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've been teased a bit by staff for giving in on things and of course I worry that the snark behind my back is less benign, but I really don't want to be a nurse who just tells people to "knock off their BS" instead of helping with medication or spending 1:1 with the patient trying to help them to relax. I have never yet had to e-medicate a patient. 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.
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...
Specializes in Hospice, corrections, psychiatry, rehab, LTC.
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??
It seems to me that this is condoning compulsive behavior, and it also opens the door for other patients to request similar things. It didn't happen this time, but it could well have. Once you have said "yes" to one patient, how are you going to say "no" to others? Perhaps a better approachwould have been to tell the patient that smearing butter on her face has no therapeutic value.
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.
Unless a patient has a documented health problem that needs attention, offering "extras" like heat packs will wind up tying you in knots. Same thing with offering massages to borderlines - something I never did in my years in psychiatric nursing.
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.
As you gain experience you will get a better feel for what is right and what the correct course of action is in a given situation. You seem to realize that you are not always making the proper decisions now - and no one does in the beginning. Teaching patients coping skills is a good thing. I had rather give them something that might be of use to them from then on, than to teach them to always depend upon medication to solve their issues. There are times when meds are the only thing that will work, but patients need to depend upon themselves first.
It seems to me that this is condoning compulsive behavior, and it also opens the door for other patients to request similar things. It didn't happen this time, but it could well have. Once you have said "yes" to one patient, how are you going to say "no" to others? Perhaps a better approachwould have been to tell the patient that smearing butter on her face has no therapeutic value. Unless a patient has a documented health problem that needs attention, offering "extras" like heat packs will wind up tying you in knots. Same thing with offering massages to borderlines - something I never did in my years in psychiatric nursing.
This, especially the bolded part. Consistency with the rules and boundaries is VERY important in psych nursing. If you start rearranging requests/privleges, rules and perks for one patient, other patients are going to wonder why they can have accomodations made for them too. And once you do say "Yes" to a patient, it's becomes harder to say "No" to other patients...and to actually mean No.
Heat packs are not bad...but I would reserve judgment when it came to issuing them. Ideally, get a MD order so other patients can't claim favoritism.
And I would never ever EVER offer a massage to ANY psychiatric patient regardless of diagnosis. That is a boundary that is very dangerous to play with. It's very easy for the patient to take the rubdown the wrong way and think that you have a romantic interest in them. It could trigger a flashback in some patients with a history of abuse or sexual assault.
Or even worse: even if they consented to it, said patient could claim (and may actually even believe!) that you were trying to physically or sexually assualt them. And it doesn't matter how delusional or psychotic the patient is: any such claims by patients ARE taken seriously and investigated. So even if you were acting in what you thought were the patient's best interests, it could blow up in your face big time.
So please stop this practice ASAP if you value your career. If a patient's pain is so bad that massage is required, let the MD put in an order for a physical/massage therapist to provide services.
Thanks for the input, ladies. I have definitely decided as far as the heat packs and massages go to only offer packs if there is a documented reason (confirmed diagnosis indicative of pain) and to eliminate offering massage. At my nursing school we always offered massage and heat as part of a pain-management program so I'm not going to lie, I feel sort of neglectful omitting them from my nursing interventions but I totally get the gist behind NOT going that route in psych.
I feel like I'm doing better with setting boundaries as well. Tonight I had a very borderline and very staff-splitting patient and remained kind and professional in interacting with her but just very kindly and professionally set and stuck to my limits and I'm working VERY hard to recognize giving in vs. being attentive and accommodating to my patients' needs. I do feel like I'm (finally!) getting more comfortable with psych.
At my nursing school we always offered massage and heat as part of a pain-management program so I'm not going to lie, I feel sort of neglectful omitting them from my nursing interventions but I totally get the gist behind NOT going that route in psych.
Remember that nursing school is all about ivory-tower nursing, where everything is perfect or nearly so, interventions work exactly as the textbook tells you they would, and your patient won't flip out and assume that your pain-relieving massage is an attempt to take advantage of them
In a non-psych nursing setting, massage as a pain-relief intervention makes perfect sense. In a psych nursing setting, massage is a hand grenade. There's a ton of other non-med pain-relief interventions that you can offer so don't let yourself feel guilty about being hands-off with the hands-on.
Yup I echo what the others have said about massage. Once you step into psych, gone are the nursing school days of bed baths followed by lotion and a back rub:). Although I have bed bathed catatonic patients who hadn't bathed in weeks and reeked to high heaven with another staff present.
I think you have the IDEA of picking battles right, though. I tend to be Tue same and to not let myself get dragged into power struggles. I once had a very axis 2 20 something male who's bedroom was right next door to the bathroom whip his shirt off in this bedroom in preparation to hop in the shower. Staff was down there reading him the riot act, getting him worked up. I walked down, said to the pt very matter of factly "I can't have you in the hall without a shirt on". It was this pt's first day on the unit. Pt apologized, I walked away but staff was still there arguing with the pt. I pulled them back down the hall and said, "guys, is this really the hill you want to die on today?". The pt did end up being very whiney and manipulative, but I had no further problems with him.
I DO work with quite a few power hungry, burnt out staff and it's frustrating. Keep that compassionate side and easygoing demeanor, it will serve you well. Just keep in mind there are times when you will have to learn to tow the line.
Orca, ADN, ASN, RN
2,066 Posts
It seems to me that this is condoning compulsive behavior, and it also opens the door for other patients to request similar things. It didn't happen this time, but it could well have. Once you have said "yes" to one patient, how are you going to say "no" to others? Perhaps a better approachwould have been to tell the patient that smearing butter on her face has no therapeutic value.
Unless a patient has a documented health problem that needs attention, offering "extras" like heat packs will wind up tying you in knots. Same thing with offering massages to borderlines - something I never did in my years in psychiatric nursing.
As you gain experience you will get a better feel for what is right and what the correct course of action is in a given situation. You seem to realize that you are not always making the proper decisions now - and no one does in the beginning. Teaching patients coping skills is a good thing. I had rather give them something that might be of use to them from then on, than to teach them to always depend upon medication to solve their issues. There are times when meds are the only thing that will work, but patients need to depend upon themselves first.