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  1. As I have progressed in my career as a nurse I discovered a passion. Stress management. Stress management touches all aspects of our lives with increasing urgency. As we move forward each day we are expected to manage more, accept more, think more, and accommodate more. For more what do you ask? For more of everything. In our home lives we are expected to be Pinterest parents, cooks, home makers, and community leaders. At work we are expected to carry more patients, give ever increasing levels of customer service, contribute to shared governance, chart with legal precision, and still have compassion left for our patients. On Facebook we are expected to offer comfort to friends, get excited about petitions, try to get the best deals and sale prices on goods, and make sure we are sending back gifts in frivolous online games. While one can say, "Well just stop doing X, Y, Z and you will be fine" have you ever stopped to ask yourself "Do I even know how to recognize that there is too much on my plate?" Nursing and Stress Management Prior to the birth of my first child, and while completing my undergraduate requirements, I started brewing a plan of stress management tailored for acute care hospital nurses. I chose this population because, well, I was one of those nurses. I knew the limitations, expectations, and resources available. I also knew the anxiety and stress that could come with it. As I began formulating my plan I started asking questions of co-workers such as: "Would you go to a group therapy session of all nurses?" "Would you consider one-on-one counseling if it were available once or twice a month?" "Would you want debriefing time after a traumatic patient event?" Many of the responses were dismissive, uninterested, and withdrawn. I was surprised by this because I often found discussion to be a therapeutic route for myself, so I wondered "Where is the disconnect happening?" I didn't realize it until I was hospitalized for a weekend during my first trimester of my second pregnancy for suicidal ideation. From the Bed of the Depressed In November of 2012 I went into my OB-GYN in tears. We had discussed Zoloft as a possibility for post-partum depression, which I had read can be much worse with two children. I knew I had PPD with my first, and was worried it would be worse this time around, so I wanted to be prepared. My tears and discussion of thoughts of swallowing Tide laundry pods because I was so miserable with morning sickness scared my practitioner and settled me in for three days in the High Risk Perinatal ward. For three days I felt what others have felt when admitted for anything mentally related. I felt pitied, tip-toed around, and brushed off. Even though I had been cleared of all suicidal tendencies within hours of being admitted, I was still treated differently. During this time I was dehydrated from vomiting, anxious, and miserable. Most of these ailments were related to my morning sickness, which is notoriously bad. When I was discharged that Sunday, I went home with a prescription of Zoloft. For two weeks I convalesced at my in-laws battling to find passion for my daughter again and to gain some reprieve from my nausea and anxiety. Thankfully, after getting to 100mg/day I was finally coming around. I found myself engaging with my daughter again, feeling less anxious, and feeling the ability to participate in my life again. Shortly after my discharge I started therapy sessions with a psychologist who specialized in women's health issues and Eye Movement Desensitization Reprocessing (EMDR) therapies. EMDR is a treatment used primarily in Post-Traumatic Stress Disorder (PTSD) patients, but also has benefits for depression and anxiety. In a nutshell EMDR teaches you how to reprocess memories so that they no longer haunt or hold you back. I was skeptical of this approach, however after my first session I was a believer. The process of EMDR helped guide me down pathways I had never seen before in processing my anxiety. Currently I have completed several sessions of EMDR, which has reduced anxiety over past circumstances, helped me develop new coping mechanisms, and is helping me wean off my Zoloft completely prior to delivery of my second child in May. So how does this all affect my perceptions of stress management in nursing? Stress and Nursing Stigma Mental health fears Weakness Vulnerability Incompetence After I was first prescribed Zoloft I was open with everyone about it, because it was helping tremendously. It felt amazing to feel like myself again, to be able to move, function, and love my life again. So when people asked about my pregnancy I would admit it was rough and that I was on Zoloft, but doing well. I was met with basically the same reaction from nearly everyone. Moderate discomfort. For comparison, when you tell someone you are on a new medication for any chronic or acute disease most people will show enthusiasm for you. Often praising the wonders of medication, telling you how glad they are that you are feeling better, or agreeing that maybe they should look into this option for themselves. This is not true of medications for mental wellness. The idea that you might be imbalanced somehow outweighs that you are working hard to manage both on a pharmaceutical and therapeutic level. While I was never swayed to silence my story by this reaction, it did make me understand why nurses are reluctant to seek stress-management options. No nurse wants the stigma of weakness, vulnerability, or incompetence tagged to their credentials. We often think of being blamed first for drug diversion if we are on Xanax or Zoloft. We fear lawsuits if something goes wrong with a patient because we have been in therapy for depression. For me I had seen first-hand, from the bed, how those diagnosed with mental ailments were treated, and I understood all too well why most nurses I talked to cringed at even the thought of therapeutic conversations about work. As my therapy, pregnancy, and time on Zoloft have come to end I have learned a valuable lesson, despite stigma, stress can be addressed without creating labels on the nurses participating. Getting to the root of stress related problems can help prevent occurrences of depression and pharmaceutical intervention; it just has to be presented in the preventative health arena. My Commitment From here on forward I am committed to bridging the gap between prevention and mental health awareness. I am committed to finding a way to let nurses recognize areas of stress and reduce them without being afraid of being labeled. My commitment starts with my own openness about my struggles and revelations, available here, in this story.
  2. Maureen Bonatch MSN

    Look Beyond Your Older Patient's Medical Complaints

    Many of us imagine getting older as a time when we're free from constraints of work and can enjoy traveling or spending more time with family and friends. Although some discover that those golden years don't turn out how they expected. Physical, social or financial losses may coincide with the later years of life. Dealing with these issues may result in feelings of depression or anxiety. Although trips to the physician may become more frequent for a variety of medical ailments, many older adults neglect to mention mental health issues-often because they don't believe they are issues or realize they might benefit from treatment. According to the World Health Organization, the over 60-age population is expected to double from the years 2015-2050. Mental health or neurological disorders affect 20 percent of adults over age 55, although less than 3 percent seek help. The high rate of suicide is alarming, with men age 85 and older having the highest rate of any group. When older patients make light of feelings of unhappiness, dig a little deeper and educate caregivers, family, and friends to help increase awareness of mental health concerns. Not So Golden Years Some losses are expected with aging, but that doesn't make it easier to cope. It can be especially difficult when several losses coincide and the patient's support system or coping skills is lacking. There can be many challenges associated with growing older such as: Loss of spouse Loss of mobility and independence Declining physical and mental health Chronic illnesses Financial challenges Change in socioeconomic status Isolation and loneliness Increase Awareness We're aware that mental health is essential to overall health and well-being. Although detecting mental health issues in the older adult can often prove challenging and may present with barriers to seeking or receiving mental health care. Symptoms of mental health concerns may be overlooked if they're incorrectly attributed to aging. Prescribed medications can affect mood or mimic symptoms of depression and may be misdiagnosed. Many elderly are reluctant to seek help due to the stigma associated with mental health treatment, which was especially prevalent during earlier eras. Often older patients are more comfortable seeing their primary care physician and may be more receptive to discussing mental health concerns. A lack of access to mental health care may occur due to challenges with transportation, or available providers. Consider telemedicine for rural patients or those who have difficulty leaving their home due to physical challenges. Many older patients may deny mental health issues or don't perceive a need for treatment. Providing additional education to the patient, and their family may help increase awareness. Mental Health Promotion Common mental health concerns of older adults include depression, anxiety, and substance abuse, although elderly patients often have unique mental health needs. The same symptoms that might spur additional questions regarding mental health for a younger patient may be attributed as a normal part of the aging process. Neglecting to treat mental health can affect the patient's ability or desire to care for physical health. Symptoms of depression may be overlooked or untreated because they coincide with other life events. Depressive symptoms with an older adult may present differently and not have overt signs such as sadness and instead be noted within other physical complaints. Exploring complaints, providing education to caregivers and offering resources may help increase the awareness that: Depression isn't normal for older people and is more than just a passing mood - Persistent sadness, withdrawal from family and friends, unexplained weight loss, and sleeping too much or too little are a few indicators of depression Living alone doesn't mean you're lonely - Encourage the development of a social support system and nurturing interests and hobbies The uncertainty of finances and healthcare expenses can be stressful - Discuss coping skills for dealing with stress Don't ignore vague threats - Elderly that attempt suicide are often more successful due to the use of methods with more deadly intent, having less chance of being discovered in time and frailty Patient expectations may not be realistic - Treatment for mental health issues is often a process of developing coping skills and social support in addition to therapy or medication and not a quick fix There is often a stigma surrounding mental health that is even more prevalent in the elderly - Fixed beliefs and discomfort may remain despite the strides made in acceptance of mental health treatment Coping with Aging There are many stressors that accompany aging that can contribute to feelings of depression and other mental health issues. In a world that is continuously speeding up, take some time to slow down to uncover mental health issues that may accompany your elderly patient's physical complaints. Providing education on the symptoms of mental health concerns, coping methods, and potential treatment might help improve your patient's quality of life and make those years a little more golden. Share Your Tips On Increasing Mental Health Awareness.
  3. Ironically, it was nursing school that made me realize that my symptoms of self-perceived madness weren't just eccentricities. I'm sure we all were self diagnosed hypochondriacs but the shoes actually fit and it clicked that I was the symptoms and cluster of behaviors that I'd wondered about in my high school psychology class. What kind of teenager thinks to themselves, "If I had any sort of mental illness, it would probably be bipolar disorder?" I'd never done much in depth exploring of mental illness prior to being plunged head-first into it while taking my psychiatric nursing class in undergrad. Hell, I minored in psychology and had even taked abnormal psychology, but it was learning the nursing interventions that made everything come full circle in my head. It was the group projects about coping skills that had me applying my classwork to my mundane life outside of the classroom. It turned on a switch that triggered me to seek wellness and health and to organize the clutter inside my head. Despite the fact that my mother and I saw a therapist while I was in high school for what she remembered as six sessions and I remember as two, I was constantly told that I was just "moody" and (my favorite) "just a teenager". Somehow, my early symptoms of hypersexuality, irritability and impulsivity were me "acting out" or "attention seeking". That didn't stop my mom from calling my after-school job, picking me up in the middle of my shift with silence, and then her and my father threatening to ground me and take away all of my privileges and electronic devices because I was writing sexually explicit notes with a freshman although I was a senior getting ready to graduate and was in a relationship. I spent way too much of my french class thinking of getting into people's pants rather than realizing the similarities between the Spanish I'd already learned and the French that was placed in front of me. That night, I threatened to walk out with none of my possessions and never come back, and I was serious. I screamed louder than I ever had in my life and though my mother threatened to drive me an hour and a half away to the only psychiatric hospital in the state that she knew of, she had no idea of what to really do with me. I spent the night at my grandmother's house, swearing to never talk to my parents again. There were other warning signs, like the deep pits of despair that caused me to stop "applying" myself in my classes, nearly failing AP English Lit and Biology, even though I ended up acing both of those exams at the end of the school year. There was my very first panic attack, during my timed AP biology exam where I felt like I couldn't breathe and that I was going to implode if I couldn't get out of the room. There were my nights of staying up until 0200 and getting up at 0600 without any problems OR caffeine. There were the notebooks full of exceptionally morbid poetry. I'm not even going to go into more depth about my dysfunctional relationship with my family because although it certainly doesn't make my diagnosis of mental illness any easier, it's *MY* problem to live with. Whenever clinicians ask me about my family history of mental illness, I always have to clarify, "You mean are there *symptoms* of mental illness, right? Nobody gets diagnosed in my family." I spent most of my spare time at the beginning of the Fall semester reading my psych nursing textbook cover to cover, devouring everything I could about bipolar disorder, GAD, anxiety disorders and it wasn't enough. I had quickly conceptualized what was wrong with me, but it wasn't until I found myself sitting on the floor of my apartment after having run out to the grocery store at 0300 to buy glitter glue, die cut letters, stickers and colored paper to embellish my teaching plan for my the next day, where presentation was only worth 5% of my grade for the assignment that it actually clicked that I was likely driving everyone else around me absolutely insane and that I might be having a hypomanic episode. I was working 2-3 on campus jobs in addition to my classes and that still wasn't enough for me to keep the bills paid and afford everything that I thought I just *NEEDED*. I promptly scheduled an appointment with the counseling center on campus to see a therapist and then the school psychiatrist shortly after. I don't much remember the counselor that I saw at the time, but I do remember the psychiatrist and the first few words he said to me. "I'm no better than you are. I have the prescription pad and you don't, but you know what's going on in between your ears better than I do." He started me on Klonopin after our first appointment and then he started Lamictal shortly afterwards. It's been a whirlwind of ups and downs, back and forth, and side to side ever since. I've scared a therapist, who had no idea how to get me to the hospital after a session in which I told her that I just couldn't handle things anymore. (Gee, why didn't she just call 911?) She actually let me drive home to pack some things for the hospital, on the promise that I'd keep her posted. I've quit a job because I was bitten by a patient and nearly had a panic attack on the floor in front of my colleagues, and even though another staff member was hurt too, there was no de-briefing with security or my nurse manager present to explore how we could avoid the situation from happening again or what warning signs in the patient we had missed. I decided to apply to teach at a high school although I was in no way really prepared for the job (my teaching practicum at a community college didn't cut it) and I stressed myself out even more than I had been on the floor. I burned myself out even more and found myself wanting to go back to what I knew, seeing and helping people who weren't that much different than me. It's been almost 5 months since my last medication overhaul and although things are still shaky in my world, I feel more grounded than I ever have. I pull out all of my prescription bottles at the beginning of the week and fill two medication calendars, one for my AM/PM meds, and one for my afternoon meds. I know I'll probably never be able to work straight night shifts ever again. I know that I need to work harder at setting limits with patients than any of my colleagues will ever have to do. I know that I need to check and double check things and then still spot check because I end up letting myself get over-confident. It will always sting when I hear a co-worker say, "Oh that patient is just attention seeking." (Maybe if you pay attention to what they're doing or saying, rather than how that makes you feel, you'll remember that they're in the hospital for a reason.) I'll bite my tongue when I get told, "That patient needs PRNs around the clock because they're out of control." (Is there something that's triggering them that we should be more mindful of? Are we doing our best to notice warning signs and address them *before* the patient gets out of control?) They say "It takes one to know one," and I think that's a pretty accurate statement. I'm not saying that you need to have mental illness to work with patients suffering from mental illness, but a.) it helps and b.) we all have our issues and lie somewhere on the mental health/illness spectrum. It helps to acknowledge that we're human and mental illness is the most pervasive illness among those 18-25. Take a look around and recognize that it's not a death sentence but it can become one if it's ignored or not treated. After all, we're all a little bit mad, right?
  4. After thirty years psychiatric nursing experience in various roles, locum tenens is perfect for me. When I want to work, I sign up with a few agencies, tell them my availability and hope something will come through. This time I can only work in 2 month blocks- a normal assignment is three months so I was not sure anyone would take me for only two months. Luckily my recruiter found me a spot. "The position is in corrections." She said. My husband was immediately worried about my safety. I had my interview and I found out the facility was a forensic hospital, not a correctional setting and that I would have inpatient responsibilities. I have many years of inpatient experience working as a staff nurse and a manager. This will be my first inpatient experience as a provider. After a week of orientation mostly about HIPAA, and using the computer system, I start on the units. I have two inpatient units and one 4 hour block of outpatients. I am on transition units where patients are preparing for discharge to the community. They work at least 15 hours per week at on campus jobs, go to groups, and have privileges to go outside, some alone.. For admission to the facility patients are committed by a judge as mentally ill and dangerous. Many of these patients have caused harm to other people, usually when they were not taking medications or were abusing substances. The average length of stay is seven years and the patients home community has input into advancing privileges and determining discharge. My role is to do a psychiatric interview and review psychiatric medications at least every three months on my assigned units. On the inpatient units, this is called "rounds". Patients are invited in one at a time by appointment. Several staff are in the room to observe or participate in my interview. I have never interviewed patients like this before. One of the social workers told me she likes to come in the room to make sure the patients are giving me the correct information and this can be helpful. A pharmacist is there also, to take notes and sometimes participates. I try to talk to her before or after my time with the patient so I am not distracted by medication information during my interview. Since I am doing the assessment and making the medication decisions, I have to make sure I am comfortable. I also put in my own orders which is a change for them. Because of the cumbersome computer system, previous locums had operated using mostly verbal orders which were inputted by either the nurse or the pharmacist. There is a shortage of psychiatric providers at this facility. Systems like the pharmacist taking notes, which are minutes of the interview, and verbal orders are a way to provide some continuity and compensate for the shortage. I am the sixth psychiatric provider in two years. They are recruiting and in the meantime I learn a lot. The main things I learn about are high dose neuroleptics, polypharmacy, and clozapine. Traditional psychopharmacology tells us to streamline medications. With these patients, it is not entirely clear if patients could do as well on lower doses or if they need the high dose for stability. There also seem to be a lot of negative symptoms of schizophrenia, ie poor motivation, blunted affect, which one of the psychologist says is not treatable with medication. My research tells me medication is worth a try but I am not there long enough to introduce this. I wonder if some patients are overmedicated but I am reluctant to adjust doses very much because of being new, unless, of course it was clearly indicated. And I become proficient in laboratory guidelines for long term medication monitoring. Every patient has a primary MD who has been treating them for years and each patient gets a comprehensive physical every year. These MD's are readily available for consultation. The pharmacists are also available for consultation and also seem to like attending my rounds. There are also other professionals including psychologists, social workers, nurses, and security counselors. I found out later that there are some psychology fellowship classes I could have attended if I had known about them. I am scheduled to return to this facility in a few months. Locums gives me the opportunity to learn. When I return, I look forward to getting a better understanding of high dose neuropletics and polypharmacy and I may try to medicate negative symptoms . Or since I now know the system, I may be assigned to an acute admission unit where I will learn about rapid titrations of psychiatric medications and ordering seclusions and restraints. If I come back to this unit, I will better be able to treat the patients since I have interviewed everyone at least once and have the trust of some of the staff. Forensic psychiatry is not a popular area of psychiatry. Many of these patients are severely and persistently mentally ill and have crossed the line into criminal activity. They are well care for at this facility as the long term psychiatric patients which they are. Many of them will never be able to live in the community. In the old state hospitals and if they hadn't committed a crime, many of these patients would have stayed for years living in a community within the hospital. Some may have been discharged to group homes with case management. Some of my forensic patients may also be discharged. Evaluating stability, degree of outpatient containment and likelihood of relapse is very challenging and the focus of much of their treatment.
  5. The alarm clock jolts you awake as it does every morning at 0500, alerting you to the fact that today is yet another work day. You groan and pull the covers over your head momentarily, wishing for nothing more than to crawl into a warm cave like a hibernating bear until you feel human again......if you ever do, that is. And you're beginning to doubt that more with each passing day. The prospect of another shift filled with unceasing demands and busy-work tasks threatens to overwhelm you as you force yourself into the shower, and once again you suspect that there really are worse things than death.....namely, going on like this. Certainly no one appreciates the fact that you have to throw yourself against a metaphorical wall every day: not your family, who counts on you to put food on the table; not management, who calls you on the carpet for every minor infraction of their million-and-one rules; and definitely not the patients who run you ragged with endless requests for warm blankets and Coke, and then complain when you're not fast enough. You're depressed and very much aware of it, but other than taking the medication the doctor gave you at your last visit, there doesn't seem to be many options. You can't be in your therapist's office every afternoon; you don't want to burden your friends with your troubles; and you certainly can't talk to your co-workers. They're all dealing with their own stresses (both on and off the job), and besides, you don't want to end up in the unemployment office, like one fellow nurse did after suffering a 'nervous breakdown' at work. So what can you do? You heard what people said about her.....that she was crazy. Looney-tunes. Psycho. What if they were to say the same things about YOU? The truth is, if you need medication and/or therapy to cope with your condition, you are among the one in five Americans said to have what authorities call a diagnosable mental illness. Depression and anxiety are the most common of these, and while they are treatable, they are two of the major reasons why workers call in "sick". It doesn't stop there, of course. Nurses are human, and as such we're subject to the same psychiatric issues as anyone else: schizophrenia, manic-depressive illness, personality disorders, even dissociative identity disorder (formerly known as multiple-personality disorder). The fact that the general public has no idea of this speaks well of the thousands of nurses who battle mental health problems and still manage to take good care of their patients. For the most part, we struggle in silence, fearing the stigma that surrounds those who carry such a diagnosis. Everyone has seen news stories about people with whispered rumors of mental illness being accused of all sorts of horrible crimes; who wants to be associated---even remotely---with the likes of the Sandy Hook school shooter or the Aurora, CO theater killer? But sometimes, our 'nonconformity' is discovered despite our best efforts to hide it. A nurse with depression may stop coming to work and fail to notify her supervisor; one with bipolar disorder may have a manic episode that increases her productivity at the same time it creates inappropriate levels of hostility which she cannot control. And if we are unlucky, we may find ourselves being eased out of our jobs, or even terminated outright when our employers deem it "unreasonable" to make accommodations for our disabilities. This short series of articles on dealing with mental illness in the workplace is inspired not only by events in my own life over the past couple of years, but by conversations with others here at AN and with former co-workers who have shared their stories with me. It is my sincere hope that one day, healthcare professionals with brain disorders will be viewed with the same compassion as those who suffer from other medical conditions. To be continued......
  6. Many psychiatric facilities and settings allow or require that nurses and support staff wear street clothing instead of scrubs. Those entering into psychiatric nursing often ask, "If I can't wear scrubs, then how should I dress?" Likewise, a common question asked by nursing students and their instructors is, "What should I (or my students) wear for psych clinicals?" I would like to offer some guidelines regarding how to dress for working or attending clinicals on a psychiatric unit. I've been a psych nurse for a few years; when it comes to nurses and students dressing for the job, I've pretty much seen it all. So here's some tips to get you started; as you feel out the atmosphere on the unit, your attire will probably evolve to match it. Please keep in mind that your school or facility's dress code policy trumps whatever guidance I give here. If anything I say conflicts with how your facility/school wants you to dress, go with their guidelines. 1. Don't Dress to Attract Some people, especially students, often see "street clothes" as an excuse for them to cut loose. The psych unit is not the time or place for self-expression, showing off your body, or trying to attract the romantic attentions of a classmate. And trust me, you DO NOT want to attract the attentions of my psych patients! 2. Do Dress to Impress A good guideline is to dress like you're going to church or court: the more conservative, the better. A nice pair of slacks/pants paired with a blouse, dress shirt or polo shirt is usually a safe bet. Whatever you wear should be clean, neat and well fitting (neither too tight nor too baggy). Learn to iron, or at least do what I do: throw your clothing in the dryer for 15 minutes to take the wrinkles out. 3. Don't Wear Anything That You Don't Want to Risk Having Stained or Ruined Even though this isn't med/surg, there's a real chance that you will come into contact with vomit, dirt, water, urine, blood, and other gross products. 4. Big NOs No rips, wrinkled, ratty or stained apparel No cutout, see-through or sheer items No garish colors or prints No jeans, shorts or skirts No hats Sneakers: No if you are student. Otherwise, the plainer the better No visible undergarments (bra straps, "whale tail", red underwear under white pants, etc.) Nothing sleeveless or strapless. Long sleeves or 3/4 sleeves are preferred Nothing with strings, trim, or decorations that can be pulled out and used as weapons. Shoelaces and belts are OK No logos or sayings on your clothing other than designer trademarks. The Izod crocodile on your polo shirt is acceptable; a "Budweiser: King of Beers" patch is not Sports logos: No if you're a student. Otherwise, get a feel for the environment first. Depending on the level of sports spirit the facility has, it may not go over well if you're not a fan of the local team 5. Wear Larger Size Shirt / Pants Whether you are sitting, standing, reaching, bending over, whatever position you get into, all of the "Bs"--boobs, belly and butt -- should remain covered at all times. If one/all of your "Bs" are ample in size, wear a larger size of shirt and/or pants so you don't look like you're about to burst at the seams. 6. No High Heels, Open-Toes, Sandals or Anything Strappy Shoes should have a gentle heel (1 inch or less) or no heel, be closed-toe, and have non-skid soles. They should be shoes that you can move fast in without difficulty. 7. Keep the Bling to a Minimum In my opinion, a watch should be all the jewelry that is worn. But if you insist on the bling, keep it to a minimum. No rings with large stones or multiple rings per hand. No hoop or dangle earrings. If you have gauges, use a solid plug in them. If you insist on wearing a necklace, keep it under your shirt so it can't be grabbed. No unusual piercings (eyebrow, lip, nose, etc.). 8. Miscellany Go easy on the hair products, as the scents can trigger reactions in some patients. No false nails. Tattoos should be covered. If you wear your ID on a lanyard, it should be a breakaway lanyard. And no no NO perfume! 9. Wearing Cultural or Religious Items Some students and nurses wear apparel and items for religious or cultural reasons. While I support the right for everyone to practice his or her beliefs, the safety of the milieu is of the utmost importance. A head wrap may be snatched from your head and used as a weapon; the act of it being snatched may even cause you injury. Paranoid patients or those suffering from PTSD may not react well to a caregiver whose face is partially or fully covered. Shawls, stoles, rosaries, and anything worn around the neck can be used to choke someone, possibly you. If this applies to you, I strongly suggest that you talk to your facility's HR department or your clinical instructor for guidance and for making any necessary accommodations. If necessary, you may wish to consult your religious advisor to discuss whether any modifications to your apparel, or even a dispensation to forego wearing the items while at work/clinical, would be possible. In many (but not all) instances, the nurse/student will be able to wear the items with little to no modification necessary.
  7. Among the challenges of being a healthcare professional with a mental disorder, perhaps none is so difficult as maintaining one's composure during an exacerbation of illness. Not only is it undignified to be so out of control that you disrupt a staff meeting or hear voices coming from the desk fan at the nurse's station, it's potentially disastrous to your career. Obviously, you want to avoid manifesting signs of your illness at work (and it would be nice if you can keep your cool at home, too). But medications and therapy will only take you so far; you have to help yourself along the way by practicing good self-care techniques. These don't have to be elaborate or expensive; in fact, they're the basic health habits everyone should follow---namely, eat well, find some form of exercise that you'll do regularly, take time to de-stress every day, stick with your meds, and of course, get plenty of sleep. A few words about sleep: This is one of the most vital components of mental health, and it's also one of the easiest to get wrong. Lack of sleep is a double-edged sword that can hurt you in multiple ways---it can be a sign that your condition is deteriorating, as well as a trigger for an episode of illness. It also feeds on itself; the less sleep you get, the stronger the grip of the illness, and as the episode itself escalates, the harder it is to sleep. Often it takes medication to break the cycle, and then you must commit yourself to going to bed AND getting up at the same times each day.....even on your days off. That can be extremely difficult to manage (my argument is always "But what the deuce is there to DO at six AM?!"), but it's necessary to maintain optimal sleep function. Still, there are times when you're doing the best you can to stay well, but trying circumstances or life events may knock you off course and a breakthrough episode results. You find yourself forgetting details such as charting meds you've given or calling lab results to a physician. Or instead of chatting with co-workers on breaks, you retreat to your car and gobble down a handful of cookies. Or you notice that you're more and more anxious and you start dreading work, fearing that you'll make a mistake or embarrass yourself in front of a patient or supervisor. Or you start getting funny looks from co-workers and criticized by managers for talking too much and too loud, rushing around too fast and making amateurish errors, and lacking attention to detail. Of course, you're going to be in contact with your healthcare provider (correct?) to try to bring the episode to a swift end, but in the meantime you are probably going to need some time off to deal with it. DO NOT be afraid to take it. An exacerbation of mental illness is just as legitimate as a bout with the flu, and it deserves every bit as much attention. You don't have to tell anyone why you need time off unless you need a formal medical leave of absence or FMLA. Use your vacation days or other personal time off---that's what it's for. Often it takes only a few days to get things under control, but depending on the severity of your symptoms and the degree to which they disrupt your life and work, you may have to go out on LOA and exhaust your earned-leave benefits. Do it anyway, even though at this point you will need a note from your doctor stating why you need it and providing a date when you may return to work. Trust me, going back before you're ready is a recipe for disaster, and in any case your facility will not allow you to return until your doctor releases you. Of course, by the time your episode resolves, the rumor mill at work will probably have been churning, and you may face some curious glances and perhaps even some questions from your co-workers as to the nature of your absence. You are under no obligation to discuss this with anyone. If you're comfortable doing so, you certainly can, but as a general rule it's best to avoid the gory details. Unfortunately, there is still a great deal of stigma associated with mental illness, and while your friends may understand, chances are that some of the higher-ups may take a dim view of nurses with MI, and they can make your life so miserable that the stress tips you into another episode or even forces you to quit. In the final installment of this series, we'll discuss what to do when a nurse finds her/himself in an untenable position at work because of a mental health condition, and what (if any) recourse is available when one's employment is in jeopardy as a result of that illness.
  8. If you are a nurse who suffers from a serious mental illness such as bipolar disorder or schizophrenia, you probably have had difficulties in obtaining, and then keeping a job. Many of us have spotty work histories filled with multiple jobs where we stayed only a brief time (AKA job-hopping) and jobs we've lost because of inconsistent performance or poor attendance. Others have spent time on disability due to severe MI that kept them from working for months or even years; once stabilized, they become bored and restless, and decide that it's time to go back to work. Obviously, there are going to be some gaps in your employment history that you'd just as soon not have to explain. Say you've been inpatient and then had to follow up with intensive outpatient treatment, or you left your last job without notice, and/or you took a few months off to heal. Now you want (and need) to get back into the working world, but first, you have to figure out your next career move. It's only natural to have reservations about this process. You've heard the horror stories about interviewing and being asked questions that you'd rather not answer; you've heard stories about nurses who had to supply a health history and med list to Employee Health. How do you dance around these delicate situations without either telling the honest truth, or furnishing false information that will get you fired if it's ever discovered? Though there are no foolproof methods, here are a few pointers for interviews. One of the most common questions asked of applicants with gaps in employment is, of course, why you left the previous job and what you did during your hiatus. This can be hard to explain when you had a nervous breakdown and then spent some time in the psych unit getting straightened out. One way to handle this is to say you left to care for someone close (not your frail, elderly grandmother---everyone has one of those!) who suddenly became acutely ill; the prospective employer doesn't have to know that the person who needed the care was YOU. Be sparing with details; for one thing, the interviewer really doesn't care, and for another, you don't want to tell a story so elaborate that you'll forget some small thing and expose your truth-stretching to the light of day. OR---you can say that you yourself were ill, but that you were treated and the problem no longer exists. They don't need to know what kind of illness you had, and in fact have no right to know. That is personal health information protected by HIPAA. Which leads to another critical matter of concern: the dreaded employee "physical". This is something I personally have never had to undergo, with the exception of the urine drug screen and TB testing. But it's a common enough requirement to present a problem for the nurse with a mental health history that s/he would rather not share with an employer. Hopefully, you'll have done your homework and applied at a facility which doesn't ask for PHI. Talk to people who work there, ask them how they like working for this company, and casually ask them what is involved in the hiring process. If they tell you they had to supply their health information and a med list, you may want to bypass that company and apply somewhere else; but if your employment options are limited, you may have little choice but to proceed with the application. If/when you are faced with disclosing your medical history and/or furnishing a med list to employee health, ASK why that information is needed, what it is to be used for, and who may have access to it. In good facilities, only the employee health and infection control nurses can see your information; managers and company officers have no authority to access it, and they can even face sanctions for attempting to view it. Remember, we do not give up our right to privacy when we become healthcare professionals! Insist upon complete confidentiality when providing your PHI to anyone outside your doctor's office. If it cannot be guaranteed, you're better off looking elsewhere, even if you have to commute. So why all the secrecy? Why not tell a prospective employer, your boss, or your co-workers about your mental health condition? You know it's not your fault, nor is it a moral failing. You do everything you can to manage it, including taking your medication and seeing your doctor regularly---what is there to be ashamed of? Why must you hide it? Short answer: you don't, if you're lucky enough to work in an environment that's nurturing and accepting, like my current workplace. Unfortunately, however, most are NOT like that, and nurses who disclose a psychiatric diagnosis---whether voluntarily or through an exacerbation of their illness---all too often find themselves unemployed in some fashion. Even if they remain on the job, they are all too often passed over for promotions and discriminated against in other, more subtle ways, such as being left out of committees and disciplined for mistakes that other nurses get away with routinely. Ultimately, it's up to the individual as to when, how, and whether to disclose a mental illness that may affect them at work. Now I'd like to invite you, the membership, to share how you have handled these issues, both now and in the past, as well as to offer suggestions to other nurses who are struggling. To be continued.....
  9. VivaLasViejas

    The Stranger Within: One Year Later

    It's always been a source of wonder and amusement to me that during my frequent searches for an item I've misplaced, I always seem to find something else that brings back a memory or two. And, like many of the elderly Moms and Pops at the assisted living community where I work, I often get so lost in the new distraction that I completely forget what I was doing before. It happened again earlier this evening as I was going through some of my old blog entries here on AN and ran across a piece I barely even remember writing, called "The Stranger Within: Living With Mental Illness". At the time, I'd just been diagnosed with bipolar disorder and was so confused I didn't know whether to pick my watch or wind my nose. Psych had never been one of my favorite subjects in nursing school, and not only did I not have even a grade-schooler's level of understanding, I was thunderstruck by the diagnosis. It wasn't like I hadn't suspected it---I'd always been mercurial and prone to fits of rage, as well as times of soaring rapture and high energy. But there's a yawning gap between merely suspecting a thing and hearing it confirmed by a medical professional with several impressive degrees on his office wall next to the framed print of Pluto (the dog, not the demoted planet). I'll explain that bit of cognitive dissonance later. Then followed weeks and months of medication trials and changes; side effects triggered weight gain, spun my blood sugar out of control, and made me crazier than I already was. I struggled at work. I developed suicidal ideation and thought the new bottle of Ativan I'd just refilled might be the way out, only I didn't know how many pills it would take NOT to wake up in the ER with a tube up my nose. Only a few weeks later I was dancing on the moon and being so disruptive at work that I was sent home under strict orders not to return until I got the mania under control. By that time, I was logging more hours on my psychiatrist's sofa than my own. In other words, I was a hot mess. I'm not sure exactly when the meds got straightened out and life began to settle into something resembling a rhythm, but January of this year was the most stable month I'd had since the onset of the nightmare. Actually, it might have been the most stable month ever. Of course, nothing lasts, and recently my 'stranger within'---or Big Ugly as I call it---raised its dual heads and began to growl again; it seems to enjoy pulling sneak attacks when I can least afford them. But the boundless get-up-and-go and the surge of goal-oriented activity have pulled me out of a serious jam at work, and this time I seem to be floating down gracefully, rather than crashing into the pits as I have after some of my other manic phases. There's a sunny side to everything; bipolar is nothing if not an optimist at times. In my case, it's the sheer amount of learning that's taken place over the last year. For one thing, my diagnosis has solved a great number of mysteries: it explains why I've always felt like the odd man out, even when surrounded by friends and family. Why I experience moments of great truth and beauty, and then bouts of rage and black depression. Why I'm so creative at some times and brain-dead at others. Why I've had to learn absolutely EVERYTHING the hard way. There is also a certain peace in realizing that my difficulties in life haven't been all my fault, even though I know it's up to me to choose how I'll react to a given situation. This is not to say I'm happy about carrying this albatross around my neck for the rest of my days, let alone that the headhunters at the next company I work for may very well snoop around in my health history and find Big Ugly right there in stark black and white. But it's for this reason that I find myself now, a year after the diagnosis, as something of a poster child for my kind of crazy: SOMEONE has got to help put an end to the stigma of mental illness. And who better than a person who lives with it by day, and takes it to bed with her by night? However, the real bright light in all of this distress is the amazing people who have come into my life as a result. First among them is my beloved "head doc", who never once has allowed me to leave his office without feeling better than I did when I walked in. Though much younger than I, he is a veteran of both Iraq and Afghanistan, and thus far wiser than most people twice his age. He is also funny (how can you not like a doctor who collects funky items featuring a dopey-looking cartoon hound?), smart, caring....and he is the only person alive who's allowed to call me on my BS without getting an earful. And there are countless members here at allnurses who have shared their own stories with all of us, and from whom I'm learning the everyday coping skills I need to get through the rest of my life with Big Ugly. It seems as though every day there is some new discussion of mental health issues in the outer world, but while those conversations are often biased and sometimes downright scary, the growing dialogue here at allnurses reflects the intelligence and compassion of its membership. That gives me hope for the future....not only my own but that of millions of mentally ill Americans, too many of whom aren't fortunate enough to have a team of family, friends, and professionals who won't let them slip beneath the waves and drown. I may not know when my next mood swing will strike, but I do know that with proper help, the stranger within---a shadowy entity who exists within ALL of us---will never again take control of my mind or my life. And if I never learn another thing from living with mental illness, that alone is enough.
  10. pinkiepieRN

    Getting Back in the Saddle Again

    After being bitten by a patient with no concern or debriefing from my nurse manager, I made plans to high-tail it out of that unit as fast as I could because my mental health was already a little fragile and there would be no accomodations made for me. I have a 20 credit post-baccalaureate certificate in Nursing Education from my alma mater, so I thought it might be a smart decision to try my hand at teaching. I should have known that it was a bad idea from the fact that I was hired mid-year with no practical teaching experience but I saw a way out and wanted to take it. I was given next to no orientation and then tossed into the spring semester, already 2 weeks in. I struggled and although I did increasingly better on my performance reviews and observations, I was asked to re-sign in early May. My principal told me that he was thankful that I took the position because it definitely saved his ***, but that the only way I could expect to be re-hire would be for me to complete another post-bac, this time directly in the Education department. I didn't have that kind of money and couldn't handle the stress from the students and lack of support, so I submitted my resignation letter. Having given almost 3 years in my first job as an RN, I was really concerned that I'd never be able to get another job in my specialty or transfer to a new specialty. I've essentially been out of the workforce since then due to both personal problems and needing to take care of family. I was terrified of both applying for jobs and going on interviews, in fear that I'd face the inquisition as to the large gap in my resume and work history. That has luckily not been the case. I've had one interview with a local ED and have done really well with a SNF in the area. I had interview #1 on Monday and I just had a follow-up interview this morning with the ADON and NM of the unit that I've applied for. I surprised myself by not choking when it came to my weaknesses and using critical thinking/judgement in an emergency prioritization situation. I didn't remember critical lab values for an INR, so I told the interviewer that and she explained the situation in more depth to me. I have shadow time scheduled on Tuesday from 0700-1200 and I'm hopefully going to either receive the job offer after my shadow time or by the end of next week. This new job is not in my specialty (adult psych) but I'm confident that I'll be able to apply my therapeutic communication skills and learn all that I can about the geriatric population, as well as their co-morbidities such as CHF and ESRD. There is hope and promise even if you've beaten yourself up for leaving and taking time for yourself. Not only is it *NOT* the end of the world, it's a chance for both personal and professional growth. You know, that whole thing about doors closing and windows opening.
  11. Liddle Noodnik

    The Stigma of Mental Illness and Suicide

    There has been quite a lot of conversation about Mindy McCready's suicide and mental illness,and it amazes me the different opinions people have about suicide and mental illness. I thought that I should "come out of the closet" once again about this issue, and talk about my own experiences with it. (The article below was written by a man who has the illness and his experiences and thoughts. I thought it would be good springboard for what I am going to write, below: A Tragic story that applies to millions.) I had a serious suicide attempt in 1985, and I had no thought whatsoever of what effect it might have on my family and friends. For that matter, I didn't realize that I had a mental illness and alcoholism. I just wanted out of the pain. Even though I have come a long way in recovery, and even though now I am a Christian, depression can be a very powerful thing. It is like a vacuum pulling you away from everything that is logical and good - even from the knowledge of God sometimes. I found out later that I have bipolar illness, like Ms. McCready, and I have to be on medication to keep it under control (some don't seem to). I am ashamed to admit it and I hide it. People judge it, in themselves and in others - which I think is one reason that there is such a bad outcome to the disease. If people knew that they had it, and sought help and treatment, I don't think there would be so many suicides. This woman did seek help, however, so treatment is not always successful. I hate to even bring this up, but it seems that even in the Christian community, where we are to have compassion and understanding, there is a huge stigma. Many believe that if you do what you are supposed to do, and if you have enough faith, you won't need medication. The implication is that you basically won't have bipolar or depression (or other mental illnesses). This belief is found in the secular community as well. Pull yourself up by the bootstraps, do what you are supposed to do, and all will be well. I haven't found this to be true for me. I even went off medications for two years and the results were almost disastrous for me and for those around me. Trust me, I tried, and I "did everything I was supposed to." Still, God did not heal me; still, I could not get and keep my act together. But read about Paul in the Bible, who suffered physical affliction that was not healed: (1)For this thing I besought the Lord thrice, that it might depart from me. And he said unto me, My grace is sufficient for thee: for my strength is made perfect in weakness. Again I feel ashamed about this. Not that I have the illness, but about admitting in the open that I have it. Admitting that I still struggle sometimes. Even in the nursing community, where we have been educated, and where we have access to a lot more information, the stigma persists.Hang out at any nursing station and you will hear it: "That" woman, that "nutjob," etc. But I answer to God, and I take responsibility for keeping myself and others safe from my symptoms. What can I say. I'm thankful for all God has done and is doing for me. He is so good! I'm thankful He has kept me sober and has kept me out of a psych hospital for several years, and I hope I never take these things for granted! (2) ... Most gladly therefore will I rather glory in my infirmities, that the power of Christ may rest upon me. What has your experience been? How do you feel about mental illness, recovery, and suicide? Kudos to the other nurses who have "outed" themselves about this issue. One that I admire is Viva las viejas here on allnurses. She has given me a lot of courage in this regard! 1) 2 Corinthians 12:7-9 2) 2 Corinthians 12:9
  12. xwill327

    Interview with the Psych Nurse

    It’s great when a psych nurse can be empathetic to their patients from the education they received in nursing school combined with previous patients they have cared for. I believe they can give even better care when they had experienced it first hand. Countless times patients have yelled at me, “you have no idea what I am going through.” My one colleague has experienced being admitted to an inpatient psychiatric unit. I wanted to understand her experiences and how it impacted her career as a Registered Nurse in Psychiatry. We worked together and I was immediately drawn to her passion for the field of psych nursing and just her as a person. We became close and were able to share stories about work and eventually our life struggles. We disclosed personal experiences with each other. Not only was she a runway model (super cool), but she also struggled with an eating disorder and mental illness. To my surprise, she had been admitted to an inpatient psych unit. I had always wondered what it would be like to be the patient. Here are some views of the psych nurse as the patient: Has anything on the job ever triggered you from personal experiences? My first week on the floor, I was called to a behavioral health crisis on the medical floor: essentially meaning a medical admission lost their mind… I was called in to help restrain an anorexic patient who was refusing treatment. She was not a danger to herself or others and restraining her would go against my ethics, as well as, and more importantly, it was against the law. I did nothing though! I just stood there, watching her be tied down so they could enforce the treatment that she had refused. All I could think of was, “what if I had been restrained for my anorexia turning my hospital stays.” It would have been nothing less than scarring. That thought repeated in my mind as I remembered back to a time when I still denied my emotional disturbances, just as that girl was as she screamed she was fine. Since then I have learned to be an ally to ED (emotionally disturbed) patients, as I know the world of medicine as a whole for the most part avoids them like the plague! How do you feel when you know you helped someone who had a similar issue as you? I will always think back to this one patient in particular who I will refer to as K. If I can think back to someone I feel I helped, it would be her. I was placed on a one-to-one with her following her attempt to hurl herself through the glass window in her room. She was placed on a suicide watch one-to-one which meant one person watching K. Usually this job is given to a PCA (patient care assistant) or a Behavioral Health Tech. However, we were short staffed that evening so as charge nurse I took the role. I had to be within arm distance of her at all times. To say the least, K. was not having me when I entered the room. My close proximity only bothered her more. Despite her attempts to avoid even eye contact I continued my attempts to make conversation. After my relentless conversation prompts, she began to engage with me. We began to joke and she laughed with me. I stayed with her for nearly three hours that evening. The next day K. approached me and said, “I think I get what you were talking about with good things still having a bad side and bad things having a good, like last night, bad-I tried to jump out a window, good- we got to talk and have fun.” My heart sunk and it remains the largest thank you of my career. I am not out to save the world; that would only be a disappointing pursuit. But, if I can help a suicidal patient laugh for a couple hours, I cannot go home with my head hanging down. What is your take on the inpatient experience? Is it beneficial? How would you change it? I don't know if you meant my personal stay in the psych ward or my time working in them. Seeing that I have now experienced both I can say that after my 4th stay I stopped attempting to make light and accepted I would do anything for them never to have happened. Despite this speaking in terms of my work they each had enormous importance. My first stay at 18yrs I learned how to relate to the fear that comes with admission and of its great unknown. My second, I learned the shame that comes along with it and the anger when you have to be admitted against your will. My third stay was due to a head trauma, not psych symptoms, I was placed in the ward purely because of my history. There, as I came back to reality from the two cracks in my skull, I found out what is was like to lose your voice to your overshadowing past. My fourth stay I went in attempting to get ECT, which I was denied. Already a psych nurse at the time, I had far more insight into the world of outpatient but not inpatient. I learned about the frustration in delaying the discharge process. Only because of my further protest did my 72 hour letter not continue to stretch in time. Most patients don't know their rights: such as a 72hr letter to demand discharge. Are you open with your coworkers on your background or remain private? I remain more than private. I was having vicious side effects causing me to shake and tremor constantly. I looked like a wreck as well. To explain this I would blame my other and more acceptable meds treating for my epilepsy. At times, I went as far as to claim having other disorders to explain my symptoms away. My anorexic appearance I denoted to marathon training despite not having worked out in a year for fear of increased hunger. I wish I could be more honest with my coworkers but the way they talk about these disorders and how they talk about the patients afflicted… I just cannot imagine them thinking of me that way. How do you strive to break the stigma of mental illness? How can others in your opinion? I strive by simply getting up everyday. I have a fortune I carry in my wallet that has the quote, “Heroism is the endurance for one more moment more,” which is far easier said than done. It was only recently that I have admitted to myself I am in fact disabled by my disorders. Despite being crippled by them my unwillingness to let them win as well as at times pure denial of them… has allowed me to achieve both personal and professional success even when it seemed everyone else assumed I would fail. How others can break the stigma is to talk about it. If there were simply more numbers of people talking about their disorders, I truly believe even more would come forward and the rest of the world might not be so uncomfortable. Thank you to my colleague and cheers all!
  13. TheCommuter

    Do Not Over-Share!

    I first met Toni in the summer of 2010. Toni (not her real name) was an average-height woman in her late 40s with a medium build, gray eyes and dark brown hair that fell several inches below her shoulders. She was a floor LVN at the same specialty rehab hospital where I still work. And she was one of the most proficient, highly skilled nurses I had ever met. With nearly 30 years of experience, this woman was a valuable resource who could run circles around virtually every other nurse on the unit. It's unfortunate I only got to work with her for a grand total of three months. Toni lacked a verbal filter. She talked too much about her personal issues: the perpetually unemployed husband who cheated on her, the slacker adult children, and so forth. Once she revealed to her coworkers that she had bipolar disorder, they began to whisper to themselves, "This woman is so crazy!" As soon as she disclosed that she was not being treated for her issue, some coworkers placed a bulls-eye on her back and began to target her. And eight years of dedicated employment went down the drain as she was forced to resign over a questionable accusation made by a student nurse who was completing clinical rotations in the facility. Prior to Toni's revelation that she suffered from bipolar disorder, no one bothered her. Bipolar disorder and other mental health issues are still stigmatized in healthcare settings, whether or not anyone wants to believe it. I am cognizant that many state boards of nursing require nurses to disclose certain mental illnesses. However, if management or the employee health department at your place of employment is not asking about your health conditions, I would not divulge to any of your coworkers that you have any type of mental illness, because it is unfortunate and inevitable that some of these people will label you as 'nutty' or 'unstable.' Also, develop an internal filter that will prevent you from sharing your personal problems that are none of your coworkers' business. Smile, be pleasant, and play the game. Do not over-share! It took me some time to learn this lesson because I also have a history of mental health problems. I was treated for depression and post-traumatic stress disorder (PTSD) in the distant past and took medications for a while. I am also an extreme introvert who doesn't particularly enjoy mingling and small talk. Prior to sharing too much information at a previous workplace several years ago, coworkers largely respected me. However, once I casually mentioned my childhood traumas and other personal issues surrounding depression, people began to whisper that I was "weird." To wrap things up, Toni's forced resignation taught me a couple of lessons that will remain in my awareness for the rest of my working career. For starters, if no one is asking about your mental health issues at the job, do not share unless you wish to be stigmatized. Second, if no one is asking about your physical health problems at the job, I also see no need to share this information unless your employee health department has a specific reason to know. Finally, get an internal filter as soon as possible. Talk about superficial topics such as the vacation you recently took, the wedding you attended or your kid's birthday party. Anything more personal is none of your coworkers' business.
  14. VivaLasViejas

    The Eagle Has Landed

    The eagle has indeed landed.....and landed softly, instead of crashing and burning as she's done so many times in the past. Thank God. This morning I felt completely normal when I woke up to get ready for work (even though I maintain that 5 AM shouldn't even be on the clock). I marveled at this new sensation of well-being, and have continued to enjoy it all day. This is what it must feel like to NOT be bipolar.....to wake up each morning and not have to run a self-check for symptoms, to go to work and stop by the store for a gallon of milk without picking up a new car on the way home. (Well, I've never done that exactly, but I did drop a wad of cash in Wally World last summer that could have sheltered, clothed, and fed four of their employees for a week.) Now, for most people that statement would prompt a response along the lines of "Yeah, so what? I feel normal too, just like I do every day." But for me, it's nothing shy of a miracle.......especially after soaring as high as I did this time. This was far from the worst manic episode I've ever had, but I still let it get pretty out-of-hand before I called my psychiatrist, who promptly bumped up my medication. And once again, there are lessons to be learned; this time, I did better at getting help before things escalated to the point of no return, but I could have, and indeed should have called sooner. Why, I ask myself after each go-round, do I think my will is stronger than the disease? Have I ever been able to contain the crazy by simply wishing it away? And why, oh why do I still enjoy my hypomanias so much when I know they will almost always progress to full-blown mania, turn on me, and bite me in the butt? Already, much of the past two weeks has faded into history and there are large blank spots in my memory, which are entirely too much like the alcoholic blackouts I used to experience. I'm fortunate that I was able to recall most of my two-day orientation to the long-term-care hall at work, because I was able to carry it off on my own today without forgetting TOO much of what I learned. However, I barely remember the events that led to my deciding to call my doctor, and significant chunks of time are missing from the days following the med change as well. What's more, I was just reading over some of the blog entries that I made during the episode, and I don't even recall writing them for the most part. THAT is how jacked-up I get sometimes; by the time I get to admitting that I might---just might---have a little hypomania going, I've crossed the border into manic territory. I think this last time I coined the term "pre-hypomania" to describe what I was feeling, but looking back I realize that I was already hypomanic then......and things only got worse after that. As I told a close friend recently, mania is in many ways as intoxicating (literally)---and as attractive---as alcohol. It's also every bit as dangerous for me, because when I'm in that state I do not CARE if I annoy people, spend money I don't have, upset my family, or make a scene in a restaurant. (Which I did. On my son's birthday.) Oh, maybe once in awhile a little common sense may slip through and make me stop short, but it's only a minute or two before I go back to doing whatever it is I feel like doing. And the worst part of it is that I don't get scared about ANY of this until I've come out the other side of the episode. So this post is more than just another story about taking a walk on the wild side; it's documentation of what happens when I let a 'high' get away from me, and a cautionary tale to which I can refer the next time I'm tempted to let the sweet madness wash over me.
  15. VivaLasViejas

    Three Clicks of a Mouse

    As those who study the social habits of humans have observed, Internet forums are a reflection of society as a whole, no matter how exclusive the community. And as the spate of recent threads here on Allnurses indicates, the events at Sandy Hook Elementary School have spurred many a debate about the Second Amendment......and as an unfortunate by-product, the rights of citizens with mental illness. Strangely, nowhere is the latter issue more divisive than in the healthcare professions. We have a reputation for being compassionate, non-judgmental, caring; yet within our ranks we are often merciless to those who suffer from diseases of the brain. It starts early with nursing students, who are under immense pressure to begin with and who sometimes crumble under the weight of lengthy written assignments, skills labs, frequent tests, and clinical experiences. While the process of becoming a health professional is (and should be) challenging, sometimes students are winnowed out who could be excellent nurses, if only they were offered assistance with their mental health issues instead of condemnation. If one is fortunate enough to make it through school and apply for licensure, however, her/his state Board of Nursing is ever ready to put a screeching halt to career plans. In many states, both the initial application and the renewal paperwork require the applicant to answer questions such as "Do you have a physical or mental condition which impairs, or may impair, your ability to practice nursing safely?" To answer this ambiguously-worded inquiry honestly means, at minimum, a delay in receiving clearance to practice and at worst, mandatory participation in a monitoring program that can subject one to restrictions on her/his license, frequent (and costly) urine drug screens, even daily reporting to a case manager or counselor. And God help you if you should run into trouble during your career. An inpatient hospital admission will both cost you dearly and put your license at risk, especially if a 5150 (involuntary commitment) was necessary. But the worst scenario is the one that a fellow nurse shared with me recently: some states actually publish personal information about a nurse who has been sanctioned by the BON that anyone with two minutes and a computer can find easily. That's right, folks. This nurse, who answered the mental-health question honestly, had restrictions placed on her license and was mandated to participate in a health professionals' monitoring program. The document supporting the nursing board's decision contains confidential information about her diagnosis and her psychiatrist's evaluation of her fitness to practice, yet her board order can be found with three mouse clicks. Can we say HIPAA violation, anyone? To say that this is outrageous only scrapes the tip of the iceberg; if this were an issue of a bad back or an incurable (but non-contagious) skin condition, we would not be having this conversation. Why, then, is it acceptable to share the intimate details of a nurse's psychiatric disorder on a public website that anyone who merely knows her name can access? Why is it necessary to make it harder for a nurse whose illness is well controlled, who sees her doctor regularly and complies with her treatment program, to find a job? And if the intention is to "assist" the "impaired" nurse, why is the focus on schizophrenia, bipolar, borderline personality etc. when the most prevalent mental disorder among nurses is depression? Please share your experience of being a nurse with mental illness, especially if you've ever tangled with the BON or been discriminated against because of your disorder. There is strength in numbers, and if a significant segment of the nursing population stands up together to say ENOUGH, the powers that be will no longer be able to ignore us, or worse, strip us of our privacy in the name of "protecting the public". Thanks in advance for your responses.
  16. On my computer desk stands a brightly painted wooden figurine of a toucan, a souvenir of a part of Mexico I've never visited and probably never will. His garish red, green, and pink feathers are reminiscent of a certain tank top I bought a couple of summers ago that I would have laughed at had I been in my right mind at the time. (I don't know where the garment is now; I'm afraid it'll leap out of the closet one night and try to strangle me.) Yes, it really happened: my psychiatrist gave me the bird. And the colorful critter serves as a good reminder that the illness he's treating me for requires constant vigilance, and that mania is NOT my friend. It's been a long, hard road to this relative state of wellness. Many AN users who have been around for awhile know something of the process I've been through to wrestle the bipolar beast into submission, and some of them have become part of what I consider to be the most awesome support system on the planet. That support system is the reason I'm still here, the reason I've been able to reclaim a good portion of my life. I would never have learned to believe in myself again without it. That's not to say that there haven't been losses. I am weary of losing bits and pieces of myself to this illness, and the fact that I'm a lot better than I was doesn't negate the fact that it imposes limits which have been difficult to accept. I didn't want to leave clinical nursing, but with my anxiety and inability to focus, I couldn't hold peoples' lives in my hands anymore. I don't like having to take a fistful of meds twice a day or go to bed by 11 PM every single night, even on the weekends. And I hate it when I have to go to a healthcare facility where they don't know me, and the doctor wants to go over my psych history before he even looks at what I came in for. But there have been a great many opportunities for growth, too. I used to be a very angry person before therapy and medications; now there are few things worth getting worked up over. Once in awhile the process slips and I start arguing politics, usually on social media; when I do that, it's a good clue that I'm becoming manic and my friends and/or family will call me out on it before I can do too much damage. I've also gotten much better at catching mood episodes in the early stages and being proactive by using my PRNs and/or calling my doctor. During a recent appointment, I expressed some frustration with the fact that I still have breakthrough episodes; it seems inconceivable to me that one can take as much medication as I do and continue to have symptoms. Actually, I had a meltdown and cursed the unfairness of it all, which wasn't very adult of me, but after two years in his care I'm comfortable enough with him to let it all pretty much hang out. Fortunately, he has studied me very thoroughly and knows most, if not all, of my little quirks; he also respects me greatly as a nurse, and that puts the therapeutic relationship on something of a higher plane because we speak the same language. Even when I'm acting like a bratty ten-year-old because I want to be FIXED, dammit! I am still coming to terms with the knowledge that I can't be fixed, although my condition can be managed. As he reminded me yet again, I have an illness that is episodic in nature and will recur from time to time, no matter how strict I am with myself regarding meds, therapy, and sleep. And no matter how hard it is not to beat myself up for it, I didn't ask for this and it's not my fault that I have it. Those are difficult concepts to grasp when you're fifty-five years old and didn't even know you were sick until you were fifty-three. That was a lot of years to go untreated, but it just goes to prove that with good care and lots of support, anyone can get better. All of us who live with mental illness have a stranger within: someone we don't like, someone we may not even want to acknowledge exists. But the only way to make peace with this person is to bring her out of the shadows and introduce her in a safe place, like a psychiatrist's office or mental-health clinic. Maybe even at your dinner table.....after all, the chances are pretty good that your family and friends have already met her. It DOES get better. Be happy. Be well.
  17. If you are a nurse diagnosed with depression, anxiety, or any other psychiatric illness, you are probably doing all you can to maintain your mental health: you're taking your medications as ordered, keeping your therapy appointments, seeing your psychiatrist and/or PCP on a regular basis, plus taking appropriate self-care measures to keep your body as healthy as possible. Unfortunately, almost everyone with these conditions will experience a relapse at one point or another; it's the nature of the beast. Even more unfortunate is the fact that stigma is very much alive and well in the workplace, both due to the sensitive nature of the healthcare business and to the relationships between nurses and the public, which trusts us to hold lives in our hands. So when stress and strain exacerbate an underlying mental disorder, it can become very difficult to keep it under wraps.....and sometimes, we wind up paying a terrible price, as I did earlier this year when a severe mixed-manic episode cost me a well-paying executive level position. "But what about the Americans with Disabilities Act?" you may be asking. "Doesn't it protect us from being fired for getting sick?" Short answer: Yes, and No. It didn't do a thing for me when I was relieved of my responsibilities because my employer deemed my request for "reasonable accommodations" to be unreasonable, and it was clear that I could not perform my job without them. But to be fair to the company, they had tried on a previous occasion to accommodate me by changing my schedule to a four-day week to help reduce stress, which unfortunately didn't provide enough relief to prevent the catastrophic mood episode that sent me out on a three-week medical leave of absence in lieu of hospitalization. I could have fought the termination. But since the best I could have hoped for was being given my job back with retroactive pay---and because I had neither the desire to return to the job nor the intestinal fortitude for a bruising battle at that time---I decided against it. The Equal Employment Opportunity Commission allows 180 days for the filing of a formal discrimination complaint, or charge, against an employer; however, they will not always file a lawsuit on your behalf even if they find the employer in violation of anti-discrimination laws. You have the right to sue the employer after the EEOC makes that determination, and of course you can choose not to involve the EEOC at all and file suit on your own. We have discussed elsewhere in this series the pros and cons of "coming out" with your illness at work. But what if you have a public breakdown, or worse, are admitted to the same hospital where you work? These defining moments change the game, as the illness can no longer be kept secret and you're not in control anymore. Or are you? The answer is a guarded "Yes". No matter what happened or who was present when it happened, you always have the right not to discuss it with your supervisors or co-workers. Both HIPAA and your employer's policies protect you from unwanted intrusions into your files and provides for discipline, up to and including termination, for anyone who accesses your medical records without authorization. But there are also situations in which experience can be an excellent teacher, and depending on the circumstances (and your own feelings about sharing it with others), you can do much to educate your fellow nurses about mental illness. You need not be ashamed of it; it's not a character defect and it does NOT define you. But it is a part of you, just like brown eyes or freckles. The fact that you are a nurse who holds down a responsible job proves that you don't have three heads and you're not an ax murderer; no one should fear you because you have something that makes you act oddly at times. As a nurse living with a mental health diagnosis, you may also be the right person to instill compassion and empathy into those who are lacking. You can gently persuade co-workers not to use words such as "loony" or "psycho" to describe patients. You can offer insight into what makes some tick by talking about the time you had an episode because you couldn't keep your meds down for several days due to an intestinal virus. You can even place yourself in the patient's shoes and encourage others to do the same, even though they will never truly know what goes on in his brain.....or yours. My thanks to all nurses, students, and others who have been following this series. I hope that it has proved useful in helping readers to understand not only their co-workers and patients, but also family members and friends who struggle daily with bipolar disorder, schizophrenia, ADHD and other mental health challenges.
  18. Matua is not his real name, it is a Maori term meaning father, used for a Maori gentleman who is 50+ and respected in the eyes of the community. A lot of the staff call him that, whether they are Maori or New Zealand Europeans. Matua believes that I am the resurrected Joseph Smith Junior, founder of the Church of Jesus Christ of Latter Day Saints and that my colleague Rod is King Arthur of the Knights of the Square and Round Tables. And together with my colleague Justine (a.k.a. Justine Just-In-Time Ziggy Stardust), we all have to get into a yellow pink and blue Learjet, and set off to save the world, with of course a stop-over on the Isle of Patmos, as Matua is Saint John The Redeemer, Saint John The Divine, Saint John the son of Zebedee and of Salomne, but not Salome because she was the hussy that danced naked before her father and got John The Baptist's head chopped off. On top of all this - (mental health diagnosis of Bi-Polar Disorder), he has plenty of medical co-morbidities. He has diabetes mellitus (adult onset, insulin dependent), hypertension, congestive heart failure, and has had several myocardial infarctions. He is also extremely overweight - (height 180cm, weight 160kg, BMI 49.38). He is literally eating himself to death - despite all this, he takes off down to the shop every time he has left from the ward, buys a ton of fizzy drink, chips, lollies, and chocolate, carts it all back to the psychiatric unit, and eats the lot. Despite his mental illness, he knows what he is doing - as with a lot of my patients, in most ways he is very delusional, but in some ways, he is surprisingly logical and knowledgeable and knows exactly how things are. One night, in particular, he was very ill, demanding to have the Learjet summonsed and readied for an immediate departure for Salt Lake City and on to Patmos. After picking me up, giving me a cuddle, and crying about me being tarred and feathered and then murdered in jail, and telling me I was his poor little Joseph Smith Junior, he then became very, very angry. He set me down and banged and crashed on the doors, using his considerable weight, desperately trying to escape, and demanding that I come as well to help save the world. He would not take any direction, and to keep everyone safe a restraint team was formed. For most people, three is enough to wrist-lock them and take them down to the locked ward, but for Matua, we needed eight. He kicked. He punched. He screamed at the top of his lungs. "You wicked people! You evil nurses! You... you... SATANISTS!" Even when we got down there and got him on a mattress in the seclusion room, with me on his feet and four heavy - and determined - nurses holding him down, I was still being raised three feet into the air... Finally, we injected him with clonazepam and haloperidol and made a run for it, the door bolts being shot just as he threw himself at the door, howling, banging, and threatening murder, mayhem, and blood running down the walls once he got his hands on us... Seclusion is not great for anyone, patient or nurse, but particularly not for Maori patients as they find it particularly disgusting to have a bedpan and food in the same room. However, there is no help for it and we can only put those two things as far apart as possible. The drugs took hold and he fell asleep for an hour or so, but soon enough he was up again - and he'd put a mattress against the door - knowing full well that would mean we had to come in as we have to be able to see secluded patients at all times. But our Lois was on duty, and she knew him very well over many years, as she went to the Latter Day Saints Church too. "I think he's up to something," she said. "Let's take a look outside." So, at 2 am, the nurses were creeping around in the bushes outside the Psychiatric Unit. Three pairs of eyes rose slowly over the windowsill - to find Matua stomping around, and a full urine bottle balanced precariously on top of the mattress, ready to douse the staff... For the next hour or so, we continued to do our checks via the outside window, wondering if we were going to get an agitated telephone call from the hospital operators, warning us that the security guards had seen people sneaking around outside our ward, and the Police were on their way. Thankfully, that didn't happen. Matua then took the mattress and urine bottle down in disgust, sat on the floor, and sulked. As the staff does not have to do room entries if it is too unsafe and we only have four available staff during the night shift, we had to leave him in there until 7 am. Then it was all on again - he sat on his bed as asked, in we went with breakfast, drinks, and a fresh cardboard bedpan and urine bottle - and the shrieks for Learjets, King Arthur, Joseph Smith Junior, and Justine Just-In-Time Ziggy Stardust started up yet again. Just as we were about to hold him down and get another lot of injections out, he slumped to the floor, wailed, and then the poor man sat and cried about my horrible fate. Thankfully, all this had a happy ending. It took many months, but eventually, he stabilized on his medication, the doctors were able to trust him to take his tablets, and we sent him off to a supported flat complex, where nurses on-site keep an eye on them. He walks every day, is starting to lose some weight, and eats rather more healthily. Better still, we haven't seen him in at the ward for eight months, which is a record. He's still one of my favorites - I like people with florid delusions as you never know what will happen next, and the things they come out with are highly original and often rather entertaining Looking after Matua when unwell is very hard work, but rewarding in the end. He also reminds me that even if you are totally delusional, you can still be respected in the eyes of the community, even if that community extends no further than the boundaries of the Mental Health Service.
  19. PS1CK

    A (Long) Note to New Grads

    So you graduated, eh? Now you're in the big leagues. Maybe you're getting ready to graduate and on the brink of your journey into and onto the field. The only thing in your way that separates you from those sweet, delicious fruits of your labor is the NCLEX. Go kick its ass. Why? Because you can. Believe it. But then what? So many of your classmates are lining up jobs at ICUs, NICUs, ERs, and telemetry floors. But not you. Oh, no, not you. You never liked those things. The smell of death too much for you, maybe? Don't feel comfortable around the terminally ill? Seeing too many family members bereave at bedside taking a toll on your heart? Can't stand the thought of working 12 hours in a HOSPITAL of all places? You may be wondering why you even entered the field at all. You thought it was to help people get better. To be a good provider of care. To exercise compassion to your fellow humans. To promote and propagate health and good habits of living. Yes to all. But why doesn't the thought of hanging an IV bag of Flagyl excite you? I'll tell you why. It doesn't have to. In fact, none of the things a nurse would typically do in the traditional hospital setting has to excite you. If you've ever considered, or are open to, a career in psychiatric nursing, read on. If not, find something you like to do and good luck (you won't make a good nurse). I... "disliked" the traditional hospital setting from day one. It was interesting, sure, and sometimes fun. But I did it because I had to. The experiences I had in clinicals were fundamental to my growth as a student and, ultimately, as a nurse. They were stepping stones to my ultimate destination. They were necessary. I learned how to interact with patients, I gained confidence in my ability to target the areas of care that they each needed, and I learned about the procedures and medications that would be around in the field for as long as I'd be in it. Those days of getting up at 0500 in December on a short night's rest when it was still dark, cold, and often rainy outside, by and large, were of paramount importance. There's a line in an Oasis song ("All Around the World") that really stuck with me as I'd listen to it on the path to my clinical destinations, and I hope it sticks with you too: It's a bit early in the midnight hour for me, to go through all the things that I wanna be. Read that one more time. I'll wait here. That one line summed it all up for me so well that I'll never forget it. I did my time and got through it, just like you did or are doing. Even though I knew I would never be a "medical" nurse. Ever. From day one, and well before I ever got accepted into nursing school, I knew that I wanted to and would be a psychiatric nurse. So as soon as I finished up my bachelor's degree in psychology, I applied to the nursing program at the same school. The only school I applied to. If I got in, I'd be a psychiatric nurse. If I didn't, well, I didn't have a Plan B. I got in. The field interested me from the time I decided to get a bachelor's degree in psychology. It's new, it's fresh (relatively speaking), and there's a whole hell of a lot that we still don't know about it. Just like the patients we serve have, historically, had stigmas attached to them for being born different, psychiatric nursing has its own. First of all, don't ever let anyone think psychiatric nursing is "easy", or that psychiatric nurses "don't do much". We may not read EKGs all day, hand over surgical instruments, get STAT orders for an IV antibiotic, start a PICC for chemotherapy, or triage 20 patients with stuffy noses in an ER, but we work just as hard as any other nurse you'll ever come across. So don't be fooled yourself. Don't think it's a walk in the park, easy money, or "just listening to people's problems". It's work. Hard work. And doing it well will make you a better human being. You will, and I promise you this, make a difference in someone's life. You will also save lives (although not necessarily in an exciting, right-before-the-commercial-break-in-a-made-for-TV-medical-drama way). You know, without the AED pads. "What's so hard about being a psychiatric nurse?" you wonder to yourself, having made it this far in my meandering post. The hardest part about being a psychiatric nurse is this: doing all the things they don't teach you how to do in school. Knowing what's going on where without looking. Recognizing "that look" in someone's eyes before they explode. Picking up on when someone's actually suicidal versus the borderline with the short end of a broken plastic knife making empty threats for an extra snack. These skills are all skills you will acquire in the trenches. What about your other skills? The Foleys and the IVs and the... just stop. Relax. Take a breath. Now reach into your pocket of skills, remove the ones you don't need right now, and put them up in a mental shelf. Now close it, lock the door, and tuck the key somewhere safe. Those skills aren't going anywhere. They may collect a little dust, but they're still there. You can wipe them clean later and freshen them up a bit if you ever have to. Do you use every skill you've ever learned your whole life all the time? No. You'd go crazy (and be crazy) if you did. You use what you need to use to get the job at hand done. If you find that one day you suddenly have the burning itch to remember how to put a Foley in, I assure you with 100% confidence that someone, somewhere in the world, will know how to do it and can show you. And if you're one of the millions (billions, maybe?) of people on the planet with access to the Internet and nobody's reading this to you over the phone due to the fact that you're not, there's always YouTube. It's 2015. You can look up just about any instructional video on any skill in any field from anywhere in the world... in an instant. Amazing, ain't it? I assure you that you'll still keep the necessary knowledge of general medicine with you in your career as a psychiatric nurse. Who the hell told you that mentally ill patients don't get sick? They do. All the time. You'll still know what Metoprolol is. You'll still know the therapeutic range for an INR. And I guarantee you'll get your fair share of wound dressings. And who doesn't like wound dressings? Oh what fun! (and I mean that!) You'll still be calling the medical doctor for orders, deal with the damn pharmacy (yes, it's always their fault), and have to explain Synthroid to a curious party of the patient's family. So really, what are you afraid of losing? So what if you have to look something up later in life to remember how to do it? Do you think physicians remember everything they ever learned in school? Hell no. Why do you think Physician's Desk References are about a quarter mile thick? Nobody remembers everything. Nobody has to. And nobody will ever need to. Now I can see the gears churning in your head, cranking out all the possibilities. You're starting to feel a little better about being part of the dirty stepchild of nursing that is psychiatric nursing. And you should. If that's what you're considering or that's what you know you want to do, take pride in it. That goes for anything you do in life. Stand up for what you do and the people you serve. I can't stress this enough: they need you to. They can't always do it themselves. Your patients will be part of a demographic of the human population that is globally stigmatized. No other type of patients were ever tied to a pole by the hundreds, thousands, and were literally beaten and enslaved to their label like psychiatric patients have been. No other type of patients can be stereotyped from across the street as they're seen talking to themselves while others shuffle over to the other side to stay away from "them" as if they're sub-human. No other type of patient needs a voice in today's world more than the ones you will serve. Look around you. Read the headlines. Police have been on trial for killing them over the most trivial, frivolous, non-violent offenses. Why? Because of this exact reason. I told you earlier that the field of psychiatry is young. It's the new kid on the block. Not everyone understands it, so what do people do when they don't understand something? They become afraid of it. Maybe a small part of you is afraid of it too. Perhaps that's a natural response to everything you've ever come to know about it through popular media and everything else that's been force fed to you before you decided to become a nurse. But that's where you need to look inside yourself and realize that you became a nurse to help others. To do this, you must first understand others. Take that initial step, for when you do, you can then help them. By "them", I'm not only talking about the patients but everyone around them. It's your job to help break the stigma associated with the individuals whose only crime was being born with a neural anomaly that gives them the gift of seeing the world in the unique way that they do. Nothing else. That's why I did it and that's why I love it. I've been doing it for all of six years now, mostly inpatient. I started out as a new grad and got hired without any experience as a per diem nurse and worked the floors as a charge at a small 35 bed hospital. To this day, I have never set foot in a medical hospital as an RN providing care and I haven't one regret about it. I jumped straight into what I wanted to do because I knew I would love it. I knew it would be a challenge, but one that I could rise to. I also knew the reward was rather a mystery. In other departments, the rewards seem rather obvious. It's not as flashy as running a code blue in an ICU with 20 people around you while you pump out compressions and save a dying man. It's not as sterile as an operating room, either, where every minute and movement is so precisely calculated and planned for all to go accordingly. Nor is it as fast paced and edgy as a busy emergency department in a metropolis where lives are saved by the minute based on keen observation and assessments. So what IS the reward of psychiatric nursing? I'll give you my answer and, hopefully, someday you'll have your own: making my patients feel like everyone else, no different. You'd be surprised how many times I've had patients come in to my assessment area as transfers from emergency departments who had been there all day and were never once offered a bite to eat or a sip of water. It infuriated me. The patients aren't all going to ask for what they need. Part of being a good nurse in general is knowing what they need before they even have to ask, because many won't ask at all. Ten, twelve, fourteen hours or more in an ER at some of the worst times in their life, often feeling ashamed of themselves and unable or unwilling to speak up, and never offered the most rudimentary, basic, and necessary elements of care all day: food and water. Note to ER nurses who may be reading this: Please, be a kind human and make sure this isn't you. Although I did one semester of being a mental health clinical instructor for the BSN students at the university I attended (where the clinical site was my main job site, which was nice since I knew the staff and patients), I eventually got out of inpatient nursing. Towards the end of my career at that hospital, which was all of 5 years and a month, I also was on the clinical informatics team for a year where I helped design the charting system that would eventually (and to this day) be used there. I left because the administration was becoming a problem and at odds with what I thought was proper nursing care and because I felt patient safety was being compromised in the interest of saving money. I left and started teaching again (I have a BSN so in my state I can lecture and be clinical instructor for LVN students). Teaching was fun, though short lived. It was nice to be able to give back to academia. I was lucky enough to have been able to give about four to five lectures on psychiatric nursing to the students at a vocational school. It felt good to stand up there and talk about it to a room full of young, enthusiastic people, providing real life experiences and putting my own little flavor into the content and delivery. If you've ever wanted to be a teacher at any point in your life, consider being a nursing instructor. The beauty of being a nurse are the endless permutations and pathways you can take to providing a variety of experiences to both your life and career. I would have kept at teaching had my dream job not landed right in my lap when I least expected it. During a lecture I was giving, a recruiter from a large, well known health care organization called me with a mental health opportunity at a nearby clinic. The job? Serving as a liaison between patients and their psychiatrists. Monday through Friday, nine-to-five with weekends and holidays off. Full time, benefitted, $140K/year (it makes for comfortable living, yes, but don't ever do it for the dollar sign alone. Nurses who do can be spotted a mile away, just ask their patients. I only mentioned money at all to share what's possible with a BSN in California since this site is seen coast to coast and it may influence someone's decision to make a move out west!) In my head, during some of the most stressful, infuriating, and seemingly helpless nights working the floor, this was what I had in mind for myself... some day. This offer was seven years in the making and I wasn't going to turn it down. If you ever feel like you're getting burnt out where you are, that's okay. Chances are, no matter what you do, you will at some point. Even if you don't, you'll want a change after awhile. You'll want new experiences and to learn new things. You may have something in mind already for your future. A company you'd like to work for, a city you'd like to live in, a pay range you'd like to be at. Just remember one thing, everything you've ever done to this point and everything you'll ever do, EVERYTHING (every experience, every patient, every interaction, every good day, every bad night, every medicine you give or forget to give, everything) matters. Not only does it matter, it makes you who you are; as a nurse and as a person. Be your best and the best things are yours. Even if it doesn't look that way now, it will later. Even if it's dark, cold, and possibly rainy outside and you're tired, burnt out, and hungry; and even if it's a bit too early in the midnight hour for you, to go through all the things that you wanna do, it will be worth it. Peace, love, and compassion. Sincerely, A nurse who has never worked a medical/surgical floor his whole career and still found happiness. P.S. - Don't ever let anyone tell you the direction you HAVE to take. I didn't.
  20. BCgradnurse

    Coming Out of the Darkness

    I sat in my hospital bed, cradling my newborn son, with tears streaming down my face. However, these were not tears of joy. I was in despair, afraid and miserable. Wasn't this supposed to be the happiest day of my life? This child was planned, eagerly anticipated, and very much wanted. At least that's what I thought. My first pregnancy had been relatively easy, once the morning sickness subsided after the first trimester. I went into labor a few days before my due date, and I hoped for an easy delivery and a wonderful birth experience. Thirty hours later I was undergoing a C-section for failure to progress. My son had some respiratory issues and was whisked away to the NICU. Nothing had gone as I anticipated. My baby was fussy and wouldn't nurse, my incision was extremely painful, and I was exhausted. Everyone kept telling me I would feel better once I got some sleep. But I couldn't sleep, and I couldn't shake the feeling that I had somehow failed. A feeling of heaviness descended upon me, and I couldn't eat or sleep. I didn't want any visitors and I didn't want to see my baby. I didn't know what was happening to me, but I knew something was wrong and I was scared. Hospital staff and my family brushed it off as exhaustion and the "baby blues". Everyone assured me I would be fine and said these feelings would soon pass. This was 21 years ago and I had never heard of post partum depression. However, these feelings only got worse once I was home. I was anxious, I couldn't stop crying, and I wished I had never had a baby. I felt so guilty about having these feelings, and I tried to make up for them by being excessively diligent about caring for my son. I obsessed over how much he ate and slept. I made charts tracking when he ate, slept, peed, and pooped that covered the refrigerator and counters. I felt my emotions were completely out of control and I wanted my old life back. Meanwhile, I still was having great difficulty sleeping and eating. That heaviness I first felt in the hospital was growing worse. It felt like I had been attacked by the Dementors from the Harry Potter books. All the joy had been sucked out of my world. No one could tell me what was wrong with me. I started to notice family and friends exchanging worried glances when I would dissolve into tears over nothing. My grandmother told me to grow up and "snap out of it". Nothing relieved this darkness that I felt was swallowing me whole. When my son was 4 weeks old I decided to go visit my mother, who lived about an hour away. I felt I had to get out of the house before I lost my mind. I was driving on the interstate, crying, and found myself thinking about letting the car cross the median into oncoming traffic. I wanted relief from this depression and pain, and I was desperate enough to consider ending my life. Fortunately, my son was with me and I could not fathom hurting him. I made it to my mother's house and told her what I had been thinking. She told me to go take a nap, and to stop being so dramatic. I had a beautiful baby and had absolutely nothing to be upset about. Meanwhile the depression continued and I struggled through the days, caring for my son but watching the clock til my husband came home, and I could just crawl into bed and cry. My OB was shocked when she saw me at my 6 week postpartum visit. I had lost the 25 lbs I gained during the pregnancy plus an additional 10 lbs. I was a small person to begin with and now I was gaunt. I had big dark circles under my eyes, my hair and skin were dull, and I sobbed through the entire appointment. I begged her to admit me to the hospital, so they could find out what was wrong with me. Instead, she sent me right over to a wonderful psychiatrist who specialized in women's mood disorders. He told me I was experiencing postpartum depression (PPD). Finally! My feelings had a name. I wasn't being weak and I wasn't crazy. I had never heard of PPD before. It was never discussed in pre-natal classes and my OB had never mentioned it to me. My psychiatrist prescribed an anti-depressant and saw me twice a week for therapy. He also steered me towards a peer led support group of other women who had had the same experience as me. I no longer felt alone. Within 3 weeks my mood started to brighten and I felt a part of the world again. I will never forget the day, 5 weeks after first seeing the psychiatrist that I fell in love with my baby. I had just finished feeding him when the flow of tears started. This time, they were tears of joy. I couldn't stop hugging and kissing him, saying "I love you, I love you" over and over again. I finally felt like a mother, and not a failure. It is though that postpartum depression affects anywhere from 10%-25% of all women after childbirth. Most women have some sort of transient depression, more commonly known as postpartum or baby blues, which passes within days or a week. Postpartum depression is characterized by mood changes, sleep and eating disturbances, frequent crying, detachment from the baby, and feelings of hopelessness. PPD responds well to both pharmacological and non-pharmacological treatments. It can be mild or severe. Screening and education are key to recognition and prompt treatment of this disorder. No woman should suffer through weeks or months of depression and anxiety following the birth of a child.
  21. traumaRUs

    Suicide Screening in the ED?

    New research from the Emergency Nurses Association encourages more in-depth suicide screenings in the emergency department in an effort to better identify individuals at risk for suicide. The study, recently published in the Journal of Emergency Nursing, explores current screening procedures while identifying opportunities for improvement. Forty-one emergency nurses participated in two focus groups to share their experiences with suicide-risk assessments and current practice challenges for this study. All Nurses staff were recently fortunate to interview the lead researcher of the research study. Lisa Wolf, PhD, RN, CEN, FAEN, is the Director of ENA's Institute for Emergency Nursing Research. According to the Centers for Disease Control and Prevention, suicide is the tenth leading cause of death in the U.S., and research shows a substantial percentage of people who die by suicide present for healthcare in the year before their deaths. Screening for suicidality is a critical nursing function in the ED and provides healthcare professionals an opportunity to identify patients at risk for suicide and intervene appropriately. ED nurses, like all nurses today, are being tasked to do yet another assessment. How would you convince these nurses of the necessity of asking every patient about suicidal thoughts? It is estimated that about 3% of patients disclosed SI at triage (it's the reason they are there). However, it is also estimated that about 11% of patients actually are suicidal on presentation, so there's a significant percentage of patients who need care for SI, but don't immediately disclose it. This is why the Joint Commission recommends universal screening for SI in emergency departments. What our study suggests is that the assessment for suicidal ideation is a process that should extend across the ED visit, especially if the patient denies suicidal ideation, but has a concerning presentation. So, the onus is on the triage nurse to at least do the initial assessment and then pass on concern to other providers. This is a critical assessment that can really be a life or death matter, and it relies on the communication between nurses and other providers. What are some easy scriptings in order to fulfill this requirement? The initial question that is commonly asked is some version of "Do you have feelings of wanting to hurt yourself or anyone else?" Our study findings suggest that this question as a single data point may not be as useful and that some follow up questions for those who raise concern but do not disclose might include, "Are you feeling hopeless about things right now? Have you done anything recently that 's scared the people close to you? Or even more directly, "I am concerned that there's something you're worried about. Do you want to kill yourself?" Many small EDs at critical access hospitals don't have mental health resources. What advice would you give these nurses? It's really important to have post-licensure education in the care of patients presenting in behavioral health crisis; they are a significant percentage of the ED population, and correct management can yield lifesaving interventions. There are a number of courses in behavioral health nursing management available. If the CAH is part of a system, we would recommend ED staff requesting an in-service by psychiatric staff. Also, protocols for transfer of these patients who require inpatient care should be determined by the healthcare system to which the CAH belongs. Many rural or CAHs also do not have the resources to care for patients having cardiac events, but emergency nurses in these facilities receive education on how to identify and stabilize these patients, and there are processes for getting them to the care they need. Critical access hospitals without mental health resources should get the same type and targeted training to manage behavioral health emergencies that they get in managing cardiac emergencies. Recognition, stabilization, transfer are the three pieces. Mental health emergencies are as much of an emergency as a cardiac event in the sense that you still need to identify, stabilize and transfer to a higher/different level of care. Contingency plans for mental health care are at best hit and miss in the US. What kind of improvements would you like to see to increase mental health care availability to the US population? Better care available in communities, so BH patients have fewer crises that require emergency care Follow up and connection between acute care and primary care for BH Immediate availability of psychiatric assessment, treatment, stabilization, and disposition in emergency departments. In Australia, this is often done by MHPNPs (mental health/psychiatric nurse practitioners) who are in the ED or on-call with good results Expanded services for inpatient care and transitional care back to communities Improved and expanded training for emergency nurses in behavioral health Standardized protocols (core measures) for the care of behavioral health patients in emergency departments
  22. Mental health has a stigma. Nobody wants to talk about it because everybody feels like they are the only one suffering. I want the world to know mental health is important. I would like to give mental health a platform and an open and free space to talk as loud as it wants. There is nothing wrong with feeling "out of sorts". It is how a person copes with the "out of sorts" that makes a difference. Society needs to start communicating on how they cope with stress and anxiety. Learning from each other is important. Though no one talks about it because being "out of sorts" is taboo. I want to help facilitate an open environment for the discussion of mental health. Providers, and society in general, are more apt to talk about diabetes, high blood pressure, or high cholesterol. When anxiety, depression or eating disorders is mentioned a hushed tone appears. Almost a look of failure appears on the patient's face. Like they are not "good enough" to be "normal." I want us to shout from the roof tops we are all have a bit of "crazy" in us. We all handle the "crazy" a different way. Maybe we need to not work as many hours at work, how about exercise, or maybe a day at home in bed drinking hot chocolate watching the movie "Frozen" and learning to just "let it go." Life is how we perceive it and society needs to perceive mental health as an open and free topic to discuss. We are a fast paced, over worked, understaffed and under paid society. Companies have yearly goals and growth expectations. Employees are pushed further and further to perform faster and more efficient. Days off of work are shied upon. Nobody has "time" to be home from work. Vacation is now used for "sick" days. Now being sick is a punishment to not be able to go on a well deserved vacation. This leads to more stress, anxiety and fatigue. Leading to a hostile work environment, anger with our co-workers that are able to keep up and frustration that we have to work harder for the coworker that is out "sick" for the day. I find many in my office wanting something to calm them down. Something to help them "focus." Something to allow them to work 60 hours a week, be a mother/father of kids, keep the house spotless and be "involved" in school activities. I start the conversation with "why is all of this so important and what can give to help you cope?" Most of the time the answer is "nothing can give I HAVE to do this." I then discuss "pills don't teach skills." As a society we want to "pop a pill" to feel better without trying. We have to stop looking to pills to cure our insecurities. Medication has a role, don't get me wrong, but we need an open and honest dialogue to help those that struggle know they are not alone. Keeping up with the Jones's or I guess now it is the Kardashian's, is our societies downfall. The "reality TV" should really show what is behind those walls. A torn family, alcoholism, drug abuse and chaos. The nursing field needs to step up the game to help facilitate the mental health dialogue. Care and compassion is the focus of nursing and we as a profession are unique to open and guide the "acceptance" of mental health in society. Please take a moment to sit back and reflect on how you, as part of society, can help transform the mental health discussion.
  23. Working in psychiatry as a nurse is a challenge, to say the least. As a travel nurse, it is possible to take a new contract every 2-3 months which means 4 new employee orientations a year. Yikes! Being THE new nurse is not easy. How To Make Teamwork a Priority Teamwork is of the utmost importance to maintain safety. A safe unit means the day will be a good one in psych nursing . We get accustomed to our coworkers and their ways, as in any job. The goal is making your day go as smoothly as possible for you and your coworkers. You are spending forty hours a week together so this is crucial. You build a bond and a routine together. Then a new travel, temporary nurse comes in. This can be a challenging for the staff. You can also be replacing someone they enjoyed who was unfortunately fired or is even ill. This can make for a difficult transition. Even if you are just filling in because the unit is short staffed: still a challenge. You are filling gaps in the schedule but must prove yourself worthy! How much experience? Travel nurses are required to have 1-2 years experience in their specialty. When you arrive to this new facility, you are pretty much determined to be competent enough to function with basic training of policies and their EMR system. There’s an unspoken competitive edge due to this. You have to enter the position with the attitude of: I can handle anything you throw at me! You are firstly asked, “Where have you worked before?”, once you walk into your unit. I believe this is the staff sizing up your experience. They want to know if you are up to par with the expectations of their unit. Can you keep up with the workflow? Will you know what to do during a crisis? How to Please Both Staff and Patients? The second step, despite being in a new place with a new process, can you still provide patient care, with knowledge combined with compassionately? This is one of the biggest challenges. The duality of pleasing the staff and the patient seems to be a tough one. You do not want to step on the toes of the nurses you have just met. You will have to work with them for at least three months. A shaky start will not be helpful. In situations I am involved in during the first week or two I remain laid-back. I will offer advice if a situation is unfolding in front of me. Sometimes the nurse proctoring me may be unsure of what to do But I’ll still tread lightly. No one likes a know it all. Once you overcome this short period of conflict with-in, you feel more at home. You can then voice your opinions about plans of action, within crisis and even discharge plans. Crisis? Now this leads to managing a crisis. I remember intervening my first day of a new contract. A staff member was getting punched by a patient and luckily I was able to safely intervene and diffuse the situation. I immediately proved myself to the staff and they were happy to have me. That’s not always the case. Once you are comfortable, and one of your patients are in crisis, your skill set should really come to play at this moment. It will show the staff that you are more than just a fill in, but someone who is a skilled nurse and there to work hard. The ones who just fade into the background during a crisis because they are a travel nurse make a bad name for travelers. Don’t be that person. Most importantly, providing the best patient care daily stands out the most in any unit. Putting the patients needs first will always help avoid a crisis. Let’s not forget that also. A jovial, warm approach succeeds all when doing psych travel nursing! Cheers. What do you do as a psych travel nurse to make the transition smoother?
  24. madwife2002

    Let's talk about Depression

    Depression touches most people's lives at some point; like all illnesses it has no consideration for age, race, gender or status in life. Depression can creep up slowly or hit you straight in the face when you least expect it. For many people, especially those who have always considered themselves strong and able to manage without support or help, it is a shock often taking a long time before they identify themselves as being depressed. It is comparable to the grieving process and there are several stages, before you accept and come to terms with the diagnoses. After all is it not the weak, uneducated, lower classes of our society who have mental health issues, isn't it? When the Doctor first informs you that you are depressed, sometimes it is a relief that the way you have been feeling actually has a name, then you may feel embarrassed because there is a appears to be a stigma attached to the diagnoses of depression. Years ago people who were diagnosed with a mental health problem, were often shunned and shut away from society. Up until the 1960's/1970's you could have been institutionalized if you had been diagnosed with depression, some patients were locked away for all their lives because of this diagnosis. Often depression was mismanaged, doctors would feel it was a waste of time dealing with patients who were unable to help themselves, after all they had much more serious illnesses to deal with. Often they would send patients away with mind numbing drugs and no follow up. Surprisingly in the year 2012 scientist still don't completely understand the brain, and they will openly admit that whilst they are able to send a man home without a heart and an artificial one on his back, the brain remains a mystery. I don't think we will ever see the day when the brain is removed and an artificial one replaces it. Although I know somebody somewhere is inventing an artificial brain and a scientist will be attempting brain transplants sometime soon. Depression is like a poison slowly polluting your mind and life, you know you shouldn't feel so negative about all aspects of your life but you can't stop the overall feeling of dread and misery. You are told by well-meaning friends and family how lucky you are to have such a wonderful life, which makes you fear worse because you know you do but you cannot see it clearly. Life becomes a drag, you get easily annoyed with situations and people, you no longer care about your appearance, you feel life is miserable and you have no control over situations. It is embarrassing for a lot of people and often they won't admit to anybody that they are or have been diagnosed with depression. Many people with depression do not discuss it with their own family and friends, they will hide it from co-workers and bosses fearing the negative way it may be received as people often have strong opinions regarding depression. Marriages are strained; friendships are ruined because you no longer want to interact with people. You don't want sex, you find fault with your partner, you may even want arguments as this can reinforce and support your feeling of misery. You can however hide that you are depressed and carry on a 'normal' life. You can get up and go into work but you may be very short tempered and quick to anger when things appear to be going wrong. Often you look on a situation negatively and can see the solution as quick as you used to, often you cannot see the end result and get stuck in the middle. Relationships at work can suffer badly, especially if you are always 'the naysay' of your team. The important relationship with your boss can become strained, you may say things you regret and they may come back to haunt you. I often say I pick my battles but when you are depressed you do not pick your battles wisely. Although the media is now more understanding the way it portraits depression, a lot of people remember back in the day when somebody was diagnosed with depression they were started on medications that made them zombified. Then shock and horror these patients then became addicted to the medication which had terrible side effects. Today modern medicine has improved; different kinds of medication are available to treat the many kinds of reasons which cause depression. Counseling is offered alongside the medication and although not everybody will benefit from counseling it is something which should be encouraged. Why do we become depressed? For some people it is because they have had a serious illness, others some sort of accident, death and illness of a loved one, work stress, loss of job, money problems and for some it just happens. It can be a small trigger or it can be a large one, for some it has always been around but they were just able to control it better than others. I became depressed after we moved countries and 8 weeks in had a serious car accident which caused me to become desperately homesick, we didn't know anybody we had no support mechanisms in place yet and we didn't understand the system or culture of the US. I often laughed at people who said they were homesick not giving it the correct respect it deserves. Homesickness is real I know, you feel miserable almost like when your first boyfriend finishes with you and you see him with somebody else. You don't actually know what you are missing but you miss it. It wasn't perfect but you are now placing it on a pedestal. You feel like somebody has died music reminds you of time and situations, you left behind. I was homesick for 4 years, can you imagine wasting your time being homesick for 4 years! Then we moved states and I found myself settling down in a new place which was a more suitable family environment for us. My homesickness became a thing of the past, and only reared it's ugly head at certain times of the year. For a couple of years things went ok, there were issues with my job but it was doable. Depression was still around but I had placed it on the back burner. Then I got a manager from hell and my whole world tipped upside down again. This manager made my life a misery; I became extremely depressed although now I was blaming my feelings on 'change of life'. I was quick to temper and actually mismanaged my work life and although this manager was awful, it became about me! I went to the doctors actually to be signed off work with a mystery illness, when he diagnosed me with depression. I wasn't surprised that he thought I was depressed I was happy that he was going to give me medication which would help me feel better as I was tired of feeling so bad. I started on medication which turned my life around, I lost weight which was intensifying my depression and I took back control of my life! Around the same time I had seen a chiropractor who actually helped me to become pain free for the first time in 7 years, pain that was caused by the car accident back in 2005. I would like to tell you this happened quickly it didn't it took a year, yep one whole year and I am still working on repairing the damage to my reputation. I have a new manager who is very supportive, the old manager is still around but more and more each day it has become obvious that she is incompetent. I don't need to be involved anymore and I actually smile at her when I attend meetings she is at, and I am sorry because of my depression that I didn't manage my manager better and more appropriately.
  25. NurseDirtyBird

    Mental Illness Can Be Terminal

    Dentistry has the highest rate of suicide by occupation, right? According to the APA, studies show that occupation is not a predictor of suicide risk. In one study of suicide rates between 2001 and 2005, dentists did not make the top 30 at all, for men or women. However, female nurses made the list - at #30. Age, gender and ethnicity tend to pose more of a suicide threat than occupation (Link to the chart High-risk occupations for suicide). White Americans and Native Americans are more likely to commit suicide than those of other ethnicities in the US. In all age groups, men were more likely to commit suicide than women, although women were more likely to attempt suicide and fail. According to the NIMH, "Older Americans are disproportionately likely to die by suicide," even though suicide was the third leading cause of death of people ages 15-24 in 2007. For example, 12.7 young adults age 20-24 of both genders, out of 100,000 committed suicide. At the same time, there were 47 suicides per 100,000 85+ year old white males. It goes without saying that most people who commit suicide are under the influence of drugs or alcohol. These are attempts at self medication that have apparently failed. Other risk factors include a history of abuse, chronic illness, chronic pain, family history of mental illness and/or suicide, and previous suicide attempts. Suicidal ideation is just an attention getting tactic most of the time. Sort of. Most of the time, suicidal ideation is a cry for help. The person disclosing these thoughts is in extreme distress and can think of no other option to relieve their suffering. Life sucks. It's hard. Only cowards and weaklings "opt out." If suicide is merely an act of cowardice, then so is pulling your hand away from a burning stove. Most people who commit suicide or express the desire to do so, are in extreme emotional pain and death seems to be the only relief possible. The fact is suicide is what makes some cases of mental illness terminal. Over 90% of people who commit suicide are afflicted with a major mental illness, including but not limited to major depression, bipolar disorder, schizophrenia and PTSD. You just need to think positively. Cheer up! Stop being such a downer. Count your blessings! Think of all the people in the world who have it so much harder than you! NO. Mental illness does not work that way. You cannot wish your way out of it. Disordered thinking is pathological and a symptom of an actual, real illness. Just because it isn't visible on the outside doesn't mean it doesn't exist. It's real, it's painful, it's disabling, IT KILLS PEOPLE. If someone had terminal cancer, you wouldn't tell them to think of all the people in the world who had worse diseases, would you? Suicide is selfish. Yes, it absolutely is. A person who can think only of suicide is thinking only of themselves. If you had a broken leg, you certainly would not be thinking of your family and friends. You would be thinking about nothing but the horrible pain you were in. Same concept, different pain. If you keep guns out of homes, people will be less likely to kill themselves. Yes and no. Firearms are linked to more COMPLETED suicides. Of course if there are access to guns, that will likely be the weapon of choice, and they are far more reliably lethal than almost anything else. If you keep guns out of homes, you keep people from shooting themselves, but there's always the rope in the garage or the aspirin in the medicine cabinet. If we don't talk about it, people won't get the idea to kill themselves. If you keep mental illness and thoughts of self harm or suicide under the covers, you're never going to know if someone close to you is ready to die. Talking about it is one of the first steps in preventing suicide. You can't stop someone from killing themselves if they really want to. Again, yes and no. If someone has confided suicidal thoughts to you, you CAN stop it by getting them help, because they've essentially begged for it. A situation like this is an emergency and should be treated as such. Do not leave them alone, call 911, get them to the ER, call a crisis line, and take away the means - guns, knives, medications, etc. They need the intervention of mental health professionals. There is always the possibility that they may walk out of the hospital and kick rocks on the train tracks until the 0315 comes along, but you can't control other people, and sometimes they're going to get their way. I don't want this to seem like I am relieving suicide victims of all responsibility, because I'm not. People suffering from mental illnesses are unable to think clearly, but it's still up to the individual to choose to ask for help if they are capable, or to end it all. I hope this was as much of an educational experience for you as it was a therapeutic experience for me. I've included links to my sources and other resources as well for further education. Resources American Association of Suicidology http://www.afsp.org National Institute of Mental Health Suicide by profession: lots of confusion, inconclusive data