Working with Staff on the Inpatient Unit

Author: Daniel Carlat M.D.
Last Updated: 4/1/20

There are many staff members on an inpatient unit and especially when you’re new to the job it can be somewhat overwhelming. For clinicians who have been used to working on their own in a private practice, there are adjustments to make. You no longer call all the shots, and you will have to work closely with unit staff to get anything done. The upside is that suddenly you are part of a team, and you have a lot of people helping you do your job. In addition, you are in a social situation which can be a relief from the isolated experience of much psychiatric work.

In this chapter I’ll introduce you to the cast of characters who will be your work family during your time on the unit. You’ll learn who does what, how each member contributes to your patients’ treatment, and how to work most effectively with them. I want to begin with a piece of general advice. Studies of inpatient ward morale have shown that the psychiatrist’s behavior can have a large impact, for better or worse ((Totman J, Hundt GL, Wearn E, Paul M, Johnson S. Factors affecting staff morale on inpatient mental health wards in England: a qualitative investigation. BMC Psychiatry. 2011;11:68. doi:10.1186/1471-244X-11-68.). You do want to be a strong leader, because staff appreciate psychiatrists who are competent and can make good decisions about patient care. At the same time, give staff a voice, so they don’t feel like they are just mechanically going through their day following orders. Make them feel like they have a role in decision-making, ie., be a leader but not a dictator.

NURSES

Nurses are the most important staff members of the psychiatric hospital, because they allow the unit to run smoothly. It’s important to understand how nurses work, because the more you can work in sync with them, the more efficiently you can get your work done.

Training

There are two different types of nurses: RNs (registered nurses) and LPNs (licensed practical nurses). RNs must have at least an associates degree in nursing, which usually takes two to three years, depending on the program. Some RNs also get a bachelors degrees in nursing (a BSN) and some hospitals require this degree. LPNs, on the other hand, can get a certificate after only one year of training.

There’s also a category of nurses called “psychiatric mental health nurses” (abbreviated as PMH nurses) who are board certified in psychiatry. The requirements are having an RN license, plus 2 years of full time practice as an RN, 2000 hours of practice specifically in psychiatric nursing (about one year of full time work).

To a casual observer (ie., you) it will be very hard to tell the difference between an RN and an LPN. While more extensive training is desirable, in reality nursing competence is related closely to degree of experience on a psychiatric unit.

Duties

Nurses do pretty much everything, and their duties include:

• Administering medications, both in pill/capsule form and more complicated delivery systems such as nebulizers, patches, and shots.
• Providing psychotherapy or counseling as needed. They talk to patients when they are agitated and upset, and they decide when to give them prns.
• Behavioral management. This means overseeing plans to monitor patients for harm to self or others, and managing restraints when needed. (Though the actual work of doing things like 15 minute checks is generally done by psychiatric technicians, see below).
• Help with self care, including bathing, toileting, dressing/grooming.
• Vital signs
• Finger stick glucose
• Managing physical symptoms, such as constipation, nausea, pain, wound care etc….

During any particular shift, different nurses on duty will be assigned different roles. While each hospital has its own procedure for assigning roles, here are some common ones.

• Charge nurse. There is often a designated ”charge nurse,” otherwise known as the nurse manager, nurse supervisor, or “the boss.”  
• Patient assignments. Nurses are often assigned specific patients.
• Admissions/discharges. One nurse may be assigned to all admissions and discharges on a shift.
• Medication. One nurse is often assigned the role of administering medications during a shift.
• Vital signs. Vitals are usually done once a day in the morning. It’s helpful to know who is in charge of vitals for the day since you might have questions about abnormal vitals and this nurse will do a recheck of vitals if you ask for it.

Staffing ratios and patient acuity

One of the more confusing things about a unit is how staffing is determined. You’ll notice that staffing varies from day to day. There are no specific national guidelines for the ratio of nurses and other staff to patients. Neither the Joint Commission nor CMS provide numeric staffing standards; they just say that hospitals have to decide for themselves the staffing that allows them to take care of patients appropriately. One state—California—passed a law in 2004 mandating minimum nurse to patient ratios. These ratios required by this law vary by type of hospital, and for psychiatric hospitals there can be no fewer than 1 nurse per 6 patients. Nurses associations have lobbied other states to pass similar laws, but so far they’ve been unsuccessful. Nonetheless, law or no law, in my experience the nurse:patient ratio tends to be in the range of 1:5.

Clearly, more staff are needed when the unit is full than when it is nearly empty. But even at a given census level, the intensity of patients will vary. The intensity of the patient mix is termed “acuity,” and you’ll often hear this mentioned when the charge nurse is deciding whether they can take a new admission. “We’re too acute right now for this kind of patient.”

There are various acuity rating scales, and here is a typical breakdown:

1. Low acuity: Patients who are ready for discharge.
2. Medium acuity: Patients in need of treatment who are cooperative with treatment plan.
3. Higher acuity: Patients who are highly symptomatic, such as those who are manic, who are actively responding to delusions and hallucinations, or who are suicidal. They are usually on at least 15 minute checks.
4. Highest acuity: Patients at high risk for suicide or violence. They may be on constant observation and may be at risk for needing to physically or chemically restrained.

Generally hospitals determine their baseline staffing needs based on most patients being at medium acuity, and more staff are added as needed.

How additional nursing staff are brought in is a source of tension at times. If you are working in a large hospital with more than one psychiatry unit, you’ll notice that nurses for other units may “float” to your unit when acuity is higher. They might be asked to help out for a specific task (like discharges or giving medications) when the regular staff is stretched thin. If there are no floaters available, the hospital administrator will start contacting nurses to ask them to come in for extra shifts. If that’s not successful, they may go to the big guns, which is “mandating.” When issues of patient safety are at stake, hospitals can essentially force nurses to put in extra hours, and when this happens you’ll likely hear staff complaining about it. Be sympathetic to these over-worked nurses and do what you can to relieve their burden—even if that means no more than bringing in a care package of donuts in the morning.

Collaborating effectively with nurses

• At the beginning of the day, make sure you know which nurses are on the unit, that you know them by name, and that you know who is assigned to which jobs—especially who is assigned to your patients. Knowing team-members’ names is critical for effective team work throughout medicine. For example, in Atul Gawande’s The Checklist Manifesto, he points out that knowing names in the operating room decreases surgery complication rates by 35%. The better you know your co-workers, the easier it is to communicate with them, and patient care benefits as a result.
• Read nursing assessments. Nurses write brief shift notes, which are descriptions of the patient’s symptoms and behaviors over that particular 8 hour shift. These will help you to write your notes.
• Determine which nurses are the most competent. Like doctors, nurses vary in their degree of skill and competence. This may seem obvious, but unless you spend some time talking to the nurses you work with, you may not recognize these variations in clinical prowess. This is important because the best nurses will give you the best advice, and you should get in the habit of consulting them on difficult patients.
• When asking nurses about patients, rather than simply asking “how is the patient doing,” ask for specifics like, “Can you give me a quick report on Mr. Jones? How do you think the medications are working? How many hours of sleep did he get last night?”
• Since nurses are on the front line of dealing with complaints/agitation/suicidal ideation, they can often have insight to help you deal with these problems. Ask them what they think helps an agitated patient.

SOCIAL WORKERS

Training

Social workers all must complete an MSW (masters in social work) after college, and these programs include both coursework and placements in different social work agency settings. Many social workers end up becoming psychotherapists—those who do often go on to earn an LCSW (Licensed Clinical Social Work) which requires about 2 years of clinical experience after the masters.

Social workers learn a lot of the same clinical information that psychiatrists learn, except with more emphasis on psychosocial treatments. They learn how to interview patients to understand their social and psychological problems/diagnoses. They learn a lot about theories of psychopathology, including psychodynamic theory. They also learn a lot about public programs to help the indigent, such as Medicaid, social security disability, various human service agencies.

Duties

Like you, social workers have to see all their assigned patients everyday (or nearly every day) and write a note. Their schedule will be similar to yours, and for this reason it’s often helpful for you and the social worker to see patients together. Their tasks may include all or some of the following:

• Psychosocial assessment of all new patients.
• Contact family members and outside caregivers to gather more information about the patient and see if there are problems that can be solved while the patient is hospitalized.
• Discharge planning. Includes scheduling outpatient appointments, coordinating services like day treatment programs and visiting nurses, and making referrals to the Department of Mental Health when appropriate (some hospitals hire separate staff as dedicated discharge planners).
• Utilization review to obtain authorization for more inpatient care from insurance companies (some hospitals have dedicated utilization reviewers who take care of this).

Collaborating effectively with social workers

• Communicate. One of the most common complaints I’ve heard from social workers is that the psychiatrist comes in and writes a bunch of orders and then leaves. Often the patients are not told about the med changes, and then the social worker bears the brunt of the patient’s questions/complaints. I suggest you schedule a quick check in with the social worker before you leave the hospital so that you can explain your thought processes behind orders.
• Be involved in family meetings. Usually the doctors ask the social workers to do family meetings, but families usually have many questions for the doctors, such as why certain medications were chosen and what side effects they might have. They also often want to find out the rationale for why the patient is not being discharged. These are rarely questions that the social worker can answer completely, so it’s helpful for you to at least peak your nose into these meetings, when you can schedule it.
• Coordinate filling out forms with the social worker. Some forms, like applications for guardianship and for DMH follow-up, require a lot of clinical information about medications that might be considered and possible side effects. Doctors often hate forms and leave them for the social workers, who then have to struggle through the clinical portions—whereas these would be easy for the doctors to fill out.

PSYCHIATRIC TECHNICIANS (mental health aides, mental health specialists)

Training

Requirements for psych techs vary widely from state to state. Some states require only a high school diploma, whereas others require specific psych tech licensure. The American Association of Psychiatric Technicians is the main organization offering certifications, and there are four certificate levels, corresponding with increasing training requirements. The lowest level, level one, requires a high school diploma or GED, while the highest level, level 4, requires a Bachelor’s degree in the mental health field plus at least three years of experience in a mental health setting. There are nearly 65,000 psychiatric technicians in the United States.

Duties

To the uninitiated psychiatrists, psych techs may appear to be random staff members milling around. When I was new to inpatient work, I didn’t know if they were nurses, custodians, or security staff. In some ways, psych techs are all of these things, plus being therapists. Duties include:

• Observation of patients throughout their shifts, and documentation of observations.
• Monitor patient safety, such as doing 15 minute checks.
• Help with ADLs, including dressing, toileting, and eating.
• Participate in restraints.
• Escort patients off the unit, such as for outdoor breaks or for 12 Step meetings.
• At the higher levels of training, they may take vital signs, write shift notes, and run therapeutic groups such as coping skills or mindfulness.
• Provide emotional support and counseling.

Collaborating effectively with psych techs

Get to know the psych techs who are working with your patients. Don’t write them off as “low level” or “menial” staff. They are usually insightful, intelligent and highly motivated young people who see this job as stepping stone to future professions. Many are in college, nursing school, or other professional training and working part time on the unit for the experience and extra money. Some are pre-med and will eventually end up as psychiatrists.

Make a point of asking psych techs about their impressions of your patients. You’ll certainly find out a lot about the “person” behind the psychiatric symptoms, because the psych techs will have usually spent a lot of time just chatting with them.

OCCUPATIONAL THERAPISTS

It took me a long time to figure why “occupational therapy” is part of inpatient treatment, and especially why OTs are the ones who run most groups on the unit. The history of OT as a profession is closely linked to the history of psychiatric treatment. Before the 20^th century, psychiatric wards were essentially storehouses for the insane. Treatment involved little more than providing food, shelter, and restraints (chains and shackles) when needed. Occupational therapy was a big part of the reform of mental health treatment, operating under the theory that mental illness was caused by an imbalance of work and leisure. In the early 1900s, the Johns Hopkins department of psychiatry created a program called “Habit Training,” in which patients were taught skills like basket weaving and bookbinding, in order to re-balance their lives.

Over the years, OT expanded to other fields of medicine, always with a focus on helping patients learn how to reengage in meaningful life activities after illness—whether physical or mental. According to the American Occupational Therapy Association, the primary goal of occupational therapy is to support and enable each person’s “health and participation in life through engagement in occupation.”

OT is important, because it fills a gap in treatment in units. Psychiatrists and nurses are focused on relieving symptoms through medications and therapy. But there is still a chasm between improved mental status and improved functioning in the community. OT helps patients to apply the psychological gains they’ve made in treatment to the reality of life in the real world.

Training

Most states require a masters degree to become a licensed occupational therapist.

Duties

• Initial OT assessments for ADLs (activities of daily living), social skills, work skills, money management skills and others.
• Specific assessments for patients in need of them, such as fall risk assessments and cognitive functioning assessments.
• Run groups, such as goal-setting, life skills, leisure skills, art therapy, music therapy, substance abuse, others.

Collaborating effectively with occupational therapists

• I suggest you attend one or two groups run by OTs. You’ll find out what goes on in groups, which is important because groups constitute the major source of psychosocial treatment on units. And you’ll get to know your patients better.
• Like all staff, OTs document their activities in the chart. This will include an initial evaluation as well as ongoing records of patient attendance and participation in groups. You will sometimes want to add some of this information to your notes. Group attendance is sometimes an indication that a patient is improving.