Psychiatric / Mental Health NursingWest Coast University

ObjectivesDescribe theoretical perspective in understanding

violenceIdentify the presence of behavioral and verbal

cues that indicate impeding violenceDescribe nursing measures to de-escalate

potentially violent behavior within the context of the principle of least restrictiveness.

Implement a variety of nonpharmacological nursing strategies for intervening with violent clients.

Identify common staff responses to violence.

Objectives Analyze personal feelings and attitudes that

may affect professional practice when caring for clients with aggressive behaviors.

Identify problem-solving framework.Identify principles of documentationReview types of restraintsPractice evasions from attacksIdentify principles of evasion

Violence in the Healthcare SettingDefinition:Verbal or physical threats and/or injury to

persons or destruction of property 60-90% of nurses experience violence.Psychiatric setting is area of high risk and

incidence.

Basic PremiseStudents who have reviewed the systematic

approach to intervention during incidents of potential assault are less likely to injure or be injured than those who have not.

Biopsychosocial TheoriesBiologic Theories

– 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 - continuedPsychosocial Theories

Psychoanalytic – aggression an innate drivePsychological – impairment in impulse control,

coping, and social skillsSociocultural – child abuse, dysfunctional

family

Biopsychosocial Theories - continuedPsychosocial Theories

Psychoanalytic – aggression an innate drivePsychological – impairment in impulse control,

coping, and social skillsSociocultural – child abuse, dysfunctional

family

Biopsychosocial Theories - continuedBehavioral Theory

Learned behavior (exposure to violence in media/entertainment)

Humanistic TheoryBasic drives unmet

Aggression and the BrainHypothalamus

Alarm system, controls pituitary functionDysfunction leads to overreaction to stress and

overactivation of pituitaryHippocampus

Regulates the recall of recent experiences and new information

Dysfunction associated with impulsivity

Aggression and the Brain - continuedAmygdala (limbic system)Frontal cortex

Behavioral CuesClenched jaws and fistsDilated pupilsIntense staringFlushing of face and neckFrowning, glaring, or smirking PacingIncreased vigilanceAnxietyDestruction of property

Verbal CuesThreats of harmLoud demanding toneAbrupt silenceSarcastic remarksPressured speechIllogical responsesYelling, screaming, cursingStatements of fear or suspicion

ExerciseKinds of physically injurious behaviors that you may observe in the clinical setting?What needs clients are trying to meet?What alternative behavior will your patients use to meet these needs

ProfessionalismOur attitudes influence client’s behavior. Cynicism, pessimism, and other destructive attitudes frequently aggravate assaultive incidents. When we accept responsibility for our career choice, then we are less likely to contribute to unnecessary violence.

Attitude

Mood

Motivation

PreparationWe should prepare to respond to aggressive

behavior before they enter the workplace. Then they are less likely to injure during an assault. The fully prepared student has proper attire, adequate mobility, well-practiced observational strategies, and an organized plan for self-control.

Attire

MobilityPrecautions (Psychiatric and Medical Problems)Observation

Self-Control

Nursing Process: AssessmentRisk factors:• 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• Agitated delirium / Acute excited state• Substance abuse

AssessmentAssess client’s:Perception of precipitating event/current

situationSupport systemUsual coping patternsWithdrawal symptomsConfusion Pain

Assessment - continuedEnvironmental factors

Availability of dangerous objectsOvercrowdingStaffingSupervisionActivity level

Nursing Diagnoses: NANDARisk for Other-Directed ViolenceRisk for Self-Directed ViolenceAnxietyIneffective CopingChronic Low Self-Esteem, and Situational

Low Self-Esteem

Other ConsiderationsImpulse controlSensory-perceptual functioningCognitive functioningSocial skillsImpaired communicationHelplessnessPowerlessnessProtection of vital interestAn aggressive or hostile staff memberChanges in role identityLack of personal space

ImplementationDevelop a therapeutic relationship.Establish trust, maintain safety, and convey respect.Use active listening and calm demeanorAddress client needs.Use problem solving with the individualBe empatheticOffer assistance and avoid an argumentative stanceAllow venting and pacingUse open ended questions and give the client time to

think

InterventionsAvoid saying “you must” or “you need to”Avoid power struggles and judgementsBe aware of your nonverbal behaviorBe clear and use simple languageDecrease environmental stimuli

Five Phases of “The Assault Cycle”Phase 1: The triggering eventPhase 2: EscalationPhase 3: CrisesPhase 4: RecoveryPhase 5: Post-crises depression

Nonpharmacologic Strategies - continuedDe-escalationAssemble a team and brief team members.Clear the area of other clients.Choose a leader.Evasion

Appropriate for responding to situation in which assault and battery is attempted

Prevents injury and avoids the pitfall of retaliation or over-reaction

Reasonable force

Pharmacologic InterventionsPharmacologic agents

Antipsychotics (typical and atypical)Benzodiazepinescombinations

Restrictive MeasuresRestrictive measures

PharmacologicSeclusion

Involuntary confinement Restraint

Device attached or adjacent to client’s body which restricts movement or normal access to one’s body

Documentation requiredDenial of Rights

SafetyMinimizing personal riskNonthreatening communicationAwareness of environmentAvailability of other staff membersAwareness of clothing and objects

Health Professional’s RoleHelp person in crisis understand what led to

the crisis and guide him/her toward positive resolution

Acute phase: restore the person to pre-crisis level of functioning as quickly as possible

Professional Education and SupportBehavioral crisis management programs

Increase awareness of risk factors, teach staff de-escalation strategies and teamwork for behavior management/restraint

Critical Incident Stress Debriefing (CISD) Staff who experience violent situation discuss

feelings in safe, supportive environmentReduces long-term negative consequences

Nursing Self-AwarenessHow do I feel about this patient/setting? How are my feelings affecting my behavior?Fear is a normal response.Avoid personalizing.Use intuition.

Practice Evasion From AttacksEvasion from punches, slaps and scratchesEvasion from kicks, and kneeCover and deflect when trapped or corneredEvasion from blows with heavy objectsEvasion from holding attacks:

To the skin: pinching, digging nails, bitingTo the hairTo the limbTo the torsoTo the neck

Principles of EvasionControl yourselfKeep “talking”Be patientStay out of the wayGet out of the wayPat attentionMake a plan

Track the attackMove in an arc close the attackEscape holding

attacksMinimize, release,

evadeCall for helpAvoid inflicting pain

and injury