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.

[Little Panda RN, ASN, RN]

I think I just met my first borderline patient. When I was working on the adolescent side. This adolescent proceeded to complain about the night shift nurses stating ,

"all the want to do is control me, like they are my mother. I hate the night shift nurses, they all have problems and they are the ones who should be the patient here."

Apparently the night shift charge would not let the patient pace and made the patient stay in their room which is in low stim away from others. The patient complained so much the patient was getting themselves worked up and agitated. The patient tried to no avail to get us to agree. Which we did not.

The nurse I was with did very good with communication. Stating the reasons why they are asked to stay in their room at night. She mostly just listened and spoke in a calm manner.

Patient never did escalate, but was defiant the rest of the day.

[Thunderwolf, MSN, RN]

Thanks for sharing....now the proof in consistency is on the staff to follow thru. The team needs to discuss and to continue to be on the same page. Splitting the staff is one of the BPD's golden commandments. The staff needs to remain solid. Policy, procedure, teamwork, and training. Otherwise, like a hungry lion, the BPD will pick off the weakest member in the group and split one against the other.

Splitting is most likely to happen when a team member wishes to be an individual and not a team player...a BPD has an excellent radar and can pick those members out quite easily. Splitting also occurs when members are not familiar with policy, procedures, or team decisions. Policy and procedure should roll off your lips automatically. Splitting also occurs when team members fail to discuss readily on an ongoing basis, reaching decisions about unit/patient issues as a team...the team being of one mind...not many. BPDs honestly do search out for and hone in on team inconsistency...to help justify their own actions and emotional angst on the unit. And one good thing to remember is "the one who raises one's voice---> loses". The team member who loses one's cool or shows frustration in the eyes of a BPD is seen by that BPD as easy pickings, easily to exploit now or later (antisocials look for this too). Team members model appropriate behavior...if not, it is but another means to split one staff member against the other. With a BPD, you are as "cool as a cucumber". Hope this helps.

[Thunderwolf, MSN, RN]

Another tip:

The other thing about folks with BPD is that they live and prefer to live in their emotional angst...much due to lacking the personal strength or experience to pull themselves up into their heads (cognition/cognitive structure). As a psych nurse, you do yourself and the BPD person better service to not gravitate back into the emotional mire pit. I hardly ever, EVER ask a BPD "how does that make you feel? or what are you feeling? or how are you feeling?" or et cetera. That is their problem most of the time...they like their emotional mud...don't explore it...like a drowning person, they will pull you and self into the void. You as a nurse can offer them a better alternative...to explore things other than feelings/emotions...like actions and consequences, critical thinking and problem solving, and homework (exercises to practice) and processing it afterward. It is often much better to ask, "what are your thoughts today/at this moment? or what are your plans/goals today/at this moment?" 1:1's and groups are best spent processing in these areas. The goal with folks with BPD is to get them out of their hearts...and into their heads.

[Thunderwolf, MSN, RN]

Good job, nd_mom...and bravo to your team.

[RN007]

Thank you, Thunderwolf. Excellent teaching.

[Little Panda RN, ASN, RN]

another tip:

the other thing about folks with bpd is that they live and prefer to live in their emotional angst...much due to lacking the personal strength or experience to pull themselves up into their heads (cognition/cognitive structure). as a psych nurse, you do yourself and the bpd person better service to not gravitate back into the emotional mire pit. i hardly ever, ever ask a bpd "how does that make you feel? or what are you feeling? or how are you feeling?" or et cetera. that is their problem most of the time...they like their emotional mud...don't explore it...like a drowning person, they will pull you and self into the void. you as a nurse can offer them a better alternative...to explore things other than feelings/emotions...like actions and consequences, critical thinking and problem solving, and homework (exercises to practice) and processing it afterward. it is often much better to ask, "what are your thoughts today/at this moment? or what are your plans/goals today/at this moment?" 1:1's and groups are best spent processing in these areas. the goal with folks with bpd is to get them out of their hearts...and into their heads.

thunderwolf, this is such good advice. i understand what you are saying. when i read this post it clicked for me:lol2: (if you know what i mean). i will always take the time to think about what i am going to say to my patient. i having been reading up on the different disorders and trying to understand how i can best communicate with this type of patient.

but, being able to come here and gain knowledge from all of you is a wonderful resource in itself.

[angelchick]

Well I too, am only a student nurse, but have an interest in mental health, particulary BPD. I have only read about 20 of the posts, but get the general idea of the conversation, and what a great one it is!!

Borderline Patients need BOUNDARIES!

I believe through personal experience and research that at least 90percent of persons that suffer from BPD have endure some form of childhood abuse, more than often 'sexual abuse'. I believe that most people have borderline traits, and depending on the environment in what they grow up in, depends on whether these traits become active and are played out by the borderline person. A person with borderline feels out of control, and needs to gain allies and control in any way possible, they will manipulate intentionally and UNINTENTIONALLY, sometimes the only way they have survived is through doing this. A person with BPD is exactly that a PERSON, with an illness that they are trying to make sense of, like all people BPD persons have similar traits BUT are all different PEOPLE, it upsets me alot when I hear professionals labell, and refer to patients as "Borderlines", these patients have names, history and a story to share, sometimes an ear is all that is required, someone who "truely" cares and shows some compassion, I don't make these staements in naievity, I have been dx with BPD/PSTD for the last 20years, my husband was told that I would not live to 30years of age, today I am 36 and a 2nd year nursing student, wanting a career in mental health, wanting to advocate and make a difference in this arena, some may read this and think , "she's one person", what diff can she make? but i believe that through the hospitalizations in my 20's through my BPD behaviours (as that's all they are), all the trials and tribulations I have an inner wisdom and strength that is only growing on a daily basis.

Sorry I have gone off the subject of the actual two scenario's, but i felt very strongly about this subject. I have been in both those situations as a patient, and I believe that (like a child) if you fight and make it difficult for the BPD patient it just add's fuel to the fire so to speak, "they" want to create a fuss, they want attention, whether it be good or bad, if the BPD patient continues to push boundaries, than I believe they "should" be MADE to do as they are told, give them the option to comply first, then because they already feel outta control and need someone else to take control, do so! (they will fight it, but they need and want it).

Sounds very contradictory, i know, But i believe that BPD patients are one of the most misunderstood in all mental illnesses, and also the most unliked by staff, please all those working with BPD patients before you treat them as BPDer's get to know them as the person first and not their Label or Dx.

Thanks for listening.:nuke:

[sereneintexas]

BPD is a developmental disorder in which, for a variety of reasons, some patients may have the social/emotional maturity of a young child. ............................... treating borderline patients with success.

:yeah:WOW! that was really good and helpful. Thanks to you rn/writer.

But I wonder, does the few rules thing apply to adolecent borderlines?

[The_Wonderkid]

I have been reading some of this thread and find some comments very insightful and helpful and others, well, plain hilarious/unimaginable. I have worked with a number of people suffering from Borderline Personality Disorder (if you suffer from Heart Disease are you called 'The Heart Disease'? Borderlines? Hmmm Interesting phrase but anyway!), and I genuinely believe that this is one of the most (if not the most) destructive Mental Illness/Disorders which get the least amount of attention and sympathies from Mental Health Services.

I can see the general impression of working with these people is rules rules rules... and control control control... The one thing that strikes me is how BDP patients always seem to want to pass off responsibility to nursing staff, teams and psychiatrists. They use their behaviours as a way to achieve this. So when every bit of control is taken away from them where does that leave the patient? In stalemate. They are kept in set boundaries and rigidity and then when they are going to be discharged their behaviours worsen for fear of all that control coming back.

The way it was dealt with at my Unit (which was VERY effective) was the nurses would give the responsibility and control over their actions back to the patient. Along with this teaching about coping strategies and the like were involved as well as CBT. It was shown that if a patient could use these skills to make appropriate choices regarding not only their own care but also their actions, this had a positive effect on the long term prognosis of getting back into community and living a more constructive life.

I understand that there is a need for control/rules in a more Secure environment however I do believe that the more you take away from the patient the more of a patient they 'become'.

My rule (in the unit) was always consistency. If your staff are consistent you develop a rapport and trust and the rest can be achieved. If you set rules the person will undoubtably fight against them. If you enable the person to choose and make their own decisions on their actions and responsibilities then they are more likely to work with you longer term. Of course do this in a safe environment and assess danger and take action where required however the myth that Personality Disorder Sufferers just want to 'manipulate' and 'split' teams is more to do with ineffective planning and implementation of services rather than a conscious effort to thwart peoples efforts.

[kiwipsychnurse]

Boderlines in general mental health suck you dry and cause mass disruption. No easy answer will solve this one. As stated you need the whole team coming from the same direction and that is hard to achieve with causual/temp staff.

In foresics I saw some of the borderlines come from the general mental health wards to the forensic ward I now worked in. So I looked after them in general and now had them in forensic. No longer a problem, enviroment was much different, staff ratios better and more experinced staff.