PMHNP and violent patients

[TexanRN10]

I am currently enrolled in a FNP program but I am thinking of switching to PMHNP. I have worked 3 years as a psych nurse and I went for FNP because I liked learning about medical diseases and pathophysiology. It also appealed to me that there was a wide variety of jobs available to FNPs. Now I am thinking that there is too much to diagnose in a 15 minute visit with history, exam, and prescription or referral. I understand that PMHNPs usually get 1 hour exams with 20-30 minute followups. I also wanted to get away from psych because I have been attacked 4 times in less than 2 years and threatened numerous more times. We use CPI training and I have learned SAMA, but it still amounts to being a punching bag while trying to grab a patient understaffed. For all you practicing psych NPs, how do you handle violent or threatening patients such as under mental health warrants? Is it safer outpatient? If you must round inpatient, have you had trouble with violent patients and how do you examine them? How do you examine patients that are not violent but are disruptive-i.e, cursing, incoherent, etc? Thank you for your insights!

[TheDude77]

I've been a psych nurse for two years and never been attacked. Cussed at?....Yes. Just out of pure curiosity, each time you were attacked, was there plenty of staff on the floor?

As far as PMHNP assessments, our MDs don't go over 15 minutes a patient....even initially...on my inpatient unit.

[TexanRN10]

No, our hospital (UHS) is chronically understaffed. Twice there was a tech present but the patients were sizable. They were pounding on a dayroom window with a small table and kicking an exit door as hard as possible and screaming, respectively. The other two times there was no one in the immediate area and I managed to evade them while calling for help long enough for someone to come to my aid. The assessment times were for outpatient not inpatient. Our MDs also are brief on inpatient assessment. The question is: what do docs/PMHNPs do with such violent patients or even just the unruly ones? How are assessments performed?

[TheDude77]

Probably the same way we do our assessments as nurses when we get an admission. When you get to questions you can't answer due to the state of the patient you state "unable to assess due to patient......." At least that is my guess.

[TexanRN10]

I used to work admissions at a local MHMRA and I also had to omit certain items if the patient was uncooperative. However, the next morning a doctor would have to come in and assess them. What you say sounds reasonable but I would really like to know what practicing PHMNPs do with these violent/uncooperative patients for assessment. Do they rely on report from the ED or police and guess at the rest? Is this enough to start prescribing meds for them? I don't have PM capability but if you do or anyone else, let's hear it from the experts like zenman, PsychiatricNP, or resilientnurse! Thanks for your views.

[PeacockMaiden]

Hi TexasRN,

I was also thinking about that very same question that you asked. I am currently an AGNP student, but I have been working as a psych RN now (also at a UHS facility- I totally understand the chronic under staffing problem) and I determined that I love psych so much, I am applying to psych NP programs now instead of finishing the AGNP certification.

I have been threatened verbally several times, one time the patient said they wanted to kill me. Only once did a patient lunge at me when I was on the floor, and thank goodness one of our awesome floor staff MHTs was able to prevent the patient from grabbing at me.

But I wondered too if working as a psych NP will be less dangerous than working as a psych RN?

[PsychiatricNP]

I currently practice in a number of different settings: acute inpatient, correctional, emergency department and have a small outpatient private practice. The environment that I feel safest in is probably the correctional setting, I have never been threatened or felt even remotely unsafe. The environment that I feel most unsafe in (though I still feel safe) is in my outpatient office. This is an environment that I have little control over other than use of therapeutic communication and respect when a session escalates - this is pretty rare - with some experience you will have a pretty good sense of when you have "pushed" a patient to his limit - when I see that we are approaching this threshold by watching body language, affect, etc., I start to wrap up the session. I have had a few patients who have left my office upset, but have never threatened me or made me feel unsafe.

When I round inpatient and in the emergency department, if a patient is violent and cannot be de-escalated by staff, then I will likely order IM Haldol/Geodon/Ativan/something to calm the patient. Most times, when staff who have mental health experience approach the patient they can de-escalate the situation without meds, this is usually not the same for the average ED nurse (no offense intended, we all have our talents). When I am on the unit, I can also count on the experienced MHTs to control the milieu and intervene before a situation becomes dangerous to other patients or staff. I sometimes find that the MHTs are more therapeutic than our unit therapists. The key is ensuring that you are part of a team that you trust to intervene when a situation escalates - this includes MHT/RN/MD/NP/SW/security. An MD/NP who is on the wrong side of the unit MHTs can expect little support during those situations.

About examining uncooperative patients - I usually redirect the encounter and remind them that the encounter is their opportunity to get the treatment that they are in the hospital for. If they continue to be disruptive or otherwise inappropriate, I terminate the encounter and move on to my next patient. If I know that a particular staff has a good rapport with the disruptive patient, I might ask them to come in with casually during the first few minutes of the encounter and then drift out. On the inpatient unit, I typically have as much or as little time as I need to evaluate new patients - sometimes I spend 10 or 15 minutes with the patient (if they are uncooperative, sedated, etc.) and gain the rest of the history from collateral sources, other times I spend 50-60 minutes with the patient for the evaluation, especially if they are insightful and can/want to engage in the therapeutic process. Overall, violent/disruptive patients are manifesting maladaptive behavior - our job is to model appropriate behaviors and set limits. I offer respect and courtesy to all of my patients and expect the same in return - if the patient cannot provide this in return, then our job is to set limits and help the patient to learn appropriate behaviors. Just my thoughts - maybe others will chime in.

[TexanRN10]

Thank you, PsychiatricNP! A very informative post. I am wondering only one thing: that disruptive patient that you had to cut off - can you still determine what appropriate meds to give them despite the brevity of the encounter?

[dctessMHAPN]

PsychiatricNP said it all very well. I'd only add that as a mental health NP you are evaluating behavior, so even though the patient might not be cooperative, that itself is behavior to evaluate. You're looking at their mannerisms, their tone, is their affect matching the mood they express?

In cases with adolescents who are unwilling to talk, I often find that moving on to something familiar will open them up or change their attitude. For example, taking their vital signs (which I usually do WITHOUT parent/guardian present) will let them show me what they know about themselves, how they feel about their body, I get them to walk up and down a hallway for me to look at gait and do some neuro assessments and evaluate for movement issues or extrapyramidal symptoms.

You can often find a "hook" - something that opens a person up to you - by talking about the people they know outside clinic, be it family, friends, care providers, even people on TV! I always try to ask people what their days are usually like, and what's it like where they were staying?

I think psychiatry can be an amazing field if you like to listen and observe people, you have a sense of optimism about individuals, and you're open-minded and accepting of diversity in all its forms (including every variation of culture, gender and sexuality, ethnicity, and disability). I just genuinely like individual people; I tend to see their strengths, and I like to point those out to them, and find ways to see how they use their strengths to build their resilience. These are my traits that I think lead me to feel comfortable in what is often viewed as an unenviable field.

[Barnstormin' PMHNP]

"I think psychiatry can be an amazing field if you like to listen and observe people, you have a sense of optimism about individuals, and you're open-minded and accepting of diversity in all its forms (including every variation of culture, gender and sexuality, ethnicity, and disability). I just genuinely like individual people; I tend to see their strengths, and I like to point those out to them, and find ways to see how they use their strengths to build their resilience. These are my traits that I think lead me to feel comfortable in what is often viewed as an unenviable field." dctessMHAPN

Finally! I have been struggling to put my love for psych into a short version, this is it! Thanks!

[NPs4health]

It's more difficult when you're in an open space like a day room. As an NP, I've always tried to position yourself with your back to the wall when I'm talking to patients and also hold something like a binder or clipboard in my hand. When the patient's aggression/agitation improves then you know you've got them on the right med. If it's their personality/negative coping skills that's a different story.

In the outpatient setting it's much easier because you usually have your own office. In my office I make sure there's a clear and easy exit path. In the outpatient setting, I've never had anyone be aggressive towards me unless it has to do with someone seeking controlled substances and doesn't want to take no for an answering. When I sense that happening, I get up close to the door and end the session. I remind them the purpose of their visit, that their behavior is not acceptable and we can potentially discharge them. Of course a drug seeking patient and a psychotic patient would be handled differently.

Also, don't assume all initial visits are one hour. In the hospital, I had 40 mins max and in the outpatient private practice I got 45 mins, and in community mental health I got 30 mins and always ran behind.