Combative/Violent Confused Patients

[missmiamoore]

I am feeling traumatized and numb at the moment. Maybe it is because I am 6.5 weeks pregnant and my hormones are out of control. There was an "incident" at work tonight that threw me right off and has left me feeling disturbed. I am sure it is not new to most nurses.

I had just started my night shift, received report, and began my initial rounds. One patient in for Falls, 80 year old, with CKD, on daily hemodialysis, appeared confused. The patient had been admitted late in the day shift. On report, the day nurse told me that he had been projectile vomiting and they had to change the curtains, but she said he was alert and oriented with no behavioural issues. That is not what I encountered.

I approached him and after introducing myself and him seeming appropriate, I attempted to put the bed rail up as he was sliding down and his legs were hanging out. He then kicked at my stomach. I was able to back away quick enough so I didn't receive the full impact of his kick. He said if you touch this bed I will knock your head off. He then appeared like he was going to vomit and I went to pass him the basin, and when I was just in front of his face, he spat blood-tinged thick sputum into my face.

I was shocked and disgusted. I was frightened for mine and my baby's health as the sputum went into my eye, nose and mouth. I screamed when he spat in my face I couldn't help it. My colleagues came running and told me to wash off. I did as best I could and reported to the ER. I was a basket case at this point. I told them of my pregnancy and they could tell I was traumatized.

They were quite wonderful. The ER charge nurse was like a kind mother, who told me confidently that she had found someone to cover my shift. The ER doc told me he was generous with time off and gave me the week off with pay.

I am just so upset that we as nurses have to be exposed to this type of abuse. These patients are confused and I know they are out of their minds, but how can nurses be protected against this type of violence?

I am feeling resentful towards the management as it seems that they do not give a s__t what happens to their employees, as long as they have bodies to cover staffing needs.

[PSYCHEE]

I'm sorry this happened to you, violent or combative patients are never easy to deal with. However, I find it AMAZING that your employer gave you ANY time off for this, let alone an entire week?! PAID?! Holy sh*t. Please don't say management doesn't care, because trust me, I have worked at a few different hospitals and seen many patient/staff injuries and I can't believe anyone gave you time off when you weren't actually injured. (Not saying that being spit on isn't scary, or gross, but you didn't sustain any wounds.) We just had an incident where a patient attacked a nurse and knocked out three of her teeth and she was back two days later...

I've been choked three times, once choked to unconsciousness, hit with various objects, bit, had my hair pulled, had my arms twisted, my hands slammed in doors, etc... Granted, I've worked Psych and Geri, so this comes with the territory, but it's not like psych patients are magically immune to medical problems and psych units generally can't manage patients who are medically unstable, so SOMEONE has to take care of them... it does take a very special person to do my job, take the beating and not lash out back at the patient.

That being said, if you can't stomach these kinds of situations, finding a specialty that you can abide is in order. What that is, I have no idea, because I hear stories from my nurse friends in nearly every sub specialty that they had "one of *MY* patients" the other day and how wonderful/horrible/funny it was. But surely someone else here can point you in the right direction. OB maybe? Outpatient?

Edited to add: I agree that there should be specialty units for particularly difficult to manage patients, because while I feel most patients with psych issues can be at least temporarily managed on a medical floor, I've worked with levels of psychosis and dementia that need very skilled psych nurses to manage. Many of my patients at the state hospital are nearly incapable of communicating due to psychosis or dementia, AND they have medical complications. For this reason, I recently interviewed with a special med/surge unit for behavioral patients. Hopefully I get it, because I'd love to increase and freshen up my more acute medical skills while still providing care to the patients I find most interesting.

[Anthony South]

I'm sorry for what has happened to you. Unfortunately, as long you and I work as bedside nurses, we are always going to have to deal with these types of people. When I do have to take care of these individuals, I always ASK if I could do this or that for them; I will ask them if they want this or that medicine before I scan a medication. If they say NO! or say something much worse, I just say "ok" and I walk away. I'll call the family to let them know their family member refused treatment, otherwise the family will report me for "not caring" for their loved one. I hate uncooperative Pts, even if they are confused.

[RNGummy40]

I am sorry you experienced violence from a patient. Objectively, we don't know if that violence was intentional or not, but appearing confused was the first cue to unpredictable behaviors. Being prepared for impulsive behaviors is a skill that is learned in nursing.

Learning how to deal with violent patients is required training as per OSHA and the ANA. Hospitals should be providing training to ALL nurses in how to prevent violence. Unfortunately, the cost of training is the barrier that some hospital's use as an excuse to not train staff. Whether it is CPI, Handel with Care, or MOAB, they each teach verbal deescalation and defense techniques. Based on what your patient had said to you and that he tried to kick you, you should have walked away. Communicated you would be back to check on him. Immediately gotten a coworker, recheck the patient together. I understand the compassion to help him when you believed he was going to vomit, but your personal safety should have been a priority. Increasing distance and not entering his personal space by yourself should have been recognized.

If you have not had violence training then that's a big problem. Management should be requiring it. Floor staff should be using a consistent system to flag violent/ aggressive patients. A system should be in place to alert staff at shift change as to which patients are considered high risk: assault/sexually aagressive behaviors, verbal aggression.

I do find it FUNNY that many posts recommend finding another area of nursing as a solution. It really sounds like, "don't talk about the problem too much, or that's just your problem." Sadly to say, 1/5 new nurses entering our profession are planning to leave within 1 to 3 years. Why is that? Is it because we don't provide them enough training? Are new nurses prepared to deal with violent and aggressive patients and are experienced nurses?

Training to deal with violent and aggressive patients is generally isolated to Psychiatric and ER Nurses. Why is this? Patients are admitted or discharged. If they are admitted they go to the most appropriate bed in the hospital and the floor staff needs to be equipped to safely manage the patients. Patients that are harder to discharge due to violent and aggressive behaviors have longer length of stays. Psychiatric patients who are too violent, are sex offenders (level 3), delevelopmentally delayed, or have TBI's are harder to place as well. They get admitted and the floor staff needs to be able to provide safe care. Learning verbal deescalation and proximity awareness is essential to any aggressive situation.

I don't think you experienced lateral violence from your coworkers. If anything, they were asking for pay for each time they experienced violence themselves. Management should be providing training, yes security. Unfortunately security can't be in all places at all times. That's why the training is essential. Common sense is not common.