|
 Anger
and hostility are not uncommon in nursing situations whereas actual violence
is considered uncommon. If expression of anger is viewed as an attempt
to maintain or regain control, then the solution is to provide situations
in which the person does not feel powerless. This is applicable whether
a person is already a patient or is being evaluated for treatment.
Anxiety
and agitation may be expressed in angry, violent behavior. These feelings
are generally the result of two categories which stem from emotional or
organic causes - confusion and misperceived attack.
1.
Confusion: The person is experiencing a fight-or-flight reaction after
some sort of alteration of consciousness through trauma, drugs, alcohol,
sensory deprivation or toxic processes. He/she simply does not know what
is happening and, in panic, lashes out.
2.
Misperceived attack: Fear of assault or belief of being assaulted
may relate to psychosis or intoxication. Hospital procedures may be misinterpreted
by patients who are partially conscious, post MI, postictal, sedated,
unsophisticated, elderly or brain-damaged, and they strike back in an
attempt at self-defense.
Violent
behavior is a symptom. It is important to discover the etiology so that
appropriate treatment can begin. Differential diagnoses include temporal
lobe epilepsy; explosive personality; acute organic brain syndrome secondary
to drug ingestion, especially hallucinogens; schizophrenia, especially
paranoid type; alcohol intoxication; antisocial personality disorder;
uncontrollable violence secondary to interpersonal stress; organic states,
including tumor, infections, and brain response to toxins; and dissociative
states.
It
may take extended time, observation and diagnostic testing to determine
which of the above fits a particular patient. While the state of psychiatric
emergency is occurring, rapid treatment must take place to protect everyone
- the intended victims, the staff and the violent person. Safety is
the first consideration.
There
are three levels of urgency: 1) acute: when the person is actively
violent, combative and dangerous and no cooperation is obtainable; 2)
subacute: when the person is threatening and acutely agitated,
but violence has not occurred; cooperation may or may not be obtained;
and 3) chronic quiescent: when the person has recurrent episodes
of violence but is currently in good control and judged to need help to
prevent future outbursts; cooperation may or may not be obtained.
In
the first two cases, control of the person is the first order. Medication
is generally indicated. It should be prepared ahead of actually restraining
the patient, if possible. For acute patients the medication will probably
be given via injection, either IV or IM. The room or bed should be readied
and open, and if restraints become necessary, they should be available.
Specific issues related to medications and environmental interventions,
including restraint, are covered in a later section of the course.
Assessment
of Violence
As
in other types of psychiatric emergencies, the question with violent behavior
is, "Why now?" What event or combination of events has created the situation
that may lead to destructive, even lethal, behavior?
As
part of the psychosocial history and mental status evaluation, the following
questions should be asked of those calling or bringing the person in for
evaluation: What has the person done? How threatening was the action?
Has it ever happened before? Do you know whether alcohol or drugs were
involved? The person being evaluated should be asked: With the problems
and feelings that you have, have you thought of harming someone else?
What are your thoughts and feelings about this person? Why? What do you
think the outcome will be? Have you ever felt like killing someone? Tried?
How about now? Have you had trouble with the police? These questions,
along with the nonverbal aspects of behavior in the situation, help to
determine the three most significant factors: previous history of violent
behavior, the type of violence already expressed or expected, and the
degrees of impulse control expressed both physically and verbally.
There
are many other questions that help not only to round out the picture of
possible violent behavior but also suggest the appropriate treatment.
Some of these include questions that deal with life experiences that have
resulted in feelings of bitterness, resentment, and the desire for revenge;
frequent quarrels with family members; association with a significant
person who is violent; violence as a way of life; low self-esteem or defective
self-image; interest in and availability of weapons, especially guns;
violent fantasies and daydreams; childhood history of parental brutality
and/or seduction; childhood history of arson, enuresis or cruelty to animals;
alcohol and drug abuse; and impaired reality testing with specific fears
of attack from others.
Dangerousness
and murder potential are much easier to assess in hindsight than foresight.
This becomes a medical, legal and moral problem. Medical personnel are
dedicated to saving lives and alleviating distress. When someone who is
potentially homicidal comes in for evaluation and treatment, most staff
react with some degree of fear and uncertainty.
Profiles
of those who have committed murders generally highlight early as well
as immediate circumstances. The person often comes from a family in which
the quality of life was poor, especially between father and son. There
was often violence in the home with brutality, beating and whippings,
which were directed at the child and between the parents.
Often
people who murder have backgrounds in which relationships with other children
were very limited. They have little evidence of early team or sport activity.
They have little peer mastery and generally have been very isolated. Deep-seated
feelings of inadequacy, rage and desire for revenge become part of their
personality. This lack of family and friend development has left the person
particularly susceptible to derision and shaming. What leads to the homicidal
crisis is a gradual decompensation at school, work and in social situations.
The person has repetitive feelings of helplessness, along with a great
need to succeed and to be approved. The person feels generally hopeless
in regard to other people's being able to help.
Within
this context a crisis situation develops. The potentially violent person
is often devoid of pleasure, feels helpless in inner life and begins to
experience stress in the extreme. Impulse control slips and use of alcohol
or drugs may increase, which increases the potential for violent action.
These factors precipitate a state of actual or threatened violence
that is a psychiatric emergency, requiring immediate assessment, treatment
and disposition. Nurses play an important part in many of these areas.
Problems
and Goals
The
immediate problem presented by these patients is one of safety. They are
acting or are about to act on angry feelings in ways that will be harmful
to other people and/or property. After the initial behavior is brought
under control, other problems will be identified. Some of the ones to
anticipate are low self-esteem, low frustration tolerance, anxiety, and
difficulty with interpersonal relations.
The
long-range goal in working with a person who acts violently is to help
him/her find other means of expressing feelings, especially fear and anger.
With increased self-esteem, the person is less likely to feel as powerless
and afraid of others.
Aggressive,
assaultive behavior causes many difficulties in interpersonal relations.
Spouse, parent and child abuse are all related to this problem. Many times
the abusing parent has been a battered child. In this way maladaptive
patterns that lead to misery, injury and death are perpetuated. Those
who work with people who resort to physical violence hope to help them
learn more adaptive ways of handling feelings and relating to others.
Aggressive patients who use physical threats and acts to manipulate and
bully others may, however, lack the motivation to understand and change
their behavior patterns after the initial crisis is over.
Nursing
Action with the Person who is Angry and Violent
The
type of nursing intervention with an angry, potentially violent patient
will depend on several factors: the degree of danger, the treatment setting,
the cause of anger and the skills of the nurse. The degree of danger ranges
from minimal to life threatening. Verbal expression of anger can relieve
the feeling or can escalate into physical action. People who are acutely
angry must be evaluated in terms of what action they may take with their
thoughts, feelings and impulses. Violence does not usually occur without
a warning through behavior and verbal signs.
A
patient in a general hospital may show angry behavior in reaction to the
stress of illness. Anger is part of the basic personality and toxic effects
of the illness and treatment, especially drug interactions, may evoke
it. The nurse may or may not intervene. If the behavior escalates to violence,
action must be taken. Immediate safety and control of the patient are
the first actions. Psychiatric consultation may be requested. Drug and
environmental interventions are used for immediate resolution.
If
the person is being evaluated in an emergency room or crisis center, nurses
are the prime crisis workers or helpers in the immediate situation. They
participate in the evaluation, treatment and disposition aspects of this
psychiatric emergency.
A
person may be hospitalized on a psychiatric unit to regain control over
angry, violent behavior. In this setting, patients are helped to control
this behavior and to express themselves in ways that lead to greater awareness,
understanding and social adaptation rather than violence and destruction.
It
is important to find out why the patient is angry to the point of violence.
If there are external, realistic reasons, the nurse can correct these
if possible. If the anger stems from deep-seated conflicts and habit patterns,
intervention is limited to the immediate situation.
Nurses
can increase their skills in working with patients who are angry, aggressive
and violent. At first, they may feel frightened and threatened. As knowledge
and experience increase, they become more comfortable. In acute situations,
it is probably always helpful to have some sort of wariness to adequately
protect all parties involved.
|
National Center
of Continuing Education
