A casual walk through an ER will confirm that the physical attributes of the nurses working there (both male and female) are often not matching the physical youth, athleticism, raw power and determination of the patients they are looking after who might be in crisis. Although this is a sweeping generalisation, it nevertheless informs us that, in order to gain control of a violent, larger person, the staff at an ED may need:

1. More time in training the technical aspects of any skills.
2. The skill-set itself must take into account the staff’s likely athletic deficit vis-a-vis their subject.
3. This brings up the issues of use of distraction strikes and the use of pain during restraint.
4. It also point to the possible need for ERB and Soft-Cuff solutions for safe management.

For example, in one hospital where we worked which had separate-sex departments for male and female psychiatric patients, on the Female Psych ward, procedures were already in place for the female nurses to call for help from the male ward in the event of their not being able to contain or restrain a large female client. This also raises issues of Fatigue Threshold:

In engineering, the fatigue threshold is the stress level at which steel or wood cracks, bends, or breaks. In regard to physical intervention & restraint the term can be defined as “the sudden physical exhaustion experienced during a force encounter when an officer cannot effectively perform to either control a subject or defend himself.”  It is “not the same as just being tired”; instead, it’s the abrupt and utter depletion of energy “to the point that you cannot physically function.” For some officers, that moment can strike “in extreme cases” after as little as 30 seconds of maximum physical exertion. Others might last up to 5 minutes. On the whole, it is estimated that “an officer will be lucky if he or she has 2 to 3 minutes of effective strength in an all-out fight.” The closer an officer gets to his or her personal fatigue threshold, the more dangerous the situation becomes, not only to the officer, but often to the suspect as well. You’ll do anything to avoid it, including using what may otherwise be considered excessive force.” Force Science Institute  Bulletin  “Fatigue Threshold”

We recommend that training and policy enable the staff to escalate to the use of more restrictive methods of control (e.g. distraction strikes and pain-compliance methods e.g. wrist locks) when absolutely necessary in exceptional circumstances to achieve the goal of a safer and more secure facility during an incident of violence. We also recommend that staff escalate to the use of Soft-Cuff and/or ERB in order to reduce the risk of reaching the fatigue threshold during incidents. ---------------------------------------------- Gerard O’Dea is a conflict management, personal safety and physical interventions training consultant.  He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes and the European Adviser for ‘Verbal Defense and Influence’, a global programme which addresses the spectrum of human conflict.  www.dynamis.training