Aggression and Violence: Perennial Concerns for Psychiatric-Mental Health Nursing

Aggression and violence, perennial concerns for psychiatric-mental health nursing, are the focus of this special issue of the journal. I am pleased to introduce a collection of significant articles that address diverse facets of violent behavior, including adolescent aggression, sexual violence and its connection to disordered eating, violence occurring in inpatient psychiatric and geriatric facilities, nursing management of aggression and violence, and support for nurse victims of assault by patients. Authors of the articles hail from Denmark, New Zealand, Finland, Australia, and Turkey, as well as the United States.

Although violence is the theme of a special issue of the journal this month, violence is actually interwoven into almost every volume we publish. Aggression and violence are among the most challenging aspects of clinical practice for nurses in all settings. Patient-inflicted injuries cause nurse victims considerable anguish and may even result in post-traumatic stress disorder (Jacobowitz, 2013). As shown in Biggin Moylan and colleagues′ article in this issue, nurse victims are not properly supported by employers. On the other side of the coin, studies show that nurses may experience anguish when they must participate in restraining or secluding aggressive patients (Moran et al., 2009). Coercive procedures induce ethical challenges as well (see Korkeila et al., this issue).

Psychiatric patients are not more violent than other types of patients–contrary to popular misconception—but nevertheless assaults by psychiatric patients on nurses and other staff do occur far too often. In a survey of 14,877 injurious assaults by psychiatric patients in U.S. hospitals from 2007–2013, registered nurses were the most severely injured victims (Staggs, 2015). Nurses and other staff in psychiatric facilities often view security measures insufficient, as shown in a Turkish study (Bilici, Sercan, & Izci) appearing in this issue.

Elderly patients (especially those suffering from dementia and other cognitive impairments) are among the most likely perpetrators of verbal and physical aggression, and the nursing staff are the most likely targets (Lanza, 2016). A study published in our January issue showed that 75% of nursing staff on geriatric inpatient units either experienced aggression themselves or observed it being directed at others during every single shift they work (Lanza, 2016). Research reported by Zhang, Punnett, Mawn, and Gore in this issue highlights the vulnerability of nursing assistants to assault in nursing homes, and research conducted by a team in New Zealand highlights vulnerability of staff in community healthcare settings where security measures are even less prevalent than in hospitals and aged care facilities, thus requiring staff to rely mainly on police when patients become aggressive (Baby, Swain, & Gale, this issue).

As I was preparing this editorial, it seemed as though I was being bombarded by societal aggression and violence with every television newscast, magazine article, and newspaper headline that I encountered. Episodes of road rage, fights over trivial grievances, and riots at sporting events are occurring all over the world. Aggression in young people seems to be on the increase. We know that many youth are growing up witnessing violence in their homes, which often leads to display of violent behavior toward their peers. Avci's research team found high levels of aggression in one out of four adolescents in Turkey, and their literature review indicates that this high level is not unique to Turkey (see Avci, Kilic, Selcuk, & Uzuncakmak, this issue). Violence has even been widespread during America's presidential campaign, particularly at venues where candidate Donald Trump has been speaking, “where numerous protesters have been punched, kicked, and shoved by his supporters,” with the encouragement of the candidate himself (Dees, 2016, p. 3).

Barriers to decreasing societal violence include the following:

• It is often rewarded. For example, Donald Trump's audiences cheer when he encourages his supporters to punch protesters. Bullies continue bullying because this behavior gets them what they want.

• Victims are often unsupported. For example, in a study by Gonzalez-Guarda, Ferranti, Halstead, and Ilias study (2016), mothers of the perpetrators of dating violence often protected their sons when police were called. In some cases, no one called the police or came to the aid of the victims, as reported by a female victim of dating violence interviewed by Gonzalez-Guarda et al. (2016, p. 234):

Society must learn to care about other people because I'm telling you on the day of my last problem, I yelled ‘help,’ asked for relief, my son screamed, glass was shattered, crystals broke, stones flew and no one called 911.

The veneer of civilization seems awfully thin these days. Have we become desensitized to the violence occurring all around us? Is aggression inherent in human beings or is it learned? I recall a vigorous debate about this in a social psychology class after the students had completed assigned reading by ethologist Lorenz (1966), who asserted that aggression is an instinctive drive in humans as well as animals (a view also endorsed by Freud), and the contrasting claim by anthropologist Montagu (1968), who asserted that aggression is learned behavior (a view also endorsed by E.O. Wilson, 1978). I leave you to ponder the ongoing debate regarding innate/learned aggressive behavior, because I return now to the topic of aggression and violence within the specialty of psychiatric-mental health nursing.

I do not have concrete evidence suggesting that the increased aggression we are seeing in our roadways, schools, and neighborhoods is linked to the increased aggression reported within inpatient facilities, although the link is plausible. It is beyond the scope of my editorial (and the purview of nursing expertise) to suggest remedies for the many forms of violence plaguing contemporary society. But we can take steps to decrease the aggression and violence that we encounter so frequently within the specialty of psychiatric-mental health nursing. I believe the articles in this special issue enhance our knowledge base and constitute a mandate for action.

You, my colleagues, have shared excellent advice in the pieces you have submitted to this journal, not just for this special issue, but over the years. For example, Marilyn Lanza's work has been in the forefront of the psychiatric-mental health literature for decades, documenting ways to create a non-violent inpatient culture and help nurses who have been victims (e.g., Lanza, 1992; Lanza, 2016; Lanza, Demaio, & Benedict, 2005; Lanza, Rierdan, Forester, & Zeiss, 2009; Lanza, Zeiss, & Rierdan, 2009).

Psychiatric-mental health nurses have demonstrated exceptional skills in dealing with angry and aggressive patients. I smiled when I read the example given in the article by Berring, Hummelvoll, Pedersen, and Buus (this issue) about the patient who became unreasonably angry when given sugar in tea. The anger was so volatile the staff thought mechanical restraints would be necessary, but the nurse apologized. Such a simple nursing intervention! The patient calmed down, and an incident of struggle and restraint was averted.

Astute nurses such as this serve as role models for less-experienced coworkers, whose fear in a volative situation may cause them to move too quickly toward application of physical or mechanical restraints. In a recent article about modeling, a nurse described such a peer whose expertise she greatly admired, “who is astoundingly good in the really acute, heated situations, amazingly good, and she's calm and she talks and talks and before you know it, the patient's taking the medication and it's all good” (Ennis, Happell, & Reid-Searl, 2016).

The skillful psychiatric nurse knows that a violent patient may feel trapped or desperate. Confinement in a treatment facility may replicate earlier experiences of egregious abuse. A paranoid patient may strike out because he fears imminent harm to himself. Therefore, conveying authentic concern is paramount (Thomas, in press). Here is an example provided by a patient whose aggression was diffused by the demeanor of the caregiver:

You could tell that there is some warmth and authenticity. You can tell that she is serious, that she cares about you…it is authentic, not ingratiating, just so that I will behave.

–psychiatric patient interviewed by Carlsson et al., 2006, p. 299

Modification of the milieu is essential, to reduce power struggles over rules and provide places such as comfort rooms where agitated patients can voluntarily take time out and listen to soothing music (Barton, Johnson & Price, 2009). Sensory modulation provides another tool for de-escalating aggressive behavior; patients may choose among a variety of items, such as aroma therapy, weighted blankets, and massage creams, discovering what sensory resources work for them (Blackburn et al., this issue). One example involved a youth on an acute inpatient unit. As described by staff:

He was getting really paranoid and people around him were feeling really unsafe. He kept saying like ‘it's my protection, it's my protection’ and he just had this weighted snake [sensory resource] around his neck for the whole shift and he was really calm

(Blackburn et al., this issue, p. 522)

Psychiatric nurses everywhere, not just those employed in hospital settings, can work with patients who have dysfunctional aggressive behavior to help them gain greater control over outbursts. Nurses can seize “teachable moments” to convey principles of disrupting the patterns of escalating aggression (e.g., breathing and calming techniques, removing oneself from volatile situations). Obviously, the best time to teach the patient techniques for managing anger and aggression is when the patient is not experiencing the provoking event (Thomas, in press). Unless the patient has organic brain disease such as dementia, I believe there is always potential for learning healthier patterns of behavior. As always, I invite your manuscripts about what you are doing in your practice and research to reduce aggression and violence.

Declaration of Interest: The author reports no conflict of interest. The author alone is responsible for the content and writing of this article.