10 ANGER, HOSTILITY, ANDAGGRESSION 199
the situation could have been defused more effectively.
It also is important to encourage other clients to talk
about their feelings regarding the incident. However,
the aggressive client should not be discussed in detail
with other clients.
In the postcrisis phase,the client is removed from
restraint or seclusion as soon as he or she meets the
behavioral criteria. The nurse should not lecture or
chastise the client for the aggressive behavior but
should discuss the behavior in a calm, rational man-
ner. The client can be given feedback for regaining con-
trol, with the expectation that he or she will be able to
handle feelings or events in a nonaggressive manner
in the future. The client should be reintegrated into
the milieu and its activities as soon as he or she can
participate.
Evaluation
Care is most effective when the client’s anger can be
defused in an earlier stage (Morales & Duphorne,
1995), but restraint or seclusion is sometimes neces-
sary to handle physically aggressive behavior. The
goal is to teach angry, hostile, and potentially aggres-
sive clients to express their feelings verbally and safely
without threats or harm to others or destruction of
property.
COMMUNITY-BASED CARE
For many clients with aggressive behavior, effective
management of the comorbid psychiatric disorder is
the key to controlling aggression. Regular follow-up
appointments, compliance with prescribed medication,
and participation in community support programs
help the client to achieve stability. Anger manage-
ment groups are available to help clients express their
feelings and to learn problem-solving and conflict-
resolution techniques.
Studies of client assaults on staff in the commu-
nity become increasingly important as more clients ex-
perience rapid discharge from inpatient or acute care
settings. Lewis & Dehn (1999) found that assaults by
clients in the community were caused partly by stress-
ful living situations, increased access to alcohol and
drugs, availability of lethal weapons, and noncompli-
ance with medications. These authors also suggested
that staff at private outpatient mental health clinics
may have limited experience dealing with aggressive
clients.
Flannery et al. (2000) studied assaults by clients
in community residences including physical or sexual
assault, nonverbal intimidation, and verbal threats.
Clients who were assaultive were most likely to have
a diagnosis of schizophrenia, be equally divided by
gender, and have an average age in the late 30s. These
authors described the assaulted staff action program
(ASAP) established in Massachusetts to help staff vic-
tims cope with the psychological sequelae of assaults
by clients in community-based residential programs.
In addition, ASAP works with staff to determine bet-
ter methods of handling situations with aggressive
clients and ways to improve safety in community set-
tings. It is their belief that similar programs would
be beneficial to staff in residential settings in other
states.SELF-AWARENESS ISSUES
The nurse must be aware of how he or
she deals with anger before helping clients do so. The
nurse who is afraid of angry feelings may avoid a
client’s anger, which allows the client’s behavior to
escalate. If the nurse’s response is angry, the situa-
tion will escalate into a power struggle and the nurse
will lose the opportunity to “talk down” the client’s
anger.
It is important to practice and gain experience in
using techniques for restraint and seclusion before at-
tempting them with clients in crisis. There is a risk of
staff injury whenever a client is aggressive. Ongoing
education and practice of safe techniques are essential
to minimize or avoid injury to both staff and clients.
The nurse must be calm, nonjudgmental, and non-
punitive when using techniques to control a client’s
aggressive behavior. Inexperienced nurses can learn
from watching experienced nurses deal with clients
who are hostile or aggressive.
When verbal techniques fail to defuse a client’s
anger and the client becomes aggressive, the nurse
may feel frustrated or angry, as if he or she failed. The
client’s aggressive behavior, however, does not neces-
sarily reflect the nurse’s skills and abilities. Some
clients have a limited capacity to control their ag-
gressive behaviors, and the nurse can help them to
learn alternative ways to handle angry or aggressive
impulses.Points to Consider When Working
With Clients Who are Angry,
Hostile, or Aggressive- Identify how you handle angry feelings;
assess your use of assertive communication
and conflict resolution. Increasing your skills
in dealing with your angry feelings will help
you to work more effectively with clients. - Discuss situations or the care of potentially
aggressive clients with experienced nurses.