Violence and Acting Out

Question 1

what are factors influence violence?

Answer 1

limitations within the criminal justice system and a fractured system

Question 2

what type of crime/charge is staff assaults against mentally impaired persons (e.g. patients in psych units)?

Answer 2

it is felony

Question 3

what are limited value in the real world and should not be counted on to protect?

Answer 3

protective orders

Question 4

who are at risk for PTSD and/or other psychological disorders?

Answer 4

persons who are victims or witnesses of highly traumatizing events

Question 5

who experience both direct and indirect exposure to trauma and are at risk?

Answer 5

nurse, police, and other responders

Question 6

what is indirect exposure called?

Answer 6

vicarious traumatization

Question 7

what is increasingly recognized as an occupational hazard within nursing and others working with survivors?

Answer 7

indirect exposure/vicarious traumatization

Question 8

what is expressing one’s feelings behaviorally rather than verablly?

Answer 8

acting out

Question 9

what are the two main causes of acting out?

Answer 9

1. an inability to communicate
2. a sense of desperation (more desparate)

Question 10

what are the ways a nurse can prevent acting out?

Answer 10

1. help the patient to communicate his feelings and meet his needs, effectively
2. reduce the patient’s degree of desperation
3. prevents secondary gains via self awareness
4. helps the patient cope with his own repsonses

Question 11

what are secondary gains?

Answer 11

are factors that unintentionally reinforce a behavior

Question 12

what are interventions to promote communication?

Answer 12

1. teach and role-model communication skills
2. observe for signs of increasing desperation and preemptively engage patient
3. convey empathy and openness; do not respond punitively
4. teach ways to identify and convey feelings
5. make staff available and actively convey desire to communicate with patients and hear their concerns
6. avoid overloading patient with info, feedback, or expectation that will evoke strong feelings and overwhelm the patient

Question 13

what occurs when feelings are not communicated, or when they accumulate too quickly for the patient to be able to communicate or resolve them?

Answer 13

desperation

Question 14

what are interventions to prevent or reduce desperation?

Answer 14

1. monitor for developing desperation (signs of escalation) and address the patient’s feelings/needs
2. promote communication by being receptive, actively encouraging interaction, and actively eliciting the expression of feelings in 1:1, via journaling
3. provide alternative outlets for the energy that accompanies desperation
4. anticipate patient’s frustration and process/manage it
5. decrease demands on the patient in general

Question 15

what can become part of the desperation cycle (part of the problem) by further increasing the patient’s desperation?

Answer 15

staff actions

Question 16

what can also lead to further acting out in the desperation cycle?

Answer 16

patient’s own responses

Question 17

what another phenomena that can lead to further aggression?

Answer 17

secondary gains

Question 18

what are interventions related to staff’s and patient’s own responses to the acting out?

Answer 18

1. process events and patient’s feelings about them; discuss what happened and why
2. convey empathy; do not absolve the patient re: negative behavior, but do forgive and convey acceptance of the patient
3. manage own emotions to stay objective; if anger is shown, apologize and process with patient
4. as above, correct/undo punishment
5. monitor, correct secondary gains; process with the patient

Question 19

what are the causes of aggression in patient care?

Answer 19

frustration- unmet needs
response to loss
response to threat or fear
physical or emotional distress
a learned response (e.g. comes from a violent subculture)
psychosis or other impaired thinking (in particular paranoia internal stimuli such as hallucinations)
punitive or non-therapeutic staff behaviors
conflict about rules or limits

Question 20

what are factors affecting one’s tendency to violence?

Answer 20

anxiety and impaired coping
impaired ability to cope with negative emotions, such as fear, anger, shame, embarrassment, and humiliation
ability to communicate
ability to defer gratification- impulsiveness
ability to process information
psychosis- impaired reasoning ability and/or reality testing, paranoia, and command hallucinations
unmet expectations
pain or other sources of irritability
cultural beliefs that sanction/support violence
build up of microinsults
healthcare system variables
chaotic or overly stimulating environment
staff are disconfirming, judgmental, or disapproving
staff who are unduly fearful
institutional rigidity
ineffective limit setting
insufficient staffing

Question 21

when are health care staff assualted?

Answer 21

conflicts over rules, requirements, restrictions
ineffective limit setting
shift change- confusion and reduced staff availability
interventions that cause pain
when nursing care requires that they become physically close to the patient
intervening with patients who are delirious or confused
intervening with patients who are psychotic
intervening with patients who are menacing or violent

Question 22

what are the therapeutic goals during behavioral crises?

Answer 22

everyone remains safe
arousal is reduced to manageable levels
patient is able to use internal and external resources to de-escalate him/himself further
likelihood or recurrence is reduced

Question 23

what are the non-therapeutic or unrealistic expectation goals during behavioral crises?

Answer 23

patient will admit he/she’s wrong, apologize
patients are restrained, secluded, or punished
there will not be any anger or conflict

Question 24

what to do to address external factors that contribute to aggression?

Answer 24

active self awareness- monitor our own situation and feelings in an ongoing manner
be empathic- put ourselves in other’s place, walk in their shoes; imagine you are the patient
take care of our own mental health- be well-rested, manage your stress, etc. so you can cope effectively with your own stress and frustrations
assure the staff’s expectations are realistic
reduce screw-ups and other provocations

Question 25

what is part of intervening when a patient is escalating?

Answer 25

always make sure that help is on the way; do not respond alone
stand with your side towards the patient
stay out of the range of assault
manage your own demeanor- present in the same way you want the patient to act (calm and in control), and neither over nor under-react
reduce stimulation (without isolating)- remove other patients, unnecessary personnel from the area
determine level of arousal and match your response to the patient’s level
convey awareness and empathy, but without stating the obvious
give feedback judiciously, as tolerated, and only when it will help the client
use the state, seek, do method
use a “fair trade” or partnership approach- trade what the patient wants for what you want
reframe the situation to emphasize working together on a common goal
offer food, fluids, yourself
use dislocation of expectations
use altercasting
instill hope
use anticipatory fantasy

Question 26

what is the state, seek, do method?

Answer 26

state what you see and what you’d like to see
seeks info on how patient sees things, and his ideas on what he/she thinks would help
do those reasonable things the patient suggets, or guide patient’s responses to be more “doable”

Question 27

what is dislocation of expectations?

Answer 27

do what the client does not expect

Question 28

what is altercasting?

Answer 28

convey positive expectations so that patient will tend to assume the desired qualities

Question 29

what is anticipatory fantasy?

Answer 29

talk about what is likely if things continue on the same trajectory

Question 30

how to effectively give bad news?

Answer 30

understand likely impact news will have on the patients and others and convey it empathetically
give news privately but in public area of unit, never in small closed room
alert staff of need to share the info, seek input on best way to do so
give news with another staffer present and with additional staff standing by
provide support and share ways to cope with the news
assure that staff subsequently follow-up with patient to continue support and encourage effective coping

Question 31

what requires the doctor’s order, but an RN may initiate in an emergency?

Answer 31

seclusion and restraints

Question 32

what are nursing cares during restrain and seclusion?

Answer 32

1. constant monitoring to prevent injury
2. prevention of excess isolation
3. attending to elimination needs
4. attending to nutritional needs
5. providing for ROM and preventing damage to tissue
6. all nursing care must be done in manner that keeps everyone safe
7. as appropriate and when tolerated, help the patient to understand the purpose of the seclusion or restraint
8. after restraints or seclusion ends, help the person to understand the purpose of the seclusion or restraint, master ways to prevent or cope with whatever circumstances or feelings contributed to the loss of control, and cope with unintended distress or trauma from the seclusions/restraints itself