Newbie psych nurse seeking feedback (long)

  1. I am a second career new grad RN. My first job was six months at a nursing home, and I have now been working for 2 months at a freestanding psych hospital. I have loved psychology since childhood, and am enjoying this opportunity, but would like some feedback on how to better handle some situations. Prior to nursing school, I recognized that I have codependent issues, and I worked on them for several years and continue to do so. I no longer worry about what people think of me, but I must still present as a people pleaser, based on how people react to me - that is part of my problem. So, I am working on becoming more assertive and confident in my reactions to people.
    Yesterday at the start of PM shift all the rooms were taken, so we decided to do report in the day room. One patient I'll call A was in there. I asked him to leave temporarily, and he said in a very irritated voice "I'm not leaving, you people treat me like crap, I have a right to this room." I need to exert my authority, but I feel like if you meet anger with anger, it escalates the situation. What would have been a good response? How about "A, we're just asking you to leave the dayroom for 15 minutes so we can take report. You can come back here then." Is that too soft a response? Do I need to confront A's bad attitude because he is being disrespectful and if I don't confront it it will just lead to more of the same? I truly am not bothered by whether or not A is respectful to me or what he thinks of me, I just want to get my job done and have a good milieu.
    Next scenario: recently a "frequent flyer" came back, a young woman. Another fairly new nurse assessed her. She appeared completely out of it, kept repeating some nonsense phrase, and had to be practically carried to her room because she was too limp to walk. A little while later, she walked to the day room and calmly ate a snack, stating "I was just tired". My colleague said "She was just faking it!" (which I think she had suspected already, this just confirmed it). What would be a therapeutic response to this behavior?
    Next scenario: a 40-ish female pt is admitted. She claims to be a BSN who just got fired from her job "for teaching the MAs how to give IVs", had her two kids taken away by CPS because of her boyfriend's drug use, etc. She claims to be in a lot of pain. I call for initial orders and am able to get her 1 Percocet every 6 hours. She isn't happy about this, but I explain that this is all she can get now and will have to talk to the internist tomorrow if she needs more pain meds (our hospital is cracking down on pain meds so as not to enable drug seekers). She is constantly at the nurses station and tries to split the nurses. I am polite to her, but not real attentive as I don't want to encourage her attention and pain seeking behavior. I was off for a few days, and then she was my pt again. By this time we had found out she was not an RN or any other licensed professional by checking the BON website. She told me that she had 10/10 chest pain that was radiating down her arm. I thought I detected BS, so I had her VS taken and they were OK (BP a little high, but not majorly). Since she had no other objective s/s, I didn't do anything else. I found out yesterday that a colleague sent her out to the ER while I was off for these same complaints (she was sent right back after getting some morphine, which I guess is what she wanted). My colleague stated "she knew just what to say". My question: should we call her on her BS i.e. "we checked and found out that you are not a nurse"? I don't feel offended by her behavior but just want to be wise and therapeutic. Also, what's the best way to chart on this? "pt c/o chest pain 10/10 radiating down arm but after assessment & VS found no objective evidence so just continued to monitor"? Doesn't seem very CYA which they are always telling me to do.
    Sorry this is so long! I appreciate any feedback.
  2. Visit elizabethgrad09 profile page

    About elizabethgrad09, BSN, RN

    Joined: Dec '09; Posts: 45; Likes: 40
    from AZ , US
    Specialty: 7 year(s) of experience

    10 Comments

  3. by   Davey Do
    " Prior to nursing school, I recognized that I have codependent issues, and I worked on them for several years and continue to do so. I no longer worry about what people think of me, but I must still present as a people pleaser, based on how people react to me – that is part of my problem. So, I am working on becoming more assertive and confident in my reactions to people."


    Self-awareness is always a good place to start. We need to know ourselves, our strong and weak points, in order to grow and develop and effectively deal with the Mentally Ill.


    "I need to exert my authority, but I feel like if you meet anger with anger, it escalates the situation."


    I found this to be true, in that the like-energy will esculate the situation.


    What would have been a good response? How about “A, we’re just asking you to leave the dayroom for 15 minutes so we can take report. You can come back here then.”


    You gave an appropriate resonse, in that your statement gives clear, concise gudelines. You're also making the Patient privy to some information so nothing is vague. I like to initially use the line, "I need your help." Very few people do not like to "help" if they can. We all need to feel like we're needed. I often get a response of a look of surprise, as if they are saying, "What? You need MY help? What can I do for you?" I continue, by saying something like, "We need to use this room for report, so could you assist us by making sure confidentiality is not breached..." Have them move chairs, or some other small task, to make them feel as though they are a part of the process.


    If the soft approach doesn't work, then I tend to lay down the law: "We need to use this room for a confidential report. You need to leave so we can get on with our business. If you refuse or otherwise act inappropriately, you will need to deal with the ramifications of your actions or inactions."


    These two examples are both ends of the spectrum. The soft approach is a sugar-coated manipulation technique. The law approach is a reality check. The appropriate approach usually lies somewhere within the spectrum and you'll know which way you will need to lean by accurately reading the Patient.


    "My colleague said “She was just faking it!” (which I think she had suspected already, this just confirmed it). What would be a therapeutic response to this behavior?"


    Hopefully your colleague didn't make this statement in the presence of the Patient. That would not have been therapeutic. I could critique the statement and give you rationales, but, instead will answer your question:


    These People are Mentally Ill. Expect inappropriate behavior from them. Inappropriate behavior is a classic symptom of Mental Ilness. I would suggest your response to be one of a concept called "Being Lovingly Indifferent". We care about our Patients, but we do not invest in them emotionally. Be professional, factual, and document the outcome of your interventions.



    My question: should we call her on her BS ”?

    Our job as Medical Professionals does not have within its guidelines to be a Judge, Jury, or Executioner. We Assess, Plan, Implement, and Evaluate Care. Taking a subjective statement from the Patient, obtaining Facts, and determining the best route of action is a typical Nursing Process. The Psychiatrist and Therapist need to be informed of the Patient's behavior. Be factual, concise, and objective in your reporting.

    I could have discussed these situations with you 'til the cows come home, elizabethgrad09. I would have like to point out more that you're doing right, and discuss some points at a greater length, but my time and energy are finite.

    Generally, I want you to know I truly appreciate your actions in dealing with Menatlly Ill Patients and the fact that you are endeavoring to grow as a Person and a Professional.

    My very best to you.

    Dave
  4. by   elizabethgrad09
    dave,
    thank you for your feedback, it is very much appreciated!

    my colleague did not make the statement "she was just faking it!" to the patient, but privately to me. i don't think she has been there a year yet, so we are both still trying to figure out the best ways to be therapeutic with pts. unfortunately, there are only a couple of experienced psych nurses around, and we are usually so busy that we are limited in the questions we can ask them, thus the reason that i came to this forum.

    thanks for your thoughts on the continuum of responses, from soft to hard, and explaining the idea of "being lovingly indifferent".
    >"we care about our patients, but we do not invest in them emotionally"
    i will chew on this.

    also, thanks for pointing out that my attitude toward my pt was judgmental. i do understand that the pts are mentally ill and will behave inappropriately. i understand that the axis ii pts have learned their behaviors as a way of coping, sometimes as a result of horrific abuse. what i am struggling with is understanding my role as a psych nurse and how i can best assist such a person. if someone has gotten into a habit of habitually lying or clearly appears to be drug seeking, is it helpful to discuss this with them? or is it is better to simply react to the behaviors by setting limits, etc? interestingly, a pt who was constantly at the nurses' station the other night with multiple requests remarked to the bht "i know i'm very demanding and a princess". if a person shows insight, would it then be appropriate to discuss it with him/her? by the way, our supervisor came by and told us how to set limits with her by telling her she could only approach the nurses' station once per hour with 5 written requests.

    the best to you as well.
  5. by   pandora44
    I've been a psych nurse about two years, after moving over from medical. I well remember where you are right now. It takes awhile to learn to deal with challenging patients!

    When I've had a patient who is obviously "faking it" but suddenly appears much improved, I don't focus on it. I might say something like, "I'm glad you are feeling better" then move on to other things. I will call a patient on their behavior if their symptoms just suddenly appeared when I know they were fine a few minutes prior. For example, a patient recently told me she couldn't get out of her bed, even though she had been up walking in the lounge a few minutes before. Nope, I told her, you can get up. You were just in the lounge. She got up.

    Chest pain and S/S of other major medical issues are tricky. I would always report chest pain, c/o seizures, overwhelming pain, etc. Just because they have mental illness doesn't mean that they might not have a heart attack. And yes, I know, 99% of these complaints are requests for attention and/or medication. But is it really worth your license to not report it? I work in a medical hospital with multiple psych units. CP gets reported to the psychiatrist, who almost always consults our medical residents, who of course order an EKG at the minimum and usually labs.

    Calling pts on obvious BS stories? Generally I wouldn't, at least until I had developed a good relationship with them. But in most cases it's probably not therapeutic unless their stories and/or behavior is outrageous. Calling pts on excessive use of pain and/or anxiety meds? Maybe, depending on the patient. Again, I would have to have a good working relationship with them. If it's someone with some insight into their issues, I usually mention it and suggest that they cut back. And yes, when a patient shows some insight is exactly the right time to bring these things up. For a pt who calls herself a princess, I might say, "Well, yes, you are a bit of a princess," with a little smile to take the sting out of my words. I might add, "Let's talk about that in our 1:1 after supper. Right now I need to check on my other patients and check my paperwork."

    Setting appropriate limits on demanding patients can be a real challenge. On our unit we will sometimes do hourly requests with these patients. Works pretty well. I think it's also appropriate to say to a demanding patient that you need to check on your other patients and it will be 45 minutes (or whatever time) until you can get to their latest request.

    Hope this is helpful.
  6. by   Davey Do
    Quote from elizabethgrad09
    i understand that the axis ii pts have learned their behaviors as a way of coping, sometimes as a result of horrific abuse. what i am struggling with is understanding my role as a psych nurse and how i can best assist such a person. if someone has gotten into a habit of habitually lying or clearly appears to be drug seeking, is it helpful to discuss this with them? or is it is better to simply react to the behaviors by setting limits, etc? interestingly, a pt who was constantly at the nurses' station the other night with multiple requests remarked to the bht "i know i'm very demanding and a princess". if a person shows insight, would it then be appropriate to discuss it with him/her? by the way, our supervisor came by and told us how to set limits with her by telling her she could only approach the nurses' station once per hour with 5 written requests.
    your perspective, insight, and thirst for knowledge is commendable, elizabeth09! i choose to copy this portion of your post because it exemplifies your understanding of the patients you serve. it also exemplifies your pertinent questioning is right on target.

    in a way, you've also answered your own question: with some patients, discussing behaviors will be therapeutic endeavor which will result in a fruitful product. with other patients, expended energy in attempts to increase insight will be exercies in futilty. i believe you pocess the where-with-all to differentiate between the two.

    my own rule of thumb is to titrate my expenditure of energy according to the particular patient's resolve to help themselves. i fulfill my responsibilities as a professional to all patients. for those patients willing to better themselves or their situation, i will go to the ends of the earth in assisting them in their therapeutic endeavor. i will not cast my pearls before swine but i will take a bullet for a few.

    in closing, i encourage you to keep on this path that your on. you are right on! and, thank you for the kind words!

    dave
  7. by   pandora44
    [QUOTE=
    My own Rule of Thumb is to titrate my Expenditure of Energy according to the particular Patient's Resolve to help themselves. I fulfill my responsibilities as a Professional to all Patients. For those Patients willing to better themselves or their situation, I will go to the Ends of the Earth in assisting them in their Therapeutic Endeavor. I will not cast my Pearls before Swine but I will take a Bullet for a Few.

    [/QUOTE]

    Dave - what a lovely and delicate way of phrasing that sentiment. On my unit, we short hand it to "don't work harder than your patient." I hope no one blasts me for that, as I believe that's the credo of every good psych nurse. I have spent hours and hours of my time with patients and their families who are terrified, motivated, and desperately looking for answers and guidance.

    On the other hand, I've lost track of the number of patients who have told me that it's my job to "fix them" when I ask what they are doing to speed their recovery. This always leads to a discussion about their responsibility to themselves to get well and do what they need to do to stay well. Then there are patients who are in no way willing or ready to make any changes in their lives. Sometimes a patient is just not in a place mentally to respond appropriately to challenges from staff to work on their issues.

    Of course, these are not discrete categories but a continuum of motivation and desire to change. Patients move back and forth on this continuum all the time. As a psych nurse, being able to recognize where a patient falls on that continuum on any given day will save you a lot of energy and time.
  8. by   elizabethgrad09
    pandora44 and dave, thanks to both of you for your feedback, it is so helpful! i'm sure that my instincts will get better as i go along, but hearing how other people respond to similar scenarios and the philosophies they employ to be the most professional and therapeutic really feels like it is speeding up the learning curve for me. thanks again for being a blessing to me as well as your patients. i am proud to be one of the company of psych nurses j
  9. by   jimkusters
    First of all, remember, Psych nursing is unlike any other kind of nursing. What seems like a simple, logical request to us, can sound like you just asked the patient to jump off a bridge.

    I often find myself trying to step back and think about what I'm saying to patients. Being nonconfrontational is almost always the best approach to start with. Sometimes, unfortunately, you will have to resort to taking a more authoritative tone.

    As for having to have report in the Day Room, at the facility I work at (a stand alone facility, also), we have a room designated for report, and taking breaks for the staff. It is locked from the outside of the room so patients cannot enter it. Maybe you could suggest this to your management.
  10. by   elizabethgrad09
    jimkusters,
    Thanks for the feedback. Can you elaborate on your statement "What seems like a simple, logical request to us, can sound like you just asked the patient to jump off a bridge." It sounds like you are saying that because these are psych patients, they interpret requests differently than the average population. Is that correct? Can you give an example?

    I agree about being nonconfrontational. It seems to me that just about no one likes to be told what to do, and even more so with psych patients. As an ancient text puts it "A soft answer turns away wrath."

    Regarding where to give report, we do usually use a separate room. But on that particular day, those two rooms and even the group room were all being used by Drs and social workers, so we resorted to the day room. Maybe we would have been better off using the conference room down the hall. I can understand the pts feeling like the day room is "their" room and objecting to being asked to leave it. After all, they are locked in, have an assigned roommate, have to eat at prescribed times, etc. etc. and then even their room is taken away.
  11. by   jimkusters
    I'm sorry, maybe I phrased it poorly. I'm just saying that some psych clients, because of either being disorganized, delusional, and/or paranoid, what we say to some clients can be interpreted by the client as something very different from what you were trying to say to them.
  12. by   Shanna M
    I think some nurses tend to not give as good of care as they could to mentally ill patient's d/t their dx. Yes sometimes psych pt's will tell you they are having chest pain to get sent to the er for meds or just to get off the ward, but there are times also when it is accurate. We had a pt once who complained of chest pain that radiated down the arm and we sent the pt to the er and come to find out they had a heart attack. What would have happened if we chalked it up to oh they are mentally ill there is nothing wrong with them? I see it too often from people in the psych hospital and it saddens me all of the issues surrounding psych patients...not receiving adequate care because staff doesn't believe them, being treated as less than a human being d/t their dx, not receiving compassion and empathy. Even while borderline personality disorder pt's are difficult to work with and many do not like to work with them their need for attention is a problem they have- part of their diagnosis, these people are ill, they are not in the hospital for no reason or because it's the Ritz Carlton.

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