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Discussion

How often do you encounter violence?

Going to be starting an internship in psych soon and am a little nervous. Just wondering how often you deal with violent patients and does it vary depending on unit? I am going to be rotating though adult and child/adolescent. Also, would appreciate any tips! Thanks

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    Going to be starting an internship in psych soon and am a little nervous. Just wondering how often you deal with violent patients and does it vary depending on unit? I am going to be rotating though adult and child/adolescent. Also, would appreciate any tips! Thanks

    My clinical rotation at a psychiatric facility was one of my most rewarding clinical experiences. Please don't assume that these patients are any more violent than the average person because they're not.

    I was in both the chronic and acute adult units. Admittedly, I was a little fearful the first day of my clinical but I got over it in the subsequent rotations. Speaking and interacting with some of the people there really helped me to disregard many of the stereotypes I had about the mentally ill in addition to learning a lot from them.

    Please try and keep an open mind. Go into this internship like any other without expecting something negative to happen. Be positive and open to the experience.

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    Almost never, if you mean violence against others. You're much more likely to see patients trying to hurt themselves than other people.

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    Verbal aggression or physical aggression? We have patients verbally escalate at times but rarely do we have a physical outburst.

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    Just wondering how often you deal with violent patients and does it vary depending on unit? I am going to be rotating though adult and child/adolescent. Also, would appreciate any tips!

    Regularly, working with the so-called Psychotic, but probably merely Demented, Geriatric Population. A few Patients have a tendency to swing out at just about anyone who touches them.

    LTC Facilities tend to send their problem Patients to Behavioral Health for combative behaviors experienced during episodes, for example, of direct care. Since Dementia is not an Axis I Diagnosis, Patients are admitted with a Diagnosis of Psychosis NOS. These Patients tend to benefit from Antipsychotic, Antianxiety, and Antidepressant Medication Therapy and are usually returned to LTC.

    In the areas of Child, Adolescent, and Adult Behavioral Health, Verbal and/or Physical aggression happens now and then. Learning Techniques to De-escalate an agitated Patient comes in handy with this Population.

    You will find some past Threads on De-escalation Techniques if you do a Search.

    Here are a few basic/general pointers, off the top of my head:

    Don't raise or strain your voice. Speak calmly and matter of fact in a low voice. Let them know you hear what they say. Use verbal listening. Don't be confrontative. Give them options. Praise appropriate responses/actions. Don't get into their Biological Space. Don't be wide eyed- keep your eyelids at half mast. Don't be Animated. Slightly nod your head when they exhibit any positive behavior. Slightly shake your head when they exhibit any negative behavior. Stand loosely with your hands at your side, knees slightly bent. Stand at least an arm's length away from them, facing slightly away from them, turned away from their predominate side. Always have another Staff Member with you when dealing with an agitated Patient.

    These are not all the pointers there are, and not all of these pointers will apply to every situation, but it's a start. There are many other Techniques that you will learn as you progress in the field.

    The best to you, studentnurse9806!

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    Not too often: maybe 1x a month max. Unless I'm working the psych ER, but even then its not much more. And we shut down almost all of the situations before they escalate to the point of violence.

    That is the key in psych: don't wait for the explosion before you act. The minute you see the warning signs of escalation in a patient/situation, start doing something about it.

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    Always have another Staff Member with you when dealing with an agitated Patient.

    One point I neglected to add was, when you are dealing with an agitated Patient and have another Staff Member with you, only one Staff Member needs to do the talking.

    More than one Staff Member talking can be interpretted as a power play, and/or be overwhelming to the Patient. These interpretations can cause an escalation in agitated behaviors.

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    Thanks for the advice it is very helpful. Anyone have tips as what to say and not to say to a patient? Im afraid of being awkward and not knowing how to respond

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    Don't show fear, even if you are scared in the beginning. There are always other staff members around (at least in my inpatient acute unit) who will come to help. A minute may seem like an hour, but you should always have support.

    I've been in inpatient acute women's for a year. I now know my 'frequent flyers' and what sets them off an how to deescalte them...

    It's never a dull moment - enjoy it!!

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    If you must wear earrings, don't wear dangly ones.

    No necklaces.

    Don't ever turn your back on or turn away from any psych patient.

    Don't ever allow yourself to be alone with a patient ... ever!

    If a particular patient gives you the willies or ever tries to intimidate you, always take someone else with you or delegate what you can.

    I remember one patient who was in a psych hospital when I was doing my student psych rotation who followed me around, got within about two inches of my nose and would say, "Kiss me like you mean it, Sweetie!" [/i] About ten years later, I arrived for my shift at my then job, and heard those immoral words, "Kiss me like you mean it, Sweetie!" yep...

    Trust your gut hunches. Always! You will develop what my Mom used to refer to as an "Oh YUCK!" feeling and an "I just don't trust him/her" feeling and an "I don't feel safe." sense. Trust them and follow them.

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    My first job as a new grad in 1986 was as the relief charge nurse of an acute, locked adolescent unit. It was a behavioral modification unit. None of the kids were on that unit voluntarily. Most of them did not have mental illness, they were normal kids acting out, being teenagers. They were often tricked into being locked up and were understandably angry. Daily violent and dangerous situations occurred. I was frightened of doing something wrong, of being hurt, of letting someone else get hurt.

    What worked for me was this; I decided that I would just pretend I was one of the older, more experienced RNs. I had watched the other nurses handle several conflicts a day. I just did what they did. I pretended it was Mary Anne or Nathan talking. I would use their phrases and terminology. And it worked. Over times I adopted and skills and adapted them.

    This is what works:

    Remain calm. Respect personal space. Respect the individual. Set firm limits. Speak BRIEFLY and concisely. Do not make promises you cannot keep. Do not state consequences you cannot implement.

    Remember that you are not alone. The experienced staff will not allow an agitated individual be assigned to you. The patients are also watching out for you. They know you are a student and want your time and attention.

    Violence in MH is often associated with drug abuse. Know the population you are working with. There are a few diagnosis associated with violence, but most MH patients are not violent, in fact no more violent than the general population.

    Things have changed drastically and for the better since 1986. We collaborate with the patient and try to work through situations. We rarely resort to confrontation which leads to assaultive behavior.

    I wish you the best of luck

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    Anyone have tips as what to say and not to say to a patient? Im afraid of being awkward and not knowing how to respond

    You've rexcieved some outstanding advice from the other Posters, studentnurse9806. As I read their responses, I could hear myself saying, "Yeah ...yeah!"

    It's great knowing there are such competent, on-the-ball Mental Health Professions out there!

    One other thing that I'd like to ad is regarding "what to say" when a psychotic Patient is saying some bizarre things. When I first got into the Field, I had difficulty responding to Psychotic or Delusional verbalizations.

    Generally, I'd advise you to remain calm and as objectively factual as possible. "Reality Orientation" is what it's called. But don't try to confront or talk a Delusional Patient out of their Delusion. The Definition of a Delusion is "a firm fixed belief in spite of evidence to the contrary". Let the Medications and the other Mental Health Professionals deal with this.

    You'll develop your own technique if you work in this Field very long. As it was previuosly advised, watch the other Professionals and emulate their approach.

    Once again, Good Luck!

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    I work on a lock down forensic behavioral stabilization Psych unit. Violence directed towards staff happens every day. These patients are criminally insane and the majority are guilty with exception of insanity. None of them want to be here and many will attack staff because they want to get new charges and go to prison. Some believe that if they're violent enough, the state will wash their hands of them and they'll get to go back to the community (sadly, this has happened- corrections can't handle them and they cause so much damage to the state hospital- one guy did 2 million dollars worth of damage- that the state can't afford to keep them, so they just get sent back out).

    We get training in crisis management, learn safe containment (least restrictive means to stop violent behavior), and if a patient is having a behavioral crisis we always make sure to have 2x to 3x the weight and height of the patient standing off to the side (so as not to provoke the patient while still being prepared) while one person attempts to deescalate (starting by giving the most amount of choice, "It's okay to be upset but you can't do that -observed behavior- here", to the least amount of choice, "Right now, could you please return to your room or walk with me to the side room." Ect.).

    sometimes patients give no indications prior to attempting assault, so we follow basic safety precautions- always work in pairs, don't turn back on a patient and basically be aware of your surroundings.

    Acute psych - non- criminal was very different however and I never personally experienced physical violence.

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