A basic guide for management and prevention of aggressive behaviours and violence for new graduate nurses in Mental Heath

A basic guide for management and prevention of aggressive behaviours and violence for new graduate nurses in Mental health

Learning Objectives

Learning objectives

After completing this learning module the learner will be able to:

  1.  Define the terms violence and aggression
  2.  Recall the prevalence of assaults against mental health nurses
  3.  Recognise triggers for aggressive behaviour and violence
  4.  Identify safe interventions to manage aggression and violence
  5. Identify ways to prevent aggression and violence

Define violence and aggression

Reflection

Reflect on...

What is your definition of aggressive behaviours and violence?





Image retrieved from https://www.medprostaffing.com/wp-content/uploads/2016/06/Nurse-Thinking.jpg.

Definition of violence

World Health Organisation (2017) defines violence as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation."

Examples of violence include:

  • Pushing
  • Kicking
  • Spitting
  • Punching
  • Scratching
  • Hair pulling
  • Strangling
  • Purposely setting fire

(Coverdale, Gale, McKenna Poole & Smith, 2003; Kvas & Seljack, 2015; Elder, Evans & Nizette, 2013).

There are different sources of violence when working in mental health services such as client initiated violence, external violence from individuals outside of the service and internal violence from colleagues; each of these sources of violence have varying management interventions (Chappell & Mayhew, 2003; Chang & Cho, 2016). 

This learning resource will focus on client-initiated violence.

Definition of aggression

Aggression is defined as “actions or behaviours ranging from violent physical acts such as kicks or punches through to verbal abuse, insults and nonverbal gestures. The overall feeling projected is an attempt to dominate” (Elder, Evans & Nizette, 2013, p. 522).

Examples of aggressive behaviour include:

  • Threatening
  • Increasing volume when speaking
  • Pacing
  • Sexual harassment
  • Swearing
  • Stalking
  • Increased respiration rate
  • Staring
  • Attempting to violate personal space

(Elder, Evans & Nizette, 2013; Coverdale et al., 2003; Berring, Buus & Pedersen, 2015).

Client-initiated aggression and display of aggressive behaviours has a significant effect of the safety and quality of care for the patients as the aggressive behavior can weaken an established therapeutic relationship and create feelings of apprehension and uncertainty (Coverdale et al., 2003; Berring et al., 2016).

Recall the prevalence of assaults against mental health nurses

Reflection

Reflect on...

Have you ever experienced an assault while at work?

What were your actions following the incident?

What did others do to support you?


Image retrieved from https://www.medprostaffing.com/wp-content/uploads/2016/06/Nurse-Thinking.jpg.

Mental Health Facilities and assaults

Mental health facilities can be a dangerous workplace where patients have assaulted and threatened nursing staff, with “75-100% of psychiatric nursing staff experienced an assault at least once during their career” (Baby, Carlyle & Glue, 2014, p. 648; Elder, Evans & Nizette, 2013).

Compared to their peers, new graduate nurses in mental health are largely targeted by patients and have a higher occurrence of experiencing aggressive behaviour and violence (Coverdale et al., 2003; Victorian Government Department of Human Services, 2005). 

Baby et al., (2014) and Coverdale et al., (2003) describe the detrimental effects of workplace violence and assaults on mental health nurses such as loss of confidence and feelings of fear, anger, helplessness, anxiety and can cause a declined retention of new graduate nurses in mental health services.

Many incidents involving workplace violence and aggression are not reported, Chappell & Mayhew, (2003) describes if every incident is reported and all of the required documentation completed it would take away a significant amount of time away from the patients (Coverdale et al., 2003).

Recognise triggers for aggressive behaviours and violence

Factors contributing to aggressive behaviours and violence

There are many factors that contribute to the escalation of aggressive behaviors and violence with clients, these factors can be categorised into two main groups; these include external and internal factors (Elder, Evans & Nizette, 2013; Daffern, Hollander, Lee & Podubuski, 2017).

Internal factors include:

  •  A history of aggressive behaviours and violent actions
  • Neurological disorder or mental illness
  • The age of the client
  • Personality
  • The client’s gender

(Queensland Health, N.D.; Elder, Evans & Nizette, 2013; Daffern et al., 2017; Berring, et al., 2015)

External factors include:

  • The setting where the client is in
  • A controlling practice from a nurse
  • If the client is being disrespected
  • If the client is being goaded

(Queensland Health, N.D; Elder, Evans & Nizette, 2013; Daffern et al., 2017; Berring, et al., 2015)

Identify safe interventions to manage aggression and violence

Safe management of aggressive behaviours and violence

There are many interventions used to assist with management of aggression and violence, however this learning resource will focus on what is a code black and psychological interventions that entail de-escalation techniques (Dickens & Stubbs, 2008; Sydney Local Health District, 2017; Australian Nursing and Midwifery Federation, 2015).

Avoiding escalating aggressive behaviours from the client by using therapeutic communication skills with the client is de-escalation (Dickens & Stubbs, 2008).

De-escalation techniques include:

  • When addressing the client avoid moving quickly, focus on an open body posture and walk calmly
  • When talking to the client maintain a normal volume and tone, maintaining professional language
  • Be aware of your exits at all time and do not put yourself in a position where you could be trapped
  • Discuss with the client what is bothering them
  • Refrain from promising the client anything
  • Be careful of challenging a client, it is best to avoid challenging their behaviour when the client could easily escalate
  • Work together on a conclusion, discussing available options for the client

(Dickens & Stubbs, 2008; Health and Training Institute, 2017)

In some local health districts using a duress alarm to call for help is called a ‘Code Black’ this allows a selected group of staff come to your location and provide you with needed assistance during a clinical incident such as a client being violent (Sydney Local Health District, 2017; Australian Nursing and Midwifery Federation, 2015).  Using a duress alarm is invaluable in maintain staff and patient safety by assisting in managing a clinical incident involving aggressive behaviours and violence (Sydney Local Health District, 2017; Australian Nursing and Midwifery Federation, 2015).

Identify ways to prevent aggression and violence

Ways to prevent aggression and violence

Ways to prevent aggression and violence include:

  • Build a therapeutic relation with the client based on trust and respect
  • Familiarise yourself with clients’ history of previous aggression and violent acts
  • Work together with the client to reach health goals
  • Have established times for activities
  • Actively partake in risk assessments
  • Report clinical incidents through the appropriate pathways

(Coverdale et al., 2003; New South Wales Health, 2012; Elder, Evans & Nizette, 2013)

Multiple-choice quiz. 100% is needed to pass. You can choose more than one answer.

What are some examples of violence?

(Coverdale, Gale, McKenna Poole & Smith, 2003; Kvas & Seljack, 2015; Elder, Evans & Nizette, 2013; World Health Organisation, 2017)

  • Cold shoulder
  • Throwing furniture
  • Pulling hair
  • Punching

What are some examples of aggression?

(Elder, Evans & Nizette, 2013, p. 522; Coverdale et al., 2003; Berring, Buus & Pedersen, 2015)

  • Crying
  • Punching
  • Yelling
  • Ignoring someone

How many mental health nurses are assaulted at least once in their career?

(Baby, Carlyle & Glue, 2014, p. 648; Elder, Evans & Nizette, 2013).

  • 60-70%
  • 75-100%
  • 40-50%
  • 25%

What are some factors that contribute to aggressive behaviour and violence?

(Queensland Health, N.D.; Elder, Evans & Nizette, 2013; Daffern et al., 2017; Berring, et al., 2015)

  • History of aggression
  • Playing violent video games
  • Neurological disorder or mental illness
  • Their star sign

What are some examples of safe interventions to manage aggression and violence?

(Dickens & Stubbs, 2008; Sydney Local Health District, 2017; Australian Nursing and Midwifery Federation, 2015; Health and Training Institute, 2017; Australian Nursing and Midwifery Federation, 2015)

  • Open body language
  • Raising your voice to match theirs
  • Use the duress alarm
  • Work together on a conclusion, discussing available options for the client

What are some options to help prevent aggressive behaviours and violence?

(Coverdale et al., 2003; New South Wales Health, 2012; Elder, Evans & Nizette, 2013)

  • Build a therapeutic relation with the client based on trust and respect
  • Work together with the client to reach health goals
  • Actively partake in risk assessments
  • Refuse to let the clients make their own decisions

References

All references for assignment 3

Abuatiq, A., Boren, D., Davis, C., Fike, G., & Menke, R. (2017). E-learning in Nursing: Literature Review. International Journal of Nursing Education, 9(2), 81-86. doi 10.5958/0974-9357.2017.00041.1

Ally, M. (2008) Foundations of educational theory for online learning. In T. Anderson (Eds.), The Theory and Practice of Online Learning (2nd ed., pp. 15-45 ). Edmonton, Alberta: AU Press.

Australian Nursing and Midwifery Federation. (2015). Prevention of occupational violence and aggression in healthcare. Australian Nursing and Midwifery Journal, 22(10), 34-35.

Australian Nursing and Midwifery Federation. (2016). Nurturing graduate nurses entering mental health. Australian Nursing & Midwifery Journal, 24(3), 1. Retrieved from http://eds.b.ebscohost.com.ezproxy.newcastle.edu.au/eds/pdfviewer/pdfviewer?vid=1&sid=97e483ec-4203-4538-aabe-a8bdbae4e83b%40sessionmgr103

Baby, M., Carlyle, D., & Glue, P. (2014). ‘Violence is Not Part of Our Job’: A Thematic Analysis of Psychiatric Mental Health Nurses’ Experiences of Patient Assaults from a New Zealand Perspective. Issues in Mental Health Nursing, 35, 647u-655. doi 10.3109/01612840.2014.892552

Berring, L., Buus, N., & Pedersen, L. (2015). Discourses of aggression in forensic mental health: a critical discourse analysis of mental health nursing staff records. Nursing Inquiry, 22(4), 296-305. doi 10.1111/nin.12113

Berring, L., Buus, N., & Pedersen, L. (2016). Coping with Violence in Mental Health Care Settings: Patient and Staff Member Perspectives on De-escalation Practices. Archives of Psychiatric Nursing, 30, 499-507.

Bognar, B. (2016). Theoretical backgrounds of nursing. Croatian Journal of Education, 18(1), 225-256. doi: 10.15516/cje.v18i1.1475

Browne, G., Hooper, M., & O’Brien, A. (2016). Graduate nurses’ experiences of mental health services in their first year of practice: An integrative review. International Journal of Mental Health Nursing, 25, 286-298. doi 10.1111/inm.12192

Butler, A., & Roediger, H. (2008). Feedback enhances the positive effects and reduces the negative effects of multiple-choice testing. Memory & Cognition, 36(3), 604-616. doi: 10.3758/MC.36.3.604

Chan, A., & Ng, A. (2012). Evaluation of three multiple-choice assessment methods in a human factors engineering course. Journal of the Chinese Institute of Industrial Engineers, 29(7), 466—476. Retrieved from http://dx.doi.org/10.1080/10170669.2012.727478

Chang, H., & Cho, S. (2016). Sources of workplace violence against nurses. Asian Nursing Research, 10, 271-276. Retrieved from http://dx.doi.org/10.1016/j.anr.2016.09.001

Chappell, D., & Mayhew, C. (2003). Workplace Violence in the Health Sector – A Case Study in Australia. The Journal of Occupational Health and Safety — Australia and New Zealand, 19(6), 1-45. Retrieved from http://www.who.int/violence_injury_prevention/violence/en/wpv_australia.pdf?ua=1&ua=1

Coverdale, J., Gale, C., McKenna, B., Poole, S., & Smith, N. (2003). A survey of threats and violent behaviour by patients against registered nurses in their first year of practice.  International Journal of Mental Health Nursing, 12, 56-63. doi: 10.1046/j.1440-0979.2003.00269.

Curtis, R., Patterson, C., & Reid, A. (2008). Skills, knowledge, and attitudes expected of a newly-graduated mental health nurse in an inpatient setting. International Journal of Mental Health Nursing, 17, 410-418. doi 10.1111/j.1447-0349.2008.00572.x

Daffern, M., Hollander, Y., Lee, S., & Podubuski, T. (2017). Patient characteristics associated with aggression in mental health units. Psychiatry Research, 250, 141-145. Retrieved from http://dx.doi.org/10.1016/j.psychres.2017.01.078

Dickens, G., & Stubbs, B. (2008). Prevention and management of aggression in mental health: An interdisciplinary discussion. International Journal of Therapy and Rehabilitation, 15(8), 351-157. Retrieved from http://eds.b.ebscohost.com.ezproxy.newcastle.edu.au/eds/detail/detail?vid=0&sid=6327eb9e-e078-47e4-9e33-bcaa9b7831aa%40sessionmgr101&bdata=JnNpdGU9ZWRzLWxpdmU%3d

Downie, J., McGowan, S., Orb, A., & Wynaden, D. (2000). Are universities preparing nurses to meet the challenges posed by the Australian mental health care system? Australian and New Zealand Journal of Mental Health Nursing, 9,  138-146. Retrieved from http://eds.a.ebscohost.com.ezproxy.newcastle.edu.au/eds/pdfviewer/pdfviewer?vid=1&sid=f2abb358-d63f-4853-9b35-f42cf2168ecd%40sessionmgr4006

Elder, R., Evans, K., & Nizette, D. (2013). Psychiatric and Mental Health Nursing(3rd ed.). Chatswood, N.S.W: Elsevier.

Farrell, G. (2006). Scoping workplace aggression in nursing: findings from an Australian study. Nursing and Healthcare management and policy, 778-787. doi 10.1111/j.1365-2648.2006.03956.x

Hazleton, M., Rossiter, R., & Sinclair, E. (2011). Encounters with the ‘dark side’: New graduate nurses’ experiences in a mental health service. Health Sociology Review, 20(2), 172- 186. Retrieved from http://eds.b.ebscohost.com.ezproxy.newcastle.edu.au/eds/pdfviewer/pdfviewer?vid=1&sid=5356f64b-d724-46d8-a78a-3b6b1f97772f%40sessionmgr102

Hunter New England Local Health District. (2016). Mental Health New Graduate Nursing Program. Retrieved from http://www.hnehealth.nsw.gov.au/Careers/Documents/Mental%20Health%20New%20Graduate%20Nursing%20Program%202016.pdf

John Hunter Children’s Hospital. (2017). First Year Registered Nurse New Graduate Program. Retrieved from http://www.hnehealth.nsw.gov.au/Careers/Documents/NMTPP_John%20Hunter%20Childrens%20Hospital%20Profile%202018.pdf

Karimi, L. (2014). The effect of constructed-responses and multiple-choice tests on students’ course content mastery. Southern African Linguistics and Applied Language Studies, 32(3), 365-372.  Retrieved from http://dx.doi.org/10.2989/16073614.2014.997067

Kvas, A., & Seljack, J. (2015). Sources of workplace violence against nurses. Work, 52, 177-184. doi 10.3233/WOR-152040

Queensland Health (N.D.) Caring for a person who is aggressive or violent. Retrieved from https://www.health.qld.gov.au/__data/assets/pdf_file/0031/444586/aggressive.pdf

Reeves, P., & Reeves, T. (2008). Design considerations for online learning in health and social work education. Learning in Health and Social Care, 7(1), 46-58. Retrieved from  http://eds.b.ebscohost.com.ezproxy.newcastle.edu.au/eds/pdfviewer/pdfviewer?vid=1&sid=f34038ec-c20a-46be-85d4-a839c454b36d%40sessionmgr103

Rutherford-Hemming, T. (2012). Simulation Methodology in Nursing Education and Adult Learning Theory. Adult Learning, 23(3), 129-137. doi 10.1177/1045159512452848

Sydney Local Health District. (2017). Duress Response - Code Black Policy. Retrieved from https://www.slhd.nsw.gov.au/pdfs/Policies/SLHD_PD2016_008.pdf

Victorian Government Department of Human Services. (2005). Occupational violence in nursing: An analysis of the phenomenon of code grey/black events in four Victorian hospitals. Retrieved from http://www.health.vic.gov.au/__data/assets/pdf_file/0008/17585/codeblackgrey.pdf

Wienclaw, R. A. (2015a). Validity. Research Starters: Sociology (Online Edition). Retrieved from http://eds.a.ebscohost.com.ezproxy.newcastle.edu.au/eds/detail/detail?vid=0&sid=9925149b-9a37-458f-9b6c-e6d5052199c9%40sessionmgr4006&bdata=JnNpdGU9ZWRzLWxpdmU%3d#AN=89185805&db=ers

Wienclaw, R. A. (2015b). Reliability. Research Starters: Sociology (Online Edition). Retrieved from http://eds.a.ebscohost.com.ezproxy.newcastle.edu.au/eds/detail/detail?vid=0&sid=dac6a7b7-f6b2-449d-840e-77967e8ead1c%40sessionmgr4007&bdata=JnNpdGU9ZWRzLWxpdmU%3d#AN=89185672&db=ers

World Health Organisation. (2002). Framework guidelines for addressing workplace violence in the health sector. Retrieved from http://who.int/violence_injury_prevention/violence/interpersonal/en/WVguidelinesEN.pdf?ua=1&ua=1

World Health Organisation. (2017). Definition and typology of violence. Retrieved from http://www.who.int/violenceprevention/approach/definition/en/