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CE: Professional Issues
For patients who have an altered mental
status and cannot control their aggressive
behavior, proper management and treatment
are needed. The initial management
of patients who are agitated but cooperative
is to utilize verbal de-escalation techniques.
This should be attempted prior to the use of
physical restraints or sedative medications.
The interaction and patient’s response to the
techniques will provide information and
assessment of the patient’s mental status.
When therapeutically communicating
with the patient in this way, the provider
should use a calm tone of voice, avoid direct
eye contact, stand at least two arm’s length
apart, and not make any sudden movements.
6 The clinician should be honest,
nonthreatening, and straightforward. Some
suggest that offering food or drink as a
friendly gesture appeals to basic human
needs and builds trust, which in turn will
enable the patient to decompress.
It is important to be an active listener
when interacting with a violent or verbally
aggressive patient. Identify and confirm
the patient’s feelings and offer choices and
optimism as an alternative to altercation.
Avoiding arguing or commanding is crucial
during conversation.
A key mistake that clinicians make while
interviewing patients is that they fail to
address violence directly. A relevant question
to ask is “Do you feel like harming
yourself or anyone else?” 6 If the patient
becomes more agitated, it is important to
speak in a conciliatory manner and offer
supportive statements to defuse the situation.
An alternative is to offer medication
or restraints to prevent further escalation,
however this is a controversial approach.
Restraints should be applied when patients
become combative and verbal techniques are
unsuccessful. Effective use of restraints can
aid in prevention of injury to both the patient
and the healthcare professional.
Visitor and Family Member Violence
Family members who are angry about the
patient’s condition account for about 55% of
all abuse cases. 8 The most common reasons
for assault by family members and visitors
are anger related to hospital policies, the
patient’s condition or situation, long wait
times, or the healthcare system in general.
When family members perceive that the
healthcare staff is not meeting the needs of
the patient, increased violence occurs; this
can be associated with the stages of grief.
During the anger stage of grief, the person
often formulates a “lashing out” at a third
party. 8 Within the healthcare setting, this
person is often the nurse caring for the
patient.
The family member is often formulating
someone to blame for their loved one’s
suffering and hardship related to caregiver
guilt. The family member in this situation
often experiences feelings of fear, guilt,
anxiety and frustration. 8
Nursing Staff Education
Organizational risk factors include lack
of facility policies and staff training for
recognizing and managing escalating hostile
and assaultive behaviors by patients,
visitors or staff. Other indications for risk
include high worker turnover, working when
understaffed, and inadequate security and
mental health personnel on site. 8
Long waits for patients and families in
overcrowded and uncomfortable waiting
rooms have been associated with increased
violence. Most importantly, institutions that
form a perception that violence is tolerated
can increase risk.
Facilities can reduce workplace violence
by using effective strategies, such as management
commitment and worker participation,
worksite analysis and hazard
identification, safety and health training,
recordkeeping and program evaluation.
The most important reminder is to take
every threat seriously.
Violence prevention programs reduce the
risk of assault by training workers to recognize
cues such as drug use and threatening
body language. These programs educate
clinicians about strategies to defuse situations.
Accurate incident reporting is crucial
and a part of intervention because it helps
hospital personnel identify specific hazards
and take proper steps to remediate them.
Reporting Violence
Assault by patients or family members is
highly underreported. Data show that only
85% of incidents are reported only verbally
to hospital administration; no formal written
documentation occurs.
Nurses often assume that reporting violence
may affect hospital satisfaction survey
scores. Other data suggest that nurses and
No specific diagnosis or type of patient is predictive for
violence, however, epidemiological studies consistently
demonstrate that the highest level of risk exists in inpatient
and acute psychiatric services, geriatric long-term care
settings, high-volume emergency departments, residential
and social services.
other medical providers are fearful that
the hospital administration will retaliate
against reporters of violence by patients
or family members.
It is important for all nurses to be familiar
with their hospital’s reporting policy,
which should include verbal abuse as well
as physical assault.
One survey found that nurses avoid
reporting violence because they believe
that their supervisors will suspect they
somehow provoked the incident and label
them as confrontational employees.
As much as 70% of abuse toward nurses
is not reported, and most nurses who are
injured do not seek any medical treatment
for their injuries—which reflects the prevailing
attitude that being abused by patients
and visitors goes with the territory. 7
Consequences of Workplace Violence
Occupational violence is associated with
reduced productivity, increased staff turnover,
absence, counselling costs, decreased
staff morale, and a reduced quality of life.
Abuse can also decrease the quality of
patient care.
www.advanceweb.com/Nurses n MAY 2016 n ADVANCE FOR NURSES 39