01.04 Aggressive & Violent Patients

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Outline

Overview

Violence and agression can no longer be seen as “part of the job”. It can affect patient care, ED flow, and the workplace environment. Knowing first how to deescalate, and then how to respond when conventional methods fail will protect both you and your patients.

Nursing Points

General

  1. What is considered an aggessive or violent patient?
  2. How do we respond?
  3. What is acceptable?
  4. What to do when deescalation fails?

Assessment

  1. What is an aggressive or violent patient?
    1. Profane or dissrespectful language
    2. Sexual comments
    3. Inappropriate touching
    4. Racial jokes
    5. Outbursts of anger / throwing things
    6. Retaliation
    7. Aggressive physical contact or restraint
      1. Medical vs behavioral vs situational
  2. Obstacles to addressing these patients
    1. “Just part of the job”
    2. Lack of communication skills
    3. Fear of reprisal (no one will back us up)
    4. Lack of resources
  3. Prevention first
    1. Initial contact
    2. Use the patients name
    3. Give generous time estimates (If you know it takes 10 minutes…tell them 20, dont undersell)
    4. Dont cross your arms
    5. Establish availability
    6. Sit near the patient
    7. Dont write or type while patient describing main concern
    8. Therapeutic touch
    9. DONT FORGET THEY ARE THERE!
  4. Dealing with the situaion
    1. Descilation
    2. Challenging the nurse / doctor
      1. Let the patient vent
      2. Be emphatetic
      3. Repeat information and speak to patients feelings
      4. Watch your body language
    3. Noncompliance
      1. Set limits
      2. Provide time frame for choices
      3. Establish consequences
    4. Emotional release
      1. Let the person vent… privatley (remove the audience)
      2. Undivided attention
      3. Listen to what is not being said
      4. Dont turn your back
    5. Intimidation
      1. Maintain space (at least 2-3 feet away)
      2. Open stance
      3. Open hands (not in your pockets)
      4. Remove anything that could be a weapon (pens, shears, stethoscope, badge lanyard)
      5. Always have an exit
      6. Show of force
      7. GUN! GUN! GUN!
    6. Physical Violence
      1. Never acceptable
      2. Protect yourself above all else
      3. RUN!
      4. Know how to get your team (If unexpected violence)

Nursing Concepts

  1. Communication
  2. Coping
  3. Safety

Patient Education

  1. Violence and aggression are not acceptable in the Emergency Department
  2. If there is an issue, let someone know

Transcript

Hello everyone and welcome to today’s lesson on dealing with aggressive and violent patients in the Emergency Department.

Aggression and violence unfortunately is not uncommon in today’s emergency departments. It’s our job to recognize when these situations come up and how to deal with them.

What do we consider an aggressive or violent patient. Well, aggression does not have to be physical. It can be in the form of disrespectful language, profanity, sexual or racial comments, inappropriate touching, outbursts of anger or throwing things, and then of course, physical contact. This can be actually being struck by a patient or being restrained physically. 

In dealing with aggression, we need to understand its basis. Is this a demented patient who is cursing at us or a mentally ill patient acting out, or is it s family member who just lost a loved one and is now looking to retaliate?

There are some obstacles to dealing with these patients. One of the most common among ED nurses is that it’s “just part of the job”. Im sorry guys, but its not. We do not have to stand for aggression and we certainly should not accept violence.

We may not have the best communication skills for dealing with these patients. A lot of that comes from experience.

Some of us may have a fear of reprisal, we don’t think our administrators have our back. If we stand up for ourselves, will it cause more of an issue?

And the lack of resources…we will talk about the show of force…but to do this, you actually need people. Not every ED has security on staff.

The best way to avoid violence and aggression is with prevention. It usually starts with the initial contact. Creating that report with the patient, use their name! We want to give generous time estimates…always overestimate. Don’t tell a patient it will be 10 minutes before they go to CT when you can’t guarantee that. Even if you can’t control the timeframe, if the timeframe passes, you are seen as liar and losing your patients trust is hard to get back. If you know it takes an hour to get labs back, tell them best case is 2 hours. Never cross your arms, it blocks you off and looks agressive. You want to establish your availability…can anyone say call bell? When your talking with your patient, pull up a chair and sit next to them. Do not write on  a pad or type in the computer when the patient is pouring their heart out. That is actually something i do with my students in clinical. I never let them bring anything to write with during the initial interview, Go get to know your patients!

And never forget your patients are there. I know we get busy, and if they don’t need anything urgently, we tend to focus on our sicker patients. Time stops of patients in the ED so 10 minutes seems like an hour. Don’t forget they are there, swing by every so often just to check in with them.

Now….how do we deal with the situation. The most thing to do is try to de-escalate, basically, talking the patient down. 

If they are challenging the nurse or doctor, let them vent. You want to be empathetic to their feelings. When they tell you something, repeat it back to them so they know that you are listening and understanding. And watch your body language, those closed arms can set a lot of people off. Patients see everything, never forget that. 

If a patient is noncompliant, we need to set limits. Let them know what behavior is acceptable and what is not. If there is a choice to be made, give them a time frame and establish consequences of the behavior continues. 

If they are having an emotional release, let them vent, but remove the audience..try to move them to a private area. Make sure you give them your undivided attention. And do not turn your back on these patients. They are emotional and if they think you are ignoring them, they could lash out physically.

Some patients try to intimidate nurses. If you see this happening, maintain space between you and the patient, at least 2-3 arms lengths. Keep an open stance with open hands. Closed hands mean fists and are seen as aggressive. Take off anything that can be use as a weapon… pens, shears, stethoscope, lanyards (and yes,m i have been choked by my own lanyard when i leaned over the patient i thought was unconscious). Always have an exit. Try to put yourself between the patient and the door. Call for a show of force. This is simply a numbers game. Get as many people as you can to simply stand with you when interacting with the patient. This can be other nurses, security, ancillary. If an aggressive individual finds that they are up against 5 or 10 people, they suddenly may not feel as intimidating. If you see a gun….scream GUN GUN GUN and get the hell out of there. You are not bulletproof!

Physical violence is never acceptable and you need to protect yourself. If you find yourself in this situation, know how to get your team or run. It really doesn’t matter why someone is hitting you…you just need to not be hit!

When dealing with these patients, usually communication is the best prevention. There outbursts or aggression are just there way of coping with the situation and we have to do our best to redirect them. And of course, our safety first and then the safety of our patients. 

A few key points. We discussed what is considered aggressive and you need to know what is acceptable and what is not.

We need to overcome the obstacles to dealing with these individuals.

Prevention is the best tool in dealing with aggression but if it does escalate, know how to deal with it.

And if all else fails, get the hell out of there!

Thanks for joining us today and please check out the rest of the emergency medicine series here on NRSNG.com and as always…

HAPPY NURSING!!!