I am a final semester nursing student. I intend on going into psychiatric nursing as soon as I graduate. I have done clinical rotations at one particular facility for about two years now. That is the facility in which I intend to work.
Today I was able to attend a portion of orientation. It was based on how to protect yourself, the patient, and deescalate a violent or potentially violent situation.
I am starting this thread primarily for my fiance, who is very concerned about my safety in a psychiatric facility. I intend to work on the adult acute unit. We have rarely had violent outbursts on my unit. I understand that psychiatric patients are not 'out to get' the nurses/staff/mental health workers. However, in the case of violence, when 'approved moves' are not adequate, your take down team is taking too long, and you have no help, what is expected of the nurse? (I understand that you should ALWAYS be vigilent, never put yourself in that situation, and have team members on your unit in sight at all times.) The question was posed by my fiance ("If you were in a life or death situation, would you defend yourself however necessary"), and I told him that I would do whatever was least harmful, approved, and that would get me out of the situation. He believes that if my life were at risk, I should be able to do what I need to do to survive. Part of me agrees with this, and another part realizes that it is not appropriate, or legal in all instances.
I would really like your thoughts on this situation. Also, I would like any situations that you have been in as psych nurses that may be similar. It would be very helpful, as this topic has caused a lot of hurt feelings and strife for me.
Ending note: I realize that this situation is highly unlikely, especially where I would be working, but the question is "What if..."
Thank goodness we have acts of law that prevent this type of issue. If someone is trying kill you and you are sleeper hold and you punch them in the groin you get fired?
So basically you need to be a punching bag? And not defend yourself because of fear you may lose your job? Is that the same for police,corrections officers or anyone else that deals with violence?
In NZ we are allowed to use resonable force to protect ourselves or others.
Not only fired, but you can be facing criminal charges for assault, if the client chooses to press them, and your nursing license will probably be in jeopardy.
I'm v. surprised by your comments about psych nursing practice in NZ -- I was always under the impression that NZ was a lot more "civilized and enlightened" than the US. I'm really surprised to hear that inflicting intentional pain on psychiatric clients is considered appropriate practice there.
Not only fired, but you can be facing criminal charges for assault, if the client chooses to press them, and your nursing license will probably be in jeopardy.
I'm v. surprised by your comments about psych nursing practice in NZ -- I was always under the impression that NZ was a lot more "civilized and enlightened" than the US. I'm really surprised to hear that inflicting intentional pain on psychiatric clients is considered appropriate practice there.
Could it be that the difference between our psych system and yours is you select which patients are suitable for your hospital and if they are too violent and aggressive then you send them to prison? This ensures your hospital's patients are relatively settled and at low risk of extreme violence.
My workplace takes those that are extemely violent that have killed, raped, maimed etc. from prison and the community.
What do you suggest we do with an extemely violent gang member that is mentally ill?
Sometimes de-esclation and all the nice things in life just don't work. Restraint, seclsuion and medication is the only option.
By the way we are quite civilised. In New Zealand, 100% of our citizens have access to comprehensive mental health services.
Could it be that the difference between our psych system and yours is you select which patients are suitable for your hospital and if they are too violent and aggressive then you send them to prison? This ensures your hospital's patients are relatively settled and at low risk of extreme violence.
My workplace takes those that are extemely violent that have killed, raped, maimed etc. from prison and the community.
What do you suggest we do with an extemely violent gang member that is mentally ill?
Sometimes de-esclation and all the nice things in life just don't work. Restraint, seclsuion and medication is the only option.
By the way we are quite civilised. In New Zealand, 100% of our citizens have access to comprehensive mental health services.
In the US, there are many killers, rapists, maimers, other violent people, etc. from prison and the community in mental hospitals. Some of them probably do belong in prison. The reverse is also true - some prisoners don't get the mental health care they need.
Mentally ill persons should not be intentionally caused physical pain. If they are on the rampage, of course, staff do need to protect themselves. Unfortunately, self-protection can come at the cost of one's job, livelihood, and freedom. It's not so for nurses in the ER or for police. Attack them and you are in trouble.
Of course, so much of how patients treat a staff member is due to how the staff treat the patient. Being calm and courteous, using humor when possible, making every effort to be kind and empathetic all go a long way to prevent violence.
In the US, there are many killers, rapists, maimers, other violent people, etc. from prison and the community in mental hospitals. Some of them probably do belong in prison. The reverse is also true - some prisoners don't get the mental health care they need.
Mentally ill persons should not be intentionally caused physical pain. If they are on the rampage, of course, staff do need to protect themselves. Unfortunately, self-protection can come at the cost of one's job, livelihood, and freedom. It's not so for nurses in the ER or for police. Attack them and you are in trouble.
Of course, so much of how patients treat a staff member is due to how the staff treat the patient. Being calm and courteous, using humor when possible, making every effort to be kind and empathetic all go a long way to prevent violence.
I have seen cell take outs of mentally ill inmates in a psych wing of the prison in Ohio. The guards went in with pepper spray, shields and body armour. The patient was extreme pain while they restrained him and carted him off to off to another room/cell. That was filmed in 2009 for all the world to see. I show the doco to a students when I do a teaching session. So not only does the US prison/mental health service intentionally cause physical pain but they film it and make a doco out of it.
Why should a person, just because they are mentally ill not be subjected to pain/physical force if they are hurting/killing someone. They are no different to anyone else. Violence is violence. If your daughter, son, mother father was being assaulted by someone with a mental illness would say to the police please dont cause them any pain as they have mental illness.
What do you do with a patient that randomly punches nursing staff in the face and doesnt care if you are male of female? You have done all the respect, caring, kindness and humour. Sometimes that just doesnt work and you are dealing with someone that is totally irrational that is totally out of control. Sometimes force is nessessary. If you get sacked,lose your registration, sued and prosecuted for defending yourself then thats a sad state of affairs.
On a side note:
We use no pepper spray, no tie down beds, no restraint chairs, no sheilds and no body armour. We do use physical restraint to contain the situation and seclusion for the minimum amount of time possible. On the rare occasion we use those leather restraint belts that go round the waist and bring the arms in to the waist.
I have seen cell take outs of mentally ill inmates in a psych wing of the prison in Ohio. The guards went in with pepper spray, shields and body armour. The patient was extreme pain while they restrained him and carted him off to off to another room/cell. That was filmed in 2009 for all the world to see. I show the doco to a students when I do a teaching session. So not only does the US prison/mental health service intentionally cause physical pain but they film it and make a doco out of it.
Key word here being "PRISON" ... There is a big difference between correctional officers in a prison and healthcare workers in a hospital setting in the US (there's even a big difference between the correctional officers and the healthcare staff within a prison). There's also a big difference, legally, between someone who has been convicted of a crime and sent to prison and someone who has been admitted medically to a psychiatric facility (although, of course, they may be equally mentally ill). Hospitals and prisons are v. different milieus in the US, and there are v. different expectations of the staff.
Key word here being "PRISON" ... There is a big difference between correctional officers in a prison and healthcare workers in a hospital setting in the US (there's even a big difference between the correctional officers and the healthcare staff within a prison). There's also a big difference, legally, between someone who has been convicted of a crime and sent to prison and someone who has been admitted medically to a psychiatric facility (although, of course, they may be equally mentally ill). Hospitals and prisons are v. different milieus in the US, and there are v. different expectations of the staff.
I suspect we will never agree on this issue. Makes me thankful for the country I live, the laws we have around Health and safety in the workplace and the strong union nursing has in New Zealand.
Note: you can't sue for personal injury in NZ (that is any personal injury even traffic accident)
One of the things to remember about nursing in general, is that the nurse gets report. One would hope that when shift change happens, anything that occurs with a patient or information on new patients is shared with the incoming shift. It is then that the nurse is best able to prepare for the shift they're about to undertake. We find out what PRNs were given, what behaviors were exhibited, and who's on or on their way to a one-to-one.
In short, when you know your patients, you know who poses the potential threat and plan your approach accordingly. Are people unpredictable, sure. Is report always accurate, nah. But information on who your patients are is key to safety on the unit.
And another thing, sparked by something I heard about the other day. We hope we're alert. But after numerous shifts, sometimes we're not. We don't always keep on our toes, but we hope that the unit as a whole is run well. This way there's adequate staffing, which means multiple sets of eyes and ears and people to back us up when something goes down. I guess we do the best we can.
Since my prior post I heard about an unfortunate incident on a unit where better staffing and management would have been helpful in prevention. Sad.
Seated holds sounds like you require a great deal of strength for this method to work. I have no idea how this works I'm guessing you have a nurse either side and sit the patient down and prevent them standing up.
If we tried to use such techniques in our forensic facility I foresee at great deal of staff injuries. People being put in hospital by patients, massive amounts of sick leave.
We use restraint called C & R. It basically bends the patients wrist back and inflicts a great deal of acute pain. Very effective and had been in place for 18 years now. Not one broken wrist in our work place.
Our work place is very unionised and when we are confronted with people attempting to change the way restaints are done we can always make it a union issue or health and safety issue.
Oh a note about night shift. Kick back watch TV bring in a laptop play some games. Reading polices and patient histories at 3.00am is useless, your brain is all mush. Do the basics but just relax. This is my opinion. When you look back on your career will you say I read polices at 3.00am or watched Dexter on my laptop and got paid for it. :)
Seated holds don't work, are hard to do, and don't work. We used to have an excellent program, but have recently traded it in for a program called "Response." It's a crock. The seated hold is one person on either side, you slip your arm under their armpit from the back in sort of a hook fashion. Then you are to back that person to a wall, and slide them down the wall. When they are sitting down you are to sit on either side of them with your closest leg on top of theirs and the person on the other side does the same. To prevent spitting and biting another staff member is supposed to hold their head. The patient is usually so violent that their thrashing, so you and them end up being slammed off the wall instead of slid down it and it doesn't prevent spitting and biting in the least.
Specializes in med-surg, post-partum, ER, psychiatric.
I am on one of the most violent and active units in our psych hospital. People who get hurt are those who generally are not using approved verbal or physical SIT procedures. As the charge nurse, I have watched staff many times approach a patient who is being violent and how they approach them. Sometimes, when patients are going "off", they are in "animal mode".........and to be able to work with a violent patient is also similar as to how to approach an animal (understanding animal behavior). Sorry for the comparison there but those who have worked psych know exactly what I am talking about.......First and foremost (and somethign I also learned in Martial Arts and also taught my students when I was teaching Martial Arts).....avoid the situation as much as possible.....don't get yourself into a bad situation (i.e., ALWAYS be vigilant and expect the unexpected)........secondly, if the situation arises you cannot totally avoid it, that is when Verbal SIT comes in. Being able to know how to use the right THERAPEUTIC sentence starters and avoid the "fighting words".........remaining in control, but firm and matter of fact (but not making "threats" such as "if you don't calm down, you will end up in restraints/seclusion", "you are going to lose your home visit because I will knock down your level", etc. Remain out of power struggles/plays.......... Thirdly, IF it comes to the point of having to use Physical SIT, then if it becomes to the point YOUR life is in danger, etc., as our campus police have told us, you do whatever you can to protect YOUR life. In RARE instances, has that actually happened...........we have received oustanding physical and verbal SIT training at our facility. That is one of the major benefits we have, by working in major psychiatric facilities, is that we get that training, whereas in hospitals/EDs, they do not get that same training..............I also work EMS as a medic/RN. And I have worked Med Surg et al. Believe it or not, Forensic units are actually the safest of all the units as a whole, and the most violent units are the adolescent and pediatric units. I LOVE working psych and outside of wanting to work ER, I have no desire to work anything else.......been there, done that! I have been with psych for a few years...........it is one of the most stressful specialty areas, and most misunderstood on many levels, but it is also one of the most rewarding.
Specializes in Psych- child, adolescent, adult, and CD.
Good luck with your nursing career! I also went straight from graduating to working in child/adolescent psych--on night shift (and was promoted to house supervisor within 6 months). I used my down time to read the charts to learn more about things I wasn't familiar with. I also picked up extra shifts days or evenings when I could so that I could get some "real" experience with being with the patients when they were awake. I love psych nursing and I love working nights!
As far as the violence goes...yes, I have been injured a few times, never anything major, but like many have said: you can get hurt working as a nurse on most any unit where you come across an angry patient. Hopefully, when you get ready to have a baby you will have a supervisor who will look out for you. If things every started looking like they were going to get bad, I sent my pregnant nurses to another unit, or had them take their patients to another area of the hospital til things calmed down.
I wish you the very best in your nursing career, and hope you enjoy psych nursing as much as I do. People are right when they say that it takes a certain, and sometimes special kind of person to do the work we do.
I am on one of the most violent and active units in our psych hospital. People who get hurt are those who generally are not using approved verbal or physical SIT procedures. As the charge nurse, I have watched staff many times approach a patient who is being violent and how they approach them. Sometimes, when patients are going "off", they are in "animal mode".........and to be able to work with a violent patient is also similar as to how to approach an animal (understanding animal behavior). Sorry for the comparison there but those who have worked psych know exactly what I am talking about........
I agree completely, and have often used the "wild animal" comparison to working with psych clients in emergency/crisis situations (with the same apologies and explanations).
elkpark
14,633 Posts
Not only fired, but you can be facing criminal charges for assault, if the client chooses to press them, and your nursing license will probably be in jeopardy.
I'm v. surprised by your comments about psych nursing practice in NZ -- I was always under the impression that NZ was a lot more "civilized and enlightened" than the US. I'm really surprised to hear that inflicting intentional pain on psychiatric clients is considered appropriate practice there.