Want to create a treatment plan for the nursing staff

[McNabK9, BSN, RN, APN]

Greetings,

I work in a forensic psych facility with mainly PC 1026 and PC 1370 patients. Occasionally we get a patient without mental illness but a personality disorder. Recently we received a 28 year old man that is classic Borderline Personality Disorder. He is 6'9" 300lbs. He has been performing self injurious behavior since he was 12 and continues to do so. The nursing staff, comprised of RN's and PT's is becoming burned out. We had two staff assaulted by him today. We have had to send him out almost daily due to SIB because he was dumped on our unit without a plan specific to his illness. This patient now has a treatment plan which is walking restraints, spit hood and mittens when not in locked room seclusion with a suicide blanket and gown. Even with that, he continues to be assaultive when the opportunities arise, like removing his restraints to put him in locked room seclusion. In talking with a co-worker, I thought that maybe the nursing staff needs a treatment plan of their own. It would probably look more like a set of agreements among staff, but I want to give them something to hang onto and I thought treatment plan would be more promising. Since our management is not capable or maybe interested in preventing burnout, we can take it upon ourselves to help ourselves within our unit. I work in a state facility without electronic charting and the repetitive charting in different places is an opportunity for burnout on it's own.

Some ideas I had:

-Honor your schedule by taking breaks, lunches, and leaving on time.

-Submit an Assignment Despite Objection to management anytime you question the safety of the assignment.

-If the workload cannot be completed because of lack of resources, staff, or time, don't kill yourself to do so. Document and let management know that a take down or restraint event took up your entire morning.

-Speak up and ask for what we need to get our job done instead of trying to accomplish the impossible in certain situations. This could be handled different ways. It would be great if we could provide metrics to qualify.

-Utilize ancillary staff as back up for times when we need a lunch hour covered.

I would really appreciate any suggestions. We have a very strong team that love working together and respect each other. We can practice autonomy and use our power to create what we need within our team instead of waiting, like victims, for management which is not going to happen.

[SinMiedo]

Just a quick reply, (actual suggestions to follow, hopefully!), but thank you so much for approaching this issue so thoughtfully. We have a similar environment at my facility, and reading it described by someone else has started the mental gears turning..... Let me get back to you on this. :)

[avahnel, ASN, RN]

I like the ideas that you have posted. I would also say this patient needs to be shared among many nurses meaning that one nurse done not get stuck with him all week. So, I would say that (staffing allowing) he will only be with one nurse for 2 shifts (or another relatively low number) a week. You can ask nurses if they would rather have those days back to back or spread out. I would rather have them spread out...but I could see some people wanting to have him two days in a row and then having 3 shifts off from him. I would have the charge nurse keep that in mind when doing staffing. Sharing the load is a great deterrent for burnout.

I said the above assuming you do 8 hr shifts 5 days a week. If you do 12s, I would think that 1 shift a week would be more appropriate.

[TriciaJ, RN]

Sounds like you have martyrs for coworkers, if they have the tendency to keep trying to do more with less. You are absolutely right to suggest limit setting and hold management accountable. From what you are saying, it seems obvious that your management has no intention of providing any support or leadership, but are content to watch all of you kill yourselves.

Since you all work well as a team I think it's worth getting everyone on board about refusing to constantly go above and beyond. Time to be professionals and not indentured servants. Absolutely put the turd back in management's pocket when it belongs there.

As for your troublesome patient, I'm sad for him and you. (It's easier to be sad for him when I'm not the one who has to look after him.) Sounds like he's gotten himself in a very negative spiral and has nothing to lose. Maybe a behavioural contract would give him something to hope for. If he refrains from certain behaviours in x amount of time, is there some way he can earn something? I know there are not a lot of fun things to earn in that setting and maybe you've already tried that approach.

When I worked in a jail, we had a similar situation. One young kid could get the whole place in an uproar, which was like winning the lottery. We had to educate the corrections staff about how not to feed the unwanted behaviour. A secretary brought in children's books that we were allowed to give the inmate if he held his end of the bargain. It did give us all a break from the previous vicious cycle of his self-destructive behavours.

I think you're on the right track. Good luck.