Nurse versus aggressive patient

Introduction

Aggression can be found all around us, it is part of the life of people and animals. According to experts, aggressive manifestations are currently increasing. Aggression itself is an offensive action directed at the surroundings. It belongs to the basic psychological reactions, in an adequate form it is one of the ways of removing obstacles. Civilization directs aggression into certain socially acceptable or recognized activities such as sports. However, aggression can also be hidden (without physical manifestations). Some psychopaths or psychotics can show more aggressiveness (Vokurka, Hugo, 2005).

Aggression in medical facilities

Aggression and violence in healthcare facilities is increasing worldwide and it is therefore important to investigate aggressive behavior (Sato et al., 2013). It is often explained and tolerated by a stressful environment (McPhaul, London, Lipscomb, 2013). Experts allude to the inconsistency of the emergence of aggression. There are various theories explaining the emergence of aggression and aggressive breeding from different points of view. Malá distinguishes aggression according to the causes that lead to it, into factors conditioned by the individual's genetic makeup and organic factors, psychological-neurological factors, and into developmental and sociological factors (Malá, Pavlovský, 2002). Some studies do not confirm the heredity of aggression, but others prove that genes are more important than environmental influences (Čermák, 1999). Abroad, scientists deal with the aggressive behavior of patients quite often and more deeply than in the Czech Republic. Therefore, the presentation of the results of the Czech research focused on the prevention of violence in health care and social care from 2010 can be considered positive. The research was carried out under the auspices of several trade unions and was paid for by European funds. This research confirmed the presence of violence in the healthcare sector in the Czech Republic (Hofmanová, 2010). The project was entitled "Strengthening of social dialogue with an emphasis on handling crisis situations in the event of violence at workplaces, especially medical facilities and social service facilities". The project dealt with identifying problems related to aggression, training healthcare workers in the field of self-defense, communication with aggressive patients and psychological approaches to these patients. The project was very successful in its outcome and the output is a handbook entitled "Prevention of violence and management of crisis situations at the workplace" (ČMKOS, 2012). The research also found that nurses in the Czech Republic most often encounter verbal abuse - verbal violence.

Aggressive behavior

  • the individual asserts himself at the expense of others,
  • disregards the rights and legitimate demands of others,
  • people have a reserved and often even negative attitude towards him,
  • the aggressor uses not only violence and rudeness, but also sarcasm and irony,
  • attacks in advance, preventively (Pokorná, 2006).

What does an attack look like?

I. Launch phase. Aggression is triggered by the interplay of several factors. 1. First, the actor must be attuned to aggression. 2. Triggering factors must also be present: a) the perpetrator of aggression expects appreciation of his aggressive behavior (group), b) the presence of stressors, including our inappropriate behavior towards the patient, c) wrong interpretation of reality, e.g. due to mental illness, d) influence of alcohol and non-alcoholic drugs, e) apparent threat to the patient's interest. 3. When is there a threat of aggression? Characteristics of the aggressor: Mental state – the presence of a mental illness, most often schizophrenia with delusions of persecution, organic mental disorders, mental retardation, addictions. They are often younger people. Violent manifestations in the past (arguments, fights), criminal act in the past, hostility towards a potential victim, hypersensitivity to someone or something.

II. Escalation of violent expressions. Steps leading to violent expression. In this phase, the interaction between the aggressor and the potential victim is important. Actions manifesting power contribute to the worsening of the situation. In fear, we sometimes try to control the situation, which can cause feelings of threat in the patient. Then he reacts with an inadequate defense.

Soothing effects: We need to dominate. If we accept this idea, the tension between us and the potential aggressor can be significantly reduced. If I don't want to go into a confrontation, it can be seen from my behavior and the patient notices this signal. On the contrary, the desire for conflict escalates violence. Slow pace of speech. It is verified that the patient gradually accepts our pace of speech and as the speech calms down, the overall psychomotor pace slows down (Venglářová, 2005).

Signals of impending aggression: Does he seem nervous, is he upset? Is he looking straight into your eyes? Is he gesticulating threateningly or conspicuously? Does it stomp, does it indicate a kick? Does it bang or kick the equipment in the room? Slamming the door? Is he clenching his fists? Is he consciously or unconsciously showing a clenched fist? Does he seem like a tense person, only to explode? Is the face tense, does an aggressive grin appear? He blinks nervously, are there tics that he didn't have before? Does he have pursed lips? Are there gestures reminiscent of beatings? Is he starting to push me? Is he behaving differently than usual, does my intuition indicate that danger is approaching?

How to react in case of signs of an impending explosion? We try to make the patient sit up. We maintain a safe distance, at least within reach of the patient. It is advisable to leave a way of retreat for yourself and the patient. Empathy towards the patient's needs. Even a person who behaves aggressively has his needs. It is not our job to investigate his motives. In an acute situation, we try to identify and, if possible, fulfill his human needs. Calming down will help, for example. smoke, make a phone call, etc. We turn our attention elsewhere. At the stage when we feel tension, it is better to postpone the urgent topic. It is not necessary e.g. perform a medical procedure when the patient and I are alone. We are asking for help. The situation is all the more serious if the patient is armed with literally anything.

** III. Crisis**. Clash with the patient. The consequences are physical, material, but above all psychological. If the nurse has to deal with open aggression, she pays particular attention to the safety of the patient, the safety of other patients and the safety of the staff. The protection of the device comes last (Marková, Venglářová, Babiaková, 2006).

** IV. Calming**. There is a biological discharge of aggression, and thus relaxation.

V. Post-crisis depression (Venglářová, 2005).

Glynis Breakwell's questionnaire to reveal the risk of attacks

  1. Is the person I am dealing with under the influence of significant stress?
  2. Is he drunk or under the influence of drugs?
  3. Has he already shown himself as a violent person in the past?
  4. Has he ever been convicted of aggressive criminal activity in the past?
  5. Has he suffered or is he suffering from a mental illness that reduces sanity?
  6. Does he have health problems reducing self-control?
  7. Has the person attacked or threatened us in the past?
  8. Has he threatened us with specific violence in the past?
  9. Has he ever attacked me before?
  10. Does the person in question think that I threaten his children or other persons very close to him, or am I in one way or another associated with an institution that could do something similar?
  11. Does the person in question think that I threaten his freedom or that in some way I belong to those who could threaten his freedom?
  12. Does that person have unrealistic ideas about what I can do for them?
  13. Is he convinced that I deliberately do not want to help him?
  14. Was I afraid of this person in the past?
  15. Does he have viewers who are directed against me and who could directly or indirectly support, admire or appreciate his aggressive behavior towards me?

The more YES answers, the greater the risk of an aggressive attack. After five YES answers, the risk is quite significant, 10 answers make a subsequent attack quite likely. If we evaluate the situation as 15 times YES, the attack can be considered practically clear (Marková, Venglářová, Babiaková, 2006, p. 112).

Treatment of an aggressive patient

The treatment of aggression, or securing the patient, can be divided into two groups. They are short-term and long-term interventions to secure the patient. In the short-term, we include correct communication and efforts to stop the patient from aggressive behavior or administration of medication according to the doctor's office. Long-term interventions include the administration of sedatives, the use of restraints or transfer to another department (Hahn et al., 2012). Pharmacological treatment for managing aggression should be the last resort, after unsuccessful non-pharmacological treatment. It is always necessary to find out the cause of restlessness (Nawka, 2012). In aggressive patients, the doctor may prescribe the use of restraints or pharmacological sedation. Antipsychotics, benzodiazepines and antihistamines with a short onset of action are the most commonly used drugs. The use of restrictive means is considered the last option to calm the patient, if other attempts to calm down were not effective. This is a restriction of the patient's freedom without his consent. It must be properly considered and used only if the patient's condition worsens or the patient's safety is threatened. We can use the so-called net beds, protective belts, tethering to the bed using cords or straps, placement in a closed ward or isolation room. Where restraints are used, it is necessary that the medical facility has created the appropriate standard of nursing care. It is also necessary for personnel who use restraints in their practice to be trained on this topic at least once a year. For such limited patients, increased nursing care is necessary, connected with the control of physiological functions and high-quality documentation. Both a doctor and a health worker qualified for this activity may indicate the use of restraints, but the latter must immediately report this situation to the doctor. The nurse is responsible for the nursing care of a patient with a restrictive restriction. If the pharmacological treatment does not work and if the other possibilities of relaxation have been exhausted, we proceed to the use of restraints. Currently, the problem of physical restraint is highly publicized. Restrictive measures should be used for as long as necessary. The patient secured in this way is given increased nursing care. The nurse measures the patient's physiological functions, monitors the hydration and circulation of the limbs. Proper documentation must be maintained about the restrictive measure. We pay attention to the prevention of bedsores and the staff should be regularly trained. The use of an isolation room that is not closed, the use of side rails at the bed or the tying of a limb for the administration of medication are not considered physical restrictions (Hanušová, 2008).

Conclusion

Handling restlessness and contact with an aggressive and uncooperative patient is one of the many specifics of a nurse's work, and not only in the psychiatric ward. Nurses should actively learn techniques for managing restlessness and aggression, strengthen their self-confidence and learn to communicate with these people. In conclusion, we present a beautiful quote from the psychologist Paulínová, who says: "You cannot play with the animal in us without becoming animals, play with lies without losing your right to the truth, play with cruelty without losing sensitivity." (Paulínová, 1997, p. 31).

Authors: PhDr. Jarmila Verešová, Mgr. Miroslava Kubicová Literature:

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