I don't psych nurse like the other psych nurses here

Davey Do · Dec 2, 2013

I guess I'm more of a "pick your battles" kind of person. I would rather give some small concession than end up having someone blow up and have them explode and hurt someone.

This is a sign of good Mental Health, expending energy where the energy is best utilized.

A sign of Cognitive Dissonance is expending voluminous amounts of energy in a futile attempt to not have to expend energy.

I just don't see what the big deal is in being kind, accommodating, and medicating upon request or offering meds if it looks to me like someone is struggling. Most of the nurses here seem to have a really tight rein on handing out PRNs for some reason and they also tend to be very snippish and unprofessional toward the patients.

It seems like the Nurses who practice this sort of approach to Patient care are into Power Struggles. That feeling of Power gives them some comfort, in that they probably feel a sense of control over the situation.

It's not the healthiest way to deal with obvious feelings of insecurity, but we all use the techniques that work for us.

I guess I'm just feeling a little frustrated because I am doing things differently than everyone else here.

Your feelings of frustration are appropriate. Whenever we choose to go against the Mainstream, we will experience Stumbling Blocks.

I just worry if I'm the one in the wrong and I need to be a little more strict or something, and I also worry that I will turn into one of these Nurse Rachets if I stay in this field...

Adhere to your Sound Beliefs. It is never wrong to put Principles before Personalities.

It is doubtful that you will turn out to be like "Them", since your approach, your actions, are an extension of who you truly are, Umberlee.

Keep on keeping on, and continue to fight the Good Fight.

The very best to you.

Dave

Bouncyball · Dec 3, 2013

Hi, I am also new to psych and feel the same way you do. I am happy to hear I am not the only one who feels this way. Most of the other nurses I work with are so rude and snippy to the patients. I can't believe they way they talk to them!

I do not seem to have a problem with setting boundaries with pts, but go about it in a different way than the other nurses. Seeing how different I was than the other nurses used to make me wonder if I was going about things all wrong. Then I really started watching how the patients were reacting towards me.

I noticed the patients were responding to me really well. For the most part I have a good rapport with my patients, and they seem to open up to me and will tell me about their delusions or SI. I frequently have other nurses patients open up to me and not want to talk to their nurse about things. I decided not to let the way other nurses do things affect me, since I seem to be doing my job just fine.

Just keep doing what you are doing and don't worry about the other nurses.

NurseJamie8 · Dec 4, 2013

Hi I'm new to psych too! I feel the same way you do, but there is a fine line. Some patients will manipulate you into getting what it is they want. You do have to be firm and set limits for them because they can't control their behavior or don't know how which is why they are in a psych unit. That being said I think approach is everything. They pick up on frustration and insecurity, you want to be a strong role model for them. As for the PRN medications I give them out as necessary. I would rather spend 1:1 time with patients and use other approaches first and medication last. Lucky for me lots of the nurses I work with are great so I'm learning everyday on what works and what doesn't!

Retired APRN, MSN, RN, APRN · Dec 4, 2013

It's true that a lot of us old timers get a bit crusty, but there are a couple of possibilities from what I can glean from your post.

You say you get teased for "giving in on things". What kind of things? PRNs? Privileges? Rule bending? That makes a difference.

Unfortunately a lot of people are attracted to nursing because they like the favorable power differential, and far too many of them find their way into psychiatric nursing. That could be the case with your colleagues. It may also be that there is a toxic environment on the unit.

It may also be, however, you may miss some subtleties of the milieu. (I have the impression that you are either new to psych nursing or new to this facility.) Have you asked (in a non-confrontational manner) the other nurses to explain the reasoning behind their decisions so you can learn from them? Are you carrying the same patient load? When you are 1-to-1 with a patient, do the other nurses have to take care of your other patients? That's a really quick way to build resentments!

I agree that there is no excuse for unprofessional behavior. If you can offer some *generic* examples, maybe we can all put our heads together for a solution.

You write, "I would rather give some small concession than end up having someone blow up and have them explode and hurt someone." I understand that. At the same time, sometimes it is important for a patient to experience frustration and delayed gratification in the safe environment of an in-patient unit so that they can start to learn new behaviors and practice their coping skills.

There is no quick and easy answer and no one-size-fits-all solution. What kind of unit are you working on? What is the average length of stay?

tareija · Dec 4, 2013

I think other people have asked some good questions, e.g. what kind of unit are you working on, how long have you been working as a psych nurse and/or working in this facility, etc. I have been working as a RN, in psych, for a bit over a year (I am a second career nurse in my 30s, and this is my first nursing job.) I would say my style is similar to yours, I try to be laid back, respectful of my patients, flexible, etc. I have had to learn over time to be a bit more discerning, and how to respond assertively, towards when patients may be trying to be manipulative or push boundaries inappropriately. However I don't think there is ever a cause to be snippy or rude to patients. I agree with you unfortunately that there are some nurses out there who do seem to be on a power trip or enjoy having power over their patients. I sometimes wonder if nurses like this are attracted to psych because there is the chance to have a lot of power and control over patients. However, there are also a lot of psych nurses who are genuinely helpful and caring, too.

It is a fine line and a balancing act and it takes time to get it right - I am definitely still learning! Let's take your example of "I'd rather give them some small concession than having them blow up/explode." Often I think this is an okay approach. However it is also important, from a safety point of view, for patients to be able to follow direction from the staff, and have a reasonable level of control over their behavior. There are so many variables and context in psych nursing that I think the right thing to do varies from one patient/situation to the next. When patients are getting frustrated, I may often say something very calmly like "Listen, I can understand you are upset, and I want to help. For us to work together well, I will talk to you respectfully, and I need you to talk to me respectfully as well." Often this helps them calm down a bit and then you can discuss whatever the concession is they're asking for and whether or not that's reasonable.

It sounds like you generally are coming from the right place in your philosophy, though, and are establishing a good therapeutic rapport with your patients. One nurse I work with, who has been a psych nurse longer than I've been alive and is very good at her job, put it well. She says, we (nurses) all have different personalities and strengths and weaknesses. We are here to work together as a team. Specifically I was upset one day because some nurses had been talking about me behind my back with complaints of the type you are getting. This experienced nurse said to me, well, that is just your style, and that's okay. You are calm and soft spoken, and many patients respond well to that. We are here to help each other, not criticize each other.

Anyway that was a bit long winded, hope it was helpful.

sharpeimom · Dec 5, 2013

Psych nursing is like any other type of nursing. You have to develop your own style while remembering to keep yourself safe from your patient outbursts. Most of my twenty year psych nursing career was spent at our state psych hospital dealing with a great variety of patients. One of the very first hard lessons I learned was to never turn my back on any patient or to let a patient physically back me into a corner. Another lesson was never to wear a necklace, dangly earrings or anything a patient could grab.

By nature, I'm a very laidback, relaxed, barefoot, former hippie leftover from my college days in the '60's and early '70's type of person. I have always hated imposing my way onto someone else, but I quickly learned many of my state hospital patients interpreted that as weakness and "Oh boy, I can really manipulate this one!" As my mom used to say about rearing me: "choose your battles wisely" and "being the one in charge doesn't mean becoming a fascist." It was only with the forensic patients, when I was assigned to that building, that I had to come down hard and leave no margin of doubt as to who was in charge and that they would take their meds.

Other than when I was in that building, I usually did better with a softer lighter touch, but not always. Assess every patient every shift.

Don't assume anything. Ever! There is no such thing as a one-size-fits-all psych patient. Just as there are diabetic, cancer, MS, dementia patients all together on a med/surg floor, psych patients vary by diagnosis and what day it is too. The longer you do this, the more confidence you'll gain. You will eventually gain a sense of what works and what doesn't for you. Just ignore the snarkiness. If you don't let them know that it bothers you, it will stop sooner. I promise.

New Angel · Dec 5, 2013

I began psych nursing a year ago, and graduated 2 years ago. I work in a tiny office with many high energy, big attitude, sometimes seemingly anxious staff members who have 5 to 10 to 15 years med/surg & ER experience....many are cynical, sarcastic, and I am in disbelief over some of the things my coworkers say abput patients. I often take it as a cue on what NOT to be and how to NOT get crotchity as I move through my nursing career. I said something one time to a supervisor because the nasty mouths were going way too far, and simply asked if this type of work, or this office imparticular, is really for me? I'm not an anxious, or terribly assertive nurse yet, but i am efficient and have done very well this past year learning my job person. I'm more passive, relaxed, and I still think to myself, almost every week at work: I am too nice for this office. I hope I never get to the point where I talk about patient the way my coworkers do.

I second guess myself sometimes, thinking, 'I should take a letter from these seasoned psych nurses. they have the experience.' but no. some people get hard...and cynical. and I want to try not to have that so soon in my career.

I have resided myself to not follow suit....not to go with the crowd and maintain my soft side. I don't allow pt.'s to take advantage of me and I set appropriate boundaries. My unit's safety is always my first priority. I am fine being nice to the patients and interested in their emotional state, not just their meds & clinical behaviors. I am comfortable with my nursing style and so are my supervisors.

tareija · Dec 5, 2013

I should also add, I don't think that becoming hardened or cynical and thus being rude or sarcastic to patients is inevitable. Some of the worst examples of that behaviour I've met are nurses who have less than five years experience. Some nurses I work with who've been at it for decades are not that way, they definitely set firm boundaries when needed but aren't on a power trip and don't badmouth patients.

JustKeepDriving · Dec 5, 2013

I knew from the get-go I would have a hard time setting boundaries because I am a big softie. But seriously, these other "seasoned" psych nurses just seem so...MEAN! I can understand the need for boundaries but I guess I'm more of a "pick your battles" kind of person. I would rather give some small concession than end up having someone blow up and have them explode and hurt someone.

I have a hard time with the whole small concession thing. I agree that one should always be professional in their interactions with patients - leave the venting to the break and chart room- however, I don't always agree with giving in to my patients. Maybe it's the forensic aspect of my work - but my patients aren't just mentally ill - they also have a criminality aspect to them and criminality and mental illness can both be dependent and independent from one another. There are many patients that will work to break down boundaries by getting one small concession... then one small concession... then one small concession - up until the staff member breaks a rule and then they will hoard it over that staff member's head. More than one nurse has been escorted off the premise because they ended up breaking a rule for a patient and that patient used that as power to get contraband/sex whatever.

I also have a strong belief in the philosophy that my patient's will one day leave the mental health system and integrate back in the community. That means learning how to live with the word "No" (No is part of life, we don't always get what we want). My unit is considered the behavioral ICU - patient's are transferred here or admitted here from correctional institution because they are too violent to be on other wards in the hospital. In order for them to progress to less restrictive areas in the hospital they have to show that they can work with it behavior wise. That means being able to deal with the word "NO".

I would much rather be the one telling the patient "NO" and have that patient try and hit me - then have another patient or even someone on the outside tell the patient no. I'm trained to take a hit and not react. I can't say so much for that patient's grandma (it's happened) or another patient. There are some people on other wards that think we're too tough with the rules/that we're mean. I'm here to stabilize my patients - I'm attentive to their needs, I listen to them when they're in crisis - but I don't want to just give in and give in and minimize their maladaptive behaviors - transfer them on to a less restrictive unit where they have more privileges available (like pens) and then have that patient stab a staff in the face with a pen for saying "You're going to have to wait a few hours for your PB&J" (this has happened too).

I'm also a firm believer on pushing my patient's a bit if I think they're not in a good place. In no way am I saying that I'm unprofessional - I always am. But if a patient is getting annoyed merely by my assessment, "Hey how are you feeling today?" then I'm not just going to stop assessing them so that they can go on a contact visit with their mother. I'm going to continue saying, "Hey, you sound like you're getting upset with me, what's going on?". If they continue to escalate from there than they are clearly not safe enough to go on their contact visit - or off the unit where there is less staff to help out in the event of a behavioral emergency.

You're right - I might not press someone in med-surg the way I press individuals in psych. I figure they know how to hear "No" and that if they're ornery about an assessment it's because they aren't feeling well - not because they might be having a command hallucination to assault someone. I'm not as worried about the med-surg patient punching their visiting granny in the face and trying to stab her with a fork.

I'm not sure about your facility as I've only had experience in mine. Maybe your nurses are on a powertrip - it can happen in psych. All I'm trying to do is give a different perspective. As a psych nurse my number one priority is patient and staff safety. Sometimes that means saying no and assessing my patient to see if he/she is in a good space. If he/she is getting upset when I ask him/her how they are doing - I'm not going to just stop. I'm going to continue and ask because I would much rather have a patient throw a punch at me than have that patient throw a punch at their mother - or another patient. We have had staff members end up with permanent injury because the nurse was too soft in her assessment and gave the patient a concession - 'I know she just threatened you, but she said she'd be good so we're going to send you out to yard with her.'

I would beat myself up till the end of my days if I made a call like that and someone got hurt.

Orca, ADN, ASN, RN · Dec 6, 2013

I knew from the get-go I would have a hard time setting boundaries because I am a big softie. But seriously, these other "seasoned" psych nurses just seem so...MEAN! I can understand the need for boundaries but I guess I'm more of a "pick your battles" kind of person. I would rather give some small concession than end up having someone blow up and have them explode and hurt someone.

If you are too conciliatory, you could be facilitating staff splitting. If patients know that they can dodge whatever limits have been set on them by going to you, that is just what they will do. Not every blunt statement is unkind. Some people simply do not understand unless you are very direct with them. It is not necessarily your coworkers being mean. It could be, but take a closer look before you make that judgment.

I just don't see what the big deal is in being kind, accommodating, and medicating upon request or offering meds if it looks to me like someone is struggling. Most of the nurses here seem to have a really tight rein on handing out PRNs for some reason and they also tend to be very snippish and unprofessional toward the patients. I doubt they would speak to someone in a med-surg bed that way, or if a family member were present to complain and hold them accountable for their tone.

Being compassionate is a good thing. I have worked with nurses who were stingy with PRNs, and I have also worked with nurses who handed out PRNs like candy, whether they were needed or not, just so that their shift would be more peaceful. I always told my staff, the order says "as needed", and that is pretty self explanatory. If the patient says that he/she needs it and it is within the allowable time frame, give the medication. Don't try to decide whether the patient "really" needs it. If it appears that a certain patient is manipulating PRNs, discuss that with the psychiatrist.

I guess I'm just feeling a little frustrated because I am doing things differently than everyone else here, including most of the long-term staff (though there are a couple nurses, mostly on nights, like me who are much more laid-back). It's almost like some of these nurses are on a power trip. I just worry if I'm the one in the wrong and I need to be a little more strict or something, and I also worry that I will turn into one of these Nurse Rachets if I stay in this field...

If there is a marked difference between how you operate and how your colleagues operate, you will not make a good team. This doesn't mean that you must have the same personalities or styles, but you should at least be in agreement with how you approach each patient. Take a look at how you work and how your coworkers work, and try to determine why the differences exist. Are your coworkers burnout cases who have become jaded, or does your relative inexperience just make it seem so? The transition from textbook mental health nursing to the real world can be an eye opener. Ask one of your veteran colleagues to explain the reasons for a certain action. If you do so in the context of trying to learn rather than trying to judge, you may learn something useful.

Another rule I learned very early on: Not all of the nut cases are on the other side of the desk. I have worked with some very strange individuals, and people with mental health issues of their own often gravitate toward this specialty.

In one mental health facility where I worked on a geropsych unit, I had a good team on my shift. We treated the patients well, we spent an appropriate amount of time with them, set limits when it was called for and left the patients alone when it wasn't. The nurse who usually relieved me in the afternoon was a burnout case. Angry demeanor, always came in with the mindset that she was there to "restore order" after my team had "let the patients do whatever they wanted all day." I could sense the tension level in my patients rising as we got to within about an hour of shift change and my crew was due to leave. She was one of the unhappiest, most cross people I had ever met. A good shift for her was one during which she was never bothered, and the patients stayed away from the desk. Her unpleasantries ensured that this happened more often than not - although she managed to escalate some patients who I had spent an entire shift with and never had a problem. The restraint situations on that shift were about 8-10 times what we ran on mine - and I was on day shift, so it wasn't as if it were a simple matter of opportunity.

Take some time to get the lay of the land, so to speak. After you gain a bit of seasoning, then decide whether your coworkers are being mean or just firm. They can appear to be the same thing until you are able to recognize the difference.

Umberlee · Dec 6, 2013

I am definitely inexperienced in this setting and feel like I'm over my head. Some other nurses who trained about the same time as I did seem to feel much more comfortable than I do. I try not to let it show to the patients that I am wishy-washy or nervous but the truth is that I really am. As far as picking my battles, lemme see...one of the first shifts I worked we had a very manic patient who was upset that she didn't have face cream. She asked me if she could put butter on her face. This sounds so ridiculous as I write it. I didn't really see any safety concerns so I just asked if she would please put it on in the bathroom privately and then be sure to dispose of her trash with staff so they could see, per our milieu rules. She did this, it didn't become a milieu thing with psychotic patients all asking for butter for their faces, and I thought it was all good. I heard one of the other nurses say later that she couldn't believe I had done that...I just didn't see the big deal??

When I care for borderline patients I often spend 1:1 with them but set a timeframe and I do stick to it. I will even offer things like back massage or guided imagery and do that if the patients want, and I have time. Then the other nurses I work with say things like "I sure hope she enjoyed that tonight because I guarantee it ain't happening tomorrow" (I only work relief). So I feel like...should I not be doing this?

There was one time when a patient who was only allowed to come up for groups because of behavior was allowed to come up for "sports therapy" which was watching the football game on Sunday. I did give in on that but I was kicking myself all week and if I had to do it over I would not have said yes. I do feel like I learned from that one, and even though I didn't get in trouble for it or anything I realized in hindsight that I should not have allowed it.

Also heat packs. If a patient is complaining of pain I often offer heat packs as I would if I were dealing with a non-psych patient. One time I have had this go out of control where I had an axis 2 patient wanting her heat pack reheated every half hour and then her roommate asking for one...and since she had been consistently rating her pain as 10/10 with or without the pack, the nurse I was working with just took it away and said since it wasn't working we weren't going to do it anymore (which I agreed with). Yet the next time I worked with that same nurse and had a patient I have a heat pack to, her roommate also asked for one and I gave her one as both had been complaining of pain throughout the day. This time I did let them know I would just be doing the heat pack at HS so it would not be going out into the milieu and we would not be reheating packs all night. I thought this was a more effective use of boundaries but the nurse I was with was alluding to it becoming a "milieu thing" again and I definitely got the impression she wanted me to at least have said no to the second patient. I'm wondering if I should just stop offering heat packs or what if they're always going to be milking it.

I do think I may lean toward overmedicating which is probably being subconsiously still pretty uncomfortable with the setting. It's something I'll consciously work on and try and encourage use of coping skills in my patients first.