IMustBeCrazy

I'd be long gone from that environment. Your facility is not providing safe and proper resources, monitoring or policies for milieu control. Is it any wonder that your unit is experiencing a spike in acting-out behavior? It has become sport for your patients to see who can win the acting-out contest. I find that the administrators that advocate the fluffy hands-off approach are the same ones that haven't been out of their office for several decades. Restraint policies, when properly (and rarely) used, keep both patients and staff safe. On the other hand, I will also say that the greater than 50% of the time if you have to resort to quiet room, you've had insufficient careplanning and behavioral contracting with that patient. Our job is not to be the Behavioral SWAT team. Our goal should be to work with the patient to provide an environment of trust where patient and staff have similar goals to recognize and intervene in behaviors before they are out of control. Does your intake process require that you ask the patient 1) what types of triggers cause behaviors and 2) what their beginning upset looks like? Have them describe this to you in their own words, and don't accept generalizations like "I get ****** when people are yelling." Ask them, "how would I, as someone that does not know you, observe that you are becoming upset?" Drill down for specifics, focus on the cues that come prior to an outburst such as tapping their fingers, red-faced, staring at a wall, pacing in the hall, swearing, crying, sitting by the nurses station, isolating to their room, etc. Careplan it, assist them in recognizing their cues, provide alternatives such as 1:1 time with staff, listening to music/a calming solo activity or PRN medications and ultimately hold them accountable for their own behaviors. Above all consistency, consistency, consistency from shift to shift! If you don't take the time to careplan it, then don't be upset when the next shift does something completely different and derails the structure you have initiated. Lastly, since you are having such high unit acuity, it also sounds like your manager should be helping to provide you with extra staffing for the short term. There needs to be extra eyes and ears down the halls to provide a calming influence and to redirect minor behaviors that escalate quickly if unaddressed. If they balk, remind them that paying an extra person for a couple days is much better than having to explain to Joint Commission on their next survey why they had 10 restraints in 2 days!

If she's not suicidal, taking overdoses, harmful to others or such a self care deficit that she a harm to herself (for example so grandiose/delusional she is walking out in the snow in the dead of winter in bare feet), then she is beyond your reach at the moment. The family needs to start an intervention NOW with her. That means taking the car, cutting off the credit cards, stopping all financial support, taking away the house key or changing the locks, etc. You don't get your lunch for free in this world. It's about tough love and not enabling. If you have even one enabler in the family, she will gravitate quickly toward that person and not learn a thing except manipulation. You can't make her go to treatment/get help, but you can stand firm. Say, "We are DONE. When you go to your doctor's appointment, get on meds, etc, we will be supportive, and not until." Until she decides to meet up with her life responsibilities, get your family into some counseling sessions. The family is always the last to get help, since they are so focused on the wayward child. That stops now. Help yourselves to be strong and functional, inevitably you will be more of a help for her.

Acuity tools on inpatient psych are very misleading IMO. Acuity is supposed to be a numeric measure of the TIME spend with a patient or on their care (med rec, getting orders, completing admit paperwork etc.), based on their condition. So, theoretically a "1" is someone with few needs (INCLUDING few needs of your support staff), stable, very few or no meds, all discharge completed and waiting to leave. We rarely have a "1" on our unit. In addition, acuities are flexible and can change during a shift. If you are not willing or unable to dynamically update and reassess the state of unit acuities during your shift, then they are useless.

IMO you are just a call away from a HIPAA violation (privacy, remember?) and losing your license. Former patients? All attached to you on the internet?? Scary stuff.

Law Enforcement officials can NOT deny you the opportunity to give a written statement. In fact, you can hand write a statement and deliver it to the nearest LE office. I don't care if the situation occurred 2 weeks ago. Sounds like someone is trying to dissuade you. And, it is not up to LE to press charges, that would be the purvue of the local district attorney. So pooh on them! My biggest concern is that you have been assaulted so many times. No need to be a punching bag. Nursing has too many choices to continue to be disrespected by your facility and battered by patients in your current position. I would talk to a psychologist, get on FMLA and use your short term disability/vacation/PTO and take that time to find another position. I would also encourage you to do some soul searching to determine if you had somehow unwittingly put yourself in the line of fire. Sometimes it does come down to misreading situations or violating cardinal rules like "always be between the patient and the door" or "2 armlengths away" kinds of things. Good luck!

I have no problem being compassionate. However, in the U.S., stinky = unclean. Unclean is probably not what we want to project in a hospital environment. It makes patients (as well as staff) uneasy and feeling like they're getting poor care. Press Ganey, anyone? My mom always used to say, people can always afford 50 cents for a bar of soap, there is just no excuse. If someone is truly in a personal predicament, I can't imagine any manager that would not allow someone to use the hospital locker/shower area and provide a bar of soap, maybe even hospital scrubs. When in Rome, do what the Romans do. When in a hospital in the U.S., bathe regularly and wear clean scrubs. This is not difficult.

bingo! i had viral meningitis, and it was nasty. my head was splitting, i wanted no one or nothing to come near me. any stimuli is too much. you better remember to turn the lights off or very low when you are done assessing your pt. no or very low noise. visitors? no thanks! morphine and i were best friends for a couple days! isolation gown/mask/glove yourself. have your pt wear a mask (reverse isolation) when you're in the room and keep them clean. primary transmission mode is saliva/sputum/nasal mucus/fecal matter. don't expect them to be able to answer heavy duty questions other than pain scale for a few days. i didn't feel like eating, so find out what kinds of fluids are best tolerated (water, juice, soda, ensure, whatever) and keep it coming!

CPI is a complete joke. I suspect it was put together by corporate bean counters who have never had to be out from behind their desks in their entire career.

Amen!!! I agree 150%! I have said it before and I will say it again, psych nurses need to have EXCELLENT assessment skills AND the fortitude to advocate for their patients, no matter what their diagnosis is. The often thought but extremely incorrect sentiment of "You don't have to be a REAL nurse to be in psych" is a complete joke. If anything, you need to be even more on your game and be willing to be outspoken for the patients that are not able to do so on their own.

Understood. But this doesn't even qualify as a "compromise." It is merely a shell game where you lose sight of the real issue via and smoke and mirrors. The ANA, with their purported massive resources, is proprosing schlock like this when CA has state ratio LAWS?? This is pathetic and unacceptable *and* and they have the unmitigated gall to pretend this is some sort of progress???? The reason we are in this situation is due to hospital mandated 'ratios' in the first place. I respectfully disagree.

This sounds like a great idea in theory, how many of you have read the letter in its entirety? (bolds are my emphasis): --------snip---------- I am writing to urge you to cosponsor the Registered Nurse Safe Staffing Act (S. 73/H.R. 4138), legislation that would hold hospitals accountable for the development and implementation of unit-by-unit nurse staffing plans, in coordination with direct care nurses and based on each unit's unique needs. The RN safe staffing requires the establishment of a staffing system that ensures a number of RNs on each shift and in each unit of the hospital to ensure appropriate staffing levels for patient care. The also bill provides public reporting of staffing information. Hospitals must post daily for each shift the number of licensed and unlicensed staff providing direct patient care, specifically noting the number of RNs. Safe staffing is among nurses' top concerns and is key both to patient safety and retention of nurses at bedside as we face a growing nursing shortage. The link between patient safety and nursing care is well-established. According to a 2002 study by Linda H. Aiken, PhD, RN, each additional patient added to the average workload of staff registered nurses (RNs) increased the risk of death following common medical procedures by 7%, and the risk of death was more than 30% higher in hospitals where nurses' mean workloads were 8 patients or more each shift than in hospitals where nurses cared for 4 or fewer patients. Furthermore, research has shown that when there are more registered nurses (RNs), there are lower mortality rates, shorter lengths of stay, reduced costs and fewer complications. When it comes to addressing the nursing shortage it's important that we address both recruitment and retention. The latest RN National Sample Survey of Registered Nurses by the Health Resources and Services Administration showed that on average in the US 16.8% of Registered Nurses are not practicing in nursing. Higher patient care assignments put nurses in the stressful situation where it becomes difficult to provide the level of care needed to assure the best possible outcomes for their patients. Under these circumstances, it is not surprising that staffing conditions are among the chief reasons nurses leave the bedside. In order to truly address the shortage we must create environments that retain nurses. S. 73/H.R 4138 recognizes that the complexity and variability of today's hospitals requires the determination of staffing patterns at the hospital and unit level, with the vital input of the RNs caring for patients at those institutions. I urge you to cosponsor this important bill. I look forward to your reply. ----------end of letter---------- IMO, this proposal is weakly worded with reference to a study that has little bite (the risk of death was more than 30% higher in hospitals where nurses' mean workloads were 8 patients or more each shift than in hospitals where nurses cared for 4 or fewer patients - lots of gray area there to exploit by hospitals.) So, we are empowering hospitals who, by the way, have already exploited us, to implement adequate staffing patterns?? We are expecting the public to understand the difference in care on a unit that may have 3 nurses, and 3 aides for 24 patients compared to, say, 5 nurses and 1 aide? Are we stupid? Who is the ANA really backing, nurses or hospital franchises? I leave you with a thought. My manager dreamed up the idea in the last six months that our nurse-driven acuity system was broken. My manager's "fix" to that was we are to systematically lower each patient's acuity, thereby allowing even more patients onto our unit. Why would I trust a hospital to implement an adequate staffing pattern?

1. No 2. I haven't seen a compelling reason to join. They seem to be their own best enemy, for example in proposals that seek to divide rather than bring together nurses from all backgrounds, from Diploma to ADN to BSN and beyond. In addition, I don't see them pushing for mandated ratios, which is the #1 bane of nurses working today, causing high turnover and burnout within the profession. IMHO, it's a sad day when a state nursing association (California) has more momentum than a national organization. It is my *opinion* that they are more concerned with making nice with the national medical/hospital "franchises" than backing solutions relevant to the current nursing crisis. 3. I can't endorse this organization at this time.

No flame here, just another viewpoint. I work with families all the time that are crazier than the one admitted. Here is my take: The bottom line is that the POA-HC is *supposed* to act in the best interests of their charge, unless there is some reason in writing that makes sense, such as: pt declines transfusions, this is noted on the POA-HC document and the agent is simply carrying out their charge's wishes. When they have gone this far off the deep end, and are pushing for things that are patently unsafe for the pt, my institution initiates guardianship proceedings and guides the crazy agent out the door with a "no trespass". This is not common, I haven't seen it a lot, but it does happen. I can't think of any judge that would not endorse this. And thank heavens for it when we need it on behalf of the pt. :bowingpur

How typical for mgmt to say "just make it work" rather than meet with staff to come up with a decent working model. /vent off

The suffering that I refer to is the change in the therapeutic milieu that occurs for the patient when it is obvious that the nurse is also having problems with mental health issues. This is completely different than, say, a nurse with cardiac issues that works on a cardiac unit. General medical units are more "task-based", so as long as he/she is proficient and can monitor rhythms, hang cardiac drips, assess pt, monitor labs, etc., there is little impact on the nursing or patient milieu there unless he/she is unpleasant, which is a different thread altogether. Behavioral Health units are very different. Patients generally are "walking and talking" to themselves and others :wink2:. On a medical floor, the only time you will generally see patients out of their room is when they are ambulating in the hall, etc. In most medical units, pts don't usually talk amongst themselves, and other than their assigned nurse, the other nurses on that unit probably do not have any idea of who that pt is. Medical units don't have 'activity group', 'community meeting' or 'group therapy' designed to bring patients together and learn to cope and function within a small group/society. The reason mental health pts go to the hospital is to be surrounded by a solid, supportive therapeutic milieu *in addition to* getting the help with general medical problems/medications that they may need. Maybe it's one of those things that you need to observe for yourself as a staff member to understand the importance, because it is tricky to explain. One of the problems I observed firsthand was a willingness for the nurse with their own mental health issues to form some type of alliance (whether knowingly or unwittingly) with the patient that allowed that nurse to be more easily manipulated by the patient. In my opinion, there should never be a reason for a patient to know a staff member's mental health or medical diagnoses or for that matter *any* personal information - 99% of the time it turns into a problem. I can't tell you how many of our patients, especially the returning pts, are able to staff split very effectively in this way. And that is only one example. Generally, the reason BH pts decompensate and require hospitalization is due to stressors in their lives. Running an effective BH unit is full of stressors for staff as well. How will you feel when you need to be involved in putting your pt in 4-point restraints? How will you feel when a pt attempts to hit/kick/bite you? How will you feel when your patient brings harmful contraband that could potentially hurt other pts or staff members onto the unit? How will you feel when a pt calls you repeated foul names just for doing your job? How will you handle 2 or more pts that have made it clear that they do not like each other and *will* physically confront each other? How will you handle families that come to the unit reeking of alcohol/marijuana and demand visiting time? How will you deal with family members that are even more profoundly mentally ill (but not generally diagnosed) than the pt that is in your care? How will you feel when you find out that a pt has blatantly lied to you about their health history i.e. being abused as a child for example, just to elicit sympathy from you? These are just some of the things that are very difficult to deal with, and make it necessary to bring your "A Game" to work every day. And, more importantly to keep that "A Game" going when things get rough on the unit - there is no time to counsel a staff member as well. Do I believe the nurses on my unit are perfect? Not at all. But I have no doubt that any or all of them will "have my back" and not hesitate to jump in if things get rough. More importantly, I trust each and every one to "de-escalate" a situation before it becomes a problem. And many times, that "de-escalating" process means being able to understand and comprehend their role in the situation and how they contribute to it. I wish you the best on whatever career path you choose!