Zero Tolerance Against Aggression and Violence in The Health Care Settings

This is the reflection of the article presented by Wand & Coulson (2006) on zero tolerance against aggression and violence in the health care settings. This article states that there is a zero tolerance policies in the Australian health care settings. This article mainly examine the current recommendations from the nursing and medical literature that is in relation with the “management of aggression and violence in the health care”. There are numerous reasons like waiting in the noisy environment, they are supposed to wait for protracted period, excessive pain and fear of unkown people that makes these kind of acts of aggression and violence common in the ED settings.

These numerous risk factors possess certain risks to the nursing and other health care professionals working in the ED settings. This article aims to present some “management strategies for aggression and violence” in the ED settings that are not based on zero tolerance but the use of de- escalation strategies to make them more convenient approaches. It states that zero tolerance policies are impractical and there is a requirement of practical protocols and procedures that would help in managing the issue of violence and aggression in the ED (Morphet et al., 2018).

This assessment is a reflection of the article that starts with the short summary of the article that covers the main points that this article presents. This will be followed by a description of the feelings in relation to the article that will state the feelings of a reader after learning new things from the article. This will be followed by a section of analysis where a specific issue from this article is chosen to be discussed that is new to the reader and different as compared to the previous learnings. This will be followed by outlining the changes in the understanding of the concept that is influenced by reading this article.

This article is on the “management of aggression and violence” that is faced by the nurses and other medical health professionals because this is the common practice in most of the emergency departments of the health care settings. I read the entire article and realised that the events that leads to the aggression and violence are prolonged waiting times and high stimulus environment such as noisy environments. I read that this article includes several recommendations for the implementation of interventions that will improve the response to aggression and violence in the ED.

I am shocked to read that this article states that zero tolerance policies are the last resort and before the implementation of such policies, the medical health professionals must know the way to deal with such circumstances. It states that zero tolerance policy is an impractical approach and the health care professionals especially the clinicians must have the capability to initially use comprehensive understanding and the willingness of listen and to negotiate appropriately to solve the problem. They must also have a proficiency in the early recognition of the reasons and the constant pattern of “aggression and violence in the emergency department” (Schablon et al., 2018). I have gained a lot of knowledge in relation to the de- escalation strategies that this article presents as the tool for fighting against aggression and violence in the emergency department. It states that the practical and continuous education is required through the local protocols.

I learnt that the clinicians hold the power to make appropriate decisions when they face a situation where the patient becomes highly aggressive and starts to misbehave with them despite having policies and guidelines in place because ultimately they have to deal with the situation in which they are being criticized. The factors presented by this study are true to my knowledge and the risk factors that are associated with aggression and violence in the ED also includes limited spaces and provisions for privacy, high temperature and crowded waiting rooms (Spencer, Johnson & Smith, 2018).

The people that are relatives and the patients are under high stressful situation in the ED due to the tension and stress that is related to the patient admitted in ED like their critical illness and the complications of iatrogenic issues. It was not a different feeling when I read that the greatest risk of aggression is in the males who have significant substance issues.

The article also states that many measures have been taken in past for the “management of aggression and violence” and zero tolerance policy is also one of the measures taken in past for the management of this issue (Vieta et al., 2017). The zero tolerance can be interpreted by different people in respect to their own perception but the main perception that may lead to an interpretation is that it may be considered as the step by government that interferes into the clinician’s right to make judgements of meaning and advantages of individual patient behavior.

I was amazed after reading this because I never thought of zero tolerance policy to be interpreted in this manner because according to me it is for the benefit of the clinicians and it is not about incursion into their decision making right. The clinicians plays the most important role in the assessment of aggression and violence risk in the people. They are also the predictors that correctly predict the wrong behavior in the people as per their actions and mental health (Hallett & Dickens, 2017). The people who have committed some offences in past are at highest risk of developing such behavior as per the clinicians.

My previous learning states that zero tolerance policy always has a positive meaning which states that no one will ever tolerate any aggression and violence against the clinicians and other medical health professionals (Hassankhani & Soheili, 2017). As per my existing knowledge the zero policy is about positive strategy for the medical health professionals but this article changed my learning. I had the knowledge of various risk assessment tools that helped the clinicians in assessing the risk of violent and aggressive behavior in the patients (Price & Baker, 2012).

This study gives more detailed knowledge on the success and failures of the risk assessment tools used by the clinicians and also on their power of predicting the specific behavior in their patients. After reading this article, I have realized that I had limited knowledge of the zero tolerance policy that many of the health care institutions across the globe has and its meaning upon the implementation of this policy (Considine et al., 2017). This article created a lot of curiosity in me as I wanted to research on this topic where I wanted to find the comparison of zero tolerance policy and other de- escalation strategies that allows the clinicians in dealing with such patients on their own depending on the circumstances.

This article presents the de- escalation strategies for the clinicians that are contrary to the notion of zero tolerance and also some early recognition techniques that shows positive results when used by the clinicians. The de- escalation strategy is the psychological technique in which the clinician talks to the person to calm a distressed individual and redirect them to highly comfortable emotional room (Spencer & Johnson, 2016). This psychological technique has various components that starts with the “assessment of immediate situation and the implementation of verbal and non- verbal communication” ways that aims to develop problem solving skills.

The clinicians must have some specific skills to be able to use de- escalation technique and the clinicians must also early recognize the risk of development of this behaviour. The literature states that the violence erupts suddenly in rare cases therefore it is possible for the clinicians to early detect such behavior development in an individual (Ramacciati et al., 2016). It also states that the proficiency required for the implementation of de- escalation techniques and the early detection of the development of this behavior can be best developed through continuous education and training.

All the health care settings must have policies and guidelines in place that formalize the protocols that will help in dealing with the abusive patients. According to Spencer & Johnson (2016) the use of de- escalation techniques must be the first resort intervention measure that must be defused to minimize the potential for harm that is caused by an escalating episodes of aggression. This talk- down approach is helpful in talking with an agitated patient in a manner that the violence and aggression can be averted that leads to the person regaining the sense of calm. The use of de- escalation techniques is wide in the health care settings but there is a scarcity of the literature on the efficacy of this psychological technique.

This talk- down technique is not for the long term benefits but has high potential in ameliorating the immediate aggressive behavior of the person. This technique is based on inhibiting the progression of the escalation phase of “The Assault cycle” (Richmond et al., 2012). There are some special skills required by the clinicians to arrest the progression of the escalation phase of “The Assault Cycle” like communication skills, awareness of the emotional and personal space of an individual and so on. There are many techniques that oppose the use of de- escalation approach but the key recommendation by most of the articles for the “management of aggression and violence” in the ED is based on de- escalation approach only. This technique is recommended by the variety of guidelines like The American Psychological Association (APA) and NICE but still there is less research on the effectiveness of this method as compared to other methods.

According to Rao, Ley- Yeung & Jayaram (2012) this method is highly effective because it is a preventative measure that aims to early stop the prevention of deterioration of the condition of the patient. This is the primary management technique and the secondary management techniques like seclusion and physical interventions must only be used when the application of de- escalation technique fails. The de- escalation technique is most favorable to be used in the emergency department to control the aggressive and violent behavior (Searby, Snipe & Maude, 2019). Two of the most important skills of nursing that are most applicable in implementing the de- escalation techniques are therapeutic engagement and the second is establishment of the rapport with the patients. This psychological technique allows the therapeutic use of nurses’ personality as it allows the nurses to interact therapeutically with the patients (Sutton, Wilson, Van Kessel & Vanderpyl, 2013).

It is up to the clinicians and they should have the power to decide the manner in which they will act in a particular situation. This intervention of de- escalation can be given through verbal communication methods, setting few restrictions for the patients so that they can follow them, using risk assessment tools such as prevention and recognition methods and also some environmental controls like reducing noise and light as it helps in managing the aggression in the patients (Callow et al., 2016). The primary outcomes includes improvement in the aggression to an important extent and improvement in the incidences that led to the violation.

This knowledge in the article that is contrary to the notion of zero tolerance has influenced me in a manner that I too support the use of this technique of de- escalation and early recognition as better primary outcomes are associated with this technique (Waseem et al., 2017). My previous knowledge did not allow me to research on the technique of de- escalation but looking at the evidences I have learnt that this is one of the highly effective ways for the management of aggression and violence towards the health care professionals.

The mental health care is very important for such patients so it is important that the power of handling such cases should be in the hands of clinicians only. Some of the positive outcomes that are related to de- escalation are prevention of the violent behavior, enabling the patients to manage their own behavior, maintenance of staff and patient safety, reduction in the anger levels and frustration levels of the patient and avoiding the use of restraint (Du et al., 2017). The literature suggests that few skills and qualities that are of paramount importance in the clinicians to facilitate the psychological technique of de- escalation are skilled communication, negotiation, non- confrontation and relationship- establishing.

This article has played an important role in shaping my knowledge of the practices that are used for managing the aggression and violent behavior of the patients that have a direct impact on causing unsafety to the patients and staff members in the emergency department. Many changes in my understanding of the topic has taken place like I have learnt the real meaning of zero tolerance policy and it being considered as impractical approach. It should be the last resort and the clinicians must be given the power to handle the situation using their own decision making power and skills because they are the ones that are capable enough to use risk assessment tools and predict the risky behavior of the patients. Such volatile situations can be best handled using de- escalation and early recognition approaches as these approaches aim to prevent the situation (Baig et al., 2018).

I used to support the zero- tolerance policy in the health care settings but this new learning and deep research on the de- escalation strategy along with the early recognition strategy has enhanced my knowledge. This will also help me in shaping my nursing professional practice. I am more confident on establishing therapeutic relationship with the patients because the best of mental health care can be taken when the patient trust the medical mental health professionals (Elnazer & Agrawal, 2017). I have learnt the importance of establishment of the therapeutic relationship in not helping the patient to recover fast but also its importance in helping the patient to de- escalate the development of aggressive and violent behavior. As a nurse, it is our responsibility to provide protection to the patients admitted in the health care setting so de- escalation of the aggressive and violent behaviors in the patients helps in providing adequate security to the emergency department.

The provision of the security to the patients help in delivering the safe and high quality of nursing care to the patients (Bilgin & Ozaslan, 2018). The assessment and observation of such behavior in the patients helps the health care professionals in controlling the high risk to the patients. The nursing professional requires working with the patients in which every patient receives safe nursing care where high quality of practice is required. The clear articulated policy, protocol and the guidelines must always be in place and they serve as an important resource of the information among the health care professionals (Price, Baker, Bee & Lovell, 2015).

The method by which the health care professionals can be educated on providing de- escalation strategy that would help in protecting the patients of the ED from aggression and violence that some of the mental health patients do is the continuous education and training sessions. The main aim of these training sessions is to educate the health care professionals to employ inter- personal strategy that are automatic and requires huge amount of cognitive input by them. They are educated to facilitate de- escalation technique in contrast to zero- tolerance policies or the physical control techniques like sedation, isolation, restraint and so on. This also trains the health care professionals in allowing the development of more confidence and also makes them comfortable in managing the aggression and violence in the ED.

They teach them appropriate methods of intervention that help in achieving better patient outcomes and is a holistic approach (Oyelade, Smith & Jarvis, 2017). This technique od de- escalation is also effective and more convenient because the nurses find these protocols and guidelines difficult to access when incidences related to aggression and violence takes place. The nurses also play an important role in making other people aware of these unwanted behavior by some patients that may use aggression and violence to threaten people and the staff members of the health care settings.

The principle of early recognition is also important and this requires advanced level of verbal and non- verbal interpersonal skills. the nursing professionals must always acknowledge the patient’s feelings and concerns so that they feel comfortable in discussing their issues with them. The reassurance from the nurses help the patients in learning about their own concerns and their status of mental health and well- being. Thus, the nurses plays very important role in managing the violent and aggression that takes place in ED in the health care settings.

It can be concluded that this article served as a great learning for the nurses as this will assist them in managing the aggression and violence in the health care settings. The de- escalation approach that is in contrast with the zero tolerance policy is more effective and can be more conveniently used by the medical health professionals. This approach helps in learning the behavior of the individual as they can make use of the assessment tools that helps the clinicians in learning the mental health status of the patients thus they can easily and more effectively predict the development of aggressive and violent behaviors in the patient. The zero tolerance approach is known to incurs with the power making skill of the clinicians as it does not allow the clinicians to handle the situation using their communication skills and other competency skills.

The two most important nursing skills that are require in the de- escalation approach are establishing therapeutic relationship with the patients and establishing a good rapport with them. These assists in setting a good relationship with the patient that helps in facilitating this talk approach. This talk approach that is de- escalation is more effective than the physical control approaches like sedation, isolation and restraint because this approach is associated with more positive patient outcomes. This is best provided to the health care professionals through continuous education and training in which they are trained to manage the aggression and violence in the health care settings using de- escalation approach which will help them in providing adequate security to the other patients admitted in the health care settings.


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Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Mental Health Nursing Assignment Help

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