IamA Mental Health Nurse, working that night shift...AMA!

First of all thank you for everything you do!!! Now my question is, what do you find the most challenging about the job?

Why thank you!! I would have to say how mentally draining it is, the verbal and physical assaults are quite common but it's just constantly reminding yourself you are working with a mentally ill population who don't always have judgement and insight into what they do. Reminding yourself not to take things personally can be quite challenging!

I screamed at a psychiatric resident once and I still feel incredibly guilty about it. I'm sure most patients regret abusing their nurses once they get better.

They do! I had a patient who threw a table at me, every time I see him now he makes sure to say sorry..again.

Do you ever see signs of mental illness in your family and friends?

Yes I do, I always joke around about diagnosing them with a personality disorder, but I have had the time where I realized they are suffering from what appears to be a psychotic or mood disorder. I have talked to them and provided them some guidance in how to find treatment if they are willing.

I always joke around about diagnosing them with a personality disorder

TBF, there's tons of people with borderline structures (not to be confused with fulfilling the criteria for DSM's BPD). Not everyone needs to be an always-suicidal, drug using, can't-hold-a-job patient in order to suffer from some of the common and very distressing phenomena that lie at the core of BPD.

Oh for sure, and some of my friends and family do exhibit traits of certain personality disorder including narcissistic and borderline.

Did you choose mental heath or did you just happen to end up there? Thanks for what you do.

I'd say I chose it, I initially wanted to major in psychology but was scared of not finding a career once graduating so I decided to do nursing. On my first mental health rotation it kind of just clicked that this was where I was supposed to be, never left it since!

Edit: I truly appreciate the thank you, it means a lot!

See I'm a nursing student who is realizing I might be more interested in psychology. I'm absolutely terrified. Any possible suggestions?

Try out psychiatry - even within this specialization there are many more options..inpatient, outpatient, etc. You can also specialize in psychotic disorders, mood disorders, geriatric psychiatry, the options are endless!

I too was one of those nursing students who just hated regular medical bedside nursing, I could never go back to it!

What lotion do you use? Your hands look fab

Only the best non-scented hospital lotion!

What do you do for stress relief?

I spend time with my dog, take him for walks or to the beach. He listens very well!

What kind of puppy? Do you have a picture of him we can see?

It's a shitzu-poodle mix! He's blind but the sweetest gem!

http://imgur.com/a/cJG2A

First, I want to thank you for doing this AMA, now for my question; Have you ever encountered or experienced weird/spooky stuff during your shift?

Thank you for the kind words. Last year we had a completed suicide on one of the units, during the night shift the patient who was staying in the room, and completely unaware of what had happened in the room months prior, woke up and kept asking who was screaming in her room, we told her it was no one and she was safe in hospital, she asked so switch to another hallway. We switched her the next day and moved a gentleman into the room, the next morning he walked out of the room, looked tired as hell and asked who was screaming all night...

That is some creepy stuff alright. Thanks for responding so fast!

No worries, it's been a slow night thankfully!

How did the patient succeed in suicide in the hospital?

Unfortunately a question I get asked too often, I'm not really sure if there is a right answer to this, he was deemed stable at the time and between the 15 minutes clinical monitoring he was able to successfully complete a suicide. He had planned this out very carefully.

But to add to this, I always am so interested how we try to destigmatize mental health but when a suicide occurs in hospital it is easy to point the fingers at the front line workers, I've never seen a nurse in cardiology be blamed for a heart attack. We have to understand that 2/3 of these patient have some risk of suicidal behaviours, and most of these people are here against their will, under a mental health act. The amount of people I have talked down and physically cut down from attempted suicide is tremendous, but unfortunately some people are very certain of this decision, and no amount of help will change this.

Sorry just my little rant, nothing against you just a point I like to share.

As someone who has been in a 5150 situation and was totally confused, and decently intelligent, I can easily say that if I had been certain I wanted to end my life I could have easily done it. Don't underestimate human ingenuity even during psychosis and even in very sheltered circumstances. I did not know why I was there or why I couldn't leave, and I was suffering tremendously. I truly feel that nobody: not caregiver, nor family, nor loved one, should ever be blamed. Thank you so much for your work and for saving countless lives... also.... just sayin... nurses do the most, and get commended the least. Here is to you

I needed to hear this. Thank you for validating what I have been trying to tell myself.

I work in a mental hospital, as well, as a psychiatric care tech (fancy word for nurses assistant). I love the work and my coworkers, but we have continuous issues with staffing. Is this common?

For example, I worked a weekend a little while ago where we had 3 nurses for 26 patients and two assistants with two 1:1 patients. We got a sitter for one patient, but me and the other tech had to switch off doing the 1:1 and managing the 15 minute checks. This meant that basically all I could do during the shift was the 15 minute check when I wasn't doing the 1:1; this meant other responsibilities didn't get done like drawing labs and doing EKGs, and if a nurse did ask for my help with something while I was doing checks it meant that I'd be taken away from the checks and thus the frequency with which I'd be able to check in on patients would be reduced.

Management oftentimes fails to staff appropriately and won't let nurses take shifts if need exists elsewhere (for example, if a nurse on my floor calls off and gets a replacement, management will block the replacement from working the shift if another floor is down a nurse). We don't use on call nurses. We had a couple falls, a nurse got punched, etc... And it all seemed very chaotic. I understand keeping staffing costs in-line, but I feel like we are regularly low staffed enough to impact quality of patient care.

This is an extreme example but staffing is a regular concern. I'd say we are regularly in need most every time I'm there. Is this a problem throughout the industry or is our management just bad?

I work for a huge hospital system and sometimes I feel the types of people who are promoted to manager positions are not those who should be there i.e. individuals who care more about being in a position of power than providing for our patients.

I am so sorry to hear that, seems like a very stressful and busy environment. I have always felt management can make it so difficult to provide safe and efficient care due to issues like this.

A few years back we had a few assaults and issues, that staffing was deemed to have been a problem during the incidents. We now are always fully staffed and at times even have extra nurses. We also have float staff during the day, they cover sick calls and 1:1. There is also a lot of calls for overtime, basically everyday I am off I can decide if I want to come in for overtime. I am incredibly lucky this is the case, we are almost never understaffed. I think management is almost afraid to understaff if another incident was to occur.

Who is the most interesting person that you've worked with so far ??

And thank you for all the work that you do in such a difficult and stressful field !!

Most interesting, oh there has been so many, I had a young girl who would swallow anything and everything, on my one shift alone she swallowed 3 chopsticks, a tweezer and a battery! I've worked with the queen, God and even people who aren't alive.

What tasks are you required to perform during your shift? Also, what unit did you find the hardest/easiest to work at and why?

Depending on what unit, on a regular inpatient floor I have my patient assignment from 4-8 patients. I'm required to do all their patient care, including a mental status assessment, medication etc. I also am required to do clinical rounds, basically checking up on all patient every 15 minutes. At times we also have 1:1 care which requires sitting next to a patient for various reasons. In psychiatric emergency I complete mental status assessments, blood work etc and collaborate with the doctor to see if a referral or admission is needed. I find concurrent inpatient unit very difficult, it's very hard to deal with a mental health issue on top of a drug addiction, this is the unit that seems some of the most "code whites" which are aggressive situation. Easiest, I would have to say forensics, some of these patient have been in the system for 10+ years, they are very stabilized and are on their way to community living so they come to you for their medications and then just attend their own agenda for the day!

How would you describe forensics/what that means to the every day person?

Forensics is a unit where people who are not found criminally responsible stay and receive help until found stable enough to be reintegrated in the community. The crimes range from criminal harassment to first degree murder. The period of time is usually longer then the average jail time for the similar crime. They over time gain privileges to leave hospital grounds, and eventually are reintegrated back in the community. This process however can take a few year.

How often in emergency do you feel you get 'time wasters' (people who don't need to be in emergency psychiatric care)?

Do you think the increase in knowledge about mental illness these days mean you have more people presenting at the ED when really they just need someone to talk to?

Reason I ask is I was in an emergency ward for 36 hours a few years back and the registrar basically told me I was wasting their time. It was very traumatic considering I was so depressed I had conspiracy theories (not quite psychotic but almost) yet she wouldn't discharge me until I admitted was wasting their time and wasn't suicidal.

Yes, unfortunately we have our "regulars" in psychiatric emergency, sometimes they want a dry place to sleep, sometimes a sandwich and other times someone to talk to. However, we also complete a full assessment on every patient that comes through. I have never seen anyone have to wait more than 6 hours or be turned away at the door.

I think it is becoming more common to come through emergency and know you can get mental health help. If not an admission, it is very helpful to connect people to the right resources and give them that 30 minutes just to talk to someone.

I am really sorry to hear about your experience, I really hope this was a one time thing and you can feel comfortable to go to a hospital or mental health facility if you are ever feeling the need to again.

Has there been a favorite patient or just very nice patient that still sticks to your mind?

Will always remember the actively psychotic patient who saw I was down in mood one day, he told me to "cheer up" and then proceeded to say "it's all in your control, all in your brain!"

Even in his lowest time, a time he didn't have control over his own brain, he made effort to make sure I was happy and remind me I have control over that.

What advice would you give to a student Mental Health Nurse?

It will be scary, you will see things that will scare you, it will become easier and you will become tougher.

Remember just to listen and validate, a patient really does know if you are listening or just sitting there getting your notes so you can chart on it. They know the difference when you are being genuine or not.

1) Working nights affects health adversely, what do you do to compensate for it? 2) Are toxoplasmosis screens done on mental patients? 3) What do you think about meditation?

1) I would be lying if I say I do much to compensate for it, but suggestions would be great!

2) Upon admission, we do a toxicology panel on all patient, up to 9 tubes of blood to screen for any diseases or drugs that could be directly affecting the patient prevention. I am not sure however if toxoplasmosis is completed in this, I will have to get back to you.

3) I think they can be helpful WITH the support from certain types of therapies etc. Since mental health is so multifactorial, we have to find ways to treat trauma and poor coping mechanism, medication will not do this.

I think he actually meant meditation. Not medication. I had to read it twice as I read medication as well.

Haha you're right! I'm around medication to much!

I think meditation and mindfulness are awesome, as nurses we actually do a meditation/mindfulness exercise at the the start of shift, just after report to start the day.

The same group nurse that completes this, does exercises through out the day for patients, they seem to enjoy it and use these techniques as coping mechanisms for anxiety!

Current mental health PCA here, just got off working graveyard on a forensics unit myself. They let you use your phone/the computer for Reddit? No phones allowed on my floor (privacy concerns) and our computers have everything tracked like crazy.

Well to be fair I was using my phone with my own data! We do not have our phones on the unit too and most games and stuff are blocked on the computer. But I usually reddit away on nights, never had an issue.

About a decade ago I attempted suicide, gunshot wound. I survived and, apart from my normal care staff, also had a mental health nurse with me the whole time who was absolutely vital to my recovery. Thanks for what you do.

A question... one of my friends, a nurse, says that she is threatened/called names on nearly a daily basis, from all sorts of people, not just what you would call the "dregs of society" or something like that. I'm sure you've experienced this, too. Anything particularly bad? What do you think should be done to help address this issue?

I am so glad you are here and so nice to hear the role that nurse played in your recovery.

Threats are unfortunately common, we try to mitigate risk and stop an incident before it occurs. A patient last week kept telling me he will rape me once he is out. Definitely scary to hear, these kind of threats are taken extremely seriously. Prior to discharge, he was arrested and charged with assault and uttering threats. He was not in a psychosis, he had full understanding of his behaviours and threats, which is why the decision was made to contact police.

Hi there! How are suicidal patients dealt with? (And thank you so much for doing this AMA)

You're welcome, good question!

It all depends if this person is actively suicidal. If they are actively attempting they are usually put into 4-7 point pinel restraints. A nurse is sitting with them through this whole experience. I know it sounds cruel, but the reality is this is the only way to physically stop someone from harming themselves it to have them strapped to a bed.

If someone is passively suicidal with no plan or intent, we keep close clinical monitoring and at times to distant 1:1 where we always have our eye on them.

Either way they are kept safe on the unit, they are provided with support during the day through their nurse and programs on the unit. They are however, on the same unit as psychotic patients, but did you know that 10-15% of schizophrenia patients have historically completed suicide. They are a population we monitor very closely.

What is the most rewarding part of your job?

Of course the corny line comes out...seeing them get better.

Seeing the psychotic patient who was smearing shit all over the room, barely making sense and stating there are bugs crawling all around the room, making their first trip to Walmart with the recreational group.

Or when the forensics patient has finally received community living and finally gets to be discharged. Seeing them hug their family and friends after 10+ years of incarceration in the mental health system is quite a feeling. Seeing these people become working members of society again is so great!

One time I had a extremely paranoid patient, refusing to eat and extremely agitated. We had him on a IV running for fluids that we could barely keep on him. He was losing weight at an alarming rate. His mom would come in everyday, try to feed him but nothing. The one day, him and I had a long talk, he agreed to start intaking sealed liquids, we moved onto solid food and by the end of the week he was eating full meals again and the IV was out. His mom came up to me and said "You gave me my son back, I don't know how to thank you"

My mom used to be a nurse for the psychiatric floor and she talked a lot about how many of her patients were homeless because of their illness. Have you seen the same trend?

Yes, a large part of our population includes homeless patients who have been kicked out of group homes due to aggressive or bizarre behaviour. Our social workers, work hard to integrate them back into the community once they are stabilized!

Hey there fellow mental health nurse! I work in Australia and love our job. I'm just wondering how restrictive the mental health legislation is where you are from? For example, what kind of restraints are you allowed to use, and when can you detain a patient against their will?

Kudos to you buddy. We both know how ridiculous and draining this job can be at times. Feel free to chat to me any time if you ever need support.

Hi there! That's awesome, I have actually considered working in Australia!

Here we are allowed to use a few different type restraints, this includes mechanical (pinel restraints and seclusion) or chemical restraints (injectable medications). We can detain a patient against their will, and able to restrain when they are under a mental health form which is issued by a psychiatrist.

If they not under a mental health form, we are unable to do any restraints.

How about in Australia? Would love to hear the similarities and differences!

What did you have for lunch ? or dinner?

I slept through lunch and dinner today! But when I woke up I made a delicious chicken alfredo then my fried night shift brain forgot to turn the stove off and my alfredo burnt but I saved the top and had just enough for night shift!

It seems in our society that physical health is more important to assess and cure and mental health often takes a backseat. Do you think this is because of the stigma around mental health issues, because mental health issues are harder to diagnose, or there a varying degrees of many kinds of illnesses that can't be assessed as easily as they physical problems? Or of course it could be a combination of many factors. What are your thoughts?

I think there is a lot that plays into the stigma of mental health. I think it includes the understanding that mental health is in fact a flaw in chemistry, not character. I think certain cultures are still understanding this, I still have families believe there loved one is possessed by the devil, when in fact they have schizophrenia.

I think also mental health is multifactorial, making it hard to diagnose. When dealing with mental health, we have to create healthy coping mechanism, reduce triggers and deal with trauma on top of medications to balance the neurotransmitter. There is a lot that goes into treating a mental health disorder, other then just medication. This is what makes it much more difficult then a physical disorder.

What are some effective ways to help treat delusional patients or help with psychotic episodes?

At time, its reminding them they are safe and you do not see or hear the same thing they do, at times they respond well to this.

Other times, collecting the snakes in their room in a bag, so they can sleep at time, is most effective.

All depends on situation and acuity.

As a nurse (of any specialty), are you frequently sexually harassed by patients?

Yes, unfortunately as a "younger female nurse" this is quite common. Verbal most often, but physical occurs too. Firm limit setting is very important in this population, you must show 0 tolerance to this behaviour.

We always hear about mentally ill people who don't know they are mentally ill (they think they are Napoleon, or have powers or something), but how often do you deal with severely mentally ill people who are 100% aware of their illnesses? Does that help them at all, or only stress them further?

Thank you for working a very difficult field and for helping people!

Great question and sorry for the delayed response! I think it is important to show insight into their disorder. In our forensics system, a very important key in being reintroduced into the community is showing insight into your mental illness. The reasons for this is that you know what your symptoms might be, this way you can get help if anything changes and are more likely to stay on your medications. I find it is immensely helpful in recovery outside of hospital, there are less readmissions for medication adherence and overall they tend to reach out for help when noticing changes, prior to needing a hospitalization again. I think having awareness in your mental illness is one of the most helpful things for recovery.

Does your job affect your own mental health?

Yes, I would be lying if I said it doesn't. It's a mentally draining job and you have to find health coping mechanisms to deal with this. I have great support at home, which makes it much easier.

When I attempted suicide when I was 16 (ik edgy right) one thing I remember is the nurses always shining lights into our rooms. So my question is do you hate doing that?

I absolutely hate doing this, sleep is so vital in recovery and I feel like an annoying pest constantly opening door and shining lights, but its for patient safety and that comes first!

Do you use restraint and seclusion? If so, how do you feel about the documentation process?

Yes we do, I find the documentation very important but at times tedious. It is important to provide valid reasons for restraints!

What do you eat for "lunch" on your shifts?

Leftovers usually but we have an awesome bistro that is run by former patients, they make bomb food!

I know you’re not a doctor but still a professional.

My wife is undiagnosed but strongly suspected to be borderline or manic depressive.

She recently told me she wants to kill herself but simply doesn’t know how to. She said she was reading about it online and it said to tell someone she trusts, so she told me.

What can I do?

Hi there,

Please find a crisis line if there any in your area, these are extremely helping in linking you to proper resources. If the risk is more imminent, call 9-1-1. Even if she does not want you to do this, it will help her.

Hi there! Mental health nursing student here, just curious about your experiences. Are you UK based? (NHS or private?) And recently I've done a lot of reading about personality disorders. Do you find any negative attitudes towards them in your job as I have found on my placements?

Hi there! No I am not UK based.

There is a lot of negative attitudes, especially towards BPD. These patient can be very difficult and mentally draining. It takes a lot of team effort and education to properly treat these patient. I definitely hear the negative attitude and try my best to provide patient care without getting into the personal opinions!

What is the saddest thing you’ve ever heard or experienced at your job?

We found a patient unresponsive in a room, during the code blue and when CPR was initiated, his phone started to ring on his night stand. I looked at it, and it was his mom was calling at 5 in the morning. Still gives me chills. He did not make it.

Have you had any experience with patients that have dissociative identity disorder?

I have not, I have asked endless psychiatrists, I have only had 1 who has seen it. Often times they even question if this disorder is true.