Acute in patient psych gowns vs street clothes

Long Term Care Columnist / Guide · May 12, 2018

From a patient's point of view: I think it would be humiliating to have to wear hospital gowns in a psych unit. It's hard enough being locked up without being stripped of one of the last vestiges of our humanity. If you absolutely MUST take patients' clothing away, have scrubs available; they are comfortable and warmer than gowns (psych wards are *cold*!) and they are much more dignified. The unit I was in provided scrubs, although we were allowed to wear street clothes if we chose (most of us wore scrubs to bed). I wore sweats because I was always freezing.

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verene, MSN · May 12, 2018

I float between residential and sub-acute locations, and I am most frequently on a "step-down" psych unit. Everyone (patients and staff) wear street clothes. We keep a "clothing closet" of donated clothing items for those whose clothing is inappropriate for the unit, or for those who don't have anything (majority of our patients lack stable housing). We have a washer & dryer on the unit and patients can do their own laundry (with staff assistance). If people come in with dirty clothing we set them up with clean clothing from the closet and help them wash their dirty items. I think allowing personal clothing can go a long way to promoting patient dignity and allowing for expression of individual identity. There are times where it would be easier to do physical assessment if everyone wore gowns, but in general wearing street clothing is not an issue on this unit. We do not accept medically complex patients. It's a small unit with good staffing and self-harm is typically caught very quickly even with patients in street clothes.

I feel like wearing gowns would be more harmful psychologically to our patients. I'd rather put in the extra work in assessments and vigilance and keep my patients feeling less vulnerable. Most are anxious enough as is about seeking treatment with out being stripped of all personal belonging.

mmutk, BSN, RN, EMT-I · May 12, 2018

All our psych patients wear hospital gowns. All our here against their wishes and patients without clothes don't tend to try to escape.

KelRN215, BSN, RN · May 12, 2018

Are many of your patients homeless or without family support? I don't really see why the facility would need to launder their clothes for them if their typical length of stay is only 3-5 days unless they have nowhere to wash their own clothes on the outside. I don't do laundry every 3-5 days.

I'm not aware of any psych units that require patients to wear gowns- every one I've known (eating disorders unit as a patient, acute short term unit for clinical that sounds most like the one you're describing or units where I've visited friends), the patients wore street clothes.

elkpark · May 12, 2018

Every place I've ever worked, clients wore their own clothes unless there was some specific reason why a specific individual was considered too acutely dangerous to do so.

Tenebrae, BSN, RN · May 13, 2018

From a patient's point of view: I think it would be humiliating to have to wear hospital gowns in a psych unit. It's hard enough being locked up without being stripped of one of the last vestiges of our humanity. If you absolutely MUST take patients' clothing away, have scrubs available; they are comfortable and warmer than gowns (psych wards are *cold*!) and they are much more dignified. The unit I was in provided scrubs, although we were allowed to wear street clothes if we chose (most of us wore scrubs to bed). I wore sweats because I was always freezing.
Thank you for your post. And welcome to Allnurses!

This, and a thousand times this

Eris Discordia BSN, RN · May 13, 2018

I think patient dignity has a high value here...this is psych, after all. There is just no medical need for a patient to remain gowned. I cannot imagine denying a patient the right to wear pants or long sleeves, on the off chance they are a crafty self-harmer. It's more of a safety risk to allow them to wander around wrapped in blankets if they are cold, and it's cruel to make someone freeze just for easier access for staff to view arms. A dedicated self harmer would just switch from the forearms and cut somewhere less visible. Scrubs would be a better option if you had a seriously dedicated self-harmer that you had to relegate to institution clothing. Good visual access without feeling as institutionalized.

Over a decade ago, I was in a psych ward after a suicide attempt. Gowns did feel humiliating; it's hard to explain unless you have been there. There was no safety reason for me to be in a gown and I felt so much more like a human when my family brought in street clothing. That facility didn't allow underwire bras, so I was wandering around with huge, flappy breasts in a gown for all to see my glory, double gowned, and still feeling massively exposed. My street clothing with a sports bra felt like heaven. It sounds silly, but that was a big reason I isolated in my room to begin with...I felt so exposed and uncomfortable out of my room dressed like that. I got clothing and then I came out of my room.

I would rather focus on removing environmental issues where patients self harm on these things and correct those. For example, we have no call bells. We also do medical psych, and for bedbound patients or patients with mobility issues, we put a small silver bell on a bedside table for them to ding. There are fire-alarm style wall pulls in the bathroom for safety (no cords). Otherwise, they are healthy and ambulatory, so no need for a call bell.

We had a cutter use her institution hair comb to cut...we still quickly found out and she lost her comb. She took her roomate's, so she got put in a single and blocked and we tossed her her room for any other unlikely risks. She even lost her arm band for cutting with that. Remove the environmental problems, don't strip the patient. She eventually started head banging. She got a sitter. Better environmental care is what she needed, and solid and quality safety checks...not to be stripped and placed in a gown.

Our medical beds have super short cords and adapted side rails, and nursing needs a key to adjust the height of the bed or the head or foot angles, so there is no ligature risk. If a patient is medically ill enough to need a true medical bed, an air bed, or a bariatric bed, they are blocked and made a single, so ambulatory patients cannot get to the cord. If they manage to still be a self harm risk, they get a one on one sitter, or a line of sight. Patients on O2 are also singled and use a heavy O2 concentrator, so no wall access to cut themselves on or to potentially hang on.

In psych, dignity is often stripped, and loss of dignity can be traumatic to patients. This is DIRECTLY related to their care plan. As a former psych patient, I felt like I was a prisoner when I was in institution attire. I just did.

In psych, we have no business making new trauma. And believe me, being braless in a large, flapping institution gown felt like a small trauma to me, as a victim of sexual assault. I felt...exposed. Wearing gowns only has quite the institutionalized feel to it. You don't need gowns; you need stronger search policies for clothing prior to wear, a solid dress code and hygiene policy, and better environmental safety.

And for heaven sake, if staff is supervising the laundry, it is entirely their fault for ruining clothing! That takes some top notch skill. If it looks fancy, read the tag. Ask if its washer safe. Don't wash leather or wool. We don't do fabric softener, just fragrance free laundry detergent pods. Pop two in, put in clothes, hit button, you're done. We only wash it if the patient asks. So we make them understand if they want it washed and it shrinks, their fault. It is part of our psych unit consent that they sign that if something messes in the laundry and they asked for it to be washed, it's on them. If they didn't ask for it to be washed, but we washed it...and it gets ruined...that's on us. Still, if something truly gets screwed up and it is on us, then yes, our Director will reimburse them. Rarely happens. If they stink, we offer to wash. If they refuse, well, yes, we have blocked patients into a single for poor hygiene. Can't force them to shower or wear clean clothing.

As for bed bugs or lice, the facility needs to have infection control institute a bed bug or mite policy. We make bed bug infested clothing be double bagged, placed in a large sealed storage bin, and stored by EVS. The patients have to be decontaminated per policy with special pharmacy ordered washes and rinses. Those patients then must either wear gowns or have family bring in non-infested clothing that is not from the infested dwelling...or we set them up with a couple outfits from the charity "clothing closet". We never launder those items because regular washers don't get hot enough to kill the buggers...and bed bugs and lice ARE a health and safety issue, so that trumps everything else.

The off chance that someone might get extra crafty and self harm is not a high enough risk to warrant a widespread gowning policy. By all means, no strings, no provocative or exposing clothing, no belts, no hoodies, no clunky shoes or laces, nothing that is a fall risk...heck, I've even worked places where we don't allow underwire bras to prevent poking out the wires and self harming. Those are reasonable. But I have no need for full time unfettered access to a patient's body like a medical patient would need...unless our patient is incontinent and bed bound, then yes, we gown them in their rooms. But if they have clothing and we can put on a brief, place them in a recliner and wheel them out on the milieu, then yes, we will street clothes them up.

Yes, I feel pretty strongly about this. Clothing should be allowed. Sounds like your facility needs a much better environmental safety and some rudimentary lessons on how to launder clothing for the staff.

The only time we "made" a patient not wear street clothes, it was because she was bedbound and on hemodialysis...with a subclavian dialysis line dangling out of her chest (visually looks like a double lumen Broviac line with a standard central line dressing), IV fluids because she was catatonic and not drinking or eating, and incontinent. She got a medical air bed and was on 02 as well. She also had a little silver call bell, not that she used it when in catatonia. She was with us for ECT and IM Ativan therapy.

Those are just my thoughts.

FolksBtrippin, BSN, RN · May 13, 2018

Street clothes. Unless there is a real reason on an individual basis to prohibit street clothes. It's very important to maintain as much choice and dignity as possible.

As far as someone cutting with a call bell... Why are there call bells on the unit? Not necessary and the cord is dangerous. That's the change to make.

Legit reasons to use gowns are always safety reasons. If a patient tried to strangle self with pants for example. You should have paper gowns available for folks who need this intervention.

Patients should do their own laundry with supervision if necessary. That takes care of clothes getting ruined and it being the techs fault. Also, wash everything that comes in in hot water and allow 3 sets of clothing only to prevent bugs.

I have seen units where cutters have to wear gowns. I don't get that. How does a gown prevent cutting? Also, I've seen it used for elopement risk patients and I sort of get that.

Cutters should be allowed to cover scars with sleeves. Cutters should never be made to expose their scars or wounds in the milieu. That's not therapeutic for them or others. If you are concerned you can assess privately.

I had a patient that I put in paper gowns because she ate things, including fabric. She tore off pieces of the gown and ate that too, but I figured it was better than fabric. She had a history of obstruction from it. Ate her comb. The bristles off her toothbrush. This is another reason why you go to gowns and it almost always needs to be paper for safety anyway.

Buckeye.nurse · May 13, 2018

I've never worked inpatient psych, but I've worked on med-surg units where psych patients are awaiting an inpatient bed at at treatment facility. Since they don't generally have all the lines/tubes/drains of acute care medical patients, we have specific gowns designed for them that resemble a nightgown top more than a hospital gown. It's thicker fabric, and doesn't have snap arms. It also closes completely in the back. We give them hospital scrub pants to wear with it.

allnurses Guide · May 13, 2018

Well weather psych patients wear street cloths or not is a moot point where I work. It is a patient's right for them to keep and wear their own cloths and those rights are on a poster at the entrance of every unit in the hospital. Taking someone's cloths away and placing them in a gown would involve getting a "Denial of Rights order which would then have to be renewed every 24 hours. Being placed in a gown can be demoralizing and humiliating for the psych patient so they keep their cloths. Many of our patient's are frequent guests and it sometimes seems that they come to get fed, their laundry done and a somewhat comfortable bed to sleep in. it's raining now so I expect the adult units will be full tomorrow.

Hppy

Medic_Murse, BSN, RN, EMT-P · May 13, 2018

I can only speak from an ER perspective, but psych patients that come in, their room stripped of everything except the stretcher. The patients have to strip to their birthday suit, not even underwear or socks are allowed. All their items, including cell phones, etc. are collected and given to security to hold for their duration. They have a tech or a sitter that stays with them 24/7, if they have to use the bathroom, a tech, sitter, or nurse will accompany them into the bathroom.

Some people may find it "inhuman". Part of it is for their safety, but ultimately, it's for your and the staff's safety. Those patients are there for a reason and you'll be surprised how created some patients can get. In addition, you don't know what all those patients have on them. You can search them all you want, but they clever peeps and this isn't their first rodeo. They know what people are looking for, where they are going to look, and find different ways to hide things.