Dan McFeeley

In your second post you said "Since my original post, this resident has not had a behavior change unfortunately but has continued to hurt staff and did have resident-resident altercation" -- that sounds to me like grounds to send the patient out again. I'm employed at a local ER as a crisis worker and have been on the receiving end of situations like this. We're required to call a psychiatrist for disposition, either the patient's own psychiatrist at the LTC, if s/he has one, or the psychiatrist on city call. I've been in situations where the psychiatrist elected to send a patient back, but when I called the RN at the facility to give report, the RN would respond with something like, "I talked with our DON and we simply cannot accept the patient back because of the risk to staff/residents," or "don't send the patient back until I talk with the DON" after which the RN will say the same, the DON says we can't take the patient back. It can get awkard -- on the one hand a nursing home can't refuse a patient, on the other hand a nursing home can't accept a patient that poses a significant risk to staff and/or residents. I've also been in situations where a patient was sent back after the psychiatrist decided it was a one time kind of thing, the patient had a similar behavior outburst and was sent back, and I would tell the psychiatrist "the patient was sent back but is still being aggressive, we need to admit the patient this time." Sending the patient back ER for continued aggressive behavior after previous ER admits for the same sends a signal that this is not an issue that the facility is supposed to deal with. If the patient is being seen by a psychiatrist at your facility, and the psychiatrist has admitting privilages at a nearby psych unit, call the psychiatrist before the patient is sent out. If the patient doesn't have a psychiatrist, see if you can get one. It can be a problem in admitting a patient for aggressive behavior when underlying medical causes are ruled out, or if they can't be attributed to a psychiatric condition. None the less, an LTC facility can be liable for continuing to house residents who are a threat to staff and other residents. If a serious injury happens to one of the residents or your staff because of your resident, and there is continued documentation of aggressive behaviors in her chart, a lawyer feeding frenzy will likely ensue. If your doctor had given an order for psychiatric evaluation, and the documentation you've been able to find shows that it wasn't done then I'd call the doctor and have him/her look into the matter. Did the ER call you with report before the patient was returned? If not, then maybe that is something your DON should look into. Hope this is helpfu! -- Dan M.

It shouldn't be a factor at all. Your medical records are your own private business, and HIPAA forbids a potential employer from forcing a disclosure. Think about it. It's nothing unusual at all for people to seek mental health services. Maybe about 50% of the population needing services of one kind or another? Do a search yourself for the per capita rate (since I'm too lazy to do it myself) and you'll get a realistic figure of how many people, *already in the mental health field*, who have received mental health services, psychiatric or otherwise.

Questions like this, and others, are good to bring up in the hiring interview, but you've already started the job and have prior experience? Try checking with Human Resources and asking what their policies are. At my place of employment we have a task force on hospital violence -- is there anything similar at your hospital? It could also help to ask discretely if anyone at work has been injured in the past, and what the response was, including Workmen's Compensation. Another good question to ask -- does the facility have a policy of prosecuting criminal assaults against staff members? Staffing can also be a contribution to injuries. You need to have sufficient staff, and the staff you do have on the floor have to be the kind of people who are proactive in spotting potential situations where aggression can occur, and intervene beforehand. Insufficient staffing can lead to minor injuries, such as chronic back pain or lumbar area injuries. Quite some time ago, there was an item in the news about a nurse who was severely injured by a patient at a state facility. The patient was being admitted to the hospital unit, had a record of violence. He erupted unpredictably and slammed the nurse's head into a door frame. She suffered brain damage from the injury. Afterwards, news reports indicated that a factor in the incident was insufficient staffing. What took us aback was, the staffing on the floor of that hospital unit which they did have, reported as inadequate, was more than the staffing on our own hospital unit. The figures for injury in the mental health field are high -- mental health professionals lead the pack with a rate of 69.9 out of 1,000 (National Crime Victimization Survey (199) and The Bureau of Labor Statistics Data). The risks are high, but with good staffing and experience people, they can be minimized. --

On both of the psychiatric units where I've worked, the majority of the psych techs tend to be women. Movies and tv may give the impression that the floor staff are big burly men, but in real life these kinds of psych techs are scarce. Generally, if a situation comes up on the floor where you need some muscle, you're going to call for security, or call a hospital code. Even if you're set on being a psychiatric nurse, it would be good to find places more solidly in the medical areas, such as being an ER tech. You'll need to polish your medical skills as much as possible, and places like the ER will give you that opportunity. --