Caring for Aggressive or Violent people.

Mental illness does not necessarily mean accompanying aggressive or violent behaviour, however these reactions can be associated with mental illness. The following is an overview on how to care, nurse and approach persons who may show violent or aggressive behaviour as outlined in an article we came across by Queensland Health.

Nurses who have worked with aggressive or violent people have reported the following:

Feelings and reactions:

Anger

Ironically, aggressive or violent behaviours can cause a nurse to experience similar feelings of rage and anger, as they may come to resent being treated abusively by the person. This may result in a subconscious or even a conscious desire to punish the patient.

Desire to appease

A desire to appease the person may develop as staff attempt to avoid confrontation. This may be the reaction of someone who has personal problems dealing with anger and who may wish to ‘buy peace’ at any price.

Avoidance

Fear of being hurt or spoken to aggressively can lead to a nurse wanting to avoid the person. However, if staff members do not intervene when appropriate, an aggressive or violent situation may become out of control.

Inconsistency of care

The fact that some staff may wish to avoid and others appease the person may lead to inconsistency of care. This in turn can lead to conflicts arising between staff members.

Goals for nursing the person who is aggressive or violent

Appropriate goals in a community or hospital setting when caring for a person who is aggressive or violent include:

1. Ensure the safety of one’s self, other staff and other people.
2. Ensure that the person remains free from injury.
3. Develop a relationship with the person based on empathy and trust.
4. Promote effective coping and management strategies for frustration, fear and anxiety, which may be acting as triggers for an aggressive or violent episode.
5. Promote the person’s engagement with their social and support network.
6. Ensure effective collaboration with other relevant ser vice providers, through development of effective working relationships and communication.
7. Support and promote self-care activities for families and carers of the person who is aggressive or violent.

To consider prior to face-to-face contact:

1. The fact that a person has been known to be violent in the past is good reason to take extra care. However, it does not mean that the person will be aggressive on any particular occasion. Do not prejudge the situation.
2. Determine whether a male or female member of staff will have a more calming influence on the person. At times, the presence of a man is too threatening. At others, it is reassuring that a male may have greater physical control over the situation. A male may see a female member of staff as nurturing and supportive and be less likely to tr y to hurt her.
3. Communicate to co-workers when you are entering the person’s room or cubicle.
4. A person’s cultural background can influence the way symptoms of mental illness are expressed or understood. It is essential to take this into account when formulating diagnosis and care plans.
5. Health Centre are available for advice and assistance in understanding these issues.

During face-to-face contact:

1. Remain calm. This will communicate that you are in control. Speak in a calm, firm voice (slowly with measured tones) without emotional response or yelling.
2. If the person is standing, ask him or her to sit down, and tell you what is causing the frustration.
3. If a person is violent/aggressive, the nurse should immediately contact security and ensure the safety of all people in the vicinity.
4. To protect yourself in a person’s room or cubicle, ensure you have clear access to the exit door in case the person becomes agitated or wants to leave. Leave the door to the room open and pull the curtain if privacy is necessary. This will avoid the person feeling trapped and will also ensure your protection. Work with a colleague if possible.
5. Power struggles can result in violence, so do not force a person who is agitated to have blood taken or to go for tests. Instead, prioritise what care must be administered, and place your focus on that. Ensure that all procedures are explained to the person and that his or her permission has been gained prior to carrying them out.
6. Regularly orientate yourself to the situation and your role. This can help de-escalation and will help you maintain your focus.
7. Encourage the person to articulate his or her feelings by clarifying and reflecting on your own understanding of them. Use non-confronting eye contact, ask questions and restate in your own words what you understand the person is trying to tell you.
8. Reflecting a person’s feelings can be very effective, if it is done in a genuine and appropriate way.
9. Recognise and accept that the person has a right to express anger, and that expression of anger towards you does not mean that you are doing a bad job. Avoid reacting defensively and taking things personally; instead, try to look for the feelings that are behind the behaviour. Reinforce to other staff the person’s right to express angry feelings.
10. Avoid verbal confrontations. Reassure the person that you are there to help.
11. Avoid becoming emotional or defensive in your responses. Try to focus, instead, on the current issues. Let the person know that you are interested in what he or she has to say.
12. Recognise that in some situations where people are frustrated or fearful, there may be little nurse can do to help except to allow expressions of anger and listen empathetically.
13. Distinguish between verbal aggression and a person’s customary language. Some people use swear words and slang as part of their everyday language and may not have the intention of being aggressive or offensive.
14. Encourage the person to speak with a mental health worker or social worker, or to accept medication voluntarily, if appropriate. Try dialogue such as: ‘It seems that things are a bit out of control at the moment. Will you let us help you? Taking this medication will help calm things down.’
15. Help them to identify triggers and any management strategies, if appropriate. It is important to do this when the person is calm and open to discuss the issues. If the person has a mental illness it may be important to consider to what degree the symptoms are contributing to the tendency towards aggression and violence.
16. Provide family members and carers with information about aggression and violence, if appropriate, as well as reassure and validate their experiences with the person. Encourage family members and carers to look after themselves and seek support if required.
17. Be aware of your own feelings when caring for a person who is aggressive or violent. Arrange for debriefing for yourself or for any colleague who may need support or assistance — this may occur with a clinical supervisor or an employee assistance service counsellor

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