Forensic Psychiatric Nursing: A Unique APRN Opportunity
This is an article about my locum tenens assignment at a state run psychiatric forensic facility. Patients are committed here for an average of seven years. As a provider, with a two month assignment, I learned about patients who have crossed the line into criminal activity during psychiatric decompensations and strategies to help them achieve stability.
SpecialtiesPsychiatricArticle
After thirty years psychiatric nursing experience in various roles, locum tenens is perfect for me. When I want to work, I sign up with a few agencies, tell them my availability and hope something will come through. This time I can only work in 2 month blocks- a normal assignment is three months so I was not sure anyone would take me for only two months. Luckily my recruiter found me a spot.
"The position is in corrections." She said. My husband was immediately worried about my safety. I had my interview and I found out the facility was a forensic hospital, not a correctional setting and that I would have inpatient responsibilities. I have many years of inpatient experience working as a staff nurse and a manager. This will be my first inpatient experience as a provider.
After a week of orientation mostly about HIPAA, and using the computer system, I start on the units. I have two inpatient units and one 4 hour block of outpatients. I am on transition units where patients are preparing for discharge to the community. They work at least 15 hours per week at on campus jobs, go to groups, and have privileges to go outside, some alone.. For admission to the facility patients are committed by a judge as mentally ill and dangerous. Many of these patients have caused harm to other people, usually when they were not taking medications or were abusing substances. The average length of stay is seven years and the patients home community has input into advancing privileges and determining discharge.
My role is to do a psychiatric interview and review psychiatric medications at least every three months on my assigned units. On the inpatient units, this is called "rounds". Patients are invited in one at a time by appointment. Several staff are in the room to observe or participate in my interview. I have never interviewed patients like this before. One of the social workers told me she likes to come in the room to make sure the patients are giving me the correct information and this can be helpful. A pharmacist is there also, to take notes and sometimes participates. I try to talk to her before or after my time with the patient so I am not distracted by medication information during my interview. Since I am doing the assessment and making the medication decisions, I have to make sure I am comfortable. I also put in my own orders which is a change for them. Because of the cumbersome computer system, previous locums had operated using mostly verbal orders which were inputted by either the nurse or the pharmacist.
There is a shortage of psychiatric providers at this facility. Systems like the pharmacist taking notes, which are minutes of the interview, and verbal orders are a way to provide some continuity and compensate for the shortage. I am the sixth psychiatric provider in two years. They are recruiting and in the meantime I learn a lot.
The main things I learn about are high dose neuroleptics, polypharmacy, and clozapine. Traditional psychopharmacology tells us to streamline medications. With these patients, it is not entirely clear if patients could do as well on lower doses or if they need the high dose for stability. There also seem to be a lot of negative symptoms of schizophrenia, ie poor motivation, blunted affect, which one of the psychologist says is not treatable with medication. My research tells me medication is worth a try but I am not there long enough to introduce this. I wonder if some patients are overmedicated but I am reluctant to adjust doses very much because of being new, unless, of course it was clearly indicated. And I become proficient in laboratory guidelines for long term medication monitoring.
Every patient has a primary MD who has been treating them for years and each patient gets a comprehensive physical every year. These MD's are readily available for consultation. The pharmacists are also available for consultation and also seem to like attending my rounds. There are also other professionals including psychologists, social workers, nurses, and security counselors. I found out later that there are some psychology fellowship classes I could have attended if I had known about them.
I am scheduled to return to this facility in a few months. Locums gives me the opportunity to learn. When I return, I look forward to getting a better understanding of high dose neuropletics and polypharmacy and I may try to medicate negative symptoms . Or since I now know the system, I may be assigned to an acute admission unit where I will learn about rapid titrations of psychiatric medications and ordering seclusions and restraints. If I come back to this unit, I will better be able to treat the patients since I have interviewed everyone at least once and have the trust of some of the staff.
Forensic psychiatry is not a popular area of psychiatry. Many of these patients are severely and persistently mentally ill and have crossed the line into criminal activity. They are well care for at this facility as the long term psychiatric patients which they are. Many of them will never be able to live in the community. In the old state hospitals and if they hadn't committed a crime, many of these patients would have stayed for years living in a community within the hospital. Some may have been discharged to group homes with case management. Some of my forensic patients may also be discharged. Evaluating stability, degree of outpatient containment and likelihood of relapse is very challenging and the focus of much of their treatment.
