What this article is about
In brief
A single-patient case study at BLUD Banjar City Hospital found that assertiveness training, delivered within an SDKI/SIKI/SLKI nursing-process framework, was associated with improved anger control in a patient with paranoid schizophrenia and violent behavior. As an n=1 descriptive case study with an internally...
For nursing students
Study summary
This case study, published in Jurnal Vocational Nursing Sciences (VNUS) by Asep Gunawan and Sulistiarini, looks at how a nurse used assertiveness training to help one patient with paranoid schizophrenia control anger and stop violent behavior. The authors start from a well-known clinical problem: paranoid schizophrenia tends to relapse in cycles, and those relapses are often set off by upsetting events that reawaken anger. When a patient cannot manage that anger, it can turn into violent behavior directed at people, objects, or the environment. Citing WHO figures from 2021, the authors note that mental illness is a massive global burden: about 35 million people live with depression, 60 million with bipolar disorder, 47.5 million with dementia, and 24 million with paranoid schizophrenia. That scale is part of why the authors argue nurses need reliable, low-cost, non-drug tools for anger management alongside medication.
The tool they studied is assertiveness training, a verbal intervention that teaches a patient to express feelings, requests, and refusals honestly and calmly instead of exploding into aggression. The study itself was a single-patient case study conducted at BLUD Banjar City Hospital in Indonesia. The authors used the standard nursing process: assessment, diagnosis, intervention planning, implementation, and evaluation. Instead of using a generic care framework, they charted the case using Indonesia's official nursing standards: SDKI for diagnosis, SIKI for interventions, and SLKI for expected outcomes, with day-to-day documentation recorded in SOAPIER format (a structured note style used widely in Indonesian nursing education).
At intake, the abstract reports that the patient showed clear signs of violent behavior: frequent tantrums, hitting walls, kicking doors, and speaking harshly and abruptly. Based on this presentation, the nursing team assigned a primary diagnosis of "violent behavior" under SDKI. The care plan built around that diagnosis used three linked strategies, with assertiveness training as the central technique. In practice, assertiveness training usually walks a patient through structured steps: naming the feeling that triggered the anger, practicing calm ways to ask for something, practicing polite refusal, and rehearsing these skills with the nurse through description, modeling, role-play, and feedback until the patient can use them independently. By the evaluation stage, the authors report that the anger-management/assertiveness program had a positive effect on this patient's ability to manage violent behavior, and they conclude that assertiveness training is an effective intervention for anger control in paranoid schizophrenia with violent behavior.
A few things are worth flagging for a careful reader. First, this is a single case, so it cannot tell you how well the intervention would work across many patients, settings, or cultures — it demonstrates plausibility, not proof. Second, the abstract itself contains a passage that describes sampling a patient with auditory hallucinations and a thought-stopping intervention, which does not match the rest of the case, which is about violent behavior and assertiveness training. That looks like a copy-paste inconsistency in the published abstract rather than a change in the actual study design, but it means the publicly available summary should be read with some caution until the full case report is checked directly. Third, the paper does not give a PMID and the full text was not reachable during this review (the publisher's page returned an access error), so this summary relies on the published abstract rather than the complete case report. For nursing students, the value of this article is less about generating new evidence and more about seeing assertiveness training modeled as a concrete, teachable technique inside a real structured nursing-process write-up: how a violent-behavior diagnosis gets built from subjective and objective data, how an intervention gets matched to that diagnosis using a national standard (SDKI/SIKI/SLKI), and how outcomes get tracked day by day. It's a useful worked example of psychiatric-mental-health nursing documentation, even though its conclusions about effectiveness should be treated as a single clinical observation rather than a generalizable finding.
Original publication
Source abstract and study details
Read the source abstract
Introduction: Paranoid schizophrenia is characterized by a cycle of relapses. This relapse is usually caused by bad events before they are revived with anger. Violent behavior is that and anger or rage. A problem that usually results from violent behavior is the patient's inability to control his anger. Anger management must be done to prevent unwanted things, one way to control violent behavior is through verbal interventions, namely assertiveness training. Based on WHO (2021). 35 million people have depression, 60 million have bipolar disorder, 47.5 million have dementia and 24 million have paranoid schizophrenia. Purpose: The purpose of this case study is to provide a nurse for patients with violent behavior with a self-efficacy training intervention for anger management. The method used is a descriptive and case study approach. The sampling technique was adopted by one patient with paranoid schizophrenia and violent behavior problems in BLUD Banjar City Hospital. Method: a nursing process-based method using a qualitative descriptive design that includes assessment, diagnosis, intervention, implementation, and evaluation. Nursing refers to SDKI, SIKI, SLKI, and nursing assessments are documented using the SOAPIER method. A researcher conducted a thought-stopping therapeutic intervention for patients suffering from auditory hallucinations. A random sampling technique was used in this case study, ie one patient with auditory hallucinations was included. The analysis method uses interviews, observations and documentation. Result: The results of this study in the evaluation phase showed that the patients often threw tantrums, hit the walls, kicked the doors, spoke rudely quickly and sharply. Prescribed nursing diagnosis is violent behavior refers to Indonesian Nursing Diagnosis Standards (SDKI), intervention refers to Indonesian Nursing Intervention Standards (SIKI), Indonesian Nursing Outcome Standards (SLKI), evaluation and documentation refers to SOAPIER. The intervention uses 3 strategies to implement violent behavior and the focus of the intervention is assertiveness training. Conclusion: Providing an anger management training program for patients with violent behavior has been shown to be effective in paranoid schizophrenic patients with violent behavior problems.
Reviewed findings
Main findings
- The case study focused on one patient with paranoid schizophrenia and violent behavior at BLUD Banjar City Hospital, treated with a nursing-process-based, non-pharmacological approach centered on assertiveness training.
- At assessment, the patient displayed violent behavior symptoms including frequent tantrums, hitting walls, kicking doors, and speaking rudely, quickly, and sharply.
- The nursing diagnosis of violent behavior was established using Indonesia's national nursing standards (SDKI for diagnosis, SIKI for intervention, SLKI for outcomes), with evaluation documented using the SOAPIER method.
- The intervention combined three linked strategies for managing violent behavior, with assertiveness training as the central focus of the care plan.
- By the evaluation phase, the authors concluded that the anger-management/assertiveness training program was effective in helping this paranoid schizophrenic patient manage violent behavior.
For teaching and learning
Education implications
- Assertiveness training can be considered as a non-pharmacological, verbal-behavioral adjunct for helping patients with paranoid schizophrenia and violent behavior express anger, requests, and refusals more safely.
- Structuring psychiatric-mental-health nursing care around a formal diagnosis-intervention-outcome framework (such as SDKI/SIKI/SLKI) can support consistent, traceable clinical decision-making for violent-behavior cases.
- Ongoing, structured documentation (e.g., SOAPIER notes) through assessment, implementation, and evaluation helps nurses track whether an anger-management intervention is producing observable behavior change day to day.
- Because the reported benefit came from one case, nurses should treat assertiveness training as a promising component of a broader care plan rather than a stand-alone, proven-effective substitute for pharmacological and other established interventions.
- Given the abstract's own internal inconsistency (mixing this violent-behavior case with a reference to auditory hallucinations and thought-stopping), clinicians reading this literature should verify intervention details against the full case record before applying them directly to practice.
For educators
Teaching and appraisal notes
Gunawan and Sulistiarini publish a single-patient case study in Jurnal Vocational Nursing Sciences (VNUS) describing the use of assertiveness training to manage anger and violent behavior in a patient with paranoid schizophrenia at BLUD Banjar City Hospital, Indonesia. The paper is framed around the clinical reality that paranoid schizophrenia relapses cyclically, frequently triggered by adverse events that reactivate anger, and that unmanaged anger frequently escalates into violent behavior toward self, others, or property. The authors situate the case within global mental-illness burden estimates attributed to WHO (2021): roughly 35 million people with depression, 60 million with bipolar disorder, 47.5 million with dementia, and 24 million with paranoid schizophrenia.
Methodologically, this is a descriptive case study using the standard psychiatric-mental-health nursing process (assessment, diagnosis, intervention, implementation, evaluation), documented against Indonesia's national nursing standards: SDKI (Standar Diagnosis Keperawatan Indonesia) for diagnosis, SIKI (Standar Intervensi Keperawatan Indonesia) for interventions, and SLKI (Standar Luaran Keperawatan Indonesia) for expected outcomes, with progress notes in SOAPIER format. One patient was purposively sampled based on a presentation of violent behavior with paranoid schizophrenia; data collection used interview, observation, and documentation review. This is a useful teaching artifact for showing students how a national diagnostic taxonomy maps onto an individualized care plan, but by design it offers no comparison group, no blinding, and no statistical inference — it is an n-of-1 descriptive account, not an efficacy trial.
The reported clinical picture at assessment included frequent outbursts, wall-hitting, door-kicking, and harsh, rapid speech, consistent with the SDKI diagnosis of violent behavior. The care plan built three linked strategies around that diagnosis, with assertiveness training as the central verbal-behavioral technique — teaching the patient to name feelings, make requests, and refuse appropriately, generally taught through description, modeling, role-play, feedback, and transfer to daily life (a structure well established in the broader Indonesian psychiatric nursing literature on this topic, which the authors do not fully detail in the abstract). By the evaluation stage, the authors report that the assertiveness-focused program was associated with improved anger control in this patient and conclude that the intervention is effective for this population.
For classroom use, this case is well suited to a discussion of nursing-process documentation discipline and non-pharmacological adjuncts to psychiatric care, but instructors should flag several appraisal points. The abstract contains an apparent internal inconsistency: alongside the violent-behavior case, it describes sampling a patient with auditory hallucinations and a thought-stopping intervention, which is inconsistent with the rest of the case narrative. This is very likely a template or copy-paste artifact in the published abstract, but it is a good prompt for teaching students to read abstracts skeptically and check for internal consistency before trusting a source. The full case report (methods detail, patient demographics, before/after anger measures) was not independently verifiable during this review, since the publisher page returned an access error, no PMID is listed, and no open-access PDF could be confirmed; conclusions here are therefore anchored to the abstract, not full-text verification. Faculty should also note that similar case studies from the same journal and hospital use nearly identical language and structure, which reflects a common template in vocational-nursing case-report training in this program rather than shared results — useful context when comparing multiple case studies from this source in a course pack.
Critical appraisal
Limitations
- This is a single-patient (n=1) case study, so findings about the effectiveness of assertiveness training cannot be generalized to other patients, settings, or cultures.
- As a descriptive case study, there is no control or comparison group, no randomization, and no statistical testing, so causal claims about the intervention's effect are not supported by this design.
- The abstract contains an apparent internal inconsistency, referencing a thought-stopping intervention and a patient with auditory hallucinations in a study otherwise centered on violent behavior and assertiveness training; this raises questions about the abstract's precision or possible template reuse.
Classroom use
Discussion Questions
- Why might a single relapse-triggering event be enough to reactivate the cycle of anger and violent behavior described in patients with paranoid schizophrenia?
- What are the strengths and weaknesses of using a single-patient case study design to evaluate a nursing intervention like assertiveness training?
- How does documenting care with a national standard like SDKI/SIKI/SLKI change the way a nurse builds and justifies a care plan compared to an informal or ad hoc approach?
- What steps would you expect an assertiveness training session to include, and why might description, modeling, role-play, and feedback all be necessary components?
- How would you interpret the abstract's inconsistent reference to a thought-stopping intervention for auditory hallucinations within a case otherwise about violent behavior? What does this teach you about critically appraising published abstracts?
- What other non-pharmacological strategies could be combined with assertiveness training to manage violent behavior in patients with paranoid schizophrenia?
Source-based questions
Frequently asked questions
What is assertiveness training in nursing?
Assertiveness training is a verbal intervention that helps patients express feelings, make requests, and refuse things honestly and calmly, as an alternative to reacting with aggression or violent behavior.
How many patients were studied?
Just one patient; this is a single-case (n=1) descriptive case study, so results should not be generalized without further research.
What symptoms of violent behavior did the patient show?
According to the abstract, the patient often threw tantrums, hit walls, kicked doors, and spoke rudely, quickly, and sharply.
Why does paranoid schizophrenia relapse cyclically, according to this article?
The abstract explains that relapse is usually caused by bad events, which are then 'revived with anger,' contributing to violent behavior if anger is not managed.
What should nursing students take away from this case study?
It offers a concrete, real-world example of how a violent-behavior nursing diagnosis, intervention, and outcome can be structured using a national standard (SDKI/SIKI/SLKI), while also serving as a lesson in critically appraising single-case evidence and checking abstracts for internal consistency.