Psych, sex, and cigarettes

[noyesno]

I am a nursing student in the last semester of my nursing program and I am currently in my psychiatric rotation at a (locked) long-term inpatient facility with 210 beds. Most patients have schizophrenia, major depression, bipolar disorder, or a combination of a few disorders. Since this is my only experience with this type of environment, I wanted to ask if the following two practices this facility allows are commonplace in most long-term inpatient psych facilities:

1. They can have sex with each other at the facility

The sex concerns me because what happens in the event that a female becomes pregnant. The women here are not capable of taking care of themselves, so, who would take care of the baby?

Another issue with the sex is how can it be assured that people aren't getting taken advantage of. Since these individuals are not thinking clearly at times, can they really consent to sex?

2. They are provided cigarettes by the staff and can smoke INSIDE the building during frequent smoke breaks throughout the day (in the common areas)

The smoking inside is a hazard to everyone in the facility, why would a health care facility agree with this? My instructor keeps saying, "it is their right to smoke." I keep thinking, isn't it the right of the non-smoking residents (doesn't seem to be many of these) and staff (doesn't seem to be many of these either) to have a smoke free environment?

Most of the residents are on Medicaid, why would Medicaid pay for these individuals to smoke? I would understand if they provided them with patches or gum, but cigarettes?

*I should mention I live in a state that does not allow smoking in restaurants or bars. So, it seems really strange to me that a health care facility would be exempt from this law.

Any insight?

Thanks!

[netglow, ASN, RN]

Well, of course your patient demographic/type of facility/state preferences/MD preferences/patient preferences/patient dx are what determines how that facility works. These things are not possible in every type of facility, or for every patient. If you do some research, you'll find it varies greatly and is highly dependent on many factors.

Psych was an interesting rotation. Although I learned a lot about all of this intellectually, I really don't think I have the stamina to deal with it day in and day out and work psych as an RN.

[d2k2ross]

I am right there with you 2ndwind. It definitely takes special people to work psych...I am not one of them.

[RNperdiem, RN]

Why smoke inside?

When I did psych as a student, the smoke break for the residents was the only chance these men got to experience fresh air and sunshine.

[EarthChild1130]

We allow neither at my facility.

[diane227, LPN, RN]

I have worked in psych but not at a long term facility. I have not had the experience of patients having sex with each other when I was in psych (although I have seen this working in other areas). I would ask the manager or charge nurse to clarify this with you. I think your concerns about pregnancy are valid. Also, I would be very concerned about the fact that allowing this behavior could be viewed as abuse and the hospital and staff would be liable for allowing it to occur. I would NOT want to work in that facility. I think they are skating close to the edge by allowing sexual behavior between patients to continue.

Smoking was not allowed on our unit. We gave nicotine substitutes. This was hospital policy. State rules stated that hospitals had to be non smoking and this was not viewed as a violation of patient rights.

Psychiatric patients do have certain rights under the law but people carry this thing too far sometimes without really knowing what their state would view as a right under the law. We usually just called the state department of health psych surveyor and they would give us the OK one way or the other.

[noyesno, MSN, APRN, NP]

Should patients be forced to quit smoking? Maybe not. But, should staff and residents who are nonsmokers have to be exposed to harmful carcinogens? NO! Smoke outside.

As for sex between residents.. How would staff determine whether relationships are consensual or not? And the OP brings up a very valid point about the risk of pregnancy. I wonder what the protocol for that would even be?

I wish they smoked outside...

Today at clinical, I was informed they offer the women DepoProvera shots and they also have condoms available. Makes me feel a little bit better but the consent issue is still a concern.

[noyesno, MSN, APRN, NP]

Thank you everyone for your feedback. :)

It was very interesting to read the responses to my question. I'm glad these practices aren't common at other facilities.

[pagandeva2000, LPN]

I worked in short term care psych for 12 years, and worked for the mentally retarded for one. They were allowed to smoke, but sex was not allowed. I am sure that sex has happened behind the scenes, though.

There were plenty of ways for the patients to obtain cigarettes. Some of their families bring them, friends, and sometimes, there were petty cash funds that provided generic cigarettes. When on the unit, they were allowed to smoke certain times of the day in a designated place and those who had grounds priviledges of course, were able to smoke while outside. Others that had escorted priviledges were sent outside with staff that also smoked.

Later, after I left, I heard that they no longer allowed patients in short term care to smoke at all, but those who were in for the 'long haul' were allowed to, because, again, basically, this is their home.

I had no issues with it and I didn't smoke at that time. If anything, my main concern about allowing sexual contact is as mentioned-if the patient is suddenly not in their right mind, what starts out as an obtaining consent has suddenly turned to an attack. And, then, there are the families who would also make a big deal about it.

What I HAVE seen, though, is patients that have been allowed on grounds priviledges that have actually gotten pregnant, though. In those cases, the patient has to be escorted to their prenatal appointments, and they are chaparoned if they are admitted into the hospital. We had a medical infirmary for those that were still in the facility when they reached 35 weeks, I think. One time, a pregnant patient who was on one to one stated she had to go to the bathroom, and the aide reported that the patient beared down and had her baby in the toilet. When the aide tried to get the patient off of the toilet, she started fighting her. Luckily, the baby was safe, though.

When I was a psych aide, I had to sit as a one to one with a patient who just had her baby. I think her family planned to take the child home until she was discharged. In any event, that was actually a pleasure for me because we were allowed to go to the nursery for her to breast feed her baby, and she actually let me hold her daughter afterwards. We took turns holding her daughter until it was time to leave.

Usually, social work gets involved and families intervene, but there were also many that went into foster care. Sad, really.

[noyesno, MSN, APRN, NP]

Despite my asthma and allergies, I made a point to observe the 9:00 am smoke break at the facility yesterday.

Here is how it goes:

-The residents line up

-The psych techs bring out a box with about thirty small drawers filled with different brands of cigarettes

-One by one, the psych techs hand out and light the cigarettes for the residents

-After everyone is lit up, music is blasted and they sit together in the activities room

They only get one cigarette per each smoke break and there are three smoke breaks a day. When I asked the psych tech about this, she said they used to get two cigarettes during each smoking break but funding was recently cut. It costs $21/month for each resident to smoke and she thinks this come from their social security or from another source.

It was an interesting process to observe.