Violent patients.

[0.adamantite]

We get quite a few patients who are verbally and physically abusive. Many of them are confused, but some are not. Our unit culture allows this type of treatment of staff. There is no support from physicians or management when patients such as this are admitted, and many of them are frequent flyers.

I received one last week and have had them follow me through the week. It has been miserable. I try my best to provide them with cares but they refuse repeatedly, even when I have others offer later. I continue to offer and re-attempt and often I can see them starting to boiling over like a pressure cooker. This patient is very volatile and unpredictable. They have thrown things, threatened bodily injury/death to me, yelled obscenities at staff. Accused me of neglect when I know that I have been rounding, verbally trying to beat me down. I am frightened for my safety each time I enter the patient's room. This is a very sick patient, too. I worry that they will be dead, or something's going on and I have no way of knowing because they are refusing blood pressures, etc.

Then I also get it from the nurses at hand-off. Asking me X didn't get done, etc. They have never met the patient before. I try to explain, but I still get the "look." That is, until they meet the patient.

Management shrugs their shoulders. MD says, "well they shouldn't do that, but what can you do?"

Why is the patient here if they won't accept treatment? They have left AMA countless times, no facility will take them any longer. Why is this behavior allowed/ignored? I wish management would put their foot down, but I know I wouldn't have the guts.

[jadelpn, LPN, EMT-B]

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.

[Altra, BSN, RN]

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?

[dudette10, MSN, RN]

I feel for you. I've been at my facility for a year, but my old facility did not have the type of patients you speak of in such great numbers. It took me at least six months to get emotionally accustomed to the refusals of important care, the verbal abuse, and their leaving AMA. I learned to say to myself, "I cannot continue to emotionally care about this patient more than he cares for himself." You still do your job, by all means, but you separate yourself from it. These patients are the 1 out of 10 that you just can't "fix."

Good luck.

ETA: I have to point out that, unlike your experience, my facility doesn't have a lot of violent patients...just verbally abusive ones. Like others have said, policy needs to be created to protect staff from the violent ones.

[0.adamantite]

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.

[nurseprnRN, BSN, RN]

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."

[Nurse SMS, MSN, RN]

Safe harbor.

[jadelpn, LPN, EMT-B]

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.

[K+MgSO4, BSN]

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

[SoCalGalRN]

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.

[NurseOnAMotorcycle, ASN, RN]

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!!

[sandyfeet]

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.