Post on 26-Sep-2020
You Mad Bro: Kevin McFarlane 5/12/19
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You Mad Bro?Dealing With and Defusing
Aggressive Behavior
Kevin McFarlane MSN,RN,CEN,TCRN
Anyone can become ANGRY. That is easy. But to be ANGRY with the right person, to the right degree, at the right time, for the right purpose and the right way… that is not easy.
-Aristotle
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Epidemiology of Violence in Healthcare
• Over 5 million in the U.S. work in healthcare: • Exposed to many safety and health hazards• According to the Occupational Safety and
Health Administration (OSHA), approximately 75 percent of nearly 25,000 workplace assaults reported annually occurred in health care and social service settings
You Mad Bro: Kevin McFarlane 5/12/19
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There are lots of causes for
potential violence
Diagnosis Associated with Violence
• Functional • Schizophrenia• Mania
• Personality disorders• Antisocial• Borderline • PTSD
Diagnosis Associated with Violence
• Infectious – CNS Infection–Meningitis – Encephalitis – Sepsis
You Mad Bro: Kevin McFarlane 5/12/19
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Diagnosis Associated with Violence
• Neurologic– Head Injury – Seizures– Postictal states – Aids relate dementia
Diagnosis Associated with Violence
• Drug Related • ETOH intoxication• Amphetamines • Cocaine • PCP (Phencyclidine)• LSD• Narcotic/benzo
withdrawal
Diagnosis Associated with Violence
• Metabolic/Endocrine – Electrolyte disturbance – Hypo/hyperthermia – Anemia– Hypoxia– Hypoglycemia– Thyroid storm – Cushing’s disease
You Mad Bro: Kevin McFarlane 5/12/19
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Question?
What makes people angry?
What Makes People Angry?
• Losing power• Losing status• Losing respect
• Being insulted• Not having things turn
out the way they expected
What Makes People Angry?
• Expecting pain• Feeling that you have been treated unfairly and
unjust• Believing that things should be different• Rigidly thinking “I am right
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Predicting Violent Behavior
• Warning signs:– Pacing or restlessness– Clenched fist– Increasingly loud speech– Excessive insistence– Threats – Cursing
Physiological Signs of Anger
• Heart beating faster• Breathing rate increases• Fists clenched• Face feels hot or cold• Hands shaking• Profuse sweating• Higher body temperature
Physiological Signs of Anger
• Sudden dry mouth• Stuttering• Muscles tensing• Goosebumps• Face turns pale or red• Teeth grinding, jaw clenching
You Mad Bro: Kevin McFarlane 5/12/19
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What will we see
• Warning signs:– Pacing or restlessness– Clenched fist– Increasingly loud speech– Rapid speech– Threats – Cursing
The Trigger
• Occurrence perceived by the individual as a serious threat to him/her.
• TWO TYPES: – Fear Inducing Events – Give the person the
perception he/she is under threat or about to lose something of value.
– Frustrating Circumstances – Give the person the idea that his/her efforts or demands have been useless
What Do We Know About Anger
• Follows a predictable pattern of levels
• Levels have observable characteristics
• Opportunities for intervention are present at every level
• May be about something other than situation at hand (lack of sleep, work problems, fight with significant other, illness, etc..)
You Mad Bro: Kevin McFarlane 5/12/19
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Levels overviewThe Anger Cycle
1. Questions
2. Back Talk
3. Refusal
4. Challenge5. Outburst
6. Quiet Period
7. In Control
Anger Cycle by Chuck York
Level 1 - Questions
• Description–May be legitimate questions about an activity,
missed information, etc..
• Examples– “Why do I have to go?”– “How does this stuff help me?”
• May be an attempt to question your authority– “Why do I have to listen to you?”– “Who died and made you boss?”
Appropriated Intervention for Questions
• The easiest way to prevent escalation from this point is simply to answer the question
• Assume that questions are real. Do not assume the person is trying to “start something” or be manipulative by asking questions
• Use “Effective Listening” to maintain clear communication
You Mad Bro: Kevin McFarlane 5/12/19
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Effective Listening
• Let the person do the talking• Focus on what the person is saying• Focus on the person’s emotions (look at body
language, sound of voice, etc..)• Restate what the person is saying to you to
show you understand• Keep your answers short and clear
Level 2 - Back Talk
• Description• Person is showing their anger and trying to
incite you to be angry• Examples– “You’re always telling me what to do! Why don’t
you do it?”– “You don’t know what you are talking about”– “This is all just stupid”
Appropriate Intervention for Back Talk
• Stay calm and in control• Be aware of your facial expressions, your posture,
and how your voice sounds– Keep a distance of at least 3 feet between you and the
person– Speak slowly and be civil– Do not cross your arms or make yourself look
“closed
• Redirect the person back to the topic of the discussion
You Mad Bro: Kevin McFarlane 5/12/19
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Level 3 - Refusal
• Description– The person is challenging your control of the
situation by refusing to comply with a direction
• Examples– “I’m not going”– “I’m not going to do that”– Crossing arms, turning head, ignoring you– “Do it yourself”
Appropriate Intervention for Refusal
• Stay calm, cool and collected• Your behavior impacts the situation. • If you are responding to the person’s anger,
the person will become more angry• Give the person two clear choices that are
reasonable and appropriate. Explain the consequences for each of the choices
Level 4 - Challenge
• Description– The person is attempting to directly challenge
your authority
• Examples– “You can’t make me do it!”– “I don’t have to do that!”– “Pick on somebody else!”
You Mad Bro: Kevin McFarlane 5/12/19
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Appropriate Intervention for Challenge
• Try to remove either the person or the audience
• The person may escalate faster if the others are watching
• Seek help if you think this will escalate further
• Check your own behavior and make sure you are in control
Appropriate Intervention for Challenge
• Increase distance between the person and yourself
• Restate choices
Level 5 - Outburst
• Description–The person is no longer able to maintain
control
• May take 2 forms: Verbal or Physical–Verbal Outburst - screams, yells, shouts
profanity, cries, etc..–Physical Outburst - attacks, kicks, throws,
breaks, runs, etc.
You Mad Bro: Kevin McFarlane 5/12/19
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Appropriate Intervention for Outburst
• If the outburst is verbal– Keep a space between the person and yourself– Allow the person to vent– Do not attempt communication at this point– Show of force
Appropriate Intervention for Outburst
• If the outburst is physical– Remove the other bystanders from the room– Exit the room yourself, and attempt to maintain
visual contact with the person– Show of force– Consider physical interventions
Level 6 - Quiet Period
• Description– After every outburst, the person will reach a
“quiet period” in which their emotional status is below their average state
• Usually represented by being quiet, lack of energy, sometimes crying, moving to a protected area, etc..
You Mad Bro: Kevin McFarlane 5/12/19
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Appropriate Intervention for Quiet Period
• Give the person space and time to calm down
• Quietly offer support• Be respectful and kind
Level 7 - In Control
• Description• The outburst is over, and the person has
regained control• Still a sensitive time, and care should be given
not to re-escalate the situation
Appropriate Intervention for In Control
• Invite the person to rejoin communication• Ask the person to join clean up of any messes
or damage caused• Ask the person which of the choices they have
selected
You Mad Bro: Kevin McFarlane 5/12/19
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Self Protection
• Always be aware of • Stethoscopes around
your neck• Badge lanyards that are
not “break-away”• Long necklaces
• Dangling earrings• Long hair (always pull
back)• Men’s ties
Things That Can be Used as Weapons
• Scissors, Hemostats, Eating utensils (even plastic), plates, plate warmer, water pitchers, vases, anything glass or ceramic
• Belts, robe ties, tubing (IV, 02, etc.)• Sheets, pillowcases, gowns• Pens/pencils• Furniture
Let’s Review
1. Anger follows a predictable and observable pattern
2. There are appropriate interventions for each level of the anger cycle
3. You are an active participant in the cycle, and can escalate or de-escalate the behavior with your actions
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4. When a person reaches the outburst level, they are no longer in control of their actions
5. The key point during an outburst is to create the safest environment possible to prevent injury
6. NEVER attempt a physical intervention unless you have received proper training and it follows your organizational policies and guidelines
Chemical Restraint
• Rapid tranquilization– Safe – Reliable – Titratable
• Agents
• Benzodiazepines• Neuroleptics• Ketamine
Benzodiazepines
• Midazolam– Im or IV–Max effect 10 min lasts ~2hours
• Diazepam– IV – So so IM absorption – Longer acting
You Mad Bro: Kevin McFarlane 5/12/19
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Benzodiazepines
• Midazolam (Versed)– Im or IV–Max effect 10 min lasts ~2hours
• Diazepam (Valium)– IV – So so IM absorption – Longer acting
Complications with both • Oversedation• Hypotension• Airway compromise • Paradoxical reaction • Tolerance
Neuroleptics
• Droperidol/Haloperidol• IM/IV• 2.5mg/10mg
• Olanzapine (zyprexa)• IM
Physical Restraints
When do you decide to restrain a patient?
You Mad Bro: Kevin McFarlane 5/12/19
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Physical Restraints
• Risk of harm to self or others• Failed negotiations • Sometimes in conjunction with chemical
restraints
3Things to
Remember
3 things to remember
• Reasoning with an angry person is not possible.
• De-escalation techniques go against our natural ‘fight or flight’ reflexes.
• One of the people in the equation MUST stay calm and centered.
You Mad Bro: Kevin McFarlane 5/12/19
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3Things to Forget
3 things to forget
• It’s not your emergency
• Forget thinking you can do this alone. Bring a buddy
• Forget your feeling….It’s not about you
Be carful out there
Check out my new podcastThe Art of Emergency Nursing
Thanks for Listening