Preventing and Managing Aggressive Behavior

Gail W. Stuart

Healthy children raised in decent conditions among loving people in a gentle and just society where freedom and equality are valued will rarely commit violent acts toward others.

Ramsay Clark, A Few Modest Proposals to Reduce Individual Violence in America

Learning Objectives

1. Compare passive, assertive, and aggressive behavioral responses.

2. Describe theories on the development of aggressive behavior.

3. Identify factors useful in predicting aggressive behavior among psychiatric patients.

4. Assess patients for aggressive behavioral responses.

5. Analyze nursing interventions for preventing and managing aggressive behavior.

6. Develop a patient education plan to promote patients’ appropriate expression of anger.

7. Describe the implementation of crisis management techniques.

8. Evaluate prevention strategies related to the workplace, including addressing lateral violence and staff education and support.

http://evolve.elsevier.com/Stuart

People who enter the health care system are often in great distress and may exhibit maladaptive coping responses. Nurses who work in settings such as emergency departments (EDs), critical care areas, and trauma centers often care for people who respond to events with angry and aggressive behavior that can pose a significant risk to themselves, other patients, and health care providers (Lanza et al, 2009). Thus, preventing and managing aggressive behavior are important skills for all nurses.

Violence against ED nurses is common, with reports of 25% to 50% of ED nurses reporting that they have experienced physical violence (Gacki-Smith et al, 2009). Psychiatric nurses also are at risk for violence as they work with patients who have inadequate coping mechanisms for dealing with stress. Patients admitted to an inpatient psychiatric unit are usually in crisis and not thinking clearly, so their coping skills are even less effective. During these times of stress, acts of physical aggression or violence can occur.

Nursing staff members on psychiatric units are likely to be involved in preventing and managing aggressive behavior and are at risk for being victims of aggressive acts by patients. Thus, it is critical that psychiatric nurses be able to assess patients at risk for violence and intervene effectively with patients before, during, and after an aggressive episode.

Critical Reasoning

Members of different disciplines sometimes have different views on how to manage aggressive behavior. Talk with nurses and physicians who care for psychiatric patients about their personal experiences and clinical judgments regarding this problem.

Behavioral Responses

Within each person lies the capacity for passive, assertive, and aggressive behavior. When in a threatening situation, the choices are to be:

1. Passive and fearful and to flee

2. Aggressive and angry and to fight

3. Assertive and self-confident and to confront the situation directly

The situation and the characteristics of the people involved determine the appropriate response.

Passive Behavior

Passive people give up their own rights to their perception of the rights of others. When passive people become angry, they try to hide it, thereby increasing their own tension. If other people notice the anger by observing nonverbal cues, passive people are unable to confront the issue, further increasing their tension. This pattern of interaction can seriously impair interpersonal growth. The following clinical example illustrates passive behavior.

Clinical Example

Ms. J was a staff nurse on a busy surgical unit who enjoyed her work and liked the patients. She also placed a high value on getting along with her co-workers. Other staff members always spoke positively of her. The head nurse valued Ms. J as an employee, stating particularly, “She’s not like the rest of them. She never complains.”

Ms. J made it a practice never to refuse a request made by a patient or another staff member. If patients who were assigned to another nurse asked her to explain their diet or straighten their bed, she would do so, even if she was then behind in her own work. She never asked for help from others because she felt that her assignment was her responsibility. If a co-worker asked to change days off with her, Ms. J always agreed even if she had plans, rationalizing that the other person probably had more important plans.

The head nurse began to sense tenseness when she was around Ms. J. Because she could not think of any problem at work, she assumed that Ms. J must have been having a problem at home. She was concerned and asked Ms. J if she could help. To her amazement, Ms. J recited a long list of angry feelings related to the work situation. The head nurse then felt guilty when she realized that she and the other staff members had been taking advantage of Ms. J.

Although Ms. J thought that she was acting in a healthy way, she was actually ignoring her own needs and diminishing her self-respect. Her co-workers, who superficially liked her, in reality felt uncomfortable with her because they were never allowed to reciprocate her acts of kindness. The head nurse’s guilty response quickly changed to anger when she realized that she had been a victim of Ms. J’s passivity. If Ms. J had informed the head nurse of her feelings, she would have treated her more fairly.

Passivity can be expressed nonverbally. The person may speak softly, often in a childlike manner, and make little eye contact. The person may be slouched in posture, with arms held close to the body.

Sarcasm is another indirect expression of anger. This usually provokes anger in the person who is the target. It is different from assertive behavior because it usually infringes on the rights of the other. A sarcastic remark generally conveys the message, “You are not worthy of my respect.” Sarcasm may be disguised as humor. Confrontation may then be responded to with a disclaimer such as “Can’t you take a joke?” Humor that disrespects another person is hostile and is done for the purpose of self-enhancement. It tends to backfire because the joker is often revealed as insecure.

Aggressive Behavior

At the opposite end of the continuum from passivity is aggression. Aggressive people ignore the rights of others. They think that they must fight for their own interests, and they expect the same behavior from others. For them, life is a battle.

An aggressive approach to life may lead to physical or verbal violence. The aggressive behavior often covers a basic lack of self-confidence. Aggressive people enhance their self-esteem by overpowering others and thereby proving their superiority to themselves. The following clinical example describes aggressive behavior.

Clinical Example

Suzy was a 9-year-old girl brought to the child psychiatric clinic by her mother on referral from the school nurse. She was described as a tomboy who loved active play and hated school. She was the first girl to make the neighborhood Little League baseball team and had proved her right to be there by beating up several male team members. Suzy was sent to the clinic after the teacher caught her forcing younger children to give her their lunch money.

When Suzy came to the clinic, she acted tough. She did not deny her behavior and explained it by saying that the “little kids don’t need much to eat anyway. I let them keep some of the money.” Suzy was saving money for a new baseball glove. When she was asked about school, she said angrily, “I’m not dumb. I could learn that junk, but who needs it? I just want to play ball.”

Psychological testing revealed that Suzy’s IQ was slightly below average. She attended school with a group of upper–middle-class, college-bound children. Even in fourth grade she was feeling insecure and unable to compete. She masked her insecurity with her bullying behavior, striving for acceptance in sports, where she did have ability. The medical diagnosis was conduct disorder, undersocialized, aggressive.

When Suzy’s problem was explained to her parents and the school, some of the pressure for academic achievement was relieved. Her parents spent extra time helping her with her homework. Also, she was given genuine recognition for her athletic ability, demonstrated by the gift of a new baseball glove. Suzy gradually responded to the positive input from others by developing a sense of positive regard for herself. As she did so, she no longer needed to bully other children and began to grow into some real friendships.

Aggressive adults are not unlike Suzy. They try to cover up their insecurities and vulnerabilities by acting aggressively. The behavior is self-defeating because it drives people away, thus reinforcing the low self-esteem and vulnerability to rejection.

Aggressive behavior also can be communicated nonverbally. Aggressive people may invade personal space. They may speak loudly and with great emphasis. They usually maintain eye contact over a prolonged period of time so that the other person experiences it as intrusive.

Gestures may be emphatic and often seem threatening (e.g., they may point their fingers, shake their fists, stamp their feet, or make slashing motions with their hands). Posture is erect, and often aggressive people lean forward slightly toward the other person. The overall impression is one of power and dominance.

Assertive Behavior

Assertiveness is at the midpoint of a continuum that runs from passive to aggressive behavior. Assertive behavior conveys a sense of self-assurance but also communicates respect for the other person. Assertive people speak clearly and distinctly. They observe the norms of personal space appropriate to the situation.

Eye contact is direct but not intrusive. Gestures emphasize speech but are not distracting or threatening. Posture is erect and relaxed. The overall impression is that the person is strong but not threatening.

Assertive people feel free to refuse an unreasonable request. However, they will share their rationale with the other person. They will also base the judgment about the reasonableness of the request on their own priorities.

On the other hand, assertive people do not hesitate to make a request of others, assuming that others will let them know if their request is unreasonable. If the other person is unable to refuse, assertive people will not feel guilty about making the request.

Assertiveness involves communicating feelings directly to others. As a result, anger is not allowed to build up, and the expression of feelings is more likely to be in proportion to the situation. Assertive people remember to express love to those to whom they are close. Compliments are given when deserved. Assertion also includes acceptance of positive input from others.

Table 28-1 summarizes the major characteristics of passive, aggressive, and assertive behaviors.

TABLE 28-1

COMPARISON OF PASSIVE, ASSERTIVE, AND AGGRESSIVE BEHAVIORS

	PASSIVE	AGGRESSIVE	ASSERTIVE
Content of Speech	Negative Self-derogatory “Can I?” “Will you?”	Positive Self-enhancing “I can” “I will”	Exaggerated Other-derogatory“You always” “You never”
Tone of Voice	Quiet, weak, whining	Modulated	Loud, demanding
Posture	Drooping, bowed head	Erect, relaxed	Tense, leaning forward
Personal Space	Allows invasion of space by others	Maintains a comfortable distance; claims right to own space	Invades space of others
Gestures	Minimal, weak gesturing, fidgeting	Demonstrative gestures	Threatening, expansive gestures
Eye Contact	Little or none	Intermittent, appropriate to relationship	Constant stare

Critical Reasoning

Do you use passive, assertive, or aggressive behaviors most often in your personal life? How does this compare with your behavior in your professional life as a nursing student?

Theories on Aggression

It is useful for nurses to view aggressive and violent behavior along a continuum with verbal aggression at one end and physical violence at the other. Violence is the result of extreme anger (rage) or fear (panic). Specific reasons for aggressive behavior vary from person to person. Nurses need to communicate with patients to understand the events that they perceive as anger provoking.

Anger usually occurs in response to a perceived threat. This may be a threat of physical injury or, more often, a threat to the self-concept. When the self is threatened, people may not be entirely aware of the source of their anger. In this case the nurse and patient need to work together to identify the nature of the threat.

A threat may be external or internal. Examples of external stressors are physical attack, loss of a significant relationship, and criticism from others. Internal stressors might include a sense of failure at work, perceived loss of love, and fear of physical illness.

Anger is only one of the possible emotional responses to these stressors. Some people might respond with depression or withdrawal. However, those reactions are usually accompanied by anger, which may be difficult for the person to express directly. Depression is sometimes viewed as anger directed toward the self, and withdrawal also may be a passive expression of anger.

Anger often seems out of proportion to the event. An insignificant stressor may be “the last straw” and result in the release of a flood of feelings that have been stored up over time. Nurses need to be aware of this and not personalize anger expressed by a patient. The nurse may seem to be a safer target than significant others with whom the patient also may be angry.

Aggressive behavior is the result of the interaction among psychological, sociocultural, and biological factors that must be considered when providing nursing care.

Psychological

The psychological view of aggressive behavior suggests the importance of predisposing developmental factors or life experiences that limit the person’s ability to use nonviolent coping mechanisms. Some of these experiences are listed in Box 28-1. They may limit a person’s ability to use supportive relationships, leave the person very self-centered, or make the person particularly vulnerable to a sense of injury that can easily be provoked into rage.

BOX 28-1 DEVELOPMENTAL FACTORS LIMITING USE OF NONVIOLENT COPING TECHNIQUES

• Organic brain damage, mental retardation, or learning disability, which may impair the capacity to deal effectively with frustration

• Severe emotional deprivation or overt rejection in childhood, or parental seduction, which may contribute to defects in trust and self-esteem

• Exposure to violence in formative years, either as a victim of child abuse or as an observer of family violence, which may instill a pattern of using violence as a way to cope

Figure 28-1 shows how these factors can contribute to an intergenerational transmission of violent behavior. Box 28-2 presents background information about the patient that also may be associated with violence.

BOX 28-2 BACKGROUND INFORMATION ASSOCIATED WITH VIOLENT BEHAVIOR

• Childhood cruelty to animals or other children

• Fire setting or similar dangerous actions

• Recent violent behavior toward self or others

• Recent accidents, threats, or poor judgment in potentially dangerous situations

• Altered states of consciousness

• Escalating irritability, sensitivity, or hostility

• Fear of losing control

• Efforts to obtain help

• Bothering family, neighbors, or police

• History of abuse of alcohol or other disinhibiting substances

Social learning theory proposes that aggressive behavior is learned internally and externally. Internal learning occurs by the reinforcement a person experiences when behaving aggressively. This may be the result of achieving a desired goal or experiencing feelings of importance, power, and control.

For example, 4-year-old Johnny wants a cookie just before dinner. When his mother refuses, Johnny has a temper tantrum. If his mother then gives him a cookie, Johnny has learned that an aggressive outburst will be rewarded and he will get what he wants. If similar situations also produce the desired response, Johnny will continue to use an aggressive approach.

External learning occurs through the observation of role models, such as parents, peers, siblings, and sports and entertainment figures. Sociocultural patterns that lead to the imitation of aggressive behavior suggest that violence is an acceptable way of solving problems and achieving social status. According to this view, activities such as violent crime, aggressive sports, and other forms of violence depicted through the media or witnessed in person reinforce aggressive behavior and desensitize the viewers to the consequence of violence.

Sociocultural

Social and cultural factors influence aggressive behavior. Cultural norms help define acceptable and unacceptable ways of expressing aggressive feelings. Sanctions are applied to violators of the norms through the legal system. In this way, society tries to control violent behavior and maintain a safe existence for its members.

Unfortunately, this prohibition against violent behavior also may be extended to include any expression of anger. This can inhibit people from the healthy expression of angry feelings and lead to other maladaptive responses.

A cultural norm that supports verbally assertive expressions of anger will help people deal with anger in a healthy manner. A norm that reinforces violent behavior will result in physical expression of anger in destructive ways.

Physical crowding, environmental issues, and seasonal heat appear to be related to violent behavior. Other social determinants of violence are linked in a cycle and include poverty and the inability to have basic necessities of life, disruption of marriages, unemployment, and difficulty in maintaining interpersonal ties, family structure, and social control.

Biological

Neurobiological research has focused on three areas of the brain believed to be involved in aggression: the limbic system, the frontal lobes, and the hypothalamus (Figure 28-2). Neurotransmitters also have a role in the expression or suppression of aggressive behavior.

FIG 28-2 Structures of the brain that are implicated in aggression.

The limbic system is associated with the mediation of basic drives and the expression of human emotions and behaviors such as eating, aggression, and sexual response. It also is involved in the processing of information and memory. Synthesis of information to and from other areas in the brain influences emotional experience and behavior. Alterations in functioning of the limbic system may result in an increase or decrease in the potential for aggressive behavior.

In particular, the amygdala, part of the limbic system, mediates the expression of rage and fear. The surgical removal of this region makes aggressive wild rhesus monkeys docile and lethargic, unable to respond to threats to their safety. Perhaps in those prone to violence, the amygdala may be overresponsive, perceiving threats where there are none.

The frontal lobes play an important role in mediating purposeful behavior and rational thinking. They are the part of the brain where reason and emotion interact. Damage to the frontal lobes can result in impaired judgment, personality changes, problems in decision making, inappropriate conduct, and aggressive outbursts.

The hypothalamus, at the base of the brain, is the brain’s alarm system. Stress raises the level of steroids, the hormones secreted by the adrenal glands. Nerve receptors for these hormones become less sensitive in an attempt to compensate, and the hypothalamus tells the pituitary gland to release more steroids. After repeated stimulation the system may respond more vigorously to all provocations. That may be one reason why traumatic stress in childhood may permanently enhance one’s potential for violence.

Neurotransmitters are brain chemicals that are transmitted to and from neurons across synapses, resulting in communication between brain structures. An increase or a decrease in these substances can influence behavior. Changes in the balance of these compounds can aggravate or inhibit aggression.

Low levels of the neurotransmitter serotonin are associated with irritability, hypersensitivity to provocation, and rage. People who commit impulsive arson, suicide, and homicide have lower than average levels of 5-hydroxyindoleacetic acid (5-HIAA), the breakdown product of serotonin, in their spinal fluid.

Other neurotransmitters often associated with aggressive behaviors are dopamine, norepinephrine, acetylcholine, and the amino acid gamma-aminobutyric acid (GABA). For example, studies in animals indicate that increasing brain dopamine and norepinephrine activity significantly enhances the likelihood that the animal will respond to the environment in an impulsively violent manner.

The prefrontal cortex also may play an important role in inhibiting aggressive behavior. The specific area of the prefrontal cortex known as the orbitofrontal region appears to inhibit aggressive behavior. Stimulation of this area leads to inhibition of anger and aggression, whereas lesions lead to impulsive behavior.

Predicting Aggressive Behavior

The best single predictor of violence is a history of violence. Mental illness is not a risk factor for violence. Psychopathic and antisocial personality traits are more predictive of violent behavior than mental illness. Demographic variables, such as age, gender, race, marital status, education, and socioeconomic level, are not useful in predicting violent behavior. However, two populations of psychiatric patients are at increased risk of violence:

• Patients with active psychotic symptoms. In particular, those patients who have symptoms related to a perceived threat or an overriding of internal controls, such as delusions of thought control, are at increased risk of committing violence.

• Patients with substance abuse disorders. The prevalence of violence is 12 times greater for those with alcohol abuse or dependence and 16 times greater for those with other drug dependence compared with those who have no psychiatric diagnosis. Co-morbid substance abuse has an added effect in increasing the risk of violence for people with major psychiatric disorders.

Situational and environmental factors also are important in escalating patient behavior from dangerous to violent. These factors include aspects of the physical facilities and the presence of staff and other patients (Hamrin et al, 2009). Several studies have found that the number of violent incidents is greater when patients move or gather in groups, are overcrowded, lack privacy, or are inactive.

Clinicians may intentionally or inadvertently precipitate an outbreak of violence because staff attitudes and actions have a powerful impact on patient behavior. Inexperienced staff, provocation by staff, poor milieu management, understaffing, close physical encounters, inconsistent limit setting, and a norm of violence may all negatively affect the inpatient environment (Knutzen et al, 2011).

Finally, a patient’s appraisal of a situation and level of perceived stress affect one’s response. When an environment is interpreted as hostile, the response is likely to be hostile in return. Those with psychiatric illness, substance abuse, past traumatic experiences, or brain damage may have distorted perceptions that can lead to aggressive responses. A model for the development of aggression in inpatient settings that incorporates these various factors is presented in Figure 28-3.

FIG 28-3 Model of inpatient aggression. (From Nijman H et al: *Psychiatr Serv* 50:832, 1999.)

Critical Reasoning

What role do you think culture plays in the expression and interpretation of aggressive behavior?

Nursing Assessment

Accurate prediction of patient violence is not possible. For this reason it is important for psychiatric nurses to be alert for symptoms of increasing agitation that could lead to violent behavior (Box 28-3).

BOX 28-3 BEHAVIORS ASSOCIATED WITH AGGRESSION

Motor Agitation

• Pacing

• Inability to sit still

• Clenching or pounding fists

• Jaw tightening

• Increased respirations

• Sudden cessation of motor activity (catatonia)

Verbalizations

• Verbal threats toward real or imagined objects

• Intrusive demands for attention

• Loud, pressured speech

• Evidence of delusional or paranoid thought content

• Inappropriate or excessive euphoria

• Affect lability

Level of Consciousness

• Confusion

• Sudden change in mental status

• Disorientation

• Memory impairment

• Inability to be redirected

Using a hierarchy of aggressive behaviors (Figure 28-4) in which lower levels of aggression may lead to more violent behavior is helpful in evaluating patients. Some of these early behaviors include motor agitation, such as pacing, inability to sit still, clenching or pounding fists, and tightening of jaw or facial muscles. Verbal clues also may be present, such as threats to real or imagined objects, intrusive demands for attention or swearing (Stone et al, 2011). Speech may be loud and pressured, and posture may become threatening.

FIG 28-4 Hierarchy of aggressive and violent patient behaviors.

Another critical factor in the assessment of a potentially violent patient is the affect associated with escalating behaviors. Anger often is seen in patients who are imminently violent. Inappropriate euphoria, irritability, and lability in affect may indicate that a patient is having difficulty in maintaining control. Changes in level of consciousness, including confusion, disorientation, and memory impairment, also may indicate future violent behavior.

In summary, psychiatric nurses should carefully assess all patients for their potential for violence. A screening or assessment tool can be particularly useful (Fluttert et al, 2011). One such tool is presented in Figure 28-5. Once completed, a violence assessment tool can help the nurse do the following:

FIG 28-5 Assault and violence assessment tool.

• Establish a therapeutic alliance with the patient.

• Assess a patient’s potential for violence.

• Develop a plan of care.

• Implement the plan of care.

• Prevent aggression and violence in the milieu.

If the patient is believed to be potentially violent following the assessment, the nurse should do the following:

• Implement the appropriate clinical protocol to provide for patient and staff safety.

• Notify co-workers.

• Obtain additional security if needed.

• Assess the environment, and make necessary changes.

• Notify the physician and assess the need for prn medications.

Nursing Interventions

The nurse can implement a variety of interventions to prevent and manage aggressive behavior. These interventions can be thought of as existing on a continuum (Figure 28-6). They range from preventive strategies, such as self-awareness, patient education, and assertiveness training, to anticipatory strategies, such as verbal and nonverbal communication, environmental changes, behavioral interventions, and the use of medications. If the patient’s aggressive behavior escalates despite these actions, the nurse may need to implement crisis management techniques and containment strategies, such as seclusion or restraints.

Self-Awareness

The most valuable resource of a nurse is the ability to use one’s self to help others. To ensure the most effective use of self, it is important to be aware of personal strengths and limitations. Personal stress can interfere with one’s ability to communicate therapeutically with patients.

If nurses are tired, anxious, angry, or apathetic, it will be difficult to convey an interest in the concerns and fears of the patient. If nurses lack confidence in managing aggressive behavior or are overwhelmed with personal or work problems, their effectiveness will be compromised.

When dealing with potentially aggressive patients it is important to be able to assess the situation objectively despite the positive or negative countertransference that might be present. Countertransference is an emotional reaction of the nurse to some aspect or behavior of the patient (Chapter 2). Both positive and negative countertransference reactions may lead to nontherapeutic responses on the part of the staff. Ongoing self-awareness and supervision can assist the nurse in ensuring that patient needs, rather than personal needs, are addressed.

Patient Education

Teaching patients about communication and the appropriate way to express anger can be one of the most successful interventions in preventing aggressive behavior (Table 28-2). Many patients have difficulty identifying their feelings, needs, and desires and even more difficulty communicating these to others. Thus, teaching healthy anger management skills is an important area of nursing intervention.

TABLE 28-2

PATIENT EDUCATION PLAN
Appropriate Expression of Anger

CONTENT	INSTRUCTIONAL ACTIVITIES	EVALUATION
Help the patient identify anger.	Focus on nonverbal behavior. Role play nonverbal expression of anger. Label the feeling using the patient’s preferred words.	Patient demonstrates an angry body posture and facial expression.
Give permission for angry feelings.	Describe situations in which it is normal to feel angry.	Patient describes a situation in which anger would be an appropriate response.
Practice the expression of anger.	Role play fantasized situations in which anger is an appropriate response.	Patient participates in role playing and identifies behaviors associated with expression of anger.
Apply the expression of anger to a real situation.	Help identify a real situation that makes the patient angry. Role play a confrontation with the object of the anger. Provide positive feedback for successful expression of anger.	Patient identifies a real situation that results in anger. Patient is able to role play expression of anger.
Identify alternative ways to express anger.	List several ways to express anger, with and without direct confrontation. Role play alternative behaviors. Discuss situations in which alternatives would be appropriate.	Patient participates in identifying alternatives and plans when each might be useful.
Confront a person who is a source of anger.	Provide support during confrontation if needed. Discuss experience after confrontation takes place.	Patient identifies the feeling of anger and appropriately confronts the object of the anger.