safety on an inpatient psychiatric unit

Diane K. · Jun 17, 1999

I have looked into our "carefully screen list" and found that the plan is documented in our admission's office. The unit only has the names of these pts. I think you can supervise visits of a select few with documentation of need and a Doctor's order.

nurse lala, BSN, RN · Sep 18, 1999

Our visitors are informed that they are not allowed to give anything to the patients without going through the staff. Purses and backpacks are placed in large paperbags and stapled shut, then kept at the nurses station or kept by the visitor. If we have reason to believe a visitor has contraband, we ask them to empty their pockets, refusal is a reason to deny visitation. Everything is well documented.

As far as smoking, we limit the # of smoke breaks to 9 times in 24 hours. Outside only.

None of the staff want to go with them because they do not smoke. I read in nurseweek about a hospital in San Francisco that abolished smoking secondary to second-hand smoke. I would love to learn how that was done!

shambley · Oct 30, 1999

Forensic admisssions on general care units are inappropriate. Forensic psychiatry is a clinical specialty and the local jurisdictions need to have a place to send these folks for pre-trial examinations and need long-term care facilities for post-trial admissions. Most pre-tial pts receive little if any medications so that their exams for competency and productivity (an exam to measure whether the alleged crime was committed as a part of mental illness) can properly progress. Incompetent pts may be handled on pre-trial for the first 90 dsys, and after 90 days should be transferred to a post-trial unit. It is inappropriate to place antisocial clients on units where staff are not properly prepared in the specialty of forensic psychiatry to manage these pts. Civil cases on general units do not deserve to be housed with criminal committments. If the antisocials do not prey on the staff they will prey on the civially committed pts. Definitely not acceptable on voluntary pt units. Forensic units need "security nursing" staffing. Need training in how to manage violence and behavior codes, etc. Should require specialty pay and if a government facility the forensic staff need to be placed on law enforcement retirement system since they are involved with the care and housing of criminal committments (ie they are responsible for keeping the criminal committments from AWOL or escape situations-how to transport with escorts and proper application of cuffs+belts+ankle restraints &/or handcuffs/leg-irons. Escape of such a client places the facility at risk due to suits from placing the local community at risk. Risk of injury to staff increases as criminal committments often feel they have little to lose from any additional counts of assault or attempted murder of staff.

Roz · Jan 6, 2000

Originally posted by Callan:
That is a different way to look at it and I believe some of my staff see it that way; however, it still dosn't answer my question/concern about the contraband.

Searches are done on patients--what about visitors? We can't search them.

Another question,
Anyone working in an inpatient facility have smoking for their patients??? We presently have a smoking room on the unit. It is causing havoc for a variety of reasons. The unit is on the 5th floor so we don't have a "wing" to go outside. The other alternative is to have patients go outside with a staff member.
Has anyone run into trouble with this??

We do not allow patient's smoking priviledges on our units. This has been in effect for several years now. I am surprised when I hear of smoking in hospitals even mental health units. This has not been the problem you would expect. Patient's have coped well and are offered Nicorette gum or patches. We do contraband checks in the form of nightly room searches. If a patinet is found smoking on the unit their visitor priviledges are restricted for that day and reevaluated later.

[This message has been edited by Roz (edited January 05, 2000).]

jimbob · Feb 6, 2000

I am finding this whole topic fascinating. Here in New Zealand we still allow patients to smoke, they have a smokers room and they are supposed to be in this room for the duration of their smoking time. We continue to have problems with staff smokers who feel that the patients rights are being challenged unnecessarily - and then there are those of us who feel that our non-smoking rights are being usurped also - the battle continues. Like you Callan, we have similar problems with regards to forensic patients having insufficient services available to them and taking up beds in acute units (like ours) on a more or less long term basis. Again, the battle continues with this issue also. On a slightly different theme - does anyone have any suggestions as to how "we" (psych. nurses) can encourage nurse educators and trainers to recognise and acknowledge in their programmes the specialised field that psychiatric nursing is? When I look at the new grads coming through the system, they simply don't have the skills to enable them to work effectively in this area - therefore they are having some very unpleasant experiences which only serve to further highlight their disenchantment with this specialised area of nursing. Any comments/suggestions, opinions would be read and re-read carefully :-)

dkain167 · Sep 20, 2000

You have to have staff that are committed to maintaining a safe environment.-- All patient on my unit are searched- placed in a hospital gown and all belonging searched throughly- (inservice required to show how search's should be completed). Our patient's do not go off the unit without supervision. All packages are searched- These patients will still find ways to bring in contraband- however there must be consistant consequences to these violations.

(ie. privelege levels).

good luck- it's a difficult job!

psych-rn · Nov 21, 2000

Issue 1. We have had a huge drug problem at our hospital. management have employed security staff to monitor the activities of clients and others around the grounds which has decreased the amount of drug deals. We also have warnings that those who are drug taking if caught will be immediately reviewed by treating team with the idea of discharge. Police are also contacted who confiscate the drugs and fines are given. We also treat individuals purely in closed ward environments and then discharge thus preventing a relapse in their condition due to drug abuse while in hospital

The second issue is about cigarettes. Our medical hospitals has purpose built pysch units that now prevent 5th floor management. Each locked unit or unit that is locked only at night has annexes attached for smoking. One hospital has a purpose built smoking room with good ventilation.

blindog45 · Jan 7, 2001

Well, well, well. I can see the unit I work at is not the only one with these problems.

As for the smoking, we have a "smoking lounge" which used to cause problems. Our pts., who the night before were in such a crisis, would just sit in the lounge and refuse therapies and other types of therapies. They would be in there all day just puffing away. Well, this started being annoying, especially when these pts. were our regulars, you know, once a week crisis junkies who were ready to kill themselves if they were'nt admitted, and we started closing the smoking lounge at therapy times, so if they were refusing therapies, fine, they however werent going to smoke at these times. It appears to have given them "something else to do".

As for the clients who continually come in all the time, with contraband, or whatever, we have found a physician with some backbone will help. Some of our physicians do not do anything about anything, others will let the patient know what is expected of them and if they are noncompliant with therapies and rules, they can leave, or be discharged. On our locked unit, all pts are searched, belongings are searched and the pt is placed in PJ's for 24 hours. But still, visitors have brought drugs in and lighters, cans, glass etc. I believe the visitors need a list of unit rules also, so they know what is expected of them too, and, if they do not comply, they can be ask to leave. As far as I know, ANYBODY who is not behaving or contributing to the best interest of our pts should not be there. RIGHT? We have found, again, that having the physician to back up our decisions is important. Isnt bringing in drugs detrimental to our pts?

We just have to remember we are dealing with disfunctional people and expect the disfunction to continue even in the hospital.

Will Benson · Feb 16, 2001

Hi Callan, There are several things you might consider. Restrict your visitors to one or two at a time. You DO have the right to inspect any packages that your visitors bring for clients. Have staff at the entrance to your unit to greet visitors as they come in so as to inspect packages before they come onto your unit. Post a sign outside your entrance, notifying visitors what items are considered contraband and that bringing these items will result in visiting privileges (and they are privileges - not RIGHTS) being restricted. Consult with the attending psychiatrist about no visitors for the first 24-48 hours as an observation period. Create a set of unit guidelines that you can give to new admissions, have them sign and keep a copy on their chart. When you suspect a client has had a substance brought by a visitor, call the attending physician and obtain an order for a drug screen to be done. If it comes back positive, notify the attending and tell him you are also calling the Department Head with the same information. Get Nursing management involved, too.I hope some of these things help.

Callan · Mar 4, 2001

Since the last reply (feb) my department has become a Chapter 51 unit (In the state of Wi. this means we now accept involuntary patients from the county.) We have changed several policies, one being the visiting policy. We restrict visitors to 2 at a time. No children under the age of 12. In the future, we will be giving all patients a locker with a key so as to allow them to place their coats and personal belongings in so as to decrease the potential for bringing in contraband. Visitors are signing in and out and identify on the log who they are visiting. We do inspect all packages when they are brought in. In fact we have a sign posted at the entrance of our (locked) unit stating "all packages brought into the unit are subject to inspection".

Visiting hours are also changing to 1.5 hours a day.

Since I started this discussion back in 1999, my department now has security cameras located throughout the department. These "secured" areas are monitored not only by my unit secretary but the security department as well by TV monitors. We also have Duress Alarms. These are pager-like devices which the staff wear on their belt buckle, etc. and are acivated when a staff member feels unsafe or there are patients acting out. This alarm is sounded to the nurses' station as well as to the Security department. At the sound of the alarm, all available staff are dispatched to the location where the device was activated. This is a wireless system. It works great. Staff feel safe.

As for those who we suspect have brought contraband onto the unit, give "it" to the patient--and suspecting it was a illegal substance, we do order drug screens. when they come back positive, we let the docs know(even if the results are negative)---unfortunately, if the patient is still with SI (@#!@#^**$) as we may know may not be the true diagnosis--the doc will not discharge them--however, their visiting privileges may be revoked.

BarbRPN · Mar 9, 2001

Hi, I'm a registered practical nurse in Ontario, Canada. I have worked in a variety of settings, all within a large Provincial (Similar to State) Mental Health facilty. I have worked in Psychogeriatrics, Chronic Care Psychogeriatrics, Chronic Brain Syndrome, Chronic Care Assessment, Rehab and currently Admissions. Our catchment area comprises a large portion of south western ontario and we admit voluntary and involuntary clients. One of the hot issues on our unit at this time is "unit safety". Whether it is a result of ambivallence, rapid staff changeover, shortage of staff or any other reason, our unit has become a very unsafe place for staff, client and visitors. We too have a problem with contraband, lax policy on search and seizure, and lack of leadership with our particular nurse manager (no offense to any other nurse managers). We have a flagging system for agressive and suicidal clients. Our unit has 36 beds which are currently filled, we regularly have at least ten "grey flags" which are high potential for agression. We also have black flags (assaultive client) and often have a "pink flag" client (potential for suicide) or "red flag" (extreme high potential for suicide or has currently attempted suicide). Being an admission unit we have a wide range of diagnoses and our clients spend anywhere from one month to upwards of ten or more years on our unit. It's not a good mix at all and DOESN'T WORK. Never the less we do what we can but we have new admissions walking around with contraband and suicidal patients with access to walkman radios, pop cans, electrical cords etc...they are seated at dining tables with paper plates but have 2 or 3 others at the same table with glass dishes and metal cuttlery. We have clients who burn or set themselves on fire and half the clients are keeping lighters on them 24/7. These kinds of things are a drop in the proverbial bucket as to what goes on on a daily basis. The issues are brought to the attention of our nurse supervisor/ward manager but nothing is ever done and those of us who bring issues to her attention are treated like "sh*t disturbers" rather than concerned nurses. In my 15 years at this facility, I have never seen anything like it.

As for the smoking, we also have a "smoking room" in one far end of our ward but it is the staff and not the clients who consistently break the rules about smoking onsite. I myself am a nonsmoker and although I don't say much about the staff smoking in non-smoking areas, I think it sets a very poor example for the clients who are expected to follow strict ward guidelines.

Anyone who has any comments on unit/ward safety and/or lax attention to the same, please jot a note.

Regards,

------------------

Barb

Registered Practical Nurse

Psychiatry

Ontario CANADA