Exam 2-Anger aggression and violence nursing Flashcards
Cultural myths about anger
-anger is a knee-jerk reaction to external events
-it can be uncontrollable, resulting in crimes of passion such as involuntary manslaughter
-anger behavior in adulthood is determined by temperament and childhood experiences
-men are angrier than women
-people must behave aggressively to get what they want.
anger facts vs. fiction
-anger is normal healthy response to violation of one’s integrity
-maladaptive anger is detrimental to mental and physical health
-anger can be expressed outwardly, in either constructive or destructive behavior.
-destructive anger alienates other people and invites retaliation
-constructive anger can be powerful force for asserting one’s rights and achieving social justice
-anger is a signal that something is wrong, thus the angry individual has the urge to act!
-anyone can become aggressive.
anger
a strong, uncomfortable emotional response to a provocation that is unwanted and incongruent with one’s values, beliefs, or rights.
-internal affective state that may or may not be expressed by overt behavior.
-may be expressed constructively or destructively.
-a signal that something is wrong
-meaning of an angry episode depends on the relational context.
-nurses’s should NOT withdraw from angry patients!
maladaptive anger
too frequent, too intense, and managed in unhealthy ways
-excessive outwardly directed anger or suppressed anger
-linked to depression and a plethora of medical conditions
-outward anger: CHD, metabolic syndrome, MI.
-suppressed anger: arthritis, breast and colorectal cancer, chronic pain, HTN, risk factor for PPD.
anger management
-when handled constructively, there is benefit to BP, better general health, increased sense of self efficacy, less depression, lower likelihood of obesity
-when controlled through calming strategies, delivers health benefits
-effective anger management is important to maintain emotional wellness and holistic health. essential to social and professional success
-people with poor anger control have more conflict at work, change jobs more frequently, take more unwise risks, and have more accidents, than those with adaptive anger behavior.
the experience of anger
-physiologic sensations: cerebral cortex involvement, sympathetic nervous system, adrenal medulla (secretes adrenaline and noradrenaline), adrenal cortex (secretes cortisol), CV system, immune system. heart pounds, BP rises, breathe faster, muscles tense, clench jaw or fists as you experience an impulse to do something with this physical energy.
-biologic viewpoint: partially originating from developmental deficits, anoxia, malnutrition, toxins, tumors, neurodegenerative disease, or trauma affecting the brain.
expression of anger
-physiologic arousal similar in all people, but the ways of expressing anger differ!
-suppression can result in a greater, more prolonged physiological arousal. in response, there’s a need to find a safe method to release physical energy: suppression, unhealthy outward anger expression, constructive anger discussion.
-ideally, the clear expression of honest anger may prevent aggression and help to resolve a situation.
-suppression of anger, prolonged rumination about the grievance, and malevolent fantasies of revenge do not resolve a problem and may result in negative consequences later.
-if anger is expressed assertively, beneficial outcomes are possible.
nurse-patient relationship and anger
-nurses may withdraw from angry patients or try to hind their own anger
-nurse’s perceptions and beliefs influence their response to aggressive behaviors: they may believe anger is inappropriate, past family experience with anger, previous victim of assault, potentially by a former patient.
-some patient’s target a nurse’s vulnerable characteristics.
-distancing and coldness from staff are acutely painful to patients- patients want and need a steady, dependable, confident caregiver who will remain connected to them when they are angry.
-nurses must maintain personal control when becoming defensive if feeling vulnerable. without this, potential for punitive interventions is greater.
-threatening an agitated patient will only worsen a volatile situation.
assessment of anger
-outwardly directly or inwardly directed- either producing adverse consequences!
-difficulty in regulating the frequency and intensity of anger
-extent to which anger is creating problems in social, occupational, or intimate relationships
-presence or absence of self-soothing techniques
-evaluation for underlying psychiatric or medical disorders- anger and aggression can be symptomatic of underlying psych or medical disorders, such as PTSD, bipolar, toxicities, head injuries. SO first any underlying disorders must be properly evaluated!!!!!
-using EBP tools like STAXI= spielberger state-trait anger expression inventory.
cultural and gender considerations of anger
-anger is one of six universal emotions with identifiable facial features and emotionally inflected speech
-culture determines how an individual reacts
-must take into consideration gender, culture, and ethic differences before planning interventions.
-western cultures: generally promote more aggressive behaviors in males and more conciliatory behavior in females
-eastern cultures: disapproval of anger for both genders
psychoeducational intervention for anger management
-for maladaptive but nonviolent anger
-anger management for violent behavior can often be ineffective!!!!
-goals= effectively modulate the physiological arousal of anger, alter any irrational thoughts fueling the anger, modify adaptive anger behavior that is preventing problem-solving.
-anger management is an effective intervention that nurses can deliver to people whose anger behavior is maladaptive in some way but NOT VIOLENT.
-psychoeducational anger management courses cannot be expected to modify violent behavior!!!!
anger management implementation
-group leader is a teacher and coach NOT a therapist.
-exclusion criteria: paranoia, organic disorders, severe personality disorder
-group work includes both didactic and experiential components
-members must commit to group meetings and homework assignments
-anger management may be useful to conduct gender specific or culturally specific groups.
-groups may incorporate religious/spiritual anger management strategies.
-group work is valuable to anger management clients since they need to practice new behaviors in an interpersonal context that offers feedback and support.
-potential participants should be screened and referred to individual counseling or psychotherapy if anger is chronic.
-some individuals may have deeper developmental issues that mitigate against their successful participation in anger management groups
-candidates for psychoeducational anger management classes must have some insight that their behavior is problematic and some desire to enlarge their behavioral repertoires.
CBT for anger
-recommended for uncontrolled anger
-provider must establish therapeutic alliance with client
-incorporate avoidance of provoking stimuli
-content includes self monitoring cues of anger arousal, stimulus control, helpful response disruption, guided practice of more effective anger behaviors.
-relaxation or mindfulness training is often introduced early in the treatment because it strengthens the therapeutic alliance and convinces clients that they can indeed learn to calm themselves when angry. when the body relaxes, there is less physical impetus to act impulsively in a way that one will later regret.
aggression and violence
-both are concerns for the criminal justice system and the healthcare system
-factors influencing aggressive and violent behavior: experience of childhood abandonment, physical brutality, sexual abuse, confinement may provoke earlier experiences, behavior does not occur in a vacuum-nurse must consider both the patient and the context!!!
-use of a multidimensional framework is essential for understanding and responding to these behaviors.
-the violent individual may feel trapped, frightened, or desperate, perhaps at the end of their rope.
-humane care may kindle hope of recovery and rehabilitation. the response of the nurse may be critical in determining whether aggression escalates or diminishes.
aggression definitions
aggression: OVERT behavior intended to hurt, belittle, take revenge, or achieve domination and control.
-verbal: sarcasm, insults, threats
-physical: property damage, slapping, hitting
impulse aggression: occurs in situations of anger and anxiety when the individual lashes out.
instrumental aggression: goal directed, premeditated, unrelated to immediate feelings of frustration or threat, is means to secure a goal or reward.
violence
extreme aggression!!!
-use of strong force or weapons to inflict bodily harm to another, possibly to kill
-greater intensity and destruction than aggression
-all violence= aggression, BUT NOT ALL AGGRESSION=VIOLENCE.
assessment of violence: psychosis and homicide
the most important predictor of potential for violence= PREVIOUS EPISODES OF VIOLENCE
-other predictors of patient violence: schizophrenia, young age, alcohol use, drug misuse
-evidence suggests the risk of homicide is higher in the prodromal phase of schizophrenia
-emergence of persecutory delusions may prompt violent behavior.
assessment for aggression and violence: impaired communication and physical condition
-impaired communication, including hearing loss and reduced visual acuity, and disorientation have been found to be consistently associated with aggressive behavior among nursing home residents with dementia.
-important to anticipate basic needs like thirst and hunger, especially when adult or child cannot readily express those needs.
-urge to void can be a powerful stimulus to agitated behavior
-other discomforts can arise from impaired communication.
-physical conditions- patients with long standing poor dietary habits- dietary intake is relevant including prompting good tryptophan sources and limited stimulants.
milieu and environmental factors
-the unit is part of the treatment plan and an important factor in provoking behaviors.
-a busy, noisy hospital unit can quickly provoke an aggressive episode.
-a rude comment or staff denial of a patient’s request can trigger physical assault
-documented times of increased violence includes meals, medications, and shift change.
-crowding and density during times of high patient census are also associated with patient aggression.
-inadequate staffing has been identified as a contributing factor in units with a high incidence of assault.
promoting safety and preventing violence
goals: safety promotion, violence prevention
-interventions: establishment of nurse-patient relationship, creation of therapeutic milieu, begins with assessment history and predictive factors.
assessment for aggression and violence
-predictive characteristics: schizophrenia, alcohol use, drug misuse, hostile-dominant interpersonal style, staring or glaring in intimidating manner, raising voice tone or volume, making sarcastic or demanding comments, pacing.
-early life circumstances: inadequate maternal nutrition, birth complications, TBI, lead exposure
-patient history of episodes of rage and violent behavior, escalating irritability, intruding angry thoughts, fear of losing control.
STAMP= Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling, Pacing
other factors contributing to violence: impaired communication, disorientation, depression, urge to void, bowel movements, ingrown toenails, adverse medication reactions, poor nutrition, caffeine intake.
Social factors:crisis conditions and patient’s home, family, or community.
-patient’s behavior shows important clues to their response to authority figures, opposite sex peers, same-sex peers.
milieu and environmental factors: busy, noise level, rude comments, crowds, rigid rules, violation of boundaries, denial of requests.
priority of nursing care for aggression and violence
focused goals:
-maintaining safety for everyone in vicinity
-situational awareness
-prompt de-escalation of situation
-prevention of injury to patient and staff
-this is not the time to attempt to reason with the patient!!!
interventions for promoting safety for aggressive patients
-use of communication skills and therapeutic nurse patient relationship
-nurse level of self-awareness
-listen to patient illness experience and their concerns
-provide validation, being empathetic, and responding
-providing choices as appropriate- offer concrete choices
-cognitive interventions: provide education and prevention strategies, reduce stimulation from environment, time management of patient techniques for managing anger.
-manage environment
-use de-escalation techniques: use nonthreatening body language, respecting personal space and boundaries, safety awareness and immediate access to the door of the room, knowing where colleagues are and make sure they know where you are, wear appropriate clothing and accessories.
-therapeutic dialogue
-medication management PRN, seclusion and restraining as LAST RESORT
evaluation and outcomes of interventions for the aggressive patient
-is the patient in good emotional control? specifically, are they regaining or maintaining control over aggressive and potentially aggressive thoughts, feelings, or actions?
-is there evidence of risk factor reduction treatment setting?
-hold debriefing with all involved staff, staff to debrief with the patient (always if restraints or seclusion were used)
