Milieu Disruptive Behavior

arbasham3363 · Jun 30, 2015

That sounds like an excellent tool for my unit. Those are all things I have talked to my regular staff about. How would you deal with the staff being inconsistent with following plans or straight out ignoring what you tell them? I go to my supervisor and she just shakes her head.

TCASII, ADN · Jul 9, 2015

Here's the problem with nursing today...saying no results in behavioral issues. Setting limits increases the risk of assault and problems. Saying no and setting limits is viewed as demeaning to the patients and "picking a fight". When calling an NP or MD for orders, you often hear "You have to pick your battles, so just give them the Oxy early". Oh ok. Or when saying no results in an escalation and subsequent IM, the doctor will insist that you give PO meds, usually nothing the patient will take, and a serious reluctance to order IMs. Management are so anti-seclusion/forced meds that they do not want problems. Doctors are paranoid for a variety of reasons, so you are on your own with no real back up. That is psych, at least in AZ.

arbasham3363 · Jul 9, 2015

We do pick our battles every day. Most things aren't worth fighting and arguing about. But when a patient is clearly getting other patients upset and you have a potentially dangerous situation on your hands, something has to be done. Also when the patient has "friends" on the outside who call nurses and threaten them because the patient didn't get what she wanted, there has to be boundaries. I believe that saying no and setting boundaries is essential because that's what "real life" is all about. If they can't handle being told no, they can't have their Oxy early and have a behavior then that is on them and they should have a natural consequence for their actions. Our Docs are pretty good about putting PRN IMs out there for nurses to use at their discretion. Nurses here make the decision to give IMs or put patients in restrains/seclusion then notify the Doc after it's done.

TCASII, ADN · Jul 10, 2015

I agree. I set limits as much as I can. If someone uses the phone as a disruptive tool, then phone time is eliminated. As I said, unfortunately, my experience working in 5 major facilities is that the administration and/or MDs don't back up nurses at all.

pigginsrn · Mar 14, 2016

I'm so.

elkpark · Mar 14, 2016

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.

What do you mean by you're "not allowed" to press charges?

JustKeepDriving · Mar 29, 2016

What do you mean by you're "not allowed" to press charges?

This is the hard part about working in state hospitals. In any other type of psychiatric setting we could very much press charges and even get patient's administratively discharged if they posed too much of a risk to the staff.

When you're working with people who have already been found "Guilty with the Exception of Insanity" the legal system has already said that due to their mental illness they are basically not responsible for their criminal actions because they are so mentally ill that they are not in control of their behavior.

We were allowed to press charges but often did not and are discouraged from doing so. Administration does this whole thing of "You understand when coming here that this is a high risk work environment" and the detective that worked state hospital cases would basically say, "Dude is nuts, yeah your staff got stabbed in the face but charging him would just get him more time... in the state hospital".

It's really a no-win situation pressing charges. It's like charging criminals that are already in prison - okay, you assaulted an officer, now you're going to spend more time in prison probably assaulting more officers. Many of these patients in state hospitals have like 20+ years of time they have to carry out being monitored due to their crimes (every state does this differently though) - giving a patient an additional 10 years is often not worth the effort of pressing charges.

Throughout my career we've only moved 1 patient out of the state hospital and to corrections for an assault on staff. Historically, I think we've only managed to do that with 2 other patients. Two of them will end up coming back to the state when they finish up their time in corrections because a state hospital sentence is always longer than a corrections sentence because of how the crimes are tallied - so they might do 5 years corrections for assaulting a staff, but they'll come back to finish their 20 years at the state hospital for attempted murder.

Only one of the patient's we successfully moved out of the hospital is not allowed back but that has caused it's own problem because basically right now the state hospital is saying, "This guy is Malingering and Just a donkey" and corrections is saying "He's a psych patient not our problem"... due to the nature of his crimes (bad) I'm unsure of what the state is doing with him.

elkpark · Mar 29, 2016

This is the hard part about working in state hospitals. In any other type of psychiatric setting we could very much press charges and even get patient's administratively discharged if they posed too much of a risk to the staff.
When you're working with people who have already been found "Guilty with the Exception of Insanity" the legal system has already said that due to their mental illness they are basically not responsible for their criminal actions because they are so mentally ill that they are not in control of their behavior.
We were allowed to press charges but often did not and are discouraged from doing so. Administration does this whole thing of "You understand when coming here that this is a high risk work environment" and the detective that worked state hospital cases would basically say, "Dude is nuts, yeah your staff got stabbed in the face but charging him would just get him more time... in the state hospital".
It's really a no-win situation pressing charges. It's like charging criminals that are already in prison - okay, you assaulted an officer, now you're going to spend more time in prison probably assaulting more officers. Many of these patients in state hospitals have like 20+ years of time they have to carry out being monitored due to their crimes (every state does this differently though) - giving a patient an additional 10 years is often not worth the effort of pressing charges.
Throughout my career we've only moved 1 patient out of the state hospital and to corrections for an assault on staff. Historically, I think we've only managed to do that with 2 other patients. Two of them will end up coming back to the state when they finish up their time in corrections because a state hospital sentence is always longer than a corrections sentence because of how the crimes are tallied - so they might do 5 years corrections for assaulting a staff, but they'll come back to finish their 20 years at the state hospital for attempted murder.
Only one of the patient's we successfully moved out of the hospital is not allowed back but that has caused it's own problem because basically right now the state hospital is saying, "This guy is Malingering and Just a donkey" and corrections is saying "He's a psych patient not our problem"... due to the nature of his crimes (bad) I'm unsure of what the state is doing with him.

I understand all that. I've spent >30 yrs working in psych nursing, in all kinds of settings. Everywhere I've worked, the administration has strongly discouraged pressing charges against clients (and I've never found myself in a situation in which I thought it would be appropriate), but I was just questioning the OP directly about what, specifically, she meant by "not allowed" to press charges. I don't see anything in her posts about working in a forensics unit. Most clients in state hospitals are not there because they've been ruled NGRI or have committed some kind of crime.

JustKeepDriving · Mar 29, 2016

I understand all that. I've spent >30 yrs working in psych nursing, in all kinds of settings. Everywhere I've worked, the administration has strongly discouraged pressing charges against clients (and I've never found myself in a situation in which I thought it would be appropriate), but I was just questioning the OP directly about what, specifically, she meant by "not allowed" to press charges. I don't see anything in her posts about working in a forensics unit. Most clients in state hospitals are not there because they've been ruled NGRI or have committed some kind of crime.

Interesting, I actually didn't know that most were not forensic based. My state has a very small amount of civil patients - and almost all of them were forensic's patients prior to becoming civil (Sentence timed out and they were deemed such a risk to themselves or others that we had to civilly commit them).

TXMedPsych, BSN, RN · Apr 2, 2016

Interesting about the Illinois law. Texas passed such laws regarding ER nurses (and other non-nursing emergency personnel.) Psych nurses have not yet been included because there is a contingent that thinks since the behavior is symptomatic patients shouldn't be charged.

elkpark · Apr 2, 2016

Interesting, I actually didn't know that most were not forensic based. My state has a very small amount of civil patients - and almost all of them were forensic's patients prior to becoming civil (Sentence timed out and they were deemed such a risk to themselves or others that we had to civilly commit them).

In my experience in a few different states, most of the clients in state hospitals are the same as clients in community hospital psychiatric units; they have an acute psychiatric problem (or acute exacerbation of a chronic problem) for which they are admitted, and they are going to be returning home to their community when the acute problem is resolved. They only reason they are in the state hospital instead of a community hospital psychiatric unit is because they don't have insurance or their behavior is such that the community hospitals (which have the luxury of "cherry picking" admission) don't want to take them. Then there is a small population of long-term clients who are sufficiently impaired to be unable to function or be safe out in the community and are probably there forever, but, again, not because they committed a crime and have been found NGRI (or whatever the acronym is in various states). Then, there are one or more forensics units within a state that house the population you're talking about.

Of course, other states may have other systems.