NUR 343 Exam 1: Anger, Aggression, & Violence

what is anger?

- a emotional response to frustration of desires, a threat to one's needs, or a challenge that varies in intensity from mild irritation to intense fury and rage

- anger is a normal human emotion that, when handled appropriately and expressed assertively, can provide an individual with a positve force to solve problems and make decisions concerning life situations

- anger becomes a problem when it is not handles appropriately and when it is expressed assertively

- anger is capable of being under personal control

what is aggression?

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

- tends to be used synonymously with violence

- a behavior that is intended to threaten or injure the victim's security or self esteem

- can cause damage with words, strikes to the body, fists, kicks, or weapons, but it is virtually always designed to punish

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

what is violence?

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

what is epidemiology of anger, aggression, and violence?

- healthcare and social service workers are 5x as likely to suffer a workplace violence injury than workers overall

- 1 in 4 nurses reported being ohysically assaulted according to a 2019 ANA survey

- workplace violence is underreported and may impair the ability to provide effective patient care

- leads to psychological distress, job dissatisfaction, and absenteeism, all leading to higher turnover and costs

in the hospital setting, violence is most frequently seen in:

- emergency departments

- psychiatric units

- geriatric care units

- intensive care units

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 fists

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

- making increased demands

what are feelings that may precipitate anger?

- anxiety

- discounted

- embarrassed

- frightened

- fear

- humiliated

- hurt

- ignored

- inadequate

- insecure

- unheard

- out of control of the situation

- rejected

- threatened

- tired

- vulnerable

what are situations that may precipitate anger?

- withdrawal/substance abuse or addictions

- diagnosed psychiatric illness

- internal stimuli - auditory hallucinations

- attention seeking

- sleep deprivation

- pain

- stress

- past trauma

- loss of personal power

- difference in expectations or goals

- difference in knowledge

- poor communication

- inaccurate or incomplete information

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

what are warning signs of potential violence?

- hyperactivity (pacing, restlessness) - most important predictor of immenent violence

- increasing anxiety and tension (clenched jaw or fists, rigid posture, fixed or tensed facial expression, mumbling to self)

- loud voice, change of pitch, or very soft voice

- verbal abuse (profanity, argumentativeness)

- possession of a weapon or object that could be a weapon

- stone silence

- intense eye contact or avoidance of eye contact

- recent acts of violence

- isolation that is uncharacteristic

what are milieu characteristics that are conducive to violence?

- environemnt too hot, too cold, or too loud

- overcrowding

- staff inexperience

- controlling staff

- poor limit setting

- revocatiom of privileges

- difference in expectations or goals

general risk identification includes assessing the following:

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

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

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

- hisotry of limited coping skills, including lack of assertiveness or use of intimidation, indicates a higher risk of violence

what are risk assessment identifiers for aggression?

- agitation, restlessness, escalating anxiety

- resistance to suggested treatment

- hisotry of assaultive or threatening behavior

- aggression management has been required at time of a transfer

- known history of drug or alcohol misuse

- cognitive changes that may cause the person to misinterpret the environment of staff care activities (confusion, disorientation, delirium, psychosis/acute hallucinations, delusions)

what is a self assessment?

- like patients, nurses have their own history

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

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

- the nurse must be aware of their choices of words, tone of voice, non verbal communication through body posture and facial expression

what are general interventions?

- ideally interventions should begin prior to any signs of escalation

- having numerous brief non-threatening, non-directive interactions will help in developing a therapeutic relationship

- approach the patient in a controlled, non-threatening and caring manner

- allow the patient enough space so that you are perceives as less of a threat (always stay approximately 1 foot farther than the patient can reach with arms and legs)

- make sure that you csn have an escape route

- patients may invade your space or be verbally abusive. do not take this personal or respond unkind

- speak to the patient slowly and in short sentences using a low and calm voice. never yell but continue to model controlled behavior

- use open ended statements and questions rather than challenging statements

- identify what is behinf the angry feelings and behaviors

- identify the patient's options and encourage the individual to assume responsibility for chouces made

- pay close attention to the environment: choose a quiet place to talk to the patient but one that is visible to staff, staff should know you are working with the patient, keep an eye on the interaction, and be prepared to intervene if the situation escalates

what are consideratios for staff safety?

- maintain appropriate eye contact

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

- try to get the patient to talk to you

- avoid wearing items that dangle (earrings, necklaces, etc.)

- ensure that there is enough backup staff

- always know the layout of the area

- do not stand in front of the patient or in front of the doorway. the patient may view this as confrontational. always stand off to the side and encourage the patient to sit down

- if the patients behavior escalates, provide feedback possibly allowing the patient to explore feelings and hopefully deescalate

what are deescalation techniques?

- respond as early as possible

- assess the patient and the situation

- identify stressors and stress indicators

- determine what the patient considers to be needed/goals

- maintain calmness (your own and the patient's)

- use a calm clear tone of voice

- be genuine and empathetic

- be assertive not aggressive

- avoid arguing

- give several clear options

- remain honest

- maintain the patient's self esteem and dignity

- avoid invading personal space, in times of high anxiety, personal space increases

- do not take chances, maintain personal safety

what are pharmacological interventions when a patient is showing signs or symptoms of anxiety or agitation?

- it is appropriate to offer PRN medication to alleviate symptoms

- when used in conjunction with psychosocial intervention and de-escalation techniques this could prevet aggression and/or violence

- long-term treatment of anger, aggression, and violence is based on treating the underlying psychiatric disorder

how can the nurse respond to strive to offer support, de-escalate, and control the situation?

- noticing changes in the expressions of anxiety, anger, and frustration

- being observant of nonverbal cues

- approaching the person as soon as you suspect a problem

- acknowledge the person's feelings - OK to guess wrong, trying to understand is most important

- initiating dialogue with the person

- encouraging the person to respond/talk to you

what are the do's of nursing responses?

- stay calm and in control, use a calm voice

- try to understand the person's concern

- reflect their emotion

- appear as personable as possible

- offer comfort measures

what are the dont's of nursing responses?

- take the bait

- get defensive

- counterattack

- be easily offended

what does defensiveness look like?

- beginning loss of rationality

- patient asks challenging questions

- the person is stanfing in your personal space, staring/glaring

- refusing your requests, loudly and adamently refusing to go along with treatment, to cooperate for his/her own care or adherence to policy/safety concern, becoming very angry, defensive

- releasing: table pounding, loud sighing, thowing things but not at you, not meant to cause harm

what should the nurse's repsonse be?

- isolate the interaction: move the patient, move others way from the patient, allow yourself an exit

- reduce stimulation in the environment

- speak clearly and slowly

- use non-verbal communication to show what you want the person to do

- use few words

- be firm but with empathy

- allow loud, verbal expression of anger as long as its not threatening

- its not a win-lose situation

- watch your paraverbal, it's how you say what you say

what does intimidation/acting out look like?

- when angry expression turns to hostility and abuse or aggression (any activity that is intended to cause or can cause physical harm)

- may begin as accusations, comments about competence, irrelevant personal remarks

what are danger signs of intimidation/acting out?

- persistent swearing

- sexist or racist comments

- personal or specific threats of harm

- intimidating comments

- terroristic type threats

- any physical behavior directed at a person

what should the nurse's response be for intimidation/acting out?

- call for help/assistance/security/law enforcement/assistance please

- protect yourself: remove yourself from the situation, remove objects in reach of patient that can be used as weapons, position yourself between patient and exit

what are verbal nursing interventions for intimidation/acting out?

- be aware of your non-verbal: don't sign, roll eyes, show frustration, impatience, mutter, laugh, or other actions that further provoke the hostile person

- limit words and actions to focus on directing the patient's actions, "please stay seated" "stop please"

- avoid agreeing just to agree

- if you think patient/person hears you: explain that aggression will no achieve the desired goal

what does tension reduction look like?

a decrease in energy, rationality returns, reachable teachable moment

what are staff interventions/responses for tension reduction?

- re-establish therapeutic rapport with the patient

- revise the plan of care to include the behaviors that may result in repeat subsequent interventions using restraint or seclusion

what is seclusion?

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

what is the goal of seclusion?

- SAFETY for the patient and others

- never punitive

- may only be used for the management of violent self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member, or others

what is restraint?

any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a pateint to moce arms, legs, body, or head freely

seclusion and restraint may only be used:

- as a last resort

- when the patient becomes a danger to themselves or others

- when less restrictive interventions have been determined to be effective to protect the patient or others from harm

- in conjunction with a written modification to the patient's plan of care

- ONLY in accordance with safe and appropriate techniques as determined by hospital policy and state law

what are guidelines for the use of mechanical (physical) restraints?

- indications for use

- legal requirements

- documentation

- clinical assessments

- observation

- release procedure

- restraint tips

what are indications of use for physical restraints?

to protect patients and others from harm

what are legal requirements for physical restraints?

- multidisciplinary involvement

- appropriate healthcare provider order according to state law

- patient advocate or relative notified

- seclusion and restraint discounted as soon as possible

what is documentation for physical restraints?

- behavior(s) leading to seclusion and restraint

- least restrictive measures used prior to seclusion and restraint

- interventions used and patient's response

- plan of care for seclusion and restraint use implemented

- ongoing evaluation by the nursing staff

what are the clinical assessments for physical restraints?

- patient's mental state at time of seclusion and restraint

- physical examination for medical problems possible causing behavior changes

- need for restraint

what observations/assessments must happen at regular intervals with restraint use?

- LOC

- activity level

- assess range of motion

- vital signs

- blood flow in hands and feet

- observe that restraints are not rubbing

- provide for nutrition, hydration, elimination, and comfort

what are release procedures for physical restraints?

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

- termination of restraints

- debrief with patient

what are restraint tips?

- never restrain a patient in prone position

- room that is completely safe without any objects than can be used for self harm

- physical holding of a patient against will is a restraint

- 4 side rails up is a restraint except for seizure precautions

- keeping the patient in their room by physical intervention is seclusion

- tucking sheets in so thightly the patient cannot move is a restraint

- orders fro seclusion/restraint cannot be PRN

what do you need to determine prior to seclusion and restraint?

- who is going to take the lead/be in charge

- who is going to talk to the patient

- who is going to check the seclusion area to ensure that it is ready

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

- who is going to prepare to administer medication

- who is going to do the 1:1 once the patient is in seclusion

- who is going to document

- who is going to lead the debriefing

what are considerations for seclusion and restraint monitoring?

- increased danger in child restraint due to underdeveloped trachea, intercostal muscles and diaphragm, more pliable and more easily restricted by a restraint device

- ALWAYS respond to patient complaints of difficulty breathing - look for intercostal muscle retractions and use of accessory muscles

what might a restrained patient's increased struggling movements indicate?

- attempt to increase airflow

- look for signs of respiratory distress

- check O2 saturation

- late signs include cyanosis around lips and mouth

what might decreased struggling in restraints indicate?

decreased LOC

which medical diagnosis and patient condition might compromise breathing in a restrained patient?

- asthma and obesity - restrain in semi-fowler's position

- pulmonary embolism may pccur due to decreased movement

- since intoxication and withdrawal related to substance use are common reasons for acting out, the nurse must observe for withdrawal s/s

what are contraindications for seclusion and restraint?

- patients who have extremely unstable medical and psychiatric conditions

- chronic obstructive pulmonary disease

- spinal injury

- seizure disorders

- pregnancy

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

what are components of critical incident debriefing?

- could anything been done that would've prevented the episode?

- did the team respond as a team?

- was safety maintained?

- were policies followed?

- how did the actual restraining process go?

- what could be done differently?

- were lessons learned?

- was the patient's dignity respected?

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

what teaching and health promotion can the nurse do?

- model appropriate responses and ways to cope with anger

- teaches a variety of methods to appropriately express anger

- educates about coping skills, de-escalation techniques and self-soothing skills to manage behavior

- assists in identifying triggers for anger and aggression