Anger, aggression, and violence

CHAPTER 27


Anger, aggression, and violence


Lorann Murphy



Objectives



1. Compare and contrast three theories that explore the determinants for anger, aggression, and violence.


2. Compare and contrast interventions for a patient with healthy coping skills with those for a patient with marginal coping behaviors.


3. Apply at least four principles of de-escalation with a moderately angry patient.


4. Describe two criteria for the use of seclusion or restraint over verbal intervention.


5. Discuss two types of assessment and their value in the nursing process.


6. Role-play with classmates by using understandable but unhelpful responses to anger and aggression in patients; discuss how these responses can affect nursing interventions.




image


Visit the Evolve website for a pretest on the content in this chapter: http://evolve.elsevier.com/Varcarolis


image


Anger, aggression, and violence are the subject of daily news headlines. In the United States, the National Football League recently suspended coaches and players for promoting and using unnecessary aggression against players of other teams (Maske, 2012). Evidence of the scope and prevalence of the problem can been seen in an expanding list of terminology used to describe specific types of aggression. Road rage is a dangerous habit rampant in high-stress, industrialized societies and is accompanied by cursing, offensive gestures, and cutting others off while driving. Air rage is manifested as objectionable behavior, aggressive utterances, threats, and violence within the confines of an aircraft. Desk rage includes lashing out at work. Hospitals, as 24-hour-a-day, high-stress environments, have even earned a term for their own brand of confrontation: ward rage.




Clinical picture


Anger is an emotional response to frustration of desires, a threat to one’s needs (emotional or physical), or a challenge. It is a normal emotion that can even be viewed as positive when it is expressed in a healthy way. It can be used as a motivator or an aid in survival (Kassinove & Tafrate, 2006), but problems begin to occur when anger is expressed through aggression or violence.


Aggression is an action or behavior that results in a verbal or physical attack. Aggression tends to be used synonymously with violence; however, aggression is not always inappropriate and is sometimes necessary for self-protection. On the other hand, violence is always an objectionable act that involves intentional use of force that results in, or has the potential to result in, injury to another person.


Coping with a patient’s anger is a challenge. Effective nursing intervention becomes more difficult when the anger is directed at the nurse. Nursing interventions for anger and aggression should begin when patients experience increased anxiety. Refer to Chapter 15 for interventions that can be used when anxiety is escalating.




Comorbidity


Although anger is a universal emotion, not everyone responds to anger with aggression and violence. A great deal of research has been done on aggression and violence in persons with post traumatic stress disorders (PTSD) and substance use disorders (Sirotich, 2008). Anger also coexists with depression, anxiety, psychosis, and personality disorders (Kassinove & Tafrate, 2006).


Anger and hostility have effects on physical well-being; they are risk factors for hypertension and cardiovascular disease, including ischemic heart disease and cerebral vascular attacks (Kassinove & Tafrate, 2006). Suppression of anger has been shown to increase the rate of major cardiac events, and anger has also been shown to increase a person’s perception of pain (Denollet et al., 2010; Middendorp et al., 2010).



Etiology


Biological factors


Many neurological conditions are associated with anger and aggression. For example, certain brain tumors, Alzheimer’s disease, temporal lobe epilepsy, and traumatic injury to certain parts of the brain result in changes to personality that include increased violence. Many patients with brain injury have severe behavior disorders, including aggressiveness, that disrupt their lives.


One area of the brain known to be associated with aggression is the limbic system, which mediates primitive emotion and behaviors necessary for survival. The limbic system contains several structures that appear to have a role in the production of aggression. The area of the brain called the amygdala mediates anger experiences, judging events as either aversive or rewarding. In animal studies, stimulation of the amygdala produces rage responses, whereas lesions in the same structure produce docility. The temporal lobe of the brain shares some structures with the limbic system. Memory is thought to be integrated in the temporal lobe; memory of previous insult is important in the cognitive appraisal of threat in the face of new stimuli. This lobe is also the source of complex partial seizures, which may give rise to aggressive behavior (Ito et al., 2007).


The prefrontal cortex also has been identified as playing an important role in aggressive behavior. This was first noted in persons who had lesions or injury that caused aggressive behavior (Siever, 2008). Individuals with antisocial personality disorder have been shown to have less gray matter in their prefrontal cortexes (Narayan et al., 2007). Neurotransmitters play a vital role in anger and aggression. Serotonin, dopamine, norepinephrine, gamma-aminobutyric acid (GABA), glutamate, and acetylcholine all have an impact on anger and aggression (Comai, 2012). Studies have shown a relationship between impulsive aggression and low levels of serotonin (Gross & Sanders, 2008). Dopamine has also been linked to aggressive outbursts in patients with neurological impairment (Ramírez-Bermudez et al., 2010).


Some individuals are biologically more predisposed than others to respond to life events with irritability, easy frustration, and anger. This predisposition may be a function of genetics or of neurological development that occurs in the context of certain infant and childhood environments. Individuals who have a history of aggression have been shown to be more acutely aware of subtle facial cues of anger (Wilkowski et al., 2012). If all the dimensions of anger are centrally mediated, then successful interventions can be designed to target any of its manifestations. This is likely the reason biological, pharmacological, behavioral, and cognitive strategies are all useful in the management of anger and aggression.



Psychological factors


Freud wrote in Civilization and Its Discontents that the conflict between sexual needs and societal norms was the source of mankind’s dissatisfaction, aggression, hostility, and ultimately violence. More recently, Menninger (2007) asserted that the struggle for control over our lives is fundamental in every person. If that control is threatened, we experience trauma, and it is from that trauma that anger, aggression, and violence may originate. Interventions should be focused on realizing that the patient may be experiencing trauma and helping the patient feel as though he has some control in his or her life.


Early behaviorists held that emotions, including anger, were learned responses to environmental stimuli (Skinner, 1953). The stimulus is often a perceived threat, and this cognition leads to the emotional and physiological arousal necessary to take action. Although the threat is usually understood as an alert to physical danger, Beck (1976) noted that perceived assault on areas of personal domain, such as values, moral code, and protective rules, can also lead to anger. For example, clinic patients kept waiting for long periods of time without explanation may interpret this as neglect and a lack of respect. Anger may escalate when the initial appraisal is followed by cognitions such as, “They have no right to treat me this way. I am a person too.” These additional cognitions lead to escalating behavior that can erupt into violence unless the situation is defused through successful interventions.


In some individuals, the period of escalation can be rapid. In contrast, patients less predisposed to anger might interpret the wait as a sign that the clinic is busy. These patients might be frustrated by the situation, but in the absence of anger, they might access and utilize skills such as asking how much longer the wait is likely to be, finding distractions in the environment, or rescheduling the appointment.


Social learning theorists conducted research that showed that children learn aggression by imitating others and that persons repeat behavior that is rewarded (Bandura, 1973). Thus children who watch television violence or experience violence in the home learn violent ways of resolving problems. Not only is television violence portrayed as an option for resolving conflict, but most of those violent acts are presented as having no negative consequences. Bullying is another less extreme form of violence that is far more prevalent and has significant consequences. Bullying is any negative activity, including teasing, kicking, hitting, and spitting, intended to bother or harm someone else.



imageCONSIDERING CULTURE


The Anger Sundrome


Cho Hyun-Ja, a 42-year-old Korean female, comes to the clinic with complaints of irritability, quick to anger, feelings of emptiness, insomnia, and general feelings of unfairness. She also complains of dry mouth, headaches, and palpitations. You note that she is sighing frequently during the interview. She may be suffering from hwa-byung, an anger syndrome that is found in 4.1% of Koreans, mostly in middle aged or older women. Anger, irritability, cardiovascular symptoms, generalized anxiety, depression, anorexia, insomnia, and frequent sighing are characteristics of this syndrome. The best approach to treating hwa-byung is a holistic approach consisting of stress management education, psychotherapy, psychopharmacology, acupuncture, music, and drama therapy.


Choi, M., & Yeon, H.A. (2011). Identifying and treating the culture-bound syndrome of hwa-byung among older Korean immigrant women: Recommendations for practitioners. Journal of the American Academy of Nurse Practitioners, 23(5), 226-232.




imageHEALTH POLICY


Workplace Violence Legislation


Assault on inpatient psychiatric units is of worldwide concern. Recently, there has been an increased emphasis on violence toward emergency room nurses. These concerns have resulted in the development of laws and policies regarding violence against hospital workers. In 2008, the American Psychiatric Nurses Association wrote a position statement on workplace violence. Its recommendations included calls for creating a culture of safety, increased intervention and reporting of incidents from nurses, increased education regarding how to deal with aggressive patients, and increased research on workplace violence.


The Emergency Nurses Association recently released the results of a 2-year survey of violence against emergency room nurses. It found that 54.4% of the nurses reported being victims of workplace violence over the past 7 days.


Growing recognition of this problem in many states has resulted in the passage of legislation to protect health care workers. States such as Massachusetts, New York, and Ohio have passed laws that increase penalties for convicted offenders.


American Nurses Association. (2011). Workplace violence. Retrieved from http://ana.nursingworld.org/workplaceviolence; American Psychiatric Nurses Association. (2008). Position statement on workplace violence. Retrieved from http://www.apna.org/i4a/pages/index.cfm?pageid53786; Emergency Nurses Association (2011). Emergency Department Violence Surveillance Study. Retrieved from http://www.ena.org/IENR/Documents/ENAEDVSReportNovember2011.pdf.




Application of the nursing process




Assessment



General assessment

When patients are experiencing anger, it may manifest as increased demands, irritability, frowning, redness of the face, pacing, twisting of the hands, or clenching and unclenching of the fists. Speech may either be increased in rate and volume or may be slowed, pointed, and quiet. Any change in behavior from what is typical for that patient must be addressed. Box 27-1 identifies signs and symptoms that indicate the risk of escalating anger leading to aggressive behavior.



BOX 27-1      PREDICTORS OF VIOLENCE




1. Signs and symptoms that usually (but not always) precede violence:



2. Recent acts of violence, including property violence


3. Stone silence


4. Alcohol or drug intoxication


5. Possession of a weapon or object that may be used as a weapon (e.g., fork, knife, rock)


6. Isolation that is new


7. Milieu characteristics conducive to violence:



It is also important to assess the patient’s history of aggression or violence. Most of our reactions to stimuli come from our previous experiences; therefore, identifying patients’ triggers is essential. Initial and ongoing assessment of the patient can reveal problems before they escalate to anger and aggression. Such assessment also leads directly to the appropriate nursing diagnosis and intervention.


Trauma-informed care is an older concept of providing care that has recently been reintroduced. It is based on the notion that disruptive patients often have histories that include violence and victimization (Sansone et al., 2012). These traumatic histories can impede patients’ ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions (such as restraint) by staff. Trauma-informed care focuses on the patient’s past experiences of violence or trauma and on the role these experiences currently play in their lives.


Careful assessment can reduce the potential for violence. In a study conducted at New York State Psychiatric Institute, patients filled out a questionnaire that identified things that made them upset, how they responded to being upset, and how they wanted to be treated when they became upset. Examples of how they wanted to be treated included talking with them and allowing them time out alone. Making use of the patients’ suggestions resulted in a decreased amount of time in restraints and seclusion and a reduction in the number of fights and assaults on the unit (Hellerstein et al., 2007).



EVIDENCE-BASED PRACTICE


Reducing the Use of Restraints


Vernberg, E. M., Nelson, T. D., Fonagy, P., & Twemlow, S. W. (2011). Victimization, aggression and visits to the school nurse for somatic complaints, illnesses, and physical injuries. Pediatrics, 27(5), 842–848.









Self-assessment

Like patients, nurses have their own histories. The nurse’s ability to intervene safely depends on self-awareness of strengths, needs, concerns, and vulnerabilities. Without this awareness, nursing interventions are marked by impulsive or emotion-based responses, which may be nontherapeutic. Self-awareness includes knowledge of personal responses to anger and aggression, including choice of words and tone of voice, as well as nonverbal communication via body posture and facial expressions. Awareness of the personal and cultural norms is also essential. In addition, staff must be aware of personal dynamics that may trigger emotions and reactions that are not therapeutic with specific patients. Finally, the nurse must assess situational factors (e.g., fatigue, insufficient staff) that may decrease normal competence in the management of complex patient problems.


Self-assessment promotes calm responses to patient anger and potential aggression. The following further supports these responses:




imageASSESSMENT GUIDELINES


Anger and Aggression


Aggression assessment tools have been developed to assist in predicting violent behavior on inpatient psychiatric units (Oglaff, 2006). These tools can beneficial, but general risk identification includes the following:



1. A history of violence is the single best predictor of future violence.


2. Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence.


3. Assess patient risk for violence:



4. Aggression by patients occurs most often in the context of limit setting by the nurse.


5. Patients with a history of limited coping skills, including lack of assertiveness or use of intimidation, are at higher risk of using violence.


6. Assess self for personal triggers and responses likely to escalate patient violence, including patient characteristics or situations that trigger impatience, irritation, or defensiveness.


7. Assess personal sense of competence when in any situation of potential conflict; consider asking for the assistance of another staff member.





Outcomes identification


When interventions are planned for angry and aggressive patients, having clearly defined outcome criteria is important for identifying the behaviors that staff can encourage if their interventions have been successful. The Nursing Outcomes Classification (NOC) outlines specific outcome criteria for use with angry and aggressive patients (Moorhead et al., 2013). Table 27-1 identifies signs and symptoms commonly experienced with anger and aggression, offers potential nursing diagnoses, and suggests outcomes.



TABLE 27-1   


SIGNS AND SYMPTOMS, NURSING DIAGNOSES, AND OUTCOMES FOR AGGRESSION
























SIGNS AND SYMPTOMS NURSING DIAGNOSES OUTCOMES
Body language (rigid posture, clenching of fists and jaw, hyperactivity, pacing), history of violence, history of family violence, history of substance abuse, impulsivity Risk for other-directed violence
Impaired impulse control		 Identifies when angry, identifies alternatives to aggression, refrains from verbal outbursts, avoids violating others’ personal space, maintains self-control
Impulsivity, suicidal ideation (has plan, ability to carry it out), overt or covert statements regarding killing self, feelings of worthlessness, hopelessness, helplessness Risk for self-directed violence
Risk for suicide		 Expresses feelings, verbalizes suicidal ideas, refrains from suicide attempts, plans for the future.
Difficulty with simple tasks, inability to function at previous level, poor problem solving, poor cognitive functioning, verbalizations of inability to cope Ineffective coping Identifies ineffective and effective coping, uses support system, uses new coping strategies, engages in personal actions to manage stressors effectively
Demonstrates feelings of anger, impatience; reports feelings of pressure, tension, difficulty in functioning, anger, impatience; experiences negative impact from stress; reports problems with decision making Stress overload Expresses feelings constructively, reports feelings of calmness and acceptance; physical symptoms of stress are reduced or absent; decision-making is optimal

From Herdman, T. H. (Ed.) Nursing diagnoses—Definitions and classification 2012–2014. Copyright © 2012, 1994-2012 by NANDA International. Used by arrangement with John Wiley & Sons Limited; Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Elsevier.



Planning


Planning interventions necessitates having a sound assessment, including patient history (previous acts of violence, comorbid disorders), present coping skills, and willingness and capacity of the patient to learn alternative and nonviolent ways of handling angry feelings.


Does the patient have:



Does the situation call for:



Does the environment provide:



Do the skills of the staff call for:




Implementation


Ideally, intervention begins prior to any sign of escalation. It is important to develop a relationship of trust with the patient by having numerous brief, nonthreatening, nondirective interactions (e.g., talking about the weather, sports, or something of interest to the patient).


In settings in which staff can reasonably expect episodes of patient anger and aggression, regular teaching and practice of verbal and nonverbal interventions are essential. This fosters nurses’ increased confidence in their own abilities and those of co-workers.



Psychosocial interventions

As you try to determine what the patient is feeling, you have already begun to intervene. During this process, you are attempting to hear the patient’s feelings and concerns. Frequently, this can be accomplished by telling the patient that you are concerned and want to listen. The patient needs reassurance that others are interested and willing to help. It is essential to acknowledge the patient’s needs, regardless of whether the expressed needs are rational or possible to meet. It is important to clearly and simply state your expectations for the patient’s behavior: “I expect that you will stay in control.”


However, patient behavior may escalate quickly, or the patient may mask early signs of distress. Nurses may be distracted and miss those early signs. Other patients may be acutely ill and not amenable to early nursing interventions. In these situations, the problem with anger may not be resolved before the risk for violence arises. When anger and aggression are the priority problems, de-escalation of anger is the primary nursing intervention. Seclusion, restraint, or pharmacological means of de-escalation may be necessary to ensure the safety of patients and staff.


When you approach the patient, convey that you are calm, controlled, open, nonthreatening, and caring. Maintain a relaxed posture. If you are experiencing fear, you may find that this is quite challenging. Maintaining a calm exterior while your interior is in an upheaval requires considerable self-discipline and will come with experience.


It is important to demonstrate respect for the patient’s personal space. Your eyes should be on the same level as the patient’s to decrease a sense of intimidation and communicate to the patient that you are speaking as equals. Allow the patient enough personal space so that you are not perceived as intrusive but not so much space that the patient cannot speak in a normal voice. Be sure you have left yourself an escape route if the patient becomes out of control. Always stay about 1 foot farther than the patient can reach with arms or legs.


Patients who are poised for violence need much more space than those who are not. While you are giving the patient space, the patient may be invading your space with verbal abuse and the use of profanity. This may be the only way feelings can be expressed. As uncomfortable as this may be, you cannot take the patient’s words personally or respond in kind. It is also important not to end the conversation because of the patient’s verbal abusiveness or to forbid the patient from communicating in this way.


When anger is escalating, a patient’s ability to process decreases. It is important to speak to the patient slowly and in short sentences, using a low and calm voice. Never yell but continue to model controlled behavior. Use open-ended statements and questions such as “You think people are always unkind to you?” rather than challenging statements such as “What is wrong with you?” Avoid ending statements with “okay?” because it may create ambivalence in the patient and give the erroneous impression that choices exist. It is also important to avoid punitive, threatening, accusatory, or challenging statements to the patient; rather, find out what is behind the angry feelings and behaviors. Honestly verbalize the patient’s options, and encourage the individual to assume responsibility for choices made. You may want to give two options, such as, “Do you want to go to your room or to the quiet room for a while?” This approach decreases the sense of powerlessness that often precipitates violence.


It is vital to pay attention to the environment. Choose a quiet place to talk to the patient but one that is visible to staff. This is most beneficial in helping a patient regain control. Staff should know who is working with the patient, keep an eye on the interaction, and be prepared to intervene if the situation escalates. At this point, other patients should be moved away, and the environment around the patient should be free from any object that could be used as a weapon.



Considerations for staff safety

There are six basic considerations for ensuring safety:



1. Avoid wearing dangling earrings or necklaces. The patient may become focused on these and grab at them, causing serious injury. Such jewelry should be removed before dealing with an agitated patient.


2. Ensure that there is enough staff for backup. Only one person should talk to the patient, but staff need to maintain an unobtrusive presence in case the situation escalates.


3. Always know the layout of the area. Correct placement of furniture and elimination of obstacles or hazards are important to prevent injury if the patient requires physical interventions.


4. Do not stand directly in front of the patient or in front of the doorway; this position could be interpreted as confrontational. It is better to stand off to the side and encourage the patient to have a seat.


5. If a patient’s behavior begins to escalate, provide feedback: “You seem to be very upset.” Such an observation allows exploration of the patient’s feelings and may lead to de-escalation of the situation.


6. Avoid confrontation with the patient, either through verbal means or through a “show of support” with security guards. Verbal confrontation and discussion of the incident must occur when the patient is calm. A show of force by security guards may serve to escalate the patient’s behavior; therefore, security personnel are better kept in the background until they are needed to assist.

Related posts:

  1. The nursing process and standards of care for psychiatric mental health nursing
  2. Somatic symptom disorders
  3. Sexual dysfunctions, gender dysphoria, and paraphilias
  4. Biological basis for understanding psychiatric disorders and treatments

Stay updated, free articles. Join our Telegram channel
Tags:
Feb 3, 2017 | Posted by in NURSING | Comments Off on Anger, aggression, and violence

Full access? Get Clinical Tree
Get Clinical Tree app for offline access