Nursing Communication Strategies to Reduce Aggressive Behaviour in Patients in ED

This research paper evaluates the effectiveness of nursing communication techniques in managing aggressive patients in the emergency department. The study reveals de-escalation and effective communication skills training as a widely used strategy to control violence in ED setting. The paper highlights the need for future research in areas such as direct patient-related outcomes and observation-based studies. The PICO question for the study is whether nursing communication techniques help in the reduction of violence and aggression in aggressive patients in the ED.

Running head: RESEARCH IN NURSING
Research in nursing
Name of the student:
Name of the University:
Author’s note

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Abstract:
As aggression and violence is a common occurrence in ED, the main aim of the research
paper was to conduct a literature review to understand whether nursing communication strategies
can reduce aggressive behaviour in patients in ED or not. By the use of specific search terms in
relation to the research question and searching for articles in CINAHL, PubMED and
PyschINFO database, the study revealed de-escalation and effective communication skills
training as a widely used strategy to control violence in ED setting. However, limitations and
gaps in research methodology such as lack of direct patient related outcomes and no observation
based studies points out to the need to conduct future research in these areas.

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Table of Contents
Research topic: Nursing management of aggressive patients in emergency department................3
Introduction (Background and research question):..........................................................................3
Problem analysis/literature review:.................................................................................................4
Objectives:.......................................................................................................................................5
Hypotheses:......................................................................................................................................5
Methodology and methods:.............................................................................................................5
Results:............................................................................................................................................6
Conclusion:......................................................................................................................................9
References:....................................................................................................................................10

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Research topic: Nursing management of aggressive patients in emergency department
Introduction (Background and research question):
Violence and aggression is a common occurrence in the emergency department (ED). It is
a high risk area that increases the likelihood of aggression and Tan, Lopez and Cleary (2015)
reports that majority of nurse experience physical injuries because of aggression in the ED.
There are a number of factors that increases risk of aggression in the ED. Firstly, many patient
related factors such as age, gender and exposure to alcohol and substance abuse is strongly
associated with violent behaviours. Secondly, environmental factors like poor staffing levels,
overcrowding, increased waiting time and poor security increases the chance of violence and
aggression in the ED. Another possible cause of high risk of violent episodes in the ED includes
exposure to lack of communication between patient and nursing staff and demanding behaviour
or attitude of patients and their family members (Angland, Dowling and Case 2014). Hence,
addressing these risk factors might be a solution to control aggressive events and manage
aggressive patients in the ED.
The review of study regarding nurse’s perception regarding violence in ED suggest that
nurses are psychological affected by the event as they experience physical injuries as well as
stress and burnout due to such experience. Nurses were found to be frustrated while delivering
patient care in overcrowded areas. In case of nurse-patient related factors, poor interpersonal
communication is identified as one of the factors contributing to violence in the ED. However,
Swain and Gale (2014) improving communication skills and implementing good communication
strategies can be an approach to avoid violence and manage aggressive patients in the ED.

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Hence, as an ED nurse, I think that having good communication can help to manage violent and
aggressive patient. Finding relevant literature related to the role of communication in
management of aggressive client may help to determine whether valid evidence exist regarding
the efficacy of this interventions in ED. In accordance with this assumption, the PICO question
for the study is as follows:
P-Aggressive patients in the ED
I- Nursing communication technniques
C-No communication strategies
O-reduction of aggression and violence
Question: ‘Does nursing communication techniques helps in the reduction of violence and
aggression in aggressive patients in the ED?
Problem analysis/literature review:
High incidence of violence and aggression in the ED is the main research problem and
the main goal of the research paper is to assess the role of therapeutic nursing communication
skills in managing aggressive patients coming to the ED. Literature review has been chosen as a
method for problem analysis as this would help to identify effect of various nursing
communication training programs and strategies on controlling aggression in the ED. It may help
to further understand the best method to address the research problem and implement evidence
based nursing intervention in the ED (Dang and Dearholt 2017). It may also facilitate developing
hospital specific protocols to address aggressive behaviour of patients in the ED.

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Objectives:
The key objectives of the literature review are as follows:
 To evaluate the effectiveness of nursing communication techniques in management of
aggressive clients in the ED
 To assess outcomes of nursing communication intervention in the ED
 To assess best communication techniques to control aggressiveness in patients
Hypotheses:
The research hypothesis is that therapeutic nursing communication technique can control
aggressive behaviour in patients visiting ED and it can increase their satisfaction with care.
Methodology and methods:
Search strategy: To retrieve articles related to the role of the nursing communications
techniques in dealing with aggressive patients in ED, articles have been retrieved from databases
like CINAHL, PubMed and PsychInfo. These are databases that published peer-reviewed articles
related to the field of health care, bioscience, nursing and mental health. Additional references
have also been taken from Google scholar. Based on the research question, the key words used
for conducting the search included ‘nursing communication techniques in ED’, ‘Nursing
communication training for managing aggressive patients, ‘nursing communication to manage
aggressive behaviour in patients and communication and prevention of aggressive behaviour in
ED.
Inclusion and exclusion criteria:
The search for research articles were guided by many inclusion and exclusion criteria:

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These were as follows:
 All research articles must evaluate must have nursing communication techniques as the
main intervention
 The main outcome for each study should be reduction of aggression in patients
 The research must be published within 2008 to 2018
 The research articles must be published in English language
 Articles reporting about other interventions other than communication intervention must
be excluded.
Data analysis:
The title and abstract of articles were analysed first to determine its relevance with the
research question. In the next phase, the full-text articles were reviewed against inclusion and
exclusion criteria to take decision regarding inclusion of the articles for literature review. Critical
analysis of articles has been done by evaluating credibility, reliability and applicability of
research findings.
Results:
Various research literature gave evidence regarding the effectiveness of nursing
communication techniques in controlling aggressive behaviour in patients visiting ED. In the
area of nursing communication related interventions, de-escalation technique has been found as
the first line of intervention to manage violent patient in the ED. De-escalation is the technique
to modify behaviour of aggressive patients by non-coercive verbal techniques. The main aspect
of de-escalation technique is that it helps health care staffs to understand and acknowledge
patient’s feeling. Validation of feelings and empathy helps to control aggressive behaviour of

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patient (Boulger, Werman and Pinto 2017). The review of literature suggest that de-escalation
technique can be the first strategy used by nurse to control violent situations and ensure that
patient’s cooperated during health care decision making and delivery.
Various studies reported use of de-escalation techniques in many aggression management
training program. Nau et al. (2010) reported about the effect of aggression management training
program on nursing student’s ability to manage aggressive patients. A pre-test and post-test
research design was used to assess nurse’s performance in de-escalation techniques. The
intervention consisted of 24 training sessions within one week, training nurses to learn rapport
building and problem solving skills. Verbal and non-verbal communication, body language and
non-provocative interventions were some content of the training session. De-escalating
behaviour of nursing students were tested by De-escalating Aggressive Behavior Scale (DABS).
The results findings revealed that training was effective in improving nursing student’s
performance in de-escalation techniques and managing aggressive patients. Although the
research shows the effectiveness of de-escalation training on nurse’s performance, however lack
of reliability and validity testing of the DABS scale limits the credibility and transferability of
the research findings. There is lack of reliable evidence on the effective of communication
techniques like de-escalation in the management of aggression. However, its application in other
health setting is found. Heckemann et al. (2015) gave evidence regarding the inclusion of-de-
escalation techniques in an aggression management training program in acute care setting. It
gave a contradictory finding as it revealed that aggression management training can increase
skills of nurse in dealing with aggressive patient, however it does not provides nurse the ability
to emotionally cope with patients. Hallett and Dicken (2015) also argues that future research

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should be done on the role of timing in de-escalation as this may enhance nurse’s ability to cope
with emotional aspects of aggression management too.
Tan, Lopez and Cleary (2015) recommended communication training for ED to control
aggression. Gerdtz et al. (2013) gave an insight into the outcome of a communication program
on prevention of aggression by means of a multi-site evaluation. Mixed method was used to
survey nurses and midwives who had taken part in the rapid training program. The training
focused on encouraging nurse to use de-escalation techniques and effective communication skills
to deal with aggressive patient. The evaluation of outcomes related to nurse’s attitude towards
aggression management revealed significant changes in the prevention and management of
aggression in patient. However, one crucial finding was that despite training, nurse found
environment as an important predictor of violence and aggressive behaviour in patients. Multi-
site evaluation is the strength of the study. However, relying on self-reported data instead of
direct observation is a limitation in relation to assessment of de-escalation performance. There is
a need to conduct further research to observe nurse’s skills and confidence in managing
aggressive patients.
Discussion:
Based on the review and analysis of research literature, communication skills training and
training programs related to de-escalation strategy has been identified as one major nursing
management strategy to cope with aggressive behaviour in ED. There is lack of research studies
that has evaluated communication related intervention in ED, however interventions related to
aggression management in mental health setting has been widely published. The outcomes
obtained literature review is considered significant as it shows the potential of communicating

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training in improving nurse’s performance in aggression management. However, the evidence
also shows some limits in training programs. For example perceptions related to the avoidance of
physical constraints and role of environmental factors has not been changed post the
interventions (Nau et al. 2010). This points out to the need to conduct large longitudinal studies
in emergency department to understanding the impact of effective communications skills on
reducing violent behaviours in patient presenting to the ED.
Conclusion:
To conclude, the paper summarized the outcomes from the literature review of nursing
communication interventions to manage aggressive patients in the ED. The research aimed to
address the problem of high prevalence of violence and aggression in the ED. The literature
review focused in evaluating the effectiveness of communication strategies on aggression
management as patient-staff factors was identified as one of the risk factor of aggression. The
review shows potential of communication training. However, more studies are needed in the
future to get validated findings that reports about reduction in violence episodes in patient post
intervention.

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References:
Angland, S., Dowling, M. and Casey, D., 2014. Nurses’ perceptions of the factors which cause
violence and aggression in the emergency department: a qualitative study. International
emergency nursing, 22(3), pp.134-139.
Boulger, C., Werman, H. and Pinto, A.J., 2017. Management of the Violent Patient in the
Emergency Department. Emergency Medicine Reports, 38(9).
Dang, D. and Dearholt, S.L., 2017. Johns Hopkins nursing evidence-based practice: Model and
guidelines. Sigma Theta Tau.
Gerdtz, M.F., Daniel, C., Dearie, V., Prematunga, R., Bamert, M. and Duxbury, J., 2013. The
outcome of a rapid training program on nurses’ attitudes regarding the prevention of aggression
in emergency departments: a multi-site evaluation. International journal of nursing
studies, 50(11), pp.1434-1445.
Hallett, N. and Dickens, G.L., 2015. De‐escalation: A survey of clinical staff in a secure mental
health inpatient service. International journal of mental health nursing, 24(4), pp.324-333.
Heckemann, B., Zeller, A., Hahn, S., Dassen, T., Schols, J.M.G.A. and Halfens, R.J.G., 2015.
The effect of aggression management training programmes for nursing staff and students
working in an acute hospital setting. A narrative review of current literature. Nurse education
today, 35(1), pp.212-219.

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Nau, J., Halfens, R., Needham, I. and Dassen, T., 2010. Student nurses’ de-escalation of patient
aggression: A pretest–posttest intervention study. International journal of nursing studies, 47(6),
pp.699-708.
Swain, N. and Gale, C., 2014. A communication skills intervention for community healthcare
workers reduces perceived patient aggression: A pretest-postest study. International Journal of
Nursing Studies, 51(9), pp.1241-1245.
Tan, M.F., Lopez, V. and Cleary, M., 2015. Nursing management of aggression in a S ingapore
emergency department: A qualitative study. Nursing & health sciences, 17(3), pp.307-312.