“risk” is fundamental to prevention and management of violence. Definitions for terms such as “safe”, “unsafe”, “acceptable risk”, “unacceptable risk” and “high risk” will vary according to the organization. An awareness of risk of aggression from clients due to past history of violence, life problems, anger, frustration, grief, loss or loneliness is essential all are contributors to the risk of aggressive behavior. Risk is also related to the environment. When the care-giver is aware of risk and has the skills to notice early warning signs of aggression, he or she will be in a better position to prevent escalation and less likely to unwittingly escalate the behavior.
Successful prevention depends on early recognition of the signs of risk and understanding of the appropriate response that will help or reduce the risk of aggressive behavior. There is a combination of factors which can be used to predict in which situation a client is more likely to be at “risk” for assaultive episodes.
Risk factors for violence include:
•History of violence or assault
•Previous exposure to past incidents of aggression and violence
•Age (younger, majority age 20-40)
•Gender (males more than females)
•Alcohol/drugs (dependence/intoxication/withdrawal)
•Socio-economic status (low more than high)
•Estimated IQ (low more than high)
•Residential mobility
•Marital status (lack of)
•Violent/abusive family or friends
•Difficulty communicating
•Diagnosis (mental or physical illness or injury)
•Treatment setting
•Legal status (involuntary or voluntary)
•The environment. (crowding)
•Sensitivity to disruptive events
•Patients who feel loss of power or control
•Employee related: negative staff attitudes, new inexperienced staff with minimal education, male staff more likely to be assaulted than female, lack of or limited violence prevention training.
Another contributing factor is the approach of the care provider.
History of Violence
Many of those clients who lose control may never do so again; however, a past history of violence or aggressive behavior is the single most reliable predictor of future episodes. Information about a client’s past history is vital in determining risk and should be communicated to the care providers in contact with that client.
The more you know about your client or resident, the more you will be able to anticipate risk. All care providers require knowledge of the client history in order to be able to assess risk.
When taking a nursing history, it is important to gather information related to past incidents of violent behavior. Asking questions in a nonjudgmental, caring manner is very important and will help you to determine and assess risk of violence or aggression. Many care facilities include a precaution page as part of their clinical record. History of violence, the form of violence (verbal, physical), who it was directed at, involvement with law enforcement agencies, and suicidal ideation and/or gestures should all be noted on the precaution sheet.
Criteria: Prior history of assaultive behavior
Behavior:
•has assaulted in the past
•has been violent under stress in the past
•has never been assaultive in the past
Comment: One who has been violent in the past is likely to do so again. One who has never been violent and suddenly becomes so may be suffering from organic illness.
* See Cognitive Impairment
Assessment Questions:
•How do you behave when you are anxious?
•How do you deal with your frustration?
•When people disturb or upset you how might you respond?
•What will you do when you become agitated? angry?
•How can we best help you when you become agitated or angry?
•Have you ever considered suicide?
•If so, did you have a plan?
•Did you ever make an attempt at suicide?
•Are you currently or have you ever been in trouble with the law?
* It might be necessary to ask a family member these questions!
Criteria: Previous exposure to past incidents of aggression and violence:
Comment: Recollection of specific stressful events that occurred in the past may cause clients to strike out at workers.
Criteria: Violent/abusive family or friends:
Comment: Workers must deal not only with patients but also their family m.0embers and friends, sometimes in stressful circumstances. Families and friends share patient’s sadness and frustration over illness and physical disability, sense of inadequacy, and loss of control and independence. Such unhappy circumstances can turn routine contacts with workers into confrontations.
Criteria: Difficulty in communicating:
Comm.0ent: Misunderstandings due to language or a lack of understanding of cultural traditions may lead to conflict between client and worker.
Diagnosis:
Cognitive Impairment:
Reversible: Examples of causes: delirium or acute confusional state related to fluid and electrolyte imbalance; medication side effects; infection; trauma; certain types of head injuries; psychiatric disorder; substance use (alcohol, drugs); history of post-traumatic stress disorder; by anaesthetic/analgesia for pain management
Criteria: Increase in motor agitation
Behavior:
•pacing
•inability to sit still
•sudden cessation of motor activity
Comment: These are attempts to
