Do it yourself!?!?!

[SweetLemon]

So I work in a rather unique hospital that allows the nursing administration A LOT of leeway in running the overall care of the patients. On the one hand its kind of cool and in my opinion allows for a much more holistic level of care but sometimes I feel like our administrators go a bit far...

Last week I had a patient who had schizophrenia who was very sexually preoccupied with the opposite sex. Needles to say he was one we had to keep a close eye on and had talked to the Doc, about possibly implementing a 10ft restriction from female peers. The Doc declined stating he wanted to give the patient a boost in his meds and see if that did not allow him to gain a little bit more control with his inappropriate behavior. All of the staff was aware of the situation and we were keeping a close eye on this patient regardless. Honestly I can see both sides to this. Boosting the meds for a lot of these patients helps them gain control and function in the milieu appropriately but we also need to keep the safety of our other patients in mind.

So I get a call from the Assistant DON stating that I needed to TELL the doc he HAD to place this patient on Q15 min checks with a 10ft restriction from female peers... Not that I should suggest it or that I should highly recommend it but more or less that I needed to demand it. Okay I get where the Assistant DON is coming from because I myself had recommended it to the doc just the previous day but in what world do nurses tell docs how to do their job (just like I would be angry if a doc tried to tell me how to do mine). I don't doubt that these restrictions would be a good idea but if you want to demand it, do it yourself!?!?! Ideas, thoughts, or comments???

In the end I told my unit supervisor about it and she talked to the Doc, they have a very good rapport and the restrictions were implemented but still was this out of line to ask this of the floor nurse or am I just being a chicken???

[Morning-glory]

Out of line. I work forensic psych and we have the same problem with sexually inappropriate behaviour. It can cause a lot of distubance on the floor really quickly. Docs don't always get how volatile it can get. Right now we have a few out of control women. I don't think you are being a chicken. I think that the doc need to spend time on the floor to experience the negative vibes this causes. Meds take a while to kick in and short of using acuphase or haldol and ativan, some limits need to be there. Recommending is OK, but ordering the doctors around is just increasing the negativity. Let the powers that be deal with that. We have the ability to impose a Constant Observation order on the patient and to keep them in their room. Doc needs to assess within 24 hours, but this can be an effective way to deal with these out of control guys and gals without getting nasty with the docs. They may roll their eyes at the CO order, but all they have do is D/C it. We can slap it back on if the behaviours become disruptive again. All of our patients are in custody and are with us because they need assessments to stand trial, fitness, or be made "not criminally responsible". They sometimes come back from court with a treatment order. Then they have to take the meds. Even before they go to trial, we do get emergency meds PRN for extreme agitation or aggression.

I think your DON is out of line to order you get orders from the docs. You might talk to her about another way of doing it with out annoying them.

P.S. we don't need an order to impose q15 minute checks, it can be made a nursing decision, at least in my facility.

[SweetLemon]

No, you are absolutely correct we can "unofficially" monitor Q15min as needed and go as far as to ask a staff member to monitor the patient more or less on a 1:1 status without an order that is most definitely within our scope to decide. With a patient like this whenever he is out of his room I would personlly have a staff memeber watching him just to keep everyone safe. Getting an order allows us increased staffing (well actually it doesn't but in a perfect world it is suppose to). I think in the case of the Assistant DON she more or less wanted it to help cover our behinds in case another patient (and we always have a couple of them) wanted to falsely accuse us that they had been inappropriately touched/rapped. Thanks for the feedback morning-glory, its so nice to have this site to get a little clarity when things within your own facility start to seem a little backwards

[Morning-glory]

Our nursing Intermittent observations and Constant Observation orders are equal to a doctor's order. It is not unofficial.

That said, we came close to a riot last weekend because of these women.

[canoehead, BSN, RN]

If the DON needs the doc to do something she needs to talk to them herself. More people relaying means more communication mistakes.

I like morningglory's policy- if the patient is inappropriate the nurses have a protocol that allows them to place restrictions immediately and notify the doc. The doc then comes in (I assume) and verifies or lifts the restrictions. Immediate consequences are very effective.

[Morning-glory]

We are also allowed to apply restraints (standing order), then call the doctor. There is a move towards being restraint-free for the whole facility, but that is still a couple of years away.

My facility used to have seclusion rooms (rubber rooms) but that went the way of the dodo bird a couple of years ago.

Now if a nasty situation develops, we call a code white. PRN meds are pre-ordered for pretty much all of the patients, so we give meds, put them on Constant Observation (CO) and apply restraints if the situation calls for it. If restraints are applied they are removed as soon as the meds kick in. They may stay on the bed without being used a while longer just in case. We have a "least restraint" policy so as to minimize the time spent in restraints. If a patient is in restraints, there is a trained orderly with the patient and the nurse needs to do q30 minute checks for circulation, vitals and need for the restraints.

Attempts are always tried to talk the person down, but we have the tools to keep everyone safe in an emergency.