StuPer

I think I would be right in assuming that the law in regard to when a person is sufficently unwell that it is appropriate to enforce treatment/hospitalisation changes depending on your state or country. They mostly follow the principle of harm to self or others in determining when the patient requires involuntary treatment, in NSW Australia we also have the term 'harm to reputation' this is intended to help with patients who are manic or hypomanic, and who are ruining their standing in the community and in relationships as a result of their illness. StuPer

Clinical Supervision is a valuable tool in maintaining your sanity and keeping perspective in a psych role. It is not part of the management structure and certainly nothing said in a clinical supervision session should ever leave the room. It is supposed to be carried out by your clinical peers, but is also supposed to be someone you respect and trust, it is never, ever supposed to be your manager or anyone who functions in a management capacity who has some line management responsibilities that include your position. StuPer

I too have a poor opinion of Abilify, not least of which was the test trial data submitted to the FDA which showed it destroyed the cornea of albino rabbits, the company was ordered to do post approval testing to look at any implications for humans, but as far as I know it hasnt been done. I had an opportunity to attend a sponsored meal at the end of a valauble conference a few years ago, and had great pleasure in laying into the Abilify presenter about the poor wabbits StuPer

Apart from the ongoing issues which rotate primarily around medication side-effects, most psych facilities only complete a physical assessment of a client on admission, and that is to rule out a physical cause/contributor to the actual psych presentation. However an ongoing psych assessment is very much the bread and butter of psych nursing, MSE, social history, changing symtomatology in response to treatment. All of this can be obtained via informal and formal questioning. Ask yourself this, if you were in a state of severe mental distress, how readily would you respond to the nurse who breezed up sat you down and said 'tell me how your feeling today' while holding a clipboard and notepaper. Just because you have observed nurses behaving diferently to your previous clinical experience, does not mean they are lax or failing to meet patient need.. StuPer

Having read the posts in this thread there are 2 distinct points being made 1) the frustration at people, while having no treatable mental illness are using mental health facilities to avoid an uncomfortable life, or criminal conviction, and 2) that along with the people who are exploiting the system come those who have a genuine need for treatment and are very very hard to distinguish from the manipulators. Both issues are real in modern healthcare, regardless of state, or country. But I would like to add a few points: It is a well researched fact that a huge chunk of the 'mentally ill' have poor health, poor socioeconomic status and often live itinerant lifestyles. People with personality disorders, even anti-social personality disorders, are in mental distress. That does not mean they can be helped, or that they want help, but some aspect of their pathology/past is maladaptive (abusive family etc). I personally find when approaching this group the easiest thing to do is try and meet some basic needs, at the same time testing receptiveness to some sort of therapy. Key things I guess are not to get into the 'florence nightingale' mode and think you can 'save' people, and conversly not to be hostile or dismissive, just in case you do miss the acute crisis buried under a few weeks of filth. All the best. StuPer

this is an absolutely brilliant point, i had forgotten to mention in my response, without diggin up the research i think i'm accurate in saying both lithium and clozapine metabolism is affected by nicotine levels. if we initiate a therapy based on unrealistic levels of nicotine in a patients system, we are potientially exposing them to toxic or sub-theraputic levels once they return home... something that may open up an avenue for litigation should an adverse event occur. stuper

Over the years on this forum I have seen repeated stories from students saying their lecturers have advised them to do med/surg for a year or two before going into psych. Invariably the reasoning offered is losing of skills, being unemployable if they go straight into psych and then dont like it. I have always been very annoyed at hearing this, as to be honest it appears to be at best an ill advised attempt to 'steer' a 'misguided' student down the 'right' path. If you have had psych experience and loved it, or if you have always wanted to do it..... then do it! Psych has probably the hardest time recruiting staff partly due to the above scenario and also because of misinformation and predjudice about the patients/diagnosis, so anyone is passionate about it should be encouraged. Skills..... well as a few others have said, I wouldnt dream of functioning in a general ward capacity after all these years in psych, but I can still do the basics. I do however have a whole gamut of skills associated with my field which general nurses do not have. What you may lose, you regain in new skills. Ultimately its up to you, if you are certain psych is for you go for it, ignore the naysayers, if your unsure however, it maybe wise to hedge your bets. StuPer

Sorry for the delay in answering, I dont check these forums as often as I used too, and I've been crook for a few days. Anyway, as for money, well its a tough one to answer as a simple monetary figure doesnt really give perspective. On top of that I am a fairly senior nurse and therefore work monday-friday 0830-1700 (they dont like to pay me overtime.. I cost too much ). Other things include cost of living etc. which I believe is cheaper here in Australia than much of the US... currently the exchange rate between the two countries is about 1au$ = 0.96c US, I think the average ward nurse including penalty rates for evenings and weekends would be earning around 70k before tax. I dont know how that compares over there, but its a reasonable wage considering the average. We also get 4 weeks holidays a year plus some public holidays etc... overtime is not compulsory, you can take as much or as little as you want. StuPer

not good

I'm afraid I have some experience of this as we recently enforced a no-smoking policy across the area in all health care facilities. Now don't get me wrong I understand the reasoning behind non-smoking policies, both for the health of staff and that of clients, however I do believe mental health settings have an arguement to be considered different. Firstly the ethical issue, we often lock people up in hospital due to mental illness, they do not have a choice in the matter. To then impose our standards on patient regardless of history (eg having smoked for decades with no intention of stopping) smacks of big brother and we are supposed to be advocating for greater autonomy and inclusivness in mental health care for patients. Secondly, how do you think your attempts to form a theraputic relationship with someone is going to go when you have deliberately denied a drug of addiction, that outside of the hospital grounds is a legal entity. Thirdly I dont know about other areas, but here, staff have been told that they cannot visit the home of a patient in the community unless that person has agreed to not smoke while staff are present.... even if they are on a Community Treatment Order (compulsory MH care in the community). Now imagine the not unlikely scenario where a CTO client (who does not want our care or treatment) refuses not to smoke when staff are present... are we really going to breach that person and force them into hospital because they wont stop smoking?? The 'educator' who came to explain the policy to us had a real hard time with that one. How many PRN's/sedation/restraint actions are going to occur as a result of patient agitation due to lack of access to 'smokes'. Well as I said I have some experience via the local staff in the Acute Unit, the answer is many many incidents. None of which can be attributed to anything other than the smoking policy. The Area managment seem to have adopted a wonderful strategy in order to implement this and keep the State Health service happy. Staff initially religiously reported incidents via the online incident system. However over a course of weeks and months staff simply stopped reporting as there was absolutely no action taken by management to reduce the level of incidents or review the policy. This pattern was perfect to evidence to State Health that while there were some inital problems, things seem to have settled down (using the reporting stats). All I can say, is please think very, very, carefully about implementing such blanket policies into health care, especially MH facilities. Patients who smoke do so often for a theraputic reason associated with their illness, it may not be the healthiest or best strategy, but who the hell are we to tell people how to live their lives on something like smoking, when we have forced them into the facility in the first place. I would hope that even non-mental health workers can see the potential for violence that this can lead to, and which is a reality in this area. StuPer

Hello Cherilee, RN2begin ofers excellent advice and in order to get a good insight into BPD the DBT books are gold. Just some words of caution though, people surrering with BPD can be very very needy and will happily soak up any sympathy and 'understanding', this is not a malicious act, but a 'need' that comes as a result of the traumatic events which led to the BPD. Unfortunately filling this 'need' is the primary driver around their actions, and the risks, or inappropriate nature of some of the behaviours escapes them. This could potentially lead to a well meaning nurse giving of themsleves in order to 'help' a sufferer, but finding ultimately that the sufferer rejects them when the nurse tries to steer them towards a theraputic goal. I guess what I'm saying is that this client group are in need of help, their behaviours are largely a consequent of maladaptive coping strategies developed when the BPD was formed. But.... in order to help this group the sufferer MUST be ready to change their behaviours, and recognise the catastrophy which their life has become. Then they will be prepared to put in the work required to succeed at DBT, but they honestly have to be in that space before they can be helped. The best thing you can do to help is to really familiarise yourself with the illness and then offer help that guides sufferers on the path of help. There will be many times that sufferers will reject that help, but eventually they will recognise the need to change and remember the help that has been offered. I have personally seen many BPD sufferers, some of whom had been totally written off, who completed a DBT program and have regained a sense of normality in their lives, to their great relief. StuPer

Hey Guys, I have to say I'm truely amazed at the level of staff/patient ratios you guys in the States will put up with. There is no way on god's green earth that either the staff or the public would put up with that kind of care here in Australia, especially in an acute facility. Locally in a small rural community we have a 20 bed acute unit with 8 high needs beds, the staff share the load across the areas so no one person is overloaded. Typically they have 5 staff for a morning shift and a couple of security/cleaners, 4 for an afternoon and 3 overnight. Obviously I dont know what is the reason behind the situation over the big 'pond', but I suspect the private nature of healthcare and the need to provide profits to companies and shareholders is no small part. Whereas here of course everything is funded primarily via taxes and state run. Anyway, as they say... horses for courses, and each to their own... but, I hope you guys working in these horrendous environments get some help soon... as working in that kind of setup would be a real danger to your own sanity imo. StuPer

Hey Guys, I work in the ED, or ER as you guys seem to call it, and usually have to deal with crisis scenarios, so communication is a big key. Generally I find, while yes it is important as to the content of what you say to a younger person, the way it is said is by far and away the most important. How you tackle 'breaking the ice' is dependant on many things, actual age, diagnosis, current mood. If we say that the primary issue is depression/suicide, a younger person often feels there is a communication barrier with older people, that we 'don't understand'. Breaking down that barrier is I think the key to enable frank and open discussion about the younger persons feelings and hence risk factors. Discovering interests, showing knowledge of and understanding of whatever is 'their thing' can help break that down. Talking to the young person on an equal basis at this stage can enable them to think you take them seroiusly and give an avenue into discussing the illness and hopefully disclosing risk situations. Once a younger person 'trusts' you treatment becomes a whole lot easier... I'm aware that this maybe teaching people to 'suck eggs', but that is unintentional, I just worry that a 'cheat sheet' of one liners, while helpful, may not always work. Invariably I find that if given sufficent time people of any age come to accept that you DO actually care and are interested in them as a person, at that point your onto a winner StuPer

Hey guys, This is an issue every where it seems, and there is no easy answer, however admiting terminally ill people to a psych ward because they are depressed is just in one word a 'dump'. Good god have they not heard of palliative care, that is their field, being depressed in that scenario is a 'normal' function of the grieving process, pally care assist individuals and families to come to terms with this and to help them prepare for 'the end'. Putting people like this in a psych ward is an absolute injustice, no wonder you are struggling to cope. Frankly if your administration see's no problem with this practice I'd be looking for alternate employment. Take care of yourself because under that kind of stress your own mental health could suffer. Ohh and we to do not admit people with IV's for the same reasons JentheRN05 stated, no mental health facility I know does. regards StuPer

Thanet, Sorry for the late response, but I trawl these threads a little too infrequently. Could you highlight the changes please, there has just been a review of the MHA here in NSW, wonder if the new Act will be as similar to the UK one as the old one here was. regards StuPer P.S. On arriving in Oz I worked in Forensics as well, its how I got my work visa here.

While I dont doubt that some people have the belief that demonic possession is possible, I don't believe there is a place for that in a clinical setting. If you acknowledge demonic possession as a possibility, then you either acknowledge every other religion's versions of 'demonic possession' or you are infact invalidating any non-christians religious belief's. That could be a big problem in a multicultural society where as a clinician you will inevitably have to deal with someone who has differing religious views than yourself. I personally have never met anyone who was 'possessed', but I have met a few who felt they were, but only until they recieved treatment and their psychosis resolved. regards StuPer

Hello Thanet, Originally trained as an RMN in the UK, moved to Oz in 2000..... why are you asking incidentialy? regards StuPer

Hi lavarn, I cant speak for Vic, but I imagine it won't be much diferent from NSW, you shouldnt need a diploma to start working in the MH field, particularily in ward work. Some specialist units may make a requirement of a post grad diploma, because of the nature of the work. In any case if you have applied and been accepted for a post grad MH diploma, that would be in most cases proof of interest I would imagine. regards StuPer

Hi I guess I would say no I havent seen anyone successfully treated with this diagnosis, but I would measure that against the fact I havent worked in any specific programs/facilities that cater for this client group. The other thought is that, as with many personality disorders, until the person themselves see the impact and consequences of their behaviour AND want to change it, your chances are virtually zero. When the defining characteristic of APD is a lack of ethical and moral consideration for others, frequently with violent and criminal behaviour, its difficult to see how best to approach this group. It appears to peak in the early 20's and by age 35 most people are in remission, but still have problems. Much of what I've read indicate that it is the natural progession that finally puts a stop to the behaviours rather than any formal treatment/programs. Sorry I couldnt be of much help. regards StuPer

hsieh, I seriously have to wonder about your ability to compare like with like, and then draw very poor comparisons as a result. You cannot draw any parallels between someone going to college and someone with a psychiatric illness being dumped in a 3rd world country, that to be frank is just mindboggling. I'm aware that this post is not particularily constructive, but I am coming to the conclusion that a reasoned and well thought out debate is not going to happen, as I result I dont think I can add anything further to this thread. regards StuPer

hsieh, I'm sorry to say I find your posts largely lacking in any evidence to back up the ideas/approach you promote, and the idea that sending someone to a 3rd world country will somehow resolve a BPD lacks any basis in reason. You have mentioned they do not have BPD in developing countries, when in fact the reality is they have neither the resources to treat or the means to measure BPD in these countries. So the people who suffer with this personality disorder simply go untreated, they do not simply vanish, the prevalance of BPD in sexually abused children is in the high 70% mark, there is sufficiently rife child sex abuse in many 3rd world countries to establish that BPD does exist in these countries, end of story. Your suggestion is simliar to a psychological technique that has been found to be traumatic and unethical, that being 'flooding'. A person with a particular phobia is put in an environment where he/she is bombarded with overwhelming ammounts of the subject of their phobia. The theory is that by being exposed to such a situation they will learn that the threat posed by the source of their phobia is wildly over-exagerrated. In reality people with a BPD have an established set of destructive learnt behaviours (as opposed to fear/anxiety associated with phobias), during the course of the original trauma they learnt these techniques as ways of surviving, and coming to terms with their lives. The only way of treating these traumatised people is by helping them to see there is a better way, that offers greater benefits then their current behaviours. Sometimes it takes many many years for an individual to see past their immediate needs for love/affection/attention before they are capable of attempting DBT. All a clincian can do is offer immediate support and safety management for the current crisis, all the time consistantly telling them they can change their rollercoaster life when they are ready. So in summary we have BPD clients in developed countries, not because we chose to create the diagnosis, but but we recognise the overwhelming impact of trauma/abuse has on young lives, and we establish resources to help treat people in that situation as an adult. Where as in 3rd world countries where child abuse is often far more prevalent than in developed countries, the issue is not seen as important enough to warrant resources, as they struggle to meet the medical needs of the population, let alone their psychiatric needs. regards StuPer

Firstly it is an absolute fallacy to say that by simply not having psychiatric services that a diagnosis will not exist. Simply because, as a result, you are unaware of these people, doesnt mean they dont exist. In areas and countries where psychaitric services are limited, people suffering with these illnesses often are unaware they have a diagnosable illness. Instead they continue to suffer in the abusive misery that is the environment they grew up in, I would suspect that a large percentage of the suicides (and they happen in large numbers) in these service deprived areas are simply people with borderline personality disorders giving up on existence, chosing death rather than continuing to live. Someone in the other thread indicated there was no link between childhood abuse and personality disorders, I am sorry but that is balantantly wrong. I can say with complete certainly every man/woman I have assessed and treated with a borderline personality disorder was a victim of some form of childhood abuse. That is not to say all people who have suffered with CA will develop a BPD, not at all, it often depends who is the offender and the level of support in the family environment. hsieh, you have indicated on 2 threads now your belief's in regard's to BPD, we all understand your point of view. As you have seen, no-one agree's with you, continuing to reiterate that view is simply creating alot of angst with the majority of posters. For the sake of harmony I would ask you not to continue to post this view, it seems clear to me that you have a fixed view on this, and so do those that disagree with you, merely recycling both sides serves no-one. In return I ask that other posters don't write inflamitory replies to hsieh, that way we can get back to the actual topic of this post which is how to approach the management of BPD in a ward environment. In regard to the OP, both approaches are not without their problems, 1stly having a less prescriptive attitude to clients during the night can be a useful way of preventing a potential aggressive incident on a ward. Do you really have to insist that a person retires to bed if they are doing nothing to disturb the ward and/or other patients, on the other hand, by being too lenient you run the risk of developing a ward culture where there are frequently multiple people up all night, refusing to go to bed. The second approach can be seen as an attempt to establish a 'normalised' sleep regime and ensure that other people in the ward are undisturbed while they sleep. On the other hand adhering to a strict policy of sleeping in rooms during the night and not allowing people to stretch their legs who maybe agitated or ruminating on traumatic events, can lead to a violent outburst that could have been entirely preventable. In reality you have to make a decision based on the curcumstances you are faced with. I have seen people allowed to sit for a while go back to bed and sleep the remainder of the night, I have also seen some manic patients running riot in the early hours because they were not given strict limits. If you have reason to suspect a patient is trying to test the system, as opposed to needing a real theraputic break from their bedroom, it maybe suitable to impose strict limits. If someone is clearly in distress and identifies they cannot sleep due to ________ reason, it may also be suitable to allow them to stay up. If its the latter I would normally say something like 'ok, you can stay up for 30mins, as long as your quiet, and after that time you must try and get back to sleep. If they comply but get up again I would normally offer night sedation. If they refuse to go back to bed then it maybe appropriate to enforce it, or apply IM sedation. This approach allows you to maintain some limits, without being too strict, it also is fluid depending on what the person presents like. Sorry everyone for the megapost. regards StuPer

I agree with your post Charlie, and would love to see Nurses acting together for the the better of their profession and their patients. Unfortunately in my experience we as a profession seem to spend more time working against each other than together. As for union power, well again, I often see nurses finally coming to the point of strike action, only to find half their colleagues will not strike out of a misguided Florence Nightingale belief that they need to stay by the patients bedside. I beleive we are our own worst enemies when it comes to pay/conditions, nurses have a massive ammount of power and leverage, if they are simply willing to walk off the job. In the 2 countries I know of where EVERY nurse walked out of hospital (Ireland and Sweden I think) both got what they were asking for within 24hrs, people were dying and the public accepted that it was the fault of the government that nurses were striking, no politician spin their way out of that. regards StuPer

Ummmm reading your post, I think you handled it very well, particularily as you didnt rise to her aggressive outburst. Im not sure but, I think there maybe other issues here, for a start dilaudid can be a drug of addiction, so dependency may explain her behaviour. As for her schizophrenic diagnosis, I'd be interested to know if it was originally a drug induced psychosis, as paraniod ideation is very prevalent in that group. regards StuPer

TitaniaSidhe... I feel your burnout..... I cannot for the life of me understand how hospital administrators the world over are under the delusion that it is more cost effective to have a highly qualified nurse doing administrative tasks than a secretarial worker. Admittedly there are some tasks that need a clinician, but it seems that there has been some fool who after seeing a nurse working at a computer, thought.. ouuuu ... if we can get the nurses doing more of that we can do away with ward clerks etc... think of the cost savings.... doh!! My colleagues in community mental health services in this small area alone spend the equivalent of 2 fulltime staff just doing statistics for their daily activities... and when services are so stretched.. thats just criminal. regards StuPer