lishka15

Hi everybody, Last week I had to "guard" a Borderline patient overnight, and it didn't go well, so I was hoping for some advice from you wise and experienced psychiatric nurses. My apologies if this story is too long, but maybe it will make it easier to give some in-depth guidance if you know the details. I work as a nursing assistant in a somatic department for the summer. This patient was supposed to stay overnight for a procedure and then go back to her treatment facility the next day. My job was to keep her from harming herself, and I was told that she seemed calm and nice, and that she was about to fall asleep. When I got into the room, a young doctor and her nurse was trying to convince her to agree to the treatment she was there for, as she kept changing her mind. She barely answered, and had a sulking vibe. I had expected the doctor to be more firm, but both he and the nurse were very accommodating. The trouble began after an hour, when she obviously got tired of pretending to sleep, and turned around and started looking at me as if she was trying to figure out what kind of person I was. I smiled and tried to be nice, casual and relaxed, yet not seem insecure. I am aware of borderline splitting, and didn't want to go into her "bad person" category and trigger rage or difficult behavior. She was nice for about two minutes and seemed to accept me, but then she started asking why I had to sit in that room with her. I sensed that she was about to pick a fight, so I tried to answer as light and casually as I could, and said something like "The doctors are probably worried that you're going to hurt yourself". Obviously the wrong answer, and she started arguing, saying that "she would never do such a thing". (Although I knew that the last time she was in that hospital, she hurt herself badly.) What should I have done differently here? Then she suddenly asked to go to the restroom, and it dawned on me that I hadn't been informed about the rules (unlocked/open door or go in ther with her), so I asked the nurse, who told me that the door to the bathroom had to be unlocked, and that I had to stay in her room (She had a private room with an en-suite bathroom). Then she began arguing again, saying she was "unable to go to the restroom when I was right outside the door", sulked and shouted. What should I have said? I was really unsure about how "firm" I was allowed to be, after observing how accommodating the doctor and the nurse had been, and my mind was on high gear trying to find a strategy to de-escalate the situation. After a while I gave up and the nurse (who obviously was in her "good people" splitting category) went in to talk to her, and she agreed to an unlocked door. But when the nurse was gone, she started the same argument again. Then she went over to her bed and put on her shoes. I asked: "What are you doing?" and she said: "I'm leaving! I can't be here when I'm not even allowed to... (some obscure angry mumbling)". So she left. The nurse went after her to make her sign the discharge papers (The treatment she was there for wasn't "life or death" enough to make her stay against her will, and she wasn't considered acute suicidal), but she wouldn't sign anytning and just left. I felt really shaky inside after this incident, and would really like to know what I could have done differently, in order to prevent such an outcome next time I encounter a Borderline patient. I tried to ask the nurses, but they said they - as somatic nurses - aren't very good with such patients, because they don't encounter them very often at that department. A young nurse even seemed surprised that the patient had acted that way, ("because she seemed like the calm type"), as if it was something I had done wrong (As a female medical student, some of the nurses are already extra critical towards me, and I really try to be good at my job so that we can co-operate well, and this for sure didn't make them any less critical or condescending.) Any advice...?

Dear wise psychiatric nurses - yet another case where I would be very grateful for advice... Today and yesterday I had to be a sitter again, and this time for a young male who OD'ed a few weeks ago. Several of the experienced nurses were scared of him the first days he was there, because he had an "evil stare" and would suddenly start laughing. There used to be three people in the room with him at all times to keep him under control, but now they consider it safe with one person only. (He is still involuntarily committed) Yesterday was ok. I sat with him at the High Dependency Unit, where the nurses are very observant and careful, i.e. emphasized the importance of him taking his meds. He said some really weird things during my shift, but seemed to like me and we even talked about trivial stuff. He was still weak and got up with help once. Today he was transferred back to "my" department. He did not remember me from the day before, and seemed completely different, colder and more suspicious, and didn't connect. (And he is much stronger, sits up by himself and even gets up on his feet) I tried to tell the only available nurse (straight out of school, the "know it all" kind of person who loves to criticise) about my observations (see below), but she just said: "I do not consider him psychotic at all", and had all kinds of explanations for the examples I mentioned. I.e. him talking about missing body parts, was "probably because of the pain in his foot". I carefully tried to say that she hadn't been with him all day, and the few times she was in there, he was mostly quiet and his few answers could seem adequate enough, but no - according to her I was totally wrong and she even rolled her eyes a little. Some examples: - He seemed paranoid about the meals, and once stared at the meal and said: "What is the code?" (To which I replied: "The meal has no code, you can go ahead and eat"). He didn't eat at all. - He said: "Where are my body parts?" (I said all his body parts were attached to him, and that we were taking good care of him and had everything under control.) - He stared at his hands as if they were unreal - He looked at me with that "evil" stare and asked if he could have a pair of scissors. (I said we didn't have any) - In general he looked at me with this hard to describe look, it's like a mix between suspicious and calculating. - He lied to the nurse about taking his meds, and she believed him just like that (...they were still on his tray...) - He asked me stuff like "are we still in the same time and space?" ..... His sentences made no sense half of the time. I asked him if he felt confused, and he said yes - that he had no control over his mind now and didn't know what to think. - He has a scary laugh. And suddenly laughs at nothing. He is on Zyprexa (+ morphine etc), but I suspect he's good at "pretending" to swallow them (And the young nurses at my department are so relaxed about the medication, that no-one make sure he actually swallows. They show him the different pills, explain thoroughly, and ask him if he wants that pill - and given the choice, he can't decide. In the end I told him the pill would probably improve his thinking, and that if it was me, I would take it. I don't know if that's appropriate to "influence him", but frankly - since the High Dependency Unit nurses emphasized the meds, I am a little scared what can happen if he doesn't take them. (The High Dependency Unit just gave him a small plastic cup with all his pills and asked him to take them, which worked well) It worries me that the young nurses seem very naive, and might consider him "safer" than he truly is. They seem to see this young, handsome man their own age, and rationalize every very weird thing he says into something "normal". As a student I don't really want to disagree and "go over their heads" to talk to the leading nurse, because of course they probably know more than I do and it could seem disrespectful. But I am worried. The few times I have met psychotic people, there has been the same talk about missing body parts and that "evil, calculating" expression and scary laugh (one of them were full of antisocial traits and ended up almost killing his girlfriend). How would you consider the examples I mention above? Is it something to report to the head nurse, or should I listen to the younger nurses? (I might have to sit with him again tomorrow :/ ) (For those of you who didn't read my borderline thread: I am just a clueless med student who work as a nursing assistant in a somatic department that is short on staff. And sorry again about the lengthy text and improvable grammar )

Come to think of it, I have also seen it happen more often with surgical residents... I stay faaar away from surgeons

Maybe... I will make sure to suggest that the next time :) But if a psych nurse had seen him when he was in a good mood, she might have concluded that he was just fine... I sat there for 8 hrs straight, and his weird behavior came and went several times... in between he seemed fine.

Interesting thread - I just have to comment :) I am a med student and have dated some med students and doctors. One of the doctors turned out to be too full of himself, the other doctor was a manipulative player (...and is now dating a nurse who chooses to turn a blind eye to his affairs - she is known to be a co-dependent and so desperately wants a doctor and admire them so much, that I guess the title is more important to her than the person behind.) One of the med students had to be in charge all the time, and it wasn't my cup of tea. The other two was just normal guys :) Several of my friends in med school are truly good guys, and I would be happy to date some of them if they didn't have girlfriends already. Some of them might not handle all the attention they get as fresh doctors and become players, but I think most of them are solid enough to stay true to themselves. So I guess it's impossible to say something about med students in general :)

Thanks again Jules, you are the best :) I voiced my opinion in report at the beginning of my shift today, although the reporting nurse said he had been "okay". Luckily the others believed me :) When I got to his room, the sitter on the last shift told me the patient was much stronger today, had been aggressive and threatened physical harm. So he got transferred to the psych ward. I will make sure to trust my observations next time, and talk to more experienced nurses if, like yesterday, I am told I'm wrong by a young self-proclaimed expert nurse :)

Hi everybody, Last week I had to "guard" a Borderline patient overnight, and it didn't go well, so I was hoping for some advice from you wise and experienced psychiatric nurses. My apologies if this story is too long, but maybe it will make it easier to give some in-depth guidance if you know the details. I work as a nursing assistant in a somatic department for the summer. This patient was supposed to stay overnight for a procedure and then go back to her treatment facility the next day. My job was to keep her from harming herself, and I was told that she seemed calm and nice, and that she was about to fall asleep. When I got into the room, a young doctor and her nurse was trying to convince her to agree to the treatment she was there for, as she kept changing her mind. She barely answered, and had a sulking vibe. I had expected the doctor to be more firm, but both he and the nurse were very accommodating. The trouble began after an hour, when she obviously got tired of pretending to sleep, and turned around and started looking at me as if she was trying to figure out what kind of person I was. I smiled and tried to be nice, casual and relaxed, yet not seem insecure. I am aware of borderline splitting, and didn't want to go into her "bad person" category and trigger rage or difficult behavior. She was nice for about two minutes and seemed to accept me, but then she started asking why I had to sit in that room with her. I sensed that she was about to pick a fight, so I tried to answer as light and casually as I could, and said something like "The doctors are probably worried that you're going to hurt yourself". Obviously the wrong answer, and she started arguing, saying that "she would never do such a thing". (Although I knew that the last time she was in that hospital, she hurt herself badly.) What should I have done differently here? Then she suddenly asked to go to the restroom, and it dawned on me that I hadn't been informed about the rules (unlocked/open door or go in ther with her), so I asked the nurse, who told me that the door to the bathroom had to be unlocked, and that I had to stay in her room (She had a private room with an en-suite bathroom). Then she began arguing again, saying she was "unable to go to the restroom when I was right outside the door", sulked and shouted. What should I have said? I was really unsure about how "firm" I was allowed to be, after observing how accommodating the doctor and the nurse had been, and my mind was on high gear trying to find a strategy to de-escalate the situation. After a while I gave up and the nurse (who obviously was in her "good people" splitting category) went in to talk to her, and she agreed to an unlocked door. But when the nurse was gone, she started the same argument again. Then she went over to her bed and put on her shoes. I asked: "What are you doing?" and she said: "I'm leaving! I can't be here when I'm not even allowed to... (some obscure angry mumbling)". So she left. The nurse went after her to make her sign the discharge papers (The treatment she was there for wasn't "life or death" enough to make her stay against her will, and she wasn't considered acute suicidal), but she wouldn't sign anytning and just left. I felt really shaky inside after this incident, and would really like to know what I could have done differently, in order to prevent such an outcome next time I encounter a Borderline patient. I tried to ask the nurses, but they said they - as somatic nurses - aren't very good with such patients, because they don't encounter them very often at that department. A young nurse even seemed surprised that the patient had acted that way, ("because she seemed like the calm type"), as if it was something I had done wrong (As a female medical student, some of the nurses are already extra critical towards me, and I really try to be good at my job so that we can co-operate well, and this for sure didn't make them any less critical or condescending.) Any advice...?

Oh, and one last thing!! Is this "having a patient storm out and not return" something that has happened to other sitters as well, or is it so unusual that I can expect to be the talk of the department for the next weeks?

I will do that first thing tomorrow! Thank you :)

BRILLIANT, Jules Thanks a million!!

Thank you very very very much, Jules!!! I really appreciate that you took the time to share your insights. (And what a relief that I actually did try some of the strategies you proposed - distracting by asking where she's from etc when she wanted to act out, + taking the "I'm just the sitter" friendly approach. I think it went out of control because she sensed my insecurity, and the break when I had to go and ask the nurse. Next time I will definitely make sure to talk to the nurse more thoroughly beforehand (and make sure we all agree on the rules, so that I don't end up as the bad guy if I stick to it and then the nurse intrudes and gives in.) .... and I will remember to stick to the cool "it's up to you" attitude! :) I would really appreciate any feedback and advice from others, too! Especially on how I can deal with "such patients" when I've graduated and am supposed to treat them. I.e. when a patient such as her changes her mind a hundred times about whether to accept the treatment or not, to prevent the staff from running back and forth with the equipment and medications in an already busy department. I mean, sooner or later I guess I would have to give such a patient an ultimatum after they have changed their mind for the fifth time in an hour... any tip on how to do such efficiently (maybe from the start, to prevent forseeable problems related to the disorder)

Hmmm.... If I were to go with the flow, I would have said something like this: (Am I "allowed" to say something like this, in a firm way - if a borderline starts arguing, or would it be counter-productive or even out of line?) She wants to fight because she isn't allowed to be alone in her room: "I know what happened the last time you were here (hurt herself by injecting disinfectant into her pvc), and we don't want that to happen again. You might say that it won't, and maybe next time - if you prove to the doctors this time that you are willing to cooperate and meet us half-way, you will have more freedom. But in the meantime - what we all have in common, is that we are all judged by others based on our previous actions. And if we would like to change how other people view us and what they expect from us, we have to show them over time that we have changed. That's just the way life is, for all of us". I have a few more of these kinds of responses in my mind.... but is it appropriate, or can the nurses fault me for it? And does it have a chance of having a positive effect?

Thank you so much! If you don't mind, I have a few questions to what you wrote. ...speaking of "appropriate" - what would not be appropriate? What am I supposed to accept, and when am I allowed to draw the line and i.e. say that I won't tolerate verbal abuse, etc? Will a firm "NO" always (usually) be counter-productive, or can they respond well to firm boundaries and resistance? So what you're saying is, you don't let her bend the rules, and if she doesn't agree to them, she doesn't get to use the bathroom (her choice being: either use the bathroom with your rules, or not at all)? What if it escalates and gets physical? I mean, she was anorexic and I am pretty fit, but still... I am terrified of doing something wrong, and breaking some kind of rule I wasn't aware of, or in worst case - having someone harm or kill themselves on my watch. (Or attack me. Or report me to the health authorities with some manipulative fabrication.) Btw - is the "toilet rules" a common rage-inducing thing with such patients? But how far can I go in regards to discussing their problems - I mean, I sit there as a nursing assistant, clueless medical student and am only supposed to watch her... Can I somehow sabotage the work her therapist is doing, by talking to her about her disorder? Is it appropriate to initiate a conversation about it? Actually, I used to (used to!) have a high functioning borderline "friend", and as her "best friend" I was the target for some crazy, surreal "damned if you do, damned if you don't" fights. So I did read up on it, but I never found an effective way to deal with her and had to end the friendship. I tried just about everything. And even though I might seem calm and strong on the outside when borderlines go off like that, I'm terrified, shaky and my heart races like crazy. It's hard to remember what you have read, when you're in full fight-or-flight mode yourself. I will definitely never, ever become a psychiatrist, but it would be nice to get to the point where I can stay calm and feel safe even when they act out. I wish there was some disarming general comments I could learn.

I live in a country where the use of restraint is avoided at almost all costs. I'm only a medical student, have never been with a restrained patient and have no experience from the psychiatric ward (I'm only here in this forum because I needed advice about how to deal with borderline patients in somatic departments), but I'm concerned that the "protecting patients right to freedom and not doing anything against their will" goes too far, and claims too much of already limited resources - and that other patients suffer for it. What I hear from fellow medical students who have worked as nurse assistants on psychiatric wards, is that there are a lot of patients who come in with self-inflicted problems, and are acting out due to the use of illegal drugs. Because they aren't allowed to use restraint, they need several male nurse assistants there to help control the patient. Meanwhile, in "my" department (somatic), old patients suffer, because there aren't enough nurses and assistants. I am well aware that many psychiatric patients have had extremely difficult lives and are doing the best they can. However, I also think some of them "like" to self sabotage, and aren't accepting the help they are offered. And when the psych ward aren't "allowed" to use restraint, they occupy several nurses and assistants (and time!!!) - while a lot of old and sick people don't get the care they need. Why is protecting self-sabotaging people's "rights" more important than giving others the help they need? It is heartbreaking to see old, sick people (- who have worked hard all their lives and tried their best and never had the "luxury" of acting out and to experiment with drugs) suffer. Sometimes I wonder if a more strict line would be better in some cases. "If you choose to do drugs instead of dealing with your problems, then expect restraint when you act out. The society can no longer afford to protect your rights when you try to sabotage the help you are offered". Just my two cents. And just to point it out again, I am well aware that a lot of psychiatri patients truly do their best, and of course I hope they get all the help they need. I am just worried about what seems to be a "emo trend" and cultivation of destructive self sabotage.