borderline-help: 2 different nurses/2 different approaches

[gcja]

I have about 4 months in psych and love it. I work 11x7 shift for a psych hospital. unfortunately, it seems our patients don't get the 1:1 they need. course of treatment is usually meds. problem w/this psych hospital is they utilize mostly agency and per diem. so there is no consistency with the staff for the patients. everyday we have new nurses. we do have a few permanent employees (me being one) but not many. here is the problem: we have a f/borderline on our unit who is extremely attention seeking and constantly acting out "according to earlier shifts". she will not comply with the rules of the milieu. when asked to get away from nursing station - she won't. when asked to take her meds - she won't. when asked to go to her room - she won't. constantly looking to talk to nurses at desk and being shooed away. when she won't leave she ends up being put in restraints/seclusion. when report is given it is always "pt. is acting up looking for attention. problem is due to lack of staff it seems patients aren't getting any attention. anyway, here is the problem. I come into work on friday midnight. pt. indicates she cannot sleep. she looks physically exhausted but refuses to go to her room. she states that she doesn't like being alone in the bedroom and when she goes to her bedroom thoughts of suicide pop into her head. she indicates that she doesn't want to take all the meds that they are giving her because it makes her very tired in the day (which they let her sleep all day) and keeps her in a fog. she supposedly told the doctor this but to no avail. she shows me her diary about her feelings of loneliness and anxiety she experiences, how she wishes she didn't feel so lost. how she wants to fit in and have a job and lover like everyone else. she spends the next hour or so going from nursing station to sitting area in the back of unit. she pops up at nursing station every 20 minutes looking to talk. she finally requests prn for 2 mg ativan and 50 thorazine and goes to back of sitting area and falls asleep. the senior nurse (15 years) has no problem with this because patient is quiet and not disturbing anyone else so he lets her sleep on day couch in back room until she wakes up at 5:30 am and goes to her room. Now, Saturday night: same situation but different senior nurse. instead of allowing patient to sit in back sitting room. at 12 am nurse calls doctor for an order to put patient in seclusion because she is not complying with the rules of the milieu and won't go to bed. Senior nurse states patient is testing limits and has a history of not complying with staff. Pt. does what she wants and wont listen to anyone. there are now two other patients ( who can't sleep either) quietly sitting in sitting room with patient. this is part of the problem with allowing borderline to stay up. we will have the whole unit up. Mind you, the 3 patients up are quietly sitting and talking. a couple of techs from other units show up for support of the anticipated seclusion. the physician comes up to unit to personally interview patient and see what problem is. the dr. convinces patient to go to her room and issues a room search and a c/o (one on one) because patient indicated that she has suicidal thoughts and a plan. Dr. leaves. Patient spends about 10 minutes in her room when she is back out of it. This time senior nurse puts her in open seclusion room where she spends the night following voluntary administering of 2mg ativan/50 thorazine. So, as a new psych nurse which is the better way to go. I just experienced two different approaches. On Friday night, it required alot of effort on my part to listen and talk to her every 20 minutes until she passed out about 3 am. On Saturday, by 12:45 she was in seclusion and the rest of my night was easy. Help which is right approach.

[Thunderwolf, MSN, RN]

What a wonderful topic!

To limit or not set limits and what does this mean for the BPD, the unit, and world at large?....I meant to say this as amusingly.

The thing about limits and limit setting is the concept of "Limits". I prefer to look at "limits" as establishing "structure"...for which all human beings need to feel safe and secure (see Maslow's hierarchy of needs from the other recent BPD thread found in this forum). Structure also helps remove uncertainty, provides routine, and allows for predictability in one's life.

Now, setting limits or providing structure...choose your own terms...needs to be realistic, nonpunitive, generalizable to others (aka reasonable), and fairly applied/ given out by those who hold that power.

I would like to hear more from other members first before I comment any further. This IS a very important topic....so let's continue the discussion some more...sharing some more viewpoints on this. I will come back later myself to add some more of my own.

[hsieh]

in places where psych hosp are nonexistant they don't have this problem.

[LydiaNN]

It is an excellent topic, which kind of makes me wonder why we have to discuss in a different thread, since the other great thread was closed this morning. Is there really any point to sharing our thoughts when lockdown seems to be predestined?

[hsieh]

i had nothing to do with the shut down of the other thread. i suspect the moderators did it because these are for discussion and debate and members take it personally and start going off track taking jabs at the members who write an opinion they don't like. discussion and debate is about the SUBJECT not the member making the subject.

[EricJRN, MSN, RN]

Here's the problem: The OP does work in a psych hospital, so making the psych hospital non-existent is not an option for her. I think she's asking about the best solution to the problem under her current conditions.

[NurseCard, ADN]

Ya know, since I am about to enter the wonderful world of psych nursing and I know that I will be dealing with many difficult borderline patients, I WOULD actually like to offer my thoughts on this topic and see where it all goes!

Being the type of person who does have difficulty setting limits, I know that that is something that I'm going to have to really improve on in order to be even remotely successful in my work. Having said that... my own instinct in the situation would probably be to let the patient stay in the TV room as long as she isn't being disruptive and/or causing any of the other patients to want to get up and go do the same.

I know however, that it's VERY important to make rules on a unit and have the patients stick with them to the letter, especially borderline patients. Is there anywhere that you actually can draw a line, though?

Furthermore, what IS it about borderlines that makes them want to test the limits of what they can get away with, with you?

Interested topic. Can we keep it constructive? I REALLY want to learn, here.

:biggringi

[StuPer]

Firstly it is an absolute fallacy to say that by simply not having psychiatric services that a diagnosis will not exist. Simply because, as a result, you are unaware of these people, doesnt mean they dont exist.

In areas and countries where psychaitric services are limited, people suffering with these illnesses often are unaware they have a diagnosable illness. Instead they continue to suffer in the abusive misery that is the environment they grew up in, I would suspect that a large percentage of the suicides (and they happen in large numbers) in these service deprived areas are simply people with borderline personality disorders giving up on existence, chosing death rather than continuing to live.

Someone in the other thread indicated there was no link between childhood abuse and personality disorders, I am sorry but that is balantantly wrong. I can say with complete certainly every man/woman I have assessed and treated with a borderline personality disorder was a victim of some form of childhood abuse. That is not to say all people who have suffered with CA will develop a BPD, not at all, it often depends who is the offender and the level of support in the family environment.

hsieh, you have indicated on 2 threads now your belief's in regard's to BPD, we all understand your point of view. As you have seen, no-one agree's with you, continuing to reiterate that view is simply creating alot of angst with the majority of posters. For the sake of harmony I would ask you not to continue to post this view, it seems clear to me that you have a fixed view on this, and so do those that disagree with you, merely recycling both sides serves no-one. In return I ask that other posters don't write inflamitory replies to hsieh, that way we can get back to the actual topic of this post which is how to approach the management of BPD in a ward environment.

In regard to the OP, both approaches are not without their problems, 1stly having a less prescriptive attitude to clients during the night can be a useful way of preventing a potential aggressive incident on a ward. Do you really have to insist that a person retires to bed if they are doing nothing to disturb the ward and/or other patients, on the other hand, by being too lenient you run the risk of developing a ward culture where there are frequently multiple people up all night, refusing to go to bed.

The second approach can be seen as an attempt to establish a 'normalised' sleep regime and ensure that other people in the ward are undisturbed while they sleep. On the other hand adhering to a strict policy of sleeping in rooms during the night and not allowing people to stretch their legs who maybe agitated or ruminating on traumatic events, can lead to a violent outburst that could have been entirely preventable.

In reality you have to make a decision based on the curcumstances you are faced with. I have seen people allowed to sit for a while go back to bed and sleep the remainder of the night, I have also seen some manic patients running riot in the early hours because they were not given strict limits.

If you have reason to suspect a patient is trying to test the system, as opposed to needing a real theraputic break from their bedroom, it maybe suitable to impose strict limits. If someone is clearly in distress and identifies they cannot sleep due to ________ reason, it may also be suitable to allow them to stay up. If its the latter I would normally say something like 'ok, you can stay up for 30mins, as long as your quiet, and after that time you must try and get back to sleep. If they comply but get up again I would normally offer night sedation. If they refuse to go back to bed then it maybe appropriate to enforce it, or apply IM sedation.

This approach allows you to maintain some limits, without being too strict, it also is fluid depending on what the person presents like.

Sorry everyone for the megapost.

regards StuPer

[CharlieRN]

Let me state, as a starting point, that I like borderlines.

In treating psych patients who have primary personality disorder one needs to consider first the limits of the envirornment. You just can't let them do something that will but them at lethal risk. Other than that they are free human beings entitled to respect.

Then you need to consider what it is you wish to teach them. The most import mode of teaching is modeling or demonstrating the behavior you wish to have the patient adopt. So you need to practice what you preach. If talking to them would have done the job they would never have gotten to be inpt.

I think the one thing most objectionable about borderline is their efforts to manipulte or force others into behavior that reinforces their beliefs.

The thing that needs to be taught is that you can't control others, only your self. The corrolary to that is that your behavior is your own responsiblity not anyone else's. The way to model this, is to not attempt to control your patient's behaviors unless they are clearly lethal. Control your own behavior. Having the pt sleep all night is a minor goal, changing their world veiw is a major one. So the pt stays up all night, so what? After 72 hrs awake she will sleep. The patient keeps talking to the nurses at night? OK, but the nurses do not have to answer. Control your own behavior. ie: "Ms x, it is time for sleep not theraputic interactions, the night staff's job is to help you sleep so they will not engage in conversation with you, either for therapy or to entertain you. If you have a specific need, say for another blanket, a medication or a drink, we will try to meet it, within these limits." Then follow through with it.

By attempting to force the borderline to "follow the rules" you confirm their world view: That the way to get you needs met is to force others to do what you want. They seek to make their world safe by controling others. If they can force you to put them in restraint then they are in control.

It is essential that the entire treatment team be onboard with the treatment plan. No matter how correct your approach it is not ok to go it alone. Do not allow the client to split the treatment team. If you are told, by the patient, of unprofessional behavior by a coworker, take it with a large grain of salt. Remember that the coworker is a responsible professional and is being accused by a person who is confined to a psych ward.

Finally, for your own protection, keep your back firmly against your institutions policy manual. If you put yourself in the wrong even a bit in your interactions around the borderline she will grab the opportunity to back stab you. Her subconscious object is to acquire power and safety by being able to control others in her environment.

Beware of the borderlines effort to deify you. "You'er the only one who understands me." etc. Don't buy it and don't let the patient believe you buy it. "Thanks but I'm nothing special, Just doing my job," etc. Again this is an effort to gain control over you. remember your relationship is a professional one. You need to be friendly but you are not her friend. If you don't cooperate getting up on the pedistal you will have less of a fall when she pushes you off.

[hsieh]

i would go by the rules - if you're not allowed up - then that's it. i would then discuss the situation with my nurse manager the next day and let them have the final decision. and if the nurse manager doesn't decide (unlikely) i would ask the psychiatrist. it's not in your scope as a nurse to decide how to treat patients but what the rules of the facility you work at tell you how to treat them.

[LanaBanana]

Okay, I'm only a student nurse, but this interests me. If there is not an opportunity for good therapeutic communication on the day shift and there is a possible opportunity for it at night when the pt seems more open to it, wouldn't this be appropriate? To me, putting someone in seclusion because they are "borderline" and won't go to sleep is ridiculous. I have a lot of nights I can't go to sleep and the thought of how I would feel if I was told I was doing something wrong because I can't sleep makes me upset. Don't we all know something is wrong when we can't sleep - if we could fix it we would.

???

[hsieh]

when you take care of a large number of people who are considered "acute" and you don't have a lot of staff you must follow the rules for everybody's safety. it's a hospital where people go to "get better" not a frat party.