Violent patients.

You need some serious policy change. If the patient is admitted and declines treatment, then they should be discharged. End of story. This is not the Hilton, or 3 hots and a cot. There also should be some security that will go into rooms with you on patients who are that unpredictable. We have even had the local police sit 1:1 with patients who are violent.

See if you can have a staff meeting to talk about and brainstorm ideas for patients of this nature. See if you can set policy. Do some research and use your resources. Start a crisis intervention team. There are nurses (myself included) who--I wouldn't use the word enjoy--but find crisis intervention nursing a strong point. See who on your unit are these nurses. A crisis intervention team can come when you call them, much like a rapid response. Partner with the local police department on this.

Unfortunetely, there are patients who are so severely mentally ill, addicted, demented that no amount of "reason" will calm them. But there needs to be a policy and plan in place. If an MD is going to section someone who is a danger to themselves and others, then they need to be available for restraints when indicated.

Everyone could take a crisis intervention certification course if that is their "thing". The local sheriff's department as well as the court system also has other avenues to take. An inservice of all of these details would be a good thing.

Why is this behavior allowed/ignored? I wish management would put their foot down, but I know I wouldn't have the guts.

So even if you were in a position to change policy/practices ... you wouldn't?

I mean, I wouldn't have the guts to stand up to the patient most times because if it was just me, I'd fear for my safety. If I was management, I would talk to the physicians about discharge and bring security into the room with me to eject the patient if necessary.

The thing is, the patient is so sick that they do need to be the hospital (but they are mostly sick because of noncompliance). This is one of those patients who never follow-up, probably wouldn't go to a facility, and has refused home care.

You can't save every kitten. If the physician feels strongly that the patient needs to be in a care situation, that physician can initiate a guardianship or section. Otherwise, let the physician feel the wrath of policy that states "be adherent to medical/nusing plan of care or leave."

No matter how ill you believe the patient to be, they still have the right to refuse. And the MD has the right to discharge in that instance, or to follow through with court/department of mental health avenues.

I have been a after hours hospital manger I.e. the senior nurse in the hospital in charge of allocating bed for ed pts, resource for the staff emergency controller for all codes.

2 of our codes repeats to aggression 1 is unarmed the other armed threat which can be any kind of weapon from an iv pole that a pt is swinging to a gun. I attended all of these codes with security. If the pt was 'mad' its one thing but just 'bad' I would call the registrar and inform them what was happening. They had to give me a very very good reason not to have them discharged to the cells with the police who attended every armed threat. I have had pts that could not be discharged, arrested on site have a police presence and after they had been charged moved to the jail ward in the hospital that provide that service.

You need to get policy changed ASAP for everyone's physical and emotional safety

I had a similar patient a few times over the course of a couple weeks. I was so happy when he went ama. He threatened us with violence as he was leaving and I was just flabbergasted. I'm 7 months pregnant and he was threatening me physical harm. I hate my job so much. I won't be going back. I'm so tired of being treated like that.

1. Call security and tell them you're scared. They will come just because you asked.

2. Tell your charge that you want the pt on security watch.

3. Call the MD and get an order for a security watch on the pt. (1:1 watch, considered to be restraints, pt not allowed to leave the room.)

Document verbatim the threats the pt is making to you and/or anyone!!

Document verbatim what the patient says. Document "Patient unaware of RN observing patient. Patient noted to be calm, watching tv, in NAD." On your vital signs sheet make notes that patient refuses to allow BP taken, etc. Inform MD and chart "MD aware of patient declining interventions. No new orders at this time". And definitely have security involved. It is frustrating to have truly sick patients refusing treatment, but the patient always has the right to refuse. And you can make yourself crazy trying to get through to each patient, or you can recognize your limits and save your mental health. In the ED I see a lot of this and I used to get myself all worked up over them. But after a while you realize you can't help people who won't help themselves.

Is this person dementia/high crazy or just hateful? If they are high we give them IM shots and then put them in restraints if they are violent- if the pt physically attacks you or acts like they are, or verbally abusive call security, call your charge and call your manager. Verbal Abuse from the hateful you sternly look them in the eye and say " Excuse me, I will not tolerate being spoken to in such a way. You have a right to refuse treatment, I am here to help you, if you refuse my help I will let your doctor know and your doctor can discuss with you your health options. or if you feel you are not getting the care you need, here are the papers to leave AMA."

I have called dr and put them on the phone with there patient to talk to. I have also had some strung out physically abusive pt that were too much for the floor staff to handle that I have in the called a doctor and said " Either you give me an order to move them to our Intermediate Care with a sitter and some heavier sedatives or I will find a doctor that will. They are too dangerous for our Med/Surg floor and pt has already assaulted many staff member. " (the first two medical doctors I called said no, pt psych doc said yes. persistence pays off- don't be afraid to move up the chain of command but always let your charge or manager know what is going down.)

They are looking into making it a felony if you assault a nurse.

Finally after any high stress time, when you find a moment in your shift shut yourself in a bathroom look yourself in the mirror and say " Even though you felt attack, and it was a high stressful moment, you are safe, you are strong, you are at peace." Then vent with a co worker or friend and when home watch something funny or exercise ( I like tap dancing, Zumba, running or boxing) I say this last part because in the human body when we perceive a threat we either fight, flight or freeze. Since you are at work and you have to ignore those responses and essentially your bodies chemical signs it is best that you address it in a healthy way as quick as possible so that you do not start to experience the physical damaging effects of stress.

Perhaps you already have some of the effects - it is part of being a nurse

Physiological effects

Headaches Muscle tension and pain Chest pain Fatigue Changes in sex drive Upset stomach Problems with sleeping Urinary Problems

Psychological effects

Anxiety Restlessness Lack of motivation or focus Irritability or anger Depression

Behavioral effects

Overeating or undereating Drug or alcohol abuse Social withdrawal

If you are experiencing any of the symptoms over a course of time then it is your body trying to tell you-" HEY Notice me! Help!" Do not forget to be first a nurse to yourself.