new to psych....afraid of being harmed by pt.'s

rn/writer, RN · Jul 13, 2007

I was a psych nurse for a long time and I was never injured by a patient.

Couple of important things:

Don't turn your back on a patient. This is awkward at first, but you learn to do it automatically and naturally.

Don't let a patient get between you and the door. Again, it takes some practice, but pretty soon you'll just do it without thinking about it.

When people tell you they never saw a patient's attack or outburst coming, about 90% of the time they didn't correctly interpret what they were seeing. Only occasionally with truly psychotic patients do they just "go off" with no warning. Usually, there are some indications that this person is starting to escalate. Typical signs that are missed--they get quiet, they do funny things with their mouths (clenched jaw, pursed lips) or hands (clenched fists, cracking knuckles), they develop a "thousand-yard stare," they stop talking, they close their eyes (as if to block out what they don't want to see, etc. Many more possibilities. Some of these clues are subtle, but visible to the trained eye.

When you see any of these signs or anything else that catches your eye, back off. Give the patient space. Ask if they're ready before you resume what you were doing.

Ask your patients right up front what they might do if they feel overwhelmed and how you can help them through it. Some patients are open to having a signal or a special word that lets others know they are reaching a high stress level.

As scary as all this might seem, try to limit your feelings to a healthy fear and resist going into paranoia. You'll find your comfort level with time.

Remember, many, many, many psych patients have been abused, pushed, violated, traumatized, and generally mistreated. They have much to be angry about. Many are also severly wounded and tend to lash out at those who get too close, even those who want to help, because help often feels worse before it feels better.

Probably the most important thing is--don't take their behavior personally. Set limits, by all means, but don't get stuck in a punitive mindset.

Even the most disturbed psych patients can usually sense when someone cares. Don't be a bleeding heart or you'll be manipulated all over the place. But connect when you can and care within the framework of the unit.

Be skeptical of almost anything a psych patient tells you, especially if they say that you're the only one who understands them. This is a frequent ploy tried on newbies looking for affirmation. You really do need the affirmation, but get it from peers or superiors or away from work entirely so you're not a sucker for a treatment-wise patient.

Come back here often for fresh infusions of moral support, knowledge and fun.

This was probably waaay more than you bargained for, but I just kept thinking of things I wish someone had told me when I was starting out.

I wish you the best.

elkpark · Jul 13, 2007

I second everything rnwriter says. I've been a psych nurse (in a wide variety of settings) for >20 years now, and have experienced only minor injuries.

Although I've seen plenty of staff attacked/injured over the years, it's almost never been the case that the attack was "out of the blue" with no warning, as people will often say later. In nearly every situation, the client was clearly telegraphing that s/he was getting more agitated, angry, whatever, and the situation was becoming more dangerous -- but the staff member involved either didn't know enough to recognize the signals being communicated, or was on her/his own power trip and didn't care.

A large part of how you are treated by psych clients will be the result of how you treat them. One thing I've always told my students over the years is to never pass up the opportunity to build a little positive rapport with a client. You never know when the little moments that don't seem to matter at the time -- e.g., someone complains about their room being too cool and asks for an extra blanket; do you take the extra minute to get them the blanket or forget because you're too busy and don't feel like walking to the far end of the unit? -- are suddenly going to matter a great deal. When you suddenly find yourself in a situation where you're saying, "Steve, I need you to give me the piece of glass ..." or an angry client feels like punching someone, how that situation turns out is going to depend largely on what kind of relationship you've already established with the client and how s/he feels about you. Once you're actually in the situation, it's too late to start building the relationship then! And I don't mean by this that you only tell people what they want to hear and go along with whatever they want, but I mean that you consistently treat people with respect, dignity, compassion, and fairness. Clients on psych units are tremendously observant of staff and their interactions with each other and the clients -- they usually know much more about the dynamics of the unit than the staff do. Even when clients are so psychotic they seem unaware of their surroundings, they are still usually paying much more attention than you realize to your attitude and your interaction with them and the other clients.

Best wishes for your new career!

nmb81 · Jul 14, 2007

Thanks so much for the helpful advice.

And no that wasn't too much info...i actually also had the concern of how to set boundaries too.

I know alot of it is common sense...but it's not always easy. Especially when you're trying to establish rapport...and the pt.s asks you something personal.

For example...i'm young and don't look like i'm in my late 20's, more like 16. So my young pt.'s sometimes ask me how old i am, after a long vent about how know one cares about them etc and they thank me for listening. So a good thing is going and then they ask me that....can you guys give me senarios on possible things that pt.'s could say and some scripting that doesn't sound harsh. When asked my age i said, "well, you don't need to know that". But i felt like i could have handled it a little better, or maybe it was awkward because i'm not used to doing that. I dunno.

I'm having a hard time feeling it out sometimes and knowing what's appropriate to say or not. I watch some nurses who are very professional and talk about setting boundaries, but then i see their pt. interaction and sometimes they say things and i wouldn't think coincided with "boundaries" so i'm totally confused.