Preventing and Managing Aggressive Behavior, Chapter 28

Preventing and Managing Aggressive Behavior Assaultive Injuries Emergency services called to scene Increasing violence in society Increasing patient acuity

Preventing and Managing Aggressive Behavior Response to threatening situations: Respond passively: Subordinate own rights to perception of rights of others Respond aggressively: Ignore rights of others Respond assertively: Self-assurance and respect for others

Preventing and Managing Aggressive Behavior Theories on aggressive behavior Psychological Predisposing life experiences that limits capacity to select nonviolent coping mechanisms Organic brain damage, MR, etc. Severe emotional deprivation, rejection in childhood, parental seduction Exposure to violence in formative years as victim or observer

Intergenerational Transmission of Violence (Stuart, 2013, p. 575)

Preventing and Managing Aggressive Behavior Theories on aggressive behavior (cont.) Sociocultural Cultural norms define unacceptable/acceptable behaviors Biological Limbic system, frontal lobes, and hypothalamus

Brain Structures Implicated in Aggression (Stuart, 2013, p. 576)

Preventing and Managing Aggressive Behavior Neurotransmitters Low levels of serotonin associated with irritability, overreacting to provocation, and rage Impulsive arson, suicide, homicide: Low levels of 5-HIAA (breakdown product of serotonin) in spinal fluid Other neurotransmitter associated with aggression: GABA, dopamine, norepinephrine, acetylcholine

Preventing and Managing Aggressive Behavior Expect aggression Active psychotic symptoms Substance abuse disorders History of violence Behaviors associated with aggression Motor agitation Verbalizations Affect Level of consciousness

Hierarchy of Aggressive and Violent Patient Behaviors (Stuart, 2013, p

Preventing and Managing Aggressive Behavior Nursing Interventions-assessment tool is Assault and Violence Assessment Tool (See Stuart text, p. 579) Self-awareness Patient education Assertiveness training Communication strategies (verbal & non-verbal) Environmental strategies (comfort rooms, exercise) Behavioral strategies- (limit setting, time out, token economy) Psychopharmacology (examples next slide)

Preventing and Managing Aggressive Behavior Psychopharmacology examples for aggression: Antianxiety - Benzodiazepines: Lorazepam [Ativan]) Antidepressants (SSRIs) Mood stabilizers (Valproate, Lithium, Carbamazepine [Tegretol]) Antipsychotics (Haldol given with Ativan and/or Benadryl; Risperidone with Ativan) Others: Beta-blockers, e.g., Propranolol

Preventing and Managing Aggressive Behavior Crisis response Team: Show of force Identified crisis leader Notifications – (security) Move others to safe distance Leader uses calm, steady voice Follow leaders plan Debrief (staff and patients)

Preventing and Managing Aggressive Behavior Containment Strategies – patient must be removed from any containment as soon as possible Seclusion – involuntary confinement Purpose: Quiet room with minimal furnishings to decrease stimuli or sensory input Must have continual assessment, monitoring, and reevaluation Always use least restrictive measures

Preventing and Managing Aggressive Behavior Containment Strategies (cont.) Restraint (physical or chemical) Emergency intervention for safety when less restrictive methods have failed Purpose: Protect patient from self/others Must have continual assessment, monitoring, and reevaluation

Preventing and Managing Aggressive Behavior Containment Strategies (cont.) Chemical restraints Medications used to restrict patient’s freedom Emergency control of behavior

Preventing and Managing Aggressive Behavior Debriefing Team debriefs and discusses Patient feedback What helped the patient What could have been done better What to do different next time

Preventing and Managing Aggressive Behavior Employers have a duty to provide a safe and hazard free environment A written plan is required by JACHO describing how security is provided to patients, staff, and visitors. Nurses may be subjected to aggressive behavior and abuse from their nursing and physician colleagues (Stuart, 2013, p. 588)

Preventing and Managing Aggressive Behavior Horizontal or Lateral Violence Aggression and intergroup conflicts Verbal abuse Intimidation Bullying Excessive criticism Denial to career opportunities Withholding of information

Preventing and Managing Aggressive Behavior OSHA guidelines for a safe workplace environment include: Management commitment & employee involvement Worksite analysis Prevention & control Safety and health training Response plan

Preventing and Managing Aggressive Behavior Staff Development: Education What to do, what to say, who to notify, how to manage Nursing interventions grounded in theory and current research Pharmacological interventions Crisis management

Preventing and Managing Aggressive Behavior Staff Support Allow adequate time off after assault Validation from others re: clinical competence and appropriate interventions can help in healing Peer support group use a nursing consultation support service for the victims of assault