Discussing the management of
Marcia Gafa`
Psychiatric Nurse
Mount Carmel Hospital, Malta
 Hospital perspective
 Overview of the some of the methods used to
manage aggression within the context of the hospital
Who’s the aggressive patient?
Aggressive patients can be defines as those displaying
the following behaviours:
 Verbal and/or physical aggression against staff and/or
other patients and/or visitors
 Physical aggression towards self or against objects
(both lethal and non-lethal)
 Exhibiting high risk behaviours
Why manage aggression?
Management of acutely disturbed individuals in an in-patient
setting poses a particular challenge. Some patients may be
actively suicidal, or actively interested in harming themselves
or others around them, may be over-stimulated by the ward
environment, may be actively psychotic, pose a risk of
absconding, confused, sexually disinhibited etc…
The greatest challenge is to maintain safety and harmony
whilst providing safe and therapeutic environments.
Muralidharan & Fenton, (2006)
Choice of managing aggression
Safety for ourselves;
Safety to self or others (others patients feel threatened);
Control over the situation;
The hospital is a place of care not a place where aggression
is permitted
However, if aggression threatens the well-being and safety
of others why is a person nursed within a psychiatric context?
Foster et al., (2006)
Clinical perspective
It’s a highly personalised subject, little agreement and a lot of debate.
Is managed in a psychiatric setting based on:
 Previous history
 Present during admission
 Psychopathology of illness/diagnosis
 Age
 Assessment
 Involuntary admissions to hospital
 Ward/hospital culture
Bowers et al., (2009)
Types of management
PRN medication
Alternative therapies
Seclusion & Restraint [S&R]
S&R are both highly restrictive interventions
Seclusion involves the placement of a patient alone in a
locked room from which s/he can’t freely exit.
This coercive measure is used frequently after an aggressive
Decisions for seclusion:
 Containment of individual;
 Isolation;
 To reduce sensory stimuli.
Restraint has the intent to control an aggressive patient whilst
restore the safety of the ward environment. It should be
implemented as the last resort, when other options have failed.
Nevertheless this method could be traumatic for the patient and
staff, effecting the therapeutic relationship (which is paramount
within the mental health field), perceived as punishment for their
actions, profound distressing, and may reduce patients for seeking
help once out of the hospital.
NICE, (2005), Stubbs & Dickens, (2008)
Their use!
A reliance on restrictive interventions could be a result of:
 Lack of policies and guidelines within a given organisation;
 Burden to administration;
 Limited human resources;
 Staff perspective such as burnout or fear;
 No other options.
Vruwink et al., (2012)
PRN/Pharmacological intervention
Often used at the nurse’s discretion to help manage
aggression and agitation within the ward environment.
Most common form of PRN medication would be:
 Benzodiazepines (p.o./i.m./i.v.)
 Antipsychotics
 Anti histamines
 Sedatives
Ideally nurses base their decision to administer a PRN
medication based on sound clinical judgement.
However, one can not underestimate the powerful
influence of the ward/organisational culture and how
that influences the nurse’s decision making. Lack of
organisational criteria, lack of professional knowledge
and experience (effect of drug), lack of human
resources all influence the use PRN medication.
Usher et al., (2003)
Safer alternatives!
Comprehensive Assessment – if the opportunity allows for it!
 Done within the first 24 hours
 Use of risk assessment tools
 In agreement with the person
 Characteristics that may indicate aggression
 Identify short term goals to control aggression - de-escalation
 Other options if these fail
 Long-term goals for management of aggression – alternative
Donat., (2005); Jayaram et al., (2012); Jonikas et al., (2004)
A gradual resolution of a potentially violent and/or
aggressive situation through the use of verbal and
physical expression of empathy, alliance and nonconfrontational limit setting that is based on respect.
In a simpler explanation, de-escalation is defusing using
communication and the therapeutic relationship
Stubbs & Dickens, (2008)
Some of the techniques include:
 Observation for signs of agitation leading to aggression
 Teaching self to remain calm to help control the situation
 Using distraction techniques
 Verbal techniques
 Withdrawing the person of the situation
 Removing stimulation
 Using the therapeutic relationship
Muralidharan & Fention, (2006); Stubbs & Dickens, (2008)
However, de-escalation is not a standardised programme
taught to professionals: may include breakaway techniques
and physical restraint in training thus clouding the
effectiveness of solely using de-escalation to diffuse the
While training programmes are renowned for reducing
aggression, negatives outcomes can be attributed to an
increase of physical restraint as staff would feel more
confident to confront aggression after training
Livingston et al., (2010)
Yet staff training program install a sense of group cohesion
and working as a collective group may reduce aggression.
Therefore rather it being training which reduces aggressive
incidents in wards, it would be a cultural bond of staff
supporting each other and patients which reduces
Also de-escalation needs to be supported by the organization
and it’s implementation has to be culturally driven!
Livingston et al., (2010)
Alternative therapies
In response to most training programmes relying upon
the medical model, i.e. control and restraint, alternative
therapies focus on the patient.
Can range from talks with the professional to
behavioural contracts and behavioural modification
programmes such as anger management
Effectiveness: alternative therapies allow the patient have
control over the situation and deal with their aggression.
Nevertheless these are time consuming, individual desire and
require a period of time for adjustment.
Requires support and follow-up:
 Staff to patient
 Management to staff (ongoing training)
 Changing polices and organisational agenda.
In conclusion
 S&R should be used as the last resort
 PRN may have negative effects such as drowsiness
 The above methods are effective when no other
options are available
 De-escalation is effective at the right opportunity
 Alternative therapies may take time but do help
change behaviour, thus reduce aggression.
Bowers, L., Allan, T., Simpson, A., Jones, J., M, & Jeffery, D. (2009). Identifying key factors associated with aggression
on acute inpatient psychiatric wards. Issues in Mental Health Nursing, 30(4), 260-271. doi: 10.1080/01612840802710829
Donat, D. C. (2005). Encouraging alternatives to seclusion, restraint, and reliance on PRN drugs in a public psychiatric
hospital. Psychiatric Services, 56(9), 1105-1108.
Foster, C., Bowers, L., & Nijman, H. (2007). Aggressive behaviour on acute psychiatric wards: Prevalence, severity and
management. Journal of Advanced Nursing, 58(2), 140-149.
Janikas, J. A., Cook, J. A., Rosen, C., & Laris Alexandra, K. J. (2004). A program to reduce use of physical restraint in
psychiatric inpatient facilities. Psychiatric Services, 55(7), 818-821.
Jayaram, G., Samuels, J., & Konrad, S. (2012). Prediction and prevention of aggression and comprehensive seclusion
documentation. Innovations in Clinical Neuroscience, 9(7-8), 30-38.
Livingston, J. D., Verdun-Jones, S., Brink, J., Lussier, P., & Nicholls, T. (2010). A narrative review of the effectiveness of
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Muralidharan, S., & Fenton, M. (2006). Containment strategies for people with serious mental illness. Cochrane
Database of Systematic Reviews (Online), (3), CD002084.
Stubbs, B., & Dickens, G. (2008). Prevention and management of aggression in mental health: An interdisciplinary
discussion. International Journal of Therapy & Rehabilitation, 15(8), 351-356.
Vruwink, F., J., Noorthoorn, E., O., Nijman, H., L.I., VanDerNagel, J., E.L., Hox, J., J., & Mulder, C., L. (2012).
Determinants of seclusion after aggression in psychiatric inpatients. Archives of Psychiatric Nursing, 26(4), 307-315.
doi: 10.1016/j.apnu.2011.10.004

Discussing the management of aggression and violence