Skill List > Anger Diffusion (Mental Health)
Clinical Alert
Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation. Assault and violence in mental healthcare work has become a common occurrence creating a major safety concern, with violence occurring across the range of healthcare settings. It is estimated that a nurse has a 1 in 10 chance of being injured as a result of an act of aggression by a patient. Reasons for such anger and violence are wide and ranging but centred within this the nurse has a duty of care for patients and must act to use the least restrictive and least punitive response possible. Use of restraint and seclusion need to be avoided if at all possible and alternative strategies need to be explored before such use. In the Republic of Ireland, Nurses must abide by the Mental Health Commission Rules on restraint and seclusion which flow from the Irish Mental Health Act (2001).
Authors:
Based on Mosby Nursing Skills
Adapted by: Neil Murphy BSc(Hons) MSc RMN; Naomi Sharples BSc MBA PGCE ProfDoc RMNH RMN; November 2014: Tommy Healy RPN RGN RNT MA BA GradCertEd CertCBT
Updated by: Catherine Johnson RGN RMN
Last updated: July 2017
Learning Objective
After reading the skill overview, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of anger diffusion with patients with mental health issues.

Introduction

Patients present to Mental Health Services from a range of diverse populations with a variety of physical, social, and mental health problems. Each is unique and in need of individualised care that respects their situation and presentation. Some patients become angry, probably not as a cause of any one identifiable incident, but created by a mixture of misinterpretation, culture and emotional ill health. Many of the aggressive or violent incidents witnessed are linked to poor emotional control and this in itself hints at the way to manage such incidents. Diffusion of anger that can lead to a potential increased risk of aggressive or violent incidents is a skill that mental health and all other healthcare staff need to develop.

Cultural considerations


  • Be aware that differences in patients’ values and beliefs may affect their responses and nurses should respond accordingly.
  • Differences in language may interfere with the nurse’s or patient’s understanding and the nurse should seek ways to increase understanding immediately.
  • Assess within the patient’s culture for what are considered normal behavioural changes or responses to illness and care. Cultural awareness is vital to avoid unconscious bias on the part of the nurse, which remains a contributory factor in minorities receiving lower quality healthcare (Lonneman 2015). 
  • The nurse should maintain awareness of their own verbal and non-verbal interactions with the patient.
  • The nurse should be aware of the patient’s nonverbal cues, including eye contact and facial expressions.
  • Males aged 14–24 years are thought to be at a higher risk of engaging in aggressive or violent behaviours.

Young people and anger diffusion


  • Children and adolescents who observe or experience aggression or violence in the home or local community may subsequently learn to use aggression or violence as a means of resolving problems. Identify any history of experienced abuse or trauma and any related trigger factors (NICE 2015).
  • Adolescents should be not lectured to and must have their concerns acknowledged.
  • Establishing a relationship that is caring and collaborative is vital.
  • Involving the family in the adolescent’s treatment is imperative.

Older people and anger diffusion

  • Show respect and use language that the person is familiar with and may understand (take care not to use jargon or street language). If you identify a problem with understanding, aim for clarification as soon as possible.
  • The use of some medications can lead to the possibility of anger, aggression or violence. This could be a result of the sedating effect of certain drugs leading the patient to misinterpret other individuals’ intentions or feelings of a loss of control and ability to protect oneself from perceived threats.
  • People with dementia can experience changes to their premorbid personality, and an increase in aggression or violence has been noted in some centres for the care of people with dementia. Nurses working within older adult services are more likely to be exposed to aggression or violence than those in working-age services, with 64% having experienced physical assault (Khwaja & Beer 2013).
  • Any patient with a heightened level of confusion can have an increased risk of aggression or violence. Many mental health problems in the population involve a level of confusion and the older person is no different. Aggression and violence on older adults' mental health wards may relate to active symptoms or to underlying issues, including unmet needs (Brown et al. 2015).
  • Reality orientation can decrease agitation and provide comfort for some agitated patients with cognitive deficits.

Special considerations

Medication is commonly used when psychological and de-escalation measures have not had a beneficial effect. The use of medication has some inherent problems with the older person:

  • The anti-anxiety drug lorazepam (a benzodiazepine drug) should be used with caution in patients with a history of hepatic dysfunction.
  • Neuroleptic drugs carry a risk of neuroleptic malignant syndrome.
  • Chlorpromazine and risperidone can cause hypotension.
  • The use of any sedating drug will have the potential (even if given in a subtherapeutic dose) to cloud consciousness further, and in agitated individuals may increase the chance of misinterpretation and aggression or violence.

Patient and family education

  • Ask about the family’s present coping strategy for the behaviour.
  • Explore escalating factors and identify protective factors as well.
  • Explore what the family think is causing the anger and if they believe it is illness related.
  • Educate the patient and family in respect to illness and the impact and side-effects of medication.
  • Identify potential triggers that may arise in the near future.
  • Explore what coping strategy presently used is felt to have the most benefit.
  • Try to get the patient and family to develop a list of further coping strategies that could be employed.
  • Advise against hypothetical contradiction.
  • Identify early signs of anger.
  • Explore the use of strategies such as distraction and reduction in stimuli and avoid stimulants.
  • Explore what the patient wants to happen when they become angry.
  • Avoid confrontation and stand-offs.
  • Identify de-escalation techniques.
  • Teach the patient to take a ‘time out’ as needed.

Preparation and safety

Most risk assessment tools try to establish both clinical and factors associated with the patient’s presentation. They collate demographic details to establish a baseline from which the nurses and the multidisciplinary team can gauge changes in the thinking and behaviour of the patient. They tend to address:

  • History of aggression or violence towards self or others.
  • Presenting plan of aggression or violence and factors driving the decision.
  • Imminency to carry out the plan of aggression or violence.
  • Level and presence of impulsivity, hyperactivity, irritability, hallucinations, substance misuse, or delusions.
  • Modulating factors and in particular protective factors.
  • Establishing the use of and adherence to medication.
  • Identifying the patient’s support system.
  • Assessing the patient’s coping skills (past and present associated with anger control).
  • Identifying if the patient has or intends to use a weapon (history of this is also important).
  • Establishing the patient’s mood state and potential for increased risk of suicide.

 

Box 1   SOME PREDICTIVE FACTORS OF VIOLENT OUTCOMES.

Adapted from Varcarolis E 2016 Essentials of Psychiatric Mental Health Nursing. 3rd edn. A Communication Approach to Evidence-Based Care. Elsevier, St Louis

1.Signs & Symptoms that sometimes but not always precede violence:

a   Angry irritable effect
b   Hyperactivity…most important predictor of imminent violence (e.g. pacing,
      restlessness, slamming doors)
c   Increasing anxiety & tension: clenched jaw or fist, rigid posture, fixed or tense
     facial expression, mumbling to self (patient may have shortness of breath,
      sweating & rapid pulse rate)
d    Verbal abuse, profanity, argumentativeness
e    Loud voice, change of pitch, or very soft voice forcing others to strain to hear 
f    Intense eye contact or avoidance of eye contact

2.  Recent acts of violence including property violence

3.  Stoney silence

4.  Suspiciousness or paranoid thinking

5.  Alcohol or drug intoxication

6.  Possession of a weapon or object that may be used as a weapon (e.g. fork, knife, rock)

7.  Milieu characteristics conducive to violence:

a.  Loud
b. Overcrowding
c. Staff inexperience
d. Provocative or controlling staff
e. Poor limit setting
f. Staff inconsistency (e.g. arbitrary revocation of privileges)

Procedure

  1. Monitor the patient’s safety to self and others.
    Rationale Early identification of safety issues can lead to the introduction of a plan of action that may avert any agression or violence. This reduces the incidence and risk for violence and promotes safety of the patient and others (Varcolis & Halter 2010). Monitor the patient for changes in behaviour such as isolation, hyperactivity, restlessness, or pacing.
    RationaleThese are behaviours that precede aggression or violence and are important predictors of imminent risk (Varcolis & Halter 2010).
  2. Monitor the patient for any early warning signs that their behaviour is moving away from their baseline, a potential antecedent to aggressive or violent behaviour.
    Rationale Early warning signs of agitated  behaviours are often seen in isolation and as such are acceptable as merely idiosyncratic type behaviour. The history of causal factors identified through assessment may, however, indicate them as markers for a series of behaviours that may lead to identifiable actions such as isolation, hyperactivity, or restlessness and consequently aggression or violence. Early identification and action can reduce the development of an aggressive or violent response.
  3. Monitor the unit for changes in the atmosphere.
    Rationale Commonly patients will react to an environment that has become charged by incidents and outbursts of behaviour. Behaviours can commonly escalate and spikes in aggression or violence often occur when notable incidents are not managed or are poorly controlled.
  4. When talking with a patient who has become angry, use a calm, clear tone of voice and ensure that the content of address is unambiguous.
    Rationale – Helps to prevent further escalation in behaviour. The use of unambiguous content reduces the risk of misconceptions.
    The patient’s ability to process information can become compromised during episodes of agitation. Clear messages are easier to process.
  5. Give the patient the opportunity to choose from a couple of clear options.
    RationaleConveys the nurse’s interest in the patient and the nurse’s willingness to help. Not offering too much choice will reduce the difficulty in decision making. Remember that the language of the patient may not be that of the nurses and modification to ensure understanding will be needed. Keeping things simple is a good approach.
  6. Use empathy and a non-aggressive posture when communicating with the patient.
    RationaleConveys that the nurse is calm, controlled, and non-threatening.
  7. Listen to the patient’s conversation and determine what the patient is thinking and feeling. Give appropriate feedback and acknowledge the impact of such thoughts and feelings.
    RationaleFosters reassurance for the patient and conveys that the nurse is interested in helping the patient.
  8. Maintain eye contact with the patient (care is needed not to stare or allow facial expressions to indicate disapproval). Position yourself in a non-confrontational manner, e.g. try to mirror where appropriate, for example if a person is sitting do not stand over them, maybe you can sit or crouch if you are able to do so, with a safe exit available to you should it be required.
    RationaleMaintaining appropriate eye contact is a way of communicating to the person that you are interested and want to hear what they have to say (Egan 2013). This decreases the sense of intimidation and communicates to the patient that the nurse is an equal. Care is needed to accept that certain cultures find prolonged eye contact threatening. Also in other cultures, the gender of the nurse maintaining eye contact may need to be considered.
  9. Ensure that the patient’s personal space is not encroached upon.
    Rationale All people have a varying distance at which they feel comfortable in social interchanges. Care is needed to neither come too close (potentially) making them feel anxious nor be too far away so implying that the patient is not approachable. Some patients who have the potential for aggression and violence need additional space. Be mindful to position yourself so that both you and the patient have equal access to the doors or exits; this reduces a sense of either person feeling trapped, a known trigger of the fight or flight response and allows opportunities for either of you to exit safely. 
  10. Use open-ended questions while communicating with the patient and avoid ending sentences with ‘okay’.
    RationaleClosed-ended questions and ending sentences with ‘okay’ can create ambivalence in the patient (Varcarolis & Halter 2010). Tone of voice and opportunity to answer are also important. Take care not to sound patronising nor negate the patient’s responses by cutting into the response and advising.
    The key here is to listen as well as talk.
  11. If the patient asks for some help to deal with the perceived trigger to their presenting behaviour, then act where possible. This may be the use of ‘time out’ in a quieter part of the unit or even medication that is prescribed to be administered for a specific sign or symptom (such as agitation) or in a specific situation.
    Rationale – ‘Time out’ is a behavioural intervention, agreed as part of a care plan, that reduces stimuli. It may involve the patient leaving the immediate ward area and using a room vacated by others. It does not have the opportunity of locking a door, is voluntary, part of a care plan, and lasts for no more than 15 min. Use of medications on request can be useful in helping the client to identify that staff listen and respond to requests, but should be avoided unless felt totally necessary and psychological interventions have been exhausted.
  12. Monitor the patient for the use of and awareness of the efficacy of healthy coping skills.
    RationaleIndividuals with limited coping skills and lack of assertiveness are at a higher risk of exhibiting aggressive or violent behviour (Varcolis & Halter 2010).
  13. All conversations should be accurately documented with a timeline of behaviours established.
    RationaleAccurate records can help to identify antecedents to aggression or violence and in future reduce outbursts. The timely management and offer of help can reduce the risks of potentially avoidable violent acts.
  14. Where a patient finds it impossible to desist from violence, then restraint or even seclusion may be necessary.
    Rationale If aggression or violence persists, restraint or seclusion may be necessary. These can only be considered if all other possible ways of handling the situation have been tried.
    Only appropriately trained staff can get involved in the restraint and seclusion of a patient. If seclusion is needed, only a room designed for this can be used. Many Trusts and ward areas do not have such a room and in that circumstance will need to follow the Trust policy for management of an aggressive or violent incident.

Ongoing care, monitoring and support

  • Establish the current level of risk of aggression or violence to self or others.
  • Is there still a plan of aggression or violence and factors driving the decision?
  • What is the imminency to carry out the plan of aggression or violence?
  • Identify the present level and presence of impulsivity, hyperactivity, irritability, hallucinations, substance misuse, or delusions.
  • What are the current modulating factors and in particular protective factors?
  • Establish if medication has been used and the effect identified.
  • Evaluate the patient’s support system.
  • Assess the patient’s coping strategy utilised.
  • Establish if the patient still has or intends to use a weapon.
  • Evaluate the patient’s mood state and potential for increased risk of suicide.

Documentation and reporting

Document in the patient’s nursing notes the following:

  • Detail the event needing intervention, remembering to include the five Ws (who, what, where, when, why). State clearly – who was there, what happened, where did it happen, when did it happen, and why do you or the patient believe it happened.
  • Establish the rationale for intervention.
  • Clearly record narratives or actions of threats to self harm or harm others.
  • Identify any potential antagonists and victims.
  • Utilise the least restrictive measures but record all measures used.
  • Establish the mental state of the patient.
  • Identify escalating behaviours.
  • Record the nursing interventions performed and the patient’s reactions. Identify the impact of these measures including reaction to medication.
  • Complete any standardised measures and observation sheets.
  • Evaluate the interventions implemented.
  • If restraint or seclusion was used, then follow the local Trust policy for both use and recording.
  • Detail the reintegration method used by staff to assimilate the patient back into the ward environment. 

Special considerations

Nurses who work in the Republic of Ireland must make themselves aware of the Mental Health Commission Rules pertaining to Seclusion and Mechanical Restraint. See Additional Resources for reference. Section 69(2) of the Mental Health Act 2001 states that "The Commission shall make rules providing for the use of seclusion and mechanical means of bodily restraint on a patient." (MHC 2010)




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