Dealing with violence Aggression

1. Dealing with violence & Aggression Principles of De- escalation Eula Miller (RMN)

2. Areas of highest risk of aggression Health care environments rated as high risk are: Acute mental health settings Acute learning disability settings Accident & emergency departments G.P. surgeries Community care settings (home) Hospital wards

3. The legal protection for staff Under the �Health and safety at work Act� 1974 employers must: Protect the health & safety of others who might be affected Under the �Management of Health & Safety Regulations� 1992 employers must: Assess the risk to the health & safety of their employees

4. The protection for staff should include: Identification of precautions needed (risk assessment) Arrangements for the effective management of precautions Provision of information & training to employees Appointment of competent people to advise on health and safety matters

5. Understanding anger, aggression and violence Anger: an emotion common to all Usually generated in a situation that we experience as frustrating or out of our control Anger is a powerful motivator and if channelled effectively, can assist in problem solving

6. Aggression Aggression is an action or behaviour that has many forms: Physical kicks, punches, slaps Verbal insults, threats Non-verbal gestures, body posture Aggression is the intention to hurt/ harm self or another inflicting �pain� It can be active or passive

7. Violence Violence within health care settings is defined as: �Any incidence/situation where a person in the workplace is verbally abused, threatened, or assaulted by a patient or member of the public in circumstances relating to his /her employment� (Heath & Safety commission 1997)

8. Factors that influence aggressive behaviour in care settings Illness/pain and psychological stress Powerlessness- loss of control/independence Fear of unknown/vulnerability Mental illness Medication Illicit drug use Alcohol Sleep deprivation Disorientation Not being heard/ignored Misunderstood

9. Factors that trigger aggressive behaviour in care settings (Fern, 2007) Overcrowding Noisy environments Poor staffing levels Inapproachability of staff Personality differences/clashes Poor communication Perceived poor care experience Over stimulating environments Boredom Feeling under pressure Time management issues

10. Behaviours classed as violent

11. Physiological response to conflict/ confrontation Body perceives confrontation as threat: Fight or flight syndrome Adrenalin prepares body for action- usually results in �fight� protective mechanism but results in �flight� if the threat is overwhelming What usually decides our action depends on how much we have to lose e.g. our job, our life, our pride

12. Code of conduct for professional practice NMC (2004) The duty of the nurse is to act always in such a manner which promotes and safeguards the interest and wellbeing of patients If situations escalate to the point of needing to restrain an individual you can only use methods of interventions which are deemed reasonable As a student you are not permitted to be involved in the restraint of a patient. This is training that will be undertaken post qualifying if your job role dictates the necessity

13. Role of student nurse You have a major role to play in the prevention (where possible) of situations escalating into a crisis situation The first rule to consider at all times is your personal safety be aware of your actions especially if you feel threatened as adrenalin will be charging your response

14. Use of observation skills Pro-dromal behaviours in anger & aggression: Stammering Pacing, staring Repetition Exaggerated gestures Hitting self Defensive posturing Tearfulness Stamping Raising volume of voice

15. Use of observation skills Screaming Insulting Clenched fist Grimacing Refusal to listen Demanding Jerky movement No (or intense) eye contact Grinding teeth Nonchalant gestures Invasion of personal space

16. De-escalation in the management of aggression and violence Reduce stimuli within the immediate environment Maintain adequate distance Move, if possible, to a safe place Always keep the patient in eye view Talk to patient in a calm but confident manner Listen and try to quickly ascertain what triggered the situation Acknowledge the individual�s concerns and feelings Ensure your verbal/nonverbal communication and behaviour is non�threatening

17. De�escalation in the management of aggression and violence Elicit the facts as succinctly as possible and try to negotiate a reasonable course of short term action Do not make promises you cannot keep Avoid entering the individual�s personal space Encourage the person to sit down If in doubt about touching a patient, don�t Make sure you know where the exits are in case an speedy retreat becomes necessary

18. De�escalation in the management of aggression and violence If a patient has a weapon encourage them to put it down If they pick a weapon up, your safety becomes paramount leave the situation as quickly and as calmly as possible Only in the extreme of cases will restraint become the chosen course of action

19. De-briefing session After any incident it is good practice to engage in a de- briefing session as it allows for: Support Review of situation Discussion of what has been learnt Resettling after �adrenalin rush� Clarification of events � important as all violent incidences have to be reported

20. References Dept. Environment. 1992. �Health and Safety, The Workplace (Health, Safety and Welfare) Regulations 1992�, No. 3004. Department for the Environment. Health and Safety at Work Act 1974 Chapter 37. Secretary of State for Employment. Heath & Safety Commission 1997 No. 1713 �HEALTH AND SAFETY: The Confined Spaces Regulations 1997�. Department of the Environment. Fern (2007). Factors that influence aggressive behaviour in acute care settings. Nursing Standard, 21(33), 41-45.