GT Wijiastuti.
Hargiana | Application of De-Escalation Nursing InterventionsA.
Journal Educational of Nursing (JEN) Vol.
7 No.
1 Ae January Ae June 2024.
page 23-32 p-ISSN: 2655-2418.
e-ISSN: 2655-7630 journal homepage: https://ejournal.
DOI : 10.
37430/jen.
Article history:
Received: November 23th, 2023 Revised: November 29th, 2023 Accepted: December 29th, 2023 Application of De-Escalation Nursing Interventions with Emotional Experience Writing in Clients With Risk of Violent Behavior Galuh Tyas Wijiastuti1.
Giur Hargiana2 Ilmu Keperawatan Universitas Indonesia Jalan Profesor Dr.
Bahder Djohan.
Depok.
Jawa Barat Kode Pos 16424.
Indonesia E-mail: galuh.
tyas@ui.
Abstract The risk of violent behavior in nursing diagnosis is usually arise because of aggressiveness which is often associated with people with schizophrenia.
Affects and emotions in schizophrenic patients affect behaviors such as hand and body movements, facial expressions, and tone of voice that can be seen clearly when a person expresses and experiences feelings and emotions.
This study aims to analyze the effectiveness of applying de-escalation with expressive writing exercises in reducing signs and symptoms of risk of violent behavior.
The client is a 23-year-old woman with schizophrenia.
The therapy given is generalist nurse intevention and by applying Emotional Experience Writing as a form of de- escalation.
Emotional Experience Writing is part of expressive therapy that is used to help recovery and improve mental health.
Emotional Experience Writing is one of the intervention techniques developed from expressive writing therapy techniques used in counseling, psychotherapy, and rehabilitation.
The procedure for implementing emotional experience writing is also based on expressive writing, which is oriented towards disclosing the emotional experiences experienced.
The evaluation was carried out using an evaluation sheet for signs and symptoms of risk of violent behavior developed by the Department of Psychiatric Nursing.
Faculty of Nursing.
University of Indonesia.
The results of this study indicate that the application of Emotional Experience Writing is effective in reducing the signs and symptoms in client with the risk of violent behavior.
Emotional Experience Writing exercises are recommended to be an alternative de-escalation intervention, especially for clients with the risk of violent behavior.
Keywords: Emotional Experience Writing.
Risk of Violent Behavior.
Schizophrenia.
Nursing Interventions Introduction Indonesia experienced an increase in mental illness cases in 2018, with approximately 450,000 severe mental This increase can be seen based on the prevalence of households with Patients with mental disorders (ODGJ) in Indonesia.
The number increased to 7 per thousand households, meaning that every 1,000 households have 7 households with ODGJ (Data and Information Center of the Indonesian Ministry of Health, 2.
The top three types of mental illness in 2017 in Indonesia were depressive disorders, anxiety disorders, and schizophrenia (Ministry of Health Information and Data Center, 2.
2019, the number of people with Journal Educational of Nursing (JEN) Vol.
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GT Wijiastuti.
Hargiana | Application of De-Escalation Nursing InterventionsA.
schizophrenia in Indonesia reached 829,735 people (Institute for Health Metrics and Evaluation, 2.
Schizophrenia is a serious mental disorder that affects the way a person thinks, feels, acts and behaves (Videback.
People with schizophrenia experience decreased ability to think, behave and relate to others due to cognitive impairment (Stuart.
Keliat, & Pasaribu.
Therefore, schizophrenia can cause individuals to commit violent acts that harm themselves, others, and the environment (Pardede.
Siregar, & Hulu, 2.
Extreme and sudden changes in behavior pose a risk of violent behavior.
Several studies have shown an association between schizophrenia and the risk of violent behavior.
People with schizophrenia are five times more likely to commit violent acts than the general population (Sari & Dwidiyanti, 2.
Several studies have been conducted to assess the risk of violent behavior and schizophrenia, in 18,423 people at high risk of violent behavior.
A systematic review analyzing 20 articles found that the rate of violent behavior in schizophrenia patients was 13.
2%, while the rate of violent behavior in the general population was 5.
3% (Fazel et al.
, 2.
The results of this study support the statement that people with schizophrenia may be at risk of violent behavior.
Violent behavior is the actualization of feelings of anger by committing actions that harm oneself, others, and the Violent behavior can be physical or verbal against oneself, others, or an object (Keliat & Akemat, 2.
Common symptoms of violent behavior include sharp eyes, clenched hands, highpitched voice, tense face, and broken objects (Keliat & Akemat, 2.
The more signs, the higher the risk of violent behavior (Fahrizal.
Mustikasari, & Daulima, 2.
According to Indonesian national data in 2017, the risk of violent behavior is around 0.
8 per 10,000 people (Pardede et al.
, 2.
Based on this, interventions are needed to reduce the incidence of violent behavior.
Nurse interventions for patients with nursing problems at risk of violent behavior help patients understand the causes, signs and symptoms of the risk of violent behavior, as well as the consequences of violent behavior and teach how to overcome the risk of violent behavior by controlling their emotions.
Strategies to reduce violent behavior Psychiatric drugs used are antipsychotics, both typical, atypical, and a combination of typical and atypical (Rueve & Welton, 2008.
Volavka, 2.
Nursing psychotherapy actions are carried out in the form of generalist nursing actions and specialist nursing actions for clients with violent behavior (Keliat & Akemat, 2.
Nursing actions to reduce violent behavior are by taking deep breaths, hitting mattresses and pillows, gymnastics, speaking well such as expressing feelings of anger, and refusing well, deescalating, namely expressing feelings of anger verbally or in writing, performing worship activities such as prayer, prayer, other worship activities and obeying taking medication properly (Keliat, et al.
, 2.
The author is interested in combining existing nursing actions with deescalation actions with emotional experience writing.
Emotional Experience Writing can be considered as a subset of expressive writing, but it focuses on the release of emotions based on the emotional experiences one has lived through (Sanjani et al.
, 2.
Writing about stressful experiences and emotions experienced can help to manage emotions (Nurmaliza, 2.
Expressive Journal Educational of Nursing (JEN) Vol.
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writing is part of expressive therapy used to help recovery and improve mental health (Kurniawan & Kumolohadi.
In a study, it was found that expressive writing is quite effective as a medium for expressing pent-up feelings or increasing to improve self-disclosure abilities in patients with hebephrenic schizophrenia (Rohmah & Praktikto.
Not only in patients with hebephrenic schizophrenia, other studies have also been conducted on paranoid schizophrenia patients with the same results, namely expressive writing can be a medium for someone to express the feelings or emotions they experience (Nisaa.
Masruroh, & Praktikto, 2.
Providing therapeutic interventions Writing emotional experiences can be used to help clients with violent behavior towards the ability to control emotions in clients Violent Behavior (Damaiyanti and Purwanti, 2.
hopes and desires, entering the closing session the patient is asked to reflect on what has been written.
The procedure is carried out in an open space with a writing table and chair by maintaining the client's privacy in The comfortable for the client to do the writing process.
The tools used for writing are writing tools in the form of a puplen and HVS paper and a walking Method This study was conducted in the Utari room of Dr.
Marzoeki Mahdi Mental Hospital Bogor (RSJMM) on Mrs.
A .
years ol.
with a diagnosis of Schizophrenia.
The evaluation was carried out using an evaluation sheet of signs and symptoms of risk of violent behavior developed by the Department of Mental Nursing.
Faculty of Nursing Science.
University of Indonesia.
The implementation of the emotional experience writing procedure was carried out in 5 sessions for five consecutive days with a length of time for each session of approximately 15-30 minutes.
Each meeting is carried out opening, providing explanations and motivating clients to continue to follow the procedure until the end, entering the writing session the client is asked to write with the theme Childhood experience, love me, listen to me, goodbye stress, goodbye angry, goodbye worry, my Figure 1.
Measurement Results of Signs and Symptoms of Violent Behavior Generalist Intervention Results Generalist Nursing Interventions Generalist nursing on Mrs.
A began on September 26, 2023 until September 27, 2023.
During the two days of implementing the intervention.
Mrs.
was evaluated for signs of symptoms and the ability to control violent behavior.
Cognitive Affective Physiolog Behaviour Pre-Test Social Post-Test Results Measurement of signs and symptoms of violent behavior Mrs.
experienced a decrease in several aspects after two days of generalist intervention.
Aspects that experienced a decrease in the value of symptomatic signs were cognitive aspects (Saying hate / upset with someone.
Being easily offende.
, affective .
nstable affection and unnatural or excessive euphori.
, physiological (Feeling palpitation.
Journal Educational of Nursing (JEN) Vol.
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Hargiana | Application of De-Escalation Nursing InterventionsA.
ike yelling, dominating the conversation, high tone of voic.
In the social aspect, there is no change in the value of symptomatic signs.
Figure 3.
Measurement Results of Signs and Symptoms of Violent Behavior Before and After De-escalation Exercise with Emotional Experience Writing.
Figure 2 Measurement Results of Ability to Control Violent Behavior Generalist Intervention Pre-Test Pre-Test Cognitive Affective Physiolog Behavior Pre-Test Post-Test Post-Test Social Post-Test The results of measuring signs and symptoms were carried out before the writing intervention was given.
The measurement results after being given the Emotional Experience Writing deescalation exercise intervention for five days obtained a score of 5.
The measurement results show a significant decrease in the signs and symptoms felt by the client Mrs.
The aspects that have decreased are cognitive aspects .
Affective .
nnatural or excessive euphori.
, physiological, behavioral .
ngry expressions when talking about other.
In the social aspect .
ominating the conversation, high tone of voic.
there are assessors who show that there are still signs of natural The results of measuring the client's ability to control violent behavior show an increase.
Before applying the generalist intervention the client applied 6 abilities and after being given a generalist nursing intervention the client applied 9 abilities.
Nursing Intervention De-escalation Exercise with Emotional Experience Writing Nursing interventions Deescalation Exercise with Emotional Experience Writing on Mrs.
A began on September 28, 2023 until October 03, 2023.
Before Deescalation Exercise with Emotional Experience Writing the author conducted a pre-test of signs of symptoms and ability to control violent behavior in Mr.
A on September 28, 2023 and conducted the first post-test on October 03, 2023.
on September 28, 2023 and conducted the first post test on October 03, 2023.
Then the second post test was conducted on October 07, 2023 after independent writing exercises on October 04, 2023 October 6, 2023.
Figure 4.
Results of the second Measurement of Signs and Symptoms of Violent Behavior Before and After Deescalation Exercise with Emotional Experience Writing.
Cognitive Affective Physiolog Behaviour Pre-Test Journal Educational of Nursing (JEN) Vol.
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Social Post-Test GT Wijiastuti.
Hargiana | Application of De-Escalation Nursing InterventionsA.
The results of measuring signs and symptoms were carried out before the writing intervention was given.
The measurement results after being given the Emotional Experience Writing deescalation exercise intervention independently, the measurement results show a significant decrease in the signs and symptoms felt by the client Mrs.
Signs and symptoms that still remain in the cognitive aspect .
rritability and dominating the conversatio.
Figure 5.
Measurement Results of Ability to Control Violent Behavior Before and After De-escalation Exercise with Emotional Experience Writing Pre-Test Pre-Test Post-Test Post-Test The results of measuring the client's ability to control violent behavior show an Before applying the intervention the client applied 7 abilities and after being given a generalist nursing intervention the client applied 13 abilities.
Discussion The client is a 23-year-old woman.
The client's initial diagnosis is Schizophrenia and has been diagnosed approximately since 2018.
This means that the client has been suffering from Schizophrenia since the age of 18.
The age of 10-18 years is in the adolescent age range (Ministry of Health, 2.
One of the neuropsychiatric groups.
Schizophrenia, has a typical onset in adolescence because the end of this age is a critical period in brain development, psychosocial problems (Gogtay.
Vyas.
Tasta.
Wood, & Pantelis, 2.
The client had a vocational high school education and did not go to college due to economic constraints.
Economic conditions and lack of financial resources can be life stressors (Shives, 2.
The level of education influences how people think, handle problems, make decisions and assess Coping strategies are closely related to cognitive function (Stuart.
The results of research conducted by Hastuti .
as many as 46.
5% of clients who committed violent behavior had secondary education and above.
The level of education and poor economic conditions can be a factor in violent In the second session of de-escalation training with emotional experience writing, the client wrote that the people who love her are her biological mother, biological father, her three younger siblings, her ex-boyfriend, stepfather and six close friends, and her husband.
The results of this client's writing show that the client can remember who are the people who always provide support and affection for her.
Continued on the next day with the third session the client wrote with the theme listen to me .
lients write things that make sad, things that make happy, things that make angr.
The client wrote down his feelings of sadness because he was far from family, felt sad to be in the hospital, the thing that made him happy was that he could make his mother proud because of his achievements at school, felt angry when his younger siblings did not listen to what he said.
Furthermore, the client is given praise for what he has done well.
The writing exercise here provides a platform to pour out previously unexpressed emotions and in this way allows the client to make peace and make an end to the Because generally when traumatic Journal Educational of Nursing (JEN) Vol.
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events occur, individual expression of emotions is suppressed (Barcaccia et al.
In de-escalation exercises with emotional experience writing in the fourth and fifth sessions, emotional experience writing with the theme in the fourth session is Goodbye Stress.
Angry, and Worry and in the fifth session with the theme of hopes, desires, and ideals.
The client wrote down the lessons and experiences he gained while in the The client also wrote down ways to overcome stress, anger and The client wrote down hopes to want himself and his friends to recover.
The client also hopes that the family can understand his situation and get together with the family.
The client's wish is to go home quickly and gather with family and family harmony.
From the results of patient writing shows a form of selfregulation.
This regulation process is to control individual emotions, thoughts, and behavior towards an event.
Expressive writing works by increasing clients' confidence in their ability to regulate emotions, which was previously lost after a traumatic event (Barcaccia et , 2.
Writing about stressful experiences and emotions experienced can help to manage their own emotions (Nurmaliza.
Emotional Experience Writing is one of the techniques in the implementation of expressive writing therapy, which is commonly used in rehabilitation, and other medical fields.
Expressive writing can help individuals understand themselves better, help deal with depression, distress, anxiety, addiction, fear of illness and loss and changes experienced in life (Pennebaker & Seagal, 1.
Therefore, expressive writing can be used as an adaptive coping strategy to improve cognition, and increase social interaction (Tonarelli et , 2.
However, after deescalation exercises with emotional experience writing for five consecutive days left 5 signs and symptoms out of 16, some signs and symptoms of risk of violent behavior were still found.
After doing independent writing exercises for 3 consecutive days and doing a post test, it showed a decrease in signs and symptoms to 2.
This is in line with previous research that nursing actions can reduce signs and symptoms of violent behavior (Pertiwi.
Sulastri, 2.
After de-escalation exercises with emotional experience writing, some signs and symptoms of risk of violent behavior are still found.
The results of evaluating the symptoms of violent behavior in clients after the application of emotional experience writing interventions have The client experienced a decrease in the value of signs of symptoms in the cognitive aspect from 5 Signs and symptoms that are still found are in the objective cognitive aspect, namely irritability.
As is known, signs and symptoms of risk of violent behavior are related to aggressiveness.
Aggressiveness according to Buss and Perry .
is a personality trait that is grouped into four factors, namely, physical aggression, verbal aggression, anger and hostility.
Aggression is also characterized as the result of the relationship between emotions .
, thoughts .
, and aggressive According to research by DeWall.
Finkel, and Denson .
people behave aggressively because of a failure of self-control for acts of aggression and violence.
Self-control involves a variety of responses, including how to regulate emotions, suppress thoughts, and control behavior.
The results of the first post test found that the social symptom sign did not Journal Educational of Nursing (JEN) Vol.
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decrease from number 2 after the This is not in line with previous research.
The author concludes that emotional experience writing interventions carried out without other interventions have not been able to reduce signs of violent behavior The results of the second post test conducted after independent writing exercises showed a change in the sign of social response symptoms in clients from a value of 2 to 1.
Assertive Communication taught to clients includes good word selection and volume and tone of speech.
Although the client had difficulty during the exercise, after being asked to familiarize the client could do well gradually.
The client also showed progress in socializing skills, when the first few days of the meeting the client seemed lazy to do activities.
However, after being given the emotional experience writing intervention, the client seemed eager to participate in routine activities and interact with other This is in line with the statement (Damaiyanti and Purwanti, 2.
that emotional experience writing therapy intervention helps clients with violent behavior to control emotions in clients with violent behavior.
The results of the post test conducted showed changes in the signs of affective response symptoms in the client from a value of 3 to 0.
The affective response that was previously still shown by the client was annoyance / upset / anger, unstable affect and unnatural or excessive euphoria.
After carrying out nursing actions and emotional experience writing interventions on patients, signs and symptoms have decreased.
The author when intervening focuses on the client's ability to control violent behavior and helps clients recognize feelings.
Action on this affective aspect is necessary because clients sometimes have difficulty identifying, expressing, and regulating feelings.
In every interaction, the author motivated and guided the client to manage his emotions.
Nurses must use a variety of communication skills for the successful implementation of nursing actions related to the affective needs of clients.
Communication skills that are important for clients are the ability to empathize.
reflection of feelings.
open, feelingoriented questions.
and confrontation (Stuart, 2.
According to Freud's psychoanalytic theory, behavior is influenced by subconscious feelings and thoughts (Videbeck, 2.
The concept of the theory is in accordance with Mrs.
A's condition where every interaction seems enthusiastic, excited, and motivated.
The implementing nursing interventions encourages clients to continue to express their opinions, feelings, and practice analyzing a It is possible to be a stimulus for clients to change their perceptions and behavior for the better.
Thus, signs of violent behavior symptoms can be reduced after nursing interventions to control violent behavior.
The emotional effectively reduces behavioral response symptoms in clients at risk of violent The results of the post-test ability to control client nursing behavior have Before being given nursing care intervention the client applies 6 out of 9 abilities.
After being given nursing care the client applies 7 out of 13 The client's ability to show improvement is seen in the independence of doing writing exercises.
In addition, it is also seen in the ability to speak well, do activities to make the bed, sweep, interact with the environment, and enthusiastically do morning exercises and group activity therapy.
The increased Journal Educational of Nursing (JEN) Vol.
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ability displayed by the client can be due to exercises that are carried out regularly and recorded in the daily activity The daily activity schedule is prepared to make it easy for clients to remember and increase client awareness of doing activities according to plan (Stuart.
Keliat, & Pasaribu.
, 2.
This de-escalation exercise with emotional experience writing is emotionfocused coping.
Emotion-focused coping aims to reduce the emotional consequences of stressful or traumatizing events by helping to evaluate emotional experiences to be resolved and their (Schoenmakers et al.
, 2.
Behavior control is carried out on generalist nursing care actions, starting from deep breathing, hitting pillows, speaking assertively and doing spiritual With the signs and symptoms that still arise until the completion of emotional experience writing exercises, there are factors that influence during the provision of nursing care, namely the lack of maximum provision of generalist nursing care that focuses on behavior When compared to when doing emotional experience writing exercises, clients are more enthusiastic about doing emotional experience writing exercises.
When given generalist nursing actions, clients tend to be less excited and more often divert the conversation.
As a result, the provision of generalist therapy is still not optimal and still leaves signs and symptoms after generalist therapy and emotional experience writing exercises.
Conclusions This study was conducted on respondents, namely Mrs.
A with nursing problems at risk of violent behavior.
The main nursing problem found in Mrs.
who received treatment in the Utari room of Dr H Marzokei Mahdi Bogor Hospital was the Risk of Violent Behavior with signs and symptoms of feeling powerful, saying upset, irritable, not confident, unstable affect, unnatural or excessive euphoria, feeling palpitations, angry expressions when talking about others, conversation, and high and loud tones of Generalist nursing care for the risk of violent behavior that is compiled and implemented is deep breath relaxation training, pillow hitting training, speaking well, deescalation with emotional experience writing, spiritual activities, and taking medication.
After generalist nursing care, signs and symptoms that still appear are saying hate or annoyance with someone, irritability, unstable affect, unnatural or excessive euphoria, like yelling, like arguing, feeling conversation, and high and loud tones of After the Emotional Experience Writing exercise, the client showed a decrease in signs and symptoms of risk of violent behavior.
Until the last termination, the signs and symptoms that are still shown are still irritable and dominate the conversation.
References