Nursing Management of Aggression

INTRODUCTION Aggression arises from an innate drives or occurs as a defense mechanism and is manifested either by constructive or destructive acts directly towards self or others. Aggressive people ignore the rights of other people. They must fight for their own interests and they expect same from others. An aggressive approach to life may lead to physical or verbal violence. The aggressive behavior often covers a basic lack of self confidence. Aggressive people enhance to their self esteem by overpowering others and there by proving their superiority. They try to cover up their insecurities and vulnerabilities by acting aggressive. Types of aggression Instrumental aggression -- aggression aimed at obtaining an object, privilege or space with no deliberate intent to harm another person Hostile aggression -- Aggression intended to harm another person, such as hitting, kicking, or threatening to beat up someone. Relational aggression -- A form of hostile aggression that does damage to another's peer relationships, as in social exclusion or rumor spreading SOCIAL FACTORS a). Frustration: The single most potent means of inciting human beings to aggression is frustration. Widespread acceptance of this view stems from John Dollards frustration, aggression hypothesis. This hypothesis indicated that frustration always leads to a form of aggression and that aggression always stem from frustration. Frustrated persons do not always respond with aggressive thoughts and words, or deeds. They may show a wide variety of reactions ranging from resignation, depression and despair to attempts to overcome the sources of frustration. Examination of the evidence indicates that whether frustration increases or fails to enhance covert aggression depends largely on two factors. First, frustration appears to increase aggression only when the frustration is intense. When it is mild or moderate, aggression may not be enhanced. Second frustration is likely to facilitate aggression when it is perceived as arbitrary or illegitimate, rather than when it is viewed s deserved or legitimate. b). Direct provocation: Evidence indicates that physical abuse and verbal taunts from others often elicit aggressive actions. Once aggression begins, it often shows an unsettling pattern of escalation; as a result even mild verbal slurs or glancing blows may initiate a process of in which a stronger and stronger provocation are exchanged. c). Television violence: A link between aggression and televised violence has been noted. The more televised violence children watch, the greater is their level of aggression against others. Mechanisms underlying the effects of televised and filmed violence on the behavior of the viewers d). Computer games: Similar concerns have been raised the bout computer game with violent themes. Some studies indicate that adolescents become desensitized to homicidal activities after repeated exposure, especially if the game involves killing the virtual opponents, which is common in many computer programs. ENVIRONMENTAL FACTORS Air pollution: Exposure to noxious orders ,such as those produced by chemical plants and other industries ,may increase personal irritability and therefore aggression , although this effect appears to be truly up to a point. If the odors in question are truly foul , aggression appears to decrease perhaps because escaping from the unpleasant environment becomes a dominant goal for those involved. Noise: several studies have reported that persons exposed to loud ,irritating noise direct stronger assaults against others than those not exposed to such environmental conditions. Crowding: some studies indicates that overcrowding may produce elevated levels of aggression, but other investigations have failed to obtain such evidence of such a link.

Nursing Interventions Nursing interventions can be thought of existing in a continuum . They range from preventive strategies such as self awareness, patient education and assertiveness training to anticipatory strategies such as verbal and nonverbal communications, and the use of medications. If the patients aggressive behaviour escalates despite these actions the nurse may need to implement crisis management techniques and containment strategies such as seclusion or restraints. Self awareness The most valuable resource of a nurse is the ability to assess ones self to help others .to ensure the most effective use of self , its important to know about personal stress that can interfere in ones ability to communicate with patients. Anxiety, angry, tiredness, apathy, personal work problems etc... from the part of nurse can affect the patient. Negative countertransferance reactions may lead to non therapeutic responses on the part of the staff. Ongoing self awareness and supervision can assist the nurse in ensuring that patient needs rather than personal needs are satisfied. Patient education Teaching patients about communication and the appropriate way to express anger can be one of the most successful interventions in preventing aggressive behaviour. Teaching patients that feelings are not right or wrong or good or bad can allow them to explore feelings that may have been bottled up, ignored or repressed. The nurse can then work with patients on ways to express their feelings and evaluate whether the responses they select are adaptive or mal adaptive. Assertiveness training Interpersonal frustration often escalates to aggressive behaviour because patients have not mastered the assertive behaviours. Assertive behaviour is a basic interpersonal skill that includes the following Communicating directly with another person. say no to unreasonable requests Being able to state complaints. Patients with few assertive skills can learn them by participating in structured groups and programmes .In these settings patients can watch demonstrate specific skills and then role play the skills themselves. Staff can provide feedback to patients on appropriateness and effectiveness on their responses. Homework also can be given to these patients to help them generalise these skills Expressing appreciation as appropriate outside the group milieu.

Communication strategies Nurses have to: present a calm appearance speak softly speak in a non proactive and non judgemental manner speak in a neutral and concrete way put space between yourself and patient show respect to the patient

avoid intense direct eye contact Demonstrate control over the situation without assuming an overly authoritarian stance. Facilitate the patients stance. Listen to the patient Avoid early interpretations Do not make promises that cannot keep.

Environmental strategies Inpatient units that provide many productive activities reduce the chance of inappropriate patient behaviour and increase adaptive social and leisure functioning. Both the unit norms and the rewards associated with such activities may reduce the amount of disorganised patient behaviour and the number of aggressive acts. Units which are overly structured with too much stimulation and little regard for the privacy needs of the patients may increase aggressive behaviour. Aggressive behaviour is more effectively managed by allowing those at risk to spend time in their rooms away from the hectic day room rather than encouraging them to interact with others in a crowded milieu. The environment that may have been therapeutic in the days of extended hospital stays may no longer be suitable for patients with who are hospitalised on short term, acute inpatient units where the acuity of the patient is extremely high. Inpatient units should adapt the environment to best meet needs of the patient they treat.

1. Room programme In an inpatient setting the use of structured programme is an effective tool for the management of agitated patients. A room programme limits the amount of time patients are allowed in the unit milieu. Egg. Patients initially are asked to be in the rooms for a certain length of time, or conversely be allowed out of their rooms for a specific amount of time every hour. The amount of time in the milieu may then be increased by increments of 15 min as patients tolerate the environment. Another way of implementing a room program is to allow patients to come out of their rooms during designated hours, such as when the unit is quite when the other patients are off the unit. Such a structured programme allows patients time away from situations that may increase agitation and provides away to regulate the amount of stimulation patients receive. Its purpose is prevention of a crisis that could result in more serious patient complications. 2. Cathartic activities The use of cathartic activities may help the patients deal with their anger and agitation. These can be of 2 types: a). Physically cathartic activities It is based on the assumption that some physical activity can be useful in releasing aggression and can prevent more explosive or destructive forms of aggression or violence .Some traditional nursing interventions, such as encouraging patients to release tension through the use of exercise equipment or allowing patients to pace the hall in the expectation that their tension will decrease. Because these strategies are not supported by research and may increase patients agitation they are not recommended now. b). Emotionally cathartic activities these are evidence based. Having patients write their feelings, do deep breathing or relaxation exercises, or talk about their emotions with a supportive person can help the patient regain control and lower feelings of tension and agitation.

Behavioral strategies Nursing interventions include applying principles of behaviour management to aggressive patient. a) Limit setting Limit setting is a non punitive non manipulative act in which patient is told what behaviour is acceptable and what is not acceptable , and the consequences of behaviour unacceptably. By explaining the rational for the limit and communicating to the patient in a calm and respectful manner, potentially aggressive behaviour can be avoided. If nurse communicates in an authoritarian, controlling or disrespectful way patients respond in an angry, aggressive manner. The patient has the right to choose behaviour and understands its consequences. Limits should be clarified before negative consequences be are applied. One a limit has been identified; the consequences must take place if the behaviour occurs. Every staff member must be aware of the plan and carry out it consistently. If staff do not do so, the patient is likely to manipulate staff by acting out and then point out areas of inconsistent limit setting. Clear, firm and no punitive enforcement of limits is the goal. When limit setting is implemented, the maladaptive behaviour will not immediately decrease, in fact, briefly increase. This is consistent with behavioural principles and testing behaviour.

b). Behavioral contracts If the patient uses violence to win control and make personal gains, the nursing care must be planned to eliminate the rewards patient receives while still allowing the patient to assume as much as control, as possible. Once the rewards are understood, nursing care must be planned that does not reinforce aggressive and violent behaviour. Behavioural contracts with the patient can be helpful in this regard. Eg. Head injured patients with low impulse control can be told that staff will take them for a walk if they can refrain from using profanity for 4 hours. To be effective contracts require detailed information about: unacceptable behaviours. acceptable behaviours. consequences for breaking the contact.

The nurses contribution to care. Patients also should have input into the development of the contract to increase their sense of self control. c). Time out In an inpatient setting, the use of time out can be an effective tool for the management of agitated patients. It is a strategy that can decrease the need for for seclusion and restraint. Time out from reinforcement is a behavioural technique in which socially inappropriate behaviours can be decreased by short term removal of the patient from over stimulating and sometime reinforcing situations. Time out usually will be in a quiet area of the patients unit or the patients room. They remain there until they become non aggressive for a couple of minutes. It may be initiated by the patient or staff. Patient is allowed to be out of the time out area when he is able to remain calm. Patient determines their own readiness to leave the time out area. Time out is not considered to be seclusion.

d). Token economy

In this intervention, identified interpersonal skills and self care behaviours are rewarded with tokens that can be used by the patient to buy items or receive rewards or privileges. Behaviours to be targeted are specific to each patient. guidelines has to be made for desired behaviours required to receive the tokens, the number of tokens to be received for each behaviour and the Length of time a desired behaviour must be exhibited to receive tokens.

e). Crisis Management Team Response Effective crisis management must be organised and should be directed by one clearly identified crisis leader. Procedure for managing psychiatric emergencies. Identify crisis leader Assemble crisis team Notify security officers if necessary Remove all other patients from the area Obtain restraints if appropriate Device a plan to manage crisis and inform team Assign securing of patients limbs to crisis team members Explain necessity of intervention to patient and attempt to enlist cooperation Restrain patient when decided by the crisis leader Administer medication if ordered Maintain calm, consistent approach to patient Review crisis management interventions with crisis team Process events with other patients and staff as appropriate Process event with patient Gradually reintegrate patient into milieu.

f). Seclusion Seclusion is the involuntary confining of a person alone in a room from which the person is physically prevented from leaving (Brown, 2000). Degree of seclusion varies. They include confining a patient in a room with a closed or unlocked door or placing a patient in a locked room with a mattress but no linens and with limited opportunity for communication. The rational for the use of seclusion is based on 3 therapeutic principles:

Containment using this principle patients are restricted to a place where they are safe from harming themselves and other patients.

Isolation addresses the need for patients to distance themselves from relationships that, because of illness are pathologically intense. Some patients, particularly those with paranoia, distort the meaning of the interactions around them. Their distortions create such psychic pain that seclusion may provide some relief and may be the only place to feel safe from their persecutors". The third principle is that seclusion provides a decrease in sensory input for patients whose illness results in a heightened sensitivity to external stimulation. The quiet atmosphere and monotony of a seclusion room may provide some relief from the sensory overload.

g). Restraints Indications used when the client is no longerexerting control over his/her own behaviour. to prevent harm to others and to patient to prevent serious disruption of treatment environment.

Physical restraints are any manual methods or physical or mechanical device attached to or adjacent to the patients body that she/he cannot easily remove and that restricts freedom of movement or normal access to ones body, material or equipment (Brown, 2000) Chemical restraints are medications used to restrict patients freedom of movement or for emergency control of behaviour, but it is not a standard treatment for the patients medical or psychiatric condition (Murphy, 2002). Because seclusion and restraints represents restriction of patient freedom and can result in harm to both the patient and the staff who implement them, they should be used only as an emergency intervention to ensure the safety of the patient or others and only when other less restrictive interventions has been ineffective. They are a violation of patient rights if used as a means of coercion, discipline or convenience of staff (Brown, 2000). Restraints should be applied efficiently and with care that not to injure a patient. Adequate personnel must be assembled before the patient is approached. Each staff member should be assigned responsibility for controlling specific body parts. Restraints should be available and in working order. Padding of cuff restraints helps to prevent skin breakdown. For the same the patient should be positioned in anatomical alignment. Guidelines for use of restraints 1. Restraints must not be used to punish a patient or solely following the convenience of staff or other patients. Staff must take into consideration the medical/psychiatric status of patient. Written policy must be followed. In non-emergency situation physical restraints should be used very sparingly and only after careful and comprehensive review, assessment and documentation provide substantial evidence that no safer alternative or setting can be found to prevent their use. The least restrictive device should be used. All mechanical restraints must be padded to decrease the chance of pressure damage and abrasion to skin and underlying tissues; proper size and type must be used. Both the patient and restraining device must be checked frequently and the restraining device removed periodically. A restrained limb should be periodically exercised and, if possible the patient should be ambulated at reasonable intervals. Attention to need fro hydration, elimination, comfort, and social interaction must be assured. Behaviour that precipitates a decision to restrain patient should first trigger investigation and treatment aimed at understanding and eliminating the cause of the behaviour.

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ursing staff should observe the patient every 15 min.

10. All the needs of the patient must be met with caution. 11. With four point restraint each limb should be released or restraint loosened every 15min. 12. Patient should be gradually decreased from seclusion or restraint. m) Patient should not be made to feel guilty after being released from restraints of his past behaviour. 13. Documentation is necessary. Risks with restraints Falls, strangulation, loss of muscle tone, pressure sores, decreased mobility, agitation, reduced bone mass, stiffness, and frustration, loss of dignity, incontinence, and constipation.