Words Matter

Thank you for sharing your experience. If you don’t mind my asking, what was your benzodiazepine daily use, and what was the starting point of taper? I had a patient recently propose to his psychiatrist using the Ashton Method for tapering. Is this the model/schedule you are using, or is there another resource informing your specific taper?

LOVE IT!! Talk about perspective :)

When I was acquiring my pre-reqs for my BSN program, I actually had virtual labs for the anatomy, physiology and Microbiology courses. I was so grateful at the time to have found this option as I tried and failed two semesters to enroll in the courses with on campus labs. Real Life Nursing 101 - Adapt and Be Flexible The recommendation for applying to a New Grad program is solid as these programs will have ample opportunity to benefit from the support of experienced nurses. More than likely, programs have already made accommodations to the orientation phase with the knowledge of the challenges newly graduated nurses faced due to COVID. Your situation is exactly the same as every other nurse soon to be graduating. You will be OK. Skills can be taught and learned on the job. What can't be taught are integrity, compassion, humility, and respect for self and others which are all a much bigger part of nursing than striking gold with a catheter insertion. You may be green and inexperienced, but definitely NOT useless! Keep in mind, even the nurse with 30 years experience started their career green and inexperienced too. You will make mistakes - we all do. Take responsibility immediately, get direction from your supervisor/charge on what to do next, and learn from it. Practice good self care so you don't burn out. You cannot care for others if you haven't cared for yourself first. Be well and all the best to you!

I found Cy Wakeman humorous. What I got out of her talk was leading others to uncover they often do have the ability to create their desired solution to meet many challenges. Many times I've observed intelligent and experienced professionals going to their leaders to "fix it now". So many little fires need to be extinguished before making actual progress on projects which can have real long term benefit. I would love to get that time back! Maybe because I share the professional background in mental/behavioral health, one of the foundational statements she made about not being able to be in ego (I.e. self centered, self serving, blaming, judging) and higher self (e.g. serving others, collaborating, creative solutions) at the same time is a game changer. This is cognitive behavioral therapy applied to leadership!! I've been teaching CBT coping skills to my patients for years and never considered application in the workplace (mind. blown.). Thanks for the recommendation - I just downloaded No Ego to my Kindle app. Since I have a brief hiatus from my Master's program, I am looking forward to this read.

Thank you so much Nurse Beth! I am beyond grateful not to be alone in navigating this situation, both within and outside of my organization.

I appreciate your feedback and strong opinions. We all have so many experiences, personal and professional, informing our opinions, responses and reactions. I like what was said in one of the earliest comments about going high when someone comes in low. This is something I need to take ownership of to the point it is ingrained in my character. Honestly, I'm not there YET (AEB the thoughts and silent dialogue that sometimes occurs between my ears!), though at the very least I want my actions to communicate I am a fair and approachable leader. There is too much us v. them in the world in general. I appreciate the awareness of this problem and direction toward collaboration in healthcare. Though I don't foresee getting away from "doctor's orders" anytime soon, interdisciplinary teams/councils/committees, patient centered care, trauma informed care, the care continuum are all the result of working together ?

Thank you everyone for your suggestions, experience, and conversation. Here is the latest update: I met with our interim HR manager for 2.5 hours. I was expecting no more than an hour meeting as the original intention was to review the current bargaining contract, review my documentation of anecdotal notes and get direction on future account documentation. The reason the meeting was so lengthy was a majority of the time was spent on the HR manager getting my perspective of the unit needs, complaints from other staff (r/t both staffing and said nurse), and solutions I or management have offered/initiated. It turned out the nurse had met with HR just two days prior to my scheduled meeting. I received good direction from HR specifically in regards to not labeling behavior, just being factual. She educated me on the disciplinary process, my involvement as a supervisor, and the responsibilities of management. I then met with my manager and learned of other reported actions by this nurse related to her now documenting timelines of my comings and goings during the shifts I work with her. My soul ached learning this because I want my team to be able to rely on one another. I have nothing to hide, and my manager voiced she knows I do my job and more each day. My manager has given me a gift by calling an all staff meeting at which she and our Director of Inpatient services shared the timeline of what has been in the works for nearly a year to address our budgeting and staffing needs. Joint Commission survey followed by COVID put a halt on progress for a while, but an additional FTE has been posted meaning both AM and PM shifts have an aide for the full shift rather than 1 cross shift aide. Our current full-time and per diem cross shift aides chose to transfer to my shift over morning shift, so I can't be that terrible of a leader :). Hopefully, this addition to staffing will squash any further complaints. Annual evaluations are due so there are a couple of points in regards to her performance which are necessary to address. I will be certain to help her to focus on the topic at hand being her performance, rather than who she feels is to blame. "...we are here to discuss your performance." Talking this situation over with my mom and a couple of friends who are also in leadership roles, I have identified for myself the most important actions I need to take right now is pray. I need to pray for peace and happiness for this nurse. I need to pray to gain compassion for this nurse. And I need to pray to remain focused on having an open heart so that I can serve as the leader I know I am and the leader my team needs. I will continue to document as needed, but rather than "coach", I will role model. I have been asked to trust there is a solution in the works. This is such a relief, because now I have more time and energy to channel into patient engagement and unit/program improvements; the stuff that brings me joy and a sense of accomplishment as a nurse.

AMEN

Thanks - this is a great tip. I absolutely agree regarding the importance of a slow taper. My original intention in this post was to learn from others what tool they may use to document benzo withdrawal assessment. The response of our informatics nurse to my inquiry of adding the CIWA-b as an option in our EMR program was it is too long. Only COWS and CIWA-ar have been programmed in our EMR, along with a comments section. Recently, I printed the attached CIWA-b and keep it on the patient's chart, note this in the comments section that CIWA-b is appropriate for benzo detox, and I document a narrative of my findings in the IPOC notes noting the written assessment on the pt chart. And Hppy is right, the assessment doesn't take very long. The charting is what takes forever - 10 minutes of charting for a 5 minute assessment! Guess I'd better take some typing courses!! benzodiazepine_withdrawal_scale_ciwab_dassa[1].pdf

I am just curious if anyone is aware of a brief benzodiazepine withdrawal assessment tool, like the CIWA-A. The CIWA-B just has too many questions! Many of our nurses use the CIWA-A because our only two options are that or COWS which of course is completely unrelated. Thanks in advance!!

You are absolutely right. And we have had several 1:1 conversations at her request which end with her sending a text or email stating she appreciates feeling heard and supported. I want her to succeed and feel she's done good for at least one patient during each shift. During the short time with my new team we have gained a person who is dedicated to patient rounds (in behavioral health, because the patients are engaged in milieu therapy and have varying types of safety risk factors, we must document each patient's location and affect/behavior Q30 minutes), and fast tracked RN's ability to assess an intoxicated pt at intake rather than waiting until they arrive on the unit, which will lead to a reduction in immediate ED transfers for medical clearance, reduction in Code Greens responding to belligerent patients, and hopefully decreased AMA's < 12-24 hours. RNs used to do the rounding until a few months ago. I like your suggested scripting in the last major paragraph of the referenced post. I am going to borrow that.

I'll keep trying on this effort. I have faith people will rise to the occasion. So far, recommendations I have made have been shot down by her, "I did that before, and nothing came of it". I encouraged her to try again. I have even coached her on the type of data she can document to support her effort for another FTE. We must have the data to back up any proposed changes and requests. I invite her to our monthly UPC which meets through Microsoft Teams, and request input on the agenda with an invitation to be part of the conversation. Currently, her personal annual goal is to attend a seminar on nursing management/interventions for the anxious patient, and I suggested I could request admin hours from the manager for her to prepare a brief presentation for her peers during UPC to apply interventions with our detox patients. All annual reviews are to be done a month early this year, so I hope the seminar is prior to her review. I would love to know her excited about the material she was exposed to in the seminar. BTW - no next level conversation yet. She was on PTO, then worked the following weekend when I directly observed two instances of misconduct and defiance while she was charge RN and I was on admin. Per my manager's recommendation, I have reached out to HR for guidance on appropriate documentation leading up to and throughout the disciplinary process, if this is the necessary path. Everything must be just right, so we follow all union agreements and the law. I took this role because I was excited about the ways we could improve our patient engagement, care and programming. This whole experience with this nurse has been too much reality...

Thank you Nurse Beth! I'll let you know how the conversation goes, and will be certain to keep the focus on her performance. Sounds to me like you have rumbled with this type of employee. The good news is my manager completely supports my efforts, has faith in my abilities, and is available for guidance.

I am also a CARN, 5 years in psych dual diagnosis and mood disorders, though now I have the opportunity to focus on inpatient detox. The term "addiction" does not solely encompass substances. There is gambling, sex, relationships, food, sugar, drama, etc. Evidence shows the same parts of the brain are engaged when the individual is partaking in their drug of choice, even when it comes in the form of a donut. Naltrexone is being used for craving management in prevention of opiate use (IM-Vivitrol), alcohol abuse (PO-Revia), and binge eating disorder (PO-Contrave). Similar interventions and therapies are used to teach our patients no matter what they are recovering from. Why do you think you can find a 12 step recovery program for alcohol, narcotics, overeating, gamboling and sex? Because people have successfully learned a different way of life through the same concepts. Words only have power we give to them as a culture. In my experience, "addiction" is a condition, period. "Addict" can carry the same stigma as "alcoholic" or "dope fiend", and whether or not to identify with the label is up to the individual who is living the experience. Do some research on the use of person first language. I believe you are correct in a clinical "PC" or diagnostic regard of using SUD over the term addiction. I'm uncertain there is a DSM-V diagnosis for addiction, though I do know SUD and AUD are in the DSM-V. But, when we are talking with our patients, we use the terms they prefer. For many, it will be addiction.

I work at an inpatient acute care freestanding psych hospital. As a violence predictor we use the Broset Violence Checklist (BVC). The main con is users not assessing properly. The various categories are assigned a score based on that behavior being Present or Absent/Baseline. For example, if confusion is a person's current presentation, but it is also the patient's baseline, the nurse should tick Absent/Baseline which would score 0 for this part of the assessment. An uneducated nurse may tick Present and unknowingly flag the patient as an increased assault risk. Proper education and follow up can prevent this from happening. A lot of research went into choosing this assessment tool for our facility.

Thank you for the post. I have also wanted to get into psych nursing since before my nursing program. I was told this specialty is where nurses go to retire; so I was hesitant to announce my interest until our psych nursing rotation. Where others were uncomfortable asking about SI or talking to a depressed patient, I thrived. Monday will be my first day with patients at an acute care psychiatric hospital. I am fortunate to be part of the RN residency program. We met with a few leads from the specialty units, and I have an idea in mind of where I am hoping my home unit will be. I feel that nursing is such a broad career path of opportunity and specialization, there is absolutely NO REASON to enter an area of practice without excitement and passion for the work to be done. The bonus of my particular residency is that the hospital is part of a larger healthcare system. If I decide I would like to get some Med Surg experience under my belt, I am welcome to request a unit transfer. We also have a Geri Psych unit; I was told this is where we would utilize more of our technical nursing skills. ECT is an option for cross training (opportunity to keep IV skills in check). I am interested in knowing more about your liaison position and how this is different or more involved than being a direct care RN as we are responsible patient advocates.

If you know the school you will be attending, I advise you speak with the nursing clinical coordinator about your situation. The person in the school of nursing tasked with arranging clinical assignments will have the best insight and direction to share with you. The reason is, that more than likely, limitations are based on requirements of the facilities where clinical placements are made. Do not speak with a general admissions counselor if at all avoidable. Your situation requires very specific knowledge. Additionally, know what your state's laws are regarding expungment for a felony. The requirements and allowable offenses are different than misdemeanor expungements.

If you are getting ready to enroll in an upcoming cohort, or are trying to figure out if this program is for you, I just want to let you know to have faith. There is a reason that students who have passed Med Surg are smiling. If you can keep a positive attitude, and manage your time well so that you are able to make the connections between theory and clinical days along the way, THERE IS HOPE AFTER MED SURG! Make the most of your time in Pharm. When it is suggested to learn the classifications of the drugs and how they work in the body, this is good advice and will serve you well during clinicals especially when interacting with your CI and mentoring shift nurse. Regarding FINANCES (personal) - during my initial orientation I was told to be prepared not to work by Med Surg. I was able to arrange with my current long term employer (non medical related) a planned leave of absence. I am a single mother to an elementary school aged child and I have a pet in particular who requires a bit more care than the average bear. Please know that if you are in a similar situation and use to being self supporting, financial aid will not cover ALL living expenses even with the additional allowance. Be prepared with a back up plan to cover your essentials. I cannot compare this program to any others. This was the only path I looked into. If you are debating between this program and another, there are two major points I would like to share which I have learned along the way. First the bad: There is no externship after our program is complete. We have great clinical experiences along the way, but no foot in the door with an externship. Now the GOOD: Again, I have no experience with other schools, but I can say that our clinical rotations occur concurrently with our theory course of study. This means, that when we are learning about Maternity Nursing and newborn care in theory, we are also attending clinical days on the L&D units of our assigned facilities. I have heard through Clinical Instructors and staff nurses that this is not the case for all schools and that sometimes a clinical site may be assigned without any baseline classroom or textbook knowledge. It is truly a benefit to the patients, staff nurses, and student to have this experience of concurrent theory and practice. Just though I would share a bit of my experience in hopes that this is helpful to a future nurse.