margo123

I've been a nurse for 21 years and a charge nurse for the past seven. My unit is under new management and the new boss wants the charge nurse to take more responsibility for the actions of the other staff. I have experienced capable and conscientious RN's under me and see no need to micromanage them. I myself must assume a full patient load due to staffing restrictions. I'm being asked to check their documentation to see that it's up to par, check up on them when they're doing assessments to make sure they are thorough, and generally breathe down their neck. I don't want to do anything to create anamosity and find it all pretty condescending considering that they have such excellent skills. Aside from that, I don't have the time to tend my patients, do my charge nurse duties and micromanage my staff. This isn't being required because of any problems my staff has had but because we are in a hospital that's moving toward magnet status and the bar is being raised higher and higher. Fine, let's raise it but give us the staff to make it happen.

I'd be interested to hear from nurses out there who work weekend option jobs. My hospital is treating us badly. They are only allowing one weekend a year for sick time. We're allowed a total of three weekends a year off including vacations. Our jobs will be posted if we exceed this. Most of us are foregoing our vacations in case we get sick or have family emergencies beyond the one allowed weekend. Our jobs will be posted then as regular eight hour shift jobs. The hospital wants rid of weekend option but firmly denies it. Are any of you experiencing this?

Your advice is much appreciated and I know I must do something and soon. There was a staff meeting today and I was very vocal about my thoughts re all this. I told my director that I think this unit is a disgrace and a tragedy waiting to happen. She agreed with me and said, "I know but my hands are tied. I have bosses, too." I asked her if she thought they realized how many fundamental care principles have been breached and she said, "They don't care, they just want to fill beds." She made all kinds of promises about how things are going to be reworked to make it a safe unit. When I mentioned specifics, she got evasive. I think I'm pretty much out of luck getting anywhere thru her. She feels compelled to "go along" with her higher-ups. Her personality is one of the people pleaser and people pleasers talk from both sides of their mouth. After a half hr she announced that we had "talked enough" about this subject and moved on to subjects that are trite in comparison. I have considered the options you have suggested and think I'll put the wheels in motion next week. Thanks to all for the input.

I really need some help here. I work on a small thirteen bed unit in a community hospital. My boss has opened up six more beds for observation patients. The original concept was for it to be a 24 hr. short stay area, during which time it would be decided if pt was able to be discharged or needed rolled over to inpatient status. This unit is tucked away at the back of the Gero Psych unit separated only by a curtain from the elderly patients. The unit hasn't been used as was originally planned. Pts are being held there who are too violent to be incorporated into our general population, borderlines are being held there. One bpdo set himself on fire last week. They had to do a take down on him in the Gero hallway when he escalated one day. All the oldsters were present. It was a miracle nobody got knocked down in the ruckus. This unit was initiated without any forethought. No extra staff was hired. We're expected to come in extra hours and staff it through mandatory overtime. I worked there last night and admitted four patients. I had one who was MMR, schz, and has second degree burns over 20% of her body, IV's, dressing changes, paranoid and fragile as all get out. Admitted a bpdo, who wanted to take the thermostat apart and carve herself, an alcohol detox came in early withdrawal, a 24hr detention with cut wrist who had come with screwed up paperwork on her detention papers. I had to iron that out with state police officer standing there glaring at me like it was my fault. I was loaned a new clerk for a couple hrs. She was too green to be much help at all. My equiptment was a small table, a laptop in the hallway. The charts were placed on the floor. There is NO confidentiality because the patients mill around where all the documents are exposed and try to read charting over your shoulder. All the supplies were located up the hallway about eighty feet, well out of sight and sound of my patients, so in effect, everytime I had to run to get supplies, I was leaving patients alone. I know that this breaks every regulation in the book and I'm putting my license and life on the line by working in that area. My boss poo poo's every concern staff mentions. She calls us "Queen Bees". I don't want to quit my job but I'm about ready. There are about four other nurses who are as fed up as me. The rest of the staff is fed up but too afraid to complain to the boss. Am I over- reacting here?

I've been working one day a week for the past eighteen months helping administer ECT. I think the screening process is key. Some of the personality disorders slip by our docs and usually we see no improvement with them. Our clients who have real depression make amazing improvement. We treat a lady who is bipolar and can become catatonic. It truly has saved her life. The turnaround she has made is astounding. Our list of success stories is a very long and gratifying one. Many of our clients are troubled with memory loss immediately following the treatment ie not being able to remember where the dressing room is, who drove them to treatment, etc. They report that this is transient. Virtually all of them report what they have traded in memory loss for the immense relief from depression is well worth it. I can't think of a single case where severe memory loss has happened. A few have complained of headache and/or muscle soreness afterwards. We treat this with Toradol and usually our clients are soon comfortable. I can say with all honestly, that I would have it if needed. I'd recommend it to a loved one if they were suffering. The positive effects can subside after a few months of stopping treatment (not always). Those clients come back for more ECT because they know they're going to feel better again soon. Hope this helps and the best of luck to you.

This unit will have a capacity of 6 beds. That means 6 beds and a hallway that is the only area for the patients other than their rooms. Yep, no activity area available. The rooms have no tv, so the only distraction other than sleeping for 24hrs is to be out in the hallway. Not good.

My unit has opened up a new observation unit intended for patients who may only need short-stay care. This might include somebody who has suicidal ideations and no beds are available on the regular unit, or a borderline who was just stitched up in the emergency room. It also could include somebody who just needs to talk, as we all know can relieve the current angst and then the patient is asking to be discharged. The unit really was formed because our emergency docs were pressing us constantly for beds we just didn't have. Management has opened this unit without hiring any new nurses. We're staffing it with mandatory overtime. Also, the beds are located on our gero psych unit. The only thing dividing it from the gero beds is a curtain. I have some serious concerns about safety. We're told that no patients with potential for violent escalation will be admitted there but anybody whose ever worked psych can tell you that you just can't always predict that. We're staffing this with one nurse, with the plan being that "you can always yell for one of the gero nurses if need be." Would love to hear your feedback on this.

You're absolutely right about staffing. I wouldn't have any reservations about an open station if we had more staff. True, we only have 13 beds but they're always full and sometimes the acuity is through the ceiling. I've had to beg to get that third person on my shift, 7p to 7a. Most times, we work with two because our gero unit (three floors down) needs her worse. Staffing is lean all over my hospital due to cost-cutting measures. I'm hanging on because I love psych and we just got a new DON who thinks we need more staff. Some new jobs just got posted, so I'm hopeful.

I'd like to comment on this. If you are moving about in the milieu when a patient is agitated, you usually take a buddy along. Hopefully, a third person is at the desk or close to a phone. Many times a nurse will be alone at the desk and it seems to me odds are that the desk is where the angry patient usually comes to make demands or to vent. I work with a nurse who was held hostage for two hrs because a pt came in the nurse's station and got between her and the phone. He actually ripped it out of the wall. Fortunately, a psychiatrist happened to let herself in the back door of the unit and overheard the situation. She quietly slipped out and made the emergency call.

I've asked myself the same question about HIPPA regs. The patients who are prone to hanging around the desk can hear everything we say, even if we keep our voices low. I've even seen patients run and tell other patients what we've said in re to their case. A case in point would be an instance where the social worker had taken a call letting us know a bed had opened up at a state facility. The patient who was going there actually heard it from another patient before he could be informed by staff. This is not fair.

I wouldn't mind having an open nurse's station if we handled the types of patients that are usually seen on our unit. I do get uneasy when we have antisocial personalities. Some of these people have done some very bad things in the past. Unfortunately, our little unit is not equipped to handle these patients. They slip by our admitting docs because the history is taken by phone from the other doctor requesting the admission and isn't usually very accurate. I guess you could say they "bend the truth" a little to get our docs to say yes. Believe me, I feel better in an enclosed station when dealing with them. Then you have the borderlines who are constantly scanning the environment to get something to hurt themselves with. They can be very crafty at reaching over to grab a pen or paperclip or whatever. If I had my say, we'd go back to having a closed station. We are forced to work with a staff of two at times and this would lend a small measure of safety for the staff. We are also very proud of our restraint and seclusion records. I think some of the new antipsychotic meds are so effective that usually some verbals and a prn are all you need. Thanks for the letters. I love hearing how the rest of the country is doing it!

I worked ICCU for five years right out of nursing school. I still apppreciate the good solid med-surg base I got there. Psych patients are getting more physically ill all the time. I really love working psych. It sure isn't ever boring! By the way, I spoke with my director today and she said that the patient ended up in the intensive care unit due to severe tachycardia. The cardiologist thought it was all the zyprexa. He's doing ok now. Mind is clear, manic episode is passed. Started Depakote today.

Thank you for passing this on to me. It alleviates some of my concerns. I have come to see in twelve yrs of psych nursing that controlling mania can become an extremely confusing and clouded issue. Pts get bombarded with so much medicine in an effort to curtail the episode, that staff begins to wonder if some of the meds are "fueling the fire" so to speak. My experience with using zyprexa at this high dose is limited but my observations and my gut instinct tell me that it isn't the ticket in most cases. Over the years, all told, most of my nursing colleages agree with me that IV haldol and ativan bring the patient out of mania faster and safer than anything. The beauty of using haldol IV is that you don't get the unpleasant side effects. I also think zyprexa is a great drug for psychosis. I've seen many folks clear up in a couple of days on low doses.

Thank you for this info. It makes me a little more comfortable but still have strong reservations about dosing so high. I haven't been greatly impressed by the results I've seen so far with control of mania and agitation by the third day or so.

Are any of you seeing psychiatrists ordering really high doses of Zyprexa intramuscularly? A couple of docs at our facility are ordering it 10mg tid times 9 doses. This is usually to treat bipolar mania. I have some real reservations about this much as most of the literature I have consulted suggest 20mg as the ceiling in 24 hrs. These patients generally become tachycardic by the second day and I really think a lot of them are getting more agitated at this high dose. Yesterday I assumed care of a young patient who was in his third day of this tx (about seven injections). He was so agitated that we had to eventually restrain him. His agitation only escalated then. He was tachycardic, diaphoretic and for about an hr temp was 99.9. I feared NMS but with good hydration his temp came back down to normal. Psychiatrist came in to do the mandatory face to face for the restraints and was baffled. We had given this pt. Ativan 2mg q2hrs x3, seroquel 200mg stat, geodon 20mg stat. Nothing was slowing him down. As I was going off shift this morning psychiatrist was at the bedside ordering Valium 10 iv. He had a suspicion that pt was withdrawing from alcohol. This was his fifth day in the hospital, so no way! UDS was neg for benzos, pos for thc. My feeling is that this pt simply didn't react well to all this Zyprexa. Any thoughts on this? I'd like to hear from some of you re this. I'm about to the point of refusing to admin this much.