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

2. 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

3. 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.

4. 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

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

6. 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

7. 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.

8. 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.

9. 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

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

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

12. Nursing Diagnosis
Risk for other-directed violence
Ineffective coping

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

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

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

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

17. 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

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

19. 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

20. 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

21. 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

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

23. 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

24. 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

25. 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)

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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.)

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

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