CH 24- anger, aggression, & violence

Exam #2 Mental

Anger

emotional response to a frustration of desires, threat to one’s needs, or a challenge.

• emotional/physical

Aggression

anger’s motor counterpart; goal-directed action/behavior resulting in verbal or physical attack.

universal differentiation among anger, aggression, and violence is difficult because of 

perceptions and social backgrounds

a normal and not always logical human emotion

anger

anger varies in 

intensity from mild irritation to intense fury/rage 

true or false; aggression may be appropriate

true

aggression is not the same as

violence

aggression is

self protective,

• protecting urself or one’s family 

• as in protecting self from being bullied 

aggression is the act of

initiating hostilities

aggression is hostility that

arouses thoughts of attack and/or a disposition to behave aggressively.

violence does not always

have its roots in anger

• it does have the discrete intention of doing harm to a specific person/group

violence is defined as an

unjust, unwarranted, or unlawful display of

• verbal threats, intimidation, or physical force

intent of violence is 

to inflict harm, damage, or violate

what is bullying?

it is offensive, intimidating, malicious, and condescending behavior

• designed to humiliate & terrorize 

bullying infers

persistent, systemic violence toward a person/group

bullying is

an intentional display and uses violence

the term bullying is often used

when a person/group has power over another

lateral bullying

bullying by a person of equal status

bullying in the health care environment

ANA survery of nurse’s health and safety (2015)

ANA survey (21%)

“significant level of risk” for violence at work

ANA survey (25% to 50%)

experiencing bullying at work

ANA survey (50%)

verbal/nonverbal aggression from a peer

ANA survey (42%)

verbal/nonverbal aggression from a person in higher authority 

bullying behaviors in health care examples

unwanted/invalid criticism, excessive monitoring of another’s work

• gossip, lies/false rumors, and assigning derogatory nicknames

• taking credit for someone’s work w/out acknowleding the contribution, blocking career pathways, & other work opportunities 

• public derogatory comments about staff/their work; using body language (eye rolling, dismissive behavior) 

attributes that may make one more likely to be bullied

• new grad/new hire

• receiving promotion/honor others believe is undeserved

• difficulty working well w others

• receiving special attention from physicians

• working under conditions of severe understaffing

violence in the hospital is most frequent in:

• psychiatric units

• emergenecy departments

• geriatric units

• waiting rooms 

risk factors for violence

Objective:

• discuss interplay of neurobiology, medical/personal history, sociologic & demographic issues contributing to risks for violence. 

comorbidity

• PTSD

• substance abuse disorders

• Co-occurring illnesses;

  • depression

  • anxiety

  • psychosis

  • personality disorders 

strongest predictor of adult violence is

childhood aggression

majority of perpetrators are

males

• aged 15-24 years old

red flags of environmental/demographic correlates of violence:

• setting fires

• animal cruelty during childhood

• diagnosis of a conduct disorder

many violent adults also suffered violence..

in childhood, with a family history of violence

violence in clinical settings may be related to the

abuse of alcohol/other substances (intoxication,withdrawal)

low socioeconomic status

hight rate of perpetrators & victims

poor populations

experience alienation, discrimination, family breakdown, & survival reaction

learned angry reactions

family/societal norms

neurological factors and brain structure:

• no one site in the brain is responsible for anger & aggression

• hypothalamus & limbic system

hypothalamus and limbic system contribute to

emotions

cultural considerations:

• socioeconomics, health, & psychiatric issues

• social factors within each subculture

• sex: males vs. females

• lower economic class

• substance abuse disorders

• subculture > supports intimidation & aggression as a way to problem solve/achieve social status 

subjective data on admission:

gather history from;

• informatics, medical & psychologic history, family, friends, & pt when calm 

subjective assessment

• history of pt’s background, usual coping skills, and pt’s perception of the issue

• does pt have history of violence, substance abuse, or psychotic behavior???

Subjective data questions:

• have u ever thought of harming someone else?

• have u ever seriously injured another person?

• what is the most violent thing u have ever done?

Signs/Symptoms that usually precede violence are:

angry/anxious, irritable affect

hyperactivity

increasing anxiety & tension

hyperactivity (objective data)

most important predictor of imminent violence (pacing, restlessness, slamming doors)

increasing anxiety & tension (objective data)

• clenched jaw/fist, rigid posture, fixed/tense facial expression, mumbling > (pt could have SOB, sweating, rapid pulse).

• expressed thru verbal abuse (profanity, argumentativeness). 

objective data: predictive factors of violent outcomes:

• loud voice, change of pitch, very soft voice, forcing others to strain to hear

• intense eye contact/avoidance of eye contact

• recent violence; property violence

• stone silence

• suspiciousness/paranoid

• alcohol/drug intoxication/withdrawal

• possession of weapon (fork, knife, rock)

Milieu characteristics conducive to violence:

• loud

• overcrowding

• staff inexperience

• provocative/controlling staff

• poor limit setting

• staff inconsistency 

safety of patients & others is always 1st priority:

• risk for self-directed violence

• risk for other-directed violence 

de-escalation objectives

• promote safety 

• identifiy specific safety measures

• use evidence-based practice; optimum milieu

• patient centered care

stages of the violence cycle

• Preassaultive stage:

  • de-escalation approach

• Assaultive Stage:

  • meds, seclusion, restraint

• Post-assaultive stage:

  • seclusion and restraint 

delusion is a ***

false fixed belief

Preassaultive Stage:

• ur on the pt’s side

• stand at angle to appear nonconfrontational

• assess for personal safety

• appear calm/in control, do not speak when person is yelling

• speak softly; nonprovocative, nonjudgement

• ask “what will help now” 

pre-escalation technique

• set clear, consistent, enforceable limits

• the nurse/patient should sit at 45 degree angle 

• do not tower over/stare at pt

• listen & use clarification

• listen to pt’s needs 

assaultive stage interventions

• Seclusion: 

  • involunatrily confined alone in room, pt physically prevented from leaving

• Restraints:

  • manual method, physical/mechanical device, material/equipment, restricting freedom of movement. Least restrictive is TRIED first!

• Medication: 

  • IM injection of benzodiazepine, antihistamine, or antipyschotic. depends on physician order/underlying condition. 

Reintegration Interventions (after restraint & seclusion):

• constant observation & documentation every 15 mins

• gradual reintegration 

• structured reintegration 

Constant observation & documentation every 15 minutes:

• face-to-face thru locked door, window for seclusion/in person restraint.

• must have constant 1:1 observation 

Gradual reintegration

geared to pt’s ability to handle increased stimulation

structured reintegration

from 4-point to 2-point restraints

• when out of seclusion, use planned time-out periods to leave the room and move slowly into milieu of unit. 

• time-outs are gradually lengthened 

nonadherence is the reason for

high rates of in & out of hospital

• not taking meds

alternatives to seclusion/restraint

• no therapeutic value to seculsion & restraint

• new recovery model approaches; 

  • comfort rooms 

  • trauma-informed approach - 6 key principles, instead of prescribed set of procedures 

6 principles of the trauma- informed approach

1. safety

2. trustworthiness and transparency

3. peer support

4. collaboration and mutuality

5. empowerment, voice, & choice

6. cultural, historical, & gender issues 

staff analysis (post assaultive stage)

critical incident debriefing

• assures quality of care

• opportunity for self care for staff

Documentation

• violent episode

• staff response 

self care- planning:

knowledge of personal responses to anger/aggression

• choice of words

• tone of voice

• nonverbal communication

• personal triggers

• personal sense of competence 

interventions for Patients w cognitive deficits:

• reality orientation

• “catastrophic reaction” - give calm, unhurried, soothing response

• validation therapy:

  • do not attempt reorientation if pt is unable to perceive life situation

• psychotherapy

Medications for acute aggression:

• benzodiazepines (lorazepam): 1st choice for acute aggressive episodes; episodic dyscontrol, & incipent rage episodes

• second generation antipyschotics: emergencies

  • ziprasidone IM

  • olanzapine IM/oral disnintegrating 

Medications for Chronic Aggression:

• Anticonvulsants (carbamazepam): labile mood, poor impulse control, organicity/dementia

• Beta Blockers (propanolol): organically based violence (dementia)

• Antipsychotics: disorganized behavior 

• Buspirone: organicity

• Clonidine: anxiety, agitation

• Lithium: labile mood, impulsivity

• SSRIs: anger “attacks”