Managing Disruptive Patients _ ________________________________________________________________
• Alert other members of the healthcare professional staff of a potential problem. Do not call on new and inexperienced staff members. Additional personnel should be available to help with a crisis. WHEN VIOLENCE ERUPTS If the risk for violence escalates and a patient is behaving in a threatening manner, the healthcare professional staff must act quickly. This may mean administering medication against the patient’s will. In such situations, following the textbook protocols may not be possible. The best rule of thumb is to follow hospital policy and state laws, protect the patient, and provide for the safety of all present. Careful and timely evalu- ation of the situation means containing any violence using the least restrictive means possible. Rigid adherence to precise procedure may not result in the desired outcome. When patients, families, or visitors are experiencing a crisis, a person’s ability to think rationally may be diminished. This can lead to unpredictable behavior. Urbanek & Graham (2022) suggest when staff are being threatened, they should: • Stay calm and communicate in an even tone and manner. • Attempt verbal de-escalation strategies to calm the person in crisis. • Keep a safe distance away from the person to avoid being physically assaulted. • If things begin to escalate further, staff should remove themselves from the situation as quickly as possible and seek further assistance from other staff, the internal response team, Public Safety, or even police if necessary. • Do not attempt a hands-on approach with a person who is an active threat, unless required by your role and trained to do so. Healthcare professionals should always seek assistance in an emergency. They should get help from the security staff, other available healthcare professionals, or any other facility personnel. A patient who has a weapon should be disarmed by persons who are trained to do so. If the patient cannot be disarmed easily, the safety of healthcare personnel and that of others in the area must be considered. Shields and barriers may protect against knives but not against a patient with a loaded gun. Other patients and visitors should be moved to safe and secure areas, and local police should be engaged in such a situation. If the patient is unarmed, anti-anxiety or anti-psychotic medica- tion, physical restraints, or possibly both may be needed. This is often the decision that needs to be made by appropriate medical staff, quickly and with assurance, based on existing protocols and appropriate training. Erring on the side of cau-
PRELIMINARY ACTIONS The healthcare professional staff should carefully manage patients who are agitated and seem to be at risk for violence. The following steps are important for healthcare professionals to remember in these situations (NIOSH, 2024; OSHA, 2024): • Maintain a demeanor that helps defuse anger. Present a calm, caring attitude. • Give patients who exhibit irritability choices and options, but make sure they are valid, true choices and options. • Do not be demanding and argumentative; perhaps some rules or procedures can be waived temporarily. Patients who are angry and potentially violent generally feel helpless and powerless. They need help with their self-control. • To avoid power struggles with these patients, do not confront them. This approach will help de-escalate the patients’ behavior and the situation. • Open and consistent communication should be ongoing among staff members and between the patient and the staff. Talk to the patient. Try to find out what is precipitating this crisis. • Do not match the threats. Do not give orders. Acknowledge the person’s feelings (e.g., “I know you are frustrated”). Ask the patient what they would like done (e.g., “How can the staff help?”, “How can I help?”). • Decrease the stimuli for the patient. The loud and unfamiliar noises of the hospital may be particularly stressful and bright lights may be bothersome. • Avoid any behavior that may be interpreted as aggressive (e.g., moving rapidly, getting too close, touching, or speaking loudly). Physical touch can be a trigger. Patients may misinterpret the contact and feel threatened with bodily harm, and they may feel the need to defend themselves. Delay procedures that may escalate a patient’s potentially violent behavior. • Before the situation gets out of control, check the environment. Look for potentially dangerous objects and remove them if possible. Items such as glasses, scissors, food utensils, and other breakable or sharp objects can be used as weapons. • Avoid being alone and vulnerable with a patient who is potentially violent or being trapped in a room away from the exit; stay between the patient and the door. Team up with another member of the staff when encountering such a patient; there can be safety in numbers.
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