Being groped or grabbed by a patient while carrying out work duties is not okay in any clinical setting on any level. Yet, a recently published Monash University study found that 70% of nurses surveyed reported being physically assaulted in the workplace. The patient was identified as being the perpetrator of many of these assaults.
The challenge for nurses is that they are caring for patients who may be aggressive due to an acute or untreated medical condition such as dementia, delirium or brain injury. One such medical condition that may lead to incidents of physical assault is Alien Hand Syndrome (AHS) which can occur in patients recovering from stroke, particularly due to disruption of the anterior cerebral artery (ACA) blood supply.
AHS is defined as being a phenomenon which refers to involuntary motor activity of a limb in conjunction with the feeling of estrangement from that limb. In many instances, patients speak about their limb in the third person and as having a will of its own.
Research has provided evidence to support the theory of there being two variants—posterior (PV) and anterior (AV) with the later having two subtypes—frontal (AVF) and callosal (AVC). Each variant and subtype presents in a clinically different manner and there have been reported cases of mixed variants.
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The AVF subtype presents with the disinhibited groping and reaching for objects that are within arms reach without the patients will or control. If the object happens to be the arm or any other body part of a nurse this can be upsetting for both patient and nurse. Particularly distressing, is if the patient’s grip tightens as the patient and nurse try to release the affected hands’ grip.
Purposeful hand movement signal originates in the frontal lobe where the movement is planned and organised. A message is then sent through to the motor strip also located in the frontal lobe to move the limb. Alien hand movement signal originates in the motor strip itself due to the location of the lesion and does not involve the frontal lobe. There is no conscious decision for movement, nor is there any planning or organising of the movement hence the alienness of the limb movement.
Management of Alien Hand Syndrome
Protecting the patient as well as the staff providing care to the patient is an important component of care management. Providing education to the patient, family and staff is the first and most important step in promoting safety and optimising functional recovery.
Protective strategies that can be considered include:
- Keeping the affected hand occupied (e.g. with a stress or tennis ball) when working in close proximity to the patient.
- Ensuring the environment is clutter free and objects are not in reach of the affected hand (reduces the risk of minor spilling accidents or use of objects as weapons).
- Restrain the affected hand by positioning the hand in the patient’s pocket or placing a mitten type garment over the affected hand.
- Creating a calm and stress-free environment (i.e. accommodating the patient in a single room, which also promotes sleep hygiene).
- Use visualisation tactics such as positioning the affected hand within patient’s visual field and encouraging the patient to mentally practise functional tasks using both limbs.
- Providing reassurance to the patient and family that AHS generally resolves as recovery occurs.
- Minimise distractions for the patient when providing care or therapy.
- Manage fatigue by scheduling therapy and care throughout the day dependent upon patient fatigue levels.
In the event of a situation occurring where the patient does grip or grope a staff member, then patience is required in managing the incident. If required, release the patient’s grip gently by prising off the little and ring finger followed by the remaining fingers and grip will loosen. Pulling away or forcing the release will in many instances only increase the force of the grip. Panic will increase anxiety for both staff and patient which could exacerbate the situation further.
Raising awareness of Alien Hand Syndrome (AHS) post-stroke and providing information on how to minimise the effects should decrease gripping and groping incidents attributed to AHS occurring within the workplace.
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- Schaefer, M., Heinze, H. and Galazky, I. (2010). Alien Hand Syndrome: Neural Correlates of Movements without Conscious Will. PLoS ONE, 5(12), p.e15010.
- Sarva, H. and Deik, A. Servert WL. (2014). Pathophysiology and Treatment of Alien Hand Syndrome. Tremor and Other Hyperkinetic Movements. [online] Available at: http://www.tremorjournal.org [Accessed 5 Dec. 2014].
- De Cieri, H., Shea, T., Sheehan, C, Donohue, R. and Cooper, B. (2015). Leading Indicators of occupational health and safety: A report on a survey of Australian Nursing and Midwifery Federation (Victorian Branch) members. [online] Melbourne: Institute for Safety Compensation and Recovery Research. Available at: https://www.anmfvic.asn.au/ [Accessed 23 Apr. 2015].
- National Stroke Foundation (2010). Clinical Guidelines for Stroke Management 2010. Melbourne Australia 155 BNO-978-0-9805933-3.4
Annette Horton is a Registered Nurse with over 30 years extensive nursing, rehabilitation and management experience. Since 2004 Annette has held a Nurse Unit Manager position of a regional rehabilitation unit in Queensland. Annette is a member of the Australasian Rehabilitation Nurses Association (ARNA) and has presented several papers at ARNA national conferences. Annette has her own nursing blog entitled Nurseconvo, and more recently has become a contributing writer for Ausmed. Interests include stroke, rehabilitation, continence, leadership and management, coaching and case management.