How to manage violent patients
When a psychiatric patient was brought to the ED by the police department and searched, a loaded "zip gun" was found in the patient’s front pocket. "This looks like a writing pen, but actually holds a bullet and has the capacity to kill someone," says Sherlene Stepp, RN, MICN, clinical nurse supervisor at University of California at Irvine Medical Center in Orange.
Another patient was brought in by the police department and was placed in the exam room. When the nurse went into the room to examine and search the patient, the mentally ill patient was found trying to ignite a bullet with a lighter, reports Stepp.
These are just two examples of potentially violent scenarios that are all too common in today’s EDs, Stepp stresses. Signs of a potentially violent patient are varied and hard to determine, says Carol Buschur, RN, CEN, clinical coordinator for the ED at the University Hospital in Cincinnati. "However, we can be aware of a patient becoming more anxious, less rational, and more defensive." Crisis development ranges from anxiety to loss of physical and emotional control, she adds. "Each person is going to react to crisis in different ways, as we are all individuals with different backgrounds, different cultures, different experiences, and different issues each day."
Here are ways to manage potentially violent patients:
• Set limits.
Staff can defuse an angry person by setting limits that are reasonable and enforceable, says Buschur. "When a person displays anxiety, staff should be supportive, empathetic, and nonjudgmental," she says. "You should be direct and set clear limits."
However, setting limits can sometimes escalate the problem, says Diane Presley, RN, MSN, director of nursing for emergency services/critical care at Seton Medical Center in Austin, TX. "For example, if you say to a patient, This is not appropriate,’ it may get him or her to escalate even more," she warns. Instead, give clear, nonthreatening cues that this behavior will not be tolerated here, advises Presley.
• Avoid medical jargon.
Avoid using any abbreviations that a patient would not understand, for example, saying "GI pain" instead of "stomachache," says Buschur.
• Involve others.
If a patient becomes violent, avoid taking the behavior personally, and stay in control of your own behavior, Buschur recommends. "Acknowledge that this person is attacking you, and get support from your team. As you evaluate and assess the situation, develop alternatives."
Be proactive in alerting others to a potentially violent patient, recommends Presley. "Tell your charge nurse there may be a problem and give an early heads up to security."
• Consider nonverbals and paraverbals.
Nonverbals include personal space and body language, explains Buschur. Paraverbals are "how we say what we say. For example, a patient’s tone, volume, and cadence can be strong indicators of escalation."
• Watch for signs of potential violence.
Look for the following signs, advises Presley.
— alcohol and drug abuse;
— anger and or high stress;
— psychiatric problems;
— history of abuse;
— injuries from a violent encounter;
— repeat visits with a history of violent behavior;
— delusional behavior;
— angry tone of voice;
— demanding attention;
— paranoid or suspicious behavior;
— loud speech patterns;
— actual aggressive statements or threats;
— clenched fists;
— facial tension and clenched jaw;
— tense, closed posture;
— increased activity such as pacing or getting up and down out of bed.
Explain delays to patients
• Keep patients informed.
"Long wait times also anger patients if there is no communication about why there are delays," says Presley.
• Create seclusion rooms.
The ED at University of California-Irvine converted two rooms in its fast-track area to use as seclusion rooms, says Stepp. They have been stripped of anything that the patients could harm themselves with. "The room has only a gurney, which has leathers attached to it at all times, so we eliminate that frantic search for a full set of leathers during a crisis."
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