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 Psych, ER, Resp/Med, LTC, Education.
Wait....did you say PUNCHED?? As in staff would punch the patient???? The point of the restraints is not only for staff safety but for patient safety. They are ill and we are responsible to care for them not purposefully harm them.
Wait....did you say PUNCHED?? As in staff would punch the patient???? The point of the restraints is not only for staff safety but for patient safety. They are ill and we are responsible to care for them not purposefully harm them.
ok let me expand - I meant a pt would punch a victim (staff/pt) but it would only be one punch - not a prolonged assault. I'm not in the habit of punching patients - but yes it could have been read that way (obviously).
As for restraints to protect patients - what we do in psych is like any other nursing - we provide to the patient the necessary interventions to fulfill the needs they lack to do of their own ability. The need we are meeting is self control and emotional regulation.
The interventions we provide are based on what we choose to use out of what we have available.
There are better and worse options depending on the situational need, the availability of resource and the desired outcome.
I find it better option to avoid use of restrictive measures when least restricitve ones can be used.
If you're able to get two staff to sit with a patient and work through their delusions using CBT - that's far less restrictive than enforced medication and restraints. The level of response is clinically measured according to the patient's expressed level of distress - ie prolonged violence = very distressed and intense input is required. This doesn't mean the patenralistic approach has to be used every time. There are times where the patient is crying out for 'help' and medications is a way to support them - but often I find people reach for the PRN before using other interventions.
Like I said - it depends on several factors as to what interventions can be utilised - but let's not kid ourselves - many times decisions on enforced medication or restraint are made for operational convenience - there are many alternate ways to assure safety; but they often require more time, effort, skill or resources.
Very often we determine the level of our interaction based on organisational need and resource availability; patient choice or best 'clinical' practice becomes a secondary aim.
I was lucky that we were able to deploy our resources in such a way that we had more options and chose clinically over operationally for the most part.
Specializes in Psychiatric, Detox/Rehab, Geriatrics.
I worked at a state hospital facility, we had some pretty violent patients, and we still didn't use seclusion or mechanical restraints. This facility hasn't used them in a few years, only the physical holds that had to be done a specific way, and the use of stat psych meds ordered by the physician, we didnt have prn psych meds, we had to call the doctor on call, as there was always a doctor in the hospital, to get an order every time there was an incident and they had to come down and assess the patient.
Specializes in Psych, ER, Resp/Med, LTC, Education.
Sorry but I have to stand on my opinion that the use of mechanical restraints is safer for both the staff and the patient then physically holding tha patient.
The only time I may say that I do see the restraints make the patient worse is with small children......we start seeing them at age 4.......Sometimes it's useful to put them in just for long enough to get a shot of Benedryl in ...or what ever the doc orders and then hold......Not all my peers are with me on that one. But with little kids......say under 8 or 9.....the restraints scare them so much that they get worse in them. So using them just long enough to safely get a med in them releasing and staying with the child is often, but not always, better.
We get some adults who will ask for them though....some patients have insight to know they need them, its weird. Like the newborn who finds comfort in being swaddled tightly or the young child who likes the blanket wrap....this is comforting for them and they can settle this way. (Course you always have the bad borderline who begs for them for the wrong reasons.....we purposfully don't let them have them!)
Specializes in Med-Surg, Geriatric, Behavioral Health.
thanks for the clarify, mr ian.
and just jumping back to your other previous post...totally agree with you on this.
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.
Like I said - it depends on several factors as to what interventions can be utilised - but let's not kid ourselves - many times decisions on enforced medication or restraint are made for operational convenience - there are many alternate ways to assure safety; but they often require more time, effort, skill or resources.
I agree 100% with recognizing and heading off meltdowns before they happen and that the least restrictive environment is the best but still feel that in the majority of cases a prn is warranted whether the patient agrees or not when they have escalated to a certain point. This is for their safety as well as the safety of my other patients and staff. I guess it depends on the acuity of your patients. We have had quite a few serious staff injuries like broken noses, bites and even a broken leg, because of a lack of control over the patient and/or a staff member hesitating when they should have acted, imo. I used to take my time and try to talk them down before pulling out the needle however with experience I have found that if they are to that point it is more likely that even if you can de-escalate them they will fire up within the hour anyway and a prn of one route or another is almost always needed. I now immediately get the needle and just keep it in my pocket in case I can't talk them down and get them to take a PO and I feel that is a safer strategy.
It sounds like you had a really rough night. i have found that sensitive psych nurses come off as being compassionate and understanding. What distressed pt would not benefit fom that? I agree that you should not have to feel guilty for declining the extra shift.
I just need to find the middle ground as a sensitive psych nurse who can be tough in an emergency and see the big picture. I've been processing this so much that I really feel like I could really improve my performance next time around. For the most part, very few patients escalate with me and I am known for it. I am an extremely expressive person and patients can feel my sincere concern for them. Some of the most irritable, agitated people get their fires extinguished with kindness and sensitivity. Although, acute psychosis and completed peak escalation don't usually apply (which I guess it is one of my issues). One of the therapists today complimented me on my therapeutic manner. After such a hellish week, it made me feel really good.
I was told today to not call the doctors and talk to the charge (which I try and do anyway). Awhile ago, they relieved me of charge nurse (after 6 successful first shifts) because a few people didn't like me. So this is just getting ridiculous. They are putting me on the next schedule, but I'm starting to feel like persona non grata. I've applied to a few others jobs, but I am unsure about it and I'm not looking forward to dealing with new job stress again. Same ol' workplace, different people, but perhaps I can start over.
I think your capacity to empathize with others and feel is a great asset to you as a psych nurse,it is people who can no longer feel the tragedy of such situations that are at risk,i would want someone who feels strongly the way you do to care for me should i have a psychotic break,i am sorry you felt bad and hope you feel better now,i agree with these other posts that it is a part of psych nursing and that it is the equivalent of a medical code,thankyou for being there.
I just need to find the middle ground as a sensitive psych nurse who can be tough in an emergency and see the big picture. .... but I'm starting to feel like persona non grata.
ok ... here it is straight from the hip.
Institutionalisation doesn't just effect the patients. In fact - it is in the staff it manifests most. For without it - the patients wouldn't know it existed.
Even in acute turnover units - it's there. Everything is run to the pleasure of the organisation and its staff.
When it comes to most the incidents I've had to intervene with because a patient became highly distressed - well, here's a few reasons:
It's that one nurse who doesn't seem to realise s/he starts more trouble than they resolve.
It's that other nurse who would rather spend the day sat in the office and not out on the floor talking with patients.
It's that other nurse who doesn't think there's much hope so why bother?
The other nurse who hands over to all the other new starters - "Watch him" and "Whatever you do, don't let her have her own way or we'll be doing it forever"
The one who says "No you had a cigarette 5 minutes ago ... you don't need another one. Go and watch TV" then closes the door.
The one who doesn't spend any time talking with the patients but feels informed enough to tell the doctor everything about everyone.
The one who observes, assesses and identifies a patient in distress - then reaches for the first tablet so they can sleep it off.
I recently wrote an online article on "Stigma" and MH - talking of how it's time to destigmatise the mentally ill in the community - which a lot of places are doing.
The loudest response I got back tho was from the service users who said - it's not the community that stigmatises the most - it's the service.
And they're right.
I've talked to people with "BPD" who get more frustrated at the treatment they get by ED staff than for the reasons they presented there.
All I hear about are nurses who say "Not that one again? She's a 'Pee Dee' "
What can I do? These are my colleagues. I shrug and say - "Well what can you do?"
I never tell them that in my counselling sessions I hear about how they were raped, bashed and ignored for years.
Not just once or twice - repeatedly.
Sexually, physically and emotionally abused by a 'trusted' friend, relative or even parent until the only thiong they have left to let out the pain is to OD - cut - or harm themselves in some other way.
But to the staff - eh, 'they're nothing but a pain in the a$$ - taking up time we could use for 'really' sick people.'
Lucky I guess they don't have to sit and listen to her whine for 3 hours about .. well, y'know, all 'that'.
inthesky:
Don't change - at least not the way you deal with the patients. You're fine.
Learn to tolerate staff.
Most of them panic and over react.
If you have "rapport" you can do miracles.
Many never know what it's like to 'share' an experience with the patient.
Face it - if some of those nursing colleagues really were able to disaply 'empathy' and 'care' about the distressed patient - don't you think one of them would have the decency to come up and say to you "How do you feel?" - rather than scumming off to managers about this and that?
Unfortunately many think that doing something 'to' the patient is as good as doing something 'for' the patient.
They don't even get to know about doing something 'with' the patient.
If anything - learn to deal with the staff. They're the ones with the biggest insecurity.
And often they're the ones that rate higher as a PeeDee.
:loveya:Thanks so much! I read this before going to work this morning. I wonder if there has ever been a study of staff institutionalization. I have wondered about it before. I once found myself talking to a patient about the effects of staying too long and thought...hmmm.. I spend 40 hours a week in this place every week... I can no longer control the high pitch of my voice and things I say which sound contrived.. I choose my battles with limit-setting. For example, if someone is on the phone more than the rules (10 minutes), I will only say something if other patients need to use the phone and we turn off the phones anyway for groups and meals (it is very rare that a patient does not respect another patient's right to use the phone if he is alerted). I try and weigh things with the situation. One staff member treats the patients exactly like her kids. It doesn't go over very well and she does not read cues very well.
Mr Ian, you remind me of my new grad preceptor (whom I still keep in contact with "he is my nurse dad"). He has been in the field for 25 years and still experiences each patient as individuals. He taught me to not get into power struggles as it is not the point and is destructive. He also told me that I am something special and to keep fighting. He also probably held my hand way too much in emergencies (which didn't help me recently..but no one is perfect =P)
When I worked nights after graduation, I worked with all male nurses and at least half the techs were males as well. It was much more relaxed. People didn't wait in line at the managers office trying to make others look bad in the name of "patient safety". There were some occasional evenings of testosterone-fueled patient escalation as there are some things male patients won't do or say to a bunch of women.
:loveya:Thanks so much! I read this before going to work this morning. I wonder if there has ever been a study of staff institutionalization.
When looking for the problems in a relationship - it is seldom we look to ourselves first.
It's a well known thing. I've seen it in absolutely every establishment I've worked in - ~ 20 or so.
What's really odd is this -
In mental health institutions - the "patient" IS the illness... everything about them is "BPD" ... or "psychoses". It's like they lose the 'person' - which is sad.
However - staff - who are meant to be - compelled by their profession and their employer - to be "staff" - are more often 'the person' and base their value judgments as if it were their kids they were treated.
It's not an easy issue - and I'm not simply going to say it falls to 'bad staff' - very often the institution wants it that way - all in order. It's about striking a balance with many many things.
Heaven knows the trouble I've been in over the years for 'siding with a patient' in trying to make that balance.
I've been ejected from clinical review by the consultant cos I said the patient had rights - and told him I was acting as the patient's advocate as my nursing body tells me to and I would not allow him to just 'sign off' on detention papers without raising dissent.
:crying2:
RochesterRN-BSN, BSN, RN
399 Posts
Wait....did you say PUNCHED?? As in staff would punch the patient???? The point of the restraints is not only for staff safety but for patient safety. They are ill and we are responsible to care for them not purposefully harm them.