Practice Matters

How to meet the challenge of disruptive patients

The patient waiting in the emergency department (ED) has been pacing for the past 45 minutes; now he strides towards the triage nurse and shouts, “Nurse! It’s been two hours. I’ve had it!” His jaw is tight, and his fists are clenched. How should the triage nurse respond?

Disruptive behavior

Disruptive patient behavior, with escalation to violence, is becoming an increasing concern. The annual rate for nonfatal violent action is 21.9 per 1,000 nurses compared to 12.6 per 1,000 employees in other occupations. Up to 80% of all hospital staff have been physically assaulted at least once in their career.

The ED is a particularly high-risk area. Every day 5.6% of ED nurses are victims of physical violence and 28.2% of ED nurses are victims of verbal abuse. But disruptive behavior occurs in nearly every practice setting. Cited causes for this growing problem include deteriorating social controls, patient feelings of entitlement, patient impairment (drugs, alcohol, psychiatric), stress of illness, treatment waits and delays, and strained medical environments.

High-risk groups

The best protection from disruptive behavior can be early detection. Some patient conditions result in a higher risk for this type of behavior. Closely watch for:

Delirium

Up to 24% of hospitalized older adults have delirium, yet in one study, nurses failed to identify delirium in their patients 69% of the time. Perform the Confusion Assessment Method (CAM) assessment to identify patients with delirium. Delirium fluctuates from hyperactive agitation/restlessness to hypoactive: don’t be lulled into believing all is well just because an agitated patient becomes more subdued.


Confusion Assessment Method (CAM)

Delirium is present if BOTH are present

  • Mental status alteration from baseline
  • Inattention (test by asking to spell “world” backwards)

AND at least ONE of the FOLLOWING is present

  • Disorganized thinking (hallucinations, paranoia)
  • Altered LOC (anything besides alert, e.g. lethargy, agitation, etc)

Source: Inouye SK, vanDyck CH, Slessi CA, Balkin S, Siegel AP, Horwitz RI. Clarifying confusion: the Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-8.

Alcohol withdrawal

Symptoms from alcohol withdrawal can start as soon as 4 to 6 hours after the last drink and is more likely in someone who chronically drinks. The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is a standardized screening method to assess key symptoms such as nausea, tremor, paroxysmal sweats, anxiety, agitation, headache, and clouded sensorium.

Establishing a therapeutic relationship

Creating a therapeutic relationship from the initial contact can help avoid disruptive behavior. Listen therapeutically: clinicians tend to interrupt by 23 seconds into a patient’s response to a comment. Be careful with the therapeutic technique of rephrasing. Nurses tend to paraphrase. For example, when a patient states, “My arm is sore,” the nurse tends to conclude “Your arm bothers you,” rather than reflecting what was actually said. Check with patients on a regular basis as to how they are doing and pay attention to “service transitions,” a time of transfer between providers, shifts, or departments. This is a time when problems are more likely to occur. Address any issues as soon as possible and offer a blameless apology (“I’m sorry you’ve had a problem.”)

Continuum of disruptive behavior

Disruptive patient behavior is on a continuum from irritation to violence. The nurse needs to de-escalate patients and/or families’ behaviors early before they progress to violence.

Challenging questions

The first step beyond normal irritation begins with a challenge to the nurses’ authority and competence. There is a noticeable change in the individual’s tone, volume, and demeanor; for example, restlessness, tension in the body and voice, and expressions of anger.

To avoid creating a power struggle, ignore the stated challenge, but not the person. Allow the person to “vent” and then respond to the situation, needs, and emotions. If the person persists, use the “broken record” technique.

“Nurse, I’ve been waiting for an hour!”

“I know it is frustrating to wait. We should be able to see you in 30 minutes.”

“This wait is ridiculous!”

“I know it is frustrating to wait. We should be able to see you in 30 minutes.”

“You people are all incompetent.”

“I know it is frustrating to wait. We should be able to see you in 30 minutes.”

Each time your respond, use an empathetic tone.

Refusal/noncompliance

At this stage, the person’s challenges and argumentative statements intensify. Set limits, but avoid quoting rules or giving ultimatums. Telling someone that he or she “can’t act like that because this is a hospital” is rarely effective.

Identify what is unacceptable, why, and consequences to avoid the “normalcy of deviancy” (for instance, allowing screaming or threatening staff gives the impression that this behavior is acceptable.) Keep the limits simple and enforceable. For example:

“I feel threatened by ____(described action). I am asking you to stop that behavior because it is not appropriate.” Or

“The comment (swearing, use of profanity) you made was inappropriate. I am asking you to discontinue making comments like that or you will need to wait by security.”

Release

At this point the individual has an emotional outburst and starts to lose rational thought. Allow the person to blow off steam but remove him or her from the public area. Try a verbal contract, such as “Can you do _____ (wait here, sit quietly) while I do ____ (check on how long it will be).” If the person appears unable to agree to controls, leave and obtain back-up security. Do not remain in an unsafe, volatile situation.

Share your emotional response (“Sir, now your behavior is scaring me.”) to make the person realize (perhaps for the first time) that he or she is losing control. A good rule is to trust your gut: If you feel fear, there is probably a good reason.

Intimidation

If the person progresses to this level, safety is your key concern. Stand 2 to 3 feet away (1 leg length) at an angle to avoid being seen as a threat or being within reach if the person strikes out. If the person physically advances, step back towards the exit. Ignore any distractions such as ringing phones or people talking and keep focused on this person who is at risk to “explode.” Speak loudly so other staff become aware of your situation and have security come for a show of force.

Tension reduction

After the situation is under control, establish reassuring contact so the patient can receive the needed care.

Scenario

In the case of the man at the start of the article who is impatient, the nurse should acknowledge his feelings in an empathetic tone of voice. Use his name frequently (it pulls in the rational part of the brain) and offer a cup of coffee to focus on his concrete needs. Because of safety concerns from his behavior, call security and do not allow the man to come into the triage area alone with the nurse.

In this situation, after venting, the man sat down, avoiding violence. Proper nursing management kept the situation under control.

Resources

ANA brochure on Preventing Workplace Violence. Available at http://www.nursingworld.org/Bullying-Workplace-Violence.

Emergency Nurses Association. Position Statement: Violence in the Emergency Care Setting. Available at www.ena.org

Verbal De-escalation Techniques for Defusing or Talking Down an Explosive Situation http://www.naswma.org/?page=StudentMembership&hhSearchTerms=%22Verbal+and+De-escalation+and+Techniques%22

Polly Gerber Zimmermann is an associate professor at Harry S Truman College in Chicago, Illinois and the author of the chapter “Disruptive Behaviors” in the Manual of Emergency Care.

Selected references

Crisis Prevention Institute. Available at www.crisisprevention.com. Accessed April 2, 2013.

Emergency Nurses Association (2010). The Emergency Department Violence Surveillance Study. Des Plaines, IL. Available at www.ena.org/IENR/Pages/WorkplaceViolence.aspx. Accessed April 2, 2013.

Gacki-Smith J, Juarez AM, Boyett L, Homeyer C, Robinson L, MacLean SL. Violence against nurses working in US emergency departments. J Nurs Admin. 2009;39(7/8):340-9.

Inouye SK, vanDyck CH, Slessi CA, Balkin S, Siegel AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-8.

Waszynski CM. How to try this: detecting delirium. Am J Nurs. 2007;107(12):50-9.

Zimmermann PG. Disruptive behaviors. In: B Harmon, ed. ENA Sheehy’s Manual of Emergency Care. 7th ed. St Louis: Mosby; 2012.

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