24

Chapter 24: Anger, Aggression, and Violence

Objectives

• Discuss the interplay between neurobiology, medical history, past history, and sociological/demographic issues that contribute to risks for violence.

• Promote safety by demonstrating the physical indicators of a patient who is beginning to escalate out of control.

• Provide patient-centered care by comparing and contrasting interventions for a patient who is angry and loud in the pre-escalation phase with those for a patient escalating to a more aggressive phase.

• Identify specific safety measures to take when engaged in de-escalating an aggressive individual.

• Plan patient-centered nursing care for a patient in seclusion.

• Incorporate evidence-based practice that describes the use of communication and procedures implemented when placing an individual in restraints.

• Discuss teamwork and collaboration as vital in applying seclusions or restraints to a patient who is a danger to self or others.

• Discuss quality improvement methods that can develop from the process of critical incident debriefing.

• Document an example of the areas for which the nurse must provide written information when violence was averted or occurred.

• Incorporate evidence-based practice by identifying calming and reassuring communication and the optimum milieu in managing a patient whose behaviors are escalating.

Key Terms and Concepts

• Aggression

• Anger

• Bullying

• Catastrophic reaction

• Comfort rooms

• Critical incident debriefing

• Deescalation techniques

• Lateral bullying

• Restraint

• Seclusion

• Violence

Definitions and Explanations

Anger

• Definition: An emotional response to frustration of desires, threat to one’s needs (emotional or physical), or a challenge.

• Characteristics:
    - Indicates a normal, not always logical human emotion.
    - Varies in intensity from mild irritation to intense fury and rage.

Aggression

• Definition: Anger’s motor counterpart; a goal-directed action or behavior that results in a verbal or physical attack.

• Characteristics:
    - Aggression may be appropriate in contexts such as self-defense or self-protection.
    - It is the act of initiating hostility and involves thoughts of attack or a disposition to behave aggressively.

Violence

• Definition: An unjust, unwarranted, or unlawful display of verbal threats, intimidation, or physical force with the intent of causing harm.

• Characteristics:
    - Does not always stem from anger but has a discrete intention of causing harm.
    - Intent is to inflict damage or violate.

Bullying

• Definition: Offensive, intimidating, malicious, and condescending behavior designed to humiliate and terrorize.

• Nature:
    - Implies persistent, systemic violence toward a person or group.
    - Often involves a person or group exerting power over another.

• Lateral Bullying: Occurs between individuals of equal status.

Bullying in the Health Care Environment

• Statistics from ongoing ANA survey:
    - 21% reported significant risk for violence at work.
    - 25% to 50% reported experiencing workplace bullying.
    - 50% reported verbal or nonverbal aggression from peers, and 42% from superiors.

• At-Risk Attributes:
    - Being a new graduate or hire.
    - Receiving undeserved promotions or honors.
    - Handling severe understaffing.

• Examples of bullying behaviors among nurses:
    - Providing unwanted criticism, gossiping, taking credit for work, public ridicule, unrealistic workloads, using sarcasm or ridicule, etc.

Prevalence

• Settings with most frequent violence:
    - Psychiatric units.
    - Emergency departments.
    - Waiting rooms.
    - Geriatric units.

Comorbidity

• Commonly associated conditions:
    - Posttraumatic stress disorder (PTSD).
    - Substance abuse disorders.
    - Co-occurring illnesses, including depression, anxiety, psychosis, and personality disorders.

Theory

• Key Factors Contributing to Violence:
    - Childhood aggression is the strongest predictor of adult violence.
    - Majority of perpetrators are males aged 15 to 24 years.
    - Red flags include setting fires, animal cruelty, and diagnosing conduct disorder in childhood.
    - Many violent adults exhibit a history of childhood violence.
    - Violence related to alcohol or substance abuse and socio-economic status influences victims and perpetrators alike.
    - Neurobiological factors include genetics and brain structure. No single brain site exclusively governs anger and aggression.

Assessment: Subjective Data

• History Gathering:
    - Obtain from a variety of sources including family, friends, and the patient when calm.

• Questions to Assess Risk:
    - 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?

Assessment: Objective Data

• Precursor Signs of Violence:
    - Angry or anxious affect, hyperactivity (most important predictor), increasing anxiety and tension through body language (clenched jaw, rigidity, tense expressions).
    - Recent violence history, substance intoxication, possession of weapons, staff inconsistency, etc.

Assessment Guidelines

1. A history of violence is the best predictor of future violence.

2. Paranoid ideation or psychosis may indicate aggression or violence potential.

3. Hyperactive, impulsive patients present higher risks.

4. Assess intent to harm and demographic risk factors (e.g., male gender, age 15-24, socioeconomic factors).

5. Aggression often occurs during limit-setting by nurses.

6. Recognizing personal triggers and a sense of competence in conflict situations is vital.

Diagnosis

• Prioritization of Safety:

• Common Diagnoses:
    - Ineffective impulse control.
    - Risk for self-directed and other-directed violence.
    - Ineffective coping, risk for stress overload, confusion, and disturbed thought processes.

Outcomes Identification

Short Term Goals

• Patient will display nonviolent behaviors and recognize the onset of anger and aggressive tendencies.

• Plans for long-term therapy aiming at violence prevention and coping skills improvement.

Long Term Goals

• Freedom from injury for the patient and others, cessation of hostile behaviors, and effective use of anxiety reduction techniques.

Planning

• Management Approach:
    - Includes staff proficient in de-escalation techniques.
    - Essential questions to determine planning:
      - Does the patient possess good or marginal coping skills?
      - Does the situation call for immediate intervention?
      - Is the environment conducive to a safe therapeutic milieu?
      - Are staff trained adequately in verbal de-escalation techniques?

Implementation: Ensuring Safety

1. Move individuals to a calm space.

2. Search for contraband upon admission.

3. Give patients space and set clear limits with de-escalation techniques.

4. Use a single spokesperson when addressing the patient.

5. Prepare for restraint/seclusion as per protocols, considering team dynamics and responsibilities.

Stages of the Violence Cycle

• Preassaultive Stage: De-escalation approaches.

• Assaultive Stage: Medication, seclusion, restraint.

• Post-assaultive Stage: Recovery, evaluation, and reintegration protocols.

Preassaultive Stage: De-escalation Techniques

• Pay attention to signs of aggression, maintain self-esteem and dignity, and express genuine concern.

• Use soft, nonprovocative communication, sit at a 45-degree angle to the patient, listen, and clarify their needs.

Assaultive Stage

• Ensure Safety:
    - Move individuals to a quiet place and allow space for retreat.
    - Establish limits clearly and avoid contact unless necessary.

• Restraints and Seclusion:
    - Only used when patients pose threats, with physician orders and thorough documentation required post-incident.

Nursing Care: Seclusion/Restraint

• Seclusion: Involuntary confinement; must be the least restrictive means employed after other interventions have failed.

• Team organization is critical before approaching any patient for restraint/seclusion.

Alternatives to Seclusion and Restraint

• Evidence demonstrates psychological harm caused by these practices.

• New approaches include comfort rooms for self-management and trauma-informed care principles.

Trauma-Informed Approach Principles

1. Safety

2. Trustworthiness and transparency

3. Peer support

4. Collaboration and mutuality

5. Empowerment, voice, and choice

6. Cultural, historical, and gender issues

Post-assaultive Stage

• Critical incident debriefing for staff analysis to ensure quality care and evaluate the effectiveness of responses.

Documentation

• Must include reason for seclusion/restraint, assessment, nursing interventions and responses, and time of application.

Anticipating Anxiety and Anger

• Self-knowledge and recognition of personal responses to aggression are critical for therapeutic nursing care.

Audience Response Questions

• Questions based on patient scenarios assessing best initial nursing interventions in situations of aggression or agitation are critical to developing practical decision-making skills.

Pharmacologic Interventions

• Acute Aggression: Use of benzodiazepines and second-generation antipsychotics.

• Chronic Aggression: Utilization of anticonvulsants, antipsychotics, beta-blockers, and SSRIs.

Evaluation

• Accuracy of assessments, applicable diagnoses, appropriateness of interventions, and adherence to protocols should be evaluated post-incident to inform future care practices.

Conclusion

• Understanding anger, aggression, violence, and their clinical management through structured interventions, documentation, and self-regulation strategies is vital for maintaining safety in health care settings.