New Angel

I began psych nursing a year ago, and graduated 2 years ago. I work in a tiny office with many high energy, big attitude, sometimes seemingly anxious staff members who have 5 to 10 to 15 years med/surg & ER experience....many are cynical, sarcastic, and I am in disbelief over some of the things my coworkers say abput patients. I often take it as a cue on what NOT to be and how to NOT get crotchity as I move through my nursing career. I said something one time to a supervisor because the nasty mouths were going way too far, and simply asked if this type of work, or this office imparticular, is really for me? I'm not an anxious, or terribly assertive nurse yet, but i am efficient and have done very well this past year learning my job person. I'm more passive, relaxed, and I still think to myself, almost every week at work: I am too nice for this office. I hope I never get to the point where I talk about patient the way my coworkers do. I second guess myself sometimes, thinking, 'I should take a letter from these seasoned psych nurses. they have the experience.' but no. some people get hard...and cynical. and I want to try not to have that so soon in my career. I have resided myself to not follow suit....not to go with the crowd and maintain my soft side. I don't allow pt.'s to take advantage of me and I set appropriate boundaries. My unit's safety is always my first priority. I am fine being nice to the patients and interested in their emotional state, not just their meds & clinical behaviors. I am comfortable with my nursing style and so are my supervisors.

Hello! I work at a psychiatric hospital that has a casual dress code. It is suppose to help create good rapport & relax the patients who identify scrubs/uniforms as being 'establishment' oriented. Psych nursing involves a lot of one-to-one verbal contact, and the hope is that patients who are highly paranoid feel they can open up & tell you personal history/feelings. Everyone mostly wears jeans and a nice shirt. Some wear more business type of casual & some wear street casual. With the Restraint situations, some of us have literally been on the floor with assaultive/combative patients so its not always the best to wear a pant suit or long skirt. Some wear scrubs and I have not personally observed a breakdown in rapport with patients due to wardrobe. Maybe a 'white coat' would cause tension.... Never anything provocative, of course. Some psych patients have issues with boundaries. I use the second guessing rule: if I have to review whether or not I am wearing appropriate clothing, then I probly need to change.

Our voices and phone paging systems are our personal alarms. If we yell the word 'Staff!', then people know to run to the voice, and beyond our unit doors we use a phone paging system for good ol' Dr. Strong over the phone intercoms, they run through the entire building. It has been troublesome, but we are a 20 bed psych locked county unit..and the only one for over a hundred miles in any direction. Our space is very small and our budget is VERY tight.

This is a hot topic around my office as well....Some say that certain employees have higher propensities for antagonizing pt.'s then others. I try to have the optimist's mindset and hope that noone would ever purposely antagonize a pt.. Firsty, I commend you for not cutting off your coworkers while they work with other patients....It's so important that we have eachothers back in our kind of working environment. I also know how difficult it is to correct coworkers or suggest different interventions/styles.....people can be sensitive. If you feel a coworker is causing an unsafe work environment, then I would bring it up immediately. If it seems that their work behavior just makes life at work more difficult for them, then the best way is to lead by example. I quite appreciate the hard line some of my coworkers use with pt.'s, I see that we all have our own ways of working with clients, and that some staff get along better with some clients more then others. I also have a more, "pick your battles" type of approach....it can be very challenging with BPD clients testing their boundaries.

Its a very strange job market out there right now for new nurses.....Your previous experience means nothing to human resources if it is not straight up acute care as an RN. I know the feeling of having phat ER experience and not getting hired. I graduated last year and was unable to secure a job at the local hospitals or MD offices. I got hired at a nursing home the day I walked in, which was a delight! The job was hard, it's as difficult at a nursing home as everyone has told you with less pay then the hospital, but you are working...as a nurse! Getting paid & gaining experience, rather than not working while you hold out for the acute care jobs. It was much easier for me to get into the hospital I am at now from the nursing home job...Noone is too good to work in a nursing home, and you get quite a bit of medication, insulin, wound care, dementia, nebulizers, pain management, medicare charting, and supervising experience to church up your resume. Don't shut out the nursing homes, I made many great contacts there that helped me get into my hospital job.

I am also a Night nurse at a 24 hour psychiatric locked facility. Thank goodness I have a manager that will always work when others call out sick, she's the best! However, one sunday morning, she was out of town and my morning nurse relief-coworker called in sick at 4am...It's almost impossible to cover Sunday morning shifts within 3 hours notice....and I had obligations/was unable to stay past 8am. Unfortunately, this is the business we have chosen, and it is ultimately our responsibility not to walk out the door without relief to care for the patients. No, you should not be made to work overtime hours when you do not want to....however, you will soon see, that many employees do double shifts in 8-hour-shift facilities...yes, it's tiring, especially when you're not prepared and it comes up last minute, but it is not as outrageous an idea as one may think. {great $ too.} I am aware that the possibility may arise that staff doesn't come in, and I will have to stay for a double shift...that's just the biz. However, I would no want to work somewhere that admin/supervisors were not willing to step up and help you out when this situation arises and you cannot stay. If this is a persistent preoblem for you, perhaps working as a nurse in a doctors office, where the facility is only open 8-12 hours a day is better for you....more stable. I am considering that option too, simply because a 24-hours facility may not be the best fit at this time for my schedule {and life.}

I don't necessarily think the whole story is fiction...It sounds like a typical scenario: If you are hitting walls/kicking or banging doors and cannot stop yourself you are at a risk of self harm and are escalating into severe agitation with some violent behavior. The woman may have escalated herself into a seclusion & restraint situation, because staff asked her to wait for the doctor, offered her medicine and she refused meds/was too agitated to wait. You're not allowed to hurt yourself inside of a locked psychiatric unit, so if you are banging/kicking walls/doors, and cannot stop yourself, then Seclusion/Restraint is appropriate. It is meant as an intervention to prevent self harm & assaultive behavior, and keep people from physical harm, exactly what the person describes doing. People think that just because you walk into a psychiatric facility voluntarily that you will be released voluntarily at any time you wish,,,,,that is not the case if you become a danger to yourself or others while you are in the facility. The criteria for discharge is that the person is not a danger to themselves, to others or gravely disabled. Kicking/Hitting a door without stopping when staff asks, is dangerous to yourself and demonsrates physcially agitating/aggressive behavior. You walked into an emergency psychiatric facility for a reason: you were in crisis. When you didn't get to see the doctor immediately, you flipped out and became psychotic enough to not be able to sit down and wait an hour for a doctor or take an a medicine orally that will help you relax until then. It's not burger king, and you don't get everything your way. Tie down restraints are unlikely, they have proven to cause CSM issues and have been largely upgraded, so I see this story as an exaggeration of what may have happened. Often, the moments before you are restrained and given injected emergency medication, are very confusing and blurred for people, partly because of the haldol nap you referred to. I will say, that being physically restrained feels awful for people, and I don't doubt that she felt like the situation felt much worse then it may actually have been. Staff are legally able to apply restraints to people to contain their behavior for a very VERY short time while obtaining physician's orders for restraint {CA}. And by short time, I mean less then 5 minutes you are on the phone getting physicians orders. Take the time to read up on your own facilities seclusion and restraint policies, as well as the state laws. What you do with your individual license may be where the blame falls during legal issues, and you want to be sure you have upheld patient rights and policy perfectly.

Congratulations. I commend your statements on honesty and not lying about your experiences. I am glad you are able to work and move on with your life. Honestly: initially, it is alarming that people with drug trafficking history can be licensed to pass controlled substances, however, Nursing is all about critical thinking. I applaude the BON for looking at this, and each situation, with a microscope and considering the context & reality of situations while deciding on whether or not to grant licensure. Obviously, you were young/impulsive at the time of your troubles, who turned themselves around and stayed on the right track. The BON is pretty strict, so it sounds like you got a fair shake and straight up earned your right to be Registered Nurse. Kudos!

I work in a very small psych hospital and we also have had disgruntled interactions with the local ER. My coworker has been suggesting for months that we do a training experience where the ER nurses spend a few hours on our facility and our psych nurses spend a few hours shadowing the ER nurses so we can learn how to work together better. That's a fat chance, I know. I do my very best to have polite & cooperative diction with my transferring facilities. There's no reason not to work together. It is bothersome when ER.'s think we are stalling to not take a pt. because we don't feel like it or something...We are here to work and to care for pt.'s just like you are in your facility. To assume or make statements about us stalling to take pt.'s is wrong, rude, and breaks down any team work we could bridge. Likewise, For my facility, it is damaging to the fabric of our working community to make statements about the ER lying/exaggerating about a pt.'s condition to get them out of their hair and into psych. I try to see both sides, yet my priorities of care of course, are in my facility/pt.'s.

Our facility also mandates a MD to MD consult & discussion before accepting a Pt. that is to be medically cleared. But on my night shift, I myself do a great deal of the chart review & recommending to the MD on-call {very small facility, we use an out od town on call doc for night MD orders}. If I am not comfortable admitting a pt., I don't. I consult with admin before allowing a pt. that could possibly be unstable medically into our facility. I have had the xperience of an ER attempting to send someone over who was medically cleared for psychiatric admission, but had not even a CMP/CBC/UA performed...The list of 4 questions Orca wrote above are perfect. I always ask the other Nurse: -Lines/Tubings/Catheters removed? -Is the pt. ambulatory? {meaning, can you as a nurse get them out of your facility without an elevator in the event of a fire} CBC/CMP/EKG/UA/UTOX/Blood Alcohol levels -Yes, chest xray post intubation. -Any and all ED/Medsurg/ICU reports -Sleep apnea machines? Wheel chair? or other assistive devices you may need for the pt. on your unit. -Seizure recently? how is it being controlled now? -What meds were given? -Up to the minute Emergency department summary reports/ nurses notes/ MD notes. I got a pt. once that the sending hospital considered to be "ambulatory" because they could self transfer from their wheel chair, however, they were not able to go down the stairs in the event of an evacuation {no ramps here}. {Our unit is on the 3rd floor}, and we didn't have the staffing to carry her out as well as manage our other pt.'s in a given emergency. I was lucky not to have a fire evacuation that night, but I was certainly mildly anxious about having someone on my unit that would be difficult to remove in the event of an emergency. Also: my favorite training tip: When in doubt, send them out.....anytime you are concerned that your psych pt. is decompensating into emergent or acute medical issues, call 911 and send them out to be medically cleared. Its your license on the line, and I do agree with the other poster that it could wind up being your own liability, not the doc's, if you accept & admit a pt. that is not stable and something goes wrong.

I recommend perusing the facility website and familiarizing yourself with their mission statement, values, motto, etc. Read up on your states most important psychiatric laws, such as seclusion, restaraints, emergency medication {mostly IM}, Legal Holds {ie, 5150}, Riese hearings, patient rights, etc. I don't know if you will be asked these things in your interview, but they will be good to know in general and NEED to know for the job. Good luck!

I have also been extremely alarmed by the cursing and 'venting' commentary of my coworkers. I only see this type of talk during shift change reports, and if I ever felt a patient was being mis-treated I would not hesitate to address the issues with that coworker or with my supervisor. So, because it is just an issue of 'behind closed doors' venting, I have never felt responsible t advocate on behalf of the patients to stop that talk. I take it as a cue to review myself professionaly and make sure my language remains concrete, relevant, respectful, and professional.

Wonderful responses, thank you!

I have been a psychiatric nurse for a short while and find my most challenging patients to be those with diagnosed 1>Borderline Personality Disorder & 2> Intermittent Explosive Disorder. It is especially difficult when the pt. has both diagnoses....If you add a polysubstance dependence diagnosis to the mix, then we are talking huge difficulties in providing therapeutic communication & milieu to these patients. Any tips from your experiences for dealing with these two categories of patients that have these diagnoses? I have found 1:1 to be one of the only tools that really works, but it is not always realistic in all situations to have that staffing available.

When in doubt, send them out!