Chapter 28:Preventing and Managing Aggressive Behavior

Behavioral Responses
-Each person has the capacity for passive, aggressive, or assertive behavior

-Choices in threatening/stressful situation:
-Be passive, fearful, and flee
-Be aggressive, angry, and fight
-Be assertive, self-confident,
and confront situation directly

-Situation and characteristics of the people involved determine appropriate response

Passive Behavior
-Perceive others’ rights as more important than their own

-When angry, they hide it; increases tension

-Unable to confront the issue

-Can seriously impair interpersonal growth

-Sarcasm: indirect expression of anger

-Usually provokes anger in targeted person, infringes on rights of others

-Content of speech: negative, self-derogatory

-Tone of voice: quiet, weak, whining

-Posture: drooping, bowed head

-Personal space: allows invasion by others

-Gestures: minimal; weak gesturing, fidgeting

-Eye contact: little or none

Aggressive Behavior
Aggressive people ignore rights of others

Expect the same behavior from others

“Life is a battle”

May lead to physical or verbal violence

Often covers a basic lack of self-confidence

Aggressive people enhance self-esteem by overpowering others

Attempt to prove “superiority” to themselves

Overall impression of power and dominance

Content of speech: exaggerated, other-derogatory

Tone of voice: loud, demanding

Posture: tense, leans forward

Personal space: invades others’ space

Gestures: threatening, expansive

Eye contact: constant stare

Expression of Anger
May seem out of proportion to event

Insignificant stressor may be “the last straw,” result in release of flood of feelings stored up over time

Avoid personalizing patient’s anger

Nurse may seem to be safer target than significant others

Assertive Behavior
Assertiveness: midpoint of continuum from passive to aggressive behavior

Conveys sense of self-assurance but also communicates respect for the other person

Assertive people speak clearly and distinctly, observing norms of personal space appropriate to the situation

Assertiveness
Assertive people feel free to refuse an unreasonable request

Base judgment about reasonableness of the request on their own priorities

They do not hesitate to make a request of others; assume will be told if unreasonable

If another person unable to refuse request, assertive people do not feel guilty about making it

Assertive Communication
Communicating feelings directly to others

Anger not allowed to build up

Expressed feeling proportional to situation

If dissatisfied, reason for feeling expressed

Assertive people remember to express love and compliments when deserved

Includes acceptance of positive input from others

Content of speech: positive, self-enhancing

Tone of voice: modulated

Posture: erect, relaxed

Personal space: keeps comfortable distance/claims own space

Gestures: demonstrative

Eye contact: intermittent, appropriate to relationship

Anger as a Response to Threat
External stressors: physical attack, loss of significant relationship, criticism

Internal stressors: sense of failure at work, loss of love, fear of physical illness

Anger: emotional response to stressors

Other responses: depression, withdrawal

Depression may be anger directed toward self; withdrawal, passive anger

Psychological View of Aggression
Predisposing developmental or life experiences may limit person’s capacity to select nonviolent coping mechanisms

Affects ability to use supportive relationships

May leave person very self-centered

May become particularly vulnerable to sense of injury easily provoked into rage

Exposure to violence in formative years, as either victim or observer, may instill use of violence as way to cope

Background Associated with Violent Behavior
Childhood cruelty to animals or other children

Fire setting or similar dangerous actions

Recent violence toward self or others

Recent accidents, threats, or poor judgment in potentially dangerous situations

Altered states of consciousness

Escalating irritability, sensitivity, or hostility

Fear of losing control

Bothering family, neighbors, or police

History of alcohol or other substance abuse

Predicting Aggressive Behavior
Populations at increased risk of violence
Patients with psychotic symptoms
Patients with substance abuse disorders

Prior history of violence is single best predictor

Situational and environmental factors
Physical facilities (overcrowding, lacking privacy)
Staff members attitudes and actions (understaffing)

Patient’s appraisal of situation
Interpreting environment as hostile

Nursing Assessment
-Accurate prediction of patient violence impossible

-Psychiatric nurses need to be alert for symptoms of increasing agitation:
Motor agitation
Verbalizations
Affect
Level of consciousness

Motor Agitation
Pacing

Inability to sit still

Clenching or pounding fists

Jaw tightening

Increased respirations

Sudden cessation of motor activity (catatonia)

Verbalizations
Verbal threats toward real or imagined objects

Intrusive demands for attention

Loud, pressured speech

Evidence of delusional or paranoid thought content

Affect
Anger

Hostility

Extreme anxiety

Irritability

Inappropriate or excessive euphoria

Affect lability

Level of Consciousness
Confusion

Sudden change in mental status

Disorientation

Memory impairment

Inability to be redirected

Affect with Escalating Behaviors
Anger often seen when violence is imminent

Inappropriate affect: euphoria, irritability, lability may indicate patient having difficulty in maintaining control

Changes in level of consciousness may occur, including confusion, disorientation, memory impairment

Nurse’s Role
If patient is potentially violent:
Implement appropriate clinical protocol to provide for patient and staff safety

Notify co-workers

Obtain additional security if needed

Assess environment; make necessary changes

Notify physician, give PRN medications as appropriate

Nursing Interventions
Prevent/manage aggressive behavior

-Preventive strategies: self-awareness, patient education, assertiveness training (nurse and pt)

-Anticipatory strategies: verbal and nonverbal communication, environmental changes, behavioral interventions, use of medications

-If aggressive behavior continues to escalate, may need to use crisis management

-Containment strategies: seclusion, restraints

Patient Education
Teaching patients about communication and appropriate way to express anger can prevent aggressive behavior

Many patients have difficulty identifying their feelings, needs, and desires and even more difficulty communicating these to others

Teaching healthy anger management skills: important area of nursing intervention

Assertive Behavior
Basic interpersonal skill that includes:

Communicating directly with another person

Saying no to unreasonable requests

Being able to state complaints

Expressing appreciation as appropriate

Accepting compliments

Aggression Interventions
Help pts. recognize their intense affect (thoughts & feelings) and enable them to verbalize these feelings.

Observe pt.’s behavior and listen to what they are saying.

If pt. complies with nurse’s request, violence is much less likely to occur.

Once escalation occurs: Avoid using reason or logic to calm a pt. – it will not help.

Communication Strategies
-Present a calm appearance

-Speak softly in a nonprovocative and non-judgmental manner

-Put space (3 feet) between yourself and the patient

-Show respect for the patient

-Avoid intense direct eye contact

-Demonstrate control over the situation without assuming an overly authoritarian stance

-Facilitate the patient’s talking

-Listen to the patient

-Avoid early interpretations

-Do not make promises you cannot keep

Behavioral Strategies
Limit setting: clear and firm for behaviors

Behavioral contracts: measureable, consequences and new behaviors detailed

Time-outs: room restrictions to decrease stimulation

Token economy: acknowledgement of positive behaviors

Psychopharmacology
Antianxiety and sedative-hypnotics (anxiety and sleep)

Antidepressants (SSRI’s for PTSD, violence)

Antipsychotics & Mood stabilizers (aggression)

Patient Education (more)
Help patient identify anger

Give permission for angry feelings

Practice expressing anger

Apply expression of anger to a real situation

Identify alternative ways to express anger

Discuss appropriate techniques for confrontation of the person who is source of anger

Help patients realize feelings are not right or wrong, good or bad

Can allow them to explore feelings that may have been bottled up, ignored, or repressed

Work with patients on ways to express feelings, and evaluate whether responses are adaptive or maladaptive

Provide patients with available choices to manage anger that may be effective in reducing more restrictive interventions

Ways to Manage Anger
Positive self-talk; writing about feelings

Change of environment

Thinking of the consequences

Listening to music

Watching television

Deep-breathing exercises

Taking a walk

Medication

Counting to 50

Comfort wrap with a blanket

Relaxation exercises

Talking about your feelings

Using adaptive coping skills

Reading

Being alone

Crisis Management
Identify crisis leader

Assemble crisis team

Notify security officers if necessary

Remove all other patients from area

Obtain restraints if appropriate

Devise a plan to manage crisis and inform team

Assign securing of patient limbs to crisis team members

Explain necessity of intervention to patient, and attempt to enlist cooperation

Restrain patient when directed by crisis leader

Administer medication if ordered

Maintain calm, consistent approach to patient

Review crisis interventions with team

Process events with patients and staff as appropriate

Process event with the patient

Gradually reintegrate patient into milieu

Seclusion
Involuntary confining of a person alone in a room from which the person is physically prevented from leaving

Used only as emergency measure

Based on principles of containment, isolation, decrease in sensory input

Careful records and observation required

Restraints
Physical – any manual method or physical or mechanical device attached to or adjacent to the patient’s body that the patient cannot easily remove and that restricts freedom of movement or normal access to one’s body, material, or equipment

Mechanical – medications used to restrict the patient’s freedom of movement or for emergency control of behavior but that are not standard treatments for the patient’s medical or psychiatric condition

Use of seclusion or restraints
Good nursing care: fulfill basic needs and maintain personal dignity.

Recommend: once calm talk with clients about issues that led to psychiatric emergency and identify alternative coping methods to avoid future seclusion/restraint.

Staff Debriefing:
review events that led to decision to isolate pt.

identify future preventive measures to help pt. gain control and promote adaptive functioning

staff may need to ventilate or process feelings about the event and clarify rationale for seclusion/restraint.

RN Responsibilities Restraints
Ensure documentation of assessment every 15 minutes.

Perform baseline assessment every hour.

Attempt least restrictive measures no less than every 4 hours.

Document progress note each time restraints are initiated and discontinued.

Provide assistance to meet behavioral criteria for discontinuation of restraint.

See Care of Restraints Handout

Lateral Violence in Nursing
Nurse-on-nurse aggression and intergroup conflict

It includes a range of disruptive behaviors:
verbal abuse
intimidation
bullying
excessive criticism
denial of access to career opportunities
withholding of information

Preventing Workplace Violence
Educate staff about professional and respectful behavior

Hold individuals accountable for behavior

Organizational policies endorsing “zero tolerance” for intimidating or abusive behaviors and protection of those who report such behaviors

Leadership training to ensure standards of behaviour are upheld

Educate staff about professional and respectful behavior

Hold individuals accountable for behavior

Organizational policies endorsing “zero tolerance” for intimidating or abusive behaviors and protection of those who report such behaviors

Leadership training to ensure standards of behaviour are upheld

Surveillance and reporting systems for unprofessional behaviors

Documentation of bullying behaviors

Code of conduct that defines acceptable and disruptive and inappropriate behaviors

Staff development

Staff support

Important Points
Personality Disorders are disturbances in relatedness. Individuals have rigid, inflexible, & maladaptive ways of viewing & behaving in the world.

Hallmark behaviors of Personality Disorders are manipulation, narcissism, & impulsivity.

Behavioral response options to stress include passive, aggressive & assertive (positive coping) behaviors.

Prior history of violence is single best predictor of present violence.

Safety (suicide/homicide), structuring the milieu, & limit setting are important priorities in handling aggression, manipulation, narcissism, and impulsivity.

Violence preventive, anticipatory, & containment strategies move from:
recognizing escalating symptoms (anger)
verbal interventions
seclusion &/or restraint (chemical/physical)
crisis management