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 agency’s 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 speaker simply 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 specific intervention 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 alternate strategies to avoid similar incidents, and arrange for the patient to make amends or restitution to those injured whenever possible.

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 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.