AND THE REDUCTION OF PATIENT AGGRESSION AUTHENTIC
ENGAGEMENT
Slide 3
OBJECTIVES Upon completion of this in-service, participants
will be able to : Examine consequences of being exposed to client
aggression Describe research addressing aggression Identify
authentic engagement components to improve inpatient psychiatric
nursing practice and prevent escalation in client aggression
Demonstrate the implementation of authentic engagement during a
role play session
Slide 4
INTRODUCTION
Slide 5
AUTHENTIC ENGAGEMENT: A CORE CONCEPT IN REDUCING SECLUSION AND
RESTRAINT Reducing seclusion rates is challenging and typically
requires the implementation of multiple interventions (Gaskin,
Elsom, & Happell, 2007). Finfgeld-Connets Nursing Theory of
Authentic Engagement provides tools to help prevent client
aggressive behavior.
Slide 6
LEVELS OF AGGRESSIVE BEHAVIOR Agitation - nervous excitement,
excessive motor or verbal activity, irritability and
uncooperativeness (Zeller & Rhoades 2010) Aggression - a
readiness to attack or confront Assault Simple assault- has ability
and shows intent to injure, however threat would not require
medical attention Assault and battery- has the ability and shows
intent to injure, and makes physical contact Aggravated assault- Is
separated from simple assault because there is an intent to
seriously injury. This injury would require immediate medical
attention.
Slide 7
ASSESSMENT OF AGITATION Experienced psychiatrist and
psychiatric nurses have been shown to be able to accurately predict
violent behavior. One study found that psychiatrist and psychiatric
nurses correctly predicted violent behavior in 82% and 84%
respectively, of newly admitted psychiatric patients (Zeller
&Rhoades, 2010 p.420)
Slide 8
FACTORS CONTRIBUTING TO PATIENT AGGRESSION Internal These
include individual patient variables such as age, gender and
serious mental illness diagnosis Suggested that young males are
most prone to violence External Limited space or privacy,
overcrowding, hospital shifts and raised temperatures Staff
experience, gender and training also have an impact on patient
escalation Handover periods and meal times are problematic
Situational A combination of internal and external factors.
(Duxbury, 2002)
Slide 9
CONSEQUENCES OF BEING EXPOSED TO INPATIENT UNIT AGGRESSION
Staff Mental health second most violently victimized group
(Finfgeld-Connett, 2009) 61% of nurses working in psychiatric
settings had been physically assaulted in their career (Zuzelo,
Curran & Zeserman, 2012). Interdependent relationship with
staff burnout Physical injuries Emotional damage
Slide 10
CONSEQUENCES OF BEING EXPOSED TO INPATIENT UNIT AGGRESSION
Patients Can result in seclusion or restraint Psychological
injuries resulting from activation of traumatic memories of
pervious incidence of abuse and violence (Bonner et al. 2002)
Physical injuries Patient aggression may delay discharge or make
placement more difficult
Slide 11
WHY IT IS SO IMPORTANT TO REDUCE AGGRESSION Foster et al.
(2007) write, daily exposure to swearing, threats and verbal abuse
can cause lasting emotional damage to nursing staff (Foster et al.,
2007 p. 146). This emphasizes the need for interventions that take
place during the agitation phase of an incident rather than waiting
for the verbal or physical aggression.
Slide 12
LITERATURE REVIEW OF RESEARCH EVIDENCE
Slide 13
THERAPEUTIC INTERVENTIONS FOR AGGRESSION Staff and patients had
different beliefs about the causes of aggression Patients-poor
communication the number one precursor to aggression Staff- patient
illness the number one cause (Duxbury &Wittington, 2002)
Slide 14
THERAPEUTIC INTERVENTIONS FOR AGGRESSION (CONTINUED) Effective
de escalators are open, honest, supportive, self-aware, coherent,
non-judgmental and confident without appearing arrogant (Price
& Baker, 2012 p.312). Successful management of aggression
involves creativity and flexibility. Tailored to specific patient
needs (Price & Baker, 2012). Embodied moment (Carlsson,
Dahlberg & Drew, 2000).
Slide 15
THERAPEUTIC INTERVENTIONS FOR AGGRESSION (CONTINUED) Early
intervention is key in success. Acting proportionately to the risk
the patient is presenting (Bowers, McCullough &Timmons, 2003).
Soft, calm and gentle tone of voice and appearing calm (Ryan &
Bowers, 2006) Balance support and control (Delaney and Johnson,
2006) Stressed the importance of offering face saving alternative
to violence (Gertz, 1980)
Slide 16
EFFECTIVENESS OF TRAINING PROGRAMS There is a lack of research
that identifies evidenced- based components of aggression
management programs (AMP). One review suggested that there is lack
of consistency between the content covered between AMPs and that
there is a lack of evidence surrounding the ability of these
programs to change staff behavior (Farrell & Cubit, 2005).
Slide 17
A COMPARISON OF MOAB AND PRO- ACT MoabPro act Emphasizes
planning and teamworkYes Teaches preventionyes Includes
de-escalation techniquesyes Addresses triggers and alternativesyes
Employees critical thinking and problem-solving techniques yes
Keeps patient at the center of care, attempts to meet the
underlying patient need yes Focuses on problem behavioryes
Emphasizes patient rightsyes Teaches self-awarenessyes Includes
documentation componentyes Teaches techniques to defend and
subdueyes (Osborn, 2013)
Slide 18
AUTHENTIC ENGAGEMENT: METHODOLOGICAL CONSIDERATIONS
Meta-synthesis of 15 qualitative research articles for nursing
management of aggression Data included direct quotes, coding
schemes and discussion Authentic engagement was the core category
around which the data was organized. From this work, the author
proposed a model of therapeutic responses to patient agitation.
(Finfgeld-Connet, 2009)
Slide 19
Slide 20
MODEL OF THERAPEUTIC AND NON THERAPEUTIC RESPONSES TO PATIENT
AGGRESSION (Finfgeld-Connet, 2009)
Slide 21
MODEL FOR THERAPEUTIC RESPONSES
Slide 22
ESCALATING OF PATIENT NEEDS Finfgeld-Connett asserts that
aggressive episodes are preceded by an escalating series of stages
where patient needs go unmet. Aggression was defined as any verbal
or non verbal behavior that is threatening or actually results in
harm to nursing personnel (Finfgeld-Connet, 2009 p. 530) As
agitation increases the patients cognition decreases. This
highlights the importance of acting early.
Slide 23
RESPONSES STYLES Therapeutic Intuitive Patient's needs are
immediately understood Adaptable interventions match these needs
Emergent Acting in a carefully measured way Rely on education and
training Non-Therapeutic Inflexible The use of rigid rules and
physical methods to control patient behavior. Excessively task
oriented Disengaged Nurse managers are authoritarian, but distant
Administrative abandonment (Finfgeld-Connet, 2009)
Slide 24
AUTHENTIC ENGAGEMENT Finfgeld-Connet found that authentic
engagement was a core component of both the intuitive and emergent
therapeutic response styles. Becoming and staying genuinely
connected to the patient Keep communication lines open, while being
steady and dependable This person to person bond helps patients to
regain control. (Finfgeld-Connet, 2009)
Slide 25
SITUATIONAL CONTEXT Aggression is a way to express feelings Can
serve as a catalyst to get things done, if the underlying need can
be identified Therapeutic interventions may fall outside the
standardized rules and guidelines. Appreciation for the patient
strange world Awareness of general environment milieu, such as
noise levels and other patients on the floor (Finfgeld-Connet,
2009) Click here for more information
Slide 26
RECIPROCITY Approach a situation with recognition and
reciprocity rather than a sense of self-importance or superiority.
Help patients maintain a sense of dignity by bargaining and
negotiation. Show respect and fair mindedness. Letting patient know
what you are doing ahead of time. (Finfgeld-Connet, 2009)
Slide 27
LIMIT SETTING The importance of a well organized and
predictable milieu. Group schedule, rounds, favors Clearly
communicate that inner control is expected from the patient. If the
patient is unable to do this then external control will be
necessary. Matching the response to the level of dangerousness.
(Finfgeld-Connet, 2009)
Slide 28
TEAM WORK Effective multiple disciplinary teams plan ahead and
talk openly about how to manage patients who have an increased
potential for violence. The team approach is also important for
direct care staff. Staff debriefings (Finfgeld-Connet, 2009)
Slide 29
NON THERAPEUTIC RESPONSE Nurses feel demoralized and
traumatized, which may become a self-perpetuating cycle Patients
feel mistreated and ignored. Erodes patient trust that the hospital
is a place where they can get help in a time of crisis (Duxbury,
2002) Poor management of aggression and the Impact on the unit
Burnout Absenteeism Reassignment Resignation.
Slide 30
IMPLEMENTATION COMPONENTS OF AUTHENTIC ENGAGEMENT Situational
context Providing a low stimulation room Providing pre packaged
food to a paranoid patient Reciprocity Negotiating with patients
who may want a restricted item, instead of saying no try to look
for a way to balancing safety and patient preference Limit setting
Clearly communicate that inner control is expected in the patient
handbook There are times when negotiation is not appropriate
Teamwork Charge nurses attending 1700 Resident report Finding the
balance between reciprocity and limit setting is a team
effort.
Slide 31
AUTHENTIC ENGAGEMENT IN PRACTICE Aligning with the patient who
wanted to be discharged. Negotiating with a patient refusing to
have a photo taken
Slide 32
Slide 33
POTENTIAL BARRIERS The belief that seclusion is the only way to
keep the unit safe. Disempowerment of nursing staff. Difficult to
describe the balance between limit setting and reciprocity in
words. Stressors in a nurses personal life Incomprehensible
underlying patient needs.
Slide 34
CONCLUSION Authentic Engagement is one interventional model
that can help nursing staff to intervene before a patient become
aggressive. There are many causes of aggression that are outside of
our control. For example, the long wait times for court order
medication. However, authentic engagement techniques provides a
pathway to more effective care and a safer work environment.
Slide 35
REFERENCES Bonner, G., Lowe, T., Rawcliffe, D., & Wellman,
N. (2002). Trauma for all: a pilot study of the subjective
experience of physical restraint for mental health inpatients and
staff in the UK. Journal of Psychiatric and Mental Health Nursing,
9(4), 465473. Bowers, L., Nijman, H., Simpson, A., & Jones, J.
(2010). The relationship between leadership, teamworking,
structure, burnout and attitude to patients on acute psychiatric
wards. Social Psychiatry and Psychiatric Epidemiology, 46(2),
143148. doi:10.1007/s00127-010-0180-8 Carlsson, G., Dahlberg, K.,
& Drew, N. (2000). Encountering violence and aggression in
mental health nursing: A phenomenological study of tacit caring
knowledge. Issues in Mental Health Nursing, 21(5), 533545. Delaney,
K. R. (2009). Reducing Reactive Aggression by Lowering Coping
Demands and Boosting Regulation: Five Key Staff Behaviors. Journal
of Child and Adolescent Psychiatric Nursing, 22(4), 211219.
doi:10.1111/j.1744-6171.2009.00201.x Duxbury, J. (2002). An
evaluation of staff and patient views of and strategies employed to
manage inpatient aggression and violence on one mental health unit:
a pluralistic design. Journal of Psychiatric and Mental Health
Nursing, 9(3), 325 337. Duxbury, J., & Whittington, R. (2005).
Causes and management of patient aggression and violence: staff and
patient perspectives. Journal of Advanced Nursing, 50(5),
469478.
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REFERENCES Farrell, G., & Cubit, K. (2005). Nurses under
threat: a comparison of content of 28 aggression management
programs. International journal of mental health nursing, 14(1),
4453. Finfgeld-Connett, D. (2009). Model of Therapeutic and
Non-Therapeutic Responses to Patient Aggression. Issues in Mental
Health Nursing, 30(9), 530537. doi:10.1080/01612840902722120
Gaskin, C. J., Elsom, S. J., & Happell, B. (2007).
Interventions for reducing the use of seclusion in psychiatric
facilities: Review of the literature. The British Journal of
Psychiatry, 191(4), 298303. doi:10.1192/bjp.bp.106.034538 Gertz, B.
(1980). Training for prevention of assaultive behavior in a
psychiatric hospital. Hospital and Community Psychiatry, 31,
628-630 May, B. (2010). Orlandos nursing process theory in nursing
practice. In M. R. Alligood & A. M. Torney (Eds.), Nursing
theory: utlization & application (4th ed., pp. 337357).
Maryland Heights, MI: Mosby Elsevier. Orlando, I. J. (1990). The
dynamic nurse-patient relationship. New York, New York: National
League for Nursing. Price, O., & Baker, J. (2012). Key
components of de-escalation techniques: A thematic synthesis.
International Journal of Mental Health Nursing, 21(4), 310319.
doi:10.1111/j.1447-0349.2011.00793.x
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REFERENCES SAMHSA Seclusion and Restraint - Statement of the
Problem and SAMHSAs Response. (n.d.). Retrieved September 8, 2012,
from http://www.samhsa.gov/seclusion/sr_handout.aspx Scanlan, J. N.
(2009). Interventions To Reduce the Use of Seclusion and Restraint
in Inpatient Psychiatric Settings: What We Know So Far a Review of
the Literature. International Journal of Social Psychiatry, 56(4),
412423. doi:10.1177/0020764009106630 Sullivan, A. M., Bezmen, J.,
Barron, C. T., Rivera, J., Curley-Casey, L., & Marino, D.
(2005). Reducing Restraints: Alternatives to Restraints on an
Inpatient Psychiatric Service/Utilizing Safe and Effective Methods
to Evaluate and Treat the Violent Patient. Psychiatric Quarterly,
76(1), 5165. doi:10.1007/s11089-005-5581-3 Zeller, S. L., &
Rhoades, R. W. (2010). Systematic reviews of assessment measures
and pharmacologic treatments for agitation. Clinical Therapeutics,
32(3), 403425. doi:10.1016/j.clinthera.2010.03.006 Zuzelo, P. R.,
Curran, S. S., & Zeserman, M. A. (2012). Registered Nurses and
Behavior Health Associates Responses to Violent Inpatient
Interactions on Behavioral Health Units. Journal of the American
Psychiatric Nurses Association, 18(2), 112-126.
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presentation
Slide 40
ROLE PLAY PRACTICE SESSION: 30 MINUTES A patient demanding
discharge A patient refusing a search after coming back from a pass
Denial of a request for pain medication A patient who is
disorganized and psychotic An intrusive patient Role Play
Instructions