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Mental Health - Anger & Aggression


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- universal emotion
- one of the most difficult for people to deal with
- last stages of a response (underlying reason for aggression is frustration)

Agression/Violent Behaviour:
- reflect a continuum
- consider patient/context
- patients with disorder will be aggressive/violent [FALSE]
- most useful interventions would be instituted during initial phases
- assessment skills - KEY
- damage to FRONTAL LOBE can lead to aggression
- sometimes caused by LOW SEROTONIN levels
- Catecholamines may be affected - ex. serotonin, norepinephrine
- situations when anger has escalated & threat of violence is imminent
- need different interventions/strategies
- nurses encounter angry/aggressive patients in various settings
- no nurse need ever to accept or tolerate anger or aggression

Settings - Nurses may work with violent offenders
- Forensic population
- Correctional system
- stigmatized and stereotyped population
- nurse work with patients with a proven capacity for violence

Patient admitted to unit involuntarily and is threatening to kill anyone who comes close to him. You have attempted to administer his PO antipsychotic medication but he accuses you of trying to poison him and refuses to take it. His behaviour is escalatin
- be empathetic
- we want you to take this medication
- tell patient we will have to restrain you
- remain calm
- this is a difficult time for you
- last resort is to call code white
- less people around in uniform is better because aggression may escalate; key is safety; follow policy

Nursing Guidelines
- hospital: safety for patients & others
- follow legal & ethical guidelines/agency policy (restraint/seclusion)
- psychopharmacology agents
- follow least restrictive guidelines - start with verbal restraints, chemical, final physical restraints/seclusion

Assessment Violence Potential
- History [any past history of violence - best predictor of future behaviour is past behaviour
- Paranoia
- Alcohol/Drug Ingestion
- personality disorder
- medical disorder (ex. schizophrenia, psychosis, hallucinations, cognitive disorders such as dementia, conduct disorder)
- Oppositional Defiant Disorder or Conduct Disorder
- patients experiencing command hallucinations
- any patient with psychotic features (hallucinations, delusions, or illusions)
- patients with a cognitive disorder (ex. dementia)
- patients with intermittent explosive disorder (ex. domestic violence)
- certain medical conditions [chronic illness/loss of body function]
- there are sicker people on the wards
- sometimes nurses can cause aggression in patients because they may be rigid; not listening to the patient

What in environment may contribute to violence?
- overcrowding
- staff inexperience
- staff provocative/controlling
- poor limit setting
- arbitrarily taking away privileges

Presenting S&S of Anger/Aggression:
- violence is usually, but not always preceded by:
1. Hyperactivity
2. Increasing anxiety & tension
3. Verbal abuse
4. Loud Voice
5. Intense eye contact or avoidance
- recent acts of violence
- carrying a weapon or object

Sample Questions:
- "Tell me about a time you lost control"
- "Have you ever hit/attacked anyone?"
- "What do you do when you get very upset?"
- "Have you ever or do you now hear voices telling you to do things to hurt other people?" [command hallucinations]

Setting Limits:
- set limits only in those areas in which a clear need to protect the patient and others exist
- establish realistic & enforceable consequences of exceeding limits (don't tell lies; be truthful and realistic)
- make the patient aware of limits & consequences [clear, polite & firm manner; do not quiver in your approach; do not raise your voice; call the person by name to get the person to focus]
- all limits should be supported by the entire team [written in plan of care - need consistency]
- discuss when to discontinue
- address staff difficulty in maintaining consistency with patient
- awareness of own feelings

Nurses Role for Anger/Aggression:
- take assertive training courses
- nonviolent crisis intervention training
- using nonthreatening body language
- respect patient's personal space & boundaries
- access to door/exit
- let colleagues know where you are
- use active listening & validation
- apologize when appropriate (ex. I'm sorry the food is cold)
- patient abusive: leave room & return (approx. 20 mins)
- do not respond with sarcasm
- patients responsible for behaviour [tell patients they are responsible for their behaviour]
- neutral approach
- be aware of your own feelings in the situation
- avoid power struggles
- teach problem solving
- provide outlets for stress (ex. exercise)
- role playing with patient
- administer medications (ex. atypical antipsychotics, SSRI's, Lithium)
- community - in home (quick exit)
- leave home immediately
- never turn your back on patient
- be aware of what you wear [never wear clothing/jewelry that can be used to harm]

- What is our understanding of families?
- In Canadian context, have definitions of family changed? (family is whoever the person says it is)
- all families have strengths, resources and capabilities
- involves families from day 1
- impacted greatly by mental illness of a family member

Effects of mental illness on family:
- 1950s, 1960s, 1970s initially families were perceived by mental health professionals as the blame for causing the problem of illness
- mental illness, influences the way families function
- caregiver burden literature (inconvenience; can end up with problems from not looking after themselves)
- high level of burden on parents who have son or daughter with serious mental illness
- identified greater risk of poorer health & marital disruption

Family & Mental Illness
- families can have a significant impact on relative's recovery [TRUE]
- provide emotional/instrumental support [good support leads to a faster recovery]
Effects of Mental Illness for Patients:
- stressful event
- feelings of guilt [genetic transmission]
- shame/embarrassment
- diagnosis - behaviour - involvement of other agencies in community

Families and Health Professionals
- healthcare professionals have been recognized as the least helpful in assisting families during their experience of caring for a family member who is ill
WHO Report:
- skills for care
- family cohesion
- networking with other families
- crisis support
- financial support
- respite care

Family Assessment:
- family assessment [comprehensive]
- many models - what to use???
- Calgary Family Assessment / Intervention Model [multidimensional frameworks]
- Stigma & shame impact issue for families
- Circle of Care (PHIA)
- Physical health status & mental health status
- problem-solving skills
- stress and coping abilities
- communication patterns
- social and financial status
- formal & informal support networks
- family spiritual domain

Nurses Role:
- inpatient/community involvement
- family interventions [flexibility]
- counseling [short-term] - referrals
- promoting self-care activities
- support family functioning
- provide education & health teaching

- in any setting
- violence by patients & sometimes their families
- CHALLENGE for nurses!

Family violence:
- Is an important public health issue in Canada & the world (why?)
- Violence permeates throughout society, prominent societal concern [news]
- direct & indirect health & financial costs
- Definition refers to victims of violence from a powerful person to less powerful person [power & control]
- Other terms: domestic violence, interpersonal violence
- encompasses the physical, emotional & sexual abuse of children, child neglect. spouse battering, marital rape & elder abuse
- What are the characteristics of violent families?

Characteristics of Violent Families:
- social isolation
- power and control
- alcohol & other drug use
- intergenerational transmission process

Violence [myths]

- Abusive people and their victims often excuse the abuse by blaming alcohol, stress or drugs [True]
- Children who only witness family violence are usually safe from its effects [False]
- Family violence is most prevalent among families living in poverty [False]

Family Violence in Canada
- In 2007, 40,200 incidents of spousal violence were reported. About 12% of all police-reported violent crime in Canada
- spousal violence has steadily declined
- majority of victims - females (83%)
- children & youth physically/sexually assaulted (85% of incidents)

Long Term Effects of Family Violence
- depression
- suicidal feelings
- trust - relationship impact
- self (low self-esteem)
- children/adolescents - impact! [interpersonal relationships/school]
- antisocial behaviours

Conditions for Violence:
- reinforced by society/culture
- occurrence:
1. Perpetrator
2. Someone who is vulnerable
3. Crisis situation
- individuals family violence - use substances
- "He was drunk and he didn't know what he was doing"
- greatest risk: when they attempt to leave the relationship

Cycle of Violence:
1. Tension Building Stage: minor incidents [pushing]
2. Acute Battering Stage: brutal & uncontrollable beatings
3. Honeymoon Stage: kindness & loving
4. Escalation-de-escalation: conditions of anger & fear escalate until an incident of violence takes place

Nursing Role!
- CNA position statement on violence
- What setting would you see these patients [emergency is where most of them end up]
- many locations! [psychiatric centres, medsurg units]
- Assessment: should be completed with victim alone - DOCUMENTATION
- Tools: Abuse Assessment Screen

Assessment - Kramer
- nurse and physician collaborate re: assessment
- conduct interview in private (TRUST)
- be direct, honest & professional [active listening: sensitive questions - nonjudgmental]
- do not display horror, anger, shock!
- identification - assessment
- assessing of anxiety/coping responses
- assessing family coping patterns
- assessing support systems
- assessing suicide potential
- assessing homicide potential
- assessing drug/alcohol use
- maintaining accurate records [legal action]
- duty to report - provincial/federal legislation
- primary prevention
- secondary prevention [early intervention]
- tertiary prevention

- counselling - safety plan
- chooses to leave - shelters/or safe houses
- case management: victims/perpetrators
- Milieu therapy: stabilizing the home situation
- health teaching: self-care activities
- family therapy: short-term & long-term goals

Working with persons who experience partner abuse:
- don't preach, moralize or imply you doubt patient
- don't direct the patient to leave the relationship
- don't take charge & do everything for patient
- don't express outrage with the perpetrator

- Do express: "I'm concerned for your safety"
- Do listen "I am sorry you have been hurt"
- "You have a right to be safe and respected"
- "The abuse is not your fault"
- Offer to help contact a shelter, police or other resources

Why women stay?
- can you think of reasons why they stay in the relationship?
- Situational: finances, unable to drive, children, nowhere to go, confusing - because the abuser may say they are sorry but then continue the cycle
- cultural factors: arranged marriages
- Situational, emotional, cultural factors!

Nursing Interventions:
- provide respect, empathy, support & acceptance
- advocate
- teach management of difficult behaviours
- teach/encourage self-care activities

NL Provincial Initiatives:
- increased funding for the 8 women's centres
- $304,000 specialized Family Violence Court
- $1.2 million to establish Iris Kirby House in Carbonear
- Media campaign: prevent male violence

Summary of Family Violence
- spousal violence has declined over the past 10 years

Deck Info