Right to defense against violence on adolescent unit

Jules A, MSN · Dec 11, 2009

This probably isn't a good fit for a single Dad that is getting attacked on a regular basis, imo. Personally while my patients have violent histories they rarely strike out at the nurses. In psych generally I think the expectation is that we can get hurt based on the nature of our jobs but again even in my adolescent unit, which is forensic, it is rare for them to just attack us like you describe.

I don't think it is ok for us to be punching bags but I also don't see much point in pressing charges on someone with a documented mental illness. While I would advocate for someone to defensively protect their self I can't advocate staff striking out even in defense at a psychiatric patient. I absolutely do administer a IM cocktail for patients that have assaulted anyone no matter how calm their demeanor after the fact.

Since you are trained in martial arts I'd think you would be better able to subdue a patient without actually harming them. Without trying to come off as critical I really wonder why there is such an animosity between nurses and patients. Mine aren't boy scouts by any means but for the most part they like our staff.

Meraki · Dec 11, 2009

I'm wondering why there is so much violence on your unit as well and if anything could be done to prevent some of it. We deal with a lot of really angry kids but they are rarely violent. Part of it is asking questions as to why, how, what if... Such as...

Are the teens bored? Is there a good program in place to structure their time and keep them occupied? Is it meaningful to their lives?

Are they being treated with respect or are they seen as violent thugs?

Are staff working to form therapeutic rapports with them (fast) to have a connection in order to deescalate? Is someone getting to know them, do they feel someone is genuinely invested in them and validating their feelings and experiences?

Do they feel they are being treated unfairly or that the rules are very restrictive or harsh taking away any remaining sense of control they have?

What are the options when they start to get upset - is there a place they can go to let off steam safely, are they given space, can they exercise?

Is there an understanding on the unit of trauma informed practice - many violent youth have been traumatized and react from a place of defensiveness to a perception of threat?

Are they in gangs because in the neighborhood they come from if they aren't then their lives are at risk, and is violence the only model they have really seen to deal with conflict or vulnerability?

When they aren't violent can they talk at all about their anger and reactions? Can they make any connections between feelings, thoughts and actions?

For me, if a kid gets really angry and violent then to me I haven't done my job - they are there because they are aggressive / violent so it is my job to address teh underlying causes of that behavior. I'm not saying I can control or prevent all aggressive behavior but I can always ask myself what I could do differently to have led to a better outcome. I am also very careful as to where I stand, my body posture, my tone of voice, how many other staff are nearby, etc... when I am dealing with a potentially volatile situation. In well over a decade I've never been in a situation where I had to fight back to defend myself.

We don't have cops or tazers or any weapons in the hospital at all.

It sounds as though there are some policy / philosophical approach issues on your unit. I'm glad you are looking for another job but I feel for the kids (and the staff being hurt) on your unit. It really doesn't sound like a great place to work or to be a patient.

CrashVector · Dec 11, 2009

I agree. I could in NO way in good concience recommend the unit where I work to anyone.

The unit doesn't practice what they (we) preach. We try to teach them coping skills like taking a walk or watching some TV until they cool off, but we don't let them go outside and the physicians have a "rule" against letting them watch TV. The physicians have to approve any books the kids can read, there is no excercise room, etc.

There are all things I have raised as concerns during staff meetings, and I tend to get looks like I have worms crawling out of my nose.

The teen in question from today isn't just your typical angry kid. I have seen probably two kids like him in all the time I've been a nurse. He beats the snot out of his crippled grandmother. He beats the snot out of his mother. He comes to our unit repeatedly (this is his 6th admit to our unit) and tries to beat the snot out of random staff members.

And yes, I am capable of subduing someone without causing injury (pressure points and the like) but its not always possible to completely rule out the case of accidental injury during the take down of an extraordinarily violent patient.

The question wasn't really for ME exactly, but what about those that are NOT able to take someone like that down? Do they simply get their heads beat in because they can't protect themselves?

It's sometimes really sad to watch...we do our dead-level best to help these kids, and every so often you get one that just wants to try and hurt other people. Doesn't matter if its out of poor self-esteem or because their mother abandonded them. The point is they are trying to severely injure staff members and we are not allowed to protect ourselves.

I personally have never been injured...and I sometimes DO work in a forensic unit. But I HAVE seen other staff members pretty beat up, as in bloodied and sent to the ER themselves.

The patient in question isn't a "psych" patient as in he doesnt have schizophrenia or bipolar or another physiological problem. His diagnosis is "ODD"...Oppositional Defiant Disorder.

I'm not saying we as nurses should get in the habit of injuring patients because we forget basic skills to de-escalate a patient, or because we're too lazy to try to bond with them. What I AM saying is that in the rare case of a patient who is explosively and unpredictably violent, nurses should be able to protect themselves without fear of being fired.

It's not a question of putting overly aggressive staff on a unit to beat the hell out of a kid for lashing out. It's a question of maintaining an atmosphere where we will have the backing of the hospital should the rare case arise where a staff member is being beaten and we have to protect them from being smashed in the face by a chair.

CrashVector · Dec 11, 2009

A few interesting facts about violence against nurses. Found this on the U.S. Department of Health and Human Services website:

http://bhpr.hrsa.gov/nursing/NACNEP/reports/fifth/intro.htm

"Violence against nurses is a complex and persistent occupational hazard facing the nursing profession. This violence can take the form of intimidation, harassment, stalking, beatings, stabbings, shootings, and other forms of assault. Nurses are among the most assaulted workers in the American workforce. "

Notice in the article that they only count it as an assualt if it results in injuries that require the nurse to take time off of work...so only God knows how many nurses are assaulted and it is NOT reported.

"The causes for underreporting are numerous. Many nurses believe that being assaulted may be viewed as poor performance on their part, or that assaults are just part of the job. "

"“Seventy percent of nurses are assaulted on duty during their careers."

Here is the scariest part: Nurses are more likely to be assaulted than prison guards or police officers.

"Health care workers are more likely to be attacked at work than prison guards or police officers. Nurses are the health care workers most at risk, with female nurses considered the most vulnerable. General patient rooms have replaced psychiatric units as the second most frequent area for assaults. Physical assault is almost exclusively perpetrated by patients. 97 percent of nurse respondents to a UK survey knew a nurse who had been physically assaulted during the past year. 72 percent of nurses don't feel safe from assault in their workplace. "

I'm just trying to say that with violence against nurses on such a scale, preventing said nurse (or CNA or MHT or Tech) from even being able to protect themselves without being fired is rediculous.

Jules A, MSN · Dec 11, 2009

It is a shame your facility isn't more supportive. If this is really only about one patient and his assaults are documented I'd see if your facility would consider not admitting him, admitting him to a more fitting unit or adding extra staff to do 1:1 with him for everyone's safety. I don't know if it is like this at your job but we have issues sometimes getting support due to the fact that staff can be lazy about filling in incident reports. If we have a kid that is problematic we document every single thing in an effort to protect ourselves and hopefully get them moved to a more therapeutic environment. Good luck.

CrashVector · Dec 11, 2009

JULES:

As I was leaving yesterday, three of the nurses were filling out incident reports, and I had already filled one out. I'm a stickler for documenting EVERYTHING I see.

I called the unit this morning, and talked to the nurse manager, who told me last evening that they were having a meeting this morning about what to do with this kid.

As it stands now, they are attempting to arrange his transfer to a juvenile detention facility due to his repeated pattern of random assaults. I was told that the physician who is responsible for repeatedly admitting this kid to the unit has also been told that the patient is no longer welcome at our facility due to the fact that we cannot adequately staff the unit while he is there.

The tech that he assaulted was his 1:1 observer. The patient had asked to leave the group room to use the bathroom, and as the tech walked along side him, he simply spun and punched him in the face without warning, and proceeded to continue to hit him because the tech tripped as he was backing away from him. The patient jumped on him while he was on the ground and continued to punch the tech. The tech was fired for striking the kid in the chest in an attempt to get the patient off of him so he wouldn't continue to be hit.

In an incident such as this, I think the tech's actions were completely justified, even though he DID in fact hit the patient. His only other alternative was to continue to allow the patient to punch him in the face while he was on the ground until help arrived to pull the patient off of him.

In a case like this, I fully feel that physical force is justified being as the tech was in a very precarious position and because the patient's obvious wish to do him severe harm.

In regards to some things I've read on the 'net about being choked by patients, I think my training gives me good perspective on how dangerous that is in particular. A proper choke will render just about anyone unconcious in 3-5 seconds. It is potentially lethal. In tournaments, I have both been choked out and have choked out other competitors. In my experience, it takes between 2 and 4 seconds due to physical exertion. A choke that is not released within 30 seconds has a good chance of causing brain injury due to the fact that neither oxygen nor blood is getting to the brain.

Although admittedly a very extreme example, would a patient ever succeed in getting me in a choke hold, I would fight like my life depended on it, because it just very well might.

License be damned. I'm smart enough to get a different degree. I'm not willing to be beat to the point of permanant injury because policy says I'm not supposed to defend myself.

In this tech's case, I'd sue. Not enough security measures in place to ensure the safety of the staff against a KNOWN violent patient.

elkpark · Dec 12, 2009

So we are supposed to take someone who is throwing full-power punches and kicks and subdue them gently in a manner that doesnt hurt the patient? ...
I want to know what, if any, legal trouble I would be in for using physical force against a patient that is actively trying to seriously injure me. ...
When do nurses have the right to use physical force to stop a patient from punching us? ...

1) Yes, you are supposed to take someone ... and subdue them gently without injury, using only the techniques approved by the facility and your state DMH.

2) Potentially, you would be in exactly the same legal trouble you would be if you assaulted the client on the street.

3) Apart from the approved intervention techniques approved by your facility and the state, you don't. You can defend yourself without harming the client, but, as soon as you assault the client using any unapproved techniques, legally, you will always be in the wrong.

jpRN84, BSN, RN · Dec 12, 2009

post deleted

kiwipsychnurse · Dec 12, 2009

If you work in such an unsafe facility that the model of care allows for nurses/staff to assaulted with no consequences for the perpetrator then best you leave.

Unless you want to become a punching bag for this character and anyone else that sees they can get away with it.

Would he get away with punching a cop, a prison officer or maybe a doctor and saying I'm calm, I'm calm.

99% of the time in our facility for a hitting staff and or other patients you will end up in seclusion. You will also most likely be restrained, and the more you fight it the more the restraint hurts. We look after some of the hardest men and violence and restraints numbers are very low. Plenty of other nursing options for you. Even if you have to go interstate. Or try a stint downunder, nice weather this time of year.

epg_pei · Apr 20, 2010

This thread has become relevant for reasons similar to the original posters. I have to work tonight with one of these kids. I once had notions of spending many years working as a nurse and retiring in reasonably undamaged condition. Fantasy? I hope the patient is still in seclusion as I left them last weekend, and not out on the unit as the doctor originally ordered.

Weather's nice down under eh.... :clown:

whodatnurse · Apr 20, 2010

Google 'Sharon Edwards murder'. She was a 28-year old murdered on her first night as a counselor at a residential psychiatric facility who was stabbed 26 times with a hunting knife by a then 16 year old hell bent on escaping. He's now serving life in prison. In a court of law he was not found to be NGRI.

The two points I wish to make are:

1. Once you're dead...it's too late. If you work for a facility where employees are left to fend for their own safety, you need to get out of there ASAP.

2. Despite having a psychiatric condition, you are still accountable for your actions, including and especially violent crimes against others. Again, if you work for a facility that doesn't apply all the various consequences other posters have mentioned to violent clients at their facilities, then you need to get your butt out of there ASAP.