Violence and Crises Intervention West Coast University NURS 204

Violence in the Healthcare Setting Definition: Verbal or physical threats and/or injury to persons or destruction of property 60-90% of nurses experience violence. Psychiatric setting is area of high risk and incidence.

Biopsychosocial Theories Biologic Theories – Imbalances of hormones (↑ testosterone), neurotransmitters (↑D and NE, ↓Achm 5HT, and GABA) – Genetic abnormalities – Neurophysiologic injuries (trauma, anoxia, metabolic imbalance, encephalitis, organic brain injury)

Biopsychosocial Theories - continued Psychosocial Theories Psychoanalytic – aggression an innate drive Psychological – impairment in impulse control, coping, and social skills Sociocultural – child abuse, dysfunctional family

Biopsychosocial Theories - continued Psychosocial Theories Psychoanalytic – aggression an innate drive Psychological – impairment in impulse control, coping, and social skills Sociocultural – child abuse, dysfunctional family

Biopsychosocial Theories - continued Behavioral Theory Learned behavior (exposure to violence in media/entertainment)‏ Humanistic Theory Basic drives unmet

Aggression and the Brain Hypothalamus Alarm system, controls pituitary function Dysfunction leads to overreaction to stress and overactivation of pituitary Hippocampus Regulates the recall of recent experiences and new information Dysfunction associated with impulsivity

Aggression and the Brain - continued Amygdala (limbic system)‏ Regulates emotion, memory storage, information processing Dysfunction affects emotion and behavior, outbursts of fear, anger, rage, hypersexuality Frontal cortex Generates thought and purposeful behavior Dysfunction leads to impaired judgement, poor decision-making, personality changes, aggressive outbursts

Behavioral Cues Clenched jaws and fists Dilated pupils Intense staring Flushing of face and neck Frowning, glaring, or smirking Pacing Increased vigilance

Verbal Cues Threats of harm Loud demanding tone Abrupt silence Sarcastic remarks Pressured speech Illogical responses Yelling, screaming Statements of fear or suspicion

Nursing Process: Assessment Risk factors: History of violence Severity of psychopathology Higher levels of hostility Length of time in the hospital Early age of onset of psychiatric symptoms Frequency of admission to psychiatric hospitals

Self-Awareness

Assessment Assess client’s: Perception of precipitating event/current situation Support system Usual coping patterns

Assessment - continued Environmental factors Availability of dangerous objects Overcrowding Staffing Supervision Activity level

Nursing Diagnoses: NANDA Risk for Other-Directed Violence Risk for Self-Directed Violence Anxiety Ineffective Coping Chronic Low Self-Esteem, and Situational Low Self-Esteem

Other Considerations Impulse control Sensory-perceptual functioning Cognitive functioning Social skills Impaired communication Helplessness Powerlessness

Implementation Develop a therapeutic relationship. Establish trust, maintain safety, and convey respect. Use active listening. Address client needs.

Pharmacologic Interventions Pharmacologic agents Antipsychotics (typical and atypical) Benzodiazepines combinations

Safety Minimizing personal risk Nonthreatening communication Awareness of environment Availability of other staff members Awareness of clothing and objects

Nonpharmacologic Strategies - continued De-escalation Assemble a team and brief team members. Clear the area of other clients. Choose a leader.

Restrictive Measures Restrictive measures Pharmacologic Seclusion Involuntary confinement Restraint Device attached or adjacent to client’s body which restricts movement or normal access to one’s body Documentation required Denial of Rights

Professional Education and Support Behavioral crisis management programs Increase awareness of risk factors, teach staff de- escalation strategies and teamwork for behavior management/restraint Critical Incident Stress Debriefing (CISD) Staff who experience violent situation discuss feelings in safe, supportive environment Reduces long-term negative consequences

Nursing Self-Awareness How do I feel about this patient/setting? How are my feelings affecting my behavior? Fear is a normal response. Avoid personalizing. Use intuition.

Situational Crises Material or environmental Personal or physical Interpersonal or social

Maturational Crises Life cycle transitions: infancy, childhood, puberty, adolescence, adulthood, middle age, older adulthood, old age Other life changes: marriage, retirement, transition from student to worker

Crisis as Turning Point Crisis = turning point that results in new equilibrium, which may be similar to pre- crisis state, or more positive or negative

Crisis Intervention Crisis is self-limiting because disequilibrium is so uncomfortable. Crisis resolves itself, favorably or unfavorably, even without intervention. Working with another person increases likelihood of favorable resolution.

Sequence of Crisis Tyhurst’s three stages of disaster: Impact Recoil Post-trauma

Sequence of Crisis - continued Caplan’s four stages of crisis reaction: Initial increase in tension Further increase in tension and disruption of daily living when crisis is not quickly resolved Increase in tension to depression levels if usual problem-solving techniques fail Partial resolution of crisis with use of new coping skills, or mental disruption/disorder if new skills are not developed

Health Professional’s Role Help person in crisis understand what led to the crisis and guide him/her toward positive resolution Acute phase: restore the person to pre- crisis level of functioning as quickly as possible

Assessment Individual: precipitating event, perception, support, resilience, coping style, ability to handle problem, suicide potential Family: stressors, resilience, resources, coping skills, interpersonal styles Sociocultural: influence of culture on sources of distress a client experiences, symptomatology, interpretation of symptoms, coping methods

Nursing Care Common diagnoses: Ineffective Coping Interrupted Family Processes Risk for Self-Directed Violence Anxiety Acute Confusion Spiritual Distress Sleep Deprivation Risk for Post-Trauma Syndrome Complicated Grieving Impaired Social Interaction

Nursing Care - continued Outcome criteria: determined in collaboration with client Planning/implementation: developed with client and family; focused on immediate problems; consistent with lifestyle/culture; time limited; realistic; mutually negotiated; provides for follow-up Evaluation: in long-term setting, review of implementation and outcomes

Balancing Factors According to Aguilera, three balancing factors for resolution of disequilibrium are: perception of the event situational supports coping mechanisms

Crisis Intervention Types of crisis intervention: Crisis counseling (brief, solution-focused therapy) Telephone counseling Assisting with environmental changes Anticipatory guidance (assistance in anticipation of the potential for crisis, thus averting it) Helping to develop social supports Critical incident stress management Disaster assistance

Critical Incident Stress Management CISM = integrative, comprehensive, multifaceted approach spanning time sequence of crisis 10 components: Pre-event planning Assessment Strategic planning Individual crisis intervention

Critical Incident Stress Management - continued 10 components: (con’t) Large group crisis intervention Small group crisis intervention Family crisis intervention Organizational/community intervention Pastoral crisis intervention Follow-up/referral

ABCs of Crisis Counseling A = Achieve contact (safety and security) B = Boil down the problem (ventilate and validate) C = Cope with the problem (predict and prepare)

ABCs of Crisis Counseling in Plan of Care A = Assessment B = Diagnosis C = Planning and implementation, including plan for follow-up (evaluation)

Nursing Self-Care Behaviors crucial to effective crisis work: Belief in a person’s capacity to grow and change Awareness of impact of repeatedly hearing horrible stories Developing outlets for stress, frustration, anger Dealing with fears and vulnerability Realistic expectations Respect for others’ timetable for crisis resolution Collaboration with others

Vicarious Traumatization Vicarious traumatization = condition in which psychological aftereffects are experienced by those who are not direct victims of the traumatic event Commonly affects next of kin, injured and uninjured survivors, onlookers, rescuers, body handlers, health personnel, people responsible for disaster, coworkers, evacuees

Origins and Risk Factors for Crisis Origins of crisis: situational, maturational Risk factors: intensity of exposure, preexisting psychiatric symptoms or diagnosis, previous trauma, family history of mental illness, early separation from parents, childhood abuse, poverty, cultural expectations, degree of threat to life