Psych Nursing: A unique field of nursing. - page 2

My car rolled to a stop at the curb about a half-block from Bev’s group home; soft instrumental music filled the interior and cool air blew softly on my face as enjoyed the peacefulness of the moment. I was pleasantly lost in... Read More

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    dear patti_rn,! that's all i have to say! what a wonderful, enlightening article on psych nursing. i really enjoyed reading it. i currently work in an acute pediatric unit but have working toward becoming a family psych np. i would like to stay in contact with you as you are an encyclopedia of knowledge and understanding. i used to work in psych nursing as an lvn but changed to where i am now because of the management and lack of support at the psych facility where i was working--not because i didn't like psych nursing any longer. i am looking forward to the day i can return to psych nursing when it will work with my school schedule.
    thanks again for a great article!

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  2. 1
    Quote from Patti_RN
    I considered doing a psych NP but settled on a FNP instead. I may return for a one-year program designed for FNPs to add a psych credential. There is so much to love about every aspect of nursing--too bad I only have one life or I'd do it all! Which NP school are you in?
    I'm still working on my BSN right now, hopefully done with it in April then I will apply. I'm still trying to decide which schools to apply to. SUNY is one of them I will probably try. I have so much going on right now that I'm not sure. I have no desire what so ever to go back to medical, lol. I love psych.
    Patti_RN likes this.
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    [QUOTE=Patti_RN;6789167]My car rolled to a stop at the curb about a half-block from Bev’s group home; soft instrumental music filled the interior and cool air blew softly on my face as enjoyed the peacefulness of the moment. I was pleasantly lost in thought and busy scribbling notes about my previous patient. Bang! Bang! Bang!! A fist hit my side window and jolted me into attention and fear. A contorted, red face filled the window and a loud stream of profanities drowned out the music. It seemed that the mouth was the largest feature of this distorted face, a face that was mere inches from my window—a face comprised of a twisted mouth and fierce, wild eyes. I then saw other details… flashes of nicotine stained teeth that suffered from years of neglect; teeth broken from previous accidents, dark gaps where teeth were missing from assaults… a face lined with the wrinkles of a person much older… jagged scars on the chin and brow—permanent reminders of torturous experiences. Blazing orange-dyed hair reflected the emotional charge of this frantic, angry person. This was Bev. Bev was one of my favorite psych patients.

    Psych, or mental health nursing, is not your typical nursing experience. Patients usually suffer from medical conditions as well as mental health issues, but a psych nurse’s focus is on caring for the mind. In my years as a psych nurse, I can’t remember ever starting an IV, inserting a urinary catheter, reading a monitor strip, or ever being burdened with back-to-back med passes. Instead, I talked to my patients. Talked and talked and talked. I learned about their lives, their dreams, their delusions and their desires for the future. Often their hopes are of simple things most people would consider basic expectations: wanting to live independently in their own apartment, wanting to be free of erratic mood swings, wanting to find a job, to have friends, and to reconnect with family who abandoned them. (Dealing with a seriously mentally ill relative is too much for many people to handle.) Sometimes I’d have a hard time figuring out what was real in their lives and what was imagined—my patients couldn’t separate the two, themselves. Schizophrenic patients don’t lie; they really believe they really were a child actor who played a bit part on Lassie, or that they invented plastic toothpaste tubes. Mental illness can be genetically linked just like coronary artery disease and hypertension can be genetically linked. Psychiatric problems also can be insidious, appearing without cause or warning. It can happen to anyone.

    Bev’s life began like yours or mine. She was the second of three children. Bev loved animals and seemed to attract all the strays in her neighborhood. She fed them, bathed them, and found homes for them. Deb’s sister describes her as a once happy person who made it her personal mission to make people laugh. Bev was a talented first base player on her high school’s softball team. She proudly kept a yellowed, creased newspaper clipping in her room at the group home; the clipping described Bev’s ability to catch wild throws and tag runners out. Next to that clipping was a black-and-white photo of a girl with an enormous, genuine smile, wearing a pale, starched dress, with blond ringlets tumbling from her wide-brimmed straw hat. Several years later, something inexplicable happened. Bev’s sister says that ‘she snapped.’ Bev doesn’t recall anything leading up to the incident—in fact doesn’t recall anything besides standing with a kitchen knife in her hand, the blade coated with glistening red, and seeing her own mother’s hands and arms covered with blood. She still cries when she talks about it. Bev spent the next 20 years in a state hospital for the criminally insane. There, her hallucinations became more constant; her demons remained. Bev was haunted every moment—every waking and sleeping moment. Bev spent more than two decades living in her own personal hell.

    Many patients were locked away in institutions for years. Some hospitals were caring, friendly places where staff genuinely cared for the patients. Others were horrible places where brutality was common and there was no treatment for the patients’ illnesses. Even where treatment was given, the psych meds of that era were generally ineffective, so patients had no relief from their internal horrors.

    I rolled the window down an inch and firmly told Bev to get herself under control. Almost like flipping a light switch to the off position, Bev’s demeanor changed. She wiped the spit from her lips, and with embarrassment (and lack of social finesse) used her sleeve to wipe the little wet spots from my driver’s window. “I’ve been waiting for you… for hours…” her voice was soft, but with a slight edge of disappointment rather than anger. “I know, Bev, it’s hard to wait. You were really looking forward to my visit, but it’s not 2 o’clock yet. I’m actually 15 minutes early.” Her eyes dropped to her wrist where tan skin outlined the place her watch used to be. Another resident took her watch and Bev had no money to buy another. This is a major setback for a woman whose life is regulated by predictability and precisely scheduled activities. “Bev, I’ll be there in 5 minutes.” Bev nodded and shuffled away. Her frame hunched, her head hanging in shame because of her outburst. I finished my short paragraph then waited an extra minute or two before moving the car 100 feet to her house. One of Bev’s goals was to learn to deal effectively with disappointment and learn patience; forcing her to wait allowed her to practice restraint and to concentrate on her emotions. It felt a bit cruel to make her wait, but it’s a skill she needed to learn. I told myself it was better for her in the long run but I still felt twinges of guilt.

    Psych nurses usually don't see progress measured by leaps and bounds. Small goals are identified and worked on until improvements can be noted. These, little, ‘baby steps’ are often weeks or months in development, but are reasons for celebration and delight when the milestone is finally reached. Sometimes years of mistreatment caused the problem, so it can take years to undo the damage. Sometimes the damage is done exclusively by the illness so the time it takes for progress can be a mystery—you just have to keep trying.

    Bev was sitting on her front porch when I stepped onto the sidewalk. Her smile was genuine and her blue eyes glistened and danced. It was as if she had no recollection of her outburst less than 10 minutes before. She jumped to her feet and greeted me warmly. Bev was almost childlike in her innocence and trust. In contrast to her occasional angry tantrums—tantrums that drive others away, her naïve trusting nature draws opportunists to take advantage of her. Besides the missing watch, she has loaned money to others who have no intentions of repaying her—often multiple times to the same people. Unscrupulous store clerks would routinely overcharge her and pocket the couple dollars they cheated from her. Bev not only suffers from mental illness, her mind is clouded from years of self-medication, alcohol abuse, lack of stimulation, and even the side-effects of anti-psychotics that keep her on a relatively even keel—an even keel for a woman who once viciously attacked her mother for no apparent reason.

    Many of those who suffer from mental illness try to chase the demons themselves with alcohol, street drugs, and risky behaviors. The worst illness must be schizophrenia. Reality and hallucinations swirl together in frenzied images. Separating imagined terrors from the reality is impossible. Voices scream. Noises echo. Faces contort. People threaten. Because children are fearful, teenagers are amused, and uneducated adults misunderstand the mentally ill, some of the taunting is real, much of the screaming and laughter is genuine, and hallucinated torment is confused with the real torment. Some memories are imagined while real memories are blurry or forgotten. It’s hard to know yourself if you don’t know your experiences. It’s hard to create relationships when much of what you share about yourself is delusion. It’s hard to know what you’re capable of if your personal memories are a mixture of fantasies and black holes.

    When I first met Bev, she was unpredictable, often angry and argumentative, and usually unkempt in appearance and hygiene. She was difficult to connect with because every comment was an accusation. Most interactions were unpleasant because she seemed to feel entitled and was exceedingly demanding. Her social skills were virtually absent and she had the combined foul odors of dirty hair, perspiration, cigarettes, and household cleaner (which she used to scrub her skin to keep germs from invading her body). Positive changes in her personality came in large part from changes in her medication regimen. Different medications allowed her to be receptive to suggestions and advice—which improved her demeanor and allowed her to adopt normal personal care habits. In time, Bev became less angry, friendlier, and her behaviors became less bizarre.

    Anti-psychotic medications are more effective than they were decades ago. Still, finding the right medication is often an exercise in trial and error. The miracle cocktail that works wonders on one patient simply multiplies the mental demons of another. If a med doesn’t work, the patient needs to be weaned off over several weeks before they can begin taking another, and the patient needs to be on the new med at least a couple weeks to judge the effect. Finding the right medication can take months or longer. Sometimes medications work beautifully for years then inexplicably stop doing their magic. Depending on the individual patient and the type of mental illness that plagues them, some patients’ mental health may improve to the point they are not discernible from ‘normal’ people who have only minor quirks and idiosyncrasies. Others, with more serious conditions like schizophrenia continue to be haunted to varying degrees, unable to work, maintain relationships, or control the emotions as we expect in our society. Like all of us, they long to connect, to be productive, to be wanted and valued, and to be ‘normal’.

    Bev apologies for the cigarette smoke wafting in my face. I offer to switch places with her so I’m upwind. As much as I dislike cigarette smoke, I was tempted to excuse this social infraction, but again, Bev’s behaviors needed to be shaped so she could more easily get along with others and have friendly interactions with other people. She needed to learn to be sensitive to others and control emotional outbursts that drive people away. Blowing smoke in someone’s face—no matter how unintentional—does not endear the smoker to others. It’s taken three years for Bev to become somewhat sensitive to other people’s comforts and rights; she needs to practice this new skill. We switch chairs.

    Most people with very serious mental illness won’t ever be 100% mentally healthy. There are countless comparisons that can be made between medical and mental health issues. Just like a patient with a chronic, debilitating medical condition, a person with schizophrenia can live with the disease for a long time, improve with treatment, see a reduction in their symptoms, and transition to a higher level of functioning. But, unlike a person with a medical problem, the mental illness itself often prevents the patient from acknowledging they actually have an illness. They sincerely believe others conspire to victimize them, to steal their money, to lock them away, to coerce them into taking mind-altering drugs, and do so by accusing them of being crazy. They trust no one; getting them initial psychiatric help is often next to impossible. This, combined with the expense of care in a population with no money, no insurance, and often little social support, treatment is not optimal if it exists, at all.

    Bev continues to live in a group home. I no longer work as a psych nurse, but I do keep in touch with Bev. Sometimes I’m amazed at the progress she’s made. Other times I’m saddened by the cruelty of her illness and how it’s robbed her of living a life that’s in any way normal or typical. In one of my more hopeful moments, I commented to Bev that she was doing well; I complimented her on her efforts and perseverance. She paused, looked at her surroundings—the porch littered with cigarette butts, the living room full of silent, sullen patients all staring at a TV that blared in the corner—then she asked, “Will I ever get out of here and live on my own? Will anyone ever really care for me?”

    Maybe someday soon psychiatric meds will bring miracles. Maybe schizophrenic patients will be symptom free by taking a monthly injection or a daily pill. Maybe love and companionship will be part of life for these patients. Until then, nurses play a major part of their social lives and are a large part of the patients’ hopes for the future.

    “I am a nurse and the mother of a son with schizophrenia. It has been a long and heartbreaking task,which is still ongoing. I take care of his needs,but feel guilty I am not doing enough. He lives on his own,with me seeing him almost everyday. I worry about when I am gone,I am already 55 years old. His sister tries to help,but has a family ,full time job,etc. He is very resistive to a group home,what can I do? THANK YOU for everyone out there who does Psych nursing, I live it every day,work 11-7am in a state run vet home. THERESA GORTON LPN
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    Quote from Patti_RN
    “I am a nurse and the mother of a son with schizophrenia. It has been a long and heartbreaking task,which is still ongoing. I take care of his needs,but feel guilty I am not doing enough. He lives on his own,with me seeing him almost everyday. I worry about when I am gone,I am already 55 years old. His sister tries to help,but has a family ,full time job,etc. He is very resistive to a group home,what can I do? THANK YOU for everyone out there who does Psych nursing, I live it every day,work 11-7am in a state run vet home. THERESA GORTON LPN
    Hugs, Theresa. Guilt is a wasted emotion, but one few caring people can rid themselves of. Your son is lucky to have you, and lucky that you're in his life. I understand completely when people can't take the stress and heartbreak any longer and exclude their schizophrenic family member from their lives. The crazy behaviors, the delusions, the resistance to common sense are really hard to deal with. But, you've endured and stuck it out with him. I admire that tremendously--you have nothing to feel guilty about.

    There may be a time when he will need to go to a group home and it won't be his first choice, but it will keep him safe. And, in the end, that's our ultimate goal for our kids--keeping them safe in the world. As you know, life with a schizophrenic family member can be all consuming and sadly, no matter what you do or how much you do it, there is no magic formula.

    To those who have never lived it: schizophrenia is one of the cruelest illness in the world. Without warning, a young, bright, charming kid turns into a person you can no longer recognize or relate to. Medical illnesses rob us of our abiliities, but often strengthen our personalities, reinforce our relationships, and solidify our values. Mental illness destroys relationships, forces family members to make choices where none of the options are desirable, and it causes uninformed others to make unfair judgments and assumptions.

    To parahprase what a mother of a schizophrenic son once told me, "When my husband had cancer, we bonded as a family, and our friends and neighbors supported us. When my son's mental health spiraled downward, my entire support system disappeared--all that was left were those who criticized and gave me unhelpful advice."

    You're not alone, virtually every mom with a child with schizophrenia has similar stories and heartbreaks. Do you know of any support groups for family members?

    Theresa, I wish you and your son luck and all my best wishes. PM me if you're so inclined.
    VivaLasViejas likes this.
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    Well said! A great reminder of why I continue as a "psych" nurse (inpatient) even though I often overhear comments about how it isn't "real" nursing and we just "babysit the crazies". I also have several family members with mental health issues so I can empathize with my patient's and their families. Unfortunately it seems that many of the newer generation entering this area of nursing see only the diagnosis and forget that there is a human being with feelings and worth connected to the diagnosis. I intend to print your the story of "Bev" and put it on the message board in the break room at work with the hope that it will help improve the care and practice on our small impatient unit.
    Patti_RN and VivaLasViejas like this.
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    This is a wonderfully written article. YOu are a blessing to the patients you care for.
    VivaLasViejas likes this.
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    This was an amazing article to read. I have great interest in Psych Nursing but never got chance to pursue that path. You are a real nurse in true meaning. I hope Bev and other clients like her feel better and stay safe. This has brought my sister's memories back. May her soul rest in eternal peace
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    I think I'm leaning towards psych nursing....
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    I enjoy psych nursing also. I work in a locked unit. When is ok to keep in contact with former patients? I have alot of questions on boundaries and ethics. Can anyone point me to a good source? Thank you for this article.
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    Quote from cargalrn
    I enjoy psych nursing also. I work in a locked unit. When is ok to keep in contact with former patients? I have alot of questions on boundaries and ethics. Can anyone point me to a good source? Thank you for this article.
    The experience I wrote about involved community nursing and I had a very long professional association with many patients. My role while working in this capacity was to provide role modeling, positive reinforcement, and counseling. The patients saw us not only as professionals, but as friends. My continued relationship with patients was very rare, and continued as a volunteer nurse, with the knowledge and permission of the agency where I worked. Some patients have experienced multiple abandonments; parents, siblings, friends, and significant others often can't deal with the roller-coaster life of a seriously mentally ill family member and break ties with that person. This makes professional boundries particularly important, and sometimes particularly cruel. Having 'one more person' desert them can be devastating.

    It's hard not to become fond of some patients, in the same way a teacher is fond of some students. And, some vulnerable patients (like vulnerable students) may not only benefit from continued mentoring, but might be far worse off without it.

    I did work in a psych hospital at one time, but in that capacity I never continued contact with a patient after their discharge. In community nursing, the role seems somewhat blurred but it is still very much a professional relationship--and in the rare situations where that relationship is extended past the nurse's job change, transfer, etc., any continuation should be on a professional basis. Contact with patients should be exactly the same as it was when the nurse was employed (this makes it virtually impossible to continue a professional relationship with an inpatient). If you do wish to remain in contact with a patient, it should be done only with the blessing of the employer--that is probably the best test of whether or not doing so is appropriate.

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