This slides explains the Management of aggression in patients with psychiatric illness. Aggression management is one of the important job responsibility of mental health nurse

1. Management of Aggression in
patients with Psychiatric Illness
Presentor: Mr. Muthuvenkatachalam

2. Aggression
• Aggression is a complex human behaviour that
has been developed through evolution to enhance
the individual’s and group’s safety and survival.
• Ferguson and Beaver1
(2009) defined aggressive
behavior as "Behavior which is intended to
increase the social dominance of the organism
relative to the dominance position of other
organisms".
1. Ferguson, C.J.; Beaver, K.M. (2009). "Natural Born Killers: The Genetic Origins of Extreme Violence". Aggression and Violent
Behavior 14 (5): 286-294. (Internet Document) Available rom: http://www.tamiu.edu/~cferguson/NBK.pdf.

3. Anger, Aggression and Violence
• Anger
– Anger is an emotion related to one's psychological
interpretation of having been offended, wronged or
denied and a tendency to undo that by retaliation.
– It is a feedback mechanism in which an unpleasant
stimulus is met with an unpleasant response.
– Videbeck1
describes anger as a normal emotion
that involves a strong uncomfortable and emotional
response to a perceived provocation.
Videbeck, Sheila L. Psychiatric Mental Health Nursing (3rd ed. 2006). Lippincott Williams & Wilkins.

4. Anger, Aggression and Violence (Contd.)
• Aggression
– Aggression is a behavior characterized by strong
self-assertion with hostile or harmful tones.
– Under some circumstances, aggression may be
a normal reaction to a threat.
– Alternatively, it may be abnormal, unprovoked or
reactive behavior. Anger, confusion, discomfort,
fear, overstimulation and tiredness can lead to
aggressive reactions.
Videbeck, Sheila L. Psychiatric Mental Health Nursing (3rd ed. 2006). Lippincott Williams & Wilkins.

5. Anger, Aggression and Violence (contd.)
• Violence
– Violence is not a synonym for acting out
behaviour.
– Violence refers to the intentional use of physical
force or power against oneself, another person,
or against a group or community where as acting
out behavior refers to problem behavior that is
physically aggressive, destructive to property,
verbally aggressive, or otherwise more severe
than simple misbehavior.
Videbeck, Sheila L. Psychiatric Mental Health Nursing (3rd ed. 2006). Lippincott Williams & Wilkins.

6. Aggressive behaviour by mentally ill
Three distinguishable reasons.
1.Violence can be directly related to psychic
symptoms such as delusions or
hallucinations
2.It can be a consequence of impulsiveness
due to the mental disorder, to intoxication or
to axis II disorders, and
3.It can be related to antisocial behaviour
and/or personality traits.

7. Types of Aggression
– Verbal aggression
– Physical aggression againstothers
– Physical aggression against property or
objects.
– Physical aggression against self.

8. Incidence of Acting out behaviour among
mentallyy ill patients
• 18% to 25% of inpatient psychiatric patients
exhibit violent behavior as per the various
studies.
• 10-25% of the patients with schizophrenia
exhibit acting out behavior during their stay in
hospital.1
• No gender differences in terms of aggressive
behaviour.
. NIH/National Institute of Mental Health (2007, July 4). Violence In Schizophrenia Patients More Likely Among Those With Childhood
Conduct Problems. (internet document) ScienceDaily. Retrieved August 30, 2011, from http://www.sciencedaily.com¬ /release

9. Causes of acting out behaviour in patient with
psychiatric disorder
• Psychopathology
• Environment
• Neurophysiological disorder
• Trauma to the brain
• Frustration
• Direct provocation
• Personality trait
• Substance use disorder

10. Impact of Aggressive behaviour by patient on
care of patient
• Violence during psychiatric hospitalization has
unique implications for both patients, treatment
facilities, and for research on violence.
• Staff and patients may get physically injured and
may become psychologically disturbed, property
is destroyed, and regimes and programs are
disrupted and thereby impoverished.

11. Management of Aggression
• Today’s ideology of humane psychiatric care
and treatment is founded upon a double set of
values.
How can these values coexist?

12. Management of Aggression
• Prevention: environment
and alarm systems
• Prediction:
antecedents,warning
signs and risk
assessment
• training
• working with clients and
family caregivers
• De-escalation techniques
• Observation
• Psychosocial
interventions
• Seclusion
• rapid tranquillisation
• physical interventions
• post-incident review

13. General Principles of Management
• The safety of patient, clinician , staff ,other
patients and potential intended victims.
• The doors should be open outwards and not be
lockable from inside or capable of being blocked
from inside.
• One must take care to reduce accessibility to
patients of movable objects as well as jewellery,
earrings, eyeglasses, lamps and pens.

14. General Principles of Management
(contd.)
• Adequate caregiver training
• Availability of appropriate supervision
• Constant Observation in a calm and firm but
respectful manner.
• Putting space between self and patient;
• Avoiding physical or verbal threats, false promises
and build rapport with client.
• Training in basic self defence techniques and
physical restraint techniques are useful.

15. Overview algorithm for the short-term management of aggressive/violent
behaviour
Prediction
Risk assessment
Searching
Prevention
De-escalation techniques
Observation
A & E Settings
Seek expert help from a
member on-call mental
health team
Interventions for Continued Management
Consider, in addition to above, one or more of the following:
Rapid Tranquillisation
• Used to avoid prolonged
physical intervention
• Medication is required to calm
a psychotic or non-psychotic
behaviourally disturbed service
user
Seclusion
• Used to avoid prolonged
physical intervention
Physical Interventions
• Better if service user
responds quickly
• Can be used to enable
rapid tranquillisation to take
effect
• When service user has
taken previous
medication
• Should be terminated when rapid
tranquillisation, if given, has taken effect
• When other interventions not yet
explored
• With prolonged
restraint
Contra-indicated as an Intervention

16. Prevention Environment
• A therapeutic environment:
– allows individuals to enjoy safety and security,
privacy, dignity, choice and independence, without
compromising the clinical objectives of the service.
• Comfort, noise control, light, colour and access
to space will all have an impact on the well-being
of both staff and clients.

17. Environment
• High traffic areas – Location for the largest
number of assaults.
• Highest proportion of assaults occur in either the
day room/communal room or in the corridors
(Carmel 1989; Coldwell and Naismith 1989; Lanza et al. 1993;
Rosenthal et al. 1992), suggesting that assault
frequency is related to either a chance
encounter or that crowding is a significant factor.
• Most assaults occur during mealtimes and
afternoons and increase in frequency until late
evening (Manfredini et al. 2001).

18. Environmental strategies
• Inpatient units that provide many productive
activities
– reduce the chance of inappropriate patient behaviour
– increase adaptive social and leisure functioning.
• Unit norms and the rewards associated with
producrtive activities may reduce aggressive acts.
• Units with too much stimulation and little regard
for the privacy needs of the patients may increase
aggressive behaviour.

19. Environmental strategies
• Allowing those at risk to spend time in their rooms
away from the hectic day room.
• The environment that may have been therapeutic
in the days of extended hospital stays may no
longer be suitable for patients with who are
hospitalised on short term, acute inpatient units
where the acuity of the patient is extremely high.
• Inpatient units should adapt the environment to
best meet needs of the patient they treat.

20. Environmental Strategies
• Beauford JE, McNiel DE, Binder RL1
found
that the patients who had poorer therapeutic
alliance at the time of admission were
significantly more likely to exhibit acting out
behaviour during hospitalization even when
other clinical and demographic correlates of
violence were considered concurrently. .
Beauford JE, McNiel DE, Binder RL. Utility of the Initial Therapeutic Alliance in Evaluating Psychiatric
Patients’ Risk of Violence. Am J Psychiatry. 1997 Sep;154:1272-76.

21. Alarm systems
• Panic Buttons
– strategically placed buttons installed throughout the
area where a threat exists.
– Useful in treatment and consulting room.
• Personal alarms
– Most effective in situations where other people may
hear them and can respond.
• More complex personal alarms
– Suitable in particularly high risk areas.
– Includes personal alarms linked to fixed detection
systems by infra red or radio systems

22. Prediction Risk
assessment
• Risk assessment is part of a “risk
management plan” that works towards
minimising disturbed/violent behaviour and
aggression, allowing both clients and staff to
feel safe.
• An essential and possibly most important
intervention, in the therapeutic management
of disturbed/violent behaviour.

23. Prediction Risk
assessment
• The NMC (UK) – report stresses that “the use
of comprehensive risk assessment materials,
followed by a properly developed plan is an
absolute pre-requisite for the recognition,
prevention, and therapeutic management of
violence.”1
• Risk assessment should be ongoing and
care plans based on an accurate and
thorough risk assessment.
1. The recognition, prevention and therapeutic management of violence in mental health care (2002) London: United
Kingdom Central Council for Nursing, Midwifery and Mental Health Visiting, p15, p22

24. Prediction Risk assessment
• Actuarial tools and structured clinical
judgement should be used in a consistent
way to assist in risk assessment, although
no ‘gold standard’ tool can be
recommended.
• Some tools for Risk assessment
– BVC (Broset Violence Checklist).
– HCR-20 (Historical Clinical Risk)

25. Prediction: Antecedents & Warning Signs
• Certain features can serve as warning signs to
indicate that a client may be escalating towards
physically violent behaviour.
• The following warning signs should be
considered on an individual basis.
– Facial expressions tense and angry.
– Increased or prolonged restlessness, body tension,
pacing
– Increased volume of speech, erratic movements.

26. Prediction: Antecedents & Warning Signs
– General over-arousal of body systems (increased
breathing and heart rate, muscle twitching, dilating
pupils).
– Prolonged eye contact.
– Discontentment, refusal to communicate, withdrawal,
fear, irritation.
– Thought processes unclear, poor concentration.
– Delusions or hallucinations with violent content.
– Verbal threats or gestures.
– Replicating, or behaviour similar to that which preceded
earlier disturbed/violent episodes.
– Reporting anger or violent feelings.
– Blocking escape routes.

27. Working with clients and family
caregivers
• Genuinely patient-centred service
• Enable clients and family caregivers to
contribute to the design and delivery of care.
• The aim is to promote a non-judgemental,
non-patronising, collaborative approach to
care.
• Provision of training to family caregivers is
essential (Department of Health (UK),Mental health
policy implementation guide 2002, p14).

28. Working with clients and family
caregivers
• Gender specific needs, such as single-sex facilities,
and to ensure that both male and female service
users feel safe, listened to and involved in
identifying and meeting gender related needs.
Other Special Concerns:
• Clients with sensory impairments are particularly vulnerable
when managed using certain interventions. Eg. Restraining
of a deaf patient’s hands, thereby preventing them from
communicating.

29. Observation
• Useful in recognising the possibility of violence
occurring and for preventing interventions.
• Observation as a ‘core nursing skill’ and
‘arguably a primary intervention in the
recognition, prevention and therapeutic
management of violence’1
must be meaningful,
grounded in trust, and therapeutic for the client.
1. The recognition, prevention and therapeutic management of violence in mental health care
2002

30. Psychosocial interventions
De-escalation techniques
• De-escalation (‘defusing’ or ‘talk-down’) involves
the use of various psychosocial short-term
techniques aimed at calming disruptive behaviour
and preventing disturbed/violent behaviour from
occurring.
• Every effort is made to avoid confrontation.
• This can include
– talking to the client, often known as verbal de-
escalation, moving client to a less confrontational area,
or making use of a specially designated space for de-
escalation.

31. De-escalation techniques (contd..)
• Both communication theory and situational
analysis emphasise
– the need to observe for signs and symptoms of anger
and agitation,
– approaching the person in a calm controlled manner,
– giving choices and maintaining the client’s dignity.
• De-escalation techniques also emphasise the
therapeutic use of the nurse’s own personality
and relationship with the person (use of self) as
one method to interact therapeutically with the
patient.

32. Room programme
• A room programme limits the amount of time
patients are allowed in the unit milieu.
• Eg. Patients initially are asked to be in the rooms
for a certain length of time, or conversely be
allowed out of their rooms for a specific amount of
time every hour.
• The amount of time in the milieu may then be
increased by increments of 15 min as patients
tolerate the environment.

33. Room programme (contd.)
• Another way is to allow patients to come out of
their rooms during designated hours, such as
when the unit is quite when the other patients
are off the unit.
• Such a structured programme allows patients
time away from situations that may increase
agitation

34. Cathartic activities
• The use of cathartic activities may
help the patients deal with their anger
and agitation.
• These can be of 2 types:
• Physically cathartic activities
• Emotionally cathartic activities

35. Cathartic activities (contd.)
a) Physically cathartic activities
• Assumption that some physical activity can be
useful in releasing aggression.
• Encouraging patients to release tension
through the use of exercise equipment or
allowing patients to pace the hall in the
expectation that their tension will decrease.
• Not supported by research and may increase
patient’s agitation now.

36. Cathartic activities (contd.)
b). Emotionally cathartic activities
• these are evidence based.
– Having patients write their feelings,
– deep breathing or relaxation exercises, or
– talk about their emotions with a supportive
person can help the patient regain control and
lower feelings of tension and agitation.

37. Behavioral strategies
Limit setting
• Limit setting is a non punitive non
manipulative act
• Potentially aggressive behaviour can be
avoided.
• If nurse communicates in an authoritarian,
controlling or disrespectful way patients
respond in an angry, aggressive manner.
• Limits should be clarified before negative
consequences are applied.

38. Behavioral strategies
Limit setting
• Once a limit has been identified; the
consequences must take place if the behaviour
occurs.
• Every staff member must be aware of the plan
and carry out it consistently. If staff do not do so,
the patient is likely to manipulate staff by acting
out
• Clear, firm and no punitive enforcement of limits
is the goal.

39. Behavioural Strategies (contd.)
Behavioral contracts
• If the patient uses violence to win control and
make personal gains,
• eliminate the rewards patient receives while still
allowing the patient to assume as much as
control, as possible.
• Once the rewards are understood, nursing
care must be planned that does not reinforce
aggressive and violent behaviour.
• Behavioural contracts with the patient can be
helpful in this regard.

40. Behavioural Strategies (contd.)
Behavioral contracts
• To be effective contracts require detailed
information about:
• unacceptable behaviours.
• acceptable behaviours.
• consequences for breaking the contact.
• The nurse’s contribution to care.
• Patients also should have input into the
development of the contract to increase their
sense of self control.

41. Behavioural Strategies (contd.)
Time out
• It is a strategy that can decrease the need for
seclusion and restraint.
• Socially inappropriate behaviours can be
decreased by short term removal of the patient
from over stimulating and sometime reinforcing
situations.
• Time out usually will be in a quiet area of the
patients unit or the patient’s room. They remain
there until they become non aggressive for a
couple of minutes.
• Time out is not considered to be seclusion.

42. Behavioural Strategies (contd.)
Token economy
• Identified interpersonal skills and self care
behaviours are rewarded with tokens.
• Behaviours to be targeted are specific to
each patient.
• Guidelines has to be made for desired
behaviours required to receive the tokens

43. Assertiveness training
• Interpersonal frustration often escalates to
aggressive behaviour because patients have not
mastered the assertive behaviours.
• Assertive behaviour is a basic interpersonal skill
that includes the following
• Communicating directly with another person.
• say no to unreasonable requests
• Being able to state complaints.

44. Assertiveness training (contd.)
• Patients with few assertive skills can learn
them by
– participating in structured groups and
programmes.
– Role play the skills themselves.
• Staff can provide feedback to patients on
appropriateness and effectiveness on their
responses.
• Expressing appreciation as appropriate
outside the group milieu.

45. Seclusion
• Seclusion is the involuntary confining of a
person alone in a room from which the
person is physically prevented from
leaving (Brown, 2000).
• Degree of seclusion varies.
• They include confining a patient in a room
with a closed or unlocked door or placing
a patient in a locked room with a mattress
but no linens and with limited opportunity
for communication.

46. Seclusion (contd.)
• The rational for the use of seclusion is based on
3 therapeutic principles:
• Containment – Restricted to a place where they
are safe from harming themselves and other
patients.
• Isolation – addresses the need for patients to
distance themselves from relationships that,
because of illness are pathologically intense.
• Seclusion provides a decrease in sensory
input for patients whose illness results in a
heightened sensitivity to external stimulation.

47. Soothing while secluding
• Afshin Meymandi1
designed an environment called
“Retreat room” to promote relaxation for the patients who
were secluded.
• During post seclusion interviews most patients could
project their individual and idiosyncratic approach to their
thought organization, preoccupations, assumptions and
outcomes.
• Although none of these patients initially volunteered to
enter the room and some had to be restrained, they did ask
their nurses several times later to use the “Retreat” for
meditation, relaxation or the prevention from getting out of
control.
Afshin Meymandi, Eileen Spahl, Department of Nursing, UNC Healthcare System, Deparment of Psychiatry, University
of North Carolina, School of Medicine, Chapel Hill , USA

48. Rapid Tranquilization
• Careful diagnosis has to be made to avoid
overuse and misuse of medication.
Medications are used primarily for two
purposes-
• To use sedating medication in an acute
situation to calm the client so that client will
not harm self or others.
• To use medication to treat chronic aggressive
behaviour.
Factors influencing choice of drug : Availability of an
IM injection, speed of onset and previous history of
response.

49. Rapid Tranquilization (Contd.)
Acute agitation and aggression
• Antipsychotics
• Atypical antipsychotic are also commonly used.
Eg. Ziprasidone IM.
• Haloperidol- 0.5 to 10 mg IM
• Risperidone 0.5mg-1mg- In dementia and
schizophrenia.
• Trazodone – 50-100mg . In older clients with sun
downing syndrome and aggression.
• Benzodiazepines
• Most commonly lorazepam, oral or injection.
• Other sedating agents used include Valproate,
chloral hydrate and diphenhydramin

50. Rapid Tranquilization
Chronic aggression
• When client continues to exhibit aggression more
than several weeks’ choice of medication is based
on underlying condition. I.e., if related to
schizophrenia-antipsychotic.
• Antipsychotic
• Anxiolytics- Buspirone
• Carbamazepine and valproate to treat bipolar
associated aggressive behaviour.
• Antidepressants –trazodone in aggression
associated with organic mental disorder.
• Antihypersensitive medication – Propanolol to
treat aggression related to organic brain
syndrome.

51. Risks associated with Rapid tranquilization
• The specific properties of the individual drugs
should be taken into consideration.
• When combinations are used, risks may be
compounded.
For benzodiazepines
• Loss of consciousness
• Respiratory depression or arrest
• Cardiovascular collapse

52. Risks associated with Rapid tranquilization
(contd..)
For antipsychotics
• Loss of consciousness,
• Cardiovascular and respiratory complications
and collapse
• Seizures
• Subjective experience of restlessness
(akathisia)
• Acute muscular rigidity (dystonia)
• Involuntary movements (dyskinesia)
• Neuroleptic malignant syndrome
• Excessive sedation

53. Care after rapid tranquillization
• After rapid tranquillization is administered, vital
signs should be monitored and pulse oximeters
should be available until the client becomes active
again.
• More frequent and intensive monitoring is required
if
– the client appears to be or is asleep/sedated
– intravenous administration has taken place
– high-risk situations
– the client has been using illicit substances or alcohol
– the client has a relevant medical disorder or concurrently
prescribed medication.

54. Physical intervention
• Physical restraint should be a last resort,
only being used in an emergency where
there appears to be a real possibility of
significant harm if withheld.
• It must be of the minimum degree
necessary to prevent harm and be
reasonable in the circumstances.

55. Restraints
• Physical restraints are any manual methods or
physical or mechanical device attached to or
adjacent to the patient’s body that she/he cannot
easily remove and that restricts freedom of
movement or normal access to one’s body,
material or equipment (Brown, 2000)
• Chemical restraints are medications used to
restrict patient’s freedom of movement or for
emergency control of behaviour, but it is not a
standard treatment for the patient’s medical or
psychiatric condition (Murphy, 2002).

56. Restraints
used when the client-
• is no longer exerting control over his/her
own behaviour.
• to prevent harm to others and to patient
• to prevent serious disruption of treatment
environment.
They are a violation of patient rights if used as a
means of coercion, discipline or convenience of
staff (Brown, 2000).

57. Guidelines for use of restraints
• Restraints should be applied with care that not to
injure a patient.
• Adequate personnel must be assembled before
the patient is approached.
• Each staff member should be assigned
responsibility for controlling specific body parts.
• Restraints should be available and in working
order.
• Padding of cuff restraints helps to prevent skin
breakdown. For the same the patient should be
positioned in anatomical alignment.

58. Guidelines for use of restraints
• Restraints must not be used to punish a patient or
solely following the convenience of staff or other
patients.
• Staff must take into consideration the
medical/psychiatric status of patient.
• Written policy must be followed.
• Physical restraints should be used very sparingly
and only after careful and comprehensive review.
• The least restrictive device should be used

59. Guidelines for use of restraints
• All mechanical restraints must be padded; proper
size and type must be used.
• Both the patient and restraining device must be
checked frequently.
• A restrained limb should be periodically exercised
and, if possible the patient should be ambulated at
reasonable intervals.
• Attention to need for hydration, elimination,
comfort, and social interaction must be assured.

60. Guidelines for use of restraints
• Nursing staff should observe the patient every 15 min.
• All the needs of the patient must be met with
caution.
• With four point restraint each limb should be
released or restraint loosened every 15min.
• Patient should be gradually decreased from
seclusion or restraint.
• Patient should not be made to feel guilty after being
released from restraints of his past behaviour.
• Documentation is necessary.

61. Risks with restraints
• Falls,
• strangulation,
• loss of muscle
tone,
• pressure sores,
• decreased
mobility,
• agitation,
• reduced bone
mass,
• stiffness,
• frustration,
• loss of dignity,
• incontinence, and
• constipation.

62. Debriefing
• Debriefing is an important part of terminating
the use of seclusion or restraints.
• Debriefing is a therapeutic intervention that
includes reviewing the facts related to an
event and processing the response to them.
• It provides the staff and patient with an
opportunity
• to clarify the rational for seclusion,
• offer mutual feedback, and
• Identify alternative, methods of coping that might
help the patient avoid seclusion in the future.

63. Crisis Management
Team Response
• Effective crisis management must be organised and
should be directed by one clearly identified crisis
leader.
Procedure for managing psychiatric emergencies.
• Identify crisis leader
• Assemble crisis team
• Notify security officers if necessary
• Remove all other patients from the area
• Obtain restraints if appropriate
• Device a plan to manage crisis and inform team

64. Crisis Management (contd.)
• Assign securing of patients limbs to crisis team members
• Explain necessity of intervention to patient and attempt to
enlist cooperation
• Restrain patient when decided by the crisis leader
• Administer medication if ordered
• Maintain calm, consistent approach to patient
• Review crisis management interventions with crisis team
• Gradually reintegrate patient into milieu.

65. Post-incident Review
• A post-incident review should take place as soon after the
incident as possible.
• The aims is to seek to learn lessons and encourage the
therapeutic relationship between staff, clients and their
family caregivers.
• The following groups should be considered during post-
incident review
– staff involved in the incidents
– service users
– carers and family where appropriate
– other service users who witnessed the incident
– visitors who witnessed the incident

66. Post-incident Review (Contd.)
The post-incident review should address
– What happened during the incident
– Any trigger factors
– Each person's role in the incident
– How they felt during the incident
– How they feel at the time of the review
– How they may feel in the near future
– What can be done to address their concerns.

67. Training
• In India, there are currently no formal regulations
governing training for the short-term
management of disturbed/violent behaviour.
• Formal training to psychiatric healthcare
professionals regarding management of
aggression is the key element in reducing risk
and increasing safety for patients, caregivers
and others.

68. Training (contd..)
• Formal education for the nursing staff on a yearly
or biannual basis in the management of
aggressive behavior (MAB) is mandatory in
western countries and Australia.
• Some of the well structured Aggressive
Management Programmes are1
– The Mandt System [Mandt], (www.mandtsystem.com)
– Nonviolent Crises Intervention [Crises Prevention
Institute Inc. 1987], (www.crisesprevention.com)
– Professional Assault Response Training [Fox et al
2000] (www.part.com)
– Therapeutic Options [Partie 2001]. (www.therops.com)
1. Morrison EF, Carney-Love C; An evaluation of four programs for the management of aggression in
psychiatric settings. Arch Psychiatr Nurs Aug 2003, 17(4) p146-55.

69. Nursing Process

70. Nursing Assessment
Nursing Assessment
• A violence assessment tool can help the nurse.
• Establish a therapeutic alliance with the patient.
• Assess patient’s potential for violence.
• Develop a plan of care.
• Implement the plan of care.
• Prevent aggression and violence in the milieu.

71. Nursing Assessment (contd.)
• Following the assessment, if the patient is
believed to be potentially violent, the nurse
should:
• Implement the appropriate clinical protocol to
provide for the patient and staff safety
• Notify co-workers
• Obtain additional security if needed
• Assess the environment and make necessary
changes.
• Notify the physician and assess the need for
p.r.n. medications.

72. Nursing Interventions
• Range from preventive strategies such as self
awareness, patient education and assertiveness
training to anticipatory strategies such as verbal
and nonverbal communications, and the use of
medications.
• If the patient’s aggressive behaviour escalates
despite these actions the nurse may need to
implement crisis management techniques and
containment strategies such as seclusion or
restraints.

73. Nursing Interventions
Self awareness
• Its important to know about personal stress that
can interfere in one’s ability to communicate with
patients.
• Anxiety, angry, tiredness, apathy, personal work
problems etc. from the part of nurse can affect the
patient.
• Negative countertransferance reactions may lead
to non therapeutic responses on the part of the
staff.
• Ongoing self awareness and supervision can
assist the nurse in ensuring that patient needs
rather than personal needs are satisfied.

74. Nursing Interventions
Patient education
• Teaching patients about communication and the
appropriate way to express anger.
• Teaching patients that feelings are not right or
wrong or good or bad can allow them to explore
feelings that may have been bottled up, ignored
or repressed.
• The nurse can then work with patients on ways
to express their feelings and evaluate whether
the responses they select are adaptive or mal
adaptive.

75. Patient education plan for appropriate expression of
anger
Content Instructional activities
Help the patient
identify anger
Focus on nonverbal behaviour.
Role plays nonverbal expression of anger.
Label the feeling using the patients preferred
words
Give permission for
angry feelings.
Describe situations in which it is normal to feel
angry.
Practice the
expression of anger.
Role play fantasized situations in which anger
is an appropriate response
Apply the expression
of anger to real
situation.
-Help to identify a real situation that makes the
patient angry.
-Role plays a confrontation with the object of
the anger.
-Provide a positive feedback for successful
expression of anger.

76. Patient education plan for appropriate expression of
anger (contd.)
Content Instructional activities
Identify alternative ways
to express anger
-List several ways to express
anger, with and without
confrontation.
-Role plays alternative behaviours.
-Discuss situations in which
alternatives would be appropriate
Confrontation with a
person who is a source of
anger.
-Provide support during
confrontation if needed.
-Discuss experience after
confrontation takes place.

77. Communication strategies
The nurse should have to
• present a calm appearance
• speak softly
• speak in a non proactive and non judgemental
manner
• speak in a neutral and concrete way put
space between yourself and patient
• show respect to the patient
• avoid intense direct eye contact

78. Communication strategies (contd.)
• Demonstrate control over the situation without
assuming an overly authoritarian stance.
• Facilitate the patient’s stance.
• Listen to the patient
• Avoid early interpretations
• Do not make promises that cannot keep.

79. Evaluation
• Post-incident review should be done by
staff nurse involving the client, family
caregivers, and others who were
involved or witnessed the incident.
• It is necessary to learn, modify the care
and to improve the management of
aggressive patients.

80. Resources
• Guidelines for The short-term
management of disturbed/violent
behaviour in in-patient psychiatric
settings and emergency
departments in UK is published by
National Institute of Clinical
Excellence (NICE). Available at
http://www.nice.org.uk/nicemedia/pdf/
cg025niceguideline.pdf

81. CONCLUSION
• Anger is a normal human emotion that is
crucial for individual’s growth. When
handled appropriately and expressed
assertively, anger is a positive creative
force that leads to problem solving and
productive change.
• When channelled inappropriately and
expressed as verbal aggression or
physical aggression, anger is destructive
and potentially life threatening force.

82. CONCLUSION
• Patients admitted to an inpatient psychiatric unit
are usually in crisis, so their coping skills are even
less effective.
• During these times of stress acts of physical
aggression or violence can occur.
• Nurses spends more time in the inpatient unit than
any other disciplines, so they are more at risk of
being victims of acts of violence by patients.
• For these reasons, it is critical that psychiatric
nurses be able to assess patients at risk for
violence and intervene effectively with patients
before, during and after an aggressive episode.

83. Bibliography
• Clinical Guidelines 25. National Collaborating Centre for Nursing and Supporting
Care. (Internet Document: Published on Feb 2005; Cited on Dec 2012).
Available from: http://www.nice.org.uk/nicemedia/pdf/cg025niceguideline.pdf
• Townsend M C Psychiatric mental health nursing- concepts of care. 5 th edn.
Philadelphia: F.A Dais company; 2005
• Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical
Psychiatry .9th ed. Hong Kong :William and Wilkinson Publishers;1998.
• Stuart GW, Laria MT. Principles and Practices of Psychiatric Nursing. Ist ed.
Philadelphia: Mosby Publishers; 2001.
• Morrison EF, Carney-Love C; An evaluation of four programs for the
management of aggression in psychiatric settings. Arch Psychiatr Nurs Aug
2003, 17(4) p146-55.
• Moyer, KE. 1968. Kinds of aggression and their physiological basis.
Communications in Behavioral Biology 2A:65-87
• Afshin Meymandi, Eileen Spahl, Department of Nursing, UNC Healthcare
System, Deparment of Psychiatry, University of North Carolina, School of
Medicine, Chapel Hill , USA.
• Beauford JE, McNiel DE, Binder RL. Utility of the Initial Therapeutic Alliance in
Evaluating Psychiatric Patients’ Risk of Violence. Am J Psychiatry. 1997