De-escalating the Aggressive Patient

Irene J. Su, RN, MSN


April 12, 2010

Vignette: A Verbal Altercation Becomes Physical

Joe was a 21-year-old patient admitted to a state psychiatric hospital for schizophrenia. This was one of several involuntary hospitalizations since Joe was a teenager. One evening during dinner, Joe got into an argument with another patient over a seat. The verbal altercation suddenly became physical when Joe threw his dinner tray across the table. Staff proceeded to remove Joe from the dining room according to his behavior modification plan, but Joe resisted and put up a fight. Team assistance was initiated. Joe was taken down by trained staff, and 4-point restraint was applied in the seclusion room. The psychiatrist was called in to talk with Joe. Joe eventually calmed down and was released from physical restraints. However, he had pain and swelling of his right hand, which he had used to punch the wall during confrontation with the staff. Joe was sent to the emergency department of a local hospital, where an x-ray was taken. The radiology report indicated that Joe's right hand was fractured. Joe's hand was splinted, and Joe was given oral analgesics and made a follow-up visit to an orthopaedic doctor 7 days later.

Responses to Aggression in Mental Health Settings

In the mental health setting, dealing with aggressive patients can be an everyday occurrence for nursing staff. Patient death or injury resulting from the use of restraint and seclusion is an increasing concern. A well-known 1998 article[1] documented 142 restraint-related deaths nationwide over a decade, 40% of which were attributed to unintentional asphyxiation during restraint. Restraint not only poses a risk for patient harm but also is physically and emotionally traumatizing for staff involved in the incident. Stefan pointed out that "high restraint rates are now understood as evidence of treatment failure."[2] Since the Joint Commission began tracking sentinel events in 1996, it has reviewed the deaths of 20 patients who were physically restrained.[3] Since then, the Joint Commission has advocated standards based on prevention as an intervention and the use of restraint as a last resort only after the least restrictive measures are exhausted.

Most facilities have a protocol to call for team assistance when a psychiatric patient begins to display aggression. Nurses often believe that there is power in numbers, which can be true in certain situations. However, the increased external stimuli of gathering staff members can also have untoward effects on the patient. The show of force may contribute to the escalation of combative behaviors.

Evidence points to a direct correlation between a high level of anxiety or perceived powerlessness on the patient's part and ensuing aggression.[4] The underlying cause of the behavior should be readily identified and handled accordingly. For instance, patients can become angry as a result of hallucinations, external provocation, or physical discomfort.

Observational studies[5] have classified patient violence as having 3 causes:

  • Patient factors: consistent assessment findings related to patient history and diagnosis;

  • Situational/environmental factors: level of staff supervision and morale of the ward; and

  • Victim factors: certain types of people who are repeatedly targeted by aggressors.[5]

When these factors are clearly identified, precautions may be taken to control and minimize the risks in the milieu.

The Third-Person Approach

Although restraint may be necessary in emergency situations for patient and staff safety, physical confrontation can usually be averted if de-escalation techniques are implemented before the patient gets out of control. De-escalation using a third-person approach, if implemented judiciously and cautiously by staff, can be very effective in managing patients in the early stages of anger and aggression.

The third-person approach is similar to hostage crisis negotiation, in which a third party is brought in to negotiate a solution. Usually, it is much easier for the third person to take a neutral stance and to allow space for the angry person to step down. Billikopf postulates that all other things being equal, an outside third party has a greater chance than an insider of successfully mediating and resolving a difference.[6] The third person is not an arbiter trying to decide right from wrong, but a nonjudgmental facilitator of communication.

A "third party" or "third person" is a trained nursing staff member who was not present at the start of the dispute or conflict. A person who was involved in the conflict may be perceived, from the patient's standpoint, as being part of the problem. The ideal third person is someone who knows the patient well and with whom the patient has a certain degree of rapport.

The value of a therapeutic relationship has been established by nurse theorist Peplau.[7] Research suggests that ineffective interpersonal relationships and interactions are major factors in escalating a volatile mental health client.[8,9] Irwin concludes that intolerable environments (of which nurses are a part) and ineffectual interactions are far more likely to influence behaviors than are psychiatric symptoms alone.[10]

Use of the Third Person in De-escalation

Whenever an outburst is anticipated, the audience should be removed immediately. If team assistance is called in accordance with institutional policy, it may be better for the team members to stay in the background, ready to provide support when needed, but allow a single, third person from the care team to approach the patient. This less-than-expected response, or "under-reaction," can promote de-escalation.[11] The Pennsylvania Patient Safety Authority also suggests shifting the method of intervention from "a show of force to a show of support."[12] A 3-month study on the use of least restrictive interventions found that patients commonly select "verbal warning or talking things through" as the most valuable tool of anger management.[13]

The third person should maintain a calm and supportive demeanor and use therapeutic communication skills. Avoid arguing with the patient or getting into a power struggle, and listen with empathy; the Greek Stoic philosopher Epictetus said that we have 2 ears and 1 mouth, so that we can speak less and listen more. In addition, state everything in clear, simple language: As anger escalates, the patient's perceptual field becomes limited; he or she probably cannot understand complex reasoning or process what you are saying. Tell the patient that you want to help, but he or she needs to calm down first. It is appropriate to say something like, "I would like to help you, but I can't hear you if you are screaming and yelling." Do not react to verbal attacks from the patient. Be aware of your own feelings of countertransference.

Staff members who take on the role of third person should have proper training in various techniques of nonviolent crisis intervention. The third person must also practice safety precautions, such as standing beyond arm's reach of the patient, positioning himself or herself for easy exit by the door, and avoiding displays of body language that may be viewed as provocative to the patient.

Sometimes patients act out because they feel threatened. Assure the patient that he or she is safe, then set firm but nonthreatening limits. Offer choices to gain the patient's cooperation, and present positive reinforcement first. Positive reinforcement does not have to be a material reward; it can be praise and encouragement, or earning a certain privilege. In Rosenheck and Neale's 6-month study of 40 Veterans Affairs Assertive Community Treatment Program teams, clients with violent behavior who were exposed to negative limit-setting interventions typically had poorer outcomes.[14]

Psychiatric nurses have an obligation to maintain the safety of the patient and others in the environment. If restraint is deemed necessary, it should be used only when all measures of de-escalation have failed. In reality, no rigid policy or clinical guideline can spell out each and every scenario when physical restraint is the lesser of 2 evils. Psychiatric nurses have to rely on their own clinical judgment to weigh the risks and benefits of the measures they are considering. When to initiate physical restraint is a situation that depends on the vagaries of the institutions in which health professionals practice.[15]

In the original vignette, physical restraint and patient injury could have been prevented if nursing staff had intervened before Joe became aggressive. Because it was difficult to remove Joe from the dining room, the other patients should have been temporarily removed. When the team members responded to the call for assistance, one negotiator should have approached Joe to talk him down. Afterward, Joe's behavior modification plan should have been reviewed to balance positive and negative reinforcements.