Mental Health Nursing

open access articles on mental health nursing

Nursing Management of Aggression


Aggression arises from an innate drives or occurs as a defense mechanism and is manifested either by constructive or destructive acts directly towards self or others. Aggressive people ignore the rights of other people. They   must fight for their own interests and they expect same from others. An aggressive approach to life may lead to physical or verbal violence. The aggressive behavior often covers a basic lack of self confidence. Aggressive people enhance to their self esteem by overpowering others and there by proving their superiority. They try to cover up their insecurities and vulnerabilities by acting aggressive.


Characteristics of aggressive behavior

Types of aggression

Moyer Classification

Moyer (1968) presented an early and influential classification of seven different forms of aggression, from a biological and evolutionary point of view.


Aggressive and violent behavior can be viewed along a continuum with verbal aggression at one end and physical violence at other end. Specific reasons for aggressive behavior vary from person to person. Anger occurs in response to a perceived threat. This may be a threat of physical injury or more often a threat to the self concept. When the self is threatened, people may not be entirely aware of the source of their anger. A threat may be internal or external. Examples of external stressors are physical attack, loss of a significant relationship and criticism from others. Internal stressors might include a sense of might include a sense of failure at work, perceived loss of love and fear of physical illness.

Anger is the only one emotional response to these stressors. Some people might respond with depression or withdrawal.  However, those reactions are usually accompanied by anger which may be difficult for the person to express directly. Depression is sometimes viewed as anger directed towards the self, and withdrawal may also be a passive expression of anger. A number of theories on the development of aggressive behavior have influenced the treatment of violent patients. They can be categorized as psychological, socio cultural and biological.


One psychological view of aggressive behavior suggests the importance of predisposing developmental or life experiences that limit the person’s capacity to select nonviolent coping mechanisms. Some of these experiences may include:

It has been also suggested that a disruption in the mother infant bonding process can lead to the development of poor interpersonal behavior that may increase the likelihood of violent behavior. When combined with neurological deficits, the risk of violent behavior is increased.

Social learning theory proposes that aggressive behavior is learned through the socialization process as a result of internal and external learning.

Internal learning occurs through the personal reinforcement received when enacting aggressive behavior.  This may be the result of achieving a desired goal or experiencing feelings of importance, power and control.

External learning process occurs through the observation of role models such as parents, peers, siblings and sports and entertainment figures. Sociocultural patterns that lead to the imitation of aggressive behavior suggest that violence is an acceptable social status.

Activities such as violent crime, aggressive sports, and war depicted through the media or witnessed, in person reinforce aggressive behavior.


Social and cultural factors also may influence aggressive behavior. Cultural norms help to define acceptable and unacceptable means of expressing aggressive behavior feelings. Sanctions are applied to violators of the norms through the legal systems. By this means, society controls violent behavior and attempts to maintain a safe existence of its members. A cultural norm that supports verbally assertive expressions of anger will help people deal with anger in a healthy manner. A norm that reinforces violent behavior will result in physical expression of anger in destructive ways.

Social determinants of violence are:


Current biological research ahs focused on three areas of the brain believed to be involved in aggression:

Neurotransmitters have also been suggested as having a role in the expression or expression of the aggressive behavior.

I. Limbic system

t is associated with the mediation of basic drives and the expression of human emotions and behaviors such as eating, aggression and sexual response. It is also involved in the processing of information and memory. Alterations in the functioning of limbic system may result in an increase or decrease in the potential for aggressive behavior. In particular, the amygdala, part of the limbic system, mediates the expression of the rage and fear.

II. Frontal lobe: 

III. Hypothalamus

It is situated at the base of the brain, is the brains alarm system. Stress raises the level of steroids, the hormones secreted by the adrenal glands. Nerve receptors for these hormones become less sensitive in an attempt to compensate and hypothalamus tells the pituitary glands to release more steroids. After repeated stimulation, the system may respond more vigorously to all provocations. That may be one reason why traumatic stress in childhood may permanently enhance one’s potential for violence.


Neurotransmitters are brain chemicals that are transmitted to and from neurons across synapses, resulting in communication between brain structures. An increase or decrease in this behavior can influence behavior. People who commit suicide and homicidal have lower than average levels of 5-HIAA, the breakdown product of the serotonin, in their spinal fluid. Other neurotransmitters often associated with aggressive behavior are dopamine nor epinephrine and acetylcholine and the amino acid GABA. Animal studies indicate that increasing in brain dopamine and nor epinephrine activity significantly enhances the likelihood that animal will respond to the environment in an impulsively violent manner.



a). Twin studies : concordance rate for monozygotic twins exceed the rates for dizygotic twins

b). Pedigree studies: the persons with family histories of mental disorders are more susceptible to mental disorder and engage in more aggressive behavior than those without such histories. Those with low IQ scores appear to have frequency of delinquency and aggression than those with normal IQ scores.

 c) Chromosomal influences: XYY syndrome contributes to aggressive behavior. The person with this syndrome are tall, below average intelligence and likely to be apprehend and in prison for engaging in criminal behavior.


Cholinergic and catecholaminergic mechanisms seem to be involved in the induction and enhancement of predatory aggression whereas seroteonergic system and GABA seem to inhibit such behavior. Dopamine seems to facilitate aggression, whereas nor epinephrine and serotonin appears to inhibit such behavior. Some human studies have indicated that 5-HIAA levels in CSF inversely correlates with the frequency of aggression, particularly among persons who commit suicide.


Epilepsy of temporal lobe and frontal lobe origin results in episodic aggression ad violent behavior .Tumors in the brain ,particularly in the areas of the limbic system and the temporal lobe ,trauma to the brain ,resulting in cerebral changes and the disease such as encephalitis have been implicated in the predisposition to aggression and violent behavior.



Freud’s view:

According to Sigmund Freud held that all human behavior stems either directly or indirectly from two instincts. These are Eros and Thanatos. Eros -It is the life the life instinct –whose energy or libido is directed towards the enhancement or reproduction of life. In this frame work, aggression was viewed simply as a reaction to blocking or thwarting of libidinal impulses and was neither an automatic nor an inevitable part of life. Thanatos: It is the death force-whose energy is directed towards the destruction or termination of life. According Freud , all human behavior stem from the complex interplay of Thanatos and Eros and the constant tension between them. Because the death instinct, if unrestrained, soon results in self-destruction. Freud hypothized that through the mechanism such as displacement, the energy of Thanatos is redirected towards and serve as the basis of aggression against others. Thus according to him, aggression primarily stems from the redirection of the self destructive death instinct away form the self and towards others.

Lorenz’s view:

According to Konard Lorenz , aggression that causes physical harm to others springs from a fighting instinct that humans share with other organisms. The energy associated with this instinct is produced spontaneously in organisms at a more or less constant rate.

Learned behavior

Aggression is primarily a learned form of social behavior. According to Albert Bandura, neither innate urges toward violence nor aggressive drives aroused by frustration are the roots of human aggression. He said that aggression is the learned behavior under voluntary control. The learning of aggressive behavior occurs by observation and modeling. For example, a child watches an angry parent strikes out another person. Learning aggressive behavior also takes place by direct experiences. The person feels anger and behaves aggressively. If behaving aggressively brings rewards, the behavior is encouraged.

Moreno believed that anger is a natural by product of the learning process; it is signal that a person wants to learn something. The more inadequate a person feels, the more anger may be present.  Moreno also believed that anger is spontaneous energy that propels an individual into new learning.


a). Frustration: The single most potent means of inciting human beings to aggression is frustration. Widespread acceptance of this view stems from John Dollard’s frustration, aggression hypothesis. This hypothesis indicated that frustration always leads to a form of aggression and that aggression always stem from frustration.

Frustrated persons do not always respond with aggressive thoughts and words, or deeds. They may show a wide variety of reactions ranging from resignation, depression and despair to attempts to overcome the sources of frustration. Examination of the evidence indicates that whether frustration increases or fails to enhance covert aggression depends largely on two factors. First, frustration appears to increase aggression only when the frustration is intense. When it is mild or moderate, aggression may not be enhanced. Second frustration is likely to facilitate aggression when it is perceived as arbitrary or illegitimate, rather than when it is viewed s deserved or legitimate.  

b). Direct provocation: Evidence indicates that physical abuse and verbal taunts from others often elicit aggressive actions. Once aggression begins, it often shows an unsettling pattern of escalation; as a result even mild verbal slurs or glancing blows may initiate a process of in which a stronger and stronger provocation are exchanged.

c). Television violence: A link between aggression and televised violence has been noted.  The more televised violence children watch, the greater is their level of aggression against others. Mechanisms underlying the effects of televised and filmed violence on the behavior of the viewers



Observational learning

Viewers acquire new means of harming others not previously present in their behavior 


Viewers restraints or inhibition against performing aggressive action are weakened as a result of  observing others engaging in such behavior


Viewer’s emotional responsivity to aggressive actions and their consequences –signs of suffering on the part of victims –is reduced. As result they show little, if any, emotional arousal in response to such stimuli.

 d). Computer games: Similar concerns have been raised the bout computer game with violent themes. Some studies indicate that adolescents become desensitized to homicidal activities after repeated exposure, especially if the game involves killing the virtual opponents, which is common in many computer programs.




Nurses provide care for patients with many types of problems; people who enter the health care system are often in great distress and exhibit many maladaptive coping responses. Nurses who work in the setting such as emergency rooms, critical care areas and trauma centre often care for people who respond to events with angry and aggressive behaviour that can pose a significant risk to themselves, other patients and health acre providers. Thus preventing and managing behaviour are important skills for all nurses to have.

General Principles of Management

Drug Treatment in Aggressive and Violent Behaviours

Careful diagnosis has to be made to avoid overuse and misuse of medication. Medications are used primarily for 2 purposes-

  • To use sedating medication in an acute situation to calm the client so that client will not harm self or others.
  • To use medication to treat chronic aggressive behaviour.

Factors influencing choice of drug –availability of an IM injection, speed of onset and previous history of response.

Acute agitation and aggression

Antipsychotic –often it is the sedating property of antipsychotic that produce the calming effect for the client. Atypical antipsychotic are also commonly used. But only Ziprasidone is available in intramuscular form.

Haloperidol-1 mg or 0.5 mg IM
Risperidone o.5mg-1mg- In dementia and schizophrenia.
Trazodone – 50-100mg . In older clients with sun downing syndrome and aggression.

Benzodiazepines- used due to the sedative effect and rapid action. Most commonly lorazepam, oral or injection. Other sedating agents used include Valproate, chloral hydrate and diphenhydramine.

Chronic aggression

When client continues to exhibit aggression more than several weeks’ choice of medication is based on underlying condition. I.e., if related to schizophrenia-antipsychotic.

  • Antipsychotic
  • Anxiolytics- Buspirone
  • Carbamazepine and valproate  to treat bipolar associated aggressive behaviour.
  • Antidepressants –trazodone in aggression associated with organic mental disorder.
  • Antihypersensitive medication – Propanolol to treat aggression related to organic brain syndrome.


Nursing Assessment

  • A violence assessment  tool can help the nurse.
  • Establish a therapeutic alliance with the patient.
  • Assess patient’s potential for violence.
  • Develop a plan of care.
  • Implement the plan of care.
  • Prevent aggression and violence in the milieu.
  • Following the assessment , if the patient is believed to be potentially violent, the nurse should:
  • Implement the appropriate clinical protocol to provide for the patient and staff safety
  • Notify co-workers
  • Obtain additional security if needed
  • Assess the environment and make necessary changes.
  • Notify the physician and assess the need for prn medications.

Nursing Interventions

Nursing interventions can be thought of existing in a continuum . They range from preventive strategies such as self awareness, patient education and assertiveness training to anticipatory strategies such as verbal and nonverbal communications, and the use of medications. If the patient’s aggressive behaviour escalates despite these actions the nurse may need to implement crisis management techniques and containment strategies such as seclusion or restraints.

Self awareness

The most valuable resource of a nurse is the ability to assess one’s self to help others .to ensure the most effective use of self , its important to know about personal stress that can interfere in one’s ability to communicate with patients. Anxiety, angry, tiredness, apathy, personal work problems etc... from the part of nurse can affect the patient. Negative countertransferance reactions may lead to non therapeutic responses on the part of the staff. Ongoing self awareness and supervision can assist the nurse in ensuring that patient needs rather than personal needs are satisfied.

Patient education

Teaching patients about communication and the appropriate way to express anger can be one of the most successful interventions in preventing aggressive behaviour.
Teaching patients that feelings are not right or wrong or good or bad can allow them to explore feelings that may have been bottled up, ignored or repressed. The nurse can then work with patients on ways to express their feelings and evaluate whether the responses they select are adaptive or mal adaptive.

Patient education plan for appropriate expression of anger


Instructional activities


Help the patient identify anger

Focus on nonverbal behaviour.
Role plays nonverbal expression of anger.
Label the feeling using the patients preferred words

Patient demonstrates an angry body posture and facial expression.

Give permission for angry feelings.

Describe situations in which it is normal to feel angry.

Patient describes a situation to which anger would be an appropriate response.

Practice the expression of anger.

Role play fantasized situations in which anger is an appropriate response

Patient participates in role play and identifies behaviours associated with expression of anger.

Apply the expression of anger to real situation.

-Help to identify a real situation that makes the patient angry.
-Role plays a confrontation with the object of the anger.
-Provide a positive feedback for successful expression of anger.

-Patient identifies a real situation that results in anger.
-Patient is able to role play expression of anger.

Identify alternative ways to express anger

-List several ways to express anger, with and without confrontation.
-Role plays alternative behaviours.
-Discuss situations in which alternatives would be appropriate

Patient participates in identifying alternatives and plans when each might be useful.

Confrontation with a person who is a source of anger.

-Provide support during confrontation if needed.
-Discuss experience after confrontation takes place.

Patient identifies the feeling of anger and appropriately confronts the object of anger.

Assertiveness training
  • Interpersonal frustration often escalates to aggressive behaviour because patients have not mastered the assertive behaviours.
  • Assertive behaviour is a basic interpersonal skill that includes the following
  • Communicating directly with another person.
  • say no to unreasonable requests
  • Being able to state complaints.
  • Patients with few assertive skills can learn them by participating in structured groups and programmes .In these settings patients can watch demonstrate specific skills and then role play the skills themselves.
  • Staff can provide feedback to patients on appropriateness and effectiveness on their responses.
  • Homework also can be given to these patients to help them generalise these skills
  • Expressing appreciation as appropriate outside the group milieu.

Communication strategies
Nurses have to:

  • present a calm appearance
  • speak softly
  • speak in a non proactive and non judgemental manner
  • speak in a neutral and concrete way put space between yourself and patient
  • show respect to the patient
  • avoid intense direct eye contact
  • Demonstrate control over the situation without assuming an overly authoritarian stance.
  • Facilitate the patient’s stance.
  • Listen to the patient
  • Avoid early interpretations
  • Do not make promises that cannot keep.

Environmental strategies

1. Room programme

2. Cathartic activities

The use of cathartic activities may help the patients deal with their anger and agitation. These can be of 2 types:

a). Physically cathartic activities – It is based on the assumption that some physical activity can be useful in releasing aggression and can prevent more explosive or destructive forms of aggression or violence .Some traditional nursing interventions, such as encouraging patients to release tension through the use of exercise equipment or allowing patients to pace the hall in the expectation that their tension will decrease. Because these strategies are not supported by research and may increase patient’s agitation they are not recommended now.

b). Emotionally cathartic activities – these are evidence based. Having patients write their feelings, do deep breathing or relaxation exercises, or talk about their emotions with a supportive person can help the patient regain control and lower feelings of tension and agitation.

Behavioral strategies

Nursing interventions include applying principles of behaviour management to aggressive patient.

a) Limit setting
b). Behavioral contracts  

If the patient uses violence to win control and make personal gains, the nursing care must be planned to eliminate the rewards patient receives while still allowing the patient to  assume as much as control, as possible.

Once the rewards are understood, nursing care must be planned that does not reinforce aggressive and violent behaviour. Behavioural contracts with the patient can be helpful in this regard. Eg. Head injured patients with low impulse control can be told that staff will take them for a walk if they can refrain from using profanity for 4 hours.
To be effective contracts require detailed information about:

  • unacceptable behaviours.
  • acceptable behaviours.
  • consequences for breaking the contact.

The nurse’s contribution to care.
Patients also should have input into the development of the contract to increase their sense of self control.

c). Time out
d). Token economy
  • In this intervention, identified interpersonal skills and self care behaviours are rewarded with tokens that can be used by the patient to buy items or receive rewards or privileges.
  • Behaviours to be targeted are specific to each patient. guidelines has to be made for desired
  • behaviours required to receive the tokens, the number of tokens to be received for each behaviour and the
  • Length of time a desired behaviour must be exhibited to receive tokens.
e). Crisis Management
  • Team Response
  • Effective crisis management must be organised and should be directed by one clearly identified crisis leader.
  • Procedure for managing psychiatric emergencies.
  • Identify crisis leader
  • Assemble crisis team
  • Notify security officers if necessary
  • Remove all other patients from the area
  • Obtain restraints if appropriate
  • Device a plan to manage crisis and inform team
  • Assign securing of patients limbs to crisis team members
  • Explain necessity of intervention to patient and attempt to enlist cooperation
  • Restrain patient when decided by the crisis leader
  • Administer medication if ordered
  • Maintain calm, consistent approach to patient
  • Review crisis management interventions with crisis team
  • Process events with other patients and staff as appropriate
  • Process event with patient
  • Gradually reintegrate patient into milieu.
f). Seclusion    

Seclusion is the involuntary confining of a person alone in a room from which the person is physically prevented from leaving (Brown, 2000). Degree of seclusion varies. They include confining a patient in a room with a closed or unlocked door or placing a patient in a locked room with a mattress but no linens and with limited opportunity for communication.

The rational for the use of seclusion is based on 3 therapeutic principles:

g). Restraints

Indications – used when the client-

  • is no longerexerting control over his/her own behaviour.
  • to prevent harm to others and to patient
  • to prevent serious disruption of treatment environment.

Physical restraints are any manual methods or physical or mechanical device attached to or adjacent to the patient’s body that she/he cannot easily remove and that restricts freedom of movement  or normal access to one’s body, material or equipment (Brown, 2000)

Chemical restraints are medications used to restrict patient’s freedom of movement or for emergency control of behaviour, but it is not a standard treatment for the patient’s medical or psychiatric condition (Murphy, 2002).

Because seclusion and restraints represents restriction of patient freedom and can result in harm to both the patient and the staff who implement them, they should be used only as an emergency intervention to ensure the safety of the patient or others and only when other less restrictive interventions has been ineffective. They are a violation of patient rights if used as a means of coercion, discipline or convenience of staff (Brown, 2000).

Restraints should be applied efficiently and with care that not to injure a patient. Adequate personnel must be assembled before the patient is approached. Each staff member should be assigned responsibility for controlling specific body parts. Restraints should be available and in working order. Padding of cuff restraints helps to prevent skin breakdown. For the same the patient should be positioned in anatomical alignment. 

Guidelines for use of restraints
  1. Restraints must not be used to punish a patient or solely following the convenience of staff or other patients.

  2. Staff must take into consideration the medical/psychiatric status of patient.

  3. Written policy must be followed.

  4. In non-emergency situation physical restraints should be used very sparingly and only after careful and comprehensive review, assessment and documentation provide substantial evidence that no safer alternative or setting can be found to prevent their use.

  5. The least restrictive device should be used.

  6. All mechanical restraints must be padded to decrease the chance of pressure damage and abrasion to skin and underlying tissues; proper size and type must be used.

  7. Both the patient and restraining device must be checked frequently and the restraining device removed periodically. A restrained limb should be periodically exercised and, if possible the patient should be ambulated at reasonable intervals. Attention to need fro hydration, elimination, comfort, and social interaction must be assured.

  8. Behaviour that precipitates a decision to restrain patient should first trigger investigation and treatment aimed at understanding and eliminating the cause of the behaviour.

  9. ursing staff should observe the patient every 15 min.

  10. All the needs of the patient must be met with caution.

  11.  With four point restraint each limb should be released or restraint loosened every 15min.

  12. Patient should be gradually decreased from seclusion or restraint.
    m) Patient should not be made to feel guilty after being released from restraints of his past behaviour.

  13. Documentation is necessary.

Risks with restraints

Falls, strangulation, loss of muscle tone, pressure sores, decreased mobility, agitation, reduced bone mass, stiffness, and frustration, loss of dignity, incontinence, and constipation.  

Terminating the intervention 

Patients should be removed from seclusion or restraints as soon as they meet criteria for release. It is important to review with the patient the behaviour that precipitated the intervention and the patient’s current capacity to control over his/her behaviour. Patients should be told witch behaviours or impulses they need to exhibit and which intervention they need to control before the intervention can be discontinued. Communication and careful documentation are critical in making an accurate assessment of a patient’s level of control.


Debriefing is an important part of terminating the use of seclusion or restraints. Debriefing is a therapeutic intervention that includes reviewing the facts related to an event and processing the response to them. It provides the staff and patient with an opportunity to clarify the rational for seclusion, offer mutual feedback, and identify alternative, methods of coping that might help the patient avoid seclusion in the future.


Workplace guidelines

Staff development

  • Staff education regarding
  • The workplace violence prevention policy
  • Risk factors that cause or contribute to assaults
  • Early recognition of escalating behaviour or recognition of warning signs or situations that may lead to assaults
  • Ways of preventing or diffusing volatile situations or aggressive behaviour, managing anger, and appropriately using medication or chemical restraints.
  • Information on multicultural diversity to develop sensitivity to racial and ethnic issues and differences.
  • A standard response action plan to violent situations, including availability of assistance, response to alarm systems, and communication procedures.
  • How to deal with hostile persons other than clients such as relatives and visitors.
  • Progressive behaviour control methods and procedures and safe methods of restraint application
  • Ways to protect oneself and fellow workers.
  • Policies and procedures, recording and reporting.
  • Policies and procedures for obtaining medical care, counselling, workers compensation or legal assistance after a violent episode of injury.

Staff support
Nurses can be supported by allowing adequate time off from work to address their physical and emotional needs. Discussing the event in a nonblaming manner is also helpful. Validation from others that assaults occur despite clinical competence and appropriate  interventions can help the assaulted nurse in healing.


Anger is a normal human emotion that is crucial for individual’s growth. When handled appropriately and expressed assertively, anger is a positive creative force that leads to problem solving and productive change. When channeled inappropriately and expressed as verbal aggression or physical aggression, anger is destructive and potentially life threatening force.

Psychiatric nurses in particular, work with patients who have inadequate coping mechanisms for dealing with stress. Patients admitted to an inpatient psychiatric unit are usually in crisis, so their coping skills are even less effective. During these times of stress acts of physical aggression or violence can occur. Also nurses spends more time in the inpatient unit than any other disciplines, so they are more at risk of being victims of acts of violence by patients. For these reasons, it is critical that psychiatric nurses be able to assess patients at risk for violence and intervene effectively with patients before, during and after an aggressive episode.


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This page was last updated on: 19/12/2020