ETA: Some people have reported they found the context of this story unclear. To set the scene a little better: I was a member of the second last group of hospital-based student nurses; in Australia tertiary education was introduced in the 1980s and completely phased in by 1990. Changes in models of psychiatric care were already in the wings when I had this placement, and the state-based center where I did this rotation was dismantled a few years later (Sept 17)
We'd had a psych module, and I'd been involved in caring for acutely ill patients with psychiatric conditions before, but never 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, is 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 into 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 admitting and discharging I was used to in acute med-surg. Partly because the staff was 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 utilize 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 into 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 schizophrenia, 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 crab's 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, a 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.
