I work on a 20 bed, acute inpatient unit at a hospital. We see everyone across the board from depressed and suicidal to psychotic. Substance abuse, malingering and everything in between.
Lately, I see more staff engaging in the hardball approach when patients don't attend groups. Typically, they will lock them out of their room to "encourage" group attendance. Then when I come in, I am expected to continue this practice so as not to "undermine" my fellow nurses or "staff split".
First off, I believe they HAVE A RIGHT TO REFUSE ANY AND ALL TREATMENTS til a court says otherwise.
Secondly, I don't engage in power struggles with my patients unless they are a danger to themselves or others. Period.
Thirdly, I believe the moment you "or else" someone for anything other safety, all hope for a trusting, therapeutic relationship is lost.
Fourthly, I believe this practice to be illegal and a violation of patients right to refuse.
Fively, I refuse to participate in punishing patients for exercising their right to refuse. If I am "undermining your authority" or "staff splitting", too ******* bad. Rethink your approach and learn the law. I will not be bullied into compliance.. I don't like it any more than our patients like it.
What is your opinion of this? Am I wrong? Can patients legally be forced/humiliated/coerced into attending groups? I have yet to see a court order requiring someone to attend groups while being a patient on our unit.
I've been on the other side of this door so to speak. I've been a patient. An involuntary patient. If you didn't attend groups, you didn't get to leave as a rule. So I attended groups. This facility (private) offered only one group that was a one size fits all type of thing. At first I didn't recognize it. What opened my eyes was when the facilitator said that we needed to chose new friends and not hang around with our old friends. It was like WHAT? My friends are a big part of my support system. When I asked for a clarification on the comment. She said that I needed to stay away from my drunk and druggie friends. I countered that I was there for a bipolar crisis and that I was not there for an addiction of any kind. In fact I have not been much of a drinker and I certainly don't do drugs. Unfortunately, the group never changed. It was still focused on substance abuse. I was in between a rock and a hard place on that one.
Fuzzy
Not very therapeutic I reckon.. it's unfortunate the system is still lumping so many diverse, unique illnesses experienced by diverse, unique human beings all under one banner of "mental health".
One size definitely does not fit all.. every individual has unique needs and too many people fall through the cracks and don't get the care they deserve in my opinion.
Like I said in an earlier post.. always about the money.. our society for the most part has been ignoring mental illness since the dawn of time. Not to mention shedding mental health beds and services for decades as the need grows exponentially. It's a broken heap of a mess..
The stigma is slowly but surely getting better I think but we still have a long way to go.
At times the TREATMENT team decides that it is in the patients best interest to be locked out of the room between certain hours. It is part of the patients individual treatment plan. The treatment plan usually says if x does not attend 3 groups x will be locked out of his/her room the following day. Not something we use a lot and those who we do use it on... most of the time frequent flyers who we all know very well and need the extra encouragement to go.
I understand that, and that is often the case on our unit too. I understand the frustration with "frequent flyers" as well. But, as I understand patient rights and the law, patients have a right to refuse and decide for themselves what's "in their best interest" til a court says otherwise.
For instance, in many cases, the treatment team would certainly decide that taking anti-psychotics are "in the best interest" of the patient.. however, the treatment team does not have the right to impose their will through any form of "encouragement" outside of an emergency situation beyond verbal encouragement and teaching. As I understand the law, the second an "or else" is uttered to a patient exercising their legal right to refuse, maltreatment of a vulnerable adult has occurred.
What happens on your unit when acutely psychotic people refuse meds? Why should group attendance be any different, even if the person is frequent flying? Why do they not have the right to refuse without fear of threats/punishment? I believe the law says they do..
Maybe people wouldn't frequently fly if proper services/treatments were available and we didn't have laws that tie doctors/hospitals hands to admit people that should never be admitted in the first place.
Competent patients and residents shall have the right to refuse treatment based on the information required in subdivision 9. Residents who refuse treatment, medication, or dietary restrictions shall be informed of the likely medical or major psychological results of the refusal, with documentation in the individual medical record. In cases where a patient or resident is incapable of understanding the circumstances but has not been adjudicated incompetent, or when legal requirements limit the right to refuse treatment, the conditions and circumstances shall be fully documented by the attending physician in the patient's or resident's medical record.
Subd. 9.Information about treatment.
Patients and residents shall be given by their physicians complete and current information concerning their diagnosis, treatment, alternatives, risks, and prognosis as required by the physician's legal duty to disclose. This information shall be in terms and language the patients or residents can reasonably be expected to understand. Patients and residents may be accompanied by a family member or other chosen representative, or both. This information shall include the likely medical or major psychological results of the treatment and its alternatives. In cases where it is medically inadvisable, as documented by the attending physician in a patient's or resident's medical record, the information shall be given to the patient's or resident's guardian or other person designated by the patient or resident as a representative. Individuals have the right to refuse this information.
Looks to me like the only legally acceptable way to deal with refusal of anything outside of an emergency is providing information and teaching. Unless of course, the person has been deemed incompetent to refuse groups by a court of law.
Personally, I don't think our local county courts with their backlog of cases would appreciate our doctors taking patients to court to force them to attend groups.. or else.
Although, for "frequent flyers" who refuse or "need extra encouragement", I believe it would be prudent and legal for doctors to say, "ya know, we really aren't doing anything beneficial for you. I'm going to discharge you immediately".
I'm from an Acute unit of 24, we do have groups running from 0900 to 1500 on weekdays and absolutely nothing on weekends. A good 30-40% attend the groups and the rest are usually to sick to join or just did not want to go. Voluntary or not we give these patients options and information regarding what they do in groups and it is up to the patient to consider it, usually nothing goes on in the unit that the majority start inquiring about groups, they try it and if it works they stay on it, if not then they tell us that it's just not working for them. We don't punish, if a person refuses to leave the room and try the groups, it's mainly because they are too depressed to do so and/or they just arrived in the unit and aren't at that stage yet. All in all I give them the information and the OPTION to join, I ask them that throughout the day and everyday that I am in at work, but at the end of the day, if they don't want to you can't make em.
When it comes to medications, if they refuse it, I'm fine with that (unless it is a medical medication and is necessary, or that they are deemed incapable for Psych meds and are too ill to even decide). At the end of it all I question them why they refuse the meds (chances are they are afraid of side effects from past experiences, maybe more education is needed, a review of their meds by the Psychiatrist is needed--because if they don't take it at the hospital, they wont take it at home, and they'll be back for admission because of another exacerbation).
I find that some people need to really step in these patient's shoes and really understand their current state of mind. The majority of staff have great intentions in mind by forcing them out of this "rot", but you have to really see HOW you can encourage them to motivate themselves.
I find that some people need to really step in these patient's shoes and really understand their current state of mind. The majority of staff have great intentions in mind by forcing them out of this "rot", but you have to really see HOW you can encourage them to motivate themselves.
Very well said. Not just what I quoted, but your entire post. Thanks for taking the time to reply.
I didn't get in on this because initially I felt there was going to be a repeat of the ever common divide among nurses who feel themselves to be therapeutic often at the expense of safety and nurses on the other side who are labeled as uncaring. Although most of us fall somewhere in between I have seen this power struggle among nurses on almost every inptatient unit I have worked. In this thread there seems to be two very different and separate issues being addressed.
With regard to groups that isn't something I feel is worth struggling over although I agree with the poster who indicated the patients who decline to participate in groups shouldn't be watching television, using the phone etc. until groups are finished and everyone has the availability of those privileges. However I also don't feel if the unit has a rule that patients are to be out of their bedrooms during groups, unless they are physically ill-detox for example, I don't necessarily see that as cruel and unusual punishment worthy of calling state authorities as one poster suggested. In fact calling state agencies into your facility is almost never a smart move, imo.
Medication administration is a totally different topic and while I agree 100% that patient's have the right to refuse at the first hints of dangerous behavior I am on board with administering emergency medications via IM if the patient refuses offer of PO. In my experience especially since we know so many of our patients by history those nurses who feel it is better to avoid this at any cost prolong the length of hospitalization, put the patient, peers and staff at risk of injury. Plus it can NOT feel good to be so agitated or psychotic. There seems to be a vague self-inflated secondary gain that I have seen in nurses who feel that verbally "de-escalating" a patient who is severely agitated illustrates their caring and expansive Nightingale-esque nursing abilities. While I totally value the ability to recognize and de-escalate patients before an incident occurs in the cases of severe psychosis this will only be a very temporary solution if medication isn't on board. I have seen amazing results by administering emergency medications for people who are suffering from severe psychosis.
During my last admission for a depressive episode (Bipolar I), I was attending groups and med-compliant, but when I wasn't eating, in group, or taking meds, I wanted to be in my room. I guess they decided this was not in my best interest, because starting the second full day on the ward, they locked me out from after breakfast until snack/night med pass.
I could see their point, but there was an additional complication... the day room's heater was barely putting out any heat at all (maintenance was up several times but wasn't fixed by my discharge). It was frigid in the ward outside of the patient rooms, and even the staff was wearing layers. I was on the locked down side, so no street clothes or jackets allowed, just the hospital-provided scrub outfits.
The power struggle that manifested then wasn't about whether or not pts could go to their rooms, but whether or not we could have blankets in the day room. Seriously! It was a "unit rule" allegedly that no blankets could be taken out of rooms. I wasn't the only cold-natured soul shivering and competing to sit directly on top of the malfunctioning heater. When one set of staff would agree it was cold enough to warrant breaking the "rule", the next set of staff got all bent out of shape over half the patients huddling under the eeeevil blankets when they came on shift.
I know consistency is key, especially when you have manipulators and people who will do their best to make anything into a crisis to feed the need for attention. Even when it's not an issue of staff splitting/manipulation/attention-seeking, confused pts do better with consistency, and even the simplest things can be confusing when under a heavy med load. But psychiatric admissions already entail a certain amount of surrender of control, which is not a comfortable feeling for many. Not saying the psych ward should be Burger King where you get to "have it your way" by any stretch, but it's one of the few times an adult has someone tell then when they have to go to bed, for example.
When staff appear to be more concerned about whether pts "respect their authoritah" than their legitimate need for heat (or rest, or quiet instead of being yakked at constantly by the manic pt in the mlleu after group, which was another reason I wanted to be in my room during that stay.... she *never* shut up)... it doesn't create a therapeutic relationship. It honestly made me wonder which side of the glass had more psychological problems, when something as silly as blankets became such a contentious issue!
We would also lock doors to get them to go to groups. It does violate their right to refuse, but for some people the only way they will attend a group I'd to be forced. You have to use your judgment.
If you feel that strongly about it you should talk to someone on the ethics committee at you work or some one I. Upper management.
In this thread there seems to be two very different and separate issues being addressed. 
wezzie, RN
118 Posts
Not very therapeutic I reckon.. it's unfortunate the system is still lumping so many diverse, unique illnesses experienced by diverse, unique human beings all under one banner of "mental health".
One size definitely does not fit all.. every individual has unique needs and too many people fall through the cracks and don't get the care they deserve in my opinion.
Like I said in an earlier post.. always about the money.. our society for the most part has been ignoring mental illness since the dawn of time. Not to mention shedding mental health beds and services for decades as the need grows exponentially. It's a broken heap of a mess..
The stigma is slowly but surely getting better I think but we still have a long way to go.