What do you do when a patient threatens harm?

[OrganizedChaos]

So far in my short few months on the floor I've already had a bunch of patients threaten to hit me. Every time I get threatened or yelled at by the public all I can think of is that I'm not getting paid enough to put up with this ****.

What do you do when someone just threatens violence? If I just called security on my ascom who knows when they would show up. But I don't feel the need to call a code since nothing is actually happening & I don't want to make the patient more irate.

Yesterday I was trying to remove a patient's IV (she was being D/C'd). She had paper thin skin & lots of tape. I was trying to go as slow as possible & use ETOH pads & then hand sanitizer. She wasn't good with pain & at one point she said she was going to punch me in the face. What do you do in a situation like that? I just quickly changed the conversation & de-escalated her, then she was fine.

[Here.I.Stand, BSN, RN]

First, I would remove myself out of their striking range and attempt to verbally de-escalate.

My hospital has a behavioral emergency code, which is responded to by security and psych charge nurse. Our security staff carry tasers, and the RN brings a set of 4-point leathers.

Security RUNS when these are called.

If I were in immediate, life-threatening danger -- e.g. hands around my neck -- I would do absolutely anything to protect myself. My husband has black belts in both kung fu and taekwondo, plus went through RoK army training, and he taught me some serious self-defense techniques... but I'm not above fingers in eyes or a knee in the groin.

If that same person was doing that same action on the street, I would react exactly the same in the hospital.

Legal trouble? People are allowed to protect ourselves -- if the assailant is killed the victim isn't charged with murder, right? Besides, Maslow's Heirarchy people. My need for survival is more than my need to avoid a courtroom.

BUT, my hospital requires "run, hide, or fight" as part of our annual required training. The "fight" option is last resort, but if we need to we fight to prevail (or something to that effect.) Methods -- per hospital's training video -- include throwing heavy and sharp objects. I guess they don't want us to be another St John's?

I do NOT recommend calling a code, unless hitting that button is all you can do. Again, if pt strangling me so can't scream but in reach of the button. 1) the vast majority of violence is not immediately life threatening. We don't need the pharmacist and chaplain and the legion of med students who typically come running to the code; nor do we need the crash cart or heavy LUCAS device. 2) It sounds like this is a frequent occurance on your unit. If each results in a code being called, I can see this becoming a boy who cried wolf situation.

[Here.I.Stand, BSN, RN]

*** I'm assuming by "code" you mean a code blue?

Also stating the obvious, but my response would vary based on the situation. Confused elderly woman who was once gang raped, and I am trying to place a Foley? That would warrant reassurance and a soft/kind voice. Young man, a&o and is accustomed to get his way by intimidation? That would warrant a behavioral emergency code.

[OrganizedChaos, LVN]

What kind of "code" would you be calling? Does your facility have a "code green" or some such that reflects a threat made against your person?

Yes, we do have a specific code that calls security.

[OrganizedChaos, LVN]

Be aware that if you "protect yourself" using any techniques or weapons outside of what hospital policy approves, you are opening yourself up to possible criminal charges, as well as discipline from your employer.

If someone is throwing punches or chairs I'll be damned if I don't protect myself. I don't care if it comes at the cost of my job. My safety comes first.

[OrganizedChaos, LVN]

Well, that's a rather entertaining thought! I respond to threats based on how credible they appear to be. Sometimes, I simply ignore the threat. Other times, I leave immediately and return with a full show of force, if need be.

Oh of course. I didn't think that woman was serious. She had been in wrist restraints earlier & was A&Ox3 maybe 4.

[OrganizedChaos, LVN]

First, I would remove myself out of their striking range and attempt to verbally de-escalate.

My hospital has a behavioral emergency code, which is responded to by security and psych charge nurse. Our security staff carry tasers, and the RN brings a set of 4-point leathers.

Security RUNS when these are called.

If I were in immediate, life-threatening danger -- e.g. hands around my neck -- I would do absolutely anything to protect myself. My husband has black belts in both kung fu and taekwondo, plus went through RoK army training, and he taught me some serious self-defense techniques... but I'm not above fingers in eyes or a knee in the groin.

If that same person was doing that same action on the street, I would react exactly the same in the hospital.

Legal trouble? People are allowed to protect ourselves -- if the assailant is killed the victim isn't charged with murder, right? Besides, Maslow's Heirarchy people. My need for survival is more than my need to avoid a courtroom.

BUT, my hospital requires "run, hide, or fight" as part of our annual required training. The "fight" option is last resort, but if we need to we fight to prevail (or something to that effect.) Methods -- per hospital's training video -- include throwing heavy and sharp objects. I guess they don't want us to be another St John's?

I do NOT recommend calling a code, unless hitting that button is all you can do. Again, if pt strangling me so can't scream but in reach of the button. 1) the vast majority of violence is not immediately life threatening. We don't need the pharmacist and chaplain and the legion of med students who typically come running to the code; nor do we need the crash cart or heavy LUCAS device. 2) It sounds like this is a frequent occurance on your unit. If each results in a code being called, I can see this becoming a boy who cried wolf situation.

Wow! I want to work at YOUR hospital!

Calling a code is when we need security there emergently. I have never called a security code... yet.

[OrganizedChaos, LVN]

*** I'm assuming by "code" you mean a code blue?

Also stating the obvious, but my response would vary based on the situation. Confused elderly woman who was once gang raped, and I am trying to place a Foley? That would warrant reassurance and a soft/kind voice. Young man, a&o and is accustomed to get his way by intimidation? That would warrant a behavioral emergency code.

We have codes for everything: patient fall, security, etc.

Most of the people who have threatened me were A&Ox3-4. Never the LoL who wasn't aware.

[hppygr8ful, ASN, RN, EMT-I]

I do acute inpatient psych and a day I don't get a threat is like a day without orange juice. I am well trained in verbal de-escalation. When that doesn't work I follow some of the suggestions you have gotten here. Always have a clear path to the door. Participate in regular exercise to keep your body limber and quick. I do two classes a week in cardio kick boxing. Learn how to stand in a natural fighting position. I am not talking about putting your dukes up but rather standing in such a way as to be able to pivot and move quickly. Know where your help is a how quickly they can arrive. We have silent or pre codes where help comes to the unit but does not engage the patient if hands on is not warranted. Also know when and how to pick your battles. In the scenario you posted where it is not a psych issue I would most likely have said something like "I know it's painful but you can't go home with this IV. Why don't we take a break and I'll come back. This might delay your discharge a bit! OK?" Also wrapping all that tape with a warm moist towel will soften it up and help it come off. I've only been seriously hurt 1 time in 17 years and that was before I learned all this stuff.

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Hppy

[hppygr8ful, ASN, RN, EMT-I]

Oh and you should ask your employer about CPI training. This includes verbal de-escalation training, some fast easy moves and holds as well as training into you own trigger/behavior which you may be doing unconsciously do that may trigger a patient. If your work doesn't offer it you can find it on the internet and get CEUs as well.

Hppy

[Here.I.Stand, BSN, RN]

We have codes for everything: patient fall, security, etc.

Most of the people who have threatened me were A&Ox3-4. Never the LoL who wasn't aware.

Gotcha. When I hear the lone word "code," I think code *blue* I'm picturing a typical code blue and figured you meant it as a way to get help quickly.

[RockinNurse2018]

Sounds like you did what you needed to do. In all honesty, if someone is threatening violence and I have no reason to doubt they're serious, I leave the room if at all possible. Sometimes I go back in later after the person has had time to settle down. Other times, if it is feasible, I send someone else into the room, especially if they have more authority than me, and let them deal with it. I am at work to care for patients, not be a punching bag, although I am a small person.

[nrsang97, BSN, RN]

Oh and you should ask your employer about CPI training. This includes verbal de-escalation training, some fast easy moves and holds as well as training into you own trigger/behavior which you may be doing unconsciously do that may trigger a patient. If your work doesn't offer it you can find it on the internet and get CEUs as well.

Hppy

Everyone should have this training. It would really help. Some of our staff are NOT good at deescalating these issues and make them worse. I would love to get our staff trained. I know I could use a refresher in this.