by John Billings

Nursing

You are an experienced nurse, but relatively new on an adult psychiatric unit at a state hospital. Jerry is a 30-year-old patient who was admitted to your unit two weeks ago. He has a history of violent behavior which is usually followed by severe depression and suicide attempts. The courts have ruled him a danger to himself an d others and have committed him to the state hospital.

A situation erupted when Jerry yells at one of the staff members this is perceived as a threat to the health of the staff member. The staff request permission to put Jerry in seclusion. When you started this shift, Jerry was calm and cooperative but has become increasingly agitated. It is your perception that the staff have taunted Jerry in subtle ways and that this incident is, in part, caused by the staff.

You feel that secluding Jerry at this time would precipitate a violent episode that would result in restraining Jerry and requiring a shot to calm him down. You feel you could calm Jerry down without use of seclusion. If you do nothing he will exhibit violent behavior within the hour. However, there is a strong precedent on this unit to use restrictive therapy. Since Jerry has "threatened" violence toward a staff member the staff feel that seclusion is the only acceptable course of action. To do otherwise would discredit you in the perception of the staff, with a real possibility of sabotage of your effectiveness as a nurse on this unit in the future.

Questions:

Should you do what you feel is best for Jerry at the risk of alienating yourself from the staff?

Or should you support the staff, with hopes of retraining them to your way of therapeutic intervention at the risk of causing physical and mental harm to Jerry?

Should your concern be for the patient, or for the unit as a whole?