Behavior Health Questions

[Dragonfly.RN]

Hi! I wanted to ask a few questions about behavioral health / psych nursing and the specialty forum doesn't appear to be so active. I am hoping this will be allowed here as I also would like some advice from other perspectives as well. Apologies for the length! 

I recently left a great hospital and position I was quite happy with (before covid) as it had just become too intense and too overwhelming.  Patient loads were increasing from 6 to 7 and then 8, more and more was being added to our workload. On top of needing to move off night shift and move to day shift, which my manager couldn't accommodate,  I just couldn't stay. 

I got a new job on days as an adult mental health RN at a small community hospital ( that seems to be on life support but is mass renovating and hiring).  Their psych unit is new as of this past Jan. Has about 24 beds. They staff at 6:1 ratio and cap admissions to the number of RNs available. Right now cap is 12 because they average 2 RNs per shift now that I have comeon board. From my understanding,  the hospital needs this unit to succeed. Needs it. This is my first psych job,  though at my previous position I did rotate through detox/SA units, and assist with crisis holds in the ER. I've been a nurse for 5 years.  

So, in the begining the unit director and the charge RN for the unit, from my understanding, set up and amazing, working and flowing unit that averaged 16 patients and had staff. Then some sort of exodus happened. I don't know the story really. I was told the director was a massive witch and was incredibly wretched towards the staff. She could run a unit great and if she liked you all was good. Anyone else she'd berate right there on the floor in front of eveyone.  She ended up getting fired. At some point in all this other staff left, including the Charge RN everyone loved. The interm director (all their unit managers are called directors) was the periop director and she did her best to my understanding. They ended up hiring a few more people, got a new director, but in the mean time the unit logistics fell to the way side. As far as I understand it, the new director is working on fixing it.

Some of the problem I am learning is that the director never comes to the floor at all, and according to the current senior RN, the director claims that she is there to "run the program,  not the unit". There no clinical manager and no unit charge. Current staff won't agree on anyone being charge and even so she'd have no ability to hold anyone accountable. There doesn't seem to be a lot of unity or responsibility and there is certainly very little accountability, especially when it comes to each shift pulling their own weight. Night shift actively refuses to do even the most basic tasks; they won't file papers in charts and will force admissions to hold till morning, they will not respond to referrals and pretend they didn't see them till morning shift change. They won't even clean trash or call EVS to do so. Day shift is left to cover slack and complaints to the director have gone seemingly unheard. Supposedly I'm told part of the issue is that much of night shift is agency/travelers/contract and should "eventually" get better.

My primary concern is the care of the patients. It's a voluntarily unit. Prior to the director change, there was a psych MD and social worker, and therapist who held groups, on the floor almost daily. None of this exists now. The psych sees the patients through tele only, social work was out sourced so they see the patient through tele when required and all they do is coordinate discharge. Which... frankly is more like they jumble together a discharge. There is no therapist at all. Instead the techs and the nurses hold groups... these range from activity groups, to "non-therapy educational groups" (so I am told). It was explained to me as we are providing them education for things like.. coping skills. Not offering them therapy, and are to just guide a topic and let the patients talk among themselves. For me this just seems like a blurry line I am uncomfortable with and I am uncertain about the scope of practice concerning this. I am also getting mixed messages from the other RNs. Some of them will take the patients and speak with them 1:1 in the group room... others won't and advise not to. I work with the one who advocates it. I honestly am not sure how I feel on that. I have no issues talking with a patient, and I do with my medical patients, but these are people in acute psych crisis. 

So, I guess my question is... is this normal for psych?  Is it okay to run groups and talk 1:1 with the patient about their crisis? I'm told it would build better rapport with my patients and that will "protect me" from them.  I agree with building rapport and being someone that can trust and are comfortable talking with... I'm just really confused about where the lines are. 

Thanks. 

[Davey Do]

No, Dragonfly this is not normal for psych. In my psych experience spanning four decades, inclusive of two community and one state hospital, I have never worked in such a poorly structured setting with an entire shift that refused to fulfill their responsibilities.

As far as the groups and 1:1 counseling, everywhere I've worked- including CD tx- nurses have done both.

One advantage is the volunteer population. Heaven knows how this unit could stay afloat otherwise.

Should you require more information, or have any other areas you wish to discuss, I'm here for you. Psych nursing was my interest and my Forte.

Good luck and best wishes.