anger, hostility, and aggression lecture version

Anger, Hostility, Anger, Hostility, and Aggressionand Aggression

Nursing 225Nursing 225

Psychiatric Mental Health Psychiatric Mental Health NursingNursing

Spring 2010Spring 2010

AngerAnger Anger is a Anger is a normalnormal human emotion. human emotion. It is a positive emotion that can It is a positive emotion that can

motivate a person to resolve conflicts, motivate a person to resolve conflicts, solve problems, and make decisions.solve problems, and make decisions.

Anger can also energize the body for Anger can also energize the body for self-defense (fight or flight response).self-defense (fight or flight response).

Anger arousal is a personal signal of Anger arousal is a personal signal of threat or injustice against the self. The threat or injustice against the self. The signal elicits coping responses to deal signal elicits coping responses to deal with the stress.with the stress.

AngerAnger

Anger is constructive when it Anger is constructive when it provides a feeling of control over a provides a feeling of control over a situation and the individual is able situation and the individual is able to assertively take charge of a to assertively take charge of a situation.situation.

Anger is constructive when it is Anger is constructive when it is expressed assertively, serves to expressed assertively, serves to increase self-esteem, and leads to increase self-esteem, and leads to mutual understanding and mutual understanding and forgivenessforgiveness

ANGERANGER

AngerAnger is a strong, is a strong, uncomfortable, emotional uncomfortable, emotional response to a provocation, response to a provocation, either real or perceived.either real or perceived.

HostilityHostility and and AggressionAggression are are inappropriateinappropriate expressions expressions of anger.of anger.

AngerAnger Inappropriate expressions of anger Inappropriate expressions of anger

may result in impulsive behavior, may result in impulsive behavior, disregarding possible negative disregarding possible negative consequences.consequences.

Communicated aggressively, conflict Communicated aggressively, conflict escalates, and the problem that escalates, and the problem that created the conflict goes unresolved.created the conflict goes unresolved.

Anger can lead to aggression when Anger can lead to aggression when the coping response is displacement the coping response is displacement (kick the cat)(kick the cat)

*Denying or suppressing angry *Denying or suppressing angry feelings can lead to physical or feelings can lead to physical or emotional problems.emotional problems.*Depression is sometimes *Depression is sometimes described as anger turned described as anger turned inward.inward.*Appropriate expression of *Appropriate expression of anger involves assertive anger involves assertive communication skills leading to communication skills leading to problem solving or conflict problem solving or conflict resolution.resolution.

Factors that Contribute to Factors that Contribute to Aggressive BehaviorAggressive Behavior

Attitudes about work Attitudes about work Level of educationLevel of education Religious choices Religious choices Exposure to the media Exposure to the media Population problems, overcrowding, Population problems, overcrowding,

limited resources limited resources Unavailability of community Unavailability of community

resources resources

Hostile BehaviorHostile Behavior

Several studies have demonstrated Several studies have demonstrated that significant immune mediated that significant immune mediated changes occur in people who changes occur in people who displayed hostile or negative displayed hostile or negative behaviors. behaviors.

Blood Pressure changes occur in Blood Pressure changes occur in people who display hostile or people who display hostile or negative behaviors during periods of negative behaviors during periods of conflict.conflict.

Hostility and AggressionHostility and Aggression

The hostile aggressive The hostile aggressive behavior may occur behavior may occur suddenly without suddenly without warning, but often times warning, but often times stagesstages or or phasesphases can be can be identified.identified.

1. Triggering1. Triggering

DefinitionDefinition-An -An event or event or circumstances in circumstances in the environment the environment initiates the initiates the client’s response client’s response which is often which is often either anger or either anger or hostility.hostility.

BehaviorBehavior RestlessnessRestlessness AnxietyAnxiety IrritabilityIrritability PacingPacing Muscle TensionMuscle Tension Rapid BreathingRapid Breathing PerspirationPerspiration Loud VoiceLoud Voice AngerAnger

(Full Metal Jacket)

Predictors for Violent Predictors for Violent BehaviorBehavior

The strongest risk factor for violent The strongest risk factor for violent behavior is a previous history of behavior is a previous history of violent behaviorviolent behavior

It is sometimes helpful to ask the It is sometimes helpful to ask the client to assess his/or her own client to assess his/or her own potential for violence-some clients on potential for violence-some clients on the unit will verbalize to you that the unit will verbalize to you that they feel angry enough to hit they feel angry enough to hit someonesomeone

Violent Aggressive BehaviorViolent Aggressive Behavior

Contract with the client to use Contract with the client to use nonviolent methods to control angernonviolent methods to control anger

Be prepared to use seclusion if Be prepared to use seclusion if escalation with potential for violence escalation with potential for violence existsexists

Nursing ImplicationsNursing Implications Approach in a calm, nonthreatening Approach in a calm, nonthreatening

mannermanner Convey empathy for their anger or Convey empathy for their anger or

frustration as appropriatefrustration as appropriate Encourage the client to verbalize feelingsEncourage the client to verbalize feelings Use clear, simple, short statementsUse clear, simple, short statements Suggest moving to a quiet area and move Suggest moving to a quiet area and move

other clients to decrease stimulationother clients to decrease stimulation

Nursing ImplicationsNursing Implications

Offer PRN medication as ordered.Offer PRN medication as ordered. Physical activity such as walking may Physical activity such as walking may

help the client to relax and become help the client to relax and become calmer.calmer.

(In the triggering phase, remember (In the triggering phase, remember we still have the ability to we still have the ability to communicate with the client-we are communicate with the client-we are still in the talking phase)still in the talking phase)

2. Escalation2. Escalation

Behavior indicates Behavior indicates a movement a movement toward loss of toward loss of control. The control. The client has lost client has lost the ability to the ability to problem solve or problem solve or think clearlythink clearly

Pale/Flushed FacePale/Flushed Face Yelling/SwearingYelling/Swearing AgitatedAgitated ThreateningThreatening DemandingDemanding Clenched fistsClenched fists HostilityHostility


The nurse must take control of the The nurse must take control of the situationsituation

Provide directions in a calm, firm, voiceProvide directions in a calm, firm, voice Direct client to a time out or cooling off Direct client to a time out or cooling off

period in a quiet area or in their roomperiod in a quiet area or in their room Emphasize to the client that aggressive Emphasize to the client that aggressive

behavior is not acceptable and the behavior is not acceptable and the nurse is there to help them regain nurse is there to help them regain controlcontrol

Time Out to Cool Off!!Time Out to Cool Off!!


If the client refused PRN medication If the client refused PRN medication during the triggering phase, offer it during the triggering phase, offer it again at this timeagain at this time

If they are unwilling to take a time If they are unwilling to take a time out, obtain assistance from several out, obtain assistance from several other staff members who will be other staff members who will be within sight, but not as close as the within sight, but not as close as the primary staff member who is dealing primary staff member who is dealing directly with the patient. (Show of directly with the patient. (Show of force)force)


This is known as a “show of force” This is known as a “show of force” and sometimes (hopefully) the client and sometimes (hopefully) the client will take meds and a timeout. This will take meds and a timeout. This also reinforces to the client that the also reinforces to the client that the staff is in control and will control the staff is in control and will control the situation if the client is unable to do situation if the client is unable to do so.so.

3. Crisis3. Crisis

The client The client completely completely loses loses physicalphysical and emotional and emotional controlcontrol

We have passed We have passed the talking the talking stagestage

BehaviorsBehaviorsThrowingThrowingKickingKickingScreaming Screaming BitingBitingScratchingScratchingSpittingSpittingInability to Inability to communicate communicate clearlyclearly


ONLY STAFF WITH SPECIALIZED ONLY STAFF WITH SPECIALIZED TRAINING SHOULD PARTICIPATE TRAINING SHOULD PARTICIPATE IN THE RESTRAINT OF A IN THE RESTRAINT OF A PHYSICALLY AGGRESSIVE CLIENTPHYSICALLY AGGRESSIVE CLIENT

The students’ role is to remove the The students’ role is to remove the “audience” i.e. escort other patients “audience” i.e. escort other patients to their rooms or community room to their rooms or community room and close the door until the situation and close the door until the situation is under control.is under control.


When restraint or seclusion is used, When restraint or seclusion is used, the nurse must then phone the the nurse must then phone the physician and obtain the order. physician and obtain the order. Requirements can vary from state to Requirements can vary from state to state and facility to facility as to the state and facility to facility as to the time frame in which the physician time frame in which the physician must evaluate the patient.must evaluate the patient.

Aggressive children, females, and Aggressive children, females, and elderly clients can be just as difficult to elderly clients can be just as difficult to restrain as adult males can be. restrain as adult males can be.


PRN Medication should be given (if PRN Medication should be given (if not already administered) as soon as not already administered) as soon as the patient is safely restrained.the patient is safely restrained.

The patient is closely observed in The patient is closely observed in seclusion and the nurse documents seclusion and the nurse documents the patients behaviorthe patients behavior

4. Recovery4. Recovery

Client regains Client regains physical and physical and emotional emotional controlcontrol

BehaviorsBehaviors Lowering of voiceLowering of voice Decreased muscle Decreased muscle

tensiontension Clearer, more Clearer, more

rational rational communicationcommunication

Physical relaxationPhysical relaxation

Nursing ImplicationsNursing Implications As the client regains control during the As the client regains control during the

recovery phase, encourage discussion recovery phase, encourage discussion about the situation or triggers that led about the situation or triggers that led up to the aggressive behaviorup to the aggressive behavior

Encourage rest, relaxation, and sleepEncourage rest, relaxation, and sleep Assist the client to explore alternatives Assist the client to explore alternatives

to the aggressive behaviorto the aggressive behavior Assess staff members for injuries, and Assess staff members for injuries, and

debrief with the staff and evaluate how debrief with the staff and evaluate how the situation was handled.the situation was handled.

5. Postcrisis5. Postcrisis

Attempts Attempts reconciliation with reconciliation with others and returns others and returns to previous level of to previous level of functioning before functioning before the incidentthe incident

BehaviorsBehaviors RemorseRemorse ApologiesApologies CryingCrying Quiet, withdrawn Quiet, withdrawn

behaviorbehavior


Restraints are removed as per Restraints are removed as per protocolprotocol

DO NOT lecture or chastise but instead DO NOT lecture or chastise but instead discuss the behavior in a calm rational discuss the behavior in a calm rational manner.manner.

Reintegrate the patient into the unit Reintegrate the patient into the unit and unit activities as soon as they are and unit activities as soon as they are ready to participate.ready to participate.

DO NOT discuss the incident in detail DO NOT discuss the incident in detail with the other clients on the unit.with the other clients on the unit.

Core Concept-AngerCore Concept-AngerAnger is an emotional state that Anger is an emotional state that

varies in intensity from mild varies in intensity from mild irritation to intense fury and irritation to intense fury and rage. It is accompanied by rage. It is accompanied by physiological and biological physiological and biological changes, such as increases in changes, such as increases in heart rate, blood pressure, and heart rate, blood pressure, and levels of the hormones levels of the hormones epinephrine and norepinephrine epinephrine and norepinephrine (APA, 2006a).(APA, 2006a).

Core Concept-AggressionCore Concept-Aggression Aggression is a behavior intended to Aggression is a behavior intended to

threaten or injure the victim’s security or threaten or injure the victim’s security or self-esteem. It means to “go against,” “to self-esteem. It means to “go against,” “to assault,” or “to attack.” It is a response assault,” or “to attack.” It is a response that aims at inflicting pain or injury on that aims at inflicting pain or injury on objects or persons. Whether the damage objects or persons. Whether the damage is caused by words, fists, or weapons, the is caused by words, fists, or weapons, the behavior is virtually always designed to behavior is virtually always designed to punish. It is frequently accompanied by punish. It is frequently accompanied by bitterness, meanness, and ridicule. An bitterness, meanness, and ridicule. An aggressive person is often vengeful aggressive person is often vengeful (Warren, 1990).(Warren, 1990).

Related DisordersRelated Disorders

About 90 percent of psychiatric About 90 percent of psychiatric patients are portrayed in the media patients are portrayed in the media as violent, but in reality only about as violent, but in reality only about 10 percent exhibit angry, hostile, or 10 percent exhibit angry, hostile, or aggressive behavior.aggressive behavior.

Clients with psychiatric disorders are Clients with psychiatric disorders are much more likely to harm much more likely to harm themselves than others.themselves than others.

CausesCauses Clients with paranoid delusions are Clients with paranoid delusions are

attempting to protect themselves from attempting to protect themselves from self-perceived threats.self-perceived threats.

Clients with auditory or command Clients with auditory or command hallucinations telling them to hurt someone hallucinations telling them to hurt someone or someone is going to hurt themor someone is going to hurt them

Clients with dementia, delirium, head Clients with dementia, delirium, head injury, and intoxication with ETOH/drugsinjury, and intoxication with ETOH/drugs

Antisocial and borderline personality Antisocial and borderline personality disorder patientsdisorder patients

Younger malesYounger males

CausesCauses

Clients with depression may have Clients with depression may have outbursts of anger due to feelings of being outbursts of anger due to feelings of being emotionally trapped.emotionally trapped.

These outbursts are verbal only-no threats These outbursts are verbal only-no threats of physical aggression.of physical aggression.

The outburst is uncharacteristic of the The outburst is uncharacteristic of the client’s personality, inappropriate to the client’s personality, inappropriate to the situation, and followed by remorse.situation, and followed by remorse.

Often related to irritable mood, Often related to irritable mood, overreaction to minor annoyances, and overreaction to minor annoyances, and decreased coping skillsdecreased coping skills

Important to NoteImportant to Note

Psychiatric patients who tend to be Psychiatric patients who tend to be more aggressive are those whose illness more aggressive are those whose illness is is more symptomaticmore symptomatic and possess a and possess a marked lack of marked lack of insightinsight (the ability to (the ability to understand the true nature of one’s understand the true nature of one’s situation and accept some responsibility situation and accept some responsibility for that situation) and for that situation) and judgmentjudgment (the (the ability to interpret one’s environment ability to interpret one’s environment and situation correctly and to adapt and situation correctly and to adapt one’s behavior and decisions one’s behavior and decisions accordingly.accordingly.

Important to noteImportant to note

The highest rates of aggression and The highest rates of aggression and hostility among psychiatric patients hostility among psychiatric patients tend to be older males with tend to be older males with schizophrenia and younger males schizophrenia and younger males and females with personality and females with personality disorders.disorders.

All patients and visitors throughout All patients and visitors throughout the hospital have the potential to the hospital have the potential to become hostile and aggressive. It is become hostile and aggressive. It is a response when one feels powerlessa response when one feels powerless

Intermittent Explosive Intermittent Explosive DisorderDisorder

RareRare psychiatric diagnosis involving psychiatric diagnosis involving discrete episodes of aggressive discrete episodes of aggressive impulses resulting in serious injury or impulses resulting in serious injury or property damage property damage

Episodes are out of proportion to any Episodes are out of proportion to any provocation, and the person is provocation, and the person is remorseful and embarrassed remorseful and embarrassed afterward. afterward.

(IED)(IED) Intermittent explosive disorder is Intermittent explosive disorder is

characterized by repeated episodes of characterized by repeated episodes of aggressive, violent behavior in which you aggressive, violent behavior in which you react grossly out of proportion to the react grossly out of proportion to the situation. Road rage, domestic abuse, situation. Road rage, domestic abuse, and angry outbursts or temper tantrums and angry outbursts or temper tantrums that involve throwing or breaking objects that involve throwing or breaking objects may be signs of intermittent explosive may be signs of intermittent explosive disorderdisorder

Client is nonviolent between episodes Client is nonviolent between episodes

Acting OutActing Out

An immature defense mechanismAn immature defense mechanism The person uses actions (verbal or The person uses actions (verbal or

physical aggression) rather than physical aggression) rather than reflections or feelings to deal with reflections or feelings to deal with emotional conflicts or stressorsemotional conflicts or stressors

Serves to help the person feel less Serves to help the person feel less helpless or powerlesshelpless or powerless

Often used by children and Often used by children and adolescentsadolescents

Etiology of Hostility and Etiology of Hostility and AggressionAggression

Neurobiological theoriesNeurobiological theories: decreased : decreased serotonin, increased dopamine and serotonin, increased dopamine and norepinephrine; structural damage to norepinephrine; structural damage to limbic system, damage to frontal or limbic system, damage to frontal or temporal lobestemporal lobes

Hormonal (testosterone)Hormonal (testosterone) Psychosocial theoriesPsychosocial theories: failure to develop : failure to develop

impulse control and ability to delay impulse control and ability to delay gratification, gratification, Monkey See Monkey DoMonkey See Monkey Do

General lack of social and personal General lack of social and personal accountabilityaccountability

Cultural ConsiderationsCultural Considerations

In certain cultures, expressing anger In certain cultures, expressing anger may be seen as rude or disrespectful may be seen as rude or disrespectful (certain Asian cultures/Native (certain Asian cultures/Native Americans); some culture-bound Americans); some culture-bound syndromes (West Africa/Haiti) involve syndromes (West Africa/Haiti) involve aggressive, agitated, or violent aggressive, agitated, or violent behavior behavior

Some cultures view cause of physical Some cultures view cause of physical illness to be unexpressed angerillness to be unexpressed anger

Treatments and Treatments and MedicationsMedications

Treatment often focuses on treating Treatment often focuses on treating the underlying or comorbid psychiatric the underlying or comorbid psychiatric diagnosis such as schizophrenia or diagnosis such as schizophrenia or bipolar disorder. If the individual is bipolar disorder. If the individual is having angry outburst due to low having angry outburst due to low serotonin for example, use of SSRIs serotonin for example, use of SSRIs such as Prozac or Paxil will often assist such as Prozac or Paxil will often assist the patient controlling inappropriate the patient controlling inappropriate behavior in social situations.behavior in social situations.

Pharmacology for Aggressive Pharmacology for Aggressive ClientsClients

Lithium for bipolar disorder, conduct disorder, or Lithium for bipolar disorder, conduct disorder, or mental retardationmental retardation

Carbamazepine (Tegretol) or Valproate Carbamazepine (Tegretol) or Valproate (Depakote) for dementia, psychosis, or (Depakote) for dementia, psychosis, or personality disorderspersonality disorders

Atypical antipsychotics such as Clozapine Atypical antipsychotics such as Clozapine (Clozaril), Risperidone (Risperdal), and (Clozaril), Risperidone (Risperdal), and Olanzapine (Zyprexa) for dementia, brain injury, Olanzapine (Zyprexa) for dementia, brain injury, mental retardation, and personality disordersmental retardation, and personality disorders

Benzodiazepines e.g. Xanax for dementiaBenzodiazepines e.g. Xanax for dementia Ziprasidone (Geodon), Haloperidol (Haldol) and Haloperidol (Haldol) and

lorazepam (Ativan) for clients with psychoseslorazepam (Ativan) for clients with psychoses

Common nursing diagnoses:Common nursing diagnoses:

Risk for Other-Directed ViolenceRisk for Other-Directed Violence Ineffective Coping Ineffective Coping

Expected Goals/OutcomesExpected Goals/Outcomes

The client will:The client will: Not harm self or harm/threaten Not harm self or harm/threaten

othersothers Refrain from intimidating or Refrain from intimidating or

frightening behaviorsfrightening behaviors Describe feelings and concerns Describe feelings and concerns

without aggressionwithout aggression Comply with treatmentComply with treatment

InterventionsInterventions

Different for each phase of the Different for each phase of the aggression cycle as we discussed aggression cycle as we discussed earlier when we defined them earlier when we defined them individually.individually.

Pages 182-185 has a detailed care Pages 182-185 has a detailed care plan for aggressive behavior.plan for aggressive behavior.

EvaluationEvaluation

Was the client’s anger defused in an Was the client’s anger defused in an early stage? early stage?

Did the angry, hostile, and Did the angry, hostile, and potentially aggressive client learn to potentially aggressive client learn to express feelings verbally and safely express feelings verbally and safely without threats or harm to others or without threats or harm to others or destruction of property?destruction of property?

Tips for Controlling AngerTips for Controlling Anger Take a 'timeout.' Although it may seem cliché, Take a 'timeout.' Although it may seem cliché,

counting to 10 before reacting really can defuse counting to 10 before reacting really can defuse your temper.your temper.

Get some space. Take a break from the person Get some space. Take a break from the person you're angry with until your frustrations subside you're angry with until your frustrations subside a bit.a bit.

Once you're calm, express your anger. It's Once you're calm, express your anger. It's healthy to express your frustration in a healthy to express your frustration in a nonconfrontational way. Stewing about it can nonconfrontational way. Stewing about it can make the situation worse.make the situation worse.

Get some exercise. Physical activity can provide Get some exercise. Physical activity can provide an outlet for your emotions, especially if you're an outlet for your emotions, especially if you're about to erupt. Go for a brisk walk or a run, about to erupt. Go for a brisk walk or a run, swim, lift weights or shoot baskets.swim, lift weights or shoot baskets.

Think carefully before you say anything. Think carefully before you say anything. Otherwise, you're likely to say something you'll Otherwise, you're likely to say something you'll regret. It can be helpful to write down what you regret. It can be helpful to write down what you want to say so that you can stick to the issues. want to say so that you can stick to the issues. When you're angry, it's easy to get sidetracked.When you're angry, it's easy to get sidetracked.

Tips for Controlling AngerTips for Controlling Anger Identify solutions to the situation. Instead of focusing Identify solutions to the situation. Instead of focusing

on what made you mad, work with the person who on what made you mad, work with the person who angered you to resolve the issue at hand.angered you to resolve the issue at hand.

Use 'I' statements when describing the problem. This Use 'I' statements when describing the problem. This will help you to avoid criticizing or placing blame, which will help you to avoid criticizing or placing blame, which can make the other person angry or resentful — and can make the other person angry or resentful — and increase tension. For instance, say, "I'm upset you didn't increase tension. For instance, say, "I'm upset you didn't help with the housework this evening," instead of, "You help with the housework this evening," instead of, "You should have helped with the housework."should have helped with the housework."

Don't hold a grudge. If you can forgive the other person, Don't hold a grudge. If you can forgive the other person, it will help you both. It's unrealistic to expect everyone it will help you both. It's unrealistic to expect everyone to behave exactly as you want.to behave exactly as you want.

Use humor to release tensions. Lightening up can help Use humor to release tensions. Lightening up can help diffuse tension. Don't use sarcasm, though — it's can diffuse tension. Don't use sarcasm, though — it's can hurt feelings and make things worse.hurt feelings and make things worse.

Practice relaxation skills. Learning skills to relax and de-Practice relaxation skills. Learning skills to relax and de-stress can also help control your temper when it may stress can also help control your temper when it may flare up. Practice deep-breathing exercises, visualize a flare up. Practice deep-breathing exercises, visualize a relaxing scene, or repeat a calming word or phrase to relaxing scene, or repeat a calming word or phrase to yourself, such as "Take it easy." Other proven ways to yourself, such as "Take it easy." Other proven ways to ease anger include listening to music, writing in a ease anger include listening to music, writing in a journal and doing yoga.journal and doing yoga.

Post Discharge/Community Post Discharge/Community Based CareBased Care

Regular follow-up appointments, Regular follow-up appointments, individual and group psychotherapy, individual and group psychotherapy, compliance with prescribed medication, compliance with prescribed medication, and participation in community support and participation in community support programs help the client to achieve programs help the client to achieve stabilitystability

Anger management groups are available Anger management groups are available to help clients express their feelings and to help clients express their feelings and learn problem-solving and conflict-learn problem-solving and conflict-resolution techniquesresolution techniques

Self-Awareness IssuesSelf-Awareness Issues How nurse handles own angry feelingsHow nurse handles own angry feelings Level of comfort with expression of anger Level of comfort with expression of anger

from othersfrom others Ability to be calm, nonjudgmentalAbility to be calm, nonjudgmental Nurse must have assertive Nurse must have assertive

communication skills, conflict resolution communication skills, conflict resolution skills, ability to see that client’s skills, ability to see that client’s behavior/anger is not a personal attack or behavior/anger is not a personal attack or a sign of nurse’s failure, and ability to a sign of nurse’s failure, and ability to deal with own fear when clients are deal with own fear when clients are aggressive or threateningaggressive or threatening

BEHAVIORAL APPROACHESBEHAVIORAL APPROACHES

Aggressive, violent clientsAggressive, violent clients

Avoid isolating yourself or being Avoid isolating yourself or being alone with a client who has a alone with a client who has a potential for violence. Remember potential for violence. Remember that a history of violence is the best that a history of violence is the best predictor of future violent episodes. predictor of future violent episodes. If a client becomes aggressive while If a client becomes aggressive while you are with him or her, give the you are with him or her, give the client space and keep some client space and keep some distance away – DO NOT move distance away – DO NOT move closer to or touch the client. closer to or touch the client.

BEHAVIORAL APPROACHES BEHAVIORAL APPROACHES for Increased for Increased

Agitation/AnxietyAgitation/AnxietyDo not turn your back on the Do not turn your back on the

client. Use a calm, quiet tone of client. Use a calm, quiet tone of voice, and encourage the client voice, and encourage the client to verbalize feelings instead of to verbalize feelings instead of acting them out. Avoid acting them out. Avoid threatening or expressing a threatening or expressing a judgmental, punitive attitudejudgmental, punitive attitude

Behavioral ApproachesBehavioral ApproachesIncreased Agitation/AnxietyIncreased Agitation/Anxiety

Use nonthreatening body Use nonthreatening body languagelanguage– Arms visible at sides-palms Arms visible at sides-palms

outwardoutward– Keep distance-arms length or Keep distance-arms length or

greatergreater– Avoid body contact-do not touch Avoid body contact-do not touch

client at this timeclient at this time

Behavioral Approaches Behavioral Approaches Escalation to ViolenceEscalation to Violence

Intercede early to diffuse the situation as Intercede early to diffuse the situation as quickly as possiblequickly as possible

Continue nonthreatening behaviorContinue nonthreatening behavior If restraint or seclusion is warranted enlist If restraint or seclusion is warranted enlist

the assistance of at least four qualified the assistance of at least four qualified staff members. (Follow policy)staff members. (Follow policy)

Move in organized, calm manner, stating Move in organized, calm manner, stating you wish to help the client and you will you wish to help the client and you will not permit him/her to harm self or othersnot permit him/her to harm self or others

BEHAVIORAL APPROACHESBEHAVIORAL APPROACHES

Call for nursing staff Call for nursing staff assistance as soon as assistance as soon as possible if a client becomes possible if a client becomes increasingly agitated or increasingly agitated or begins acting out in any waybegins acting out in any way..

Aggression: Escalation Aggression: Escalation PhasePhase

Clinical VignetteClinical Vignette– JohnJohn

Identify risk factors for Identify risk factors for violenceviolence

Risk Factors for ViolenceRisk Factors for Violence

SchizophrenicSchizophrenic– Hearing voices that the staff are trying Hearing voices that the staff are trying

to kill him. (Self preservation/survival is to kill him. (Self preservation/survival is one of our most basic instincts). John one of our most basic instincts). John feels threatened-real or perceived threatfeels threatened-real or perceived threat

– Off meds for two weeks (altered thought Off meds for two weeks (altered thought processes) Schizophrenia is a disorder of processes) Schizophrenia is a disorder of thought.thought.

Risk factors for violenceRisk factors for violence

Younger males (hormone-Younger males (hormone-testosterone) are more prone to testosterone) are more prone to aggressionaggression

Behaviors-Verbal and Behaviors-Verbal and NonverbalNonverbal

Pacing in the hall (Triggering Phase)Pacing in the hall (Triggering Phase) Muttering to himself (Triggering Phase)Muttering to himself (Triggering Phase) Avoiding close contact with anyone else Avoiding close contact with anyone else

(Trig)(Trig) Yells “I can’t take it” “I can’t stay here” Yells “I can’t take it” “I can’t stay here”

(Esc.)(Esc.) Fists are “clenched” (Esc.)Fists are “clenched” (Esc.) Appears very “agitated” (Esc.)Appears very “agitated” (Esc.) (The above behaviors indicate we are still in (The above behaviors indicate we are still in

the talking phase and the nurse can attempt the talking phase and the nurse can attempt to diffuse the situation)to diffuse the situation)

Attempted Interventions by the Attempted Interventions by the NurseNurse

Approaches John at a safe distance (six Approaches John at a safe distance (six feet)feet)

Nurse says “John, tell me what is Nurse says “John, tell me what is happening.” happening.”

Nurse correctly-Recognized signs of Nurse correctly-Recognized signs of impending violence, spoke calmly with impending violence, spoke calmly with nonthreatening body language, and nonthreatening body language, and attempted to help John verbalize attempted to help John verbalize feelingsfeelings

Signs Indicating Client has Signs Indicating Client has Moved to Crisis PhaseMoved to Crisis Phase

John runs to the end of the hall and John runs to the end of the hall and will no longer talk to the nurse (Loss will no longer talk to the nurse (Loss of emotional and physical control)of emotional and physical control)

Note-the nurse once again tries to Note-the nurse once again tries to get John to agree to take prn meds get John to agree to take prn meds and a time-out.and a time-out.

John refuses but now John picks up John refuses but now John picks up objects from a nearby table (nurse objects from a nearby table (nurse recognizes that violence is imminent.recognizes that violence is imminent.

Crisis PhaseCrisis Phase

During a period of emotional and During a period of emotional and physical crisis, the client loses control.physical crisis, the client loses control.

Signs, symptoms, and behaviors Signs, symptoms, and behaviors include loss of emotional and physical include loss of emotional and physical control, throwing objects, kicking, control, throwing objects, kicking, hitting, spitting, biting, scratching hitting, spitting, biting, scratching shrieking, screaming, and/or inability to shrieking, screaming, and/or inability to communicate clearlycommunicate clearly

Nsg. Interventions during the Nsg. Interventions during the Crisis PhaseCrisis Phase

When John began to pick up objects to When John began to pick up objects to obviously throw at the nurse, the nurse obviously throw at the nurse, the nurse then then summoned assistance from other summoned assistance from other staff members. staff members. Four to six staff should Four to six staff should remain ready and in sight, but not as remain ready and in sight, but not as close as the primary nurse. This close as the primary nurse. This technique is known as a “show of force” technique is known as a “show of force” and indicates to the client that if he is and indicates to the client that if he is unable to control himself, then there are unable to control himself, then there are those who will assist him in regaining those who will assist him in regaining controlcontrol

Review QuestionsReview Questions

anger, hostility, and aggression lecture version

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