28TH ANNUAL MEDICAL-SURGICAL NURSING CONFERENCE

CARING FOR THE PSYCH PATIENT ON THE MEDICAL SURGICAL NURSING UNIT NATALIE CENTURIONI, MSN, RN, CNL

OBJECTIVES

• Understanding the cycle of aggression• Identification, prevention and

management through therapeutic communication and verbal de escalation practices

• Guide the patient to make healthy choices • Learn how to regulate our own behavior in a

crisis, even when it is not intuitive

AGGRESSION

AGGRESSION• Usually starts out as anxiety and progresses

to agitation • Generally, does not occur abruptly or randomly

• May or may not result from a triggering event

• Escalates with frustration, when an expected goal is believed to have been intentionallyimpeded

• Presence of a perceived threat

CONTRIBUTING FACTORS

• Underlying medical conditions• Delirium/dementia

• Physical or psychological discomfort• Pain

• Psychosis• Persecutory Delusions

CONTRIBUTING FACTORS

• Known history of aggression • Cruelty toward animals

• History of trauma or physical/sexual abuse

• Intoxication/Substance abuse

• Age/gender/ethnicity

CONTRIBUTING FACTORS

We draw beliefs from:

1) Our observations 2) Our past experiences

THE AGGRESSION CYCLE

• Every stage offers a chance to step in • Our behavior influences the patient’s behavior • Always apply the least restrictive

intervention(s) first

• Your de escalation interventions must reflect the patient’s behavior

THE AGGRESSION CYCLE

THE AGGRESSION CYCLE

• Before escalation, patient is at baseline which is his or her version of calm.

Now is your opportunity to PREVENT AGGRESSION

Recognizing Aggression

• Closed demeanor

• Facial expressions

• Gestures

THE ESCALATION PHASE

THE ESCALATION PHASE Verbal Cues

• Persistent or frequent Questioning • Suspiciousness• Somatic complaints• Yelling/Crying /Mumbling/Cursing/ Name calling • Challenging/Increased complaining/“negative

attitude” • Refusal

THE ESCALATION PHASE

Behavioral Cues • Tearing objects (such as paper)

• Chewing on patient ID band

• Slamming cabinets/doors

• Isolate/act detached

• Less re-directable

• Hyper-vigilance

THE EXPLOSION PHASE

Imminent Danger to Self • Scratching self • Cutting self• Banging head • Attempting to choke/hang self • Attempting to swallow something hazardous• Attempting to elope

THE EXPLOSION PHASE

Imminent Danger to Others • Physically assaultive

• Kicking• Biting• Grabbing • Scratching

• Throwing • Posturing

THE POST EXPLOSION PHASE

• Patient is no longer imminent harm to self or others

• Situation is controlled and safe

• Patient was • Able to calm down on his or her own OR• Required physical hold, seclusion or

restraints to help calm down

THE POST EXPLOSION PHASE

• Requires ongoing evaluation, patient at increased risk to be triggered again

• Debrief • Restore therapeutic relationship• Help patient to develop a safety plan

for future • Identify individual coping skills

PRECAUTIONS FOR THE HIGH RISK PATIENT

BUILDING YOUR BANK

How to develop trust and rapport with your patient

• Should start from the moment you meet

• “Yes opportunities” when establishing

boundaries

BUILDING YOUR BANK

• Follow through • Anticipate needs • Spend an extra 5 minutes• Make yourself relatable • Explain expectations honestly• Make promises cautiously

ENVIRONMENTAL FACTORS

“Anything and Everything” • Temperature

• Light

• Sound

• Time of day (change of shift)

• People (family members or staff)

• Personal space

INITIATE A “SAFETY STANCE”

• Execute “open” body language • Do not cross your arms, keep them at

your side

• Keep your hands visible • No clenched fists • Avoid placing hands on your hips

• Remain at eye level

INITIATE A “SAFETY STANCE”

• Maintain eye contact, but do not glare • Position your body to the side• No sudden gestures • Always remain closest to exit

INITIATE A “SAFETY STANCE”

• Maintain a leg’s length distance • Respect the patient’s personal space (everyone is

different) • Ask before touching • Be considerate when handling personal

belongings • Announce what you are doing

It’s How You Say It! • Non threatening tone

• Gentle/Soft voice

• Inflection

• Cadence

• Speed

• Simple/Concise words

IT’S NOT WHAT YOU SAY…

It’s How You Say It!

Does your body language correspond to what you are saying?

IT’S NOT WHAT YOU SAY…

WHAT TO AVOID

• Evading the question

• Ignoring the patient

• Engaging in a power struggle/ acting defensive

• Condescending attitude

• Acting as an authoritarian

WHAT TO AVOID

• Appearing impatient or distracted (do not be on computer or phone)

• Sarcasm • Limit use of personal opinion or judgments• Be mindful of medical verbiage • Taking sides • Having the last word

HOW TO DE ESCALATE USING VERBAL

COMMUNICATION

DE ESCALATION INTERVENTIONS

• Address the situation

• Listen

• Validate/ Explain

• Redirect by distraction

• Limit Setting

DE ESCALATION INTERVENTIONS

• Physical Intervention • Emergency Medicine • Seclusion• Mechanical

Intervention/Restraint

EMPATHY • Having an emotional understanding of the patient’s

experience

• Put yourself in the patient’s shoes

• Essential in order develop and maintain a therapeutic relationship

• Remember, the client may be responding to the perceived threat instead of the true threat

ADDRESSING THE SITUATION

• Remain calm, maintain respect and dignity • Give Charge RN a heads up of what you are

doing, especially if you anticipate escalation• Meet with the patient one on one (no group settings)

• Second team member for safety • One person should speak at a time

• Ideally, the same person speaking should step into lead the situation

• Does the client need to cool down first?

LISTENING • Remain attentive! • Ask ACTIVE and open ended questions so the

patient shares his or her perspective

•What happened? •What were you feeling at the time? •What made you respond the way you did?

LISTENING

• Listen reflectively• Summarize what patient said in your own

words and then confirm that you are understanding correctly

• The importance of silence

VALIDATE & EXPLAIN

• Acknowledge

• Refocus challenging questions/opinions

• Find common ground

• Validate emotional responses

• Agree to disagree (if applicable)

VALIDATION & ORIENTATION

• Figure out how we can move forward • Recognize why patient was triggered • Offer available resources or additional

support • How will they regain some self control?

EXPLORING SOLUTIONS

• Only promise what is possible

• If you are unable to offer the ideal, explain why and then offer an alternative

• Give realistic timeframes

• Offer choices (generally no more than 2)

• Journaling/Drawing • Writing a letter • Watching

TV/Reading• Listening to Music • Calling a

friend/family member

• Make a gratitude list

• Cool face towel • Relaxation

techniques/Meditation

• Exercise • Take a nap • Shower• Crosswords/mind

teasers

REDIRECTION BY DISTRACTION

LIMIT SETTING

• Be firm, but polite

• Clearly verbalize what is acceptable

• What is inappropriate and why?

• Offer alternatives (no more than 2)

• Requests should be no longer than 5 words

• Focus on one issue at a time

LIMIT SETTING

• Is your direction realistic for patient?

• Hold the patient accountable, but do not

reinforce self shame

• Avoid threatening, but state consequences • Only if you can follow through with said

consequence • Consistency is key!

REFLECTIONS

PATIENT DEBRIEFING

• Opportunity to restore the therapeutic alliance between you and the patient

• How can I, as the provider do better next time?

• Do we all understand expectations moving forward?

PATIENT DEBRIEFING • Ask open ended questions so patient can

describe what happened in his or her own words • What coping skills can you use next time

you are feeling triggered? • Is there a particular person you feel

comfortable talking to if you start to feel upset?

• Do you have a safety plan?

STAFF DEBRIEFING • A time to process emotions

• Encourages team work/helps to create a positive rapport with coworkers

• Learning opportunity • What worked for you? What didn’t work for

you? • Review the “do’s and don’ts” for next time

• Was it therapeutic for the patient?

HOW DO YOU REACT IN A CRISIS?

• Panic

• Overreacting

• Delayed reactions

• Hasty or rushed reactions

• Confusion

• Avoidance

• Overly emotional

HEADS UP! An Agitated Patient Will…..

• Attempt to get under your skin • By insulting you• Testing you • Betraying you

Reminder to always maintain appropriate boundaries and nevershare personal details about yourself

HEADS UP! • Do not engage in the insult

• Practice your poker face!

• Know when to rely on the strengths of a coworker

• Embrace your individual traits and use them to your benefit

• i.e. wit, gender, age, ethnicity, physical characteristics, etc.

• Present a united front with your teammates (coworkers) • Staff splitting

REFERENCES

John Muir Behavioral Health Center (2017). Workplace Violence Training and Disruptive Behavioral Strategies. Concord, CA

Reilly, P. & Shopshire, M. (2012). Anger management for substance abuse and mental health clients: A cognitive behavioral therapy manual. Substance Abuse and Mental Health Services Administration. 27-30. Retrieved from https://store.samhsa.gov/shin/content/SMA12-4213/SMA12-4213.pdf

Richmond, J., Berlin, J., Fishkind, A., Holloman, G., Zeller, S., Wilson, R., Rifai, M., & Ng, A. (2012). Verbal de-escalation of the agitated patient: Consensus statement of the American association for emergency psychiatry project BETA de-escalation workgroup. Western Journal of Emergency Medicine. 13(1): 17–25. DOI: 10.5811/westjem.2011.9.6864

Wain, T. & Khong, E. (2011). Aggressive behavior: Prevention and management in the general practice environment. Australian Family Physician, 40 (11), 866-872.