Psychiatric Mental Health, part 9: Aggression/Violence, Abuse

July 30, 2021 Updated: September 27, 2021 9 min read

How can you tell if someone is about to get violent? What should you do if a patient gets violent? What are the phases in the cycle of abuse? In this article, we'll answer all of these and more.

It's important to understand aggression, violence and abuse as part of your psychiatric mental health nursing education, as these topics are related to and may underlie patient behaviors and disorders.

This series follows along with our Psychiatric Mental Health Nursing Flashcards which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

Aggression & violence

Aggression and violence can include a range of behaviors or actions that could hurt or injure another person, either physically or verbally.

Unfortunately, as a nurse in the psychiatric mental health setting or in general, it is likely that you will encounter an aggressive or violent patient at some point. It's important to be prepared for that. You will be tested on this on the NCLEX and in your nursing school exams, and you need to be prepared in real life for a violent or aggressive patient.

Here, we'll explain the predictors of violence, de-escalation techniques, and interventions for violent behavior.

Predictors of violence

Predictors of violence are behaviors that people may typically engage in as a precursor to becoming violent, and that can include pacing, agitation, threatening remarks, and a combative posture.

Not all people exhibit these behaviors before becoming violent, but many do.

De-escalation techniques

If a patient is becoming aggressive or violent, your first priority is to de-escalate the situation. There are some important points to remember:

  • Use a calm voice.
  • Allow for personal space around the patient (don't get in their face).
  • Set clear limits and redirect patients to other activities.
  • Encourage relaxation techniques and offer some distraction with a positive activity, like exercise.
  • Try to get the patient to a quiet area with decreased stimuli under close observation.
  • Move other patients away from the area.
  • Make sure that you have sufficient staff available very close by if needed for intervention.
  • Remove any dangerous items from the environment.

Interventions for violent behavior

Sometimes, de-escalation techniques are not effective and unfortunately, further steps may be required to provide for your safety and the safety of other patients.

Escalated interventions for violence, after de-escalation has failed and safety is at risk, can include the administration of pharmaceuticals (e.g., haloperidol, lorazepam), or patient restraints and seclusion.

Safety tips

Your most important nursing priority is to keep yourself safe — if you aren't safe, you can't help others. Here are some important safety tips for nurses or soon-to-be nurses especially in a psychiatric mental health setting:

Do not wear necklaces. You can be choked or injured with it if someone grabs it.

Know your facility layout, in the event you need to exit to safety.

Make sure the patient is not between you and the door.

Abuse

Abuse is the term for acts by a person that hurt another person, especially regularly or repeatedly. The types of abuse we'll cover here are physical, emotional, sexual, neglect, and economic abuse.

Abuse can be a risk factor for multiple mental health disorders, including PTSD, dissociative disorder, body dysmorphic disorder, and more. These disorders are covered in our Psychiatric Mental Health Nursing Flashcards.

In a psychiatric mental health setting, you may have patients that you suspect are being abused, patients whom you know have been abused, or patients who abuse others.

Physical abuse

Physical abuse is the intentional use of physical force that inflicts harm on another person, and can include hitting, kicking, burning, shaking.

Emotional abuse

Emotional abuse is the term for behaviors that harm another person's self-worth or emotional well-being, like name-calling, shaming, or rejection.

Sexual abuse

Sexual abuse is forcing a person to engage in sexual acts without their consent.

Neglect

Neglect is failure of a caretaker to provide for the basic needs of a vulnerable person; this can include housing, food, education, and medical care.

Economic abuse

Economic abuse is making an individual financially dependent through the improper use of funds by a person in a trusted relationship.

Cycle of abuse/violence

The cycle of abuse is one method for explaining the cyclical social patterns seen in abusive relationships.

Tension-building phase

The first phase in the cycle of abuse is the tension-building phase. During the tension-building phase, the abuser becomes judgmental, threatening, unpredictable, and possibly verbally abusive.

The victim may feel as if they are walking on eggshells. Attempts to reason with or calm the abuser are unsuccessful.

Explosive phase

The next phase in the cycle of abuse is the explosive phase. During this phase, there is physical, emotional, and/or sexual abuse that occurs. The victim may or may not contact the authorities.

Honeymoon phase

The next and last phase of the cycle of abuse is the honeymoon phase.

In general, the term honeymoon phase refers to a traditional honeymoon after a wedding, ostensibly the time that the marriage is happiest. So when applied to the cycle of abuse, it means that things are temporarily "better." During this time, the abuser apologizes; they might give presents to the victim. They promise never to do it again.

At this point, the victim may drop charges if they had brought charges forth previously, believing the situation will not happen again. Unfortunately, the cycle usually repeats again.

Risk factors for abuse

One part of assessing patients for abuse is considering the relevant risk factors. Abuse can happen to anyone, but there are some risk factors that are statistically associated with the perpetrator and the victim that have a correlation to abuse.

Considering risk factors when assessing patients for abuse does not mean discounting patients that do not fit the risk factors, but rather that having an understanding of the statistics is a more complete picture and can help inform pattern recognition and hopefully sooner diagnoses and better patient outcomes

Perpetrator risk factors

Perpetrator risk factors include poor education, low socioeconomic status, substance abuse, family history of violence, and low self-esteem.

As a reminder, these are factors that are correlated with abuse perpetrators.

Victim risk factors

Victim risk factors can differ based on the type of abuse and age of patient.

Intimate partner violence

Women are more likely to experience intimate partner violence than men. Pregnancy is also a risk factor for intimate partner violence.

Child abuse

"Unwanted"/unplanned children are at higher risk for being abused. Children with special needs have an increased risk of being abused.

The risk of child abuse increases greatly when domestic abuse is present in the home.

Elder abuse

Older adults with chronic health challenges (e.g. dementia) are at an increased risk for being abused.

This information on reporting suspicion of abuse is for your nursing exams and nursing practice. If you or someone you know is experiencing abuse or domestic violence, you can call the National Domestic Violence Hotline (external link) at 1−800−799−SAFE(7233). This is an immediate link to lifesaving help where they provide information, assistance, crisis intervention, safety planning, and referrals to shelters. They are open for calls 24 hours a day.


Full Transcript

Hi, I'm Cathy with Level Up RN. In this video, we are going to talk about aggression and violence, and I'm going to start in on my coverage of abuse. At the end of this video, I'm going to give you guys a little quiz, a little knowledge check to see if you understand some of the key concepts that I will be covering in this video.

So let's first talk about aggression and violence. Unfortunately, as a nurse, it is very likely that you will encounter an aggressive or violent patient, and it's going to be important for you to be prepared for that. So you'll not only get questions about this on the NCLEX and your nursing school exams, but you also need to be prepared in real life for a violent or aggressive patient.

So predictors of violence can include pacing, agitation, threatening remarks, and a combative posture. And of course, we want to try to de-escalate the situation, and we can try to do so with a calm voice. We want to allow for lots of personal space around the patient, so you don't want to be up in their face. You want to provide very clear limit setting and redirection. You want to encourage relaxation techniques and offer some distraction with a positive activity such as exercise. You definitely want to try to get that patient to a quiet area with decreased stimuli under close observation. And you want to move other patients away from the area and make sure that you have sufficient staff available very close by if needed if we need them to intervene. And then you also want to remove any dangerous items from the environment.

So we're going to try all of these things to try to de-escalate the situation. If we are not successful, then unfortunately, we kind of have to take the next step to provide for our safety and the safety of other patients.

So this can include the administration of pharmaceuticals such as haloperidol or lorazepam.

And then if needed, we can also apply restraints or put the patient in seclusion. A couple of other key points for all of you nurses or soon-to-be nurses out there, do not wear necklaces. You do not want anything that someone can grab around your neck. You also want to make sure you know your facility layout, and you want to make sure the patient is not between you and the door. So number one, you got to keep yourself safe. You do not want to get hurt or injured, so do what you need to do to keep yourself safe.

Now we're going to transition to talking about abuse. So there are five types of abuse, generally speaking.

We have physical abuse, which is the intentional use of physical force, which could be hitting, kicking, burning, shaking.

We have emotional abuse, which are behaviors that harm another person's self-worth or emotional well-being.

Then we have sexual abuse, which is forcing a person to engage in sexual acts without their consent.

And we have neglect, which is failure of a caretaker to provide for the basic needs of a vulnerable person, so this can include housing, food, education, medical care, etc.

And then we have economic abuse, which is making an individual financially dependent through the improper use of funds by a person in a trusted relationship.

Now that we have gone through the different types of abuse, let's talk about the cycle of abuse or violence. So really, there are three phases in this cycle.

The first phase is the tension-building phase. This is where the abuser becomes judgmental, threatening, unpredictable, and possibly verbally abusive. The victim feels like they are walking on eggshells, and attempts to reason with or calm the abuser are unsuccessful.

From the tension-building phase, we go into the explosive phase. During this phase, there is physical, emotional, and/or sexual abuse that occurs, and the victim may contract the authorities or they may not.

Then after this explosive phase, we go into the honeymoon phase. During this phase, the abuser apologizes, they may give presents to the victim. They promise never to do it again. At this point, the victim may drop charges if they had brought charges forth previously, believing the situation will not happen again. But unfortunately, the cycle repeats again.

Let's now talk about risk factors associated with abuse. I have divided this up on my flashcard between perpetrator risk factors and victim risk factors.

So perpetrator risk factors include poor education, low socioeconomic status, substance abuse, family history of violence, and low self-esteem.

In terms of victim risk factors, if we're talking about intimate partner violence, being a woman places the individual at higher risk for abuse, also, pregnancy places a woman at higher risk for abuse as well.

When we are talking about child abuse, unwanted or unplanned children are at higher risk for abuse. Also, children with special needs will also be more likely to be abused. And the risk of child abuse increases a great deal when domestic abuse is present in the home.

For elderly or older adults, if they have chronic health challenges such as dementia, that can place a strain on the caregiver and then makes it more likely that they will also be abused.

Okay. Knowledge check time. I have three questions for you. Question number one, failure of a caretaker to provide for the basic needs of another, so this includes housing, food, medical care, and education, is considered what type of abuse? The answer is neglect.

Second question, in the cycle of violence, what phase is characterized by the victim walking on eggshells? That would be the tension-building phase, which is the first phase of that cycle of violence or abuse.

And then last question is a true-false question. There is an increased risk of child abuse when there is domestic violence present in the home, true or false? The answer is true. Okay. In my next video, we will talk about the signs of abuse and we will talk about nursing care of abuse, so stay tuned for that. Thanks for watching.


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