Violence%20and%20Crises%20Intervention

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Violence and Crises Intervention

• West Coast University
• NURS 204

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Violence in the Healthcare Setting

• Definition
• Verbal or physical threats and/or injury to
  persons or destruction of property
• 60-90 of nurses experience violence.
• Psychiatric setting is area of high risk and
  incidence.

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Biopsychosocial Theories

• Biologic Theories
• Imbalances of hormones (? testosterone),
  neurotransmitters (?D and NE, ?Achm 5HT, and
  GABA)
• Genetic abnormalities
• Neurophysiologic injuries (trauma, anoxia,
  metabolic imbalance, encephalitis, organic brain
  injury)

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Biopsychosocial Theories - continued

• Psychosocial Theories
• Psychoanalytic aggression an innate drive
• Psychological impairment in impulse control,
  coping, and social skills
• Sociocultural child abuse, dysfunctional family

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Biopsychosocial Theories - continued

• Psychosocial Theories
• Psychoanalytic aggression an innate drive
• Psychological impairment in impulse control,
  coping, and social skills
• Sociocultural child abuse, dysfunctional family

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Biopsychosocial Theories - continued

• Behavioral Theory
• Learned behavior (exposure to violence
• in media/entertainment)?
• Humanistic Theory
• Basic drives unmet

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Aggression and the Brain

• Hypothalamus
• Alarm system, controls pituitary function
• Dysfunction leads to overreaction to stress and
  overactivation of pituitary
• Hippocampus
• Regulates the recall of recent experiences and
  new information
• Dysfunction associated with impulsivity

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Aggression and the Brain - continued

• Amygdala (limbic system)?
• Regulates emotion, memory storage, information
  processing
• Dysfunction affects emotion and behavior,
  outbursts of fear, anger, rage, hypersexuality
• Frontal cortex
• Generates thought and purposeful behavior
• Dysfunction leads to impaired judgement, poor
  decision-making, personality changes, aggressive
  outbursts

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Behavioral Cues

• Clenched jaws and fists
• Dilated pupils
• Intense staring
• Flushing of face and neck
• Frowning, glaring, or smirking
• Pacing
• Increased vigilance

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Verbal Cues

• Threats of harm
• Loud demanding tone
• Abrupt silence
• Sarcastic remarks
• Pressured speech
• Illogical responses
• Yelling, screaming
• Statements of fear or suspicion

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Nursing Process Assessment

• Risk factors
• History of violence
• Severity of psychopathology
• Higher levels of hostility
• Length of time in the hospital
• Early age of onset of psychiatric symptoms
• Frequency of admission to psychiatric hospitals

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Self-Awareness
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Assessment

• Assess clients
• Perception of precipitating event/current
  situation
• Support system
• Usual coping patterns

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Assessment - continued

• Environmental factors
• Availability of dangerous objects
• Overcrowding
• Staffing
• Supervision
• Activity level

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Nursing Diagnoses NANDA

• Risk for Other-Directed Violence
• Risk for Self-Directed Violence
• Anxiety
• Ineffective Coping
• Chronic Low Self-Esteem, and Situational Low
  Self-Esteem

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Other Considerations

• Impulse control
• Sensory-perceptual functioning
• Cognitive functioning
• Social skills
• Impaired communication
• Helplessness
• Powerlessness

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Implementation

• Develop a therapeutic relationship.
• Establish trust, maintain safety, and convey
  respect.
• Use active listening.
• Address client needs.

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Pharmacologic Interventions

• Pharmacologic agents
• Antipsychotics (typical and atypical)
• Benzodiazepines
• combinations

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Safety

• Minimizing personal risk
• Nonthreatening communication
• Awareness of environment
• Availability of other staff members
• Awareness of clothing and objects

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Nonpharmacologic Strategies - continued

• De-escalation
• Assemble a team and brief team members.
• Clear the area of other clients.
• Choose a leader.

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Restrictive Measures

• Restrictive measures
• Pharmacologic
• Seclusion
• Involuntary confinement
• Restraint
• Device attached or adjacent to clients body
  which restricts movement or normal access to
  ones body
• Documentation required
• Denial of Rights

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Professional Education and Support

• Behavioral crisis management programs
• Increase awareness of risk factors, teach staff
  de-escalation strategies and teamwork for
  behavior management/restraint
• Critical Incident Stress Debriefing (CISD)
• Staff who experience violent situation discuss
  feelings in safe, supportive environment
• Reduces long-term negative consequences

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Nursing Self-Awareness

• How do I feel about this patient/setting?
• How are my feelings affecting my behavior?
• Fear is a normal response.
• Avoid personalizing.
• Use intuition.

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Situational Crises

• Material or environmental
• Personal or physical
• Interpersonal or social

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Maturational Crises

• Life cycle transitions infancy, childhood,
  puberty, adolescence, adulthood, middle age,
  older adulthood, old age
• Other life changes marriage, retirement,
  transition from student to worker

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Crisis as Turning Point

• Crisis turning point that results in new
  equilibrium, which may be similar to pre-crisis
  state, or more positive or negative

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Crisis Intervention

• Crisis is self-limiting because disequilibrium is
  so uncomfortable.
• Crisis resolves itself, favorably or unfavorably,
  even without intervention.
• Working with another person increases likelihood
  of favorable resolution.

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Sequence of Crisis

• Tyhursts three stages of disaster
• Impact
• Recoil
• Post-trauma

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Sequence of Crisis - continued

• Caplans four stages of crisis reaction
• Initial increase in tension
• Further increase in tension and disruption of
  daily living when crisis is not quickly resolved
• Increase in tension to depression levels if usual
  problem-solving techniques fail
• Partial resolution of crisis with use of new
  coping skills, or mental disruption/disorder if
  new skills are not developed

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Health Professionals Role

• Help person in crisis understand what led to the
  crisis and guide him/her toward positive
  resolution
• Acute phase restore the person to pre-crisis
  level of functioning as quickly as possible

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Assessment

• Individual precipitating event, perception,
  support, resilience, coping style, ability to
  handle problem, suicide potential
• Family stressors, resilience, resources, coping
  skills, interpersonal styles
• Sociocultural influence of culture on sources of
  distress a client experiences, symptomatology,
  interpretation of symptoms, coping methods

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Nursing Care

• Common diagnoses
• Ineffective Coping
• Interrupted Family Processes
• Risk for Self-Directed Violence
• Anxiety
• Acute Confusion
• Spiritual Distress
• Sleep Deprivation
• Risk for Post-Trauma Syndrome
• Complicated Grieving
• Impaired Social Interaction

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Nursing Care - continued

• Outcome criteria determined in collaboration
  with client
• Planning/implementation developed with client
  and family focused on immediate problems
  consistent with lifestyle/culture time limited
  realistic mutually negotiated provides for
  follow-up
• Evaluation in long-term setting, review of
  implementation and outcomes

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Balancing Factors

• According to Aguilera, three balancing factors
  for resolution of disequilibrium are
• perception of the event
• situational supports
• coping mechanisms

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Crisis Intervention

• Types of crisis intervention
• Crisis counseling (brief, solution-focused
  therapy)
• Telephone counseling
• Assisting with environmental changes
• Anticipatory guidance (assistance in anticipation
  of the potential for crisis, thus averting it)
• Helping to develop social supports
• Critical incident stress management
• Disaster assistance

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Critical Incident Stress Management

• CISM integrative, comprehensive, multifaceted
  approach spanning time sequence of crisis
• 10 components
• Pre-event planning
• Assessment
• Strategic planning
• Individual crisis intervention

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Critical Incident Stress Management - continued

• 10 components (cont)
• Large group crisis intervention
• Small group crisis intervention
• Family crisis intervention
• Organizational/community intervention
• Pastoral crisis intervention
• Follow-up/referral

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ABCs of Crisis Counseling

• A Achieve contact (safety and security)
• B Boil down the problem (ventilate and
  validate)
• C Cope with the problem (predict and prepare)

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ABCs of Crisis Counseling in Plan of Care

• A Assessment
• B Diagnosis
• C Planning and implementation, including plan
  for follow-up (evaluation)

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Nursing Self-Care

• Behaviors crucial to effective crisis work
• Belief in a persons capacity to grow and change
• Awareness of impact of repeatedly hearing
  horrible stories
• Developing outlets for stress, frustration, anger
• Dealing with fears and vulnerability
• Realistic expectations
• Respect for others timetable for crisis
  resolution
• Collaboration with others

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Vicarious Traumatization

• Vicarious traumatization condition in which
  psychological aftereffects are experienced by
  those who are not direct victims of the traumatic
  event
• Commonly affects next of kin, injured and
  uninjured survivors, onlookers, rescuers, body
  handlers, health personnel, people responsible
  for disaster, coworkers, evacuees

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Origins and Risk Factors for Crisis

• Origins of crisis situational, maturational
• Risk factors intensity of exposure, preexisting
  psychiatric symptoms or diagnosis, previous
  trauma, family history of mental illness, early
  separation from parents, childhood abuse,
  poverty, cultural expectations, degree of threat
  to life