experienced psych nurse please chime in

[Isitpossible, LPN, LVN]

we have a paranoid schizophrenic patient who refused his PO meds.. kept politely stating "no thank you." There is no order to give IM for Po refusal. However, there are orders for PRN IM for severe agitation/aggression. I finally convinced pt to take the meds PO, however he didn't swallow it and ultimately spit it out. Co-worker immediately prepares IM. Pt is crying, no please don't give me a needle, I will take it by mouth, please give me another chance. Co-worker doesn't do second chances. He gets IM. I keep finding that seasoned RNs do things a bit different and its difficult . The PRN clearly stated increased aggravation. Co-workers rational, he was acting up last nite, up all night, and were not doing this again tonite. Though I love my job, I feel ready to leave at times based on other peoples actions. Its very hard to be the newer nurse all the time... I would never talk to management, because Im not looking to throw anyone under the bus... How long before I feel confident enough to say, NO, Give patient another chance or NO hes not being aggressive to warrant the IM... ugh, sick of this....

[elkpark]

It is a big deal to force psychiatric medication on people in the absence of an emergency situation in which the individual is acutely dangerous to self or others. There is a legal process for that in every state, and, whatever state you're in, I guarantee you the process in your state requires a lot more than a staff RN being fed up with someone. The prn is ordered for emergency situations. I'm an experienced psych RN and I would never do what you describe above, or allow anyone else to do it on my watch.

I find one way to bring these things up for discussion is to "play dumb," if you will -- instead of complaining about the other nurse (doing something unethical, probably illegal, something that could potentially leave the facility vulnerable to a lawsuit), try asking about the situation (as in, "Gee, I thought we weren't allowed to medicate people against their will outside of an emergency situation (or I thought the state law about forcing medications on people said XYZ, or something else similar); please help me understand how this scenario is okay, when it clearly wasn't an emergency situation." You might even want to ask your preceptor, nurse manager, or unit psychiatrist about the situation.

Did the client have to be held down to receive the IM injection? If so, that was a restraint per the CMS/JCAHO rules and requires an order, face-to-face eval by the physician/LIP, and all the other required documentation. Did the nurse do all of that? I worked for several years as a psych surveyor for my state and CMS, and we cited places for that all the time.

This other RN is taking a lot of chances and could end up in a lot of trouble. If that is a common practice at that facility, you might well want to look for another job, at someplace that takes people's rights seriously. Best wishes!

[Orca, ADN, ASN, RN]

If the patient was not agitated and did not pose a danger to himself or others, your coworker had no grounds to administer IM medications. This was clearly not in accordance with the physician's order for administering the PRN IM. Using the threat of IM medications to coerce a patient into taking PO meds he clearly does not want is unethical as well, and is likely illegal depending upon the laws of your state. Unless you have a court order for forced medications or you are in an emergency situation in which there is an immediate danger to the safety of the patient or others, you cannot administer medications against the patient's will. That is as plainly as I can put it.

I have known many schizophrenics who are no danger to anyone, but they choose not to take anything, which is their right.

[Whispera, MSN, RN]

I agree with what the others have written. What happened was assault (the threat of being given the IM) and battery (the forced administration of it). There's no excuse for this. It's illegal and immoral.

Is my feeling showing about this?

[Isitpossible, LPN, LVN]

Thank you for your responses. Yes, I know that patients have the right to refuse, even psych patients!! Im just so sick of this type of behavior, I truly cant report every single RN I work with. Honestly most of the seasoned nurse do this. ... And yes sadly this is very common practice where I work. There was no "threat" of IM, that was reality. And yes several techs were called in to "hold" patient while RN gave injection. It was not an official "code" per se, so of course no restraints forms filled out, no notification to physician on call. As far as playing dumb, I completely understand what your saying, but his response was "he was acting up last nite, blah blah blah, "were not doing this again tonite." This same patient received an IM last week from another nurse of HALDOL, which he is allergic to. When I asked the nurse what she gave pt, I said hes allergic to Haldol. Her response, "were not gonna make a big deal out of this". never reported, never anything. Do you see what I mean its not one RN in particular, its the culture at this facility, and it breaks my heart.

[Meriwhen, ASN, BSN, MSN, RN]

we have a paranoid schizophrenic patient who refused his PO meds.. kept politely stating "no thank you." There is no order to give IM for Po refusal. However, there are orders for PRN IM for severe agitation/aggression. I finally convinced pt to take the meds PO, however he didn't swallow it and ultimately spit it out. Co-worker immediately prepares IM. Pt is crying, no please don't give me a needle, I will take it by mouth, please give me another chance. Co-worker doesn't do second chances. He gets IM. I keep finding that seasoned RNs do things a bit different and its difficult . The PRN clearly stated increased aggravation. Co-workers rational, he was acting up last nite, up all night, and were not doing this again tonite. Though I love my job, I feel ready to leave at times based on other peoples actions. Its very hard to be the newer nurse all the time... I would never talk to management, because Im not looking to throw anyone under the bus... How long before I feel confident enough to say, NO, Give patient another chance or NO hes not being aggressive to warrant the IM... ugh, sick of this....

Reading things like this ****** me off.

Spitting it out is not severe agitation/aggression. Unless he's an immediate danger to someone or there is a court order specifying otherwise, he has every right to refuse meds. It did not merit an IM in lieu of PO. Nor did it merit an unofficial code.

If the patient had behavioral problem last night, then the patient should have had the medicine last night. No medicating after the fact. No forcing of medication as a "preventative" measure because who knows how the patient will be tonight?

If I were this patient or his family, I'd be filing grievances left and right.

Unfortunately, you will come across a cadre of nurses who like to take a hard line against patients. They'd rather not deal with the patient any more than they have to, but instead are quick to medicate, even if (and sometimes ESPECIALLY if) the patient refuses. "We're going to prevent any problems this shift," they'll say. Or they may do it to keep everyone else in line: "All they need to see is one patient getting shots, and they'll all behave."

Not right for them to do. Not fair to the patients. But it happens...and often a blind eye will be turned to it.

[Whispera, MSN, RN]

This is like forcing insulin on a diabetic whose blood sugar level doesn't require it. I hope patients sue the hospital involved in this sort of thing!

Isn't there someone to whom you can report this sort of thing, anonymously? A patient ombudsman? The local mental health association? The Board of Nursing? The Joint Commission?

[elkpark]

If you really want to, you can report this to the state healthcare licensing department and/or mental health department. In my experience, they keep complaints anonymous if requested, although that doesn't guarantee that your employer couldn't figure out who made the complaint and, in that case, you can assume you'll get fired. You might want to start looking for another job, and then make a complaint once you have a job somewhere else.

What you're describing is a serious violation of state and Federal rules/regs re: restraints and forcing medication, and state and Federal client rights.

[Isitpossible, LPN, LVN]

so in essence, actually advocating for a patient could cost me my job? wow--is this what nursing is?

[Meriwhen, ASN, BSN, MSN, RN]

so in essence, actually advocating for a patient could cost me my job? wow--is this what nursing is?

Sadly, yes. It's all about the bottom line in many places.

And employers know that there's a line of nurses who'd happily jump into your job--some will even take a pay cut--so you're easily replaceable.

[elkpark]

so in essence, actually advocating for a patient could cost me my job? wow--is this what nursing is?

In some places, yes. Not all, fortunately.

[MrChicagoRN, RN]

I would never talk to management, because Im not looking to throw anyone under the bus..

... ugh, sick of this....

I applaud your desires do the right thing, but why wouldn't you advocate for your patient? How is going to management throwing someone under the bus?

What is your manager's attitude toward patient rights? If management is unaware, nothing gets changed. What is the attitude of management I'm pretty sure they don't want a visit from CMS/DPH or the patient advocacy commission.

I expect my staff to be in full compliance with the law. If I found out that patient rights were being violated, and others were covering it up, I'd be very, very unhappy.

It's your obligation to stand up for those who have no voice. Maybe there is a valid clinical rationale for what they are doing, put based on how you've described it, probably not. It starts with moving up the chain of command.