New at Charging - Need Tips

vintagemother, BSN, CNA, LVN, RN · Aug 4, 2014

I'm a new nurse to psych, too, but not experiencing the same challenges. First, let's figure out if you are overwhelmed because you have an unreasonable work load or because you're new and still learning time management and delegation.

Do you mean that you are the "charge nurse" when you say you're "charging"?

Are you on a PHF?

How many pts? How many nurses?

At my facility, we have 16 Pts and 2 nurses, 1 of whom is the charge nurse.

This makes for some hectic days when there are numerous admits and discharges in 1 shift, but most days, it's manageable. Sounds like you're dealing with admissions also.

I don't think techs should tell you what to do. It is helpful when they let you know, "so and so needs a PRN", but they can't order you to give a med. (Brings to mind a situation at my job when I was newer and a tech told me to do something to a pt and I told Her that I don't implement orders from anyone except a Dr or my charge nurse and she told me, "this is how we run things on a PHF and you don't know how we do things" I stood my ground. (I cried later in private) that woman never told me what to do again though because I stood my ground.

Set boundaries with the techs...the only thing a tech can say to me is, "so and so needs a PRN". I say thank you for telling me. They don't get to ask me about all their other meds or anything. Some ask me what which med I administered, and I'll tell them. A sedative or a benzo or Klonopin or zyprexa. That's the extent of tech being able to question me. You must set limits.

It's the techs job to use deescalation techniques. There are many things techs can do to help the milieu remain calm and to deescalate an agitated pt. They shouldn't simply see agitation occurring and their only response is to ask for a med right now. There should have been signs that the pt is becoming more agitated and they need to use their redirection techniques while keeping you abreast of an impending problem.

I agree multiple med changes constantly consume a lot of my time.

Do you have to run groups? In our PHF, the nurses do not lead groups, techs and the clinician do.

wingding · Aug 4, 2014

Vintage Mother - I am the charge nurse if we are short handed & there is no one else with more experience - kind of the "Tag you're it" Charge Nurse. I do not know what PHF is. My floor is a locked ward with up to 21 patients - depending on staffing, up to 10-11 patients per nurse, 2 techs, & possibly 1:1 companions if needed. Staffing is always difficult - it is not below me to get up & help with patient care for toileting, clean up (I'm the only one that does puke on my unit without problems) & taking the 15 min. check sheet. I do whatever I can to help our techs out, they bust their butts! However, I do take offense when techs that have been doing it for 10+ years come behind the desk & start going through intake information & quizzing me on what we are going to do, what each pt. problem is, have I called yet, along with if pt. escalates have a tech telling me to get on it & riding me with questions of what is being done, when, what where & how...... Not just one tech doing this.

I just recently found out that night shift techs "run the show" & the RN cows to them...??????? My initial response is --- not this RN, N. O. = NO (thank goodness I'm not on nights!) I am needing examples & ideas of how to manage this unit & what to say without offending my techs to the point that they will stop working with me & start stepping back when I have combative patient & yet still keep their respect! Locked ward means we work closely together & depend on each other for our lives, but I don't want the lines so blurry between RN & Tech when I'm working.

vintagemother, BSN, CNA, LVN, RN · Aug 4, 2014

Our PHF (psych health facility) is locked. Our Pts are there because they were placed on a hold (5250, 5150, 5270) due to being a danger to themselves or others, for the most part.

Your ratios sound almost reasonable, EXCEPT for the fact that you also mentioned that your clients need assistance with their ADLs. We do not accept Pts who aren't "medically cleared" to be independent.

I keep focusing on acuity and ratios because in my experience as an aide and a nurse, high ratios can make a job almost impossible to a person who really wants to do a good job. And a higher acuity should demand lower ratios.

If it were me, I'd adopt the persona of nurses whose style and ethics or systems work for them. What phrases do they use when techs get too involved in nurses duties?

I totally agree with your statement about needing to keep allies for safety reasons, but also needing to have the aides respect you!! I deal with this issue by treading lightly for this most part. I need the aides to have my back.

On our short term unit, and the long term, the actual nurses med room is separate and there a sign posted and company policy says no non licensed staff allowed. If you keep important docs in an area like that, they won't be able to nosey through it.

Try something like, "I understand you want me to do XYZ, but I need to take care of this 1st" do not explain what "this" that your doing is. You are supposed to use your nursing judgement to prioritize tasks. If you have used clinical judgement and have decided that a certain task is more important to do first than the other, then the only people you answer to are your boss and your board of nursing. Everything you do should be justifiable. But you don't have to justify yourself to aides.

Oh, when you say "I know you want me to do XYZ" make sure you actually state what it is they asked, because that validates their concern, let's then know you heard them.

One more trick with aides---when they come to you and tell you what, respond back by telling them what to do that's within their scope to address the issue. IE- if an aide wants me to give a PRN right now but I am already drawing up a med in a syringe for someone else, I'd ask what behavior is the client having, and as long as it's truly not emergent, I'd tell tell the aide to prompt the client to come to the dining room or the common area where she can be supervised.

Or I'd tell the aide, "no. " I'm pretty sure I've done that, lol. Or I've said, a non committal "mmmm" when they tell me what to do.

wingding · Aug 4, 2014

Thanks for the advise - PHF - can't believe I've never seen that acronym! The few experienced nurses do not serve as examples in this particular dilemma of mine, unfortunately - which is why I reached out in this forum. Medically cleared --- the patient is supposed to be medically cleared as independent, but often a nurse or intake coordinator will not look closely at the information & present to doctor before everything is revealed. Sometimes I feel like we are just getting "bodies" in to keep census up. We, too, are short term acute care, but often end up with MR, elderly or injured that is not continent, along with other medical problems & issues that we have to work around. You do bring up points that I sometimes forget in the heat of putting out fires; keep it simple, keep it professional, & keep it contained. Thank you for reminding me!

vintagemother, BSN, CNA, LVN, RN · Aug 6, 2014

I hope things get better for you. I feel my facility staffs adequately. 2 nurses: 16 Pts on the short term acute. Sounds like your ratios are greater. I'm accustomed to 45 - 54 pt med passes so I adore our ratios.

It also sounds like your facility admits people who our facility would not.

We stay busy in spite of the ratios because of the order changes, and daily admits and discharges.