Um... Can you hit before you get hit?

[tarotale]

As a 1yr ms RN going into ED, one of the top things that concerns me is the safety. I'm sure you have seen lots of crazy things that happen at ed, and I'm not doubtful that one of them include violence against staff.

I have heard from others that people bring guns to the ed, sometimes you can get punched, kicked, put in choke holds, wrestled like in the octagon, etc.

In my state, we have a law that makes assaults on ed staff a felony, but I don't think that will stop the real crazies. I already have a bad back for which I go to the chiropractor, and I don't want to get disabled.

I understand that the best thing to happen is just avoid the violence when it's happening, but what if I have a coworker who is 5ft and will surely go to Valhalla if I run away? Or what if I'm cornered and have to fight? I be honest with you, if there's two options, one being a saint and risk being disabled for rest of my life or being badly hurt, and the other being "selfish " and knock the snap out of someone so I can support my family, I will happily put someone to sleep as best as I could with the blessings of Rocky Marciano. This is not really something you would worry too much about in MS setting, so I feel apprehensive about it.

As you all know this is my first ed position and I know I will defend myself and my coworkers in violent situations. So the question is probably this: what is the realistic approach in hitting someone before yourself can get hurt bad in ed? I'm not going to just simply start punching pts but I'm taking about real danger situations where you know it's either do something or get hurt.

Many ED nurses I talk to about this said they had to use "rough" methods to avoid having themselves or coworkers from getting badly injured... Or am I worrying about something that happens very very rarely?

[elkpark]

Just to be clear, u do realize I explained the situation as a case in which pt already started pummeling on u or u dodged the blows and I'm asking if it is realistic for an ED nurse to defend him/herself in that situation right?

And several people have responded that there is no situation in which it is legally, professionally acceptable for you to hit someone, even in response to being hit. My career has been in psych, and it is well-known and understood in psych that any kind of aggressive move (slap, punch, hair pull, whatever) is grounds for firing and possible assault charges, even when it is toward someone who is assaulting you and ostensibly to protect yourself. Responsible employers provide training in crisis prevention and desescalation, as well as non-aggressive interventions to control and restrain aggressive clients. Most facilities also have security personnel who have a wider range of options available to them. Brawling with clients, or even using the types of "self-defense" techniques that you could legitimately use on the street if you were assulted, simply do not fly in healthcare settings.

[NurseOnAMotorcycle, ASN, RN]

Take up judo, aikido or jiu jitsu. It's a nonviolent redirection of force and uses submission holds (restraining) rather that strikes.

[sandyfeet]

Patients usually don't get violent out of nowhere. There are many verbal and physical cues that lead up to physical violence and you should be trained to spot them so you can de-escalate the situation. If I feel threatened I back away and yell "Call a Code Gray!" and yes, situations have occurred when staff came running and the patient is looking at us innocently. But I would rather be safe than sorry. Usually once a patient starts raising their voice, if it's not my patient I will walk over to see what is going on, and other staff members will come over too. My ED also uses MOAB training and our staff is really good about backing up each other.

I think it's been made clear by previous posters that you can never hit a patient. No matter what.

[wooh, BSN, RN]

Not only is there clues leading up to the escalation, you should NEVER be cornered. Didn't it get covered in your psych rotation to always be between patient and door?

let's say the pt/family is being very belligerent and face to face with you yelling and about to strike or crush you down the ground.

De-escalate and escape... only.

at the moment the fist swings and you duck and you are cornered so nowhere to go, and you know the punches are going to reign upon you, can you strike to make space to get out. No preemptive strike haha.

Absolutely... once they attack, you may do whatever is necessarily in terms of a REASONABLE and PROPORTIONAL response, to protect yourself and escape.

No stand-your-ground...

Be sly as a fox to keep yourself from ever getting into this situation, though.

[elkpark]

... once they attack you may do whatever is necessarily in terms of a REASONABLE and PROPORTIONAL response, to protect yourself and escape.[/quote']

I've never worked as an ED nurse (although I've had psych CNS positions in which I covered the ED for psych cases), but I've never worked in any setting or situation in which it was acceptable to do "whatever is necessary" in an assault situation. Anything other than the interventions taught in the facility's approved "crisis intervention" program was grounds for firing and left you open to criminal assault charges by the client.

[tarotale]

I've never worked as an ED nurse (although I've had psych CNS positions in which I covered the ED for psych cases), but I've never worked in any setting or situation in which it was acceptable to do "whatever is necessary" in an assault situation. Anything other than the interventions taught in the facility's approved "crisis intervention" program was grounds for firing and left you open to criminal assault charges by the client.

We have police on the ground not security guards, and staff are always given choice to file criminal charges on pts or family or anyone if physically struck . Happened already last shift. It goes both ways...

[Nonyvole, BSN, RN]

I'm going to throw something out that pre-hospital responders are taught. Scene safety. (It became rote when doing in-class scenarios for both student and teacher. "Scene is safe?" "Scene is secured by police." "Scene is safe, BSI...")

Like others have said, try to avoid having anybody or anything between you and the door if you're worried. Keep the door open, if possible. Sometimes it isn't.

Listen to your gut. When I've spent time in the ED - either as an employee or as a student - there were always warning signs before a patient started to even threaten physical violence. And that was when we actively worked to de-escalate the situation. Sometimes it was as simple as bringing them a cup of soda, sometimes they just wanted somebody to validate their feelings. EDs can be busy places, and some of the ones that I've been in have been amazingly busy, so it's easy for patients to feel like they've been forgotten. I would also try to prevent things from escalating; even by sticking my head into the room and saying "Hi, we haven't forgotten about you. How are you doing?" every 30 minutes to an hour helped with some of my grumpier folks. Rounding. It works in the ED just as well as it does on the floor.

Now, in the event that it does start to feel like it's about to get physical? Stop what you're doing and get out. "Oh, I think I hear my boss calling me - I'll be right back." This is really when you want to make sure that you have a clear path to the door. The minute that they start swinging, scream, shout, yell...do your best to get out but please try to avoid hitting. That's a good way to a lawsuit against you.

Also, talk to your coworkers. Find out what they do. I know that if I'm faced with a belligerent patient, I'll be the bigger woman. "Hey. Watch your language." "You are going to stay in bed. You are not going to shout. I will bring you a snack and a drink as soon as they get here, and I have no control over that." "No, you may not have your clothes back yet." "You want to sign out? Let me get the doctor." "Ma'am, I know that this looks bad, but we're doing everything that we can so please go sit down there." It's in the tone of your voice. I'm short, I look young, so I've had to learn how to use my voice to control situations. And it works.

[michigansapphire]

They can't hit you if they can't reach you. Keep your distance and always have an escape route.

[caliotter3]

In my job, I can not respond, notice I said respond, to someone yelling, or screaming, or cursing me out. I certainly wouldn't be able to say anything to them they didn't like, prior to them telling me off, in just the manner they choose. And yes, they put words in my mouth all the time, and accuse me of raising my voice to them when it is the other way around. My employer blames me for any and all unpleasantness that occurs. The clients know this and take full advantage of their ability to push me around and speak to me with less respect than an animal. I look to my employer as the cause.

[zmansc, ASN, RN]

What sandyfeet said. When a situation starts to get hairy, you back out of it and then deescalate it. If you hear it going on in another nurses room, you check on that nurse, that situation. Never leave your coworker hanging, ever! If you think there is a remote chance that you will have an issue with a pt, then you get backup before you go to treat the pt, you discuss how your going to do what your going to do with the crew, have a plan, don't just go in guns ablazin! Confrontation is always a last resort.

As for family, first the goal is to incorporate them, it's their loved one. Second, if they are an issue, I've never had a problem booting them to the waiting room and only once has security needed to assist in that. Never seen family instigate a fight with staff. Had a couple raise their voice to me, but always been able to resolve it quickly.

I'm not saying there aren't times when patients need to be restrained, because their are. But if they came in by bus, the crew calls ahead of time and we have a show of force, and still try to negotiate the situation before we restrain someone. If it is a flair up of a previously calm patient, we back out, get a show of force and if negotiation doesn't work then we restrain them. Never strike, never use any more force than absolutely necessary to get the restraints on and as soon as possible get them off. more than nine times out of ten you can deal with the situation without having to use restraints. I've never needed restraints after a single encounter either. Only after several of us have tried to resolve the issue diplomatically and failed have we considered restraints and typically the provider is involved and standing their giving the order before we as RNs decide to go down that path.

[caliotter3]

They can't hit you if they can't reach you. Keep your distance and always have an escape route.

When the male of the pair berating me placed himself between me and the door, I told my employer. Not the first time for threatening body language. The employer didn't even acknowledge my statement.