How many patients do you have as a Psych. RN?

7student7 · May 13, 2010

I'm talking about the place I work, but I'm sure things are similar other places...

I'm a MHA at a state psych hospital. Suicides are pretty darned rare. It's true that the nurses rarely talk with the patients compared to the MHA's, but I still wouldn't worry too much. A lot of precautions are in place. Bedrooms are locked at busy times, shaving is supervised 1:1, MHAs do 30 min checks at least, 15 min. at night. The patients are usually in the day room anyway, and the patients with the highest risk are always on a 1:1 observation with a MHA.

Also, I don't think 20 is unreasonable, my regular unit has one nurse doing the charting and another for meds, and possibly a 3rd when census is high. I think 20 is low for our unit and 30 (our max) is complete chaos. The geri psych unit has a couple more nurses than that.

We've only had one unexpected death at our hospital recently - it was a drug withdrawal patient that should have been sent to the ED, not to us. The person died in bed. We were "in trouble" but no one person was singled out. It couldn't have been any one nurse's fault. Inspectors went over our paperwork (MHAs and nurses) and harassed us about our room checks and procedures and drove us all crazy, but no one was fired.

After only 6 months at my job I felt like I knew about 1/2 the patients admitted. Psych patients come and go pretty frequently. You'll get to know them and know who to watch in no time.

Also, there's always a lazy MHA or two that don't like to do regular checks. Make them! That's when bad things happen.

labdad1234RN · May 13, 2010

Are you getting cold feet about signing up? A psych unit is different from most other units in the hospital. Here is something that may be of some comfort. First, you are never alone in the unit. You will always have your techs and perhaps another nurse. We psych nurses tend to form really close working bonds. We are aware we are in a closed unit/s and given our patients, we tend to anticipate the dynamic nature of the environment. IN short, we have each others backs no matter what. In terms of patient to nurse ration, I don't know about the place wyou will be working in. In the hospital I worked in the day folks get the best ratio between 4 to 1 to 6 to 1. I worked NOCS (nights) which depending on which unit I get assigned to averages between 10 to 18 patients per nurse, discounting the clerk and or the tech, and of course security who are on call for us. We had 2 units within the big UNIT. so to speak depending on the patients condition. We had a second even more secure area. I was charge nurse on some of those shifts and it does get interesting @ nights. Think of it, we have the lowest staffing levels and the incidents with patients tend to happen more @ night. I don't know why but it seems to in my unit. That's why we are very close as staff to keep each other safe. We do have protocols if patients are placed on suicide precautions, like 30 minute rounds, security cameras all over even the patient rooms. We keep a close eye on patients who have voiced any ideation of suicide and also the ones who tend to act out.

and of course there is training. I received extra training in the hospital to be in the psych unit.

IF you do decide to work in that facility here, are some tips that may be useful for you:

_ Situational awareness. Know your surroundings at all times. Do not get into a situation where you can get cornered or the other staff cannot see you or know where you are.

_ Always inform the other staff where you are and what you are going to do.

_ Take all the training and education offered in your unit. It comes in very usefull and add to your skill set.

_ Always treat your patients with respect and try to talk with them first if they seem agitated or whatever emotional state they are in.

Psychiatric nursing is very rewarding and I think you will enjoy it.

Whispera, MSN, RN · May 13, 2010

Just one MHW? Is the medication nurse out with the patients when not giving meds?

Depending on the acuity of the patients and the safeguards in place, that staffing could be adequate on a usual day. The thing is, psych days are not always usual. Admissions can take a long time. Who would be manning the phones and available for decisions when you're tied up with an admission?

Are there people nearby (off the unit) who can come if you need help? What happens if someone needs 1:1 monitoring?

Guest321574 · May 13, 2010

I work in psych and the setup you describe is exactly how our hospital works. Our max is 25 pts, and at night there is only 1 nurse with 2-3 techs. Day has 2 nurses and 3-4 techs.

Kooky Korky, BSN, RN · May 13, 2010

Your interviewer sort of misled you. As the RN, the buck totally stops with you. If there is a suicide, injury, abuse or neglect of any kind on the part of anyone who is on duty with you, you can bet your bottom dollar that you are going to have to give a statement and will be investigated and might be dragged down along with whoever else is involved. This is true wherever a nurse works - psych or not.

That doesn't mean that other staff are not responsible at all. It does mean that you need to know what is going on with your patients, all of them, all the time, and not trust the aides to take care of them while you sit at the desk. Yes, you must chart. Yes, you will be doing admits, discharges, orders, answering the phone. No, you can't do everything for or with patients or be everywhere at once or all the time. But you need to know what is going on with your patients, your staff, your floor. You are, after all, going to be the boss.

You need to have a good report at the start of the shift, make walking rounds at least q2h, I'd say, and see all your pts at least 4 times per shift. Do it more if you think it's needed. Do it every hour on certain patients you are worried about.

That won't be as daunting as it sounds. Depending on your shift, they will be in bed appearing to sleep and have resp wnl, or in the TV room, or with select peers playing cards or games or chatting or whatever, they will be calm or agitated, they will be working puzzles or seeing the doctor, visitor, LCSW, or psychologist, rec therapist, etc. You absolutely need to know who is where and what they're doing, what their demeanor, affect, and behavior are, what problems are they having if any, are they fighting, smoking, breaking some rule, or what?

Yes, aides can take VS or blood sugars or whatever the facility policies and your state laws allow. You might want to do these yourself sometimes, as it's an opportunity to see the patients and to make sure you are comfortable with the results. Not all aides are as skilled as we would like when it comes to certain procedures.

The aides are not a substitute for a licensed nurse, you, being involved with your patients. It doesn't have to be hairy - just sit and talk with them, hang out where they hang out and look and listen, be nice and let them get to know you a little (emphasis on a little - do not tell your personal business to anyone at work), and expect them to ask for extra snacks, extra whatever, try to take advantage of you and get you to compromise your standards, break rules, break the law, etc. Some are master manipulators and would love to take you down - just because they are sociopaths. Have no $ dealings at all with them, no matter how sorry you feel for them, mail no letters for them.

Watch your back. And your sides, front, top, and bottom. You can't be too careful.

You will have to make sure your staff know what you expect of them - they, too, will try you and test you, just because they are human. Get them in line from the start and do not let them push you around. They need to put away their headphones, cellphones, etc. and do their jobs.

Is this a long term facility? Acute care? Drug/Alcohol Rehab? Eating disorders? criminally insane (forensic)? other? kids? teens? adults?

I don't know if 20 is reasonable, not knowing the facility, but you will probably be overwhelmed at first. That would be normal. That's what orientation is

for - to get you ready to be in charge. It takes time. Do not let them put you alone, even if you have a med nurse, before you feel ready. What length of O are they suggesting?

It wouldn't surprise me if you do not always have a med nurse.

You should get to be med nurse at least once or twice, so you learn who's getting what, where everything is kept, like Haldol and other PRN's, shears for cutting down someone who is hanging, etc.

While serious events might be rare, it only takes 1 to ruin your day, your career. But most of us somehow make it through the minefield. I think you will do well if you just work hard, follow the policies, do not let others walk on you. If you don't know, say so and go find out. If anyone bullies you, do not allow this. Keep a good sense of humor, read histories, double and triple check orders, do not blindly trust anyone. Sorry to be a cynic. I've just been burned before.

Always remember - a psych patient can and often does have medical or surgical problems. They can have all the usual problems that someone without mental issues can have. So many psych nurses seem to forget that and they ignore physical issues. Don't do this. Your patient could suffer and you don't want that. Even if others tell you, "Oh, he always c/o his heart" or "He always threatens to throw up so he can get attention" or "She often threatens to cut her wrists. She doesn't need to be 1:1. She won't hurt herself".

That's right. She won't. Not on your watch, because you are going to make her a 1:1 and follow the normal procedure to make sure she is alive and well when you leave. I don't mean to make it sound like the main issue is your wellbeing. But your wellbeing is totally vital and never forget that. Keeping that in mind will cause you to always know what the right thing is to do and to do it.

And the heart c/o pt - do VS, eyeball him for: skin warm and dry? cold and clammy? Neuro status? speech slurring? confused? alert or groggy? moving all extremities? SOB? edema? what's the history? resp even, full, unlabored? wheezing? cyanosis? Just because he's schizophrenic or bipolar doesn't mean he can't be having cardioresp, cardiovasc troubles, etc.

The vomiting person might want attention. She or he might also have any number of med or surg GI or other issues. And even be in your facility for a personality disorder or depression. Or alcohol withdrawal. Just do an objective assessment and relay findings to the doc. You don't have to diagnose, just do a thorough assessment and communicate your findings. Again, read the history. It could help a lot if you are dealing with a beginner doctor.

Keep after house staff. Help them as much as possible and make them help you. Do not let them get by with not seeing your patients when you know they should. Yes, do call them back if you have to.

I guess I could go on and on. I think you'll do well. Why shouldn't you? Let us know how it goes, eh? Blessings.

Kooky Korky, BSN, RN · May 13, 2010

If you're in a long term area, read at least 1 history per day. Also, try to go to Team meetings so you can be part of the Treatment Team, even if you must come in extra or stay late. The Teams meet about once weekly. Make some of these meetings.

Read the charting by others who are caring for the patient (MD, psychologist, social worker, aides, other nurses, etc., psychiatrist, therapists, anyone involved with the patient).

If you're not long term, still read the history. That will help you get to know your patients very well.

Keep a Psych textbook and a drug book handy and don't hesitate to look up things you don't know.

pinkiepie_RN · May 14, 2010

I'm a psych nurse on an adult inpatient unit. I work night shift (7P-7A) and we don't have med nurses on either shift; we all give out our own meds. RN/patient ratio is usually 6:1 but can go up to as high as 8:1 depending on staffing. We have anywhere from 3-5 nurses on night shift and 1-2 MHWs. Our unit holds up to 26 patients.

Hope this helps.

aura_of_laura · May 14, 2010

We have 33 pediatric patients on our unit, split into three sections: adolescent boys, adolescent girls, and children... when staffing is good, we have three nurses (a supervisor, a med nurse, and an admissions/float nurse), and six direct care staff/mental health techs.

Really, though, psych staffing ratios are just different than med-surg. As a nurse, you will be documenting during restraints, monitoring med reactions, and do psych assessments - there is so little direct patient care, 20 patients is not that much to handle - and you already said you'll have a med nurse, so really you'll share 20 patients.

Don't be afraid! Psych nursing can be a great experience!

ehooper80 · May 15, 2010

A 20:1 ratio for a psychiatric hospital sounds about right. I currently work at a psych hospital 7P-7A. The 7A-7P nurse usually has an LPN to pass the medications, but night shift does not. I actually prefer to pass my own medications because it gives me a chance to assess the patient and do some education on the meds if they are unfamiliar with it. And yes, you are ultimately responsible for what happens on your unit. You supervise the duties of the LPNs and MHWs.

BUT remember that psych is totally different from medical nursing. Your patients may have some medical issues, but almost always they are stable, chronic conditions, such as diabetes, stable angina, hypertension, etc. We admit ONLY MEDICALLY STABLE patients from age 3 to the elderly. We have a geriatric unit where staffing ratios are higher just because the patients tend to have more cognitive impairments and are greater falls risks.

All patients are constantly assessed for suicide risk/suicide ideation... If a patient is actively suicidal or high risk to be suicidal, they are monitored more frequently. The general patient population is on "Q 15 min checks", meaning they must be seen every 15 minutes by a staff member. We have two higher levels of monitoring: LOS (line of sight) and 1:1.

Actively suicidal patients are always kept on 1:1, meaning they must have a staff member within arm's reach at all times. It's usually a MHW assigned just to that patient for the entire shift. Patients with suicidal ideations or at high risk for suicide or that are self-harmers are kept on LOS, meaning they must be in the direct line of sight of a staff member, usually a MHW, that is assigned to watch patients for the entire shift.

Because of better assessments and monitoring techniques, suicide rates in psychiatric hospitals have declined greatly. Great precautions are taken in psychiatric hospitals to assess patients for potential self-harm and to monitor patients to prevent this from happening, but unfortunately it still sometimes happens. You would not "lose your license" because a patient harmed themselves during your shift unless you were negligent in enforcing staff monitoring or patient safety.

HeartsOpenWide, RN · May 15, 2010

In California it is MAX of six...twenty...that is scary, how can you do your rounds and take care of 20 people? With potentially suicidal patients...20 is way too many in my opinion.

Kooky Korky, BSN, RN · May 15, 2010

a 20:1 ratio for a psychiatric hospital sounds about right. i currently work at a psych hospital 7p-7a. the 7a-7p nurse usually has an lpn to pass the medications, but night shift does not. i actually prefer to pass my own medications because it gives me a chance to assess the patient and do some education on the meds if they are unfamiliar with it. and yes, you are ultimately responsible for what happens on your unit. you supervise the duties of the lpns and mhws.
but remember that psych is totally different from medical nursing. your patients may have some medical issues, but almost always they are stable, chronic conditions, such as diabetes, stable angina, hypertension, etc. we admit only medically stable patients from age 3 to the elderly. we have a geriatric unit where staffing ratios are higher just because the patients tend to have more cognitive impairments and are greater falls risks.
all patients are constantly assessed for suicide risk/suicide ideation... if a patient is actively suicidal or high risk to be suicidal, they are monitored more frequently. the general patient population is on "q 15 min checks", meaning they must be seen every 15 minutes by a staff member. we have two higher levels of monitoring: los (line of sight) and 1:1.
actively suicidal patients are always kept on 1:1, meaning they must have a staff member within arm's reach at all times. it's usually a mhw assigned just to that patient for the entire shift. patients with suicidal ideations or at high risk for suicide or that are self-harmers are kept on los, meaning they must be in the direct line of sight of a staff member, usually a mhw, that is assigned to watch patients for the entire shift.
because of better assessments and monitoring techniques, suicide rates in psychiatric hospitals have declined greatly. great precautions are taken in psychiatric hospitals to assess patients for potential self-harm and to monitor patients to prevent this from happening, but unfortunately it still sometimes happens. you would not "lose your license" because a patient harmed themselves during your shift unless you were negligent in enforcing staff monitoring or patient safety.

please, let's remember that a medically stable person can become unstable. or can have an accident and need stitches, have chest pain, incur a fracture, or anything. keep up with their labs and vs and read everyone's progress notes (md, social worker, therapists, other nurses, etc.). and eyeball your patients often.

the aide or mhw who is assigned 1:1 for a whole shift is in danger of falling asleep when sitting down at night with the patient while said patient sleeps. rotate these workers at least q2h. some night workers are on the tail end of a double shift, some work 2 jobs and have a household to run and a family to care for in addition to their employment, some don't sleep but maybe an hour or 2 before coming to work. then they sit down in a semi-dark room where it's quiet and they are away from other staff and boom - they are out. and this is who you are trusting to keep your suicidal pts. alive. need i stress making frequent rounds and rotating the 1:1 staff at least q2? heaven forbid a pt harms himself while the 1:1 staff is asleep. wake them up but if the problem persists, get the supervisor involved and do incident reports. no one is paid to sleep and they are compromising you and your patients.

and yes, as ehooper says, the charge nurse must, must, and must enforce the rules and make sure the staff are actually doing what they are assigned to do. it's impossible for you to be everywhere at once and you should be able to rely on staff to do their assignment. but. you will have to learn who can be trusted and who can't. and if you have a problem staff member, you've got to deal with this. i'm not sure i can tell you exactly how. carefully, so no one starts complaining about you. documenting, communicating with the worker and with the manager and shift supervisor.

will the charge nurse be dragged into this? certainly the investigators will want to know when you last saw the patient and saw the 1:1 staff and where was the staff person seated and did you see the pt breathing and was there anything around the person's neck or in his hands, did you search the person's body and environment in the patient's room (per your facility's policy) for contraband and weapons and anything (belts, shoelaces, strings in waistbands, etc.) that the person could use for hanging himself, and many other questions. think what questions you would ask if you were doing an investigation like this. don't lie in investigations or try to protect friends. yes, it is hurtful to see friends fall, but you must do right.

every time you accept the unit from the offgoing nurse, remember to check that windows and doors are in proper working order, not tampered with. immediately report any abnormal conditions to the nursing supervisor and security. make sure both departments come to the ward and see for themselves what you are concerned about. make an incident report and keep a copy and make sure the ward nursing director and medical director and the patient's private doctor and maintenance and god himself are all informed. i'm not kidding. you must have proof that you tried to rectify the problem in a timely manner or someone will say it's your fault. always cyb. you might not be able to do all of this inspecting at change of shift, but do it as early as possible.

same with your sharps count. this could include nail clippers, scissors, or anything else that your facility regards as a sharp. count sharps when narcs are counted (or make sure the med nurse does this if sharps are in the med room). if there is a variance, it has to be straightened out before the offgoing shift leaves. if it can't be corrected, you must notify the supervisor and do what she says about it. and make an incident report, keeping a copy.

if you feel hinky keeping copies of ir's, keep a little log instead. and do have your own malpractice insurance.