Week 3: Anger, Aggression, and Violence

What is anger?

A normal human emotional response to frustration of desires, a threat to ones needs, or a challenge that varies in intensity

What is aggression?

An action or behavior that results in a verbal or physical attack

What is critical incident debriefing?

Immediate and mandatory debriefing for staff and patients who took part and witnessed the seclusion and/or restraint episode where they talk about what went well, what could be improved, what was wrong, safety, etc.

What is restraint?

any manual method (physical or mechanical) that immobilizes or reduces the ability of a patient to move arms, legs, body or head freely

What is seclusion?

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

What is violence?

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

What does anger look like?

Varies by individual; irritability, frowning, redness in the face, pacing, fidgeting, twisting of hands, clenching of fists, speech changes (fast/loud or soft/slow), increasing demands

In the hospital setting, where is violence most frequently seen?

Emergency Rooms, psychiatric units, geriatric units, and ICU’s

What do we look for when assessing for the risk of anger, aggression, or violence?

Hx of violence, patients who are delusional, hyperactive, impulsive, non-compliance with medications, limit-setting, and limited coping skills

What is the single best predictor of future violence?

Hx of violence

What is limit- setting?

“Parenting”; setting boundaries with patients

What is delusion?

False belief of something

What are feelings that may precipitate anger, aggression, and violence?

Anxiety, frightful, fearful, feeling threatened, embarrassed, ignored, inadequate, insecure, vulnerable, tired, loss of control

What are situations that may precipitate anger?

Withdrawal, new diagnosis’, internal stimuli (auditory hallucinations-sounds or voices), attention-seeking, sleep deprivation, pain, stress, past trauma, loss of control, inadequate coping skills, poor communication, expectation vs. reality, environment (too hot/cold/loud/crowded)

What is the most important predictor of imminent violence?

Hyperactivity (pacing, restlessness)

What it the UK workplace safety signage used for?

To discreetly show that someone has been or has an increased risk of being angry, aggressive, or violent

What is self-assessment?

The nurse must be aware of their choice of words, tone of voice, and non-verbal communication (body posture and facial expressions)

What are nursing priority problems regarding anger, aggression, and violence?

Risk for violence toward others, risk for self-harm, risk for suicide, ineffective coping skills, anxiety, and impaired impulse control

What are examples of goal outcomes for anger, aggression, and violence?

No violence towards self or others, identifies and implements effective coping strategies, expresses feelings constructively, and reduction of anxiety

What are some recommended ways to de-escalate situations?

Respond early, quickly assess the situation, stay calm and use clear/slow/calm voice, be assertive but not aggressive

What are things that you should not do when trying to de-escalate a situation?

Do not argue, invade their personal space, use harsh language, make threats, or take chances; always maintain personal safety

What are considerations for staff safety?

maintain appropriate eye contact, keep facial expressions even, avoid wearing items that dangle, ensure there is enough backup staff, always know an exit

What are individualized interventions?

Something that calms them down when they are upset (reading, music, taking a walk, shower, nap, etc.)

When are the only acceptable times to use restraint or seclusion?

As a last resort- when the patient becomes a danger to self or others, when less restrictive options have been tried and were ineffective, with an order or safety emergency

What are contraindications for the use of restraints and seclusion?

Patients who are extremely unstable medically or psychiatrically, COPD, spinal injury, seizure disorders, pregnancy, delirium, or dementia

What are legal requirements for using restraints or seclusion?

Multidisciplinary involvement, order placed according to state law, patient advocate or relative notified, discontinuation as soon as possible

What is the required documentation for restraints or seclusion?

Behaviors leading to use of seclusion or restraint, less restrictive measures used prior, interventions used and patients response, plan of care for restraint or seclusion use implemented, ongoing evaluation by the nursing staff

What are required assessments while a patient is in restraints or seclusion?

Patients mental state, physical exam for medical problems possibly causing behavior changes, need for restraint, LOC, activity level, VS, ROM, circulation, signs of resp. distress or difficulty breathing

What are things that you must assess and provide opportunities for when a patient is in restraints or seclusion?

Nutrition, hydration, and elimination