aggression approach and management presentation

aggression approach and management

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 Beaver
1
(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.
– Videbeck
1
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 against

others
–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 RL
1
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 Meymandi
1
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 are
1

–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/c
g025niceguideline.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 Sep;154:1272-
76.