safety on an inpatient psychiatric unit

kate · Apr 22, 1999

Definitely! We are seeing an increase in forensic clients at our facility. Staffing is an ongoing problem, and in order to staff adequately, management is requiring us to work overtime to provide coverage. We have all been working double shifts frequently, and morale is at an all time low. I also wonder about safety when staff is fatigued, demoralized,and would rather be spending much needed time with their families.

Callan · May 8, 1999

The staffing problem has become a little better. Nursing administration has offered a bonus for those who pick up extra shifts as well as incentive bonuses for those who increase their FTE. There is a committment 6 mos up to 2 years. This has helped me to fill some of my vacancies.

The problem with the recidivism continues. Anyone out there have any creative ideas to let my staff realize I am in this with them???

nurse lala, BSN, RN · May 15, 1999

Something we have done at the VA, is to conserve patients who continue to use drugs and alcohol, while being supported by SSD.

Usually, just informing the patient that continued abuse of the system will result in conservatorship is adequate enough to keep the patient out of the system for long periods of time, if not indefinitely.

Of course, we have the recourses to keep a patient in the hospital for the extended period for all the steps. And many facilities do not...

As far as staff morale, some staff feel that conservatorship is a form of enabling the chronic forensic patient. But, in it's defense, forced recovery and a stay in a locked facility for a year is one heck of a wake-up call!

NurseBoy · May 17, 1999

ummm... Nurse Nola, I don't know what "conservetorship" or "SSD" mean - could you, or someone else, give me a definition? Thanks.

About the other (original) issue - do the staff need an explanation that some clients/client groups require (demand?) a revolving door service. Although frustrating, it does give staff an opportunity to measure progress or deterioration over time & to "chip-away" at the client so that, when they're ready, the client will know that there's a service & a body of skilled people who can help.

Staff may have to change their expectations or definition of "positive outcome" if they are to have any satisfaction. For example, "positive outcome" could be a reduction in usual length of stay, or the development of rapport with a staff member, or responding to limit-setting without abusive language.

Any traditional notions of "cure" might have to be put aside for a while - this client group tends to be slow to develop good quantities of insight & motivation, therefore are slow at making changes. Staff interventions should be aimed at making incremental improvements in these areas.

Sounds a bit glib. But that's about it, I reckon.

Callan · Jun 4, 1999

That is a different way to look at it and I believe some of my staff see it that way; however, it still dosn't answer my question/concern about the contraband.

Searches are done on patients--what about visitors? We can't search them.

Another question,

Anyone working in an inpatient facility have smoking for their patients??? We presently have a smoking room on the unit. It is causing havoc for a variety of reasons. The unit is on the 5th floor so we don't have a "wing" to go outside. The other alternative is to have patients go outside with a staff member.

Has anyone run into trouble with this??

Diane K. · Jun 7, 1999

We have similar patients and have also had contraband brought on the unit by visitors. You can't search visitors, but you can restrict where they visit and supervise the visit with a doctor's order. We have a room used for groups that we use that makes it easier to restrict their movement and a staff member sits in the room with them. The visit is allowed, assuming nothing was discovered, and the patient gets the message that we take this issue seriously. If a patient does use contraband while inpt, they are discharged and not accepted back. We don't tell them outright but we keep a list of such people putting them on our "carefully screen" list.

As for smoking, we too have a smoking room and while it does have its problems, generally it works well. It is also a marketing tool as the percentage of smokers in this population is high and the pts often remark that it is a plus to not have to go outdoors to smoke. Going outdoors often requires privileges and takes staff off the unit. I like the smoking room myself.

Callan · Jun 8, 1999

How can you get by with a "screening list"? We call it a "black list" but I always hear negatives about it.

Is more than one visitor allowed to visit in this room? How many family members can visit with the patient? Do you have a policy for visiting as well as smoking? I sure would be interested in seeing them. (Do you have cameras in this rrom or is it just the one staf member?)

Are you working in a freestanding psych facility or a general hospital?

Diane K. · Jun 8, 1999

The "carefully screen" list is a guide to use when doing admission intakes. It serves as a reminder of particular problems that we may have had in the past with those named on it in case the person doing the intake doesn't recall the pt. Those on it have notations next to their names, i.e. assaultive towards staff, brought drugs on unit, or even, malingering. It really helps if our unit is volatile to be reminded of these names but they are not necessarily banned. Sometimes they get taken off the list after 6 months, sometimes we wish more names were on the list!

We have few patients on supervised visits at any one time. The room is used by one pt and their 2-3 visitors. We also use this room when a pt's children come to visit as it is off the hallway before you get to the main part of the unit. One staff supervises and usually the checks person makes themselves obvious as well, just in case.

I don't recall seeing a written policy but we only allow visiting in the main dining and living area, not in pt's rooms. Visitors are not allowed to smoke in the smoking room or anywhere else while there. We are freestanding. Tell me how you handle these things, particularly your sharps policy.

dmnurss · Jun 8, 1999

The screening list sounds fishy to me too. Years ago we used a "do not readmit list" - I think it was the same thing without the vail. Now if a certain patient has special needs we will place a "community treatment plan" signed by the patients primary care giver. If the patient presents to our intake department, or the general hospital's ER there are certain steps that are taken. Usually a crisis plan or alternatives to hospitalization if possible. Is your hospital JCAHO accredited? I would be interested to hear their response to the list.

Diane K. · Jun 8, 1999

Yes, we are accredited, I am not sure if JCAHO knows about the list. Would like to know more about community treatment plans. If what we are doing is not on the up and up I would appreciate hearing about alternatives or resources I could check to assure that we are not put in jeopardy with JCAHO or anyone else. Thanks for the feedback.

Callan · Jun 9, 1999

JCAHO has never asked about the "list". They do ask what we do with our difficult population. They do not/have not asked about recidivism, ert. We have had our attorneys involved with some of these "do not admit" cases; however, we really need to make sure we have dootted our i's and crossed our t's. My SW works with CSP's (community support programs) in the community to ensure treatment planning is consistent. The problem is these folks are non compliant from the start so we spend a great deal of energy that never pays off except for more frustrations.

Back to the visiting: At this point, we do allow visiting in the rooms. There is not a limit on the # of visitors at one time. The doors need to remain open. We check everything that is brought in for the patient biut, again, we cannot check the visitors belongings.

I like the supervised visiting. If we did it though, it would need to be for everyone not just the selected few.