Treatment plan to place patient in seclusion

[kobri331]

At the facility where I have been working -through an agency -the treatment team makes treatment plans for the patient. These treatment plans are to be followed to the letter. These treatment plan orders for the patient to be secluded once the patient has received 3 redirections to stay in the quiet room for time out. I have a problem with these treatment plans. Has anyone else ran into this problem?

[oldladyRN]

At a State psychiatric hospital where I used to work, we had a patient that was to be secluded d/t her inappropriate behaviors and it was written into her care plan. She had bipolar disorder and when she cycled, it was pretty bad. This particular unit was both males and females, and they spent the majority of the day interacting with each other in a common dayroom. Patients were encouraged to attend classes and outings, but those that chose not to attend stayed on the unit.

When this patient would cycle, her temper and resulting physical aggression were difficult to handle. She would throw things, injure other patients, overturn and throw (heavy) furniture and generally disrupt the unit. Timid and scared patients would hide behind chairs and male patients would clench their fists, ready to fight. Things would go "to hell in a handbasket" quickly. Even if she was not acting out in a physically aggressive manner, she would strip mother-nekkid and throw her clothes at people. Either way, we ended up with a roomful of about 30 pi$$ed-off patients that would become unpredictable in a flash.

As soon as she would stand up from her chair and start acting out (usually by sweeping a magazine onto the floor or throwing a cup of water onto someone), staff would swarm in and walk her to the seclusion room, where the RN would lock the door. The walk to the seclusion room was generally uneventful, as any and all available staff (from nearby units as well, if need be) were walking with her and she didn't feel up to fighting 6-7 of us. The RN would close the door, which automatically locked and had no doorknob on the inside. She would scream and yell for a few minutes, pound on the door a little bit and then she was finished. We'd let her out, the doc would come and assess her, and she'd swear to never do it again. She'd finish up by calling me a b**** and everyone went on with the rest of their day.

It was actually very effective in taking the wind out of her outbursts. Her goal in acting out was to get attention, which we removed when we removed her from her audience. We rarely had to give her any emergency meds, which would have required several staff to restrain her (during which, someone could have really gotten hurt). She would read her magazine for a few hours, and then we'd do it all again. This would go on for about 2-3 weeks at a time.

If she wasn't cycling, she was someone you'd want to invite over for coffee.

Please look at the big picture when you see treatment plans such as these. Although the goal is always to use the least restrictive means necessary, you always have to look out for the safety of the other patients and the staff.

I hope I've given you a different perspective on things.

oldladyRN

[kobri331]

Thank you very much for your post. I can see the therapeutic value in this case. In my post I was not clear about my difficulty with the treatment plan. There are times when seclusion is a necessity for the safety of everyone. The treatment plans I am concerned about are for children or adolescents who are not combative. These children just come out of the quiet room because they do not want to take time-out, due to different reasons, ie hyperactivity, oppositional defiant disorder, pushing limits - but the child is not combative. I would appreciate your thoughts on this.

[oldladyRN]

The only thing I can think might be going on is that the child's behavior, even if not "combative", may be disrupting the unit to the point where the safety of others might be compromised. If the child is seen as a leader by the other kids, or the the child is idolized by the peers, the child holds a lot of power and control over the other childrens' behavior. This is the cornerstone of gang mentality.

Sometimes, you just have to remove the controlling child from the receptive audience. Theoretically, you should move others, but often (due to staffing or the layout of the room) it's easier to just move one person. I was a psych nurse for a long time, so I am just giving it my best guess.

You always want to work with the other children to build up their self-esteem, but sometimes you have to act quickly when the situation could get out of control.

I hope this helps. Feel free to send me a private message if you want to talk more about it.

oldladyRN

[pandora44]

It sounds like the "three directions and then seclusion" rule is being used to help the kids make positive decisions. As in, you now have a choice to do as you have been directed or go to the seclusion room; make a good decision. This helps patients, children especially, realize that the choice is theirs, and that there are consequences to their actions. This works best when every patient is treated exactly the same by every staff member. Actually, the more I think about it, the more I like the rule.

[elkpark]

I agree with your (the OP's) concerns, and question whether this is legal. It would not be in my state. Might be worth checking into the state (mental health and hospital licensure) rules. Not to try to get the facility to change its practice, since that's not likely, in my experience -- just to check on whether this is a place you want to be involved with ...