Strategies for CNA Instructors: Preparing Students to Care for Aggressive Clients
Author: Maureen Bonatch MSN, RN
As a CNA instructor, you probably use various methods and tools to teach caregiving skills to your students. Testable skills, like handwashing, have concrete steps to follow. You can review the skill and discuss what to do if something doesn’t go as planned, such as if the client’s blood pressure is abnormal.
While many CNA skill steps are predictable and can be practiced until they become second nature, it's crucial to prepare students for the unpredictable aspects of client care. One of these is the potential to care for agitated or aggressive clients, a situation they may encounter during their careers.
Caring for Agitated or Aggressive Clients
The NIH National Institute on Aging (NIA) describes an agitated client as restless, frustrated, and having verbal outbursts or physical resistance. If the client’s needs aren’t met, agitation could turn into aggression.
As instructors, we must teach our students not to take these behaviors personally. The client usually attempts these behaviors to communicate, especially with our dementia clients.
Expecting the Unexpected
Many healthcare workers have encountered agitated or aggressive clients. Your students may not encounter a client in this state during their clinical coursework, but they will most likely experience these behaviors during their careers.
The behavioral or psychological symptoms that can occur in the middle and later stages of dementia may last for years. Clients with dementia may become agitated or even aggressive for reasons we usually wouldn’t expect. A few common causes can include:
Too much stimulation or noise
Frustration with completing simple tasks
Having unfamiliar caregivers
Fatigue
Discomfort or pain
Constipation
A change in daily routine
However, agitated or aggressive behavior may be related to other conditions besides dementia. A few reasons a client may become agitated or aggressive can include:
Confusion (regardless of cause)
Various medical conditions, such as an infection, stroke, head trauma, UTI, or an electrolyte imbalance
Adverse reactions to prescribed narcotics
Changes in medications
A mental health condition or crisis
Substance use, such as drug or alcohol intoxication or withdrawal
Fear or feelings of helplessness
Family interactions
Preparing for Safe Client Care
Being unprepared for an agitated or aggressive client may result in injury to either the student or the client. Communication, critical thinking, and problem-solving skills may help students prepare for unexpected behaviors better.
A few things that will help students prepare to care for agitated or aggressive clients include the following:
Work on building confidence in providing care by examining personal biases.
Reflect on previous negative experiences and consider how you could have handled the situation differently.
Practice assertive communication skills to help handle unexpected behaviors.
Pay close attention to mental health concerns and ask questions about the client’s behavior during shift change.
Anticipate the client’s physical needs.
Examine the area within the client’s reach for items they could use as a weapon.
Addressing Behavioral Challenges
If a client’s behavior begins to escalate, your student will need to try to de-escalate the situation in a non-physical way. Without early intervention, the client may become increasingly agitated or even aggressive. Students need to recognize the signs of escalation to intervene and reduce the risk of a client becoming aggressive.
Recognize if a Client’s Behavior is Escalating
Signs of escalating behaviors can include:
Sudden change in behavior
Speaking in a loud voice or yelling
Pacing or restlessness
Avoiding or changing eye contact
Making threatening, angry, or confused comments
Increasing blood pressure and heart rate
Tense posture
Clenched fists
Kicking, hitting, or spitting
Throwing items
Removing their IV, catheters, or bandages
Attempting to leave the facility
De-escalating a Situation
Awareness and practicing de-escalation techniques can help your students prepare for unexpected situations.
To de-escalate a client, teach your students to be prepared to:
Maintain safety.
Remove other clients and visitors from the room.
Call for additional help. Use your phone, the emergency bell, or voice to call out.
Be aware of exits for your safety and to keep the client from leaving.
Check for anything that may be a safety risk. For example, the client could grab your ponytail. An aggressive client could also use equipment, such as pens, badges, lanyards, cords, sharps, or stethoscopes, as a weapon.
Minimize distractions or triggers.
Lower your voice and stay calm.
If you can, minimize bright lights and television, radio, or other loud noises that may provoke the client further.
Don’t reach for the client or try to hold them in any way.
Remove the client from public spaces and move to a safe environment to reduce stimuli.
Use active listening and communication skills.
Speak calmly and approach the client in a non-confrontational way that respects their personal space.
Use simple, easy-to-understand terms.
If possible, involve the client by providing choices to establish trust and a sense of control.
Be empathetic.
Don’t argue with the client or try to explain rules or policies now; instead, focus on what you can do to help in the situation.
Provide reassurance and a comforting presence, such as saying, “You seem upset. How can I help?”
Observe body language.
Be aware of your body language and ensure that your posture, facial expression, and tone of voice do not appear defensive.
Observe the client’s body language to help identify the underlying emotion.
Keeping Your Calm
It will take time and experience before your students become comfortable and competent in managing agitated and aggressive clients. Working with clients with unpredictable behaviors can be stressful, and it may be challenging to maintain the calm demeanor necessary for the situation.
Encourage your students to practice self-care and stress management techniques so they can look after themselves and their clients. A few ways to do that include:
Encourage students to practice meditation, mindfulness, or yoga to quiet their minds and increase their ability to focus.
Provide resources for stress management, such as the American Nurses Association (ANA) well-being initiative, and direct them to stress-relieving apps if they prefer to access resources on their phones.
Allow students to share their feelings regarding the experience with a debrief.
Debrief and Repeat
After students experience a volatile incident with a client, open up for discussion with a debrief. Clinical debriefings are a perfect setting to discuss unexpected client behaviors and situations that the students may have witnessed or have been a part of during their clinical time.
The debrief can allow your students to self-reflect about the experience and develop soft skills such as self-awareness, empathy, and critical thinking by asking questions such as:
How did the experience make them feel?
How would they describe what the client was experiencing?
What might they have done differently?
It may be helpful if your students could participate in a debriefing with their supervising nurse and the client. This experience would allow them to see the nurse’s role in reviewing alternative ways to manage stressors with the client.
Reducing the Risk
It is difficult to create and have the students role-play agitation and aggressive behaviors in the lab. Simulations may help by having the students interact with various personalities. The students decide how to communicate with dementia clients and how to react to various behaviors using problem-solving skills.
Taking advantage of the Caring4Cal initiative and using simulations may reduce the risks of unexpected client behaviors.
Caring4Cal is a program by the California Department of Health Care Access and Information (HCAI) to offer licensed or certified in-home or community care providers — and those interested in becoming an in-home care provider.
We’d love to hear from you!
What have you found is most effective when teaching your students about working with agitated or aggressive clients? Leave us a comment below.