2.4 Working with Anger and Aggression

Workplace violence consists of physically and psychologically damaging actions that occur in the workplace or while on duty. Examples of workplace violence include direct physical assaults (with or without weapons), written or verbal threats, physical or verbal harassment, and homicide.^[1] Incivility and bullying continue to be problematic among nurses and are related to nurses leaving the profession.^[2]

Violence committed by patients or family members toward health care staff can occur in many health care settings, so nurses must be prepared to cope effectively with agitated patients to reduce the risk of serious injury to the patient, themselves, staff, and other clients. Up to 50 percent of health care professionals are victims of violence at some point during their careers. There is a wide range of risk factors for patient violence, including the environment, a patient’s social and medical history, interpersonal relationships, genetics, neurochemistry and endocrine function, and substance abuse. In the emergency department (ED), substance intoxication or withdrawal is the most common diagnosis in combative patients. Known psychiatric illness is also a risk factor for violent behavior, with schizophrenia, personality disorders, mania, and psychotic depression most often associated with violence. Psychosis, delirium, and dementia can also lead to violent behavior.  ^[3]

Patients may exhibit dangerous behaviors for many reasons including substance intoxication, psychosis, dementia, and pain. Judgment is impaired in these situations and patients lack the insight to monitor their reactions and calm themselves. Additionally, patients may be brought to a hospital against their wishes, perhaps by law enforcement. Assessment of the combative patient begins with risk assessment and attention to safety measures. Violence typically erupts after a period of mounting tension. In a typical scenario, the patient first becomes angry, then resists authority, and finally becomes confrontational. However, violent behavior may erupt without warning, especially when caused by medical illness or dementia. A nurse may identify verbal and nonverbal cues of agitation and defuse the situation before violence happens. It is helpful to observe the nonverbal communication of a client’s hands as an indicator of tension. Other signs of impending violence include the following^[4]

• Confrontational behavior
• Angry demeanor
• Loud, aggressive speech
• Tense posturing (e.g., gripping arm rails tightly or clenching fists)
• Frequently changing body position or pacing
• Aggressive acts (e.g., pounding walls, throwing objects, or hitting oneself)

Patients who are agitated but cooperative may be amenable to verbal de-escalation techniques. Actively violent patients and uncooperative, agitated patients, particularly those who exhibit signs of impending violence, require immediate physical restraint per an agency’s policy. Assume that all violent patients are armed until proven otherwise, especially those presenting to an emergency department.[^{footnote]https://psychiatryonline.org/doi/10.1176/appi.focus.20220064[/footnote]}

Verbal De-Escalation Techniques

Verbal de-escalation techniques should be attempted before physical restraints or sedative medications are implemented. During initial interactions with the patient, it will rapidly become clear whether the patient will cooperate or continue to escalate. This interaction also enables the nurse to assess the patient’s mental status. If the patient remains agitated or is incapable of interacting appropriately, then restraints become necessary^[5].

When attempting to de-escalate an individual, the healthcare team should be present. The nurse or team member should adopt an honest and straightforward manner. Offer a comfortable place to sit or something to eat or drink (but not a hot liquid that could be used as a weapon) to establish trust. Many individuals will decompress at this point because offering food or drink appeals to their most basic human needs and builds trust^[6]

The nurse should demonstrate a nonconfrontational, attentive, and receptive demeanor without conveying weakness or vulnerability. A calm and soothing tone of voice should be used. Listening to the patient is paramount; patients may have pertinent complaints (a noisy roommate) that are solvable. Avoid direct eye contact, do not approach the patient from behind or move suddenly, and stand at least two arm’s lengths away. The nurse should ensure a quick exit route to the door and never allow the individual to come between them and the door. Stethoscope and badge holders should not be worn around the neck to prevent strangulation risks.

In some cases, an agitated patient may be aware of their impulse control problem and may welcome limit-setting behavior by the nurse (e.g., “I can help you with your problem, but I cannot allow you to continue threatening me or the emergency department staff”). It is difficult to predict which patients will respond to this limit-setting approach. Some patients may interpret such statements as confrontational and escalate their behavior. ^[7]

A key mistake when interviewing an agitated or potentially violent individual is failing to address violence directly. They should be asked relevant questions, such as, “Do you feel like hurting yourself or someone else?” and “Do you carry a gun?” Stating the obvious (e.g., “You look angry”) may help them to begin sharing their emotions. Speak in a conciliatory manner and offer supportive statements to diffuse the situation, such as, “You obviously have a lot of will power and are good at controlling your emotions.”^[8]

The American Psychiatric Association recommends these steps in working with agitated and aggressive patients ^[9]:

• Respect personal space: Maintain a distance of two arm’s lengths and provide space for easy exit for either party.
• Establish verbal contact: The first person to contact the patient should take the lead in communicating.
• Use concise, simple language for a clear message: Avoid elaborate and technical terms because they are hard for an impaired person to understand.
• Identify feelings and desires: “What are you hoping for?”
• Listen closely to what the patient is saying: After listening, restate what the patient said to improve mutual understanding (e.g., “Tell me if I have this right…”).
• Set clear limits: Verbalize clear expectations and consequences. Inform the patient that violence or abuse cannot be tolerated.
• Offer choices and optimism: Ask the patient what has worked in the past. Offer choices regarding route of medication delivery.

Sometimes these approaches to combative patient are counterproductive and can lead to escalation. Arguing, condescension, or commanding the patient to calm down can have disastrous consequences. Patients often interpret such approaches as a challenge to “prove themselves.” A threat to call security personnel can also invite aggression. Other potential mistakes include criticizing or interrupting the patient, responding defensively or taking the patient’s comments personally, or not clarifying what the patient wants before responding. If verbal techniques are unsuccessful and escalation occurs, physical restraint may be necessary ^[10].

Physical Restraint

Physical restraint is defined as any manual, physical, or mechanical means of preventing an individual’s movements of arms, legs, body, and/or head. This includes a staff member physically restraining patients by holding them or pinning them to the floor. Mechanical restraints include fabric or leather bands with buckles for wrists and ankles. Physical restraints have been used when verbal de-escalation techniques were unsuccessful despite a professional approach to the combative patient: it is a last resort. The use of mechanical restraints has been greatly reduced due to research evidence indicating their ineffectiveness at preventing aggression and the high potential for injury, psychological trauma, worsening of health conditions, and death. Manually restraining of patients is sometimes used to prevent injuries to the patient and staff while sedative medication is administered ^[11]. Manual restraint should only be attempted with by a trained and experienced staff member with the healthcare team present.

Chemical Sedation

Chemical sedation, through medication administration, may be necessary in a combative patient who does not respond to verbal de-escalation techniques. The ideal sedative medication for an agitated or violent patient is rapid-acting with minimal side effects. The major classes of medications used to control the violent or agitated patient include benzodiazepines, first-generation (typical) antipsychotics, second-generation (atypical) antipsychotics, and ketamine ^[12].

• For severely violent patients requiring immediate sedation, a rapid-acting first-generation antipsychotic (e.g., haloperidol or droperidol), benzodiazepine (e.g., midazolam or lorazepam), or a combination of both may be prescribed. Second-generation antipsychotics, such as olanzapine, risperidone, and ziprasidone may also be prescribed. Diphenhydramine may also be administered if a first-generation antipsychotic is used, in order to address extrapyramidal effects.
• For patients with agitation from drug intoxication or withdrawal from an unknown cause, benzodiazepines are typically prescribed. Lorazepam and midazolam are used most often. Benzodiazepines may cause respiratory depression and excessive sedation, so close monitoring is essential after administration.
• Ketamine may be prescribed when initial treatments with benzodiazepines or antipsychotics have failed, especially in patients with excited delirium. However, clients receiving ketamine have increased risk for respiratory distress and may require endotracheal intubation and mechanical ventilation.

The nurse must obtain a healthcare provider’s order for sedative medications and ensure required documentation is completed. In many states, the provider is required to examine the patient within a specified timeframe. The sedated patient should be assisted into bed and allowed to rest. Frequent staff observation is required.

Seclusion

Seclusion refers to the involuntary confinement of an individual to a room where he/she will be alone. Seclusion is generally used for patients who benefit from reduced stimuli in the hospital environment. The goal is safety for staff and all patients on the unit. Secluded patients are observed and assessed frequently by staff. Needs for food, hydration, medications, and toileting are met. When the individual is calmer and able to manage their aggressive behaviors, they are able to leave the room and rejoin the unit activities.

Post-Incident Evaluation

The cause of the patient’s agitation and aggression will be evaluated to determine if it is medical, psychiatric, or substance-use related. Patients over the age of 40 with new psychiatric symptoms are likely to have a medical cause. Older adult patients are at higher risk for delirium due to medical illness (such as a urinary tract infection) or adverse reactions to medications. Patients with a history of drug or alcohol use disorder may exhibit violent behavior as a manifestation of an intoxication or withdrawal syndrome. Violent behavior unrelated to medical illness, drug intoxication, or withdrawal should be followed by psychiatric consultation and evaluation^[13].

Team Safety: Preventing Injury and Enhancing Recovery

Teamwork is crucial for the safety of staff and patients. Safety of the unit staff can be enhanced by simple practices. The entire team needs to be aware of the plan of care for each patient. Intervention strategies for patients at risk for aggressive behaviors should be discussed. The nurse needs to ensure that enough staff are present to provide a safe environment for everyone. Patients recover faster when they feel safe.

1. Avoid wearing apparel that patients can grab or pull. This includes dangling earrings, necklaces, scarves, lanyards, and stethoscopes.
2. Keep the unit environment free of objects that can be used to injure others. Furniture should be difficult to move and have smooth edges. Any artwork needs to be bolted to the wall or painted on the wall’s surface. Keep the tables and countertops free of items like pens or clipboards.
3. Pay attention to the layout of the unit. Check around corners. Always make sure there is access to an exit.
4. Be attentive to the overall mood of the unit. Loud, delusional, and confused patients can make the environment feel unsafe. Sometimes patients do not get along with one another. Keep patients who are triggered by one another apart as much as possible.
5. Keep a safe distance from patients who may exhibit aggressive tendencies. Get an additional staff member for help.
6. Avoid entering patient rooms. If necessary to do so, ask permission from the patient and leave the door open, allowing for a quick exit if necessary. Take someone with you.
7. Always let another staff member know your whereabouts.

Every hospital should have a written plan of action to implement in the case of extreme violence. The plan should include prevention and safety measures, a means for rapid notification of security and police personnel, evacuation plans, medical treatment, and crisis intervention. A novel approach uses a trained violence management team to provide a mechanism for dealing with aggressive patients and to protect the staff. Mandatory training for clinical and non-clinical staff must also be incorporated with written plans of action. This multifaceted approach improves nurses’ ability to present a calming influence in their care of angry patients and enhance self-confidence in the face of violent behaviors.^[14]

Establishing a Safe Care Environment for Nurses and Other Health Care Team Members

The American Nurses Association states, “No staff nurse should have to deal with violence in the workplace, whether from staff, patients, or visitors.”^[15] Workplace violence is the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty. The impact of workplace violence can range from psychological issues to physical injury or even death. Violence can occur in any workplace and among any type of worker, but the risk for nonfatal violence resulting in days away from work is greatest for health care workers.^[16] Research indicates the rate of physical assaults on nurses is 13.2 per 100 nurses per year, and 25% of psychiatric nurses experienced disabling injuries from client assault. Many experts believe these figures represent only the tip of the iceberg and that most incidents of violence go unreported.^[17] See Figure 2.5c^[18] for an illustration of safety first.

Safety strategies for nurses and nursing students providing client care include the following^[19]:

• Dress for Safety
  • Tuck away long hair so that it can’t be grabbed
  • Avoid earrings or necklaces that can be pulled
  • Avoid overly tight clothing that can restrict movement or overly loose clothing or scarves that can be caught
  • Use breakaway safety lanyards for glasses, keys, or name tags
  • Do not wear your stethoscope around your neck

• Be Aware of Your Work Environment
  • When in a room with a patient or visitor, position yourself between the door and the patient so you can exit quickly if needed. This applies to patients with no history of violence as well.
  • Note exits and emergency phone numbers, especially if you float to other areas
  • Recognize that confusion, background noises, and crowding can increase clients’ stress levels
  • Be aware that mealtimes, shift changes, and transporting patients are times of increased disruptive behaviors

• Be Attuned to Patient Behaviors
  • Most violent behavior is preceded by warning signs, including verbal cues and nonverbal cues. The greater the number of cues, the greater the risk for violence. Be aware of these verbal and nonverbal cues indicating a client’s potential escalation to violence:

• • • Verbal Cues
      • Speaking loudly or yelling
      • Swearing
      • Using a threatening tone of voice

• • • Nonverbal and Behavioral Cues
      • Evidence of confusion or disorientation
      • Irritability or easily angered
      • Boisterous behavior (i.e., overly loud, shouting, slamming doors)
      • Disheveled physical appearance (i.e., neglected hygiene)
      • Holding arms tightly across chest
      • Clenching fists
      • Heavy breathing
      • Pacing or agitated restlessness
      • Looking terrified (signifying fear and high anxiety)
      • Staring with a fixed look
      • Holding oneself in an aggressive or threatening posture
      • Throwing objects
      • Exhibiting sudden changes in behavior or signs of being under the influence of a substance

• • • Use Violence Risk Assessment Tools
      • Use risk assessment tools to evaluate individuals for potential violence, enabling all health care providers to share a common frame of reference and understanding. This minimizes the possibility that communications regarding a person’s potential for violence will be misinterpreted. These tools can be used as an initial assessment upon admission to determine potential risk for violence and repeated daily to assist in predicting imminent violent behavior within the next 24 hours. See sample risk assessment tools in the box.

• Be Attuned to Your Own Responses
  • Be aware of your own feelings, responses, and sensitivities and pay attention to your instincts. For example, your “fight or flight” response can be an early warning sign of impending danger to get help or get out.
  • Be aware of how you express yourself and how others respond to you. Those who know you well may respond differently than do strangers. Effective therapeutic communication skills are an essential tool in preventing violence.
  • Use self-awareness and acknowledge if you have a personal history of abuse, trauma, or adverse childhood experiences (ACEs) that can affect how you respond to situations.
  • If coworkers are engaging in abusive behaviors, consider if you are exhibiting similar behaviors.
  • Be aware that fatigue can diminish your alertness and your ability to respond appropriately to a challenging situation.

If travelling to a home setting as a home health nurse, additional safety strategies are as follows:^[20]

• Review agency files to confirm that a background check was done on a patient regarding any history of violence or crime, drug or alcohol abuse, and mental health diagnoses. Also, check to see if a patient’s family member has a record of violence or arrest.
• If entering a situation assessed as potentially dangerous, you should be accompanied by a team member who has training in de-escalation and crisis intervention.
• Always carry a charged cell phone.
• Make sure someone always knows where you are.
• Have a code word to use with your office or coworkers to let them know you’re in trouble if you can’t call the police.