Loading...

Therapeutic Challenges. Theoretical Principles of the Management of Violence and Aggression in Hospitals and Care Environments

Lecture Notes 2010 20 Pages

Health - Nursing Science - Miscellaneous

Excerpt

Table of Contents

THERAPEUTIC RELATIONSHIP - DEFINITIONS

THE IMPORTANCE OF THE THERAPEUTIC RELATIONSHIP

THE UNPOPULAR PATIENT (MALIGNANT ALIENATION)

QUICK RAPPORT BUILDING – MAKING CONNECTIONS

PROXEMICS – DEFINITIONS

ZONES OF HUMAN INTERACTION

THE MANAGEMENT OF ESCALATING BEHAVIOUR

SUBLIMATION

PHATIC CONVERSATION

NEUROLINGUISTIC PROGRAMMING (MIRRORING)

PHYSICAL AND VERBAL MIRRORING

HANDOUT COPY OF BOOK CHAPTER

THE ASSAULT CYCLE

NEUROBIOLOGY OF AGGRESSION

THE NORADRENERGIC SYSTEM

ASSESSING THE IMMINENCE OF RISK

SITUATIONAL ANALYSIS OF AGGRESSION

CONTRIBUTORY FACTORS

THERAPEUTIC PROBLEM SOLVING

WIN / LOSE – WIN / WIN EQUATION

ATTITUDE AND BEHAVIOUR CYCLE

DEBUNKING

ALIGNING GOALS

THE ACT MODEL OF DE-ESCALATION

ROLE OF THE NAMED-NURSE

CARE PLANNING

OFFERING MEDICATION

REFERENCES AND FURTHER READING

THERAPEUTIC RELATIONSHIP - DEFINITIONS

- A mutual learning experience and a corrective emotional experience for the patient, in which the nurse uses self and specified clinical techniques in working with the patient to bring about behavioural change (Stuart and Sundeen, 1995).
- A conscious relationship between a facilitative person and a client in which each implicitly agrees to work together to help the client address personal problems and concerns (Wilson and Kneisl, 1996).

THE IMPORTANCE OF THE THERAPEUTIC RELATIONSHIP

- Peplau (1952) asserts the importance of an effective and successful ‘therapeutic relationship’ between nurse and patient, accrediting this interpersonal phenomenon with the ability to improve outcomes for both nurse and patient.
- The relationship between nurse and patient provides the “backbone upon which all other care is delivered” (Forchuk, 2002).
- Graham (2001), Lauder et al (2002), Hewitt and Coffey (2005) and Welch (2005) all describe the therapeutic relationship as forming the “cornerstone” of modern nursing practice.
- The establishment of such a relationship is a “pivotal factor in the treatment and recovery of patients” (Ramjan, 2004).
- According to Peternelj-Taylor and Johnson (1995, p. 16) the fundamental working practices of healthcare professionals, and the healthcare environment itself “are ‘ripe’ for potential problems regarding therapeutic relationships”.
- The development of an effective therapeutic relationship can present both parties with a range of significant challenges and can be a problematic and time-consuming process (Davis and Lysaker, 2007; Evans, 2001; Frank and Gunderson, 1990; Hagerty and Patusky, 2003; Hertzberg, 1990; Hewitt and Coffey, 2005; Langley and Klopper, 2005; Ramjan, 2004; Rushton et al, 2007; Suikkala and Leino-Kilpi, 2001; and Weiss and Delia, 2007).

THE UNPOPULAR PATIENT (MALIGNANT ALIENATION)

- Watts and Morgan (1994) describe the process of ‘malignant alienation’, explaining that this occurs when a label carrying a negative connotation is applied to an unpopular patient, with the progressive effect of alienating them. The conclusions of this article argue a strong association between malignant alienation and the suicide of users of the mental health services.
- Hopkins (2002) suggests that this may occur due to the behaviour of certain patients being interpreted as being “unreasonable” or “provocative” by healthcare professionals.
- Antai-Otong (1999) suggests that destructive behaviours exhibited by patients can be an expression of their “need for approval” and “fears of rejection”.
- This process can lead to an eventual “breakdown” in the nurse-patient relationship, and can culminate in the withdrawal of care and support for that patient (Morgan and Stanton, 1997).
-Patients that experience recurrent relapses of illness or are resistive to treatment may be viewed by nurses as “manipulative, provocative, unreasonable, over-dependant and feigning disability”; such alienation of patients combined with a fluctuating degree of suicidal ideation could lead to a failure to acknowledge and manage a high risk of suicide (Pompili et al, 2004).
- This process refers to a combination of factors in the healthcare setting which conspire to damage the therapeutic relationship; the resulting alienation is referred to as ‘malignant’ because it is progressive and culminates in the death of the patient (Whittle, 1997).

EXAMPLES AND DISCUSSION – Have you experienced a situation like this in your clinical practice?

Significantly, nurses may be heard to use dark humour and express feelings of frustration with regard to challenging patients; this can be acceptable, as nurses too must have a safe forum in which to ventilate their feelings.

QUICK RAPPORT BUILDING – MAKING CONNECTIONS

- Active-listening to show understanding and acknowledgment (Antai-Otong, 1999; Blum, 2009).
- Mirroring to show likeness and similarity (Clabby and O’Connor, 2004; Knowles, 1983).
- Mood-matching to show likeness and similarity (Blum, 2009).
- Use of empathy in order to present as non-threatening (Egan, 1994).
- Paraphrasing to demonstrate understanding and avoid miscommunication (Best, 2005; Bush 2001).
- Search for common ground and shared interests, but take care in doing so as this may require a certain amount of personal disclosure (Knowles, 1983).
- Remain objective, as it is imperative for nurses to avoid “emotional entanglement” with their patients if they are to be successful in caring for them (Dexter and Wash, 1991, p.12).
- Observe for incongruence of verbal and non-verbal communication. When communication is incongruent, it is the non-verbal expressions, rather than the verbal ones which are “more accurate” and “more reliable” indicators of how an individual really feels; the non-verbal messages have the ability to “reveal the true feelings” which underlie the spoken word (Brown, 1997).

PROXEMICS – DEFINITIONS

- “The interrelated observations and theories of man's use of space as a specialized elaboration of culture” (Hall, 1966, p.1).
- “The spatial interaction of man with man” (Mariotti, 1978).

ZONES OF HUMAN INTERACTION

Abbildung in dieser Leseprobe nicht enthalten

The use of different zones of human interaction can have different impacts upon the feelings and responses of an individual. Significantly, those individuals exhibiting violent or aggressive behaviours require three times as much personal space in order to feel non-threatened (Hall, 1966).

THE MANAGEMENT OF ESCALATING BEHAVIOUR

Blum (2009) describes “ten ways to avert an explosion”:

1) Deliberate ignoring of destructive and deviant behaviours.
2) Intervening before the situation reaches crisis phase.
3) Distracting in order to divert attention away from the trigger.
4) Relocation to remove the trigger.
5) Change of approach to induce a change in behaviour.
6) Use of physical contact to convey empathy.
7) Non-threatening body language to avoid creating fear and defensiveness.
8) Humour to help diffuse tension.
9) Mood-matching to show likeness and similarity.
10) Active-listening to convey empathy.

* Many of these skills will also be beneficial in the quick development of rapport.

SUBLIMATION

This describes the “transformation of unwanted impulses into something less harmful”, through the use of distraction or engagement in activites; for example, the use of sports therapy to release aggression in a safe and constructive manner (ChangingMinds.org, 2010).

PHATIC CONVERSATION

This is described as “ordinary chat and therapeutic conversation”; it may also be described as “small talk”, is aimed solely at building rapport and can be used to huge advantage in non-invasive assessments of mental state (Burnard, 2003).

NEUROLINGUISTIC PROGRAMMING (MIRRORING)

- Developing this skill “can help you master the fine art of tuning in to other people”. Individuals have a preferred or instinctive sensory system; either auditory (hearing), visual (seeing) or kinaesthetic (doing). This knowledge can be used when communicating in order to “greatly enhance” rapport building with patients; experts in this skill can even adjust their own breathing in order to more accurately mirror the body language of others (Knowles, 1983).

PHYSICAL AND VERBAL MIRRORING

- There is a “difference between imitating and mirroring”. For example, when practising physical mirroring with a patient who has crossed their legs (right leg over left) then the nurse should cross their legs (left leg over right), “as if the patient was looking in a mirror”; there is also a “difference between paraphrasing and verbal mirroring”. Paraphrasing involves editing and summarising the content of communication from a third party, and this poses a risk of distorting the original message; verbal mirroring occurs when the nurse approximates the voice tone and vocabulary of their patient. These subtle changes can make a big difference (Clabby and O’Connor, 2004).

EXAMPLES AND DISCUSSION – Can you think of a time when you have used such skills in your clinical experience?

HANDOUT COPY OF BOOK CHAPTER

THE ASSAULT CYCLE

Kaplan and Wheeler (1983) describe the assault cycle, detailing five “distinct phases of assault”:

1) Trigger phase – Each person has a distinct set of baseline behaviours; this phase is the first behavioural movement of an individual which deviates from their baseline behaviour.
2) Escalation phase – This phase leads further away from baseline behaviours and directly into the assaultive behaviour. Intensity of behaviour increases and response to intervention diminishes.
3) Crisis phase – The individual becomes increasingly aroused and less able to control impulses, moving directly into assaultive behaviour. Safety is the paramount concern during this phase.
4) Recovery phase – This begins a gradual return to baseline behaviour. Adrenalin released during the previous phase remains active in the body for a further 90 minutes; this means that an individual can quickly return to the crisis phase and assaultive behaviour can resume within this time, if appropriate steps are not taken to manage the aftermath.
5) Depression phase – During this phase it can be expected for an individual to regress below their baseline behaviour due to exhaustion and feelings of remorsefulness, tearfulness and distress; at this stage the individual will be more receptive to reparations and negotiation.

Abbildung in dieser Leseprobe nicht enthalten

(Kaplan and Wheeler,1983).

Abbildung in dieser Leseprobe nicht enthalten

(Pacific Institute for the Study of Conflict and Aggression, 2010).

[...]

Author

Share

Previous

Title: Therapeutic Challenges. Theoretical Principles of the Management of Violence and Aggression in Hospitals and Care Environments