All Nurses Are Psych Nurses: Protecting Patients and Caregivers Through Planning and De-escalation

Podcast Transcript

Carol Pehotsky:

Let's say I'm a med-surg nurse and I'm getting a report from PACU on a post-op patient I'll be receiving. Maybe as part of that report they share with me that the patient has a history of schizophrenia or perhaps they share with me that the patient or the loved ones are feeling very anxious and fearful about either the surgery itself or the recovery. So how do I take all that information in and make sure that I'm giving appropriate care, remembering the old adage that all nurses are psych nurses. We're joined by guest Jim Pehotsky today to talk about all of this and more.

Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing, from patient care to advancing your career to navigating tough on the job issues. We're so glad you're here. I'm your host, Carol Pehotsky, Associate Chief Nursing Officer of Surgical Services Nursing.

As nurses, we're charged with taking care of our whole patients - how they come to us. Sometimes those patients come to us with medical surgical needs, but sometimes they also come to us with behavioral health needs and really making sure that we are sensitive to that, really treating the whole patient, meeting them where they're at, and really focusing on everything they need as a whole person. That can be intimidating though for nurses, especially those who aren't as familiar with behavioral health care.

Our guest today is Jim Pehotsky. Jim is a bedside nurse at Cleveland Clinic Lutheran Hospital, serving the nursing needs of behavioral patients for almost four years. As you may have noticed, he's also my husband, so I'm thrilled to be joined by you today as an expert in behavioral health care.

Jim Pehotsky:

Thanks for having me, Carol.

Carol Pehotsky:

So, you have such a passion for the care for patients with behavioral health needs, no matter where they're receiving care. It's a specialty that sometimes is not well understood or appreciated by the nursing community at large. Can you start off by telling us a little bit more about why you were drawn to behavioral health nursing in the first place, and why you remain so passionate about the specialty?

Jim Pehotsky:

It's kind of a funny story. I kind of stumbled into nursing. I was between jobs as a young man, and my dear departed brother worked at Fairview General Hospital, and he happened to look on the board and said, "Jim, did you ever think about health care as a job?" I hadn't, although I had held several jobs that involved working with people and knew that I was a "people person" and liked that direction.

So, I said, "What the heck?" I went ahead and applied for that job, and they accepted me. I was working as a mental health tech on the psychiatric unit, and I did that role for many years and really enjoyed it. And then, as fate would have it, I met a wonderful lady who said "well, you know if you like this, maybe you'd like being a nurse even better." That would be my wife, Carol. So, I went ahead and went to nursing school - and the rest is history. I've had several roles in my unit, the 3C at Lutheran Hospital. It is a Cleveland Clinic higher-functioning psychiatric unit, and I've been an RN with them for, oh, probably going on 15 years now. Been the charge nurse on that unit.

I've been the person that trains new nurses on how to be a good psych nurse. So, shame on me after these years if I haven't learned a few things about being a psych nurse.

Carol Pehotsky:

So, knowing that you had some behavioral health experience before you came to nursing school, obviously part of nursing school is exposure to all sorts of different specialties. Was there ever a consideration of something else, or was it always laser-focused on, "This is where I need to be. I'm looking forward to expanding my skillset as a nurse, but behavioral health is where I'm meant to be?"

Jim Pehotsky:

I've always felt that I'd be a psych nurse. Some of the other disciplines interested me a little bit, but my passion is in mental health nursing, and I think that's where I belong and where I can serve my patients best.

Carol Pehotsky:

Certainly. We know that patients sometimes come to the hospital for very specific behavioral health needs, and they end up in a unit (perhaps like yours), but we also know that sometimes they need surgery. They have medical care needs, so they're really getting their primary care in an ICU, in an OR, in a PACU, on a med-surg floor.

Knowing that every nurse gets to take a semester of behavioral health nursing as part of their curriculum, but knowing that not everybody's comfortable in that space, what are some things that nurses outside of behavioral health should be addressing with patients that have those types of diagnoses?

Jim Pehotsky:

Well, we have a little saying in nursing, "All nurses are psych nurses." The reason being is, even when you're in a medical unit, something has happened to that person; we call it stress. And stress can change a lot of things for a person. It's common knowledge that patients that come in with heart trouble, heart attacks, heart surgeries, etc. almost always get some kind of depression - it's a little something extra to go with their diagnosis. And it's important for us to be mindful of that as nurses because that might be something that, a) needs to be treated, and b), if it's treated, it may improve the prognosis of that patient.

Carol Pehotsky:

Absolutely. How do we best advocate for patients who have an additional behavioral health diagnosis when they're having surgery? Maybe their medications have been put on hold as part of that surgery, or they came in unable to tolerate their medications. What are some things that a medical-surgical nurse, for example, should be looking for to advocate for that patient's needs?

Jim Pehotsky:

Well, every kind of mental health diagnosis - and there are many, many different kinds of diagnoses - can involve a patient having a physical problem as well. A person with a diagnosis of paranoid schizophrenia, for example, may need knee surgery at some point. A person with profound depression may have some type of diagnosis where they end up having that heart surgery. What's gonna happen to the person who's already depressed when they come out of that heart surgery?

So, a good nurse is going to make sure that before that patient has that surgery, they're gonna want to know that patient's history. It would be important to know that a patient, such as someone who has delusions, someone who has some type of paranoia, may have to go off their medications in order to have that surgery for various reasons. Some medications may have an adverse effect on anesthesia; some medications may affect bleeding, etc. The surgeon may say, "Well, I will go ahead and do this surgery, but this patient needs to be off this medication for X number of days." Well, what does that mean for someone who relies on that medication to be stable mentally?

Carol Pehotsky:

Sure.

Jim Pehotsky:

It could really cause a problem. Plus, when that patient comes out of anesthesia, we don't know how that patient is gonna react. So, if the good nurse is making sure they know that patient's history, then that is a one big step to helping that patient stay safe. Especially when they come out of that surgery, they may not have their faculties about them. They may get anxious; they may be confused or delusional; they may be afraid.

What do people do when they're afraid? They may strike out. They may grab something as a weapon to defend themselves because they're frightened. What could those weapons be? They could be the stethoscope that's around your neck. They could be the pair of scissors that's sitting on the bedside table. When you think about it, in that area, there are lots of things that can be used as a weapon against someone who is not expecting it.

Now in mental health, we're trained to expect those things. We take classes to expect those things. When we are rounding in our psychiatric units, we're always looking for ways that a patient may be able to use an object as a weapon or something to hurt themselves. But our med-surg nurses, our ICU nurses, etc., they may not have that training, so they may neglect to think about what the patient's mental state is gonna be, and that's when they're vulnerable.

Carol Pehotsky:

Sure, and you know you mentioned obviously my specialty is mostly PACU nursing, and there's even a phenomenon in recovery from anesthesia called emergence delirium, where somebody without any history of behavioral health needs has a reaction to anesthesia that is literally a delirium. They are extremely confused; they can start that fear, like you mentioned. There's no intentionality there, they're fearful for their lives and are in that true fight or flight syndrome. It has nothing to do with any other input other than how their body is reacting to that anesthesia. Nurses have to jump back from that situation because that patient is so incredibly terrified that they think they're protecting their lives. It can do really dramatic things for people.

Jim Pehotsky:

Well, absolutely, and it has happened where nurses, PACU nurses, nurses that have been taking care of patients who are coming out of anesthesia have been hurt by these types of patients. And it's not that the patients are looking to hurt anybody intentionally, it's an issue of fear.

Jim Pehotsky:

Many of our patients have had anesthesia before, and they're always asked, "Have you ever had a reaction to anesthesia?"

Carol Pehotsky:

Yeah. Yep.

Jim Pehotsky:

But what about the person who's going under anesthesia for the first time?

Carol Pehotsky:

Right.

Jim Pehotsky:

Taking those steps to keep the patient and yourself safe at that moment, when that patient comes out of anesthesia, is the smart move.

Carol Pehotsky:

You mentioned really being cognizant of your environment. So, we think about the typical medical-surgical unit. What are some of the number one thing that, you know, [make] a med-surg nurse walk into a room and think, "This is everything I need in here to take care of the patients"? But you're looking at it from a different lens.

So, appreciating that, you know, whether there's a, a diagnosis or not, somebody who's afraid or stressed may be looking, unfortunately, to harm themselves, or in that fear reaction, protect themselves against their caregiver. What are some things that nurses should be assessing in their physical environment and perhaps taking measures to remove or make less available?

Jim Pehotsky:

Well, our psychiatric units are much more spartan than the medical units, first of all, and that's by design.

Carol Pehotsky:

Sure.

Jim Pehotsky:

Because we know that patients can use virtually anything as a weapon. We've had nurses get hit with food trays, something as simple as that. Part of it is using your assessment skills, and – depending on how far away you are from your mental health training – remembering what it was like to work on a psychiatric unit, remembering what it was like to see the looks on patients' faces. When you walk into a room, sometimes you're greeted with a smile; sometimes you're greeted with a look of fear. That tells you something.

Carol Pehotsky:

Sure.

Jim Pehotsky:

After all my years in mental health, I've become a pretty good reader of people's faces. You can kind of tell when people are in distress, and that's the moment where you have to ask yourself, "What's going on here? How can I assess this correctly?" You might want to start asking questions, but you also might want to start assessing your environment for weapons. In the event you're in a situation where a patient looks like they're about to strike out, you want to make sure that your exit is not blocked because you might want to get out of there and then go get some help. There's always strength in numbers, and if you're alone in a room with a patient, you're much more vulnerable than if you have a team there – especially a team that's had some training or experience in dealing with this kind of patient. The patient that comes in and is on the medical unit and has that history of paranoid schizophrenia may be very frightened at this time.

And, well, we know what happens to frightened people, frightened animals, frightened anything. They're very capable of striking out. 

Carol Pehotsky:

And so sometimes we, one of the interventions that anyone would use in health care is having a sitter with that patient, somebody who stays with them to get them what they need and also to sort of survey the environment. So, what are some things that we need to make sure our sitters know? These are often unlicensed caregivers of varying levels of experience, and maybe they're used to sitting with somebody who's at risk for falls. So now we're saying, "Yes, we still need you to sit with this patient," but while there may also be a falling need, the primary focus is really on the safety of that patient as well as the safety of their caregiver. What are some different pieces of advice you'd give to a sitter in that situation to make sure that they know when to call for help or what they should be looking for in the room?

Jim Pehotsky:

Well, at Lutheran Hospital, for instance, we have many people that serve as sitters. They are usually our behavioral health techs. These are employees that we have; they're like nursing aides, but they're specially trained in the psychiatric field. So, they're trained to keep their eyes open to things that the patient may do to either harm themselves or harm other people.

The sitters at our hospital will be mindful of, for instance, the patient's access to sharp objects and other items that might be used as a blunt instrument. Our sitters also need to be mindful of the patient's ability to stay stable. These patients are, for whatever reason, in the hospital. They're on medications; they could be on pain medications; they could be on sleeping medications; and they may be at increased risk for a fall.

Carol Pehotsky:

Sure, maybe they didn't come in with a fall risk, but we know that many of these medications can affect people's blood pressure, for example, and make them a risk for falling, sure.

Jim Pehotsky:

Well, when that patient needs to be toileted, for example, they may need some assistance in the bathroom. That means that that sitter will be in very close proximity to that patient.

Carol Pehotsky:

Sure. Yeah.

Jim Pehotsky:

Both things can occur, the patient can a) need to go to the bathroom, and b) be confused.

Carol Pehotsky:

Yes.

Jim Pehotsky:

And when that happens, the sitter is vulnerable. So, the sitter needs to be able to assess the patient's ability to understand reality at that point because both are at risk. So, my advice to that sitter would be to assess the patient's cognitive abilities every chance you get and let that patient's nurse know what's going on.

Carol Pehotsky:

Especially in acute changes, sure.

Jim Pehotsky:

Sure, because that nurse may be able to treat something or may even be able to consult a psychiatrist or a resident to come over and assess the patient further. Maybe we can better serve this patient by not just treating the patient's physical but also treating this patient's mental state.

Carol Pehotsky:

Right. And you know you mentioned sharp objects and blunt instruments, but it can be as simple as the cap of a pen or a paperclip, things that, if somebody, again, in that fight-or-flight instance could really use to hurt them or at least attempt to hurt themselves. Sometimes it's the big things, but it's little things, too.

I remember we were given lanyards as a Nurses Week gift specific to the unit I worked on at the time, and I brought it home and you said, "You can't wear that!" There wasn't a breakaway latch on it; it was just a continuous lanyard, and you right away said, "Someone's gonna get hurt." It was that moment where you're like, "Oh, wow, you're absolutely right." Again, assuming no bad intents, it's right there, and somebody in that fight-or-flight moment could use it to really hurt me.

So, it's things that the rest of us as nurses maybe aren't looking for, to really take that breath and reflect back on our behavioral health training to determine, "Is this the right move or not?" So, let's say I'm that med-surg nurse and I've been taking care of a patient who has a history of schizophrenia, but they came to us for a knee replacement, for example, and it's time to start doing discharge planning. Obviously, there are lots of physical care needs I need to be thinking of, but what can I be doing as a medical-surgical nurse to really advocate for the psychological wellbeing of this patient upon their discharge?

Jim Pehotsky:

Well, these patients may have been taken off their meds for this surgery. At some point, the doctor is going to want to restart those medications. Depending on how long that patient's been off the medications, there may be side effects involved in restarting these medications.

Carol Pehotsky:

Sure.

Jim Pehotsky:

The nurse needs to be mindful of those side effects, as well as any reactions that the patient may have to any new medications that they've had to start because of the surgery.

Carol Pehotsky:

Sure.

Jim Pehotsky:

So, those are all things that are being looked at by the doctor and the nurses to make sure that restarting the patient on those meds doesn't cause other problems or more complications.

The patients themselves may or may not have received follow-up care on the outside. Fortunately for us at Lutheran Hospital – and I believe it's the case for all Cleveland Clinic hospitals – there is a team of social workers on the premises that's more than happy to come out, speak with this patient, assess this patient and make sure that this patient is set up with all the services they may require when they get out.

Our patients with schizophrenia, for example, stop seeing their outpatient services for various reasons.

Carol Pehotsky:

Sure, getting reconnected to that.

Jim Pehotsky:

Help getting reconnected to that service is something that they may desperately need. Also, our psychiatrists are available, as well, to come in and do a consultation – and the nurses may suggest that we consult. We have a team at Lutheran Hospital that makes sure that all of our patients that are on the med-surg units can get full mental health services so that they can thrive when they get discharged.

Carol Pehotsky:

Yes, it's not just about discharge, it's about thriving and – no matter where you're listening from – really making sure that we [rely on] the knowledge that we have to be taking care of this whole person. Can we set them up with appointments on the outside or perhaps connect them to services they haven't been connected to make sure that their whole body is healing and that they're safe? Depending on how long they've been off these medications, they may not have, for lack of a better term, kicked back in. So is there a, a window of time where we need to be worried about their safety after they leave us because the full effect of their medications hasn't kicked back in yet?

All right, thank you. I want to switch gears a little bit and talk about, you know, both patients and family members. As you mentioned, certainly it's incredibly stressful to either be in a hospital or have your loved one in a hospital, and sometimes that stress comes out in certain behaviors.

So, obviously we want to do everything we can to prevent that harm or that escalation, where somebody feels like they have to physically do something because they've gotten to that point. What as nurses should we be assessing to determine if a family member or a patient is feeling escalated, and what can we do about that?

Jim Pehotsky:

Well, when it comes to the escalation of patients, we get to know our patients. Our patients are usually with us for a period of time, and we have spent enough time with them to know when they start to escalate. That's an important part of my training for the new nurses; I want to help them understand what's going on mentally with that patient in their medical. However, for us visitors, it's not so easy. You might be seeing these people for the first time, and as you said in the very beginning, stress can happen. Stress is very important to understand as a psych nurse because it's stress that can take a person from being a regular, normal person to a state of mental duress, and things can happen in that state.

Carol Pehotsky:

Or we think about the med-surg patient we've just met. So, I have to be able to assess, I don't know what your baseline is. So, what are some behaviors or some “tells,” if you will, where we can see without really – like your example of the family member, where I'm just getting to meet this person – but I can tell that I might need to intervene?

Jim Pehotsky:

I would think that most people are like me. If something happens to one of my loved ones, my stress level has gone up.

Carol Pehotsky:

Sure.

Jim Pehotsky:

And my ability to reason has gone down. So, a lot of times we will get visitors that are very worried about their people; and when that happens, well, I don't know what their ability to handle stress is.

Carol Pehotsky:

Sure.

Jim Pehotsky:

Many of them can get angry pretty quickly, especially if they think their loved one isn't being served properly. I want to make sure that person is reassured that we're offering top-notch care to that patient and will communicate with them to the extent that the patient will allow us to. Our patients all do still have HIPAA rights, and those HIPAA rights do play a part in what kind of communication we can give to the visitors, who sometimes get very irritated if our patients have not signed HIPAA rights. We can't just, willy nilly, tell family members and friends every detail about what's going on with a patient without the patient's permission.

Carol Pehotsky:

And that's everywhere, not just behavioral health, yeah.

Jim Pehotsky:

That is everywhere. That's a law. That can trigger loved ones as well.

Carol Pehotsky:

Sure.

Jim Pehotsky:

But the good nurse makes sure that the visitors understand that because most visitors do understand that. Also, as a good mental health nurse, you use your skills. Part of your skills are de-escalating stressed-out patients; you can do that with the visitors, too. A good psych nurse probably uses it everywhere, maybe even at the grocery store.

Carol Pehotsky:

Or perhaps with his wife.

Jim Pehotsky:

Exactly. So, using all your skills and all your powers to de-escalate the patients and de-escalate the staff is gonna serve you best.

Carol Pehotsky:

And so, listening, making sure that the patient or family member feels reassured by being very descriptive and concrete in the plan of care in the next step. Anything else in terms of tools that a nurse could use to de-escalate either a patient or their loved one?

Jim Pehotsky:

Our de-escalation skills for our patients often involve, at least for me, trying to bring that patient back down to some reality. Patients and visitors, as well, get angry – and when you get angry, sometimes you let your emotions take you places.

Carol Pehotsky:

Sure.

Jim Pehotsky:

Where I'm going with that is having that patient take a step back, "Take a deep breath, remember where you're at, you're in a hospital surrounded by nurses and doctors that want to care for you. You don't want to hurt anybody here. We want to help you, remember that. I understand you're in pain. I understand things aren't going the way you'd like to have them, but we're here to help. Let us help." And most of the time, unless the patient's going through some extreme delusion, most of the time that works.

Carol Pehotsky:

Sure. All right. Well, you've given our listeners some great tools and pieces of advice moving forward, so we thank you for sharing your expertise. We're gonna wrap up with just a couple questions that are more about you as a nurse and person of the world. It's our speed round. So, I'm wondering if you'll tell us what's the best piece of advice you've ever received?

Jim Pehotsky:

Ah, that's a tough one. I've received so much good advice over the years, especially from my loved ones, my wife, going into nursing with some pretty good advice because it's a career that I love. Sometimes I think to myself, "You know, I would do this for free even if I had plenty of wealth." I did read something years ago that I thought was quite profound. It was by, I believe, Eleanor Roosevelt, who said, "Nobody can make you mad without your permission."

Carol Pehotsky:

Yep, yep.

Jim Pehotsky:

And I gave that a long and hard think because, you know, when you're young and you're still trying to figure things out, sometimes little things trip your triggers. Then I realized, you know, when you get mad or you let somebody get you mad, you give that person a heck of a lot of power over you. Because I don't like how I feel when I'm mad, I never have, and that's helped me stay a little more even keel. I like to think I'm an even-keeled person because I don't get too mad about things anymore.

Carol Pehotsky:

I can attest to that. All right, well thank you, Jim, so much for joining us and sharing your wisdom with us today.

Jim Pehotsky:

Well, it's my pleasure.

Carol Pehotsky:

As always, thanks so much for joining us for today's discussion. Don't miss out! Subscribe to hear new episodes wherever you get your podcasts, and remember we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at nurseessentials@ccf.org. To learn more about nursing at Cleveland Clinic, please check us out at ClevelandClinic.org/nursing. Until next time, take care of yourselves and take care of each other.

The information in this podcast is for educational and entertainment purposes only and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.