TCASII

I'd be surprised if they wouldn't hire a new grad RN for a psych job. Around here, they'll hire anyone, regardless of past experience. I wouldn't start on NOC as an RN working in psych. Medical is a different story. You'll learn faster on days. All you'll do on NOC is chart review/audit, med pass, admits and trivial stuff. I worked NOC for 5 years and I am glad to know how to do old school audits; however, computer charting has changed a lot of that. Day shift will expose you more to actual patient interactions, discharges, admits, providers, and possibly groups. When you get admits at night they're almost always irritated about being awake and don't really want to tell you much. Doing NOC also exposes you to providers who low-ball on meds during crisis or sometimes don't answer the phone. The providers we have on call at my current facility are a joke. Patient has BHT in a choke hold - "Okay, give them 5 mg of Haldol PO" I think it'll depend on where you live in terms of how many patients you have or what your exact duties will be. We always get 10 patients and 95% of what we do are treatment plans, charting, and administrative work. The problem is, the RN is supposed to also pass meds and do assessments. There just isn't any time for all that, and the part that gets put on the far backburner is the patient interaction. Med pass is a "Hey, here's your meds" and the assessment is a "Doing OK?". Because at the end of the day, all they care about is our charting and treatment plans. As you can tell, I'm a bit disillusioned with mental health nursing. Most of the patients are only personality disordered, and that's cluster B (e.e, antisocial and borderline). We rarely get true bipolar patients, schizophrenics, or others that are substance-induced. It's unfortunate because on paper, the field is fascinating. Hopefully SoCal is better. I've heard the hospital in California that is part of my corporation is much better.

+1 on paycheck. And I agree about the police bringing in people who are just trouble makers, as opposed to mentally ill folk. The police love to dump folks on psych hospitals, just so they can avoid work. Outside of that, not much is rewarding. The tiny percent who need and want help are few and far between.

I'm a little put off by some of the remarks in here. It's as if people don't understand sociopathy, psychopathy, drug-seeking, or personality disorders. I work exclusively in inpatient psychiatry. After 8 years, I'd say that 80% of the patients I see are simply substance-use disordered and/or personality disordered. Very few are truly psychotic or AMS. Just because you happen to work in a system that is setting limits on people for safety (e.g., involuntary hold due to SI or HI, withholding addictive drugs) does not mean you should be subjected to injury. It's one thing to understand how some medical conditions and a few mental disorders can impair reasoning, but I would venture to guess that a large number of assaults in the ER, psych, or other acute care facilities are not AMS. I have seen a handful of assaults, and 90% of them were born out of med-seeking or restrictions on leaving a hospital AMA or simply getting to do whatever they want.

I mostly agree with the OP. I've worked in TIC facilities, and despite not fully knowing the ins-and-outs of TIC, the overall theme seems to be allowing patients to determine how their treatment plays out. In theory, TIC is good on paper. You work collaboratively as a team, thus including the patient in the care plan and treatment goals. This concept makes perfect sense when dealing with select patients who have specific disorders (e.g., hoarding, OCD, PTSD, MDD, eating disorders). The problem is that most IP facilities are not treating true mental illness as a single Dx. I would say the number of cluster B (e.g., antisocial, borderline, narcissistic, histrionic) substance abusers is approaching 80%. These patients are highly resistant to treatment, and in most cases, do not want to improve. We're assuming that we can impart improvement in 7-10 days to sociopaths, and that's a fantasy. The TIC and recovery model I've encountered seems to put a high emphasis on eliminating seclusion, restraint, or even physical holds. Essentially, you are housing common criminals who spend a fair amount of time in jail or prison, but you have zero leverage for enforcing rules or preventing harm. My current facility has banned S&R and now only allows "standing" CPI-approved holds. The SW, and even AT department, have appointed CPI instructors, and they have been playing a heavy role in running codes. We had a patient in a hold, standing, and fighting aggressively, which was 100% necessary d/t this patient's attempt to assault staff. We were preparing to give IM medications and the SW coaxed the BHTs into letting the patient go. This patient went on to obtain a weapon and threaten staff with harm. This was partially avoidable had we been able to seclude and medicate this antisocial patient who voiced a desire to harm and was not mentally ill. After two events that were very traumatizing to staff, this individual was arrested; however, it took a monumental escalation to even get the police to take this person away. The bottom line, is that allowing patients to have zero accountability for their aberrant behavior is detrimental to staff and patients alike. This type of free-will attitude perpetuates an atmosphere plagued with negative outcomes. I always ask people who think the patients should be self-directed - "Would you allow your child to run free without consequences?" I'm all for reducing holds and physical intervention, but in some cases it's unavoidable. I managed to rarely do physical holds in an involuntary unit for over one year, but in reality, the notion that you can avoid physical intervention and forced medications is ludicrous.

There have been some fatalities with IM olanzapine, and I believe it has occurred without the combo as well. I know the depot olanzapine has caused some deaths too. It's generally recommended that IM olanzapine not be given with an IM benzodiazepine (e.g., lorazepam). I have given lorazepam and olanzapine IM as a combo before and nothing happened. In fact, the patient was not affected at all. It has nothing to do with QTc prolongation, such that QTc prolongation is less than haloperidol. It is simply d/t the increased prevalence of respiratory depression/CNS depression when used together. I know of a particular patient who died after receiving a Geodon IM during a bout of agitation. He also had an underlying heart condition no one was informed about. I am sure part of the reluctance and recommendation against using olanzapine and a BZD IM is hysteria over the deaths. I'm sure if we had actual numbers of deaths from other similar drugs, it wouldn't be much different. A lot of FDA warnings have caused similar responses in the past that born out to be dispelled. Time will tell. As of now, most doctors and institutions have avoided using IM olanzapine, but a lot of that also has to with the efficacy compared to other rapid tranquilizations and worry of litigation. There isn't a perfect RT, they're all essentially the same. And if you've worked long enough in the field you will find that Thorazine, Haldol/Avitan, Geodon, or similar RT meds are hit or miss. I wanna say that I had read somewhere that the olanzapine/lorazepam IM combo thing was considered overblow, but I do not recall where atm.

The number of patients is contingent on the workload. Where I currently work, 10 patients if often too many. The amount of charting and treatment plan work is very high. If all the patients are calm and not needy, then 10 is ok. I would do a much better job if I has 6 total, however. I've had 18 on a locked emergency unit and managed to survive, but I also had 4 great techs that handled a lot of the commotion. I also wasn't expected to document half as much as I do now. Not to mention, my techs at my current job are largely uninvolved with assisting the RNs.

It might depend on where you live. Some states are a little better about staffing and making the environment tolerable. Where I live companies are not too good about staffing or providing decent work conditions. We have no state ratio limits or unions. It's right-to-work, so they can dump 20 patients on the nurse. Personally, I don't feel that psych is much better, regardless of where you work. You have to know whether the company is good about staffing and limiting the number of patients a nurse gets. I've worked in psych for 7 years and never been punched, spit on, or physically attacked. I have been accosted verbally, but nothing too awful I suppose. I've mostly worked IP, but did have an OP job. OP was terrible. Way too many patients. An impossible job. Getting yelled at on the phone or in the building because the provider wouldn't prescribe controlled meds wasn't any fun, just like IP. Every job has it's ups and downs. Psych can be as hard as you make it, and that often means deciding to set limits and be the bad guy, or placate them and make things go smooth. I typically placate them, since we aren't allowed to do holds or anything. We have no leverage.

We just went through JCAHO inspection and they knew we pre-pulled. Nothing was said about it at all. It's psych, so I can't imagine the seriousness of of it. I understand a med-surg, ED or ICU type of environment however.

This is becoming the norm, unfortunately. In a psychiatric setting, if the patient has a psychiatric Dx, then the police will not take them to jail. This means that nearly 98% of the patients will not be arrested for an assault. Even the detox patients are admitted with co-existing psych Dx's, such as MDD (major depressive d/o). Those admitting Dx's are just for billing, they aren't a valid or accurate Dx. Just a preliminary ICD code. We had a supervisor get punched in the face 4 times by a patient a while back. The patient had a psych Dx and flat out told the police that they weren't sorry and would hit her again. Yet, no arrest. Even more ridiculous is that so many psych patients are malingering or partial malingering (exaggerating for secondary gain). Healthcare has really devolved into an unsafe atmosphere and patients are not held responsible for anything. ETA: What gets me, is that the police would taze, nightstick, or shoot a psychotic patient if they were being assaulted, but the rules only apply to some it appears.

EMTALA, malingering, partial malingering, noncompliance. To be honest, most of the patients I see are homeless and substance abusers. The majority have no desire to get better. They make a mockery of the system and don't even try when they discharge. They use the hospital as a hotel with meds, a social network setting (drug connections) and hook-up joint. They know that reporting suicidal or homicidal ideation is a bed. And frankly, the providers enable them. I have dozens each week who report "detox", yet only left the same hospital a few days prior. 95% of the time they are prescribed buprenorphine and/or a benzo. There is zero accountability or moral practice in mental health treatment nowadays.

I pull my meds around 0730, med pass is a 0900. I can give between 0800 and 1000. Same goes for midday meds - One hour before, one hour after. The only reason I can see not to pre-pull is impending order changes. Our meds go in a book with pockets containing the patient's photo and MRN sticker. Unless I'm afraid the meds will be lost or taken, but I can leave them in the med room and we have a camera. Seems odd not to pre-pull.

I wish I would tell you how. Aside from removing contraband. I mean, aside from holds and S&R, your options are limited. The patients knowing you can’t do anything just exacerbates the problem. My hospital has decided that any hold that isn’t CPI is against their rules, so I’m getting out ASAP. I refuse to work in a place that harms staff.

Around my area, nearly all the hospitals are just meds, assessments, and busy work. I wouldn’t have time to run a group; I barely have time to talk to my patients. I have 10 or more patients asking for PRNs and acting out all day. Plus, several discharges and admits. Lots of documentation and treatment plans. Some places do IVs, but it’s not common. Those are just the facilities with medical units.

You couldn’t pay me enough to work in that environment. It’s unfortunate that all anyone cares about in psych is money. Staff have no protection nowadays. I’ve been in the field for 7 years and I’m disgusted by most hospitals. Doing away with seclusion, restraint, and even holds is recipe for serious injury. I sure hope the staff that are injured sue these places. I know I would.

Wrong, methamphetamine and halogenated amphetamines are neurotoxic, therefore they destroy parts of the brain and can leave otherwise normal people with hallucinations for life. What are the long-term effects of methamphetamine abuse? | National Institute on Drug Abuse (NIDA) Drug-induced psychosis can last years. Never assume hallucinations will clear. I've had many who were brain damaged from it. Most of what you say is true, but in all honesty, interaction with true MI is rare compared to drugs and/or co-occuring drugs use and MI. I have worked petition, court-order, outpatient, state (forensic), and voluntary inpatient. I've seen it all.