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Mental Health Nursing · Chapter 9

The Unit Board: Delegation, Milieu and Keeping People Alive

One rule governs the whole shift: assistive personnel may perform tasks, never assessments or therapeutic interventions requiring nursing judgement. Assign each job on the board, then switch modes and sort the harm-reduction claims that students most reliably get backwards — because a person who dies cannot recover, and that is the whole argument.
Evening shift, behavioural health unit. You are the RN. With you are one LPN and one unlicensed assistive personnel. Assign every job below to the lowest level of the team who may legally and safely do it — and keep what cannot be given away.
Some students arrive believing harm reduction enables use. Decide each claim, then read the evidence. Nothing here asks anyone to approve of substance use. It asks you to keep the patient alive long enough for recovery to be possible.

Scoreboard

0
Tasks assigned correctly
0
Claims called correctly
Unlicensed assistive personnel may
Obtain and report vital signs · perform one-to-one observation or 15-minute safety checks and document them · walk environmental safety rounds · assist with hygiene and activities of daily living · escort patients · gather belongings for contraband search under RN supervision · record intake and output · report verbatim what a patient said.
Unlicensed assistive personnel may not
Score a CIWA-Ar or COWS · perform a suicide-risk assessment · administer medications including naloxone in most facilities · conduct group therapy · lead de-escalation · evaluate the response to an intervention · provide patient teaching · make a decision about restraint.
An LPN or LVN may
Reinforce teaching the RN has already provided, administer many medications and collect data — while the initial assessment, the care plan and the evaluation stay with the RN.

The milieu, and the ladder before restraint

Limit-setting is a therapeutic act, not a punishment. Set it in advance, in plain language, with the rationale and the alternative attached: “Medications are given at the window at the posted times so nobody gets a wrong dose. If you feel you need something sooner, come find me and I will assess you.” Then follow through exactly as stated. Negotiating limits under pressure teaches the unit that pressure works; applying them coldly teaches that the unit is punitive. Warm and consistent is the target.
When staff apply limits inconsistently, patients experience the environment as unpredictable and unsafe — and the resulting behaviour gets labelled “splitting” when it is a rational response to inconsistency. Handoff and huddle are the fix.
EarlyRestlessness, pacing, raised voice. Reduce stimulation. Voice low and slow, hands visible, non-threatening posture, generous personal space. Use the person’s name. Ask what would help right now.
RisingDemanding, refusing, escalating volume. Name the feeling out loud. Offer two real choices. Address the driver — most agitation on this unit is withdrawal, intoxication, pain, nicotine or fear, and all of those respond better to symptom treatment and time than to force.
AcuteThreatening, unable to be redirected. Clear the area, call for staff, keep the exit behind you, offer medication and space. Physical intervention is a genuine last resort — never a response to staff convenience or a substitute for adequate staffing.
Two legal points specific to this population. Capacity fluctuates with the substance: a patient who is acutely intoxicated, in florid withdrawal or delirious cannot give an informed refusal, so a demand to leave inside that window calls for a capacity assessment and vigorous symptom treatment, not a signature — and the demand very often evaporates once the withdrawal is treated. Once sober and oriented, that patient has exactly the same right to refuse as any other adult. And 42 CFR Part 2 protects substance use treatment records more tightly than ordinary privacy rules: without specific written consent, a Part 2 programme generally cannot release records to family, employers, courts or even other treating clinicians, or confirm the person is enrolled at all.