r/nursing • u/strawbqu • 3d ago
Nursing Hacks Verbal approach to involuntary psych patients
I am a newer ER RN in Canada, I’m looking for advice on approaching patients that are placed on an involuntary hold. Specifically with approaching an individual with restraining and chemical sedation (I know.. seems brutal but if you know you know. I’m not sure if this is legally relevant in all countries but it’s how we do it here). I find it difficult particularly with paranoid and manic patients. What is your spiel for the reasoning of the intervention, when you especially know they need it and they are refusing (and ultimately will have no choice but to take the medication and/or be restrained)
I tend to start off with the fact that the doctor needs them to take sedation.. if they are compliant they will not need to be restrained etc..
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u/torturedDaisy RN-Trauma 🍕 3d ago
For the extreme out of control/combative situations, you need a game plan and your team members involved. Having to get a pt chemically restrained/sedated is as coordinated as a code situation. You preplan (rapidly) who will go where. What med you’re using and where you specifically inject. Someone to distract, someone to hold the extremity, etc.
These are extreme cases though. In my experience talking and therapeutic communication go a long way. True psych pts seem to actually want the help 9/10. You just have to use communication skills to convey that you’re there to help not harm. I typically use the fact that the medicine will help them feel a lot better.
Oh and never walk directly at them with your hands behind your back.
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u/strawbqu 3d ago
I totally agree, my main goal is to improve my therapeutic communication to avoid the last resort of chemical/physical restraints; while also being prepared for worst case scenario. In my area, we have a lot of substance induced psychosis which unfortunately require these interventions. Thanks for your help!
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u/Grump_NP 3d ago
Substance induced psychosis aka “meth”. There isn’t a lot therapeutic communication can do here. Therapeutic communication works on suicidal patients, extremely anxious, emotional distress, manic but not psychotic, etc. But, a psychotic patient under the influence of meth or other stimulant needs to be treated with antipsychotics or benzo’s every time. There is no talking them down. Give some Zyprexa, let them sleep it off, and when they wake up you have a decent chance of having a human patient instead of a meth monster.
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u/Bambino316 RN - ICU 🍕 3d ago
YES, you are 100% right!!! It takes a plan and a Village at times. You can be nice and extremely firm at the same time but you need to remain very calm and speak in a non-threatening manner. Humor helps ALOT too if you can get them to go there!!!
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u/Balgor1 RN - Psych/Mental Health 🍕 3d ago
At least in California, by the time we get a reise order for involuntary meds they’ve refused PO meds for a number of days. I go in with the IMs drawn and the code team briefed and ready to go. I explain to them you’ve been court ordered to take medications you can take them via mouth or via injection you do not have the choice to refuse. They usually scream something like “I’m Jesus you can’t violate my body. I’m going to kill all you demons. (Yesterday)” That is documented as a refusal. I then ask them to lie down i bed (they’re in seclusion or in their room by now) the code team will go in quickly each of us will grab a limb and bring them as gently as possible into the bed. Quick IM in glute, hold until calm and we exit. We’ve done it so many times it’s like clockwork.
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u/Nurseytypechick 3d ago
"Your behavior is not safe for you and everyone else. If you are not able to show safe behavior, we will need to give you injected meds and place you in restraints until you are able to safely regain control of your actions.
This is to keep you safe. You are not being punished. You are not in jail. Once you are able to be safe again we will get you out of these restraints."
Less words if less decisional capacity but maintaining calm statements and giving info and reassurance
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u/shinebright222 3d ago
Every situation is different but if I think there is some ability to reason with them, I would try to give them options first. I would state I’m here to help you. The doctor ordered some medication. You have a choice, you can either take the medication or be restrained. Which do you choose? If they escalate, I would get security involved (if they aren’t already) to ultimately restrain for safety of patient and staff. Document if patient is verbally or physically aggressive, uncooperative, anything the patient says in response that is evidence why they need to be restrained (document word for word in quotes). Hope this helps.
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u/BabaTheBlackSheep RN - ICU 🍕 3d ago
Assuming we’re already at the point where intervention is necessary (ie past the point of de-escalating) I always try to relate it back to safety, both the patient’s safety and the safety of others (if relevant). For example, you aren’t making safe decisions right now. We’re going to do (blah blah blah) in order to keep you safe until you can show us that you’re able to keep yourself safe on your own.
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u/Additional_Draw_6483 ED Tech 3d ago
Can you elaborate on what you mean regarding approaching them to notify them of safety practices that include those?
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u/strawbqu 3d ago
Basically yes.. like what is your spiel? When they say “I’m not taking that” or “I don’t need that”
How do you tell them basically you need to calm down because you’re manic/unwell/delusional and tell them that you can willingly take it or we will have to force it
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u/Additional_Draw_6483 ED Tech 3d ago
Some nurses act really abrasive and authoritarian with psych patients due to the fact that they can't deny any interventions so they assume the lack of right to refusal means lack of right to respect and it sucks. I always quietly wish baldness upon them.
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u/AlabasterPelican LPN 🍕 3d ago
Some respond to being given the choice between interventions. A lot of times it's easier with lubricant. Like for instance the doctor orders PO Ativan (lorazepam) for agitation. Bringing it to them and explaining that the doctor ordered something for their anxiety or nerves, or hell if they're displaying symptoms of anxiety via high blood pressure/heart rate and are concerned about that, explaining that the medication will help with those are often helpful too. You're not lying, an Ativan will help with all of those things. Never lie. Selective information is often more helpful than direct information though.
Also tailoring your approach to the cohort you're addressing is helpful. You can't talk to geri psych patients the same way as adult patients.They have different concerns and life experiences.
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u/strawbqu 3d ago
As a former LTC PSW and nurse I definitely agree! Geri psych is entirely different and I’ve mastered that lol Thanks for your advice!
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u/AlabasterPelican LPN 🍕 3d ago
Unfortunately in the ER you're not going to have much time for trouble shooting individually. But another tip is bring the medication to them in an unaltered package and a sealed drink. Paranoia is a bitch and makes people suspicious even when they know it's not rational. I've legitimately had to print out a patients MAR, their labeled baggie with the unopened or marked packages, a pill splitter, and an unopened bottle of water and lay it all out in front of a patient and match them up with them before administering them one at a time because I have to remind them what I'm giving. That usually falls under the patients in manic episodes who are also severely paranoid. The key that I've found with most patients is trust building.
There are however instances where "mom" voice is incredibly useful. Unfortunately I don't seem to be able to manifest this voice so I usually have to get my unit secretary (an mht for many decades). Being firm but kind and instead of choices telling them of actions and consequences "you need to take this med or we will have to put you in restraints" is a useful tact to take.
Also having male standby when a mom voice isn't available is extremely handy. I think a lot of people think that when I say this I mean have a macho-man stand behind you menacingly. No, they can be a skinny twerp just walking to the room and checking the supply's and it often changes behavior quickly. There is a perceived authority for some reason.
I'm trying to think of other tactics to help across a spectrum of patients so I may come back and add comments.
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u/Additional_Draw_6483 ED Tech 3d ago
Not my spiele as I only am there to assist and defend the nurses but the empathetic ones generally say something like " we want you to be calm, we're here to help you and you are safe. Sometimes we are our own worst enemies and hurt ourselves and others. We're going to do everything in our power to ensure you're safe. " When they resist you simply sat "you are safe and were not hurting you. We're keeping you safe. " Usually this is aided by gently informing the patient of how you're touching them and why while you restrain them provided they refuse further.
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u/Old_Glove9292 3d ago
Gentle reminder that the World Health Organization considers both forced restraints and involuntary hospitalization to be human rights abuses, and is advocating for those interventions to be banned globally:
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u/pillslinginsatanist Pharm Tech 3d ago
I used to feel this way too, but after knowing more healthcare people, I wonder like... what else can you really do? If they're a danger to others, to the care team, etc., what option do you have other than restraints or involuntary hospitalization? Wait for them to hurt someone and imprison them? That would arguably be worse....
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u/strawbqu 3d ago
In a perfect world, I would totally agree. But when you have someone charging around the emergency department climbing the walls, throwing chairs at people, spitting in the faces of other patients.. that is unfortunately not safe for anyone. But it is always a last resort.
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u/Old_Glove9292 3d ago
Spitting in someone's face is assault. I agree that shouldn't be tolerated, but restraints and involuntary hospitalization are not the answer. Call the police.
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u/strawbqu 3d ago
Do you believe you’d have the same opinion if you or a loved one was being assaulted while hospital staff watched and waited 10-15 minutes for police to arrive while you fend for yourself?
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u/Old_Glove9292 3d ago
Absolutely. Two wrongs don't make a right, and security should be equipped to handle unruly patients until the authorities arrive. Don't take my word for it. It's the official stance of the World Health Organization.
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u/strawbqu 3d ago
I genuinely hope for the safety of both the public and the patient that this does not become the standard. I would not expect anyone who has not experienced what it’s like to understand why.
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u/Old_Glove9292 3d ago
I would expect a prison guard who has abused criminals to use the same line of reasoning... Wrong is wrong. Period.
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u/flannellavallamp 3d ago
Do you think the police aren’t restraining them? They’re getting restrained one way or another - it’s better to be restrained under the care of medical professionals than put in a straight jacket in a prison cell. Your being a bit delusional here.
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u/Old_Glove9292 3d ago edited 3d ago
No. What's delusional is thinking that there's any reasonable justification for human rights abuses... Detention and prosecution are functions of law enforcement and not medicine-- period. This is basic common sense, which unfortunately, I'm realizing many clinicians desperately lack. Don't be Nurse Ratchet...
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u/arcanistmind 3d ago
Truthfully, many of these patients lack insight into their conditions and treatment of the precipitating condition will not occur in custody of law enforcement. An elderly patient with a UTI does not need law enforcement as their capacity (or lack thereof) would preclude conviction of any criminal offense. There are times where law enforcement is necessary, this is the place for clinical judgement and de-escalation.
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u/Old_Glove9292 3d ago
An elderly patient with a UTI should never be abused with restraints and seclusion. Clinicians are trained in medicine, and should defer legal matters to law enforcement and the courts. Restraints and seclusion encroach on basic human rights, and suspending those without due process is a human rights violation. It's insane to me how much liberty clinicians take with this stuff. I mean talk about a God complex... The arrogance is unreal.
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u/arcanistmind 1d ago
I'm largely curious as to your background. I personally struggle with this often working in healthcare and I generally agree with you as it relates to especially patients with dementia as there is currently no effective cure and their experience is obviously terrifying to many of them, which is heartbreaking and a deep ethical dilemma that I do not enjoy. However, we have a duty to care for these people under both the principles of implied and explicit consent from next of kin or legal guardian. I am not sure that restraints and seclusion for the purpose of safety and necessary medical care to alleviate the UTI that is the proximate cause of the confusion constitutes abuse. This may just be that we take the use of the tool seriously and understand the harm of the tool and weigh the risks and benefits of it. Healthcare regularly operates with tools that come with a high risk for abuse. This is why we have accountability, but we do not abandon those in need when we have tools that can alleviate disease and suffering.
Capacity is a critical component in ethical considerations of medical autonomy, which is why it is removed for children and those who lack insight and understanding of their situation. I'm not sure the harm they could do to themselves would be an acceptable alternative. Do we simply allow them to die because they refuse to take medicine that they are incapable of understanding the purpose of? Swaddling an infant is a form of restraint yet it is done routinely to temporarily calm and assist in medical care. Would you have law enforcement swaddle an infant? Anesthesia is a chemical restraint and physical restraints are routinely used in surgery to prevent nerve damage while the patients are under the effects of anesthesia. Would you have all anesthesiologists be law enforcement officers first? Writing this out, it kind of seems like we effectively already do this via licensure. As an RN and paramedic, I have guiding principles of my role and I am authorized by law to assist a licensed provider to utilize restraints in a limited capacity to deliver necessary medical care with provisions to de-escalate them. We as a society routinely already engage in this debate as evidenced by nursing homes limiting the use of side rails to prevent them from acting as restraints.
Licensure and assessment from a professional for the need for temporary emergency use restraints for the immediate safety of a patient or staff is the due process. (In FL, not sure of all other states, but many follow suit) Psychiatric holds greater than 72hrs require a face to face with a judge. Extended (>4hrs violent or 24hrs nonviolent) use of restraints almost always requires a licensed psychiatric specialist (not just a licensed medical provider) and appropriate initiation of involuntary hospitalization and the court required procedures for that or allow the situation to become unsustainable thus requiring re-initiation of emergency measures. Required documentation, accreditation, limitations on the duration of restraints, and the ability to sue for improper use of the tools are the accountability mechanisms.
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u/arcanistmind 3d ago
The article you provided is a summary about the guidelines which seek to end human rights abuses, but you're likely conflating the language and interpreting restraints as the human rights abuse. Hopefully this does not come from personal traumatic experience in healthcare with restraints for you or a loved one.
The language on restraint and use of seclusion or isolation in the actual guidelines is far less strict where it calls for monitoring for use rather than an outright ban on these things as limited use of them when acutely necessary for the immediate safety of the patient and providers alike is generally considered appropriate standard of care when paired with patient safety monitoring and appropriate de-escalation.
Sorry you're being downvoted into oblivion for passionate defense of patient autonomy and human rights.
Source for the full 2020-2030 WHO guidelines: https://www.who.int/publications/i/item/9789240031029
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u/Old_Glove9292 3d ago
I appreciate you. Thank you for treating this matter with the gravity that it deserves. On page 17, I read "prevention of coercive practices", which includes any form of restraint or involuntary hospitalization, to mean a ban on those type of interventions.
"Human rights standards include provisions for: (i) transition to mental health services based in the community, (ii) promotion to exercise legal capacity, (iii) prevention of coercive practices, (iv) procedures to file appeals and complaints and (v) regular inspections of mental health services."
And from this source:
Ending coercive practices
Ending coercive practices in mental health – such as involuntary detention, forced treatment, seclusion and restraints – is essential in order to respect the right to make decisions about one’s own health care and treatment choices.
Moreover, a growing body of evidence sets out how coercive practices negatively impact physical and mental health, often compounding a person’s existing condition while alienating them from their support systems.
The guidance proposes legislative provisions to end coercion in mental health services and enshrine free and informed consent as the basis of all mental health-related interventions. It also provides guidance on how more complex and challenging cases can be handled in legislation and policies without recourse to coercive practices.
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u/tarpalogica 3d ago
My approach is usually along these lines:
"Hey, I get that you don't want to be here, but there are a lot of people who are worried for you and want to help you. And we know this is a really awful environment, with lots of sudden noises and bright lights and that can be really stressful. A lot of people get stressed out just by being here, even if they're only visiting someone. You seem a bit stressed out to me, given you've just been yelling etc etc.
Is there anything we could get you? Food, drink, an extra blanket, a nicotine patch? (They're often withdrawing)
I'd also like to help you by giving you some medicine to help you deal with the stress. I don't want to just knock you out! After all we're waiting for the mental health team to talk to you! But it might help you deal with being here, as much as that sucks. Now, you can choose between a pill, a wafer that will dissolve away, or a needle that's one and done." "No! I don't want any medicine!" "That's not a choice you have right now. You had that choice before you started yelling/running away/punching. Now you have to have some medicine. I'll give you half a minute to choose, otherwise I'll choose for you, and I'll choose the needle." "I DON'T WANT A NEEDLE" "That's ok, but then you have to choose a wafer or a tablet medicine. Which one do you want?"
And then we go around for a round or two more and they take something or they get an IM injection.
And yes, this is how I approach paediatric patients who don't want me to listen to their chest. I don't mean that in a cruel or demeaning way. But I think a lot of people return to the mental state of frightened/cranky toddlers when they're sick or afraid and being the boundary -setting, appropriate autonomy giving parent-figure works well for me in these settings.