Jayesse7

If only I could count how many times I cried after a bad shift for the first couple of years (maybe more) after I graduated... Listen here, ease up on yourself. You made paperwork mistakes! Nobody died. Take the reprimand from the nurse manager and vow to do better the next time you are put in such a bad situation and let it go. It upset you because you care, don't lose that... but don't take it personally. Make yourself an admission checklist or ask for one so you can refer to it the next time. Next time you have a bad day make yourself feel better by asking some other nurses what their worst nights were. You will find it happens to all of us and you might spark a memory in someone who may have forgotten they were once a new grad too.

If only I could count how many times I cried after a bad shift for the first couple of years (maybe more) after I graduated... Listen here, ease up on yourself. You made paperwork mistakes! Nobody died. Take the reprimand from the nurse manager and vow to do better the next time you are put in such a bad situation and let it go. It upset you because you care, don't lose that... but don't take it personally. Make yourself an admission checklist or ask for one so you can refer to it the next time. Next time you have a bad day make yourself feel better by asking some other nurses what their worst nights were. You will find it happens to all of us and you might spark a memory in someone who may have forgotten they were once a new grad too.

I have found that there are people who hear voices all the time and sometimes they are laughing and talking out loud to them in their rooms and don't really seem distressed. It's noteable and should be brought up when reporting to the psychiatrist but sometimes it takes time to stabilize someone who has been off meds awhile and maybe doesn't require stat medication. If the patient gets loud or becomes angry with "the voices" I will ask them; "Are you ok? What's going on?" and maybe I will offer to call the doctor to get them some extra medication to help them relax. Usually Haldol or Zyprexa, sometimes they will order a cocktail of Haldol, Ativan and Benadryl. Personally, I think Haldol or Thorazine seems to have the most success in a crisis. You can repeat Haldol and give a lot of it if needed in a short amount of time. I like Zyprexa Zydis too because it's hard to cheek it and seems to be pretty effective. Sometimes a patient will hear something and accuse another patient or staff of calling them a name and it errupts out of nowhere which is more serious and requires immediate intervention. I usually insist the patient walk with me to another area, the quiet room or someplace out of the way and I ask them to tell me what happened. If they are shouting and angry I tell them (not ask them), calmly, I'm going to get them some medication and I ask them if they are willing to take it. The crucial part of your assessment of the situation is trying to determine if the person is able to stay calm and in control of their behavior. If you don't think they will then you need something fast acting and even sedative. People who hear voices may hear them all the time or sometimes. They may be distressed by voices or not. They may be aware of what the voices are saying or just hear whispers. Voices can be loud and commanding causing them to get angry and violent or they can be subtle and upsetting like when a person believes 'God wants me to die'. I will sit with someone like that awhile and keep asking questions; "Are you going to hurt yourself?" "Why do you think it's God who is saying that to you?" etc... I will stay with a patient or get someone to stay with a patient who tells me something like that while I get a doctor to help assess and medicate. Sometimes it's ok that the medication doesn't stop the voices completely. I've had patients say after a week or so of medication, "I don't really notice them so much anymore" or "they aren't as loud and I can sleep" and that's ok. I have a lady who talks constantly to hers, like they are roommates. Mostly she is happy and laughing but when she starts to get mean with staff (she says things like; 'go on and be a whore if ya want to', as I'm walking away, for instance) and fight loudly, in her room, with her voices, then she needs more medication if for no other reason, because it's upsetting her.

I guess you could have brought it to everyone's attention by phrasing it into a question and saying something to the effect of; "Is it ok that the patients are unsupervised or would you like me to do that while everyone is charting?" The reality is that sooner or later something is going to happen that will cause the hospital to have to implement some new safety guidelines and I know I wouldn't want it to be on my watch. The hospital where I work has what is referred to as "milieu management". The charge nurse assigns someone to milieu at all times, usually in one or two hour increments. That person is responsible for knowing what is going on. They are supposed to be continuously walking the unit and signing off on a flow sheet every 15 minutes. In the beginning it was highly monitored by supervisors to make sure people were actually doing it properly. However, over time, it has relaxed quite a bit. It's a big problem sometimes. I've worked there long enough to have seen or known of plenty of "incidents" and that keeps me vigilant but that's my busy time too and I get tired of having to interrupt my own charting to check on things myself or fuss at staff who have seemingly stopped working an hour before their shift ends. I get really irritated sometimes which has led to me stomping into the break room and shouting at everyone; "Look around! If you are all in here, who is out THERE?! I'm trying to do an admission and chart and you guys seem to be done-for-the-day!" As you get comfortable in your new job, try to remember how important it is and don't let yourself get too comfortable or fall into the bad habits of others. Just say to yourself; "Not on my watch".

My admission note format looks like this: Pt brought to unit(location) at (time) escorted by (police officer/nursing supervisor/admitting doctor). Dressed in hospital gowns/pajama pants, gait (steady, unsteady, shuffling, etc). Appeared (disheveled with strong body odor...or...bright, heavy make-up, etc) Speech (soft and difficult to understand...or...loud and pressured, interrupts frequently, etc). Affect (flat, distant, tearful, irritable, demanding, threatening...or...friendly, pleasant, intrusive and difficult to direct, etc) Pt was offered meal tray and (ate/didn't eat) Oriented to unit, staff and room (#). Given (medication if any was given upon admission, time, route and reason) Denies food/med allergies. Placed on special observation q 15 min for risk of (aggression/suicidal behavior, etc) Personal belongings checked and logged by (staff) Pt was cooperative for assessment/interview. Pt was (forthcoming with information...or...guarded throughout the interview/reluctant to answer questions) Stated; "(I like to use quotes to show the overall mental status)" Made good eye contact throughout. or Appeared to be watching/responding to unseen others, poor eye contact. Denies auditory/visual hallucinations. Pt reports mood as; "I feel great!" or "sad", "ok" "depressed". Meaningfully contracts for safety.(Presence of any involuntary movements/EPS, etc) Pt has (fine rash or superficial scratches in varying stages of healing/signs of infection...if so, where) Conversation was relevant, thoughts logical and organized...or...delusional ideas present throughout interview, believes wife and children are being held in the White House and someone is trying to make him "look crazy"....special powers to "move between death and living", (etc...) VS: (enter them) weight: (X). Pt is calm and currently watching TV and interacting with peers appropriately at this time. *Doesn't have to be too long because the nursing assessment picks up all the details. You just want to give a thumbnail impression of how they were when they came in and document what you did. The first part is visible data, initial appearance. Then actions: what I did for them and last: what were their psychiatric symptoms/thought process/ mental status or physical issues related to psychiatric symptoms that were discovered during the assessment. So... data-action-response, if you are allowed to write in that format. If it's straight narrative, just think in that format. Easy! Right?

I usually wear jeans and sweaters or blouses with a scrub jacket but I have gradually started to wear scrub pants sometimes and t-shirts. I tend to NEED pockets. Where I work it is scold-worthy to wear anything around your neck that can be used to choke you. They don't even like the velcro break-away kind since it can be snatched from behind...so I need deep front pockets for my keys, pens and report sheets. Jeans or casual pants work better than elastic waisted scrub pants for my pager if I'm on the support team. I don't wear skirts or dresses because I can't move well in the event of a struggle putting somebody into restraints or breaking up fights...nurses have to get too involved unless you are in management. Another tip, keep a change of clothes in your locker. I had a patient snatch my shirt once and tore it down the front. I've had grape juice thrown in my face. There's also the dreaded spitters or urine-feces flingers. It's just nice to be able to change if you need to. Not that ANY of these things happen often but I've been in psych for 8 years now and there have been times....

I have this debate at work from time to time. There's a number of things in play. First of all it's a dangerous setting to work in so it's important that staff back each other up. I cannot stand it when staff begin to take personally things that an angry patient is spewing from their mouths. As the charge nurse I try to step in when I hear that banter begin and ask the patient to come talk to me. Usually allowing them to vent diffuses the situation and I can talk them into PO meds in the end, if they need them, which satisfies the "punitive" nature of the incorrect staff person....whom I will counsel behind closed doors, ironically, in the same way I did the patient; "What's going on? What happened that made you so mad?", etc... BUT also... where is it written that a code or an escalated pt REQUIRES S/R or even injections? EXAMPLE: My facility has forensic units where people stay for years...so many of them are very well known. This pt "X" is a large, well built young man who can be pretty dangerous when he fights. He wanted an extra snack and was told no. He got angry and flipped the plastic tray that holds the sugar/creamer packets onto the floor and went to his room and shut the door. The supervisor who happened to be standing there said to call a code and get an order for injections. She's new. I was absolutely shocked. I wasn't even working that unit but had come to get a medication from their med room when I witnessed this whole thing. I am seasoned. I KNOW this patient. This was a case of the supervisor being afraid (?) I don't know, but since she doesn't have to be involved in the fight she was about to create she didn't worry that "X" would be waiting and ready in his room to punch somebody in the face as soon as staff opened the door. It would take 6 big guys to subdue him if he fought... over an extra cup of hot chocolate! I respectfully (well.... I meant no disrespect I should say) when I jumped in to offer a different plan. "Just give him a minute in his room while we talk about this. You want to call a code that is surely going to end in restraints, injections and unnecessary danger over a snack?" Not saying he should've gotten the extra snack. Thats their call. And nobody has to ignore the situation completely either...but somebody neutral who has a rapport with him could go to the door of his room and knock...ask him to come talk a second...no code...no meds...just vent your feelings. I promise, most of the time, when pts react that way, they want an out too before it escalates. As it turned out that night, he vented to one of the aids he likes and apologized for his outburst. Problem solved without risk of injury. Hopefully his team remarked on his good choice to handle it peacefully in the end for positive reinforcement. So much of the time staff become so bent on "showing pts who's boss". If it was a prison I would understand the purpose of swift and severe consequences. BUT in a hospital you have to think differently. We don't put people in restraints or give them injections for punishment. The reason should be "you are out of control of yourself and I will help you to regain control of yourself"... and you exhaust your least dangerous methods first... remove them from the situation or remove the person they are in conflict with so that talking, negotiating, PO meds... whatever you think may be appropriate can have a chance to work. AND Algebra... if you are in charge be wise and take charge... if you are not talk to the one who is about this repeated problem. Stand your ground because you are right. I will back off when an aid steps up to diffuse a potentially bad situation. They often have built rapport with pts and are most effective.

Don't worry about your nerves. I remember when I started, my hands were trembling sometimes. Take a deep breath and focus on what you are doing. I predict after the first few you'll be fine. My facility has a compatability chart in each med room. If yours doesn't, try asking a pharmacist for one. Some tips: *Open a bandaid and remove only one tab, then stick it on your non-dominant shoulder so you can reach it quickly if needed. * Put a bunch of alcohol pads in your pockets * (Our Ativan comes in 1 ml=2mg vials) If your order is for haldol 10mg ativan 2mg, draw up the Haldol first and inject it into the ativan vial. Ativan is thick and the haldol makes it easier to draw it back into the syringe. * Make sure you don't try to inject anyone who is thrashing around until your support staff gets them still. * Sometimes it happens that you can go through a blood vessel so that when you aspirate your site looks clear but when you remove the needle blood begins to flow....IT'S OK! Thats why you need extra alcohol pads in your pocket. Just put pressure on the site til the bleeding stops. * You can ask another nurse to hold stuff for you too. In the case of a combative person you do need to be fairly quick about what your doing so dont be shy...get in there! Climb under or around til you get a good space and don't feel some kind of need to lay everything out and measure out your injection site like you did in school but pay attention to what you are doing and DO IT, then leave. Give good shots. You don't have to stab like a dart but don't go slowly when inserting the needle. I've seen newbies kind of set the needle on the skin and then push... don't. A smooth steady insertion is most comfortable. BUT above all remember, nobody is as critical as you are on yourself. Tell yourself; "You've got this".

I used to be an OB nurse and I once had a patient who was just plain nasty. She had grown uncomfortable in her labor and was demanding an epidural. When the young black anesthesiologist walked in the door to see about giving her one and introduced himself, she turned to me and yelled "NO WAY! I want a somebody WHITE!" That doctor just turned around and left. Fine with him, her loss. It made me instantly mad and my response was very direct "Ok look...what's this really about? You are afraid that somebody might mess up? So you're thought is to insult the EXPERT?! I don't understand that logic. WE understand that you are scared and in pain and WE overlook you're foul-mouthed complaints and demands and still WE take care of you. None of your nurses or doctors have announced that they will not care for a small-minded, ignorant jerk....(ok I might have said ass instead of jerk) but guess what? An epidural is NOT a medically necessary procedure and I'm guessing since you ran off the only anesthesiologist on call here tonight you won't be getting one from him now... which is kind of a shame because he's positively the best and can do them in under two minutes with his eyes closed." Maybe I was wrong and my response wasn't professional but it felt GOOD to say it. AND having gotten satisfaction from speaking my mind I did not feel any residual anger toward her and treated her with kindness after that. I even dropped in to check on her postpartum and told her how cute her baby was and wished her well. As I was about to leave she asked me, in so many words, how she should go about informing my boss. I brought her a pen and paper and said "Put it in writing.... After I told the nurse that I only wanted a white doctor to do my epidural she implied that I was a small-minded ignorant ass... I'm not sure how that will play out for you but you are absolutely welcome to do it." That was years ago and now I am a psychnurse. We all have to deal with patients who yell racial slurs at us. Sometimes they hate white people, sometimes black people or foreign people. It's uncomfortable at times and we give each other pep talks and reminders that we can't take it personally. As a charge nurse I offer sometimes to those who may be getting burned out and effected to take a pull to another unit for a day or so if they want to, but I also found a way to respond when a patient calls a co-worker "the n word". Doesn't always work and sometimes the situation is too escalated to talk in that moment but when I can, it feels good to address it. I use a calm maternal voice and say; "Hey listen... don't do that. We're here to HELP you. (He or she) is here to help and he/she is my friend. You don't HAVE to like any of us but you can't be disrespectful like that. So please don't call us names... Besides one day you're going to wish you could get an extra snack or something and you aren't making anybody want to do you any favors THAT way." There are a lot of mean people in the world but they know they are saying things that will electrify the situation thats why they say it! So it's best to just try not to take it personally and kill 'em with..... well, indifferent professionalism.

I'm a psychnurse in a state facility. We have 1 psychologist for every unit (9 units) and there are usually psychology interns helping as well. On my unit, which is an acute civil population, the psychologists meet with the patients (1 to1) who have been through trauma or if they need grief counseling and also when the psychiarist refers a patient for testing (MMPI, etc..) until their discharge. On the longer-term, forensic units the psychologist runs (among other things) a Restore To Competency program and is half of the Forensic Review team and/or half of the Risk Assessment team. All psychologists and interns run two-three groups a week that are broad and generalized information usually about anger management or coping skills and sometimes just discussions about mental illness diagnoses. RNs are also required to do 11 groups per week. Topics include; illness and symptom management, medication education, smoking cessation, substance abuse/mental illness and coping skills. The sad truth where I work is that the groups are desperately needed and could be the most important piece of patient care that is lacking. The reality is that the RNs are so bogged down with redundant but required shift notes, treatment team and treatment plan updates, admissions and discharges, MD orders, management of behavior issues and stat medication, medical monitoring, staff management and patient families (and much more that can't even be listed). Rollerskates couldn't even help ease my load on any given day. RNs have a piece in everything... but we're spread so thinly that there is almost never a time when I can relax and engage in a group effectively... so I hate them. We meet our requirements most of the time by plopping in a DVD or handing out some info sheets or giving patients some art activity to color. Its really bad. It's also frustrating because I know there are staff who wish they could do nothing but groups all day but they need some training/education so they don't just randomly make up things that aren't based on fact or sometimes even consistent with unit rules. In my opinion, the counseling and talk therapy is what nearly every patient desperately needs for one reason or another but they need it long term. If they get it in the hospital the one area of focus should be about what they need to know about obtaining it, what to get out of it and sticking with it after dischargebecause seeing a psychiatrist for 15 min a month to renew their medication doesn't address their other issues. Apparently there's a conflict of interest that prevents a hospital psychologist from seeing patients outside of the hospital in private practice and we don't have any hospital-run, out patient support groups. We don't even know or communicate with community agency counselors, beyond some of the case managers at discharge. No continuity. So this population of uninsured, mentally-ill people who are very vulnerable to physical, sexual, emotional abuse and exploitation rarely get exposed to resources and effective therapy to improve their situations at all. (I have always wanted to do something to focus on women's issues and relationship counseling, maybe even mother/baby wellness for our female patients.) My best advice is to try to think about what you wish to be your main focus. As an RN the work will be fast paced and while it is quite often rewarding and the money IS fairly good, it's also exhausting and can be frustrating because of a ridiculously dysfunctional chaotic system. I believe that with some thought, organization and diligence you could create a niche for yourself. Possibly find a way to make a dream job within a community psych agency serving the mentally ill by counseling them outside of the hospital. If you were near me I'd team up with you and refer clients! Or brainstorm for a better way. Good luck to you.

I'm very curious about this.I'd like to hear/read the details of what you are being criticised about. It is unfortunate that you find yourself in such a difficult working environment. Definitely you have not had enough orientation in 6 shifts. My facility also kind of throws new folks "out there" too but the rest of us are very supportive and try to be helpful. Two things to keep in mind: Cliche as it may sound you've surely heard it said; "Nurses eat their young". I deeply disagree with the notion but have found it is common for whatever reason (probably insecurity and personal unhappiness) for older seasoned and (obviously bitter) nurses to be less than supportive/helpful to new ones. BUT not everyone is that way. Do your best and ask for help. Find good people to befriend. Secondly, don't get too sucked in by the negative venting and "beware of the administration" warnings that the senior employees can dish too much about. Like rumors, the stories can cause you unnecessary worry and may not have that much truth in them. I remember being very fearful of who to trust and who had it out for me when I started. Probably it is a little bit that way whenever you start a new job. If you are really unhappy then I agree with the others, you should leave. Life is too short to hate your job. BUT if you like what you do then look at each individual circumstance and think about solutions. Do you feel unwelcome? Talk to people. Why are they making you feel like they are against you? Is it a misunderstanding? If you are making mistakes ask for more time with a preceptor. Show that you are trying to understand. Psychnursing is hard and there's so much about it that gets better with experience and confidence in yourself. And lastly... I think that most institutions are kind of 'all about money'. Sadly. When you are working on the floor, in the trenches, most of the administrative decisions seem ridiculous and defy logic and common sense. We're all frustrated by that. If you are not, then you will go into administration yourself one day, where its about money and politics. :) Good luck. Keep talking it out.

Be an agent for change Blue!!! That is if you are still working there. Investigate the hospital's policies...and investigate incident history. Even a panic alarm that you can wear on your person...not around ur neck though. And I agree with Meriwhen. "Develop your spidey senses" and never ignore them. Terrible things can and do happen. However; luckily, not very often. Patients are people and you have to ask yourself, are you safe alone and isolated with anyone you don't know? Not really. But... I advise you to think about what you would do in dangerous scenarios. NOT obsessively. If you are really fearful it's not the job for you. When I was a cute, young and new psychnurse (a long time ago) the male patients used to occasionally hit on me. I once had a male patient follow me into the linen room. He was between me and the door and he started to close it. I yelled LOUDLY; "Dont you dare close that door Malcolm!" and I kept on shouting in a stream of exaggerated oh-my-god don't you know that is a BIG no-no here? What are you thinking! Are you trying to get us both in trouble? Sheesh! etc... ad lib. All the while I was moving quickly past him to the door, then into the hallway. And of course he began to apologize which I gratiously accepted with a smile and said "I know you didn't mean anything. It's okay but never never do that again. Sneakin up on your favorite nurse like that about to give me a heart attack." Because the thing was...I couldn't show him vulnerability by freezing and being quiet- pretending we didn't both know he had me in a bad spot and he could've done something terrible... My loud and constant exclamations served to make noise so maybe somebody would hear me and they'd know what was going on by what I was saying, BUT also I caught him by suprise and distracted him, allowing me to push past him without having to fight or challenging him to a struggle. My immediate attitude of 'no harm no foul I know I'm your favorite nurse' gave him immediate resolution and became part of my style. I don't like for patients to think I'm uncomfortable with them even when I sometimes am. I allowed him the chance to play it off like it was an honest mistake so I didn't create an air of nervousness between us in the future. Even though he did try again later to "talk to me", you know like chat me up...then I said "Malcolm...stop it. I'm your nurse. Don't make me give you my lecture on appropriate talk." But I said it playfully and warmly. Not nurse ratchet-like. I don't want to anger anyone. People who like you are more likely to come to your rescue, but you HAVE to have clear boundaries. I got in the habit of just blurting things in moments when I was really vulnerable. A very simple trick is to just say; "What are you about to do?!" If you jump the gun you can play it off..."ok thats acceptable, carry-on then" and laugh. If you are right and they were about to move in on you or even if somebody is about to swing...with the appropriate tone and volume OFTEN you will suprise them and change the course of the whole incident. Once, I yelled from the doorway of the unit as I was coming in, "Hey! You aren't about to hit your doctor are you?!"... and I rushed over, coat on, purse on my shoulder; to the patient: "What happened? Why are you so mad?" taking the guy's fist like I was his loving mama, pulling him over to the alcove of chairs and sat us both down...."tell me what happened." He started pouring out all kinds of horrible stuff that evil psychiatrist (haha) lied about him, blah blah blah...and that evil psychiatrist bought me lunch that day. I have used my femininity as an alternate advantage. I am not big or strong and I was NEVER a fighter. If someone starts beating somebody up I probably cant physically overpower anybody- alone. But I am the queen of immediate distraction, which will hopefully at least buy somebody 3-5 extra seconds and hopefully they will use them well and get out of the way or get to the phone...or hit a panic button or whatever. I've also been beat up too. Doesn't always work. But 3 times in 10 years in acute psych (pretty good) and never really really bad. I GUESS my point is... you should develop a style, ways that work for you, (if you are going to stay in psych) so that if you are in less than ideal settings, under less than ideal circumstances, you can manage the situation. Because let's face it, I don't see any governors or administrators shouting "give the psych units more staff!" "Keep our mental health care workers as safe as possible!" It's really more about damage control after the fact, these days. So you're on your own. Good luck!

I'm a psychnurse and I LOVE students taking over the one and only task I really stress about. The reason I stress about it is because I am sooooo busy I don't have a lot of time to do groups but I'm expected to anyway even though I ALWAYS get interrupted when I do... but that's another topic. First of all: Patients LOVE the snacks but don't overdo it. There are diabetics remember. Sometimes the well meaning students make these incredibly loaded grab bags full of cookies and candy and crap and everybody's blood sugar is sky high. If you just bring some hard candy you'll be a hit and get a big turn-out. If you do any self-sharing type discussion groups, try passing a candy dish for each person who participates. Every time you participate you can select a piece. Collages usually do well and we do allow children's scissors but you have to count them before and after collection. Self-portraits are a favorite of mine... just to see what people draw. And you can win points with the staff if you have patients draw their favorite staff person etc... (I had a schizophrenic patient who couldn't remember her doc's name but she was convinced he had one leg that was substantially shorter than the other. This became completely endearing to all of us since it was not true...but his name was Dr. Shirtlek >>>short-leg?) Any craft is fun for them just use non-toxic supplies. If you want something that is a bit more educational you can do match the symptom to the diagnosis games. We did a bulletin board once that featured patient-decorated hot air balloons but in the baskets they had to write 3 wishes. You could modify that to 3 things you know about your mental illness and name the balloon itself with the diagnosis. Or if you don't want to get that deep- you could lighten it to your 3 favorite songs or something about themselves. Somebody once had patients decorate socks with colored sharpie markers. That one sort of depends on your resources. Our hospital gives each pt a pair of socks on admission though... so you could ask if you could have enough for each person to decorate. Believe me the hospital wastes so much more money on much less useful things than that they ought to thank you for doing something cheerful for the pts. Zumba dvd is a favorite standby for fitness groups. People love to line dance! And make your classmates do the group too. I hope this helps. ?

I would like to post a topic for discussion along the same lines as this "What would you have said to this CNA"... and I'm new to the site so I don't know how to go about that, ( please help) but... I work in a Psychiatric Hospital. Psych is not for everyone and it's a pretty strange environment for so many reasons. Of course in my hospital we deal primarily with Psychiatric illness. I have been very frustrated lately with two things (I'll just give one for now) about the "team" of folks I am (technically) in charge of as the RN. This team includes; med nurses (LPNs) and our equivalent of "aides" or "techs" (trained but not licensed, paraprofessionals). In my setting we expect to be called names, sometimes accused of everything from poisoning people's food to stealing body parts, writing lies...eating babies...you name it. They are Psychiatric patients, it's understood. Sometimes patients assault staff, spit, hit, kick, or accuse the staff of slightly more plausible atrocities; rape, physical abuse, theft, etc...Again, it's not a fun thing but there are policies, procedures and processes in place to investigate and respect patients' rights and safety AND we're trained to handle all of this appropriately. However; human nature can begin to influence the 'human beings' who are working in this setting. Understandably a patient can effect people over time. People become effected by dealing with so many difficult patients over a long period of time too, but...it can't be an excuse for losing objectivity and most of all you can't lose your compassion or I think ya gotta get out. I've been in this hospital a little over 5 years. I've always been a gentle nurse with a touch for the small details like an extra pillow/blanket or a few extra minutes to hear someone's worries. I feel strongly though about the importance of boundaries and sticking to the rules of the unit because it's psych. Psych patients can escalate if you aren't careful about those little things and you can put coworkers at risk if you don't maintain boundaries and rules. I say all that to illustrate here, that I'm not picking on staff who have a kind of 'all business' bedside manner. That is okay if someone doesn't feel the need to fluff a pillow...My issue is that I am increasingly troubled with what I see are coworkers allowing themselves to make judgement calls about patients they think are "faking symptoms" for instance... therefor they begin to ignore them or refuse their requests. They don't want to take 5 minutes to stand with someone and allow the person to shave, as an example, since they can't have a razor alone. They don't want to get up and unlock the laundry room door so they tell them they can't do laundry "yet", not because they are soooo busy, (like I am with the unbelievable amount of crap only an RN can do) but because they are chatting with each other perhaps...and they have developed a dislike for some patients or a "type" of patient and just don't want to, what they refer to as; 'jump to their every request'. I could, as the charge nurse, stop what I am doing and say to the person, "Please go unlock the laundry room now." Believe me I have my own style of handling things. One way is pretending I didn't hear the exchange between the patient and staff...I get up from charting and go out to the desk where the patient will immediately ask me to unlock the door so I can say "I can't at this moment but I'm sure 'so-and so' would be happy to do that for you...Could you please, 'so-and-so'? Thanks." I also try to address these attitudes while we're all in report when people freely express their irritations with certain patients behind closed doors and try to say, "I know he called you all those names yesterday...do you feel like you need to work a different unit today? Or are you okay with him?" I truly address the dynamics when I see them developing, but...people have prejudices. They just do. Sometimes they don't even know it. I do it too sometimes but I seek out a mentor or one of the docs and I take a few minutes to discuss it and change my perspective and then I try to work with the patient I am having trouble with so it doesn't grow. BUT that isn't the norm. Usually, coworkers create and perpetuate a bias in each other. If so-and so doesn't like someone she vents to her friend/coworker about what the patient did to her and they build each other and it spreads that way. I have too much to do. I cannot complete my charting, my paperwork, my overwhelming amount of daily duties and all the stupid unexpected crap that comes up AND diffuse and address these issues so that the staff will actually take care of the patients and not escalate the behavior they may even be causing in some cases. I'm very loyal to coworkers. We are often in physical danger and we have to look out for each other. I do it for them and they've done it for me but I cannot go to mangement because they will want names and to discipline people. How can it be addressed and how do burned out psych workers get inspired again? I recently had a pt who was of a different ethnic background and did not speak English. He was terribly psychotic and scared, (I would assume). It was clear that he was hallucinating sometimes and everyday I came in to reports of how he hit staff or kicked someone during the night, etc... I worked hard to get interpreters and asked family to bring him food from home and asked alot of questions about things he was used to doing related to his culture and then I let him do those things, like pray on the floor, or even sleep on the floor. I prepared his food from home, at mealtimes and I let him eat with everyone while I stayed close in case he was just randomly hitting folks without provocation...but he never did. It upset my coworkers for about 4 days. But then, after he started to get better with meds and they weren't so freaked out by his cultural oddities they started to enjoy him and his behavior also improved tremendously. BUT I had to answer for some of those things that I did. I don't care. I'd do it all again.

This is a topic of increasing interest to me. I read through many of the posted replies and it seems the consensus is that the CNA in this scenario was insubordinate and could have been written up legitimately for a couple of valid reasons...reality though; Then what? 1. In my facility- I'm a charge nurse when most senior RN of the shift or "on the floor" though most of us kind of share the burden together if there are more than one working at a time...Many refer to this mythical power of being able to "write up" someone of equal or lesser ranking...but basically what would be done involves either a union grievance or calling a supervisor or unit manager- who then determines the path of the complaint and there are complex, somewhat uncontrollable repercussions most of us deem "not worth the headache". -so we do what was done in this scenario...we handle it ourselves, in the moment, professionally, respectfully and 'smooth and soothe'...but sometimes it sticks in your side and you want to do more to address the issue. You have to act so that you maintain your own authority and respect while promoting a sense of insight and understanding of others issues without breaking down the "team". 2. The CNA described is a personality I have seen before...ever vigil for someone out to disrespect her so she can pounce and shout about how undeserving she is of that and what a "not-so-awesome" person you(RN) are, like she imagines you think you are...(confusing, there I know) but, I'm sure that she frequently behaves inappropriately in situations because this is a personality issue. (Does she do enough good to outweigh her bad points though?) The complication that can happen if you do the formal reprimand is that the CNA person never gets the message that she was wrong. She probably isn't able for too many reasons to go into... She gets angrier and begins to recruit supporters via venting about you- wherever. Next thing ya know you have this low level air of tension that can escalate, and negative opinion spreading through your "team" of co-workers that can lead to uncooperative staff. In my setting, I've seen it get unbearable for someone over something small that was just misinterpreted and the poor nurse who didn't mean anything by "leaving a note..." is now subjected to no less than a hostile working environment to deal with daily. *So much of this is something that either you understand about people or you don't (and I think you are one who understands). I know many would disagree with me on this and keep it simple and concrete by doing a "write-up" because she has it coming, period, and move on...but I would be tempted to sit down with this person and "have it out". My show of respect, which I would point out very clearly and firmly is that I would do it behind closed doors and not involve managment/or formal paperwork that would reflect on her negatively but- "I'm sorry that I offended you by leaving you a note, etc... like I did. I was interested in saving time so I could do what I needed to do and the important info- (what I needed you to do) didn't get lost- but do not forget what I listed for you to do, is what I expected to be done. That's your job and it's important you 'get that part' so patient care isn't compromised. I will try to be more considerate of your sensitivity in the future but you also need to improve how you address me...because I am offended by all the things you implied about me- not the least of which is that you think I will take that kind of crap from you- ever- in the future... that you can use the tone, the language- as if you thought it's even a little okay to use that word with me..." (etc...ad lib) After I was done, I would give the CNA free reign to unload any attitude she had/has with me without repercussion and listen to it without getting defensive. Then I would say ultimately, sincerely, with a smile..."Is this over? We can move on, issue resolved?" Smooth and soothe...but we have to be a team and the team has to function. So you, as the leader, have to figure out a way to keep it functioning the best way you can. I know I struggle with that more often than I wish I had to. Even, on occasion, with some co-workers whom I absolutely love who have moments of unacceptable, inappropriate behavior.