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Certified Nurse Assistant Online Lesson – Understanding Aggression

Aggression in general is a strong, antagonistic and a violent manner. It may be a result of the reprisal without aggravation. Aggression can be physically and verbally or non-verbally communicated. It is a common problem, or let me say a huge problem in nursing homes or patients from hospitals undergoing medication. It may be an effect of the environment or medical side effects. We as a certified nurse assistant has the role in preventing it from happening and make the patient calm if it already occurs.

Facing aggression is part of our everyday job. Statistics show that nurses especially in the emergency department have a higher chance of facing aggression. It is because injuries or anything caused by accident or the accident itself can trigger tough feelings that leads to aggression or violence.

In this post, we would like you to have a deeper understanding of aggression. Here is an insert from nursingtimes.net tackling aggression.

AggressionTriggers of violence and aggression
Research by Schnieden and Marren Bell (1995) showed an increase in violence during antisocial working hours (6pm-7pm) that may be linked to the easy access of casualty departments. Sains (1999) cites the frustration caused by lengthy waiting times as a major causative factor. Findings by Schnieden and Marren Bell (1995) back this up with research they conducted that showed 80% of verbal violence was related to waiting times.

The RCN (1998) describe how low staffing can be linked to an increase in violence and aggression, as a decrease in the number of staff can lead to increased waiting times for patients. Lack of personal space and the waiting room ‘audience’ can also lead to aggression (Sains, 1999).

A sudden illness or accident can trigger strong emotions leading to stress, which can manifest itself in a number of ways, including violent or aggressive behaviour (Needs, 2000). In his report into violence in a US emergency department, Kuhn (1999) showed how an irrational individual who was grieving for a family member injured a member of staff. Other triggers include: adverse stimulation of pain; lack of any options; frustration and the nature of the task being undertaken (Breakwell, 1989).

A major trigger of violence and aggression in the emergency department is the consumption of, and withdrawal from, alcohol and drugs. Intoxication with alcohol and drugs reduces the individual’s capacity to understand and interpret situations, and also decreases inhibitory responses during stressful times (Dolan and Holt, 2000).

Reporting violent incidents in hospital settings
Rose (1997) questioned 36 members of staff in the A&E department of a large Irish teaching hospital. Staff at the hospital are required to document all incidents of physical and verbal abuse on an incident form. Interestingly, findings showed 63% of incidents and 29% of physical assaults went unreported. The tendency to report violent incidents increased according to length of service: 71% after 10 or more years, decreasing to 20% among nurses with less than 10 years’ experience.

There is a tendency for community staff not to report incidents, because they find the formal procedures too time consuming, believe incidents are not serious enough, or because they see violence as part of their job (Beale et al, 1999). Research by Whittington et al (1996) found that inexperienced staff were more likely to report incidents of violence. However, although Whittington et al targeted 1006 members of staff, only 36% responded.

With the increase in medical litigation in recent years, it is likely that reporting and documentation of incidents has begun to improve to reflect this.

Preventing problems
One important question is how we can reduce or prevent aggression and violence. Brennan (2000) states that: ‘For too long violence has been accepted as part of a nurse’s job.’ He discusses the need for ‘zero tolerance’ when dealing with violence in a hospital setting. Poor communication between staff and patients is a trigger to violent outbursts (Dolan and Holt, 2000). The triage system should not only provide a way of prioritising patients in terms of urgency but also of obtaining information. Williams (1992) cited in Dolan and Holt (2000) emphasises that during triage the patient can be assessed and can obtain information on their illness and on waiting times. Due to the sheer unpredictability of the workload, however, the frustration caused by changing waiting times can be difficult to address (Sains, 1999).

Managing violence and aggression
In the document Dealing with Violence Against Nursing Staff the RCN states that: ‘Raising staff knowledge and awareness, while rehearsing and developing interpersonal skills for defusing such behaviour are important first steps in managing the problem of violence’ (RCN, 1998). It should be acknowledged that most of the research included in this review would have been undertaken before the RCN produced these guidelines.

If a patient becomes aggressive, staff need to know how to de-escalate the situation (Sains, 1999). Work by Patterson et al (1997) cited in Sains (1999), defines these skills as: ‘A set of verbal and non-verbal responses which, when used correctly, may reduce the person’s hostility.’

The literature discussed supports the view that staff both in general wards and in A&E could benefit from training to help them handle aggression and violence. Schieden and Marren Bell (1995) found that only 50% of staff working in accident and emergency had been trained to deal with violence. Of those who had been trained, half had been taught how to deal with violent patients and half had been taught to deal with verbal abuse.

While all those who took part in this research attended an induction programme, only 18.4% had received training as part of the programme. Less than one-fifth of staff had been trained in violence management techniques in one particular hospital (Rose, 1997). Beale et al (1999) also found that many staff were still not received training.

Sains (1999) describes how training should address understanding aggression and violence, assessing danger and taking precautions when dealing with violent individuals. Of those attending the RCN Emergency Nurse Forum, the majority had attended only lectures and role-play sessions, with 80% never having attended an update. There was no research relating to the content of the training sessions (Schnieden and Marren-Bell, 1995).

Schnieden and Marren Bell (1995) provide no evidence of staff training in ‘break-away’ techniques, an area Dolan and Holt (2000) describe as giving nurses the confidence to deal with violent situations. While most of the reviewed literature shows the importance of risk assessment in the effective management of aggressive and violent situations, none offered any evidence of how it is carried out, what needs to be assessed, or records of improvements made in the hospitals surveyed. It must again be noted that most of the reviewed literature and research would have been carried out before the publication of the RCN guidelines.

Read the complete details of aggression here.

After understanding what aggression and how to possibly prevent it, we will be discussing the ways on how to deal with aggression in the next post.

Feel free to leave your thoughts in the comment section. Thank you.

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