What Psychiatric Nurses Do (Part Seven – Managing Violence and Aggression)

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This is part seven of my series on what psychiatric nurses do. You can read the other parts of the series here.

I distinctly remember the first time I had to participate in the restraint of a patient. Student nurses are not allowed to lay ‘hands on’ patients, so it was after I had qualified and soon after I had started working on the ward I recently left. A male patient had started to become agitated and needed medication to calm him. A team was assembled and under the guidance of an experienced nurse, I drew up the medication in a syringe and took it to where he was being pinned on the bed. I remember being terrified and standing there immobile. I said I didn’t feel ready to give an injection under these circumstances. And Maria, a brilliant nurse who I highly respect (then and now), told me in her straight-to-the-point, no nonsense way, that this is what nursing is like and I needed to get over it. I gave the injection, my hand shaking, feeling terrified and embarrassed at my anxiety and fear.

That was the first of many incidents I was involved in. And though my fear eventually left me and I developed a fairly strong stomach and cool head in difficult circumstances, I still felt that heart-pounding anxiety each and every time those alarms sounded.

Managing violence and aggression is an unfortunate but necessary part of the psyche nurse’s job. Fortunately I was never injured, but I’m a rarity. In the four years I worked as a nurse I saw colleagues beaten, bitten, strangled… dislocated shoulders, beaten and bruised bodies, damaged tendons, broken feet… It’s a truly dangerous job. Psychiatric patients can be unpredictable, and though 99% are only a danger to themselves if anyone at all, there is always that 1% that will present a risk.

Throughout the training to become a psyche nurse, and periodically once you’re qualified, you undertake intense training on how to manage violence and aggression. You’re taught, in detail, the laws regarding self-defence and appropriate reactions to threats to your safety. You’re taught de-escalation techniques. And finally you’re taught self-defence and how to restrain a patient safely. It’s all a lot of fun when you’re training with your colleagues on the crash mats in your trainers, but when it comes to the real thing knowing this stuff is vital.

During your day to day tasks as a nurse, occasionally you see situations escalating. A patient may be distressed and wish to leave. They may be hallucinating and agitated. Or they may have taken a dislike to a fellow patient or staff member. As a nurse, it’s your job to step in and de-escalate the situation. You may offer medication, listen to the patient’s concerns, or intervene in an argument. Usually you will be able to calm the situation, and laying ‘hands on’ is always a last resort. But occasionally the situation will reach a tipping point where you need assistance. This is why all members of staff carry an alarm, or pin-point.

When you pull the pin-point the alarm sounds throughout your ward and the neighbouring wards. All staff on the ward will stop what they are doing and run to the location specified on the wall display. A member of staff from each of the neighbouring wards will also answer. Often simply the presence of more people will be enough to diffuse the situation, but sometimes the noise and sudden influx of staff can escalate things. The patient may attempt to attack you or others.

This is when your training kicks in and as a team you restrain the patient. They may be taken to their bedroom, pinned and given medication to calm them, held until they’re calm, or even taken into seclusion. Each situation is different and will be assessed on a case-by-case basis by you and the team. This is when injuries can occur. Patients will often struggle, may bite or kick, and will often spit at you. It’s not a nice thing to be involved in. Restraint can also be dangerous for the patient. People have died being restrained. One member of staff will be responsible for monitoring the patient’s vital signs and ensuring they are conscious and safe.

Once the incident is over and has been managed; everything is calm, it’s your job to acquire medical attention for the patient and maybe even colleagues if they’ve been hurt. All restraints can be dangerous for the patient and they should see a doctor as soon as possible. The nurse then has incident forms, restraint records and other bits of paperwork to complete. There should be a debriefing for all the staff involved, and the patient once they’re in a suitable condition. Sometimes, after discussion among the nursing team, the police might be called. But this is not usually the case: it depends on the circumstances.

Managing aggression and violence is not the only type of incident-management nurses are involved in. Next time I’ll discuss self-harm and suicide.