11.2 Violence and Safety

Risk Factors for Aggression or Violence in Serious Mental Illness

Nurses should be aware of and understand risk factors in each client’s history in order to inform preventative care. Medical causes, such as substance withdrawal or hypoxia, or metabolic conditions, such as fever or delirium, may also contribute to uncooperative or acting-out behaviors. Early childhood events, exposure to trauma (including traumatic brain injury), and substance use can shape behavior and mental health in general. These factors may contribute to potential for violence due to acquired protective responses, learned ineffective coping behaviors, dysregulated neurological responses, substance influence or substance withdrawal, work demands, or stressors in the home. Other risk factors for aggression by clients with mental illness are related to mental health symptoms, including persecutory delusions often related to schizophrenia, grandiosity and mania, and antisocial personality traits (DeAngelis, 2021).

Cues in Types of Behavior

According to the Centers for Disease Control, there are a number of common cues indicating an increased potential for violence (2020). They include screaming or loud talking, cursing, menacing voice, uncared-for physical appearance, pacing, panting, arm crossing, hand clenching, staring, looking fearful, throwing items, or being drunk or high.

Some behaviors distressing to the person may not appear as problematic to others. Behaviors such as social withdrawal, silence, or guarded body posture may not be reported by family members or seen as relevant by health-care workers. Yet these behaviors, especially if noticed as a change, could be outward expressions of fear or pain that nurses should note in the context of safety. Highly active, disruptive behaviors, such as damaging property or threatening others, are likely to draw more attention. Impulsivity may be driven by paranoia or hallucinations or the energy of a manic episode. Socially inappropriate remarks, insults, or actions that evidence disregard for others may be associated with disorders of conduct or personality, or may be learned intimidation behaviors. Persons with low self-esteem and ineffective coping abilities may present as deceitful or manipulative. Medications that are ineffective or not taken or have agitation as a side effect can also account for client behaviors. No matter the cues, respect for client autonomy and early detection are key to appropriate interventions.

Least Restrictive Alternatives to Managing Aggression

The foundational guideline to handling aggressive behavior is that providers must use the least restrictive measures that are safe. Nursing management of aggressive behaviors starts with client-centered care, which includes an introduction, respectful interview processes, and professional exchange of information at handoff of care reports. Nurses must have a keen awareness of their own body language, like where they place their hands, and their own tone of voice when interacting with clients.

Early nursing interventions, such as distraction and redirection, engaging the client in problem-solving, managing environmental stimuli, offering calming techniques, and providing comfort measures or physical activity can be highly effective, unrestrictive methods to redirect behaviors away from violence. Honest praise for the client’s ability to maintain personal control is part of these interventions. Taking a break from a situation through having time-outs, which are temporary, brief removals from adverse stimulation to reduce stressors, and medications are also less restrictive alternatives to managing aggression. With a time-out, the client is offered a choice to withdraw from a stressful situation and go to another location. This may be to the client’s bedroom, a designated quiet room, or a recreation area. A client in time-out is free to leave the time-out area at their will.

Stress reduction teaching, another less restrictive method of managing aggression and often used in conjunction with medication, is most effective approximately thirty minutes after medication administration, when the client will be getting some benefit from the pharmacological effect. This, together with the calming techniques prompted by the nurse, gives the client a chance to experience personal success. Such empowerment can transfer to future situations.

The Use of PRN Medication

Medication works best when offered to clients in early stages of anxiety before escalation of aggression. The term PRN is a medical abbreviation for the Latin pro re nata, meaning, “as it is needed.” In many situations, clients request PRN medications, such as needed for headache, sleep, or pain. Psychiatric nursing is somewhat unique in this regard in that PRN medications can be part of the nursing intervention when the nurse recognizes cues of potential aggressive behavior during assessment. Clients may not ask for antianxiety medication and may not be able to ask for antipsychotic medication, so the nurse determines the need. Nurses should offer PRN medication along with supportive interaction within the therapeutic relationship.

Nurses should not administer medication covertly, such as hiding it in food, or misrepresenting the type of medication or its action to the client. An ethical dilemma exists, however, for families and care providers when a client refuses medication as part of their illness or incapacity for decision-making, and the person’s health is deteriorating. Each state provides guidelines for administration of medication without the client’s consent. Only situations where there is an extreme threat to safety to the client or others merit this type of medication administration, and it requires specific documentation. Medical staff and supervisory nursing staff must be part of this decision and the documentation must clearly show what information was provided to the client and the client’s response (Latner, 2022).

Emergency medication orders are interim measures only, with care planning ongoing.

Nurses should confer with mentors and colleagues regarding trauma-informed care during mandated medication administration. Medication in these situations will likely be administered by intramuscular injection. The client’s movement may be stabilized by physical holds or restraint devices, though best-case scenario involves the client accepting the injection. Statements such as, “you need this,” or “we have to give this to you” are unhelpful, as is leaving the client alone after medication administration. Nurses should remain with, or near, the client after the medication is given to monitor medication effects and provide support.

Medications to treat severe mental illness have significant side effects and some potential lethality. Ideally, persons in need of these medications should be full participants in treatment decisions. The rationale for medically and legally ordered medications without the person’s consent is that with improvement from the medication, the person will be able to engage in their own care.

The Use of Seclusion

The American Psychiatric Association Resource Document Seclusion or Restraint (2022, page 2) describes seclusion or restraint as interventions “of last resort in the management of severe agitation” (e.g., violence). Both are highly regulated by local, state, and federal law and other health-care accreditation organizations, and both carry significant risks. As one of the most restrictive methods to manage aggressive behavior, seclusion is one form of coercive treatment. Restraint is the other most restrictive form. The ethical and legal challenges posed by these interventions should prompt mental health nurses to invest fully in the therapeutic relationship and embrace the role of client advocate.

While time-out is an intervention that the client can choose at the lower stages of anxiety, seclusion, by contrast, is staff placement of the client in a room designed for protective confinement. If there is furniture, it is generally fixed to the wall or floor. If there are windows, the covering is of a safety material. There are no electrical outlets or light switches and the door cannot be opened from inside once it is closed or locked from the outside. A ceiling light fixture and a security camera will be encased and the door may have a small, covered opening for observation or an intercom. Some seclusion rooms have padded covering on the walls and floor; some have drain openings in the floor. The person must be escorted out to toilet facilities, and there should be emergency resuscitative equipment nearby. Seclusion has traditionally been used when clients are dangerous to others or self-destructive and less restrictive measures have not proven effective. The person must be observed continually by staff or via camera with frequent documentation and provision of care.

Using Restraints

A measure designed to confine the person’s bodily movements and, subsequently, access to their own body is called a restraint. There are a number of different types of restraints: soft restraints, chemical restraints, medical restraints, behavioral restraints, and environmental restraints. In medical/surgical care facilities, some of these types of restraints prevent dislodging medical support interventions, such as oxygen masks, intravenous lines, or feeding tubes. Chemical restraint is the sedating effect of medication. All types of restraints are intended to limit the person’s movement, require specific documentation and provider orders, and present ethical and legal considerations.

Devices applied to the person’s limbs or body may be made of soft material, hard rubber, plastic, canvas, or leather. Straps of leather or fabric are buckled or tied to a fixed object, generally a bed or chair. The client may be positioned supine or sitting in standard or semi-Fowler’s position. Prone position is not safe or ethical.

In general, restraint in psychiatry has been used when clients are injurious to themselves or others. Time in restraint should be minimal with continuous nursing assessment. According to the APA, “these details (‘last resort,’ ‘less restrictive means’ and ‘minimum time requirement’) are codified in many state and federal laws” (2022, page 4). Nursing judgment can determine when clients can demonstrate personal control. As with seclusion, the restrained person must be observed continually by staff, and staff must document their observations. During a restraint episode, the nursing observations include assessment of the limbs, circulation, food, water, toileting, and when and how to know when the client can be released from the restraint.

Individual facilities have specific guidelines for application of restraints, and the cleaning, storage, and maintenance of the devices. Employees usually learn these guidelines during new employee and annual skills training. This training includes care of the person in restraints, such as provision of hygiene. Hygiene entails inspection of the client’s skin, nourishment, airway protection, proper positioning, and assessment for release. Additionally, each state sets specific guidelines regarding provider orders, documentation, and time limits on seclusion or restraints. All will likely contain the following:

• Intervention must be ordered by licensed practitioners permitted by the state and the facility.
• Least restrictive emergency safety interventions are required.
• Verbal orders must be verified in a signed, written form, outlining all details.
• The provider must be available for contact and consultation.
• Orders for restraints and seclusions should be renewed every four hours for adults over the age of eighteen, every two hours for children and adolescents ages nine to seventeen, and every hour for children under the age of nine.
• Within one hour, a licensed practitioner permitted by the state and the facility must conduct a face-to-face assessment to determine physical and psychological well-being.
• Staff must document the intervention in the health record:
  • the time the intervention began and ended
  • the time and results of the one-hour face-to-face assessment
  • the emergency safety situation that required the intervention
  • the names of the staff involved in the emergency safety intervention
• The facility must maintain records of each emergency safety situation, the interventions used, and their outcomes (Legal Information Institute, 2001).

Seclusion and restraint may cause substantial detrimental psychological and physical outcomes, including death. The therapeutic relationship, and early intervention in clients’ anxiety and stress states, can preclude the need for seclusion and restraint. They are emergency safety measures of last resort.

Staff Training

Many health-care settings teach the “Management of Aggressive Behavior,” sometimes abbreviated MAB. These programs have several concepts in common, with specifications made for child/adolescent, older adults, or forensic populations. Early programs (1970–1980s) were largely based on self-defense techniques, relying on blocking attacks or releasing from holds. Currently, programs present more therapeutic interventions. Some may be provided as part of first responder training, or are based on trauma-informed care, such as the Safe Crisis Management (SCM) Program. The following programs are available for MAB training.

• Association for Psychological Therapies
• Crisis Prevention Institute (CPI)/Nonviolent Crises Intervention (NCI)
• Essentials of Aggression Management
• Healthcare Aggression Response Training
• Mandt
• MOAB
• Professional Assault Response Training
• TEAM
• Therapeutic Options, Inc.

These models may be part of the organization’s quality improvement process and chosen based on feasibility and cost. General concepts of MAB include that staff should:

• communicate clearly and in a nonthreatening manner
• allow the client time to process the information; repeat information
• listen to the client; validate their feelings
• use open-ended questions; ask for the client’s input
• provide the client with alternative solutions

If there is a potential need for more restrictive interventions, consider and plan them in advance:

• Only one staff person should give direction.
• Members of the staff group should move quickly and efficiently to escort the client away from the scene to the area of seclusion or restraint.
• Room and equipment should be readily available.
• Attend to other clients.

Ulrich et al. (2018) make the point that the environment itself (furniture type and placement, light, sound, and space) can be a form of prevention of aggressive behavior and reduction of need for most restrictive interventions. Features like an accessible garden, nature paintings, low density communal settings, and noise reduction design have been proven to decrease the need for the most restrictive interventions. Mental health treatment settings can offer newly admitted clients a questionnaire to complete, designating which stress reduction methods they find helpful (Ulrich et al., 2018).

The Use of Security Staff in Clinical Situations

Safety officers in health-care facilities likely see their role as prevention, protection, and security by patrolling, monitoring, and managing threats (Parker et al., 2020). When called to client situations, they may be more prepared for hands-on rather than therapeutic communication. In reality, the role of security officers may by defined in facility policy (Lawrence et al., 2018). Still health-care workers in various departments may have differing views of the role of security staff.

From a nursing perspective, if security personnel are called to assist with client care, they should be functioning under direction of the nurse. The relationship dynamic between nursing staff and security staff may be one of respect and cooperation, or not. Resentment can be part of the scenario if security staff believe they are called for hands-on interventions and the nurses are “still talking” to the client. Psychiatric-mental health nurses should participate in planning management strategies that involve security staff with client-centered care in mind. These efforts should be proactive in nature and well communicated to all stakeholders in the organization.

An alternative to assistance of security personnel for mental health clients is implementation of behavioral emergency response teams (BERT). Based on the concept of rapid response teams’ proactive intervention for medical status changes, BERT offers the opportunity to bring specialized knowledge and care to an urgent situation wherein the client is experiencing extreme psychological stress. BERTs have been proven to assist with reducing assaults directed at staff and advancing staff cooperation, client satisfaction, and client and staff safety (Rajwani et al., 2023). A BERT’s multidisciplinary team may include clinicians, social workers, and counselors, who will learn or improve their skills, which in turn may reduce the need for the BERT (Choi et al., 2019).

Debriefing after a Violent Incident

Violent incidents are critical events and should be followed with debriefing measures similar to a cardiac code or client injury. The focused, purposeful discussion employed to enhance education or make improvements is called debriefing (Edwards et al., 2021). In this case, it will assist all staff members to process the event to help them cope and recover. It will offer resources for further assistance in order to prevent post-traumatic stress and burnout. It will involve a review of all elements of the event, prior and during, including areas in need of improvement. It will include a brainstorming session about how the incident could have been handled better operationally. The debriefing should also consider the client’s perspective and offer staff members emotional support and an opportunity to express feelings, fears, and learning needs.