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Aggression Control Training Back to Course Index

 

INTRODUCTION:

Violence in psychiatric settings is a complex workplace problem. Frequent serious incidents have been reported in studies. In one study, 60 percent of psychiatric staff who had experienced violence felt that help was not readily available, 42 percent were dissatisfied with procedures after the incident, and 43 percent felt their work environment to be unsafe.

To help predict aggressive and violent behaviors, the frequency and types of these behaviors have been examined through various methods and studies. Through these methods complex relationships between staffing, patient mix, and violence were found. In general terms, across the studies, relative risk increased with more nursing staff (of either sex), more non-nursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. The relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness. Violent incidents in psychiatric settings are a frequent and serious problem. Incidents appear to be under reported, and the seriousness of an incident does not guarantee it will be reported.

Aggression in its broadest sense is behavioral, or a disposition or tendency to act in a particular manner that is either forceful, hostile or attacking (or some combination of the three). It may occur either in retaliation or without provocation. In narrower definitions that are used in social and behavioral sciences, aggression is an intention to cause harm or an act intended to increase relative social dominance. Predatory or defensive behavior between members of different species may not be considered aggression in the same sense. Aggression can take a variety of forms ag-bomb-1and can be physical or be communicated verbally or non-verbally. Aggression differs from what is commonly called assertiveness, although the terms are often used interchangeably among laypeople, e.g. an aggressive salesperson.

Ethologists study aggression as it relates to the interaction and evolution of animals in natural settings. In such settings aggression can involve bodily contact such as biting, hitting or pushing, but most conflicts are settled by threat displays and intimidating thrusts that cause no physical harm. This form of aggression may include the display of body size, antlers, claws or teeth; stereotyped signals including facial expressions; vocalizations such as bird song; the release of chemicals; and changes in coloration. The term agonistic behavior is sometimes used to refer to these forms of behavior.

Most ethologists believe that aggression confers biological advantages. Aggression may help an animal secure territory, including resources such as food and water. Aggression between males often occurs to secure mating opportunities, and results in selection of the healthier/more vigorous animal. Aggression may also occur for self-protection or to protect offspring. Aggression between groups of animals may also confer advantage; for example, hostile behavior may force a population of animals into a new territory, where the need to adapt to a new environment may lead to an increase in genetic flexibility.

 

BETWEEN SPECIES AND GROUPS

 

cat

The most apparent type of aggression in the between species and groups is that observed in the interaction between a predator and its prey. However, according to many researchers, predation is not aggression. A cat does not hiss or arch its back when pursuing a rat, and the active areas in mouseits hypothalamus resemble those that reflect hunger rather than those that reflect aggression. However, others refer to this behavior as predatory aggression, and point out cases that resemble hostile behavior, such as mouse-killing by rats. In aggressive mimicry a predator has the appearance of a harmless organism or object attractive to the prey; when the prey approaches, the predator attacks. An animal defending against a predator may engage in either “fight or flight” in response to predator attack or threat of attack, depending on its estimate of the predator’s strength relative to its own. Alternative defenses include a range of anti-predator adaptations, including alarm signals.

 

Theories of Aggression

The most influential theories of aggression can be broadly divided into the following:

  • Theories that see aggression as an instinct.
  • Theories that suggest frustration is an important factor in aggression.
  • Theories that suggest aggression is learned behavior.

 


Aggression as an Instinct

There are a number of theories (e.g. the Psychoanalytic Approach, the Ethological Approach and the Biological Approach) which attempt to explain aggression by suggesting that aggressive behavior occurs because each individual is born with an aggressive instinct. 

Such theories suggest that aggression is innate, i.e. inborn, and, therefore, unavoidable.  Outlets such as competitive sport and creative pursuits serve to reduce socially unacceptable aggressive behavior. 


Frustration as a Factor in Aggression

The Frustration-Aggression theory proposes that aggression occurs as a result of frustration.  The inference is that if individuals are frustrated in achieving their aims, the most likely response is aggression.  Such individuals are motivated to be aggressive towards whoever or whatever is standing in their way.  While frustration often leads to feelings of aggression, critics of this theory have argued that it does not explain all the causes of aggression. 


Aggression as Learned Behavior

The theory of aggression as a learned behavior is called the Social Learning Approach.  This theory argues that aggressive behavior is not inborn, rather it is something that is learned, either through direct experience or through observation or imitation of others.  The more that an individual’s aggression is rewarded, perhaps by getting what is wanted or by parental approval, the more likely that person is to be aggressive in the future. 



CONFLICT MANAGEMENT 

 

ag3Aggression between groups is determined partly by willingness to fight, which depends on a number of factors including numerical advantage, distance from home territories, how often the groups encounter each other, competitive abilities, differences in body size, and whose territory is being invaded. Also, an individual is more likely to become aggressive if other aggressive group members are nearby.  One particular phenomenon, the formation of coordinated coalitions, that raid neighboring territories to kill con-specifics has only been documented in two species in the animal kingdom: common chimpanzees and humans; however, a number of classifications and dimensions of aggression have been suggested. These depend on such things as whether the aggression is verbal or physical; whether or not it involves relational aggression such as covert bullying and social manipulation; whether harm to others is intended or not; whether it is carried out actively or expressed passively; and whether the aggression is aimed directly or indirectly. Classification may also encompass aggression-related emotions (e.g. anger) and mental states (e.g. impulsivity, hostility).  Aggression may occur in response to non-social as well as social factors, and can have a close relationship with stress coping style.  Aggression may be displayed in order to intimidate.

The operative definition of aggression may be affected by moral or political views. An example of this is the axiomatic moral view called the non-aggression principle and the political rules governing the behavior of one country toward another. Likewise in competitive sports, or in the workplace, some forms of aggression may be sanctioned and others.

 

APPLICATION

 

Every day counselors, nurses, psychiatric technicians and others in the helping vocations are called upon to intervene in crisis situations which may become dangerous if not handled properly.  In most cases staff members receive comprehensive training that adequately prepares them for the realities of working with a potentially aggressive population.   This is also crucial for the well-being and therapeutic benefit of the population, as well.

 

This course will explore crisis intervention techniques, which can include verbal de-escalation and physical interventions.  Our focus will primarily be on positive and behavioral supports with a strong emphasis on prevention and verbal strategies rather than physical interventions. However, we will briefly explore restrictive measures such as seclusion, physical restraint, mechanical restraint and chemical restraint so that the learner will have been introduced to the concepts.  Use of physical force with this population predictably leads to resistance, and resistance to restraint as well as potential harm to the patient and staff.  

 

Effective aggression control is relationship centered.  It is necessary to have an understanding of the source of the immediate problem, and then have the ability to use resources, relationships, rules and desired outcomes to manage ag-bomb-2behavior.  Staff must vigilantly safeguard the patient’s physical and emotional safety by utilizing professional judgment and skills during times of stress, by being at their best when patients are their worst: in crisis.

 

This course will explore:

 

*Definitions of aggression

*Warning signs of aggressive behavior

*Strategies for diffusion of aggressive situations

*Steps to take to reduce risk of aggressive behaviors

*Crisis Intervention Techniques

*Staff & Managerial Responsibility after the event

 

Please note that this course will use the terms patient and client interchangeably.

 

 

DIAGNOSES

 

In psychology, as well as other social and behavioral sciences, aggression, also called combativeness, refers to behavior between members of the same species that is intended to cause pain or harm.  Frequently it is used to regain control when someone feels as though they have lost authority over their decisions or well-being.

 

Aggressive behavior may be a symptom of a number of DSM psychiatric diagnoses, including conduct disorder, oppositional defiant disorder, behavior disorder not otherwise specified, intermittent explosive disorder, impulse control disorder not otherwise specified and some personality disorders, as well as can be seen throughout alcohol and other drug addictions. Thus, aggressive behavior may be related to a very wide range of diagnoses.

 

Aggression takes a variety of forms among people based upon culture, personality, psychosocial history, gender and situation.  Aggression can be physical, mental, or verbal.

 

As noted previously, there are two broad categories of aggression. These include hostile, affective, or retaliatory aggression and instrumental, predatory, or goal-oriented aggression. Empirical research indicates that there is a critical difference between the two, both psychologically and physiologically.

 

Some research indicates that people with tendencies toward “affective” aggression, defined as being “impulsive, unplanned, overt, or uncontrolled” have lower IQs than those with tendencies toward “predatory” aggression, defined as being “goal-oriented, planned, hidden, or controlled”.

 

Culture is a distinctly human factor that plays a role in aggression.

Empirical cross-cultural research has found differences in the level of aggression between cultures. In one study, American men resorted to physical aggression more readily than Japanese or Spanish men, whereas Japanese men preferred direct verbal conflict to their American and Spanish counterparts. Within American culture, southerners were shown to become more aroused and to respond more aggressively than northerners when affronted. There is also a higher homicide rate among young white southern men than among white northern men in the United States.

 

Behaviors like aggression can be learned by watching and imitating the behavior of others. A considerable amount of evidence suggests that watching violence on television, movies. Video games and social media increase the likelihood of short-term aggression in children.  We are programming the youth on how to resolve conflict.

 

Gender is a factor that plays a role in both human and animal aggression. Males are historically believed to be more physically aggressive than females. This observation is validated by the result of studies that have found more males than females exhibit aggression. Further, aggressive behavior is exhibited more frequently or more intensely in adolescents and young adults. It usually declines in middle and later adult- hood. However, aggressive behavior is often very stable over time. This is one of the most robust and reliable behavioral sex differences, and it has been found across many different age groups and cultures.

 

Aggression is more likely in persons with one or more of the following attributes:

 

  • Greater degrees of intellectual disability;
  • Organic brain damage;
  • Sensory disabilities;
  • Difficulties in language;
  • Poor coping skills;
  • Poor problem-solving skills;
  • Limited social skills;
  • Weak or non-existing social support system;
  • Psychiatric disorders

 

With psychiatric and alcohol and other drug treatment populations you frequently have:

 

  • Limited social skills
  • Multiple legal and social problems and
  • A history of substance abuse 

Each of these can exacerbate a tendency toward aggressive behavior.

 

Common physical and emotional reactions associated with anger – which may lead to aggression


Physical Reactions:

  • Dry mouth
  • Sweating
  • Rapid heartbeat
  • Rapid breathing
  • ‘Butterflies’ in the stomach
  • Muscle tension
  • Shaking
  • Legs feel weak and shaky
  • Clenched fists, teeth and jaw

Emotional Reactions:

  • Frustration/feeling powerless
  • Anger
  • Impatience
  • Restlessness
  • Hostility
  • Depression and/or anxiety
  • Feeling upset and/or starting to cry

 

Types of Aggressive Behavior

Aggression can be distressing or harmful to the recipient.  Types of behavior that may be considered aggressive include the following:

  • Shouting
  • Swearing
  • Personal insults and name calling
  • Racial or sexual comments
  • Verbal threats
  • Posturing and threatening gestures
  • Abusive phone calls, letters, online messages
  • Other forms of harassment
  • Emotional abuse
  • Sarcasm

ASSESSMENT OF AGGRESSIVE BEHAVIOR TRIGGERS

 

Aggression is often an escalation of a disturbed behavior triggered by a range of contributing factors, including:

  • Clinical conditions (e.g. mental health illness, brain disorder, intellectual disability and cognitive impairment)
  • Undesired interpersonal interactions
  • Personally interpreted stress
  • Environmental disturbances (e.g. noise, confined space).

 

The most important role in regards to assessment is to identify the contributing factors, to understand why aggression is occurring and to treat the underlying cause(s) or condition(s). A common cause of aggression in older people is their misinterpretation of the environment and miscommunication, where aggressive behavior is often triggered by fear.

On-going engagement with the patient and their family / carer through clear, respectful and open communication allows early detection, identification and appropriate management of triggers that may lead to aggressive behavior. Where necessary, input should be sought from staff who have expertise and knowledge in identifying precursors to aggressive behavior during the clinical risk assessment, as part of a multidisciplinary approach to the care of the patient. When a disturbed behavior occurs, do not enter the patient’s / individual’s personal space without their permission (unless there is an immediate risk of self-harm or harm to others) as this could escalate their distress, anger and / or behavioral disturbance.

 

Key points to note:

  1. Engage with the patient, their family / carer and other health professionals (using a team approach) to identify stressors/ triggers for disturbed behavior as part of the initial and ongoing patient care

    2. Undertake appropriate clinical assessment to obtain information on the patient’s condition. For example, cognitive screening tools for older persons, medical assessment of mental health patients and Drug and Alcohol assessment tools

    3. Develop ways to manage stressors / triggers of disturbed behavior and document a management plan for health care teams to follow.



 

WARNING SIGNS OF AGGRESSIVE BEHAVIOR

 

Aggressive behavior and violence is a serious issue for psychiatric and alcohol and other drug treatment facilities.  In most cases it is potentially images-3predictable because of warning signs exhibited by patients. Often times, it is also evident that staff plays a very large part in the escalation or preferably the de-escalation of a crisis situation.  It has been discovered that a relative lack of response by staff members to the violent acts of patients is of concern.   It is very important for staff to be trained to identify warning signs and act accordingly to avoid an intensification of negative behavior.

 

 

Potential Triggers for Violent or Aggressive Behavior:

 

  • Recent relapse
  • Severe stress
  • Violent history
  • Social isolation
  • Significant loss or frustration (e.g. losing parental rights)
  • Receive a warning about their behavior
  • Believe they have been treated unfairly or disrespectfully
  • Failure to receive a privilege they expected or counted on
  • Have a hostile relationship with another client
  • Receive negative news (from courts or DCF)
  • Feel they have nothing to lose (total emersion into the present situation; nothing else matters)

 

Signs include:

 

  • Poor relationship with peers
  • Poor personal hygiene
  • Drastic changes in personality traits
  • Making threats of violence, getting back at someone, etc.
  • Intimidating others (bullying)
  • Getting very angry easily or often; loss of control
  • Using abusive language
  • Believing others are out to get him or her
  • Blaming others for their problems (playing the blame game)
  • Being rigid and inflexible (generally introverted)

 

Staff should avoid:

 

  • Letting threats go (Staff from the old school would often let the situation continue with a statement like they will outgrow this behavior pattern.  History has proven this to be an incorrect approach as most individuals need professional help to change their attitude and behavior.
  • Ignoring aggressive behavior or warnings signs of aggressive behavior
  • Failure to report abnormal client behavior to other staff members
  • Failure to follow established rules and procedures
  • Treating clients differentially (playing favorites)
  • Treating clients disrespectfully
  • Speaking in very loud or aggressive tones of voice
  • Expressing their own frustration to a client inappropriately
  • Ignoring client requests, frustrations or angry feelings
  • Staff awareness of client behaviors and coping styles; this information is key to identifying situations that could lead to aggressive behaviors.

 

 

STRATEGIES FOR THE DIFFUSION OF POTENTIALLY AGGRESSIVE SITUATIONS

 

Anger management and stress reduction techniques are important components of prevention in psychiatric and alcohol and other drug treatment facilities and should be a component of a psycho-education program. How staff treats clients who are angry and/or frustrated has a direct impact on the probability of aggressive or violent behaviors. Helping to keep the unit or group positive and peaceful begins at intake with the assessment and collection of the history regarding aggressive behavior.  This assessment will continue through the admission process, and be part of the psychiatric, nursing and social work assessments throughout treatment. 

 

Intake staff, admission staff, and program staff should systematically communicate with patients and their families, when appropriate, about treatment goals, progress and that patients will be encouraged and expected to make every effort to manage their own behavior.  When patients are a part of the treatment goals and have control over parts of their progress they are less threatened and frustrated by the loss of control of a program with rules and parameters.

The management of aggressive behavior continues after the intake and assessment with diagnosing and treating the underlying psychiatric illness and being aware of the propensity for aggressive behavior in certain situations. The evaluation of a patient should include a review of aggressive behavior, including triggers, warning signs, repetitive behaviors, response to treatment, and prior seclusion and restraint events that are associated with aggressive acts. Cultural factors may influence the triggers and expression of aggression by patients and the response to aggression by staff and these factors should be considered in treatment facilities. Cognitive limitations, neurological deficits and learning disabilities should be noted during the intake evaluations.

The treatment plan should include strategies to prevent aggressive behavior, de-escalate behavior before it escalates, and initiate or refer out to, when necessary, psychological treatments for treating the underlying psychopathology when present.

Patients with a history of aggressive behavior may benefit from anger management, problem-solving and psycho-educational programs.

 

Staff can help to prevent aggression by:images-3

 

  • Attend and support current training programs; maintain skill level consistent with job requirements
  • Learning and applying applicable policies and procedures
  • Being aware of each clients history
  • Following the rules and boundaries established by the program and facility
  • Treating all clients fairly and with respect

 ag-bomb-3

Staff should always treat the patients with respect. Judgmental attitudes, authoritative directives will likely result in anger and shame, feelings that in turn can result in negative behaviors.

 

As mentioned previously, communication is crucial for effective treatment and for the patients compliance, as well.  Staff members should explain who they are, what they are going to do and why it is necessary.  Speak to the patients about their treatment and offer them choices wherever practical.   Staff should frequently check with the patient or client about their level of comfort with the physical surroundings and so forth.  If it is impossible to comply with a patients request, explain why. 

 

Staff must always provide for the safety of all other patients, as well.  As tensions rise, it is important to enlist the help of staff that are familiar with the patient, and have successfully redirected behavior(s) in the past.

 

Before aggression is apparent staff can verbally redirect and assist the patient to a quiet area of the facility that is free from all stimuli, and is away from other patients or residents. Time outs can be utilized for behaviors, which place others in potential danger.  This can be offered as an opportunity for the patient to manage their emotions on their own rather than a directive as if from a parent to a child. 

 

Positive reinforcement for a patient who successfully calms their potential aggression should be offered through comfort measures and words.  Always document the effectiveness of interventions on the part of the staff and the individual.

 

Be Alert to Situations that could lead to aggressive behavior. The earlier staff intervenes, the easier it is to de-escalate a potentially dangerous situation. 

 

Pain and discomfort increase aggression.  Assess for signs of acute pain. If the cause of the behavior is believed to be pain related, perform a pain assessment and notify a physician as warranted for tests, treatments, or alterations to the current plan.

 

Alcohol impairs judgment, making people much less cautious than they usually are. It also disrupts the way information is processed. An intoxicated person is much more likely to view an accidental event as a purposeful one, and therefore act more aggressively. It is likely that similar impairment occurs during drug treatment, especially during the detox phase. This means that people in the early stages of recovery are more likely to misinterpret events and become angry or aggressive.

 

 

Tips to Avoid Aggression:

 

  • Follow established policies and procedures
  • Be alert for signals that a potentially violent persons problems are getting worse
  • Don’t ignore troubling client behavior, statements, or attitudes
  • Be aware of clients personal situations that could trigger an aggressive reaction
  • Have another staff member present when you have to give bad news to a client if you’re concerned about possible violence
  • Model calm and appropriate behavior for clients
  • Be knowledgeable about warning signs for aggressive/violent behavior
  • Treat all clients fairly
  • Be aware of client histories, personalities and coping styles
  • Pay attention during change of shift reports
  • Watch clients behavior and affect
  • Intervene as early as possible to prevent incidents from escalating
  • Use common sense
  • Make sure that movies/TV shows etc are appropriate for the therapeutic environment
  • Speak in soft and calm tones when confronting a client

 

 

 

CRISIS INTERVENTION TECHNIQUES 

 

Sometimes, even if staff members are able to identify warning signs and use appropriate de-escalation techniques violence and/or aggression still occurs.  In this situation it is important to employ crisis intervention techniques.

 

  • Call other staff for assistance
  • Remove other patients from the area by sending them to another area of the facility
  • Scan the area for potential weapons such as chairs or large objects and if possible keep them away from the aggressive person.
  • Verbally attempt to calm the violent person down
  • Avoid becoming physical
  • Maintain a safe distance
  • Call 911 if needed
  • Notify supervisors
  • Use your agencys established policy 

Once a patient has become aggressive it is crucial to maintain composure, act swiftly to manage the situation and protect the patient, the other residents and the staff.

 

Keep in mind that it is important to:

 

  • Return the feeling of control, as much as possible, to the individual acting out.  They have a choice as to how this situation will play out.  Allow them to be a part of the solution when possible.
  • Help the patient determine self-capacities, strengths and resources.

 

When faced with an angry patient:

 

  • Acknowledge an angry patients concerns,
  • Allow the person to express their feelings
  • Use non-confrontational language
  • Maintain eye contact
  • Avoid yelling or speaking loudly
  • Let the patient know you are there to help
  • Focus on acknowledging the feelings of the client
  • Speak slowly and softly (use a calming voice)
  • People read body language to decide how to act if you appear relaxed and in control of yourself the client is much more likely to calm down
  • Move to solving the problem if at all possible
  • Offer alternatives if at all possible

 

Here are a few phrases staff can use:

 

“It seems like you’re upset about . . . is that right?  Let’s see what we can do.”

 

“It has to be frustrating to have to . . .”

 

These utilize active listening skills.  They help you ensure your understanding of the situation, get and give information, build trust and achieve what is necessary for the safety of everyone and possibly help to achieve what the patient wants or needs.

 

 

ACTIVE LISTENING (PARAPHRASING AND ACKNOWLEDGING)

  

The ability to listen is an important therapeutic skill.

It improves inter-personal relationships by:

 

  • reducing conflicts
  • strengthening cooperation
  • fostering understanding
  • calming others (it is comforting to be understood)

 

Active listening is a structured way of listening and responding to others.  It focuses attention on the speaker.  It is important to observe the other person’s behavior and body language.

 

Having heard, the listener may then paraphrase the speakers words. It is important to note that the listener is not necessarily agreeing with the speakersimply stating what was said. 

 

The benefits of active listening include getting people to open up, avoiding misunderstandings, resolving conflict and building trust

 

Always, present the facts without making judgments or getting emotional, state expectations calmly and simply.  If you are directing the patient to change a behavior, be specific and clear as to what you are requesting of them to end the situation.  End with a question to gain agreement.  Allowing the patient to be a part of the solution is always best, but the safety of the unit must be at the forefront of any discussion.

 

STAFF RESPONSIBILITY AFTER THE EVENT

 

Once a crisis situation is over it is important to assess the other patients.  An aggressive incident can lead to problems with other clients such as:

 

  • Aggression/violence
  • Sadness
  • Grief
  • Anxiety

 

Use the agency’s incident report and follow established protocols and procedures.

 

When writing the incident report:

 

  • Be as specific as possible
  • Do not use vague pronouns or emotional language
  • Do use concrete language
  • Write in simple, straightforward sentences
  • Identify the perpetrator and victim/s
  • Explain behavior clearly
  • Identify any known precipitating events

 

Be sure to communicate with the next shift.   Patients who were victims or witnessed the event may be upset or agitated.  Aggression often leads to more aggression; therefore staff on subsequent shifts should be alert.

 

  • Supervisors or managers should process the event (be aware of what happened and follow-up as appropriate)
  • Identification of precipitating events is important
  • Root cause analysis may be done
  • If possible, identify steps to take or changes to make to prevent a similar incident from happening again

 

RESTRAINTS

 

Physical intervention on psychiatric inpatient units remains a highly controversial ethical issue.  Professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients in regard to personal safety and patient rights have changed the mental health and addiction fields.

 

Many facilities do not employ restraints.  However, in an effort to inform we will briefly discuss these.

 

The term restraints include the use of seclusion, physical restraint, mechanical restraint and chemical restraint. 

 

The only indications for the use of seclusion and restraint are to prevent dangerous behavior to self or others and to prevent disorganization or serious disruption of the treatment program.  The use of restraints must be in accordance with the facilities policies and procedures.

 

Seclusion and restraint should not be used as punishment for patients, for the convenience of the program, where prohibited by state guidelines, to compensate for inadequate staffing patterns, or instituted by untrained staff. In facilities that employ these measures, for the safety and well being of the patients, the autonomy and dignity of the patient must be preserved as much as possible.

The decision on when to seclude or restrain a patient must be made by the professionally trained staff working with the patient at the time of the aggressive behavior in consultation with a physician. Seclusion, physical restraint, and chemical restraint should not be ordered on a prn (pro re nata = as the occasion may arise) basis. All patients in seclusion or restraint must be monitored continuously. There are strict requirements for the monitoring of pulse, blood pressure, range of motion, nutrition, hydration and comfort.  With a release in place, the patient’s family should be informed of use of seclusion or restraint.

Physical and mechanical restraints that cause airway obstruction must not be employed, such as choke holds or covering the patient’s face with a towel, bag, etc. With supine (face up) restraints, a patient’s head must be able to rotate freely. With prone (face down) restraints, the patient’s airway must be unobstructed at all times (i.e. not buried), and the patient’s lungs must not be restricted by excessive pressure on the patient’s back.

Physical Restraint

Physical restraint, the most frequently used type, is a specificintervention or device that prevents the patient from moving freely or restricts normal access to the patient’s own body. Physical restraint may involve:

  • applying a wrist, ankle, or waist restraint

  • tucking in a sheet very tightly so the patient can’t move

  • keeping all side rails up to prevent the patient from getting out of bed

  • using an enclosure bed.

Typically, if the patient can easily remove the device, it doesn’t qualify as a physical restraint. Also, holding a patient in a manner that restricts movement (such as when giving an intramuscular injection against the patient’s will) is considered a physical restraint. A physical restraint may be used for either nonviolent, non self-destructive behavior or violent, self-destructive behavior. 

 

Restraints for Nonviolent, Non self-destructive Behavior

Typically, these types of physical restraints are nursing interventions to keep the patient from pulling at tubes, drains, and lines or to prevent the patient from ambulating when it’s unsafe to do so—in other words, to enhance patient care. For example, a restraint used for nonviolent behavior may be appropriate for a patient with an unsteady gait, increasing confusion, agitation, restlessness, and a known history of dementia, who now has a urinary tract infection and keeps pulling out his I.V. line.

 

Restraints for Violent, Self-destructive Behavior

These restraints are devices or interventions for patients who are violent or aggressive, threatening to hit or striking staff, or banging their head on the wall, who need to be stopped from causing further injury to themselves or others. The goal of using such restraints is to keep the patient and staff safe in an emergency situation. For example, a patient responding to hallucinations that commands him or her to hurt staff and lunge aggressively may need a physical restraint to protect everyone involved.

 

Chemical Restraint


Chemical restraint involves use of a drug to restrict a patient’s movement or behavior, where the drug or dosage used isn’t an approved standard of treatment for the patient’s condition. Chemical restraint is to be distinguished from the pharmacological management of a patient’s underlying illness.  For example, a provider may order haloperidol in a high dosage for a post surgical patient who won’t go to sleep. (If the drug is a standard treatment for the patient’s condition, such as an antipsychotic for a patient with psychosis or a benzodiazepine for a patient with alcohol-withdrawal delirium, and the ordered dosage is appropriate, it’s not considered a chemical restraint.) Many healthcare facilities prohibit use of medications for chemical restraint.

 

Seclusion

With seclusion, a patient is held in a room involuntarily and prevented from leaving. Many emergency departments and psychiatric units have a seclusion room. Typically, medical-surgical units don’t have such a room, so this restraint option isn’t available. Seclusion is used only for patients who are behaving violently. Use of a physical restraint together with seclusion for a patient who’s behaving in a violent or self-destructive manner requires continuous nursing monitoring.


Mechanical Restraint

Mechanical restraint refers to the use of a mechanical device to restrict a person’s movement in an emergency situation of aggressive behavior, where the person is at an immediate risk of harm to self or others. Examples of manufactured mechanical restraint devices include (but are not limited to) belts, harnesses, manacles, straps and mittens.

 

The use of seclusion and or restraint should be followed by a debriefing discussion that allows the patient to process and understand what has happened. The staff should review with the patient the events that triggered the seclusion or restraint; discuss with the patient alternate strategies to avoid similar incidents and arrange whenever possible for the patient to make amends or do restitution to those who have been injured.

Every episode of seclusion and restraint must be documented in the patient’s medical record. The Joint Commission requires that patients be allowed written comments about the experience. Staff participating in seclusion or restraint should review the episode in a separate debriefing session and document recommendations and findings for the facility’s committee that reviews seclusion and restraint reports.

Strong clinical leadership is essential in the management of aggressive behavior in order to minimize the need for seclusion and restraint. Facilities must have a committee that provides oversight of the practice of seclusion and restraint. This may include a review of restrictive interventions; restraint equipment; staff training; staff retention; and peer review of the application and use of seclusion, mechanical and chemical restraint, and restraint equipment. A patient and family ombudsman should also be available to review concerns about restrictive interventions if a facility wishes to employ these methods.

PROTECTION OF HUMAN RIGHTS

Human rights include the right to one’s own mind, and to protect oneself and one’s loved ones against any abusive or harmful “treatments” given under the guise of mental health. Every man, woman, and child are entitled to fundamental human rights.  

When dealing with an aggressive patient it is a critical balance to keep.  Safety is so very important but at the same time, the identified patient’s rights should not be violated.  Staff should never ignore a patient, or punish a patient.  The safety of the environment is and the health of those on it, both physical and mental health, should always be considered.

All patients have the following human rights:

  1. The right to full informed consent,  including:
  2. The scientific/medical test confirming any alleged diagnoses of psychiatric disorder and the right to refute any psychiatric diagnoses of mental “illness” that cannot be medically confirmed.
  3. Full disclosure of all documented risks of any proposed drug or mental “treatment.”
  4. The right to be informed of all available medical treatments which do not involve the administration of a psychiatric drug or treatment.
  5. The right to refuse psychiatric drugs documented by international drug regulatory agencies to be harmful and potentially lethal.
  6. The right to refuse to undergo electroshock or psycho-surgery.
  7. No person shall be forced to undergo any psychiatric or psychological treatment against his or her will.
  8. No person, man, woman or child, may be denied his or her personal liberty by reason of mental illness, without a fair jury trial by laymen and with proper legal representation.
  9. No person shall be admitted to or held in a psychiatric institution, hospital, or facility because of their political, religious, or cultural or social beliefs and practices.
  10. Any patient has:
  11. The right to be treated with dignity as a human being;
  12. The right to hospital amenities without distinction as to race, color, sex, language, religion, political opinion, social origin, or status by right of birth or property.
  13. The right to have a thorough, physical and clinical examination by a competent registered general practitioner of one’s choice, to ensure that one’s mental condition is not caused by any undetected and untreated physical illness, injury or defect, and the right to seek a second medical opinion of one’s choice.
  14. The right to fully equipped medical facilities and appropriately trained medical staff in hospitals, so that competent physical, clinical examinations can be performed.
  15. The right to choose the kind or type of therapy to be employed, and the right to discuss this with a general practitioner, healer or minister of one’s choice.
  16. The right to have all the side effects of any offered treatment made clear and understandable to the patient, in written form, and in the patient’s native language.
  17. The right to accept or refuse treatment but in particular, the right to refuse sterilization, electroshock treatment, insulin shock, lobotomy (or any other psychosurgical brain operation), aversion therapy, narcotherapy, deep sleep therapy and any drugs producing unwanted side effects.
  18. The right to make official complaints, without reprisal, to an independent board which is composed of non-psychiatric personnel, lawyers, and laypeople. Complaints may encompass any torturous, cruel, inhuman, or degrading treatment or punishment received while under psychiatric care.
  19. The right to have private counsel with a legal advisor and to take legal action.
  20. The right to discharge oneself at any time and to be discharged without restriction, having committed no offense.
  21. The right to manage one’s own property and affairs with a legal advisor, if necessary, or if deemed incompetent by a court of law, to have a State appointed an executor to manage such until one is adjudicated competent. Such executor is accountable to the patient’s next of kin, or legal advisor or guardian.
  22. The right to see and possess one’s hospital records and to take legal action with regard to any false information contained therein which may be damaging to one’s reputation.
  23. The right to take criminal action, with the full assistance of law enforcement agents, against any psychiatrist, psychologist, or hospital staff for any abuse, false imprisonment, assault from treatment, sexual abuse or rape, or any violation of mental health or other law. And the right to a mental health law that does not indemnify or modify the penalties for criminal, abusive, or negligent treatment of patients committed by any psychiatrist, psychologist, or hospital staff.
  24. The right to sue psychiatrists, their associations and colleges, the institution, or staff for unlawful detention, false reports, or damaging treatment.
  25. The right to work or to refuse to work, and the right to receive just compensation on a pay-scale comparable to union or state/national wages for similar work, for any work performed while hospitalized.
  26. The right to education or training so as to enable one better to earn a living when discharged, the right of choice over what kind of education or training is received.
  27. The right to receive visitors and a minister of one’s own faith.
  28. The right to make and receive telephone calls and the right to privacy with regard to all personal correspondence to and from anyone.
  29. The right to freely associate or not with any group or person in a psychiatric institution, hospital, or facility.
  30. The right to a safe environment without having in the environment, persons placed there for criminal reasons.
  31. The right to be with others of one’s own age group.
  32. The right to wear personal clothing, to have personal effects, and to have a secure place in which to keep them.
  33. The right to daily physical exercise in the open.
  34. The right to a proper diet and nutrition and three meals a day.
  35. The right to hygienic conditions and non-overcrowded facilities, and to sufficient, undisturbed leisure and rest.

 

 

SUMMARYimages-2

 

Aggression is broadly defined.  It can be physical, mental, or verbal.  Aggression and violence are frequently preventable by being watchful of warning signs and knowledgeable regarding individuals’ triggers for aggressive behavior.

 

Active listening and cognitive restructuring can be used to de-escalate an angry or potentially aggressive patient.

If an incident does occur, employ crisis intervention techniques, notify supervisors immediately, and complete an incident report. 

 

Repeated training in the management of aggressive behavior is necessary to develop a high degree of competence this work requires. Good training promotes the retention of qualified staff, the safety of patients and staff, and better treatment outcomes.

 

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