What can you do in 7 - 14 days?

[NCindasun21]

Greetings!

I work in an acute child and adolescent setting where the typical stay is 7 - 14 days. I've only been there for 3 months and I'm still getting a feel for the job.

I had a disagreement with a MHW/Tech yesterday when I over ruled a decision she made. It's not important what the issue was but it ended with her telling me I needed to get a backbone and not let the kids take advantage of me.

It got me to thinking, what is my role and responsibility in this setting? As I see it, I cannot "fix" their problems in 14 days. I can't take away their PTSD, their paranoia, their ADHD, their sociopathic traits. What I can do is protect them, make sure they stay compliant on their meds, protect the other kids from them, and prepare them for discharge to a therapist and psychiatrist who can take over and do the "real" work.

To do this, I feel I have to make therapeutic decisions. I sit on the ground and let them talk. I pay attention and for some of these kids very few people do. I've yet to have a kid who defiantly tells the doc he's not taking meds refuse them after we've talked. I get the aggressive ones to learn to walk away and come tell me they need to talk, not just for them, but to protect the little ones around them. Sometimes letting them wear an inappropriate article of clothing (tank top) underneath their shirt seems more important that creating a scene that escalates.

Does this mean I don't have a backbone? I understand rules are defined for keeping order but what if the rule in a certain situation causes more harm than good? I really believe that I'm not avoiding conflict but rather picking my battles. Am I wrong to think that the definition of a good day is

- no one was hurt

- no code was called

- medication was administered as ordered

- therapists were informed of pertinent information shared by patients?

I mean, what more can I do in 7 - 14 days?

[Jules A, MSN]

I agree that there isn't much more we can do besides keep them safe, administer medications and hopefully plant a few seeds of coping skills as they go on with their journey. That said I almost never over-rule one of my tech's decisions in front of the child unless it is downright unsafe. FWIW I have seen new employees of all disciplines get a bit of a honeymoon feeling that no one else is as therapeutic and your statements "I've yet to have a kid who defiantly tells the doc he's not taking meds refuse them after we've talked. I get the aggressive ones to learn to walk away and come tell me they need to talk, not just for them, but to protect the little ones around them." kind of sounded like so just be aware of that. Don't allow your value of how you do your job fall to hard on whether a kid takes medication from you or not because I promise you will eventually meet one that will refuse and please don't forget to be aware of where they are and what they are doing because even one you think you know and trust can become assaultive. We also take any contraband like inappropriate clothing from their possession so wearing it is not even up for discussion. Good luck, you sound like a caring nurse but make sure you keep your wits about you.

[NCindasun21]

Thank you for your comments. I do appreciate them and will try hard to keep them in mind. I guess I'm just a bit frustrated. Perhaps I should have just journaled. Guess I need to work on my coping skills.

[Meriwhen, ASN, BSN, MSN, RN]

It's hard to deal with kids because on one hand, we want to treat them like kids. At the same time, this age group is definitely one of the ones that will try to pull one over on staff if they can. Kids are crafty little buggers and they're not afraid to play the dramatic card to get what they want.

Not knowing exactly what the issue was (as you won't tell us), it is possible that what your tech said had merit. Nursess in psych need to learn to be firm with patients, particularly kids. This doesn't imply that you have to be uncaring, but you do need to set and stick to consistent boundaries and rules. If you bend the rules once (such as the clothing), then it gets harder to say No the next time. The rules are there for a reason, and while it may seem more beneficial to bend/break the rule, 99% of the time that is not the case. Rule-bending is not a therapeutic decision. And that 1% of the time where it's necessary to bend a rule, it's usually done with a doctor's order and heavily documented.

If you're worried about a scene, then let the kid create a scene--it won't kill them, they'll learn to use their coping skills...and you'd be surprised how fast that scene will stop when you tell them that if they can't calm down you'll have to give them a shot.

Trust me, you have NOT failed if a kid makes a scene or if they refused your meds. Nor does it make you a bad nurse. Nor will the rest of the staff be thinking, "oh, she's a lousy nurse--look at what that kid did". You'll get into more trouble for rule-bending than you will for having a kid throwing a fit. So that's a habit that you need to get into check before it bites you.

I do agree with Jules A in that unless the tech was making an unsafe decision, you should have not overruled him/her in front of the child. Kids are pros at staff splitting and so you always want to present a united front to them--any disagreements should be addressed in private. And I also agree: please don't fall into the "no one else is therapeutic to them but me!" trap. Yes, it's easy to, especially if you are fairly new in psych. But realize that patients respond to some staff or approaches better than others. Patients can also be very manipulative.

You'll keep learning as time goes on. Heck, after a year I'm still learning something new every day. Just keep at it, keep self-assessing and reflecting on your performance, and don't hesitate to ask more experienced staff (this includes techs as well as nurses) for help and guidiance. Some techs have been around a long time, and the fact that they're not nurses doesn't mean that they don't know what they are talking about regarding the unit and the particular population/patient you are working with.

And FWIW, I agree: any day without a code is a good day in my book

[NCindasun21]

I am taking everything being said to heart. I had teenagers so I know how manipulative they can be

I didn't (and wouldn't) do anything in front of the children, and in fact, the tech over ruled what I had already decided on. When I told her no, that I had already made the decision after discussing it with another nurse who agreed, that's when the trouble started.

Trust me when I say that I let plenty of scenes and tantrums occur. That's why I have a headache most of the day from the noise level.

The issue with the tank top occurred when a very well-endowed teen had her bra taken away from her because of the underwires. She spent the whole day covering her chest with her arms and sitting by herself because she was embarrassed. I felt that giving her a tank top that would at least hold her breast somewhat in place was better as long as she kept it under another shirt. That's it. I felt letting her worry more about her boobs than participating in group was not therapeutic.

I've asked the techs to teach me their side of their job and I will do the same to the extent that I can. Some are very gracious and really work as if we are a team. I guess I'm just hurt/embarrassed/frustrated with someone getting up in my face in front of the staff and kids when all I was doing was trying to do the right thing.

Thanks again for your help.

[Jules A, MSN]

I guess I'm just hurt/embarrassed/frustrated with someone getting up in my face in front of the staff and kids when all I was doing was trying to do the right thing.

.

This should not have happened out on the unit and you have every right to feel frustrated.

It is awesome that you are so receptive to the feedback offered here. Hang in there. :)

[Meriwhen, ASN, BSN, MSN, RN]

This should not have happened out on the unit and you have every right to feel frustrated.

Agreed, that should have been done in a staff area or off the unit.