I Hear Voices

[kidpsych]

I have been in psychiatry most of my nursing career bth with adults and children and I have to say, I have never encountered a place like the one you described. It sounds as if the staff are the ones who have most of the issues here and do little to protect the clienst right to dignity respect and understanding. Psych is not for everyone, but in this area of practice, you actually get to know your patient as more than a disease, a proceedure or a scheduled dose. You hear their fears, their celebrations and their struggles. In the case of kids, you get to have a huge impact on the way they view the world and their relationship to it. It may not be your cup of tea, but remember, you will use psych in every type of patient care you do from this point on. Good luck with whatever you choose!

I was nervous about doing my psych placement - most of my specialty rotations had been in my training hospital, where students further ahead than me could tell me a little about what to expect. But my class had been divided into those rotating through our very modest, unlocked inpatient unit, and the state's big psych hospital, and I was in the latter group. We'd had a psych module, and I'd been involved in caring for acutely ill patients with psychiatric conditions before, but neve when that was the main focus of their admission. I knew how to manage IVs and take vitals, but was concerned about screwing up this vulnerable and unpredictable population.

When we arrived, conspicuous in starched white aprons, with matching white collars and cuffs, we were taken on a tour of the old institution. Now dismantled, it comprised of several locked wards, a reintegration unit, a frighteningly secure forensic building, and a network of psychogeriatric rooms housing patients who'd be resident there for decades. The nurse showing us around told us that the grounds were open, and that sometimes people paid the residents for sex with cigarettes, a shocking concept to a sheltered student. This sense of displacement was compounded by the bowls of condoms available throughout the facility - I was used to patients who were too sick, too supervised and too appropriate for sex in public places.

That was nothing next to the shock my friend Niah had when we were having lunch outdoors one day. We were sitting at one of the outdoor tables, facing each other, when she looked over my shoulder and whispered, eyes wide, "we have to move!" When I asked why, she said with urgency, "Now!" She told me a short time later that there was a couple, naked from the waist down, having sex against a tree about 10 meters behind us.

My friends were allocated to the acute locked wards, but Niah and I got the reintegration ward. The patients were being mainstreamed back in to the community, and lived in a nearby building. There was little movement - in the six weeks I was there the population was unchanged, a stark contrast to the busy aditting and discharging I was used to in acute med-surg. Partly because the staff were all familiar with the patients, and partly because of some kind of special privacy requirement never made clear to me, handover consisted of a recital of the patient's names, all followed by "no real change" or "still progressing." The only change was when an outbreak of pubic lice affected half of the fifteen or so patients. Niah and I were not officially told anything about the patients, though one RN told us never to go to the resident's building alone, and whispered that one patient - the only one interested in talking with us - had transferred from the forensic unit after plunging a knife in a relative's back, "just missing the spinal cord."

In the lead up to Christmas almost all the usual programs had been out on hold, the sole exception being a cookery class that, because there was no requirement for handwashing, resulted in very grimy White Christmas. Desperate to utilise some of our painstakingly researched activity concepts, and bored watching patients play pool and smoke while the staff locked themselves in the office, we tried a visual imagery session. We only had two attendees - one fell asleep and the other seemed to be getting into it, until two orderlies burst in to the room and shackled him. He'd escaped from one of the locked units, getting out as one of my fellow students was getting used to using the unit keys.

After a fruitless attempt to get three residents interested in going horse riding (mostly because Niah and I wanted to), I went for a walk. As I said, we weren't told about any of the patients - their diagnoses, family or social histories, plans or treatment. It seemed likely that many patients had schitzophrenia, and we had escorted some for their weekly Modecate injections, but as for the rest it was anyone's guess.

I'd gotten know one of the female patients a little. Jenny was in her late twenties, slight and a little slow, perhaps because of her illness, or her medication. I was a little cautious when she approached me near the medical building, because it was only a day or so after the crabs outbreak and I knew she was considered the initial patient.

"Hi Jenny. How are you?" I asked.

"Oh, T - I'm hearing voices." Jenny sat next to me; she wasn't distressed, but wanted to talk.

Help! Voices? How am I supposed to help with auditory hallucinations? Maybe I can help her - "Jenny, what are the voices saying?"

"Terrible things, terrible things."

Help! "Don't listen to the voices, Jenny." Hmm - don't deny the patient's reality: "I know you can hear them but they're not real."

We went back and forth for almost half an hour, with me alternating between fear and making this vulnerable woman worse off, and pride at possibly getting information that could help the people who knew what they were doing. After twenty minutes Jenny seemed calm and though she was still hearing her mother's voice telling her she was a terrible person who deserved to die, she said she didn't believe it and wasn't going to hurt herself.

Filled with trepidation, and a little triumph, I hastened back to the nurses' office, where I told the nurse in charge all about my discussion with Jenny.

"If that happens again, tell her she doesn't hear voices," he replied, matter of factly.

What? Deny the patient's symptoms? I looked at him with shock and horror.

"Nah, she doesn't hear anything, she's just copying the ones who do."

The next day Jenny came up to me again - "I'm hearing voices."

"Um, you... you don't hear voices, Jenny," I tried.

"Oh, okay," she replied, and went off to play pool. Which is when I suspected that psych was not only even more complicated than I expected but also not the specialty for me.

[Anise1]

Wow.You are clearly working in a difficult environment, BUT... this story also helps to make me feel better about my own decisions. I am a psych social worker, and I'm seriously considering moving into a DE psych NP program in a couple of years. Increasingly, I can see how there really IS a big advantage to having the MSW training, and working extensively with the SPMI population, as I definitely have. How can psych RN training not have included how to work effectively with people who are experiencing AH/VH?!? It's not your fault, so please understand that I'm not saying I think you did anything wrong-- I just never imagined that a more experienced RN wouldn't have gotten this training, and that at least from what was said, I'm not so sure you really did either. (Acknowledging the patient's reality is a beginning, but there's so much more...) There's really something to be said for getting both sides of the training, to say the least.

[morte, LPN, LVN]

please note this is a student's description from more than 20 years ago......note the starched apron and cuffs??

[felixfelix]

I would have loved to have worked there.....

[talaxandra]

Perhaps I should have been more clear, but I thought it was long enough already :)

As morte pointed out, this is my recollection of a student placement during my general (hospital-based) training, some two decades ago, at a large, very much institutionalised facility.

What I remember most vividly are the sense of dislocation from the familiar to the thoroughly alien, the lack of information and support, and the sheer terror of screwing up an already vulnerable patient by saying the wrong thing. I hoped to convey this through the writing, but perhaps should have better set the scene. Thank you all for your input and comments.

[Grace Oz]

well mate, i had no problem reading nor understanding your story! :)

you've done well!

when the written word is actually read, word for word, the story in it's full context is easily comprehended.

[quowhen we arrived, conspicuous in starched white aprons, with matching white collars and cuffs,te]

anyone reading this would surely understand the era about which you write!

furthermore ... the way things were/still are, done in australian hospitals/institutions, did and can do so today, vary from other countries.

i can totally well imagine that rn responding to you as he did. have witnessed such myself! and yes, i'm referring to the same era of which you've written.

i enjoyed reading your account of your experience and thank you for sharing it.

[Anise1]

[quowhen we arrived, conspicuous in starched white aprons, with matching white collars and cuffs,te]

anyone reading this would surely understand the era about which you write!

um, well... no. probably because a.) nothing was specified regarding the era in which this anecdote was set, which would lead one to believe that it was in the very recent past

and

b.) not knowing *where* it was set made it impossible to know what sort of dress code was expected in that region.

i don't think that this is important in the grand scheme of anything, and i really do appreciate your sharing this story. but please understand that my self-esteem was stomped flat by the utter impossibility of finding jobs these days (i'm determined to resurrect it by working as a cna!) and i need to hold onto what i *am* good at it, such as the knowledge of my adequate reading comprehension abilities.

[District46]

I had a similarly shocking psychiatric placement about 15 years ago. I arrived, certain that I would love the world of psychiatry and eager to learn more about the talking cure, etc.. and how life situations had led to these vulnerable breakdowns. I thought I would get to see staff spending time with patients, helping them back to reality and normality! How wrong was I! Staff only ever encountered patients to get them up for medication time. One time a young girl approached me saying she needed to see her keyworker now or she was going to cut herself. WHen I ran and told he, he instructed me to tell he she would have to wait as he was busy. He explained that she was attention seeking and that it shouldn't be encouraged. I told her and she ran off. A few minutes later she reappeared - she had slashed her own throat! I will never forget it. One time I was given the honour of escorting a patient to his ECT treatment that they still did back then - it was horrible. On the bus journey I had his notes and a quick scan showed me that he was in for having murdered his wife horrifically. He was not shackled, just sat opposite me with his head down, and didn't say a word the whole journey there and back so I guess there was no danger but as a young student it gave me the creeps. Finally I had some experience in the day ward, but after a week of sitting in group sessions I was called in to the managers office and warned that one of the young men had taken to having a fixation on me, and had related to him that he had the urge to rape me. I was just told to be careful and not be too friendly with him. My God. The nurses quarters were on the same grounds as the unit and the patients were free to come and go. I never felt safe after that. Anyhow, the whole experience put me off psychiatry for good, which was a shame! Just wanted to relate my own horror story. I hope that things have changed for the better now!!

[talaxandra]

a.) Nothing was specified regarding the era in which this anecdote was set, which would lead one to believe that it was in the very recent past, and

b.) Not knowing *where* it was set made it impossible to know what sort of dress code was expected in that region.

According to my public info I'm a hospital-trained nurse with 20+ years experience, and an Aussie, but I suspect that a. a lot of people don't look at that section before reading an article, and b. that this information wouldn't make much difference to most members, who don't have a clear picture of what contemporary standards and practices in this region are like anyway.

I've taken all this feedback on board and added a paragraph to the top situating the annecdote more clearly. Thanks

[SuesquatchRN, BSN, RN]

Starched white aprons are a quite clear indicator of a bygone era.

T, your story was heartbreaking. I remember the days of the huge institutions. Unfortunately, when these were dismantled the ex-inmates were turned loose with little money and less support, resulting in huge homeless populatons in urban areas.

[mizfradd, CNA]

This pretty much sums up what happened after de-institutionalization: