Got slapped by pt. Staff splitting. Need feedback.

[wonderbee]

I got slapped by a pt. at the med window. Pretty hard too I might add. She took a dislike to me for no particular reason she can articulate and I can't fathom. Her consequences were wing restriction. While on wing restriction, I brought her a PRN for agitation. Of course she was verbally abusive and told me she wanted another nurse. I told her I was her nurse today and that wasn't going to change. She could choose to take her meds or not take her meds. The choice and the right was hers. I was professional and kept my cool with her.

What do you think happened? The charge nurse told her she would assign another nurse to administer her meds. Every nurse that went in there to give her her meds listened to a tirade of how she hated me. I felt that she was rewarded for her bad behavior, and this set up a staff splitting situation. Now she thinks she can get what she wants by misbehaving and worst, physical aggression against staff.

There are two schools of thought here that came up. 1. The goal is to get the meds in the patient and stabilize so let's get another nurse. The other is 2. The patient was successful in her staff splitting and has learned that physical aggression works to her benefit.

I'd like to know what others think.

[NurseyBaby'05, BSN, RN]

::Burp!::

I'm sure someone is going to think that I eat my young.

::Rubs tummy in contentment::

[MassED, BSN, RN]

::Burp!::

I'm sure someone is going to think that I eat my young.

::Rubs tummy in contentment::

there's a difference between eating your young and putting someone in the proper place. Ahem! Nothing worse than a new grad (or student) thinking they know more than the ones doing the work. Puuullllleeeaaassssseeee. There's a whole other thread for those know-it-all's that come into the workplace - it won't be pretty if there isn't some major adjustment. I'm just sayin'

[NurseyBaby'05, BSN, RN]

I know I'm not eating my young. The post was meant tongue-in-cheek. But . . . . . . I wouldn't be surprised if something of it wound-up on the ever poopular thread.

::Feeling full now::

[aloevera]

People need to be responsible for their actions, whether it be you, I or a pt. in a psych hospital.....There has to be consequences for their behavior

BUT......(ALWAYS A BUT) there are always exceptions to the rule, depending on the situation at hand...

If I am alone on the unit (at that particular time ) and a pt. refuses my care, all the while escalating to agitate the other pts, becoming out of control, I will do whatever it takes to calm this pt. and remove from others..if it means telling her "I will see if I can get someone else to help you"..then I will...this is the real world...If I see a crisis arising with this and have 3 big MHT within LOS I may tell her that I am the only one here, and we can either do this the easy way, or the hard way.....(she still has right to refuse med)

what I am not so eloquently saying is....it all depends on the circumstances..there is no "set in stone" rules in mental health...

just my:twocents: I have handled similar situations differently, depending on other factors (no. of staff, hx. of pt, etc.)

[MassED, BSN, RN]

I know I'm not eating my young. The post was meant tongue-in-cheek. But . . . . . . I wouldn't be surprised if something of it wound-up on the ever poopular thread.

::Feeling full now::

yes, I know. :chuckle

[wonderbee, BSN, RN]

Wow, this thread kind of took off. I just want to clarify that this patient didn't just target me. There is only one RN left on the unit that has not been either physically assaulted or verbally abused. That RN digs into her own pocket and buys her snacks to keep her quiet. It's a lot like the story of the school bully who shakes down other students for their lunch money. I won't be part of it.

Also, it's often difficult to tell when she's going to "go off". She often doesn't say a thing. Just gets physical with no warning.

On a unit with violent patients, it is imperative that the milieu is managed. That doesn't mean the patient doesn't have choices. It means that safety is the first consideration. I think we lost this battle the first time she slapped someone (me) and we rewarded her with another nurse. I would have come back the next time with a security officer, not a soda from the vending machine.

Like I said, I'm going casual. I see so much that rubs me the wrong way. I do take it personally when someone is wailing on me with fists flying. No one is going to look out for my safety but me. I do not like this client. I have not cared for her since. But she's running out of staff.

[aloevera]

oh, my....it sounds like that pt. is running the unit:o

I agree, no rewards for bad/assaultive behavior....on my unit, we would have gotten an order for restraints/seclusion if pt. continued to be aggressive...and only allowed her out if calm and agree to behave....she would have seen that there are consequences for that type of action....

I would give a snack/soda as a reward for good behavior....after so long, remaining calm, no threat...then a soda could be given, but NOT after the episode described...

[justme1972]

This patient is mentally retarded, MR, which would make her mentally either unable or diminished in the capacity of decision-making.

The original post that I responded to didn't say a single word about the OP's patient being mentally retarded.

[elkpark]

a patient that is in a psych facility may very well be an INVOLUNTARY commitment, which means they cannot refuse treatment. If they are agitated and there is an order to medicate PRN agitation, you medicate. Period. Where I live it's called a Section 12 - they have human rights (bathroom, phone calls, etc) but cannot refuse treatment that is medically indicated for a psychiatric illness. This patient is mentally retarded, MR, which would make her mentally either unable or diminished in the capacity of decision-making.

I'm in a different state than you, so what you say may be legally correct in MA, but, in most states, it is NOT the case that involuntary/emergency commitment clients in psychiatric settings automatically lose the right to refuse treatment (and since MA is known for being one of our more liberal/enlightened states, I'm willing to bet a fair amount that that is the case in MA, also). Anyone can be medicated involuntarily in an emergency situation, where the person is acutely dangerous to self or others, on an emergency basis without consent, but (in most states) an involuntarily committed client to a psychiatric facility does not lose any rights other than the right to leave the facility. Most states now have a separate, established process that must be implemented in order to legally force medication on an involuntarily committed client who is refusing treatment outside of an emergency situation, and specific conditions must be met in order for that to be possible. Plenty of facilities ignore/violate these laws and rules and get away with it because they haven't been caught yet, but that doesn't mean it's legally or ethically right to do so.

Also, just because someone is diagnosed as MR, you cannot assume that the person is legally incompetent and unable to make her/his own decisions. A diagnosis of MR also does not automatically strip you of any of your legal or civil rights.

(However, in psychiatric settings it is very rarely the case that a client would refuse a particular nurse or physician and the staff response would be to automatically honor that request and supply a different nurse or physician. Psychiatric settings are a very different kettle of fish than other healthcare settings, with very different issues and dynamics. There are plenty of psych clients with significant Axis II pathology who would demand a new physician every day just for entertainment purposes if that were allowed!)

[MassED, BSN, RN]

Pt. in question is MR with a diagnosis of impulse control disorder. A behavior plan was drawn up for her which emphasized reward and contraindicated consequences. Of course most of us snickered at it but we complied. This is how it worked out. She would wait until she got her reward, then she would assault and threaten staff. She got her first taste of locked seclusion after she slapped the charge nurse. But it was the second locked seclusion the following night that put the behavior plan on ice. When she didn't like the reward she was being offered, her slap turned into a beating and I was the victim. I wasn't injured but quite shaken up over the attack. I want her off the unit. I would have pressed charges but because she is MR, I didnt think they would stick. Now most staff approaches her for care with a security officer. I really do not want to care for this patient at all even with security present. I'm just so done with her and get the willies getting close to her. Do I have a choice? Would it be unprofesional of me to pass her on to the other nurse?

here's to Hopefull2009 for the reference to MR - not in the original post, but there nonetheless. I asked if there were other medical conditions going on with the patient, which prompted a response from RNKittyKat. Being MR doesn't mean she does not have the right to refuse treatment, but it merely sheds more light onto the situation. All I can say, is not being there or observing her behavior, it's a tough spot to be in. I wish you luck, RNKittyKat, and I'm sure you do an excellent job.

[MassED, BSN, RN]

I'm in a different state than you, so what you say may be legally correct in MA, but, in most states, it is NOT the case that involuntary/emergency commitment clients in psychiatric settings automatically lose the right to refuse treatment (and since MA is known for being one of our more liberal/enlightened states, I'm willing to bet a fair amount that that is the case in MA, also). Anyone can be medicated involuntarily in an emergency situation, where the person is acutely dangerous to self or others, on an emergency basis without consent, but (in most states) an involuntarily committed client to a psychiatric facility does not lose any rights other than the right to leave the facility. Most states now have a separate, established process that must be implemented in order to legally force medication on an involuntarily committed client who is refusing treatment outside of an emergency situation, and specific conditions must be met in order for that to be possible. Plenty of facilities ignore/violate these laws and rules and get away with it because they haven't been caught yet, but that doesn't mean it's legally or ethically right to do so.

Also, just because someone is diagnosed as MR, you cannot assume that the person is legally incompetent and unable to make her/his own decisions. A diagnosis of MR also does not automatically strip you of any of your legal or civil rights.

(However, in psychiatric settings it is very rarely the case that a client would refuse a particular nurse or physician and the staff response would be to automatically honor that request and supply a different nurse or physician. Psychiatric settings are a very different kettle of fish than other healthcare settings, with very different issues and dynamics. There are plenty of psych clients with significant Axis II pathology who would demand a new physician every day just for entertainment purposes if that were allowed!)

Elkpark, I appreciate you clarifying some information. Yes, I specified that is how we handle emergency psych patients in the ER here in Mass. I do not presume to know all the ins and outs of psych nursing, so I appreciate the information. I never wrote that MR would incapacitate a person's decision making. The fact that she has MR does shed a little more insight into that situation and might help with formulating a plan to care for her during these moments of extreme agitation. We also don't know the degree of MR.

[holiday2525]

guess what, sometimes even med/surg pts don't get to choice who there nurse is!! But psych pt. who are known to be manipulitive and and boundaries have other issues. And it was not about taking her meds, it was who the heck was bring them to her. The treatment plan and how people treat her during her stay should somewhat mesh with what is the over long term best interest of the pt. Now, of course if there are safety issues those must be addressed first, but letting her ick and chose her care staff will not help her all that much in the long run. It is the manipulitive behavior that needs to be addressed.