So lately we are seeing more and more patients who are really violent. This has crossed over into the adolescent psych unit I run. Our policy and agreement with law enforcement is that we do not turn away police drop offs and it seems that even someone who has "allegedly" committed felonious assault can say he/she is suicidal in the back of the police car and get dropped off to us rather than be booked into jail. We are a locked facility but "Patient's Rights" do not allow us to confine a patient to his/her room or to restrain chemically or physically for more than 4 hours (2 for adolescents) at what point can we push back on the police to take these folks to jail.
I have tons of empathy for any patient - but having these types on the unit disrupts the therapeutic milieu as well as putting patient's and staff in danger.
Specializes in Psych, Addictions, SOL (Student of Life).
On 7/10/2019 at 8:48 PM, pixierose said:
Hppy, I usually agree with you on most things, but you seem awfully blamey in your last two posts.
The worst feeling, the very worst feeling, is *anticipating* that violence and *knowing* you can’t stop it from happening, and wondering how you’ll make it out on the other end.
We get everybody and anybody the ED sends us. The unit I am on is “older adult,” meaning we now get *anybody* 50 and up ... could be ambulatory, MDD and polysubstance abuse scoring 5-> on a CIWA (we are med-psych, so we do IVs and can do IV Ativan) or an 80 year old, 2-assist using a rolling walker with major neuro cognitive disorder that requires frequent IMs r/t their dementia. Or that paranoid schizophrenic that has been a frequent flyer, is on visit 4 and we are now waiting for a long term placement.
The nursing staff at the psychiatric hospital that I am employed at are top notch, trained well and frequently. We are also a relatively happy bunch... until recently with the new policies hospital and system-wide (in our case, the 30-40 year age gap where we get all things psych-medical).
We can and do indeed anticipate. But you pile all these patient behaviors in close quarters with staffing such as they are (3 long term techs are out on leave due to violence from patients), and even the best of us (anticipation or not) can get injured.
I watched a 250lb man come in on a stretcher after receiving an IM 5-2-50 in the ED ... sit quietly for almost a full 30 seconds, stretch, then jump off and slam his beefy fist into the wall next to my face. I had 4 techs, two security guards, and two paramedics next to me. He was here for detox and MDD, using those magic words “I want to kill myself.”
I anticipated that he might be problematic. We worked with the ED. I worked with the patient as we let him slowly out, one 4 point at a time. I had staff. I was a safe distance. I utilized my CPI techniques.
It’s a horrible feeling, watching that quick decompensation take place. Sometimes, people don’t belong on psych floors.
I agree that sometimes behavior cannot be anticipated - and the staff is not to blame if they haven't been properly trained or are not properly supported by administration.So what I said was not meant to "blame" anyone but rather to empower nurses and staff to demand better training. I was actually injured about 12 years ago when I was punched in the face. It was however entirely my fault that it happened. As I was frustrated with a pretty borderline patient and in trying to make a point I pointed my finger at him. Next thing I knew I was on the floor with little tweety birds flying around my head. I had no time to react in any way and I acted inappropriately with that patient. I actually left psych nursing for about a year because the incident shook me so badly. I did go back and to the same facility because I love psych nursing and psych patients.
We are a 110 bed free standing acute facility. Some of our patients come from ER's but most are PD drop offs and our contract with the county states we cannot refuse a police drop off. So we get all kinds as well. In California the law is moving away from putting patients in 5 points - we are currently doing physical hold for as long as it takes which can be up to two hours in some cases. We also have closed circuit video so every behavior and take down is filmed and staff actions scrutinized by our "risk management team" What we found from examining the evidence and doing evidence based research is that most (not all) negative behavior at least in our facility resulted from staff inattention and/or poor staff leadership on the part of the charge nurse. I am 56 years old and can drop at 6 foot 200 lb man like a bad habit. I do go to the gym often and spar with my son who is a black belt in mixed martial arts. Mostly I am just really fast on my feet.
Med/Psych and gero/psych can be different as you can not use reason with a person suffering from dementia and the medically frail or person on drugs will react differently. We went from 10 to 20 Seclusion and restraint episodes a month to 1-2 and we cannot give a patient an IM unless we have first offered the medication by mouth. No standing PRNs for emergency meds - we have to call the physician each and every time so you can bet we are out talking to our patients finding out how we can meet their needs and what methods work for each patient.
All behavior cannot be prevented but if you have staff and patients being continually injured your facility is doing something wrong. It is that simple.
I have had some very aggressive patients on my unit which is primarily very acute adolescents. It is a mixed gender unit and quite frankly girls scare me more than boys. I have worked adults, gero, detox, intake and I have gone out into the community as part of my job to assess individuals sitting in ERs, nursing homes and psych holding facilities, high school and college campuses. I am currently getting training to be a crises intervention negotiator with our local law enforcement so that we can help our law enforcement learn better ways to handle psych patients in the field.
We do an actual post conference/debriefing after every incident to discuss what we all thought contributed to the behavior, what we could have done differently as well as what everyone did that was effective. And all of our team has to leave their ego by the door and be open to constructive criticism.
In my humble opinion CPI is useless - if you are not using advanced MAB you are going to have problems. It is not the fault of staff if they haven't had proper training. If I felt that I was not fully supported and did not have the training I needed to maintain unit safety I would walk out immediately.
I am sort of all over the place with this and I truly feel that every nurse, floor staff, therapist, physician, house keeper and maintenance person who comes on the unit needs to have this training. If you are not getting it demand it. Once a particular patient is identified as having a potential for violence the staff needs to discuss in advance how emergencies are going to be handled.
What I get from reading these forums is that in most facilities it seems as if the nurses and behavioral staff don't get the training and support they need to do their job safely and effectively. It's a shame because we as the people in charge of unit safety need to be given the tools and training to do our job.
So I am sorry if I made it sound like I was blaming staff. It was not my intention. I want everyone to have the experience in team building that I have been a part of. that way we can stay safe and deliver high quality trauma informed care to our patients and go home whole and healthy each and every day.
Specializes in Psych, Addictions, SOL (Student of Life).
On 7/10/2019 at 6:24 AM, unknownjulie said:
The randomness to the attacks that I witnessed at my last Psych job had nothing to do with how the staff interacted with patients. I am glad that you and your staff have been lucky thus far.
Thus far? I have worked with psych patients in both acute and community settings for close to 20 years and physical attacks are rare and when they occur it can almost always go back to action or inaction by staff. We have specified patient whisperers who engage patients without confrontation.
"IMHO physical attacks and aggressiveness has a lot to do with how staff manages patient behavior. Especially now that we can't just put someone in restraints anymore. Physical attacks are rare in our facility but our staff is tops."
I'm not comfortable blaming any staff for not "managing patient behavior" well enough to decrease aggression. Connecting and communicating with a psych patient is a fine art and not something you can just take a class on. The risk of violence is always there.
Specializes in Hospice, corrections, psychiatry, rehab, LTC.
On 4/26/2019 at 3:28 PM, TheMoonisMyLantern said:
In my experience usually administration is useless in these circumstances.
Precisely my experience. I worked geropsych on a hospital inpatient unit. Theoretically we were only supposed to admit patients with treatable conditions. In practice, if they had Medicare, in they came - Alzheimer's, end stage Huntington's chorea, you name it. Trying to help people who had anxiety disorders or depression was difficult when we had people wandering into rooms all over the unit and taking things, threatening people, etc.
Specializes in Psych, Addictions, SOL (Student of Life).
On 8/26/2021 at 7:18 PM, NurseScribe said:
"IMHO physical attacks and aggressiveness has a lot to do with how staff manages patient behavior. Especially now that we can't just put someone in restraints anymore. Physical attacks are rare in our facility but our staff is tops."
I'm not comfortable blaming any staff for not "managing patient behavior" well enough to decrease aggression. Connecting and communicating with a psych patient is a fine art and not something you can just take a class on. The risk of violence is always there.
I had a very good Mentor who described what psych nurses do as mental chess in that you have to be thinking three or more reactions ahead to determin which moves to make in response toescalation. the escalation might take. Sometimes an aggressive patient becomes focused on a particular staff, In such situations the staff should be moved to a different unit or administrative duties.
Having worked with violent criminals who have psychiatric disorders, I would say that staff have been pressing charges against these patients who commit bodily injury in the workplace. When a patient has multiple charges, it is easier to get them discharged to corrections.
hppygr8ful, ASN, RN, EMT-I
4 Articles; 5,211 Posts
I agree that sometimes behavior cannot be anticipated - and the staff is not to blame if they haven't been properly trained or are not properly supported by administration.So what I said was not meant to "blame" anyone but rather to empower nurses and staff to demand better training. I was actually injured about 12 years ago when I was punched in the face. It was however entirely my fault that it happened. As I was frustrated with a pretty borderline patient and in trying to make a point I pointed my finger at him. Next thing I knew I was on the floor with little tweety birds flying around my head. I had no time to react in any way and I acted inappropriately with that patient. I actually left psych nursing for about a year because the incident shook me so badly. I did go back and to the same facility because I love psych nursing and psych patients.
We are a 110 bed free standing acute facility. Some of our patients come from ER's but most are PD drop offs and our contract with the county states we cannot refuse a police drop off. So we get all kinds as well. In California the law is moving away from putting patients in 5 points - we are currently doing physical hold for as long as it takes which can be up to two hours in some cases. We also have closed circuit video so every behavior and take down is filmed and staff actions scrutinized by our "risk management team" What we found from examining the evidence and doing evidence based research is that most (not all) negative behavior at least in our facility resulted from staff inattention and/or poor staff leadership on the part of the charge nurse. I am 56 years old and can drop at 6 foot 200 lb man like a bad habit. I do go to the gym often and spar with my son who is a black belt in mixed martial arts. Mostly I am just really fast on my feet.
Med/Psych and gero/psych can be different as you can not use reason with a person suffering from dementia and the medically frail or person on drugs will react differently. We went from 10 to 20 Seclusion and restraint episodes a month to 1-2 and we cannot give a patient an IM unless we have first offered the medication by mouth. No standing PRNs for emergency meds - we have to call the physician each and every time so you can bet we are out talking to our patients finding out how we can meet their needs and what methods work for each patient.
All behavior cannot be prevented but if you have staff and patients being continually injured your facility is doing something wrong. It is that simple.
I have had some very aggressive patients on my unit which is primarily very acute adolescents. It is a mixed gender unit and quite frankly girls scare me more than boys. I have worked adults, gero, detox, intake and I have gone out into the community as part of my job to assess individuals sitting in ERs, nursing homes and psych holding facilities, high school and college campuses. I am currently getting training to be a crises intervention negotiator with our local law enforcement so that we can help our law enforcement learn better ways to handle psych patients in the field.
We do an actual post conference/debriefing after every incident to discuss what we all thought contributed to the behavior, what we could have done differently as well as what everyone did that was effective. And all of our team has to leave their ego by the door and be open to constructive criticism.
In my humble opinion CPI is useless - if you are not using advanced MAB you are going to have problems. It is not the fault of staff if they haven't had proper training. If I felt that I was not fully supported and did not have the training I needed to maintain unit safety I would walk out immediately.
I am sort of all over the place with this and I truly feel that every nurse, floor staff, therapist, physician, house keeper and maintenance person who comes on the unit needs to have this training. If you are not getting it demand it. Once a particular patient is identified as having a potential for violence the staff needs to discuss in advance how emergencies are going to be handled.
What I get from reading these forums is that in most facilities it seems as if the nurses and behavioral staff don't get the training and support they need to do their job safely and effectively. It's a shame because we as the people in charge of unit safety need to be given the tools and training to do our job.
So I am sorry if I made it sound like I was blaming staff. It was not my intention. I want everyone to have the experience in team building that I have been a part of. that way we can stay safe and deliver high quality trauma informed care to our patients and go home whole and healthy each and every day.
Hppy