Advice from psych nurses to others?

mia · Aug 9, 2001

Hi, I hope this does not come across as nasty but I agree with Molly J. Psych nurses do not seem to respond to posts like the other specialty nurses do. This is especially troublesome for student nurses (like myself) who are interested in pursuing a career in psych nursing. Its not just on this site either. Ive approached quite a few psych nurses to get employment information and they have all been very tight lipped. What is the big secret????? I personally just want to know how you like your job, what kind of career opportunities there are for psych nurses, is it better to get an MSN as a clinical nurse specialist or as a psychiatric nurse practitioner or to not pursue an advanced degree at all? Is the pay comperable to other nursing specialties? Is there a high turnover rate for psych nurses? Do you recommend getting some Med-Surg experience first? Somebody please break the code of silence. I would REALLY appreciate it.

Thank you so much!

Mia

:) :)

mia · Aug 9, 2001

Hey Molly J, I am sorry I just kind of intruded on your post. I will go ahead and post it again as a new topic. Your concerns take priority over mine.

Mia :)

tarawyton · Aug 22, 2001

Well, I will attempt to answer your email, although, the post in response to you email leaves me a little steamed. Anyway, I will de escalate and continue. I am currently working on a locked female ward, with chronically ill patient, who require long term care. We have a range in pt age from 20 to 62. I work in an intitution and we are intitutionalized, often moves to deinstitutionalize are met with strong resistance from pt. I often wonder if it is fair to now be turning their lives and schedules, the world the know upside down because it has become politically correct to "deinstitutionalize." Often structure and limits, provide pts with a great sense of safety and security. A constant in their lives that are so often chaotic, in both mind and body.

De escalation seems to occur every 5 minutes on our ward and the trick seems to be a repoire and relationship with the pt. Having pts and nurses who respond well to one another working together, despite nursing assignments. As far as fresh compassion, I think a nurse needs to constantly look at pt through different eyes. It is often the pain you see a pt in when they don't know anyone is watching, or speaking to a friend or family member of theirs. And I guess the most important thing to remember it that we are all just a turn of fate away.

As far as teen psych patients go, I would encourage parents to be understanding and supportive, but at the same time firm with limits. All of the young women we have on are ward have been abandoned by there families, either pre or post illness. I believe that had these pt's not been deserted by their families they would not be in a long term care facility. Family support is soo important to recovery, these teens have long battles ahead of them and they need all resources avaliable to them.

As far as telling the families of the chronically mentally ill anything, I would have to say most importantly, share with the nurses and drs. your experience. The family knows their loved one better than anyone, and as far as staff go, LISTEN! These families have been on long journeys and could possible help point you and your patient in the right direction. Also to the families, never give up, these pts need you. However, part of these pts needing you means you being healthy. Families need to live a healthy life, with not just focusing on nursing the sick among them but making sure they nurse themselves.

pattyjo, MSN, RN · Aug 22, 2001

Hi Molly, and Mia, also: I've worked in psych for waaaay long and it is still my true love in nursing. It is a field rich in experiences, frustrations, and satisfaction. It has taught me patience like nothing else has (with the exception of having my own teenagers;)!!) Right now I am working on a pysch unit in a community hospital, but I have also worked in state hospitals which tend to be much more long-term. I like both, but sometimes I do miss the opportunity to develop a deeper relationship with patients and families. 3-5 days feels like drive by therapy to me!

How to de-escalate? Like anything else, try to prevent situations from reaching melt-down if possible. That means knowing your patients, identifying times that may cause unrest on your unit(change of shift, that kind of thing) and being alert for changes in individual patient's behaviors. My first concern is always for safety for the patient, other patients and staff. Maybe that means getting the agitated patient out of the environment and away from whatever is triggering the agitation. Talk, quiet music, diversion, what ever works. Obviously there are times when the patient escalates so quickly that these measures aren't practical....or safe...then maybe prns, time alone in a quiet area, whatever.

I don't work often with adolescents, our unit takes above age 16, but sometimes we have to assess emergency admissions under that age and then refer to a more appropriate facility. To be honest, it is not my favorite area, but that may be because I have little experience there (aside from the aforementioned teenagers!!) I will say that I think treatment for this age group is abysmally lacking in this country and too many kids who really need help end up in detention facilities where they further decompensate.

I keep compassion for chronically ill patients because I do. I never thought about why or how before. I think there is enough stigma still attached to this illness, and such fragmented care due to a whole variety of factors, that patients at least deserve my professionalism. Perhaps that sounds naive and if so, fine, but I have been a nurse for a very long time, and that is the only way I can continue; losing compassion would be the quickest way to burnout for me.

And now to the biggie, should you get med surg experience before going into psych. I don't know; I did, but in all honesty, I don't know that it made a huge difference in my practice. Regardless of what area we practice in, it is up to each of us to stay on top, go to workshops, read professional journals etc. I have taken care of patients with mental illness who are also pregnant, have barely controlled diabetes, heart problems, MS, and on and on. I certainly couln't rely only on the education I received back when I went to nursing school. So, I don't know. You'll get opinions that are strongly pro med surg experience and some who will say go for what you love. Whatever you decide, remember it is your professional responsibility to stay aware of changes in practice, updates and so on. And anyway, why doesn't anyone think you should have a year in pysch before going to med surg? :)

Good luck to both of you, I love hearing that new nurses are interested in psych.

KRVRN, BSN, RN · Aug 23, 2001

MollyJ, how do you figure that there are a lot of psych nurses lurking here but not responding? I hope you are not merely looking at the number of views under each topic. I'm a NICU nurse, so I know very little about psych and have little to offer any inquries, but I sometimes read the topics in this forum out of curiosity. Maybe other non-psych nurses do too, but without responding.

MollyJ · Aug 25, 2001

KV, I really thought that psych nurses lurked, but the response has given me second thoughts. Too bad.

still, I appreciated the responses we got.

Pattyjo, I liked what you wrote about "drive by therapy". all too true. Alot of my kids barely get calmed down in that much time and they felt that the hospitalization was little more than an unjust punishment and they haven't even gotten close to the question of, "how did my behavior play into this situation."

Hey, tara, re: de-institutionalization. I think there's a certain core of people that get "mis-treated" (ie over or under treated) when the sway is toward or away from institutionalization. Wouldn't balance be a wonderful thing?

nurse lala, BSN, RN · Aug 25, 2001

*what are your favorite ways to de-escalate angry situations?

compassionate listening. determine cause of the anger. let the client vent if it can be done in a safe manner.

humor is another effective way to break a tense and dangerous situation.

*how do you keep your compassion fresh for chronic mentally ill patients and return chemical dependency patients? or what re-evokes your compassion in these cases?

i keep in mind that they are indeed suffering. but for the grace of god goes i.

the addicts have not been ready to learn before, so today may be the day. i will be open to that possibility.

and the chronic (frequent fliers) are usually not to blame for their disease, and even if they were, they are humans and worthy of the best care possible.

*how is de-institutionalization working for your population?

i work in a locked acute unit at the va. i have not been impacted by this.

*what role do you see chemicals having in teen emotional problems?

all addicts stop learning how to grow emotionally, socially etc when they start to use.

*for those of you who work in private psych hospitals, how do you see those 3 to 5 day hospitalizations working for those teens that come to you because their parents cannot take them anymore? (we have one private psych hospital and we used to have a charter hospital in our state. i used to say that their discharge planning looked mostly like jonah being discharged from the whale.)

i too worked in a number of private psych units.

it was pitiful the way the sick parents would dump their kids, then take a vacation...the kids were great kids. the problems were usually the parents.

*nurses caring for teen psych patients, what are 5 things you would tell parents if you could be guaranteed their attention?

1. go see a good councilor for yourself.

2. remember: almost all teens go through the phase of being a teenager. it isn't personal.they must go through tremendous change to come out a functioning adult. they need your unconditional love and support.

3. listen to your teen.

4. withhold judgement.

5. go do something with your teenager.

*what are 5 things you would tell the families of chronically mentally ill patients? sick :rolleyes:

Thunderkat · Sep 10, 2001

to de-esculate a patient:

I would highly recommend CPI training Crisis Prevention and Intervention training... This is a big deal in Pysch, Forensic, and correctional Nursing. I found this concept of restraint and protective action to be very helpful.... I have found that it helps if you have a patient who is having an episode, that it helps to have a teamwork approach with your staff. Having a repoire with the patient is helpful, using behavior modification techniques such as the "broken record" where you you calmly request a change in behavior ie.... "John, please sit down" and repeating until compliance, or redirecting, refocusing, .... "john, look at this...." These techinques are usually successfull... Knowing your patient is tantamount to ensure safety. I am sure some nurses might be falling out of thier chairs laughing at how lame this sounds... but I have found that loosing it and becoming physical generally puts you at risk for injury and lawsuits... Mental health Advocates can be a real nightmare......

Aerolizing · Oct 16, 2001

I just found this site and I love psych nursing so I hope to be responding a whole lot but since it is so late, I will only respond to a couple questions.

De-escalation hmmm....What works for me is really just listening. If I had a patient make angry demands at the front desk for the phone, I would talk to her and try to problem solve. So many things are resolved very quickly if you just take the time with these patients. If she wanted discharge, I would ask her to go to her room so we could talk privately about personal things not meant for everyone's ears. If she started to throw things, I would clear everyone out of the area and then try to get her to go to her room on her own but without an audience. If she comes at me trying to kill me, I do know how to use non-violent physical crisis interventions and I have put my hands on patients to help them gain control but I really don't do this very often. I also use humor to try to get the patients to ease up a little. I found the most important thing to do is treat them like human beings and sit down and listen.

As for deinstitutionalization......I have many thoughts on that too. I was just talking to my friend who is an LPCC and she works for a community mental health center. She told me of a patient that had died of an accidental overdose. Since she was dead, no confidentiality issues. She was one of my fav frequent flyers. We had built up great repoir (gosh that doesn't look right). She never acted out when I worked with her because I told her what I expected from her and I talked to her and listened. My LPCC friend thought the system sets up so many people to fail because she could not live independently, even with daily contact with social workers and case managers. It was not enough. Group homes not an option here, too many people, not enough beds. For this patient, she would have been alive if she had an institutional setting to live in. I know states are looking to get everyone out into community settings but for what reason? Money? There is not enough staffing for our community mental health centers. The pay is low, hours are bad and you just don't have great job satisfaction. My friend feels like an overpaid babysitter. I would love to be able to start up a nursing home type setting for mentally ill who would benefit from institutionalization. I think we lose too many people out there because they have no voice. Who cares if a homeless schizophrenic freezes to death? Things like that should not happen. Even if they want to be free. Who knows what they would be like with a year of med compliance and the security of knowing where your next meal is coming from and maybe the ability to actually participate in group therapy while on meds.

Just some thoughts.

Diane

victoreia · Feb 3, 2002

I have just started coming to this site and I love it. I work with kids in a behavioral health setting that has a variety of different aspects. I work with kids in RTF (residential treatment facility) and community kids who cannot function in public school and mentally challenged kids (MR)

Deescalation is my main goal. Each client is different and different things work for them. You have to have a rapport with them and know what works and what does not. Most importantly, listen to them and do not think the problem they are having is not worth getting upset over. To them it is. Always try to remeber when working with kids that they are just that, kids. Hormonal changes, developmental changes... all play factors in behavior. How would you like to be starting your period and not even knowing what it is or what is happening. I find that many of the kids in RTF are very uneducated. Advise to parents: Hmmmmmm I find the parents are usually the problem. They do not know or do not have the capacity to deal with the behaviors. Teach parents and clients according to their level of understanding. Setting limits and being conssitent is the foremost important thing you can teach them, I think. It is easier to give in and give them what they want to prevent an outburst but in the long run it only contirbutes to the problems. Hope this helps. I have been in just about every psych setting there is and each one requires different approaches. Finding the right ones is the challenge... :rolleyes:

Mary Dover · Feb 10, 2002

Hi all. I'm new here and love that this BB exists. Have been in inpt and outpt psych nursing for 12 years. Have lots of stuff I'd like to share and talk about, but I'll keep this post short and sweet. If anyone cares to correspond, please do so. I love meeting new people and sharing ideas. I do believe that psych nursing is a special 'calling' and can even remember being referred to by other nurses early on in my career, as not being a 'real' nurse, but I certainly beg to differ. I just think we kinda 'march to the beat of a different drummer' is all. God bless you all and take care.