Case Scenario 2In this case, a client named Wong Kai Long who is a 56 years old taxi driver. He is living with wife and son in a public house unit. He worked as a bus driver for 23 years and was being dismissed 1 year ago after involving in a bus traffic accident. For the information collected from Mr. Wong’s, Mr. Wong had mental problems since 3 months ago and elicited paranoid ideas for several times that staffs of previous bus company had ganged up to victimize him in the traffic accident. Moreover, his wife stated that he had a poor sleep problem, self-muttering and even scolded her and their son with foul language for no apparent reasons. In three days earlier, he scolded to air as if he was hearing voices and verbal threatened that he would kill those people who were against him in the traffic accident. On September 5, 2017, in the morning, Mr. Wong’s wife found that Mr. Wong drank 8 cans of beer. After that, she had a heated conflict with him when she attempted to stop him from further drinking beer. He fisted her initially and later attempted to attack her with a knife after discovering she called the police for help. She left home immediately and sustained no sharp injury. At 1430, under the assistance of police officers, he was escorted to Accident and Emergency Department (AED) of Princess Margaret Hospital accompanied by wife and ambulance officers. When he arrived AED, he was restrained on a stretcher and struggled vigorously. He was surrounded with the smell of alcohol, emotionally agitated and loud spoken with foul language. Constantly, he claimed that he was conspired by ex-bus company staff and expressed ideas to revenge along with yelling to air. Later, Mr. Wong was then admitted to a gazette admission ward in Kwai Chung Hospital under Mental Health Ordinance Section 31.IntroductionThreats of violence, active paranoid ideation, persecutory delusions, and history of violence of Mr. Wong were predicted to commit violence after admitted to the ward. In a study, violence was committed by 20% of people who pose a threat to kill in the previous 12 months (Warren, 2011). Violence by a patient poses serious risks to the patient himself, co-patients and staffs (Kettles, Woods & Collins, 2001). Mr. Wong was likely to commit serious violence to others. Nursing staffs always have high risk being assaulted by patients. In a recent survey of 762 registered nurses, 54.2% of them had verbal abuse by patients and 29.9% of them had physical abuse by patients (Speroni, Fitch, Dawson, Dugan, & Atherton, 2014).Especially in mental health settings, the rate of violence against mental health professionals is three times more than that in general health care settings (Hartley & Ridenour, 2011). Inside a forensic psychiatric setting, 70% of nursing staffs reported being assaulted in the previous year (Kelly, Subica, Fulginiti, Brekke, & Novaco, 2015). Violence usually occurs when a patient is detained for observation and treatment (Flannery, LeVitre, Rego, & Walker, 2011). Undoubtedly, violent incident is troublesome in the process to provide care (Kettles, Woods & Collins, 2001). It deviates the quality of care, patient integrity, and nursing staff safety. For short-term consequences, injuries to the head, open wounds and bruises might result to co-patients and nurses (Daffern, Ogloff & Howells, 2003). Moreover, violence among co-patient may worsen other patient’s mental state like anxiety and depression. Acutely, victims might suffer from post-trauma stress disorder with symptoms including sleep disturbance, social withdrawal and difficulty trusting others.In a long run, the aggressive behaviour of patients would impair psychological and social wellbeing of nurses (Fujishiro, Gee & De Castro, 2011). The impact of patient’s aggression toward nurses was likely to induce ripple effects for patient itself. Perhaps, the performance of nurse in implement health care and ward routine tasks could be disturbed (Bowers et al., 2011). Although many psychiatric nurses claimed that violence is foreseeable in their work nature, there is still a demand for prevention so as to ensure safety and delivery of therapeutic health care.Considering the high incidence and severe consequences of patient violent behaviors in psychiatric health settings, assessment and prevention of patient violence is critical as a security measure for overall patient and staff and important as a learning issue to expand knowledge (Underwood, 2017).Natures of ViolenceInpatient violence refers to a range of behaviors or actions by patients that abuse, threat, injury and hurt to objects, co-patients, and nursing staffs. (Nicholls, Brink, Greaves, Lussier & Verdun-Jones, 2009) There were three forms of inpatient violence which were verbal threats, physical aggression against objects and physical aggression against other people. 3.1 Verbal ThreatsVerbal threat means that patients expressed intimidatory statement to hurt others regardless of whether they actually intends to do so or having any concrete act. For example, patients may make loud noises, shout angrily, curse viciously, use foul language in anger, and make clear threats of violence toward others like ‘I’m going to kill you’. 3.2 Physical Aggression Against ObjectsPatients may express their aggression or throw a tantrum through throwing objects down, kicking furniture and marking the wall. Some patients may even break objects, smash windows and set fires. 3.3 Physical Aggression Against Other PeopleOutraged patients may initially make threatening gesture and swings at other people (Jalil, Huber, Sixsmith & Dickens, 2017). Afterward, they may grab their clothes, pull their hair and push them down. This kind of violence may cause mild physical injury to victims like bruises and sprain. For some hard attack, it may cause severe physical injury to victims like broken bones, deep lacerations, and internal injury. Violence Risk Assessment ToolsThe Dynamic Assessment of Situational Aggression (DASA) has been utilized in different mental health settings, such as psychiatric intensive care units, voluntary, and involuntary inpatient units (Griffith, Daffern, & Godber, 2013). The DASA assessment is a concise and organized instrument developed for assessment of impending aggressive behaviour within the next 24 hours. It consists of seven items which were negative attitudes, impulsivity, irritability, verbal threats, sensitive to perceived provocation, easily angered when requests are denied and unwillingness to follow instructions (Ogloff & Daffern, 2006). Additionally, these items aim to enhance predictive validity and assist in targeting patient for intervention so as to facilitate the prevention of violent behaviour (Ogloff & Daffern, 2006). There were studies showed that use of DASA was more precise in identifying forthcoming violence than the use of clinical judgment and experience only (Griffith, Daffern, & Godber, 2013). Some people argued that this standardized risk assessment tool is only effective in a forensic psychiatric settings (Underwood, 2017). However, in the crisis or emergency psychiatric settings, where urgent assessment and management are crucial in patient and staff security, risk assessment instrument may not be applicable (Sands, Elsom, Gerdtz & Khaw, 2012)Identification of Early Warning SignsAlertness of the different forms of violence is also essential to reduce and prevent violence incident (Tusaie & Fitzpatrick, 2012). Early identification and speedy assessment of potentially violent patients favor the interventions that can diminish violence incidents (Bowers et al., 2011). By assessing whether patient’s facial expression become tense and angry, movement becomes erratic or restlessness than usual and speech become thunderous with prolonged eye contact and glare, a nurse would recognize patient is hostile and aggressive or not. Besides, when patient elicited delusion or hallucinations with violent content, unobtrusive observation should be maintained to further investigate its frequency and intensity. Moreover, nurse should be alert and leave the scene once if a client started to express verbal threat with dilated pupils and increased breathing and heart rate. Furthermore, a nurse should pay special attention to patient’s behavior similar to that which preceded earlier disturbed or violent episodes. Lastly, a nurse must apply breakaway technique and call for help immediately when a patient attempted to block escape routes and use of physical violence. The identification of risk factors and early warning signs of violence during the initial assessment processes enhances the possibility for prevention (Sands, 2007). Nursing Management to prevent violence from Mr. Wong First, from the environment, no potential dangerous objects should be presented within any area that is reachable to Mr. Wong. Trigger, weapon, arousal, and target are four key elements leading to violence (MacKay, Paterson & Cassells, 2005). Removing any elements could cut down the risk of violent incident. That means the risk of violence incident would be greatly reduced when weapons around him were removed. Moreover, provide a safe, quiet and comfortable place for him is also helpful to reduce the risk of violence (Tusaie & Fitzpatrick, 2012). A clear code of conduct indicating acceptable and disruptive behaviors with reporting and consistent consequences will be explained to Mr. Wong. Second, from risk assessment, DASA would be utilized to review violence risk of Mr. Wong regularly. If Mr. Wong already shows signs of progressively agitated, de-escalation may be applied. He will be evacuated from the conflict zone immediately. A nurse will then set boundaries to his aggressive behaviour and negotiate with him to prevent further escalation of violence (Lowe et al. 2003). Third, from training to staff, violence management training should be prevailed by a proactive manner instead of a reactive manner (Tusaie & Fitzpatrick, 2012). That means nursing teachers should emphasize and educate students that prevention on violence is superior to violence management. A nurse should never be in the ward alone to control a furious patient. The violence management on psychiatric wards should be carried out by multidisciplinary healthcare professionals (Farrell & Cubit, 2005). ConclusionIt seems that the limitation of this assignment is not comprehensive and provide workflow management on violence outbreak. It is argued that even if preventive strategies are implemented, aggressive and violent incidents will still occur in most acute psychiatric wards (Winship 2006). However, remember that prevention beats a cure any day. The cost in making prevention on violence is more easily to provide than that in making intervention when violence outbreak. Risk management to prevent violence nowadays are commonly used to minimize, monitor, and control the possibility and negative consequences of unfortunate events. Simultaneously, it can maximize the quality of health care delivery.