Managing Assaultive Behavior
University of San Francisco
Anger and Violence
Skip Davis, RN, PhD, CARN
Learning Objectives
• Students will be able to describe the
differences between anger, aggression,
passive aggression, and assertiveness
• Describe the five stages of the assault cycle
• Explain the verbal nursing interventions for
anger and nonviolent aggression
• Describe the nursing care of patients in
seclusion and restraints
Key Terms
• Anger: Normal emotional response to the
perception of a frustration of desires or
threat to ones needs.
• Assault: Legally defined as any behavior
that physically or verbally presents an
immediate threat of physical injury
• Battery: Inflicting physical injury on
another individual
Key Terms
• Assertiveness: Direct expression of feelings and
needs in a way that respects the rights of others
and of the self.
• Passive aggression: Anger expressed indirectly
through subtle and evasive ways
• Restraint: Physical control of a patient to prevent
injury to the patient, staff, and other patients
• Seclusion: Process of placing a patient alone in a
specially designed room for protection and close
observation
Intervention Strategies for
Patients With Aggression
.Because high rates of aggressive behavior are associated
with many major psychiatric disorders, treatment must be
individualized. Dealing with aggressive patients has
become more challenging because the closing of state
hospitals has made long-term care less of an option. Care
of potentially violent patients with mental illness has
shifted to the community. Yet community-based programs
are often ill equipped to handle these difficult patients.
Risk of Aggression in Patients
With Mental Illness
Binder and McNeil found that the target of assaultive
behavior was the family 54% of the time.
Families in which additional members had a mental
illness or were violent were at particular risk.
Delay of treatment also increased the risk of violence.
Wallace and associates looked at individuals
convicted of violent crimes over a 3-year period and
found that 25% had a history of contact with the
mental health system.
Psychopathology and Violence
Co-morbidity of personality disorders and substance
abuse significantly increased the risk of aggression
(Swanson and Holzer,1991).
Schizophrenia co-morbid with substance abuse
increases the rate of violence.
In a Finnish study, all 13 homicide recidivists had a
psychiatric disorder. Most had severe alcoholism in
addition to a personality disorder (85% of the sample)
or schizophrenia (15% of the sample).
Psychopathology and Violence
McNiel and Binder (1994) studied 330
psychiatric inpatients with a variety of
diagnoses in order to determine whether
particular symptom clusters were associated
with higher levels of aggression.
Violence levels were higher in individuals
manifesting increased levels of hostilesuspiciousness, agitation-excitement, and
thought disturbances.
Psychopathology and Violence
Flannery (2002) reviewed 28 studies and noted
that patients who were repetitively violent tended
to be younger and more frequently received a
diagnosis of schizophrenia or a personality
disorder.
Males and females were equally represented in the
studies reviewed.
Characterization of Aggression
in Children
Aggression in children is a major public health
problem and a significant cause of morbidity and
mortality.
Homicide is the second leading cause of death
among adolescent boys and the third-leading cause
of death among adolescent girls.
From 1985 to 1994, the number of homicides
increased by 158% among boys and 64% among
girls. The number of aggravated assaults increased
by 88% among boys and 134% among girls.
• Unmet needs. Individuals with cognitive impairments
who are in an environment that is not responsive to
their needs are at particularly high risk for
aggression. These needs should be adequately met.
• Relationship with caregivers. Caregivers vary in skill
and compassion, and aggression is often directed
toward them. The caregiver should attempt to reflect
the expected behavior. This is termed behavioral
contagion.
•Stress. Many environmental factors may cause
stress. These stresses vary as the disease
progresses and must be reevaluated continually.
•
•Negative learned behaviors. Negative patterns
of learned behavior should be replaced by
positive habits. A behavioral program involving
the treatment team is often required to institute
such changes.
Categories of Aggressive
Behavior
Aggression has been divided into several subtypes:
• Predatory
• Anti-predatory
• Dominant
• Maternal
• Fear-induced
• Impulsive aggression.
Categories of Aggressive
Behavior
• Predatory aggression is planned in advance
and involves a specific target.
• Dominant aggression relates to challenging
or maintaining rank in a community.
• Maternal aggression relates to defense of a
mother's young.
• Fear-induced aggression arises from the
inability to escape while cornered.
• Impulsive aggression involves spur-of-themoment behavior that is often unpredictable.
Executive
Function
Amydala
• The amygdalae send impulses to the hypothalamus
for important activation of the sympathetic
nervous system, to the thalamic reticular nucleus
for increased reflexes, to the nuclei of the
trigeminal nerve and facial nerve for facial
expressions of fear, and to the ventral tegmental
area, locus coeruleus, and laterodorsal tegmental
nucleus for activation of dopamine,
norepinephrine and epinephrine.
• In a 2003 study, subjects with Borderline personality
disorder showed significantly greater left amygdala
activity than normal control subjects. Some borderline
patients even had difficulties classifying neutral faces or
saw them as threatening.
• In 2006, researchers observed hyperactivity in the
amygdala when patients were shown threatening faces or
confronted with frightening situations.
• Patients with more severe social phobia showed a
correlation with increased response in the amygdala.
Impulsive aggression
• Central nervous system executive inhibition
of this behavior is deficient, and higher
levels of executive control cannot therefore
be put into place.
• Aggression may thus be one of several
manifestations of the tendency to act in an
impulsive manner.
The Assault Cycle
From Keltner, N.L., Schwecke, L.H., Bostrom, C.E.: Psychiatric Nursing, ed 4, St. Louis, 2003, Mosby.
Prevention Strategies
Anticipatory Strategies
Containment Strategies
Continuum of nursing interventions in MAB
Self-awareness
Communication
Crisis management
Patient
education
Environmental
change
Seclusion
Assertiveness
Behavioral actions
Training
Psychopharmacology
Restraints
Assault Cycle
Triggering Phase
Escalation Phase
Crisis Phase
Recovery phase
Post Crisis Depression Phase
Nursing Interventions Based on
the Assault Cycle
• Goal: Is to strengthen the patients control
of feelings and impulses.
• Documentation of attempts to use less
restrictive measures (talking and oral prn
medications, if ordered) before more
restrictive measures such as seclusion or
restraints are used.
Nursing Interventions Based on
the Assault Cycle
Triggering Phase
Behavior
Muscle tension, changes in voice quality, tapping of fingers, pacing, repeated verbalizations, non
compliance, restlessness, irritability, anxiety, suspiciousness, perspiration, tremors, glaring
changes in breathing
Nursing Intervention
Convey empathic support.
Encourage ventilation.
Use clear, calm simple statements.
Ask patient to maintain control.
Facilitate problem solving by offering alternative solutions.
Ask patient to go to a quiet area.
Offer safe tension reduction.
Offer oral medications (prn)
Nursing Interventions Based on
the
Assault
Cycle
Escalation Phase
Behavior
Pale or flushed face, screaming, anger, swearing, agitation, hypersensitivity, threats,
demands, readiness to retaliate, tautness, loss of reasoning ability,
provocative behavior, clenched fists
Nursing Intervention
Take charge with calm, firm directions.
Direct patient to a quiet room for a “time out”.
Use oral medications (prn)
Ask the staff to be on stand-by at a distance.
Prepare for a “show of determination” to take control.
Nursing Interventions Based on
the Assault Cycle
Crisis Phase
Behavior
Loss of self-control, fighting, hitting, rage, kicking,
scratching, throwing things.
Nursing Intervention
Use involuntary seclusion, restraints, or IM medications.
Initiate intensive nursing care.
Nursing Interventions Based on
the
Assault
Cycle
Recovery Phase
Behavior
Accusations, recrimination, lowering of voice, change in
conversation content, more normal responses, relaxation.
Nursing Intervention
Continue intensive nursing care.
Process the incident with the staff and other patients.
Assess patient and staff injuries.
Evaluate patient’s progress towards self-control.
Nursing Interventions Based on
Post Crisis
the Assault Cycle
Depression Phase
Behavior
Crying, apologies, reconciliatory interactions, repression
of assaultive feelings (which may latter appear as
hostility, passive aggression)
Nursing Intervention
Process incident with patient.
Discuss alternative solutions to the situation and feelings.
Progressively reduce the degree of restraint and
seclusion.
Facilitate re-entry to the unit.
Patient Education Plan
Appropriate Expression of Anger
Content
Help patient identify anger
Instructional Activity
Focus on nonverbal behavior.
Role play nonverbal expression of anger.
Label the feeling using the patient’s own words.
Evaluation
Patient demonstrates an angry body posture and facial expression
Patient Education Plan
Appropriate Expression of Anger
Content
Give permission for angry feelings
Instructional Activity
Describe situation in which it is normal to feel angry
Evaluation
Patient describes a situation in which anger would be an
appropriate response
Patient Education Plan
Appropriate Expression of Anger
Content
Practice the expression of anger
Instructional Activity
Role play fantasized situation in which anger is an appropriate
response
Evaluation
Patient participates in role play and identifies behaviors associated
with expression of anger
Patient Education Plan
Appropriate Expression of Anger
Content
Apply the expression of anger in a real situation
Instructional Activity
Help identify a real situation that makes the patient angry. Role
play a confrontation with the object of anger. Provide positive
feedback for successful expression of anger.
Evaluation
Patient identifies a real situation that results in anger.
Patient is able to role play expression of anger.
Patient Education Plan
Appropriate Expression of Anger
Content
Identify alternative ways to express anger
Instructional Activity
List several ways to express anger, with and without direct
confrontation. Role play alternative behaviors. Discuss situations
in which alternatives would be appropriate.
Evaluation
Patient participates in identifying alternatives and plans which each
might be useful.
Patient Education Plan
Appropriate Expression of Anger
Content
Confrontation with a person who is a source of anger
Instructional Activity
Provide support during confrontation if needed. Discuss
experience after confrontation takes place
Evaluation
Patient identifies the feeling of anger and appropriately confront the
object of anger.
Seclusion
• Containment in seclusion room
– Goals:
• Prevent patient injury to self or others
• Decrease stimuli
• Increase intensive nursing care
• Degrees of seclusion vary
American Psychiatric Nurse
Association (APNA) Position Paper
• Seclusion and restraints must never be used
for staff convenience or to punish or coerce
patients
• Seclusion and restraint must be used for the
minimum amount of time necessary and
only to ensure physical safety of the
individual, other patients, or staff when less
restrictive measures have proven ineffective
American Psychiatric Nurse
Association (APNA) Position Paper
• Clients who are restrained must be afforded
the maximum freedom of movement while
assuring the physical safety of the client and
others. The least number of restraint points
must be utilized and the client must be
continuously observed.
American Psychiatric Nurse
Association (APNA) Position Paper
• S & R reduction requires preventative
interventions at both the individual and the milieu
management levels using evidence based practice.
• S & R use is influenced by the organizational
culture of a setting that develops norms for how
patients are treated. S & R reduction efforts must
include a focus on necessary culture change
American Psychiatric Nurse
Association (APNA) Position Paper
• Nursing leadership groups must make
commitments of adequate professional
staffing levels, staff time and resources to
assure that staff are adequately trained and
currently competent to perform treatment
processes, milieu management, deescalation techniques and seclusion and
restraints.
American Psychiatric Nurse
Association (APNA) Position Paper
• Oversight of the S & R must be an integral
part of an organizations P&P and these data
open to inspection by internal and external
regulatory agencies. Reporting requirements
must be based on a common definition of
seclusion and restraint.
Approved by
APNA Board of
Directors, May
15th, 2000
Restraint
•
•
•
•
•
Six to eight staff members needed
Show of force
Impose physical control/restraint
Administer IM medication
Physician evaluation within one hour and
written order required
• Follow agency protocols for care and
documentation
Staff Members: Assault Victims
•
•
•
•
•
Debriefing and recovery complicated
Similar to being victim of a crime
Loss of trust, sense of control, self-esteem
PTSD may result
Supportive interventions needed
Assault Victims
Assaults on psychiatric healthcare practitioners are
frequent. Between 40% and 70% of psychiatrists are
assaulted at some time in their careers (Bell et al., 2000).
Patients who assault doctors often externalize their actions
and put blame on the physician. Clinicians often believe
that a patient's positive feelings or respect will act as
protection against violent acts (Goin,2001) Although this is
true for many disorders, individuals with schizophrenia
may act irrationally and tend to assault individuals whom
they know well.
S.M.A.R.T. TRAINING
Safety Management And Response Techniques
Goals and Objectives
By the end of this course you will be able to:
• Demonstrate basic skills for managing crisis safely
• Assess and modify your own behaviors to deal effectively
with crisis
• Use the basic principles and techniques of verbal deescalation
• Improve team work and team cohesiveness
• As a last resort, utilize basic defensive maneuvers to keep
staff and resident safe
Background
• Allentown PA
– Restraint free state psychiatric hospital
• SFGH decreased injuries with SMART
• SFGH/LHH collaboration
Keep yourself and the resident
safe
Property is replaceable:
People are NOT!!!!
Maintaining personal safety means assuring
you have evaluated the situation, making
sure everyone is safe and maintaining
control
Incident
⇩
Safety
⇩
Is everybody safe?
Pause
Deep Breath
Relax
Assess situation
Call for back-up
Choose to intervene
Choose to have someone else intervene
Choose not to intervene
What is Anger?
•
•
•
•
•
Anger is a feeling
Anger is NOT behavior
Range of affect – mild to intense
Sense of power
May be related to loss of control, frustration
or anxiety
Let’s look at communication and
behavior that triggers anger
“5 Easy Pieces”
• Communication can either escalate or deescalate a potential crisis situation
Cycle of Escalation
C
B
A
D
A= Trigger
B= Escalation
C= Crisis Phase
D= Recovery Phase
E= Post Crisis Depression
E
Assessing Risk and Coping
Mechanisms
• It is essential that risk of assault or self-harm
behaviors are identified in the initial assessment
and captured in an ongoing manner
• Update “Nursing Assessment for Behavioral Risk”
form – all residents
• “Problem Behavior Triggers in Residents” –
Dementia Screening Tool
• Identify triggers that precipitate aggressive
behavior
• There are signs/symptoms that warn us
Verbal Defense during Crisis Phase
• In a strong commanding voice
- Tell the resident to STOP!
- Call out the resident’s name
- Tell him/her what to do
- Do not argue
- Do not tell him/her how to feel
“Gina, sit down!” “ John, drop that now!”
Keep yourself and the resident
safe
Effective Verbal Interventions
• Avoid saying “NO”
• Use short statements
• Connect with the
resident
• Divert attention
• Respond confidently
• Over-emphasize
• Gentle persuasion
How to help the resident cool
down
•
•
•
•
•
Regain sense of control
Use their strengths
Be respectful
Compromise
Provide win-win situation
Connect with the resident in
crisis
•
•
•
•
Stand at 2 arms length
45 degrees to resident and not directly in front
Avoid direct and close confrontation
Attempt to maintain some eye contact
Connect with the resident in
crisis (cont’)
•
•
•
•
Avoid using clinical clichés
Avoid judging
Avoid “Why” questions
Imagine yourself in the resident’s shoes
before you speak
Protecting yourself from the
physically aggressive resident
• Evasion Evasion Evasion
- Stand 2 arm lengths away at a 45-degree angle
- Positioning yourself closest to the exit
- No dangling jewelry
- Wear shoes you can run in; no open-toe shoes
• Getting out of resident’s holds
- Don’t resist
- Relax
- Stay in control of yourself
Keep yourself and the resident
safe
Fireman’s Tap
• This is used when the intervention is not
working in a particular situation
• Tap the staff person on the shoulder and tell
them, “You have a phone call.”
• Person tapped backs out of the situation
Tag Teaming
• Doing what works
• One person interacts with the resident at a
time
• If it’s not working (meaning if the resident
is not de-escalating), someone else will take
over the verbal interaction
• We often know that things are not working
but keep on trying
Early interventions
• “Come down the hall with me”
• “Let’s go talk at the end of the unit”
• “Wait a minute. I did not understand what
you just said”
• “Mr. Smith, help me understand this”
Early interventions (con’t)
More examples:
• Show resident that you sincerely care
• Provide genuine emotional support
“The Notebook”
• Each resident is an individual
• Knowing the resident’s cognitive status will
help determine the intervention that will
most likely be effective
Repetitive Behaviors
Examples of repetitive behaviors:
• What are some repetitive behaviors you
see on the unit
•
Effects of repetitive behaviors:
–
–
–
Increase irritability
Increase hostility
Increase frustration
Repetitive behavior scenarios
• What is going on?
• Dropping the specifics, what is the
repetitive behavior?
• Using the concept of understanding anger,
what intervention tools could you use
during the crisis and then what intervention
strategies could you use?
Keep yourself and the resident
safe
Debriefing is Crucial!
• Debriefing is one way to decrease staff’s
stress caused by an incident.
• The purpose of debriefing is not to assign
blame or point fingers at anybody from
the team
Why Debrief ?
1. To re-establish a sense of stability
2. To understand what happened
The Debriefing Process
•
Describe the incident
•
•
Brief description of the incident
Document incident
•
What went well during the incident?
•
Provide positive feedback
•
What might have helped during the
incident?
•
Air views about the incident without
having to point fingers at anybody
•
Was the communication process clear
to all unit staff/Assist Team?
•
Was everybody on the same page?
The Debriefing Process (con’t)
• Identify ways to improve
future responses to similar
incident
• Discuss least restrictive
measures
• Formulate an action plan
and determine who will
carry it out
• Create an action plan and
consider patient’s rights
issues
• Notify immediate
supervisor if there were
injuries sustained from the
incident
• Make sure that your
supervisor is aware of any
staff injuries as a result of
the incident.
Assist Team
• Roles and responsibilities
*Respond promptly to an assist team call
*Gather relevant information from unit staff
*Initiate verbal de-escalation techniques
• Assist Team report
*To be filled out by the person who called the assist team
*To be submitted to the Assist Team Coordinator via the
Nursing Office or Nurse Manager/Nurse Supervisor
What is the policy and procedure at your
clinical site?
Keep yourself and the resident
safe
Almost Done…
• Training evaluation
• Training certification
The End
Thank you