The Role Of Communication Techniques In Managing Aggressive Patients In The Emergency Department

Patient and Environmental Factors that Contribute to Violent Behavior

Discuss about the Nursing Management Of Aggressive Patients In Emergency Department.

Violence and aggression is a common occurrence in the emergency department (ED). It is a high risk area that increases the likelihood of aggression and Tan, Lopez and Cleary (2015) reports that majority of nurse experience physical injuries because of aggression in the ED. There are a number of factors that increases risk of aggression in the ED. Firstly, many patient related factors such as age, gender and exposure to alcohol and substance abuse is strongly associated with violent behaviours. Secondly, environmental factors like poor staffing levels, overcrowding, increased waiting time and poor security increases the chance of violence and aggression in the ED. Another possible cause of high risk of violent episodes in the ED includes exposure to lack of communication between patient and nursing staff and demanding behaviour or attitude of patients and their family members (Angland, Dowling and Case 2014).  Hence, addressing these risk factors might be a solution to control aggressive events and manage aggressive patients in the ED.

The review of study regarding nurse’s perception regarding violence in ED suggest that nurses are psychological affected by the event as they experience physical injuries as well as stress and burnout due to such experience. Nurses were found to be frustrated while delivering patient care in overcrowded areas. In case of nurse-patient related factors, poor interpersonal communication is identified as one of the factors contributing to violence in the ED. However, Swain and Gale (2014) improving communication skills and implementing good communication strategies can be an approach to avoid violence and manage aggressive patients in the ED. Hence, as an ED nurse, I think that having good communication can help to manage violent and aggressive patient. Finding relevant literature related to the role of communication in management of aggressive client may help to determine whether valid evidence exist regarding the efficacy of this interventions in ED. In accordance with this assumption, the PICO question for the study is as follows:

P-Aggressive patients in the ED

I- Nursing communication technniques

C-No communication strategies

O-reduction of aggression and violence

Question: ‘Does nursing communication techniques helps in the reduction of violence and aggression in aggressive patients in the ED?

High incidence of violence and aggression in the ED is the main research problem and the main goal of the research paper is to assess the role of therapeutic nursing communication skills in managing aggressive patients coming to the ED. Literature review has been chosen as a method for problem analysis as this would help to identify effect of various nursing communication training programs and strategies on controlling aggression in the ED. It may help to further understand the best method to address the research problem and implement evidence based nursing intervention in the ED (Dang and Dearholt 2017). It may also facilitate developing hospital specific protocols to address aggressive behaviour of patients in the ED.

Communication Strategies to Manage Aggression and Violence

The key objectives of the literature review are as follows:

• To evaluate the effectiveness of nursing communication techniques in management of aggressive clients in the ED
• To assess outcomes of nursing communication intervention in the ED
• To assess best communication techniques to control aggressiveness in patients

The research hypothesis is that therapeutic nursing communication technique can control aggressive behaviour in patients visiting ED and it can increase their satisfaction with care.

Search strategy:  To retrieve articles related to the role of the nursing communications techniques in dealing with aggressive patients in ED, articles have been retrieved from databases like CINAHL, PubMed and PsychInfo. These are databases that published peer-reviewed articles related to the field of health care, bioscience, nursing and mental health. Additional references have also been taken from Google scholar. Based on the research question, the key words used for conducting the search included ‘nursing communication techniques in ED’, ‘Nursing communication training for managing aggressive patients, ‘nursing communication  to manage aggressive behaviour in patients and communication and prevention of aggressive behaviour in ED.

The search for research articles were guided by many inclusion and exclusion criteria:

These were as follows:

• All research articles must evaluate must have nursing communication techniques as the main intervention
• The main outcome for each study should be reduction of aggression in patients
• The research must be published within 2008 to 2018
• The research articles must be published in English language
• Articles reporting about other interventions other than communication intervention must be excluded.

Data analysis:

The title and abstract of articles were analysed first to determine its relevance with the research question. In the next phase, the full-text articles were reviewed against inclusion and exclusion criteria to take decision regarding inclusion of the articles for literature review. Critical analysis of articles has been done by evaluating credibility, reliability and applicability of research findings.

Various research literature gave evidence regarding the effectiveness of nursing communication techniques in controlling aggressive behaviour in patients visiting ED. In the area of nursing communication related interventions, de-escalation technique has been found as the first line of intervention to manage violent patient in the ED. De-escalation is the technique to modify behaviour of aggressive patients by non-coercive verbal techniques. The main aspect of de-escalation technique is that it helps health care staffs to understand and acknowledge patient’s feeling. Validation of feelings and empathy helps to control aggressive behaviour of patient (Boulger, Werman and Pinto 2017). The review of literature suggest that de-escalation technique can be the first strategy used by nurse to control violent situations and ensure that patient’s cooperated during health care decision making and delivery.

Various studies reported use of de-escalation techniques in many aggression management training program. Nau et al. (2010) reported about the effect of aggression management training program on nursing student’s ability to manage aggressive patients. A pre-test and post-test research design was used to assess nurse’s performance in de-escalation techniques. The intervention consisted of 24 training sessions within one week, training nurses to learn rapport building and problem solving skills. Verbal and non-verbal communication, body language and non-provocative interventions were some content of the training session. De-escalating behaviour of nursing students were tested by De-escalating Aggressive Behavior Scale (DABS). The results findings revealed that training was effective in improving nursing student’s performance in de-escalation techniques and managing aggressive patients. Although the research shows the effectiveness of de-escalation training on nurse’s performance, however lack of reliability and validity testing of the DABS scale limits the credibility and transferability of the research findings. There is lack of reliable evidence on the effective of communication techniques like de-escalation in the management of aggression. However, its application in other health setting is found. Heckemann et al. (2015) gave evidence regarding the inclusion of-de-escalation techniques in an aggression management training program in acute care setting.  It gave a contradictory finding as it revealed that aggression management training can increase skills of nurse in dealing with aggressive patient, however it does not provides nurse the ability to emotionally cope with patients. Hallett and Dicken (2015) also argues that future research should be done on the role of timing in de-escalation as this may enhance nurse’s ability to cope with emotional aspects of aggression management too.

Effects of De-escalation Training Programs on Nurse Performance

Tan, Lopez and Cleary (2015) recommended communication training for ED to control aggression. Gerdtz et al. (2013) gave an insight into the outcome of a communication program on prevention of aggression by means of a multi-site evaluation. Mixed method was used to survey nurses and midwives who had taken part in the rapid training program. The training focused on encouraging nurse to use de-escalation techniques and effective communication skills to deal with aggressive patient. The evaluation of outcomes related to nurse’s attitude towards aggression management revealed significant changes in the prevention and management of aggression in patient. However, one crucial finding was that despite training, nurse found environment as an important predictor of violence and aggressive behaviour in patients. Multi-site evaluation is the strength of the study. However, relying on self-reported data instead of direct observation is a limitation in relation to assessment of de-escalation performance. There is a need to conduct further research to observe nurse’s skills and confidence in managing aggressive patients.

Based on the review and analysis of research literature, communication skills training and training programs related to de-escalation strategy has been identified as one major nursing management strategy to cope with aggressive behaviour in ED. There is lack of research studies that has evaluated communication related intervention in ED, however interventions related to aggression management in mental health setting has been widely published. The outcomes obtained literature review is considered significant as it shows the potential of communicating training in improving nurse’s performance in aggression management. However, the evidence also shows some limits in training programs. For example perceptions related to the avoidance of physical constraints and role of environmental factors has not been changed post the interventions (Nau et al. 2010). This points out to the need to conduct large longitudinal studies in emergency department to understanding the impact of effective communications skills on reducing violent behaviours in patient presenting to the ED.

Conclusion:

To conclude, the paper summarized the outcomes from the literature review of nursing communication interventions to manage aggressive patients in the ED. The research aimed to address the problem of high prevalence of violence and aggression in the ED. The literature review focused in evaluating the effectiveness of communication strategies on aggression management as patient-staff factors was identified as one of the risk factor of aggression. The review shows potential of communication training. However, more studies are needed in the future to get validated findings that reports about reduction in violence episodes in patient post intervention.

References:

Angland, S., Dowling, M. and Casey, D., 2014. Nurses’ perceptions of the factors which cause violence and aggression in the emergency department: a qualitative study. International emergency nursing, 22(3), pp.134-139.

Boulger, C., Werman, H. and Pinto, A.J., 2017. Management of the Violent Patient in the Emergency Department. Emergency Medicine Reports, 38(9).

Dang, D. and Dearholt, S.L., 2017. Johns Hopkins nursing evidence-based practice: Model and guidelines. Sigma Theta Tau.

Gerdtz, M.F., Daniel, C., Dearie, V., Prematunga, R., Bamert, M. and Duxbury, J., 2013. The outcome of a rapid training program on nurses’ attitudes regarding the prevention of aggression in emergency departments: a multi-site evaluation. International journal of nursing studies, 50(11), pp.1434-1445.

Hallett, N. and Dickens, G.L., 2015. De?escalation: A survey of clinical staff in a secure mental health inpatient service. International journal of mental health nursing, 24(4), pp.324-333.

Heckemann, B., Zeller, A., Hahn, S., Dassen, T., Schols, J.M.G.A. and Halfens, R.J.G., 2015. The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting. A narrative review of current literature. Nurse education today, 35(1), pp.212-219.

Nau, J., Halfens, R., Needham, I. and Dassen, T., 2010. Student nurses’ de-escalation of patient aggression: A pretest–posttest intervention study. International journal of nursing studies, 47(6), pp.699-708.

Swain, N. and Gale, C., 2014. A communication skills intervention for community healthcare workers reduces perceived patient aggression: A pretest-postest study. International Journal of Nursing Studies, 51(9), pp.1241-1245.

Tan, M.F., Lopez, V. and Cleary, M., 2015. Nursing management of aggression in a S ingapore emergency department: A qualitative study. Nursing & health sciences, 17(3), pp.307-312.