EP30EO-6 Annotated Bibliography
Barlow, C.B., Rizzo, A.G. (1997). Violence against surgical residents. Western Journal of
Medicare, August 1997, 167:74-78.
This article focused on violence against surgical residents which at the time (1997) there was not much research completed on their subject and felt to be under reported; this violence believed to exist for over 100 years. Contributing factors were noted as hospital downsizing, patient frustration, environment, inexperienced staff, poor interpersonal relationships, power conflicts, low morale poor occupational therapy, fear. Authors are PhD’s from the laboratory setting at Wright Patterson AFB in Ohio. The article had some good information related to triggers but article had narrow focus of violence toward surgical residents.
Bernstein, K.S., Saladino, J.P. (2007). Clinical assessment and management of psychiatric
patients’ violent and aggressive behaviors in the general hospital. Med/Surg Nursing
16(5), 301-309 and 331.
This qualitative article focused on risk assessment, building rapport with patients, crisis prevention strategies. Authors are professors from the school of nursing in New York and advance nurse practitioners from the universities Psychiatric Department. A helpful article providing a brief history of violent and aggressive behaviors and challenges that nurses face when caring for this population in general medical settings.
Deltmore, D., Kolanowski, A., Boustani, M. (2009) Aggression in persons with dementia: use of
nursing theory to guide clinical practice. Geriatric Nursing, 30(1), 8-17.
2009 literature addresses incidence of dementia in the US and the difficultly in managing aggression in the demented patient and related poor outcomes. Limited success related to risk factors, various triggers, and focus on pharmacology. Key intervention is to identify and address the unmet needs rather than control the behavior with drugs. Steps identify persons with high risk for behavior language difficulties, cognitive deficits, per morbid personality characteristics by non-agreeability are at greater risk. Steps include to assess impact on safety and if present prevent harm. If aggression continues then crisis management includes short term pharmacological, profiling behavior by identifying behavior and associated factors. Causes include constipation, pain, hunger thraist sleep disorders, environmental factors are helpful. frustration; logs are useful to document behavior. Most valuable was addressing non-
pharmacologic interventions which are considered ethically sound but receive less research funding. Targeting unmet needs, environment, inadequate activities of daily living, many issues
surrounding feeding, avoiding showers, promotion of continence, addressing boredom and overstimulation, relaxation, pet therapy, exercise, teaching how to interact to avoid attack on caregiver are addressed. Pharmacologic intervention includes short acting benzodiazepines, anticonvulsants, selective serotonin reuptake inhibitors and antipsychotics. Authors are doctorates in geriatric nursing and physicians. A good article and identifying difficulties in treating dementia and the success and failure of using medication to treat this population.
Flores, N. (2008). Dealing with an angry patient. Nursing2008. May, 30-31.
Anywhere from 80-100% of nurse’s experience verbal or physical assault in the last year (2008 statistics). Aggression is triggered by alcohol and drugs, history of violence, metabolic disorders, social isolation, mental illness, and psych diagnoses. Stages include aggression anxiety, verbal aggression then physical aggression; nurses must be alert. Intervention at these three stages are important, 1) anxiety include, eye contact, good communication, calmness, do not leave alone, address patient symptoms e.g. with medications. Verbal aggressions- speak calm, normal tone, unhurried, identify the cause, and encourage cooperation. Physical aggression- keep safe distance, call for help, restraint is mentioned and the importance of communication. Author is a staff RN from the Med/Surg setting at a Washington Medical Center, good to have the perspective of a bedside nurse in care of this patient population. Informational article chronicling a medical/surgical nurse’s personal experience when dealing with angry patients. Experience is a level of research but on the lower end of the strength of evidence continuum but I felt this was an extremely pertinent article to address my practicum; still useful information.
Hollinworth, H., Clark, C., Harland, R., Johnson, L., Partington, G. (2005). Understanding the
Arousal of anger: a patient-centered approach. Nursing Standard. 19(37), 41-47.
This article explores factors that trigger anger and aggressive behavior including fragmented care and distress at time of surgery. Information suggests the reader to believe arousal of anger can be pre-determined key is to counteract situations of stress, prevent frustration that escalates from angers to violence then to aggression. Most often anger preceded violent behavior and there is a learned connection. Anger exists in 10% of violent episodes and men and women express anger differently. Nurse’s response to anger is a focus topic; hospitals are stressful and are a perfect recipe for the storm. Often patient can provoke anger in the care provider making it difficult for care provider to be pleasant and makes them feel vulnerable, lack empathy, lose patient centered Anger is a coping mechanism for stress, coping is learned from family and social groups Strategies to prevent anger include self-awareness in reaction of anger, disconnect from blame, establish trust, remain calm, speak soft, listen, active engagement, acknowledge the right to be angry, set limits, communication, reassurance, address the patient concerns. Authors are teaching practitioners. A good article that validates triggers of aggressive/violent behavior and interventions.
Hudek, K. (2009). Emergence delirium: a nursing perspective, Association of Perioperative
Registered Nurses, March 2009, 89(2), 509-520.
This article addressed the incidence of delirium in all patients but higher incidence in pediatric and adult patients post operatively; occurs in slightly over 5% of patients. Identified risk factor such as age, anesthesia received, anxiety level, pain and pre surgical conditions. Nursing care includes quick identification of underlying cause, using an agitation scale in assessment, medication, reducing stimulus. Authors are peri-operative nurses at an Arizona Medical Center. Useful information in care and treatment of patient population from a surgical perspective.
Jaworowski, S., Rauch, D., Lobel, E., Fuer, A. Cropp, C. & Meguii, F. (2008). Constant
Observation in general hospital: a review. Journal of Psychiatry Related Science, 45(4),
278-284.
This article addresses acute psychological disturbance in general hospital settings in Israeli and using constant observation as a treatment option. Authors are physicians from the Department of Psychiatry. Appropriate setting but main focus in on suicidal patients needing constant observation.
Linck C., Phillips, S. (2004). Managing disruptive behaviors in an acute medical/surgical
service: A Strategy for Success. Holistic Nursing Practice 18(5), 223-227.
This is a quantitative research article documenting the evidence collected on a pre and post survey related to outcomes when introducing a Clinical Nurse Specialist (CNS) as an effective strategy in managing disruptive behaviors in hospitalized patient on a Medical/Surgical units. Emphasis of the negative effects of this behavior on quality of care and the well-being of the nurse. Many emotions the bedside nurses experience when dealing with hostile patients; anger, frustration, avoidance, moral distress, negative work environment, distracted nurses, stress, feeling overwhelmed, ill prepared, powerlessness. Key points limited resources for managing these patients and their families, understand agitation and anger and eliminate the source, lack of experience in interpreting behaviors or critical thinking. Patients act out because of pain, anxiety, constipation, hunger, thirst, incontinence, delirium and cravings. Cognitive patients are unique, they communicate with their behavior, a basic human need, and this can be misinterpreted and they are labeled as non-compliant and manipulative. Nurses need successful anger management techniques, knowledge of interventions and evidence-based tools to master conflict, lack of interdisciplinary/coordinated care and communication, protocol for restraint use and care of CIWA is helpful. The authors speak of first interventions being costly by using sitter
hours and dollars. Creation of the role of a special trained CNS who can coach, guide, consult, collaborate, lead, make decisions, and conduct research. The CNS rounds and evaluates all
restrained patients, sitters, disruptive patients, altered mental status (delirium, dementia), agitation, elopement, psych disorders, alcohol withdrawal, high fall risk, plans of care, staff education. Research conducted data collection via survey pre /post- improvement noted in nurse’s satisfaction and morale. Authors are advance degree RN’s from a Banner Health system in Arizona. Excellent article of useful information in care and treatment of patients who become disruptive in the general med/surg environment.
Loucks, J., Rutledge, D.N., Hatch, B., & Morrision, V. (2010). Rapid response team for
behavioral emergencies, Journal of the American Psychiatric Nurses Association, 16(2),
92-100.
Rapid Response Teams (RRT) are teams of specially trained staff that proactively de-escalate potential volatile situations which allows early treatment of behavioral issues. Team are interdisciplinary and include RN and social workers who have knowledge and skill in acute psychiatric disorders, and competence to manage assaultive behavior, consultation, assessment, to identify triggers, set limits, calm verbalization, use of selective medications. Benefits include decrease restraint, improved collaboration, communication and improved outcomes. As result of implementation, RRTs have improved compassion and care from beside nurse, learning from debriefings, surveys to gather information from the RN, awareness, self-learn module for new nurse members that address role expectations and reduction in calls. Authors are certified RNs from inpatient psychiatric units in California hospitals and affiliated with California State University, Fullerton. This article offers valuable information about instituting a RRT to assist with behavioral emergencies of patients who are hospitalized on a non-behavioral health unit.
Macdonald, M. (2007). Origins of difficulty in the nurse-patient encounter, Nursing Ethics
149(4), 510-521.
The article documents the root problem of difficult encounters with patient but instead of focusing on the patient the study reveals that actual encounter is the trigger. A qualitative design, constructivist approach to grounded theory was used and involved the care provider and the patients and their personal feelings and experiences a result of the encounter. Institutional Review Board (IRB) approval was required because interviews with patients and staff were conducted as a well as observation and taped recording of interactions. The research findings revealed that the time or lack thereof played was the number one key factor to a positive or negative nurse-patient interaction. Other factors that led to negative encounters include 1) not having a family member present, lack of supplies and equipment (delay in getting medications),
notable teamwork among the staff working, environment space, control. This was a very relevant article full of helpful information.
McCoy, C., Johnston, K. (2011). Behavioral emergencies: a closer look. Journal of Emergency
Nursing, (37(1), 104-108.
Current information from January 2011, this article addresses behavioral emergencies in the emergency department (ED) setting. Includes incidence, trends in practices such as patient contracts, boarding, pharmacology, restraints, and seclusion. Emphasis on safety, the importance of timely assessment and screening for mental illness, and limited treatment options, as a result restraint and seclusion may be used both which are highly discouraged. Authors are professors of Nursing at Auburn State University School of Nursing and staff RN’s in the ED. ED focus, applicable care, and treatment modalities to inpatient care of violent and agitated patients.
Nadler-Moodie, M. (2010). Psychiatric emergencies in med-surg patients: are you prepared?
American Nurse Today, 5(5), 23-28.
RNs can expect encountering psychiatric emergencies in general medical hospital settings and should prepare themselves proactively to have a successful outcome. Understanding psychiatric problems to include identification of triggers, cause and intervention are key. Top three categories associated with behavioral emergencies include psychiatric diagnoses, substance intoxication, and withdrawal, and delirium in the med/surg patients. The author is an MSN and advance practice nurse (APN) in psychiatric and mental health nursing. A qualitative article that includes current information addressing my practicum subject precisely; valuable resource.
Policy-ACT Health (2011). Management of patients with mental health and medical surgical co-
morbidities, June, 1-34.
This 34 page document is the guideline developed by the administrative and clinical team of a hospital in Canberra, Australia. The policy and procedures guide a hospital in the care of patients with mental health and medical /surgical co-morbidities; developed June 2011. The documents purpose is to provide clear direction and process for the staff. Includes policy statement, scope, supporting regulatory and legislative policies in the management of this patient population. A very current, prescriptive, and comprehensive document emphasizing a holistic and collaborative approach to care delivery. No references included that show the research or best practice that were incorporated into the guideline.
Rada, R. (1981). The violent patient: rapid assessment and management. Psychosomatics, 22(2),
101-109.
Classic reference from 1981, author was the Professor and Vice-Chair of the Department of Psychiatry at New Mexico University. Takeaways include management of violent patient including assessment to discover the cause of the behavior. Violence is placed in categories of
preassault, assault, post assault. Triggers include insensitive care providers, forced dependency, organic brain syndrome, and provoked behavior. The ED is a risk area if anything validates that the issue has been documented for decades. Violent patients are afraid; fear is underlying key factor and treatment with drug.
Somes, J., Donatelli, N.S., Kuhn, S. (2011). Controlling aggressive behavior in the geriatric
patient, Journal of Emergency Nursing, May 2011, 37(3), 275-277.
This short article offering continuing education addressed how an emergency department (ED) staff can reduce the incidence of injuring the geriatric patients who displays aggressive behavior. Recommendations included how to avoid skin tears, how to conserve energy when physically restraining the aggressive patient, controlling swinging arms, securing extremities, transporting aggressive pts. Some useful information included causes of delirium the need to rule out cause of delirium such as infection, fluid and electrolyte imbalance, hypoxia, drug toxicity, renal failure, hypoglycemia, shock and withdrawal from alcohol, and sedatives. Agitation is caused by pain, hunger, sensory deprivation, need to void or BM, soiled garments, over simulations, feelings of insecurity, changes in environment, upset schedules, inadequate sleep, fear, boredom confusion, unfamiliar environment and restraints can cause older adults to become agitated. Authors are staff RNs and educators at a hospital in St. Paul, PA. A current article, with helpful treatment suggestions to include snacks, pain medication, toilet, decrease stimulation, provide familiar items, white noise, provide glasses or healing aids, inc lighting, decrease visitors, reduce sensory overload, evaluating the need to reorient, non-agreement, go along with conversation that is familiar to the patients, show picture, videos, talk with family on phone, intentional distraction, familiar sights, sounds, smells, music, a warm blanket, reposition, check tight clothing, medications, and restraints if needed.