Working within the aged care sector can be rewarding, but it requires an immense level of compassion, diplomacy and tact. With many residents in aged care facilities suffering from illnesses such as delirium, depression, and dementia, their mental states are likely to be changeable and unstable due to the results of drugs, therapy, pain, and indeed the illness itself. As a result, aggressive behaviour is not uncommon.

As an aged care nurse, handling the emotional, physical and mental demands of each resident can be challenging. However it can be made easier by taking the time to get to know the individual and by forming a bond with them. By having an understanding of what makes them “tick” and an idea of what can ultimately trigger aggressive behaviour in that individual, then it is possible to recognise the signs early enough before problems occur. There are times, however when aggression occurs without warning so what should you do?

Coming face to face with aggression

If you find yourself involved with a resident who has turned aggressive then it is important to deal with the situation in a non-confrontational fashion (Poole's Algorithm p.4 ). Remain calm and behave in a friendly and empathic manner.  If you were doing something that may have been the catalyst for the aggressive behaviour such as taking their blood pressure or encouraging them to eat up their food, then immediately stop and keep your distance from them. Remove anything or indeed anyone which could be antagonising the issue. This could be other people, equipment or even noise. Remember they may be feeling very frightened and confused.

Speak to them using whatever name they like to be called by and don't argue or disagree with them. Show empathy by making it clear that you understand that they are upset and ask if you can help them. Be sure to listen closely to their reply and follow up any accusations or claims. Also think about whether to contact a member of their family and ask if they would like to make a telephone call. At this stage your aim is to try and deal with the immediate need of the resident without risking anyone's safety, since sense and reason will not return until this need is met.

Should you think an element of dementia may be involved then another course of action may be to change their focus onto something different. This could  mean handing over to someone else, offering them something different to eat or drink, walking away and returning with an upbeat smiley approach, suggesting a walk, or doing a different activity.

What to do if the behaviour persists

If the aggressive behaviour persists then you must seek help from senior staff, the medical officer and/or the family. Restraint in the form of medication or even mechanical restraint may be necessary in the short term. If there appears to be a real threat of danger then don't hesitate to call on your facility's security staff.

After the event

Rather than brushing aside this kind of behaviour as “just one of those things which happens” each and every incident of resident aggressive behaviour should be reported and investigated. All efforts should be made to understand the cause of the aggressive outburst and consideration given to minimising the risk of it happening again. This can done by reviewing their medication and/or pain management and also by working in pairs to minimise risk

Using a behaviour chart can be useful in tracking events leading up to the incident and can help to understand what may have caused it. This should include events leading up to the disturbance, what behaviour occurred, and how did others respond. Try and look at actions which took place before the incident such as you taking hold of Mr X's arm to take his blood pressure or another nurse raising her voice to wake him. See if you can discover the event which triggered the aggressive response as well as any other patterns of behaviour which could have played a part in the incident. Sometimes it's a result of frustration, other times fatigue. It could be down to a loss of hearing or bad vision, or simply a change of routine which the resident is unfamiliar with. Alternatively, they could be trying to tell you that they feel unwell or are simply bored.

Support each other

Finally as a manager, always arrange a time to talk to the nurses involved about their part in the proceedings and how they felt. Being involved in aggression is frightening for anybody and staff morale will definitely be raised once everyone sees that their emotional needs are considered and supported too.

References: Poole's Algorithm: Nursing Management Of Disturbed Behaviour in Aged Care Facilities by Julia Poole, Clinical Nurse Consultant, Department of Aged Care and Rehabilitation Medicine, Royal North Shore Hospital & Community Health Services, St. Leonards, NSW 2065
First printed 2000