Preventing and Managing Aggressive Behavior

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Presentation transcript:

Preventing and Managing Aggressive Behavior Victoria Selby, MS, PMHNP-BC University of Maryland School of Nursing

Objectives Compare and contrast passive, assertive, and aggressive behavioral responses Identify factors useful in the prediction of aggressive behavior among psychiatric patients Utilize the nursing process in the prevention and management of aggressive behavior Describe the implementation of crisis management techniques Discuss aggression in the context of lateral violence and bullying

Definitions Behaviors Assertive – self-assurances & respect for others Passive – rights of others ahead of own Aggressive – ignore rights of others Enhance self-esteem by overpowering others Overall impression of power and dominance Anger is an emotional response to internal (sense of failure, loss of relationship) or external stressors (physical attack, criticism) Violence is the result of extreme anger or fear.

Theories on Aggression Neurobiologic Psychological – impulse control, learned behavior, developmental factors Sociocultural – anger seen differently (i.e., rude, disrespectful) or as syndromes Society determined what is acceptable and unacceptable

Brain Structures Implicated in Aggression Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Risk Factors for Aggression Psychosis Dementia, delirium, head injuries Drug/alcohol intoxication Psychopathic and antisocial personality traits are proving to be more predictive of violent behavior than mental illness

Situational and Environmental Factors Affect patient behavior escalating from dangerous to violent, including: Aspects of physical facilities, presence of staff and other patients; studies found greater number of violent incidents when patients gather in groups, are overcrowded, lack privacy, or are inactive Staff attitudes and actions When environment is interpreted as hostile, response is likely to be hostile Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Predicting Aggressive Behavior Researchers have tried to determine which patients more likely to become violent Demographic variables, e.g., age, gender, race, marital status, education, and socioeconomic level, not useful in predicting violent behavior Past history of aggression best predictor Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Preventing Aggressive Behavior Nurse self-awareness Assertiveness training Patient education Anger management Identifying feelings Permission to feel angry Role playing situations Alternate ways to express anger Coping skills Box 28-4 on p.581 Lists a variety of ways to manage anger Positive self-talk Change environment Writing about feelings Activities such as music, TV (distractions) Deep breathing Counting Relaxation techniques Go for a walk

Hierarchy of Aggressive and Violent Patient Behaviors Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Nursing Assessment Prediction of violence is impossible h/o violence biggest predictor Symptoms Motor agitation Verbalizations Affect Level of consciousness

Nursing Diagnosis Risk for other-directed violence Ineffective coping

Outcomes No harm to self or others Refrain from intimidating/ frightening others Describe feelings without aggression Comply with treatment

Interventions Most effective, least restrictive Environment management Structure and informal discussion 1:1 Problem solving Safety

Continuum of Nursing Interventions Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Interventions for Escalating Behavior Non-threatening, calm manner Convey empathy Encourage verbal expression Suggest quiet area PRN meds Suggest physical activity (e.g., walking)

Aggression Management Take control and provide direction with calm, firm voice Direct to quiet area Offer medication Set boundary (i.e., let person know that the behavior is not acceptable) Gather staff/show force

Interventions for Crisis Inform patient – staff taking control to provide safety Use of restraint or seclusion if necessary

Seclusion and Restraint Seclusion is the involuntary confinement of a person alone in a room from which the person is physically prevented from leaving Physical restraint is manually/physically/mechanically restricting a person’s freedom of movement Chemical restraint is the use of medication to restrict person’s freedom Ethical and legal implications

After the Crisis Debriefing patient and staff Help with relaxation Explore alternatives Document any injuries Removal of restraint or seclusion Problem resolution, expression of feelings Return to activities

Lateral violence Nurse-on-nurse Includes verbal abuse, intimidation, bullying, excessive criticism, denial of career opportunities, and withholding information Risk factors Being a student or new grad Receiving a degree, promotion, or other kudos Pursuing higher education Having difficulty working with others Receiving special attention from others at work

Lateral violence How to prevent Education Accountability “zero tolerance” Leadership training to uphold standards Surveillance and reporting (protect reporter) Documentation Code of conduct

Bullying among youth “unwanted, aggressive behavior among school aged children that involves real or perceived power imbalance” Use of power (physical, access to embarrassing info, popularity) to control others Repetition of the behavior

Types of bullying Verbal Social Physical Teasing, name calling, inappropriate sexual comments, taunting, threatening Social Leaving someone out purposely, telling others not to befriend, rumors, embarrassing someone in public Physical Hitting, spitting, tripping/pushing, destroying someone’s belongings, hand gestures

How Pervasive is Bullying? 28% of students in grades 6-12 (National Center for Education Statistics) 20% of students in grades 9-12 (Youth Risk Behavior Surveillance System)

Victim of Bullying Risk Factors Perceived to be different Perceived to be weak or unable to defend themselves Depressed, anxious, low self-esteem Those who do not get along with others

Perpetrators Aggressive, low frustration tolerance Less parental involvement, issues at home Think badly of others Difficulty following rules Positive view of violence Have friends who bully

Specific Groups May be protected by federal civil rights laws LGBT Youth - increased risk Youth with disabilities or special health needs – increased risk Race, ethnicity, and national origin Religion and faith

Signs of a Child Being Bullied Unexplainable injuries Lost or destroyed stuff Faking sick Changes in eating habits Changes in sleep/nightmares Academic decline Social avoidance/ loss of friends Feeling helpless, decreased self-esteem Self-destructive behaviors

Why Children Don’t Speak Up Feeling helpless, want to handle it Fear of judgment Fear of retaliation Social isolation Fear of rejection from other kids

Signs of a Bully Getting into physical or verbal altercations Friends who bully Aggressiveness Getting into trouble Unexplained extra money or other stuff Blame others Are competitive, worry about reputation

Prevention Talking about it School prevention Education and Policies Environment that fosters acceptance, tolerance, respect, communication, parental involvement Community strategies/support Partners (i.e., mental health providers, law enforcement, businesses, faith—based org.’s, etc.)

Responding to Bullying Consistently give the message of unacceptable Find out what happened Support the kids Do something about it

References U.S. Department of Health and Human Services (n.d.). Stopbullying.gov accessed on February 15, 2015 at http://www.stopbullying.gov/index.html Stuart, G. W. & Laraia, M.T. (2013). Principles and practice of psychiatric nursing. (10th ed.) St. Louis, MO: Mosby Elsevier.