Patients who get admitted in psychiatric units are often in immense crises or distress and may demonstrate maladaptive coping responses. These responses may end up into aggression or violence. Nurses spend most of their time with patients and are likely at risk for being the victims therefore, it is a crucial matter for nurses who are working in psychiatric units to be able to assess those patients who are at risk for aggression and intervene effectively. Mental health nurses are required to learn good interpersonal skills in order to make nursing happen. These crucial skills are the building blocks or, as Stevenson (2008, p.109) expresses them, “the nuts and bolts – the basic techniques and principles in which everyone engaging in clinical practice in mental health needs to be fluent”. With the purpose to communicate efficiently mental health nurses should make efforts towards being proficient in using the communication tools. Moreover, As Stevenson (2008, p.109) points out, “one size does not fit all” similarly mental health nurses should use communication skills differently with different patients in a mental health setting.

During the clinical in psychiatric ward I was asked by one of the registered nurse to accompany her in the patient's room who was just admitted in the ward. When we entered the room the nurse directly asked the patient to go and change her home clothes and wear hospital clothes. The patient become very aggressive and violent, while the nurse forcefully took the patient in washroom and threatened the patient to change her clothes otherwise she would call her husband and a male staff. After this comment by the nurse, the patient tried to hit the nurse and in result the nurse pushed the patient. I was observing all this, and was forced to stop the nurse and I asked her to be gentler rather than being rude to the patient. In response, she said “let me do whatever I am doing. She comes to psychiatric ward every second day to get admitted, I know better how to treat her”.

This unpleasant incident was the eye-opener for me and urged me to reflect on this incidence and the role of therapeutic communication as a health promoting practice and how this practice helps in dealing with the aggressive and violent patients. It is one of the most important skills which a nurse should develop in the therapeutic relationship with their clients. Although it is important in every nursing specialty, therapeutic communication is especially essential with the patients requiring psychiatric care, in order to apply nursing process effectively and perform successful intervention. In my paper ahead I will discuss about aggression among psychiatric patients, and using of verbal and non-verbal communication techniques as a mental health promoting practice. Moreover, I will discuss nursing process and finally I will be giving some recommendations.

Aggression is defined by the American Psychological Association as “behavior performed by one person (the aggressor) with the intent of harming another person (the victim) who is believed by the aggressor to be motivated to avoid that harm. 'Harm' includes direct physical harm (e.g., a punch to the jaw), direct psychological harm (e.g., verbal insults), and indirect harm (e.g., destroying the victim's property)” (APA 2000, p.163). A swiss study reported that 47% (n =114) experience threats and that 37% had been attacked one or more times in psychiatric nursing settings (Abderhalden, Needham, Dassen, Halfens et al., 2007). Violence result in frustration and stress among psychiatric nurses and thus they leave the job or may behave and communicate rude to patients. According to Nau, Dassen, Halfens, and Needham (2007) it is known that relating to verbal and physical aggression, staff experience feelings such as frustration, anger, feeling hurt, fear, resentment, helplessness, anxiety and irritation.

In order to bring a change in any practice it is essential to apply nursing process. In the situation mentioned above I was not directly involved to apply nursing process. However, there are strategies which should be used by nurses while encountering patients with aggression. A nursing assessment is an important step to predict patient's behavior. Although, one cannot accurately predict the upcoming situation, Stuart (2009) has given the hierarchy of aggressive and violent patient's behavior which can be a helpful tool in assessing the aggressive patient. He has also talked about early behavioral signs including motor agitation sings such as pacing, inability to sit still, clenching fists, increased respiration and catatonia, along with this; verbal clues which may or may not be present like verbal threats, intrusive demands, loud speech and paranoia. Assessment of the affect is also important which includes anger, irritability, extreme anxiety and euphoria. There may be the change in level of consciousness like confusion, disorientation, and memory impairment. However in this case nurse was unable to assess these behaviors and react promptly. After assessment, planning is a critical step in which nurse plans for interventions according to the situation and next comes the intervention phase.

There are several theories on aggression which includes psychoanalytical, behavioral, and cognitive theories. In accordance with the scenario mentioned above, this paper will discuss one of the cognitive theories. Boyd (2005) proposed that cognitive schema such as judgments, self-esteem, and expectations influence angry responses. If an aggressive patient perceived any situation as intentional, unprovoked, dangerous, and perceived offender as undesirable the recipient's reaction will be exaggerated. Similarly, in that particular case nurse was threatening the patient due to which patient's aggression was intensified and resulted in physical violence.

There are varieties of interventions which can be implemented to manage aggressive behavior in psychiatric settings in order to promote mental well being of patients. Stuart (2009) has given the continuum of nursing interventions in managing aggressive behavior. These interventions can be divided as preventive, anticipatory and containment strategies. Firstly, Preventive strategies includes patient education, self awareness and assertive training. Secondly, Anticipatory strategies include verbal and nonverbal communication, medications and behavioral changes. Thirdly, Milieu strategies include environmental changes. Moreover, crisis management techniques and containment strategies for instant restrain and seclusions are used as a last resort if despite all strategies, aggressive behavior persists. In addition, these interventions can also be divided as biological, social and psychological domain given by Boyd (2005) added as (Appendix A). However, this paper will only discuss about verbal and non verbal communication techniques which fall under psychological domain and anticipatory strategies.

Psychological interventions help patients to achieve control over their aggressive behaviors. In addition, these interventions also eradicate the need for chemical or mechanical restraints and communication strategies are significant intervention which can prevent a crisis situation. According to Boyd (2005) in recent years, interest has arisen in developing communication techniques that promote the expression of anger in non-destructive ways. Moreover, patients admitted in psychiatric wards re “being understood” as a result of the feelings of importance, worthiness, and empowerment (Gaillard, Shattell, & Thomas, 2009) .

According to a study done by Chen, Hwu, and Williams (2005) nurses indicated that most frequent methods which are used to manage aggressive patients are keeping patients in the isolation room, medications, and physical restraints. However, there are some more therapeutic communication skills which can be taken into account in managing aggressive behaviors. Aggressive patients often speak loudly and use bad language, therefore, it is important that nurse speaks in a calm and low voice and do not raise their voice in response because this may be perceived as competition and further set up impulsive circumstances. Moreover, nurse should avoid inappropriate smiling and laughing and should use simple, short and easy sentences. However, the case mentioned above clearly states that nurse shouted on the patient and in result physical violence occured. Secondly, acknowledging and validating patient's feelings and reassuring them that the staff is there to help them is one the good strategy which can reduce the level of agitation, because this gives permission to patients to communicate their feelings and concerns without interruption. Moreover, this can also reduce patient's feelings of isolation. Though, in the above mentioned case, nurse did not allow the patient to express her feelings nor acknowledged her will. Thirdly, the nurse should communicate with patients in such a way that encourages them to have control of their violent impulses. It helps in facilitating self control because patients may be willing to remove themselves from over stimulating environment. Conversely, in above mentioned case nurse threatened the patient which destructed the whole situation. In one of the study carried out by Shattell, Andes, and Thomas (2008) in psychiatric settings nurses experienced “caged-in by the Plexiglas-enclosed nursing station”, and patients experienced “caged-in by the locked doors of the unit”.

Nonverbal communication techniques of the nurse are also important in managing patient's aggressive behaviors. Stuart (2009) suggested some non verbal communication techniques, which include calm and relaxed posture with the nurse's head lower than the patient's head. It is less threatening to the patient and this communicates that nurse is willing to help patients. Conversely, hands on hips and nurses impending over the patients and arms across the chest are postures which communicate reluctance to help and emotional distance. Furthermore, nurses should avoid frightening, nervous and impulsive gestures. Therefore, nurse's hands should be kept open and out of pockets. Nurse's should also keep their eyes at the same level as those of patients or lower in order to allow patients to communicate from an equal level and patient would not feel inferior. Aggressive patients need four times more personal space than non-aggressive prone people. Interruption into personal space can be perceived as a dangerous and aggravating situation. Hence, Stuart (2009) recommended that nurses should remain at an angle to the patient so as to respect the patient's need for personal space. Therefore, it is important for the nurse to observe patient's behavior, for instance, clenched fists, tightening of facial muscles and moving away from the nurse can give clue that the patient is feeling threatened and may get aggressive so that we need to perform early interventions. However, in the above mentioned case, rather giving space to patient, the nurse was holding patient's hand and pushing her in the bathroom to change her clothes. Moreover, nurse's expressions were threatening to the patient which was showing unwillingness to help. Finally comes evaluation phase, where it is important that nurses must evaluate that the patients have maintained control over aggressive feeling, thoughts, behavior and actions. Lastly, before discontinuing the intervention let patient know that which behavior is acceptable and how to control over their aggression.

Along with the above mentioned interventions, one of the important strategies is that nurse should behave in an assertive manner. The midpoint of the continuum which runs from passive behavior to aggression is assertive behavior. According to Stuart (2009) “assertive behavior conveys a sense of self-awareness but also communicates respect for another person.” (p.574). Moreover, assertive people always speak clearly and conspicuously. Their gestures are non-threatening and they maintain appropriate eye-contact and respect personal space. Furthermore, assertiveness helps people in refusing an irrational request. However, they always give justification for a particular action. If I reflect back that situation the nurse was continuously asking the patient to wear hospital clothes without providing a sound rationale. Rather being assertive, nurse was behaving rudely to patient.

There was a research study done in Pakistan by Iqbal, Naqvi, and Siddiqui (2006) which aimed to study the inpatient violence in psychiatric patients and its management. The study concluded that out of 393 patients, in most of the cases (14%) physical restraints and seclusions are used to control an aggressive situation or sometimes it is done with the combination of chemical restraints like heloperidole and benzodiazepines which was estimated to be (44%). Though, there is a high risk of abuse attached with physical restraints, the authors have not given other methods to control aggressive and violent patients like communication skills.

In recommendation, the author would like to highlight that nurses working in the psychiatric ward should be competent in dealing with psychiatric patients. Nau, Dassen, Halfens, Needham (2007) affirmed that psychiatric ward nurses should be able to detect and remove causes of aggression, interpret aggressive situations correctly, de-escalate and cope with their own perceived stress. This can be only done If there are proper training programs arranged which increases awareness, enhance self confidence in dealing with aggressive patients rather ignoring or blaming them, and with strategies to cope in an appropriate manner via communication skills like assertiveness and empathy. Moreover, there should be a safety policy in the hospital for patients and staff who deal with aggressive patients and proper ordinance guidelines.

A therapeutic relationship for patients with mental illness needs thorough individual knowledge, which is attained only with time, understanding, and expertise (Shattell, Starr, & Thomas, 2007). Nurses are in the best position to bring about a transition in traditional forms of practices. To conclude the scenario of above mentioned patient, I think it was nurses responsibility to oblige by patients will, and the nurse should not have forced the patient to change her clothes or threaten her because this act of the nurse increased patient's aggression. Rather, she should have behaved in calm, soft, and non-judgmental manner. The nurse should also have heard the patient's concerns and given space to patient so as to avoid physical violence. However, communication is building block for the therapeutic relationship. Therefore, in order to intervene effectively in controlling patient's aggression the nurse should use proper verbal and non-verbal communication techniques.