patient aggression

8/13/2019 Patient Aggression

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Patient Aggression

01/07/2013

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Recommended Practice

RISK ASSESSMENT:The patient may pose a risk for aggression if they have any of the following risk factors:

• The person appears agitated or restless.• There is resistance to suggested treatment.• Aggression management has been required at time of transfer.• The person has assaulted a health worker within the past 12 months.• There is a known history of threatening or aggressive behaviour.• The person has made a threat of aggression directed towards people or property.• The person has friends or family members whose aggressive behaviour may place staff orothers at risk.• There is a known history of drug or alcohol misuse.• A medical condition is present that may cause the person to misinterpret the environmentor staff care activities (eg, confusion, disorientation, delirium, acute hallucinations, anddelusions).

AGGRESSION PREVENTION PROGRAM:To combat aggression, healthcare workers should participate in an aggression managementtraining program. Persons who have been exposed to violence should receive timely supportand assistance following the incident. Management should focus on preventative strategiesto reduce risk factors known to be associated with workplace violence, this may includeviolent or psychotic patients and the use of force against patients. Employers and nursingorganisations should develop policies in response to ongoing aggression and violence frompatients allowing healthcare workers reporting avenues and taking legal action if required.Mental healthcare organisations must look beyond staff training if they are to achievemeaningful reductions in aggressive incidents and staff injuries. Those exposed toemotional/psychological injury following violence/aggression has a strong negative influenceon staff and needs to be treated. Characteristics of an aggression prevention programinclude:

• The promotion of a philosophy that violence and aggression are unacceptable.• A promotional campaign to convey to staff that the organisation values their wellbeing andsafety in the workplace.• A promotional campaign to convey to hospital patients and consumers that violence will notbe tolerated and that sanctions will be applied.• A response to incidents of aggression that considers both patient and staff safety.• A risk management framework that includes a process for assessing potential risk ofviolence and developing subsequent strategies.




• Active involvement of senior clinicians and administrators in the incident response system.• Debriefing and defusing mechanisms to support staff who have been exposed toaggression and violence in the workplace.• Ongoing evaluation and development of programs to ensure the needs of staff, patientsand the hospital continue to be considered.• An educational program, accessible to all staff, that focuses on controlling the risk ofviolence and aggression.

References

Evidence Summary: Healthcare Facilities:Patient Aggression/Violence

2013

Author

Nasreen Jahan MBBS, MPH

Summary

Question

What is the best available evidence regarding the management of aggression and violencein healthcare facilities?

Clinical Bottom Line

Healthcare workers are now recognized as being at high-risk of assault in the workplace.The effects of violence are wide and varied, including increased absenteeism, and sickleave, property damage, decreased productivity, security costs, litigation, workers’compensation, reduced job satisfaction together with recruitment and retention issues.1

Potential sources of workplace violence in healthcare settings include both clients/patientsand co-workers, with the majority of healthcare workers subjected to workplace violence atleast once during their professional careers.2 (Level III)A study revealed that 95% of nurses in Australian hospitals had encountered verbalaggression several times in the preceding 12 months.2 (Level III)A systematic review examined the risk factors and consequences of nonfatal violencetowards staff at work. The findings showed that management should focus on three risk




factors, these are:3 (Level I)

Individual: staff in the young age group and previous exposure to violence.Situational: interpersonal conflicts, having to use force towards a patient, and dealing withpsychotic patients,Structural: working in the evening or at night.

The review also found three prevention strategies:3 (Level I)

Primary prevention: is the reduction of risk of violence,Secondary prevention: is the reduction in duration and extent of the violence,Tertiary: refers to the exposed person receiving timely support and assistance following theincident.

A study revealed that nurses and other health professionals are second only to the policeand security staffing terms in their likelihood of experiencing violence at work. Nurses hadthe second highest risk of being physically assaulted, at four times the British nationalaverage, while their exposure to verbal threat and intimidation was calculated to be twice theBritish national average.4 (Level IV)A study examined the experiences and perceptions of healthcare workers at three hospitalsand one health clinic towards violence. The study found that staff were reluctant to reportincidences of violence and felt vulnerable to abuse with criticism leveled at management,police and the courts for their attitude towards assault victims/employees. Staff also cited thedesire for – ‘breakaway’ training, increase in the number of security guards on duty, issuingof personal alarms and encouraging of official reporting of incidents.5 (Level III)A study evaluated the effectiveness of an aggression management training program. The

results revealed that training of staff in assertive and aggression management is an effectiveintervention in dealing with violence and aggression.2 (Level III)A study aimed at identifying the types of violent and aggressive incidents that staffexperienced in an Accident and Emergency Department over a period of one month. Thefindings revealed that nurses working in Accident and Emergency departments have a highlevel of exposure to a range of aversive experiences, with 81% and 89% of respondentsexposed to verbal aggression.6 (Level III)The aforementioned study also revealed that patients were the single largest source ofaggression and violence toward nurses. The findings suggested that violence andaggression in the workplace are becoming normalized features of work life in such settingsand that policy responses were required from both nursing organizations and employers.6

(Level III)A narrative review of the literature reported that although aggression management staff

training has been proven effective in some areas, such as reducing the use of restraints andother coercive control devices, relying too heavily on aggression management staff trainingwill have limited effect on addressing the range of issues related to patient-perpetratedviolence in psychiatric hospitals. Mental healthcare organizations must look beyond stafftraining if they are to achieve meaningful reductions in aggressive incidents and staffinjuries.7 (Level IV)A study indicated that a sharper awareness of the effects of violence on staff is vital at alllevels of management. Most attention is given to physical injury but verbal aggression andthreats, often disregarded, may have the strongest negative influence.




Emotional/psychological injury was rarely treated and needs to be.8 (Level III)A randomized controlled trial found that intramuscular droperidol and midazolam resulted ina similar duration of violent and acute behavioral disturbance, but more additional sedationwas required with midazolam. Midazolam caused more adverse effects because ofoversedation, and there was no evidence of QT prolongation associated with droperidolcompared with midazolam.9 (Level II)Routine application of structured risk assessment measures might help reduce incidents ofaggression and use of restraint and seclusion in psychiatric wards.10 (Level II)Internet training is a viable approach to shape appropriate nurse aides (NAs) reactions toaggressive resident behaviors. This format has future potential because it offers fidelity ofpresentation and automated documentation, with minimal supervision. 11 (Level II)A systematic review on the use of zuclopenthixol acetate for the management of psychiatricemergencies found that use of zuclopenthixol acetate may result in less numerous coerciveinjections and low doses of the drug may be as effective as higher doses. This review didnot find any suggestion that zuclopenthixol acetate is more or less effective in controlling

aggressive acute psychosis, or in preventing adverse effects than intramuscular haloperidol,and neither seemed to have a rapid onset of action.12 (Level I)

Characteristics of the Evidence

The evidence included in this summary is from a structured search of the literature andselected evidence-based health care databases. Evidence in this summary is from:

Expert opinion.1,4

Two systematic reviews.3,12

Two comparative studies.2,5

Two cross-section studies.6,8

A literature review.7

Two randomize controlled trial with 223 and 597 participants.9,10

A randomized treatment and control design with baseline, 1-, and 2-month assessments for158 nurse aides (NAs).11

Best Practice Recommendations

Healthcare workers should participate in an aggression management training program.(Grade B)




Persons who have been exposed to violence should receive timely support and assistancefollowing the incident. (Grade B)Management should focus on preventative strategies to reduce risk factors known to beassociated with workplace violence, this may include violent or psychotic patients and theuse of force against patients. (Grade B)Employers and nursing organizations should develop policies in response to ongoingaggression and violence from patients allowing healthcare workers reporting avenues andtaking legal action if required. (Grade B)Mental healthcare organizations must look beyond staff training if they are to achievemeaningful reductions in aggressive incidents and staff injuries. (Grade B)• Emotional/psychological injury following violence/aggression has a strong negativeinfluence on staff and needs to be treated. (Grade B)

References

1. Farrell G, Cubit K. Nurses under threat: A comparison of content of 28 aggressionmanagement programs. Int J Ment Health Nurs. 2005; 14: 44-53. (Level IV)2. Oostrom J, Mierlo H. An evaluation of an aggression management training program tocope with workplace violence in the healthcare sector. Res Nurs Health. 2008;31: 320-328.(Level III)3. Hogh A, Viitasara E. A systematic review of longitudinal studies of nonfatal workplaceviolence. Eur J Work Organ Psychol. 2005; 14(3): 291-313. (Level I)4. Beech B, Leather P. Workplace violence in the health care sector: A review of stafftraining and integration of training evaluation models. Aggress Violent Behav. 2005; 11:27-43. (Level IV)

5. Reol H, Gokdogan M, Erkol Z, Boz B. Aggressive and violence towards health careproviders – A problem in Turkey? J Forensic Leg Med. 2007;14:423-428. (Level III)6. Ryan D, Maguire J. Aggression and violence – a problem in Irish Accident andEmergency departments? J Nurs Manag. 2006; 14: 104-115. (Level III)7. Livingston JD, Verdun-Jones S, Brink J, Lussier P, Nicholls T. A narrative review of theeffectiveness of aggression management training programs for psychiatric hospital staff. JForensic Nurs. 2010; 6: 15-28. (Level IV)8. Yarovitsky Y, Tabak N. Patient violence towards nursing staff in closed psychiatric wards:it's long-term effects on staff's mental state and behaviour. Med Law. 2009; 28: 705-24.(Level III)9. Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomizedcontrolled trial of intramuscular droperidol versus midazolam for violence and acutebehavioral disturbance: the DORM study. AnnEmerg Med. 2010;56( 4):392-401. (Level II)

10. Van de Sande R, Nijman H, Noorthoorn E, Wierdsma A, Hellendoorn E, Van Der StaakC, et al. Aggression and seclusion on acute psychiatric wards: effect of short-term riskassessment. Br J Psychiatry. 2011;199(6):473-478. (Level II)11. Irvine AB, Billow MB, Gates DM, Fitzwater EL, Seeley JR, Bourgeois M. Internet trainingto respond to aggressive resident behaviors. Gerontologist. 2012;52(1):13-23. (Level II)12. Jayakody K, Gibson RC, Kumar A, Gunadasa S. Zuclopenthixol acetate for acuteschizophrenia and similar serious mental illnesses. Cochrane Database Syst Rev 2012, 4.(Level I)

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