Setting Limits W/ Pts on Medical Floor Who Also Have Psych Concerns?

nursesaideBen · Aug 7, 2007

Manipulative patients love to pit staff members against staff members "Well day shift never did this or that or That nurse I had today didn't do this or that and said this and said that." Don't buy into it. I generally just say "I'm sorry you had a bad experience." document when appropriate, make sure the charge nurse is aware of the pts behavior, and pass it on in report. Hope this helps.

NursingAgainstdaOdds · Aug 14, 2007

Somebody help me here! :)

I was talking to the CN about this issue the other day, I told her if I ever win the lottery I'm building a psychiatric-medical wing on the hospital and naming it after myself. :lol2:

crossbow · Aug 20, 2007

Being also in NY, I can commiserate with you. Its hard to believe the patient which most of administrators do until proven otherwise. You just have to make your clinician(nurse clinician = charge nurse) see how this patient is being manipulative. How document, document. Once she gets into how the patient becomes manipulative...you know thats going to go all the way to the top (Nurse manager and guest relations).

I've been on a medical/tele floor for just over 2 months, and I'm noticing a trend in our patients who have concurrent medical and psych diagnoses. Namely, we're just not good at it.
Some issues are rather typical staffing ratio concerns. Sometimes (not always) a patient with a mental health issue can be more demanding and take-up more time for a range of reasons, from basic safety concerns to patients who are manipulative and/or abusive toward staff members. We're doing OK with the former - generally our nursing supervisors and admitting MDs ensure that if a pt needs a 1-1, they get one. We have back-up plans in place for people that need more than that, or pts who fall through the cracks, etc (i.e. a behavioral response team).
My question is more directed at pts who are manipulative, demanding beyond reason, abusive toward staff, etc. I don't have a lot of experience with psych (or anything, for that matter ), but one thing I took from my mental health rotation in nursing school was the importance of limit-setting and boundaries in the psych setting. The nurses there were excellent caregivers who were trying to help their pts learn boundaries by setting limits.
Is this appropriate on a medical floor as well? Part of me feels that I have a responsibility to my pt in this capacity. At the same time, a pt on a medical/tele floor is probably experiencing a great deal of stress, and it seems unlikely that I could effectively impact overall functioning in those conditions. Thirdly, this type of behavior can be really detrimental to other patients who will receive almost no one-to-one attention simply because they aren't the "squeaky wheel" in the group.
There are a lot of things to consider, and I don't do so lightly. I just feel like we could be doing this better.

confused101 · Sep 14, 2007

Are we working on the same floor??? I am too in your shoes. Our hospital had a medical psych floor for at least 20 years. I work with a nurse that worked there. It is sometimes unreal what we have to do on our floor. In one day, remember only one day... We had LOL in a posey screaming her head off, a young man throw a tray at a tech, someone else screaming about something only God knows what, another pt. who has a history of psych and he is yelling and crying. Oh then we didn't have enough sitters one day, so they had the nurse doing 15 minute checks on a nursing home pt. who said he wanted to kill people. He was in posey and bilateral wrists. Oh, I forgot the lady who waders the halls. One night she got mad at me because she wanted to go down the stairs. I got her back to bed. She was much better the next day. That is just the tip of the iceburg for me on one shift. I hope that it gets better for everyone. We are having problems with pt.'s who need medical care not getting to psych. One time a dressing dry with kerlex needed to be done. Couldn't go to the ward. Oh, if they have a code, we have to go up. What a crock. Didn't we all go to nursing school??

meownsmile, BSN, RN · Sep 17, 2007

Communication is key when dealing with any type of manipluative patient. Ive seen DD individuals, drug seekers/addicts, chronic pain patients try to be very manipulative with everything from getting as much food and snacks as possible to pitting staff against each other. When the situation is recognized, communicating any limits you have made to the next shift is vital. Ive even added limitations to the patients action lists and put sticky notes on the computer next to their name to help with communication and avoiding problems.

confused101 · Sep 18, 2007

Sometimes it helps to put when a patient can have prn medications on dry erase boards. It has helped us in the past. Setting limits works only if everyone does it. I have seen pt's pit one nurse with another. Good communication between caregivers is key in this case. Stand firm and don't forget to document. Sometimes that is the only thing that will help you when managers want to know what is going on. Happy days!

newlifecalling · Oct 15, 2007

Just an opinion to consider, I understand where u r coming from, I have seen this . My question is shouldn't we treat these pt's with the same kind of compassion as we would with a pt with other problems? In school I learned we cannot judge the position that the patient is in, nor the pt. Someone nedds to care for them, right? I am not a psych nurse either, I just care for anyone I am taking care of with the same respect and compassion.

newlife calling

Daytonite, BSN, RN · Oct 15, 2007

The very first medical unit I worked on decided to set aside four beds for alcohol detox patients. This opened the door for our unit to get anyone with a psych problem. You have to keep in mind that psych problems require nursing interventions that are not as physical as those for patients with medical problems. They are, nonetheless, nursing interventions. They are nursing interventions that require a different set of skills. And, I think that is where much of your frustration is arising from. Communication interventions are more of a cerebral type of skill rather than a hands-on skill and I think many nurses don't see this as a real important part of their job. However, it is. The demands of a psych patient are just as important as the demands of a patient with a colostomy or other physical problem. When we were inserviced to deal with the alcohol detox patients we were told that the worst thing we could do with a manipulative acting out patient was to get authorative or confrontational with them. It only eggs them on. What you do is learn to recognize manipulation and deal with it by falling back on the policies and doctor's orders that you have in place and use a moderate and friendly tone to your voice. A medical unit is NOT the appropriate place for one nurse to set limits with these kinds of patients unless there has been a meeting of the care providers, including the doctor in charge of the case and a defined care plan set in motion that all nurses on the unit are to follow to the letter. Setting limits never works with these patients unless the entire healthcare team of care givers is working together and in unison. This was hammered into us by our clinical psych nurse specialist. These patients will pick up on the confusion as some people follow the plan and others don't and really create a lot more havoc for you. Answer all call lights as if each is important because you never know when these people are crying wolf or if they are really in need of something. That's just part of being nonjudgmental on the job. At the end of shift, yes, they have tired you out. But, you can go home knowing you weren't abusive to them and you treated them kindly, as was only right.

I just want to address your comment that "this type of behavior can be really detrimental to other patients who will receive almost no one-to-one attention simply because they aren't the "squeaky wheel" in the group." I don't think that is accurate and it speaks badly of your nursing skill. I worked med/surg for many years. Many medical patients are "squeaky wheels" for some reason or another. An IV goes bad and one nurse after another can't get it started. A patient starts vomiting blood and the fun of getting it under control begins. A patient has chest pain and we are tied up for an hour or more taking care of it. A patient codes and we spend how much time attending to them? So, your comment is just not true. When a patient needs acute one-to-one attention, they will get it because the nurse has prioritized the patient's need for it. And if any nurse denies a patient care for an acute problem that comes up by prioritizing and attending to it incorrectly, what should happen to him/her as an employee?

NursingAgainstdaOdds · Oct 19, 2007

Thanks for your insights, Daytonite. That is precisely the kind of information I was looking for. :)

I found this particularly helpful:

A medical unit is NOT the appropriate place for one nurse to set limits with these kinds of patients unless there has been a meeting of the care providers, including the doctor in charge of the case and a defined care plan set in motion that all nurses on the unit are to follow to the letter. Setting limits never works with these patients unless the entire healthcare team of care givers is working together and in unison.

I have given your post a lot of thought, and while the first part of your post was very enlightening and helpful, the latter part was a bit confusing for me. Particularly, I'd like to address this:

Answer all call lights as if each is important because you never know when these people are crying wolf or if they are really in need of something. That's just part of being nonjudgmental on the job. At the end of shift, yes, they have tired you out. But, you can go home knowing you weren't abusive to them and you treated them kindly, as was only right.
I just want to address your comment that "this type of behavior can be really detrimental to other patients who will receive almost no one-to-one attention simply because they aren't the "squeaky wheel" in the group." I don't think that is accurate and it speaks badly of your nursing skill. I worked med/surg for many years. Many medical patients are "squeaky wheels" for some reason or another. An IV goes bad and one nurse after another can't get it started. A patient starts vomiting blood and the fun of getting it under control begins. A patient has chest pain and we are tied up for an hour or more taking care of it. A patient codes and we spend how much time attending to them? So, your comment is just not true. When a patient needs acute one-to-one attention, they will get it because the nurse has prioritized the patient's need for it. And if any nurse denies a patient care for an acute problem that comes up by prioritizing and attending to it incorrectly, what should happen to him/her as an employee?

Of course I answer every call light and take the requests of my patients seriously. However, I have to say that if a patient is being especially demanding, and I'm in their room every 20 minutes (because I DO take them seriously), it will take away from my other patients. Like Shroedinger's cat, I can't be in 2 places at once. Frequently, we do know when someone is likely to go bad, often we don't. In my (admittedly limited) experience, I've found people deteriorating unexpectedly - stroking out, or what-have-you - on my rounds or when just walking by their room and looking in. If one of my 7 patients is requiring my attention very frequently, it simply follows that I will spend less time with other patients who aren't on the call bell or requesting my attention in other ways, because I am taking my patients seriously, and in my opinion does not "speak badly of my nursing skill". Furthermore, of course a patient requiring acute attention will receive the needed attention - I'm not going to ignore someone with CP in order to answer someone else's call light. However, patients frequently don't tell us unless we ask, or are unable to call for help and tell me something is explicitly wrong.

NursingAgainstdaOdds · Oct 30, 2007

A medical unit is NOT the appropriate place for one nurse to set limits with these kinds of patients unless there has been a meeting of the care providers, including the doctor in charge of the case and a defined care plan set in motion that all nurses on the unit are to follow to the letter. Setting limits never works with these patients unless the entire healthcare team of care givers is working together and in unison.

I just wanted to come back and thank you heartily for this advice!

Of course, I've had ample opportunity to work with more patients with psych issues recently, and I've really taken your advice to heart. I "use the tools in the toolbox", as it were, and advocate for patients as best I can.

VaPsychRN · Oct 30, 2007

I agree in that "difficult" patients on a medical floor require a case conference and a "united front" (a term we use in psych) from all the staff involved in the patient's care. Sometimes the nurses do a great job and then the MD happens to get manipulated, and the plan falls through. Same thing could happen with any particular staff member who is not sticking to the plan. That being said, as a dedicated nurse, your role may very well be to coordinate the treatment team to get together and discuss the case.

Of course, you can set limits within your shift for your own sanity, that patient's need, and your other patients. I sometimes tell my "needy" patients that I will come see them once an hour and during that time, they can make any reasonable request. Between that time, I will not be able to respond to their needs (you have to word this very carefully). Also, when you have "difficult" patients, make sure you are taking care of yourself and getting feedback from your nursing peers. A "complaint session" behind closed doors can help burn off steam. If the patient is really pushing your buttons, have another nurse take care of him/her so that you can keep your sanity. Remember, we cannot be effective nurses until we take care of ourselves first.

I work in psych... most of our patients are "difficult"... but use compassion, boundaries, and empathy and you will be able to handle those more challenging clients.