1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 11 Anger, Hostility, and Aggression

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anger Normal human emotion Handled appropriately, a positive force for resolving conflicts, solving problems, making decisions –Body physically energized for self-defense (“fight-or- flight” response)

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anger (cont.) Expression inappropriate or suppressed: negative force –Physical or emotional problems; interference with relationships –Possible hostility, aggression Catharsis: alleviate or increase feeling of anger

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Hostility and Aggression Hostility = verbal aggression, usually when feeling threatened or powerless Physical aggression: attack on or injury to another person; destruction of property –Both to harm or punish another person or force into compliance Sudden, unexpected Identifiable stages or phases

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Related Disorders and Anger, Hostility, or Aggression Paranoid delusions Auditory hallucinations Dementia, delirium, head injuries Intoxication with alcohol or other drugs Antisocial, borderline personality disorders Depression Intermittent explosive disorder Acting-out behaviors

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology of Hostility and Aggression Neurobiologic theories –Possible role of neurotransmitters: decreased serotonin; increased dopamine, norepinephrine –Structural damage to limbic system; damage to frontal or temporal lobes Psychosocial theories –Failure to develop impulse control –Inability to delay gratification

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cultural Considerations In certain cultures, expressing anger seen as rude or disrespectful Some culture-bound syndromes involving aggressive, agitated, or violent behavior –Hwa-Byung –Bouffee delirante –Amok

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Hostility and aggression are terms that can be used interchangeably.

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: Hostility and aggression are two different terms. –Hostility means verbal aggression. Physical aggression involves attack on or injury to another person or destruction of property.

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatments Underlying/comorbid psychiatric diagnosis –Lithium: bipolar and conduct disorders; mental retardation –Carbamazepine or valproate: dementia, psychosis, personality disorders –Atypical antipsychotics: clozapine, risperidone, and olanzapine: dementia, brain injury, mental retardation, personality disorders

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatments (cont.) Underlying/comorbid psychiatric diagnosis (cont.) –Benzodiazepines: irritability and agitation in older adults with dementia –Haloperidol and lorazepam: decrease agitation or aggression and psychotic symptoms

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Assessment Factors influencing aggression in psychiatric environment/unit milieu Individual patients (history of violent or aggressive behavior in past and how patient handles anger) Patient’s behavior to determine phase of aggression cycle (see Table 11.1)

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Data Analysis and Outcome Identification Data analysis –Risk for other-directed violence –Ineffective coping Outcome identification: patient will –Not harm self or threaten others –Refrain from intimidating/frightening behaviors –Describe feelings, concerns without aggression –Comply with treatment

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Interventions Most effective, least restrictive when implemented early in cycle of aggression Environmental management –Planned activities; informal discussions –Scheduled one-to-one interactions (letting patients know what to expect) –Assistance with problem solving or conflict resolution to avoid expression of anger –Safety of other patients

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Interventions (cont.) Aggression management: triggering phase –Approach in nonthreatening, calm manner –Convey empathy; listening –Encourage verbal expression of feelings –Suggest patient go to a quieter area –Use PRN medications –Suggest physical activity such as walking

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A patient with a history of violent or aggressive behavior is more likely to exhibit similar behavior in the future.

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: A history of violent or aggressive behavior is one of the best predictors of future aggression.

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Interventions (cont.) Aggression management: escalation phase –Take control; provide directions in firm, calm voice –Direct patient to room or quiet area for time-out –Offer medication again –Let patient know aggression is unacceptable; nurse or staff will help maintain/regain control –If ineffective, obtain help from other staff (show of force)

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Interventions (cont.) Aggression management: crisis phase –Inform patient that behavior is out of control, and staff is taking control to provide safety and prevent injury –Use of restraint or seclusion only if necessary

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Interventions (cont.) Aggression management: recovery phase –Talk about situation or trigger –Help patient relax or sleep –Explore alternatives to aggressive behavior –Provide documentation of any injuries –Debrief staff

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Interventions (cont.) Aggression management: postcrisis phase –Remove patient from any restraint or seclusion to rejoin milieu. –Calmly discuss behavior (no lecturing or chastising); allow patient to return to activities, groups, and so forth. –Focus on appropriate expression of feelings, resolution of problems or conflicts in nonaggressive manner.

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Evaluation Was patient’s anger defused in an early stage? Did angry, hostile, and potentially aggressive patient learn to express feelings verbally and safely without threats or harm to others or destruction of property?

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question During which phase does staff debriefing occur? –A. Escalation phase –B. Crisis phase –C. Recovery phase –D. Postcrisis phase

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Recovery phase Rationale: Staff debriefing occurs during the recovery phase to allow for discussion of the event, how it was handled, what worked well or needed improvement, and how the situation could have been defused more effectively.

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Workplace Hostility Sentinel event alert of intimidating, disruptive behaviors by Joint Commission in 2009 Overt actions: verbal outbursts, physical threats Passive activities: refusing to perform assigned tasks, uncooperative attitude

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Workplace Hostility (cont.) New standards of leadership –Code of conduct defining acceptable and disruptive, inappropriate behaviors –Creation, implementation of process for managing these behaviors –Education regarding expected professional behavior –Zero tolerance = all are accountable

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Community-Based Care Effective management of comorbid conditions –Regular follow-up appointments –Compliance with prescribed medication –Participation in community support programs Anger management groups to help patients express feelings, learn problem-solving and conflict-resolution techniques

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues Methods for handling own angry feelings Use of assertive communication skills, conflict resolution Comfort with expression of anger from others –Not taking other’s anger or aggression personally or as measure of effectiveness as nurse Ability to be calm, nonjudgmental