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Did We Do the Right Thing? Choosing Tenderness Over a Strict Behavioral Plan

By Jeannie Kingsley, RN

September 18, 2015 Print

My name is Jeannie Kingsley. I’m a nurse on the Short Term Unit. Our patients are in crisis and need a brief hospitalization in order to stabilize. They arrive with all sorts of diagnoses, including post-traumatic stress disorder, anxiety, depression, borderline personality disorder and occasionally psychotic disorders. We keep them safe, evaluate their needs and begin discharge planning as soon as they arrive. The average length of stay is several weeks because a fair number of patients receive a course of electroconvulsive therapy.

As “Sara’s” nurses, our first concern was her falls: they were sudden. She could be walking, chatting, and instantly she would be down, in seconds, usually face first, without blocking her fall with her arms. She would regain consciousness about one minute later, appear slightly confused, but after lying down for 20 minutes or so, appear fully recovered. She was assessed by the medical doctor on call each time, without any significant injuries or precipitants found.

Jeannie Kingsley, RN
Jeannie Kingsley, RN

Sara was 18, pretty, with lovely long, straight light brown hair that was a source of pride for her. I used to tell her that she reminded me of Mona Lisa, with her pensive, enigmatic features. She was quiet—even timid—and polite. In addition to the falls, Sara had also been superficially cutting herself (it was hard to find a part of her body that she hadn’t cut) and banging her head. She had a permanent wound on her forehead that she would cover with her bangs. Sara had lost a job and then been prevented from beginning college the week she was admitted, disappointments that had exacerbated her already present suicidal ideation. Her mother had a long history of depression and substance abuse. She had been often absent from the home due to hospitalization and detoxes, including one shortly after Sara was admitted to our unit. Sara had been sexually abused by her stepfather for many years, which her mother may have known about and tolerated.

Before admission, Sara’s cardiac and neurologic workups had been negative, including a CT scan, EEG and EKG. She was on our unit because her falls were now deemed psychiatrically driven. As nurses who had been learning for many years that prevention of falls is one of the most important of the Joint Commission’s goals, it was impossible to simply allow her to fall, which she was doing multiple times a day. Though we thought that a behavioral program might help, we first needed to protect Sara. Ignoring the falls entirely, as part of such a program, seemed contrary to excellent nursing care. Despite some disagreement within the team, Sara was kept in a wheelchair for the first two weeks or so of her stay. And nurses, who were usually the people witnessing the falls, couldn’t help wondering if every diagnostic tool had been utilized. Were the physicians missing something? Was there a medical reason for the falls that just hadn’t been picked up on? The falls mimicked cardiac symptoms related to arrhythmias, also seizure activity, and Sara often appeared postictal, sleepy and somewhat confused after each fall.

However, the doctors who were evaluating her, medical and psychiatric, made it clear that they viewed the falls as at least partially volitional—perhaps attention-seeking, self-injurious behavior related to her trauma history. They also surmised that the falls occurred during dissociative episodes. The nurses collaborated on a behavioral program in which Sara earned time out of her wheelchair connected to a decrease in falls, head banging and cutting.

Sure enough, the falls and self-injurious behaviors decreased slowly, and Sara was completely out of the wheelchair in a few weeks. She had one-to-one supervision, was on five-minute checks and lived in the quiet room, which ironically soon looked like a teenager’s bedroom, cluttered with reminder and strategy cuing posters on the walls, stress balls, stuffed animals, art supplies, playing cards and Sara’s phone and computer. Clearly, the original intention of the room had been lost in our desire to nurture her, so we eventually moved her into a regular room.

To some extent, the falls and head banging could be predicted and explained by the occasional and random phone call from Sara’s mother, who had been discharged from rehab during Sara’s stay. Her mother visited only twice during her four-month stay, the first time showing up unannounced one morning, causing a dramatic scene in which both were tearfully clawing at opposite sides of a window in the unit door as the team discussed whether to let her in (she eventually was allowed in). Despite acknowledging her mother’s many shortcomings, Sara continued to cling to this tenuous relationship, as many victims of abuse do.

But the falls, head banging, and superficial cutting never completely went away. And efforts to discharge Sara home or find a residential program failed. After several months, with her insurance exhausted, our staff began to realize that, on the Short Term Unit, we had a long-term patient. And her plight, as a traumatized young person who appeared quite abandoned by her family, began to work on the nursing staff’s sympathies. Several nurses who worked frequently with Sara, including myself, were becoming close to her, developing more and more trust, always focusing on increasing her ability to express her emotions instead of acting them out. We played endless card games, which literally could keep her from self-harming. We joked with her, looked at pictures of her beloved cats, walked with her. We focused on grounding techniques, mindfulness and tried to tease out the precipitants to each of her falls, bangs and cutting events. She was able to go out on walks without falling, although she would still fall about once a week on the unit and self-injured occasionally. Sara became quite social with other patients, even greeting and helping new ones. Her mood improved and her insight grew. When Sara showed progress, which she continued to do slowly, we glowed. But we realized that her improvement would probably take years, and we were only at the beginning.

When her birthday approached and we discovered that no family would be visiting, we were very worried about the day triggering a major setback. Sara had told several people that she would commit suicide on her birthday, so we decided we would make the day as special for her as we could. The team approved getting a cake and a small gift, something we’d never done for a patient before. The day went better than we could have expected.

We were all getting quite comfortable when suddenly, shortly after four months, a bed in the state hospital opened up. She had 24 hours notice to pack. Sara seemed surprisingly eager to move on. We had reassured her that this would be just another step in her progress. She had hopes of being closer to her family, geographically anyway. Soon after she left, many of us received heartfelt letters of thanks from her. But six weeks later, we heard she was not doing well. Had we adequately prepared her for this next step?

I know that I, as a nurse with almost 40 years of experience, have learned that my intuition is usually the best tool I have in assessing the situations I encounter in this field. My intuition was telling me that this girl needed a bridge, a steppingstone, from her severely fractured and painful childhood, to adulthood. The normal course of development, and especially the ability to trust, had been interrupted and damaged. Whatever came next, which ideally would be a long-term, strict behavioral care plan, would rest on a foundation formed by the ability to trust. So my intuition told me to focus on creating a haven of both physical and emotional safety. Put her in a wheelchair if she fell. Bandage each abrasion. Have her seen by a medical doctor after each fall. And talk, endlessly, about her feelings and her childhood, teaching her that secrets are childhood coping strategies and that she needed to learn adult ones. And yes, show her affection, a clear message that she is worthy of love.

Did we do the right thing? Did we lose sight of boundaries? Should we have started the strict behavioral approach immediately? Did we affect her ability to progress in the future? I question my own practice here. Being a mother and having worked for eight years on a children’s unit in a long-term facility have softened me. We never restrained Sara, which may have been necessary if we had implemented a stricter plan. In conclusion, I’m satisfied that we did no harm, added no further trauma to her life. And as our RN coordinator Terri Quinn, who worked with me on a children’s unit, has said, “We showed her that there are caring people in this world.”