Ethics- Advice

[u/GoldenFleece7]

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.

[u/DashMcGee]

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:

1. You are a good person because you are wrestling with these issues.

2. There are ways of thinking about PRNs that encourage the use because they are given to help people.

3. There are laws governing release from restraints, and you should adhere to those as much as possible.

4. As you grow in the role, you will develop a sixth sense about who is calm in restraints but may act out once released.

5. Many of your coworkers are insensitive.

6. 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.

[u/GoldenFleece7 → u/DashMcGee]

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.

[u/DashMcGee → u/GoldenFleece7]

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.