What can I say to psych patients that does not exceed the scope of nursing practice?

[22314]

Hi,

I'm doing my psych clinical right now, and I'm not sure exactly what I'm allowed to say to the patients, so I thought I would ask here.

I listen to the patient's stories.

I ask them about their signs and Sx of mental illness.

I ask them about their medication side effects.

I would also like to give them information about other things, but I don't want to exceed the scope of nursing. For instance:

Is it totally inappropriate for me to say to a patient who is impoverished and facing homelessness "have you heard about Social Security Disability benefits? Why don't you ask the social worker about it to see if you are eligible?" Just knowing there is help available can relieve some of his anxiety.

If I am talking to a depressed patient who has ODd 4 times because she feels hopeless about her future, and I find out she wants to be a teacher one day, can I say to her "I have heard that some state schools don't charge tuition to the mentally disabled. Why don't you ask the social worker or the schools about it?" It does give her something to be hopeful about.

If I am talking to a patient who thinks recovery from major depression is impossible, can I tell them "my friend recovered from this after 3 years of therapy and meds and he's a happy person today, so some manage to do better after years of therapy and meds." I know I can't say "don't worry, you'll recover!"

It doesn't feel right to withhold info that can help people when you see how helpless they are, but I don't want to exceed the scope of nursing practice either.

[RochesterRN-BSN, BSN, RN]

I can't say that those things are "out of scope", not all. The longer you are working with these patients the more comfortable with a term known as "therapeutic use of self". This is a big concept.....talk to your instructor about it and look it up in your text...this may be helpful.

As far as telling them about things out in the community that may be available to them.....that is hard to say. You want to give them hope but try not to give false hope...which can be worse. You have to remember to be supportive and positive but realistic. Like the lady wanting to be a teacher........keep in mind, is it really the best kind of position for someone that unstable...at least right now? Maybe, but she needs to work on having better insight and judgement as well as coping skills long before she would be stable enough for such a responsibility. Maybe down the rode but she has a lot of work/therapy to do.

Maybe being encouraging in the fact that she is thining about the future and has some goals for herself. --Being future oriented is what we call a "protective factor" when assessing lethality--- its like a scale. Risk factors vs. protective factors. The more protective factors a person has the lower their risk may be for self harm. You are weighing the two. How strong are the risks vs the PF's. Make sense. Another concept that is good to know....ask your instructor.

Okay so you can point out that it is encouraging that she is thinking about her furture. You might better talk to her about the steps she needs to take to get there. BEFORE she is running off and getting funding. You can talk about coping skills to deal with stress, rejection, anger, etc. A safety plan and suppports.

With a pt. dx with Borderline PD you can ask if they have done any DBT work with a therapist.....a concept to become familiar with as well....they can talk about this with you. So baby steps to as to not have them jumping into something they may not be ready for....less apt to fail this way.

This is the kind of stuff nurses can do. It's really pretty broad what we can do-- just can't diagnose or tell a patient that they will be discharged or when. That stuff all has to be decided by a doc. Questions that may involve why a doc started a med, changed a med, etc. I usually keep my answers very general and tell them I will let the doc know they have questions about their meds.

The most important thing to remember is that if you are an an acute stay psych unit.....stabilization is the focus. Working on things like coping skills and such is fine if there is time. Safey plans. For a patient with a CD issue, talking about addiction stuff and how they can be most successful with staying clean on d/c, that kind of thing......they don't like you to get too outside the immediate needs.

I hope this all makes sense and is helpful. I love to teach NS in psych rotation and new psych nurses....so let me know if I can be of help in the future.

Good luck........and just know that with psych it gets easier the more you do it.

[inthesky]

Sounds like some things I say to my patients :) In my opinion, hope and drive is the backbone of mental illness recovery. Don't forget that true mental illness cannot be 'cured', but it can be managed and people can live quality lives. It's hard to have meaningful interaction as a student. It sounds like you are doing very well.

[Whispera, MSN, RN]

I'm really impressed that you care so much as to ask what's appropriate! It sounds like you'll be a very caring nurse!

I have some comments and please don't take them as a slam. I think you don't have much experience with mental illness though, and I want to help.

Don't ask them about the signs and symptoms of their illness if you use those words. Lots of psych patients do not think they are ill. It's better to ask them for the reason they're there. Definitely encourage them to talk about what's going on with them.

Your role is not so much to suggest alternatives as to help them find their own, so you could as what they've thought of to help them live a happy life (emotionally, financially, etc.) and then you can throw in things you've thought of too, but lots of times people have already thought of everything you could mention. Definitely let the social worker know if you discover a need. Sometimes you'll figure out a need and the patient will not be able to work toward fixing it due to the illness. Then the social worker can do lots to help.

Try not to refer to patients, to their face or in their presence as mentally disabled. That could be something that isn't taken in the way you intend. Those that don't believe they have an illness are going to be particularly offended by this.

A depressed person often feels helpless and hopeless...that's part of the illness. You can surely make encouraging remarks, but they might not have any impact until the person is better. I think I'd hold off on talking about that long a recover period too. Three years can feel like forever if you are in a gray cloud of smokey gloom.

Honestly, in your interactions, your role is to use interpersonal communication skills to help the person vent about their problems, and find their own solutions if at all possible...or get others involved if needed. You also assess as you interact, and always, always, always monitor for safety.

I think you're going to do a great job. Enjoy it it. Psych patients can be quite fascinating!

[Mr Ian]

A learned psychiatrist gave me some advice one time when I was stuck in therpay session with a female adolescent arsonist and didn't know what to say sometimes.... trying not to upset or trigger things - but not wanting to sound stupid and patronising either. He told me it was the advice given by his psychotherapy supervisor which went like this:

For any given situation, say there are 10 different possible responses.

1 will be the best ever.

1 will be the worst ever.

8 will be mediocre and neither great nor bad.

As long as you avoid the worst one - and hope for the best one - you're doing fine.

[Jules A, MSN]

You have gotten great replies so far and I'd just like to echo kudos to you for inquiring about how to be the most therapeutic. These were the kind of questions I used to ask my professor or the nurse if they weren't too busy. Even now there are times when I call my pt's therapist to ask questions and bounce ideas off them for continuity of care. I love Mr.Ian's tidbit about the best/worst/mediocre answers. Are you thinking about doing psych nursing?