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Presented by Yvette Johnson, BSN Alverno College Graduate Student
Patient Centered Approach for Managing the Combative/Aggressive Patient Presented by Yvette Johnson, BSN Alverno College Graduate Student
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Learning Objectives The learner will be able to discuss theories of aggressive behavior & identify patient risk factors, which may contribute to aggressive behavior The learner will be able to identify staff and environmental risks factors that may contribute to aggressive patient behavior
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Learning Objectives The learner will be able to identify possible early signs and symptoms of escalation and discuss appropriate safety measures to manage the potential combative/aggressive client The learner will be able to identify potential consequences of mismanagement of the combative patient
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Introduction Aggression by either patients or visitors is a prominent risk and a great challenge for healthcare professions Hahn et al’s (2008). recent literature review demonstrated 50% of healthcare professionals have experienced verbal aggression & 25 % have experienced patient or visitor aggression
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Anger – A strong, uncomfortable response to a perceived injustice, a violation of rights,
negation of self, or a compromise of beliefs and values that occur to maintain the status quo
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Human aggression – Behavior carried out by a person with the intent to harm another person the aggressor believes to be motivated to avoid that harm(APA 2000) Combativeness – Having a readiness to fight
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Theoretical Perspectives on Aggression
Social learning theory – Aggressive behaviors are learned through direct experience of through observation Cognitive theories – Aggression comes from a complex interplay among cognitive factors, such as scripts, attributions, mood
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Social Cognitive Management Approach
Explains how people acquire & maintain certain behavioral patterns While also providing basis for intervention strategies (Bandura, 1997) Evaluations involve examining the environment, people and behavior Hollinworth (2005)
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Social Cognitive Theory
Source: Pajares (2002). Overview of social cognitive theory and of self-efficacy From
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Statistical Data Aggression/violence is a widespread problem in healthcare. Nurses are most often the victims-younger, less experienced nurses are at highest risk Verbal aggression most common form in healthcare setting. Physical aggression/violence poses the greater risks to nurses with reports ranging from 13% to 21% Source: Kynoch (2009)
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Extra, Extra, Read all About It!
Ohio considers increasing penalty for assaulting nurses The Wisconsin Federation of Nurses & Health Professionals says work conditions at the complex are unsafe, violate state and federal law, and have contributed to "burnout" and high staff turnover. New York Law Makes Assaulting a Nurse a Felony By Lisette Hilton Monday November 22, 2010
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Extra, Extra, Read all About It!
Girl, 16, dies during restraint at an already-troubled hospital Use of Unnecessary Chemical Restraints on Patients Can Be Grounds for Orange County, California Nursing Negligence Lawsuit and Criminal Charges
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Patient Risks Factors Substance use disorders(ETOH, DRUGS)
Personality disorder Brain injuries i.e. frontal ventromedial areas or temporal lobes Dementia Cognitive delays, sensory deficits Other diseases or disorders affecting the brain Victims of abuse/violence Other factors, such as infections, stress hypoglycemia, pain or illness, seizure activity, sleep deprivation
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Staff Risks Factors Inadequate or lack of training
Controlling or disrespectful attitude Harsh verbal and nonverbal communication Predisposition for anger Work load and stress
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Environmental Risks Factors
Noise Crowded spaces Temperature Odors Restraints Behavior of other disturbed patients
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Early Signs of Escalation
Changes in the patient mood Loud or aggressive speech or actions Increasing psychomotor activity Isolation Care giver’s visceral perceptions
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Escalation Trajectories
The beginning Reaching the point Beyond the point Calming with intervention Dissipating on its own
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12 Aggression Prevention Skills
1. On first approach stay at least 1 foot away form the patient 2. Begin the interaction by acknowledging by name. 3. Introduce one’s self before touching the patient 4. Give the patient a choice over actions to be taken on his/her behalf 5. Ask the patient to help with the care; do not take over the entire interaction. 6. Tell patient what you are going to do before doing it(before touching the patient)
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12 Aggression Prevention Skills
9. Back off physically when the patient demonstrates verbal or physical aggressiveness 10. Validate the patient’s emotional state/Mirroring 11. Use distraction or time outs to defuse aggressive behavior 12. Use a soft, calm voice at all times 7. Face the patient at all times to watch for aggressive movements 8. Block aggressive actions appropriately(put arms up to protect yourself from blows, do not grab the patient’s hands or arms, or push back
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The nurse who serenades her patients
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Managing the Aggressive Patient
Risk Assessment Medication De-Escalation measures Documenting & reporting Restraints as last resort
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Managing the Aggressive Patient
Conduction of Risk Assessment Medication Medications are treatment for target behaviors in behavior emergencies, not for the purpose of chemical restraints. Commonly used meds are: Olanazapine, risperidone, quetiapine, zipraisdone,ativan Should entail determining risks factors for violence including triggers, previous history of restraints, and trauma and abuse history.
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De-Escalating Strategies
Project calm & attentive demeanor Avoid making aggressive signals Assess the situation promptly & intervene early Be empathetic Reassure 4s model
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Four S Model Support – Listening & talking in supportive way
Safety – assuring the pt’s physical & emotional wellbeing Support – Listening & talking in supportive way Structure techniques – Limit setting, convey expectations and problem solving Symptom management – Stress and relaxation measures, diversion activities, or medication Source: Delaney, Pitula, and Perraud
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Special Consideration Brain Injury
Frontal & medial temporal or limbic structures are one of the most troubling consequences of Acquired TBI Resultant behavior problems can include verbal & physical aggression Sexual disinhibition & self injury, self-injurious behavior Chemical & physical restraints may create additional physical & psychological effects
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Current Perspectives Eight years after the Hartford Courant investigative report “ Deadly Restraints” the Centers for Medicare and Medicaid Services(CMS) released final revised standards regarding restraint and seclusion for the management of violent or self- destructive behavior
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CMS Definitions Restraints - Any manual method, physical or mechanical device, material or equipment that immobilizes of reduces the ability of a patient to move his/her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the pt’s behavior or restrict the pt’s freedom or movement and is not a standard treatment or dosage for the pt’s condition.
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CMS Definitions Seclusion – Involuntary confinement of the patient alone in a room or an area where the patient is physically prevented from leaving Chemical restraints – Those medications that are designed to put a person to sleep, and not treat the underlying condition, are considered chemical restraint
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Froedtert Hosptial Policy
Patient Safety Observation Purpose Statement: To provide guidelines for the appropriate use of a Patient Safety Attendant and expectations of staff Performing the Patient Safety Attendant assignment Restraint Purpose Statement: To establish a procedure for the safe and consistent use of restraints
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Appropriate Use of Restraints
Should never be used to introduce consequences Obligations of the nurse to the patient increases when restraints are used Without other measures to address the violent behavior can increase the level of agitation Are to be used as a last resort & every effort should be taken to plan for the restraints to be removed as soon as possible
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Appropriate Use of Restraints
Depends on factors ,such as patient’s competency & health status Likelihood of harm to self or others Institutional policy Nursing staff’s responsibilities regarding patients Should be regarded as a temporary measure & always with the best interest of the patient in mind
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Consequences of Mismanagement
Injuries to staff and/or patient Increase cost Damage to therapeutic relationship between patient & client Increase level of stress on the unit and negative impact on quality of care Diminished job satisfaction Poor morale & clinical performance High staff turn over
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Conclusion It is imperative that staff recognize that by developing effective verbal and non-verbal communication skills, building therapeutic relationship we are developing self efficacy skills. Which are needed for therapeutic intervention when managing the potentially aggressive/combative patient.
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References Blake, P.,& Grafman, J. ( 2004, December). The neurobiology of aggression. Medicine, Crime, and Punishment, 64, Retrieved from http: Chang, M.A., Chiung, J., & Kynoch, K. ( 2009). The effectiveness of interventions in the prevention and management of aggressive behaviors in patients admitted to acute hospital setting: a systematic review Clark, C., Harland, R., Hollinworth, H., Johnson, L., & Partington, G. (2005, May 25). Understanding the arousal of anger: a patient – centered approach. Retrieved from Delaney, R.K., & Johnson, E.M. (2010, April 4). Keeping the unit safe: the anatomy of escalation. Journal of the American Psychiatric Nurses Association, 13(1), Fitzwater, E., & Gates, M. D. (2004, January/February). Clinical consultation: how do you manage the aggressive behavior of cognitively impaired patients? Rehabilitation Nursing, 29(1), Haddad, A. (2004, May 1). Ethics in Action: a violent patient. Retrieved from http: Luikens, R. ( uploaded by). (2007, February 3). One flew over the cuckoo’s [ Cigarettes scene]. Category: Film & Animation. Podcast retrieved from Magee, L.W. ( 2009, March 16). The use of music therapy in neuro-rehabilitation of people with acquired brain injury. British Journal of Neuroscience Nursing, 5(4) Skyes, L. (2011, May 13). The nurse who serenades her patients. Scrub MagazinePodcast. Podcast retrieved from Stokowski, L. ( 2007, May 3). Alternatives to restraint and seclusion in mental health settings:questions and answers from psychiatric nurse experts. Retrieved from
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