How do you keep a calm milieu?

Mandychelle79, ASN, RN · Apr 20, 2014

Make yourself more visible on the unit, redirect the biggest offenders, offer 1:1 time to see what is causing the tension, call them out on their behaviors. I have noticed if the unit is hyped up ( usually someone escalating that has went unnoticed all day :rolleyes: ) if an restraint or seclusion occurs the rest of the night ( barring an axis 2 shout out for attention) is typically much more low key.

But the biggest way is to try to stop the escalation, be proactive not reactive. When I see a patient escalating, I take them aside, try to work through the issue, offer them the seclusion room as a place to get away ( open so they can come out when they have calmed down). Sometimes the only end to the chaos is when the "pot stirrer" is discharged. It always amazes me how one or two people can have such an effect on a unit.

Mandychelle79, ASN, RN · Apr 20, 2014

Oh and having a reputation of being a nurse that doesnt take any nonsense helps, especially when frequent flyers are on the unit. I have overheard them say, She's the cool nurse, but dont make her mad.

Penholder · Apr 21, 2014

Own the situation/floor. Psych is one area where the patient is less the consumer and more the patient. Yes you can offer choices and respect them, but set the tone. I work in Geri-psych with a lot of dementia and am cool as a cucumber on ice , but make it clear that behaviors that impact discharge/other patients isn't tolerated. Bear in mind I am a CNA, but even on my level it works.

With my group I go by are they Hungry, Angry/Ambulated/Lonely/toileted or in pain. It works.

Davey Do · Apr 21, 2014

Make yourself more visible on the unit

having a reputation of being a nurse that doesnt take any nonsense

I say, "AMEN!" to Mandychelle's Posts.

The Bad Cop who walks the Beat may not be Well Liked, but does keep the Order.

Meriwhen, ASN, BSN, MSN, RN · Apr 21, 2014

Also, YOU need to learn how to keep calm and collected no matter what storm is swirling around you. If you're clearly anxious/angry/frazzled/scared/overwhelmed by what's going on, the milieu will pick up on that and react accordingly.

Likewise, if you project being calm and in control of the ship (even though internally you feel like you're standing at the seventh level of Hell), the milieu will notice that too.

Mandychelle79, ASN, RN · Apr 21, 2014

And RESPECT the patients. That is a huge one. Often times when I have asked patients why they act out on one shift and not the another one the recurring theme is that they can tell that I respect them and actually do care about them.

How to show respect varies on the patient. Yes, I do my assigned 1:1 during my shift, but most likely by the end of my shift I have acknowledged each and every patient on the unit. I have sat up and played 500 rummy when patient's cant sleep, sat in for another patient in a game of spades so they can go for their 1:1 session. On Friday, I took cupcakes in for a patient's birthday. I gently call them out for their behaviors. If I overhear swearing on the unit, if it is a one time thing, I do not aknowlege it, if it is repeated, I just throw out a "Language" warning for everyone in the room, without calling out the person who is swearing and during a 1:1, they can cuss and swear all they want.

Isastorm · Apr 22, 2014

Thanks for the responses everyone, I really appreciate it. Lots's of good advice and tips. I am okay with the acutely psychotic and those with mood and thought disorders, even detoxing and violent is manageable. Our current problem seems to be too many patients with personality disorders who are also violent (and maybe bored?). Currently the unit where I work has 3 male patients who will punch someone in the head at least once a day, either staff or other patients. Two people were sent to the hospital last week. We are understaffed and even when these patients are on 1:1 they still manage to strike, either because the person observing them is intimidated by them or they just wait for the right moment. Afterwards they will either laugh or deny that it happened, emergency meds don't seem to do much and unfortunately we do not have padded seclusion rooms. If it were up to me these people would be sent to jail (especially after the 5th head punch in a week!) but I guess this is not how it works and the place where extremely violent (and basically untreatable d/t PD) patients used to be sent is now full and not accepting new admits. It makes the whole unit tense, with more and more violence, everyone is on edge. Not a therapeutic environment for anyone, especially the other patients. Guess I'm just venting now....this too will pass. Thanks for listening. :)

Davey Do · Apr 22, 2014

Currently the unit where I work has 3 male patients who will punch someone in the head at least once a day, either staff or other patients. Two people were sent to the hospital last week. We are understaffed and even when these patients are on 1:1 they still manage to strike, either because the person observing them is intimidated by them or they just wait for the right moment. Afterwards they will either laugh or deny that it happened, emergency meds don't seem to do much and unfortunately we do not have padded seclusion rooms. If it were up to me these people would be sent to jail (especially after the 5th head punch in a week!) but I guess this is not how it works and the place where extremely violent (and basically untreatable d/t PD) patients used to be sent is now full and not accepting new admits. It makes the whole unit tense, with more and more violence, everyone is on edge. Not a therapeutic environment for anyone, especially the other patients.

Wow, Isastorm- this is some Intense Stuff.

Individuals not having to deal with the Ramifications of their Behavior will continue that Behavior because it fulfills some sort of need for them, like in this Instance, a Power Trip Thing or Something.

These Patients NEED to Experience the Ramifications of their Aberrant Behavior.

In the State of Illinois, since I think about 2008, it is a Felony to Physically Aggress against a Hospital Employee. The Law works. I've used it to my Advantage on at least two Occasions. I know of another Instance where a Nurse was Physically Aggressed upon and the Patient went to Jail. The Police were waiting to take the Patient away as the Patient left the Unit after being Discharged.

There was a Discussion on this not too long ago. I'll see if I can bring it up and get you a Link to that Particular Thread.

Davey Do · Apr 22, 2014

https://allnurses.com/general-nursing-discussion/violence-against-nurses-514904.html

The Discussion was a little longer ago than I remembered, and I found Other Threads that were Pertinent, so you may want to do a Search, Isastorm.

The Very Best to you, hope things work out, and please let us know the Outcome.

Mandychelle79, ASN, RN · Apr 22, 2014

Thanks for the responses everyone, I really appreciate it. Lots's of good advice and tips. I am okay with the acutely psychotic and those with mood and thought disorders, even detoxing and violent is manageable. Our current problem seems to be too many patients with personality disorders who are also violent (and maybe bored?). Currently the unit where I work has 3 male patients who will punch someone in the head at least once a day, either staff or other patients. Two people were sent to the hospital last week. We are understaffed and even when these patients are on 1:1 they still manage to strike, either because the person observing them is intimidated by them or they just wait for the right moment. Afterwards they will either laugh or deny that it happened, emergency meds don't seem to do much and unfortunately we do not have padded seclusion rooms. If it were up to me these people would be sent to jail (especially after the 5th head punch in a week!) but I guess this is not how it works and the place where extremely violent (and basically untreatable d/t PD) patients used to be sent is now full and not accepting new admits. It makes the whole unit tense, with more and more violence, everyone is on edge. Not a therapeutic environment for anyone, especially the other patients. Guess I'm just venting now....this too will pass. Thanks for listening. :)

So sorry that you are going through this right now. We once had a patient that would do things similar to what you are describing, simply because he was an addict and knew that acting out would get him the shot of ativan he was wanting. A few days after d/c he tried to come back and during the discussion I said " Well you know, so and so is on the unit ( an ex boxer who could be very intimidating himself) and while he can be a jerk to most of the staff, for whatever reason he likes me and is protective of me and when the other guy acts out and he decides to beat the crap out of him, theres no way Im breaking up those two big boys." The other guy wasnt admitted.

Not to sound uncaring, crude or whatever, but it sounds like those guys need a good old country butt whoopin. Ive never worked on a psych ward that didnt have a way to restrain or seclude a violent patient. What does your management say?

Davey Do · Apr 22, 2014

it sounds like those guys need a good old country butt whoopin.

Of course, in an Appropriately-Administered Therapeutic Way with Subsequent Objective Documentation, right Mandychelle?