Prevention and management of aggressive behavior

Question 1

Define Aggression

Answer 1

1: a forceful action or procedure (as an unprovoked attack)
especially when intended to dominate
2: the practice of making attacks or encroachments; especially : unprovoked violation by one country of the territorial integrity of another
3: hostile, injurious, or destructive behaviour that may be caused by frustration

*towards self OR others

Question 2

Discuss the five stages of the assault cycle+ behaviour

Answer 2

1) Triggering phase
Stress-producing event occurs, initiating the
stress responses
Behaviour:
 Muscle tension
 Voice quality (High)
 Tapping of fingers
 Pacing about
 Repeated verbalizations
 Non-compliant
 Restlessness
 Irritability
 Anxious looking
 Suspiciousness
 Perspiration
 Tremors
 Glaring
 Changes in breathing

2) Escalation phase
Responses represent escalating behaviors that
indicate a movement toward the lost of control.
Behaviour:
 Pale or flushed face
 Screaming
 Anger
 Swearing
 Agitation
 Hypersensitivity
 Threats
 Demands
 Readiness to retaliate
 Tautness
 Loss of reasoning
ability
 Provocative behaviors
 Clenched fists

3) Crisis phase
Period of emotional & physical crisis during which loss of control occurs.
Behaviour:
 Loss of self-control
 Fighting
 Hitting
 Rage
 Kicking
 Scratching
 Throwing things

4) Recovery phase
Period of “cooling down” during which the
person slows down & returns to normal
responses.
Behaviour:
 Accusations
 Lowering of voice
 Decreased body tension
 Change in conversational content
 Relaxed posture

5) Post-crisis depression phase
Period during which the person attempts reconciliation with others.
Behaviour:
 Crying
 Apologies
 Reconciliatory interactions
 Repression of assaultive feelings (which may later appear as
hostility passive aggression)

Question 3

Identify the possible causes for aggression in patients due to HCW, Environment and self.

Answer 3

Health Care Worker
 Own anger or frustration
may intensify patients’
anger or aggression
 Staff biases
 Poor attitude

Environment
 Excessive stimuli &
overcrowding
 Lack of space &
resources
 Lack of control of life &
boredom
 Lack of diversional
activities
 Rigid institution’s
philosophies & policies

Patients
 Psychological Phenomena: delusion, hallucinations
psychotic symptoms with association for harm to
self or others, presence of antisocial personality
traits/disorder
 During changing of shift, meal-times, visiting hours & evening
 On admission
 Denied of discharge
 During transportation to outside areas

Question 4

State the risk factors for violent behavior.

Answer 4

Demographic
 Young age; Male
 Lack of employment
 Limited education

History
 Violence to self or others
 Antisocial behavior
 Arrests for criminal acts
 Violence within family (e.g. physical abuse, sexual abuse)
 Aggressive childhood behavior, including cruelty to animals

Behavourial
 Poor impulse control
 Escalating anger or agitation
 Coercive, exploitative interaction style
 Antisocial & criminal acts
 Statements of intent to harm self or others

Question 5

Describe the nursing management of aggressive patients.

Answer 5

Self-awareness
 Control over own behavior.
 Not to escalate patient’s aggression & invite a challenging response.
 Be safe yourself (Don’t be a hero)
 Develop a therapeutic alliance with your patient.
 Encourage verbalization of feelings
 Provide direction for patients if they cannot make
constructive choices.
 Use verbal de-escalation method

Question 6

10 domains of verbal de-escalation

Answer 6

1. Respect personal space
2. Do not be provocative
3. Establish verbal contact
4. Be concise
5. Identify wants and feelings
6. Listen closely to what the patient is saying
7. Agree or agree to disagree
8. Lay down the rules and set clear limits
9. Offers choices and optimism
   10.Debrief the patient and staff

Question 7

What is having a safe milieu steps?

Answer 7

Having a Safe Milieu
 Lightweight &
unbreakable
accessories.
 Heavy furniture.
 Conducive & non-stimulating room.
 Remove potential
weapons from patient &
environment.
 Turn down lights &
music
 Create an alliance with
patients
 Maintain enough
personal space
 Always approach
patients from the front
& side
 Teach anger
management
techniques
 Discuss with patients
behaviors regarding
acceptable behavior.
 Familiar staff should be
present & available.
 Do not be a hero.
 Move other patients and
objects away when
patient is getting
aggressive.
Teach Impulse Control
 Count to ten.
 Think of what to say
before saying.
 Physically remove
oneself from the
irritating person or
element.
 Participate in a regular,
rigorous exercise
program

Question 8

list the stages of crisis Intervention (4):

Answer 8

1. Activate Crisis Alarm
2. Wait for arrival of Team (Care Team)
3. Maintain a Safe Millieu: Seclusion (Quiet
   Time)
4. Restraints – Physical & Chemical

Question 9

A nurse is conducting anger management classes. A client
admits that she is verbally abusive to her teenagers when
they defy her. She comments, “That’s how I was raised!”
Which of the following interventions is best in this situation?
a. Suggest the client use positive reinforcement to affect her
children’s behaviour.
b. Teach the client to identify and monitor anger cues.
c. Explore how social beliefs about parenting has changed.
d. Suggest to client and her children to begin family therapy

Answer 9

c

Question 10

Which one of the following factor is the cause of decline in
the use of physical restraints in the recent years?
a. Insufficient staff to monitor client who is on restraint.
b. Studies revealing no therapeutic benefits to its use.
c. Increasing number of restraint associated death among patients.
d. The increasing need for proper detailed documentation
with the use of restraints

Answer 10

b

Question 11

Gary is a psychiatric–mental health nurse. He wants to
decrease frustration and potential anger among clients
on the unit where he is working. Which of the following
would be an appropriate intervention?
a. Isolate clients who appear to be angry.
b. Ensure clients comply with their medication regimens.
c. Develop rules that prevent clients to opt out of activities.
d. Allow appropriate access to phones, televisions, or
rooms.

Answer 11

d