Which nursing intervention is most important when restraining a violent client?

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Nursing management of patients with violent behaviour

1 Reader, College of Nursing, CMC, Vellore, Tamil Nadu, India
2 Former Junior Lecturer, College of Nursing, CMC, Vellore, Tamil Nadu, India

Correspondence Address:
Mrs. Jeeva Sebastian
Reader, College of Nursing, CMC, Vellore
India

Source of Support: None, Conflict of Interest: None

DOI: 0.4103/IJCN.IJCN_129_20

Violence means the behaviour involving physical force intended to hurt, damage or kill someone or destroy something. Violence is a part of the national mythology. Generally, if something or someone has been harmed, then it is regarded as violence. Violence seen among patients in acute psychiatric setup imposes a greater risk on the staff, other patients as well as the treatment process. Certain psychiatric illnesses such as personality disorders and substance dependence are highly associated with violent behaviour in those patients. Care of such patients and family requires collaboration with various members of the health team. Nurses can play a pivotal role in identifying early warning signs, assessing the risk and in mitigating and managing violent behaviours and situations. The nursing management of a patient with violent behaviour in a mental health facility is discussed in this article.

Keywords: Behaviour, mental illness, nursing management, violence, violent behaviour

How to cite this article:
Sebastian J, Debnath S. Nursing management of patients with violent behaviour. Indian J Cont Nsg Edn 2020;21:129-34

Violence is the most problematic behaviour in the management of patients with mental illness or mental health issues. This can be challenging for both the patient and the health professional. Aggressive people ignore the rights of other people. They feed their self-esteem by overpowering others and thereby proving their superiority. They try to cover up their insecurities and vulnerabilities by acting aggressively.

Violence

Violence is defined by the World Health Organisation as 'the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation'.[1]

Prevalence of violent behaviour in mentally ill

Violent behaviour in psychiatry inpatients ranges from 3% to 15% in the high-income countries.[2] A meta-analysis review found a mean of 9.3 aggressive incidents per patient per year, incidents ranging between 0.4 and 33.2 incidents per patient per year.[3] A study from Bangalore, India, reported that 87% of psychiatric nurses experienced violence in the inpatient setting.[4]

In India, the incidents of violence being reported are comparatively higher than that of the higher income countries due to some unclear reasons. Danivas et al. found that 63% of the inpatients were responsible for the 229 violent incidents being observed in the psychiatric facility. Among the patients, 44% were with psychosis, followed by 33% with alcohol dependence, 19% with mania and 4% with other mental disorders. However, there was no statistically significant difference between diagnostic categories and the frequency of incidence per day.[5] The risk for violence was on average, 3–5 times greater for men with schizophrenia and 4–13 times greater for women with schizophrenia, compared with their counterparts without schizophrenia in the general population. The overall risk for violence was similar in bipolar disorder.[6] Patients with psychosis have a relatively higher risk that of 49%–68% increase in the odds of violence.[7] The most frequent primary diagnoses of patients with violent behaviour include schizophrenia spectrum disorders [41.3%], personality disorders [37.3%] and current comorbidity with substance use-related disorders [17.8%].[8]

Predisposing factors

The best single predictor of violence is a history of violence. Mental illness is not a risk factor for violence. Psychopathic and antisocial personality traits are more predictive of violent behaviour than mental illness. There are few theories of anger and violence which are discussed below:[9],[10],[11]

• Modelling: Children usually remodel their parents
• Neurophysiological disorders: Tumours of the brain, trauma and diseases such as encephalitis trigger violent behaviours
• Biochemical factors: Hormonal dysfunction can lead to violent behaviour
• Neurotransmitters: Low levels of the neurotransmitter serotonin are associated with irritability, hypersensitivity to provocation and rage
• Socioeconomic factors: Economic inequalities can trigger violence
• Environmental factors: Substance abuse due to peer pressure and indulgence can also lead to violent behaviour.

Presenting sign and symptoms

To prevent violent incidents, one must be able to predict their onset. Violence is presented as anger and aggression. Awareness of the symptoms of anger and aggression will help in these.

Anger

Anger is a normal, healthy emotion that serves as a warning signal and alerts us to a potential threat or trauma. Anger creates a state of preparedness by arousing the sympathetic nervous system. The activation of this system results in increased heart rate and blood pressure, increased secretion of epinephrine [resulting in additional physiological arousal] and increased levels of serum glucose, among others. Anger can be associated with a number of typical behaviours, including [but not limited to] the following:

• Frowning facial expression
• Clenched fists
• Yelling and shouting
• Avoidance of eye contact
• Easily offended
• Continuous state of tension.

Aggression

Aggression is one way individuals express anger. Aggression is a behaviour intended to threaten or injure the victim's security or self-esteem. Aggression can arise from a number of feeling states, including anger, anxiety, guilt, frustration or suspiciousness. Aggressive behaviours can be classified as mild [e.g., sarcasm], moderate [e.g., slamming doors], severe [e.g., threats of physical violence against others] or extreme [e.g., physical acts of violence against others]. Aggression may be associated with [but not limited to] the following defining characteristics:

• Pacing, restlessness and tense facial expression
• Verbal or physical threats and increased agitation
• Disturbed thought process
• Threats of homicide or suicide
• Panic anxiety
• Anger mood, often disproportionate to the situation.

While anger is a felt emotion, aggression is an expressed behaviour. Aggression is often follows or is associated with anger.

Assessing the risk of violence

Prevention is a key issue in the management of aggressive or violent behaviour. The individual who becomes violent usually feels an underlying helplessness. Assessing the risk of violence is crucial in its management. Changes in the level of consciousness, including confusion, disorientation and memory impairment, also may indicate future violent behaviour. While assessing the risk, one must keep in mind the potential factors associated with it, as discussed below:[12],[13]

History of violence

Individuals who have acted violently in the past are more likely than others to become violent again. This constitutes a significant risk.[12]

Age and gender

Young people are more likely than older adults to act violently. In addition, men are more likely than women to act violently.[12],[13]

Social stress

People who are poor or homeless, or otherwise have a low socioeconomic status, are more likely than others to become violent.

Personal stress, crisis or loss

Unemployment, divorce or separation in the past year increases a patient's risk of violence. People who were victims of violent crime in the past year are also more likely to assault someone.[13]

Early exposure

The risk of violence rises with exposure to aggressive family fights during childhood, physical abuse by a parent or having a parent with a criminal record.

Psychodynamic factors

1. Substance use – Alcohol and drugs impair a person's ability to judge, make rational decisions and alter their mental balance. Individuals with or without psychiatry disorders who abuse alcohol or drug lack cognitive inhibitions and therefore may exhibit violent acts. Substance abuse also may lead to exacerbated symptoms of paranoia, grandiosity or hostility. Patients who abuse drugs or alcohol are also less likely to adhere to treatment for a mental illness and that can worsen psychiatric symptoms[13]
2. Personality disorders – Borderline personality disorder, antisocial personality disorder, conduct disorder and other personality disorders, especially in childhood, often manifest in aggression or violence[13]
3. Nature of symptoms – Patients with thought disturbances, suspiciousness, paranoid delusions,[12] command hallucinations and florid psychotic thoughts may be more likely to become violent than other patients.

Assessment tools

There are few standard measurement tools available to assess aggression. One such tool is Buss Durkee Hostility Inventory.[14] It measures seven specific types of aggression: assault, indirect aggression, irritability, negativism, resentment, suspicion and verbal aggression. The most frequently used screening tool is the Overt Aggression Scale [OAS], developed by Silver and Yudofsky in 1991.[15] On the OAS, aggression is divided into four categories: verbal aggression, physical aggression against objects, physical aggression against self and physical aggression against others.

Management of violence

The management of violent patients can be discussed under the following strategies.[9],[10],[16],[17],[18],[19],[20]

• Psychopharmacological interventions
• De-escalation technique
• Restraint: seclusion, chemical versus mechanical.

Psychopharmacological interventions

Management patients with mental illness may include multiple strategies. Medications prescribed and administered early in the hospitalisation period for potential aggressive behaviour can reduce the need for seclusion or mechanical restrains in high-risk patients.[20] Patients should be given the option of an oral medication whenever possible. Liquid preparations are preferred because they are rapidly absorbed. It is also easy to confirm the medication intake in liquid form. Intramuscular injections may increase the risk of side effects as well as trauma to the patient when the patient is exhibiting violent behaviour.

Antianxiety and sedative-hypnotic medications

Benzodiazepines [lorazepam] are preferred to manage agitation due to its quick onset and as it can be administered either orally or intramuscularly. Buspirone is also effective in the management of aggressive behaviour associated with anxiety and depression, also has been shown to decrease aggression and agitation in patients with head injuries, dementia and developmental disabilities.[11]

Antidepressants

Selective serotonin reuptake inhibitors [SSRIs] are used to reduce agitation associated with post-traumatic stress and anger attacks.

Mood stabilisers

Lithium and valproate are useful in reducing violence associated with mania, labile mood and impulsivity. However, lithium can increase the aggressive that acts among patients with temporal lobe epilepsy, instead carbamazepine can be effective.

Antipsychotics

The most effective and common strategy to manage aggression is the administration of high potency typical antipsychotic Haloperidol in combination with benzodiazepine orazepam. Reasonable doses of these medications – 5–10 mg for the neuroleptics and 2–3 mg for the benzodiazepine – can be given orally or intramuscularly and repeated every 1–2 h until the patient's aggression has ceased.[17] Long-acting antipsychotics such as injection fluphenazine decanoate, injection risperidone [Risperdal Consta] can effectively reduce the severity of hostility, aggressivity and number of violent incidents, mostly in Schizophrenic patients with high risk of violence.[13]

Others

Beta-blockers, such as propranolol, have been shown to decrease aggressive behaviour in children and adults and particularly in patients with an organic mental disorder.[11],[21]

De-escalation technique

De-escalation can be described as a combination of strategies intended to reduce a patient's agitation and aggression. These can include communication, self-regulation, assessment, actions and safety maintenance to reduce the risk of harm to patients and caregivers as well as the use of restraints or seclusion. Few things to be kept in mind before starting verbal de-escalation techniques include a safe physical environment, i.e., limited moveable furniture and free from any hazardous material; proper access to exit for both patients and staff; well-trained and well-equipped staff with the skills of verbal de-escalation techniques and adequate number of well-trained staff.[22] There are 10 domains of de-escalation techniques:[23]

1. Respect personal space
2. Do not be provocative
3. Establish verbal contact
4. Be concise
5. Identify wants and feelings
6. Listen closely to what the patient is saying
7. Agree or agree to disagree
8. Lay down the law and set clear limits
9. Offer choices and optimism
10. Debrief the patient and staff.

Restraints

Seclusion and restraints are the most restrictive interventions used in psychiatric facilities. Literature explains different types of restraints, namely physical–chemical, seclusion and environmental.[24]

• Seclusion is the involuntary confining of a person alone in a room from which the person is physically prevented from leaving. The rationale for the use of seclusion is based on three therapeutic principles: containment, isolation and decrease in sensory input[11]
• Chemical restraints are medications used to restrict the patient's freedom of movement or for emergency control of behaviour but that are not standard treatments for the patient's medical or psychiatric condition. One study found haloperidol, midazolam and diazepam [59%] as commonly used agents as chemical restraints[11]
• Physical restraints are any manual method, or physical or mechanical device attached to or adjacent to the patient's body that the patient cannot easily remove and that restricts freedom of movement or normal access to one's body, material or equipment.[11]

Guidelines for restraining a patient

1. Get doctors order to restrain patients. In emergency situation, verbal order is acceptable
2. Make sure that adequate personnel are present [ideally there should be five people, one for each limb and one to hold patient's head]. The patient and/or his/her family members or guardian should be informed of the needs, risks and benefits of restraint before the possible use of restraint
3. Ensure consent for restraints are obtained from the immediate relative and also the fact sheet is provided to support the relatives
4. Provide privacy
5. Gently place the patient in a supine position with one arm extended above the head and other arm at the side. Apply restraint to upper limbs followed by application to lower limbs. Do not apply restraints too tight
6. Do not leave the patient alone after restraints have been applied
7. Observe the patient every 15 min. Document the restraint site and vital signs
8. Document administration of medication
9. Monitor and document the relevant information in the physical restraints record
10. Release or loosen after obtaining the order from the doctor. Release with caution to meet a personal need
11. Document the following in the daily nursing care record
1. Event that leads to the use of restraints
2. Alternative interventions [verbal communication] and patient's response
3. Time of initiation and discontinuation of restraints
4. Patient's mood, affect and psychomotor behaviour.[24],[25],[26],[27],[28],[29],[30]

Nursing management

The nursing management of a violent patient with the help of case report is discussed below using a nursing process approach.[10],[11],[18]

Mr. X, 29-year-old male, got admitted for the third time in acute care room of mental health facility of a tertiary hospital. He was with a diagnosis of paranoid schizophrenia for the past 10 years and was on medications with poor compliance. In the present admission, he presented with complaints of increased anger, irritability, abusive and assaultive behaviour towards others, talking, muttering and smiling to self, irrelevant talk and decreased sleep for the past 2 weeks. He drinks occasionally and smokes 5–6 packs of beedi per day. He also had a fight with his neighbours and strangers 1 week prior to admission and had sustained an injury in the right cheek. During admission interview, he complained about hearing unknown female voices crying to him [auditory hallucinations]. He expressed his suspicions about his parents engaging in black magic against him and mixing poison [paranoid delusion] in his food. He also expressed that a camera had been fixed in the bathroom by his neighbours and they were watching him. Further, he claimed that his father was the owner of the hospital who wanted to help the patients and could control anyone. He also added that he knew about all the treatments and was involved in politics [grandiose delusions].

He was admitted into the facility for evaluation of his medication requirement, compliance and management of symptoms. During his stay in the facility, he absconded from the ward once and had reached home. He was brought by his parents the same day and appeared very agitated; he assaulted his parents and staff who were involved in his care. He never used to take his food and water at home because he had suspicions that his parents were poisoning him. He exhibited behaviour such as hitting, biting and kicking both at home and in the hospital.

He was on frequent physical and chemical restraints for his constant agitation. He received injection haloperidol, injection phenergan and tablet chlorpromazine and had 8 ECTs. Continuous monitoring was done for assessing any early signs of aggression to prevent escalation of violence. Restraint policies and protocols were followed in hospital to prevent any complications. Regular psychotherapy, milieu therapy and occupational therapy [OT] were continued. After 2 weeks, he was shifted from acute care to the general ward as there was decreased violent behaviour.

Nursing management

Nursing diagnosis

High risk for violence directed towards others related to inaccurate perception of the environment [delusions and hallucinations] and impairment of impulse control disorientation.

Expected outcome

Patients will not harm to self or others.

Interventions

An environment with low level of stimuli [dim lighting, reducing the buzzers, reducing the noise from telephone, other patients and staff and keeping the equipments like bin lids and trolleys in good working condition] was maintained to reduce triggers of violent behaviours. Objects that can cause injury were removed from the vicinity to ensure safety. He was oriented often to reality. Medication such as injection haloperidol 10 mg with injection promethazine 50 mg IM were given twice a day and whenever needed during the 1st week of admission as a form of chemical restraint; the same dose was given once a day during the 2nd week. Tablet lorazepam 10 mg was continued during 1st week and was later tapered to 1 mg twice a day. Physical restraints were used as a least option. Restraint care was given. Relaxation exercises were taught. Family members were encouraged to report if any anger, irritability or mood swings were noticed.

Evaluation

Assaulting and abusive behaviour towards parents and staff was noticed during the first 2 weeks and reduced gradually in the 3rd week.

Nursing diagnosis

Actual injury related to substance intoxication, psychomotor agitation, hallucinations and disorientation.

Expected outcome

The patient remains free from injury as evidenced by the absence of wound and abrasions.

Nursing interventions

He was placed in a calm and conducive environment. Nurses checked to see that he remained free from injury and ensured safety of self and others; health team members made an effort to avoid confrontation; gave choices and maintained his dignity [behaviour therapy techniques used to reduce the frequency of smoking, he was allowed to come out of the designated room]. Relative were taught about safety precautions, especially to avoid verbal confrontations, to be non-judgmental while communicating with him, to look after themselves and to seek support if required. His vital signs were monitored every 2 h and he was observed regularly for any behavioural changes. The side rails in hospital bed were on all the time for safety. Physical restraints were used judiciously. Wound dressing was done twice a day with saline.

Evaluation

The patient's swelling reduced and the injury healed within 1 week and he did not develop any injuries after that.

Nursing diagnosis

Disturbed sensory perception related to disorientation, lack of adequate support and psychosocial stressors.

Expected outcome

The patient ceases to talk to self and demonstrates ability to continue conversation without hallucination.

Nursing interventions

Clear, direct verbal communications were used by all healthcare members rather than nonverbal gestures. He was allowed to explain about his hallucinations without interfering with judgmental comments. He was taught the techniques to interrupt hallucinations such as listening to music, plug the ears and drawing and craft works. Therapeutic communication technique such as 'presenting reality' [expressed that I could hear only his voice and mine] was used/taught. His feelings underlying the hallucinations were accepted. Prescribed antipsychotics were administered, taught him about the effects of medications in reducing psychotic symptoms.

Evaluation

At the time of discharge, he verbalised that he did not have any hallucinations. His violent outbursts had completely stopped at discharge.

Nursing diagnosis

Disturbed thought process related to psychosocial stressors and inability to process the external stimuli.

Expected outcome

He verbalises reality-based thinking in verbal and non-verbal behaviour.

Nursing interventions

Used simple, concrete explanations in explaining and communicating and maintained appropriate facial expressions when conversing with him. Instructed him to approach the healthcare personnel if any frightening behaviours occurred. Encouraged him to involve in activities that helped him to handle delusions and taught him thought stopping technique. Did not attempt to argue or agree with the delusions as false and unreal when he was expressing self-inflated ideas and when he refused to take food. Provided packed food items. Encouraged him to go for regular OT sessions.

Evaluation

At the time of discharge, he did not express any delusions.

Nursing diagnosis

Ineffective denial related to loneliness, lifestyle of projection, denial and rationalisation; omnipotence and marital discord.

Expected outcome

He seeks treatment for alcohol and nicotine abuse.

Nursing interventions

Approached him in a non judgmental manner and provided continuous positive reinforcement. Addressed his substance abuse behaviour with a caring attitude. Assisted him to accept his responsibility for his own recovery, without allowing him to use rationalisation or projection. Instructed him to avoid situations that triggered him to consume alcohol and nicotine. Encouraged him to perform activities according to his interest which promoted satisfaction. Realistic goals were set along with him. Gave teaching on ill effects of smoking and alcohol on health, interpersonal relationships and family dynamics. Encouraged him to attend regular OT sessions.

Evaluation

He was receptive and cooperated with the treatment process. At the time of discharge, he verbalised that he will try to avoid smoking and consuming alcohol.

Nursing diagnosis

Disabled family coping related to feelings of guilt, shame, anxiety and anger.

Expected outcome

Relatives should accept and support the patient.

Nursing interventions

Encouraged the relatives to ventilate their feelings. Encouraged them to accept the reality. Taught the relatives about home care, coping strategies and importance of medication intake and regular follow-up.

Evaluation

His relatives verbalised that they will support him and encourage him to continue his medicines and follow-up.

Most patients with schizophrenia and bipolar disorder are not violent. Nevertheless, the risk of violence in patients with these disorders is greater than in the general population. This risk is particularly high in schizophrenia and bipolar disorder with comorbid substance use disorders and personality disorders, but it exists even without such comorbidities. Pharmacological treatments are the principal tools to manage violence in psychoses. However, their effectiveness is limited due to inherent treatment resistance and treatment non-adherence, and the fact that some violent behaviour in patients diagnosed with schizophrenia or bipolar disorder is not directly caused by psychosis. Comorbidities are frequently implicated in violent behaviour of psychotic patients, and their detection and treatment are therefore of primary importance. Psychosocial treatments are necessary components of the management of violence in psychosis.

The number and impact of violent incidents in mental healthcare settings can be reduced by the appropriate, therapeutic and effective use of the full range of interventions. This can only occur if adequate numbers of professionals are properly trained in the different techniques and organisations have robust system for auditing and monitoring the prevention and management of violence. Nurses play a vital role in not only on prediction, identification and management of violent behaviour but also change the attitude and misconception of the public that mental illness is always associated with violence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient [s] has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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