Is this really what psych nursing is like?

[Nickytoto]

I've just had two week of hospital clinical experience at a subacute mental health ward (shizophrenic, depressed, BAD, drug-induced psychosis patients etc). Prior to my experience, all the mental health education I had was a three hour tutorial class, which primary discussed mental state examination and the class asessment. We didn't cover communication in class, but I wasn't too concerned because I figured it would be like my children's nursing prac where I would see lots of interactions between clients and staff.

For the entire two weeks I barely saw the staff interacting with the patients... The main interaction seemed to come when it was time for meds. It seemed like everytime somebody was upset, nurses dished out the diazepam (Valium) and other PRN meds like it was lollies. At lunchtime there would be no RNs on the floor, both RNs took their break at the same time so I would get labile, anxious or delusional pts asking for their meds. As I hadn't seen anybody de-escalating the patients before I had no idea what to do and the patients would just get worse and worse until the RNs got to the floor. I found that time always made me feel frustrated, as I felt like I couldn't do anything. I've discussed this with my facilitator and she admitted this wasn't the best facility to have students. I'm concerned about working in mental health later to find the same sort of situation.

I guess I could just be an idealist, but I had hoped meds would be a last resort and that there would be more talking to create a therapeutic environment. Is this what psych nursing is really like at most hospitals?

[medsurgrnco, BSN, RN]

Each facility and each nurse is likely to be different. I try to de-escalate patients rather than resort to meds.

[Jules A, MSN]

I did three psych rotations between LPN and RN school and my first one was like you described. I was so disappointed because I had really thought that Psych was an area I might want to work in but after that dismal experience I kind of shelved it.

Fortunately my 2nd and 3rd clinicals were wonderful and renewed my interest. Make no mistake, medications are a huge part of what I do. Therapeutic communication and de-escalation techniques are only so effective, imo and very often a combination of the three work best. It depends on the individual patient also. I have a couple of kids that I know from past experience will de-escalate in the quiet room with someone talking to them but without a PRN also will go off within the next hour often with more severity putting themselves, their peers and staff at serious risk. If you are interested in psych why don't you arange some share time at facilities with a good reputation in your area? Good luck.

[Thunderwolf, MSN, RN]

for the entire two weeks i barely saw the staff interacting with the patients... the main interaction seemed to come when it was time for meds.

this is indeed a very sad use of milieu on a psych unit. staff really need to be making frequent rounds "among" the patients. med rounds really need to be viewed as just "another activity" of the day...not the activity for staff to interact with them. how depressing.

think of it this way too.

by engaging patients frequently on the unit, you are better able to assess patient needs and address them. you also become better attuned to your patients and keep the environment safer, evaluating when that deescalation needs to happen now, way before it snowballs into something bigger requiring a code with all hands on deck.

yes, if the milieu is such where all the nurses sit behind the desk away from the patients most of the time and only interact when passing meds, it is a poor use of the therapeutic milieu...and a poor use of psychiatric nursing.

psychiatric nursing is not just passing meds (although you do have to be knowledgeable of the meds you pass).

psychiatric nursing is in engaging patients.

a monkey can sit behind a desk or pass out pills.

a true psychiatric nurse does much more than that.

[jjjoy, LPN]

Psychiatric nursing is NOT med passing. Psychiatric nursing is in engaging patients.

I'd agree. But to be a devil's advocate... what about facilities that DO consider psychiatric nursing as just more or less med passing? That is, staffing, job description, and general expectations are such that it's clear that the nurses are there for medical concerns and that's about it? In other words, psych nursing doesn't have to be only med passing, but in some situations, it might be just that? Of course, even in med passing, the nurse ought to be assessing the patients and not just handing out meds without consideration, so they might hold a med or contact a physician about a change in status. Would you consider this a legitimate psych nursing role? We as nurses can choose to avoid this type of job but can we as a profession keep organizations from limiting a nurse's job description to the bare minimum of med passing?

[Thunderwolf, MSN, RN]

i'd agree. but to be a devil's advocate... what about facilities that do consider psychiatric nursing as just more or less med passing? that is, staffing, job description, and general expectations are such that it's clear that the nurses are there for medical concerns and that's about it? in other words, psych nursing doesn't have to be only med passing, but in some situations, it might be just that?

i understand the point you are making...if a facility limits a nurse to meds and no more. to be honest, these type of facilities rarely exist. most facilities do expect interaction with patients....some expect the minimal, some expect a lot more...a whole lot more. and, this is not unreasonable to expect this.

of course, even in med passing, the nurse ought to be assessing the patients and not just handing out meds without consideration, so they might hold a med or contact a physician about a change in status. would you consider this a legitimate psych nursing role?

yes, very legit. this is one reason i do not believe in med techs passing out pills. the passer of the meds needs to know when to give a med and when to hold...and when to call the doc. it is part of our skills in nursing assessment. it is part of our education. it is a professional expectation as a psychiatric nurse.

we as nurses can choose to avoid this type of job but can we as a profession keep organizations from limiting a nurse's job description to the bare minimum of med passing?

yes, by not becoming couch potatoes behind the desk...and for advocating for the better use of our skills.

also...in many ways, nursing is part social worker, part case management, part counselor, part medical (labs, meds, assessments), and part educator (meds and illness education). but, no way are we limited to meds...unless we limit ourselves to it.

in many ways, it is the nurse's personal choice, not the facility.

[aloevera]

At our facility we RN's do not even do the med pass...we take time each shift to assess and talk with our patients. We lead groups with them, we talk with them during their treatment team meeting (along with psychiatrist and therapist) we are available for our patients and only "sit at the desk" when charting.

[missjennmb]

At our facility we RN's do not even do the med pass...we take time each shift to assess and talk with our patients. We lead groups with them, we talk with them during their treatment team meeting (along with psychiatrist and therapist) we are available for our patients and only "sit at the desk" when charting.

that sounds like such a rewarding place to work :)

[wonderbee, BSN, RN]

Alovera, it does sound like a rewarding place to work. Our facility used to use RNs in the milieu and LPNs gave the meds until someone found it more cost effective to replace the RNs with milieu therapists, many of whom had no or little training in psychiatric situations previously. The RNs replaced the LPNs in the med room. Now our RNs interact with the patients only when it is time for meds or deescelation/PRN meds are needed. Yep, we're the ones who sit in the room behind the glass most of the day.

[jjjoy, LPN]

Thanks for sharing your experience RNKittykat. It does seem like some places work that way. That's a shame for nurses who would prefer to more involved with the patients.

I can see where employing a minimally trained milieu therapist would be of concern. I imagine too many facilities use underqualified staff.

However, with proper training, I'd imagine a non-nurse could provide an effective quality of therapeutic interaction for otherwise medically stable psych patients. It's not as if RNs get all that much training in the specific skills for working in a therapeutic milieu. One term of coursework and clinical would be what most students will have had exposure to in nursing school in addition perhaps to a pre-req psych and/or abnormal psych course. The rest will be learned on the job and isn't really related to the rest of world of clinical nursing. Someone with an AA or BA psych degree would seem like just as good a candidate to work as a milieu therapist as an RN. What do you think?

It would seem to me that the main reason RNs were originally used in the milieu is that it was cost effective since the facilities already had to have licensed nurses on board. Why hire more staff for milieu therapy when the nurses were already paid to be there and could be trained to fill this role? But with licensed nurses demanding higher wages, it now might seem more cost effective to limit the nurses' role to medical issues and hire specific milieu therapists. Just thoughts! I only have minimal first-hand exposure to this specialty.

[insatiable]

I can see where employing a minimally trained milieu therapist would be of concern. I imagine too many facilities use underqualified staff.

However, with proper training, I'd imagine a non-nurse could provide an effective quality of therapeutic interaction for otherwise medically stable psych patients. It's not as if RNs get all that much training in the specific skills for working in a therapeutic milieu. One term of coursework and clinical would be what most students will have had exposure to in nursing school in addition perhaps to a pre-req psych and/or abnormal psych course. The rest will be learned on the job and isn't really related to the rest of world of clinical nursing. Someone with an AA or BA psych degree would seem like just as good a candidate to work as a milieu therapist as an RN. What do you think?quote]

Thank you for your opinion and understanding that non-nurses can provide care to psych patients. Personally many of these posts regarding non-nurses providing less adequate therapuetic treatment to patients is disturbing to me. I have a BS in Psych and an M.Ed in Counseling so I work with people with mental illness everyday. Although I have an advanced degree I still feel the training I recieved at the BS level would have outweighed any mental health training/therapuetic interventions a RN recieves. I am currently looking in MSN programs for psych and I hope the attitudes Im seeing here regarding RN's being more qualified to handle psych patients is not the same across the board of psych nursing. I think it would be difficult for me working in an atmosphere like that coming from a background with a lot of training in psychotherapy.

I realize that every person and every hospital is different. I also know that maybe some RN's are more qualified than other mental health professionals and vice versa, but as a general rule I dont like seeing nurses bringing down other professionals...we are all here for the same purpose...to help people.

[medsurgrnco, BSN, RN]

Insatiable, I think your comments and concerns are valid. My guess is that many psych nurses feel frustrated that the therapy part is passed off to other professionals (with or without reasonable qualifications for the role) while the nurses are busy with the meds, assessments, admissions, etc. I think psych nurses should have more training in therapy with psych patients and also have the time to provide more therapeutic interactions with patients.