Yet another unnecessary takedown

[algebra_demystified]

I'm fed up with the number of unnecessary takedowns at my current employer. We had another one tonight. I'm the "big guy" on my unit and refused to escalate a conflict, so staff called another nurse in to pop this patient's bubble.

I guess staff got what they wanted. They got to tackle this patient into a corner again, hold him down, and get an order for S&R from the on-call PMHNP. Whoop de doo. Congratulations on putting your fellow staff at risk for injury over nothing. This pt was running his mouth, threatening this and that, but never engaged in any threatening behavior. It certainly did not reach the level of danger to self/others.

I've posted about this in the past and turned in a supervisor for taking things way too far for no good reason. Of course staff covered for her and supported her illegal and morally wrong behavior.

Most of the reason for my disgust is because this is bush league psych-out nonsense that should have been handled without confrontation. It takes skill and balance to convince somebody that you are going to do what it takes to handle their complaints properly while knowing all the time that the patient isn't going to get what they want. No, you're not going to be released from the hospital while on a psychiatric hold. No, I'm not personally responsible for that set of circumstances. You don't want to hurt me over this, do you? Why would you? I'm not doing anything to you, the county sheriff has decided that this is what's best for you and I am obligated to carry out the wishes of the county sheriff. We can talk more about how the county sheriff intersects with other law enforcement entities later, but it's really important to recognize that the county sheriff is the highest law in the land. I cannot disregard the instructions of the county under the current circumstances, which place you under the guardianship of those people. Unfortunately for you, you have made direct threats to the safety of yourself and others, blah blah blah.

Doing the deescalation talk with the patient is extremely important. Shoving in to blow up the patient's safety net is something a two year old could do. Nothing against two year olds... I just don't feel the need to follow their examples.

I'm looking for another job right now.

[Fuzzy]

Good luck to you. you sound like a very compassionate person.

Fuzzy

[psychRN319]

Are you saying that the staff actually provokes the patients just so they can call a code and do a take down? This is absurd, why would they do that to the patient and to the staff? Often I see that some staff members, while not provoking the patient, do not do enough to de-escalate the situation before it gets serious or they "jump the gun" so to speak and give meds for agitation when less drastic measures would have worked. I find that some staff members, nurses and techs alike, like to exert their power and it results in unnecessary confrontations with the patients. I have always believed that "less is more" when dealing with angry or agitated patients. If you take the time to talk to them to see what can be done it makes a big difference. If you neglect to hear the patient out and call a code, of course the patient will get defensive and more agitated, seeing this huge group of people in scrubs surrounding them----who wouldn't feel threatened? I think that if a nurse or tech doesn't feel it is important to do everything possible to avoid this situation the they do not need to work with psych patients. Talking and listening goes a long way. As a nurse (who obviously cares about his patients) its up to you to advocate for them. If someone is provoking your patient, step in and get your patient away from those who are "popping his bubble" as long as it is safe for you and the patient. Your heart is in the right place. Only when you recognize injustice can you intervene for what is just.

[Meriwhen, ASN, BSN, MSN, RN]

Are you saying that the staff actually provokes the patients just so they can call a code and do a take down? This is absurd, why would they do that to the patient and to the staff?

If that's the case then that is truly a tragedy. Psych nursing shouldn't be about power struggles.

I agree that some people are quick to call codes if the patient shows the slightest bit of agitation, and quick to IM medicate "to prevent potential problems." Neverminding that in the process of doing that, they're actually escalating the situation.

You'd be surprised how far taking some time to listen to (key words: listen to) and talk to the patient can get you. Sometimes all they want is to just let it out. Let's face it, being in a psych facility as a patient isn't fun for most of them. It can be very frightening, stressful and overwhelming...especially if there are staff that are treating the patients as though they don't have any feelings or rights whatsoever. But those patient do have them.

Is this always the answer? No. Sometimes the answer is in fact to call the code and give the emergency meds. But calling the code shouldn't be the first line treatment--it should be when used when the other options have failed.

[Jayesse7]

I have this debate at work from time to time. There's a number of things in play. First of all it's a dangerous setting to work in so it's important that staff back each other up. I cannot stand it when staff begin to take personally things that an angry patient is spewing from their mouths. As the charge nurse I try to step in when I hear that banter begin and ask the patient to come talk to me. Usually allowing them to vent diffuses the situation and I can talk them into PO meds in the end, if they need them, which satisfies the "punitive" nature of the incorrect staff person....whom I will counsel behind closed doors, ironically, in the same way I did the patient; "What's going on? What happened that made you so mad?", etc...

BUT also... where is it written that a code or an escalated pt REQUIRES S/R or even injections?

EXAMPLE: My facility has forensic units where people stay for years...so many of them are very well known. This pt "X" is a large, well built young man who can be pretty dangerous when he fights. He wanted an extra snack and was told no. He got angry and flipped the plastic tray that holds the sugar/creamer packets onto the floor and went to his room and shut the door. The supervisor who happened to be standing there said to call a code and get an order for injections. She's new. I was absolutely shocked. I wasn't even working that unit but had come to get a medication from their med room when I witnessed this whole thing. I am seasoned. I KNOW this patient. This was a case of the supervisor being afraid (?) I don't know, but since she doesn't have to be involved in the fight she was about to create she didn't worry that "X" would be waiting and ready in his room to punch somebody in the face as soon as staff opened the door. It would take 6 big guys to subdue him if he fought... over an extra cup of hot chocolate! I respectfully (well.... I meant no disrespect I should say) when I jumped in to offer a different plan.

"Just give him a minute in his room while we talk about this. You want to call a code that is surely going to end in restraints, injections and unnecessary danger over a snack?" Not saying he should've gotten the extra snack. Thats their call. And nobody has to ignore the situation completely either...but somebody neutral who has a rapport with him could go to the door of his room and knock...ask him to come talk a second...no code...no meds...just vent your feelings. I promise, most of the time, when pts react that way, they want an out too before it escalates. As it turned out that night, he vented to one of the aids he likes and apologized for his outburst. Problem solved without risk of injury. Hopefully his team remarked on his good choice to handle it peacefully in the end for positive reinforcement.

So much of the time staff become so bent on "showing pts who's boss". If it was a prison I would understand the purpose of swift and severe consequences. BUT in a hospital you have to think differently. We don't put people in restraints or give them injections for punishment. The reason should be "you are out of control of yourself and I will help you to regain control of yourself"... and you exhaust your least dangerous methods first... remove them from the situation or remove the person they are in conflict with so that talking, negotiating, PO meds... whatever you think may be appropriate can have a chance to work.

AND Algebra... if you are in charge be wise and take charge... if you are not talk to the one who is about this repeated problem. Stand your ground because you are right. I will back off when an aid steps up to diffuse a potentially bad situation. They often have built rapport with pts and are most effective.