.05, the null hypothesis (No) cannot be rejected and therefore it is concluded that 
the training made no difference in these two provinces. 
• Question 20: Improved one to one relationships between staff and patients can reduce 
the incidence of patient aggression and violence 
Ninety percent of respondents across the three experimental groups felt that improved one to 
one relationships between staff and patients will reduce the incidence of violence in the 
wards. The training programme also addressed this aspect and the agreement remained in 
the high 90%. All three groups recognised the role situations play in the expression of anger 
and aggression by patients and this was the ideal response. Therefore, the researcher did not 
foresee that attitudes will change on this question, and indeed it did not. 
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• Question 23: It is largely situations that contribute towards the expression of 
aggression by patients 
None of the three experimental groups shows any significant change in attitude after the 
training programme. Gauteng shows a decreased confidence in agreement with this 
statement from 88.2% down to 70.6%. This decrease is not statistically significant as p>0.05 
namely (p=0.111 ). Even though North West increased agreement with this statement from 
87.9% to 91 .2%, this too is not statistically significant (p =0.620) and the same holds true for 
the Western Cape (p=0.620) after an increase in agreement from 62.5% to 79.2%. The 
responses here correspond well with previous agreement in question two (2) stating that 
other people make patients aggressive or violent. 
This is a similar observation as seen in the study by Duxbury and Whittington (2005:470) who 
refer to a finding by Whittington and Wykes ( 1994b), where the authors observed that 
institutional pressures compelling staff to enforce rules may lead to an increase in institutional 
factors , thereby confounding mental health care user related aggression. Often these 
situations might not be in the control of the mental health care provider. Currently, the 
researcher observes in the Western Cape that the mental health care institutions are forced 
to become smoke-free areas. This policy, which is being implemented at ward level , has led 
to a reported increase in incidences of mental health care user related violence. 
5.6.1.4 Management of aggression and violence 
Questions 8, 10, 11 , 12, 13, 18, 19, 21 , 22, 24, 25, and 26 dealt with staff attitudes towards the 
management of aggression and violence. 
• Question 8: Different approaches are used on this ward to manage patient aggression 
and violence. 
North West province was the only experimental group who showed statistical significance 
with p=0.00 where p<0.05. The null hypothesis (Ho) is rejected. The other two experimental 
groups showed no change in attitude regarding the response on this question. It is , however, 
evident that there was a slight increase in agreement with this statement after the training 
programme for all provinces, albeit not statistically significant. Gauteng increased the positive 
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response from 47.1% to 58.8%, North West 38.5% to 63.7% and the Western Cape from 
65.2% to 75%. 
The training programme focused on how it is beneficial to adapt the ward to suit the needs of 
the client. Therefore, this change in the post-test response leads the researcher to conclude 
that the respondents are in agreement with this proposal. 
• Question 10: When a patient is violent, seclusion is one of the most effective 
approaches to use 
Seclusion and the use of medication remains the method of choice to deal with patient related 
aggression and violence, as reported by the majority of the respondents. North West province 
was the only experimental group showing a statistically significant change in attitude during 
the post-test, namely (p=0.000). It is, however, uncertain what caused this change in attitude 
as they did not receive training in the management of aggression and violence; they merely 
received training in cultural sensitivity and awareness. Similarly, this group from North West 
has the fewest years of experience in mental health nursing, so it seems the logical 
conclusion to make is that due to this lack of experience, they have not been exposed to as 
much seclusion of MHCU as the other groups, hence this response. 
• Question 11: Patients who are violent are often physically restrained to administer 
sedation 
The posttest for all three groups showed no statistically significant differences. Therefore, it 
can be safely assumed that the training programme did not affect the attitudes of the 
respondents to this statement. The practice of sedating MHCU's in order to manage violence 
and aggression is common course in mental health care nursing , and a practice which will 
never be abolished. Duxbury and Whittington (2005:470) note that Wright (1999) found that 
staff is reportedly uncomfortable with these practices, yet they accept that it is part of the 
management strategy in dealing with aggression and violence. The researcher concurs with 
this finding and agrees that these practices will continue but that there is a need for policy 
guidelines regarding the practice of restraint and seclusion. 
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• Question 12: The practice of secluding violent patients should be discontinued 
North West showed a significant change in attitude from an initial 30.8% agreement with the 
statement to a 61 .5% agreement with the statement. The calculation of p=0.00 thus p<0.05 
requires a rejection of the null hypothesis (Ho) , with evidence that the training programme 
influenced the attitudes of respondents with regards to the practice of seclusion. The other 
experimental groups maintained the attitude that these practices cannot be discontinued. The 
researcher proposes approaches for question 12. This practice will be more acceptable if it is 
guided by policy guidelines. 
A possible reason why the respondents had a change of attitude cannot be linked with the 
training as they had not received training on the management of aggression and violence. It 
might be due to the influence of having received cultural sensitivity and awareness training 
that this influenced their response. It is important to note that the responses of the other 
groups are close to the ideal responses for this statement. Therefore, there was no attempt to 
change their attitudes through the training programme. The responses about not 
discontinuing the practices of seclusion in this study echo findings by Mccann et al. (2014:5) 
• Question 13: Medication is a valuable approach for treating aggressive and violent 
behaviour. 
The use of medicine remains a valuable method. All the respondents agreed with this 
statement and it is observed that the training programme did not change the attitudes of the 
participants at all. The null hypothesis (Ho) is therefore not rejected, based on the probability 
values for Gauteng (p=1 .00), North West (p=0.192) and Western Cape (p=0.257) i.e. all p-
values p>0.05. 
Noteworthy is that the North West group had an insignificant increased disagreement during 
the posttest namely from a 28.6% disagreement in the pre-test to a 36.3% increase during 
the post-test. This is inexplicable. 
• Question 18: Physical restraint is sometimes used more than necessary 
The majority of the respondents admitted that restraint is used more than necessary. This 
response correlates well with the response in question four (4), whereby the respondents 
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found it difficult to prevent patient related aggression. The slight increase in the self- reported 
response on this question bore no statistical significance. It is , however, disconcerting that 
this practice still happens in mental health care facilities. The researcher notes how Duxbury 
and Whittington (2005:470) and Mccann et al. (2014:5) also observed that it is commonly 
reported. 
• Question 19: Alternatives to the use of containment and sedation to manage patient 
violence could be used more frequently 
This question had similar strong responses in agreement with the statement by all 
respondents and the post-test means were similar to those of the pre-test. As all of these 
means were p>0.05, the null hypothesis (Ho) could not be rejected and therefore training had 
no effect on this response. 
Respondents in this research project felt that alternatives to the use of containment and 
sedation could be used more frequently. This is important for presenters of training 
programme, as it implies mental health care providers are ready to change the way in which 
things are being done. 
• Question 21: Patient aggression could be handled more effectively on this ward 
Gauteng showed a 100% response that aggression could be handled more effectively. This 
stayed constant as did North West on 93.3%. The Western Cape increased this opinion from 
70.85 to 79.2%. Even though this was the ideal response in all groups, the presence of an 
increase of 8.35% in the Western Cape shows that the training programme succeeded in 
confirming opinions and swaying some opinions towards the ideal response. Similar 
responses were noted with regards to the use of medicine, as previously stated. 
• Question 22: Prescribed medication can in some instances lead to patient aggression 
and violence 
The training programme included literature explaining paradoxical effects caused by 
medication and how this can often increase levels of aggression in MHCU. This training had 
no statistically significant effect on Gauteng or the Western Cape. It however had a statistical 
effect on North West with a probability level of (p=0.023) p>0.05. 
189 
It is uncertain what caused this attitudinal effect, as the respondents did not receive this 
training programme prior to the posttest. 
• Question 24: Seclusion is sometimes used more than necessary 
Even though the majority of the respondents in all experimental groups agreed with this 
statement, only the North West experimental group showed a statistically significant 
difference in attitude between the pretest and the posttest scores, with a p value p=0.003 
directing the researcher to reject the null hypothesis (Ho) and accepting that either the training 
programme on cultural sensitivity and awareness or the MAVAS questionnaire itself effected 
an attitudinal change in the respondents. Mccann et al. (2014:3) confirms this finding , where 
negative attitudes of staff are linked to an increase in the use of containment methods to 
manage aggression 
• Question 25: Prescribed medication should be used more frequently to help patients 
who are aggressive and violent 
All three experimental groups agreed with this statement in both the pre-test and the post-test 
and the null hypothesis (Ho) could not be rejected for any of the three experimental groups. 
Therefore, it is evident that the training programme had no statistically significant impact on 
any of the experimental groups. 
This is a similar finding as observed by Duxbury and Whittington (2005:475) and Mccann et 
a/. (2014:5) and it is being referred to as the therapeutic modality and biomedical model. 
Duxbury and Whittington (2005:475) continue to report that the use of medication and "rapid 
tranquilisation" is being followed in the United Kingdom. 
Due to staff shortages, and when it is observed that the majority of the respondents as can be 
seen in having between one (1) and five (5) years of experience. It may be a bit premature to 
recommend practices such as rapid tranquilisation in South Africa due to the lack of 
experience of staff. Graph 5.2 shows that the majority of the respondents in this research are 
students, nursing auxiliaries, enrolled nurses, registered nurses and psychiatric nurses. 
These categories are not allowed to administer rapid tranquilisation and in South Africa , this 
can only be administered by a medical doctor. Therefore, based on the categories of staff 
190 
employed in mental health care facilities , it is not a feasible practice at this stage. This 
practice is more suitable in the 72-hour facilities which are situated in the general hospitals . 
The qualified staff available in these facilities is more readily available, as is the equipment 
should it be necessary to resuscitate a mental health care user. The mental health care 
facilities in South Africa are not geared to deal with this type of MHCU who requires intense 
and rapid sedation. These MHCU's would be referred to general hospitals for such 
management. 
• Question 26: The use of de-escalation is successful in preventing violence 
It is observed that from the outset, all groups agreed with this statement. As this is the ideal 
response, it was not anticipated that the respondents would change their opinion from 
agreement to disagreement. 
These responses make it clear that respondents are prepared to use these techniques as 
from the responses in questions 3, 6, 8, 15, 19 and 21 . It is evident that respondents are not 
entirely satisfied with the way things are currently done in the respective mental health care 
facilities. 
Duxbury and Whittington (2005:476), mention that the use of de-escalation is not easy, the 
researcher concurs with this finding because the use of de-escalation is not a one cure fits all 
solution. It must be tailored to suit the individual client. Patients reported during a study done 
by Cowin et al. (2003) as mentioned by Duxbury and Whittington (2005:476) that they were 
not satisfied by the way staff used de-escalation; they rather promoted more therapeutic 
relationships. 
This observation by the patients echoes what the respondents in this research agreed with , 
namely that there could be an improvement in the communication between staff and patients 
and negotiations could be used more effectively. 
5.6.1.5 Concluding remarks 
The preceding sections discussed the findings of the MAVAS questionnaire, and the inferences 
made by the researcher, with comparison to existing literature. The next section will deal with the 
findings of the inter cultural sensitivity scale when observing the pre-test and post-test results . 
191 
5.6.2 Inter cultural sensitivity and awareness questionnaire 
This section will address the responses question by question, and inferences will be made based 
on the findings in combination with the literature as found in chapter two (2) 
5.6.2. 1 I enjoy interacting with people from different cultures 
The statistics shows that the intervention proved to be effective in changing attitudes with reference 
to interacting with persons from a different culture . For the North West province, both the other 
provinces scored p>0.05, noteworthy the one tail test for the Western Cape regarding the within 
group scoring shows p>0.05 namely p =1 .714, but it does not show a similar effect for the between 
group comparison. Subsequently, North West shows a statistically significant response which 
allows for the researcher to reject the null hypothesis (H.) , and for the within group Western Cape 
follows suit with a subsequent rejection of the null hypothesis (H.) . It can therefore be stated that 
the training programme had an effect on the attitudes of the respondents with regards to whether 
they enjoy interaction with people from a different culture. All the experimental groups were 
exposed to the training programme, but at different stages. The response in North West who had 
the youngest group of respondents , leads the researcher to conclude that the younger persons 
might be more amenable to change attitudes. 
5.6.2.2 I think people from other cultures are narrow-minded 
All three experimental groups with an overwhelming majority were in disagreement with this 
statement in both the pre-test and post-test. For all of the experimental groups, the means were the 
same, whereas p>0.05, therefore the null hypothesis (H.) could not be rejected and it is evident that 
the training programme had no impact. 
All experimental groups already showed a positive regard for persons from other cultures 
It is, however, observed that after the training programme there was a slight increase in 
disagreement with the statement that other cultures are narrow minded. 10% more respondents 
disagreed with this statement in the post-test for Gauteng and North West. The largest margin of 
observable difference is in the Western Cape, where the pre-test disagreement was at 67% and 
this increased to 83%. Even if this is not statistically significant, it is observed that there is an 
192 
attitudinal change after the presentation of the training programme for cultural sensitivity and 
awareness. 
5.6.2.3 I am pretty sure of myself in interacting with people from different cultures 
All three experimental groups had a strong agreement with this statement. Notably, even though it 
is not statistically significant, all three experimental groups showed a slight increase in the reported 
agreement with this statement. Gauteng increased from 65% agreement in the pre-test to 82% 
agreement during the post-test. North West increased from 74% agreement to 80% agreement and 
the Western Cape from 50% to 67%. Reflected as percentages, it makes this observation more 
visible yet it is not statistically significant and, therefore, the null hypothesis (No) cannot be rejected. 
5.6.2.4 I find it ve,y hard to talk in front ofp eople from different cultures 
Due to the means of the three experimental groups being similar, the null hypothesis (No) cannot be 
rejected . The training, therefore, had no effect on the different groups. The Western Cape is the 
only group with a slight change in the level of disagreement with this statement, namely from a 58% 
disagreement, it decreased to a 46% disagreement with the statement. The deduction that the 
researcher makes is that the Western Cape possibly felt more at ease to reveal how they actually 
felt about this response after rapport was built between them and the researcher who presented the 
training course. 
5.6.2.5 I always know what to say when interacting with people from different 
cultures 
The overall means show no difference and calls for an acceptance of the null hypothesis (No). 
However, a closer observation of the data reveals the one tail p value for the Western Cape to 
be<0.05 namely p=0.033, therefore the within group analysis shows a statistically significant 
difference for the Western Cape on this response and therefore the null hypothesis (No) is rejected 
for the Western Cape. At the set confidence interval of 95% there is therefore a 5% possibility that 
this phenomenon might not be linked to the training programme. Some possibilities for this 
phenomenon might be due to, the presence of the researcher, the possible influence of the 
treatment intervention or an unidentified variable. 
193 
It is noted that the responses on the previous question referring to "talking in front" of other persons 
are deemed to be vastly different from knowing what to say "to" other cultures. This is an 
interesting, almost contradictory, observation with no obvious explanation as to the cause. 
5.6.2.6 I can be as sociable as I want to be when interacting with people from 
different cultures 
The pre and post-test did not differ significantly for any of the three experimental groups. As a 
matter of fact, in all three groups the majority of the respondents agreed with the statement. 
Remarkably, the Western Cape had lower agreement responses with this statement in comparison 
with the other two experimental groups and there was a slight decrease in the agreement response 
during the post-test in comparison with the pre-test, namely a decrease from 46% to 42%. 
The researcher has made a similar observation on questions four (4), five (5) and six (6) 
contradicting each other in terms of the responses. An inference is that if one reportedly has 
difficulty in knowing what to say to other cultures, it would make it difficult to be as sociable as you 
want to be, when interacting with them. 
5.6.2.7 I don't like to be with people from different cultures 
All three experimental groups reported overwhelming disagreement with the statement. The 
Western Cape experimental group was again the exception to the rule and , whereas there was an 
ever so slight decrease in the level of agreement observable, the opposite held true for the Western 
Cape. The groups showed a 58% disagreement with the statement during the pre-test and a 75% 
disagreement with the statement during the post-test. This phenomenon might possibly be 
explained by the fact that the post-test in the Western Cape was conducted after the presentation 
of the total training programme, as opposed to Gauteng who only had training on theories of 
aggression and cultural sensitivity and North West who only had training on cultural sensitivity and 
awareness. 
5.6.2.8 I respect the values ofp eople from different cultures 
All three groups reported agreement and a slightly higher level of agreement with this statement is 
observed in the post-test for all three groups. These were , however, statistically insignificant and 
194 
the null hypothesis (No) cannot be rejected. Therefore, it is evident that the training programme had 
no impact on the respondents ' attitudes towards th is statement. 
5.6.2.9 I get upset easily when interacting with people from different cultures 
All three experimental groups agreed with this statement. Gauteng reported 88% agreement in the 
pre-test and 94% agreement in the post-test, North West showed 86% agreement in the pre-test 
and 82% agreement in the post-test. Western Cape reported 71 % agreement in the pre-test which 
increased to 75% agreement in the post-test. All the p values >0.05. There is no evidence of 
relationship between the variables and, therefore, the null hypothesis (No) is accepted. 
5.6.2.10 I feel confident when interacting with people from different cultures 
The statistical analysis of the one tail analysis for the North West experimental group shows up as 
p=0.027 because p< 0.05. The null hypothesis for this within group test cannot be rejected and the 
researcher can assume that the training programme influenced this response. Therefore, the non-
directional hypothesis (H1) is accepted. The difference of 10% for this group could not be attributed 
to erroneous response capturing by the respondents as it is too large a percentage. During the pre-
test, the North West experimental group had a 66% agreement with the statement and , during the 
post-test after the treatment, this increased to a 76% agreement within the group. The one tail and 
two tail results for the Gauteng and Western Cape experimental groups were all p>0.05 and based 
on this finding, the null hypothesis for these two groups cannot be rejected and it can be assumed 
that the training had no effect on these two groups. 
5.6.2.11 I tend to wait before forming an impression of culturally-distinct 
counterparts 
Response rates for all three experimental groups remained constant during both the pre-test and 
the post-test, thus the null hypothesis cannot be rejected due to the similar means observed for the 
one tail and two tailed calculations. 
5.6.2. 12 I often get discouraged when I am with people from different cultures 
Statistical analysis indicates through the two-tail test that the null hypothesis cannot be rejected for 
all groups. However, the p (T<=t) one-tail test for North West computes as 0.029 resulting in p<0.05 
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which shows up as acceptance of the non-directional hypothesis (N1), indicating that the treatment 
intervention has indeed significantly influenced the group. Similarly the p (T <=t) one-tail test for 
Western Cape computes as 0.048 and therefore the same holds true for this group in terms of 
acceptance of the (H1), namely the training programme influenced the respondents. 
5.6.2.13 I am open-minded to people from different cultures 
This question, similar to question 14, reflects agreement with the statement in both the pre-test and 
post-test scores for all three experimental groups, yet these changes have no statistical 
significance and are not due to the influence of the training programme. 
5.6.2.14 I am very observant when interacting with people from different cultures 
The result for this question is addressed by the statement in section 5.6.2.13. 
5.6.2.15 I often feel useless when interacting with people from different cultures 
All respondents showed similar disagreement with this statement during the pre-test and post-test. 
Gauteng and North West reported a slight decrease in the reported disagreement with the 
statement during the post-test, namely for Gauteng the scores from pre-test to post-test decreased 
from 82% to 76% and for North West it decreased from 85% to 78%. This slight difference 
stimulates thinking that perhaps the respondents were more comfortable to report actual feelings 
during the post-test as opposed to during the pre-test when they just met the researcher for the first 
time. 
5.6.2.16 I respect the ways people from different cultures behave 
After consultation with the statistician, the conclusion is that the Western Cape shows a statistically 
significant difference in their response rate as was seen during questions 5, 10 and 12 and forth 
coming question 19. These findings are made basing on the one-tail t-test hypothesis testing. This 
shows statistically significant difference for the specific group but on the contrary the two-tail t-test 
does not show this up in the between test. The assumption is therefore correct if it is deduced that 
the training programme influenced the response during the post-test. 
196 
It is important to note that Western Cape received the complete training programme as opposed to 
the other two experimental groups who received partial training programme before the 
administration of the post-test. This might have played an influence on the respondents and due to 
the nature of the training programme, the Western Cape were exposed to diverse cultural 
interactions for a longer period, prior to the administration of the posttest. 
5.6.2.17 I try to obtain as much information as I can when interacting with people 
from different cultures 
The responses for all three provinces stayed consistent during the pre-test and the post-test, with 
the only possible conclusion being that the training programme had no influence on the responses 
of any of the three experimental groups. 
Taking into cognisance that this is a sensitive topic and that this is a self-administered 
questionnaire, it is possible that this might have biased the respondents in their responses. 
5.6.2.18 I would not accept the opinions ofp eople from different cultures 
Observation of the pre-test and post-test means of all three experiment groups shows that the 
within and in-between means of these groups show no statistical difference and due to the means 
being more or less the same, the only logical conclusion being that the null hypothesis (No) cannot 
be rejected. Therefore, the training programme had no influence on the respondents. 
5.6.2.19 I am sensitive to my culturally-distinct counterpart's subtle meanings 
during our interaction 
Regardless of the graphs showing that the majority of the respondents agreed with this statement 
and that these perceptions stayed more or less consistent and were not at all affected by the 
training programme, the interesting phenomenon which shows up is the high self-reported 
uncertainty with regards to this question. None of the other questions had a similar 33% response 
of being uncertain. This is especially true for the experimental groups from North West and the 
Western Cape. 
197 
5.6.2.20 I fnink my culture is better than other cultures 
The attitudes towards this question remained firm and respondents reported that they disagree with 
this statement. A similar observation is made for Question 21 . 
5.6.2.21 I often give positive responses to my culturally-different counterpart 
during our interaction 
The respondents reported with agreement on this question in all three experimental groups. It is 
necessary to elaborate that this is an expected response or an ideal response which the researcher 
would not wish to change. 
5.6.2.22 I avoid those situations where I will have to deal with culturally-distinct 
persons 
Whereas the responses were constantly overwhelming in agreement with question 21 , for this 
particular question there was overwhelming disagreement with the statement, admittedly the type of 
response one would wish for. These responses did not change with the post-test and due to the 
means being very similar and all of them are >0.05, it allows for the acceptance of the null 
hypothesis (No). Therefore, the conclusion is that the training programme did not affect the 
respondents to change their opinion. 
5.6.2.23 I often show my culturally-distinct counterpart my understanding through 
verbal or nonverbal cues 
Whereas Gauteng and the Western Cape experimental groups show 7% to 8% increase in 
agreement with this statement during their post-test responses, the response rate stayed constant 
for the North West group. This 7% to 8% increase in agreement is of no statistical significance. It is, 
however, observable when looking at the percentages scored for the different groups. 
198 
5.6.2.24 I have a feeling of enjoyment towards differences between my culturally-
distinct counterpart and me 
There is an observed positive response amongst all three experimental groups, with Gauteng and 
the Western Cape showing an insignificant increase in this positive response. However, North West 
to the contrary showed a 2% decrease in the response, depicting agreement with this statement. 
Even though this is insignificant and overall does not allow the researcher to reject the null 
hypothesis (No) , it is nevertheless regarded as an interesting reaction from 2% of the respondents. 
Therefore, the training programme seems to have had no impact on the respondents. 
5.6.1.25 Concluding remarks 
The cultural sensitivity and training programme has been noted to have no effect on the responses 
in the self-reported lntercultural sensitivity scale. The only statistically significant changes observed 
were noted in question 5 for the Western Cape, question 10 for North West and question 12 for 
both North West and the Western Cape. When considering that the majority of the respondents in 
Gauteng had between 16 and 25 years of experience as opposed to the average work experience 
being one to five years for North West and the Western Cape, the researcher makes the inference 
that their attitudes are more set and tenacious and would therefore be difficult to sway. This will be 
further discussed in section 6.2. to highlight the observation that there are definite factors which will 
impact on changing attitudes. 
5.7 CONCLUSION 
This chapter presented the analysis of the data which were obtained through self-administered 
questionnaires during a pre-test and a post-test after the administration of a training programme. 
Frequency tables and histograms represented the data with a short description of all results. The 
results of correlation statistics in the form of one- and two-tailed t-tests were also reported and 
discussed in detail. 
The following chapter will entail the conclusions and recommendations arising. The limitations of 
this study will also be declared. 
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CHAPTER 6 
CONCLUSION AND RECOMMENDATIONS 
6.1 INTRODUCTION 
The purpose of this study was to determine if a training programme in the culturally safe 
management of aggression and violence which includes training in cultural sensitivity and 
awareness will have an effect on the attitudes of mental health care practitioners in the 
management of mental health care user related violence and aggression. Chapter one (1) 
described the background and rationale for this study, highlighting why it is significant to obtain 
insights from indigenous healers in order to determine what is deemed culturally safe in our 
dealings with MHCU from very diverse cultural groups. 
Chapter two (2) elaborated in depth on the dichotomous nature of health care in South Africa with 
two diametrically opposing views, namely Western Based Knowledge Systems and Indigenous 
Knowledge Systems being the foundation upon which these different health care approaches rest. 
This research project, being an exploratory sequential mixed method research described in chapter 
three (3), covered a novel data collection methodology, namely the use of makgotla, which was 
instrumental in augmenting current knowledge and literature, with knowledge as used by 
Indigenous healers. This newly acquired information was built into the curriculum for the training 
course in the management of aggression and violence, which formed the training programme 
(treatment) in this quasi-experimental design. The research methodology was further presented in 
chapter four (4) focusing on the qualitative phase of this project, as chapter five (5) followed with 
the quantitative phase. 
Chapter 6, being the final chapter, will elaborate on the conclusions and recommendations which 
arose from this research . The foundation for the recommendations will be the outcomes of this 
research and the literature review followed. 
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6.2 CONCLUSIONS FROM THE OUTCOMES 
The overall aim of this study was to determine, as stated in section 1.5, if a training programme 
focussing on the management of aggression, within a multi-cultural context effects attitudinal 
changes in the cultural awareness, sensitivity, and safety with reference to the attitudes of mental 
health care practitioners, towards the management of aggression and violence? Furthermore, the 
researchers wished to answer some broader objectives, thus the following section will deal with 
whether the research questions were answered 
6.1.1 What are the attitudes of Mental Health Care Practitioners towards the 
management of aggression and violence? 
Baseline data was created by means of a pretest and after the administration of a training 
programme, the posttest was conducted and the attitudes were confirmed for these respondents. 
Furthermore, a previous baseline experimental research project determined the attitudes of staff 
towards the management of aggression and violence in a former study (Bock & Pienaar, 2013: 109). 
6.1.2 An exploration of African Indigenous Knowledge Systems used to manage 
mental health care user related aggression 
Through the conducting of makgotla, it transpired that the indigenous healers without formal 
training have the ability to recognise the signs and the cultural causes for aggression and violence. 
Depending on the possible cause for the aggression and violence in section 4.9.2, the indigenous 
healer will decide on the appropriate action to take for each individual client. These findings are 
evident in sections 4.8 and 4.9. Action taken will vary from the use of verbal skills, physical 
interventions and de-escalation or diversionary techniques. These constructive actions and the use 
of diversionary techniques were included in the training programme as is evident in annexure two 
(2). 
6.1.3 The establishment of base-line data on the level of cultural sensitivity and 
awareness of mental health care practitioners 
Base line data was established but this is only applicable to the respondents and cannot be 
generalised to the larger population . The self-reported data must be viewed with some suspicion as 
it contains sensitive information, and although it was done anonymously, it may still be biased. 
201 
It is interesting to note that the experimental group from the North West province had no previous 
training in the management of aggression and violence, yet the presentation on cultural sensitivity 
and awareness played a role in effecting attitudinal changes in light of the management of 
aggression and violence attitudinal scale. 
6.1.4 Discussion of the efficacy of a training programme/ intervention (treatment) 
From this research, it is evident that neither the completion of the MAVAS questionnaire nor the 
training in cultural sensitivity had any significant effect on the Gauteng experimental group and this 
can be linked to the fact that Gauteng had an 80% previous attendance of a course on the 
management of aggression and violence and their responses on the MAVAS questionnaire was 
already as close to the ideal response as can be expected. Therefore it can be deduced that the 
MAVAS questionnaire alone and training in cultural sensitivity did not change the attitudes of this 
particular experimental group towards the management of aggression and violence in view of the 
fact that they had previous training. 
However, the training programme in the North West experimental group seems to have influenced 
their perception of the mental health care user as is reflected on their responses on the MAVAS 
questionnaire. The majority of the responses were of statistical significance in the post-test. 
Therefore, it is observed that the training programme had a bigger impact on the younger less 
experienced group when compared. 
The experimental group from the Western Cape showed statistically significant changes in attitudes 
on the MAVAS questionnaire on questions pertaining to causes of aggression, the environment and 
communication. The rest of the questions were answered as close to the ideal response as can be 
expected and therefore the researcher did not expect attitudinal changes in this regard. 
The three experimental groups all showed persistent attitudes when responses on the lntercultural 
sensitivity scale are compared for both the pre-test and the post-test scoring and it can be reported 
that the training in cultural sensitivity and awareness did not have any effect on the attitudes of the 
respondents with reference to intercultural awareness and sensitivity. In the North West 
experimental group, however, it is evident that this training most definitely played a role in their 
attitudes towards the management of aggression and violence, but not in their lntercultural 
sensitivity, as their responses were already close to the ideal responses. 
202 
The training programme is observed to have the most observable effect on the group from the 
North West. This group included third and fourth year psychiatric nursing students and it is also the 
group with the youngest respondents with between one (1) to five (5) years of experience in mental 
health care. The researcher is thus left with the impression that the younger respondents might be 
more suggestible with regards to changing attitudes as opposed to the groups with the older 
respondents. 
The above can be explained at the hand of the reported enduring nature of attitudes. Attitude was 
defined in 1860 by Herbert Spencer and Alexander Bain (as referenced by Cacioppo et al., 
1994:261) as an internal state of readiness for action which includes affect. Cacioppo et al. 
(1994:622) elaborates that attitude can become more favourable or less favourable towards a 
stimulus if it is associated with pleasure or unpleasant contexts and that attitudes are shaped and 
formed by ideas and consequences that the recipients shape and generate by themselves 
(Cacioppo et al. , 1994:265). Lakkaraju and Speed (2010:76) quotes Visser and Cooper (2003) who 
observed that individuals tend to hold sets of attitudes which are consistent with each other. 
Therefore, the researcher concludes that the person who fears the psychiatric patient and does not 
understand his culture may have a certain attitude towards him which might influence the way they 
feel about the management of aggression and violence, as found in MHCU. 
6.1.4.1 Understanding regarding the internal causes of aggression and violence 
Attitudes with regards to the difficulty of preventing patients from becoming aggressive remained 
constant and respondents continue to find this difficult to do. Based on the findings in this section , 
the respondents are aware of the role of mental illness in the manifestation of mental health care 
user related aggression and violence. The understanding that there are certain types of patients 
who are more prone to aggression and the fact that the training showed a statistically significant 
difference for Gauteng proves that the respondents in Gauteng may possibly be better equipped to 
predict violence in the wards. 
The slight decrease in the perception that MHCU should try and control their aggression, as 
observed in all three experimental groups, shows that staff are more aware of their role and 
responsibility in preventing aggression, and that aggression is not under the control of the mental 
health care user. 
203 
6. 1.4.2 Understanding of the situational causes ofa ggression and violence 
There is statistical support that the training programme effected attitudinal changes in the 
participants, which showed that they have gained insight into how situations and communication 
can lead to misunderstandings which increase mental health care user related aggression and 
violence. The respondents have taken responsibility for their role in the situational causes which 
may contribute to aggression. 
6.2 RECOMMENDATIONS 
The recommendations ensuing from this study focus on equipping the neophyte who is still 
impressionable with the necessary skills to create and sustain a culturally safe environment in 
which to manage the aggressive and violent mental health care user. The quintessential part of the 
management of aggression and violence is being able to prevent it from occurring , and this is 
where the training would be most beneficial for all staff members. Staff should be regularly updated 
with therapeutic communication skills, as the staff reported they are aware that this is an area 
where their skills lack. 
6.2.1 Suggestions for mental health care facilities 
The training of staff in the management of aggression and violence should be linked to the 
individual performance plans of the staff and should form part of the continuous professional 
development of employees and link to their annual performar,,ce agreements. 
Mental health care providers are aware of the role of the environment and confined areas in 
causing and leading to aggression. They, however, require training in order to make the 
environment more therapeutic even if it is in a closed unit. The hospitals could possibly invest in 
breakaway rooms, where a mental health care user could retire to voluntarily to calm down if feeling 
irate. 
The practice of nursing staff restraining patients should be reconsidered and one recommendation 
would be the appointment of mid-level workers, trained in safe restraint of the aggressive mental 
health care user as this would add to alleviating the fear of the nursing personnel regarding 
restraint, and the possibility of sustaining injuries. This procedure requires skilled employees and a 
recommendation would be specially trained persons to deal with the matter of restraint. If persons 
204 
other than the nursing staff are used for restraint it might have appositive impact on therapeutic 
nursing care. This approach might contribute to nursing staff adopting their role as primary care 
givers and primary therapists, as opposed to merely delivering custodial care. This will add to the 
creation of more therapeutic ward environments with MHCU as the nursing staff's attention will be 
on therapeutic interaction as opposed to fearing the clientele they serve. It is however noted that 
not all the facilities where the researcher conducted this research is as keen on using security 
officers to restrain violent MHCU, therefore it is perhaps advisable that this trained person be a mid-
level worker but not a care giver. 
6.2.2 Suggestions for nursing curricula 
Nursing curricula should include management of aggression and violence and transcultural nursing 
as this phenomenon is not restricted to mental health care only but it is also very common in 
trauma and emergency units, labour ward and reportedly also among visitors. The management of 
aggression and violence is beneficial to all medical professionals, regardless of the type of unit 
where they are employed. 
One of the hospitals in Gauteng informed the researcher that they provide training on the 
management of aggression and violence to all new appointees upon orientation of the neophytes, 
furthermore they reportedly do not use security officers to assist in the management of mental 
health care user related aggression. 
Nursing curricula should include both IKS and WBKS in the curricula as this will contribute towards 
sensitising nurses to be culturally aware, sensitive and safe. 
6.2.3 Suggestions for the content of training programme for MHCU 
As observed in section 5.6.1.2 mental health care providers are often conflicted as to when it is 
necessary to intervene, they often miss the opportune golden period for de-escalation and 
aggression flares out of hand. This then necessitates more traditional methods to manage 
aggression such as restraint, sedation and seclusion. It is, therefore, proposed that guidelines be 
drawn up for staff in the form as a protocol to indicate what type of intervention is advised at the 
different manifestations of aggression and violence. In combination with the traditional methods of 
the biomedical system, the inclusion of practices by indigenous healers such as allowing a person 
to calm down on their own if there is no imminent danger involve, and practices such as not 
intimidating and rather making the aggressor feel welcome should also be encourages as this 
205 
\ NWU I 
LIBRAl.!YJ 
harbors trust in the mental health care provider, as opposed to the too often coercive methods 
employed as referred to by Steinert et al. (2014:6). 
The training programme for mental health care providers, who are experienced in mental health 
care, cannot be the same as those of the foundational programme. These training packages should 
be geared at re-affirming existing knowledge and skills and teaching ethical principles in the use of 
restraint and sedation, Duxbury and Whittington (2005:471) made similar recommendations . 
The rationale behind this recommendation by the researcher is found in the following: creating an 
improved understanding of mental illness. 
Exposure to mental health care user's aggression and violence will influence a person's judgment 
and becomes part of the experience of the mental health care provider. Experiences lead to the 
formation of attitudes; therefore it is possible that previous experience might add to the enduring 
nature of attitudes. This deduction is confirmed by Cacioppo et al. (1994:263). In resonance with 
the abovementioned is also the attributional theory which postulates that the inference a person 
makes about the cause of behaviour directly influences attitude. 
These theories made the researcher to assume that with more exposure to mental health care user 
related violence, attitudes may possibly be less favourable towards the management of aggression 
and violence, which might possibly impact on training programmes, especially when considering 
attitudes are deemed to be enduring in nature, therefore creating an understanding of the motives 
of behaviour, might positively influences a person's attitude. 
6.2.4 Suggestions for the community 
The makgotla in the community exposed the existence of destructive practices such as beating the 
mentally ill when they are aggressive and violent, throwing stones and displaying attacking 
behaviour due to fearing the mentally ill community member. It is proposed that the researcher 
return to these communities and highlight the effective practices they have, but also give more 
health education on mental illness and how destructive practices will lead to an increase in the 
violent behaviour. 
206 
6.3 RECOMMENDATIONS FOR FURTHER STUDIES 
A proposed sequel to this study would be an immediate follow up in one of the hospitals utilised for 
this study, however the proposal is that one ward will be used and all of the staff working in this 
specific ward be exposed to the training programme with a follow up posttest to be conducted after 
four weeks and then repeated six months later to determine if there are any long-term sustained 
attitudinal changes. 
Further studies could also perhaps focus on other avenues: 
• The perspective of patients with reference to the efficacy of training programmes on staff 
attitudes. 
• The perception of the mental health care user with regards to cultural safety in mental health 
care 
• The characteristics of a culturally safe mental health care environment. 
• Research on "unlearning" destructive attitudes in the mental health care worker with more 
experience and longer exposure to MHCU. 
6.4 STUDY LIMIT AT IO NS 
The limitations identified in this study are mostly related to aspects around the research 
methodology. The use of a self-reported questionnaire, albeit anonymous can still be very biased 
especially so if it deals with sensitive issues such as self-reported with regards to cultural 
sensitivity, which is a very contentious matter in South Africa. 
Quasi experiments are not as strong as randomised experiments (Rosnow & Rosenthal, 1999: 157), 
therefore a randomised experiment is proposed for future research. 
This study focused on short-term attitudinal changes after the presentation of a training programme 
to equip participants with the knowledge to manage mental health care user related aggression and 
violence, however some limitations are observed. 
Further limitations in this study is identified to be the duration of the training course which was 
originally planned for a minimum of three days, but ultimately being fitted into one day. The content 
load of the training programme (treatment) was very high for a one day course, regardless of 
207 
justification through alluding to limited time available due to the operational requirements of the 
respective hospitals felt outside the control of the researcher. 
The researcher recommends a longer time lapse between the administration of the training 
programme (treatment) and the conduct of the posttest. Unfortunately through direct experience of 
the poor response rate in the small control group, the researcher had to ensure ·an improved 
response rate to render credibility to the findings of the study and had to resort to collecting posttest 
data whilst still in the field . 
Due to reported staff shortages as can be seen in the e-mail correspondence in Annexure seven 
(7), the researcher had to rely on the availability of respondents to be set free by their respective 
managers in order to attend the training programme, subsequently this impacted on the size of the 
different experimental groups, therefore this research cannot be generalised to the general 
population but only to the respondents in this research. 
6.5 SUMMARY 
An exploratory sequential mixed method research was conducted, investigating the effect of a 
training programme including culturally safety and awareness and the management of aggression 
and violence on the attitudes of mental health care providers. The setting for this study was mental 
health care facilities with acute admission units in four different provinces in South Africa, namely 
the North West Province, Gauteng, Western Cape and the Northern Cape and indigenous healers 
in two of the provinces where the mental health care providers from the same cultural group as the 
indigenous healers are referred to in the event of a suspected mental illness. 
The overall conclusion from this study is that indigenous healers without any official training in the 
management of aggression and violence have skills which are beneficial for mental health care 
providers. These skills should be included in training programmes and curricula to skill mental 
health care providers in the management of aggression and violence . From this research, it is 
observed that the training course during which some of these skills were demonstrated proofed to 
be more readily adopted by the mental health care providers with the least amount of experience as 
mental health care providers. This stems from the more tenacious nature of prolonged attitudes as 
observed in persons who adopted these attitudes through more years of work experience in mental 
health care facilities. 
208 
The overall recommendation is that in order to influence attitudes training in the management of 
aggression and violence should commence during the foundational programme on under graduate 
level and this must be reinforced annually and form a crucial part of the orientation of all neophytes. 
Therefore, the contribution of this thesis is the combination of IKS practices and biomedical 
methods included in curricula for the management of aggression and violence is most effective to 
use in training focused on undergraduate and at neophyte level, where the participants are more 
impressionable. This not only increases cultural sensitivity and awareness but also makes mental 
health care providers more aware of their own attitudes and how it contributes or prevents 
aggression and violence in MHCU. 
209 
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227 
ANNEXURE 1 
Transcript of the Makgotla 
Transcript of the Lekgotla with the Khoisan community in a Khoi village 2013/12/20 
Background 
The Khoisan village is quiet and humble, on arrival one could hear a cock crowing and see goats' 
running across the veld, the goats and the ants scurrying on the ground is an early sign of imminent 
rain along with the thunder clouds collecting in the distance. At the house of one of the elders a big 
pot of food was bubbling over an open fire spilling the appetising aroma of food cooking, ladies 
were busy kneeing dough for "rooster brood" (a type of bread in the form of a bun, which will be 
baked over the warm coals) , the whole of the community is in preparation of the feast to held after 
the Lekgotla. 
The Lekgotla took place after the researchers negotiated the proceedings with The Chief of A 
Khoisan village. 
Negotiations for the Lekgotla 
Negotiations for the Lekgotla took place in the humble residence of The Chief and his wife Mama 
C. On arrival of the research team at The Chiefs house the researchers enjoyed the view of the 
hills and the soccer field on which a few goats were grazing. The researchers were awaiting the 
arrival of The Chief, as he was down at the community centre making sure everything is ready for 
the research team. While waiting for The Chief the researchers sat on the stoop in conversation 
with Mama C the Chief's wife. 
When the King arrived the researchers were invited into the Chief's house (a welcome cool relieve 
from the humid heat outside. After introductions and being offered cool drink the researchers and 
The Chief discussed the aims of the /ekgotla, and what the researchers wish to discuss with the 
community. The topic disclosed by the researcher is the management of aggression and violence in 
the community and the methods the community would use when a person with a mental illness 
becomes aggressive and violent. 
228 
The Chief agreed to lead all proceedings which took place in the A Khoisan village Community 
centre, and gave the necessary permission for the /ekgotla to be captured via video recording and 
permission was also granted to take still photos of the proceedings. The Chief requested that the 
material be made available to him and that the material captured be used for the purpose of the 
research only and not for commercial purposes. The researchers agreed to this request. 
Personal conversation with The Chief prior to the /ekgotla 
The community has experienced some of the psychiatric patients to be "aspris" (Acting out on 
purpose) because their behaviour is often a means to an end. Some of the mentally ill patients 
differ from day to day, one minute they cannot do anything for themselves and the next minute they 
know how to work with money. "Vandag is hy reg en more is hy gxau/mal" (The vernacular for 
mental illness in Khoisan is Gxau and in Afrikaans is mal.) 
The Chief co~tinued to paint a picture (which is descriptive of mania) of one of the ladies who has 
since passed away. She will all of a sudden dress flamboyantly in very high heels and go visit the 
"English" church , and then during the sermon she would develop the "loop siekte" (wandering 
illness) get up from the pew and walk out of church mid-sermon. The community tolerated this 
behaviour well and ignored these symptoms as it will soon pass and she will be back to her old self. 
All of the members of the community are welcome to attend groups and activities hosted by the 
"Council of Elders, Administrative council and the group for the elderly as community involvement is 
important to the community as a whole. 
The Chief is concerned that aggression is on the rise in the community due to the influence of hard 
core drugs which has filtered into this quiet community. The Chief warned that the influence of 
drugs should not be raised with the community yet during this Lekgotla as it is a sensitive matter at 
this stage. There is currently a sub Judice court case where a member of the community was 
murdered by an outsider (non-A Khoisan community member) this makes violence and aggression 
a very real phenomenon in this humble community. 
Proceedings during the Lekgotla 
The Khoisan tribe is a deep religious tribe and opened the lekgotla with the signing of a hymn and a 
prayer by the pastor, requesting that the eyes, ears and thoughts of the members of the lekgotla be 
opened. The Pastor then blessed the members of the research team and participants in the name 
229 
of Jesus Christ, and thanked God that the members arrived safely and that the researchers and 
research assistants will have a safe return journey. 
The proceedings of lekgotla allows for members of the community to enter and leave during the 
proceedings. As each participant enters he/she is welcomed by the rest of the community. In total 
35 members attended the lekgotla. 
The Chief spoke about the use of Indigenous medicines and the role of the university in 
determining the efficacy of the indigenous medicine but that the purpose is not to make "gxeigas" 
(healers) out of the community but to shed more light on the medicines that the community but to 
explore how the community uses and prepares the medicines which they (community) have been 
using for so long. 
The Chief introduced Prof Pienaar so that he can introduce the members of the research team. 
"Hoe werk ons met mal mense tussen ons?" ('How do we work with the mentally ill people in 
our community?") 
The researcher experienced the lekgotla as very emotional as this very poor community is very 
religious and extremely accepting of the researchers through the blessing they bestowed on the 
research team. The community showed an interest in the team and is very eager to learn how they 
could benefit through the research and how their knowledge could be validated. Adding to the 
ambience of spirituality during the lekgotla was the rain and thunder that started during the lekgotla, 
for the Khoisan tribe rain is seen as a blessing, this then added to the Lekgotla being perceived as 
blessed. (This rain and thunder is audible on the video recording.) During the negotiations for the 
lekgotla the Chief made it very clear that they have been using indigenous medicines for many 
years and that they have not been killed by these medicines. 
A logistic committee is to be established along with the A Khoisan village community for future visits 
of researchers to the community. 
Antie C Baie dankie vir die goeie gebaar vir die grafstene, applous mooi ding wees as dit 
deur ons gaan. 
Members of the research team each introduced themselves to the community members and elders. 
230 
thanked the researchers for trying to let the world understand the Khoisan village and the Khoisan 
community. 
Needs of the community stated were as follows: Computers and training to use computers, First Aid 
Courses as this particular Khoisan village is far from Douglas and Kimberley where the closest 
hospitals are in the event of an emergency. Training is estimated at RB000, 00 for courses and the 
village does not have access to financial resources, training in computer literacy would greatly 
benefit the Khoisan community. The King emphasised that it is important to train the youth so that 
they can become leaders and not be led by others. 
Concerns addressed by The Chief is the protection of the indigenous knowledge of the community 
which need to be protected, in example the King used the experience of the community through the 
use of aloe, the sharing of this indigenous knowledge around the aloe plant has led to their aloe 
resources being depleted by WBKS. The Chief used the Afrikaans word for patent "patent reg" and 
used this word as a double innuendo by breaking it down into "patent" (patent) and "reg" (right) and 
reiterated that the Khoisan has the patent for the use of the veld pharmacy but their rights thereto 
has not been acknowledged. The Chief cautioned the community in sharing their knowledge willy-
nilly with researchers because money can be seen as an impetus "geel wortel" (golden carrot) to 
share knowledge but there is no guarantee that money will be ploughed back into the community 
without legal binding contracts. Without contracts the people exploiting the medicinal plants get 
millions of Rands but the community without the patent and the right gets noting. The community is 
assured that the aim of this /ekgotla is not to make any money and that Patent lawyers will engage 
with the community and that the research team will not waver from this agreement with the 
community and that the community will always be the owners of this indigenous knowledge and the 
patent will lie within the community. The Chief summarised that, "What is yours you do not give 
away" this specifically applies to the Indigenous Knowledge of the community and that none of the 
community members must be tempted by money to "give away their knowledge" The Chief used 
the analogy o "My bootjie seil al nader aan die kis" ("My ship is sailing towards my grave") to 
emphasise that "how we deal with our indigenous knowledge today will determine the legacy left 
behind for the younger generation." "Let us protect the plants and use it to our benefit." 
The members of the lekgotla emphasised the exclusivity of veld medicine in the Khoisan 
community and therefore the patent and right of these veld medicines are the property of the 
Khoisan . 
231 
The Chief introduced the topic of the researcher as follows: "Xgau" 
The Chief "Nou mense ons het nou gehoor dat hierdie mense is hier met twee verskillende 
portefeuljes. "Ek wil nou nie die gevaarlike woorde gebruik nie maar elkeen het sy eie amp. 
Ons het gehoor dat Theresa daar werk so met die xgau mense, mense wie se koppe nie so 
lekker werk nie. Ons het gehoor dat David in die waakeenheid werk Ek wil eerste by Theresa 
se storie kom. U weet kom ek lees gou hier iets. Hoe beheer ons aggressie in die 
gemeenskap. Nou aggressie is waneer mense so vining op hulle se perdjies is, vir niks 
kwaad word nie. En dan praat ons nou pure in die kryt stap. Nou maar daar was n manier 
gewees hoe die ouer mense altyd hierdie mense gekalmeer het. Hoe hulle, hulle kalm maak 
en se hierdie ding werk nie, jy is besig om jou eie ondergang te bewerkstellig. So die vraag 
is dan nou hoe, en dit gaan die oumense nou vir ons beantwoord. Hoe word daar met hierdie 
mense gewerk wat so opstandig is? Wat sommer ewe skielik hy sit nog so dan vind hy uit 
hy moet sommer nou dan besluit hy hierdie outjie is lank verby, hy moet speel hy moet horn 
nou sommer tug vir niks. Nou ons will sommer nou weet hoe word daai aggressie binne die 
gemeenskap gehanteer." Dan die tweede vraag daar uh kom ons kom nou terug na haar 
(researcher) protefeulje toe, is ok oor aggressie is ok oor kwaad word maar ons weet mos 
mense wat se koppe deurmekaar word is oor die algemeen half aggressief. Hulle wil net 
maak of breek en baklei en tekere gaan hoe hanteer ons as gemeenskap hulle. Gaan ons 
ook in en beantwoord ons aggressie met aggressie of is daar iets anders wat ons doen om 
hierdie mense te laat afsien van hulle aggressie, wat doen ons. Ek dink julle kan vir haar 
help deur daardie vrae te beantwoord. Korn ons gaan na die eerste vraag toe, hoe hanteer 
ons aggressie binne ons gemeenskap. Die opstandigheid, wat doen ons as mense 
opstandig raak. 
"People we hear why these people are here the two have different portfolios. I do not want to use 
dangerous words but each of them has their own offices. We heard that Theresa works with xgau 
people, people whose heads are not working so well. We heard that David works in ICU. I want to 
first address Theresa 's question. Let me read. How do we manage aggression in the community" 
Now aggression is when a person gets on his high horse for nothing and get upset for no reason. 
Here we refer to them getting into the "boxing ring" quickly. There was a way in which the Elders 
calmed these people. How did they calm them and convinced them that what they are doing is not 
working and that their behaviour is causing their downfall? So the question and if the Elders could 
reply is: How do we work with people who become so obstinate? The person who would sit and 
then all of a sudden feel he must punish another person for no apparent reason? We want to know 
232 
how we deal with this person as a community. The second question would be, and here we refer to 
her portfolio, it is also about aggression but those people who do not have all their faculties, we 
know that in general they are more or Jess always aggressive and they just want to make and break 
things. You can help her (Theresa) by answering those questions. Let us answer the first question, 
How do we manage aggression inside our communities? 
Member One (Elder in the community): "Jammer ek het laat ingekom, Nou vir hierdie man 
"Jy moet verstandig wees. Want waneer iemand opstandig word dan moet jy horn nie krag 
gee om op te klim nie. Hy soek trap plekke om op te klim. (Showing climbing steps with his 
hands) Maar as hy nie kry nie dan moet hy bedaar. Nou wat ek daarby bedoel is dat waneer 
jyself ook hoog word dan gee jy horn trap plekke. Maar uh as mens nou verstandig handel 
dan is dit dat jyself nou sien maar ek moet klein word ek moet minder word as die person. 
Ek moet horn op n manier paai met my gesindheid sodat hy ook self kan sien hy is verkeerd. 
Want jy sal horn nooit tot bedaring kry as jy ok daai selfde gees inhom inblaas nie. A fellow 
member confirms audibly "Ja aggressie" Nou dit is een manier wat ek nou geleer het hoe jy 
daardie person in die gemeenskap gaan optree om dan nou daardie aggressie te bekamp. 
Kort en saaklik. 
"I am sorry I came late. Now to deal with this person you need to be wise. When a person becomes 
obstinate you need to be wise, if a person is aggressive you must not provide him with a step. He is 
looking for a step, however if he does not get a step to climb on he will calm down. If you act wisely 
in this situation, you will notice that you have to get smaller than that person. You can calm him with 
your attitude so that he will see his wrongs. If you blow the same spirit as what he is in into him you 
will never be able to calm him down. This is one method which I have learned. Short and to the 
point. " 
The community applauds the contribution of each attendee who participates. 
The Chief: Is daar nog ander mense wat ander idees het? Al is dit net hoe jy gesien het 
ander mense hanteer horn ons praat mos maar nou kom ons gesels hieroor. Are there any 
other ideas, even if it is only something you have witnessed, Jet us talk about this? (This comment 
of The Chief allowed more members to share in their own experience and the one member shared 
her own domestic experience. Any other contribution even if you have only witnessed how others 
treat them. 
233 
Are there any other people who would like to share their ideas? Even if it is what you witnessed 
how others dealt with this person. Let us talk about this." 
Member Two. Hierdie person met aggressie. Jy moet kalm praat, jy moet kalm praat. Dis die 
sleutel daai. 
''This person with aggression. You must speak in a calm voice; you must speak in a calm voice. 
This is the key. " 
Member Three seated in the last row in the hall quietly mumbled "Jy fok horn op, Jy fok horn 
op. 
"You fuck him up, you fuck him up" 
Member One: Die vroue moet weet as die man so opstaan ons sien mos nou dis vroue en 
kinders maar hulle weet mos nou die man is mos altyd bevoeterds hoe tree hulle op om dit 
te kalmeer dis dieselfde. Elkeen weet na daai man so kwaai is om horn te hanteer en te laat 
bedaar maar ek weet nie soms kan ons seerkry deur die moeilikgeit van hulle maar die vroue 
hanteer hulle. 
"The ladies can answer; they know what they do when the husband is acting so upset. What do 
they do to calm him down? They do something because they can get injured by the men, yet they 
seem to manage them." 
Member four (Lady Elder) "Van my kant af goeie middag mense. Van my kant af weet ek by 
my weet ek, ek het n man wat bietjie nie lekkerrig is nie wat bietjie opstanderig is, kwaai is 
en so aan maar my antwoord vir horn is om net my mond toe te hou en kalmeergeit te doen." 
"From my side: Good afternoon." "I know with me I have a husband who is not always well and can 
get upset, my answer to him is to not backchat and this I do with calmness." 
Prof Pienaar took over when The Chief left Prof Pienaar ek sien daar n hand "Julle jong 
mense wat het ju lie gesien doen die oumense?" 
"And you young ones, have you ever witnessed how the elders deal with this?" 
234 
Member five (Young lady) "As die een stroom op gaan, probeer maar kalm bly en moenie 
praat nie (demonstrating with her hands a person who raises high). Want jy gee die person 
krag en as jy wil hierdie kant toe gaan wil die person daardie kant toe gaan dan is dit mos 
nou Ii lelike ding." 
"If a person goes up the stream (vernacular for becoming aggressive) stay calm and do not speak 
because if you do you give him power, you think you will go this way, which person will then just go 
the other way and this will only lead to ugliness." 
Member six (Elderly lady) "Ek het nou nie eintlik veel om te se nie maar jou manier van praat 
met mekaar as die een bietjie hoog is en jy kom met Ii kalm mooi gees en stemtoon wat horn 
bietjie laat afbring en veral as dit in die huis is se jy "ag my skat of my engeltjie 
(demonstrating touching the person gently on the shoulder) ek ken jou mos nie so nie. Dit 
bring horn ok Ii bietjie af. Maar ek noem my man engel ek het nie Ii ander word vir horn nie 
ek het Ii wonderlike man. Niemand sal verstaan nie regtig ek sal nooit my man prys gee nie. 
(applauded by the community). My man het so Ii mooi gesindheid en ek kan horn nie eintlik 
beskryf nie ek het nie woorde vir horn nie maar as ek Ii bietjie kwaad is dan ag my ou ding 
dan is daar nou weer vrede ons gaan slaap nooit kwaad nie. Ons praat dit uit voordat ons 
bed toe gaan. My man is baie beskeie ek verwag nie iemand van buite moet my man 
disrespekteer nie. As daar iemand van buite is wat my man disrespekteer dan raak ek regtig 
opstandig want hy is nie iemand wat opstandig raak nie, hy praat nooit lelik van ander 
mense nie. Hy sal nie vergadering kom hou met iemand anders se naam nie hy sal hou die 
vergadering vir die doel daarvoor sal hy dit hou en hy sal nooit in iemand anders se pad 
staan nie ek is werklik met aggressie. (Demonstrating with her hands a motion of moving 
from a higher level to a lower level.) 
"I do not have much to say but the way in which you speak to a person who is a bit high (upset) If 
you speak with calmness and in good spirit and tone of voice this will bring the person down. 
Especially at home if you say "O my darling or angel I do not know you like this it will bring him 
down a little bit. I call my husband "my angel" I have a wonderful husband and I will not give him up 
for anything, I do not have enough words to describe him. When I get upset he has such a beautiful 
personality he would just say "Oh my sweetheart" and then I calm down. My husband is a very 
humble person and people from outside must never disrespect him he never talks badly about 
others and never gets upset. My husband will never stand in the way of another person, he will 
235 
never host a meeting in another person 's name, and he will only host a meeting for the intended 
purpose of the meeting. 
Prof Pienaar "Is hier iemand van die ouer mense wat kan wys van die word wat ek gehoor 
het die Xarare die Khoisan Xarare is wanneer jy die een wat so is kalmeer. Wat is die word 
wat jy se as jy die een so xarrare?" 
Are there any of the Elders here who can explain the word xarrare? The Khoisan "xararre 
"that you do when you calm a person who is like that?" 
Member seven (Female Elder in the community) " So 11 iemand as jy regtigwaar nou sien so 
11 iemand is nou baie, baie, baie dan moet jy nederig raak jy moet klein raak en met respek 
met horn saam praat .Jy moet horn se (Demonstrating a lowering of the voice) Se "Nxau" 
kalm die mense daar buite het ore wat hoor. Dan xarrare jy horn so (Demonstrating how you 
would calm a person in a swaying motion). Dan voel jy hy word sommer so kalm dan sit jy 
by horn en jy praat met horn en se vir horn die kinders loop ook hier rond en as jy so 
opstandig raak more raak die kinders ook teen jou omdat jy opstandig raak. En dan voel jy 
ook bietjie beter. (Softly saying) "So kalm nou." 
"A person like that, if you see he is very, very, very (aggressive) you need to be very, very, very 
humble and calm and talk to him with respect. You must tell him to calm down because there are 
people out there who might hear him you can touch him and gently hold him. You will then feel his 
body become calm. When he is calm you can tell him that when the children notice his aggression 
they will stand up against him one day. Once you have calmed him down, you yourself will also feel 
calmer." 
Member Two: "As een so kwaai is ... (inaudible due to background noise) verander jy 
eerder die onderwerp." 
"When a person is as angry as that it is better to change the topic." 
The Chief "Die tweede vraag is min of meer dieselfde, hier kom nou net die "gxau-geid" by. 
Dis nou n geval van 11 man wat nie "all there" is nie. As hy nou aggressief raak iemand wat 
mal is wat doen jy as daai person sommer kom uitdaging. Die man is nie reg nie." 
236 
"The second question is basically the same but here there is madness involved. This is the case of 
a man who is not "all there" If he becomes aggressive what do you do if he comes and challenges 
you?" 
Member seven: (Member seven demonstrates with her hands you calm him but verbalises) 
As jy nie nou vir jou reg ruk nie dan gaan jy nou met die ambulans Bloemfontein toe 
(Bloemfontein referring to the Free State Psychiatric Complex). Community laughed at this 
description. "As jy nie nou rustig raak nie vat hulle jou Weseinde toe. Jy hou jou mal jy is 
nie mal nie." 
"If you do not pull yourself together they will take you with the ambulance to Bloemfontein. You 
must calm down or you will be taken to Weseinde hospital. You act as though you are mad but you 
are not mad. " 
Member Two: "Stuur so een dat hy eerder gaan water haal." 
"Rather send a person like that to go fetch water" 
The Chief "Ons het mos al hier mense gehad wat uitgehaak het wat is daardie tyd gedoen? 
Hoe is hulle hanteer as hulle bietjie wild geraak het; hulle was tog deur ons gekalmeer. Die 
man is 11 proses deur gegaan. Is hy maar net so gekyk dat hy sommer weer regkom of was 
daar iets gedoen? Hoe het julle gemaak met die geweldadigheid? Ons het mos maar 
dieselfde gewerk om hom te kalmeer en het ok met hom mooi woordjies gepraat so maar 
partykeer moet jy maar los dat Gods water oor Gods akker loop " 
"We have had people like that in our community, people who "lost" it, what did you do in that case? 
How did you mange than when they became a bit wild? Did you just look at that person and let him 
be until he was ok or did you do something? Did you work the same to calm him as the others or 
did you just let it be? 
Member One (Male Elder) Jy werk anders want dit is 11 opstandige gees wat so in daai mens 
ingaan. En uh vra vir die Here hoe jy ok geestelik moet optree, Jy moet die Here eers 
geestelik innooi by jouself om op te tree teen die opstandige gees. Vra hoe nou Here hoe 
maak ek nou gee vir my leiding om daai woorde wat jy van die Here vra is geseen met die 
Gees van God. En ek glo mos daar is by die Here niks onmoontlik nie. En daai woorde as dit 
237 
in die ore kom dan is dit dat dit daar mos so kalmeer. Want daai bose gees moet ook na die 
stem van die Here luister. God is magtig in die hemel en selfs op die aarde om wondere te 
doen. So dit is nie net sekere tye of by sommige mense wat Hy dit doen nie. Hy besoek jou 
waneer jy dit nodig het op die daad waneer jy Hom vra Here help my tot U 
goedertierendheid." 
"You work with him in a different manner because it is a restless spirit inside him doing it. You ask 
God how you must react. Spiritually you need to invite God into yourself to counteract the upset 
spirit in the other man. You ask God for guidance and which words you must use. Nothing is 
impossible with God even the evil spirit is compelled to listen to the voice of God. God is almighty 
in heaven and on earth and God will visit you when you need him and give you strength and 
guidance. 
The Chief: "Ons het nou n antwoord gekry uit n Geestelike oogpunt ons het nou nie gxeigas 
hier nie want hulle sou ons ook goedjies kon gese het oor hoe maak hulle dan kon ons 
hierdie goed gekombineer het tot n sterker gedagte." 
"We have received an answer from a spiritual point of view; we do not have gxeigas here who 
would have been able to give more information, to make our thoughts stronger with more 
information. 11 
Validation during the one-on-one group discussions with the community members. 
Member Three: Ek het al gesien dat waneer die gxau mens so kwaai is en jy is kalm help dit 
partykeer om nie te praat nie maar net saggies te sit en fluit tot daai person kalm is. Waneer 
hy kalm is dan kan ons praat want jy moet weet hoekom hy so kwaad was. "Jy kan eers na 
die tyd redeneer." "Dlt help nie jy praat terwyl hy opstandig is nie." 
"I have witnessed when the mad person is so angry and you stay calm it does not help to argue, 
just sit down and whistle softly until that person is calm. When he is calm then we can talk. You can 
only reason afterwards, it is no good to reason while he is angry. 11 
Member eight: (Middle aged lady who did not speak during the Lekgotla). "Somtyds raak 
hulle so kwaad omdat hulle stemme hoor of n innerlike pyn het wat net God kan genees. Jy 
238 
gee een suikerwater as jy nie medisyne het nie lat hy net kalmeer." "Jy kan hulle duwweltjie 
stamp- of grashout trek en tee maak sodat hulle ook kalmeer." 
"They sometimes get so angry because they hear voices talking to them or they get angry because 
of some inner pain which can only be healed by God. You can give him sugar water if you haven't 
got medicine to help them calm down. You can even give them duwweltjie stamphout or grashout 
(Dianthus micropetalus), (tea brewed from indigenous plants) to help them calm down. " 
Member nine: (Elder) "Ek het al gesien dat as die person so kwaad is dan gooi hulle horn 
met water nat dat hy homself uit die kwaad skrik. Maar dit werk nie altyd nie partykeer maak 
dit die gxau mens nog kwaaier. "Kyk daar daai is een van die gxau mense daai kind daar, hy 
het nie meer n ma nie en sy boetie vat sy pensioen. Die kind kan nie praat nie maar nou kom 
staan hy so voor die vrouens met n vyf rand en beduie hy will by die vroue wees. lemand het 
horn dit geleer en dit kan nie deug nie. Die jong kinders is bang vir horn want hy het dom 
krag en ashy hulle so pla dan gooi hulle horn met die klippe." 
"I have witnessed people pouring water over the mad person, who is so angry, but it does not 
always work, sometimes it makes them more aggressive. See that child there is one of the mad 
people, he is without a mother and father and his younger brother takes his pension money. This 
child cannot speak but he comes with a five rand coin to the women and shows that he wants to 
have sex with them. Somebody must have shown him that and that won 't do. The younger children 
are scared of him because he is very strong; when he bothers them they throw stones at him. 
Member seven (Lady) "Ja die kind weet wat hy wil he maar hy kan nie praat nie. Ek het horn 
al gevat om inkopies te gaan doen dan vat hy die regte goed op die rakke. Maar die winkel 
baas wil horn nie daar he nie hulle se hy is mal en steel. Die kind is nou al twee keer deur n 
kar omgery en hy raak kwaai, ons weet nie eintlik hoe om met horn te maak nie buiten om 
kalm met horn te praat en horn af te bring ashy so hoog raak." 
"Yes the child knows what he wants but he cannot speak. I have taken him to the shop to shop for 
groceries and he takes all the correct stuff from the shelves. The shop owner does not want him 
there because he says the child steals and is mad. He has been knocked over by a car twice and 
he gets aggressive. We do not really know how to deal with him except to talk to him calmly and 
calm him down when he gets so upset. " 
239 
Lekgotla in A rural village in Lesotho 
Background 
The Lekgotla was negotiated in terms of the standard protocol whereby the researchers negotiated 
with the different Chiefs and informed said chiefs of the intent and nature of the lekgotla. The Chiefs 
called upon the Head of the indigenous healers in Lesotho, who in turn called all the indigenous 
healers in and around a rural village in Lesotho and Maseru together for the intended /ekgotla. The 
researchers attended as quiet observers and the Chief of the Indigenous healers was coached 
regarding the aim of the questions and he was subsequently requested to chair the /ekgot/a. The 
chief and members of the lekgotla was assured that anonymity would be ensured and that there is 
no need to share information deemed to be sacred. 
During the negotiations the three researchers discussed the aims of the /ekgotla with the Chief 
Traditional Healer, namely to answer their respective questions. 
For the purpose of this research the researcher posed the following question: "How do you manage 
violence and aggression in the mentally ill person? 
A rural village in Lesotho, about 50km from Maseru (the capital of Lesotho). It is a quaint little neat 
village with several huts and the community centre where the lekgotla took place is on the premises 
of one of the senior secondary schools. 
This transcript is a verbatim report and translation from seSotho to English. The researchers 
colleague Mr. David Mphuthi who is a Mosotho man translated from seSotho to English and back 
from English to seSotho to ensure a valid reflection of the verbatim content of this transcript. 
The Lekgotla 
The Chief Traditional Healer welcomed everybody present and posed the questions to the lekgotla. 
Apart from the 12 members of the Research team there were 30 Indigenous healers who attended 
the lekgotla. A lekgotla is open for any member of the community to attend and all members have 
equal input into the question posed, noteworthy the researcher observed that there were male and 
female Indigenous Healers present. 
240 
The male indigenous healers were the first persons to respond to the questions, and the elders 
replied first, after the youngest male responded the female indigenous healers would take their 
turn, also in ranking of the elders first. 
The observation of the researcher is that everything is dealt with in a respectful manner and that all 
inputs were welcomed. The indigenous healers were all dressed in Traditional clothing with 
different goatskin headbands and head coverings made out of beads. During a one-on-one 
conversation the indigenous healers said that those wearing the goatskin head gear received their 
calling to become a traditional healer during a dream and those who were wearing the beds 
received their calling via a vision while they were awake. 
The Chief of the Indigenous healers in Lesotho opened the proceedings by welcoming all present, 
and explain the nature of the questions which will be posed. 
The first question raised was that by fellow researcher Mhpoofolo who queried how knowledge is 
transferred from one generation to a next. 
How can our knowledge be translated to the forthcoming generations about the medicinal plants? 
Chief Healer: "I would like each and every one of you to give an answer" (silence) .. . The Chief 
Healer then repeated the same question. 
Respondent one: 'The question difficult to understand. The Chief Healer then rephrased: "What do 
we do to take our knowledge to the young ones not only medicinal plants but life in general? How 
do we make sure the following generation get the information as it was with the older generations? 
One of the young members a young male said: It is now we do not have time for the family the 
older generations do not have the night time stories with us as young people. We look at the 1V 
and do not have time and sit with the elders as to what has been happening in the olden days." 
Chief Healer interrupts and says: "This is not what is wanted . But the question is we as Basotho, 
how do we take things back? It can be done via negotiations and sitting around the table. How can 
we pass the knowledge to the forthcoming generation? 
Young man started to reply but is interrupted by the Chief Healer: The Chief healer "No what do we 
do as people to take the knowledge to the younger generation? (laughter) 
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What do we do as Basotho, older people to meet the younger generation halfway in terms of 
knowledge? The first researcher Mhpoofolo clarifies: "Important that we get old or we die and now 
the knowledge we have goes down to the grave with us. We want to know this knowledge what do 
we do to take it to the next generation? (Silence mumbling) 
A Healer replies: "I have three children , boys that I am pressuring and making sure they get the 
knowledge I have, because I also get it from the older people. 
Chief healer: Apart from the knowledge transferred to you what will happen with the passing of 
knowledge to other children? 
Response from Healer:" It is up to an individual I do not discriminate against any child who comes 
in for knowledge as a Mosotho child the children must be taught the medicinal plants we make use 
of and when they are taught about the medicinal plants this is Lekhala (aloe) and when they play 
they would share the knowledge with one-another. (Laughter). 
Third healer: "This is very clear that it can be just one aim of the culture to be a better culture." 
"When it comes to nationality or culture I understand as Chief Healer the most important th ing is my 
kids in my house must live according to what we as Basotho are doing. If the family knows what 
they are made of they will influence other families in the community even good and bad things can 
be copied. These days unfortunately a Mosotho or Basotho is ashamed to be called Mosotho, 
Sotho as it is deemed inferior everybody should know who they are." (Coughing). 
Chief Healer interrupts: "The question is as the Basotho people how do we make sure that what we 
know does not only end up with us but can be transferred to other generations? What I think so that 
we do not find our things fading , our children must be taught from a young age about cultural things 
and knowledge which should also be taken to schools if it can be translated from schools it will be a 
good partnership and a good th ing". 
Chief Healer: "Does it mean children will be together in the school and have this knowledge?" 
Younger Healer: (speaking very animatedly) "The young man must be given a chance to say what 
he thinks he was trying to say how they as youth find there is no time for night time stories and 
maybe the young man said the TV can be used effectively through programmes with cultural 
knowledge. I also think those things and knowledge can be translated and we want our mothers 
242 
and fathers to understand it is not a competition, between them and the media. Everybody is 
entitled to have their own opinion ." Mhpoofolo says: The old man does not mean one is wrong and 
one is right I am writing what you are saying . (Everybody agrees) 
Chief healer:" Can you please make your speech to be strong. (Everybody laughs) As a young 
man you said a lot of things please put it in way for us as older people to understand." 
Young healer: "We still have older people helping us because older people in community I am of 
the opinion they can be consulted and give us advice. We can sit with them in their own huts they 
must actually have time for: Women for ladies, Men for the young boys, that would actually improve 
the knowledge generated in a culture and whoever attended will be able to inform other people." 
(Inaudible) "As a young man I th ink our old people, even I would not like to call them old people but 
rather elders ... (Members of the /ekgotla said it is fine to refer to or use the word old people) They 
should be visited not in urban areas but in villages and huts where they still have the information 
you can share. Boys should be taken to the kraal (similar to the process of lekgotla) by men to be 
taught what men do culturally. Ladies are taken by older women to a sacred place to be taught 
what is expected by women. Information should be conjoined (sic) to the chief and elders so that 
the information agreed upon can be shared with the young ones." 
"It is very important that our elder people teach us about life at least even they play important role 
because as you sit and watch you are learning about aspects of life, make sure you learn and apply 
th is. Most of the time we are expected to do things we are not sure about how to do." 
Researcher one: "Do you mean that this information to be kept by the old ladies and men only, and 
when we go to them, they can give us the information. (Silence) Chief said yes (mumble) . 
Indigenous healer with dread locks dressed in a grey blanket: (Becomes very excited as he speaks 
with almost an bewildered expression) "You know what there is something that when I tell it to you 
now, I grew up in village, some older boys in the field they had something called toloki and this 
toloki is something used by older boys to treat younger boys. (Sic) The bigger boys will send the 
younger boys to dig up potatoes. The big potatoes are then taken by older boys and the smaller 
boys are to take small potatoes it was toloki , and a way in which information was transferred to the 
younger boys." These big potatoes eaten by big boys .. .. someone interrupts. "You have missed the 
point here." Chief of the indigenous healers: "Please sit down and let the older man finish fi rst and 
clarify th is point for us." 
243 
Older man: "This issue about toloki it is the potatoes, smaller potatoes the way he is putting it I 
know the word "mampudi" is the biggest head boy ... Chief healer interrupts: "We need to 
understand as a healer working with mental health people where does this toloki comes in with 
people, it has no impact on what we want to do." Let us try and make sure we do not waste time 
about things not asked. Researcher one: "What is this toloki? Let this old man say how toloki can 
help growing men to understand the issues." 
Chief Healer replies: "Mhpoofolo I do not think it is relevant because if toloki is just a potato I do not 
understand how it comes into the picture what we understand to answer today. We are taught by 
old people what is toloki and what it leads us to understand." 
Chief Healer interrupts: (Mumbling) (Inaudible response) . "There are so many th ings; wild medicinal 
plants that we can use to cure some other diseases especially mental illnesses. This information 
must not be a secret, younger people must know what we use to cure sickness. It must stay in the 
family and parents must make it part of knowledge in the family, plants do give healing and 
cleansing aspects and this must be taught in the household. Some of them (plants) are dangerous 
and people must be made aware even though the plants are good and useful for healing it can be 
very dangerous. Some of the plants can be said just in the open others not." (Mumbling) 
Lady Healer 1: "Before we do anything we take our culture to our ancestors there is a lot of things 
we are owing to our ancestors following the type of life we lead nowadays. I still support and belief 
that yes info to be taught at school also in our villages and in small groups (thakaneng) where there 
are older people staying with the little ones teaching them about life and showing them where life 
starts. This is where the boys are grouped according to their ages each and every group taught to 
what is expect from that age group. You cannot say anything to anyone at any time. Do not give 
info beyond the age of child when they reach a certain age. You can begin to start speaking open 
about things especially in indigenous healing there are different beliefs. People are not the same 
some go for the improved way of healing even though we have our own ways of healing we lose 
hope and do not believe that our own th ings work well. Most people go for the western way of 
western medicine. Western medicine comes from the same medicinal plants we get from the veld. 
It is therefore important to know sometimes as it happens, I know a certain medicine plant can cure 
certain disease, and in conversation I say this to someone and he uses the same information to 
help someone else. We will make sure our children have knowledge about it but some information 
which is sacred because we fear of losing our own knowledge. " (Silence and mumbling) 
244 
Lady Healer 2: "I am saying go back to our culture. I am an elderly lady bringing up grandchildren 
not my own as their own mother father is not there. They know what is good and bad because I sit 
down with them and tell them, even the boys, I tell them what the consequences is. I have children 
who will not eat eggs or sheep intestines (a cultural taboo for different genders and age groups) 
even now you can go to my hut all children from the village come to my hut I sit with them and 
teach them. I do not own a child now, he is 33years old . I teach other children in the village. I call 
them together and teach them about our cultural beliefs. I tell the girls the moral aspects how to sit 
with boys as to not be revealing themselves I tell them point blank. But nowadays when I tell them 
to go back in cultural ways things have changed a lot. 
Nowadays we as old people are termed witches and we are unlikely to take a chi ld and talk to them 
as they will call you a witch we are very far from each other but I do not care I do everything and tell 
everybody. There is a tree in my yard all children come and eat leaves of my tree, they say this is 
the tree of healing from my grandmother and we will make use of it. Even at the school I do have 
teachers who come to me and say these children do not eat. I tell them if my children do not want 
to eat leave them we must make sure we grow up to use the same values. We were not asked 
anything as a child , you were taught this child comes from the river. Nowadays the children ask 
anything and you have to tell them the truth because they don't believe you. 
We should not be scared or embarrassed to talk about these things to the children now at my 
house a lot of children are waiting for me to talk to them even though their parents are against it. " 
(Laughter) It is very important that this people come here important to talk and understand the 
importance of having meetings like this ." 
Healer 2: "Nowadays it is so unusual in the families , men and women are the same in the house 
boy, girl does not know what role to play, in the olden days everybody knew what they were doing. 
Lady Healer 3: "I came in the same. Now that you say these days the girls are wearing pants when 
they sit they just sit with the boys what are the things we do? We want to understand how to bring 
back old values we talk about. Very important you sit down and teach it. Yes sit down and tell I tell 
you in my house no girl wears trousers, the trousers are for men girls have many things happening 
around them and life. In my house the girls will wear the " thethana" (Laughter) 
245 
Chief Interrupts: "Mapana we should take some things and modernise so we all understand what is 
said here." (Laughter) "It is important that each and every one participate, do not exclude people 
who do not understand our language; please interpret so all can understand what is said." 
Chief Healer: (Mumbling in between) "These things when I think backwards were very much easier 
when elder people can help in making our world to be healed because when I look at the world 
now, our world is sick. There are things that these chiefs grow and the Basotho boys are taught. 
Previously old ladies get young boys and girls and hold their private parts in their hands and say 
they (the children) are smoking. They will then sniff their hands and pretend to sneeze from the 
alleged smoking. Nowadays it cannot be done, because it is molestation of a child "ho Tsuba" 
Except for harassment the people in the village especially parents must be taught who do not know 
if they are doing right or wrong If people can be educated where and what was done initially in the 
olden days I still think most of our youth can be better nation tomorrow. Olden days no trousers. 
Girls wore thethana. Girls and boys nowadays have no respect if taught how to respect elders they 
will be a good nation tomorrow. Teach them the respect. Thank you very much I am closing this 
point. " 
Chief Healer: We are now going to move further. Nowadays we are still having a problem as 
parents we cannot talk to kids even if they arrive in the middle of the night they will go out. " "Now 
we move on to next point. "" 
Lady Healer 1: "Let me just say something on the previous point which is very important what want 
to say now. (Disagreement between researcher 1 and Lady Healer 1) (mumbling, inaudible and 
laughter) Researcher 1: "I want to come back to you to make sure what I have written is true. I 
understand from the elderly people things came up: 
1) Education should start at home in house in family, 
2) Parents teach their own children cultural issues and moral values 
3) This education goes to schools and this education also goes from village to village 
4) We are living in a changing world this affects the youth and it was suggested a TV programme 
could be used so that youth can go sit and watch the TV programme slotted for them to educate 
them in this way we can help in taking forward cultural education to the young ones. 
Chief Healer: "The next point little bit higher strong point. This is strong it affects you directly as 
healers so please listen carefully and answer what is asked. Make sure you answer what asked. 
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"When person has mental illness and show aggression how do you assist that person? To put 
under control is it clear?" (Laughter and mumbling) Question repeated by the Chief Healer. 
Lady healer 1: "I can say from my side ... (trying to answer but the chief healer interrupted her) 
"Because you answer outside of the question I am trying to help you." 
Chief healer: "It is very important to understand the question and be trained so that we understand 
what is asked. Now you as healer how do you say you will treat this person mental illness? You 
understand how violent they are, you are aware they can kill you. 
Lady Healer 1: "Yes, you as person need to be above this person remember not everybody with 
mental illness is violent. Do not be violent, be calm when working with them they are sick. To get 
them there (calm), you have to qekisa (beg), them to be calm. It is very important that with these 
people you are calm when you approach them because in their mind they are already aggressive. If 
you come in with aggression you are aggravating what is happening in their mind already as a 
healer you need to make sure you make them sit down. Talk to this person and beg before you give 
them any medication. 
Chief Healer" I was just asking this question , I happened to be there when someone was treated. I 
saw someone with mental illness when taken out of the car there was the medicine that was burnt, 
and this person had to go through the smoke of this medicine and you have to make sure you 
control him. 
Lady Healer 2: "In most of the time you find this person is allowed to go through the smoke and 
most of the time when they come they ask: Can I kiss this women? As a lady you do not allow this 
to happen to you. " 
Lady Healer 1: You must keep asking if he understands that you are not fighting him, he is sick 
even if he wants to kiss you. Do not look at what they are doing bring back their mind so that it can 
come back from what he doing. At this point if he wants to hit you do not take a stick to hit them 
back. I do not agree with this treatment you will make him mad worse (sic). 
Lady Healer 2: I want to make sure how we treat mental illness I hear you say this thing burnt 
there .. . 
247 
Chief Healer: "No no! do not talk about what burnt there I have things written down to talk about, 
what burnt I just gave example about what I saw." 
The chief healer repeats question again: When somebody with mental illness and signs of 
aggression and violence comes to you, how do you assist them to come back to normality? 
Lady Healer 3: I am saying I helped these mad people a lot because it is believed the mad are 
coming from the caves. Now I help them. When they come in my yard tied up I say "Untie him!" 
When he gets into my hut I come to him. I go to them and give them a hand of mercy protection 
and hand that calms them down these things I have I cannot say here I can only say it when we are 
in a sacred place. I touch this man with a sacred hand and he will sit down and listen to what I say. 
I don't give them anything. Now he sits. Even if violent after I give them a hand they become calm 
because I am calm. It could happen that when I am touching them with my hand I am also mad but 
my hand is calm Don't just work with people sick I even cure mad people (Mahlanya) really mad 
ones. 
Even if they are from Mohlomi (Psychiatric Hospital in Lesotho) before I am told they are from 
Mohlomi I can cure them. 
Once they get into my yard they become very calm. Somebody that knows what it is to be an 
indigenous healer and those tremendous initiations of the traditional healer; they will know how to 
deal with mad people. 
The only thing I would do is to take a mug and give him water and say "Sit here my love" and 
immediately the person becomes calm and sits down. Even if the person came in being tied with 
ropes, the only thing I do is to be calm and show no sign violence because you will make them 
mad. (Silence) 
Chief healer: "Give other man chance to say what want. 
Female Healer 4: in response to a question by researcher 1: "I am asking once you touch with the 
hand does this mean everything now done and he is healed? Is there no medicine to give? "No I do 
not give medicine when he is violent I only give medicine once everything has calmed down. When 
cool and calm then start giving medicine. (Echoed by all) I just instruct to sit down give them my 
hand then they become very soft I will do everything by hand (claps) 
248 
Researcher two asks: "Now that you say these people; Chief said medicine burnt when a person 
comes in aggressive. Is it possible to tell which medicines you burn and decoction for drinking? 
Chief Healer: "No, No, No! You are now asking me to teach you how to do indigenous healing 
without being an indigenous healer (Mumbling) 
Lady healer 2: "This medicinal plant they are there and there are medicines we use even though 
they are different I will give only these I believe would help. When done everything fine with this 
person. According to me no person is mad they just have problems which they are not able sort 
out. I need to calm them down to think straight It is very important that I do that but I will not tell you 
what we burn. 
Researcher 2: We respect that as Research team thank you very much 
Male Healer 1: I am sorry will not be able tell you the names of medicines we burn when somebody 
is sick. Not on all mad people you will give something to smoke or drink. There are mad people who 
are very mad and they take some stuff orally others need to smoke something. Some of the mad 
just need medicine for cleansing. They use this when bathing, that will help them out of the state 
they are in. It all depends on how madness got onto this person. Some of the mad people are just 
mad and just want someone to sit and talk with them then the madness is gone. Some must be 
removed from the place where they are because they are mad because of surroundings they find 
themselves in. (Mumbling) 
Chief Healer: In Gauteng I have seen that there are huge walls around the hospital for mad people 
when you are a visitor there it looks as though you are in prison. Now all of a sudden when visiting 
there I saw someone jump over the wall around houses so this man that was jumping was coming 
from another house where he was dumped by his girlfriend people thought he was mad and started 
call ing ambulances. They captured him and said he must be taken to the hospital. This issue when 
I listen to it, there is something that happened it looks like it is different but it is not I am trying to say 
in the issue of saying what kind of medicine like e.g. H/oenya What is it used for. Chief Healer: 
"Stop the question is not appropriate. I want you speak to this question not anything else." 
Older male healer: "You can help in different ways let me answer what you ask When th is man 
comes here he will find medicine burnt as he is coming through. Others will find medicine they must 
sniff there is medicine burnt when he comes into house it will make him drowsy and then when he 
249 
is mad, it is not mad it is the nerves and when the medicine makes him drowsy, this calms down 
the nerve break, and he will be soft and calm and sleep. 
Chief Healer: "If continues to be mad what do you do e.g . you are the fourth Indigenous Healer and 
payments were made to all consulted now last payment that is there, what is the easiest way that 
can be done so that the family can be assisted so this person be healed with the payment of the 
last cow or payment? This person starts here from being helped but again we must make sure he 
understands and family understands the situation he is in. Thank you very much. Let us talk about 
this. 
Researcher 2: "What can I say, I really like this people they also refuse to come to the doctor you 
just handcuff him and give tablets. 
Male healer 2: "As for me this type of sick person they way I treat them depends on what caused 
the madness. If I have to meet them at the gate I will go to the gate and inside my hand I will be 
having some medicinal plants I will not touch him but I will throw this medicine on the ground where 
he is and we will be fighting with him to step over the medicine. I will try to get him inside the yard 
or hut; the fight will be to get him to step over the medicine. When he is in the house I will touch him 
with medicine in my hands and the medicine in my hands will cause him to listen to everything I 
want to say or do. Then give him medicine to drink. When he takes the medication I will talk to the 
family about what happens I will talk to the family he will not talk. He will fall asleep in his dreams 
when he wake up I will give "can say In Sesotho we say back of mad person is corrected by 
smacking them" Is that so? (Laughter and mumbling) 
Male Healer 3: "Let me say to you it differs according to the indigenous healers. " 
Female Healer 3: "There was another female indigenous healer who would get into the house of 
the mad person and she would beat him to the extent that he would become tired, but it differs from 
one indigenous healer to another. I heal most people say when give them a hand they become soft 
but we still believe to give them a whip then give him medicine prepared when he slept. Now it will 
be him and me alone I will ask him what he sees and what he hears. This is how I treat the mad 
people who are violent and want to run away. I have achieved this status because I befriend them I 
am his friend. I work in hospital Mohlomi with the western doctors. When I am in Mohlomi I have 
seen several mad people. Some of them I only touch with my hand and they are fine. Most people 
when I touch they even agree to be injected even though they were very violent towards the nurses 
who want to inject them. When they want to give them injection that is when the fight starts. In my 
250 
presence it does not have to be violent since I have been in Mohlomi I give them my hand and 
touch and they become calm and controlled I then take them to the place where they are going to 
lie and rest. That is what I do. 
Chief Healer: "Can you explain have these people not been so mad that you feel there is nothing I 
can do but give them force. 
Female Healer 2: "Fortunately I have not met such a person; have not met such persons in my 
whole life. One person who is about a year ill (Sic) come from another village, they found him in the 
caves. I was told he is so violent he could kill, when I arrive he is not so aggressive. He became so 
happy that people asked me what happened. When he comes to my house I untie him. If I am not 
there they take him to his house and give him help. This person with no family at all ; I asked he has 
person who he works with. Maybe this is the problem that caused him into this state therefore we 
need to assist him. He went up and down the whole Lesotho but has not been helped. He is now in 
Maseru and with me; I ask the person who he is with and ask him is there anything you can help 
with? He said no I didn't know what to do I give in. This mad person has wife and children he is 
mad .There is something now that is difficult (inaudible) ... I fell in love with this man to help him, 
now he is in this state there is something impossible you cannot make. A branch in health 
department it is not allowed in any way that I arrive at the directors of the branches of Department 
of Health. And now unfortunately I am not allowed to go in the wards to help with sick persons. I 
haven't met such a person the one that I have met when I arrived at this person, I was told he is 
sick but he was very soft when I spoke to him I only talked to him. Some I met I saw they only 
became violent when other people were around them. Once given medication they get better. 
Thank you very much. 
Questions by the researcher conducting research on medicinal plants 
Chief Healer: "Can you just say in few words how did these medicinal plants come into being?" 
Most people think these plants were planted by "Other" people. When God created man He 
instructed what animals should eat He instructed man to eat everything grown in the world. 
Therefore plants from earth are the best treatment to use. 
Chief Healer: Now we will speak about the last questions I was given to discuss with you, these 
questions relate to the plants directly. The first question is: 
251 
"How important are the medicinal herbs in this community and what are they used for" 
"How do you prepare these medicinal herbs, and which ones do you frequently use?" 
Healer number 1: The medicinal plants in this country are very important because we believe in 
them and these plants they make us healthy and in most of the cases we use them in mixtures. 
Types of plants that we use Lengana, h/oenya, Phate ea ngaka, Aloe and Poho tshehla and lero la 
tlho/eho. And then we have kwena (mint). Lengana we have three types of Lengana but all of them 
are called Lengana because there are no different names for them. You must know which one you 
want to use because some of them are very dangerous as it can kill you . 
Researcher: How do you prepare this Lengana? Healer 2: Normally we boil them, we sometimes 
use green leaves and put them on the painful part. When somebody has common cold we put the 
green leaves in the nostrils or under the pillow. Some people will even smoke the dried leaves 
single as Lengana or mixed with Kwena leaves. 
What conditions are commonly treated with the medicinal plants? 
Common cold, treating of the intestinal worms, so we do deworming, menstrual pains, malaria, 
killing of germs. These plants they also help the drivers and people doing sedentary type of work 
with their kidneys. We also use these plants against witchcraft. 
Measurement: How do you use measurements about this plant? We use the fingers to measure 
how much we need. Sometimes we make use of a full hand or a half-a-hand, once the decoction is 
prepared the measurement is done with teaspoon, tablespoon and/or cups. These medicinal plants 
should not be used more than a week for the same condition. You need to change your herbs if 
there is no improvement. The leaves are boiled until the water changes its colour and the person 
that is preparing the decoction is the one that will decide when the decoction is ready for use. 
252 
ANNEXURE 2 
Curriculum for the cultural safe management of aggression and 
violence 
1 Introduction 
The management of aggression and violence is an anxiety provoking situation for all mental health 
care providers and is identified by Bj0rkly (199:57) to be "one of the most distressing and disruptive 
obstacles to effective treatment in modern psychiatry." The incidences of aggression and violence 
often goes under reported, however the implementation of an aggression report scale has proven 
successful in previous research to prevent under reporting. 
Nursing staff are the victims of aggression and violence in 90% of incidences of aggression as 
reported by Bj0rkly (1999:62) and Ukpong, Owoeye, Udofia et al (2011:46), Fottrell (1980:216) and 
Gudjonsson, Rabe-Hesketh and Szmukler (2004:261 ). 
James, Isa and Oud (2011 : 130) made a very interesting observation, namely; the older nurse are 
less frequently the center of an verbal or physical attach, this the authors associate with more 
experience gained in psychiatric nursing. 
As is evident in research by Bock: (2010), James et al (2011: 133) also concludes that there is a 
need to train nurses in the management of aggression and violence in order to change their 
attitudes towards managing aggression as associated with the mentally. 
2 Objective of the curriculum 
• On completion of this training programme the learner will be able to diagnose the early signs of 
mental health care user related aggression before it escalates into violence. 
• The learner will be able to identify potential causes of aggression. 
• The learner will be aware of their own perception of the management of aggression and 
violence. 
• The learner will be able to deal with a mental health care user in a culturally aware and sensitive 
manner, 
• The learner will be able to de-escalate aggression to a manageable level. 
• The learner will be able to apply break away techniques and will be able to apply safe restraining 
techniques. 
3 Curriculum content 
The content of this curriculum is based on inputs as received during a previous research project 
where base line data was created to determine staff attitudes towards the management of 
253 
aggression and violence. The researcher used this information and the knowledge generated 
through a lekgotla with indigenous healers to determine how aggression is managed. The 
researcher therefore incorporated the social knowledge from the community with scientific 
knowledge generated through research as referred to throughout this curriculum. 
This knowledge led to the creation of a conceptual framework for the management of aggression 
and violence. 
In turn this conceptual framework further guided the curriculum content 
IDENTIFICATION 
ANO 
ASSESSMENT 
Culturally 
OE-ESCALATION 
ANO DEBRIEFING safe PRIMARY CAUSE 
De--escaltion, 
break aw1y ind management causes of 
restniininc of aggression ) 
te.chnique.s 
nd violence 
SELF 
EVALUATION 
Self perception ) 
of aure:ssion . 
3.1 Target group for this curriculum 
This course will be presented over the duration of one week and will be on NQF level 5. 
The credits for this course are allocated as follows: 
3.2 Broad content of the curriculum 
20 periods=3 credits and 6 periods=1 credit (!hour-1 .5 notional hours) 
254 
Topic Periods Notional Credit 
45min. hours 
Determine the attitudes of staff towards the management 4 2 0.66 
of aggression and violence 
Identify the early signs of aggression and violence 4 2 0.66 
Identifying causes of aggression and violence 4 2 0.66 
Predicting violence 4 2 0.66 
De-escalation techniques 16 8 2.66 
Break away techniques 8 4 1.33 
Safe restraint 8 4 1.33 
Cultural sensitivity awareness and safety 8 4 1.33 
Total 56 28 9.2 
4 MICRO CURRICULUM 
4.1 Perception of the management of aggression and violence 
4.1.1 Learners will complete the MAVAS Management of aggression and violence Questionnaire; 
this will determine their perception of the management of aggression and violence and their 
cultural sensitivity and awareness. 
4.1.2 Learners will also be required to give their definition of aggression and violence 
4.1.3 The attitudes of nurses towards the management of aggression is influenced by the amount 
of exposure to aggression, nature of the incident, their thoughts and beliefs about aggression 
and acts towards a person as highlighted by James Isa & Oud (2011: 130) 
4.2 Early signs of aggression 
The early warning signs of aggression are very unique to each patient therefore it is imperative that 
the nursing staff get to know their MHCU's very wel l. Culture is influential in setting the norms for 
behavior as mentioned by Tjale and De Villiers (2004:69). Therefore it is essential that the nursing 
staff also take into consideration the culture of the patient when deciding upon utilizing the Model 
as developed by Fluttert et al. (2008: 214) as it might lead to ethnocentrism if the nurse wants to 
interpret the behavior of a patient in terms of her own cultural norms (Tjale & De Villiers, 2004:69). 
4.2.1 Verbal aggression is the most common form of aggression James, et al (2011 : 130), Hills. 
2008:24). However the occurrence of verbal aggression might often be at a later stage, 
aggression must be detected as early as possible in order to either manage or de-escalate it. 
To accomplish early detection of aggression the nurse must be aware or the recognition of 
the subjective causes for aggressive behavior (Fluttert et al. , 2008:213). Therefore it is 
essential that nurses and the security staff in the wards are equipped with the necessary 
skills to help them detect early signs of aggression as manifested through subtle behavioral 
255 
I NWU- I ,~IBRARYJ 
changes. The researcher concurs with Fluttert et al. (2008:213 that training on early detection 
will also help the staff to assist the client with their self-management skills. 
Fluttert et al (2008:215) continues to site Birchwood (1992, 2000) who refers to the "personal 
signature" of a person with respect to the manifestation and causes of aggression . This 
Signature implies that patients are extremely unique in terms of aggression and needs to be 
evaluated and managed as an individual and not merely according to set protocols. 
4.2.2 Early recognition model 
Fluttert et al. (2008:213) developed an early recognition model for identifying aggression 
and simultaneously preventing severe incidences. The aim of this model was to identify the 
subtle signs during activities such as delivering daily care. This model consists of four 
distinctive areas that focus on acquainting the client with the model and stipulating the 
expected behavior. The nurse patient and all of his support system are involved and asked 
to list e patient is taught how to monitor their own behavior and to recognize the warning 
signs. During phase four the preventative measures are identified and the client is advised 
to utilize these measures in the event of detecting the early warning signs of aggression. 
(Fluttert et al. 2008:213). 
Importantly all staff must be made aware of this protocol and how to apply this. Furthermore 
this recognition model concurs with the perception of indigenous healers, namely that the 
client who is aggressive must have input and recognise the factors which leads to his own 
aggression , he must form part of the management of his own behaviour and not be merely a 
passive recipient of care. 
Thus Fluttert et al. (2008:214) identified that the success of this model rests on the 
development of rapport between the nursing staff and patients. 
4.3 Causes of aggression 
4.3.1 Situational vulnerability 
• The increased probability of a person to become aggressive due to: Physical contact, 
Limit setting, Problems of communication, Changes or re-adjustment, Persons, High risk 
contact, Drugs and stimulants as per the REFA (Report form for aggressive episodes) 
scale (Bj0rkly, 1999:58). Bj0rkly (1999:59) reports that often there are more than one 
precipitant for a single episode of aggression and that 64% incidents of aggression was 
caused by limit setting. 
• 25% (twenty five percent) of incidences occurred due to delusional states, hallucinations 
or difficulty in communication this finding is similar to what the indigenous healers 
reported in terms of the association of mental illness and aggression , therefore the nurse 
must guard against the perception that [all mentally ill persons are prone to violence] .. 
256 
• There is no reported difference in the rates of aggression between male and female 
patients but noteworthy there is a reported trend for male psychiatric patients to engage 
in more serious violence than their female counterparts. 
• There was no statistically significant difference in rates of aggression during different 
seasons. 
• Often the same patients are involved in numerous incidences of violence and 
aggression. 
• In the ward setting where access to alcohol, stimulants and drugs are controlled there is 
often a decrease in incidences of aggression and violence. 
• Staff refusal of patient requests Gudjonsson et al. (2004:259). 
• Patients refusing medication as cited by Gudjonsson et al (2004:259 
• Closed-ward systems (James et al., 2011:133), (Mavundla, 2000:1576). 
• Conflicts with staff, certain staff have been identified to be more prone to attacks 
indicating problematic relationships, Duxbury & Whittington 2005:470) 
• Shift changes, admissions and discharges have also been linked with escalation in 
aggression (Delaney & Johnson, 2007: 43). 
• Past experience of being "rewarded" for violent behaviour 
• Cramped over crowded spaces 
• Very hot spaces 
• Fear and anxiety 
• Too little or too much stimulation 
4.4 Warning of imminent violence as per NHSLA Risk management standards 
• Increase in pitch and volume of the voice 
• Dilatation of the pupils 
• Abrupt answers to questions 
• Towering posture 
• Tensing of limbs and facial muscles 
• Sustained prolonged eye contact 
• Restlessness 
• Clenching and unclenching of fists 
• Threatening gestures and provocative behaviour' 
• Repeating the same thing over and over 
4.5 Predictors of violence 
• Diagnosis of schizophrenia and co-morbid substance abuse (Duxbury & Whittington 
2004:470). 
• Younger men with a psychiatric illness and co-morbid substance abuse problem are most 
likely to become aggressive (Duxbury & Whittington 2005:470). 
• Conflicts between Patients and staff. (Duxbury & Whittington 2005 
• During meal-and shower time in the mornings have all been associated with an increase 
in the incidence of aggression . 
257 
• Patients who are unknown to the nursing staff may proof to be very unpredictable and 
often poses a higher risk to staff than known patients according to Delaney and Johnson 
(2007:42), the indigenous healers also reported that extra caution must be taken where 
the person is unknown to the healer, where there is no collateral information available all 
persons must be dealt with as though they are unpredictable. 
• The better the staff are acquainted with the patient, the more equipped they are in terms 
of predicting the outcome of a situation as per Delaney and Johnson (2007:43). 
Therefore this will allow staff not only to anticipate behaviour but to focus on the best 
mode of action to de-escalate potentially dangerous behaviour. 
• History of violent behaviour and the severity of previous acts 
• Previous use of weapons 
• Known personal triggers. 
• Threatening with violence 
• History of frontal lobe damage 
The Brnset Violence Checklist has proven to be extremely accurate in predicting violence and 
aggression in a health care setting . This scale has proven to be successful in decreasing the 
amounts of seclusion due to the occurrence of aggression , as found in a study by Clarke et al. 
(2010). According to Clarke et al. (2010) the Brnset Violence Checklist (BVC) consists of six items 
and can be completed either within the presence or absence of the patient. This tool has 
subsequently been implemented in different hospital settings as a basic part of routine patient care 
(Clarke et al. , 2010:615). 
"The BVC assesses three patient characteristics (confusion, irritability and boisterousness) and 
three patient behaviours (verbal threats, physical threats and attacks on objects) as present or 
absent. It is hypothesized that an individual displaying two or more of these behaviours is more 
likely to become violent within the subsequent 24-h period than the patient who does not display 
these behaviours. " (Clarke et al., 2010:215). The BVC have proven to be accurate in the use on 
unknown and unfamiliar patients, (Clarke et al., 2010:617). 
4.6 De-escalation techniques 
In order to manage aggression it is essential that the therapist and patient both understand the 
onset of aggression and identifies the feelings experienced directly prior to an aggressive incident. 
(Fluttert et al. , 2008:212). This in essence will assist both the therapist and cl ient to gain an in-
depth understanding of the behavior of the client. 
• Once a staff member is acquainted with a patient they will get to understand what the "typical" 
behaviour of a patient would be during a situation. 
• Understand why a person would behave in a particular fashion 
• Respond immediately when a situation is particularly unsafe 
• Remember not all escalating situations will be dangerous; this is where knowing a patient is 
particularly helpful. (Delaney & Johnson. 2007:44). 
• All incidences of aggression follows a trajectory, however often the persons involved are not 
aware of the beginning of the incident. Early appropriate intervention is of extreme importance 
258 
as to be able to stop further escalation. This is supported by Hill (2008:28) as he found during 
his study that it is important to contain patient aggression at the level of verbal abuse and that 
aggression management training should focus on de-escalation strategies. 
• The intensity of the incident is a good point to determine the nature of the intervention required. 
• Aim of de-escalation is to reduce violent behaviour through the use of verbal and non-verbal 
communication skills (Price & Baker, 2012:310) 
• 
4.6.1 Characteristics of effective de-escalators (Price & Baker, 2008:312) 
• Open, honest, supportive, self-aware, coherent, non-judgemental and confident without 
appearing arrogant. 
• Express genuine concern for the patient, are non-threatening and permissive in a non-
authoritarian manner. 
• Empathize 
• The above qual ities will help the care giver to gain the client's trust and this will make the 
appeal from the care giver for the client to maintain self-control more accepted . 
4.6. 1. 1 Personal control 
Price and Baker (2008:312) refers to Duperouzel (2008) and Gertz (1980) by citing , when it 
appears as though a person is calm in dealing with an aggressive client the sense of calm will rub 
off on the client. This creates a perception in the client that the staff is not aggressive and in control 
of the situation. To accomplish this calmness a strategy proposed is to focus your attention on the 
patient rather than how you as a care giver feel about the situation. However be constantly aware 
of the propensity for violence. This technique will demand a certain amount of self-control from both 
the therapist and the patient. Even though aggression is learned behaviour so is self-control 
according to Geen and Donnerstein (1998:Loc2016) 
4.6. 1.2 Verbal and Non-verbal skills (Price & Baker, 2008:313) 
Calm gentle tone of voice The indigenous healers reports the importance of calmness and a calm 
hand because they say that the use of an aggressive tone will b\"Blow the same spirit back into the 
patient, and will give the patient a "step to climb higher" this means to become more aggressive" 
Tactful use of language and sensitive humour as long as it is not seen by the client as sarcasm or 
belittling him. 
Focus on your own body language, eye contact, facial cues and focus on expressing concern for 
the patient. 
Be aware of the appropriateness of eye contact and that it should not become a stare down which 
can be perceived as challenge or aggression. Culturally it is not appropriate for a younger person 
especially a female, to make eye contact with some older male patients. A possible meth<id to deal 
with this is to make fleeting eye contact but avert your eyes to about the height of the chest of the 
person (this way you will be able to observe any movement from hands or legs in your direction) 
259 
This will put you in the ideal position to not be caught off guard by a sudden attack from the patient 
ton you . 
4.6.1.3 Safe conditions for de-escalation (Price & Baker, 2008:314) 
Determine the level of support which might be required 
Determine the presence of weapons or potential weapons 
Be aware of exits for staff to leave the area safely 
If possible move the patient to a quieter area or remove fellow patients to a safer area. 
4.6.2 De-escalation (Price & Baker, 2008:315) 
Find out what caused the patient to feel the way he/she does. 
Find out their immediate need and what can be done to solve the problem 
Avoid sanctions or threats or entering into power struggles, the making of threats will immediately 
lead to resistance and it will worsen the situation 
Do not make unreasonable concessions or appear to be uncompromising 
4.6.2. 1 Facilitate expression (Price & Baker, 2008:315) 
The patient should be allowed to communicate his/her feelings without being judged, the patient 
must be left with the perception you understand his/her pain and that you are there to assist. In 
order for a patient to be able to express how he feels he must be able to monitor their own actions 
(Geen & Donnerstein , 1998:Loc. 2022), failure will ultimately lead to loss of self-control and the 
display of aggression. This failure can be caused by delusional states, being under the influence of 
some or other substance, de-individuation as seen when one loses one's own identity in a group 
such as a gang or lack of strength such as when admitted against your own wishes, which leads to 
emotional distress as explained by Geen and Donnerstein (1998:Loc. 2028) 
Give alternatives to the expression of anger 
Acquiescence is expected from MHCU, this is however not very reasonable as adults we are 
supposed to be self-deterministic and not overwhelmed by our situation, the mental health care 
user who feels overwhelmed might be resolved to a fight or flight reaction determined by his 
circumstances if there are no alternatives posed to him/her. Provide options the patient must feel 
they have a certain amount of control even if the options are limited, such as which staff member 
they want to talk to, where they want the injection administered buttock or arm. 
Use distraction techniques this is especially helpful in the person with a cognitive disorder, a person 
under the influence of alcohol or in children with intellectual disorders (Gallagher & Parrott 
2011 :326). Through the use of this technique you can maneuver the client away from the person or 
the situation that resulted in his feelings of anger in the first place. 
If a person becomes violent it is often necessary to use a firmer approach and to limit their 
behaviour, in such instances it is often necessary to take a person to a safer area in order to 
administer medication after which de-escalation would continue, where there are other patients 
260 
present it is often more feasible to remove the "spectators" and have them leave the area. This will 
buy some time and give the patient the opportunity to possibly think about his feelings and re-
contemplate his actions i.e. calm down without any intervention necessary from the staff members. 
4.7 Break away techniques 
Break away techniques are used when a care provider is attacked by a patient, the use of these 
techniques will allow the nurse to escape the attack from the patient without injury to herself or the 
patient and to obtain the necessary help from colleagues 
The important point to remember is that there are different techniques to be used for different types 
of attacks. 
The focus of break-away techniques is to always focus on safety without harm to the patient. The 
element of surprise is the principle to be applied where the patient will not be able to anticipate the 
nurse's reaction. 
Types of attacks most frequently occurring 
• Bite 
• Hair grab 
• Hold arm with one hand 
• Hold arm with two hands 
• Bear hug (Full Nelson) 
• Strangle hold from the front using two hands 
• Strangle hold from behind using two hands 
• Strangle hold from behind using the arm 
4.7.1 General principles to keep in mind when using break away techniques 
• Never pull away from a hold or bite, this will result in more injury, moving in towards the patient 
always comes as a surprise as the patient would normally expect the nurse to attempt to pull 
away. Pulling away is usually the normal behaviour in humans. 
• The thumbs on the human hands are the weakest points and easiest digit to break free from . 
• Once you break free, run and get help. 
Applying the techniques will be practiced and demonstrated during physical 
demonstrations. 
4.7.2 Break-away techniques to apply when in the following situations 
4. 7.2. 1 Bites 
• Push the area being bitten towards the patient's mouth and push with you finger of the free 
hand hard into the buchal area where the joint of the jaw is. This pressure point will trigger an 
automatic response in the form of the opening of the jaw of the person biting. 
261 
• Alternately use the side of your first two fingers push onto the upper lip and vibrate hard 
against the area where the septum joins the upper jaw this will cause a parasympathetic 
response forcing the patient to release the bit hold 
3. 7.2.2 Hair grab from behind 
• Grab a hold of patient's wrist with both your hands 
• Pull patient's hands towards your skull this will relieve the pulling on your hair. 
• Step backwards towards the patient 
• Quickly bend knees move downwards with whole body while holding on to arms 
• Twist your body away (outwards) from the patient (downwards and outwards) 
• If hold breaks get out of the way 
4.7.2.3 Hair grab from the front 
• Grab a hold of patient's wrist with both hands 
• Push patients hands towards your skull 
• Step towards the patient 
• Turn your body inwards while holding onto the patient's arm forcing your outside elbow over 
the arm with which the patient is pulling your hair. 
• This will force the patient's body downwards and rotate his arm outwards which will result in a 
release of the hold on your hair. 
• If the hold breaks get out of the way 
4. 7.2.4 A hold on your wrist with the patient holding your right wrist with his left hand or your left 
hand with his right hand 
• Notice where the patient's thumb is as this is the weakest point on the human hand 
• Make the hand on your arm being hold into a tight fist. 
• Place your free hand over your own fist (to help with extra leverage and strength) 
• If the thumb of the hand with which the patient is holding is uppermost you must step in 
towards the patient and pull the arm being hold upwards with a sudden sharp movement out of 
the hold. 
• As the patient releases move away 
4. 7.2.5 Wrist-hold when the patient is using both hands 
• Notice where the patient's thumbs are as these are the weakest points on the human hands. 
• Make the hand on your arm being hold into a tight fist. 
• Place your free hand over your own fist (to help with extra leverage and strength) in this case 
your free hand and arm will grab your own fist on the am which is being held (over the arms in 
the middle between the hands of the patient.) 
• Step in towards the patient and pull the arm being hold upwards with a sudden sharp 
movement out of the hold. 
• As the patient releases move away 
262 
4. 7.2.6 Bear Hug from behind 
The patient will expect the nurse to lean forward to attempt to break free . 
The surprise element here is to catch the patient off guard. (Children use this technique very 
effectively when they do not want their parents to dress them.) They simply go limp. 
The technique works best when the person being held takes a deep breath and then simply 
suddenly leans backwards, throw their arms up in the air, go limp and literally falls backwards and 
slips down against the patient. Often this might knock the patient off balance and gives the nurse 
time to escape and call for help. 
4. 7.2. 7 Strangle-hold from the front with the patient using two hands 
All strangle holds are extremely dangerous in the sense that it might be lethal and therefore justifies 
the use of some force. Additionally it requires protection of the trachea so that a degree of airway 
can be maintained. 
• To maintain a patent airway, push your jaw down as far as possible 
• Clasp your hands together in-front of your body as though you are holding an axe. 
• With as much force and speed as you can muster swing your arms with the clenched hands 
upwards and outwards while giving one step towards the patient. 
• As you swing your arms through the arms of the patient the force you use should break the 
hold on your neck. 
• Run away and immediately get help. 
• If you do not succeed in breaking the hold at a first attempt especially if you are a female being 
held by a male. You can use the heel of your hand and with a sudden upwards thrust Y?U can 
punch the person on the nose. This is extremely painful but very successful in releasing a grip 
on a neck. It will temporarily put a person out of action long enough to allow the nurse to run 
and get help. 
4. 7.2.8 Strangle-hold from behind using two hands 
• Push your jaw down notice where the thumbs are. 
• Grab a hold of both of the patient's pinkies and pull the pinkies outwards towards the patient 
this will also break the hold. 
• As the patient releases move away 
4. 7.2.9 Strangle-hold from behind using the arm 
• Push down with your chin to try and maintain a patent airway. 
• Notice which arm the patient is using 
• Make a fist with your hand on the same side as the arm the patient is using. 
• Grab your own fist with the other hand (this will give you more strength) 
• In one motion extend the fisted arm forward and jab back with your elbow hitting into the solar 
plexus of the patient holding you 
263 
• As the patient releases move away and get help 
IN All INSTANCES WHERE YOU WERE COMPELLED TO USE JUSTIFIABLE 
FORCE REPORT AND DOCUMENT THIS AND WHERE NECESSARY HAVE THE 
PA TJENT EXAMINED BY A MEDICAL PRACTITIONER FOR POSSIBLE 
4.8 SAFE RESTRAINING TECHNIQUES 
Different authors have pointed out that the use of chemical and physical restraint and even 
seclusion often leads to more violence and injuries CWynn , Kvalvik & Hunnekleiv, 201 1:133), yet 
there is a definite place for such measures if a person is extremely violent and poses a danger to 
self and others. 
4.8.1 Dangerous Techniques 
Basket holds restraint/hobble tying as this can lead to asphyxiation . 
Restraint on a soft surface a person can asphyxiate in this position especially if the face is forced 
into a soft mattress. 
Face down prone position any pressure on the back will restrict breathing and cause asphyxiation. 
Pressure on the chest, abdomen restricts movement of the diaphragm necessary for breathing. 
Pressure on the neck area can lead to asphyxiation or over the carotid area can lead to arrhythmia 
and death. 
Kneeling position with his knees on the floor torso lying face down across a bed restricts movement 
of the diaphragm and can also lead to traumatic asphyxiation. 
264 
Take extra caution in the following patients 
• Obese patients 
• Cardiac problems 
• Asthmatics 
• Sedation with phenothiazines and benzodiazepines 
4.8.2 Safe Technique in Restraining 
3 to 5 people is required for safe restraining 
One person will be the team leader, this is the person who will communicate with the patient and 
give the cue to the rest of the team that they will move in to restrain the patient. 
This person will use a towel to throw towards the patient's face to elicit the reflex whereby the 
patient will raise his arms to ward off the towel flying in towards his face. 
The next two persons in the team will make a grab for the patient's arms. Grab the arm by the 
wrist (While facing the patient) curr your arm closest to the body of the patient under his axilla and 
pull the patient close to you while pushing on the wrist with the arm extended. As per photo below. 
265 
Photo 3.1 
In this position place your leg behind that of the patient. You will now have the patient in an off 
balance position walk forward and gently put the patient down on the floor on his back. As seen in 
the next photo. 
Photo 3.2 
Immobilize arms with pressure on shoulder joint and extension of the arm holding the wrist down. In 
this position it is difficult for the patient to attempt to bite the staff member, the worst this person can 
do is spit at the staff. 
Photo 3.3 
266 
The third and fourth persons will: 
Immobilize the legs with restraint over the ankle or by sitting astride the leg and maintaining 
pressure over the area just above the knee joint. In this position the person cannot flex the knee to 
execute a kick. One or two persons can do this i.e. either one person over either the patient's legs; 
or one person per leg of the patient. See picture underneath 
Photo 3.4 
The leader will administer sedation in either the deltoid or in the leg. Do not attempt to turn the 
patient on his side to administer in the buttock as this will contribute to injuries of either the patient 
or the staff. 
In this restraint position there is no pressure anywhere on the chest or the thorax of the 
patient to compromise breathing and it will therefore eliminate the risk of asphyxia 
The leader will administer sedation in either the deltoid or in the leg. Do not attempt to turn the 
patient on his side to administer in the buttock as this will contribute to injuries of either the patient 
or the staff. 
5. CULTURAL SENSITIVITY, AWARENESS AND SAFETY 
Culture according to Leininger as cited in George (2002:491) defines the way in which a person 
perceives care, and they will relate these experiences to their general health belief and practices. 
"An understanding of culture is essential for competent nursing care as culture is interwoven 
throughout health care" (Lancellotti 2007: 180). The Nurse must be able to get to know the client 
within the context of his or her culture Lancellotti 2007: 180 refers to this as what researchers term 
the "Stranger to Trusted Friend Enabler'' This allows the nurse to value and respect similarities and 
differences. 
267 
Lancelotti (2007: 181) confirms that this movement can only start when the nurse develops 
consciousness (awareness) and take action. One such observation is highlighted by Geen and 
Donnerstein (1998: Loe. 2080), where the authors point out that culture and socialization 
determines lines beyond which internal restraint against aggression is set aside and what the 
extend thereof is, therefore people learn from their culture at which point it is acceptable and even 
expected to become violent. 
Therefore the author can safely say culture will determine at which point it is acceptable to become 
aggressive and it is imperative that therapists therefore understand the cultural background of a 
client. 
• There is also some evidence that Black patients may be managed differently by nursing staff 
when involved in an 'untoward incident' as quoted by Gudjonsson, et al. (2004:259). 
• James et al 2011 : 131) reports that nurses often show stigmatization and discriminatory 
dispositions towards the mentally ill. The researcher views the mentally ill as a sub culture in 
health care and is therefore of the opinion that this sub-cultural grouping needs nursing care 
which is culturally aware and sensitive. 
• Health care professionals often view the psychiatrically ill as more prone to violence, 
malevolent and unpredictable according to James et al. (2011 : 131 ). 
• Culture is universal. It is also diverse, as Leininger (1991 , 1995a, 1995b, 1997) refers culture to 
the specific pattern of behaviour which distinguishes any society from others. 
• care (caring) is essential to curing and healing, for there can be no curing without caring 
• every human culture has lay (generic, folk or indigenous) care knowledge and practices and 
usually some professional care knowledge and practices, which vary transculturally 
• Culture care values, beliefs, and practices are influenced by and tend to be embedded in the 
worldview, language, philosophy, religion (and spirituality), kinship, social, political, legal, 
educational , economic, technological ethno-historical , and environmental contexts of cultures. 
• a client who experiences nursing care that fails to be reasonably congruent with his/her beliefs, 
values, and caring life ways will show signs of cultural conflict, noncompliance, stress and 
ethical or moral concern 
• Culturally based care if fully known can greatly advance nursing knowledge (Leininger 
2001 :38) 
• Prejudice is explained by Lancellotti (2007: 179) to dehumanize people and deny them their 
individuality. This can be seen in the application of a one cure fits all approach when managing 
aggression and violence by means of traditional western based methods. 
5.1 Cultural safety 
Fulcher (2002:689) refers to cultural safety as the acknowledgement of and attendance to a 
person's needs to according to their cultural frame of reference even if it is not fully understood. 
Fuller (2002:699) further points out that Indigenous people (referring to Maori 's in Nieu Zealand) 
have often been subjected to "cultural racism" in the allocation of health and social services. This 
often happens unintentionally when health services makes assumptions or places as example 
WBKS's superior to Indigenous Knowledge systems, and renders care without full consideration of 
the IKS of a person from a different cultural background. 
268 
Ramsden and Papps (1996: 491) defines cultural safety as "The effective nursing of a person 
from another culture by a nurse who has undertaken a process of reflection on own cultural 
identity and recognises the impact of the nurse's culture on own nursing practice." Cultural safety 
also implies that the nurse will care for a patient taking cognizance of those things which makes a 
patient unique according to Ramsden and Papps (1996:493). 
In order for the nurse to recognise the individuality of her patient she/he must however be aware 
of her own reality and attitude which she/he brings to the practice. 
Ramsden & Papps (1996:493) identify safety as the competent practice a nurse practices in order 
to prevent risk and harm to the patient, this includes physical , mental, social, spiritual and cultural 
components of the clienUpatient relationship. With this in mind it reinforces the idea of the 
researcher that the traditional western based methods of managing violence and aggression as a 
one cure fits all approach does not guarantee cultural safe practices to all MHCU. 
6. CONCLUSION 
The management of aggression and violence is extremely difficult to do however the researcher 
concurs with Fluttert et al. (2008:215) , namely that well trained nursing staff should have the ability 
to detect the very subtle signs of imminent aggression and instability and that they should have the 
necessary skill to turn these warning signs favourably to the therapeutic advantage of the patient. 
269 
LIST OF SOURCES 
Bock, T.M. 2010. Assessment of attitudes related to the management of aggression and violence in four 
psychiatric hospitals, Unpublished MCur thesis. Tygerberg: Stellenbosch University. 
Bock, T.M, Pienaar, A.J . 2013. Management of aggressive and violent mental health care users. (In Pienaar, 
A. , ed. 2013. Mental health care in Africa: A practical, evidence based approach. Pretoria: Van Schaik 
Publishers. P. 105-115). 
Delaney, K.R. & Johnson, M.E. 2007. Keeping the unit safe: the anatomy of escalation. Journal of the 
American Psychiatric Nurses Association. 13(1):24. 
Duxbury, J. 2002. An evaluation of staff and patient views of and strategies employed to manage inpatient 
aggression and violence on one mental health unit: a pluralistic design. Journal of Psychiatric and Mental 
health Nursing, 9:325-337. 
Duxbury, J. & Whittington, R. 2005. Causes and management of patient aggression and violence: staff and 
patient perspectives. Journal of Advanced nursing, 50(5) 469-478. 
Gallagher, K.E. & Parrott, D.J. 2011. Does distraction reduce the alcohol-aggression relation? A cognitive 
and behavioral test of the attention- allocation model. American Psychological Association. 79 (3): 319-329. 
Geen, R.G. and Donnerstein, E. eds. 1998. Human aggression: Theories, research , and implications for 
social policy [Kindle ed.]. Available: http://www.amazon.com 
Goetz & Huckshorn, 2003. Creating Violence Free and Coercion Free Service Environments for the 
Reduction of Seclusion and Restraint: Presenting a U.S. Initiative: Debriefing Activities A Core Strategy© A 
Tertiary Prevention Tool. 
http://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=OCEIQFjAD&url=http%3A%2F 
%2Fwww.hogg.utexas.edu%2Fuploads%2Fdocuments%2Fdebrief_activities.ppt&ei=Tb9TU7PxL8Gl7Aav8ID 
IDA&usg=AFQjCNHlzVknKvt55U9L7eOwdzmowJ4E2w Accessed 20 April 2014 [PowerPoint presentation] . 
10 
270 
ANNEXURE 3 
Permission to use the MAVAS questionnaire 
Happy to help Teresa 
There are two versions - you may have a preference for layout but the content is the same. 
My permission is granted subject to you citing me in any papers/docs you produce. If you ever would like to 
share your data to do some comparisons that would also be helpful but not a requirement. 
Kind regards 
Good luck 
Joy 
Dr Joy A Duxbury 
Reader in Mental Health Nursing 
Divisional Leader for Mental Health 
Tel: 01772 895110 
JDuxbury@uclan .ac.uk 
»> "Teresa Bock" <Terebock@pgwc.gov.za> 2/25/2010 6:56 pm»> 
** High Priority ** 
Dear Dr Duxbury 
My name is Theresa Bock; I am a registered Psychiatric Nurse working in Stikland hospital (a Psychiatric 
hospital near Cape Town in South Africa). I have been employed as a registered psychiatric Nurse for 24 
years. 
I am currently registered as a PhD candidate with the North-West University in the North-West province of 
South Africa. I have submitted a research proposal to Stellenbosch University titled : "The effectiveness of 
policy implementation as strategy to manage Mental Health Care User related aggression. 
I am proposing a quantitative study with an experimental group and a control group with a post-test only 
design. I intended to draw up a questionnaire to test if the policy and guidelines (in the form of a training 
course outlining theories with regards to aggression, calming strategies, break away techniques and 
restraining techniques) have changed the perception and attitudes of staff with regards to aggressive mental 
health care users. My supervisor Dr Abel Pienaar however advised that I make use of existing 
questionnaires. 
271 
I have read through your research titled "The Management of Aggression and Violence Attitude Scale 
(MAVAS): a cross-national comparative study" Published 23 January 2008. The scale you designed would 
suit the purpose of my study. 
I herewith request your official permission to use your scale. Acknowledgement of use thereof will be done 
according to the University Stellenbosch plagiarism policy. If permission is granted could you kindly indicate 
any other information required prior to the use of your scale. 
The situation in the Psychiatric Hospitals in the Western Cape: South Africa is a cause of great concern with 
regards to staff and occasionally patient related injuries due to aggression and violence and a lack of policies 
and guidelines directing staff in the management of aggression and violence. 
Subsequently I am currently in the process of designing a training programme for which we will obtain 
continuous professional development accreditation; furthermore I am part of a team of psychiatrists and 
managers trying to influence the development of Provincial Policy that would make attendance of this course 
and bi-annual updates compulsory for all staff dealing with MHCU and all other potential violent patients. 
Through my proposed research I wish to determine the efficacy of the proposed training programme and 
where possible make the necessary changes to the proposed programme after analysis of the data collected. 
I have developed a keen interest in the phenomenon of aggression as I have witnessed several occasions 
where it was my perception that incidences of aggression was either caused by the way a client was 
managed by staff or due to environmental factors that must definitely be adapted. 
I am an admirer of your work. 
Yours faithfully 
Theresa M Bock 
Head of Campus 
Metro East Campus of the Western Cape College of Nursing 
Tel 021 940 4567 
Fax 021 940 4543 
T erebock@pgwc.gov.za 
"A love affair with knowledge will never end in heartbreak." 
272 
ANNEXURE 4 
QUESTIONNAIRE ON THE MANAGEMENT OF MENTAL 
HEALTH CARE USER RELATED AGGRESSION. 
NB Participation in this research project is anonymous and voluntary. 
Findings of the research project will be made available to the four psychiatric hospitals 
included in the study; no hospital name shall be mentioned. 
Highest level of education Tick off ✓ 
Current rank Auxiliary Nurse 
Enrolled Nurse 
Registered Nurse 
Registered Psychiatric Nurse 
Registered Advanced Psychiatric Nurse 
Other 
I Male I Female I I Yes I No I 
Gender Tick off ✓ Have you received 
training with regards to the 
management of patient related 
aggression? 
Tick off relevant experience in years working in a psychiatric Unit with a ✓ 
Less than 1 year 1 to 5 years 6 to 10 years 11 to 15 years 
16 to 20 years 21 to 25 years 26 to 30 years More than 30 years 
273 
The Management of Aggression and Violence Attitude Scale (MAVAS) 
► The purpose of this questionnaire is to obtain your perceptions of aggression and the management of 
aggression at this facility. 
► For each item, please darken the circle that reflects your opinion about the statement. If you wish to 
change your rating , place an X completely through the circle and then darken another circle. 
Strongly Agree Disagree Strongly 
Disagree 
Agree 
1 Patients are aggressive because of the environment 0 0 0 0 
they are in. 
2 Other people make patients aggressive or violent. 0 0 0 0 
3 Patients commonly become aggressive because staff 0 0 0 0 
does not listen to them. 
4 It is difficult to prevent patients from becoming violent or 0 0 0 0 
aggressive. 
5 Patients are aggressive because they are ill. 0 0 0 0 
6 Poor communication between staff and patients leads 0 0 0 0 
to patient aggression. 
7 There appear to be types of patients who frequently 0 0 0 0 
become aggressive towards staff. 
8 Different approaches are used on this ward to manage 0 0 0 0 
patient aggression and violence. 
9. Patients who are aggressive towards staff should try to 0 0 0 0 
control their feelings. 
10 When a patient is violent, seclusion is one of the most 0 0 0 0 
effective approaches to use. 
11 Patients who are violent are often physically restrained 0 0 0 0 
to administer sedation. 
274 
Strongly Agree Disagree Strongly 
Disagree 
Agree 
12 The practice of secluding violent patients should be 0 0 0 0 
discontinued. 
13 Medication is a valuable approach for treating 0 0 0 0 
aggressive and violent behaviour. 
14 Aggressive patients will calm down automatically if left 0 0 0 0 
alone. 
15 The use of negotiation could be used more effectively 0 0 0 0 
when managing aggression and violence. 
16 Restrictive care environments can contribute towards 0 0 0 0 
patient aggression and violence. 
17 Expressions of aggression do not always require staff 0 0 0 0 
intervention. 
18 Physical restraint is sometimes used more than 0 0 0 0 
necessary. 
19 Alternatives to the use of containment and sedation to 0 0 0 0 
manage patient violence could be used more 
frequently. 
20 Improved one to one relationships between staff and 0 0 0 0 
patients can reduce the incidence of patient aggression 
and violence. 
21 Patient aggression could be handled more effectively 0 0 0 0 
on this ward. 
22 Prescribed medication can in some instances lead to 0 0 0 0 
patient aggression and violence. 
23 It is largely situations that contribute towards the 0 0 0 0 
expression of aggression by patients. 
24 Seclusion is sometimes used more than necessary. 0 0 0 0 
25 Prescribed medication should be used more frequently 0 0 0 0 
to help patients who are aggressive and violent. 
26 The use of de-escalation is successful in preventing 0 0 0 0 
violence 
275 
Strongly Agree Disagree Strongly 
Disagree 
Agree 
27 If the physical environment were different, patients 0 0 0 0 
would be less aggressive. 
Thank you for your participation in this research project. 
276 
ANNEXURE 5 
lntercultural Sensitivity Scale 
lntercultural Sensitivity Scale 
Below is a series of statements concerning intercultural communication. There are no right or wrong 
answers. Please work quickly and record your first impression by indicating the degree to which you 
agree or disagree with the statement. Thank you for your cooperation. 
G) 
.G..)  
C) 
<( 
C 
.2:- G) >-
C) G) I!! ~ 'E, 
C G) C) 
G) C 
-.0..
 G) 
  g nl Gu ...)  II) C) .0..  C 
.I..I.)  .!? =c 
:, <..,(.  u-, "C N C"') It) 
1 I enjoy interacting with people from different cultures. 
2 I think people from other cultures are narrow-minded. 
3 I am pretty sure of myself in interacting with people from 
different cultures. 
4 I find it very hard to talk in front of people from different 
cultures. 
5 I always know what to say when interacting with people from 
different cultures. 
6 I can be as sociable as I want to be when interacting with 
people from different cultures. 
7 I don't like to be with people from different cultures. 
8 I respect the values of people from different cultures. 
9 I get upset easily when interacting with people from different 
cultures. 
10 I feel confident when interacting with people from different 
cultures. 
11 I tend to wait before forming an impression of culturally-distinct 
counterparts. 
12 I often get discouraged when I am with people from different 
cultures. 
277 
13 I am open-minded to people from different cultures. 
14 I am very observant when interacting with people from different 
cultures. 
15 I often feel useless when interacting with people from different 
cultures. 
16 I respect the ways people from different cultures behave. 
17 I try to obtain as much information as I can when interacting 
with people from different cultures. 
18 I would not accept the opinions of people from different 
cultures. 
19 I am sensitive to my culturally-distinct counterpart's subtle 
meanings during our interaction. 
20 I think my culture is better than other cultures. 
21 I often give positive responses to my culturally-different 
counterpart during our interaction 
22 I avoid those situations where I will have to deal with culturally-
distinct persons. 
23 I often show my culturally-distinct counterpart my understanding 
through verbal or nonverbal cues. 
24 I have a feeling of enjoyment towards differences between my 
culturally-distinct counterpart and me. 
Chen and Starosta (2000) first developed an instrument to explore the concept of intercultural sensitivity 
278 
ANNEXURE 6 
PARTICIPANT INFORMATION LEAFLET AND CONSENT FORM 
TITLE OF THE RESEARCH PROJECT: "Culturally safe management of aggression and violence in mental 
health care institutions." 
REFERENCE NUMBER: NWU-00051-13-S1 
PRINCIPAL INVESTIGATOR: Theresa Melodie Bock 
ADDRESS: 89 Joubert Street, Joubert Park, Bellville 
CONTACT NUMBER: 0836027097 
You are being invited to take part in a research project. Please take some time to read the information 
presented here, which will explain the details of this project. Please ask the study staff any questions about 
any part of this project which you do not fully understand. It is very important that you are fully satisfied that 
you clearly understand what this research entails, and how you would be involved. Also note that your 
participation is entirely voluntary and that you are free to decline to participate. If you say no, this will not 
affect you negatively in any manner whatsoever. You are also free to withdraw from the study at any point, 
even if you agreed to take part. 
This study has been approved by the Health Research Ethics Committee at North West University and will be 
conducted according to the ethical guidelines and principals of the international Declaration of Helsinki, South 
African Guidelines for Good Clinical Practice and the Medical Research Council (MRC) Ethical Guidelines for 
Research. 
What is this research study all about? 
The study will be conducted in four randomly selected hospitals located in South Africa and Lesotho. 
The Acute admission units of the hospital where you are employed have been selected, as 
aggression and violence is higher in acute admission units as opposed to long term units. This study 
will include all staff of the multi-disciplinary team in the acute admission unit. 
This research study will describe the attitudes of the staff towards the management of aggression 
and violence, the cultural awareness and sensitivity, by asking you to complete a questionnaire. 
If you are randomly selected to undergo training in the management of aggression and violence you 
will be invited to attend a training course. 
After the training course was presented the researcher will provide you with a similar questionnaire 
as the one completed previously. 
The answers on the two questionnaires will be compared in order for the researcher to determine 
how effective the training course presented and attended was. 
All research participants will be provided with this letter and a consent form to be completed prior to 
their participation in this research project. 
Once the consent form has been completed the research participant will place it in a sealed 
envelope. The participation is entirely voluntary and anonymous. The participant will place both the 
questionnaire and the consent form in different boxes provided by the researcher, so that 
questionnaires and consent forms cannot be linked with each other. No names or hospital names will 
be attached to the questionnaires. 
Why have you specifically been invited to take part in this research project? 
As a nurse you are employed and are working in a mental health care institution, where you are 
exposed to MHCU with often aggressive behaviour. Your perception of how we are managing these 
patients, are very important and you can provide valuable input into suggestions on how to empower 
staff to deal with these patients. 
279 
What will your responsibilities be? 
You will be requested to complete a consent form and a questionnaire to be completed and placed in 
the boxes marked "consent" and "questionnaire" as provided by the researcher. 
You will then be invited to attend training on the management of aggression and violence 
After the course you will be given a final questionnaire to complete and place in the boxes a 
described above. 
Will you benefit from taking part in this research? 
The data collected during this research will be used to develop a curriculum to assist staff to manage 
aggression and violence as associated with MHCU , in a culturally safe manner. Therefore your 
participation will benefit you and your colleagues and future mental health care nurses. 
Are there any risks involved in taking part in this research project? 
No risks have been identified for this project. However if you should feel discomfort when answering 
the questionnaire due to recollection of an event where you possibly were the victim of aggression 
and violence, the researcher encourages you to phone her at 021 940 4567 or 083 6027 097 and she 
will arrange a formal referral to your employee wellness programme ICAS, where you can speak to a 
qualified therapist about any unresolved trauma. 
If you do not agree to take part, what alternatives do you have? 
Your participation is entirely voluntary, if you select not to participate you will not be penalised in any 
manner. 
Will you be paid to participate in this research project? 
No, you will not be paid to take part, nor will you incur any cost. The training received is entirely free. 
Is there anything else you should do or know? 
You can contact the NWU Health Research Ethics committee at 018 299 1111/2222 and the Faculty 
of Health Sciences at 018 299 2092. 
You will receive a copy of this Information leaflet and consent form for your own records. 
DECLARATION BY THE PARTICIPANT 
By signing below, I 
. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Agree to take 
part in this research study entitled, "Culturally safe management of aggression and violence in mental health 
care institutions" 
I declare that: 
I have read or had read to me the information and consent for, and it is written in a language with 
which I am fluent and comfortable 
I have had a chance to ask questions and all my questions have been adequately answered 
I understand that taking part in this study is voluntary and I have not been pressured to take part 
I may choose to leave the study at any time and will not be penalised or prejudiced in any way. 
I may be asked to leave the study before it has finished , if the researcher feels it is in my best 
interest. 
Signed at (place) ......... .. .. ... .. ... .. ................. On (date) ..... . ... ........ . ... .. ... . ... ......... . 
Signature of participant Witness .... .... . ... ... ..... .. .. . 
DECLARATION BY THE RESEARCHER 
280 
I Theresa Melodie Bock declare that: 
I explained the information in this document to the participant 
I encouraged the participant to ask questions and took adequate time to answer them 
I am satisfied that the participant adequately understands all aspects of the research , as discussed 
above. 
I did/did not, use an interpreter. (If an interpreter is use the interpreter will sign the declaration below) 
Signed at (place) ...... .. ... . ...... ........ . ...... ... ...... . On (date) ....... .. ... .. .. .. ... .... ...... .. / 
Signature of researcher ........ .. .. ... ... .. ..... ... .. ...... Witness ... ... .. . .. . ... ..... . ... .. . 
DECLARATION BY THE INTERPRETER 
I, .... .. ....... ..... ... ......... ..... ...... ... . ... .. . ..... . ..... . ... ... declare that: 
• I assisted the researcher Theresa Melodie Bock to explain the information in this document to the 
participant using the language medium of 
We encouraged the participant to ask questions and took time to answer them 
I conveyed a factually correct version of what was related to me 
I am satisfied that the participant fully understands the content of this informed consent document 
and has had all his/her questions answered. 
Signed at (place) ....... ........ .. ... ... . .. . .. ... . ..... . .. . .. On (date) ... .. .. ....... .. ..... ... ... ... .... ........ ..  
Signature of interpreter ....... ... .. ... ....... ........ .. .. ...... .. Witness ........ . ... ..... .. ...... . .... ... .. .. . .. . 
281 
ANNEXURE 7 
Ethical clearance for study from NWU 
e~ Y"U"NI™BESITI ~YA "BO-K~ONE"-B'O PHIRIM•A  NOORIM'l:5-UNIVERSITEIT POTCHEFSTROOM CAMPUS 
Private Bag X6001 , Potchefstroom 
South Al(,ca 2520 
Tel: 018299-1111/2222 
Web: httpJiwww.nwu.ac.,a 
To whom it may concern Faculty of ~alt h Sciences 
Tel: 018 2992092 
Fax: 018 2992088 
Email: Mirvie.Greeff@nwu.ac.za 
5 Aupust 2013 
Dear Prof. Pienaar 
Ethics Application: NWU-00051-13-S1 "Culturally safe management of 
aggression and violence in mental health care institutions" 
All ethical concerns have been addressed and ethical approval is recommended. 
y~c::~J 
L_ 
Prof. Minrie Gre~ • 
Ethics Sub-com;;J;ittee Vice Chairperson 
Ori9-"UI ~ : Ptof. Minne Gt9eff{t01 173M) ~ \1Jse,s\1321 057~tot,\ETIEK\2013 ETHICSVM'\J-00051.1J-S1c,docm 
10Jo:y 2:J13 
File refcrent,t-: NW1J-00051·13·S1 
282 
ANNEXURE 8 
Permissions from the respective health care institutions and 
provinces 
DEPARTMENT OF H E A LTH Department of Health 
Private Bug XS049 
LEFAPHA LA BOITEKAN ELO 
KIMBERLE Y 
ISEBE LEZEMPILO 8301 
DEPARTEMENT VAN GESONDH E ID 
Enqulrio• Df'l@ 
OipollieltlO Lallh• 
lmlbuZo Dr. E shetu Worku Umhl11 18June 2 015 
N ev,.. . Datum 
Roforenoo 
Tsh up,nlo Tel : 053 830 2122 
li.olathis.o 
Vorwy&l'1Q6 · Fax: 086 541 7122 
Ms. T M Bock 
Western Cupe College of Nursing 
Metro East Campus 
/ 0 Stiklond de lo Haye Road 
Bellville 
Dear Ms. TM Bock 
TITLE: Cultunolly safe management of aggre,sslon and violence in ment.a l health care 
Iustlt:utions. 
Reference Number: NC2015/0016 
The application to conduct the stud was received a.nd has been re viewed by th e Provincial 
Health Research and Ethics Committee (PHREC) 
Approval is hereby granted to conduc t the above-me1tt·joned study in the Northern Cape 
Province 
Ple~·e note: Tl,i~· approval is vt1lid for II period of 0 11e ye,:zrf roni tit~ date of approval. 
The following conditions have to be noted: 
l . The res earch project sha ll be conducted at no cost to the Northern Cape Department of 
Health. 
2. The approval is limited to the research proposal a s submitted in the application, 
3, Variation or m o dification on the research must be notified formally t~~ PHR :BC for 
further consideration. 
4. The PHREC may monitor the project at any t ime. A 
W9 are co1nmltt8d to &chisvlnr, our vision through 6 docentra/fzed, oc.,-cot,mlubl@, occenssibto ,ind const-onlly lmp,o.A, ,{J noolt'1 Cllffl 
systom w ithin tJvailsble rosourooa. Our c1.11rinf}, multl-sklllod. eff&e/lve f)6rsonnef will usB ovldonco-.bnsod, lnlorn,atlve ht>alth c/Jro 
and maturing parm<1rstups for tno bonofit or our chonts 11nd pntlont&. 
283 
Dear Mr. Mayo 
With reference to my telephone calls on Friday 2015/25 and today I requested Mme Nkwenza to provide me 
with the necessary e-mail address to submit substantiating documents to you. I have the necessary 
permission from Dr Worku and ethical clearance e from both the North West province and the North West 
University please find attached. 
I would love to come and present the training course on the management of aggression and violence at your 
facility on 10 September and administer a pre and post test to determine the efficacy of the training 
programme. 
The training programme is free of charge with no cost to the institution. The target population would be the 
Multidisciplinary staff working with MHCU. Participation is voluntary. I have rolled out th is training in all four 
hospitals in the Western Cape and we present this on a continuous basis, participant In the Western Cape 
vary from security officers to all categories of nursing staff. Psychologists and doctors. 
I will guarantee the anonymity of the staff and the hospital. 
I would only require a venue to present the training course. 
Included in the training is the following: 
1. Understanding aggression 
2. De-escalation techniques 
3. Dignified break away techniques 
4. Safe restraining 
5. Cultural sensitivity 
I would appreciate your feedback. 
Yours faithfully 
"A marriage with Knowledge will never end in heartbreak." 
Theresa M Bock 
Head of Campus/Deputy Director 
Western Cape College of Nursing: Metro East 
Western Cape government 
Address: CO Stikland Hospital, De La Haye Road, Bellville 
Tel 021 940 4567 
Cell: 0836027097 
e-mail Theresa.Bock@westerncape.gov.za 
284 
health and 
social development' 
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285 
Thank you Mr Shuping and Theresa. 
Mr Jimmy Mapunya 
Chief Executive Officer 
Sterkfontein Hospital 
Tel: 011951 8376tel:011951%208376 
Fax: 0866225261 tel :0866225261 
Email: Jimmy.Mapunya@gauteng.gov.za<mailto:Jimmy.Mapunya@gauteng.gov.za> 
------ Original message -----
From: Theresa Bock Theresa.Bock@westerncape.gov.za 
Date:31/07/2015 07:13 (GMT+02:00) 
To: "Shuping, Herbert (gphealth)" Herbert.Shuping@gauteng.gov.za 
Cc: Abel Pienaar <abel. pienaar@gmail.com>, Ugasvaree Subramaney 
<Ugasvaree.S ubramaney@wits.ac.za>, "Mapunya, Jimmy J. (GPHEALT H)" 
<Jimmy.Mapunya@gauteng.gov.za> 
Subject: RE: Training programme in the management of aggression and violence 
Dear Ntate Shupping 
Thank you very much for your prompt response. 
There need not be a fixed number of candidates I would love to have at least a minimum of 20 respondents if 
at all possible. 
Fortunately there are statistical methods available to accurately do inferential statistics should the numbers 
be smaller. 
I am indeed looking forward to meeting up with you. 
I respect your position in terms of security officers. The course normally starts at 09:00 until 15:00. 
Yours faithfully 
Theresa 
"A marriage with Knowledge will never end in heartbreak." 
Theresa M Bock 
Head of Campus/Deputy Director 
Western Cape College of Nursing: Metro East 
Western Cape government 
Address: CO Stikland Hospital, De La Haye Road, Bellville 
286 
Tel 021 940 4567 
Cell: 0836027097 
e-mail Theresa. Bock@westerncape.gov .za<mailto:T heresa.Bock@westerncape.gov .za > 
[cid:_com_android_email_attachmentprovider_ 1_5017_ RAW@sec.galaxytab] 
From: Shuping, Herbert (gphealth) [mailto:Herbert.Shuping@gauteng.gov.za] 
Sent: 31 July 2015 07:00 AM 
To: Theresa Bock 
Cc: Abel Pienaar; Ugasvaree Subramaney; Mapunya, Jimmy J. (GPHEAL TH) 
Subject: RE: Training programme in the management of aggression and violence 
Dear Theresa 
I confirm receiving your email , 8th September will be ok but let me know how many candidates you will be 
looking for your training also be aware that our security is not allowed to have contact with our MHCU and 
thus they will not be part of the training. Looking forward to see you. 
Kind regards 
Boitumelo Herbert Shuping 
Assistant Manager: Staff Development Nursing Department 
Sterkfontein Hospital 
Switchboard: +27 11 951 8000 Mobile: +27 82 502 1590 
Direct Line: +27 11 951 8344 E-Mail: 
herbert.shuping@gauteng.gov.za<mailto:herbert.shuping@gauteng.gov.za> 
Fax: +27 11 951 8391 
Address: Sterkfontein Psych Hospital, Sterkfontein Road, Krugersdorp 1739. 
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Department of Health and Social Development Back to Basics to Make Health and Social Services Work 
Better 
From: Theresa Bock [mailto:Theresa.Bock@westerncape.gov.za] 
Sent: 30 July 2015 10:46 AM 
To: Shuping, Herbert (gphealth) 
Cc: Abel Pienaar (abel.pienaar@gmail.com<mailto:abel.pienaar@gmail.com>) 
Subject: Training programme in the management of aggression and violence 
UID09duf63i2bd 
287 
Dear Mr Shuping 
I have tried phoning as advised by Dr Subramaney. 
I am a PhD student doing research on the culturally safe management of aggression and violence, my 
supervisor is Professor Abel Pienaar. I am presenting a one day training course on the management of 
aggression, dignified break away techniques, de-escalation techniques and safe restraining . Dr Subramaney 
advised me to contact you to make the necessary arrangements to present the course and administer the 
questionnaire. 
I would love to be able to come and collect data on 8 September, and would require a venue to present the 
training. The training is free of charge and staff and Hospital anonymity is guaranteed. 
The target population is typically the all members of multi-disciplinary team such as all categories of nursing 
staff, social workers, medical staff, and security staff who deal with the mental health care user. 
Please find attached my proof of ethical clearance and permission to use Sterkfontein hospital. 
Warm greetings from a very cold Cape Town 
Yours faithfully 
"A marriage with Knowledge will never end in heartbreak." 
Theresa M Bock 
Head of Campus/Deputy Director 
Western Cape College of Nursing: Metro East 
Western Cape government 
Address: CO Stikland Hospital, De La Haye Road, Bellville 
Tel 021 940 4567 
Cell : 0836027097 
e-mail Theresa. Bock@westerncape.gov .za<mailto:Theresa.Bock@westerncape .gov .za 
288 
DIRECTORATE: WESTERN CAPE COLLEGE OF 
Western Cape 
Government NURSING 
Health Terebock@pgwc.gov.za 
Enquiries: Ms T M Bock 
Gell 2826227227 
Date: 2014/09/03 
The CEO Sterkfontein Hospital 
RE: Request permission to present a training course on the management of 
aggression and violence at Sterkfontein Hospital 
Dear Sir 
I Theresa Melodie Bock am a student Registered at the North West University. I am a PhD 
Candidate doing research on the Culturally safe management of aggression and violence 
in Mental Health Care Institutions. 
I have received ethical clearance for this low risk study, which entails the presentation of a 
curriculum for the management of aggression and violence with a pre and post test to 
determine the efficacy of this programme. 
This programme is presented to staff in acute admission units. 
Please find attached the proposal and proof of the ethical clearance 
Sincerely 
Theresa M. Bock 
289 
·- health 
Department of 
Health 3801 FIISI Streel 
New Office Park 
North West Province 
• MAHIKENG, 2735 REPUBLIC OF SOVnt AFRICA 
POLICY, PLANNING, RESEARCH, MONITORING AND EVALUATION 
Name of researcher : Ms T.M Bock 
North West University 
Physical Address NCUJ : Mttrz.o &..n 
(Work/ Institution) lo S11Q(\N) 1-tvsP Sfilv1u£ 
tc:; Lrr ftf',..y e, rz.o . tetLV1L,i..6 1 -:rs30 I 
Subject : Research Approval Lette.r- Culturally safe management of 
aggression and violence In mental health care institutions. 
This letter serves to inform the Researcher that permission to undertake the above mentioned 
study has been granted by the North West Departmenl of Health. The Researcher is expected 
to arrange in advance with the chosen facilities. and issue this letter as proof that permission 
has been granted by the Provincial office. 
This letter of permission should be signed and a copy returned to the Department. By signing, 
the Researcher agrees, binds him/herself and undertakes to furnish the Department with an 
electronic copy of the final research report. Alternatively, the Researcher can also provide the 
Department with electronic summary highlighting recommendations that will assist the 
department in its planning lo improve some of its services where possible. Through this the 
Researcher will not only contribute to the academic body of knowledge but also contributes 
towards the bettering of health care services and thus the overall health of citizens in the North 
West Province. 
Kindest regards 
Date 
Heal thy Living for All 
290 
STRATEGY & HEALTH SUPPORT 
Heolth.Re~eorch:ewe5!erncope.gov.za 
tel: +27 21 483 6857: fox: +27 21 1.83 9895 
5" Floor. orion Fo~e House .. 8 Riebeek Street. Cope ·rown. 8001 
w-NW,cqpeqq te-...voy gov.~ 
REFERENCE: WC_2015RP36_912 
ENQUIRIES: Ms Charlene Roderick 
Albert Luthuli & University Drive 
Mohikeng 
2790 
For a ttention: MS Theresa Bock 
Re: CULTURALLY SAFE MANAGEMENT OF AGGRESSION AND VIOLENCE IN MENTAL HEALTH CARE 
INSTITUTIONS. 
Thank you for submifling your proposal to undertake the above-mentioned study. We are pleased 
to inform you that the department has granted you approval for your research. 
Please contact the following people to assist you w ith any further enquiries in accessing the 
following sites: 
Vredenburg Hospital N Fortuin Contact No: 022 709 7287 
Kindly ensure that the following are adhered to: 
1. Arrangements can be made with managers, providing that normal aclivities at requested 
facilities are not interrupted. 
2. Researchers, in accessing provincial health facilities, are expressing consent to provide the 
department with on electronic copy of the final feedback {onnexure 9) within six months of 
completion of research. This con be submitted to the provincial Research Co-ordinator 
(Heolth.Reseorch@westerncope.gov .zo). 
3. The reference number above should be quoted in all future correspondence. 
Yours sincerely 
DR A HAWKRIDGE 
DIRECTOR: HEALTH I SESSMENT 
DATE: \\, I 10 
cc C 8ESTlR DIRECTOR: WEST COAST 
From: Sinazo VikilahleSent: 16 September 2015 11 :54 AM 
To: Theresa Bock 
Cc: Charlene Roderick 
Subject: WC_2015RP36_912 
Dear Theresa 
Please find the attached document to access your facilities and also the Mutual Courtesy 
Guide and Report. 
Regards 
Sinazo Vikilahle 
Intern : Health Research 
Directorate: Health Impact Assessment 
Western Cape Government : Department of Health 
Address: 5th Floor, 8 Riebeek Street, Cape Town 
Tel : (021) 483 0881 
Email: Sinazo.V ikilah le@westerncape.gov .za 
Website : www.westerncape.gov.za 
Goeie dag Sr 
Baie dankie dat u in Weskus in Vredenburg die aanbieding gaan doen. Ek wil graag as Psigiatrie 
koordineerder versoek of u nie asseblief selfde aanbieding ook in Clanwilliam of Vredendal kan 
aanbied nie asseblief. Agv personeel sender rybewyse is dit moeilik vir verste areas om opleiding 
byte woon. 
Kan u asseblief met my skakel oor beskikbare datums indien u u weg oopsien om ons behulpsaam 
te wees. 
Groete 
292 
Alta Davids 
From: Zeta Roodt 
Sent: 28 July 2015 10:16 AM 
To: Theresa Bock 
Subject: RE: Psychiatric course 5&6 Aug 2015 
Dear Mrs Bock 
The course is held at the Vredenburg Provincial hospital , in the Multi Purpose Hall. 
Thank you, I will convey the starting times to Mrs Oosthuizen . 
Kind regards 
Zeta Roodt 
From: Theresa Bock 
Sent: 28 July 2015 10:14 
To: Zeta Roodt 
Subject: RE: Psychiatric course 5&6 Aug 2015 
Dear Mrs Roodt 
The course will start at 09:00 until 15:00, can you possibly indicate where exactly the 
venue is? 
Sincerely 
"A marriage with Knowledge will never end in heartbreak." 
Theresa M Bock 
Head of Campus/Deputy Director 
Western Cape College of Nursing: Metro East 
Western Cape government 
Address: CO Stikland Hospital , De La Haye Road , Bellville 
Tel 021 940 4567 
293 
Cell: 0836027097 
e-mail : Theresa.Bock@westerncape.gov.za 
From: Zeta Roodt 
Sent: 28 July 201510:11 AM 
To: Theresa Bock 
Subject: Psychiatric course 5&6 Aug 2015 
Dear Mrs Bock 
Mrs Oosthuizen has asked me to confirm with you a time that the course will be starting in 
Vredenburg on 5 and 6 August 2015. 
Kind regards 
Zeta Roodt 
Admin Clerk: Nursing Services Manager 
Vredenburg Provincial Hospital 
Saldanha Bay Sub-District 
Address: Voortrekker Road, Private Bag x 3, Vredenburg, 7380. 
Tel nr: 022 709 7214 
Fax nr: 086 564 6817 
Email : Zeta.Roodt@westerncape.gov.za 
294 
ANNEXURE 9 
Inter-coder protocol and letter of authenticity 
PROTOCOL FOR THE INTER-CODER 
TITLE OF THE RESEARCH: The Culturally safe management of aggression and violence 
AIM OF THE RESEARCH: 
• What are the attitudes of Mental Health Care Practitioners towards the management of 
aggression and violence? 
• Are Mental Health Care Practitioners culturally aware and sensitive? 
• How effective is a proposed programme on management of aggression and violence, in 
combination with cultural sensitivity and awareness to bring about attitudinal changes in 
Mental HealthCare Providers? 
THE OBJECTIVE OF THE QUALITATIVE PHASE OF THIS RESEARCH 
• An exploration of African Indigenous Knowledge Systems used to manage mental health 
care user related aggression. 
The researcher collected the data via Lekgotla and from the audio and video recordings made 
verbatim transcripts. These transcripts were analysed by the researcher and certain themes and 
categories were identified, with the aim of answering the question "How does indigenous healers 
manage aggression and violence in the mentally ill? 
The researcher used the phenomenological analysis technique of Coliazzi (1978) as cited by Polit 
and Beck (2012:566) for data analysis. 
295 
Ullswater Street 14 
Pinelands, 
7405. 
8/10/2015. 
To whom It c:oncern, 
Since I have a vast amount of knowledge of qualitative research and the analysis of qualitative data, I was 
requested by Miss. T. Bock to be the independed coder of the qualitative data of her Doctoral Manuscript. 
On 2014/07/191 received three randomly selected full sets of unmarked interview transcripts, accompanied 
by the purpose and objectives of the study. In order to evaluate and ensure inter- coder reliability, me and 
the Internal researcher of the current study used different colour highlighters to code the same sets of data 
independently, using the same coding scheme. We later met to check for consistency and to compare the 
descriptive and interpretive codes. 
Since it was qualitative data, inductive reasoning was used because it does not allow for coding of themes to 
fit the researcher's pre-conceptions. Thus, codes are data driven. 
During the process we had regular discussions regarding the difficulties we experienced as well as the 
meaning of each code. Although we had some minor differences in interpretation, we revised the codes 
before reaching a point of agreement. This was done in an attempt to enhance the credibility of the 
process. 
Dr. EvWijk 
Senior Lecturer Advanced Psychiatric Nursing Science, Western Cape College of Nursing. 
0827842417 
\>l\••h~\( 
296 
ANNEXURE10 
Confirmation letter from statistician 
November 2015 
To whom it may concern 
A few months ago, Theresa Bock approached me to assist her with the statistical analysis 
of the data she has collected for her PHO. Another PHO student whom I have also 
successfully assisted referred me to Theresa. 
I gained my 15 years of experience in statistical analysis of data through working as a 
researcher for two global research companies (Research International and 
IPSOS/Markinor), as well as currently for SARS. The software I use and have experience 
in, is SAS, updated to the latest version. 
My qualifications are as follows: 
BSc(Hons) Genetics - UP 
BA(Hons) Psychology- UP 
MBA Strategic Marketing - University of Hull 
Continuous training in SAS, i.e. Enterprise guide, JMP. 
Sincerely 
llja de Boer 
BSc(Hons), BA(Hons)Psych, MBAStratMkt(Hull ,UK) 
297 
ANNEXURE11 
Confirmation letter from the language editor 
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DECLARATION OF LA GUAGE EDITING 
Novt-nib4>r 2015 
To Whom It May Contern 
Dear Sir/Madam 
This is to ccrtif that I h:we fully edited the PhD thesis of Ms. Theresa M. Bock entitled CULTURALL.Y SAFE 
MA AGEME TOP AGGRE • 10 AND VIOLENCE 1N ME 'TAL HEALTH CARE INSTITUT!ON (North-West 
lJniversily). Th·• text was hecked for style. clarity and ease of reading. gmmmnr and usage, spelling and punctuation. 
ro1t~is1cncy in the use of text and figures in illustrations and tables, completeness and c,0nsistency in refurenct.-s. as well as 
onsisten ) in page numbering. Headers :md footers and suggestion.-. \\ere offered. The editor mak<:5 no pretension to 
ht1vc improved the intellectual content of the thesis and did not re-write any text. The editQr·s suggestions are 10 be 
, ceeµled or rejected by the nuthor. The author cftected the final changes by him- or herself. 
Yours sincerely. 
SUADRECK 1\'EJ\<fflA WARR: <.orpor,11c otnun11\lca.tio1»Coos0Ua11r - f'•rfo!"lll3ntt l)ymnnl, 
(l)l'ftll Can:dhti.1.,.1 !<7.'I: MA Engli<ll l I.:. llA. Hon~Eft;?Ji,,bt llZ): IM\I (RS,\) 
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298