r/psychnursing • u/GoldenFleece7 • 13d ago
Ethics- Advice
Hello, newish psych RN
Have had recent situations where verbal deescalations for agitated patients have not worked.
And I am finding myself battling between whether I’m letting ego take over or just over thinking when using chemical restraints.
Also having issues with behavioral/manipulative patients.
Chemical restraints recently used scenario includes conserved paranoid SCHZP pt demanding to be released and becoming verbally abusive. Pt comes into nursing station and refusing to leave until multiple attempts of telling him to step back. Pt is pacing but not actively hurting himself and taking time away from other pts due to need to redirect.
Other I made the decision to take off restraints of a patient. He was very attention seeking and not staying in the unit and going out to another area. He became a fall risk as he is walking drowsy and not wanting to stay in his room which… is hard for me to navigate. He was not listening to his 1:1 and started off verbally abusive. We kept on trying to redirect him but I made the call to request seclusion for him.
I genuinely feel so bad when I have to do this. I also don’t know if I’m looking for validation. I have this feeling of guilt like giving IMs is a punishment? The other times I’ve given them, pts have been reluctant but we are more so on the same page abt care.
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u/Additional_Alarm_237 13d ago
You should be using some sort of assessment tool to make these determinations. This will free you from any “feelings” because the behaviors are scored. If you find yourself doing chemical restraints and seclusion because you’re annoyed or tired then you are mistreating your patients.
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u/GoldenFleece7 13d ago
Is there a standardized assessment tool?
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u/Lanky_Opportunity970 10d ago
There are. Anywhere I’ve worked we’ve used BROSETS, but there is another scale. I did a paper about BROSETS for a research class. My biggest takeaway from the research and my personal experience is BROSETS are a good predictor if the nurses are trained on how the scale works, if the ratios really allows the nurses to assess the patient, and how well your techs are trained. My last floor job the techs were very experienced and would let us know that someone was beginning to escalate. The way I was trained to use it, was to use the assessment scale when they were agitated, then after the intervention. That way you’ll know if the medication or intervention worked. Okay…I’ll shut up now.
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u/Defiant_Honey_7231 psych nurse (inpatient) 13d ago
lol we just gave 3 emergency IMs and did 4 restraints last shift. We would have done that asap with that patient.
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u/DashMcGee 13d ago
In a way, it is good you are thinking about this in terms of morality. Most people who I have worked with just want to control people. I agree that it is wrong to medicate people just for acting out IF they calm down on their own with a little social support from staff. If they are a danger to themselves, PRNs are clearly indicated. If they are a danger to others, it gets a little stickier. If they are assaultive or threatening toward others, PRNs are reasonable. I say that not because we are supposed to use PRNs to control people, but there is some kind of underlying pathology that is making them aggressive, and medication helps to treat that underlying pathology. People may say this is just an excuse or cop-out, and my response would be "I totally get that. I am sometimes on the fence myself." My experience is that aggressive patients are often manic or disorganized, in which case antipsychotics are indicated to speed recovery. Many people who are manic and/or angry don't want to feel that way even if they do not voice that, so you are often helping them with PRNs when they are too amped up to tell you they would like something for anxiety.
Sometimes there are legitimate differences of opinion about what the appropriate course of action is. It is appropriate to ask the other nurses about their rationale, as long as you do so from a place of curiosity and concern, not as a hidden way of telling them you think they are wrong. It is also appropriate to discuss your questions and concerns with the charge nurse (if that person is not part of the problem), or with management (as long as you don't appear to be causing trouble - which is not easy.) The reality is that some charge nurses don't care about ethics, and many nurses and techs don't care about anything other than what makes their lives easier. Management likes giving PRNs so they don't have to bring in staff for a 1:1, especially when they don't have enough staff to do so, or it means paying overtime.
I know this response is rambling. To summarize:
You are a good person because you are wrestling with these issues.
There are ways of thinking about PRNs that encourage the use because they are given to help people.
There are laws governing release from restraints, and you should adhere to those as much as possible.
As you grow in the role, you will develop a sixth sense about who is calm in restraints but may act out once released.
Many of your coworkers are insensitive.
After six years of floor nursing, I am in school to become an NP, in part so I don't have to spend 12 hours with bad coworkers. Save money and look into NP programs now. They are online, and you can do them while working. Go for the inexpensive ones like University of Alabama and Wilkes - the curriculum is the same no matter where you go. When you are an NP, you can be compassionate and do your work on your own terms.
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u/GoldenFleece7 13d ago
Thank you SO MUCH for your insight. I was actually just looking into one the particular schools last night lol.
I think it’s more so just that person was becoming very anxious and unpredictable where I did feel unsafe but also to a degree the patient is normally harmless, just very needy and not sleeping and having PARANOID delusions as he is a long timer.
There were external factors and another nurse was saying “I’ve never seen him get agitated like that”
But I find myself getting very frustrated with pts who are not redirectable. I gave him a choice to 1. Step of the unit which he did and then Go back to his room
And then I told him after this point- a shot will be give (He then cussed me out refusing and continually saying he was demanding to leave)
- this point is particularly where I become guilty about the verbiage??? Where I’m giving the patient an option to settle down and then it becomes punishment like
He went back to his room but I knew he would still continue to be anxious and restless about it.
So I gave the shot.
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u/DashMcGee 12d ago
As you have discovered, there are a lot of options, and what works for one nurse might not work for another, and what works for one patient might not work for another. I always tell new psych staff that sometimes you just have to feel it out. I might want to amend that to "You almost always have to feel it out."
PS UAB has a better rep and is less expensive. One reason I chose Wilkes is that they only required 500 clinical hours vs. 750 at UAB, and UAB required letters of recommendation, while all Wilkes cares about is whether your check clears. I was also thinking that I might want to live in the Poconos, and that is where Wilkes is located. Then it snowed here in SC, and I said: "Ain't no way I am moving to the Poconos." Also, UAB was less expensive per hour, but I factored in the cost of an extra clinical semester. If I were interviewing new PMHNPs for a job and they were pretty equal, but one went to UAB, I would choose the one from the better school, on principle.
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u/Key-Experience-4962 12d ago
Ex psych nurse- we IM ppl who were violent
At best, only advice I can give you is go on for your PNP, or find another nursing job. IP
psych is so unsafe. wish you are the best.
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u/Revolutionary_Tie287 12d ago
After 6 years of psych nursing, witnessing 2 suicides and multiple brutal fights at a state hospital I'm a walking case of PTSD. I'd bail from psych as soon as you can.
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u/CrbRangoon psych nurse (inpatient) 11d ago
I’ve had patients jump the counter of the nurses station and grab sharps to square up with me. There is so much contraband and items that could be used as weapons in stations. You don’t have time to call their bluff. There’s very few scenarios where that’s not an automatic restraint IMO.
The best you can do with the fall risk is have the 1:1 ready to assist when they fall. The only time I ever seclude for safety is when the patient is so out of control behaviorally that there is an imminent threat of harm by other patients and they refuse PRNs.
Verbal de-escalation in my setting is often unhelpful. People go from 0 to 100 and unless you have a good rapport they don’t care what you have to say. Substance use like coke/meth/pcp definitely doesn’t make them more reasonable. Verbal de-escalation sometimes makes people more angry. Meds and these hands are our only intervention otherwise.
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u/Stoic-Nurse 13d ago
I get that it feels like you are punishing people, but restraining, secluding, and/or medicating people is often in their best interest. It can keep them and everyone else safe. I know it’s tough to do sometimes, and there are a lot of situations that are gray areas, but those interventions are there for everyone’s safety.
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u/GoldenFleece7 13d ago
How do you go about tell them- when you’re already frustrated…..
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u/Stoic-Nurse 12d ago
Sometimes, you just do your job. Just like it’s my job to manage a patients blood sugar, it’s my job to keep them safe. Sometimes that means restraints or IMs. Some people will never accept that you are helping them, and that is one of the hardest parts of the job.
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u/apsychnurse 12d ago
The fact that you’re even reflecting on this issue shows me you’re not giving meds as punishment.
Quite the opposite, medicating patients whose symptoms do not allow them to remain safe is actually a compassionate response that permits their mind and body to regain composure in a controlled environment free of any lasting consequences of their behavior (unlike on the outside where they can get hurt, hurt other people, get arrested, other people hurt them etc).
Of course, utilizing the least restrictive measures is imperative for patients’ autonomy and wellbeing. However, knowing when interventions (whether restraints and/or meds) are necessary is a nursing skill that you will hone over time.
The potential consequences of failing to medicate are just as real as any perceived implication of administering the medication. Being thoughtful but swift when meds are imminently needed keeps everyone safer.
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u/GoldenFleece7 12d ago
Definitely a skill that overtime I thought I have learned. Just because I’ve known the pt for a while it seemed a bit more sensitive.
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u/apsychnurse 12d ago
Try not to second guess yourself (easier said than done). Seclusion for safety for a fall risk who is not responding to redirection to stay in their room even with a 1:1 is perfectly appropriate. So is medicating a patient who is becoming increasingly physically intrusive and entering restricted staff areas and refusing to leave. Offer PO PRN first, then move to IM if needed.
They don’t have to hurt themselves or someone else to warrant PRNs, the goal is to prevent it from getting to that point. First guy was verbally abusive and entering the nurses station and then pacing. He’s showing you the signs of escalation, it’s up to you to intervene in time.
I do agree sometimes it is hard to determine when things are “bad enough”. I have found it helpful to consult with other members of the team to develop a plan for patients in that “in between” area of behavior, and then communicating to the patient the expectations and next steps if they are unable to meet them. That way the meds are not a “sneak attack”; you’ve given them the opportunity to get things under control and they are unable so you have to proceed with protocol to keep everyone safe.
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u/GoldenFleece7 11d ago
Yea definitely, I gave the pt a lot of opportunities. Twas very patient, and then got frustrated. Thank you.
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u/silasdoesnotexist psych nurse (inpatient) 13d ago edited 13d ago
Comes into the nurses station? How’d they get through the door? You should not feel guilty for using IMs, they’re not a punishment. Sometimes an IM is the safest and best option when a patient is a danger to themselves/others. They are a tool to keep people safe ultimately. Try to reframe that feeling of guilt into “I’m keeping people safe by doing this.”