New ED psych unit, need advice

[mule city rn]

He everybody. I'm new here and thought maybe some of you can give me some advice.

I've been a psych nurse for 26 years. I took a job at a hospital that was opening a brand new 6 bed psych holding area connected to the e.d. I was very excited to be involved in the development of a new psych unit, although it is not a treatment unit. When I was hired, they were supposedly in the process of renovating the medical rooms to make them safe for psych patients.

Unfortunately, the managers have no psych experience at all, and they are not asking any of the psych nurses what the unit needs to function effectively. A few examples of their decisions:

1. I told them during my interview that they needed to get rid of the heavy glass mirrors in each room immediately. They removed them, as soon as a psychotic patient broke one and came after me with a huge glass shard. He was stopped by a sitter with a can of pepper spray.

2. They removed all the lights in the patient rooms except the one right over the bed, including the one at the toilet. It's so dark now the patients can't see how to urinate.

3. They ordered new psych beds to replace the hospital beds. They didn't even tell us, the beds were just there one day. They didn't bother to think that the restraints used by the hospital will not work with the new beds, and when I pointed it out they were all concerned but haven't bothered to solve the problem.

Etc, etc, etc.

My biggest concern, though, is that they have stripped all our behavioral tools from us. There are no rewards for good behavior, no consequences for bad behavior. For example, we have asked that the patients be allowed to use their cell phones, i-pods and electronic games. We were told no, "because they might throw them at us." What!!!! We tried to explain the concept of privileges to entice patients to behave, but to no avail. They won't even allow the doctor to write orders to say psychotic patients can listen to i-pods to help with the voices.

There is nothing to do on this unit but lay in bed and watch tv. They keep saying it will get better when they open the dayroom, which is a joke and an incident waiting to happen just by the way it's layed out. And psychotic patients can't handle the social stimulation, which they also don't understand.

I know this is a long rant, but thanks for letting me vent. I guess my question to you guys would be, do you know of any articles about the benefits of allowing patients to use their personal electronic equipment? I really need a short article or two to show the non-psych managers how they're limiting our ability encourage good behavior. (Also, as to the cell phones, the patients are allowed 2 5-minute calls/day on the hospital phone, none after 8 pm. They have effectively cut off most communication with family members, and psych patients need all the support they can get. Our manager calls talking to the families 'over-stimulation'.) See what we're up against.

Thanks for any help.

[MickeyTong]

I know this is a long rant, but thanks for letting me vent. I guess my question to you guys would be, do you know of any articles about the benefits of allowing patients to use their personal electronic equipment? I really need a short article or two to show the non-psych managers how they're limiting our ability encourage good behavior. (Also, as to the cell phones, the patients are allowed 2 5-minute calls/day on the hospital phone, none after 8 pm. They have effectively cut off most communication with family members, and psych patients need all the support they can get. Our manager calls talking to the families 'over-stimulation'.) See what we're up against.

Thanks for any help.

I'm based on a small inpatient unit in Scotland. Anyone who is likely to be with us for more than a few days is entitled to have their own TVs, stereos, laptops, etc. All patients have their own rooms with en-suite toilet and shower. Even patients who are newly admitted can keep their cell phones and use them as much as they want.......human rights legislation applies to people with mental illness as well as the rest of us.

I take it you work in a health care facility, and not a prison?

[mule city rn]

Hi Mickey,

I work in a general hospital. In North Carolina, psych patients have to be medically cleared through an emergency room before being sent to a regular psych hospital. The problem is they often have to wait days, frequently weeks, for a bed to open. They opened this unit to give the psych patients a place to stay until they find an open bed. It's funny you asked about this being a prison. I told my superivisor they run it like one (I did forensic psych for 16 years) and needless to say I was in the dog house. Oh well...

The people in charge won't listen to those of us with psych experience. The psychiatrist here has never worked in a hospital (he has an office somewhere where he sees patients) and he's clueless as well. I don't know how much longer I'll be able to work like this.

[MickeyTong]

Hi MC

"The people in charge won't listen....." There must be an International Handbook of Health Service Management which is compulsory reading for all the world's Deputy Assistant Project Management and Long Job Title Facilitation Co-ordinators.

Sadly, these folks need to be educated, even the ones who have actually been psyche nurses (they either forget where they came from or weren't very good as nurses). I don't know of any articles specifically about electronic equipment, but there are plenty about the importance of maintaining links with family and friends.

If patients in other parts of your general hospital are allowed these things, point out that it's actually illegal to discriminate against people purely on the basis of their mental health status (it's covered by disability rights legislation here). Your bosses won't want the hospital in any legal jeopardy. If your hospital has a Diversity Rights, er....compliance facilitation manager post (we have - he's a ****, but useful), he/she may be worth getting onto your side. Are there any service user groups in the community?

Point out that you, with 16 years of forensic experience, are more than competent at assessing a person's dangerousness and that you are aware of your own accountability for maintaining an environment which is safe for all patients and staff. Your profession requires you to have a therapeutic rationale for how you treat patients, which includes the milieu and "culture".

You need your colleagues on the ward on-side with you about this. Are unions any use in these matters where you live?

I sympathise with you. Our head of mental health services is affectionately known as The Poison Dwarf, The Toxic Turd, Little Fcuking Hitler and much more which won't get past the forum software's censor. These people have such overinflated egos that they cannot understand that they are, really, just admin support....... They add unnecessary stress to our jobs.

Sorry if this doesn't help you. You can either suck it up and knuckle under, find another job, or stand up for what your knowledge, experience and integrity tell you is right. All those options carry their own stresses, drawbacks and advantages.

By the way....the town where I live is twinned with Pendleton, South Carolina. We're almost cousins :redbeathe

[PsychRN98, ASN]

These things are sometimes trial and error unfortunately, and a lot of times it seems to be because "it hasn't been done before". And then it takes some negative event for change to come around. I was lucky enough to work for a hospital that opened up an 8 bed transitional psych ER and they did have to learn a lot through trial and error. They did get some advice from psych staff, but not as much as one would expect considering it is a specialized unit we were dealing with. For instance they learned that televisions in rooms, but not behind protective nonbreakable plexi-glass, were not a good idea. That was after one was smashed because a patient didn't like his dispo plans. Also, some silly things like having sinks out in the hallways with enough accoutrements that any savvy borderline could have a field day trying to hang themselves from. However I did like that although they had clothing racks on the doors, for instance, they were collapsible after a certain amount of weight. There were many good things, and things done right, with psych staff input. Anyway, I don't have any articles as you were asking, just adding to the conversation a bit. Good luck with your new unit and I'm sure it will add great stuff to your resume.

[PsychRN98, ASN]

Oh, and this unit also did not allow any personal devices of any kind. Pts. are admitted from the ER in hospital clothing to the psych ER and any visitors onto the unit had to pass through a metal detector. All cell phones, mp3 players, etc had to be either given to family members to hold or placed in lockers until they were discharged or transferred. All under the auspices of safety; which after you have a a few pts swallow batteries I guess is just something that is not taken for granted. Also, I worked at an acute freestanding psych facility for 8 yrs, and there also were no personal devices of any kind allowed onto the unit. In both situation, pts. were permitted to use the phones on the unit.

[Whispera, MSN, RN]

I'm just going to make alot of comments...

Wow about the lack of lighting. That needs to be fixed before someone falls or otherwise hurts self while under the influence of the illness or medications!

Pepper spray is allowed? What if a patient takes it away from the person who brings it onto the unit? I'm glad the sitter had it, but it's trouble waiting to happen, generally.

There's a benefit to psych beds in that they're heavy, not as throwable as other hospital beds (yes, people throw beds or parts of them), and they don't have something that can be used to hold something that can be used for hanging oneself. I bet the new beds were pretty expensive and management is trying to figure out what to do with them now that they have them! Do you have a separate restraint room or rooms? That would be ideal, rather than restraining in the person's hospital room. Doing that sets the room up for having negative emotional impact after the event. Besides, are these private rooms? What about the roommate of someone who is restrained?

The community room needs to be fixed so it's appropriate and opened pronto, so those that are capable can be in it. I'm generally against patients having electronic gadgets in their rooms. There's the swallowing parts of it problem, the breaking it and using parts to cut problem. Capable patients can earn privileges to use such things in the community room where they can be more closely observed. Or those that listening to music would help can be there and observed. So much can happen in a room away from caregivers' eyes! If they have a sitter that's another thing, though.

TVs in the rooms? Glass screens? Remote controls with batteries or bed controls?

The phone call limits are pretty standard on inpatient psych units. I bet that's where the rules in your unit came from. If there's no fight for the phone though, I don't see a point it making someone hang up the community phone. Patients have a right to reasonable communication with friends and family, as long as it doesn't interfere with their treatment or the rights of others.

Can you meet with the others working the unit and get some definite ideas in writing...and go to the managers as a SMALL group (maybe of 2 or 3, so as not to look like a show of force) and see what they say? I tend to think they don't know what to do and are wallowing in a bit of worried indecision, and would welcome some help from those more experienced. If not, there's probably a mental health ombudsman in your community who could help you.

Are patient rights posted on the wall somewhere? If not on your unit, how about on the psych unit in your facility. Those rights might lead you to being able to get some changes implemented.