This Just Isn’t How This Is Supposed To Work

It’s my first shift off of training and I’m assigned to the adolescent unit.  I like working with adolescents and, to my surprise, many of the nurses do not, so I comfortably take the section.  Most severe psychiatric disorders do not present until people are college-age.  Most of the adolescents on holds do not have severe mental illness: They have hard home lives and poor coping skills.  This feels workable, hopeful, if you will.  

Adults tend to fall into two categories: the non-treatment compliant who are frequently in psychotic states, frequently jobless, and frequently without a home.  These patients often no longer have ties to family.  Then there are those who have good resources and care, are in a position to follow treatment plans, and then, for one reason or another, stop taking their meds.  These patient’s family members become terrified and call obsessively. 

Many of the adolescents are from foster care or group homes.  They’ve had hard lives and just want to be loved properly. They’re often dramatic with their emotions and their stories and there is something about it that is cute to me and obnoxious to the staff that don’t like that unit. 

“You don’t understand, I just want to die!” a youth says, fully clothed but refusing to leave the shower stall where they are not supposed to be which is why I’ve been called in.

“Suuuch a drama queen!” the staff tell me as they point to the bathroom they are in.

I sit on the floor on the other side of the bathroom.

“I know I don’t understand,” I say, “But I see how much pain you are in.” They’re head is down and they cry and I sit there on the other side of the bathroom. And since they’re not looking I smile.  Not because I’m happy about it, but because I genuinely believe they will feel better and learn to function as they process the hard hand life has given them. 

We have a 17-year-old female who has been there three months.  This is unacceptable in my opinion.  I’m new, so I keep many of my opinions to myself, but a lock-down psychiatric hospital is meant to stabilize, not to house.  Three months means we’ve failed to do our jobs and failed to refer her to proper care in a timely fashion.

She is in foster care.  She’s been bounced from facility to facility because she cuts herself and threatens suicide so constantly that they don’t know what to do with her and don’t want her hurt or influencing the other kids.  She’s been on countless holds.  She’s got scarring all over body from cutting herself and picking at her scabs.  She’s very manipulative, very attention seeking, and very unsafe.  She needs one-on-one care.

The way this hospital is set up is that there is one RN per unit, an LVN for part of the shift to help with med pass, and several aids who are the ones in the units doing 15-minute checks for most patients, 5-minute checks for higher risk patients, and 1:1 for very high risk.  We’re not really set up for 1:1 though.  The idea is that if a patient is placed on a 1:1 they get an immediate RN evaluation, the MD is contacted, and we de-escalate to get them back to a Q 5-minute check and then back to a Q-15.  

This patient has been 1:1 for days.  Whenever she is left alone she scratches herself till she bleeds or hits her head against the wall.  She hasn’t eaten in days and I don’t see the last time her sugar was checked so I go talk to her first thing and she’s very depressed, not her talkative, sassy self.  She usually will share a very gruesome death fantasy when I check on her to see if she can shock me, but this time she doesn’t. She lets me check her blood sugar and it’s 60. She won’t drink anything, eat anything, will hardly talk.

I want to send her to the emergency room because her sugar is less than 70 and she’s not acting normal so I call my supervisor to let her know, figuring she’s in the other unit.  We can’t force feed here, not that that’s called for yet, but she needs medically trained eyes on her with a sugar that low and we’re not set up for that.  These patients aren’t medically ill, they have behavioral issues. 

At this point, I’ve called the doctor and have their blessing to send her out.  But, when I call the other unit to let the supervisor know I’m informed there is no supervisor on staff today, and the other unit has 18 patients and no LVN.  

I have nine patients today.  The legal nurse to patient ratio in California for psychiatric hospitals is one nurse to six patients.  There are 12 patients in the third unit.  So we have 39 patients, three nurses, and no supervisor.  This is not uncommon, it’s not uncommon for ratios to be much worse than that and at night these would be considered favorable ratios compared to the recent baseline.  But, I’m a new-grad and it’s my first day alone.

I make mental note of this second glaring red flag and lack of communication.  I call the ambulance for a non-emergent transfer to the ER.  I survey my unit with new eyes, making sure I’m clear on who is who and what risk factors everyone has in case an emergency comes up.  I work ahead as much as possible.  During my assessments I survey the level of trust they are demonstrating with their body language to get a sense of if they seem like me and will tell me if they’re having a problem and if they’re someone I feel like I need to keep a closer eye on. 

After my patient gets picked up the aid who was assigned her 1:1 tells me she is sick and just threw up and asks if she can go home.

I call bullshit the second she walks up to me.  For one, it’s my first day and I can see she wants to treat this like a test, like I’m a substitute teacher.  For another, she was taking way too long in the bathroom not long prior and I heard her giggling on the phone.  And, what is loudest in my mind, we are short staffed and everyone is overworked. 

The fact that she’s acting like a child and feigning the flu is dumb, but I know she’s worked 60 hours already this week.

I make note of my third red flag, which is that this job is requiring me to babysit not just my patients, but also my coworkers.

She says, “I would ask the supervisor but there isn’t one today.”

I quickly assess my options and risks associated with each.  About two months before my start date an adolescent suicided in this unit.  They were on a 5-minute check, but someone handed off the clip-board with the checks to someone else, or took too long on their break depending on who you hear the story from.  The patient took a bed sheet, pushed it through a crack behind the toilet, twisted and knotted it, and tied it around their neck. They were blue when they were found.

I’m still getting to know the staff but if this chick is going to bullshit me about puking she can’t be trusted to check my patients so she’s useless to me either way.

I also decide I have zero interest in playing supervisor in the absence of one.

I say, “You’re the only one who knows if you can do your job, not me or a supervisor. If you need to go home, go home and feel better”

She says, “Yeah, like, I can’t, so like, thank you.”

I take a laptop onto the unit to chart, which I am not supposed to do, but I feel much safer doing this and make sure no one can see the screen.

I get a call from the emergency room with a concerned nurse, “We got her blood sugar up and she ate and is in a good mood, honestly, but she’s telling me she’s going to kill herself as soon as she gets back to you guys. She said she hates it there.”

I say, “Thank you for letting me know.  Can you give me a minute before sending her back so I can reach out to our management? We’re short-staffed today and I need to figure out how we can keep her safe before taking her back.”

The nurse says, “Well, I mean, the ambulance is on their way to pick her up and bring her back already, this was just a courtesy call.”

I say, “I really appreciate the call, and I know it’s not your job to hold her, but we just had someone leave sick and if we can’t keep safe I can’t take her.”

She says, “I mean, OK.”

I get another call two minutes later from the charge nurse in the ER.

ER charge: What’s your name?

Me: (My name)

ER charge: Listen, Tiffany, there’s something you need to understand here, we are not here to take care of you, or pick up your slack, or babysit your patients.  This girl just came from you and she’s coming back to you, like it or not.

Me: I agree. But the staff member who was with her before she came to you has gone home sick, and with her communicating she is going to kill herself as soon as she gets back to us and with multiple real suicide attempts in her past, we need to have her a 1:1 to be safe.

ER charge: I’m sick of going through this with you guys, you don’t get it, we’re not a holding stall, and your staffing issues are not our problem. I need to talk to your supervisor.

Me: We do not have a supervisor today.

ER charge: Excuse me?

Me, pausing first: I am a new grad.  This is my first shift alone. There is no supervisor here or on call today, my aid just left sick.  I can’t keep this patient safe.  I know it’s not your job, I know it’s not fair, I believe you that this is not the first time this type of thing has happened.  But I do think we are on the same page and want to keep this girl safe and I can’t.  Night shift comes in at 1900.  Can we postpone her transport till then?

ER charge. Her tone is different, she’s lost the edge, “OK,” she says, “This just isn’t how this is supposed to work.”

Me: No, it isn’t.

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Review

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This story is intense, raw, and profoundly unsettling, delivering a powerful indictment of systemic failures in psychiatric care—particularly how underfunded, understaffed, and disorganized mental health institutions leave both patients and healthcare workers vulnerable. Through a gritty, firsthand perspective, the narrative exposes the emotional toll that comes from being forced to work in an environment where safety, compassion, and professionalism are constantly compromised by institutional neglect.

What stands out most is their ability to highlight how the system simultaneously fails those it’s meant to protect (the patients) and burns out those tasked with providing care (the staff). It masterfully blends personal vulnerability with sharp social critique, creating a narrative that feels both deeply human and powerfully political. This story paints a stark picture of a system stretched beyond its limits, leaving caregivers powerless to fulfill their roles responsibly.

Patients, many from foster care or unstable home environments, are left to suffer in systems designed to stabilize but not to heal. The story highlights how overworked staff members begin to disengage, faking sickness or neglecting duties, not out of malice, but from sheer exhaustion. The contentious dynamic between the psychiatric unit and the ER reflects a broader systemic breakdown, where different facilities fail to work together in the patient’s best interest.

The tone is urgent, exhausted, and painfully honest, capturing the emotional strain of trying to do the right thing within a broken system. There’s an undercurrent of anger and frustration, but it’s balanced by a sense of moral responsibility and deep empathy for the vulnerable patients.

This narrative exposes the devastating consequences of institutional failure in psychiatric care facilities, especially regarding patient safety and staff burnout. It is a sharp critique of the systemic negligence that normalizes unsafe working conditions, making it impossible for staff to perform their duties responsibly.