This document outlines a training program aimed at improving the knowledge and attitudes of staff regarding the prevention and management of aggressive behavior in psychiatric patients. It details potential causes of aggression, evidence-based models for identification and management, and recommends practices such as early recognition methods and de-escalation techniques. The training modules aim to address misconceptions about mental illness and aggression, promote a therapeutic environment, and employ structured approaches to mitigate incidents of violence.

1. Training
Identification and Management of
Psychiatric Patients’ Aggressive Behavior

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 This presentation includes training modules, as part of the DNP Project entitled “Impact of Staff Training on
Their Knowledge and Attitude Towards Prevention and Management of Aggressive Behavior of Psychiatric
Patients”.
 The OBJECTIVE of this training is to provide evidence-based information regarding the aggressive behavior
of the patients as part of the effort to improve knowledge and attitude of staff to help them achieve the goal
of promoting reduction in patients’ aggressive behaviors.
 The CONTENT of this presentation include three Modules entitled “What are Potential Causes of Psychiatric
Patients’ Aggressive Behavior?”, “Evidence-Based Models and Tools to Identify and Manage Patients’
Aggression”, and “Overall Recommendations for Identification, De-Escalation, and Mitigation of Incidents of
Patients’ Aggression”.
 The next two slides, provide definitions of some of the pertinent terms, and address several common
misconceptions regarding the relationship between patients’ aggression and their disorders.
Introduction

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 Aggression: Hostile or violent behavior or attitudes toward another; readiness to attack or confront or the action of
attacking without provocation, especially in beginning of a quarrel.
 Violence: Intentional use of physical power or force against another person or oneself with a high likelihood leading to
psychological harm, injury, deprivation, or death
 Restraint: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the
ability of a patient to move his or her arms, legs, body, or head freely.
 Pharmacological restraint: Administering sedative or antipsychotic medications to reduce agitation and aggression,
ensuring the safety of the patient and others while facilitating a more therapeutic environment.
 Seclusion: Involuntary confinement of a patient alone in a room or area which the patient is physically prevented from
leaving
 Prevention: Proactive strategies and interventions designed to minimize the risk of aggression by identifying triggers,
fostering a therapeutic environment, and implementing de-escalation techniques to promote safety and therapeutic
outcomes.
 De-escalation: Use of verbal and non-verbal techniques aimed at calming an agitated individual, reducing tension,
and preventing the situation from escalating into physical aggression, thereby ensuring the safety of both patients and
staff.
Definition of Terms

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 The following research-based facts go against the common misconceptions among
public, and even some healthcare providers regarding the relationship between mental
illness and aggression:
People with mental illnesses ARE NOT more likely to be violent than the general
public. The National Council for Mental Wellbeing says that having a diagnosed
mental illness is not, in the absence of other factors, a sufficient risk to warrant fear
of mass violence.
People with mental illnesses ARE more likely to cause self-harm or be victims of
violence than to inflict harm on others.
Debunking Common Misconceptions About Mental Health Patients and Aggression
Aggressive behavior IS NOT always premeditated, and in many instances of aggression in psychiatric patients are
impulsive reactions to stressors related to the environment and interaction with other patients or hospital staff.
Medication alone CAN NOT effectively prevent aggression without any negative subsequences; instead, a
comprehensive approach including therapy and environmental modifications is often needed.
It is NOT TRUE that only specific diagnoses would lead to aggression; instead, aggression can be exhibited by
individuals with a wide range of psychiatric diagnoses, not just those commonly associated with violent behavior.
Clinical assessments ARE NOT the most effective way to determine a person’s risk of violence. Instead, the use of
actuarial violence risk assessment tools are more accurate, and tools have been developed to determine risk for
specific types of violence including sexual aggression and workplace violence.

5. Module I
What are Potential Causes of Psychiatric
Patients’ Aggressive Behavior?

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Potential Causes of Patients’ Aggression (1/3)
 Internal/Biological:
Extreme cases of psychological disorders such as Antisocial Personality Disorder (ASPD), Borderline Personality
Disorder (BPD), and Post-Traumatic Stress Disorder (PTSD)
Disorders such as Conduct Disorder (CD) or Oppositional Defiant Disorder (ODD), specifically in children and
adolescents
Hormonal disbalance
History of aggression a patient’s past
Interactions between psych medications
Substance abuse in the form of intoxication or withdrawal
Psychological stressors from hospitalization
Cognitive distortions misinterpreting situations
Low frustration tolerance and/or poor coping skills for stress management
Feelings of powerlessness in the hospital environment

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 External/Environmental
Unhygienic surroundings including items such as clean bedding, adherence to cleaning protocols, regular pest
control, daily washing of floors and smoking by other patients
Quality and quantity of food, leading to fear and anxiety
Lack of privacy and personal space
Overcrowding and high noise level
Sensory overload
Limited access to preferred activities or resources
Poorly designed physical environments including the arrangement of patients’ room and furniture
Unpredictable routines or schedules
Potential Causes of Patients’ Aggression (2/3)

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 Situational/Interactional
Conflict or unpleasant interaction with other patients, especially aggressive ones
Negative attitude and behavior of nursing staff
Poor communication between staff and patients
Disrespect for patients’ culture, religion and rights
Inconsistent staff instructions
Previous negative experiences of seclusion
Unfair limit setting
Low nursing staff-to-patient ratio
Excessive use of medication and injections to keep patients quiet
Lack of structured activities
Potential Causes of Patients’ Aggression (3/3)

9. Module II
Evidence-Based Models and Tools to Identify
and Manage Patients’ Aggression

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 Aims at improving collaboration between nurses and patients to prevent aggression.
 Strongly focuses on early signs of undesirable behavioral changes, individualized to each patient.
 It is rooted in the belief that patients can learn to identify the onset of relapse during the early stages of
psychosis.
 Patients are encouraged to communicate their needs for preventive actions based on these early signs.
 The protocol for ERM includes the following phases:
1) Introduce the patient to the ERM and clarify their motivation and level of self-awareness.
2) Collaborate with the patient, nurse, and close relatives to identify the patient’s early warning signs (EWS).
3) Detail the identified EWS at three levels: mild, moderate, and severe, within a personalized ERM plan.
4) Implement systematic monitoring plan for the presence of these EWS.
5) Create a personal action plan to follow when signs of relapse are detected.
Early Recognition Method (ERM)

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 It measures (1) confusion (2) irritability (3) boisterousness*9 (4) verbal threats (5) physical threats and (6)
attacks on objects as either present or absent.
 It is hypothesized that an individual displaying two or more of these behaviors is more likely to be violent in
the next 24-hour period.
 Each of these items is scored as “1” if present or “0” if absent.
 For well-known patients, an increase in any of these behaviors is scored as “1”, whereas the habitual
behaviors* while being nonaggressive is scores as “0”.
 The sum of scores are calculated for these six behaviors and is interpreted as follows:
A sum of “0” suggests low risk of aggression, while scores of “1” and “2” suggest moderate risk of
aggression, and scores of “3” and higher indicate high risk of aggression or even violence. In the latter
case immediate preventive measures are required and plans for de-escalation and potentially handling an
attack should be activated.
Brøset Violence Checklist (in Emergency Department)
* The quality characterized by loud, energetic, noisy, and cheerful behavior.

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 An expansion on Brøset Violence Checklist based on further field research.
 It is comprised of 7 state-based risk factors which can fluctuate daily and are amendable to interventions.
These items are (1) irritability (2) impulsivity (3) unwillingness to follow directions (4) sensitivity to perceived
provocation (5) easily angered when requests are denied (6) negative attitudes and (7) verbal threats.
 Using behaviors observed in the last 24 hours, a nurse rates each of these items as “1” if present or “0” if
absent. The sum of scores are calculated for these seven behaviors and is interpreted as follows:
A sum of 0 to 1 represents lower risk, 2 to 3 represents a moderate risk, and 4 or higher represents a high
risk for the patient to engage in aggression/violence within the next 24 hours. For patients with sum score
6 or 7, risk may be imminent, and preventive measures need to be taken.
 Advantages: It should take less than five minutes to complete; it does not require interview with the patient;
and it does not have restrictive user requirements.
 It is intended that the patient’s allocated nurse, who should be most aware of the patient’s current symptom
profile and psychological state, would assess the patient with the DASA for that day.
Dynamic Appraisal of Situational Aggression (DASA)

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Dynamic Appraisal of Situational Aggression, Youth Version (DASA-YV)
 A revised version of DADA tool specialized for youth population, with four added items, (8) anxious or fearful
(9) low empathy or remorse (10) significant peer rejection and (11) outside stressors.
 The addition of these items was based on the filed research mandating consideration of these specific
parameters mostly affecting children and adolescents as follows:
The Anxious or Fearful item was added due to its link to youth aggression.
Low Empathy/Remorse addresses individuals who lack concern for past aggression or others' distress.
Significant Peer Rejection prompts attention-seeking behaviors and is related to aggression.
Outside Stressors were included as acute stress can heighten aggression, especially if unresolved during
hospitalization.
 This 11-item Youth version results in the sum score similar to original DASA tool, with 0 to 3 indicating low
risk, 4 to 6 showing moderate risk, and 7 to 11 representing high risk, as validated by field studies.

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 It offers a clear and effective explanation for the differences in the frequency and the severity of patients
aggressive behavior and violence in different wards/hospitals.
 Six characteristics of the inpatient psychiatric system can originate and/or intensify situations that may result
in such incidents including (1) staff team (2) physical environment (3) outside of the hospital (4) patient
community (5) patient characteristics and (6) regulatory framework.
 These six features of the inpatient psychiatric system have the capacity to give rise to flashpoints from which
adverse incidents may follow.
Details aspects of these variables, their role in triggering and/or intensifying of patients’ aggression and on
the other hand their potential role in mitigating such situations are explained in the next slide via a graphical
chart.
Safewards Model (Slide 1 of 2)

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Safewards Model (Slide 2 of 2)
Psychiatric Ment Health Nurs, Volume: 21, Issue: 6, Pages: 499-
508, First published: 19 February 2014, DOI: (10.1111/jpm.12129)
 Outer Ring: Summarizes key features within these
domains that may lead to conflict and containment
events.
 Next Ring (Patient Modifiers): Highlights actions patients
can take that influence how the features of the six
domains contribute to conflict and containment.
 Next Ring (Staff Modifiers): Similar to patient modifiers,
this indicates how staff actions can affect the features of
the domains to reduce conflict and containment.
 Arrows: Indicate that staff can directly modify domain
features to lower the risk of conflict or containment
events.
 Innermost Ring (Flashpoints): Identifies specific events or
social circumstances that are most likely to trigger conflict
or containment in the short term.
 Center of the Model: Conflict and containment are linked
by a bidirectional arrow, showing that while conflict can
lead to containment, the use of containment can also
provoke further conflict.

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 Based on the public health prevention model, it emphasizes on the powerful role of nursing leadership and staff in
implementing evidence-based practices to reduce coercion, violence, and events that lead to the use of restraint and
seclusion (R/S).
 In the context of seclusion and restraint prevention:
Primary prevention focuses on enhancing the administrative and clinical environment by creating policies,
procedures, and risk assessments to reduce or eliminate R/S use.
Secondary prevention aims to identify triggers for conflict and aggression early, involving staff training in de-
escalation techniques and modifying the physical environment to prevent the need for R/S use.
Tertiary prevention seeks to minimize the harm resulting from incidents of R/S use.
Six Core Strategies (6CS) to Reduce the Use of Seclusion and Restraint
 The six important pillars of this type of strategies are:
1) Critical roles of leadership and staff in successful R/S reduction projects
2) Ability of leaders and staff to change their beliefs and behaviors
3) Ability of leaders and staff to build a shared vision that is critical to the reduction of R/S use in inpatient settings
4) Identification and resolution of key challenges staff and leaders experience in reduction efforts
5) Use of a solid performance improvement view to direct changes in practices
6) Implementation of important lessons learned in the context of seclusion and restraint prevention

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Anti-Aggression and De-Escalation (ADE) Trainings (Slide 1/2)
 There are commercially available trainings regarding identification and de-escalation of aggressive behavior from
patients, two of which are briefly described in this slide and the next:
 RADAR (Recognize. Avoid. Defuse. Alert. Redirect): It aims to enhance safety for both patients and staff by promoting
proactive and effective responses to potential aggression, thereby reducing the need for seclusion and restraint in
psychiatric settings. The training promotes a therapeutic environment focused on de-escalation and positive
interactions. Below is a brief overview of each component in the context of psychiatric patients in a hospital:
Recognize: This involves identifying early signs of agitation or aggression in patients, allowing staff to intervene
before the situation escalates.
Avoid: This focuses on strategies to prevent conflict and aggression by modifying the environment or the approach
taken with patients, such as using calming techniques or providing adequate space.
Defuse: This component emphasizes techniques for calming an agitated patient through verbal de-escalation
methods, active listening, and empathetic communication to reduce tension.
Alert: This involves notifying appropriate team members or using established protocols when a situation is
escalating beyond the staff's ability to manage it safely.
Redirect: This focuses on guiding the patient toward more positive behaviors or activities, helping to shift their focus
away from aggression and towards constructive engagement.

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Anti-Aggression and De-Escalation (ADE) Trainings (Slide 2/2)
 ProDeMa (Professional De-escalation Management): It was The program was developed in Germany and
intends to reduce violent incidents through 7 “de-escalation levels”:
1) Prevention/Reduction of violence through improvements concerning external framework conditions, e.g.
aggression inducing ward rules or process flows
2) Change of reaction patterns of the staff through change in interpretation and valuation of inpatient
violence
3) Improvement of the staff’s understanding of the etiology of violent behavior
4) Training staff in verbal de-escalation techniques
5) Teaching staff techniques to escape and defend themselves against physical attacks without harming the
patient unnecessarily
6) Techniques to immobilize and restrain patients without doing unnecessary harm to them
7) Professional post-processing of escalations including inter-collegial first aid

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Positive Behavior Support Plans (PBSPs)
 A general term referring to a category of person centered plans designed to help staff prevent behavior which would
‐
require restrictive intervention.
 Here are the key elements of a Positive Behavior Support Plan (PBSP) in the context of care for inpatients in
psychiatric hospitals:
Functional behavior assessment: Identification of the underlying causes and triggers of challenging behaviors
through observation and data collection
Individualized goals: Establishment of specific, measurable, and achievable behavioral goals tailored to the
patient’s needs and strengths.
Proactive strategies: Implementation of preventive measures and interventions designed to promote positive
behaviors and reduce the likelihood of aggression or crisis.
Skill development: Teaching coping skills, emotional regulation, and social skills to empower patients in managing
their behavior effectively.
Monitoring and review: Regular evaluation of the patient’s progress toward goals, with adjustments to the plan
based on ongoing assessments and feedback.
Collaboration: Involvement of a multidisciplinary team, including mental health professionals, nursing staff, and
family members, to ensure a comprehensive approach to care.

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Psycho Motor Agitation (PMA) Protocol
 Observe behavioral signs such as restlessness (e.g., pacing, fidgeting, wringing hands), hyperactivity (increased movement or
inability to sit still), excessive talking (pressured speech, rapid speech)
 Monitor emotional indicators such as elevated anxiety or nervousness, irritability or frustration, and heightened sense of
urgency or panic
 Assess cognitive symptoms such as racing thoughts or distractibility, difficulty focusing or concentrating, overactive or
fragmented thinking
 Evaluate physiological changes suc as increased heart rate (tachycardia), sweating, tension, or restlessness in posture, and
shaking or trembling
 Review medical and psychiatric history such as history of mood disorders (e.g., mania, depression), current psychiatric
diagnosis (e.g., psychosis, anxiety disorder), and recent substance use or withdrawal
 Consider environmental factors such as presence of stressors (e.g., trauma, conflict), recent changes in routine or medication
 Identify potential triggers such as medication side effects (e.g., stimulants, antipsychotics), substance intoxication or
withdrawal, and medical conditions affecting mental state (e.g., delirium, infections)
 Check for signs of escalating distress such as heightened agitation or verbal outbursts, impulsive or unpredictable behavior,
risk of violence or self-harm
 Use standardized rating scales (if applicable) such as Agitation Behavior Scale (ABS) or the Clinical Global Impressions-
Severity Scale (CGI-S) to quantify agitation severity

21. Module III
Overall Recommendations for Identification,
De-Escalation, and Mitigation of Aggressive
Behavior from Patients

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The Purpose of This Module
 Implementing, in partially or fully, of any of the strategies, trainings, models, and methods, presented in Module II, to
address the issue of the aggressive behavior from psychiatric patients in a hospital setting, with various departments,
would require willingness, planning, and funding from the high-level leaderships of the organization to design and
implement an evidence-based Quality Improvement (QI) project.
 Once such a project is plan and being executed, the involvement and support from the hospital staff including
healthcare providers, administrative employees, and security personnel. In the case of some strategies, involvement
from the patients’ families and even patients themselves would be needed to ensure the success of the program.
 In the absence of such organized approach towards this issue, any of the staff, especially RNs, LVNs, CNAs, and
BHSs, could still benefit from the collected evidence presented in Module II. They can all try to implement any of the
items discussed in their own zone of work to improve patient experience and make their own work less stressful.
Additionally, successful implementation of such methods in part of the hospital could provide rationale for proposals to
implements similar programs hospital-wise.
 To help the staff to do so, Module III is intended to provide overall recommendations for identification, de-escalation,
and mitigation of aggressive behavior from patients, based on major takeaways from evidence.

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Early Identification of Aggressive Behavior Onset
 Foster Patient Collaboration: Encourage open communication between nurses and patients
to enhance awareness of early warning signs of aggression.
 Identify Early Warning Signs: Collaborate with patients and their families to recognize and
document individualized early warning signs (EWS) for each patient.
 Implement Systematic Monitoring: Establish a consistent monitoring plan to track the
presence of identified early warning signs, facilitating timely interventions.
 Create Personal Action Plans: Develop personalized action plans that outline specific steps
to take when early signs of relapse or aggression are detected.
 Utilize Risk Assessment Tools: Incorporate tools like the Dynamic Appraisal of Situational
Aggression (DASA) to assess risk factors daily and guide preventive measures effectively.
 Additional items focusing on children and adolescent patients:
 Implement youth-specific assessment tools such as DASA-YV to assess risk factors unique
to children and adolescents, including anxiety, peer rejection, and outside stressors.
 Focus on teaching youth coping strategies, empathy, and social skills to help them manage
emotions and reduce the likelihood of aggressive behavior.
Watch this short video re
garding early verbal and p
hysical signs of aggressive
behavior

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 Offer Choices: Empower the patient by providing options, like selecting a quiet space or calming activity.
 Use De-Escalation Techniques: Redirect conversations to neutral topics and reassure the patient about their
safety.
 Establish Personal Space: Respect the patient's space to prevent feelings of being cornered.
 Involve a Supportive Peer: If needed, bring in a trusted staff member to help mediate and support the
patient.
De-Escalation of Triggered Aggressive Behavior
 Stay Calm: Keep a composed demeanor to lower tension and demonstrate emotional
control.
 Use Simple Language: Communicate clearly and avoid jargon for better understanding.
 Practice Active Listening: Show interest by nodding, keeping eye contact, and
summarizing the patient's concerns.
 Maintain Open Body Language: Adopt a relaxed posture, keep hands visible, and
avoid crossing arms to appear approachable.
 Speak Softly and Slowly: Use a gentle tone to help soothe an agitated patient.
 Acknowledge Feelings: Validate the patient's emotions to make them feel understood.
Watch this short video
with 21 suggestions for
verbal de-escalation

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Mitigation of the Consequences of Aggression Incidents
 Immediate Safety Assessment: Conduct a thorough assessment of the situation to ensure
the safety of all patients and staff involved.
 Debriefing Sessions: Organize debriefing sessions with staff and involved patients to
discuss the incident, emotions, and responses, fostering a supportive environment.
 Documentation: Accurately document the incident, including triggers, behaviors observed,
and responses taken to inform future prevention strategies.
 Emotional Support: Provide immediate emotional support to affected staff and patients,
including access to counseling or psychological services if needed.
 Review and Analyze: Analyze the incident to identify patterns or systemic issues that may have contributed to the
aggression, using insights to improve protocols.
 Training Refreshers: Offer refresher training for staff on de-escalation techniques and handling aggression to enhance
readiness for future incidents.
 Follow-Up Monitoring: Implement follow-up monitoring of the patient involved to assess their mental state and adjust
interventions as necessary.