Staff splitting

[Seeing Myself Out]

Hello ladies and gents, it has been great reading and learning from the Allnurses community. After recent events I felt fed up with patients who staff split and it appears no recent topics have covered the issue of staff splitting.

Long story short, X was a recent transfer who was brought in for suicidal plan/attempt. After arrival on unit, X denied any symptoms reported by the transferring facility, and was calm and cooperative. After change of shift, X began to make unreasonable demands that cannot be met or against facility policies, and became verbally abusive to staff and threatened harm and destruction of environment. When X met the nurse manager for the first time, X accused of every nursing staff that had any kind of interaction for being "unprofessional, incompetent, and useless", and earned nurse manager's sympathy through a combination of manipulation and intimidation. He even got nurse manager to accuse nursing staff of agitating the patient, disrespecting patient rights, and threatening disciplinary action even after X has threatened staff, accused reliable staff members of patient neglect, and torn up the lobby to the point that the milieu had to be suspended.

At this point, what is the nursing staff's best course of action to address the staff splitting? At my facility the nurse managers are always right and subordinate nursing staff are always wrong (just like the scene during Full metal jacket thanks to its para-military culture), no matter how what takes place. X is clearly pushing the limits by doing everything X can other than active attacking staff and patients knowing that would bring a swift end to his ongoing streak of staff splitting. Should the staff just wait for the nurse manager to realize X is abusing his hospitalization stay to cause havoc without consequences he would have faced if he were in the community/correctional facility? At what point would it be necessary to contact the nurse manager's higher up(s)? Any advises would be appreciated.

[rpsychnurse]

I would recommend speaking with your manager about your concerns and, if she continues to accuse staff, I would go to her higher ups with the situation. Best of luck.

[EKUGRAD, BSN, MSN, RN, CNS]

"If at first you don't succeed, try again. Then quit. There's no use being a damned fool about it". W.C. Fields

Since you don't say what type of facility / unit you work in, it's hard to say what course to take. The behaviors you describe are classic presentation for classic Borderline Personality Disorder or Antisocial (male borderlines); lacking a conscience in each. Nothing psychotic or mood-dependent about it but it does appear to be firmly rooted in a maladaptive personality disorder. You have described perfectly the step-by-step process and outcomes of these faulty social interactions. I strongly suggest that you cultivate allies in your most experienced staff and definitely include the psychiatrists and PMHNP's. The absolute essential element in surviving a Borderline admission is to be CONSISTENT with all patients and present a united staff. Hopefully patient X was not allowed to damage the treatment and recovery of any other patients on the unit. As above, Good Luck.

I attended a two-day workshop several years ago entitled, "Treating Borderline Personality Disorder on an Inpatient unit". The presenter, MD, PHD, Phar.D., from New Jersey stepped before the crowd, announced, "How to treat Borderline Personality Disorder inpatient. In a word, Don't ! Enjoy your muffins and coffee. I'll be signing my book in the lobby."

[nurse lala, BSN, RN]

It sounds as if your nurse manager lacks mental health and leadership skills. The fact is that s/he has "drank the kool aid". When the boss buys into manipulation and sides against the team, there is a big problem. You need to be confident in the competency of the boss. Personally, I would be talking to the MH champions about a course of action. Confidence must be regained before more damage is done.

While I disdain the thought of quitting, I think it is indicated when leadership is lacking.

[JustKeepDriving]

These are the routes that you can go by:

1. Document the managers actions. If you feel like she is unable to maintain professional boundaries with this patient - and IMHO if you're throwing your entire staff under the bus because the patient cannot maintain appropriate behavior in the milieu - you're probably not acting in the patient's best interest or maintaining an emotionally healthy perspective on the patient's care. Whenever someone believes that "They are the only one that understands and can help the patient"... which if your manager is telling everyone that they're wrong with the limits they set - is highly likely - that can signify a lack of professional boundaries with the patient. I would take the managers behavior up the chain of command.

2. Be a unified front. When you have a borderline that continually staff shops trying to get privileges, have needs met that are inappropriate or items from staff using a "Staff splitting" technique - have a rule in place that all the patient's requests are to go through the patient's assigned nurse. Want to have an extra peanut butter and Jelly Sammich because I'm the best nurse ever and have really helped the patient's recovery - unlike meanie pants assigned nurse? Well, that's very nice of you to say but I cannot help you. You will have to ask your assigned nurse.

3A. Establish a behavior plan with documented precursors. This includes restricting patient from activities due to unsafe behavior. Sorry, but if you're threatening me - I'm not going to take a patient to visiting hours or the cafeteria because A. there are a lot more objects down there they can use to hurt me with and B. in the event I have to initiate a restrictive event - I don't want to put a room full of patient's at risk.

3B. I also consider verbal threats an imminent risk to others - I worked mainly in forensics and almost 100% of the time verbal threats lead to the patient taking physical action. I've seen way too many staff become disabled because someone wrote off a verbal threat. I always give my patient options but if the patient continues; I will intiate a restrictive event.

An example of the documentation,

"Patient yelling in the milieu with intense eye contact, tense spine and balled fists. Staff explained to patient that it was okay to be upset but that he couldn't do it here because it was disrupting milieu. Patient made intense eye contact with staff and said "[Expletive], I'll beat the [Expletive] out of you" at staff member. Patent offered PRN medication to help him better utilize his coping skills. Patient however refused and stated, "I'm not taking that you [Expletive]. Due to level of unpredictability and historical behavior that included tearing up milieu on (this date) and (This date) - patient was asked to walk to seclusion. Patient refused and said "[Expletive] you - I'm not going and if you try to make me I'll punch your lights out". Staff went hands on and patient dropped weight attempting to strike out at staff, spit and kick. Patient was assisted into restraints and transported to restrictive event room via mechanical transport yelling, "I'll kill you all" at ___ time. MD notified and Haldol, Ativan and Benadryl administered via IM for unredirectable agitation."

4. My documentation does contain inconsistencies between staff judgment and provider/manager judgement. It's not criticism - just an explanation for events. Whether it's right or wrong; It can be highly effective. For example:

"Patient was assessed by RN at ____ time. During assessment patient displayed psychomotor agitation - pacing back and fourth with balled fists and pounding on walls yelling "Get me the [expletive] out of here. RN asked patient what happened that lead to the restrictive event. Patient yelled, "You guys are a bunch of [expletives]!". Provider came to assess patient 2 minutes after RN assessment and patient was calm and stated that he, "Got angry because staff wouldn't get him a PB&J Sandwich and that he should have taken scheduled PRN's instead of verbally threatening staff". RN explained to provider that during the assessment minutes earlier that patient was still displaying agitation and appeared to continue to be an imminent risk to self and others and recommended continued seclusion until he could calmly engage in RN assessment. Provider released patient against nursing judgment. After provider left unit patient charged out of room at staff with balled fists and intense eye contact yelling "I'm going to get you now mother[expletives]". Staff attempted to limit set with patient and told him that aggressive behavior was not appropriate. Patient did not engage staff and continued to charge. Staff went hands on and assisted patient into restraints. Patient re-entered seclusion at ___ time. Provider notified."

I have heard different takes on doing this. Some people discourage it, and other encouraged it - stating that it shows a pattern of behavior that will warn providers/staff in the future.

Hopefully some of this helps because I lived your nightmare and it gets really, really frustrating. My end story is that the manager was removed and the patient was discharged. The one thing that really saved the unit was the cohesion between staff members (we had awesome team work) and our supervisor backed our calls 100% and would go to bat for us against the manager.