Difficult patients and testy staff

[nursemike, ASN, RN]

I had an awkward situation last night. I was pulled to the ED and assigned to sit with a psych pt. as an alternative to restraints. Patient had been wandering through the dept and was not at that time especially at risk to elope, but I'm sure that was a consideration. My role was as unlicensed assistive personnel, but I am also a nursing student--completely independant of my job.

My biggest problem is that after several hours, the pt decided to leave. He was oriented to person, and knew he was in a hospital, when asked named wrong hospital, and didn't know time of year. Honestly, I doubt he could have gotten home without help. But I'm feeling uneasy about detaining him. For the most part, I used persuasion, but a couple of times we had to call security and use force. I don't really expect to be charged with kidnapping, but it seems a bit iffy, ethically. We weren't exactly treating him, by then. Psych and social were looking for a bed, but it was taking a lo-o-o-ong time. (My 4 hr float turned into 14--pt was there about 10.)

And, frankly, it often seems that when a 1-1 caregiver is present, nurses visits can get pretty infrequent. Of course, it's ED, so those not bleeding don't get priority, but a psych crisis is a crisis, too. I don't mean to be ungrateful, but they were a lot better about checking on my needs than the patients. (Another frustration I've often had is that when you pass along a pt's requests, staff often either gets annoyed with or makes excuses to me. I'm talking about things I can't do, like pain meds. In such cases, I'm really just a highly paid call button, although I guess a call button can't try to explain what's going on to the pt.)

Finally, I've been distressed more than once by security--and occassionally nursing staff--speaking of restraints as a punishment for bad behavior. I know, I know, it sort of works out that way, but it seems to me the more you say it, the more acceptable it seems. Also very put off by people who handle the patient indelicately--not exactly abuse, but then again, it really is. Security would say you have to be firm--and Lord knows, I was grateful for their help--but there's always a little bit of anger being vented in the process. I find this troubling when the patient could be reasonably held accountable for his behavior, but this particular patient was schizophrenic.

Argh. Well, that's the bulk of my rant. My question is, how far should I go in objecting to this sort of thing. I am, after all, less experienced than many of those involved. I also recognize that my co-workers are humans subject to human imperfection. Again, there was nothing done that was blatantly bad, and as a nursing student one of my challenges is learning not to be so gentle that I'm ineffective. Still, even as a UAP, I have a clear obligation to advocate for our patients.

Looking for some real good advice, y'all.

[leslie :-D]

as far as i'm concerned, once the patient tried to leave then nsg or others should have taken over.....1:1 yes...actually detaining him, NO.

if you laid a hand on that patient, even to detain him, you could have been charged with assault.

there are too many legal implications that is NOT your duty to handle.

[nursemike, ASN, RN]

as far as i'm concerned, once the patient tried to leave then nsg or others should have taken over.....1:1 yes...actually detaining him, NO.

if you laid a hand on that patient, even to detain him, you could have been charged with assault.

there are too many legal implications that is NOT your duty to handle.

I actually feel a little cheesy in that I was consciously careful to let Security do most of the physical stuff, but I do have a future license to think about. I did "guide" the patient when he was wandering the ward--other pts also have rights--and I'm confident I was within hospital policy.

I'm also fairly confident hospital policy is lawful. Had to physically assist him to ambulate, at times--this whole deal was just one gray area on top of another. I know everyone was operating on the premise that he was not competent, and I can't dispute that, but how competent is competent. If I had been him, I would have left.

[Stitchie]

Where I work if a patient is there for a psych consult, or states that they intend to harm himself/herself, or others, that patient can be held against his or her will -- a 72 hour hold. If the physician decides the patient is unable to care for himself/herself, they can be detained, restrained and held against their will.

If a patient threatens a staff member or hits a staff member, or is an elopement risk, or refuses to comply with treatment plans (ripping out IV's, screaming, etc) after being ruled incompetent can be restrained for patient/staff safety.

It seems harsh, but when you have patients screaming at you or trying to hit you because they are drunk, high, non compos mentos, etc it gets old quick when you're trying to treat them. A patient with schizophrenia who is experiencing a worsening of symptoms cannot safely care for himself and it sounds as if he was not oriented. In IL a 72-hour hold takes over until the patient can be safely transferred to another facility to be treated for the mental illness.

I'm pretty sure you won't be facing assault charges if the patient was being treated for mental illness -- it wasn't your decision to hold the patient, it was the doc's/facility's.

[leslie :-D]

exactly.

if the patient was that high risk, then he should have been restrained.

i'm not sure if op received very specific instructions on what to do if patient tried to elope.

but it should not have been on his shoulders.

[Angela Mac]

Restraints are bad, but necessary with agitated psych patients, their behavior is unpredictable. As a PPN- I have had to 4 point restrain pts. wanting to physically injure others. A nurse friend worked at the same state hospital- a psych pt. got hold of a handgun and shot himself in front of her. Many psych patients do need 1 on 1. But I have also seen security being too rough with patients.

Thank goodness we do not live in the era of insulin shock, and electric shock therapy.

[nursemike, ASN, RN]

Amazing what a good meal and hot shower can do for your brain. I hope I didn't come across as asking for advice then getting defensive when it was offered. Only meant to clarify the situation.

But after thinking some more, I agree with all of you. I think I may have let my sympathy for the patient get the better of me. The circumstances were largely as Stitchie described, although a little deceptive since he wasn't violent or hostile, for the most part. It is a lot of responsibility for a job that only requires a high school diploma, but we do get significant training (never enough, of course) and I have been at it awhile. Actually, I rather like it when my professional colleagues value my judgement. If only I didn't have to feel so...you know...responsible!

While this gentleman was generally co-operative, he was having an acute schizophrenic crisis, including voices. So, really, letting him wander the streets would have been seriously negligent. I guess my frustration is that warehousing him in the ED for nearly the whole night seems really inadequate. But I suppose that's more a matter of a health care system that is poorly equipped to treat psychiatric illness, rather than the fault of the staff who couldn't give my patient as much care as I would have wished while people were in fact bleeding. He did get a psych bed as soon as one could be found and transport arranged. It's just too bad it took so long.

I do think we are a little too reluctant to use restraints, at times. We do have a clear mandate to reduce their use, but patient and staff safety sometimes demand them. But, in this case, we properly exhausted the less restrictive alternative (me) before going to hard restraints. And they truly were for his protection. He never was a threat to us.

Eh, well. For reasons not entirely clear to me, patient autonomy is becoming an issue I take personally.I think I may have gotten a bit more stressed about this particular situation than was necessary, but I'm still going to give it a lot of thought for future reference and welcome any opinions anyone cares to share. I certainly do want to be a diligent patient advocate, and to consider all sides of a problem.

Crap. This is probably some of the same frustration at least some of those annoying family-members feel. I say again, crap.

[nursemike, ASN, RN]

Restraints are bad, but necessary with agitated psych patients, their behavior is unpredictable. As a PPN- I have had to 4 point restrain pts. wanting to physically injure others. A nurse friend worked at the same state hospital- a psych pt. got hold of a handgun and shot himself in front of her. Many psych patients do need 1 on 1. But I have also seen security being too rough with patients.

Thank goodness we do not live in the era of insulin shock, and electric shock therapy.

There's a good reason that calling security is kind of a last resort on the floors. We handle it ourselves as much as we can. But we've been pretty happy to see them, at times.

I accompanied my patient in psych rotations this summer through electro-convulsive therapy. Definitely an improvement over the bad old days, but still...

The worst is imagining the sort of hell that makes that a desirable alternative.

[Stitchie]

Part of being a good patient advocate is making difficult choices and using clinical judgement. If your patient is acutely schizophrenic, or experiencing an exacerbation of the disease, then protecting him in an agitated state is the best you are able to do for him.

To clarify, I didn't mean to imply that your patient was agitated to the point of harming staff or himself. These are simply my own examples of when restraints are necessary -- the times when nurses set firm limits with patients. This won't work with a schizophrenic patient -- the patient will be unable to appreciate the consequences of his/her actions. Setting limits in this instance would be futile.

However, when you have patients come in that are simply belligerent, drunk/high, or combative, for whatever reason, then setting firm limits is necessary. Setting limits may also work with agitated family members, although for obvious reasons we can't restrain them, physically or chemically (but if we could...what a good shift that would be! )

Sometimes the ER feels like the wild west and our only protection is the security guard who cannot possibly respond fast enough to save our behinds. We must be ever vigilant about escalating patient behavior and do what we can to protect the patient and each other. Psych patients are unpredicatable and sometimes sending in a sitter is calming and sometimes the sitter ends up with more responsbility than they can reasonably handle.

It's good that you care enough about your psych patients to post about this. I think that sometimes our ER personnel just get frustrated with these patients and fail to treat them with the compassion they deserve.

[nursemike, ASN, RN]

I believe you have it exactly right, Stitchie. At least at that time, the patient couldn't reasonably be expected to care for himself. And there is no telling if or when he might have become a danger to others, as well. Also, as bad as it may have been, stuck in that cubicle with someone telling him, "please get back in your bed, sir," it would have seemed a lot worse to me to have him tied to his bed the whole time.

I think I'm like a lot of people in seeing a big difference in culpability between a patient who is mentally ill or (what I see a lot of) neurologically impaired and one who is drunk and/or drugged up. Probably another example of human fallibility. And then, of course, there are some who are neuro-intact and just mean.

As for my co-workers, I've been reminding myself that it isn't so easy to show your compassion at a full run. One nurse I talked to awhile back suggested that every new nurse should work in Emergency awhile to learn about teamwork and grace under fire. Great idea, but it might exaccerbate the nursing shortage.

I've been at this for six years, 3 in ortho/neuro and 3 in neuro, but I have to concur with Leslie that it seems unfortunate that someone who had been in my job for 6 weeks could have gotten the same assignment. Usually, though, he or she would have been checked on a lot more often. Still, I've heard new guys say things like, "I would never strike a patient, unless he hit me first..." Naturally, I correct them, but how many are thinking it without saying it?

That's a big 10-4 on restraints for family members, by the way. Let's get together and develop a protocol.

[Stitchie]

I believe you have it exactly right, Stitchie. At least at that time, the patient couldn't reasonably be expected to care for himself. And there is no telling if or when he might have become a danger to others, as well. Also, as bad as it may have been, stuck in that cubicle with someone telling him, "please get back in your bed, sir," it would have seemed a lot worse to me to have him tied to his bed the whole time.

I think I'm like a lot of people in seeing a big difference in culpability between a patient who is mentally ill or (what I see a lot of) neurologically impaired and one who is drunk and/or drugged up. Probably another example of human fallibility. And then, of course, there are some who are neuro-intact and just mean.

As for my co-workers, I've been reminding myself that it isn't so easy to show your compassion at a full run. One nurse I talked to awhile back suggested that every new nurse should work in Emergency awhile to learn about teamwork and grace under fire. Great idea, but it might exaccerbate the nursing shortage.

I've been at this for six years, 3 in ortho/neuro and 3 in neuro, but I have to concur with Leslie that it seems unfortunate that someone who had been in my job for 6 weeks could have gotten the same assignment. Usually, though, he or she would have been checked on a lot more often. Still, I've heard new guys say things like, "I would never strike a patient, unless he hit me first..." Naturally, I correct them, but how many are thinking it without saying it?

That's a big 10-4 on restraints for family members, by the way. Let's get together and develop a protocol.

Yep, you're right on.