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Inpatient 101

When I had my first day out of orientation on the pediatric inpatient psych unit, I was not surprised when two of my patients from residential were there.


They both came up to me and started talking my ear off about why they were admitted to the hospital and what had been going on since they were discharged from residential.


It was mildly disheartening to know that just because they were successfully discharged from residential didn’t mean that they were going to be okay. I always try to stay as positive as possible about the future of these children I care for, but in reality, mental health diagnoses don’t just disappear. You can give these kids the right coping skills and therapies and they can still relapse.


Let me paint the picture for you of what an inpatient psych unit looks like since the next weeks to come, I will be continuing to talk about my time on the inpatient unit.


I’ll start with the similarities that inpatient has with residential.


First, there are people everywhere to monitor your behavior. People following you from your room to the hallway. People asking you questions every day like, are you thinking about hurting yourself, how is your mood, and how did you sleep. There are therapists that meet with you and a psychiatrist or nurse practitioner that meets with you and assesses your overall mental status. There are nurses who give you your medications. There is breakfast, lunch, and dinner, and snacks twice a day. There is group time and free time. There is an open milieu concept in which patients do not stay in their room like on other medical floors, but come out to a main area together to communicate and do group therapy. You are provided with lots of supervision and ensured that you are as safe as you can be. Both inpatient and residential patients follow a strict schedule that helps to calm their anxiety and allows for consistency.


The differences, well, there are few, but they are major.


First, on an inpatient unit, you can use mechanical restraints. That means that you can use straps to keep a child to the bed when they are being unsafe. Inpatient units have seclusion rooms where you can quite literally lock a child into a room alone when they are being unsafe and aggressive towards others. Inpatient units have emergency medications where you can be given an injection of medication, usually a combination of Haldol, Benadryl, and Ativan, to give the patient an immediate calm down during periods of aggression and psychosis. Inpatient is more intense regarding safety because, well it must be. These patients are extremely sick and need constant monitoring, more so than in residential.


I loved the care I was able to provide in both locations. Overall, it didn’t matter where I was at as long as I was taking care of these kids and helping them to achieve the best possible outcomes. While there were things about residential that I didn’t like, there was more about inpatient that I quickly grew to despise.


Before I go further with these stories, I want to say this: I worked with some of the most incredible people on the inpatient unit. I met some of the most caring and compassionate nurses I have ever met. I had met therapists and nurse practitioners who truly gave their all when they came to work for these children. And while I met so many wonderful people, there were so many situations that I couldn’t stand to watch.


As I said in the previous post, it all boils down to the amount of training these staff members receive. If you’re a nurse, you know your education in mental health nursing is minimal. During your clinical rotations you don’t do much but follow around a patient and talk to them and watch them participate in group. Mental health nursing is so much more than that and I think that nurses are given a major disservice when they are not getting proper clinical rotations in mental health. I also think that mental health techs and aids, which believe it or not, some places will hire without them having any sort of mental health training, are also set up for failure.


You wouldn’t hire a brain surgeon who studied only early childhood education and had no neurology background, right? Why would you hire someone with no mental health schooling or training to provide care to children with mental health disorders?


The training I received in residential was great and yes, it takes time to learn everything you need to know about providing adequate care for this population, but you can’t just take a random person with no experience and toss them onto a mental health floor and hope they can fly. It doesn’t work. And honestly, it’s terrifying that that is even happening.


As I’ve always said, my goal with this blog is to spread awareness to everyone about mental health, especially in the pediatric population. My ultimate goal in these posts about my time on inpatient is not to bring people down or scare them, but to bring the truth to the forefront and allow people to see what needs to be changed. Trainings need to be improved. People working in mental health should actually have education in mental health. You might not agree with me, and trust me, I’ve met people who disagree, but when you’ve seen the things that I have, you’d understand my reasoning as to why.


Let me get off my soapbox here and continue talking about inpatient!


When a patient arrives to the unit, they have to give all of their belongings to the unit clerk to have them inventoried. We search everything they have to ensure there is nothing unsafe. As talked about in a previous post, they are made to change into purple gowns before coming to our unit. They wear the purple gown through the unit as they are walked into another room where a body check is then completed. They have to have every inch of their body checked by two people, checking for scars, cuts, bruises, and any unsafe objects they may be trying to hide. Imagine standing in only a purple gown, having to lift it up to expose your body to two random nurses. Talk about traumatic. This is where trauma-informed care comes in, remember?!


Then they are allowed to change into something else, either pants and shirts from the unit, blue pants and black t-shirts, or their own clothes as long as they have no buttons or zippers or strings or hoods. Also all jewelry has to be removed and they cannot have make-up or shoes. They can only wear socks with grips on the bottom.


Sounds like a lot, huh? Because it is. Imagine being a child with a mental health disorder, coming onto a unit going through all of these things and then be expected to go right to group and participate. It’s not that easy. Again, this is why the training is so crucial and the patience and understanding you have to have when starting this process with the patient is so beyond critical to their stay on inpatient.


Another thing that many do not know about inpatient mental health is that every single medication has to have a consent. Not just psych meds, but Ibuprofen and Tylenol and even Ensures. Everything has to be consented to by a legal guardian before it can be administered with the exception of emergency medications mentioned above. There are so many more legal aspects to mental health care than people realize and while it is all for good reason, sometimes it makes it difficult. There are times when parents don’t answer the phone and it takes longer than necessary to get them started on a medication, overall delaying their discharge from the unit.


While there are a lot of similarities, it’s the differences between residential and inpatient that have major impact on the outcome of the patients health. Every child is different and no situation is the same. Being flexible and creative in your treatment of these patients is of utmost importance because no one treatment plan will ever be the same.


Here is a peek of the topics coming up for my experiences on the inpatient unit:

LGBTQ

Pseudo seizures

Overdoses

Chemical restraints

Anorexia

Physical abuse

Sex trafficking

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