During my clinical in psychiatric ward I was asked by one of the registered nurse to accompany that nurse in patients room who was just admitted in the ward. When we entered the room the nurse directly asked the patient to go and change her home clothes and wear hospital clothes. The patient become very aggressive and violent, while the nurse forcefully took the patient in washroom and threatened the patient to change her clothes otherwise she would call her husband and a male staff, after this comment by the nurse, the patient tried to hit the nurse and in result the nurse pushed the patient. I was observing all this, and was forced to stop the nurse and I asked her to be gentle rather than being so rude with the patient. In her response, she said “let me do whatever I am doing. She comes to psychiatric ward every second day to get admitted, I know better how to treat her”.
This unpleasant incident was the eye-opener for me and urged me to write on the topic of therapeutic communication as a health promoting practice and how this practice helps in dealing with the aggressive and violent patients. It is one of the most important skills which a nurse can develop is therapeutic relationship with their clients. Although it is important in every nursing specialty but therapeutic communication is especially essential with the patients requiring psychiatric care, in order to apply nursing process effectively and perform successful intervention. In my paper ahead I will discuss about aggression among psychiatric patients, using of verbal and non-verbal communication techniques as a mental health promoting practice. Moreover, I will discuss nursing process and at last I will be giving some recommendations.
Aggression is defined by the American Psychological Association as ”behavior performed by one person (the aggressor) with the intent of harming another person (the victim) who is believed by the aggressor to be motivated to avoid that harm”. A Swiss study reports that 47% (n = 114) experience threats and that 37% had been attacked one or more times in psychiatric nursing settings (Abderhalden et al., 2002) as cited in Nau, Dassen, Halfens, Needham 2007. Violence result in frustration and stress among psychiatric nurses and thus they leave the job or may behave and communicate rude with patents. According to Zernike and Sharpe, 1998 as cited in Nau, Dassen, Halfens, Needham 2007 it is known that relating to verbal and physical aggression staff experiences feelings such as frustration, anger, feeling hurt, fear, resentment, helplessness, anxiety and irritation.
In order to bring a change in any practice it is essential to apply nursing process. Though, in the situation mentioned above I was not directly involved to apply nursing process. However, there are things possible which could have done to control over that situation which I will discuss further. Nursing assessment is important step to predict patient’s behavior. Although, one cannot accurately predict the upcoming situation stuart (2009) has given the hierarchy of aggressive and violent patient’s behavior added as (Appendix A) which can be a helpful tool in assessing aggressive patient. Moreover, staurt (2009) talked about early behavioral signs including motor agitation sings such as pacing, inability to sit still, clenching fists, Increased respiration and catatonia, along with this, verbal clues may be present like verbal threats, intrusive demands, loud speech and paranoia. Assessment of affect is also important which includes anger, irritability, extreme anxiety and euphoria. There may be the change in level of consciousness like confusion, disorientation, and memory impairment. However in my case nurse was unable to assess these behaviors. After assessment planning is a critical step in which nurse plans for interventions according to the situation and next comes the intervention phase.
There are several theories on aggression which includes psychoanalytical, behavioral, and cognitive theories. In accordance with the scenario mentioned above I will discuss one of the cognitive theories. Beck 1976 as cited in Boyd 2005 proposed that cognitive schema such as judgments, self-esteem, and expectations influence angry responses. If aggressive patient perceived any situation as intentional, unprovoked, dangerous, and perceived offender as undesirable the recipient’s reaction will be exaggerated. Similarly, in that particular case nurse was threatening the patient due to which patient’s aggression was intensified and results in physical violence.
There are varieties of interventions which can be implemented to manage aggressive behavior in psychiatric settings in order to promote mental wellbeing of patients.. Stuart (2009) has given the continuum of nursing interventions in managing aggressive behavior added as (Appendix B). These interventions can be divided in preventive, anticipatory and containment strategies. Preventive strategy includes patient education, self awareness and assertive training. Anticipatory strategy includes verbal and nonverbal communication, medications and behavioral changes. Milieu strategies include environmental changes. Moreover, crisis management techniques and containment strategies for instance restrain and seclusions are used as last resort if despite all strategies aggressive behavior persists. In addition, these interventions can also divide as biological, social and psychological domain given by Boyd (2005) added as (Appendix C). However, in my paper due to word count limit and according to my scenario, I will only talk about verbal and non verbal communication techniques which fall under psychological domain and anticipatory strategy.
Psychological interventions help patients to achieve control over their aggressive behaviors. In addition, these interventions also eradicate the need for chemical or mechanical restrains and communication strategies are significant intervention which can prevent crisis situation. According to Gerloff and Shannon as cited by boyd 2005 in recent years, interest has arisen in developing communication techniques that promote the expression of anger in non-destructive ways.
According to study done by Chen, Hwu, and Williams (2005) the nurses indicated that their most frequent methods of management of aggression were use of the isolation room, medications, and physical restraints. However, I will discuss some of the therapeutic communication skills in managing aggressive behavior. Aggressive patients often speak loudly and use bad language therefore, it is important that nurse speak in a calm and low voice and do not raise their voice in response because this may perceive as competition and further shoot up impulsive circumstances. Moreover, nurse should avoid inappropriate smiling and laughing and should use simple, short and easy sentences. However, the case mentioned above clearly states that nurses shouted on patient and in result physical violence occurs. Secondly, acknowledging and validating patient’s feelings and reassuring them that staff is there to help them is one the good strategy which can reduce the level of agitation, because this gives permission to patients to communicate their feelings and concerns without interruption. Moreover, this can also reduce patient’s feelings of isolation. Though, in the above mentioned case nurse did not allow patient to express her feelings nor acknowledge her will. Thirdly, nurse should communicate patients in such a way that encourages them to have control on their violent impulses. It helps in facilitating self control because patients may be willing to remove themselves from over stimulating environment. Conversely, in above mentioned case nurse threatened the patient which destructed the whole situation.
Nonverbal communication techniques of the nurse are also important in managing patient’s aggressive behaviors. Staurt (2009) suggested some non verbal communication techniques, which include calm and relaxed posture with nurse’s head lower than the patient’s head. It is less threatening to patient and this communicates that nurse is willing to help patient. Conversely, hands on hips and nurses impend over the patients and arms across the chest are the posture which communicates reluctance to help and emotional distance. Furthermore, nurses should avoid frightening, nervous and impulsive gestures. Therefore, nurse’s hands should be kept open and out of pockets. Nurse’s should also keep their eyes at the same level as those of patients or lower in order to allow patients to communicate from an equal level and patient would not feel inferior. Aggressive patients need four times more personal space than non-aggressive prone people. Interruption into personal space can be perceived as a danger and aggravate aggression. Hence, staurt (2009) suggested that nurses should remain at an angle to the patient so as to respect patient’s need for personal space. Therefore, it is importance for the nurse to observes patient’s behaviors for instance clenched fists, tightening of facial muscles and moving away from the nurse which give clues that patient is feeling threatened and may get aggressive so that to perform early interventions. However, in the above mentioned case rather giving space to patient the nurse was holding patient’s hand and pushing her in the bathroom to change her clothes. Moreover, nurse’s expressions were threatening to the patient which was showing unwillingness to help. Finally comes evaluation phase, it is important that nurse must evaluate that patient has maintained control over aggressive feeling, thoughts, behavior and actions. Lastly, before discontinuing the intervention let patient know that which behavior is acceptable and how to control over there aggression.
Along with the above mentioned interventions one of the important strategies is that nurse should behave in an assertive manner. The midpoint of the continuum which runs from passive behavior to aggression is assertive behavior. According to Stuart (2009) “assertive behavior conveys a sense of self-awareness but also communicates respect for other person.” (p.574). Moreover, assertive people always speak clearly and conspicuously. There gestures are non-threatening and they maintain appropriate eye-contact and respects personal space. Furthermore, assertiveness helps people in refusing an irrational request. However, they always give justification for particular action. If I reflect back that situation the nurse was continuously asking patient to wear hospital clothes without providing sound rationale. Rather being assertive nurse was behaving rude to patient.
There was one research study done in Pakistan in year 2006 by Iqbal, Naqvi, and Siddiqui which aimed to study the inpatient violence in psychiatric patients and its management. The study concluded that out of 393 patients, in most of the cases (14%) physical restraints and seclusions are used to control aggressive situation or sometimes it is done with the combination of chemical restrains like heloperidole and benzodiazepines which estimated (44%). Though, there is a high risk of abuse attached with physical restraints. However, authors have not given other methods to control aggressive and violent patients like communication skills. Therefore, more researches are needed in Pakistan to apply proper management of aggression in order to enhance patients mental well being.
This Scholarly paper proved to be a good learning journey for me; because there were few perceptions which were attached with psychiatric patients, and especially those who are aggressive and violent. This were mostly build when I heard harsh comments in the morning over from nurses that XYZ patient is violent so avoid going in there rooms, they are dramatic, they are attention seekers, do not talk to them etc. However, this is not the fact. There must be some bio-psycho-social factors attached behind that aggression. Therefore it is vital for nurse to understand them and intervene accordingly. Moreover I explored new scope of therapeutic communication specifically with aggressive patients as a health promoting practice. Although I was not able to apply nursing process mentioned above but this would defiantly help me whenever I will deal with aggressive patients. In addition, for the first time I learned about the psychiatric advance directive which was previously not known to me. This is one of the strategies which could assist the patient when they are unable to participate in their treatment decision.
In recommendation, I would like to highlight that nurses working in the psychiatric ward should be competent in dealing with psychiatric patients. Nau, Dassen, Halfens, Needham 2007 suggested that psychiatric ward nurses should be able to detect and remove causes of aggression, to interpret aggressive situations correctly, to de-escalate and to cope with their own perceived stress. This can be only done If there are proper training programs arranged which increases awareness, enhance self confidence in dealing with aggressive patients rather ignoring or blaming them, strategies to cope in appropriate manner via communication skills like assertiveness and empathy. Moreover, there should be a safety policy in hospital for patients and staff who deal with aggressive clients and proper ordinance guidelines, unfortunately mental health ordinance for Pakistan 2001given by president muhammad rafiq tarar does not addressed the issue of managing aggressive clients without using physical and chemical restraints.
In conclusion, I would like to say that the nurses are in best position to bring about a transition in traditional forms of practices. To conclude the scenario of above mentioned patient, I think it was a nurse responsibility to oblige by patient’s will. Therefore, nurse should not have forced the patient to change her clothes or threat her because this act of the nurse increased patient’s aggression. Rather, behaving in calm, soft, non-judgmental manner. Nurse should also have heard the patient concerns and given space to patient so as to avoid physical violence. However, communication is building block for the therapeutic relationship. Therefore, in order to intervene effectively in controlling patient’s aggression the nurse should use proper verbal and non-verbal communication techniques.