Milieu Disruptive Behavior

Davey Do · Jun 27, 2015

Can anyone give me examples of milieu disruptive behavior that you have experienced?

Gee, first I want to extend my empathy to you, arbasham. Physical aggression is an intensely traumatic experience.

And your axis II Patient ratio nears the "Unbearable Level"!

Back in'98, I was stabbed by a Patient diagnosed with Undifferentiated Schizophrenia with a pair of scissors. That Patient spent over 2 years in a Forensic Facility.

In Illinois, since 2008, it's a Felony for a Patient to physically assault a Nurse. The way physical assaults have been dealt with in the facility where I work spans the entire spectrum. Sometimes nothing is done, sometimes the Patient is arrested upon discharge, and other times the Police have arrested the Patient on the spot.

It all varies according to the specific circumstances.

The very best to you in dealing with this matter, arbasham.

Please take good care of yourself.

Jules A, MSN · Jun 27, 2015

If a patient is psychotic I am normally not in favor of pressing charges although there are some times when I have seen it happen with the intention to allow them to qualify for increased services. However if a patient with personality disorder assaulted me I absolutely would press charges. It might actually set a precedence and make an impression on the rest of them also. I know how hard it is to rein in cluster b behaviors especially when there is a large number of them but the fact that your staff got sucked into this is both disturbing and makes me wonder if boundaries are out of control on your unit. Best of luck to you.

arbasham3363 · Jun 28, 2015

I absolutely agree that the boundaries are out of control on my unit. It seems to be an issue with the system. I have educated and trained my staff ad nauseam on personality disorders and appropriate boundaries. One problem is that 4 out of the 5 staff are very young (2 aren't even old enough to drink) and have absolutely no experience in healthcare. Another problem is that I have little support from administration as far as disciplinary actions for staff or even plans of improvement for that matter. In fact, when this incident happened there were two staff standing outside the door watching me get hit. A 65 year old nurse had to push past them to try to help me. No one received any additional training or discipline for doing that. Am I fighting a losing battle because that's how I feel. It also doesn't help that the unit physician gives in to the patient because he feels like he's being too hard on her. She is dangerous to others as well as to herself (she recently broke a fluorescent light bulb in her room and cut her leg and wrist in three places almost down to the bone). I'm pretty much at my wits end not knowing what to do.

Davey Do · Jun 28, 2015

The way physical assaults have been dealt with in the facility where I work spans the entire spectrum. Sometimes nothing is done, sometimes the Patient is arrested upon discharge, and other times the Police have arrested the Patient on the spot.
It all varies according to the specific circumstances.

However if a patient with personality disorder assaulted me I absolutely would press charges.

I'm pretty much at my wits end not knowing what to do.

What do you think of these suggestions, arbasham?

Meriwhen, ASN, BSN, MSN, RN · Jun 28, 2015

IMO, you need more experienced staff in there. The Axis IIs are taking over because the staff is ill-prepared to handle them. Axis IIs are difficult for nurses inexperienced in psych to handle because a lot of them don't understand how Axis II works. Personality disorders are not like psychosis that can be managed with medications--instead, personality disorders are how a person is wired. No medication in the world can change that wiring; the patient themselves needs to learn how to deal with it. Plus, all non-psych-experienced nurses tend to label any and all personality disorders as being Bordeline Personality Disorder and treat it as such, which doesn't always work especially if the patient doesn't have BPD.

Axis II can be trying to even experienced psych nurses who have dealt with them for years, so to expect a bunch of newbies--both in psych and in healthcare--to successfully deal with them is just short of asking for a miracle. You need staff more experienced in psych, whether you hire them or train the ones you currently have.

arbasham3363 · Jun 28, 2015

Meriwhen, I agree with you 100%. The bad thing is I have absolutely no control over what staff I get. The two women's units have the worst reputation in the facility and no one wants to work there. So we get all the new hires until spots open on other units and they can transfer. On my unit we have one RN (me), one LPN (sometimes) and 3-5 psychiatric attendants. I have weekly staff meetings to address issues that come up and I use that time to do training on personality disorders as well as other diagnoses. I myself have a lot of experience (15 years) with intellectually challenged patients but not nearly enough with patients with mental illness and especially personality disorders (about 2 years). I am constantly looking for guidance from the nursing supervisors but they seem to be as lost as I am. That's why I was hoping more experienced nurses on here might be able to give me some advice or support that would help me.

JustKeepDriving · Jun 28, 2015

I spent most of my career as a charge on the maximum security forensic psychiatric intensive care unit at a state hospital. We were suppose to be a male/female GEI (Guilty with the exception of insanity) admission and stabilization unit but due to decisions by the administration basically became the "Unit for patients that no other unit can deal with". To say the least there were A LOT of Axis II's. I got extremely lucky because I had both amazing management and staff - and a lot of autonomy.

It sounds like your unit is under-trained, not a team, understaffed and they're placing people totally unsuited for this area of nursing. State hospitals are very high acuity and these patients are ALWAYS an imminent risk to themselves and others which has required them to be placed in such a facility. You need people that have strong boundaries, that are consistent and professionals at saying "no".

We had a lot of float staff and new staff on our unit because we were staff based on acuity. I had 13 tech's, sometimes an LPN, sometimes another RN and me. Constants would increase my base number. At one time we had so many constants our unit base was 20. Which meant we had more float/not regular staff (which could come from anywhere... transition units, Gero units, Community unit ect) than regular staff and many of them were not use to working with patients with our level of acuity. Management, the treatment team, the nurses and regular staff came together and decided to create behavioral support plans - often times with the patient to identify precursors to assault, what causes the patient to escalate and what works best for deescalation - in order to create consistency and maintain safety. It was required that everyone carry out care of these patients consistent to the behavior support plan.

A made up example would be like: Patient is a 21 year old male sex offender with a diagnosis of borderline personality disorder with antisocial traits admitted from white county. While at the hospital this patient has had frequent brutal assaults against both staff and peers. Patient is highly unpredictable and staff working with this patient need to remain a safe distance and must maintain consistency with his treatment care plan. In order to cut down on the frequency of assaults, precursor behaviors have been identified so that staff can intervene early. These include:

Perseverating about food,
antagonizing peers,
opening door to his room and making intense eye contact with a singular staff member,
pounding on walls,
yelling out in the milieu and
verbally threatening staff and peers.

Patient has identified that he gets frustrated when staff tell him "no" or when he feels like staff members don't care about him. Intervention that Patient has identified as being helpful include:

having staff talk to him and validate
Doing a behavior chain analysis
talking to his psychologist/Mental health specialist
Having behavioral incentives

Current level of precautions: Patient has been placed on a 2:1 visual behavioral precaution.

Special Instructions: Staff assigned to this patient are unobtrusively observe patient and remain ready to provide interventions when patient is escalating and go hands on in the event patient becomes an imminent risk to himself or others. When patient goes into seclusion, due to his level of self harm he is to have only 1 pair of clothes and nothing with buttons or zippers as he has a history of self harming with these items.

Now we would have documentation of patient's precursor behaviors to assault. When patient began displaying these behaviors we would utilize the interventions immediately. If patient wasn't engaging staff in these interventions and continued the behavior they would now be an imminent risk to staff safety and require more restrictive measures. We would then place the patient in seclusion until they are able to contract for safety.

A real example of how this worked: We had long term documentation showing that a patient would attack staff or peers whenever he would ask for the time. He would come by once, twice and the third time would assault. So the first time he would ask I'd have staff offer him a PRN. The second time we would redirect him to a quiet area. If he came by the third time we would hands on escort him to seclusion. Having the behavior support plans (typed out, in a binder with all staff required to read and sign off that they read them day 1 on the unit) massively cut down on assaults.

I would tell people, "If the patient asks you for something and you don't know if they can have it - tell them that you need to ask the nurse or more experienced staff. If you have any questions about what you're doing - talk to a nurse or more experienced staff. I'm not trying to scare you but the patient's on this unit have seriously hurt people and making bad decisions on this unit can cause you or other staff members to be injured." It generally worked pretty well.

Graduatenurse14 · Jun 29, 2015

I spent most of my career as a charge on the maximum security forensic psychiatric intensive care unit at a state hospital. We were suppose to be a male/female GEI (Guilty with the exception of insanity) admission and stabilization unit but due to decisions by the administration basically became the "Unit for patients that no other unit can deal with". To say the least there were A LOT of Axis II's. I got extremely lucky because I had both amazing management and staff - and a lot of autonomy.
It sounds like your unit is under-trained, not a team, understaffed and they're placing people totally unsuited for this area of nursing. State hospitals are very high acuity and these patients are ALWAYS an imminent risk to themselves and others which has required them to be placed in such a facility. You need people that have strong boundaries, that are consistent and professionals at saying "no".
We had a lot of float staff and new staff on our unit because we were staff based on acuity. I had 13 tech's, sometimes an LPN, sometimes another RN and me. Constants would increase my base number. At one time we had so many constants our unit base was 20. Which meant we had more float/not regular staff (which could come from anywhere... transition units, Gero units, Community unit ect) than regular staff and many of them were not use to working with patients with our level of acuity. Management, the treatment team, the nurses and regular staff came together and decided to create behavioral support plans - often times with the patient to identify precursors to assault, what causes the patient to escalate and what works best for deescalation - in order to create consistency and maintain safety. It was required that everyone carry out care of these patients consistent to the behavior support plan.
A made up example would be like: Patient is a 21 year old male sex offender with a diagnosis of borderline personality disorder with antisocial traits admitted from white county. While at the hospital this patient has had frequent brutal assaults against both staff and peers. Patient is highly unpredictable and staff working with this patient need to remain a safe distance and must maintain consistency with his treatment care plan. In order to cut down on the frequency of assaults, precursor behaviors have been identified so that staff can intervene early. These include:
Perseverating about food,

antagonizing peers,
opening door to his room and making intense eye contact with a singular staff member,

pounding on walls,

yelling out in the milieu and

verbally threatening staff and peers.

Patient has identified that he gets frustrated when staff tell him "no" or when he feels like staff members don't care about him. Intervention that Patient has identified as being helpful include:
having staff talk to him and validate

Doing a behavior chain analysis

talking to his psychologist/Mental health specialist

Having behavioral incentives

Current level of precautions: Patient has been placed on a 2:1 visual behavioral precaution.

Special Instructions: Staff assigned to this patient are unobtrusively observe patient and remain ready to provide interventions when patient is escalating and go hands on in the event patient becomes an imminent risk to himself or others. When patient goes into seclusion, due to his level of self harm he is to have only 1 pair of clothes and nothing with buttons or zippers as he has a history of self harming with these items.
Now we would have documentation of patient's precursor behaviors to assault. When patient began displaying these behaviors we would utilize the interventions immediately. If patient wasn't engaging staff in these interventions and continued the behavior they would now be an imminent risk to staff safety and require more restrictive measures. We would then place the patient in seclusion until they are able to contract for safety.
A real example of how this worked: We had long term documentation showing that a patient would attack staff or peers whenever he would ask for the time. He would come by once, twice and the third time would assault. So the first time he would ask I'd have staff offer him a PRN. The second time we would redirect him to a quiet area. If he came by the third time we would hands on escort him to seclusion. Having the behavior support plans (typed out, in a binder with all staff required to read and sign off that they read them day 1 on the unit) massively cut down on assaults.
I would tell people, "If the patient asks you for something and you don't know if they can have it - tell them that you need to ask the nurse or more experienced staff. If you have any questions about what you're doing - talk to a nurse or more experienced staff. I'm not trying to scare you but the patient's on this unit have seriously hurt people and making bad decisions on this unit can cause you or other staff members to be injured." It generally worked pretty well.

I worked as a milieu therapist in a child and adolescent psychiatric hospital while in nursing school. This example of a behavioral support plan is excellent. I wish we had had something like this for some of our patients when I worked at that hospital.

arbasham3363 · Jun 29, 2015

Are these behavior support plans something that are in addition to treatment plans? Our treatment plans have "problem", "goal" and "intervention" sections to them. They describe the problem, what the patient's goal is from treatment for that particular problem and the intervention needed to assist them with that goal. All staff have to read and sign off on treatment plans and I do regular trainings on these. Staff still seem to have difficulty following them however. Perhaps if they were involved with coming up with a behavior support plan they may be more apt to engage.

arbasham3363 · Jun 29, 2015

I'm not clear on what suggestions have been made here. I have no control over the legality of what happened. We are not allowed to press charges on patients.

JustKeepDriving · Jun 29, 2015

We had regular treatment plans that were the same. The treatment team and a nurse would sit with the patient and come up with Problem, goal and intervention. Generally the goal was to transfer to a less restrictive environment, enhance medication compliance, work on coping skills, get more privileges and eventually reenter the community. The staff had to know these too - but many were 10+ pages long and knowing all of them for 20 - 25 patients with the amount of new staff or float staff we had to run with - it just wasn't feasible.

The behavior support plans were different than the treatment care plan. Not every patient had one - just those that with high assault or self harm potential or significant disruptive behaviors. The behavior support plans covered the basics on how to work with these patient's safely. Basically there was a short description of the problem "Patient has frequent assaults, significant self harm behavior, is sexually aggressive with staff and peers ect", what behaviors to look for when the patient is becoming an imminent risk to themselves or others (Body language, verbal and non verbal behaviors, patterns that have been observed and documented by the staff), interventions that have worked to successfully deescalate the patient (PRN, Counseling, Problem solving, Limit setting, diversionary activities, DBT worksheets, quiet space ect.) and what to do if the patient is not redirecting (generally it's a 3 intervention deal- sometimes less depending on the potential for unsafe behavior - and if the patient isn't redirecting then we have to become restrictive in order to prevent staff or patient injury).

We would also include vital information on documented behaviors (like only allowing one layer of clothes with no buttons in the seclusion room, or that staff sitting on the 2:1 constant had to watch unobtrusively and not talk to the borderline patients and so on).

The plans were created in meetings with nursing and senior floor staff (since it was our assessments and their observations that were used for identifying precursors and interventions that have been successful). My staff's input was invaluable to the creation of these and they took a lot of responsibility in carrying them out and ensuring that newer and float staff provided continuity and worked safely with these patients.