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“Peace cannot be kept by force; it can only be achieved by understanding.”

–Albert Einstein


  • Identify patient variables

  • Describe environmental variables

  • Examine caregiver variables

  • Discuss patient and caregiver interaction variables

  • Cover other key risk factors

Aggression is defined as harsh physical or verbal actions with the intent to harm another physically or mentally (Townsend, 2015). Unchecked aggression can escalate to violence. Violence is an outburst of physical force that abuses, injures, or harms another individual or object (Sunderland, 1997).

There is robust evidence to suggest that aggression and violence are associated with several variables and risk factors. The variables are as follows:

  • Patient variables

  • Environmental variables

  • Caregiver risk factor (nursing and mental health staff) variables

  • Patient and caregiver interaction variables

It is critical to recognize aggression early so you can implement de-escalation techniques immediately. In this way it is possible to break the escalation chain and prevent violence (Distasio, 1994; Littrell & Littrell, 1998; Sunderland, 1997; Swanson, 2008). Knowing these variables is critical to ensuring this early recognition and for helping prevent patients from engaging in aggressive behaviors in all forms toward self and others. So too is identifying other key risk factors related to aggression and violence.

The Origins of Violence

History tells us that human life in centuries past was often nasty, violent, brutish, and short—but that might not have always been so. Demeo (1991) offers substantial proof that our ancestors were peaceful, nonviolent, and far more social than they are today. Demeo contends that climate change around 4000 BCE brought hardship, famine, starvation, and migrations. This forced humans into violent social patterns due to competition for scarce resources for basic survival. In other words, violence is not natural to the human species (Pinker, 2011) and does not arise from the human character. It is an aberrant form of behavior for the human species. Studies of primates also show that both violent behavior and peaceful behavior are learned (Copeland-Linder, Lambert, & Ialongo, 2013; Sapolsky, 2007).


There are several patient variables associated with aggression. These include observable behaviors such as agitation, restlessness, anger, and lack of organization. Other patient variables include the following (Barlow, Grenyer, & Ilkiw-Lavalle, 2000; Chou, Kaas, & Richie, 1996; Hamrin, Iennaco, & Olsen, 2009):

  • Mental instability

  • The presence of delusions

  • The presence of command hallucinations with violent content

  • Poor impulse control

  • Irritability

  • Attention-seeking behavior

  • An agitated state

  • Disorganized thought processes

Some patient variables are considered particularly high-risk. These include the following:

  • Carrying objects that could be used as weapons

  • Progressive psychomotor agitation such as pacing

  • Paranoid symptoms such as delusions of persecution

  • Substance intoxication or withdrawal from alcohol or drugs (Johnson & Delaney, 2007; Rueve & Welton, 2008)

  • Allergic reactions to medication or medication toxicity (Owen, Tarantello, Jones, ...

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