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Kenn S. Nuyda, RN
Aquinas University
MAN 2008
1) WORKING WITH THE AGGRESSIVE
PATIENT
2) WORKING WITH GROUPS OF
CLIENTS
3) WORKING WITH THE FAMILY
2
WORKING WITH THE
AGGRESSIVE PATIENT
ANGER
– Is it normal?
– Does it result to problem solving and change?
– Is it destructive and life threatening?
3
ANGER
What is ANGER?
– Normal human emotion crucial for growth
– When handled properly, it is a + force that leads to px
solving and change
– When handled aggressively it is destructive and life
threatening – assault, battery and violence
– PHYSICAL AGGRESSION
– PASSIVE AGGRESSION
4
HOW IS ANGER
MANIFESTED?
AGGRESSION
– Aggressive person: verbal expression (assault),
may carry out the verbal threat (battery)
– Recipient: fear. Frustration and avoidance of
that person, helplessness, defensive, guilty or
angry, may retaliate, revenge or hold grudge
towards the person
5
Questions:
6
VERBAL AGGRESSION
– Serves as warning signs of assault or impending
battery
– May provoke counteractions = fighting /
violence
7
VERBAL AGGRESSION
Passive-aggressive = expression of anger in
subtle and evasive ways, denies its source
> coz afraid of punishment and rejection
> inefficient to accomplish task
Passive – inward manifestations of anger
> may damage, destroy or avoid relationship and
intimacy
> may lead to low self-esteem, depression,
substance abuse, somatoform, suicide attempts
8
ASSERTIVENESS
– Accepted: HEALTHY ASSERTIVENESS
• Respecting the rights of others and the self while
expressing emotions
9
EXPRESSIONS OF ANGER
TURNED OUTWARD
OVERT ANGER
PASSIVE AGGRESSION
TURNED INWARD
SUBJECTIVE
OBJECTIVE
10
OUTWARD EXPRESSION
OVERT ANGER PASSIVE AGGRESSION
Verbalization of anger Impatience
Pacing with agitation Pouting
Hostility Tensed facial expression
Contempt Annoyance
Clenching of fists Pessimism
Insulting remarks Complaining
Provoking behaviors Stubbornness
Sadistic acts Sarcasm
Temper tantrums Manipulation
Screaming Noncompliance
Deviance Resistance
Rage Bitterness
Damage to property Procrastination
Threats: words and weapons Unfair teasing
Rape, assault, homicide domination 11
INWARD EXPRESSION
SUBJECTIVE OBJECTIVE
Feeling upset Crying
Tension Self-destructive behaviors
Unhappiness Self-mutilation
Feeling hurt Substance abuse
Guilt Suicide
Disappointment
Low self-esteem
Envy
Powerlessness
Somatization
Inferiority
Depression
Hopelessness
Desperation
Humiliation 12
THE DEVELOPMENT OF
AGGRESSION BY AGE
Infancy: Uncontrollable crying and screaming,
profuse perspuration, DOB, flailing of arms and
legs
Toddlerhood: temper tantrums
SAC: hitting one another
Preadolescents: hitting each other competitive
sports, “tsimis”, practical/sarcastic jokes, fighting
is controlled and purposeful, gangs
13
22 – 45 y/o: aggression and fighting
After 45 y/o: stopped fighting
70 y/o: diminished impulse control and
cognitive impairment decreased
expression of anger
14
15
INDIVIDUAL MODELS
Violence – quality of being human
and use biologically based
expressions of aggression
– Neuroanatomy
• Limbic system, frontal and temporal lobe
– Neurophysiology
• Neurotransmitters (sero, GABA, dopa)
16
Common Problems r/t aggression
Bifrontal injuries Damage to limbic
system
AD Inc. dopamine
17
Social – Psychological
– interaction with the environment and
the frustrations met
Socio – Cultural
– Social structures, norms, values
18
STRESS MODEL (GAS)
Hans Selye
Stress – wear and tear
Stressors - + / - stimuli that
requires a response
19
STAGES (A, R, E)
ALARM RESISTANCE EXHAUSTION
F or F Coping / Stress that
response defense lasts too long
Alertness mechanisms leading to
to focus initiated inability to
immediately Psychosom cope
with the px atic begins >+ 3
+1 to +2 +2 to +3
anxiety anxiety
20
21
Sm ith ’s St r ess Mo del
According to Smith, As the acuity of the
patients who are aggressive response
repeatedly assaultive increases:
exhibit behavior Dec. px solving
patterns that are: abilities, creativity,
Ritualistic spontaneity and
Stereotypical behavioral options
Automatic
22
1) TRIGERRING PHASE
- Stress- producing events
2) ESCALATION PHASE
- Escalating behaviors leading to loss of control
3) CRISIS PHASE
- Emotional and physical crisis, loss of control
4) RECOVERY PHASE
- Cooling down, slowing down and return to normal
responses
24
WHA T WI LL THE NURSE
FE EL IF PT S. B ECOM E
AGGR ESS IVE TO THEM?
FRUSTATION
PROFESSIONAL INADEQUACY
SENSE OF FAILURE
STIMULATE POWER STRUGGLES W/
PTS
25
HOW WILL THE NURSE
CONTROL PATIENT’S
AGGRESSION?
N must be know the factors that may contribute
to the escalation of aggression of the pt.
Env’t that HAS EXCESSIVE STIMULI
Env’t that is OVERCROWDED
Facility that has NO OUTLET FOR ENERGY –
DRAINING
Pt’s perceived lack of CONTROL OF LIFE
AND FREEDOM
BOREDOM d/t lack of STRUCTURED
ACTIVITIES
26
Staffing must be sufficient
Staff must have fair philosophies and
policies
– Over-controlled env’t : aggression and
rebellion
– Reasonable, flexible: reduce risk for power
27
Nurses must be able to recognize when
the patient would most likely become
aggressive or assaultive:
ADMISSION EVENING
CHANGE OF ELEVATORS
SHIFTS DURING
MEALTIMES TRANSPORTATION
VISITING HOURS PERIODS OF
CHANGE
28
Hospitalization is a stress-
producing situation.
NURSES' ROLES:
1) Explain rules and policies - the searches,
the removal/restriction of personal items,
physical examinations
2) Introduce unfamiliar professionals and
other patients
3) Integrate pt slowly to the unit
4) Decrease the stimuli if possible
29
5) Explain all medications/treatments in
advance
6) Assess history – family violence/abuse,
previous history of assault, destruction of
property
7) Render documentation
30
NURSING INTERVENTIONS
in ANGER AND
NONVIOLENT AGGRESSION
FACTORS TO CONSIDER IN
INTERVENING WITH ANGER AND
NONVIOLENT AGGRESSION
• SOURCE – manifests inwardly
• TARGET – may aim at no one in
particular
• LIKELIHOOD OF ESCALATION –
may be defused if dealt appropriately
32
• Assess at safe • If patient is less
distance verbal, take an
• Warmth and active, supportive
empathy, but be and directive role
firm in setting • Ask pts to ventilate
limits their feelings,
thoughts, situations
33
Forget these things not!!!
• CHOOSE THE LEAST RESTRICTIVE
MEASURES BEFORE
RESTRAINTS/SECLUSION
• DOCUMENT PT’S RESPONSES
• APPROACH THE PT IN CALM,
POSITIVE MANNER
34
NI BASED ON THE ASSAULT
CYCLE … TRIGGERING
PHASE
BEHAVIORS NI
Muscle tension, changes in 1) EMPHATIC,
NONDIRECTIVE,
voice quality, readiness to CONCERNED TECHNIQUE
retaliate, tapping of fingers, 2) ENCOURAGE VENTILATION
pacing, repeated 3) PROVIDE QUIETER
verbalization, noncompliance, ENVIRONMENT
restlessness, irritability, 4) USE RELAXATION
TECHNIQUES
anxiety, suspiciousness, 5) FACILITATE PROBLEM
perspiration, tremors, glaring, SOLVING BY DISCUSSING
changes in breathing ALTERNATIVE SOLUTIONS
6) PRN ORAL MEDS
7) EMPIRICAL SUPPORT
35
NI BASED ON THE ASSAULT
CYCLE … ESCALATION
PHASE
BEHAVIORS NI
Pallor, screaming, anger, 1) TAKE CHARGE WITH
CALM, FIRM DIRECTIONS,
agitation, hypersensitivity, DON’T PUNISH/THREATEN,
threats, demands, loss of AVOID LOUD SOUNDS
reasoning ability, provocative 2) DIRECT CLIENT TO A
behaviors, clenched fists QUIET ROOM FOR A “TIME
OUT”
3) ASK ANOTHER STAFF TO
BE ON STANDBY AT A
DISTANCE
4) PRN MEDS
5) PREPARE FOR A “SHOW
OFF DETERMINATION” – 4-6
STAFF WITHIN THE SIGHT
OF CT. 36
NI BASED ON THE ASSAULT
CYCLE … CRISIS PHASE
BEHAVIORS NI
Loss of self control, fighting, • INVOLUNTARY SECLUSION,
RESTRAINTS
hitting, rage, kicking, • IM MEDS
scratching, throwing things
37
NI BASED ON THE ASSAULT
CYCLE … RECOVERY PHASE
BEHAVIORS NI
Accusations, lowering of 1) CONTINUE NURSING CARE,
ALLOW CLIENT TO RELAX
voice, decreased body AND SLEEP
tension, change in 2) PROCESS THE INCIDENT
conversational content, more WITH THE STAFF AND
normal responses, relaxation OTHER PATIENTS
3) ASSESS PATIENT, STAFF
4) EVALUATE PT’S PROGRESS
TOWARD SELF-CONTROL
38
NI BASED ON THE ASSAULT
CYCLE … DEPRESSIVE PHASE
BEHAVIORS NI
Crying, apologies, 1) PROCESS INCIDENT WITH
THE PT
reconciliatory interactions,
2) DISCUSS ALTERNATIVE
repression of assaultive SOLUTIONS TO THE
feelings – hostility, passive SITUATIONS AND FEELINGS
aggression 3) PROGRESSIVELY REDUCE
THE DEGREE OF
RESTRAINT AND
SECLUSION
4) FACILITATE REENTRY TO
THE UNIT
39
NICE TO KNOW!!!
40
SECLUSION
• Principle of containment
• Placing of ct alone in a lockable room
designed with window and camera
• Minimize violence of aggressive
client to himself, others
• To reduce stimuli
• To increase nursing care to
agitated/violent/aggressive pt
41
Reasons for Seclusions
• Agitation
• Disruptive behavior
• Inappropriate sexual behaviors
• To avoid aggressive assaults and
have a responsive action
42
• “TIME OUT”
43
RESTRAINT
44
INDICATIONS
2. PHYSICAL
3. CHEMICAL
46
CHOOSING THE RESTRAINT
49
• Never be used as a a punishment or for
the convenience of the staff
• The least restrictive means of restraint for
the shortest duration should be used
• Used when physically harmful to the client
or to others
• Used when disruptive behavior presents a
danger to the facility
• Used when alternative or less restrictive
measures are insufficient in protecting the
ct or others from harm
• Used when the ct anticipates that a
controlled env’t would be helpful and
requests seclusion
• Requires a written order, reviewed, 50
• In an emergency, the charge nurse may
place a ct in restraint/seclusion and obtain
a written or verbal order ASAP thereafter
• Laws require the of the ct unless an
emergency situation exists and can be
documented
• The ct must be removed from restraint or
seclusion when safer and quieter behavior
is observed
• While in restraint/seclusion, the client
must be protected from all sources of
harm
• Documentation - behavior, time, release
• Assessment q 15-30 min for physical
needs, safety comfort = document 51
~End~
52
WORKING WITH GROUPS
OF PATIENTS
Kenn S. Nuyda, RN
WORKING WITH GROUPS
OF PATIENTS
Kenn S. Nuyda, RN
NURSING CARE in Psych Cts
24/7 responsibility
Manpower to provide therapeutic
intervention
Concern with how our clients solve their
problems, conflicts and interpersonal
relationships in order for them to learn
and cope
55
TYPES OF GROUPS
1. INPATIENT
- Open membership – adding and losing
members
- 3 – 5 x a week
- Short term
2. OUTPATIENT
- Longer duration
- Once a week
- Closed membership
56
SIGNIFICANCE OF GROUPS
Deals with “here and now”
Provides awareness and knowledge about the
ct’s behavior
Teaches ct to be aware of the alternatives in
decision making and making choices
Teaches the ct/family about their mental illness
and make them cope up with it
57
BENEFITS OF THE GROUP
Ct gains knowledge about how to relate and
communicate w/ others
Ct gains acceptance, reassurance and support from
peers and group leader
Ct gains feelings of hopefulness, sense of power
Ct tests out new behaviors
Ct shares feelings, problems, concerns and ideas w/
others
Ct’s self- esteem is enhanced and affirmed and
developed
Ct feels sense of importance and worthiness
58
11 THERAPEUTIC FACTORS
- Dr. Irvin Yalom -
INSTILLATION OF HOPE Observe others in the group
61
SUPPORT GROUPS
Nursing is supporting
To support = to accept, emphatize, show
concern while cts talk
Nurse’s presence, interest and
encouragement = ct’s ease of expressing
his/her feelings and concerns
Support groups enable the ct to cope w/
feelings and situations
Reinforces or maintains the existing
strengths/behaviors of cts
62
a) REALITY – ORIENTATION GRP
- deals with psychopathology,
confusion and short attention span
NI:
> safe env’t
> reality testing
> orientation to time, place, person
> setting limits
63
ACTIVITY GROUPS
Facilitate communication and interaction
- INDICATIONS -
For withdrawn, depressed, regressed patients
To increase self – esteem, provide openness
and expression of feelings to decrease
isolation
Used to facilitate self – expression and patient
interaction
64
EXAMPLES
TYPE PURPOSE/RN’S ROLE EXAMPLES
Recreation Fun, relief of tension Indoor/outdoor sports, field
Ct experiences sense of trips, exercise groups and
participation, acceptance and games
accomplishment
65
EDUCATION / PROBLEM SOLVING
GROUPS
Teaches ct and family about:
Medication
Stress management
Social skills
Interpersonal skills
Relapse prevention
66
The nurse’s expertise, empathy and
support help the ct to learn = ct cares for
themselves/illness
Benefits to family: improved
relationships with family members
67
EXAMPLES
TYPE PURPOSE/RN’S ROLE EXAMPLES
Psychoeducation Dynamics of illness, mgt of Addiction processes, coping
illness, crises with sx, mood mgt, relapse
prevention, community
resources
Medication Dispensing of med, s/sx of
SE, purpose of med, dosage,
and therapeutic effects, support
to prevent relapse
Problem Solving Identify and describe current Conflict resolutions, job
px, develop solutions, its concerns, relationship issues
alternatives
Stress Mgt Teach and facilitate coping Lifestyle balance and mgt,
behaviors relaxation training, tension-
reducing strategies, anger mgt
Social Skills Teach, develop and practice Social interactions
skills, focus on realistic day-to-
day needs
68
THERAPY GROUPS
69
EXAMPLES
TYPE PURPOSE/RN’S ROLE EXAMPLES
Insight – Understanding how self-esteem groups
oriented individuals affect and be
affected by others
Deals with healthier ways
on how to handle feelings to
others
Psychodrama Intense emotional release Psychodrama
are achieved through
intrapersonal and
interpersonal conflicts
Improve their roles using a
script
Sociodrama Focus insights on role > Psychodrama
communication, roles are
reenacted/role played
70
CHARACTERISTICS THAT THE
NURSE MUST POSSESS IN LEADING
A GROUP
71
Group Leadership
Model as a leader
Communication skills - reinforcement
Must be aware of the environment that affects the
clinical setting
Assessment skills of the mental status of the ct
Must be able to gain the trust of his patient
Confidentiality
Must be able to document
72
Coleadership
Useful when the primary nurse is on “off” or “on
leave”
They are the ones who collaborate/share
responsibility for the group
Teaches ct how to relate to others with respect
Active
Structured/goal-directed
Empathetic
73
PHYSICAL SETTING
Adequate space / MEMBERS: 7 – 10
private room more members will
Adequate lighting, make the group
comfortable temp, subdivide, create
seating and acting out behaviors
equipment Audio Video,
CIRCLE, handouts
SEMICIRCLE
74
FORMAL GROUPS… guidelines
N must be goal directed and focus on the here and
now in each inpatient and outpatient group session
N assesses the needs of the pt and formulates plans
Timeframe: one hour (lower functioning), 1 ½ (higher
functioning)
Participants are expected to arrive ON TIME
NO SMOKING/REFRESHMENT will be served
One person speaks at a time
May be allowed to pace/leave if pt has inability to sit
still
No hitting or throwing is allowed
“What you see, what you here leave it here”
75
At the start, the N states the purpose of
the group
Then working phase
Then before the end of the session,
summarize and close the session for 5-
10 mins.
76
GROUP MEMBER ROLES accdg
TO FUNCTION
ENCOURAGER – COMPROMISER –
praises others, resolve conflicts
agrees and accepts
ideas of others
77
ELABORATOR – COORDINATOR –
gives examples clarifies relationships
among ideas and
EVALUATOR – activities of the
relates the group group
standards to any
problem
78
ANNOYING MEMBERS
AGGRESSOR – acts HELP SEEKER /
negatively with hostility CONFESSOR – uses
toward others, jokes the group to gain
aggressively, attacks the sympathy, expresses
group/members insecurity and self –
depreciation
RECOGNITION
SEEKER – calls DOMINATOR – asserts
attention to own authority and
activities, boasts manipulates individuals
achievements and the group as a
whole
79
EXCLUSION FROM JOINING THE
GROUP
MANIC
DISORIENTED
TOO PSYCHOTIC
HOSTILE
VERBALLY THREATENING
80
STAGES… KELTNER
1. INITIAL
2. WORKING
3. TERMINATION
81
INITIAL WORKING TERMINATION
Involves superficial Members are familiar Group evaluates the
rather than open and w/ each other, the group experience and
trusting communication leader and the group explores member's
Member acquainted roles and they feel free feelings about it and the
w/ each other, to approach their impending separation
searching for similarities problems and to attempt Provides an
b/w themselves to solve their problems opportunity for
Member still unclear Conflict and members who have
about the purpose of cooperation surface difficulty w/ termination
goals of the group to learn to deal more
Norms, roles and realistically and
responsibilities takes comfortably with this
place normal part of human
experience
82
STAGES OF GROUP DEV’T…
MOSBY
1. PREGROUP
2. INITIAL
3. WORKING
4. TERMINATION
83
PREGROUP
Forming of the group
Time period before people knew each
other in the group setting
Selectgroup members
Decide length of meeting
Decide composition of members
Homogenous
Heterogenous
84
Leader Responsibilities
Establish purpose Determine member
Secures physical motivation
space Describes norms
Selects members Educates about the
Screens group
interviewees Secures commitment
of the group
Begins
leader/member rel.
85
INITIAL STAGE
86
Member Behaviors
87
Leader Behaviors
Directive
Active
Group contract dev’t
Encourages interaction b/w members
Facilitates approach/avoidance
Suggests how members might be helpful
to one another
88
CONFLICT STAGE within INITIAL
STAGE… member
Members concerned with status in group
Dependency conflict
Independent members attempt to make
leader’s roles
Subgroups form
Hostility toward leader or other members
89
CONFLICT STAGE within INITIAL
STAGE… leader
Allows expression of - / + feelings
Helps group understand
Prevents scapegoating
Directs expression of hostility
90
COHESIVE STAGE within INITIAL
STAGE… member
Form attachment to group
+ feelings toward the group/members
Self-disclosure
Suppress hostility
Limited problem solving
91
COHESIVE STAGE within INITIAL
STAGE… leader
Encourages problem solving
Demonstrates that differing opinions are
acceptable
92
WORKING STAGE
93
Member Behaviors: Group Behaviors:
Explore goals and tasks Decreases activity
Serious work occurs Serves as consultant
Explore feelings Fosters cohesion
Explore new coping Maintains boundaries
mechanisms Encourages work on
tasks
Solving the problem/s of
the group
94
TERMINATION STAGE
Types:
2. whole group ends
3. Individual member leaves
95
Member Behaviors
Anger
Regression
Dependency, competition
Avoidance
Do not come to the group, do not talk about the
termination
Devalue group
Discuss other feelings (separations, death,
aging)
Sense of resolution
96
Leader Behaviors
Reminisces about the group’s activities
Evaluates group goals
Discusses the member’s contribution to each
other
Encourages full discussion of termination for
several sessions
Shares own experience and feelings r/t the
group
Discourages premature termination of
individual group members
97
COMMUNICATION SKILLS THAT
THE NURSE MUST POSSESS IN
LEADING A GROUP
98
Giving information
Seeking clarification
Encouraging description and exploration
Presenting reality
Seeking consensual validation
Focusing
Encouraging comparison
Making observations
Giving recognition/acknowledgement
Accepting
Encouraging evaluation
Summarizing
99
INTERVENTIONS
DOMINANT CLIENT
105
EXAMPLES OF GROUPS
• PYSCHODRAMA GROUP
– explore truth through dramatic methods
– individual produces a topic to be explored
– therapists directs individual through role
playing
– audience experiences the feelings and
identifies with the action on the stage
– change occurs
106
CO MMU NITY SU PPO RT
GROUPS
107
Ex: Alcoholics anonymous
108
• Fellowship of relatives and friends of
alcoholics who share their experience,
strength, and hope in order to solve
their common problems
• Believe alcoholism is a family illness
and that changed attitudes can aid
recovery
109
NARCONON
110
Other Examples
• Overeater’s Anonymous
• Women’s Groups
• Men’s Groups
111
GE ST ALT THERAPY
GR OUP
• "here and now"
• emphasizes self-expression, self-
exploration and self-awareness in the
present
• everyday problems and try to solve them
• individual becomes aware of the total self
and the surrounding env’t, renders the ct.
capable of change
113
IN TER PER SONAL G ROUP
TH ERAPY
114
~ END ~
SALAMAT!
115