NURS6018 Acute Nursing

Psychiatric inpatient wards have been a pace that has witnessed the most number of violent and aggressive behaviors than any other wards in a facility. Psychiatric wards are home to patients of several different mental illnesses and disorders with distinct symptomatology, severity, and extent. Violence is always correlated with mental illnesses. However, violence is not synonymous with mental illness. Violent and aggressive behaviors towards others are typically witnessed in mental illnesses like bipolar disorder, intellectual disability, antisocial personality disorder (Howard, 2015), schizophrenia, substance abuse, and rarely in borderline personality disorder. Nevertheless, increased incidence of violent and aggressive behavior in the psychiatric wards leads to a number of negative consequences. Such inpatient behaviors affect the patients’ as well as the staffs’ psychological and physical health. This in turn results in absenteeism, resignation on the part of the staff. It is of paramount importance to devise measures, which are both feasible and effective to manage and reduce the occurrence of violence and aggression in the psychiatric inpatient wards. Traditionally seclusion and restraints have been universal methods to deal with aggression in inpatients. However, with the detrimental implications of such measures, mental health reformers are thinking about alternative integrative measures to implement.

The general aim of the reformers is to create a conducive ward climate and culture to minimize the risk of violence. This can be achieved when a thorough conceptualization has been made about the forms of violence and aggression, determinants of violence, and aftermath of violent and aggressive behaviors.

Violence can be defined as human aggression associated with the use of threat or force through verbal or behavioral means with an objective to cause psychological or physical harm (Lantta et al., 2016). Interestingly, violent behaviors in inpatients of psychiatric wards are unique in the regard that they occur unprovoked and lack a concrete motive. This is true especially in the case of inpatients that have gross cognitive impairment. Violence may be addressed to various targets associated with the facility – towards the psychiatric nurses, doctors, other inpatients, inanimate objects like hospital prosperities or their own belongings, etc. Aggressive behaviors can take the shape of verbal intimidation (name-calling, harsh criticisms, blaming shifting, using demeaning words) or threats (to the nurses and sometimes their family members and pets, to visitors) sexual harassment, stalking, etc. Violent behaviors can include the use of one’s own body parts (hands, arms, legs) or weapons, which are available at the facility (food knife, pieces of glass). Most often, the face, neck, arms, and torso of the nurses are points of the target. There are also reports of nurses being beaten, slapped, kicked, pushed, hair pulled, and in extreme cases, burnt with cigarettes (Pelto-Piri, Warg & Kjellin, 2020). Violent acts are often inflicted on the nurses when they are off-guard and unprepared for the attack. Violent acts can manifest through the physical expression of aggression on facility properties like throwing objects in the room, kicking furniture, or breaking windows, furniture, taps, etc. Inter-inpatient violence took the shape of physical or verbal fights and in rare cases resulted in attempted manslaughter. Violence and aggression in inpatient wards result in fear, lack of satisfaction, degraded quality of life, lack of confidence, demotivation, stress, and anxiety in the staff, leading to deterioration in the quality of services provided (Gates, Gillespie & Succop, 2011).

Facility staffs are primarily of the belief that patient-related variables were only responsible for violent and aggressive acts. However, there are disparities in the opinions of the patients and staff. Patients, on the contrary, believe that loopholes in management, unyielding ward environment and poor communication lead to violence. To gain a holistic knowledge about the determinants of violence, factors causing violence have been classified into three conceptual models – internal, external, and relational or situational models. Internal models constitute all factors related to the patients – patient’s demographics, age, gender, diagnosis, the severity of illness, criminal history, history of substance abuse, history of violence, length of stay at the facility, the past number of admissions, etc. Patients who have co-morbid substance dependence are five times more likely to engage in violent and aggressive acts as compared to patients who do not have a co-morbid substance dependence. Patients with paranoid schizophrenia have high chances of acting out their fears and delusions through violent acts in an attempt to protect themselves (Silverstein et al., 2015). External factors involve the environmental factors, the facility milieu where the inpatients reside and interact. These factors include the ward size, ward spaciousness, the structure of the ward, the location of the ward, the level of surveillance provided by the staff, the professional competence of the nurses, and the preventive techniques used for resolving violence and aggression. Lack of appropriate surveillance often results in unpredicted violence, which is more difficult to de-escalate. Inefficient preventive measures lead to increased frustration, fear, and a sense of insecurity within the inpatients leading to escalated aggression. Ward crowding has been a pervasive problem that has attracted the attention of researchers for a long. Some researchers have postulated that ward crowding might promote aggression by exposing the inpatients to a greater number of adverse and stressful situations like intense simulation, ward turmoil, and absence of privacy (Virtanen et al., 2011). However, crowding has been defined differently by different studies. Some studies mention the bed occupancy rate; others include patient density and ward density but do not clearly define ‘density’.

The relational factors include the nature of interaction and relationships in the facility. A negative therapeutic relationship between the patients and the staff can lead to more tension, hostility and aggression. Miscommunication and misinformation in the ward can lead to increased chaos and frustration. It is essential to keep in mind that some mental health patients organically get more agitated and promptly act on impulse. Violent incidents can be effectively decreased if the staff are more engaged in the caring practice and an understanding and trustworthy patient-staff relationship is created.

Several psychiatric facilities have introduced the zero-tolerance policy, which clearly states the tolerance limit after which any negatively impactful actions on the part of the inpatients will be dealt with serious consequences. Traditionally facilities would resort to measures like seclusion, involuntary restraints of inpatients to reduce physical movement by the help of either physical means or pharmacological means, restriction of voluntary movement, etc (Knox & Holloman, 2012). These techniques had several negative consequences on the patients, the staff, other inpatients, and everyone who witnessed the restraint. The method of restraint is frequently fear inducing, distressful, and psychologically damaging for everyone who witnesses it. Patients may suffer from physical consequences of these strategies like body aches, pain, lacerations, thrombosis, asphyxiation, and even death. Psychological consequences of these methods of handling violence are stress, post-traumatic stress disorder, anxiety, fear, depression, and self-harming behaviors in patients (Larue et al., 2013). Due to all of these adverse outcomes, the use of these techniques is currently being circumvented as far as possible. Instead, other non-corporal techniques are being used as alternative measures to deal with ward violence. Seclusion and medicinal restraints (use of tranquilizers and sedatives) are still used but as the last possible option when every other measure fails to de catalyst violence. Alternative measures to manage violence and aggression can involve primary, secondary and tertiary preventive measures.

Primary preventive measures will include the restructuring of the facility wards. A study proposes a model that implements several designs and infrastructural changes in the facility that can greatly reduce stressors and in turn decrease aggression and violence (Ulrich et al., 2012). Crowding stress can be reduced by the construction of single-patient rooms with private bathrooms. Several studies have found that sharing a room in the facility significantly correlates with reduced privacy, social withdrawal, increased crowding stress, more illness complaints, and behaviors that are more aggressive (Ulrich, Bogren & Lundin, 2012). Lack of privacy results in increased mental fatigue and lack of rest, resulting in irritable mood and frustration. Single rooms attached with surveillance devices make it easier for the staff to monitor vulnerable patients, reduce crowding stress, and physical conflicts. Personal space intrusion often triggers fights and avoidance behaviors in patients leading to aggression. Therefore, it is important to introduce a communal space with movable seating, sitting options, and enough sitting space. In shared sitting areas, movable chairs and ample space for each patient can enhance personal space regulation. Studies have found that unpredictable and uncontrollable loud noises can instigate anxiety, fear, stress, and aggression among inpatients. The reduction of unwanted noises helps in intelligible communication, lowers psychological stress, and improves treatment outcomes. Therefore, psychiatric facilities should opt for noise-reducing designs to regulate aggression in patients. The rooms of the patients can be designed in such a manner that improves patient’s control over their own surroundings. Rooms, which can be customized by the patients according to their needs, will allow them to evade stressors and reduce aggression. For example, in a room whose windows can be opened, lighting can be controlled and personalized with mementos and pictures. Stresses reducing positive distractors like allowing the patients and staff to access garden areas with vegetables and flowers have been seen to reduce stress. Studies suggest that viewing nature can also release physiological and psychological stress in patients. The location of the rooms and windows with nature’s view has a considerable positive impact on the stress levels. Installment of nature’s art in patients’ rooms can also bring about calming effects on them. The design of the facility should be thus that there is good visibility of the patient’s rooms from the staff base. Staff should be trained to unobtrusively monitor the patients through meaningful movements around the patients’ rooms, activity areas, day rooms, and corridors.

Secondary preventive measures constitute the use of de-escalating measures to evade flashpoints. Warning signs of violent behaviors include shouting, yelling, agitation, use of abusive languages, which can eventually escalate to physical violence (Yalcin & Bilgin, 2019). Nurses should be trained to recognize these signs and implement calming and de-escalating techniques to handle the situation. The use of non-threatening, respectful, empathetic verbal and non-verbal cues can help the patient to calm down (Spencer, Johnson & Smith, 2018). The patient’s point of view should be considered and understood and challenging, provoking questions should be ignored. Positive attitudes towards the patient can help create trust and allow sound communication between patient-staff. The staff should focus on controlling one’s emotions and impulses. If these non-physical techniques fail, breakaway and evasive self-defense strategies can be used to safely remove patients from violent conditions. Staff can wear portable duress alarms to summon other staff if further assistance is needed in emergencies.

Tertiary measures include the use of strategies to deal with the aftermath of violent or aggressive behavior. Medical assistance is to be immediately provided to victims, perpetrators, staff, and anyone who has sustained a physical injury (pain, cuts, and falls) following a violent episode. Stress management programs, psychoeducation workshops, and counseling should be conducted for everyone who has been psychologically impacted by directly witnessing the violence (Nowrouzi et al., 2015). One of the most debilitating outcomes of witnessing violence is Post-traumatic Stress Disorder in psychiatric nurses (almost about 10% of nurses have PTSD resulting from witnessing assault) (Jacobowitz, 2013).

There is no one foolproof preventive measure of violence and aggression, especially in psychiatric inpatient wards. Psychiatric wards are the birthplace of aggressive and violent behaviors due to sustained interactions between unique personalities with mental disturbances. Therefore, complete removal or aggressiveness is not possible. However, violence can be reduced and more so, prevented to a great degree, if the primary, secondary and tertiary measures as discussed in the proceeding sections, can be successfully implemented. Care should be taken to design the infrastructure of the psychiatric wards in such a manner that ensures retention of personal safety, supervision, privacy, harmony, and integrity. Effective de-escalating methods should be trained to the staff to handle violence. Advocacy and medical support can be provided to the staff, inpatients, victims, and perpetrators, to deal with post-episodic trauma and stress.

References

Gates, D. M., Gillespie, G. L., & Succop, P. (2011). Violence against nurses and its impact on stress and productivity. Nurs Econ, 29(2), 59-66.

Howard, R. (2015). Personality disorders and violence: what is the link?. Borderline personality disorder and emotion dysregulation, 2(1), 1-11.

Jacobowitz, W. (2013). PTSD in psychiatric nurses and other mental health providers: a review of the literature. Issues in mental health nursing, 34(11), 787-795.

Knox, D. K., & Holloman Jr, G. H. (2012). Use and avoidance of seclusion and restraint: consensus statement of the american association for emergency psychiatry project Beta seclusion and restraint workgroup. Western Journal of Emergency Medicine, 13(1), 35.Lantta, T., Anttila, M., Kontio, R., Adams, C. E., & Välimäki, M. (2016). Violent events, ward climate and ideas for violence prevention among nurses in psychiatric wards: a focus group study. International journal of mental health systems, 10(1), 1-10.

Larue, C., Dumais, A., Boyer, R., Goulet, M. H., Bonin, J. P., & Baba, N. (2013). The experience of seclusion and restraint in psychiatric settings: perspectives of patients. Issues in Mental Health Nursing, 34(5), 317-324.

Nowrouzi, B., Lightfoot, N., Larivière, M., Carter, L., Rukholm, E., Schinke, R., & Belanger-Gardner, D. (2015). Occupational stress management and burnout interventions in nursing and their implications for healthy work environments: A literature review. Workplace health & safety, 63(7), 308-315.

Pelto-Piri, V., Warg, L. E., & Kjellin, L. (2020). Violence and aggression in psychiatric inpatient care in Sweden: a critical incident technique analysis of staff descriptions. BMC health services research, 20, 1-11.Silverstein, S. M., Del Pozzo, J., Roché, M., Boyle, D., & Miskimen, T. (2015). Schizophrenia and violence: realities and recommendations. Crime psychology review, 1(1), 21-42.

Spencer, S., Johnson, P., & Smith, I. C. (2018). De‐escalation techniques for managing non‐psychosis induced aggression in adults. Cochrane database of systematic reviews, (7).

Ulrich, R. S., Bogren, L., & Lundin, S. (2012). Towards a design theory for reducing aggression in psychiatric facilities. In ARCH12 Conference: International Conference ARCH12 and Forum Vårdbyggnad Nordic Conference 2012. Chalmers Institute of Technology.

Ulrich, R. S., Bogren, L., Gardiner, S. K., & Lundin, S. (2018). Psychiatric ward design can reduce aggressive behavior. Journal of Environmental Psychology, 57, 53-66.

Virtanen, M., Vahtera, J., Batty, G. D., Tuisku, K., Pentti, J., Oksanen, T., ... & Kivimäki, M. (2011). Overcrowding in psychiatric wards and physical assaults on staff: data-linked longitudinal study. The British journal of psychiatry, 198(2), 149-155.

Yalcin, S., & Bilgin, H. (2019). Risk predictions of physical aggression in acute psychiatric wards: Findings of a prospective study. Nursing & health sciences, 21(3), 316-322.

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