I am still quite a new psychiatric nurse (almost one year). I still get really scared and shaken during incidents of patient violence and restraints. We had a 19 year old patient. It was her psych admit and possibly first psychotic break. She has a long history of abuse and neglect and reports that she hears the devil talking to her. She had been very distant and sedated for her first few days on the unit (probably overly sedated and she had been voicing rightful distress at being "tranquilized").
Yesterday, she just flipped. She was screaming that a plane was going to crash into the hospital and we were all going to die. She had to leave to help give directions on how to land the plane. She was so afraid and truly believed that we were hurting her and preventing her from saving peoples lives. It really cut into me. She threw a chair into a window (luckily plexi-glass) and bit one of our techs. I called a code and security came running with their K-9 unit. It took 6 people to hold her down. Fortunately, 4pts were not necessary. I got the injections ready and called the doc. She managed to sleep a bit so we held on to the injections. I made sure the other patients were safe and did some debriefing. They could probably tell that I was shaken and near tears myself.
We managed to get her to her room and she slept a bit. She awoke and began screaming again. I brought the injections and I just froze up as she was begging us not to do it (we had gotten orders to involuntarily inject and petition). I handed the injections to the other nurse and she gave them. They were given in her deltoid and there was a lot of blood as they were 22 gauge 1.5in needles supposed to be used for the gluteal muscle. She was screaming. I nearly cried again. She eventually fell asleep again. Both techs were in her room so I did the q15 rounds.
We had a new admit (unfortunately this patient had come from another hospital and we had previously accepted her). I received her and got her chart stickered up and ready to go. The nurse was really angry at me for not completing the admit as she was drowning in petition paperwork she had never done before. I honestly was just paralyzed and really wanted to go home and cry. As bad as it sounds (as I was definitely not the only person frazzled), I really needed a hug and some reassurance. It was already an hour after my shift had ended and I felt in a trance. I don't know why I feel so obsessed at how disgusted and disappointed she was with me. I ended up leaving at 1am (my shift technically ended at 1130). I am having trouble shaking it.
I cried all the way home and woke up my boyfriend to cry to him for an additional hour. I could have stopped myself from crying and sucked them up, but I didn't want to. I wanted to release and I feel like the patient deserved a few tears. I took my usual sleeping med. This same nurse called me at 0630 for me to come to work because the AM nurse had called in. I was really disoriented and my eyes were swelled shut from crying. I had finally gone to bed at 0330. I refused to come in and since I was zonked on ambien, I can't remember what I said to her. I called work at 1030 to ask if I had offered to come to work or if they still needed me. Fortunately, someone else had covered. I am hoping that there will not be consequences at the workplace for my lack of team-playerness. I am afraid to go to work tomorrow. I think anyone could be shaken by that event and by the nightmare this poor girl was suffering. I am just disappointed in myself for freezing and not being the team-player everyone wanted me to be. I know that I work in a psychiatric crisis unit and this will happen sometimes, but it breaks my heart and scares me anyway. :crying2:
Specializes in Psychiatric, Detox/Rehab, Geriatrics.
At the facility where I work, we all work together, and if someone can't give a med another nurse will do it. I guess I am spoiled with having good co-workers.
But I read this as she "nearly cried again" when she balked at giving a PRN and had to give the needle to another nurse. At my hospital this absolutely would have required an incident report and very likely a follow up before the nurse would be allowed to return to the floor. Maybe my facility is different but not a week goes by when I haven't had to give an unwanted IM and imo it is dangerous to the patient and staff if the nurse isn't able to do this quickly and safely.
Maybe it is once a week at your facility (and I respect and admire you for working with such a heartbreaking population), but it is a few times a year at mine. In my defense, I have never been in the situation to give an unwanted injection before. Next time, I am going to certainly hold my breath and slam it in. I am not doubting that it is best for the patient in the end (as I'm sure an acute psychotic episode is far more traumatizing than a shot), but it is not easy and it should never be easy for one human being to shove a needle into another human being with begs and plees not to.
I have applied to graduate school and plan to be an NP as I do believe that outpatient will fit me best. People must realize that telling me I should not work here are telling me that I should not have a psych nursing job at all. There are no psych nursing jobs for someone with a BSN without case management experience.
As good as it would feel to defend myself, that is a no-go at this facility. Defending oneself= being argumentative and not a team player. Yesterday, as bad as the real situation was, my coworkers embellished things and one of the techs actually LIED. When I told the manager that one accusation wasn't even misinterpretation, it was just blatantly untrue, there was silence and I was told that that was not the point. I almost got fired about 6 months ago due to other people feeling like I was challenging them and lost my charge nurse Wednesdays. Since then, I moved past tolerance and started getting positive feedback again about the good quality of my patient care.
Now you all might think I hate my job, but I don't. My facility is very work place toxic (the ******** about others and going to the manager is so rampant it makes me sick..i never participate because I think it's wrong), but people do truly care about the patients. Patients actually get really good care here; our satisfaction rates are continuous very high. The same day I was nearly fired and cried my eyes out.. i got back to work.. did my thing.. stayed 3 hours late because someone called in.. and had two patients tell me how much they appreciated me helping them.
Both times, I cried to my managers saying how much I wanted to stay..but I know this will only hold for so long. =(. sorry this was so long winded. thank you all for listening
to answer some of the other questions:
I didn't actually cry until I started walking to my car.
Where I work we don't have too many truly psychotic patients, but since we have a contract with the state we do have our fair share. I usually like interacting with them better then the majority of our patient population- detox is no fun for the patient or the nurse.
It sounds as though your workplace needs to team better- maybe its that our hospital is on the small side (about thirty beds for the adults and about the same for adolescents and children), but we seem to mesh pretty well together. You can't expect your co-workers to all like you, but you can expect them to be professional. Did they tell you why you were reviewed after the incident? Was is failure to come in after being called in the next morning or the incident itself? Could there be a way to change how you and your co-workers interact to prevent this from happening in the future?
One thing that psych nursing has really taught me is that we can only control ourselves and our responses but that is usually enough to change our environments.
Before you confront - be sure it was that nurse who reported. I'd also let things cool off before anything gets stirred again - since you've been 'warned'.
Don't lose your compassion. It's a psych nursing trait that is sadly abandoned by most in favour of the institutional approach.
Thanks so much for this article. As I'm sure that meds prevent some damage, I am not convinced that the meds don't contribute or at least exaggerate the presentation of some of the 'slowness'. In simplistic terms, don't anticonvulsants drugs work by slowing electrical transmissions of the brain?
Thanks so much for this article. As I'm sure that meds prevent some damage, I am not convinced that the meds don't contribute or at least exaggerate the presentation of some of the 'slowness'. In simplistic terms, don't anticonvulsants drugs work by slowing electrical transmissions of the brain?
There's a wide range now and I'm not sure at all how they're meant to work - but essentially they modulate the neurones so they don't get into that electrical overload.
I found this about extending the life span of a worm using anti-convulsants tho.....
Genetic studies have elucidated mechanisms that regulate aging, but there has been little progress in identifying drugs that delay aging. Here, we report that ethosuximide, trimethadione, and 3,3-diethyl-2-pyrrolidinone increase mean and maximum life-span of Caenorhabditis elegans and delay age-related declines of physiological processes, indicating that these compounds retard the aging process.
Specializes in Psych, ER, Resp/Med, LTC, Education.
I hear ya JULES A. Not a week goes by for me either! In fact I would say with 99% of the injections we give.......the patient is in restraints and getting the IMs BECAUSE they REFUSED the PO meds offered and were posing a safety risk to themself and/or others. In fact we are technically suppose to offer PO PRNs before we can give the IM(s) but as you know sometimes the acuity is too high and the patient is incapable of processing such a request.
Specializes in Psychiatric, Detox/Rehab, Geriatrics.
At the hospital where I worked at, we didn't have seclusion or mechanical restraints, only physical holds that had to be done a proper way and only could last up to 10 minutes at the maximum amount of time.
You said you felt as if you weren't a team player by not coming in when they asked you if you could at 0630. You hadn't gone to sleep until 0330, you were still under the influence of your sleep med. You would have been a danger to yourself and others if you had gone in. Don't think every time they call you, you need to go in. Your phone would be ringing all the time! You did the right thing. I hope you are felling better now.
I think your concerns are valid and your conscientious approach demonstrates reflective practice.
I have worked in a secure psych for 14 years (until my latest new job) and in the last year we had a purge on not using hands -on restraints or seclusion (have never used mechanical restraints and until moving country had only seen seclusion used once).
I decided to take my practice one step further and I didn't give any coerced/enforced medication. Wasn't at all difficult - based on developing good rapport and intervening before flashpoint.
Current research is looking at the validity of coercive medication and restraint and whether it really is an effective intervention in comparison to less confrontational interventions.
Specializes in Psych, ER, Resp/Med, LTC, Education.
How could that possibly be safe? Maybe your patients weren't as violent. We very often have restraints that literally take 6 or more security officers, 2 MH techs, and 2-3 nurses to get the patient physically restrained....then put onto the bed and into restraints and IMs given. We have a fair number of injuries...mostly to the security officers and sometimes to our staff....kicked, bitten, spit on......one guy we have had a few times had taken the receiver off the phone and in trying ot get to him an officer got hit in the head with it. Thank the lord the most I have ever gotten was kicked and not too hard by a 10 year old autistic kid. There is absolutley no way we could safely function without restraints. The staff would be seriously injured regularly. I have to say though that in the psych ED where I am we pretty much don't use seclution. Who's brilliant idea was it to funtion like that....that is really unsafe for the patients and the staff. The patient be restrained as well as all the other patients not to mention visitors. My complaint is that we have some very violent patients and OMH is no letting us use leathers any longer. We have to use the stupid velcro restraints and some of the patients can get out of them. The med ED can still use them but they are not under the OMH like we are and they tell us that we have no way to clean the leathers properly and we use them way to much to not be able to clean them--multiple times a day some days, and at least 5-7 times a week at a minimum. And 10 minutes! **** I have had seriously psychotic patients the were in --and needed to be!!-- for like 4 hours!!! Thats a long time and hard when you have to have a staff person 1:1 with the patient the entire time.
Horses for courses. Despite the fact we were a secure forensic psych ward - the acuity was pretty low and acutely disturbed pts mostly went to the acute unit before admission to us. Those pts who became acutely unwell when they were there were managed in-house. Changing the culture of the unit did reduce the number of incidents but I don't know if it would work in a psych ED.
Not giving out enforced medication doesn't mean PRN wasn't used - but if a patient stated they didn't want a medication then we agreed that they had a responsiblity to control and contain their behaviour; which seemed to work.
The methods used to determine our responses are governed by a few things:
1. The acuity of the unit
2. The quality and number of the staff
3. The confidence with/of the unit Management
4. The availability of things
I've never used mechanical restraints as many places don't have them. They are often used as a convenience - but if the acuity requires it then it's justified.
As for restraints - patient's who became aggressive were simply counselled; if they became violent then it was usually only a single punch thrown and once a nurse or two was on scene they were compliant with walking away to another area. Sometimes we'd interlock arms in a loose fashion - mostly when escorting thru/past other patients - no wristlocks applied.
It's certainly different from when I first began - and there were many personal ethical and emotional issues to deal with. Restraining ones own emotions when seeing someone else assaulted was difficult but the victims never felt they were 'underserved' by the nurses for not 'jumping' the perpetrator. A few perps even had a guilt trip over the fact that no one jumped on them.
:crying2:
jpRN84, BSN, RN
123 Posts
At the facility where I work, we all work together, and if someone can't give a med another nurse will do it. I guess I am spoiled with having good co-workers.