1. Anger, Aggression, and Violence
Chapter 27
Anger, Aggression, and Violence
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

2. Anger and Aggression Anger Aggression
An emotional response to frustration of desires, threat to one’s needs (emotional or physical), or a challenge
Aggression
Action or behavior that results in verbal or physical attack
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

3. Epidemiology In the hospital, violence is most frequent in
Psychiatric units
Emergency departments
Geriatric units
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

4. Comorbidities Posttraumatic stress disorder (PTSD)
Substance abuse disorders
Coexists with
Depression
Anxiety
Psychosis
Personality disorders
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

5. Etiology Biological factors Psychological factors Areas of the brain
Neurotransmitters
Predisposition
Psychological factors
Behavioral theory—learned response
Social learning theory—imitate others
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

6. Application of the Nursing Process
Assessment
General assessment
Trauma-informed care
Self assessment
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

7. Question 1
An adult with paranoia becomes agitated and threatens to assault a staff person. Select the best initial nursing intervention.
Tell the patient, “If you do not calm down, seclusion will be needed.”
Address the patient with simple directions and a calming voice.
Help the patient focus by rubbing the patient’s shoulders.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

8. Question 1 (Cont.)
Offer the patient a dose of antipsychotic medication.
Reorient the patient to the time and place.
Answer: B
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

9. Case Study
A new nurse asks a coworker which patients are most likely to become aggressive or angry.
What are some risk factors that may predict violent behavior?
1. A history of violence is the single best predictor of future violence.
2. Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence.
3. Assess the risk for violence:
Does the patient have a wish or intent to harm?
Does the patient have a plan?
Does the patient have means available to carry out the plan?
Does the patient have demographic risk factors (i.e., male gender, age 14 to 24 years, low socioeconomic status, inadequate support system, prison
time)?
4. Aggression by patients occurs most often in the context of “limit setting” by the nurse.
5. Patients with a history of limited coping skills, including lack of assertiveness or use of intimidation, are at higher risk of using violence.
6. Assess self for personal triggers and responses likely to escalate patient violence, including patient characteristics or situations that trigger
impatience, irritation, or defensiveness.
7. Assess personal sense of competence when in any situation of potential conflict; consider asking for the assistance of another staff member.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

10. Nursing Process (Cont.)
Nursing diagnoses
Ineffective coping
Stress overload
Risk for self-directed violence
Risk for other-directed violence
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

11. Nursing Process (Cont.)
Outcomes identification (Table 27-1)
Implementation
Psychosocial interventions
Considerations for staff safety
Pharmacological interventions
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

12. Case Study (Cont.)
What are some ways this new nurse can keep himself or herself safe while working?
1. Avoid wearing dangling earrings or necklaces. The patient may become focused on these and grab at them, causing serious injury.
2. Ensure that there is enough staff for backup. Only one person should talk to the patient, but staff need to maintain an unobtrusive presence in case
the situation escalates.
3. Always know the layout of the area. Correct placement of furniture and elimination of obstacles or hazards are important to prevent injury if the
patient requires physical interventions.
4. Do not stand directly in front of the patient or in front of the doorway; this position could be interpreted as confrontational. It is better to stand off
to the side and encourage the patient to have a seat.
5. If a patient's behavior begins to escalate, provide feedback. “You seem to be very upset.” Such an observation allows exploration of the patient’s
feelings and may lead to de-escalation of the situation.
6. Avoid confrontation with the patient, either through verbal means or through a “show of force” with security guards. Verbal confrontation and
discussion of the incident must occur when the patient is calm. A show of force by security guards may serve to escalate the patient’s behavior;
therefore, security personnel are better kept in the background until they are needed to assist.
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

13. Nursing Process (Cont.)
Implementation (cont’d)
Health teaching and health promotion
Case management
Teamwork and safety
Use of restraints or seclusion
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

14. Seclusion or Restraints
Involuntary confinement alone in a room that the patient is physically prevented from leaving
Restraints
Any manual method, physical or mechanical device, material, or equipment that restricts freedom of movement
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

15. Guidelines for Use of Mechanical Restraints
Indications for use
Legal requirements
Documentation
Clinical assessments
Observation
Release procedure
Restraint tips
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

16. Case Study (Cont.)
A patient becomes violent and must be placed in restraints.
What questions need to be asked after this incident?
1. Could we have done anything that would have prevented the violence? If yes, then what could have been done, and why was it not done in this situation?
2. Did the team respond as a team? Were team members acting according to the policies and procedures of the unit? If not, why not?
3. How do staff members feel about this patient? About this situation? Feelings of fear and anger are discussed and handled. Employee morale, productivity, use of
sick leave time, transfer requests, and absenteeism are all affected by patient violence, especially if a staff member has been injured. Staff members must feel
supported by their peers, as well as by the organizational policies and procedures established to maintain a safe environment.
4. Is there a need for additional staff education regarding how to respond to violent patients?
5. How did the actual restraining process go? What could be done differently? Do not focus only on whether the staff was acting like a team.
6. If injury occurred, has it been reported and cared for?
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

17. Intervening in Different Settings
Caring for patients in general hospital settings
Patients with healthy coping skills who are overwhelmed
Patients with marginal coping skills
Caring for patients in inpatient psychiatric settings
Caring for patients with cognitive deficits
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

18. Audience Response Questions
A violent patient is restrained. What is the nurse’s first priority?
Debrief the patient
Ensure the patient’s safety
Administer a sedating medication
Obtain an order from the health care provider
ANS: B
Once in restraint, a patient must be directly observed and formally assessed at frequent, regular intervals for level of awareness, level of activity, safety within the restraints, hydration, toileting needs, nutrition, and comfort.
REF: 18
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

19. Audience Response Questions
Which patient behavior is a criterion for mechanical restraint?
Screaming profanities
Assaulting a staff person
Refusing a medication dose
Throwing a pillow at another patient
ANS: B
Indications for the use of mechanical restraint include protecting the patient from self-harm and preventing the patient from assaulting others.
REF: 44
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.