APPLYING THE NURSING PROCESS
Assessment and effective intervention with angry or hos-tile clients can often prevent aggressive episodes. Early assessment, judicious use of medications, and verbal inter-action with an angry client can often prevent anger from escalating into physical aggression.
The nurse should be aware of factors that influence aggres-sion in the psychiatric environment, or unit milieu. Aggres-sive behavior is less common on psychiatric units with strong psychiatric leadership, clear staff roles, and planned and adequate events such as staff–client interaction, group interaction, and activities. Conversely, when predictability of meetings or groups and staff–client interactionsare lacking, clients often feel frustrated and bored, and aggression was more common and intense. A lack of psy-chological space—having no privacy, being unable to get sufficient rest—may be more important in triggering aggression than a lack of physical space.
In addition to assessing the unit milieu, the nurse needs to assess individual clients carefully. A history of violent or aggressive behavior is one of the best predictors of future aggression. Determining how the client with a history of aggression handles anger and what the client believes is helpful is important in assisting him or her to control or nonaggressively manage angry feelings. Clients who are angry and frustrated and believe that no one is listening to them are more prone to behave in a hostile or aggressive manner. In addition to a past history of violence, a history of being personally victimized and one of substance abuse increase a client’s likelihood of aggressive behavior. Indi-vidual cues can help the nurse recognize when aggressive behavior is imminent (Pryor, 2005). These cues include what the client is saying; changes in the client’s voice— volume, pitch, speed; changes in the client’s facial expres-sion; and changes in the client’s behavior.
The nurse should assess the client’s behavior to deter-mine which phase of the aggression cycle he or she is in so that appropriate interventions can be implemented. The five phases of aggression and their signs, symptoms, and behaviors are presented in Table 10.1. Assessment of cli-ents must take place at a safe distance. The nurse can approach the client while maintaining an adequate distance so that the client does not feel trapped or threatened. To ensure staff safety and exhibit teamwork, it may be prudent for two staff members to approach the client.
Nursing diagnoses commonly used when working with aggressive clients include the following:
· Risk for Other-Directed Violence
· Ineffective Coping
If the client is intoxicated, depressed, or psychotic, addi-tional nursing diagnoses may be indicated.
Expected outcomes for aggressive clients may include the following:
· The client will not harm or threaten others.
· The client will refrain from behaviors that are intimi-dating or frightening to others.
· The client will describe his or her feelings and concerns without aggression.
· The client will comply with treatment.
Hostility or verbally aggressive behavior can be intimidat-ing or frightening even for experienced nurses. Clients exhibiting these behaviors are also threatening to other cli-ents, staff, and visitors. In social settings, the most frequent response to hostile people is to get as far away from them as possible. In the psychiatric setting, however, engaging the hostile person in dialogue is most effective to prevent the behavior from escalating to physical aggression.
Interventions are most effective and least restrictive when implemented early in the cycle of aggression. This section presents interventions for the management of the milieu (which benefit all clients regardless of setting) and specific interventions for each phase of the aggression cycle.
It is important to consider the environment for all clients when trying to reduce or eliminate aggressive behavior. Group and planned activities such as playing card games, watching and discussing movies, or participating in informaldiscussions give clients the opportunity to talk about events or issues when they are calm. Activities also engage clients in the therapeutic process and minimize boredom. Scheduling one-to-one interactions with clients indicates the nurse’s genuine interest in the client and a willingness to listen to the client’s concerns, thoughts, and feelings. Knowing what to expect enhances the client’s feelings of security.
If clients have a conflict or dispute with one another, the nurse can offer the opportunity for problem-solving or conflict resolution. Expressing angry feelings appropri-ately, using assertive communication statements, and negotiating a solution are important skills clients can prac-tice. These skills will be useful for the client when he or she returns to the community.
If a client is psychotic, hyperactive, or intoxicated, the nurse must consider the safety and security of other clients, who may need protection from the intrusive or threatening demeanor of that client. Talking with other clients about their feelings is helpful, and close supervision of the client who is potentially aggressive is essential.
In the triggering phase, the nurse should approach the client in a nonthreatening, calm manner in order to de-escalate the client’s emotion and behavior. Conveying empathy for the client’s anger or frustration is important. The nurse can encourage the client to express his or her angry feelings ver-bally, suggesting that the client is still in control and can maintain that control. Use of clear, simple, short statements is helpful. The nurse should allow the client time to express himself or herself. The nurse can suggest that the client go to a quiet area or may get assistance to move other clients to decrease stimulation. Medications (PRN, or as needed) should be offered, if ordered. As the client’s anger subsides, the nurse can help the client to use relaxation techniques and look at ways to solve any problem or conflict that may exist (Marder, 2006). Physical activity, such as walking, also may help the client relax and become calmer.
If these techniques are unsuccessful and the client pro-gresses to the escalation phase (period when client builds toward loss of control), the nurse must take control of thesituation. The nurse should provide directions to the client in a calm, firm voice. The client should be directed to take a time-out for cooling off in a quiet area or his or her room. The nurse should tell the client that aggressive behavior is not acceptable and that the nurse is there to help the client regain control. If the client refused medications during the triggering phase, the nurse should offer them again.
If the client’s behavior continues to escalate and he or she is unwilling to accept direction to a quiet area, the nurse should obtain assistance from other staff members. Initially, four to six staff members should remain ready within sight of the client but not as close as the primary nurse talking with the client. This technique, sometimes called a “show of force,” indicates to the client that the staff will control the situation if the client cannot do so. Sometimes the presence of additional staff convinces the client to accept medication and take the time-out necessary to regain control.
When the client becomes physically aggressive (crisis phase), the staff must take charge of the situation for the safety of the client, staff, and other clients. Psychiatric facilities offer training and practice in safe techniques for managing behavioral emergencies, and only staff with such training should participate in the restraint of a physi-cally aggressive client. The nurse’s decision to use seclu-sion or restraint should be based on the facility’s protocols and standards for restraint and seclusion. The nurse should obtain a physician’s order as soon as possible after decid-ing to use restraint or seclusion.
Four to six trained staff members are needed to restrain an aggressive client safely. Children, adolescents, and female clients can be just as aggressive as adult male clients. The client is informed that his or her behavior is out of control and that the staff is taking control to provide safety and pre-vent injury. Four staff members each take a limb, one staff member protects the client’s head, and one staff member helps control the client’s torso, if needed. The client is trans-ported by gurney or carried to a seclusion room, and restraints are applied to each limb and fastened to the bed frame. If PRN medication has not been taken earlier, the nurse may obtain an order for intramuscular (IM) medication in this type of emergency situation. As notedpreviously, the nurse performs close assessment of the client in seclusion or restraint and documents the actions.
As the client regains control (recovery phase), he or she is encouraged to talk about the situation or triggers that led to the aggressive behavior. The nurse should help the client relax, perhaps sleep, and return to a calmer state. It is important to help the client explore alternatives to aggressive behavior by asking what the client or staff can do next time to avoid an aggressive episode. The nurse also should assess staff members for any injuries and com-plete the required documentation such as incident reports and flow sheets. The staff usually has a debriefing session to discuss the aggressive episode, how it was handled, what worked well or needed improvement, and how the situation could have been defused more effectively. It also is important to encourage other clients to talk about their feelings regarding the incident. However, the aggressive client should not be discussed in detail with other clients.
In the postcrisis phase, the client is removed from restraint or seclusion as soon as he or she meets the behavioral criteria. The nurse should not lecture or chastise the client for the aggressive behavior but should discuss the behavior in a calm, rational manner. The client can be given feedback for regaining control, with the expectation that he or she will be able to handle feelings or events in a nonaggressive manner in the future. The client should be reintegrated into the milieu and its activities as soon as he or she can participate.
Care is most effective when the client’s anger can be defused in an earlier stage, but restraint or seclusion is sometimes necessary to handle physically aggressive behavior. The goal is to teach angry, hostile, and potentially aggressive clients to express their feelings verbally and safely without threats or harm to others or destruction of property.