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Authentic Engagement. And the reduction of patient aggression. Objectives. Upon completion of this in-service, participants will be able to : Examine consequences of being exposed to client aggression Describe research addressing aggression

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authentic engagement

Authentic Engagement

And the reduction of patient aggression


Upon completion of this in-service, participants will be able to :

  • Examine consequences of being exposed to client aggression
  • Describe research addressing aggression
  • Identify authentic engagement components to improve inpatient psychiatric nursing practice and prevent escalation in client aggression
  • Demonstrate the implementation of authentic engagement during a role play session
authentic engagement a core concept in reducing seclusion and restraint
Authentic engagement: A core concept in reducing seclusion and restraint
  • Reducing seclusion rates is challenging and typically requires the implementation of multiple interventions (Gaskin, Elsom, & Happell, 2007).
  • Finfgeld-Connet’s Nursing Theory of Authentic Engagement provides tools to help prevent client aggressive behavior.

Click Icons

levels of aggressive behavior
Levels of aggressive behavior
  • Agitation- nervous excitement, excessive motor or verbal activity, irritability and uncooperativeness (Zeller & Rhoades 2010)
  • Aggression- a readiness to attack or confront
  • Assault
    • Simple assault- has ability and shows intent to injure, however threat would not require medical attention
    • Assault and battery- has the ability and shows intent to injure, and makes physical contact
    • Aggravated assault- Is separated from simple assault because there is an intent to seriously injury. This injury would require immediate medical attention.
assessment of agitation
Assessment of agitation
  • Experienced psychiatrist and psychiatric nurses have been shown to be able to accurately predict violent behavior.
  • “One study found that psychiatrist and psychiatric nurses correctly predicted violent behavior in 82% and 84% respectively, of newly admitted psychiatric patients”

(Zeller &Rhoades, 2010 p.420)

factors contributing to patient aggression
Factors contributing to patient aggression


  • These include individual patient variables such as age, gender and serious mental illness diagnosis
  • Suggested that young males are most prone to violence


  • Limited space or privacy, overcrowding, hospital shifts and raised temperatures
  • Staff experience, gender and training also have an impact on patient escalation
  • Handover periods and meal times are problematic


  • A combination of internal and external factors.

(Duxbury, 2002)

consequences of being exposed to inpatient unit aggression
Consequences of being exposed to Inpatient Unit aggression


  • Mental health second most violently victimized group

(Finfgeld-Connett, 2009)

  • 61% of nurses working in psychiatric settings had been physically assaulted in their career

(Zuzelo, Curran & Zeserman, 2012).

  • Interdependent relationship with staff burnout
  • Physical injuries
  • Emotional damage
consequences of being exposed to inpatient unit aggression1
Consequences of being exposed to Inpatient Unit aggression


Can result in seclusion or restraint

Psychological injuries resulting from activation of traumatic memories of pervious incidence of abuse and violence

(Bonner et al. 2002)

Physical injuries

Patient aggression may delay discharge or make placement more difficult

why it is so important to reduce aggression
Why it is so important to reduce aggression
  • Foster et al. (2007) write, “…daily exposure to swearing, threats and verbal abuse can cause lasting emotional damage to nursing staff” (Foster et al., 2007 p. 146).
  • This emphasizes the need for interventions that take place during the agitation phase of an incident rather than waiting for the verbal or physical aggression.
therapeutic interventions for aggression
Therapeutic interventions for aggression
  • Staff and patients had different beliefs about the causes of aggression
    • Patients-poor communication the number one precursor to aggression
    • Staff- patient illness the number one cause

(Duxbury &Wittington, 2002)

therapeutic interventions for aggression continued
Therapeutic interventions for aggression (Continued)
  • Effective de escalators are “open, honest, supportive, self-aware, coherent, non-judgmental and confident without appearing arrogant” (Price & Baker, 2012 p.312).
  • Successful management of aggression involves creativity and flexibility.
    • Tailored to specific patient needs (Price & Baker, 2012).
    • Embodied moment (Carlsson, Dahlberg & Drew, 2000).
therapeutic interventions for aggression continued1
Therapeutic interventions for aggression (Continued)
  • Early intervention is key in success.
  • Acting proportionately to the risk the patient is presenting(Bowers, McCullough &Timmons, 2003).
  • Soft, calm and gentle tone of voice and appearing calm (Ryan & Bowers, 2006)
  • Balance support and control (Delaney and Johnson, 2006)
  • “Stressed the importance of offering “face saving’ alternative to violence” (Gertz, 1980)
effectiveness of training programs
Effectiveness of training programs
  • There is a lack of research that identifies evidenced-based components of aggression management programs (AMP).
  • One review suggested that there is lack of consistency between the content covered between AMPs and that there is a lack of evidence surrounding the ability of these programs to change staff behavior (Farrell & Cubit, 2005).
authentic engagement methodological considerations
Authentic Engagement: methodological considerations
  • Meta-synthesis of 15 qualitative research articles for nursing management of aggression
  • Data included direct quotes, coding schemes and discussion
  • Authentic engagement was the core category around which the data was organized.
  • From this work, the author proposed a model of therapeutic responses to patient agitation.

(Finfgeld-Connet, 2009)

model of therapeutic and non therapeutic responses to patient aggression
Model of therapeutic and non therapeutic responses to patient aggression

(Finfgeld-Connet, 2009)

escalating of patient needs
Escalating of patient needs
  • Finfgeld-Connett asserts that aggressive episodes are preceded by an escalating series of stages where patient needs go unmet.
  • “Aggression was defined as any verbal or non verbal behavior that is threatening or actually results in harm to nursing personnel” (Finfgeld-Connet, 2009 p. 530)
  • As agitation increases the patient’s cognition decreases. This highlights the importance of acting early.
responses styles
Responses styles




The use of rigid rules and physical methods to control patient behavior.

Excessively task oriented


Nurse managers are authoritarian, but distant

Administrative abandonment

  • Intuitive
    • Patient's needs are immediately understood
    • Adaptable interventions match these needs
  • Emergent
    • Acting in a carefully measured way
    • Rely on education and training

(Finfgeld-Connet, 2009)

authentic engagement1
Authentic Engagement
  • Finfgeld-Connet found that authentic engagement was a core component of both the intuitive and emergent therapeutic response styles.
  • Becoming and staying genuinely connected to the patient
  • Keep communication lines open, while being steady and dependable
  • This person to person bond helps patients to regain control.

(Finfgeld-Connet, 2009)

situational context
Situational context
  • Aggression is a way to express feelings
    • Can serve as a catalyst to get things done, if the underlying need can be identified
  • Therapeutic interventions may fall outside the standardized rules and guidelines.
  • Appreciation for the patient “strange world”
  • Awareness of general

environment milieu, such as noise

levels and other patients on the


  • Click here for more information

(Finfgeld-Connet, 2009)

  • Approach a situation with recognition and reciprocity rather than a sense of self-importance or superiority.
  • Help patients maintain a sense of dignity by bargaining and negotiation.
  • Show respect and fair mindedness.
    • Letting patient know what you are doing ahead of time.

(Finfgeld-Connet, 2009)

limit setting
Limit setting
  • The importance of a well organized and predictable milieu.
    • Group schedule, rounds, favors
  • Clearly communicate that inner control is expected from the patient.
  • If the patient is unable to do this then external control will be necessary.
  • Matching the response to the level of dangerousness.

(Finfgeld-Connet, 2009)

team work
Team work
  • Effective multiple disciplinary teams plan ahead and talk openly about how to manage patients who have an increased potential for violence.
  • The team approach is also important for direct care staff.
  • Staff debriefings

(Finfgeld-Connet, 2009)

non therapeutic response
Non therapeutic response
  • Nurses feel demoralized and traumatized, which may become a self-perpetuating cycle
  • Patients feel mistreated and ignored.
    • Erodes patient trust that the hospital is a place where they can get help in a time of crisis (Duxbury, 2002)
  • Poor management of aggression and the Impact on the unit…
    • Burnout
    • Absenteeism
    • Reassignment
    • Resignation.
implementation components of authentic engagement
Implementation components of Authentic engagement
  • Situational context
    • Providing a low stimulation room
    • Providing pre packaged food to a paranoid patient
  • Reciprocity
    • Negotiating with patients who may want a restricted item, instead of saying no try to look for a way to balancing safety and patient preference
  • Limit setting
    • Clearly communicate that inner control is expected in the patient handbook
    • There are times when negotiation is not appropriate
  • Teamwork
    • Charge nurses attending 1700 Resident report
    • Finding the balance between reciprocity and limit setting is a team effort.
authentic engagement in practice
Authentic engagement in practice
  • Aligning with the patient who wanted to be discharged.
  • Negotiating with a patient refusing to have a photo taken
potential barriers
Potential Barriers
  • The belief that seclusion is the only way to keep the unit safe.
  • Disempowerment of nursing staff.
  • Difficult to describe the balance between limit setting and reciprocity in words.
  • Stressors in a nurse’s personal life
  • Incomprehensible underlying patient needs.
  • Authentic Engagement is one interventional model that can help nursing staff to intervene before a patient become aggressive.
  • There are many causes of aggression that are outside of our control. For example, the long wait times for court order medication. However, authentic engagement techniques provides a pathway to more effective care and a safer work environment.
  • Bonner, G., Lowe, T., Rawcliffe, D., & Wellman, N. (2002). Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. Journal of Psychiatric and Mental Health Nursing, 9(4), 465–473.
  • Bowers, L., Nijman, H., Simpson, A., & Jones, J. (2010). The relationship between leadership, teamworking, structure, burnout and attitude to patients on acute psychiatric wards. Social Psychiatry and Psychiatric Epidemiology, 46(2), 143–148. doi:10.1007/s00127-010-0180-8
  • Carlsson, G., Dahlberg, K., & Drew, N. (2000). Encountering violence and aggression in mental health nursing: A phenomenological study of tacit caring knowledge. Issues in Mental Health Nursing, 21(5), 533–545.
  • Delaney, K. R. (2009). Reducing Reactive Aggression by Lowering Coping Demands and Boosting Regulation: Five Key Staff Behaviors. Journal of Child and Adolescent Psychiatric Nursing, 22(4), 211–219. doi:10.1111/j.1744-6171.2009.00201.x
  • Duxbury, J. (2002). An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design. Journal of Psychiatric and Mental Health Nursing, 9(3), 325–337.
  • Duxbury, J., & Whittington, R. (2005). Causes and management of patient aggression and violence: staff and patient perspectives. Journal of Advanced Nursing, 50(5), 469–478.
  • Farrell, G., & Cubit, K. (2005). Nurses under threat: a comparison of content of 28 aggression management programs. International journal of mental health nursing, 14(1), 44–53.
  • Finfgeld-Connett, D. (2009). Model of Therapeutic and Non-Therapeutic Responses to Patient Aggression. Issues in Mental Health Nursing, 30(9), 530–537. doi:10.1080/01612840902722120
  • Gaskin, C. J., Elsom, S. J., & Happell, B. (2007). Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature. The British Journal of Psychiatry, 191(4), 298–303. doi:10.1192/bjp.bp.106.034538
  • Gertz, B. (1980). Training for prevention of assaultive behavior in a psychiatric hospital. Hospital and Community Psychiatry, 31, 628-630
  • May, B. (2010). Orlando’s nursing process theory in nursing practice. In M. R. Alligood & A. M. Torney (Eds.), Nursing theory: utlization & application (4th ed., pp. 337–357). Maryland Heights, MI: Mosby Elsevier.
  • Orlando, I. J. (1990). The dynamic nurse-patient relationship. New York, New York: National League for Nursing.
  • Price, O., & Baker, J. (2012). Key components of de-escalation techniques: A thematic synthesis. International Journal of Mental Health Nursing, 21(4), 310–319. doi:10.1111/j.1447-0349.2011.00793.x
  • SAMHSA Seclusion and Restraint - Statement of the Problem and SAMHSA’s Response. (n.d.). Retrieved September 8, 2012, from
  • Scanlan, J. N. (2009). Interventions To Reduce the Use of Seclusion and Restraint in Inpatient Psychiatric Settings: What We Know So Far a Review of the Literature. International Journal of Social Psychiatry, 56(4), 412–423. doi:10.1177/0020764009106630
  • Sullivan, A. M., Bezmen, J., Barron, C. T., Rivera, J., Curley-Casey, L., & Marino, D. (2005). Reducing Restraints: Alternatives to Restraints on an Inpatient Psychiatric Service/Utilizing Safe and Effective Methods to Evaluate and Treat the Violent Patient. Psychiatric Quarterly, 76(1), 51–65. doi:10.1007/s11089-005-5581-3
  • Zeller, S. L., & Rhoades, R. W. (2010). Systematic reviews of assessment measures and pharmacologic treatments for agitation. Clinical Therapeutics, 32(3), 403–425. doi:10.1016/j.clinthera.2010.03.006
  • Zuzelo, P. R., Curran, S. S., & Zeserman, M. A. (2012). Registered Nurses’ and Behavior Health Associates’ Responses to Violent Inpatient Interactions on Behavioral Health Units. Journal of the American Psychiatric Nurses Association, 18(2), 112-126.
picture references
Picture References

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role play practice session 30 minutes
Role play Practice session: 30 minutes
  • A patient demanding discharge
  • A patient refusing a search after coming back from a pass
  • Denial of a request for pain medication
  • A patient who is disorganized and psychotic
  • An intrusive patient

Role Play Instructions