792 Hours in Acute Psychiatric Hospital

It has been 33 days, or 792 hours, since I began working as a mental health worker in an acute psychiatric hospital. I have floated to different units and worked with the entire demographic spectrum: adolescents, youth, adults, geriatrics, and patients with dual diagnoses of mental health and developmental disabilities. In that time, I have participated in nearly twenty admissions.

Most of these occur late at night or in the early morning hours before 6:00 AM. I am still unsure if intake procedures differ during the day shift. Since my day job clashes with those hours, I cannot verify it yet. I am planning to apply to another hospital for per diem weekend shifts just to see how intake is done elsewhere before I take my own observations as universal truth.

My experience with intake so far has been eye-opening. A dedicated admissions team handles all referrals. These come from everywhere: emergency rooms, group homes, other hospitals, police, fire, paramedics, and voluntary walk-ins. The team adds the patient's name to the electronic health records. They simply appear on our unit's list. Sometimes they appear before they have even arrived physically.

When the patient arrives, the process is a clinical drill. We take vitals. We ask the police or paramedics for the transfer details. We check them in, and then the mental health workers split tasks. One inventories belongings and sorts cash from contraband. The other joins a nurse for the skin check. This requires asking the patient to cough, squat, and then patting them down to check for hidden items. We give them a unit gown and the choice of our socks or their own shoes, minus the shoelaces. We document any existing marks, sometimes with a photograph, so there are no liability questions later.

The inefficiency extends to our daily tracking. I recently learned that the hospital only adopted an Electronic Health Record system this year. Consequently, we operate in a fragile hybrid state. We administer medications using a computerized Medication Administration Record. This is a necessary safety guardrail. However, we still document our 15-minute safety rounds on paper.

The engineer in me sees the liability immediately. Paper rounds rely entirely on the honor system. There is no timestamp validation. This means rounds can be backfilled or signed in bulk. We also manually calculate total sleep hours at the end of the shift. This is a basic calculation a system could perform instantly, yet we rely on tired staff to do the math, making the data prone to error.

The paper trail expands further with our high-observation patients. We use paper for 1:1 observation logs and for ABC charts (Antecedent, Behavior, Consequence), which we use for dual-diagnosis patients to track specific incidents like head-banging. These forms are supposed to help us identify triggers. But because they are trapped on paper, spotting patterns is nearly impossible.

Later, these sheets are scanned into the patient’s digital record for the Utilization Review team. This effectively turns critical data into a static image. We are creating a digital record that cannot be searched, audited, or analyzed. We are doing the work of data entry without gaining the intelligence of data analysis.

I understand the hesitation to go fully digital. Hospitals have been hit hard by cyberattacks and ransomware recently, so maintaining manual redundancy is a valid business continuity strategy. However, relying on paper for the primary workflow creates a different kind of risk: the risk of inaccurate data and missed clinical patterns.

During this entire process, the nurse asks questions about allergies, medications, and history. Then the patient is offered food and taken to a room. What is striking is who is not there. There is no social worker. There is no psychiatrist. The questions are not therapeutic. They are administrative. A doctor and social worker are assigned only after the intake is complete. The nurse leaves a voice note for the doctor, who will not see the patient until morning rounds.

This creates a fundamental misalignment because the patient’s first contact with us is purely about risk management. In California, a hold requires the patient to be a danger to self, a danger to others, or gravely disabled. The intake is built around proving one of those criteria. The result is a generic treatment plan. The goals are always the same. Patient will comply with meds. Patient will not harm self or others. Patient will participate in activities. The nursing diagnoses are just as broad. They usually list alteration in mood, depressed mood, or altered thought process.

This clinical, non-therapeutic intake leads directly to a bigger issue. Because we are not asking the right questions, we assign rooms based on random bed availability. These rooms hold three patients at a time. I have seen several patients unable to sleep, terrified of their roommates, or constantly begging for a room change.

I cannot help but map my own recent history onto this system. When I was going through my own worries this summer, I had no thoughts of harming myself or others. I was simply terrified that I had not met my personal goals. I wanted to exit my company, retain my customer, grow my business, and not feel like I would be permanently beaten into the underclass because every means of value creation I knew felt like it was eroding. If I had walked in voluntarily, what good would it have done to put me in a room with roommates in active psychosis? Taking medications would not have solved my problems. I would not have survived in that environment.

Many of our patients are in similar situations. They are homeless, hungry, or grieving. They need a robust social safety net rather than just antipsychotics. I would put those patients in a dedicated room with a treatment plan focused on resources and support.

This environment creates a friction you can feel on the floor. To be fair, we do give patients significant autonomy. They keep their own clothes, they can pace in the hallway when it is not busy, and they get plenty of snacks. Yet some patients still say it "feels like jail." One patient told me they thought a staff member hated them. The patient got that impression simply because the staff told them to go back to their room while the hallway was crowded.

I wonder if it is the way the staff's voices come across. Many have been here for years. Many have been assaulted. I believe they want to show empathy, but the circumstances make it nearly impossible. Patients get triggered easily by tone. I do not think anyone should lose their dignity just because they are admitted here. However, I also know some patients are very hard to redirect, and staff must be firm. Even then, there is a better way. Staff should not yell at a patient or tell them to "go back to their room" with a forceful tone without explaining why. There is usually a valid reason. We are doing shift change, we are handling an admission, or we are attending to a code.

This tension is exacerbated by understaffing. We often have a census of up to 40 patients in one unit with only three nurses. This usually includes one charge nurse, one med nurse, and one other nurse along with maybe five mental health workers. If we have multiple 1:1 observations or ligature watches, the shortage becomes chronic.

This staffing shortage leads to how we handle outbursts. I believe we default to Code Grey too quickly. We should give a patient more time and try to de-escalate in a more coordinated way before ordering emergency intramuscular (IM) injections. I also do not think nurses and mental health workers should be the sole de-escalators. We need a social worker or therapist present during crises. Most patients know their social worker determines their next step, so there is an incentive for them to listen.

I am conflicted about the chemical shots. Some patients get hyper after taking them. For some, it feels like they enjoy the attention, and the meds lose their meaning. It often feels like a temporary fix rather than a cure. Frequently it is a miss, and we have to physically restrain them anyway. I heard nurses talking about one patient who has not improved at all after months of changing medications. The patient has probably received more IM shots than anyone on the unit, yet their condition remains static. The seclusion rooms themselves feel designed incorrectly. They should not be on the same unit where other patients can hear the screaming.

If these interventions are not working, we need better diagnostic tools. Maybe we just need to listen. We need to pay more attention to what the patients are saying instead of dismissing it as nonsensical. A patient showed me some drawings once. Hidden in the corner of one sketch was a note. It said "They made me do this, I don't really want to. I just need help." I wanted to ask more questions. When I showed the nurse, they said the patient was just "buffing," which means faking it.

Sometimes the problems are simpler than we think. When I worked in the developmental disability space, a patient was agitated every morning. I finally asked them why. They told me their roommate did not let them sleep at night and the staff did not intervene.

Treating mental illness is incredibly difficult, but there are glaring inefficiencies here. I have already brought this up with the chief nursing officer. My goal is to help solve this problem. Stabilizing the patients is not enough. We have to do more to improve their long-term recovery. I know that insurance is the biggest structural barrier, but inside these walls, we can do better. We are managing risk. We are not yet healing people.