anger, aggression, and violence

anger

• an emotional response to frustration of desires

• a threat to one’s needs (emotional or physical)

• can vary in intensity from mild irritation to intense fury and rage

what does anger look like

• will vary by individual

• irritability

• frowning or grimacing

• redness in the face

• pacing

• fidgeting or twisting of hands

• clenching and unclenching of fists

• speech increased in rate and volume, may be slowed or the person may become silent

• making increased demands

aggression

• an action or behavior that results in a verbal or physical attack

• tends to be used synonymously with violence

• is not always inappropriate and is sometimes necessary for self protection

violence

an act that involves the intentional use of force that results in or has the potential to result in injury to another individual

hospital settings most at risk for violence

• ED’s

• psychiatric units

• geriatric units

• ICU

general risk identification includes assessment of:

• a history of violence is the single best predictor of future violence

• individuals who are delusional, hyperactive, impulsive, or predisposed to irritability or have non-adherence to medication are at a higher risk for violence

• aggression by individuals occurs most often in context of limit-setting by the nurse

• history of limited coping skills, including lack of assertiveness or use of intimidation, indicates higher risk of violence

feelings that may precipitate anger, aggression, and violence (AAV)

• anxiety

• frightened/fearful/threatened

• embarrassed/humiliated

• discounted/ignored/rejected

• inadequate 

• insecure/vulnerable

• tired

• out of control of situation

situations that may precipitate AAV

• withdrawal/substance abuse or addictions

• diagnosed psychiatric illnesses

• resistance to suggested treatments

• internal stimuli - auditory hallucinations

• attention seeking

• sleep deprivation

• pain

• stress

• past trauma

• inadequate coping skills

• difference in expectations or goals

• difference in knowledge

• poor communication

• inaccurate or incomplete information

• environment (too hot, too cold, too loud)

warning signs of potential AAV

usually precede violence:

• recent acts of violence

• hyperactivity (most important predictor)

• increasing anxiety and tension

• loud voice, change of pitch, very soft voice or stone silence

• verbal abuse

• possession of a weapon or object that may be used as a weapon

milieu characteristics that may precipitate AAV

• environment

• staff inexperience/controlling staff

• difference in expectations or goals

• poor limit setting by staff members

• revocation of privileges

tools to gauge potential for violence

• broset violence checklist (BVC)

• dynamic appraisal of situational aggression (DASA)

• modified overt aggression scaeb (MOAS)

broset violence checklist (BVC)

• short-tern risk for inpatient aggression; used every shift

• 0 = low risk

• 1-2 = moderate risk

• >2 high

dynamic appraisal of situational aggression (DASA)

• aggression risk assessment; performed daily

• >3 = greater likelihood of acting out in next 24 hours

modified overt aggression scale (MOAS)

• tracks severity and frequency of aggressive behavior; past week

• - range 0-40

self-assessment

• ability to intervene effectively depends on self-awareness of strengths, needs, concerns, and vulnerability

• without self-awareness nursing intervention can end up being impulsive or emotion based

• nust be aware of choice of words, tone of voice, nonverbal communication, body posture, and facial expressions

hypotheses for AAV

• risk for vioence toward others

• risk for self-harm

• risk for suicie

• ineffective coping

• anxiety

• impaired impulse control

potential outcomes to solutions

• no violence toward self or others

• identifies and implements effective coping strategies

• expresses feelings constructively

• reduction in anxiety

planning for AAV

• interprofessional collaboration

• based on assessment

de-escalation techniques

• reasons and call for help/assistance

• remain calm and use clear tone of voice

• be genuine and empathetic but be assertive

• asses patient and situation

• identify stressors and stress indications

• determine what patient considers goals to be

• give several clear options 

what not to do when de-escalation AAV

• argue

• invade personal space

• use harsh language or make threats

• take chances; always maintain personal safety

interventions for AAV

should begin prior to any signs of escalation

• approach in a controlled, nonthreatening and caring manner

• speak to patient slowly and in short sentences, using calm tone of voice (never yell)

• use open ended questions and statements rather than challenging information

• acknowledge patients feelings and attempt to identify what is behind angry feelings and behavior

• acknowledge needs regardless of whether expressed needs are rational or possible to meet

• give choices

• allow patient enough space so you are perceived as less of a threat

• have an escape route

• choose quiet but visible place to talk to patient

• staff should know you are working with patient, keep eye on interaction, and be prepared to intervene

considerations for staff safety

• maintain appropriate eye contact

• keep facial expressions even, caring, confident, and engaged

• try to get patient to talk to you

• avoid wearing items that dangle

• ensure enough backup staff

• always know layout of area

• do not stand in front of patient or doorway; stand off to the side and encourage patient to sit

• if behavior escalates, provide feedback allowing patient to explore feelings and deescalate

when a patient is showing signs or symptoms of anxiety or agitation

• appropriate to offer PRN med to alleviate symptoms

• when used in conjunction with psychosocial interventions and deescalation techniques could prevent aggression and/or violence

guidelines for use of mechanical restraints

• indications for use

• legal requirements

• required documentation

• assessments

• observation

• release procedure

seclusion

involuntary confinement of patient alone in a room or area from which patient is physically prevented from leaving

restraint

any manual method, physical or mechanical device, material or equipment that immobilizes or reduces ability of patient to move arms, legs, body, or head freely

seclusion and restraints may only be used:

• as a last resort

• when patient becomes danger to self or others

• when less restrictive interventions have been determined to be ineffective to protect patient or others from harm

• in conjunction with a written modification to patients plan of care

• ONLY in accordance with safe and appropriate techniques as determined by hopital policy and state law

contraindications for seclusion and restraint

• patients who have extremely unstable medical and psychiatric condition

• chronic obstructive pulmonary disease (COPD)

• spinal injury

• seizure disorders

• pregnancy

• delirium or dementia may make seclusion and restraint intolerable due to absence of stimulation

determine prior to seclusion or restraint

• who is going to take the lead/be in charge and talk to patient

• who is going to check seclusion area to ensure that it is ready

• who is going to clear the path and remove other patients from area

• who is going to prepare and administer medication

• who is going to do 1:1 once patient is in seclusion or restraint

• who is going to document

• who is going to lead debriefing

legal requirements for seclusion and restraints

• multidisciplinary involvement

• order placed according to state law

• patient advocate or relative notified

• seclusion and restraint discontinued as soon as possible

required documentation for seclusion and restraints

• behaviors leading to seclusion and restraint

• least restrictive measures used prior to seclusion and restraint

• interventions used and patients response

• plan of care for seclusion and restraint use implemented

• ongoing evaluation by nursing staff

assessments required for seclusion and restraints

• patients mental state at time of seclusion and restraint

• physical exam for medical problems possibly causing behavior changes

• need for restraint

while in restraints, assessed at frequent regular intervals for

• level of awareness

• activity level

• vital signs

• range of motion

• circulation/restraints not rubbing

observation for seclusion and restraint

staff must constantly observe patient

release procedure

• patient must be able to follow instructions and stay in control

• termination of restraints

• debrief with patient

what to remember for restraints and seclusion

• never restrain patient in prone position

• physical holding of patient against will is restraint

• four side rails up is a restraint (except seizure precaution)

• keeping patient in room by physical intervention is seclusion

• tucking sheets in so tightly patient cannot move is restraint

• orders for seclusion/restraint cannot be PRN

monitoring considerations for seclusion and restraints

• increased danger during child restraint

  • underdeveloped trachea, intercostal muscles and diaphragm more pliable - more easily restricted by restraint device

• ALWAYS respond to patient complaints of difficulty breathing

  • look for intercostal retractions and use of accessory muscles

what might a patients increased struggling movements indicate

attempt to increase air flow

• look for signs of respiratory distress

• check O2 sats

• late signs - cyanosis around lips and mouth

critical incident debriefing

immediate and mandatory debriefing for staff and patient who took part and witnessed seclusion and restraint episode

components of critical incident debriefing

• could anything have been done that would have prevented the episode

  • if yes, what could have been done and why was it not done in this situation

• did the team respons as a team

• was safety maintained

• were policies followed

• how did actual restraining process go

• what could be done differently

• were lessons learned

• was the patients dignity respected

• is there a need for additional staff education regarding how to respond to violent patients

teaching and health promotion

• models appropriate responses and ways to cope with anger

• teaches a variety of methods to appropriately express anger

• educates about coping skills, deescalation techniques and self soothing skills to manage behavior

• assists in identifying triggers for anger and aggression