borderline-help: 2 different nurses/2 different approaches

Thunderwolf, MSN, RN · Jun 21, 2006

Great discussion so far....keep it going. Continue to be Respectful to each other. You are doing a great job sharing here... debating THE topic, not The member....ah, tis the big difference which keeps a thread open or closed. I wish to continue seeing how you all do before I place my comment(s).

Good job everyone!

TitaniaSidhe · Jun 23, 2006

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.
regards StuPer

I agree, well said

TitaniaSidhe · Jun 23, 2006

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.

Again excellent post, very good info in this, a shame you always have one or two staff/tyreatment team members that allow a split to happen, very hard to keep everyone on the same page, possible but difficult. However I guess therein lies the challenge.

cardiacRN2006, ADN, RN · Jun 23, 2006

Her subconscious object is to acquire power and safety by being able to control others in her environment.

Yes! Great post! As children, these patients were often abused, either physically or sexually. They had no control over what happened to them then. Everything they do at this point in their lives has to do with control.

The woman I know who is boarderline is very promiscuous, almost always with much older men. It's like she is trying to re-create the abuse done to her from her father, only this time she is in control of how it happens.

Interesting different approaches by both nurses. To the OP-what do you feel was the most appropriate treatment for the pt? Are you comfortable putting her in seculsion just for wanting to stay up at night?

lberghood · Jun 24, 2006

Excellent thread!!!!!! I was actually going to ask for advice on this very topic. I think Charlie said exactly what I needed to hear. I have been in nursing for 18 years, 7 yrs in psych and am now working as a night supervisor and encounter this situation frequently.

While i definitely agree with not staff splitting there was an occasion when a patient was up and agitated and wanted juice. She is VERY good at targeting the right staff and knowing just haw to push their buttons and had already been up 2 or 3 times that night for juice and the staff told her no.

I heard the screaming from my office and went to investigate the situation. The patient was all worked up about smoking and went on to say that she was thirsty and couldn't drink water etc, etc, and was probably being manipulative but i told her that she needed to calm down and get in control, offered a prn and told her she could have the juice with her meds and then she needed to go to her room and stay in control and if she was in control at smoking time (7am) she could smoke.

This decision did not win me a popularity contest with the staff as they felt that i was allowing the patient to manipulate and they had lost "control"

I asked the staff to just try to listen to me for a minute and gave a spiel about "control" and that when the patients are admitted to the hospital the are essentially locked up, their clothes are taken at times, we tell them when to eat, sleep, smoke, etc... They are adults and not criminals and i often wake up at night and get thirsty and the meds we give them do cause dry mouth. ( This pt also had thrush from HIV) While the pt was manipulating she also had a need. I asked them that if in the grand scheme of things it was really going to matter if she "got over" for a cup of juice and they had to agree with me. I also did not want to have her disrupt 24 other acutely ill patients and have a real situation on my hands.

I felt that I had made the right decision but I really was concerned about the staff feeling unsupported and was questioning myself and i asked one of my bosses and he made an excellent point. His response was that i acted appropriately as an advocate for the patient but sadly the patient got the message that if you carry on and scream and threaten you will get what you need not that we(the staff) care enough about you to give you juice if you are thirsty and pointed out that the difficulty the staff has when patients get out of control is that staff feels out of control and that is when we need to DO SOMETHING

I have seen a lot of behaviors that are "normal" in the real world escalate to codes and restraints which could have been handled in a different way and we are working really hard at our hospital to change the culture while still ensuring the safety of all staff and patients.

We are also succeeding, last year in May we had 85 restraints this year in May we had 15. We now include an anger management assessment on all admissions and include the patient in developing a safety plan

Sorry for the length of this and i hope that i didn't stray too far from the topic but many of the acutely ill inpatients we serve suffer from personality disorders including borderline.

BTW I have grown to actually like borderlines too Charlie, sadly I think that we are a minority

nursekathi · Jun 25, 2006

I have worked in psych for 1 1/2 years, and also love it! I was just promoted to evening supervisor in a child/adolescent residential facility. We have had a few borderline adolescent females, and they are very trying, but quite interesting. I feel for them, but beware just the same.

First off, if I were you, I would advocate for the patient by speaking directly to the doctor, maybe attending treatment team, and seeing if her meds could be rearranged. Can she take less in the AM and more at HS, to lift some of the day fog, and sleep better. Dayshift needs to get on the same page and prevent daytime sleeping. Our facility is great about this.

I do personally disagree with S/R for refusing to sleep, that should be solely for harm to self/others, but sometimes I guess there is no alternative. Consistency in rules is vital. Usually if someone is up late, I will offer a snack, some milk, and about 5-10 minutes of my time to talk. After that, I may try offering a book to read until sleepy.

As far as a patient being scared or suicidal at night, I will post a tech sitting in the doorway until the pt is asleep, but I have enough staff to do that, and again, I am working with kids. I don't know if this is an option for you. If it becomes a trend, we look towards DR/ treatment team to find a solution.

Good luck, and enjoy your new job. It is very rewarding.

Kat

CharlieRN · Jul 1, 2006

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.
???

You need a serious answer to this, so here goes:"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?"

Who says there is not an opportunity for good theraputic communication during the day shift? Did the day staff tell you that or did the patient? Most likely it is something the patient says. It sounds like the opening gambit in a staff spliting opperation. "No one on days has time to talk to me, they are all so busy..." You'er the only one who has time to listen to me." If you buy into this the patient is controling you. It is not therapiutic to allow her to control you. The theraputic lesson is her experiencing controlling herself. Failing that, she can observe you controling yourself.

The bottom line is always the policy of the institution and the overall treatment plan for the patient. If the treatment team and the physician want you to sit up with the patient and engage in a theraputic discussion and they put that in writing, then go for it. In my opinion that is as likely as a snowman vacationing in the Bahamas, but who knows it could happen.

Now I completely agree that there is no reason to restrain a patient just because she will not go to bed. But if she really wants to force the staff to restrain her, she will up the anty until they do. Again this is something the treatment team needs to make decisions about.

gcja · Jul 2, 2006

You need a serious answer to this, so here goes:"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?"
Who says there is not an opportunity for good theraputic communication during the day shift? Did the day staff tell you that or did the patient? Most likely it is something the patient says. It sounds like the opening gambit in a staff spliting opperation. "No one on days has time to talk to me, they are all so busy..." You'er the only one who has time to listen to me." If you buy into this the patient is controling you. It is not therapiutic to allow her to control you. The theraputic lesson is her experiencing controlling herself. Failing that, she can observe you controling yourself.
The bottom line is always the policy of the institution and the overall treatment plan for the patient. If the treatment team and the physician want you to sit up with the patient and engage in a theraputic discussion and they put that in writing, then go for it. In my opinion that is as likely as a snowman vacationing in the Bahamas, but who knows it could happen.
Now I completely agree that there is no reason to restrain a patient just because she will not go to bed. But if she really wants to force the staff to restrain her, she will up the anty until they do. Again this is something the treatment team needs to make decisions about.

while I would agree with you that it is possible and very likely for borderline to attempt to split staff, in this particular instance I don't believe that to be the case. the original problem was "which is the best way to deal with borderline female who claims she can't sleep." I worked two different nights with different nurses who had different styles. the first nurse felt it was better to allow patient to sit in "sitting area" quitely without disturbing other patients thus allowing her to settle down and eventually go to sleep. he felt it was a better outcome than to wind up in a restraint situation which would upset the whole unit. the outcome to that situation was patient hung around for about an hour or two and eventually went to sleep. the next evening, same situation, the other nurse immediately when to showdown scenario by calling for reinforcements and whith a show of force caused patient to go to her room. on the second scenario physician was called and he calmly spoke to patient and asked would she please go to her room. while doc was present patient complied. shortly after doc left, nurse called for reinforcements and informed patient either you go to your room or lockdown. I was just trying to figure out which is better approach. As far as what occurs on the day shift, we have a 24 patient unit with two nurses and two techs. In the best of situations it would be difficult to interact with the patients. unfortunately, in this facility 3 out of 7 days the two nurses are temporary agency nurses unfamiliar with the unit or the patients and only on the unit for the day. the next day we might have two entirely different nurses. So while, yes, it is very possible that a splitting situation can take place. It might also be possible that the patients are not getting the attention they deserve.

rn/writer, RN · Jul 3, 2006

while i would agree with you that it is possible and very likely for borderline to attempt to split staff, in this particular instance i don't believe that to be the case. the original problem was "which is the best way to deal with borderline female who claims she can't sleep." i worked two different nights with different nurses who had different styles. the first nurse felt it was better to allow patient to sit in "sitting area" quitely without disturbing other patients thus allowing her to settle down and eventually go to sleep. he felt it was a better outcome than to wind up in a restraint situation which would upset the whole unit. the outcome to that situation was patient hung around for about an hour or two and eventually went to sleep. the next evening, same situation, the other nurse immediately when to showdown scenario by calling for reinforcements and whith a show of force caused patient to go to her room. on the second scenario physician was called and he calmly spoke to patient and asked would she please go to her room. while doc was present patient complied. shortly after doc left, nurse called for reinforcements and informed patient either you go to your room or lockdown. i was just trying to figure out which is better approach. as far as what occurs on the day shift, we have a 24 patient unit with two nurses and two techs. in the best of situations it would be difficult to interact with the patients. unfortunately, in this facility 3 out of 7 days the two nurses are temporary agency nurses unfamiliar with the unit or the patients and only on the unit for the day. the next day we might have two entirely different nurses. so while, yes, it is very possible that a splitting situation can take place. it might also be possible that the patients are not getting the attention they deserve.

bpd is a developmental disorder in which, for a variety of reasons, some patients may have the social/emotional maturity of a young child. they constantly try to test the limits and often provoke fights/confrontations when they don't feel good (for any reason).

three things jump out at me from your description of your work situation.

one is that inpatient hospitalization may not be the best setting for borderlines. it may be necessary during crisis times involving harm to self or others, or if co-morbidities are involved, or if the consequences of their erratic behavior send them into a rage or a tailspin, but inpatient then becomes the treatment of choice for the secondary problems, not the borderline mindset itself.

the second thing is that the ultimate goal in treating bpd patients must be to help them grow toward maturity and health. to that end, any solution that offers them a chance to self regulate in a sensible and reasonable manner ought to be encouraged and even praised after the fact. "you did well the other night when you couldn't sleep. you occupied yourself quietly and waited until your body told you it was tired. then you listened to it and went to bed without any problems. you took good care of yourself."

this is, after all, what we want them to learn how to do.

which brings me to the third point. the kind of scenario outlined in red in your quote is unfortunately all too common. it comes from an extremely poor understanding of borderline issues and just reinforces the pathology.

think of the two different approaches, but picture a three year old instead of a grown-up. do you help the "child" learn to help herself and reinforce the positive behavior when she does it right? or do you escalate the tension by drawing a line in the sand and turning a great learning opportunity into a showdown where nobody wins and trust is squashed, yet again.

it takes a disciplined, kind, and firm approach to help these people. rules need to look more at goals than hard and fast regulations. yes, there will be some "non-negotiables," but these should be kept to minimum. many times, rules can be conditional--based on cooperation and other factors.

the difficulty is manifold. sometimes staff members have their own control issues and can't stand to see a bpd patient "get one over" on them. this is a terrible outlook that constantly sets up a win-lose dynamic. it makes conflict inevitable and precludes safety and trust because of its very adversarial nature.

at the other end of the spectrum are staff members who have nice-guy issues. they like hearing that they are the only one who understands the patient. they don't know how to say no and mean it. other staff members hate this and then you have internal conflict which any bpd patient worth his salt will exploit to the max.

the solution is to be very careful about the way that rules are stated. and to have as few as possible. borderline patients look at rules as invitations to a jousting match. better than rules are evaluation tools. this is what normal adults use to make many of the decisions that are not black and white. how late should i stay up? well, i have an appointment at 9:00 and i don't want to rush, so i should probably get to bed by 11:00 pm." if someone came along and said, "you need to go to bed by 11:00 pm or else," i think most of us would have a reaction. why should bpd patients be any different.

if your unit has a hard and fast rule that bedtime is such and such, it might be time to look at possible exceptions and what might make them acceptable. in other words, maybe the rule should read, "bedtime is at 10:00pm. any exceptions need to be discussed with staff."

then, when patients come forward with their exceptions, that's a good time to help them look at cause and effect and if there are other alternatives that will work. this is a wonderful opportunity to stop treating the patient like a problem child and get them to start considering what it is they really want/need out of the request. do they really have difficulty sleeping or can they just not resist bucking the rule.

if it's the former, the solution in blue was a great one. if the latter, that can be brought out into the open as well. "would it help to stay up one minute past the 10:00 mark?" when called out into the open, a surprising percentage of bpd patients will admit that just having a rule is a problem. then you have a chance to praise them for their insight. and, believe me, with a borderline patient, that is a major bit of information that you can use to build on in the future.

you can help them see other areas where they got themselves into trouble just because they didn't want to be told what to do. then you can show them how they have choices--take on the rule or the law and invite a world of hurt just to prove that no one can make them do anything they don't want to do--or--decide to cooperate enough to avoid problems and take some time later to look at where all that anger and rebellion might be coming from. what "rules" were imposed on them at a young age that harmed them and maybe should have been broken.

borderline patients are often very intelligent. many are capable of seeing that their current rebellion is misdirected way of fighting old wars if they (and we) don't get too hung up on the smokescreen problems of the present.

the trick becomes figuring out what the real need is. borderline patients need to be heard. they need to feel respected. they need to feel safe. they need to know that they can make mistakes and still be given another chance. they need to know that those in authority over them truly have their best interests at heart.

sounds complicated but it's not. this is what every man, woman, and child walking the planet needs. borderline patients just need our help getting past their own crazy-making thinking and behavior to a place where they identify their real needs and can then be less afraid (and therefore less crazy-making) in seeking after the real goals.

staff members need to understand down to their very core that treating borderlines is not about showing them who's boss. it is about setting enough rules to keep them safe and helping them to develop enough trust that they can begin maturing past their arrested childish selves. reasonable kindness, the refusal to take borderline behavior personally, and the understanding that these patients need consequences but not condemnation are all essential in treating borderline patients with success.

CharlieRN · Jul 3, 2006

while I would agree with you that it is possible and very likely for borderline to attempt to split staff, in this particular instance I don't believe that to be the case. the original problem was "which is the best way to deal with borderline female who claims she can't sleep." I worked two different nights with different nurses who had different styles. the first nurse felt it was better to allow patient to sit in "sitting area" quitely without disturbing other patients thus allowing her to settle down and eventually go to sleep. he felt it was a better outcome than to wind up in a restraint situation which would upset the whole unit. the outcome to that situation was patient hung around for about an hour or two and eventually went to sleep. the next evening, same situation, the other nurse immediately when to showdown scenario by calling for reinforcements and whith a show of force caused patient to go to her room. on the second scenario physician was called and he calmly spoke to patient and asked would she please go to her room. while doc was present patient complied. shortly after doc left, nurse called for reinforcements and informed patient either you go to your room or lockdown. I was just trying to figure out which is better approach. As far as what occurs on the day shift, we have a 24 patient unit with two nurses and two techs. In the best of situations it would be difficult to interact with the patients. unfortunately, in this facility 3 out of 7 days the two nurses are temporary agency nurses unfamiliar with the unit or the patients and only on the unit for the day. the next day we might have two entirely different nurses. So while, yes, it is very possible that a splitting situation can take place. It might also be possible that the patients are not getting the attention they deserve.

Two points: I was responding to Lana's post not the primary one.

In reference to the initial question, I'm with the first nurse. Letting her sit out her wakefulness is vastly perferable to the show of force route. There is a small but measureable chance of seriously injuring or killing a patient during a show of force. Its about 1%. The risk of staff suffering the same level of injury during a show of force is twice as high, approx 2%. Clearly this is something that should be undertaken only if there is very serious danger. At our institution we have recently gone to a "find some other way to deal with it" approach, with excellant results. Almost any danger so severe that SOF is really needed, ie: involving immediate and credible threats to injure others, is severe enough to call in the local police. This has resulted in a much lower rate of SOF.

Even if there is poor nursing coverage on days it still should be the staff, preferably the therapy staff, who ask nights to do a "check in" with a patient or engage them in theraputic discussions at night. Theraputic discussions are the primary job of therapy staff just as safety is the primary job of nursing. Nursing staff are setting them selves up for a fall when they accept responsiblity for this, particularly if not specificly asked by the professionals involved. Letting the patient be your source of information about how well your peers are doing their job is asking for trouble. This is particularly true when there may be real short comings in your peers performance.

RN writer has a really excellent post above. I agree completely.

hsieh · Jul 3, 2006

reply to rnwriter post 29: you say take the time to teach them. you're not going to teach a bpd anything because they aren't going to learn due to the nature of their disorder. that would be like taking time to teach somebody with a low intelligence calculus.

LydiaNN · Jul 3, 2006

reply to rnwriter post 29: you say take the time to teach them. you're not going to teach a bpd anything because they aren't going to learn due to the nature of their disorder. that would be like taking time to teach somebody with a low intelligence calculus.

hsieh, I don't mean to question your skills as a nurse, but if this is your attitude as regards working with the bpd population, may I respectfully suggest you consider another specialty? It alarms me that someone who is charged with caring for these patients continues to advocate washing her hands of them.