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.

[Kipahni, RN]

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.

[Kooky Korky, BSN, RN]

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.

I am confused. You say "the patient", so I think there's one pt. Then you make it sound like its more than one pt. Maybe irrelevant, but is it 1 or are there more? How many?

How do other nurses handle this patient? Those patients?

What does your Manager say about this situation?

Are you sure there are no policies in place for handling violent people? Are you not allowed or supposed to call Security?

Code Whatever that would indicate that violence is occurring and help is needed at once?

Is the Risk Manager aware?

HR?

Is this a Psych Ward? Most psych units have immediate back-up available and I have seen some violent patients either arrested and taken to jail by police right from the ward, or immediately released to the street.

We have one doctor who admits an addict today, let's him go tomorrow per his request, re-admits him next week for an overnight, let's him go the next day at his request. We really dislike this doctor because she's not helping him, she's presumably making money for this unhelpful care, and we have to do a ton of paperwork with each admission and each discharge, plus we know we're not helping him.

Also, if a pt refuses care, document your attempts and re-attempts, let your coworkers roll their eyes to the moon and back, and just ask them if they are getting all of their orders carried out for this patient.

You might consider not accepting him as your patient any more. Not all staff can work with all patients. Maybe you are just too concerned about his physical care but he really might have a death wish, might hate himself, might be mad at the world, who knows? If the docs don't know, just leave it alone, interact as little as possible with him.

Whatever path you choose, do not get hurt on account of him and his illness, whatever it might be. Getting hurt is not in your job description. Quietly watch other staff intervene and interact with him. Are they successful? Emulate them.

[Kooky Korky, BSN, RN]

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.

I know you feel particularly vulnerable while pregnant, but really, anyone who has young children feels that way.

Don't let pregnancy be a reason not to talk things over with your manager and with policymakers where you work. Rules need to be established that protect all staff from all violence. Even though you plan to not go back to your job, don't be weak on this. Get prayed-up if you are a praying person, then ask God to give you wisdom, courage, strength, blessing, and protection. Then make the appointments to start the ball rolling on those talks.

[imintrouble, BSN, RN]

Never had a pt who scared me physically.

Have had a few that spew hate, but that's just blah, blah, blah, to me.

We rarely get violent pts up to the floor, simply because they're sedated to the max. Then when they wake up they just want to leave.

One good thing about being old...er. There's not much that scares me in the hospital anymore.

[NurseOnAMotorcycle, ASN, RN]

Have had PTs try to shiv a coworker with something they ripped off a wall, had another who was lifted off the ground in a choke hold from behind. Don't mess around. Just call security if you ever feel that uneasy.

[NurseOnAMotorcycle, ASN, RN]

to clarify (dont see the "edit" button today):

a coworker was lifted off the ground by a chokehold from behind by a pt.

...after a while you realize you can't help people who won't help themselves.

That.

A nurse's role is not to help people, care for people, etc... a nurse's role is to help people help themselves. If they're not down for helping themselves, there's very little that we can do about it.

OP, realize that your employer has a legal obligation under federal regulations to provide you with a safe workplace.

Personally, if a patient is threatening violence, I categorically refuse to interact with them unless I have enough people with me and appropriate orders.

My very highest priority, in every case, is my personal safety... in that regard, it *IS* all about me.

[brandy1017, ASN, RN]

An ICU nurse wants said if you can't relate, sedate! Frankly a violent patient needs sedation such as haldol to protect himself and us! Also restraints may be in order till the patient is calmer! Also call security when necessary for added backup. We are not here to be abused, the job is stressful enough without having to put up with this crap. If the person is confused and not of sound mind, they still need medication to keep them calmer if they are violent to others! Not only is this person a danger to us they could end up harming fellow patients given the opportunity. This kind of thing frequently happens in nursing homes and psyche wards, where a violent patient attacks or even rapes other patients. This must not be ignored or tolerated! It must be dealt with appropriately!

[NurseOnAMotorcycle, ASN, RN]

Brandy, don't forget we have a bigger advantage in the E.R. and ICU. Our nurses have the advantage of having a provider right there with them. Floor nurses don't. I really don't think you'd be able to get an order like haldol or geodon from an internist or surgery.

Also, apart from the elderly dementia or confused ones who wanted to leave, I've never had any violent pts when I worked on the floors. I definitely wouldn't have had the experience to instantly known what to do in a truly violent situation.

My gut reaction to someone threatening a nurse on the floors is to get immediate unquestioning help. Security will show up instantly without any long winded discussion on why its necessary. After you have that help, then the MD or PA or NP can argue with the charge nurse about whether to restrain the pt with a security watch or medication.

Brandy, don't forget we have a bigger advantage in the E.R. and ICU. Our nurses have the advantage of having a provider right there with them. Floor nurses don't. I really don't think you'd be able to get an order like haldol or geodon from an internist or surgery.

This... I've tried to get a Geodon order from the surgeon who flat-out refused and said he'd be rounding in the morning.

"OK, I said... quite likely the patient will no longer be here..." (she was a wanderer, too)

"You can't let her leave," he said.

"You're not giving me the tools to prevent it," I retorted.

The whole thing was a freaking mess

I routinely say, "ED is nursing for cowards." People are always taken aback to which I reply, "If I'm in a room and need backup, I've got four MDs at the bedside in less than 30 seconds."

Security will show up instantly

Our security is very good... but it can still take 10 minutes or so because sometimes they're already deployed. It can be a very long wait when a patient is throwing chairs and IV poles.

[NurseOnAMotorcycle, ASN, RN]

Despite being called a coward, I agree wholeheartedly. Floor nurses have it freaking hard. OP, don't mess around, just call security.