Violence and Crises
Intervention
West Coast University
NURS 204
Violence in the Healthcare
Setting
Definition:
 Verbal or physical threats and/or injury
to persons or destruction of property
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60-90% of nurses experience violence.
Psychiatric setting is area of high risk
and incidence.
Biopsychosocial Theories
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Biologic Theories
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Imbalances of hormones (↑ testosterone),
neurotransmitters (↑D and NE, ↓Achm 5HT,
and GABA)
Genetic abnormalities
Neurophysiologic injuries (trauma, anoxia,
metabolic imbalance, encephalitis, organic
brain injury)
Biopsychosocial Theories continued
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Psychosocial Theories
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Psychoanalytic – aggression an innate
drive
Psychological – impairment in impulse
control, coping, and social skills
Sociocultural – child abuse, dysfunctional
family
Biopsychosocial Theories continued
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Psychosocial Theories
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Psychoanalytic – aggression an innate
drive
Psychological – impairment in impulse
control, coping, and social skills
Sociocultural – child abuse, dysfunctional
family
Biopsychosocial Theories continued
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Behavioral Theory
Learned behavior (exposure to violence
in media/entertainment)
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Humanistic Theory
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Basic drives unmet
Aggression and the Brain
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Hypothalamus
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Alarm system, controls pituitary function
Dysfunction leads to overreaction to stress and
overactivation of pituitary
Hippocampus
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Regulates the recall of recent experiences and
new information
Dysfunction associated with impulsivity
Aggression and the Brain continued
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Amygdala (limbic system)
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Regulates emotion, memory storage, information
processing
Dysfunction affects emotion and behavior,
outbursts of fear, anger, rage, hypersexuality
Frontal cortex
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Generates thought and purposeful behavior
Dysfunction leads to impaired judgement, poor
decision-making, personality changes, aggressive
outbursts
Behavioral Cues
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Clenched jaws and fists
Dilated pupils
Intense staring
Flushing of face and neck
Frowning, glaring, or smirking
Pacing
Increased vigilance
Verbal Cues
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Threats of harm
Loud demanding tone
Abrupt silence
Sarcastic remarks
Pressured speech
Illogical responses
Yelling, screaming
Statements of fear or suspicion
Nursing Process: Assessment
Risk factors:
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History of violence
Severity of psychopathology
Higher levels of hostility
Length of time in the hospital
Early age of onset of psychiatric symptoms
Frequency of admission to psychiatric hospitals
Self-Awareness
Assessment
Assess client’s:
 Perception of precipitating event/current
situation
 Support system
 Usual coping patterns
Assessment - continued
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Environmental factors
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Availability of dangerous objects
Overcrowding
Staffing
Supervision
Activity level
Nursing Diagnoses: NANDA
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Risk for Other-Directed Violence
Risk for Self-Directed Violence
Anxiety
Ineffective Coping
Chronic Low Self-Esteem, and
Situational Low Self-Esteem
Other Considerations
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Impulse control
Sensory-perceptual functioning
Cognitive functioning
Social skills
Impaired communication
Helplessness
Powerlessness
Implementation
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Develop a therapeutic relationship.
Establish trust, maintain safety, and
convey respect.
Use active listening.
Address client needs.
Pharmacologic Interventions
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Pharmacologic agents
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Antipsychotics (typical and atypical)
Benzodiazepines
combinations
Safety
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Minimizing personal risk
Nonthreatening communication
Awareness of environment
Availability of other staff members
Awareness of clothing and objects
Nonpharmacologic Strategies
- continued
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De-escalation
Assemble a team and brief team
members.
Clear the area of other clients.
Choose a leader.
Restrictive Measures
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Restrictive measures
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Pharmacologic
Seclusion
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Restraint
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Involuntary confinement
Device attached or adjacent to client’s body which
restricts movement or normal access to one’s body
Documentation required
Denial of Rights
Professional Education and
Support
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Behavioral crisis management programs
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Increase awareness of risk factors, teach staff deescalation strategies and teamwork for behavior
management/restraint
Critical Incident Stress Debriefing (CISD)
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Staff who experience violent situation discuss
feelings in safe, supportive environment
Reduces long-term negative consequences
Nursing Self-Awareness
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How do I feel about this patient/setting?
How are my feelings affecting my
behavior?
Fear is a normal response.
Avoid personalizing.
Use intuition.
Situational Crises
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Material or environmental
Personal or physical
Interpersonal or social
Maturational Crises
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Life cycle transitions: infancy, childhood,
puberty, adolescence, adulthood,
middle age, older adulthood, old age
Other life changes: marriage,
retirement, transition from student to
worker
Crisis as Turning Point
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Crisis = turning point that results in new
equilibrium, which may be similar to precrisis state, or more positive or negative
Crisis Intervention
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Crisis is self-limiting because
disequilibrium is so uncomfortable.
Crisis resolves itself, favorably or
unfavorably, even without intervention.
Working with another person increases
likelihood of favorable resolution.
Sequence of Crisis
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Tyhurst’s three stages of disaster:
 Impact
 Recoil
 Post-trauma
Sequence of Crisis continued
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Caplan’s four stages of crisis reaction:
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Initial increase in tension
Further increase in tension and disruption of daily
living when crisis is not quickly resolved
Increase in tension to depression levels if usual
problem-solving techniques fail
Partial resolution of crisis with use of new coping
skills, or mental disruption/disorder if new skills
are not developed
Health Professional’s Role
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Help person in crisis understand what
led to the crisis and guide him/her
toward positive resolution
Acute phase: restore the person to precrisis level of functioning as quickly as
possible
Assessment
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Individual: precipitating event, perception,
support, resilience, coping style, ability to
handle problem, suicide potential
Family: stressors, resilience, resources,
coping skills, interpersonal styles
Sociocultural: influence of culture on sources
of distress a client experiences,
symptomatology, interpretation of symptoms,
coping methods
Nursing Care
Common diagnoses:
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Ineffective Coping
Interrupted Family Processes
Risk for Self-Directed Violence
Anxiety
Acute Confusion
Spiritual Distress
Sleep Deprivation
Risk for Post-Trauma Syndrome
Complicated Grieving
Impaired Social Interaction
Nursing Care - continued
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Outcome criteria: determined in collaboration
with client
Planning/implementation: developed with
client and family; focused on immediate
problems; consistent with lifestyle/culture;
time limited; realistic; mutually negotiated;
provides for follow-up
Evaluation: in long-term setting, review of
implementation and outcomes
Balancing Factors
According to Aguilera, three balancing
factors for resolution of disequilibrium
are:
 perception of the event
 situational supports
 coping mechanisms
Crisis Intervention
Types of crisis intervention:
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Crisis counseling (brief, solution-focused therapy)
Telephone counseling
Assisting with environmental changes
Anticipatory guidance (assistance in anticipation of
the potential for crisis, thus averting it)
Helping to develop social supports
Critical incident stress management
Disaster assistance
Critical Incident Stress
Management
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CISM = integrative, comprehensive,
multifaceted approach spanning time
sequence of crisis
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10 components:
 Pre-event planning
 Assessment
 Strategic planning
 Individual crisis intervention
Critical Incident Stress
Management - continued
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10 components: (con’t)
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Large group crisis intervention
Small group crisis intervention
Family crisis intervention
Organizational/community intervention
Pastoral crisis intervention
Follow-up/referral
ABCs of Crisis Counseling
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A = Achieve contact (safety and
security)
B = Boil down the problem (ventilate
and validate)
C = Cope with the problem (predict and
prepare)
ABCs of Crisis Counseling in
Plan of Care
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A = Assessment
B = Diagnosis
C = Planning and implementation,
including plan for follow-up (evaluation)
Nursing Self-Care
Behaviors crucial to effective crisis work:
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Belief in a person’s capacity to grow and change
Awareness of impact of repeatedly hearing horrible
stories
Developing outlets for stress, frustration, anger
Dealing with fears and vulnerability
Realistic expectations
Respect for others’ timetable for crisis resolution
Collaboration with others
Vicarious Traumatization
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Vicarious traumatization = condition in which
psychological aftereffects are experienced by
those who are not direct victims of the
traumatic event
Commonly affects next of kin, injured and
uninjured survivors, onlookers, rescuers,
body handlers, health personnel, people
responsible for disaster, coworkers, evacuees
Origins and Risk Factors for
Crisis
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Origins of crisis: situational, maturational
Risk factors: intensity of exposure, preexisting
psychiatric symptoms or diagnosis, previous
trauma, family history of mental illness, early
separation from parents, childhood abuse,
poverty, cultural expectations, degree of
threat to life