1. Preventing and Managing Aggressive Behavior, Chapter 28

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

3. 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

4. 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

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

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

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

8. 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

9. 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

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

11. 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)

12. 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

13. 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)

14. 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

15. 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

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

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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