Especially in a crisis unit, there comes a time when a patient is being a danger to themselves or others, and the need for restraint is necessary. For a psychotic person, I will typically say something like "I am going to put you in restraints right now to keep everyone safe and help you stay in control until the medicine starts working." Is this appropriate?
Now, for someone who is more aware of their actions, say, a behavioral group home adolescent or a medication seeker or personality disordered patient, how do you set limits and expectations without directly threatening them? It would not be therapeutic nor appropriate (or, I'm guessing, legal) to storm in the room with security and scream "STOP THIS NONSENSE RIGHT NOW OR I'M PUTTING YOU IN RESTRAINTS" ... so, how would I say it?
Always looking for ways to improve my communication skills so any input is appreciated!
I've always described psychiatric nursing to my orientees and students as a massive game of chess between patient rights and unit safety. Patient's have the right to be obnoxious however both staff and patients have the right to feel safe on the unit. As the psychiatric nurse it is through our assessments and the observations from our staff that determines... "Is this person just being obnoxious... or this person is escalating and will become an imminent risk to themselves and others." Our assessments are more than just an assessment of the individual, but an assessment of the environment, our staff resources, and the other patient's on the milieu/milieu acuity as well. Sometimes an assessment will reveal, "yeah, this patient is being very obnoxious but we just have to deal with it", while the same behavior at other times will reveal, "This patient is acutely disrupting the milieu and the body language/verbal content of his peers is telling me that he is becoming an imminent risk to himself and might end up getting assaulted for this behavior."
Each patient is individual and different interventions work differently for different patients. Patients that have been there for a while are always easier to work with than those that are new because we have lots of documentation about their precursors to assault/self harm, multiple assessments displaying what to look for when assessing their aggression and self harm potential and identified staff members that have built rapport with them. New admits or short term stabilization patients are always more difficult because we know very little about their behavior and the staff hasn't built rapport with them.
Generally I start off by giving people the most amount of options possible, "It's okay to be upset... but you can't do this here. How can we help your coping skills right now so that you can continue the positive progress you've been making." If the escalation continues I narrow the choices available to them until I've either exhausted all the options available to me (Diversionary activities, PRN medication, Counseling/limit setting/problem solving, patient identified coping skills in their treatment care plan, offering patient quiet space) or the patient has escalated so much that they now Imminent Risk... and then it becomes, "We are here to provide a safe and therapeutic environment for all patients. Right now you are showing me that you're unable to follow staff directions and maintain safety on the milieu. Unless there is anything more we can do for you, I need you to walk with me to the side room (which is our term for seclusion), or we can escort you there" (which is generally done with a show of force with enough staff available in the event the patient makes the worst possible choice).
I go with the rule of thumb "least restrictive measures" so the last option is always the choice between entering seclusion safely or them becoming combative, leaving hands on as the only option and the patient entering restraints. Generally, I explain this as, "Show me you can go to the side room safely. Do not make any verbal or physical threats or we will have to go hands on and take more restrictive measures."
"I want you to understand that, if you aren't able to pull things together and change the path you're on right now, you're likely to end up in restraints. I don't want that to happen, and I want us to work together to figure out a way to keep that from happening."
Also, when a person is being obnoxious or is escalating, it is usually too late to tell them about the restraints in a way that they will receive the communication therapeutically.
It is best to make this known very early. When I've done geri-psych or worked with sundowners who are fairly lucid during the day, I have had "the talk" with them at the beginning of the shift.
"I know that sometimes it is hard for you to act in a way that is safe to us and yourself, so we have the option of restricting your movements until you are able to be safe again. It is only temporary and once everyone is safe the restrictions will be lifted."
Your totally correct I think, I use similar methods when dealing with acute patients on my units. I think its helpful and fair to be frank and honest with the patients, but never threatening. R+S is used when you have exhausted other methods.
Sometimes is literally is necessary to ensure safety, whether its a violent/paranoid patient trying to assault or a suicidal or self harming individual who will not/is unable to CFS. Some patients will push staff to the brink of R+S and then say, "im allright," but 10 minutes later start all over again. As an RN you need to assess 'whats really going on here?' or 'are they actually capable to being safe, do they even know how to calm down/be safe?' because often times the patients simply do not possess that skill.
The important thing and most difficult is learning when to draw the line and when it is truly necessary to initiate.
JustKeepDriving
119 Posts
I've always described psychiatric nursing to my orientees and students as a massive game of chess between patient rights and unit safety. Patient's have the right to be obnoxious however both staff and patients have the right to feel safe on the unit. As the psychiatric nurse it is through our assessments and the observations from our staff that determines... "Is this person just being obnoxious... or this person is escalating and will become an imminent risk to themselves and others." Our assessments are more than just an assessment of the individual, but an assessment of the environment, our staff resources, and the other patient's on the milieu/milieu acuity as well. Sometimes an assessment will reveal, "yeah, this patient is being very obnoxious but we just have to deal with it", while the same behavior at other times will reveal, "This patient is acutely disrupting the milieu and the body language/verbal content of his peers is telling me that he is becoming an imminent risk to himself and might end up getting assaulted for this behavior."
Each patient is individual and different interventions work differently for different patients. Patients that have been there for a while are always easier to work with than those that are new because we have lots of documentation about their precursors to assault/self harm, multiple assessments displaying what to look for when assessing their aggression and self harm potential and identified staff members that have built rapport with them. New admits or short term stabilization patients are always more difficult because we know very little about their behavior and the staff hasn't built rapport with them.
Generally I start off by giving people the most amount of options possible, "It's okay to be upset... but you can't do this here. How can we help your coping skills right now so that you can continue the positive progress you've been making." If the escalation continues I narrow the choices available to them until I've either exhausted all the options available to me (Diversionary activities, PRN medication, Counseling/limit setting/problem solving, patient identified coping skills in their treatment care plan, offering patient quiet space) or the patient has escalated so much that they now Imminent Risk... and then it becomes, "We are here to provide a safe and therapeutic environment for all patients. Right now you are showing me that you're unable to follow staff directions and maintain safety on the milieu. Unless there is anything more we can do for you, I need you to walk with me to the side room (which is our term for seclusion), or we can escort you there" (which is generally done with a show of force with enough staff available in the event the patient makes the worst possible choice).
I go with the rule of thumb "least restrictive measures" so the last option is always the choice between entering seclusion safely or them becoming combative, leaving hands on as the only option and the patient entering restraints. Generally, I explain this as, "Show me you can go to the side room safely. Do not make any verbal or physical threats or we will have to go hands on and take more restrictive measures."