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Rookie Wit & Wisdom
When Violent Patients Hurt Nurses

I work in a small ICU setting, and we have problems with confused patients who try to leave and become violent when you try to block the hallway and redirect them.

I've had a patient's husband swing his walker at a coworker who told him visiting hours were over. I've been scratched, bit, have bruises on my arms right now from patients. I've had my right wrist sprained while trying to keep a patient from pulling out their NG tube after an esophagogastrectomy--I was just trying to hold the tube in place without letting them pull my hand away from them. I've been sent to the ER for various injuries over the years. I've had coworkers kicked in the chest by patients and knocked across the room. I have one former coworker who was kicked, and she fell and hit her head; this resulted in a need for a craniotomy and long-term rehab.

Let's not even discuss the verbal abuse by families and patients.

Where do we draw the line? Security is available in every hospital I've ever worked in, but in 12 years of nursing, they've never gotten to the unit before we nurses had the situation under control ourselves.

The worst part is that it seems that there are no consequences for the person/patient who assaults a nurse or hospital worker.

I had one patient with DTs post CV surgery who told me he was going to put a hit out on my life. We don't know if these type threats are legitimate. What do we really know of our patients outside the hospital? I saw him in the hall on another unit a week later and he stared at me. I was nervous. He said, "I'm not sure why, but I feel like I should apologize to you for something. Should I?"

I wasn't really sure what to say: "You were a pretty wild man for a few days, but I tried not to take it personally. Good to know you don't remember it."

Does anyone have suggestions about violence against nurses by their patients and visitors? How can we protect ourselves and care for our patients?

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14 Responses to “When Violent Patients Hurt Nurses”

  1. nursingaround Says:

    Firstly, you mention two patients, the ones that are genuinely confused due to illness/head injury/surgery etc, then you mention relatives and other abuse that is not due to illness.
    What we did at our small emergency department to deal with the non medical/confusion related injury was to begin an advertising campaign, eg posters saying zero tolerance to violence etc. We also put an advert in the local newspaper, well it was more than just an advert, it was an article on the front page by our charge nurse talking about the sort of stuff we have to put up with. We did get quite a positive reaction, people would come in and say they read the article and really be on our side.
    What we also did was beef up security, both environmental, eg security doors, hidden alarm bells, make sure all rooms had a second exit etc, plus the increased presence of security staff.
    Most of the above ideas are preventative in nature. As for when actual confrontations occur, your reaction is different depending on if it is a confused patient, eg a head injury patient lying on bed lashing out at anyone. In these cases, never deal with it alone. Two years in the psych unit taught me that restraining one arm is pointless when they can swing at you with the other. Perhaps learn some simple restraining techniques etc, but of course if it’s a head injury patient, then you need proper medical assistance as it could be a sign of something serious going on.
    Remember, one of the first signs of lack of oxygen to the brain is agitation.
    I hope this has helped. I could keep on going, but the biggest thing is being prepared.

  2. Mr Ian Says:

    I’ve worked mostly in restrictive mental health units (lock-ups) and violence from patients is well known as being not uncommon place in such establishments.

    I would say, if it was going to kick off anywhere… I’d rather it be in there than any other part of the hospital. The staff are generally experienced and trained in managing violence and not just by using tae-kwon-do.

    Several ideas pop into my head that might be of use to you. I will surmise the legal ones.

    The bureaucratic approach
    Workplace health and safety. Not sure where you work or the laws of your land but pretty much everywhere nowadays has a Workplace Health & Safety policy and practice. Take your issue up with them and ask THEM to resolve the difficulty. Even for the aggressive confused patient, they still have a role and responsibility to ensure your safety at work.

    Resolution may involve permanent security staff at the department, if it is frequent, or at least have them close by. More secured areas may help so staff can simply evade potential violence by physical security. (Note: evade violence; not avoid relatives)

    If polite inquiry doesn’t further your cause, try union support or, if there’s a group of you who are really militant – workplace incident forms – by the hundreds – and, if you’re stressed by the event, then take 1-3 days off post incident to recover, citing “work place violence/stress” as the cause on your return.

    At the end of the day Administration remains accountable for costs – if it starts to cost them money in sick leave, they will act. Sad but true.

    The Local/Unit approach
    Brief your local unit or nursing manager on the issues. They’re not silly little events and health staff nowadays are not expected to tolerate it as part of their job. Even for the confused (meaning patient’s – not managers); there’s a limit to what is reasonably expected of staff. Getting beaten is not one of them.

    Prompt the nursing or local unit management to draw up some meaningful guidelines and plans. They may, if they’re of any use, possibly organise some training in de-escalation, management of aggression and even breakaway and restraint techniques. The simplest of knowledge in this area can prevent the severest of injuries from occurring. Simply knowing how to quickly and calmly get a patient to release a grip on you can often make the person desist if they think they’re messing with Jackie Chan/Lucy Lui.

    The individual situation
    When faced with imminent violence do like I do – run like buggery and hope they slip on the trail of urine you leave behind.

    However, several other possibilities exist before it gets to the stage of incontinence.

    (There’s an old favourite joke of mine about a lion tamer teaching his protege how to control the lion – the punchline is similar – “if the lion does not respond to the first two commands I pick up some shit and throw it in his eyes” – “But what if there isn’t any shit?” – “If 1 & 2 don’t work – there will be”)

    Back to the scenario –
    Violent/aggressive relatives –
    There’s usually a reason they’re angry/upset. Dying relatives can get you a tad emotional. Wild spouses (who probably put them in there in the first place) resolving guilt for their actions or inability to help. I’m sure you can relate to those sort of concepts and many others.
    One thing I learnt in mental health – if it’s in my power to appease their need – then do it. It’s rarely worth getting a smack in the mouth for. Stupid little things like ‘visiting hours’ or not knowing what’s going on with their loved one can often be easily overcome and are unnecessary agitators in such highly emotional areas of ED/ICU etc. Don’t just give in tho – seek a pact or alliance from the aggrieved. “Look, if you can calm down I can go see if I can get you in for 5 minutes to see them, but you have to help me here and calm down”. Don’t ever make them promises you won’t/can’t keep but try to give them a little special attention. Yeah I know, they’re eating your time and they’re a pain in the gluteus, but 5 minutes now can save an hour of trauma later.

    Ok, so there’s those that are just reckless or off their heads on crack and you haven’t got time cos your job calls first – then get security or call the police. If possible, it’s helpful for admin staff to be able to help out with relatives but in supportive ways, not dismissive ones. I highly recommend training for any admin staff who might be used in this way, even in basic communication skills. In a pro-active unit you might even find a “relative’s nurse” who is there just for such occasions who has knowledge and know-how. I’m not sure what current practices are in ED/A&E/ICU depts but I know they face a high risk of violence and such innovative ideas can make huge differences.

    Violent/aggressive patients –
    Regardless of causality, violence to staff (or anyone for that fact) is not acceptable.
    If a patient is non-ambulant – just wheel their bed/chair into a safe zone and talk to them at a safe distance. If you have to perform procedures on the patient, only do so when sufficient or suitable staff can assist. Never place yourself in harms way if avoidable. (eg patient’s husband with the walker – once he’s made his intent clear by swinging once – back off, he can hardly chase you). Don’t condescend them because it seems safe that they can’t chase you. That’ll make them worse and they can wait their time to let you know it too.
    If a patient is ambulant – (then they’re fit to leave – j/k) – then I suggest treating them as you would a relative – talk with them about their concerns. Often patients come in with serious looking injuries and to the expert it can be quickly assessed as routine stuff. However, it’s still serious to them until they know otherwise. Finding out what their issues might be can be a great help. Sometimes it’s nothing to do with the injury – childcare issues when they’ve been waiting 4 hours to get their bruised finger x-rayed, etc. Let them know how much longer or even if they can go and come back again.
    One of the biggest causes of aggression is pain – so in your setting I can justifiably recommend such sedating drugs. Narcotic ones are pretty effective but don’t use them as habit when someone is aggressive. Benzodizepines are also effective in reducing anxiety. However, if it’s recurrent aggression, still try to find the cause if you can.

    For all scenarios, assess the real dangers. If someone is just ranting – they’re not violent, just aggressive. But don’t leave it unattended or it may soon become violence. If they’re tearing their clothing – so what? If they’re tearing out tubes – hmmm… refer to narcotics.

    The most effective weapon we have in such scenarios is our mouth. Always use your communication skills. Anger is an expression. It’s used when the person has a need. It’s the wrong way to express something we know, but it’s for a reason. If you can find and deal with that reason, the anger tends to go away.

    As for legal recourse; I judge each occasion on it’s merit. I’ve only been struck a few times (4 in 14 years) and I’ve prosecuted twice. If your law enforcement doesn’t recognise your right; take it further. You have a right not to be assaulted.
    Even in mental health, violence is not accepted or tolerated and I’ve seen several mental health patient’s go to court/jail for it.

    In past places I have seen dept of prosecutions throw it out citing “They’re mentally ill so it’s not in the public interest”. Sometimes, their mental illness is not the cause and in such cases, prosecution is justified. However, in the clinically deranged, I would exercise compassionate understanding. If old Ethel didn’t recognise me as a nurse when I went to put my hands on her for whatever clinical reason – she might lash out. It’s good practice with the confused to always remind them EVERY time you interact with them “Hi, I’m a nurse and would you mind if I….” – remember, every time you return might be the first time they think they’ve met you.

    In my current place of residence they’re about to introduce “serious assault” charges for people who assault health care staff – it’s the same charge applied to assaults on police officers. I’m fairly pleased with that and feel valued.

    So, as in every teaching I ever did I can hear the – “What if….” questions from here…

    What if he’s a rough looking biker with head injury and chest drain and drunk, can’t be sedated, trying to get out of bed and all the other staff are off attending a young kid with breathing difficulties?

    When it happened to me – a simple wristlock helped him to remain where he was while we discussed it sensibly and calmed down. It wasn’t painful but it exercises physical control that buys you some time. I felt justified in using it under duty of care principles and by virtue of my (nursing-related) training in such methods.

    But if you don’t have such useful techniques – Be creative in other ways.

    Sing lullabies to him.
    Squawk like a chicken and walk like John Cleese.
    Walk around with a bandage completely covering your face chanting mantras and holding a waste paper basket.

    One thing I’ve learnt from nursing patients in mental health – they don’t mess with the really crazy ones.

  3. nursingaround Says:

    Mr Ian, brilliant. You’ve summed it up so well. I only spent a little over two years in the psych unit, I was the only male in the unit at the time I went to work there, so you can imagine what it must have been like. It was a small town unit, but not a secure unit, although the doors did lock. We had a bit of everything.
    I digress. I really enjoyed reading your comment.

  4. angiegirlie Says:

    Mr. Ian, I completely enjoyed your response and got some great ideas for our unit. Our hospital does annual training for de-escalating violent clients, but it’s usually not very effective. 40 “students” with one “instructor” just doesn’t work when you really need to have a hands on experience.
    I’ll be researching the workplace safety laws and getting info to my management team (I’m sure they will love it…) It would be interesting to find out if my state has any laws or if anything is being put out there about assault on nurses being equal with assault on a police officer.

    Thanks for the guidance!

  5. Mr Ian Says:

    More than happy to be of use. If you want more info or help please feel free to stalk me.

  6. liz Says:

    I used to work in a high care dementia nursing home and you would get hit quite often. if the person is coherent, in a normal hospital setting, you can get security up and they call the police and charge the patient with assult, same with visitors. mental health is scary-we had to wear personal alarms all the time in case we got in trouble.

  7. Mr Ian Says:

    High care dementia home? Presumably they weren’t running after you down the hallways?

    I’m trying to imagine the police interviewing dotty old Mrs Jones:
    “Do you understand your rights?”
    “Oh of course, and why did you not bring me my milk this morning Johnny? I do wish you’d grow your hair long again.”

    If they are ‘coherent’ why are they in a high care dementia home?

    Anyhow, yes, old folk can be aggressive. I know and I’m sorry to bum on your post! But it gets to me how frail old people can cause severe harm to staff – it’s one of the easiest places to NOT get hurt by a patient… (That and the morgue).

    Most assaults I’ve seen in aged care settings are brought about by carers, not the patients.
    Aggression in the elderly is usually founded in poor communication and empathy from the staff. If an elderly patient assaults staff, the first thing you MUST do, is analyse what was wrong with that persons approach and then what underlying conditions the patient has/may have that could cause distress.
    If those are ruled out, then I’d agree, you have a very dangerous violent psychopathic granny on your hands.
    Elderley people are not violent; perhaps miserable, grumpy, confused (as in – have no idea who you are or where they are); depresed; probably constipated; get dressed each morning by someone they don’t even know; get force fed food they can’t even taste or probably don’t even like after a stable diet of 60+ years of home cooking and are talked to like they’re 5 years old with nothing to offer the world.
    I’m not trying to judge the standard of care in the home you work in, but if you’re getting “hit quite often” then the statistics are pointing to you, not the patient.

  8. Erin Says:

    What about a dementia pt that the facility cant get rid of that attacks people un-provoked while staffs backs are turned…what do you do then. As a nurse what are my rights if I am being attacked, how can I stop it. What if one pt goes to attack another and I must intervene to protect the non aggressor pt? So then I get attacked and hurt? (this happened to me tonight)

  9. tracy Says:

    Long reply!

    Demented patients often can kindly and humanely be trained to accept care when it is given respectfully. The field is “neurobehavioral psych” and it’s very interesting to me.

    There are such persons as the “dangerous violent psychopathic granny”: she used to be able to tell herself, “Oh, I shouldn’t, because…” but now she cannot rationalize, if cognitive functions have deteriorated. “Disinhibition” can be more than just refusing to wear pants.

    Erin, it sucks that you got hit. The patient is now a known entity and should be on full visual field, that is, backs will never be turned on him or her. This requires teamwork. This patient creates the demand for more staff, basically. You can take turns watching him or her (believe me there are PLENTY of violent females) to give each other breaks. And take turns steering the other patients away from him or her BEFORE any incidents.
    Gather understanding about the patient. Note carefully the patterns of escalation: does this patient “ramp up” and in response to what stimuli? What has the consulting psych said? (does the patient think he’s in a POW camp?)
    Just as importantly, what positive reinforcements does he or she respond to? THe one that works most is positive attention. Reward the client for acting well. For every five minutes without violence, ask, say or do something nice. Then bump it up to ten. If he or she starts to get aggressive, only interact the minimum required to de-escalate and don’t make eye contact.
    Ask your management about behavior plans, because consistency is really important with this.

    If your facility cannot do this, the family needs to start looking for a dementia care facility. …Meanwhile there will be a lag time and you still have this patient. I don’t know what your rights are because I have never had to deal with it. I have never been hit unless during a takedown with other people (patient flailing)because our man could not be talked down. There is an art to not getting hit that I could talk a little about, if necessary.

  10. Lea Strongheart Says:

    I was brutally assaulted by a patient many years ago. It resulted in severe ptsd and the end of my career. As a matter of fact, I ended up sleeping in my car, under a tree and in a homeless shelter after my social security benefits were cut. I tried to work but could not. I was put through three years of tortuous court hearings because my employeer denied workers comp. The man who assaulted me came after me two more times and I was stalked. I was told I looked like his es wife. Criminal charges were dropped at the last minute due to a psychiatrist bailing him out. I am not bitter, even have forgiveness in my heart,but I continue to have problems on a daily basis. My advice is institute a zero tolerance for violence. Make noise..speak the case changed some laws in Pa regarding violence and nurses….but the price paid…unbelievable.

  11. Erin Says:

    the patient in question that attacked me was a little old patient… she escalated at night after 7pm, they couldn’t medicate her as all meds she could not tolerate at ALL (seriously) Unfortunately this woman, did not respond to any + reinforcement when she got in these moods, and no amount of redirecting her worked.. Often we would give her busy work and help her with it, and that would calm her, but that night she literally came away from her busy work (while another staff member was watching her) walked over to me and boxed my ears from behind while I was on the phone with HER dr. (the staff member witnessed it but the woman moved so fast she couldn’t warn me) She had total dementia and no attention span, could not remember anything even for a few minutes. Unfortunately her family also could not get her into any dementia units, she had sexual behaviors towards the other patients and they couldn’t let her wander a unit where the other residents were left defenseless. She was also known to strike out at other residents unprovoked, She wasn’t a nasty person. She was just a little demented lady. She also wasn’t this way all the time. I felt bad for her, but at the same time, felt my own safety was in jeopardy … I did end up getting hurt the night she assaulted me and another nurse together. We did eventually get her meds more adjusted, but the final outcome I feel was sad for her. I did like her, even despite getting the crap kicked out of me (you could HEAR my hair being pulled from my head!)

    I wonder what MY rights are as a nurse though, when it comes to nursing home violence from pt to a nurse.

  12. Mr Ian Says:

    Erin – I’m sad to hear you got assaulted and I agree with much of what tracy wrote.
    I’d also urge you to consider staff attitudes towards the patient – you say “the facility cant get rid of” him/her – which indicates that perhaps staff are burnt out by this pt – which makes positive interaction very hard to do. But it can make a difference.
    If you can find ways to understand his behavioural patterns – you can find ways to break them.

    Lea: I’m even more saddened to read your tale and I do agree that zero tolerance is the way. However, and perhaps like you, the consequences of violence do not always have to be punitive. We understand in certain circumstances that violence is tolerated – eg War; apprehending a criminal; self defense. But when it comes to violence out of frustration or mental health issues or grief and loss even – we vary in how tolerant we are.
    I’d still say “zero tolerance” – but “graded empathy”.
    I wish you well in your ongoing recovery and thank you for making a difference for others by your actions.

  13. Jennifer Says:

    When I was training new CNAs in a nursing home I worked in, I always told them “Go in every room knowing EVERY resident could potentially be agressive.” It was just a regular nursing home, but we’ve had new staff hit or assaulted by residents because they assumed that because “Mrs. Smith” was fine at dinner they didn’t have to be on their guard. Particularly with patients/residents with dementia, like Mr. Ian says, it doesn’t matter how many times you have been in their room, each time may be the first time they think they’ve met you. I worked as a CNA at this facility, and I think a big mistake people can make is assuming elderly people are just that, elderly and frail and can’t do harm, so they just go in briskly and try to get them dressed or whatever as quickly as possible so they can get to another patient/resident. If someone you didn’t know just came right in and started stripping off your clothes you’d fight back too. We had one resident who’s “aggression trigger” was taking her showers. She scream and try to hit anyone in her path the way down to the showers, and during the process she wasn’t much fun either. One of our CNAs had the good idea to try her in the whirlpool bathtub instead, and the bath time aggression stopped. This resident always used to take baths at home, she never liked showers. A few extra minutes to talk to her would have taught us that. But she wasn’t able to think clearly enough to communicate that with us on her own. The more choices given to patients/residents, the better. That way they still have some control in their lives. Of course, this doesn’t work with some residents, but it will cut down on some of the violent behavior overall.

  14. Keisha Says:

    I am on light duty on my med-surg/ortho unit.A patient of mine decided during her detox from alcohol that her chest tube needed to be removed NOW!! She was incredibly strong and due to the fact that I love to lift weights, I am no slouch. Our struggle went on for approx 1 full minute (felt like 20)before anyone heard my screams for help and then it took 5 people to put her back to bed. Our patient punched my supervisor in the chest.I have had fellow nurses say “I would have let her pull out the tube.” It never crossed my mind to let my patient cause harm to herself although I am sure she had her own aches and pains from being restrained.In most cases we will be caught off guard as I was and its easy to say what you may do in that situation but I dont believe that is an accurate account of what one would really do. Noone wins in these situations and I am afraid that it happens to be a job hazard. Having your employer support you fully through your recovery if you are injured is very important although it doesnt solve the problem. May the force be with you all fellow nurses!!

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