Module 3 Chapter 24 Anger, Aggression, and Violence

Anger

Emotional response to frustration of desires, threat to one's needs (emotional or physical), or a challenge; normal and not always logical human emotion; varies in intensity from mild irritation to intense fury and rage

Aggression

Anger's motor counterpart; goal-directed action or behavior that results in verbal or physical attack; may be appropriate (self-protective or protective from bullying); act of initiating hostilities

Violence

Unjust, unwarranted, or unlawful display of verbal threats, intimidation, or physical force with intent of causing property damage, personal injury, or death to another individual; does not always have roots in anger but has discrete intention of doing harm

Violence in Hospital Settings

Most frequent in psychiatric units, emergency departments, waiting rooms, and geriatric units

Violence Comorbidities

PTSD, substance abuse disorders, co-occurring illnesses (depression, anxiety, psychosis, personality disorders)

Environmental and Demographic Violence Correlates

Childhood aggression is strongest predictor of adult violence; majority of perpetrators are males aged 15-24; setting fires, animal cruelty during childhood, or conduct disorder diagnosis are red flags; many violent adults suffered violence in childhood with family history of violence

Violence and Socioeconomic Factors

Low socioeconomic status has high rate of perpetrators and victims; poor populations experience alienation, discrimination, family breakdown, and survival reaction; learned angry reactions from family and/or societal norms

Violence Assessment Subjective Data Questions

Have you ever thought of harming someone else? Have you ever seriously injured another person? What is the most violent thing you have ever done?

Predictive Factors of Violence - Physical Signs

Angry or anxious irritable affect, hyperactivity (most important predictor of imminent violence like pacing, restlessness, slamming doors), increasing anxiety and tension (clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self)

Predictive Factors of Violence - Verbal and Behavioral

Loud voice or change of pitch or very soft voice, intense eye contact or avoidance of eye contact, recent violence including property violence, stone silence, suspiciousness and/or paranoid thinking, alcohol or drug intoxication or withdrawal, possession of weapon or object used as weapon

Milieu Characteristics Conducive to Violence

Loud environment, overcrowding, staff inexperience, provocative or controlling staff, poor limit setting, staff inconsistency (arbitrary revocation of privileges)

Violence-Related Nursing Diagnoses

Ineffective impulse control, risk for self-directed violence, risk for other-directed violence, ineffective coping, risk for stress overload, confusion, disturbed thought processes; safety of patients and others is always first priority

Short-Term Violence Prevention Outcomes

Patient will display nonviolent behaviors toward self and others, recognize when anger and aggressive tendencies escalate and use at least one new tension-reducing behavior, make plans to continue with long-term therapy for violence prevention strategies and increased coping skills

Long-Term Violence Prevention Outcomes

Patient and others remain free from injury, hostile and abusive behavior ceases, use of assertive and cognitive reasoning behaviors replaces aggressive behaviors, variety of healthy anxiety reduction techniques used to keep anger in check, aggressive and violent impulses controlled

Stages of the Violence Cycle

Preassaultive stage (de-escalation approaches), assaultive stage (medication, seclusion, restraint), post-assaultive stage (seclusion and restraint)

Preassaultive Stage De-escalation Techniques

Emphasize on patient's side, stand at angle to appear nonconfrontational, assess or provide for personal safety, appear calm and in control, don't speak while person yelling, speak softly (nonprovocative, nonjudgmental), demonstrate genuineness and concern, don't treat in humiliating manner, ask "What will help now?"

Pre-escalation Limit Setting

Set clear, consistent, and enforceable limits; example: "It's okay to be angry with Tom, but it is not okay to threaten him. If you are having trouble controlling your anger, we will help you"

Pre-escalation Physical Positioning

If patient willing, nurse and patient should sit at 45-degree angle; don't tower over or stare at patient; listen and use clarification; acknowledge patient's needs whether rational or irrational, possible or impossible

Pre-escalation Environmental Management

Move individual to calm and quiet place, give patient space, provide adequate space for patient and staff to ensure easy withdrawal, set limits, have adequate staff for show of strength, do not touch the patient

Seclusion Definition

Involuntary confinement of person alone in room or area where person is physically prevented from leaving; only used for management of violent or self-destructive behavior; least restrictive means tried first

Restraints Definition

Any manual method, physical or mechanical device, material or equipment that restricts freedom of movement; least restrictive is tried first

Seclusion and Restraint Use Circumstances

Patient presents clear and present danger to self or others, patient legally detained for involuntary treatment and thought to pose escape risk, patient requests to be secluded or restrained

Seclusion and Restraint Protocol Requirements

Cannot be held without physician's order; spokesperson calmly explains what team will do and why; team organized before approaching patient; patient must be evaluated within 1 hour of application; patient protected from all sources of harm; restraints removed at earliest opportunity

Assaultive Stage Medication Options

If needed, IM injection of barbiturate, antihistamine, or antipsychotic depending on physician's order and any underlying conditions

Reintegration Interventions After Restraint/Seclusion

Monitor every 15 minutes face-to-face through locked door window (persons under 14 need constant face-to-face observation), gradual reintegration geared to patient's ability to handle increased stimulation, structured reintegration (moving from four-point to two-point restraints, planned time-out periods gradually lengthened)

Alternatives to Seclusion and Restraint

Comfort rooms where individuals can voluntarily isolate to self-manage anxiety and distress; trauma-informed approach adhering to six key principles rather than prescribed procedures

Trauma-Informed Approach Six Principles

Safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment/voice/choice, cultural/historical/gender issues

Post-Assaultive Stage

Staff analysis and critical incident debriefing assures quality of care, provides opportunity for staff to critically examine their response, staff self-care

Violence Documentation Requirements

Reason for seclusion or restraint, assessment, nursing interventions and patient's responses (time), patient's response to interventions, evaluation of interventions used, detailed description of patient's behaviors, name(s) of person(s) called to assess patient, time patient put in restraints or seclusion, interventions performed while patient in restraints/seclusion, any injuries to staff or patient, patient reintegration to unit

Self-Care for Nurses in Violence Situations

Knowledge of personal responses to anger and aggression (choice of words, tone of voice, nonverbal communication, personal triggers, personal sense of competence); without self-knowledge, nurses likely to make impulsive emotion-based responses that are nontherapeutic and may be harmful

Verbal Abuse Intervention

Leave immediately, inform patient nurse will return when situation calmer with specific time, avoid chastising or punishing; if mid-procedure and unable to leave, discontinue conversation and eye contact then leave when procedure complete; respond positively to and reinforce nonabusive communication; patients regularly verbally abusive may respond best to predictability of routine

Medications for Acute Aggression

Benzodiazepines, second-generation antipsychotics for emergencies

Medications for Chronic Aggression

Anticonvulsants, antipsychotics, beta-blockers, buspirone, clonidine, lithium, selective serotonin reuptake inhibitors (SSRIs)

Violence Intervention Evaluation

Was assessment accurate and thorough? Were diagnoses applicable to assessment data? Did nursing diagnoses drive interventions? Was plan comprehensive and individualized? Were interventions appropriate and properly carried out? If restraints and seclusion used, was protocol correctly followed and safety maintained? Were quality improvement methods used for future?