Psychiatric nursing gone wrong

[CupcakeWHNP-BC, BSN, MSN, NP]

It was his first admission to the psych unit. Initially he seemed calm and cooperative, and it was apparent the 5'4 and 162lbs, well-built Hispanic male was coming down from a high. Per report, his last recreational drug use was LSD on the same day he was admitted to the unit. He was able to answer some of the nurse's assessment questions.

"I see you have a patch on your left arm. Care to tell me what it is, sir?" the nurse asked MR. X, during her assessment.

"Yea! It's a nicotine patch with some LSD on it!" Mr. X stated, while smiling at the registered nurse, as she manipulated his flamboyant Mohawk, and noted his multiple tattoos. His eyes were low, and the nurse remembered what she was told in report.

The RN and NA were at the end of their contraband and the nurse informed Mr. X to remove his 6 ear piercings. Three metal piercings were in each ear. "Hell no!! I'm not removing my piercings! They are a part of me!" the patient angrily stated. The nurse calmly educated Mr. X about the unit's contraband policy, and reminded him of his current diagnosis, suicidal ideations with auditory hallucinations to harm self.

After the NA and RN made another attempt to encourage Mr. X to remove the piercings, he further objected. The RN notifies the facility police, charge nurse, and attending psychiatrist. "Man! Just take me to my room, before I kill all y'all asses!" the young man sincerely stated, with balled up fists, and while flinching his body towards a female staff nurse.

The RN did explain to the patient that the piercings can be used as a weapon to harm self and others. It was deemed necessary to have them removed by nursing staff (and police) considering the circumstances of the situation.

Unbelievably, the psychiatrist allowed the young man to keep his piercings in after he told the doctor they were permanent and could not be removed. The nurse became passionate about the situation and sternly interjected the conversation between psychiatrist and Mr. X. The nurse just wanted to get her point across in a professional manner, and reminded the doctor of Mr. X's report.

At this point, the nurse had been speaking directly to the psychiatrist, now educating him of the unit policies regarding contraband. The nurse was taken back by the psychiatrist's decision, and thought she really had the support of the doctor.

For her compassion of safety first for all, the psychiatrist wrote the nurse up for verbal patient abuse, and she was removed from the patient care area, and detailed to another unit

When does the nurse get support from the healthcare team? When is it necessary to break rules and policies? What happened to patient safety? What about the safety of the staff? What about exercising our rights as nurses?

One of the many responsibilities as a nurse is to carry out doctor's orders. However, we have the education, and the right, to flag orders we deem harmful to the patient or compromise delivery of care, such as prescribing an NSAID to a hypertensive patient, duplicate orders, or ?According to the company's employee union, doctors have the authority to override policies. Does this mean throwing the safety of patients, and staff, off to the side, like a used pair of gym shoes thrown over a power line?

We were taught, universally in nursing 101, that safety is first. It appears, in this situation, to be ok for a patient to disrespect, threaten staff and get their way in the end. The nurse remembered hearing, this is your job. This is psych, and patients will be become irate at times, hit and spit on you, curse you, and make threats and worse. I say to this person, you are wrong! I understand these actions come with the job, however, but one should not have to tolerate the disrespect, or anything else that is less. A psych nurse's job is to report to work, set clear boundaries with the patients, educate them on the rules during their hospitalization, and explain to them the consequences of breaking those rules or over stepping the boundaries. This helps ensure safety for all.

The purpose of unit policies and procedures are to provide organization, and to protect others. Without them, the organization goes awry. When one is in doubt of a situation or procedure, they have clear cut explanations to turn to. So why break them? Why ignore them? Why cause disruption in a system that can, or was running smoothly?

[Davey Do]

Anytime an Individual or Entity has control over the outcome of a situation and we have no power to control that outcome, a prudent measure would be to objectively document the situation. This documentation shows that we acted in a responsible manner and took every measure to assure the safety and well-being of involved individuals, freeing us from the ramifications of the unsafe practice, placing that responsibility upon those in control.

In pursuing a righteously desired outcome, we have different avenues to consider. First, follow the chain of command within the institution for resolution. Most healthcare institutions are also required to have a corporate compliancy officer to whom we can anonymously report hazardous situations.

If a situation is not resolved in a timely manner to an overt and objective therapeutic end, assuring the safety and well being of all involve individuals, outside resources can then be considered.

There are surveying, accreditation, and evaluation agencies to whom we can anonymously report.

Certain specific agencies, such as the department of public health "investigates quality of care issues, such as allegations of actual or potential harm to patients..."

We as individuals are limited in our power to control certain situations. However, if we inform these agency or agencies and elicit their power, a therapeutic end can be had.

Good luck to you cupcakeRN!

[elkpark]

Pick your battles. Which is more dangerous, the individual retaining the piercings for the time being, or nursing staff and security having to physically wrestle him down and forcibly remove them?

[Farawyn]

Document your butt off, OP.

[Here.I.Stand, BSN, RN]

Pick your battles. Which is more dangerous, the individual retaining the piercings for the time being, or nursing staff and security having to physically wrestle him down and forcibly remove them?

This is exactly what I was going to say. I'm not a psych nurse, but it sounds like this irate "well built" pt making threats is more dangerous than his piercings. Perhaps the psychiatrist was weighing these options?

As for the writeup, I'd need to see a quote to determine if the nurse's words were verbally abusive or not. I'm not going to assume one way or the other.

[elkpark]

The nurse became passionate about the situation and sternly interjected the conversation between psychiatrist and Mr. X. The nurse just wanted to get her point across in a professional manner, and reminded the doctor of Mr. X's report.

At this point, the nurse had been speaking directly to the psychiatrist, now educating him of the unit policies regarding contraband.

In my reading of the post, this is where things started to go off the rails. Getting "passionate" about any situation in psych nursing is a bad idea. It impairs your judgment. And, if I were the psychiatrist, I, too, would be inclined to "write up" a nurse for "sternly" interjecting her/himself into a conversation I was having with a client and "educating" me (I can imagine that conversation!) about the unit policies. That doesn't sound to me like communicating in a "professional" manner.

[TheCommuter, BSN, RN]

In my reading of the post, this is where things started to go off the rails. Getting "passionate" about any situation in psych nursing is a bad idea. It impairs your judgment.

I concur. As someone who once worked in psych, I believe that nurses in this environment need to strive to maintain a therapeutic milieu for the patients.

Becoming 'passionate,' butting in, and interrupting a provider about a markedly nonemergent situation is not therapeutic. In fact, it's agitating...

[hppygr8ful, ASN, RN, EMT-I]

One of the first things I learned working in psych is NEVER get in a power struggle with a patient. The second is NEVER let a patient see you argue with other members of the treatment team. Regardless of Safety issues if the patient is initially cooperative and refuses to remove jewelry or piercings even if they can be used for self harm - back off and try a different approach. I once had a patient literally chew through his radial artery so if a patient really wants to hurt themselves nothing short of five point restraints is going to stop them. It may in fact be true that the piercings could not be removed and it was certainly not worth violating patients rights to wear their own cloths and jewelry and be treated in the "Least Restrictive Environment Possible" . In the situation described the nurse lost all control of the situation the minute it became a power struggle. I will bet that patient had a hell of a time watching the staff RN argue with the doctor. Both but especially the RN lost all credibility with the patient. In the facility where I worked such a patient who was likely under the influence of LSD but not acting out at the time would have been asked to sit in an isolation room with the door open so that he could come out if he needed to but allow staff to watch him via Closed circuit Tv without hovering. The team is always nearby should a "Take-Down" be necessary. Patients especially those "Out of Contact with Reality" need to be handles creatively.

A psych nurse has to walk a fine balance between setting boundaries and gaining the patient's trust. Handled differently those earrings might have been out without a struggle had the RN remained calm and collected.

HPPY

[Here.I.Stand, BSN, RN]

The second is NEVER let a patient see you argue with other members of the treatment team

This is an excellent point! Manipulative people do NOT need to see staff conflicts.

[CupcakeWHNP-BC, BSN, MSN, NP]

Thanks for all the comments!! I'm still young and learning and I value everyone's input!! í ½í¸Š

[TerpGal02, ASN]

I concur with all that is said above. When I was a brand spankin new nurse I was all about following the letter of policy in any circumstance no matter the situation. You will see deviations from "the letter of the law" such as your doc did in psych all the time. There is no black and white.

IMO this situation went off the rails when this nurse got involved in a power struggle over the jewelry with the patient. As others have said, you often have to question yoirself in psych "is this the hill I want to die on today". On my unit, we have a similar policy with jewelry. If someone is really resisting removing peircing though, we ALWAYS consider how high a risk for self/other injury, as well as the injury potential as the actual item. In this case, the patient escalated but probably wouldnt have if not for that power struggle. If they arent actively self injuring or menacing toward others, I would let the patient keep it.

[nurse lala, BSN, RN]

I'm going to reply to address the dynamics of this process. I have been in this same power struggle from two vantage points. As the RN who did not convince the MD of the need to confiscate facial embellishments and as the RN who sided with the patient Against the NA who wanted to confiscate clothes from home. In each case there were rules in place that were dismissed.

When the Dr sided with the client against my request for his assistance, I stopped trusting him. I became less cooperative as a team member because I was resentful. I became angry and the patient saw that. I lost my authority in the patients eyes. All because I didn't talk to the doctor privately.

The NA LOST FACE WITH THE PATIENT WHEN I DIDNT BACK HER UP IN LIMITING THE NUMBER OF CLOTHES The client BROUGHT onto the unit. I thought she was being way too rigid. So what if he has an extra sweater, the unit is cold. The damage I did to her by dismissing her authority was tangible and long-lasting. The patient was gone in a week. She was mad for months.

What I learned is I Will never have this type of discussion in front of the client. Ever. This is an unhealthy dynamic for the providers to disagree and or bicker in front of the client. Whenever there is a request of another to enforce rules or a disagreement about patient care, the discussions need to take place privately. Otherwise staff splitting and resentments will happen.