This article was published on April 6, 2022. It was last edited/ updated on April 26, 2022.
Agitation/ aggressiveness is a common issue that mental health clinicians have to deal with, most commonly in acute care situations (emergency room, inpatient psychiatric unit). Unfortunately, many or most of us have been in situations in which we were subjected to verbal aggression, threats, and, not rarely, even physical aggression. So, strategies for managing agitation and aggressiveness are extremely important for us to continue to master.
Unfortunately, research evidence on what works to prevent or de-escalate aggressive behavior among psychiatric patients is very limited (Gaynes et al., 2017). The clinical tips about the evaluation and management of agitation, aggressiveness, and violence in mental health settings that we provide in different articles on this website are based mainly on clinical experience and expert opinion.
On this page, we will discuss only strategies specific to improving physical safety. All the other measures that may be used to manage agitation/ aggressiveness in mental health settings will be discussed in other articles on this website. Please see Related Pages below.
Systemic measures to improve safety
Both hospitals and outpatient facilities need to have a range of safety measures in place. If the clinical facility where we work does not have these safety measures in place, maybe we could consider bringing this up with the powers-that-be to see whether some changes may be possible.
These systematic safety measures may include:
Security staff
– Presence of security staff in the clinical location—permanently (as in an emergency room) or when requested (as in an inpatient mental health unit).
– Security cameras that security staff can use to monitor the clinical locations for safety
Points of entry and exit
– Metal detectors at the entry to the facility—to check for weapons
– Locked doors and controlled entry to the facility
– Design of clinical spaces to allow easy exit in case of a threat.
Being able to seek help if needed
– Alarm (“panic”) buttons that clinicians can use to call for help. These panic buttons can be in very visible locations or in hidden locations where they may be pressed to call for help without the patient being aware that we have called for help.
– An agreed-upon code phrase that indicates that we need help. For example, if we pick up the phone and call the nurses’ station and say the code phrase, this tells the staff that we need help immediately due to an agitated/ aggressive patient. Using a code phrase that only the staff members will understand is a way to call for help without letting the patient know that we are doing so. Also, using such a phrase allows us to call for help without upsetting other patients (Guerrero and Mycyk, 2020).
Fixed or movable furniture?
There is disagreement about whether it is better to have furniture that is fixed to the floor or walls or to have furniture that is easily movable (Richmond et al., 2012).
– The argument in favor of fixed furniture is that an aggressive patient cannot pick those items of furniture up and throw them at others.
– The argument in favor of moveable furniture is that by moving such furniture out of the way in an emergency, both the patient and staff members can equally get flexible access to exits (Richmond et al., 2012). Also, movable furniture can quickly be removed from a clinical area if this is needed for creating a safer environment (Richmond et al., 2012).
In addition to these systemic measures, what are some things that we, as individual clinicians, may do to increase the degree of safety?
Here are two things we should do before we go to see a patient who is or may become agitated/ aggressive.
Before going to see an agitated/ aggressive patient
Dress for the occasion
When we have to interact with agitated or potentially aggressive patients, we should keep in mind that some things that we are wearing or carrying could be grabbed by an aggressive patient, leading to us being injured. Before approaching a patient who is or may be agitated/ aggressive, we should pause and think about whether or not it makes sense to remove these items. These items may include:
– Lanyards hanging around the neck to hold one’s ID card
– Stethoscopes around the neck
– Ties
– Necklaces
– Eyeglasses
– Large earrings
Safety in numbers
We shouldn’t try to be “heroes”.
– Before going into a room or other clinical area to speak with a patient who may be hostile, agitated, or aggressive, we should first make other staff members fully aware of what is going on.
– If the situation is one involving particularly high risk, we should ask for security personnel and/or clinical staff to be present nearby. For example, when I worked in a locked unit for patients who were involuntarily hospitalized, I would ask one of the staff members (who, by the way, had the odd title of “mental health technician”) to go with me. That person would typically stay a few feet behind me but was available to intervene if needed and, also, to call for more help as needed.
– If we anticipate that oral or injectable medication may be needed for the patient we are approaching, it might be a good idea to have that medication brought from the pharmacy and ready for possible administration.
Location, location, location!
– If needed and possible, we should speak to the patient in an open space rather than inside a room (e.g., the patient’s hospital room; an office that we are using). While privacy is important, safety is even more important.
– If we have no option but to speak to a patient who is angry or whose history suggests the possibility of aggressive behavior inside a room, we should position ourselves in a way that we can easily leave the situation if needed.
Warning! We should never put ourselves in a situation where we are inside a room with a potentially aggressive patient between us and the door.
– Also, the patient should not feel “cornered” either. In an ideal world, the room would have two exits—one that the patient can use and one for the clinician. Since this is not usually the case, it has been suggested that the patient and the clinician should sit in such a way that both can easily exit through the door.
Space between the patient and us
– We should stay some distance away from the patient. This is not only to increase our safety but also because patients may become more agitated if we are in their personal space. As a rough guide, a distance of 2 arm’s lengths has been suggested by several experts.
– Also, if an angry, agitated patient tells us to “get out of the way”, don’t even think of “standing your ground”; move out of the patient’s way immediately (Richmond et al., 2012).
Barrier methods
If possible, it is highly desirable to have some large object or barrier between us and an angry, hostile, and potentially aggressive patient.
– For example, if we are inside the nursing station, a counter may be between us and the patient.
– Or, if the situation allows, having a large heavy desk (one that cannot easily be picked up and thrown at us!) between us and the patient might be helpful. But, we should be behind a desk only if the exit is behind us. That is, the desk should not be between us and the exit.
Next, let’s discuss tips for verbal de-escalation of an agitated/ aggressive patient, which should usually be tried first. Please see the following article on this website:
Advanced tips for verbal de-escalation of agitated/ aggressive patients
Simple and Practical Medical Education thanks Ahmad Shobassy, MD for his valuable comments and suggested edits for this article.
Dr. Shobassy is a Clinical Assistant Professor of Psychiatry at the University of Michigan School of Medicine in Ann Arbor, Michigan, USA.
Related Pages
An overview of agitation and aggressiveness in mental health settings
Safety first! Preventing injury due to violence by patients
Advanced tips for verbal de-escalation of agitated/ aggressive patients
Autism spectrum disorder: Evaluation of irritability, agitation, aggressive behavior
When calm needs to be injected: Intramuscular and intravenous injections for agitation or aggressiveness
How to manage agitation in a pregnant woman
Autism spectrum disorder: Medications to treat irritability, agitation, or aggressive behavior
How to manage neuropsychiatric symptoms in persons with dementia
Key Points from the APA Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia
Citalopram for agitation in Alzheimer’s disease
Valproate for neuropsychiatric symptoms in dementia?
Carbamazepine for neuropsychiatric symptoms in persons with dementia?
Gabapentin for neuropsychiatric symptoms in persons with dementia?
Case: Agitation in a patient with Alzheimer’s disease
Should we use droperidol, which is available again?
L-methylfolate can sometimes precipitate irritability, agitation, insomnia, or aggressiveness
References
Gaynes BN, Brown CL, Lux LJ, Brownley KA, Van Dorn RA, Edlund MJ, Coker-Schwimmer E, Weber RP, Sheitman B, Zarzar T, Viswanathan M, Lohr KN. Preventing and De-escalating Aggressive Behavior Among Adult Psychiatric Patients: A Systematic Review of the Evidence. Psychiatr Serv. 2017 Aug 1;68(8):819-831. doi: 10.1176/appi.ps.201600314. Epub 2017 Apr 17. PMID: 28412887.
Guerrero P, Mycyk MB. Physical and Chemical Restraints (an Update). Emerg Med Clin North Am. 2020 May;38(2):437-451. doi: 10.1016/j.emc.2020.02.002. PMID: 32336335.
Hankin CS, Bronstone A, Koran LM. Agitation in the inpatient psychiatric setting: a review of clinical presentation, burden, and treatment. J Psychiatr Pract. 2011 May;17(3):170-85. doi: 10.1097/01.pra.0000398410.21374.7d. PMID: 21586995.
Petit JR. Management of the acutely violent patient. Psychiatr Clin North Am. 2005 Sep;28(3):701-11, 710. doi: 10.1016/j.psc.2005.05.011. PMID: 16122575.
Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012 Feb;13(1):17-25. doi: 10.5811/westjem.2011.9.6864. PMID: 22461917; PMCID: PMC3298202.
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