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Management of Aggression

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

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Management of Aggression

  1. 1. Management of Aggression in patients with Psychiatric Illness Presentor: Mr. Muthuvenkatachalam
  2. 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:
  3. 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. 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. 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. 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. 7. Types of Aggression – Verbal aggression – Physical aggression againstothers – Physical aggression against property or objects. – Physical aggression against self.
  8. 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¬ /release
  9. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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], ( – Nonviolent Crises Intervention [Crises Prevention Institute Inc. 1987], ( – Professional Assault Response Training [Fox et al 2000] ( – Therapeutic Options [Partie 2001]. ( 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. 69. Nursing Process
  70. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 cg025niceguideline.pdf
  81. 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. 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. 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: • 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