you mad bro? - san antonio ena · you mad bro: kevin mcfarlane 5/12/19 1 you mad bro? dealing with...

You Mad Bro: Kevin McFarlane 5/12/19

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You Mad Bro?Dealing With and Defusing

Aggressive Behavior

Kevin McFarlane MSN,RN,CEN,TCRN

Anyone can become ANGRY. That is easy. But to be ANGRY with the right person, to the right degree, at the right time, for the right purpose and the right way… that is not easy.

-Aristotle

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Epidemiology of Violence in Healthcare

• Over 5 million in the U.S. work in healthcare: • Exposed to many safety and health hazards• According to the Occupational Safety and

Health Administration (OSHA), approximately 75 percent of nearly 25,000 workplace assaults reported annually occurred in health care and social service settings


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There are lots of causes for

potential violence

Diagnosis Associated with Violence

• Functional • Schizophrenia• Mania

• Personality disorders• Antisocial• Borderline • PTSD


• Infectious – CNS Infection–Meningitis – Encephalitis – Sepsis


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• Neurologic– Head Injury – Seizures– Postictal states – Aids relate dementia


• Drug Related • ETOH intoxication• Amphetamines • Cocaine • PCP (Phencyclidine)• LSD• Narcotic/benzo

withdrawal


• Metabolic/Endocrine – Electrolyte disturbance – Hypo/hyperthermia – Anemia– Hypoxia– Hypoglycemia– Thyroid storm – Cushing’s disease


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Question?

What makes people angry?

What Makes People Angry?

• Losing power• Losing status• Losing respect

• Being insulted• Not having things turn

out the way they expected

What Makes People Angry?

• Expecting pain• Feeling that you have been treated unfairly and

unjust• Believing that things should be different• Rigidly thinking “I am right


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Predicting Violent Behavior

• Warning signs:– Pacing or restlessness– Clenched fist– Increasingly loud speech– Excessive insistence– Threats – Cursing

Physiological Signs of Anger

• Heart beating faster• Breathing rate increases• Fists clenched• Face feels hot or cold• Hands shaking• Profuse sweating• Higher body temperature

Physiological Signs of Anger

• Sudden dry mouth• Stuttering• Muscles tensing• Goosebumps• Face turns pale or red• Teeth grinding, jaw clenching


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What will we see

• Warning signs:– Pacing or restlessness– Clenched fist– Increasingly loud speech– Rapid speech– Threats – Cursing

The Trigger

• Occurrence perceived by the individual as a serious threat to him/her.

• TWO TYPES: – Fear Inducing Events – Give the person the

perception he/she is under threat or about to lose something of value.

– Frustrating Circumstances – Give the person the idea that his/her efforts or demands have been useless

What Do We Know About Anger

• Follows a predictable pattern of levels

• Levels have observable characteristics

• Opportunities for intervention are present at every level

• May be about something other than situation at hand (lack of sleep, work problems, fight with significant other, illness, etc..)


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Levels overviewThe Anger Cycle

1. Questions

2. Back Talk

3. Refusal

4. Challenge5. Outburst

6. Quiet Period

7. In Control

Anger Cycle by Chuck York

Level 1 - Questions

• Description–May be legitimate questions about an activity,

missed information, etc..

• Examples– “Why do I have to go?”– “How does this stuff help me?”

• May be an attempt to question your authority– “Why do I have to listen to you?”– “Who died and made you boss?”

Appropriated Intervention for Questions

• The easiest way to prevent escalation from this point is simply to answer the question

• Assume that questions are real. Do not assume the person is trying to “start something” or be manipulative by asking questions

• Use “Effective Listening” to maintain clear communication


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Effective Listening

• Let the person do the talking• Focus on what the person is saying• Focus on the person’s emotions (look at body

language, sound of voice, etc..)• Restate what the person is saying to you to

show you understand• Keep your answers short and clear

Level 2 - Back Talk

• Description• Person is showing their anger and trying to

incite you to be angry• Examples– “You’re always telling me what to do! Why don’t

you do it?”– “You don’t know what you are talking about”– “This is all just stupid”

Appropriate Intervention for Back Talk

• Stay calm and in control• Be aware of your facial expressions, your posture,

and how your voice sounds– Keep a distance of at least 3 feet between you and the

person– Speak slowly and be civil– Do not cross your arms or make yourself look

“closed

• Redirect the person back to the topic of the discussion


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Level 3 - Refusal

• Description– The person is challenging your control of the

situation by refusing to comply with a direction

• Examples– “I’m not going”– “I’m not going to do that”– Crossing arms, turning head, ignoring you– “Do it yourself”

Appropriate Intervention for Refusal

• Stay calm, cool and collected• Your behavior impacts the situation. • If you are responding to the person’s anger,

the person will become more angry• Give the person two clear choices that are

reasonable and appropriate. Explain the consequences for each of the choices

Level 4 - Challenge

• Description– The person is attempting to directly challenge

your authority

• Examples– “You can’t make me do it!”– “I don’t have to do that!”– “Pick on somebody else!”


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Appropriate Intervention for Challenge

• Try to remove either the person or the audience

• The person may escalate faster if the others are watching

• Seek help if you think this will escalate further

• Check your own behavior and make sure you are in control

Appropriate Intervention for Challenge

• Increase distance between the person and yourself

• Restate choices

Level 5 - Outburst

• Description–The person is no longer able to maintain

control

• May take 2 forms: Verbal or Physical–Verbal Outburst - screams, yells, shouts

profanity, cries, etc..–Physical Outburst - attacks, kicks, throws,

breaks, runs, etc.


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Appropriate Intervention for Outburst

• If the outburst is verbal– Keep a space between the person and yourself– Allow the person to vent– Do not attempt communication at this point– Show of force

Appropriate Intervention for Outburst

• If the outburst is physical– Remove the other bystanders from the room– Exit the room yourself, and attempt to maintain

visual contact with the person– Show of force– Consider physical interventions

Level 6 - Quiet Period

• Description– After every outburst, the person will reach a

“quiet period” in which their emotional status is below their average state

• Usually represented by being quiet, lack of energy, sometimes crying, moving to a protected area, etc..


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Appropriate Intervention for Quiet Period

• Give the person space and time to calm down

• Quietly offer support• Be respectful and kind

Level 7 - In Control

• Description• The outburst is over, and the person has

regained control• Still a sensitive time, and care should be given

not to re-escalate the situation

Appropriate Intervention for In Control

• Invite the person to rejoin communication• Ask the person to join clean up of any messes

or damage caused• Ask the person which of the choices they have

selected


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Self Protection

• Always be aware of • Stethoscopes around

your neck• Badge lanyards that are

not “break-away”• Long necklaces

• Dangling earrings• Long hair (always pull

back)• Men’s ties

Things That Can be Used as Weapons

• Scissors, Hemostats, Eating utensils (even plastic), plates, plate warmer, water pitchers, vases, anything glass or ceramic

• Belts, robe ties, tubing (IV, 02, etc.)• Sheets, pillowcases, gowns• Pens/pencils• Furniture

Let’s Review

1. Anger follows a predictable and observable pattern

2. There are appropriate interventions for each level of the anger cycle

3. You are an active participant in the cycle, and can escalate or de-escalate the behavior with your actions


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4. When a person reaches the outburst level, they are no longer in control of their actions

5. The key point during an outburst is to create the safest environment possible to prevent injury

6. NEVER attempt a physical intervention unless you have received proper training and it follows your organizational policies and guidelines

Chemical Restraint

• Rapid tranquilization– Safe – Reliable – Titratable

• Agents

• Benzodiazepines• Neuroleptics• Ketamine

Benzodiazepines

• Midazolam– Im or IV–Max effect 10 min lasts ~2hours

• Diazepam– IV – So so IM absorption – Longer acting


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Benzodiazepines

• Midazolam (Versed)– Im or IV–Max effect 10 min lasts ~2hours

• Diazepam (Valium)– IV – So so IM absorption – Longer acting

Complications with both • Oversedation• Hypotension• Airway compromise • Paradoxical reaction • Tolerance

Neuroleptics

• Droperidol/Haloperidol• IM/IV• 2.5mg/10mg

• Olanzapine (zyprexa)• IM

Physical Restraints

When do you decide to restrain a patient?


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Physical Restraints

• Risk of harm to self or others• Failed negotiations • Sometimes in conjunction with chemical

restraints

3Things to

Remember

3 things to remember

• Reasoning with an angry person is not possible.

• De-escalation techniques go against our natural ‘fight or flight’ reflexes.

• One of the people in the equation MUST stay calm and centered.


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3Things to Forget

3 things to forget

• It’s not your emergency

• Forget thinking you can do this alone. Bring a buddy

• Forget your feeling….It’s not about you

Be carful out there

Check out my new podcastThe Art of Emergency Nursing

Thanks for Listening

you mad bro? - san antonio ena · you mad bro: kevin mcfarlane 5/12/19 1 you mad bro? dealing with...

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