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Discussion

Takedowns and Security Training?

Do most psyche nurses function as "security", too?

What's the scoop?

I interviewed for a psyche position but a friend of mine says that, to work psyche, you have to get physical with the assaultive patients and be willing to participate in a "takedown" situation? Can anyone explain.......how is it done where you work?

Thanks

Featured Replies

  • Author

Will SOMEONE answer, please? :crying2:

In certain situations, people with psychiatric issues can become violent...the physical training is for the staff and also the patients safety...in each of the hospitals I worked, when I worked in-patient, anyone that had "direct patient" contact, not only nurses and psych techs, but social workers, doctors, administrators, ALL had to be trained and certified in whatever physical safety program the facility used, AND recertified every year...many programs have modifications for folks that have limited mobility; i.e. back or knee problems, etc.

Hope that answers your question.

~Gail

I sure can answer, but the relevancy of my answer is maybe somewhat limited, considering i live in Europe, and not in the Us. In the psych facility I work (max security for violent patients), all staff except for the docs and the cleaning crew do security work. This includes holding people, flooring them, restraints and so on. The nurses float in the ward and are usually involved in some way or another when somebody gets agressive (considering most of the quarrels are about meds).

  • Experts

Well, it's not "functioning as 'security,'" it's a therapeutic intervention which is part of psychiatric nursing practice. When psychiatric clients are so out of control that they become physically dangerous to themselves or others, they have to be physically restrained until they can be safe (typically, in that sort of situation, they receive medication to help them regain control more quickly, although that depends on many different factors).

How this kind of situation gets handled depends on the individual facility. I have worked places where A) there was no one to call for help and psych unit staff were entirely on their own; B) hospital security staff could be called for help, and followed the direction of the RN in charge when they arrived on the unit; C) hospital security staff could be called for help, and they took over the situation entirely when they arrived -- nursing staff had no more say in what happened to the client (I really disapprove of option "C"). I've known some hospital security staff who were really wonderful with psych clients, and some who were downright dangerous. I've known of two psych settings where hospital security's idea of handling this kind of situation on the psych unit was to come in and spray the client with Mace ... :uhoh21: My personal preference (after 20 years as a psych nurse) is to handle physical situations with clients with just psych staff, and not involve hospital security.

State rules determine who can be involved in restraining clients, and what sort of training is required, and there are individual variations from state to state. In my state, anyone working on a psych unit, plus all of the general hospital security staff, plus anyone else who might be reasonably expected to have contact with psych clients (like ED staff) must complete a state-approved training program in safe behavior management techniques (designed to minimize the risk of injury to either clients or staff), and be recertified annually.

What did you expect happens on psych units when someone becomes physically aggressive/assaultive -- they are allowed to just run amok on the unit until they wear themselves out? :) In that situation, staff intervene therapeutically to protect the safety of everyone on the unit (including themselves). Ideally, staff intervene with an escalating client to prevent a situation getting to the point of physical aggression. However, that is not always possible/successful, and then staff intervene physically to keep an out-of-control client safe until s/he can regain self-control.

Restraining people is a big deal, legally, and there are lots of state and Federal rules/regs that must be followed. Part of your orientation to a new psych job would be educating you about your role in managing dangerous situations on the unit, and the state and Federal rules that must be followed.

Hope this info is helpful for you. Best wishes!

So glad I found this thread - anybody out there from TX? Just wondering if anybody else has been having the same problem.

I work on an acute adolescent unit of a private hospital and the rules that just came down are absolutely dangerous to follow. We cannot go hands on unless the pt is in immediate and SERIOUS danger of harming self/others. In other words, if the kid is just tearing up the unit/attempting to elope we have to let it happen... We have to try other means first, which is ok; nothing new there, but then if we DO have to go hands on, the doc has to order it and then be there face-to-face to see the pt. within some specific number of hours - I believe that that is two hours - this gives the pt. plenty of time to wreak havoc and hurt self/others before anything can be done. Since I work the night shift there is a real possibility of problems, as we have a doc that doesn't want to answer his phone when he is supposedly on call.

My question is, is this the way other psych units are run or are we just "lucky"? If anybody else operates under the same restrictions, how is the new system working for you? Is it just because we are a private hospital that the rules are so stringent?

  • Experts
We cannot go hands on unless the pt is in immediate and SERIOUS danger of harming self/others. In other words, if the kid is just tearing up the unit/attempting to elope we have to let it happen... We have to try other means first, which is ok; nothing new there, but then if we DO have to go hands on, the doc has to order it and then be there face-to-face to see the pt. within some specific number of hours - I believe that that is two hours - this gives the pt. plenty of time to wreak havoc and hurt self/others before anything can be done. Since I work the night shift there is a real possibility of problems, as we have a doc that doesn't want to answer his phone when he is supposedly on call.

It sounds like you are referring to the CMS (Federal government) rules related to restraint/seclusion, which have actually been in place for six or seven years now ... (Your facility is just implementing them now???)

While a physician or other licensed independent practitioner must do a face-to-face eval of the client within one hour, you don't have to wait until the doc gets there to put the client in restraints or seclusion!! You can take a telephone order for the restraint or seclusion (same as any other telephone order), and the doc can sign the order when s/he gets there to do the eval. If a client is physically dangerous to self and/or others and less restrictive interventions are ineffective or inappropriate in the situation, you do NOT have to let her/him just run amok for an hour until a doc is physically present! Also, it is up to your facility policies and state rules/regs whether an RN can initiate restraints/seclusion before calling the doc (in my state, we have always been able to do this) -- i.e., put the client in restraints or seclusion, and then call the doc after things are under control. (However, keep in mind that the "clock starts running" on the 1 hour for the face-to-face eval when you put the client in the restraints, not when you actually speak to the doc.)

If your doc is not cooperative with meeting her/his responsibilities to the clients on night shift (or any other time), you need to get the hospital administration and/or medical director to get after her/him -- if there is a survey and the hospital gets busted for face-to-face evals not getting done within one hour, it will be the hospital that is in trouble with CMS, not the individual doc ...

I've spent the last several years enforcing these rules as a surveyor for my state (not TX) and CMS, so I'm v. familiar with them. Best wishes --

It sounds like you are referring to the CMS (Federal government) rules related to restraint/seclusion, which have actually been in place for six or seven years now ... (Your facility is just implementing them now???)

While a physician or other licensed independent practitioner must do a face-to-face eval of the client within one hour, you don't have to wait until the doc gets there to put the client in restraints or seclusion!! You can take a telephone order for the restraint or seclusion (same as any other telephone order), and the doc can sign the order when s/he gets there to do the eval. If a client is physically dangerous to self and/or others and less restrictive interventions are ineffective or inappropriate in the situation, you do NOT have to let her/him just run amok for an hour until a doc is physically present! Also, it is up to your facility policies and state rules/regs whether an RN can initiate restraints/seclusion before calling the doc (in my state, we have always been able to do this) -- i.e., put the client in restraints or seclusion, and then call the doc after things are under control. (However, keep in mind that the "clock starts running" on the 1 hour for the face-to-face eval when you put the client in the restraints, not when you actually speak to the doc.)

If your doc is not cooperative with meeting her/his responsibilities to the clients on night shift (or any other time), you need to get the hospital administration and/or medical director to get after her/him -- if there is a survey and the hospital gets busted for face-to-face evals not getting done within one hour, it will be the hospital that is in trouble with CMS, not the individual doc ...

I've spent the last several years enforcing these rules as a surveyor for my state (not TX) and CMS, so I'm v. familiar with them. Best wishes --

So then, am I to understand that if the doc does not answer his phone and the medical director, who may not be on call at the time, doesn't either, (understandably), as long as I CYA carefully, my license is in the clear even though we supposedly failed to obtain an order/face-to-face for a takedown we already did? I find this SO confusing and am really uncomfortable with this rule... it is really putting us RNs out on a limb with no safety net, isn't it?

  • Experts
So then, am I to understand that if the doc does not answer his phone and the medical director, who may not be on call at the time, doesn't either, (understandably), as long as I CYA carefully, my license is in the clear even though we supposedly failed to obtain an order/face-to-face for a takedown we already did? I find this SO confusing and am really uncomfortable with this rule... it is really putting us RNs out on a limb with no safety net, isn't it?

I have no idea what the state rules are in TX, so I cannot advise you specifically about that. There must be a compliance person at your facility, whose job it is to make sure that your policies and procedures are in compliance with Federal and state rules/regs; that person could tell you specifically what you can and can't do in TX. Also, the state BNE (is that what it's called in TX?) can advise you about whether specific actions would or would not jeopardize your license.

If you are not able to get responses at night from the doc on call in a reasonable amount of time, you need to document that (in the client record, if appropriate) and report it up your chain of command every time it happens. If some of the docs are not doing their jobs (e.g., answering phone calls and pages at night), then someone much higher up the ladder than you needs to get after them. It is just not acceptable to not have physician coverage promptly available in an acute psych setting at night (or any other time)!

If there is any sort of Federal survey (validation survey or complaint investigation) and the surveyors find that the CMS restraint/seclusion rules are not being implemented consistently, it will be the hospital that will be in trouble with CMS -- maybe you need to remind your bosses of this when you're talking with them about the doc(s) not responding at night, and also ask them what, exactly, they want you to do in emergency situations when you can't get the doc on call to answer the 'phone.

The whole point of these CMS rules is that they want putting someone in restraints to be viewed as a medical emergency that deserves/requires hands-on involvement by physicians as well as nursing staff; same as, if a medical patient is suddenly crumping dramatically, the doc comes in to the hospital and takes a look at her/him and does something. (They also want to make it harder and more unpleasant for staff to restrain someone, so that it will only be used when absolutely necessary ...)

One thing is sure, though -- this is definitely not something that you should be having to try to figure out, by yourself, in the middle of the night.

It sounds like you are referring to the CMS (Federal government)

I've spent the last several years enforcing these rules as a surveyor for my state (not TX) and CMS, so I'm v. familiar with them. Best wishes --

Just how do you "enforce" these rules as outlined by the Fed Gov? By simply checking the facility's paperwork allows facilities to fabricate documentation. The facility I worked at were very good at producing "quality" paperwork but in reality, these union staff workers used excessive force and excessive usage of restraints without interventions because the staff were too busy attending to their own needs; eating, reading, watching tv, smoking, talking amongst themselves, sleeping to intervene early on....and re seclusions: they didn't even bother to document; just stick'em in the room and lock the door. Oh, and speak out for patient rights and you'll find yourself the target of retaliations. You want to know how to really enforce these rules: put video cams in these facilities (we did it anonymously) and you will be horrified for years to come!

Do most psyche nurses function as "security", too?

What's the scoop?

I interviewed for a psyche position but a friend of mine says that, to work psyche, you have to get physical with the assaultive patients and be willing to participate in a "takedown" situation? Can anyone explain.......how is it done where you work?

Thanks

"Takedown" I personally think this word is used by somebody relatively new to mental health. I work on a secure unit. We undergo Prevention and management of aggressive behavior trainning sessions every year and have a least restraint policy. De-escalation techniques are taught in small groups, and in case we have to restrain a patient the assigned nurse always takes the lead followed closely by security or other clinical staff. Every situation is unique and there is no standard response, just ensure patient and your safety. and yes we definitely function as security with no additional pay.

I find the word "takedown" more commonly used in certain parts of the country rather than the experience of the practitioner.

So glad I found this thread - anybody out there from TX? Just wondering if anybody else has been having the same problem.

I work on an acute adolescent unit of a private hospital and the rules that just came down are absolutely dangerous to follow. We cannot go hands on unless the pt is in immediate and SERIOUS danger of harming self/others. In other words, if the kid is just tearing up the unit/attempting to elope we have to let it happen... We have to try other means first, which is ok; nothing new there, but then if we DO have to go hands on, the doc has to order it and then be there face-to-face to see the pt. within some specific number of hours - I believe that that is two hours - this gives the pt. plenty of time to wreak havoc and hurt self/others before anything can be done. Since I work the night shift there is a real possibility of problems, as we have a doc that doesn't want to answer his phone when he is supposedly on call.

My question is, is this the way other psych units are run or are we just "lucky"? If anybody else operates under the same restrictions, how is the new system working for you? Is it just because we are a private hospital that the rules are so stringent?

Also keep in mind in TX (and I'm sure many other states) if you have to restrain a pt (if only for a few seconds) to give an emergency med and immediately let go, you still have to document the event as a restraint and file the packet of paperwork. In CA, when an order for an emergency medication is given, it is implied that there will have to be some sort of physical restraint, so there is no restraint documentation required (per one of our docs who says he worked for the state dept of mental health). IMHO, this is more reasonable, but what can ya do but what your required to do?

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