Psychiatric/Mental Health Nursing Patient Care
I have compiled a list for students and professionals on the go, trying to learn some tricks of the trade or refresh their memories from things learned long ago. If you are in a real hurry and only need a refresher, just read the headings without the explanations. Those with little or no experience will need to read deeper for further understanding.
Don’t ask “why” questions.
“Why did you do that?” “Why did you stop taking your medications?” “Why do you want to kill yourself?” All those questions have an undertone of judgment. Many patients are defensive with health care professionals and often, with good reason. They have been judged. They have been mistreated. They have been given the run-around. Any judgment the patient perceives, whether you meant it or not, will have a negative effect on your therapeutic relationship. Also, many times people simply do not know why they do some things. If they knew what the problem was and had a simple solution for it, often they would do it. Instead, say, “Tell me more about that,” “What led up to that decision?” “What was going on in your life when that happened?” or “I’d like to hear more.” These types of statements allow the patient to relax and talk rather than defend.
Don’t give advice.
Giving advice is similar to asking why questions. It implies judgment if the patient does not choose to follow your advise. Your job is to present the options to the patient without bias, then allow the patient to make his/her own decisions.
For example, a patient becomes pregnant while taking a psychotropic medication with known dangers to the fetus. The patient’s doctor has told her that she cannot continue to take the medication while pregnant. The patient is scared and confused and comes to you to ask for advice. You may be tempted to tell her your opinion. If you say, “If I were you, I would stop taking the medication and keep the baby safe,” the patient may feel uncomfortable talking to you further about it if she decides to terminate the pregnancy.
Our job is not to force our personal belief systems on others, no matter how strongly we feel on a subject. Our job is to provide thorough, unbiased healthcare and allow the patient to make her own decisions, so long as she is able. If this sounds like something that may be difficult for you, consider yourself in a similar situation. For example, a woman has very large breasts and sees her primary care doctor to request breast reduction. When the intake nurse interviews her, she says, “Are you sure you really want to have a breast reduction? I think we’re meant to have the bodies we are born with.”
While the two examples differ in content, the theme is the same: I know what is best for you.
This one seems kind of easy, but can be so difficult to do. We are human after all. We have emotions. Sometimes we just connect better with some people than others. Sometimes we experience something called countertransference, where subconsciously we relate the patient to someone in our life, past or present.
Some people are cruel and purposefully push your buttons. Some people will say whatever they can think of to get a response from you. Do not take it personally. We must be objective in our care.
Instead, try this. If you feel like you are having a strong response to someone, take a figurative step back. Consider your role and what you would do for any other patient. Showing any kind of favoritism (e.g. joking with one, but not all; allowing special privileges for some; etc.) will make other patients feel neglected and can cause damage to your therapeutic relationship. Ask a colleague, who you trust to be honest with you, if they have noticed anything about your interactions with any of the patients. Sometimes it is hard to examine ourselves objectively.
“That’s not my job.” If I had a dime for every time I heard this in any setting anywhere, from the grocery store to the hospital to the bank or wherever. We are all busy when we are working. We have a thousand things to accomplish, dozens of patients to care for, and there is not enough time to be everything for every patient every moment of every day. I know this, and I do not expect you to do everything. But just saying, “That’s not my job,” or “I don’t know,” and then walking away is a disservice to the patient.
Imagine if you were grocery shopping at a new store, and you asked someone who was stocking shelves if she knew where the cereal was located in the store, and she said, “I don’t know. I just stock the dairy case.” Then you asked someone else, and he said, “I just started working here. I don’t know,” then walked away. Most likely, something like this has happened to you before. Did you feel frustrated? Annoyed? Exasperated? Perhaps. Now imagine if you were terribly sick, anxious, scared, and locked in a hospital with very little freedom, and you asked a similar question and received a similar response. Odds are you would get upset. You would feel like you were a nuisance or like the staff simply did not care about you.
A suggestion to remedy this is saying, “I don’t know, but I will find out and get back to you in about XX minutes.” It is nice to give someone a time frame, so they know to follow up with you if they have not heard back. Delegating the task to someone else is okay as long as the patient knows. If you are heading out the door at the end of a shift and a patient asks you a complicated question, tell the patient you are leaving, but you will tell the nurse on the next shift to check it out. In an ideal world, you could stay and answer the question, but we have to keep personal and professional boundaries. Without boundaries, we would all burn out.
Give Individualized Care
It is hard when trying to maintain a sense of fairness to also give individualized care. In a group of 20 adult patients, you will find 20 different preferences for learning, coping, and more. If Patient A prefers to cope by free writing, allowing the patient to have a notebook and pencil in her room can be viewed as unfair by other patients, which can lead to jealousy, arguments, blaming, and a decreased sense of self worth.
Instead of allowing one patient special privileges, offer all patients (without restrictions) the opportunity for free writing. For example, have a mini-group session and teach briefly about free writing and then allow each person 2 pieces of blank paper to practice. Patients then can have 2-3 pieces of blank paper daily at an assigned time for free writing if they choose to do so. This allows for both individualized care and fairness.
Don't Write Generic Progress Notes
If you have completed a thorough assessment of a patient, your progress note should demonstrate that. Too often in mental health nursing, we end up writing the same note with little variation over and over. Certainly, each note should include a thorough assessment, which is similar for every patient, but the responses you receive and the interventions you implement should be unique to the patient’s needs.
Instead of writing a generic note, include the patient’s statements and what you are doing to help the patient. “Patient denies suicidal ideation” could be elaborated with, “Patient denies suicidal ideation. States, ‘I have thought about it before, but I am feeling better now.’ Patient instructed to report suicidal thoughts to staff and to continue working on her journaling of triggers. Patient verbalized understanding.” The second example demonstrates thorough assessment and individualized care.
This can be a pretty abstract concept, but at its core is a simple message. Do not just set aside time to assess your patient. Allow time to really hear your patient. That means not interrupting or expecting the patient to answer 20 questions in 5 minutes. It means listening to the underlying message. It means having open communication, both verbal and nonverbal. For example, sit leaned slightly forward toward the patient. Do not write while the patient is talking. Let the patient speak and then make any notes you need to. Give appropriate eye contact. Nod and say, “Uh-huh,” “Yes,” and “Please, continue,” as relevant. Do not be making a mental list of all the other things you need to be doing. What you need to be doing most is listening to your patients.
Keep It Professional
I was talking to a customer service representative for a clothing store recently about a problem with my order. The rep said, “God, I hate this place. They never get anything right.” Now, in a way that is a little funny given the circumstances, but it is incredibly unprofessional. As it relates to clothing purchases, it is not a huge deal, but if you say something like that about the hospital or clinic you work in, how will your patient feel about the care he is receiving?
Do not share your own personal info
Likewise, we should not be sharing our personal lives with our patients. Saying, “I’m sorry it took me so long to come check on you, but I’ve had an awful morning. It is so busy,” will make the patient feel like you do not have time to talk to him. He may be hesitant to ask you questions or open up to you. Or, the patient may take that as an okay or even an invitation to ask details about your personal life. The nurse-patient relationship requires a clear boundary. Without it, the patient does not know what to expect. In a medical hospital, this is a bit easier: the nurse will listen to me with a stethoscope; the nurse will take my blood pressure; the nurse will give me medicine; the nurse will bring me food. But in a psychiatric setting where patients are talking about very intimate details of their lives, a blurred boundary with the nurse can wreak havoc on the therapeutic relationship.
This book is one of my favorites, and I have recommended it to many patients and friends and read it myself. The information is straight-forward and easy to understand. Applying the techniques takes time and practice, but once you have it mastered, you will feel an increased sense of control of your life and greater self confidence and esteem.
One of the Best Books about Boundaries
There are hundreds more ways to be effective in the mental health care setting. This is just an introduction. Feel free to comment below on your own experiences and what has worked or not worked for you in the past.
**Please, do not give any identifiable patient information in the comment section. This is not a confidential website.**
For further reading on the ins and outs of psychiatric/mental health nursing, there are many excellent textbooks on the market. I have used each of these texts in my studies and/or in compiling lectures for my class. They provide diagnostic criteria of many of the most common psychiatric illnesses, the etiologies, planning and interventions for patients, and evaluation of outcomes.
Excellent Texts on Psychiatric Nursing
© 2012 Leah Wells-Marshburn