Describe a typical day

MDMBSNRN · Dec 27, 2014

I was a resource (float pool nurse) for a year, and worked primarily in oncology, ICU, and telemetry. When I decided to go back to school, I needed a more flexible schedule, and I was asked to fill an opening in the psych department of my hospital. Initially, I worked on a 14 bed inpatient adult and geriatric unit. After approximately six months of this, I was asked to move to a five bed psych ED, and also to float to other departments of the hospital when the psych unit was empty.

While on the inpatient unit, I worked as both a staff nurse and a charge nurse. Psych is certainly a very different environment from anything else. The doors are locked (and I mean all doors). The exits are locked, the staff break room is locked, supply rooms are locked. Everything. On our units, we conduct rounds every fifteen minutes for safety. We also do hourly rounds. During these rounds we document where the patient is, and what their emotional state is at the time (hostile, agitated, depressed, tearful, anxious, psychotic, hallucinating, suicidal, calm, asleep, aggressive, etc). Medication administration is much like any other unit, except you check the mouth to make sure that patients are not cheeking their medications.

A typical night for me on the inpatient unit went as follows: come in, get report, and go onto the unit. Check on all the patients, see if they were sleeping or awake, and assess each patient (I had up to seven patients, as there were only two nurses on the unit). Next, I checked to see what meds I would need to pass, and wrote these down. I generally assisted the CNA in obtaining vital signs following this (especially if there were particularly violent patients on the unit). Next, it was time for med pass. Once med pass was completed, I generally tried to document my assessments, suicide/homicide risk scales, fall risk information, any patient education, etc. Once this was done, it was time to check all the charts (as this is done every 24 hours at my hospital). At some point in the night, the assignment board was made for the next day, stock was counted and ordered (food supplies), and the crash cart and emergency supplies were checked.

Our psych unit was also a referral site for the entire state, so we got psychiatric referral packets from hospitals across the state all night long. These could be as short as 20 pages, or as long as 90, depending on patient condition and duration of hospital stay. As nurses, we were tasked with reading these in their entirety, writing up pertinent information, and presenting these to the doctor before our shift ended. If patients were accepted, we called the hospital, coordinated transfer, and documented all of this.

Of course, patients could arrive on the unit at any time, and we frequently received admissions at night. New admissions were weighed, stripped searched, vitals were obtained, their belongings were searched, physical and psych assessments were done, they were shown around the unit, policies were explained, and then they were taken to their rooms. An assessment took anywhere from one to two hours to complete.

windsurfer8, BSN, RN · Dec 28, 2014

I did three years med/surg and so far 5 of psych. All psych hospitals are different. The one I currently work in is fairly quiet. Often lower census and less acute. However I have worked psych where physical confrontations were fairly common. And truly I have been scared a few times. Ofcourse I never let them know that, but yes it can be scary. The positives are when I leave work my body feels 100 times better than med surg. My back doesn't hurt and I don't feel physically as tired. Mentally however is different. Sometimes my brain feels totally drained and I just need peace and quiet. I prefer it to med/surg. I feel it is something I can physically sustain longer than med/surg.

MDMBSNRN · Dec 28, 2014

Windsurfer, I agree that working inpatient psych wasn't as hard on my back. Working ED/crisis psych is a totally different story. I perform full medical, as well as psych treatment, and often have patients who are bed bound, total cares, etc. Also, I do not feel that psych is something I could do forever. The revolving door, the drug addicts, the abusive patients, those who don't care for themselves all contribute to rapid burn out in my opinion. That being said, I do work in a fairly aggressive, high acuity setting, and physical attacks, restraints, and chemical sedation are fairly common, if not nightly experiences. It has been an interesting experience, and I certainly feel that I have learned great skills, and expanded my practice, but I am ready to return to the ICU setting full time. For some, though, psych is truly their calling, and they do it for a long period of time.

windsurfer8, BSN, RN · Dec 28, 2014

mdmrn,

I agree and I probably did not express the actual challenge of working psych because I have been doing it for 5 years and I am in a quiet facility now. So I have to think back three years to the actual chaos of hardcore inpatient psych. The revolving door is for sure one of the hardest parts. The stress of physical confrontation and making sure you do everything right is also a huge challenge. I do not want to down play the work and the need for the "right" person for it. I think many associate psych with just sitting in a chair and talking to someone who is "down." So yes I agree and I apologize if I was not clear.

vintagemother, BSN, CNA, LVN, RN · Dec 29, 2014

I'm thinking of changing from medsurg to psych. Can someone describe a typical day, explain the role of a psych nurse? pros and cons of the job?

A typical day in psych?.... I think it depends on the type of unit you are working in.

When I work in the acute unit, the day starts with looking at how many empty beds we have. This tells you how many admissions you can expect. On a typical day it's 3-4. On a busy day it's 5-7. During day shift you have more discharges and on evening shift there are more admissions.

We have 2 nurses and 1 is responsible for med pass. The med pass isn't super hard, because the ratios are low: 1:16. There are 2 med passes each shift (except noc)

This unit also requires daily narrative charting on 5-6 Pts.

Some, but not the majority, of the Pts are physically aggressive. Some have court ordered IM meds which, sometimes, require staff to restrain the pt so the nurse can administer the meds.

On the other unit, which is LTC psych,with a great deal of forensic cases, the unit is active! The med passes are like aerobics--so many meds for each of the 50+ Pts.

About half of a typical day for a medication nurse is taken up by med pass. Then there are PRNs, charting of med refusals, some skin treatments, responding to physically aggressive clients, which requires charting, notification of MDs, implementing new orders, etcetera.

On both units, there are changes to meds for at least a few Pts on most days.

Both units have a charge or supervisory type of nurse, who usually takes care of admissions, discharges and is ultimately responsible to assure protocols are followed and charting is completed. The phone doesn't stop ringing. Psych nurses also work closely with mental health techs to document unusual incidents among other duties.

MDMBSNRN · Dec 29, 2014

Windsurfer, people certainly do have misconceptions about psych. The attitude does tend to be one of, "oh, I would love to have your job. You just sit around, talk to the patients, watch them, and pass meds. It's so easy to do." They don't take into account being cut with objects, bitten to the point of bleeding, having hair ripped out, being kicked in the face, having objects thrown at you, being hit, being spit on (all of which has happened to me), and never being sure of your safety from minute to minute.

It can be extremely stressful, and it's a different kind of stress. In the ED and ICU, the acuity is high, there is stress, and patients are critical. However, it is different when a violent patient is in your face hitting and kicking while actively hallucinating, and you know that your physical well being is in acute danger. I also feel like my license is acutely in danger every time someone gets violent, and I have to restrain them. Am I following procedure, does it look okay on the cameras, am I being too rough, is the patient at risk for physical harm due to my team's actions, etc.

The revolving door, inappropriate psych consults, drug addicts, and seekers are the things that bother me the most. We have a few who are homeless that magically appear feeling suicidal or hallucinating any time the weather outside is less than desirable. We have some who live in group homes or assisted living who don't like the food, and come to eat the food at the hospital, which they deem to be better. We have many who come for pain meds or benzos. We have several who routinely come in requesting detox, only to leave AMA, or get to detox and leave from there. It seems that rehab is only a good idea when it's convenient for them. And, of course, we have some who are just in it for attention.

Of course, there are some who are truly mentally ill. However, many of them refuse outpatient followup, will not take their meds, and quickly decompensate. Many have been very violent on our inpatient unit, and some are denied admission there. This leaves me attempting to find placement at an outside hospital, or a state facility. I have held patients in my department for 40-50 days while waiting for a bed to open up somewhere. All the while, they are psychotic, refusing meds, violent, hallucinating, attempting to escape, and a danger to all staff and patients.

Also, there is one nurse and one tech in this unit. That's it. We are alone, and there is no security stationed in our unit. If someone needs to use the bathroom, get a drink, or leave the unit, this leave the other party totally alone. I have been attacked while alone in the unit. I had a patient observe, and wait until my tech was gone, and I was out on the floor tending to another patient. He attacked me as I exited the room.

Crazed · Jan 1, 2015

Psych ED - there is no typical day. You can go from everyone is quiet to 2 in restraints and 2 in seclusion because they've been set off by the two in restraints quickly. The medical side of the ED feels anyone is okay to be there including patients with anxiety and the floor has no idea what we do and frequently critizises us. Oddly enough our strongest relationship is with security. Our pace is fast, our patients are very acute and at times very dangerous, and our station is not enclosed. You have to have very good situational awareness and be able to think and act fast. Oh and you have to be able to tolerate someone screaming for hours because what ever med you throw at them isn't combating the (usually) meth onboard. It's a hard job, it's dangerous if done incorrectly, and most nights I give limits to people who have no boundaries.