Violence on the psych ward

notes from case conference on violence

-50% of psych residents have been assaulted sometime during there residency

many times patients are frightened by their own lack of control, and end up thanking provider for any interventions. trust your gut, if you get that uncomfortable feeling, its for a reason.

types of interventions...

what do you do when patient is verbal, agitated, complaining-

ask the patient to room or quiet spot, dining area maybe to sit and talk, respect personal space. also your behavioral style is important so speak softly and move slowly. tell them their actions are frightening others- its all how you say it, use a small posture, hunch a lower in a nonthreatening way, don't hide your hands or turn your back. Sometimes sitting at a 45degree angle helps calm, others have said sit side by side so you both are "looking out at the crazy world like a pair of lost truckers". Be sure to leave an exit for both you and the patient, listen empathetically and hear them out. Offer food or drink, these are culturally universal symbols of nurturance. Then you want to assess the possibility of violence. Aske, are your worried you'll lose control? Can you control yourself? Is there someone you feel like hurting right now? Who? Don' use negatives, instead of saying "you can't shout" say "show me you in control". btw this is good for kids too.

PRN Meds can be PO or IM- the point is these are her for "helping the patient maintain control of himself/herself". If agitated to the point where its warranted introduce the meds by saying, "the staff doesn't want anyone to get hurt"

if you have to think about whether the patient needs stat prn meds, or you need to mobilize the "show of force" - say to the patient, "i have a call to make, i'll come back"

major point - if you decide the patient needs STAT PRN you have to go all the way, no conditions, arguing, or bartering can be allowed, do not change your mind. At this point you will need to mobilize a show of force -psychotic patients will respond to a show of force most times by agreeing to take the meds, allow them to submit without them losing face, organic person (encephalitis, meningitis, neoplasm) will not respond to show of force.

You need:

1. a leader (does all the talking)

2. someone to clear the decks, put patients back to their rooms

3. one nurse to get the seclusion and restraints ready

4. one nurse to ready the stat meds, don't forget IM,

5. one person to call security

6. five people to hold patient, more is better,

remember -never establish a show of force w/PO meds only, need to bring only IM

1 staff for each limb, 1 staff for head, neck, airway control

only the leader talks, "i need to talk to the patient alone"

when security arrives if it looks like you don't have things under control, they will take control from you, so greet security w/two sentences stating succintly what is going on.

the leader talks to the patient and gives the need and reason:

"your behavior has escalated and this medicine will help and you NEED it"

patient may dispute, bargain, question, threaten to sue, call lawyer - you have set conditions you can never back down - repeat the need for meds and give them a choice- IM or PO

restraints vs. seclusion- many patients have harmed themselves in seclusion (padded room) by scratching themselves or banging their heads, makes the case for using restraints, with mentally retarded patients go for using the restraints.