borderline-help: 2 different nurses/2 different approaches

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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.

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.

BPD is about trust, not intelligence. Once trust is established, there can be many teachable moments leading to slow but steady progress.

Trust is a by-product of respect. I don't see much respect for borderline patients in your posts so perhaps you are not seeing much improvement in the people you are taking care of. That might lead you to believe they are unteachable.

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Like mercy and RN/ said. I would add that treating BPD is all about teaching, but, as with children who have been abused, you need to show them, not tell them. You need to demonstrate, in a consistent way, what you hope to have them learn to do. This means that first they must know that you respect them and can be trusted. I don't think there is any short cut around this. This is difficult to accomplish in a short term inpatient setting, which is one of the reasons BPD is best treated in a different venue.

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AMEN to RN writer and CharlieRN!!!!!!!!

To Hseih, I wonder why you work with patients you feel are untreatable????

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Specializes in orthopedics,geriatrics,med/surg.
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.

This is scary. But I know there are nurses out there like this. I honestly believe if you treat people the way you would want to be treated they would trust you. I would like to know what you are qualified to teach "them" ?

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Specializes in Assisted Living Nurse Manager.

Okay first off let me say that I do know this thread is 2 years old:lol2:

I found this thread very enlightning. I read every single post:D even though there werent very many:lol2:.

Anyways, the reason I am bringing this thread back to life is because Thunderwolf never did post what he would have done in this situation. As a new pysch nurse I am very interested in what you "Thunderwolf "would have to say.

Please do share!

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Specializes in critical care; community health; psych.

This thread is great. As someone new to psych, one thing stands out to me. Doesn't the borderline need consistency? So if Nurse "A" is giving choices and Nurse "B" is drawing lines in the sand, what does this say to the borderline? She has to change with the winds in order to maniuplate the situation. She has to become chamelion-like. Inpatient therapy has become an exercise in learning how to be a more effective borderline and reinforces the concept that the world is a confusing and unsafe place to live. Her sense of self is served up cafeteria-style.

It seems to me that it's less important which tact is taken, but rather that it is consistently applied. Always respectful though.

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This thread is great. As someone new to psych, one thing stands out to me. Doesn't the borderline need consistency? So if Nurse "A" is giving choices and Nurse "B" is drawing lines in the sand, what does this say to the borderline? She has to change with the winds in order to maniuplate the situation. She has to become chamelion-like. Inpatient therapy has become an exercise in learning how to be a more effective borderline and reinforces the concept that the world is a confusing and unsafe place to live. Her sense of self is served up cafeteria-style.

It seems to me that it's less important which tact is taken, but rather that it is consistently applied. Always respectful though.

Borderline patients, like everyone else, learn that different people have different standards. Yes, this can lead to manipulation and staff splitting, but it can also show the difference between people they can learn to trust and others whom perhaps they shouldn't.

Borderline people have an amazing knack for trusting the wrong people and pulling back from the right ones. So even inconsistency can be used to help them see a contrast in results. That contrast can be a tool to show them how their behavior and choices influenced the outcome and to begin to learn how to evaluate who is worthy of their trust.

If you are able to earn the trust of a borderline patient, there is little that can't be used to help them learn and mature.

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Specializes in Med-Surg, Geriatric, Behavioral Health.

I remember this thread and when I posted...my, time flys...thanks for bringing it back to my attention.

Let's look at this scenario from post #1.

Both nights are described as "taking alot of effort".

In my mind, there are several issues here.

1) There is inconsistency on this unit...and whatever structure that is/has/was put into place falls apart on a routine basis. Not good...nor therapeutic.

2) The OP acknowledges being new to psych. When a patient, like a person with BPD, tests limits or may have genuine difficulties, it may seem very taxing...especially on evening/night shift...with the lack of more resources. This may be both an experience and training issue.

3) It is also a patient issue...what has the patient learned from this experience?

4) This is also a team issue...team discussion of individual patient needs and unit policy with the goal in balancing the two.

Numbers 1 and 4 can be handled congruently...but it requires staff to talk and process together...coming to a concensus as a team...in order to provide that "consistent, therapeutic structure" for the environment. The great thing about folks with BPD is that they often do find the weakest links in our milieu and in our team...nothing wrong with this. You need that feedback. So, to a large degree...the unit here seems to fail in this. If the easiest or most frequent answer to Borderline behavior on the unit is to seclude or restrain OR to give in to the behavior (the opposite), it may be more of an indication of treatment/team/milieu failure...be it in training, in policy, and/or in team building. Believe it or not, much of Bordline behavior can be deescalated, way before seclusion/restraint is called for.

Number 2 is amendable to more training, experience, and supervision. If several staff on one shift lack experience/training, it just compounds the problem immensely. Training and experience takes time. This is why supervision and/or team building is so important.

Number 3...from both scenarios...what did the patient learn from this whole experience?...about oneself, about the unit?...this is worthy to be processed with the patient...then later with the team...what did the team learn about itself? A valuable feedback loop in both assisting Borderlines in their internalizing needed structure and in our own team strengthening.

The one thing with folks with Borderline is knowing when to pick one's battles...when to apply more structure and when to back it down some...this is an individual case by case thing, tailored to each individual patient. Not all Borderlines are the same...just like not all Schizophrenics are the same, nor all Bipolars...there are degrees in any illness. Structure is needed as beforementioned by my first post. However...just like too little structure may be viewed as threatening... too much structure may achieve just the the same affect...the result, escalation of behavior. If the situation escalated, why? This is worthy to be processed. If it is not processed, a valuable learning experience for all has been missed. Is the Borderline to blame...or the team...or both? Look at the big picture objectively. So, when a patient, be it Borderline or Schizophrenic or Bipolar has difficulty sleeping and needs to unwind or may need to have that 1:1 during these off times or may be escalating for some reason, how is it handled fairly, consistently across the board as a team? What structures are currently in place in assisting the patient? Depending upon the unit, does being therapeutic end when the sun goes down/when the lights are dimmed?...and/or does night shift staff fall into the easy routine behind the desk expecting all patients to be/remain asleep?...and is that even realistic? As an adult, is that even realistic for you...especially when you are troubled or ill of mind/heart?

Things do not happen for no reason....Borderlines remind us of this simple truth.

Just my thoughts at the moment.

Thanks again.

I may revisit this thread later on.

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Specializes in Assisted Living Nurse Manager.

I think I understand what you are saying Thunderwolf and RN/Writer. Consistency can be the key to working with borderlines, but do we not need to keep in mind the patient as an individual?

It would be my opinion that nurse #1 was trying to keep the peace and let the patient relax in the day room until she felt comftorable and tired enough to sleep. This in turn kept the patient from escalating where restraint and seclusion would ensue. But on the other hand was this just giving in? This is where I get confused.

Nurse #2 went straight to "do it this way or you will go into lock down". Now would this be considered very theraputic to the patient? I wonder what the patient was thinking at that moment. Then again how often was this patient testing the limits?

Not sure what I would have done as I am just starting my first pysch position. I have a long road ahead of me and alot of trial by fire I am sure.

Thank you for the replys.

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Specializes in Med-Surg, Geriatric, Behavioral Health.

You're welcome.

My previous response can be condensed to this.

"consistent, therapeutic structure"

If the easiest or most frequent answer to Borderline behavior on the unit is to seclude or restrain OR to give in to the behavior (the opposite), it may be more of an indication of treatment/team/milieu failure...

Not all Borderlines are the same...just like not all Schizophrenics are the same, nor all Bipolars...there are degrees in any illness.

individual patient needs and unit policy, with the goal in balancing the two

If the situation escalated, why?

What structures are currently in place in assisting the patient?

Structure is not necessarily all rules. It is also procedures agreed upon by staff that assist individual patients with their individual needs, positive or negative...even Borderlines or particular Borderlines who frequently visit you. Just like patients come to know what to expect on the unit, the staff need to know this too...upfront...nothing hidden/guessed. If Borderlines/particular Borderlines consistently escalate on your unit, it may mean that your unit structure needs reevaluated and weaknesses repaired.

I know it may not seem like an answer, but it is...both scenarios and staff handling were both right and both wrong. One provided no structure, the other excessive structure...none were therapeutic...patient learned nothing...both taxing on staff. One scenario neglected the milieu, the other neglected the patient. But, both scenarios were correct in that they were attempts to remedy a given situation..even if it accomplished little. A therapeutic milieu meets the needs of BOTH unit and patient. Therefore, it goes back to team building and training with frequent review of policy and treatment options. Hope this helps.

Keep up the discussion...good thread.

Other/additional thoughts?

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We will continue to see borderlines in acute psych. These awful behaviors that we are all so painfully familiar with can be difficult to deal with. OY! Don't I know it. Bit I too like borderlines, because they can get better, I've seen it.

I find it appalling that any human being gets put in restraints for defying authority!

AMBIEN? LUNESTA? CHLORAL HYDRATE????

And of course the stuffed animal of choice.

Have the pm shift set a ritual 10pm , sleeper tea and teddy. "I know you get scared at night, but you are a strong person and you can do this, one night at a time..." Then if she/he comes out on nocs "I'm really snowed with paperwork tonight, go sit."..basically nicely ignore, it's not hurting anyone!Why would the staff want to set up a power struggle? Ridiculous!

I 'm gonna brag now.My hospital has put anyone into restraints for 14 MONTHS!

and we haven't needed to either YEAH!

I used to come here alot, but was disheartened by some of the posters POLITICS

any how, hope this helps.

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Okay first off let me say that I do know this thread is 2 years old:lol2:

I found this thread very enlightning. I read every single post:D even though there werent very many:lol2:.

Anyways, the reason I am bringing this thread back to life is because Thunderwolf never did post what he would have done in this situation. As a new pysch nurse I am very interested in what you "Thunderwolf "would have to say.

Please do share!

Thank you for reviving this thread. I'm new to psych nursing and look forward to learning on the forum.

RNKittyKat, you and I have a lot in common, it seems. I keep running into you. Great minds ... !

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