Violence and Crises Interventions

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Violence and Crises Interventions

• Psychiatric / Mental Health Nursing
• West Coast University

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Objectives

• Describe theoretical perspective in understanding
  violence
• Identify the presence of behavioral and verbal
  cues that indicate impeding violence
• Describe nursing measures to de-escalate
  potentially violent behavior within the context
  of the principle of least restrictiveness.
• Implement a variety of nonpharmacological nursing
  strategies for intervening with violent clients.
• Identify common staff responses to violence.

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Objectives

• Analyze personal feelings and attitudes that may
  affect professional practice when caring for
  clients with aggressive behaviors.
• Identify problem-solving framework.
• Identify principles of documentation
• Review types of restraints
• Practice evasions from attacks
• Identify principles of evasion

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Basic Premise

• Students who have reviewed the systematic
  approach to intervention during incidents of
  potential assault are less likely to injure or be
  injured than those who have not.

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Violence in the Healthcare Setting

• Definition
• Verbal or physical threats and/or injury to
  persons or destruction of property
• Anger
• An emotional response to frustration of desires,
  threat to ones needs (emotional or physical), or
  a challenge
• Aggression
• Action or behavior that results in verbal or
  physical attack
• 60-90 of nurses experience violence.
• Psychiatric, emergency rooms and geriatric are
  areas of high risk and incidence.

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Biopsychosocial Theories

• Biologic Theories
• Imbalances of hormones (? testosterone),
  neurotransmitters (?D and NE, ?Achm 5HT, and
  GABA)
• Genetic abnormalities
• Neurophysiologic injuries (trauma, anoxia,
  metabolic imbalance, encephalitis, organic brain
  injury)

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Biopsychosocial Theories - continued

• Psychosocial Theories
• Psychoanalytic aggression an innate drive
• Psychological impairment in impulse control,
  coping, and social skills
• Sociocultural child abuse, dysfunctional family

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Biopsychosocial Theories - continued

• Psychosocial Theories
• Psychoanalytic aggression an innate drive
• Psychological impairment in impulse control,
  coping, and social skills
• Sociocultural child abuse, dysfunctional family

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Biopsychosocial Theories - continued

• Behavioral Theory
• Learned behavior (exposure to violence
• in media/entertainment)?
• Humanistic Theory
• Basic drives unmet

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Behavioral Cues

• Clenched jaws and fists
• Dilated pupils
• Intense staring
• Flushing of face and neck
• Frowning, glaring, or smirking
• Pacing
• Increased vigilance
• Anxiety
• Destruction of property

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Verbal Cues

• Threats of harm
• Loud demanding tone
• Abrupt silence
• Sarcastic remarks
• Pressured speech
• Illogical responses
• Yelling, screaming, cursing
• Statements of fear or suspicion

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Exercise

• Kinds of physically injurious behaviors that you
  may observe in the clinical setting?
• What needs clients are trying to meet?
• What alternative behavior will your patients use
  to meet these needs

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Professionalism

• Our attitudes influence clients behavior.
  Cynicism, pessimism, and other destructive
  attitudes frequently aggravate assaultive
  incidents. When we accept responsibility for our
  career choice, then we are less likely to
  contribute to unnecessary violence.
• Attitude
• Mood
• Motivation

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Preparation

• We should prepare to respond to aggressive
  behavior before they enter the workplace. Then
  they are less likely to injure during an assault.
  The fully prepared student has proper attire,
  adequate mobility, well-practiced observational
  strategies, and an organized plan for
  self-control.
• Attire
• Mobility
• Precautions (Psychiatric and Medical Problems)
• Observation
• Self-Control

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Comorbidities

• Posttraumatic stress disorder (PTSD)
• Substance abuse disorders
• Conduct disorder
• Dementia of the Alzheimers type
• Coexists with
• Depression
• Anxiety
• Psychosis
• Personality disorders

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Nursing Process Assessment

• Risk factors
• History of violence
• Severity of psychopathology
• Higher levels of hostility
• Length of time in the hospital
• Early age of onset of psychiatric symptoms
• Frequency of admission to psychiatric hospitals
• Agitated delirium / Acute excited state
• Substance abuse

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Assessment

• Assess clients
• Perception of precipitating event/current
  situation
• Support system
• Usual coping patterns
• Withdrawal symptoms
• Confusion
• Pain

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Assessment - continued

• Environmental factors
• Availability of dangerous objects
• Overcrowding
• Staffing
• Supervision
• Activity level

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Nursing Diagnoses NANDA

• Risk for Other-Directed Violence
• Risk for Self-Directed Violence
• Anxiety
• Ineffective Coping
• Chronic Low Self-Esteem, and Situational Low
  Self-Esteem

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Other Considerations

• Impulse control
• Sensory-perceptual functioning
• Cognitive functioning
• Social skills
• Impaired communication
• Helplessness
• Powerlessness
• Protection of vital interest
• An aggressive or hostile staff member
• Changes in role identity
• Lack of personal space

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Implementation

• Develop a therapeutic relationship.
• Establish trust, maintain safety, and convey
  respect.
• Use active listening and calm demeanor
• Address client needs.
• Use problem solving with the individual
• Be empathetic
• Offer assistance and avoid an argumentative
  stance
• Allow venting and pacing
• Use open ended questions and give the client time
  to think

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Outcomes Identification

• Maintains self-control without supervision
• Upholds contract to avoid aggressive behaviors
• Help person in crisis understand what led to the
  crisis and guide him/her toward positive
  resolution
• Acute phase restore the person to pre-crisis
  level of functioning as quickly as possible

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Interventions

• Avoid saying you must or you need to
• Avoid power struggles and judgements
• Be aware of your nonverbal behavior
• Be clear and use simple language
• Decrease environmental stimuli

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Intervention continued

• Assure client that the staff will not allow
  anyone to harm themselves or others
• Expect all staff to consistently reinforce limits
• Use a calm and unhurried approach
• Offer one to one interaction
• Explain the limits and consequences in a direct
  and matter of fact language

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Five Phases of The Assault Cycle

• Phase 1 The triggering event
• Phase 2 Escalation
• Phase 3 Crises
• Phase 4 Recovery
• Phase 5 Post-crises depression

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Nonpharmacologic Strategies - continued

• De-escalation
• Assemble a team and brief team members.
• Clear the area of other clients.
• Choose a leader.
• Evasion
• Appropriate for responding to situation in which
  assault and battery is attempted
• Prevents injury and avoids the pitfall of
  retaliation or over-reaction
• Reasonable force

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Pharmacologic Interventions

• Pharmacologic agents
• Antipsychotics (typical and atypical)
• Benzodiazepines
• Anti-parkinsons
• combinations

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Restrictive Measures

• Restrictive measures
• Pharmacologic
• Seclusion
• Involuntary confinement alone in a room the
  patient is physically prevented from leaving
• Restraint
• Device attached or adjacent to clients body
  which restricts movement or normal access to
  ones body
• Documentation required
• Denial of Rights
• Clinical Assessment
• Observation

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Nursing Self-Awareness

• How do I feel about this patient/setting?
• How are my feelings affecting my behavior?
• Fear is a normal response.
• Avoid personalizing.
• Use intuition.

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Principles of Evasion

• Control yourself
• Keep talking
• Be patient
• Stay out of the way
• Get out of the way
• Pat attention
• Make a plan

• Track the attack
• Move in an arc
• close the attack
• Escape holding attacks
• Minimize, release, evade
• Call for help
• Avoid inflicting pain and injury

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Practice Evasion From Attacks

• Evasion from punches, slaps and scratches
• Evasion from kicks, and knee
• Cover and deflect when trapped or cornered
• Evasion from blows with heavy objects
• Evasion from holding attacks
• To the skin pinching, digging nails, biting
• To the hair
• To the limb
• To the torso
• To the neck