Transcript LWW PPT Slide Template Master

Chapter 11
Anger, Hostility, and Aggression
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anger
• Normal human emotion
• Handled appropriately, a positive force for resolving
conflicts, solving problems, making decisions
– Body physically energized for self-defense (“fight-orflight” response)
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Anger (cont.)
• Expression inappropriate or suppressed: negative force
– Physical or emotional problems; interference with
relationships
– Possible hostility, aggression
• Catharsis: alleviate or increase feeling of anger
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Hostility and Aggression
• Hostility = verbal aggression, usually when feeling
threatened or powerless
• Physical aggression: attack on or injury to another person;
destruction of property
– Both to harm or punish another person or force into
compliance
• Sudden, unexpected
• Identifiable stages or phases
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Related Disorders and Anger, Hostility, or
Aggression
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Paranoid delusions
Auditory hallucinations
Dementia, delirium, head injuries
Intoxication with alcohol or other drugs
Antisocial, borderline personality disorders
Depression
Intermittent explosive disorder
Acting-out behaviors
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Etiology of Hostility and Aggression
• Neurobiologic theories
– Possible role of neurotransmitters: decreased
serotonin; increased dopamine, norepinephrine
– Structural damage to limbic system; damage to
frontal or temporal lobes
• Psychosocial theories
– Failure to develop impulse control
– Inability to delay gratification
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cultural Considerations
• In certain cultures, expressing anger seen as rude or
disrespectful
• Some culture-bound syndromes involving aggressive,
agitated, or violent behavior
– Hwa-Byung
– Bouffee delirante
– Amok
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Question
• Is the following statement true or false?
• Hostility and aggression are terms that can be used
interchangeably.
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Answer
• False
• Rationale: Hostility and aggression are two different
terms.
– Hostility means verbal aggression. Physical
aggression involves attack on or injury to another
person or destruction of property.
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Treatments
• Underlying/comorbid psychiatric diagnosis
– Lithium: bipolar and conduct disorders; mental
retardation
– Carbamazepine or valproate: dementia, psychosis,
personality disorders
– Atypical antipsychotics: clozapine, risperidone, and
olanzapine: dementia, brain injury, mental
retardation, personality disorders
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Treatments (cont.)
• Underlying/comorbid psychiatric diagnosis (cont.)
– Benzodiazepines: irritability and agitation in older
adults with dementia
– Haloperidol and lorazepam: decrease agitation or
aggression and psychotic symptoms
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The Nursing Process: Assessment
• Factors influencing aggression in psychiatric
environment/unit milieu
• Individual patients (history of violent or aggressive
behavior in past and how patient handles anger)
• Patient’s behavior to determine phase of aggression cycle
(see Table 11.1)
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Nursing Process: Data Analysis and
Outcome Identification
• Data analysis
– Risk for other-directed violence
– Ineffective coping
• Outcome identification: patient will
– Not harm self or threaten others
– Refrain from intimidating/frightening behaviors
– Describe feelings, concerns without aggression
– Comply with treatment
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The Nursing Process: Interventions
• Most effective, least restrictive when implemented early
in cycle of aggression
• Environmental management
– Planned activities; informal discussions
– Scheduled one-to-one interactions (letting patients
know what to expect)
– Assistance with problem solving or conflict resolution
to avoid expression of anger
– Safety of other patients
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The Nursing Process: Interventions
(cont.)
• Aggression management: triggering phase
– Approach in nonthreatening, calm manner
– Convey empathy; listening
– Encourage verbal expression of feelings
– Suggest patient go to a quieter area
– Use PRN medications
– Suggest physical activity such as walking
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Is the following statement true or false?
• A patient with a history of violent or aggressive behavior
is more likely to exhibit similar behavior in the future.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• True
• Rationale: A history of violent or aggressive behavior is
one of the best predictors of future aggression.
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The Nursing Process: Interventions
(cont.)
• Aggression management: escalation phase
– Take control; provide directions in firm, calm voice
– Direct patient to room or quiet area for time-out
– Offer medication again
– Let patient know aggression is unacceptable; nurse
or staff will help maintain/regain control
– If ineffective, obtain help from other staff (show of
force)
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The Nursing Process: Interventions
(cont.)
• Aggression management: crisis phase
– Inform patient that behavior is out of control, and
staff is taking control to provide safety and prevent
injury
– Use of restraint or seclusion only if necessary
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The Nursing Process: Interventions
(cont.)
• Aggression management: recovery phase
– Talk about situation or trigger
– Help patient relax or sleep
– Explore alternatives to aggressive behavior
– Provide documentation of any injuries
– Debrief staff
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The Nursing Process: Interventions
(cont.)
• Aggression management: postcrisis phase
– Remove patient from any restraint or seclusion to
rejoin milieu.
– Calmly discuss behavior (no lecturing or chastising);
allow patient to return to activities, groups, and so
forth.
– Focus on appropriate expression of feelings,
resolution of problems or conflicts in nonaggressive
manner.
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The Nursing Process: Evaluation
• Was patient’s anger defused in an early stage?
• Did angry, hostile, and potentially aggressive patient
learn to express feelings verbally and safely without
threats or harm to others or destruction of property?
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Question
• During which phase does staff debriefing occur?
– A. Escalation phase
– B. Crisis phase
– C. Recovery phase
– D. Postcrisis phase
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Answer
•
•
C. Recovery phase
Rationale: Staff debriefing occurs during the recovery
phase to allow for discussion of the event, how it was
handled, what worked well or needed improvement, and
how the situation could have been defused more
effectively.
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Workplace Hostility
• Sentinel event alert of intimidating, disruptive behaviors
by Joint Commission in 2009
• Overt actions: verbal outbursts, physical threats
• Passive activities: refusing to perform assigned tasks,
uncooperative attitude
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Workplace Hostility (cont.)
• New standards of leadership
– Code of conduct defining acceptable and disruptive,
inappropriate behaviors
– Creation, implementation of process for managing
these behaviors
– Education regarding expected professional behavior
– Zero tolerance = all are accountable
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Community-Based Care
• Effective management of comorbid conditions
– Regular follow-up appointments
– Compliance with prescribed medication
– Participation in community support programs
• Anger management groups to help patients express
feelings, learn problem-solving and conflict-resolution
techniques
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Self-Awareness Issues
• Methods for handling own angry feelings
• Use of assertive communication skills, conflict resolution
• Comfort with expression of anger from others
– Not taking other’s anger or aggression personally or
as measure of effectiveness as nurse
• Ability to be calm, nonjudgmental
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