This document provides an outline for a lecture on managing anger, aggression, and violence. It discusses healthy and unhealthy expressions of anger, factors that influence aggressive behaviors, and interventions to escalate or de-escalate violence. Risks of nurse abuse are also covered. The lecture applies a biopsychosocial approach to managing these issues in patients using interventions related to biological, psychological, and social domains. Prevention is emphasized over seclusion or restraint, which are seen as last resort options. Rates of violence against nurses, especially in emergency departments, are reviewed.

1. Management of Anger, Aggression & Violence Lecture Notes 1
Objectives: Poor anger control is demonstrated in increased conflicts at
1. Explore healthy & unhealthy styles of anger management. work, frequent job changes, increased risk taking, and have
2. Review factors that influence aggressive & violent more accidents that people with adaptive anger behavior.
behaviors.
3. Identify behaviors & actions that escalate & de-escalate What exactly is “ANGER?”
violent behaviors.
4. Discuss risks related to “nurse abuse.” Descriptors are imprecise & confusing. Cultural influences
5. Apply the nursing process to the management of anger, exist.
aggression & violence in patients.
Anger: strong, uncomfortable emotional response related
This handout is an interactive guide to assist you in your provocation that is unwanted and incongruent with one’s
studies of the Management of Anger, Aggression & Violence values, belief & rights. Anger is an internal affective state and
as it relates to Psychiatric Nursing. My intention is for this may not be expressed in overt behavior. Anger and be healthy
guide to serve as an adjunct learning aid for material and not or unhealthy.
as a substitute. You are responsible for reviewing and
understanding the course objectives and the objectives for this Aggression: involves overt behavior to hurt, belittle,
chapter for testing purposes. The additional material is to help revengeful, achieve domination or control. Well-adjusted
solidify your understanding of the concepts presented in the patients are able to prevent themselves from expressing
text and to provide you with practical application of this aggression.
material.
Violence: Can be predatory or reactive, the use of force with
LECTURE OUTLINE the intent of harm.
Violence in our society is so pervasive that we can see it in the Anger is one of six emotions recognized in all cultures! (Fear,
news everyday. Thomas indicated in her chapter bullying anger, sadness, happiness, surprise, and disgust). It’s
occurs in school age children every 71/2 minutes and 160,000 expression is expressed differently cross-culturally. Verbal
children miss school everyday due to the fear of violence. verses nonverbal cues. Cultural nonverbal cues. It is all in how
it is displayed.
Have you encountered violence with school-aged children
either at home or on a professional level? Think about how loss is expressed and how anger is apart of
that expression.
Nursing students and nurses create their own form of violence-
Nurses That Eat There Own It is healthy to expression anger adaptively; relationships are
actually stronger when mates argue, so the research says!
The practical concept of managing-up or managing-down your
peers. Physiologic Experience of
Cerebral Cortex
Anger
Anger cannot be viewed on a continuum: On the left- anger as
Amygdala- processing of
a healthy response to the violation of one’s integrity and to the
emotions
right- maladaptive anger that is detrimental to one’s psyche
and well-being.
Sympathetic Response
Fight or Flight
Maladaptive anger linked to:
Adrenal Medulla
Depression
Epi & Norepi
Strong correlations to Medical conditions: CAD
Adrenal Cortex
Cortisol
Suppressed anger- correlations to arthritis, breast & corectal
CA, HTN, predictor early mortality. Physiologic response is
universal- to what extent, how the body interprets & how we
The caveat: Conflicting research that indicates anger used in a express it is what is unique. Anger arousal can be pleasant or
constructive way reduces HTN, improves general health, unpleasant & scary. Trying to suppression can prolong
better sense of self, accounts for less depression and decreased physiologic manifestations.
prevalence of obesity.
Think about the last time you were ANGERY! What symptoms
did you feel?

2. 2
Assessment of anger in individuals can be challenging, As the For this to be effective, candidates must have some insight to
authors indicated, how one directs there anger may not neatly their problem. Check out Emotional Intelligence & Who
fit into a categorize of “anger-in” or Anger-out”. The goal to Hijacked My Amygdala
anger assessment in a controlled clinical setting is to be able to
assess anger in various situations, frequency, intensity of Violence
expression, and triggers. Our environment, social issues, Violence is not random, senseless and can be understood!
occupation or lack of, level of intimacy in relationships and
the presents of coping skills all have effects on how we Predictors for violence are very sensitive. Practical Tool-
express anger. listen to your instincts!
In a very controlled setting with a client that is not presently De-escalation skill sets are an extremely valuable tool in your
anger, questionnaire can be used as assessment tools. success as a nurse!
Spielberger State Trait Anger Expression Inventory-
measures propensity to be angry, feelings of anger & What is the difference in approach by police verses healthcare
anger styles. providers in managing a violent individual?
Diagnostic & Statistical Manual of Mental Disorders-
Anger Disorder, Intermittent Explosive Disorder Those that commit acts of violence have frequently
(seen in teens) experienced childhood abandonment, physical brutality,
sexual abuse & confinement.
Can one predict violence from the display of anger?
Johns Hopkins Shooter Event Models of Anger, Aggression & Violence
Culture & Gender Considerations Not one models explains all. I find all models apply- all the
Historical trajectories (experiences), religion, language & time!
customs affect anger behavior.
Biologic Theories
A random act by a stranger in one culture can be perceived as Developmental deficits
insulting and in another culture simply dismissed. Remember Anoxia
President George Bush having the shoe thrown at him during a Malnutrition
pressing meeting! Toxins
Tumors
Gender role socialization- appropriateness of owning angry Neurodegenerative diseases
emotionality and revealing it to others. Head Injury- Look up Phineas P. Gage
Injury to cerebral cortex- increased
Western Cultures- Promote more aggressive behavior impulsivity, decreased inhibition &
in males and conciliatory behavior in females. The caveat: decreased judgment.
generalizations may not apply to marginalized individuals or Neurocognitive impairment
ethnic minorities. Social history of abuse, family violence
Eastern Cultures- disapproves of anger expression by Aggression gene: Monoamine Oxidase A- affects Norepi,
both genders when the culture(s) emphasize connectedness serotonin & dopamine (seen in male children with history of
rather than individualism. abuse)
Anger Management Sex hormones- violent male offenders have high testosterone,
Psychoeduactional intervention in persons whose behavior is violent females commit crimes during low progesterone phase
dysfunctional, but not violent. of menstrual cycle.
Court Mandated for violent individuals has limited success. Combining risk factors dramatically increase risk of violence:
Anger Management Intervention does not modify violent History, medical noncompliance, substance abuse, selective
behavior. Greater benefit when used with other psychiatric diagnoses, police involvement, pain & emotion.
psychotherapies. Set up as a group therapy, ran by a coach,
and targets interventions on modulating the arousal of anger in Cognitive Neuroassociation Model
individuals, alter irrational thoughts and modified maladaptive Adverse event triggers primitive negative response, peripheral
behaviors. Those with personality disorders, paranoia and receptors communicate response to spinal cord to
organic disorders need not to apply. hypothalamus, synthesizes input to limbic system and drives
primitive emotion- flight or flight

3. Management of Anger, Aggression & Violence Lecture Notes 3
obtain that status. Example is men and women in the Western
No cognitive appraisal in assessing rudimentary feelings and society.
higher order cognitive processing goes wild. Brain associates
stimulus to other similar physiologic sensations, memories, Interactional Theory
ideas, past experiences and previously experienced expressive This is a really prevalent assertion in the psychiatric
motor reactions. Think of a body builder running away from a community. Viewing violence and aggression with a
small, harmless snake that he just touched. biologically or psychological basis excuses the behavior.
Violence is violence no matter what setting and should be
Take a look at the Neurostructural Model and the Emotional considered a social problem. Individuals with interactive
Circuit. The focus of this model is how the meaning is styles that were argumentative or coercive (chip on there
perceived, influenced by physiologic capabilities, how to shoulder) where more likely to be aggressive or violent.
prioritize competing stimuli and interpret messages in relation Antecedent variables: history of violence, psychiatric
to stored ideas, beliefs & memories. disorders, hospitalizations and the mediating variable of
interactional style are the primary reasons for behavior.
Neurochemical Model & Low Serotonin Syndrome
Role of Serotonin in mood, sleep & appetite well researched. How Do Nurses Mange Anger & Aggression in Patients?
Low Serotonin associated with depression, irritability,
increased pain sensitivity, impulsiveness & aggression. Prevention is key. The right staffing mix, enough staff, safe
Serotonin sensitive to dietary intake tryptophan- found in high environment, having structured routine, respectful milieu,
carbohydrate foods (wheat, flour, corn, milk and eggs). timing of admissions/discharges, uses of space/personnel and
Relationship of Tryptophan depletion and aggressive behavior. the conviction of understanding the meaning of the behavior.
Psychological Theories What do patients gain by acting out?
Psychoanalytic Theories- emotions viewed as instinctual A rigid view of “my way” without a flexible self-awareness is
drive. Early work done by Freud. Contemporary sure to get any nurse in trouble. Can you keep your Amygdala
psychoanalysts- focus on patient having grater insight onto the from being HIJACKED? Threats never work. If the patient is
unconscious processes of their feelings/actions to develop able to understand the explanation, explain to process and
greater insight for better adoptive behavior. consequences. Be careful here!! Look for the opportunity to
debrief the experience with peers and later with the patient.
Behavioral Theories- Anger was viewed as a learned response.
Social Learning Theory as a classic model of this model. Predictors of Violence
Maladaptive behavior learned from parents. Treatment based
in avoidance of provoking stimuli, self monitoring, response The research is all over the place! History is universally
disruption and guided practice of effective anger behavior. agreed to be a reliable predictor.
Cognitive Theories Better Predictors Poor Predictors
How do people transform internal and external stimuli into Suspiciousness Age, gender & race- not
useful information. Socratic Questioning is used to challenge Impulsivity good predictors
distorted cognitions. Socratic Questioning seeks to get a Agitation Time of day
person to answer the question by making them think and draw Noncompliance with Mixed Predictor
out the answer. Examples of questions: Why are you saying rules Adequate staffing
that?, What else could we assume? & Can you give me an Involuntary Specific diagnoses
example of that? Change behavior by altering irrational beliefs hospitalization related to poor impulse
(unrealistic expectations) and identify workable alternatives. Crowding & high density Dual diagnosis with
Use of role play is prevalent. Cognitive & Cognitive during high patient substance abuse
Behavioral Therapies are the most researched. The patient has census Temporal lobe epilepsy
have a level of self awareness and motivation to change
Previous episodes of rage Barbiturates- increase
behavior.
Escalating irritability violence
Intruding angry thought Mood Stabilizers- less
Sociocultural Theories
Fear of losing control violence
The pursuit of status produces inequities in relationships, one
person is superior and the other is subordinate. A hazard
inherent to the pursuit of status is the view of the “entitled There are no infallible tools. No tool that has reasonable
person” and this person has the right to use whatever means to success is Nurses' Observation Scale for Inpatient Evaluation
(NOSIE). My experience is that pertinent positives and

4. 4
pertinent negatives are assessed and risk is stratified from that
assessment. RMEMBER- not all violence is because of anger Beta-blockers
Decreasing sympathetic response to anger
Violence can be the result of predatory behavior, for
secondary gain or as a result of delusions. Lithium Carbonate- Depakote or Tegretol
Intermediate effect and can poorly interact with other agents
Planning & Implementing Interventions
Nutrition
Patient needs to be a partner in the process! Thiamine is blocked by ETOH abuse and caffeine is a
stimulant.
When the patient is unable to participate, then the Nurse must
take charge. Anticipating Needs
Toileting is frequently responsible for agitation in older adults
Stepped approach, that escalates and is patient specific-
Blanket interventions don’t work. Psychological Domain & Assessment/Intervention
Disturbance in thought process- both psychiatric and
Those who act out violence or aggression, can assume substance abuse related. Chronic medical condition also play a
responsibility. part in this.
Intervention is NEVER punitive!!! Altered Perceptions
Patients may misinterpret events and objects. Illusions
Personal risk
Body language is critical Delusions
Respect personal space False or unreasonable beliefs- cause here: poorly manage this
Spatial awareness is absolutely the responsibility of the Nurse- discussion with a patient and it may precipitate aggression and
always have an out and never left anybody or anything dissuading patients usually ineffective.
interfere with egress
Plenty of support and team oriented approach The goal for psychological interventions is to help the patient
Clothing gain control over their loss of control.
Speak softly, only one person gets to speak
Listen a lot & embrace a calm presents Affective Interventions: validating, listening to the experience
& exploring beliefs
Crisis Intervention- discussed in class
Cognitive Interventions: Giving Commendations, Offering
Interventions based on Biopsychosocial Interventions. See Information, Thought Stopping, Contracting & Providing
page 829, figure 38.2 Education. A contract can be both written & verbal.
Biologic Domain & Assessment/Intervention Behavioral Interventions: Assigning Behavioral Tasks,
Biochemical imbalance may exacerbate aggression Bibliotherapy, Interrupting Patterns & Providing Choices.
(hypoglycemia, ETOH intoxication or withdrawal,
premenstrual dysphoric disorder). Social Doman & Assessment/Interventions
Factors are all about the stressors!
Sensory Impairment
Impairment in communication is seen in older males. Reducing Stimuli
Administering Medications & Monitoring for Effects- critical Seclusion & Restraint- nobody wins when this is the last
Atypical Antipsychotics- Resperidone & Zyprexa option. All other options tried and failed or clear & compelling
Mechanism not fully understood, minimal extrapyramidal side reason to immediately escalate. There are ALWAYS
effects, used of intermediate intervention consequences to this intervention. Extremely regulated,
requires continual training, carries risk before, during and
Selective Serotonin Reuptake Inhibitors- Prozac & Paxil after. Adverse events prevalent.
Gradual onset of action, antidepressant effects
Assault Against Nurses
Anxiolytics- Ativan 70% of mental health professionals report assault and or
Great for immediate sedation and can be used with other battery during their care of patients.
agents for synergistic effects

5. Management of Anger, Aggression & Violence Lecture Notes 5
Workplace violence: prevalence and risk factors in the safe
at work study. Campbell JC, Messing JT, Kub J, Agnew J,
Fitzgerald S, Fowler B, Sheridan D, Lindauer C, Deaton J,
Bolyard R.
Almost one-third (30%) of nurses/nursing personnel
experienced WPV. Risk factors included being a nurse, white,
male, working in the emergency department, older age, longer
employment, childhood abuse, and intimate partner violence.
Nurses- largest healthcare provider group and greater
incidence of assault
Theme to assaults- patient perceives the nurse restricting
action, controlling, or aggressive. Verbal or physical
Emergency Nurses
Rates of Violence against Emergency Department Nurses Are
High, Remain Steady, According to New Study, But Remedies
Exist
on a weekly basis 8-13% ED Nurses assaulted
~60% reported violence within the last 7 days of the
survey
~75% of the nurses that were assault- reported not
receiving assistance from there employer
97% of those committing assault and/or battery- patients
& family
Nurses performing triage had equal incidence to nurse
physically restraining patients for assault rate
Young male nurse- highest occurrence