I need your expert opinions on Rules and Restrictions on the Inpatient Psych Unit:

[Joandarco]

I work on a 19 bed unit at a large hospital. There is another psych ward on the same floor with 20 beds. Both are locked, adult, inpatient units. Our patient population varies in age and disorders. For example, we may have an 18 y.o acting out Borderline, a 40 y.o. male with depression and alcohol addiction, and an 85 y.o. male with severe depression. We usually have several older adults with depession and catatonia who are receiving ECT treatments. I work part time on the evening (3 -11) shift.

We always check any thing that visitors or family members bring in for the patient. Visiting hours are only for 2 hours a day, 1 in the afternoon and 1 in the evening, and the visits take place in a dayroom with a staff supervising. Of course, metal and glass objects cannot be kept in the pateints rooms, or belts, long straps, or scarves, etc. But until a few months ago visitors could bring in food or drinks such as soda. An incident occurred where a patient had a visitor smuggle in some cocaine, hidden in some food, although the details of that have never been shared with me.This patient shared the drug with a couple other patients, tox screens were done, the police as well as risk management were involved. I wasn't there when it happened, but, as bad as it was, I cannot think of another such incident in the past 20 years.

Anyway, management immediately instituted new rules: no food could be brought in for patients, not even a Pepsi in an unopened 20 oz. bottle. The patients could no longer keep a few dollars on the unit to purchase a soda from the machine, nor could they order a pizza or any food for delivery. At the time we were told that this was a temporary necessity and would be revisited, but it wasn't, until I brought it up right before the holidays. A young visitor wanted to bring in some homeade Christmas cookies for her Grandma, but was told no, no exceptions.

I was also concerned because we get quite a few older patients from other countries, such as Somalia, Cambodia, Nigeria, etc. and in the past, their families would bring in home cooked, familiar food for them. A lot of them will not eat our American food.

As an experienced psych nurse, I feel we should be able to use judgement on what is brought in and consumed by our patients. Of course we should pay extra attention to the patients with addiction issues, but these are the minority, not the majority of our population.

Since I brought it up, management has asked me to research best practices in this area, but I haven't found anything in a lit review. The other hospitals in our area don't restrict food, just caffeine. Please give me your feedback. Thanks!

[Whispera, MSN, RN]

Where I've worked visitors could bring in food and drink but nothing that was opened and nothing that could have anything injected into it (like a potato chip bag). Also, all food and drink was kept in the nurses' station and given out a bit at a time. No bottles or plastic or metal containers were given to patients. Drinks were poured into paper or styrofoam cups.

You can't make exceptions as to who can have things and who can't. Well, you could but it will lead to trouble. It's just easier all around if you stay consistent with the rules. You never know when the person you feel is ok is the person who isn't ok.

[medsurgrnco, BSN, RN]

Most places I've worked, patients could order food/drinks and visitors could bring in food/drinks. Items not consumed at that time were kept at the nurses' station or in the pt fridge. No cans allowed on the unit. No food/drinks kept in pt rooms.

[Whispera, MSN, RN]

two things about plastic bottle caps...I've had a patient huff the whole thing into her windpipe, requiring emergency removal, and I've had a patient dig the metal ring (sometimes there is one) out of the cap and use it to cut herself. Patients can also break stout plastic bottles and use them to cut (bottle caps too).

[change agent]

Our organization inpatient psych units do not allow any food to be brought in. Our dietary department has been known to respond to special dietary needs, even ordering from an outside vendor if necessary, such as for Kosher diet.

Patients are notified of this upon admission. One idea for the older adult population might be for the MD to write an order permitting family members to bring in home prepared foods.

[Joandarco]

To Whispera: Making exceptions does make things difficult. Of course it is the drug seeking patient who complains most about this. But given our diverse population, I feel we should have a more open policy, as we did in the not so distant past. We have not had any incidents with plastic bottles, and metal and glass are not permitted. In the past, patients could keep a small supply of soda in their cubicle in the nurses station and we would dole it out, especially since it was not cold, into a paper cup with ice. Currently even that is not permitted.

[Whispera, MSN, RN]

I think I'd ask the powers-that-be what the rationale is for being so restrictive.

[Jules A, MSN]

I think I'd ask the powers-that-be what the rationale is for being so restrictive.

Safety is the rationale at my facility. No outside food or drink is allowed in. Our kitchen is excellet and will make special accomodations. It is more difficult for our residential patients but they can eat whatever they want when they go home for a visit so when they are with us it has to be safety first.

[Mr Ian]

Had an absolutely identical situation. I just told the managers they were stupid and carried on. I wouldn't suggest you try the same.

Whispera has the crux :

I think I'd ask the powers-that-be what the rationale is for being so restrictive.

..but as we know... Ours is not to reason why.....

And go back to your original post:

An incident occurred where a patient had a visitor smuggle in some cocaine, hidden in some food, although the details of that have never been shared with me.This patient shared the drug with a couple other patients, tox screens were done, the police as well as risk management were involved. I wasn't there when it happened, but, as bad as it was, I cannot think of another such incident in the past 20 years.

There is no evidence to suggest one way or another and it is all based on historical subjective opinion.

1. How did the event come to the attention of staff? (ie it didn't go unnoticed - this is neither good nor bad -

2. What was the most extreme behavioural outcome - ie did someone murder everyone? Or just stay up all night long?

3. How bad was it really? A small amount of cocaine - they're not likely to share it far or OD someone else on it (having gone to that trouble to bring it in). What are the consequences of taking cocaine and having a mental episode - getting locked in a psych ward. So the 'risk management' strategy is in place - what are they further protecting against?

If it was a regular and highly prevalent issue with severe consequences - I'd accept a risk management initiative, but the issue is - they know these things might happen, hence having a security protocol to reduce - not eliminate - the risk.

Reacting by banning everyone is pejorative and is unusual and cruel treatment of those who do not have contraband issues/behaviour.

I would also give all information to the police about the visitor suspected of bringing the contraband in (if you have a VERY SURE idea - I've guessed wrong many times).

The individuals concerned do not care for everyone else's loss - so this punitive reactionary management strategy is of no use.

They would have been better off telling the identified patients they knew what they'd done... and leave it at that - they'd be more worried that no reaction came their way. And face it - what have they lost?

I would have those who tested positive on restricted 1:1 visits and restricted the items with them alone.

The alternate argument - denying culturally appropriate foods etc is discriminatory practice, as is the 'unreasonable' restriction of any 'pleasure' foods etc by this adminstrative action. The food is not the problem - just the contraband in it. So do as I did and tell the managers if they wish to 'control' the supply of such items then they need to arrange for their purchase and distribution.

If they are so worried about patients getting their hands on mind altering drugs - why do they keep letting the psychiatrist in there? S/He's the one bringing in the most.

You cannot legislate for every potential event - and trying to do so after the event is bizarre.

Often managment do this because they feel impotent and they are merely employing insitutional violence on the patient group as a 'lesson'.

I'm also concerned why they've got so many mixed up presentations in one unit. Is it not cruel (and counter therapeutic) to house a depressed elderly person with an emotionally dysregulated 18yo?

[Thunderwolf, MSN, RN]

Excellent discussion, folks.

[Jules A, MSN]

Excellent discussion, folks.

Please add your two cents and experiences! :)

[Joandarco]

Thanks for your input. No, there weren't any severe consequences, no one OD'd or died. The patients that were involved were pretty quickly released, since they were obviously not invested in treatment.

Actually, the mix of ages, disorders and ethnic groups makes for a very interesting milieu, and we do a good job of preventing conflicts between patients. But the number of psych beds in this area has been shrinking for years. I do remember the old days when this hospital had 5 separate psych units: One just for elderly patients, one for Drug and Alcohol, an adolescent unit... those days are gone at least for now.