What is it really like to be a psychiatric nurse?

Davey Do · Jul 3, 2015

Good questions, gracecov.

I am limited in my ability to answer your inquiries, but applaud your seeking the perspectives of others in your endeavors.

The population I have served has a tendency toward acute exacerbations due to treatment non-compliance.

There's a lot of quick admissions, stabilization, and discharge. Unfortunately, a vast majority won't follow up with after-care and it's recidivistic city.

According to stats I read several years ago, medication non-compliance is the most prevalent reason for an exacerbation of symptoms and subsequent inpatient hospitalization. Hence, there's a big focus on medications.

The very best to you in your endeavor, gracecov!

JustKeepDriving · Jul 3, 2015

I'm a psychiatric mental health registered nurse and I've spent the majority of my career in forensic psychiatry. My undergrad was in Psychology and Social Behavior with my research concentration in corrections with a dual bachelors in nursing. I currently work inpatient psych while I attend a Psychiatric Nurse Practitioner program (because the hours) but have spent the majority of my career in forensic psychiatry and plan on returning to it when I finish school (start in September so... 2 years given I can make it).

Psychiatry, Psychology and Nursing are all different fields. All the disciplines are complimentary... but they all have their own area of focus. In terms of inpatient forensic psychiatric nursing, I work as part of a team of mental health providers. Our educational backgrounds and areas of focus are all different and we come together as a "treatment team" with our individual focus, experiences and educational backgrounds to help our patient's stabilize and meet their mental health goals.

My Psychiatrist does medication management, forensic evaluation (everyone who commits murder comes through my state hospital and both psychology and psychiatry evaluate the individual... most get sent to corrections), behavioral orders (Places patients on constants, writes restrictions, writes orders for behavioral precautions), and works with the legal field (such as involuntary medication orders, advocating for involuntary medications in front of a judge and testifying at court that a patient needs to remain inpatient or is stable enough to reenter the community). The nurse practitioner has a similar scope of practice but in my state more restrictions on what they are able to do independently (for example, they cannot write seclusion and restraint orders) but can do medication management, behavioral precautions and involuntary medication orders (including going to court to advocate for a patient to be medicated).

My psychologist does testing (is the patient malingering, what is there IQ, personality testing, ect.) and some counseling (DBT, CBT, ect). Some of them are also part of the forensic evaluation services and evaluate offenders to see if they meet the criteria for placement at the state psychiatric facility. Mostly, they're involved in testing.

The social workers also do some counseling but their emphasis is helping the patient with transition. This means that they work with the patient to help him or her figure out community and healthcare resources to help them transition back to where they are from and maintain the conditions of their release. They also help the patient's family members and basically act as a liaison between the patient and the "outside world" (Patient's come in and have jobs, housing, outside responsibilities... and the social worker works with them to figure out how they are going to maintain those responsibilities while being in a locked mental health unit).

Mental health therapists do the majority of the counseling and behavior incentives. They meet with the patient one on one and help them with their weak areas (coping skills, social skills) and do the most one on one therapy. Mental health therapists have a background in either Marriage and Family therapy or Counseling psychology. They do the most CBT, DBT (when clinically indicated) and so on. Their primary role is to "talk" to the patient and help the patient figure our what he or she needs to do in order to be successful at reentering his/her community.

Occupational therapists work with the patient in order to help them meet their activities of daily living (getting up and showering, tying shoes, hand eye coordination) and provide patients (generally those with severe schizophrenia, autism spectrum and traumatic brain injury) with sensory stimulation that they can use as a coping skill/deescalation tool (weighted blankets, weighted stuffed animals, change of lighting in the room, and even change the entire room in order to help the patient maintain safety).

Nurse management coordinates the care of the unit. They make sure everyone is on top of their work, that the legal paperwork is up to date, bring suggestions from the floor to the treatment team and administration and deal with staffing.

Psychiatric nurses do milieu management, run the floor and meet the health needs of the patient. We utilize crisis intervention, verbal deescalation and modalities such as PMDB, CPS, Pro-Act and CPI in order to provide acute behavior management. We also administer medications, plan unit activities, call for orders, run behavioral and medical codes, initiate seclusion and restraint, manage chronic and acute health problems and our entire day involves patient interactions. We also chart daily on our patients and that charting is used to see how psychiatrically and medically stable these patients are, is used to monitor behavioral trends in correlation with medications and also for a variety of other data for the treatment team (which interventions are effective, which aren't and so on). They can also run groups (those that work on the treatment mall) and my facility give us some training in DBT.

Psychiatric Technicians/Mental Health Technicians (if CNA) are the floor staff. They observe the patients, sit on constants, report to the nurse, take the patients on outings, help them with their legal skills, and can also run groups. They get trained in Pro-Act, CPI, CPS, PMDB ect. and DBT. They help the patient with hygiene activities, getting packages, ordering clothing and generally coach them on following their treatment care plan. Some of them can administer medications (CMA's and Psych Tech's). However, they work under the nurses license and we're responsible for the tasks that we delegate to them and we must ensure that what we delegate falls under their scope of practice.

If you want to become a Nurse practitioner you generally go to nursing school, become an RN, go work in psych for a few years, then go back to school to become a Psychiatric Mental Health Nurse Practitioner. You probably won't do very much counseling... I'm not saying that there aren't possibly jobs out there where you could do counseling, just if you want to work in forensics it's highly unlikely. You will not have the time to sit down with patient's for an hour and help them with their cognitive schema. Also depending on the acuity of the ward... you won't be able to. The patient's that end up on a forensic stabilization unit (Where you're most involved with the legal system) are either so disorganized that they can barely create coherent sentences let alone do the work necessary for effective CBT. The ones that are that organized and stable... are generally very criminal/antisocial and CBT is not an effective modality for those individuals. So your focus is medication management (finding the right medication in order to help them stabilize).

Generally when my mental health team goes to court its about whether the person is "competent" to enter a plea, appropriate for a "guilty with the exception of insanity" plea, is stable enough to reenter the community under the conditions set forth by the legal system (in a community living/supervised environment) or if they need to be involuntarily medicated (meaning they have to prove that they are not competent to make medical decisions) and so on. They aren't hired by private interests... it's just another part of their job description. You make legal recommendations as part of the patient's treatment team.

The individuals that I do know that act as expert witnesses for private interests are Ph.D's with research in specific areas. Like the one I know specializes in memory recall (all of her research is in memory) and provides expert witness to discredit stuff like police lineup's and the memory recall of individuals who act as witnesses.

Forensic nurses generally collect evidence in emergency rooms after an individual has been sexually assaulted. These involve getting your SANE-A or SANE-P (which is a nursing certification - sexual assault nurse examiner). There isn't really a "Forensic Psychiatric Mental Health Nurse Practitioner" or "Forensic mental health registered nurse" degree. It's generally something that you end up specializing in based on job experience/ population you work with rather than education.

Mental health is a broad field with a lot of overlap but really educational preparation and scope of practice really details what you'll spend the majority of your time doing. If you don't know what you want to do I would try and secure a job as a Mental Health worker or CNA in a state hospital. That way you can see first hand what all the disciplines do and if you enjoy working in this area of mental health.

LadyLamp · Jul 4, 2015

What a great post, @JustKeepDriving. Thank you for taking the time to share all that info. :-)