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  1. Many years ago there were insane asylums. Some were so bad that we even got a new English word to describe mental illness based on the facility, Bedlam. When I was a child we had State Hospitals. They were filled with people who did not fit well into society. Some were severely developmentally delayed, they were called retarded, idiots, imbeciles. These were real classifications. Now we see these words as swear words. I am hesitant to even write them. Others in these institutions were alcoholics, usually late stage with what was known as "wet brain", also known as Korsakoff's Syndrome or the earlier stage of Wernicke's. The next category I recall were those who were asocial or had poor social skills. Many were very passive and followed directions well. All they wanted was to be left alone. The most difficult to care for before the mid 1950's (before my time) were those who had what we traditionally think of as "mental illness". Schizophrenia, especially those with hallucinations, catatonia, depression, paranoia, and associated symptoms were common. There were some very dangerous individuals. My first job included some of these individuals. Most were not dangerous, as is the norm with people with mental illnesses. One patient, Mr. C, frequently tried to purchase guns through the mail. We were allowed to stop this mail from going through. He was one with poor impulse control. There was once a bee in the common area. He picked up a solid metal chair to throw and attempt to kill the bee. This chair weighed a great deal but that would not stop this man, even in his 70's at that time. He could not take any of the "normal" antipsychotics of the day. Mellaril, Thorazine, and Stelazine. Haldol was just coming in at that time. He could take nothing because he had been so heavily medicated in the past his liver was on its final go round. Life in the old psych units must have been interesting. I am too young to recall wet sheet treatment except when I was the instructor we, my second year students and I once saw it used for a pregnant woman. It was torture, from my vantage point. Of course when it was used it was one of the few treatments used and found to be somewhat effective. As a young grad I saw those who had been through the lobotomy treatment. Zombies might not quite be the right word. One could not control his body temperature so every once in a while he would spike a temp of 106 degrees. Another, who was non-verbal, common with our post lobotomy patients, would regularly take off all his clothes and bless his manly parts. I was young at the time and shocked. People recognized how dysfunctional these human warehouses were and eventually they disappeared. The thought was that many people in there did not need to be hospitalized. They were capable of self care. At around the same time the Vietnam War was ending. We saw many veterans returning with many psychiatric illnesses, most not seen in the VA system because the old VA system was not user friendly at all. I know there are still long waits and appeals are difficult but in the old days, soldiers did not have mental illness. We still see that attitude in some military areas even today. So we had an influx of veterans back to the states at a time when the war was not very well accepted. Protests were common. It was the first televised war. Our veterans, who had a new kind of fighting to deal with, who had seen too much, been led by people who did not understand the enemy came home to a place that rejected them. "Fragging" an officer was not uncommon so many of these returning had multiple layers of pain that became toxic, some called it PTSD. At the same time drug culture was gaining new converts. The war on drugs started and every person with a lick of oppositional behaviors tried drugs and many became hooked. Before this time drug use was more limited to certain jobs, cultures,and classes. Soldiers in search of relief from their PTSD symptoms started to use these same chemicals. This is a bit of the history of mental illness treatment. Next installment of my nightmare will consider more modern ways of dealing with mental illness.
  2. I had a sneaky suspicion that the frequent hand-washing may point to OCD (obsessive compulsive disorder). But, I tried to rationalize the issue and wondered if perhaps the constant hand-washing was caused by some transient anxiety about an upcoming project at work. Everyone reacts differently to stress. I started asking questions. He insisted everything was fine...work was very busy, but good. However, while he was talking, I could actually tell by his body language this didn't appear to be the case. He continued talking and said something about being bothered by new housing construction in his neighborhood. He said he read on the internet that certain building materials may contain asbestos or cause cancer. He also expressed uneasiness about the dust being stirred up. I reassured him that asbestos was no longer allowed to be used in new housing construction. I suggested he request an MSDS (material safety data sheets) or PSDS (product safety data sheet) from the construction manager to confirm this information and set his mind at ease. I could tell he wasn't really hearing what I was saying as he continued to re-hash these concerns over and over again... I realized his psychological issue was much more serious than originally suspected. As time progressed, I observed additional behaviors and rituals. He insisted on a "no shoes in the house" rule. A lot of people don't like to have shoes in their house, at first that didn't seem to be a big deal, I figured. But then, there came a number of other rules / rituals / behaviors. Purses or bags were not allowed to be placed on the ground, table or counter. They had to be hung on the back of a chair. Any other item that had previously touched the ground couldn't be brought into the house unless that item was enclosed in some sort of bag (plastic or paper). Then the outer bag had to be discarded or left outside before that inner item could be brought into the house. I then started noticing when he sat in a chair, he would lean slightly forward, holding both hands up in the air, perpendicular to the ground. The way my surgeons hold their hands up in the air to keep the contaminants / micro-organisms off their hands following their surgical hand-scrub prior to surgery as they make their way into the surgical suite into the OR in my department. He wouldn't even shake people's hands and had a particular manner regarding how he touched objects. One time, his wife asked him to bring some food items in from their car for a BBQ for a family reunion. I watched in silence and agony as he awkwardly strained to open the car door to get the items of food / bags from the car only using his pinky finger or forearms, rather than his entire hand...I realized then that his OCD problem was very, very serious, whether HE wanted to admit it to himself or not. I had a bad feeling this was going to be a major up-hill battle, and knew these issues needed to be addressed asap. I wrestled with knowing exactly how to approach this situation as confrontation is never easy. This is especially true with males as males are standardly less likely to even admit they have a medical issue, let alone a psychological one. However, this was a very, very close family member whom I dearly loved. This was someone who had always been there for me, and I for him....when we both were little and I didn't have any friends, he was my best friend... when he couldn't tie his shoe, I showed him how to tie them...when I was bullied by other children in school because of a slight learning disability and speech impediment, as we walked home from school, he would tell me jokes to stop me from crying. He would tell me "they don't know what they're talking about..you're not stupid, you just learn different"..and "you sound fine to me"....and, when the older boys would shove him and steal his school lunch, I always helped him up and gave him half of my lunch so he wouldn't go hungry. We both would do anything for each other as children, and...I know he feels the same even today. So why would the approach to this issue be any different? Knowing this individual clearly had a serious psychological issue that appeared to be getting worse, I was not going to let him suffer without trying to do everything possible to help him. Although this individual usually took my advice regarding many, many things, confronting him regarding his OCD was the most difficult thing I've ever done as I wasn't exactly sure how he was going to react. I set up a time to talk with him alone and presented my observations in a gentle, caring manner. He, of course, initially denied he had an issue. Some people may initially deny they have a mental health issue because they not only have a hard time accepting they have a mental health issue, but they may also feel there is a "stigma" attached to being diagnosed with a psychological problem as well as seeing a psychiatrist or psychologist. Some males may also have difficulty accepting that they need help as it may also make them feel that "needing help" makes them appear "weak". Although it took a lot of convincing, in the end, he finally broke down and agreed that he actually did need help. He stated he actually couldn't "stop the thoughts in his head" regarding the hand washing and all the other behaviors. He said the thoughts were like a broken record that kept going around and around, and just didn't stop playing in his head. He finally saw a psychiatrist and was diagnosed with severe OCD. He was successfully treated. OCD is a lifelong illness. Although this issue was treated and his symptoms went into remission, this is an issue that he, and many others, will continue to struggle with the rest of their lives. Thought for the day: Intuition / insight can provide the opportunity to make great improvements in lives and health of others by remembering to address the absolute (physical, emotional and mental) needs of the individual.....
  3. 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.
  4. 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.
  5. spotangel

    I Lost My Baby And My Phone!

    The night Nursing Supervisor was giving me report. I was taking over half the hospital including ICU, CCU, ER, LR, NICU, Postpartum and a bunch of other units. The supervisor told me about a patient who was on one to one observation and security watch. During my rounds I went to her unit. I spoke to the nurses who were all having a rough time with her for the last few days. I could hear her yelling at the top of her lungs demanding her phone and her speech reminded me of the Jerry Springer show! Every second word was a curse word! She recently had a fetal demise and had multiple psy hospitalizations in the past. I was told that a situation developed the day before and security watch was initiated along with one to one observation. The father of the baby was barred from coming in and as he stirred up the patient and set her off every time he was at the bedside or on the phone with her. Finally the situation became so hostile that he was barred from coming into the hospital.She was refusing medications and was very labile. The doctors wanted her to sign a behavioral contract before the phone was returned and she refused. The nurses went in and offered medications for agitation and she refused. I walked in quietly into the room and introduced myself and shook her hand. She looked me up and down. I softly told her, " I am so sorry for your loss." I asked her if that made her sad and angry. She nodded her eyes never leaving my face.I asked her did it feel like a hole in her heart? She nodded again, her face crumpling. I then looked her straight in the eye and asked, " May I give you a hug?" She nodded. I took out my ID from my white coat, laid it at the bedside table along with my report and stepped closer to her bed. I opened my arms and she fell into them sobbing. I held her murmuring reassurances and acknowledging her loss. I told her that she was a brave and strong woman and would get through each day, one day at a time. I told her that it was ok to get sad and mad after losing her baby but it was not ok to hurt herself or others in the process. I requested her not to hurt herself or others. I looked behind me at the staff and the security guard and told her, " All these people you see are here to help you not hurt you. You have to remember that every day they get up from their warm beds and come out in this cold weather to the hospital to help patients like you. They have families that want them safe home and the end of the day. So please don't hurt my staff or yourself". She nodded and smiled through her tears. I was struck at how that smile transformed her face and commented, " How pretty you look when you smile!" One of the staff commented that she also had a beautiful voice and could sing! Now that she was calmer, I asked her if she would sing for us. After the initial bout of shyness, she started singing, "Amazing Grace how sweet the sound". She sounded like an angel! I joined her in the second stanza and so did half the staff there and the security guard in his baritone! It was a beautiful moment and there were a lot of smiles and tears! I thanked the lord in my heart that he choose to change an ugly situation into something beautiful that we could all relate to. I went back to the nurses station and asked security to bring up her phone.We convinced her to sign a behavioral contract. Although she was upset that she could not keep the phone for long periods of time, we reassured her that it was all dependent on her behavior. The charge RN convinced the doctor to leave her phone with her for the time being as she was calm playing on the phone and reaching out to family. She also wanted to see pictures of her daughter who had died who she had named Lilly, that she had on the phone. The last I saw her, she was quietly playing on the phone. I left the unit satisfied that she was in safe caring hands.
  6. TopazLover

    The Nightmare Part Two

    Currently we have jails to provide a majority of mental health services. In other words you may have to get into the penal system in order to get any mental health care. Is this really mental health care? Do we find skilled treatment savvy individuals? Yes, some are. Many of these individuals are recovering addicts who work with those addicts who wish a shorter sentence or real help to stop using. Guards are not psychiatric workers. Their training is in control, not assisting an individual to develop better mental health and better coping skills. Those with mental health problems will most likely be given a drug to make sure they are manageable. If someone is drugged enough there is no way to commit suicide, one of the black marks on any prison guard shift. How is mental illness identified? Schools are given the job of identifying youngsters who are out of the Bell-shaped curve for behavior. Parents are encouraged by doctors and schools to medicate active children with diseases known only by initials. I know there are children who need assistance but we seem to have allowed the drug companies to determine when enough bad behavior is enough. Parents are pushed to have their children fit into molds of the community norm. If in an area where soccer is loved the child who is not into soccer is considered awkward,asocial, and strange. If it is an area where dance by a male is frowned upon expect bullying to take place. Conforming seems to be the goal of all I have discussed. Isolate those who do not conform and find ways to hide them or make them conform. So far, we do not have a mental health system to deal with the brain illnesses that we now know are partially, at least,responsible for mental illness. Those who suffer continue to be treated as outcasts, viewed with disdain, and in many cases the continuation of bullying is the norm. We treat mental illness differently that other illnesses. The excuse given is that it is too expensive to include in insurance. Without insurance it is very difficult to get real care. Psychiatrists are at a premium. There are not enough and the ones that exist,in general, only want big money clients either through self pay or partial self pay with insurance. So, one result is that people with mental illness, especially chronic mental illness, cannot get comprehensive care. And we are shocked when it bleeds into the rest of the country. Now it is a national nightmare. We need changes in our view of mental illness and quickly. There are other voices being heard: Real voices not hallucinations. Do not let these voices become quiet. Do not let them become silenced by those who are afraid. Speak up to those who count the pennies it costs to care for mental illness properly rather than the millions it costs to keep non-violent mentally ill people in jails. Let no child be diagnosed by those who are not trained while the individuals who are trained are let go in school districts as "too expensive" I was asked what my nightmare was. My nightmare is that we continue down this path of conformity with the exceptional child being singled out as odd. That we continue our current thinking that teachers, nurses and psychologists are not worthy of living wages while we putguards in schools. As we continue our quest for conformity somehow we have lost the wisdom given down to us that to move forward one must go beyond thinking like every one else. The person must have a basic education that encourages creative thinking and action. My nightmare is that we used to warehouse people for not fitting in to a prescribed manner of behavior. We did this because we did not have the education, knowledge, skills and experience to find other ways of dealing with those who have mental health issues or those who did not fit in well for other reasons such as delayed developmental skill acquisition. How is our current system any better? We now call the warehouses "jails" rather than"Bedlam" or "insane asylums". We keep no-violent people with violent offenders. We jail people for longer times than any other developed country. We create a whole cadre of people incapable of living in the "outside" world. We have created a "nanny state" for these people who lose valuable skills. They cannot cook for themselves. They have no idea of real costs in the outside world. We stigmatize those who have been jailed so future employment is more difficult. We create a system that is self perpetuating by making sure those who are jailed cannot make it in the outside world. My nightmare is that people will not heed the call to get better mental health assessments in schools. They will continue to rely upon the penal system to house those they find unacceptable rather than look at the person and find answers to keep that person out of a system that continues to punish those with mental illness. As each person with mental illness slips through the cracks in our current systems we are in danger of the minute percent of violent mentally ill people not diagnosed. Not diagnosed because we have removed those people who might have seen the early sign posts: the experienced teachers,the nurses, the psychologists in schools. We have consolidated schools to try to save money and instead pump more money into jails. This is a call to those who find mental illness hard to understand. Open your mind and your heart. People with mental illnesses don't choose it anymore than a little person chooses to be small. It is genes and environment and we are just learning the rest of what mental illness really is. It is a call to those who have not noticed how expensive it is to continue to fund and build more jails to care for the mentally ill. It is a call to those who have looked down on those who have been in jail and decide they do not deserve a chance. In short, my nightmare is that we all have become so institutionalized so as not to see how we are pushed into a conformity that will be the end of our ability to move forward as a nation.
  7. Mental illness is a most misunderstood illness. The brain is an interesting organ, and reacts differently to/or lack thereof chemicals to make it work properly. Mental illness can be a difficult thing to treat. It can be equally challenging for a nurse to provide care. However, here are some common myths/insights surrounding the mentally ill that will perhaps make a nurse take pause the next time you are given an assignment of someone suffering from mental illness. 1. Schizophrenics ABSOLUTELY believe their delusions to be true. They don't make this stuff up. They believe that the government is watching them as much as one believes the grass to be green. So by saying "Oh, that is NOT true, stop it" you are not helping. To help in a alternate way, saying something like "let's talk about right now, and what we need to do now" can be enough to direct a schizophrenic patient into the present to be on task. It can be hard to keep a schizophrenic on meds. For the chronically long term schizophrenics, it is the only "normal" they know. 2. "I think I am having a nervous breakdown". Mentally ill people who are chronically and severely mentally ill believe themselves to be perfectly sane. It is the rest of us who are "crazy". Anxiety disorders are the most common cause of "I think I am dying/going crazy thoughts. 3. Mentally ill people are not ignorant, less intelligent, or unable to live a "normal" life. Mental illness does not equate stupid. It is not a character defect. 4. "I don't understand why you are depressed. There's a heck of a lot of suffering in this world and other people are coping JUST fine". People don't ask for depression. People can not just "snap out of it" or believe me, a number would. Most people who are depressed would do just about anything to feel well again. It is an exhausting illness. 5. People who are bipolar can tend to lean toward mania. The feeling of being on top of the world. A number of patients who abuse uppers are in fact bipolar. Reasoning includes not enjoying the downward spiral that a bipolar patient experiences. Another mentally and physically exhausting mental illness. Support for drug addicted patients should include a consult to rule out bipolar disorder. 6. Post Traumatic Stress Disorder is a multitude of symptoms under one heading. One of the most "dreaded" for some is the personality disordered. This is a tough one, however, if the nurse can keep in the back of their mind that in fact PTSD is the effect of trauma. Severe enough to cause the personality portions of the brain to not function properly. These patients have seen horrors that only most of us can ever imagine. That they have the fortitude to be alive is telling. That they can act child like is equally as telling as to when their abuses began. There are members of our armed forces that have severe PTSD. Again, remember--horrors that we can only imagine. 7. Children who are mentally ill are not automatically products of poor parenting. "Well, that kid could use a rule or 2 and a swat on the behind". That can't happen. People can not hit their children into submission, nor should they. If a child's brain is not functioning as it should, rules are gibberish. Support and coping skills for parents are equally important. Team meetings detailing support and exactly how parents are to re-enforce learned coping skills are a must. Nursing mentally ill patients can be a big challenge. Often, if we change how we see a patient who suffers from mental illness it can make leaps and bounds on how we can help each patient reach their full potential.
  8. "...found the road to nowhere"....addiction, a road that crumbles underneath you and isolates you more the longer you stand on it "Hold me now"...a cry for help, an acknowledgment of fear, a realization what one must face "I'm six feet from the edge"...despair and facing one's potentially painful climax towards resolution "Maybe six feet ain't so far down"...denial of either the difficulty or what one must face (Based upon Creed's song and video, Six Feet From The Edge) The main character is singing while standing upon a crumbling cliff edge, falls in a free fall until he hits rock bottom, faces a sand storm, then meets a woman who presents him a bowl of water containing her tears, as he looks on to view the face of the demon of his own making. At the end of the story, it is discovered that he is found once again standing upon the cliff, the fall was merely a fearful image he had. Instead of facing his fear, he chooses instead to stay planted upon the cliff. In denial, he clings to the belief that he is safer than moving forward. As a result, he stands alone, empty, and suffers. The fear of falling, going over that edge and hitting rock bottom, which the main character fears doing... imagining the worst, his outcome. The video of this excellent song portrays a path of Recovery from addiction... from whatever demon has you. Like the character, it often entails facing that very edge, hitting rock bottom, then facing that demon found in one's pit of despair (the symbolism of the vid). In genuine recovery, it is often an intimate, inward, solo journey...despite the anxiety of the free-falling, eventually coming to trust the process. The main character then sings out "...cause I still believe there's something left for you and me." A belief in something worth saving...something more than oneself. Hope...a future place more grounding and stable than standing on the current precipice. Hope provides that additional energy to sustain us, to move us forward. He comes to realize this from staring into a bowl of water, containing the bloody tears of those he has come to hurt. Yet, his recovery is his own journey. No one else can do it for him. However, as the story goes on, he actually hasn't fallen over his edge yet or hit his rock bottom as evidenced by the end of the video...he is right back at the beginning where we first met him, just teetering at the edge. Denial holds him back from what he must face, as his demon waits down below. The video then ends by his singing, "...holding on to all I think is safe." Denial at its best. In this sense, the cliff becomes nothing more than a reflection of himself...his isolation, his pain, his fears. In his shame as he looks away and downward, he holds back from what he must do for himself. The message is very deep...if not personally relevant for us all. We all have our cliff we must face...our personal crisis moment. And when facing it or leaping off it, often all we have left is our blind faith to propel us forward...not looking back. It is a cutting of the strings or the chains of our addictions...our personal weaknesses. It is a process of allowing them to die in our life in order to permit new growth. A secondary message from the story is why wait...why wait till you are "down to one last breathe" or at your worst...before you begin taking that leap of faith in a new direction? How many more tears must one cry or how many tears must be shed by another before the ball gets rolling? This is a question only one can answer for oneself. If you are a nurse in recovery, consider this little post a resting spot...a spot to give thanks and to take some time to reflect honestly...how far you've come and what must yet be done...as you also honor those who seek the same. It is also a time to appreciate those who you have in your life right now and to be grateful for them. It is not an easy road...but can be made much easier if we respect ourselves better and those who continue to touch us. Peace
  9. Dementia is not a specific disease but it is a general term for describing a decline in cognitive abilities (Alzheimer Association 2017). Dementia depicts a group of symptoms affecting memory, thinking and social abilities severely enough to interrupts daily functioning (Mayo Clinic 2016). According to the Alzheimer's disease International (ADI), the estimated number of people living with dementia is 46.8 million people worldwide and this number will be doubled every 20 years, reaching 74.7 million in 2030 (ADI 2016). Persons suffering from dementia usually suffer from under-recognition and limited capacity to express pain and discomfort and consequently, this affects their quality of life (WHO 2016, NHS 2013). Due to the deteriorating communication abilities within dementia patients, sometimes pain is reflected by different verbal and nonverbal expressions. Frequently, the lacking expression of pain could lead to physiological and psychological distress among patients resulting in what is described by dementia care providers as challenging behavior (McAuliffe et al 2012). Literature highlighted pain as a main reason behind patients' struggle and discomfort (Shega et al 2007, Horgas and Miller 2008). Pain can be caused by chronic conditions such as arthritis and vascular diseases among elderly or other conditions such as pressure ulcer, falls, cancer and post surgical (McAuliffe et al 2012). Signs of pain among dementia patients include distressed facial expressions, agitation, restlessness, anger, discomfort, confusion, crying, limited activities and disturbed sleep (Achterberg et al 2013, Alzhiemr's Australia 2011, Horgas and Miller 2008). However, Horgas and Miller 2008 argued that signs of suspected pain in dementia patients such as vocalization, breathing, and body language could be referred to factors other than pain such as anxiety or cold. They asserted the need to reevaluate the patient several times along different days if one of these symptoms existed. The WHO 2016 alerted that human rights of dementia patients are violated repeatedly due to the frequent use of chemical and physical restraints even when legislation to protect the patients are in place. As a nurse, I recognized from different situations in practice that pain in dementia is not properly assessed or managed appropriately in many occasions. Although I was graduated as a bachelor degree nurse and studied nursing for five years in Egypt, I did not have enough information about pain assessment scales for dementia patients and how to maintain comfort for those patients. Even, I used to assume wrongly that it is normal, sometimes, to find dementia patients agitated, angry, restless, crying and even restrained especially in places as intensive care units. However, experiencing many situations with patients obliged me to search for more information to understand communication challenges with dementia and what might lead to such anger or restless feelings among patients. I felt responsible to develop my knowledge and practice to achieve patient-centered care approach and respond to individualized needs for each patient. One of these situations occurred in an elderly care home where one of the residents who suffered from dementia started to avoid eating or drinking and even cry when food is served. The resident lost her communication abilities for several months and needed help in most activities of daily living because of dementia. Changing food type, time and quality did not help or improve the situation. The care plan for the patient started to include intravenous fluids and a decision was made by the medical team to start nasogastric feeding for the patient. The patient was given antipsychotic medications because of the increased agitation, distress, and restlessness. Finally, during the weekly medical check for residents, the general practitioner discovered an abscess in the patient teeth and that she was suffering from severe pain. This was one of many situations where the pain was at the heart of the scene with dementia but we can hardly recognize it or highlight its effect on patients. Situations from clinical practice influenced my career as a member in the curriculum development committee for health care assistants (HCA) programmes in Egypt. I assumed including dementia and pain assessment should be part of the HCA curriculum to achieve patient-centered care strategies and provide dignified care approach. I also believe that nursing education and HCA training programmes that are taking place in Egypt could be more patient-centered if decision makers and curriculum development specialists have a shared vision on the health care needs and worked to review and update the curriculum based on the upcoming need to service users and feedback from graduates based on their clinical experience. References: Alzheimer's Disease International (ADI). 2016. The global voice on dementia: dementia statistics. [online] available from: Dementia statistics | Alzheimer's Disease International Alzheimer's Australia. 2011. Pain and dementia. [online] available at: Helpsheet-DementiaQandA16-PainAndDementia_english.pdf Alzheimer association. 2017. What is dementia. available from: Dementia - Signs, Symptoms, Causes, Tests, Treatment, Care | alz.org Achterberg, W., Pieper, M., Dalen-Kok, A., De Waal, M., Husebo, B., Lautenbacher, S., Kunz, M., Scherser, E., and Corbette, A. 2013. Pain management in patients with dementia. Clinical Interventions in Ageing, vol.8, no.1, pp: 1471-1482. Horgas, A. and Miller, L. 2008. Pain assessment in people with dementia. Advanced Journal of Nursing, Vol. 108, no.7 NHS. 2013. Managing pain in patients with dementia. Hertfordshire: Clinical Commissioning Group.[online] available from: Mayo Clinic. 2016. Dementia overview. [online] available from: Dementia - Overview - Mayo Clinic McAuliffe, L. , Brown, D., Fetherstonhaugh, D. 2012. Pain and dementia: an overview of literature. International journal of older people nursing, vol.7, pp:219-226 WHO. 2013. Dementia factsheet. [Online] available from: WHO | Dementia
  10. 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!
  11. Many of us may have prior experience of someone close to us dealing with their own psychiatric issues. Many of us may have had psychiatric issues ourselves before walking into this field. As a result, this may often be our first contact with psychiatry, psychiatric nursing, or the issues concerning mental health. Regardless of the prior exposure, it is now time to tuck this away for a while. It is time for learning new things or restructuring the old things as you become now that effective deliverer of care. Yes, prior experience is something you can use, maybe to pull from later...emphasis later...in assisting a patient. However, your prior experience, in and of itself, is not enough to make you a psychiatric nurse...not even a good one. If that is all one has to fall back upon as a primary knowledge base, it may even hinder the new nurse from growing. In and of itself, it may possibly even render one ineffective. The issue of co-dependency comes to mind when I speak of this. So, at this time as a new nurse, it is time to set one's educational sights forward, not backward. Your learning is to become proactive, not reactive. The focus needs to be on you in the present, not your past exposure. So, what should a student nurse or a new nurse in the field focus on? There is no pat answer for this. The answers are as sweeping as the field of psychiatric nursing is broad. However, how one is coming to be introduced into the field as a professional may provide a starting point. Are you a student? If you are a student, is this a field that you simply have an interest in or is it something you plan to enter? Or, are you here just for getting the grade and hope to get thru it in one piece? Are you a new nurse now entering the field? If so, your needs are similar but different. It doesn't really matter much if you are a brand spanking new nurse or a nurse with 15 years under your belt transferring from ICU to psych...this field is a new world with different expectations. How am I entering this field? So, the first step is coming to realize for yourself: how am I entering this field, what are my personal and learning needs, what do I want or need to accomplish, and what is at my disposal to accomplish this? You are learning - Ask Questions After coming to realizing our starting point, the next step is to give yourself a break. You are learning. Many, if not most psychiatric nurses that you will come in contact with, realize this about you and are either very glad to assist you or very supportive of you in your growth. As a learner, ask questions...ask many questions. Believe me, for the most part, psychiatric nurses truly don't mind. In fact, they often want you to ask questions. Asking questions gets you answers. I truly cannot emphasize this enough. Beware of the student or new nurse who thinks that they know all the answers already, keeps silent, and asks little. If this is you, you need to change this. You don't know all the answers. You're not fooling anyone. Pick a mentor The next thing is to pick a mentor on your floor/unit where you will be having your training. This could be the person assigned to you as a preceptor and/or someone else. Developing an attitude of hunger for this mentor's knowledge is beneficial. Observe this mentor in action....how he/she carries oneself with other colleagues and with patients. Pay attention to body language, eye contact, distance, and the use of voice and choice of words. Sometimes, the best examples are played right out there in front of us. Observe interaction...relating. Truly, interaction is but a dance. As a learner, you are paying attention to the steps and to the tempo. This will serve you well as you begin starting to observe patients...their dance...their tempo. It will also provide you later insight into how the milieu is coming along on the unit as your perspective broadens. It will also cue you in (when on your own) that intervention on your part (or by someone else) may be needed before a patient escalates. Deescalations are much easier when they are but a spark. Resources The next thing is to absorb as much literature that you can handle. This field has been around for quite some time...there is good material out there for you to fill in these learning gaps. I call these gaps the technical things...like the psychiatric meds, the DSM nomenclature, policies, how to run a group, writing psychiatric nursing notes, et cetera. Again, while filling in these gaps, ask questions. Take notes. Explore the allnurses psychiatric nursing forum and ask questions there. The more concise the question, the better the answer. Have you noticed that I have said very little regarding patients and their issues at this point? There is a reason. When it comes to learning and starting off, you are only as good as your knowledge base. So, the focus needs to be on you. In psychiatric nursing, "not knowing" either will have you seeking further assistance or asking additional questions (the correct outcome) or will have you being detrimental to the patient (the incorrect outcome). When it comes to patients who may become violent or act out, "not knowing" can get you hurt (a very bad outcome). So, if you do not know...seek answers...ask...observe...get assistance... read... continue to learn as you grow into that professional psychiatric nurse. The process is never ending...even for the long term professional. At this point in time, you are at ground zero. Observation is your tool. Asking questions is your guide. Obtaining a mentor (or several) will provide you the support. Remember, all psychiatric nurses started at ground zero. You are not the first. Your job is to learn. And believe it or not, your patients that you come in contact with realizing this too. And if they can give you a break, so can you.
  12. I was so excited and grateful when I got the job. And although I don't have much experience with psychiatric patients yet, I do know that the issues I am expressing concern about SHOULD be taken seriously. The work environment is not very professional at all. Majority of the people are only there for a paycheck and it really shows in how they treat the patients and simply don't do their job. While training, my shift supervisor refused to give me any type of direction as to what I am supposed to do. Obviously, care for the patients, but when it comes to paperwork, needing help finding something or simply general questions to ensure that I am doing my job right, all I get is short, disrespectful comments as if I am stupid. But I feel that it is a legitimate question to ask about whether or not we separate or wash all patient clothing together or if we have any additional paperwork or tasks which I was not made aware of. I take my job seriously and feel like I should be taken seriously as well because I am still new and still trying to learn how things are done around there. But yep, I get those smart comments and have no time to ask any other questions before he walks off. Not only that, he disappears from the unit for sometimes an hour or so at a time and we are left unsupervised. And when he is actually there, he sits down playing on his phone or sleeping. I don't mean disrespect when I say this, but do you really call that being a supervisor? I don't. Moving right along though. As if poor leadership were not enough, majority of the other nursing assistants are just as bad and actually, even worse. The person I was training with said that they don't even take some of the vital signs but just write something down. I was like, "you do what?" And so I expressed my concern to the supervisor which in turn he said not to worry about it if I didn't know how to take them. #1, vital signs are VERY important when it comes to monitoring a patient's condition. How is the nurse supposed to catch on if something is wrong when he/she doesn't even have an accurate baseline to go by? Honestly, that puts the patient at risk and I feel that it also falls under neglect as well. #2, you are saying it is okay for them to make up something to write in the patient's chart which I am pretty sure falls under false documentation. Big no-no! So I did report this up through the chain of command, mentioned it to the nurses myself because I feel that it's important for them to know, and I haven't heard anything else about it. But there was also some other issues which I reported to the supervisor as well. A pt made allegations of being threatened and emotionally abused. (Pt did not use these terms, but that's what it falls under.) The allegations were brushed off and I was informed that the pt "lies" all of the time. However, part of me was still suspicious because my gut was telling me differently. And as I just found out, another NA said she was present when this was actually said to the pt. So as it turns out, the pt was not lying to begin with just as I had thought. I mean, why else would the accused NA tell the pt to shut up and that I don't care about what goes on in her life? Actually, I do care. That is why I chose healthcare to begin with. But back to the staff for a moment. We have pt's that are one-on-one and others who are supposed to be in visual contact at all times. But guess what? You'll find just about ALL of the NA's (except the few of us who do our job) sitting around beside each other talking, laughing, cutting up, playing on their phones, listening to inappropriate music and videos, and then not even acknowledging their pts. This upsets me. Just the other day, a pt who is elderly, immobile and requires complete care was lying back in a geri chair and began spitting up. No one acknowledged this happening except for me. Pt couldn't move to turn head to side and could have even aspirated. This same pt is one who tries pulling off bandages and pulling out tubes if unsupervised. Maybe immobile, but still has some arm strength. Pt is known for doing these things yet NA's leave pt in room alone and go do their own thing a lot of times. This makes me so mad though. Pt is 1:1 for a REASON. Another pt struggled getting the wheelchair through the door and everyone sat there continuing to do their own thing until I got up and helped since it was clear that they were not. They are rough when transferring pts to bed. The nurses have told them to use a draw sheet for transferring pts, but they still refuse. I even recommended it because not only will it make life easier, but I feel like it is a lot safer when you're trying to move a larger pt who cannot help move themselves. These people have made very inappropriate comments in FRONT of a pt concerning her genitals (and the pt said she was "use to it"). They wipe from anus toward vagina. They refuse to give pt a cup of ice or water (and no, there is no fluid restrictions on pt). They provoke some of the pts making them lash out in anger. They argue with the pts instead of redirecting that anger as we were taught to do. The chart that they have given pts a shower when the pt complains that they want one but NA refused to give them one. They do not provide oral hygiene as that was a concern expressed to me by numerous pts. When a pt asks a question or wants to do an activity, most of the time they are completely ignored until someone like myself says something or helps them if able. And then this leads me to something else that I was just informed of. Apparently, we have one NA who yells, cusses, throws, and yanks pt's around. The fact that other NA's see this type of behavior and do not report it really pisses me off (and this is another part of what I am reporting tomorrow). When the upper-level supervisor(s) are not at work, NA's will come to work out of uniform dressed in everyday clothing, stay on their phone the ENTIRE shift and not even do their job. They take twice the amount of time given for their lunch breaks (in which they do not clock out). They will disappear from unit and are nowhere to be found. We have quite a few pts who are unable to communicate, so these NA's pretty much put them alone in a corner somewhere and don't even look their way until it's time for meals or to take them to bed. And of course, when I am spending time talking to the pts and actually acknowledging them, these same NA's sit there and run their mouth about me while giving me these awful go-to-hell looks. Even though that is irritating, I deal with it because I know that the pts appreciate what I do for them as they tell me so every single day. If I didn't care about the pts though, I wouldn't stay. But I do care about them very much which is why I am seeking advice from others who might be able to give me some recommendations. As I said before, I have reported some of this (more which I will be reporting tomorrow). My only concern is that I feel like they are trying to get rid of me although I have done nothing wrong. I am constantly being eyeballed by everyone as if they are waiting for me to make a mistake so they can get me out of there. I mean, maybe I was a little out of line by telling one of the girls to move and let me provide perianal care since she was badmouthing the pt and upsetting her. And of course, recommending we use a draw sheet. And apparently speaking to the pts as if they are a person instead of ignoring them. My concern is that I am still considered "on probation," and I was also told by the nurses that all of the supervisors through chain of command are just like this one. One of the nurses said that she tried reporting something and was reprimanded. I just don't see how this corruption has been going on for this long and no one has done anything about it. How did it even get this bad? I am a firm believer that God places us somewhere for a reason though. I love every single one of our pts and I treat them just like I would treat anyone else rather than a "crazy" person who doesn't deserve to be respected. I am so heartbroken over these things. What kind of future-nurse would I be if I didn't care about the pts? I have been told to just do my job and let all of this go, but I can't do that. I believe in treating patients with the dignity and respect that they are promised to be given. Who are we to take that away from them and disregard them as being unworthy of our time? I love my job. I really do. And even though my coworkers are disrespectful to me and make working with them very difficult, I do it for the pts and because I love what I do. Not once have I had a pt to act out toward me. If they are upset about something, they will talk to me about what is going on because they know that I care. Of course they are on medication and are on their way to healing, but these people don't even care about them. They say ugly things to them and it's discouraging to me. I can't possibly imagine how the pts must feel. Every day that I go to work, I take the time to say hello to every single patient and let them know that they are important to me and that I care. I encourage them and let them know that I want to see them succeed and get better. When they are crying and upset, I offer a listening ear when others just walk on by. These people are in a situation that we may never understand because everyone's journey in life is different. They didn't ask to have a mental illness. They didn't ask to come to that hospital. They were admitted against their will. We get to leave and go home, but that is their home right now. They don't get to leave. And there is absolutely no reason that we should make their life even more of a living hell than it already is. I am scared that if I continue reporting these things that I will end up losing my job. I don't want them to see me as someone who is coming in and stirring up problems. That definitely is not my intention or else I would have already exchanged words with a LOT of ones who try provoking me as well. But that's not who I am. They can run me down in the ground all day long and hurt my feelings, but they will not sit there do that to these patients when I am there. I am a patient advocate. I am there to do my job which means caring for them and seeing that they get the best care possible. I am not there for my coworkers, to cut up, play on my phone, and get paid for sitting on my butt doing nothing. I really wish that we could all get along and they would at least show a little bit of respect and compassion to our patients, but that probably isn't going to happen. My concern is that I am going to annoy the supervisor(s) by keeping on reporting these things to them. But that's my job to take care of the patients, so what other choice do I have? I don't want to lose my job because I love working with these people and they really need someone who actually cares about their well-being. But at the same time, something has to be done. I can't be there 24/7 to take care of these patients and even I could, I couldn't possibly take care of all of them at the same time. It hurts my heart so deeply to see what is going on and not be able to do much to change it. If you were in my shoes, what would do? What are my other options? I'm obviously going through the chain of command first of all, and I can only hope and pray that something will be done. However, it seems like the problem has been going on for so long that it is going to take a lot to change this environment. Even if I report them to the proper authorities, what evidence do I have if no one else is willing to come forward and testify to the truth? It's going to be my word against everyone else employed at that hospital. But these people deserve so much better than what they are getting from us. We are failing to meet their basic needs when we don't provide adequate care. We are compromising their health and well-being in so many ways. We are neglecting them. And instead of promoting healing, these things are going to slow the process. I couldn't imagine being in their shoes when it's this hard being in mine given the situation. And sadly, it doesn't seem like too many others care. But my question is this, what can I do to make this better and not worse? I am following the rules. I am biting my tongue even though it's hard. I am remaining professional (even though it may seem unprofessional of me asking for help like this, but I'm scared that seeking guidance from someone I know will end up biting me in the butt). I am trying so hard to be strong not just for myself but also for the patients who have to live with this every single day. I will not let my coworkers run me off by being hateful toward me. I can handle it even though it is hard. But I am not going to compromise in the way that I care for our patients just to "fit in" with the crowd. I am not going to turn the other way and pretend that I don't know what is going on. I can't, and I shouldn't have to. There has to be something that I can do though to make this situation better. And even if you guys don't have suggestions, please just say a prayer with me that I will be able to make a difference in their lives.
  13. Mental illness is an equal opportunity illness; it affects persons of all races, ages, and income. Mental health nurses take care of patients who suffer from mental illness; they help in the process of recovering the patients' mental health, to help them live to their fullest potential. Mental health nurses work as members of an interdisciplinary treatment team that helps to deliver well-rounded medical care for the whole person. Mental health is an important component of overall health and wellness; mental health nurses help persons of all degrees of disability make changes in their lives for the good. There are many paths to becoming a mental health nurse but the first is completing an accredited Registered Nurse program and then obtaining licensure through the National Council Licensure Examination (NCLEX-RN). From this point the path to working as a mental health nurse is wide and varied; some go directly into working in a mental health facility while others may gain experience working in other nursing fields. Below is the first-hand account of one mental health nurse who has been working in the field for over ten years, we will call her Michelle: My path to mental health nursing was not a straight one. Once I had obtained my degree and proper RN licensure I started on night shift in a neuro/trauma intensive care unit (ICU) where the majority of my patients were intubated and required multiple disciplines to keep them alive. Once they were stabilized and able to communicate, they were transferred out. Therefore, the idea of caring for patients who required more of my communication skills than medication never entered my mind. So how did transition from this experience to finding myself knee deep in the field of mental health nursing? I realized while working in the ICU that my coworkers often "stuck" me with the complicated families. The doctors often asked me to accompany them when delivering difficult news to patients and families. I often found myself calming a patient who had attempted suicide or been in an accident due to behaviors related to their mental illness. When I had had my fill of the adrenalin rush of the ICU, I found myself wondering where my career should go. I saw an ad for a group home nurse at a community mental health center. I'll be honest; the words Monday through Friday drew me in. But I quickly found that the patients made me stay. And my love affair with mental health began. I worked with 40 patients in four group homes for a year when our community mental health center received a grant to start an Assertive Community Treatment (ACT) Team and I was asked to help with the startup of this team. An ACT Team is a service-delivery model that provides comprehensive, locally based treatment to people with serious and persistent mental illnesses. However, unlike other community-based programs, ACT is not linked to mental health case-management programs, housing, or rehabilitation agencies or services. It instead provides highly individualized services directly to the patients/person; these services are provided 24/7/365 by members of the ACT Team. These individuals receive the multidisciplinary, round-the-clock staffing of a psychiatric unit; only it is in the comfort of their own home and community. ACT team members are trained in the competencies of psychiatry, social work, nursing, substance abuse, and vocational rehabilitation. In just over a year the ACT Program had grown to 50 patients. I worked in this position for seven years before moving into inpatient mental health unit management where I've been for the last five years. I am currently the Nurse Manager of a lock-down inpatient mental health unit at a large regional hospital. I have also during this time taught nursing students and worked with students doing internships, and I have always told them the same thing, "I understand that mental health isn't for everyone. And that's okay. But I ask them to remember they will encounter patients with mental illness regardless of their field. And they always deserve patience, care, and respect."
  14. The trials and tribulations of a mental health nurse re: vicarious trauma. I am 36 years old and have been practicing for over 2.5 years as a Registered Nurse in mixed settings. Mental health is my favorite setting! Prior to nursing, I worked in aged care and disability support for five years and loved it. I am writing this post to confess my feelings and experiences because the weight of it is dragging me down. Vicarious trauma.... the act of being triggered by other people's experiences, in particular, those experiences similar to your own. PARTICULARLY if unresolved. A little about me now.... I was sexually abused by my maternal grandpa at the age of four. Nobody in my family believed me and I was deemed to have an "overactive imagination". I successfully blocked the experience out of my consciousness until I was 14 years old. In the meantime, my father died in a car accident when I was 8 years old and my aunty died of an asthma attack when I was 12 years old. I never cried or grieved for either death and as a result, they still haunt me today. Instead, I grew up putting every ounce of my being into study - and this still reigns true today. I am currently undertaking a Post-Graduate Diploma in Mental Health. My assignment grades are between 96-98%. #Winning. My point is that I never dealt with my father's death. He died on September 9th, 1988. Fathers Day is the first week of September, and his birthday is September 12th. This is an annual trigger for me and it doesn't matter what I do, or what effort I make to overcome it. It still bothers me at 36 years of age. My best friend was murdered in December 2005. To this date, the police have not found her killer. It is believed that it was her boyfriend, however, there is no evidence to support this so the killer is still at large. This distresses me every year in December. November is a funny time of year for me too. Once upon a time, I was an intravenous heroin addict and was on the methadone program. I had no hope for myself. I had managed to get off of heroin and went on to naltrexone for a period of six months. Unfortunately, I had a relapse and used heroin three times, and went to the doctor to go back on methadone. My doctor did a pregnancy test and it was positive. I was crushed. I had to go onto methadone and remain on it, and deliver my baby addicted to methadone. Words cannot describe how awful this felt. I'd failed as a mother before I'd even started. I delivered my baby in a 1.5 hour delivery and he was 6 pound 4, born one week early. My precious little angel went straight to the special care baby unit. I was scrutinized and treated like a piece of **** by the nurses who worked there. It was the most devaluing experience of my lifetime. I stayed in the hospital for one week because nobody trusted me, but eventually after delivering several clean urine drug screens, and proving that I could breastfeed and look after my baby... I was discharged. I remained on methadone until I finished breastfeeding and then I did a home detox. My son was two years old at the time and in my care. That was nearly 11 years ago. Today my son is 13 years old and he is in year 8 at high school. He knows nothing about how his mother used to pick up her methadone at the pharmacy. Sometimes he enquires about the scars on my arms, and he touches them gently and it makes me feel so awful. Now I'm a nurse and I feel like everything I've ever been through in life has guided me into being an empathetic, caring, non-judgemental individual who has hope for everybody; regardless of where they are at in life. More than often, I feel reminded of where I've been and sometimes it brings me pride whereas other times I am still filled with shame. I get survivor guilt often. I wonder to myself, "How did I end up here"? Somehow I am the nurse and I have the keys and swipe to get out of the psych ward whereas I could have very easily ended up as a revolving door patient. What makes me any different to my patients? Having unresolved issues and working in psych makes it very difficult at times because just sitting in handover can produce several triggers that make you remember things that your unconscious has hidden for several years. I know this is common for people working in mental health because there's usually a very personal reason why people choose to work in this field. When you're highly functional and you have unresolved issues, then who looks after the mental health nurses? Health professionals just look at you and think, well you're working and studying at uni, you've got money in the bank, you drive a car, you have no debts - there's nothing wrong with you! Therefore you're left to your own devices and that's not always the greatest reality. For people like me deal with anxiety and go through depressive phases, but we have learned to soldier on and hide it from the real world and we hibernate in our downtime because it's too much to deal with at times. For the nurses out there who work in psych and have their own issues, I extend my gratitude to you. I'm extending a great, big cyber hug to you because I know you need a cuddle. While we're busy caring for everybody at work, and our children and family too, we are sensitive and need caring too. Special shout outs to the single nurses, and single mums/dads, who are dealing with vicarious trauma. It's okay to take a mental health day every now and again when you need it. Don't forget to look after yourselves. This post has turned into a ramble but it's better out than in, right?
  15. "I just wanted to tell you 'thank you', I can tell you really care." Anonymous, 2015 So often I have heard this statement from my clients. Not to toot my own horn, but I began to wonder personally how much my empathy for the mentally ill population promoted my competency in providing optimal care. So I began to analyze the fundamental components of my work as a psychiatric registered nurse that are conducive to promoting my psychiatric clients' stability. The fundamental foundation in initiating competent skills as a psychiatric nurse is similar to any specialty in nursing. We must implement the necessary processes of providing the standard of care by using the method known as the nursing process. The nursing process includes the following steps: Assessment, Diagnosis, Planning, Intervention, and Evaluation. In saying such I would like to rephrase these steps into the perspective of a mental health nurse. In similar order of the nursing process assessment is viewed as "I need to know what you are experiencing so I can help you", diagnosis as "I listened and acknowledged your needs", planning as "This is what we can implement to meet your needs", interventions as "let's apply these individualized strategies and alleviate your acute circumstances", and evaluation as "How did this work for you? ". Each stage conveys the primary idea of client - focus care; centering around the client's individuality. However, with clients experiencing severe depression, paranoia, and/or psychosis establishing rapport is essential in obtaining accurate data to promote stability (Decety & Fotopoulou, 2015). This requires implementation of the vital principle of Jean Watson's Theory of Human Caring which is to promote the client to achieve HIS/HER optimal being of holistic health (Suliman, Welmann, Omer, & Thomas, 2009). For the psychiatric nurse this requires empathy that encompasses finding understanding of the client's current stressors, perceptual, and actual needs through genuine interest that encompasses calculated verbal and non-verbal communication (Derksen, Bensing, & Largo-Janssen, 2012). Finally, the "light bulb" illuminated for me on the reason why my clients felt potentially more considered than their peers. It was a simple math equation of caring by distinguishing individuality, building rapport through sincere, calculated, verbal/nonverbal communication that resulted in an accurate empathic understanding of my clients. Thus, a healthy nurse-client relationship is established providing a platform for a conducive and productive recovery from acute mental illness. The following were communicative actions implemented: "I need to know, so I can help you": Establish rapport/ building trust, by active listening, respecting individuality, giving time, maintaining individuality actions throughout each stage Nonverbal communication i.e. body movement, facial expression Removing overwhelming stimuli Discussing more than the reason for admission but general topics of conversation; "implementation of "soft concepts of empathy with hard science" (Derksen, Bensing, & Largo-Janssen, 2012, p. 2). "I listened and acknowledged your needs": (Decety & Fotopoulou, 2015) You have noted the external symptoms of this patient The patient has shared, their internal symptoms experienced You have noted the congruency or non-congruent behaviors/symptoms in their diagnosis "This is what we can implement to meet your needs": Active participation in planning with a client to meet his/ her needs; promoting compliance Confirmation of short and long term goals; the steps in which the client desires to reach these goals Suggestions offered and multidisciplinary, familial, and outpatient supports established "Let's apply these strategies according to your circumstances": Implementation begins, support measures positioned to encourage Consensus of specific supportive mechanisms implemented by the multidisciplinary team, and family The flexibility provided to the client's circumstances "How did this work for you?": The noted growth, stagnant, or regression of results reviewed Challenges acknowledged, barriers noted Suggestions on interventions that may promote his/her desired outcomes To successfully implement these steps it is necessary to seek an understanding of the clients' individuality which takes effort, establishment of rapport, and time. Empathy is an essential factor to obtain accurate data, individualize interventions, and best outcomes addressing the clients' uniqueness. As a psychiatric nurse one noted that empathy plays a significant role in providing competent care and optimizing positive outcomes for my acute mentally ill clients. (Decety & Fotopoulou, 2015). Empathy allowed me to care for the client's individuality by grasping an understanding of their personal strengths, struggles, and journey to mental stability. Likewise, empathy is the foundation for competent psychiatric care. References Decety, J., & Fotopoulou, A. (2015, January 14). NCBI Resources. Retrieved March 5, 2015, from PMS US National Library of Medicine; National Institutes of Health: Why empathy has a beneficial impact on others in medicine: unifying theories Derksen, F., Bensing, J., & Largo-Janssen, A. (2012, December 19). NCBI Resources. Retrieved March 5, 2015, from PMS US National Library of Medicine; National Institutes of Health: Effectiveness of empathy in general practice: a systematic review Suliman, W., Welmann, E., Omer, T., & Thomas, L. (2009). Applying Watson's Nursing Theory to Assess Patient Perceptions of Being Cared for in a Multicultural Environment. Journal of Nursing Research, 293-299.
  16. 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.
  17. 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.
  18. wish_me_luck

    Out With It

    I sat there in library working on one of my many papers and projects that I had due. I was exhausted--exhausted physically, mentally, emotionally; I was done with it. Suddenly, a thought came to my mind to kill myself. I finished what I was doing and packed my materials up for the day and went home. I grabbed some money, told my mom I was going to study with a friend for a test I had (I put some books in a bag to make it seem realistic), and drove to the store. I picked up some duct tape, wine, beer, and cups. I went to pay for it and the cashier made a comment something to the effect of "duct tape and wine, you must be going to have some kind of party." Little did he know that I was planning to kill myself. After I left the store, I went to the ABC store and bought vodka. Then, I got on the road. I made it approximately an hour away from where I live and then, it got dark and harder to see. I pulled off the exit and started looking for a hotel to check into. I passed the community hospital and I thought "that's where I will be taken to, if I survive or that's where my body will be taken, if I succeed." I did have a fleeting thought of going to the hospital and telling them that I was suicidal. Then, I thought "no, I want to die. I am tired of everything." I found a hotel and checked in. After I got into the room, I started pouring the wine and vodka into the cups and started drinking. I became a person that didn't mix hard liquor with anything--just straight (not shots, into cups, drinking it like a normal drink) and I drank wine in cups, as well (as opposed to wine glasses). I started feeling to affects of the alcohol. I went into the bathroom because I started vomiting. I didn't want a huge mess on the hotel room floor. I was ready to get the bag and duct tape. The plan was to suffocate myself by putting a bag over my head and wrapping duct tape around my head. I hated myself and really thought I deserved to die. I put the bag over my head and wrapped the duct around my head as tight as I possibly could, thinking of how awful I was and how much I deserved what I was doing to myself. As I wrapped the duct tape around my head (before I got eye level--I started at my mouth and went upwards), I started seeing little petechial bruising appear around my ankles. A little voice (kind of like a conscience) was screaming "Stop! Please stop! You are going to be a nurse! Please stop!". I wanted to be a nurse more than anything. I realized at that point if I didn't get the tape off, and I survived; then, I would have no future as I was quickly running out of oxygen and would likely be in a vegetative state. I left the room and went to the front desk. I have no clear recollection of what happened between going to the front desk and being in a room in the emergency room. While in the emergency room, I was visited by an officer from the police department. The original impression from the various personnel was that it was an attempted homicide. However, when they questioned me, I was honest. I told them it was a suicide attempt and I broke down. I remember sobbing that I needed help. They were very compassionate and promised that they would get me help. I went through a couple day stay in the ICU, psych evaluation, and then, I was taken in a security/police car to an in-patient psych hospital as an involuntary commit. My admitting diagnosis was Major Depression. I spent three days there and the psychiatrist could not figure out what was wrong with me. I had to go to a court hearing, where they moved to have my stay extended. My request was that I be released as I was going to fail my classes if I stayed; then, there really would be problems with me being suicidal as I would have nothing. The decision was that I be released with a court order for mandatory outpatient treatment. Any violation of the order, I would go back to in-patient. I left the facility without a diagnosis. I was compliant with the order and was completely honest in my evaluations during outpatient treatment. The psychiatrist, that I had at the time, came up with a diagnosis of Bipolar I. It was about the time to apply for my nursing license. This was the diagnosis that went down on the application. That psychiatrist retired; therefore, he was not the one who wrote the letter to the Board of Nursing. The new psychiatrist came in and did an evaluation. He came up with a diagnosis of Borderline Personality Disorder and I did not have Bipolar I. The letter to the Board of Nursing, and my Board Order, reflects this diagnosis. I was offered a pre-hearing consent order (PHCO) in lieu of an informal conference hearing, in which I had to agree to enter into the Health Practitioners' Monitoring Program (HPMP). I took the deal as opposed to facing an informal conference that could end in denial of licensure. I received my Authorization to Test (ATT) and scheduled a date for NCLEX. I took the NCLEX and passed first try with 75 questions. I received my nursing license a little over a week later.
  19. Eliminating the Stigma Associated with Mental Health Nursing through Education and the Implementation of an Enhanced Clinical Experience for Student Nurses Don't be deluded by the L.I.E.S. : Limited Learning Experiences for Students --> Increased Fear and Anxiety towards Mental Health Patients --> Encourages Continuation of Stigma of Mental Health Nursing --> Stagnant nurse workforce and ultimately poor quality of care for mental health patients As my senior year of nursing school approached, both the excitement and dread grew within me each day. I couldn't have been more excited to move on to advanced nursing skills and clinical rotations in the ICU. I longed for the opportunity to sneak a peek in places like the ED where nurses raced by like lightning flashes past curtained rooms assessing patient needs with optimal efficiency. When helicopters buzzed in the sky above, my neck craned to watch and wonder. Always thinking, "that is my ultimate plan... a year or two of med surg, a year or two of critical care experience, and then trauma work all the way , both on the ground and in the air". Senior year of nursing school was also when I was scheduled to start my mental health nursing rotation. To say I had absolutely no anticipation for this endeavor is truly an understatement. This apprehension was not due to fear of the unknown, but instead a skewed vision of the importance of mental health nursing. However, I was not alone in my distaste for the clinical rotation. My fellow colleagues also had mixed emotions that the next several weeks were going to prove to be either a waste of time or the scare of their life. Much to my surprise, that first day of stepping onto the unit of my mental health nursing clinical site would be the start of what has become a sixteen year long career in psychiatric mental health nursing. Reflecting back now as an educator, I recognize how clinical experiences can significantly impact a student's career path. The clinical experience has notoriously been a very crucial element of nursing education. It is the arena where knowledge comes to life. Students are able to make the first connection between what they have learned in theory and what they are seeing first hand. It is exciting, it is anxiety provoking, and for some it is extremely scary. Clinical practice is an opportunity for students to begin to utilize their problem solving and critical thinking skills in real patient scenarios with the assistance and safety of their instructor. Mental health nursing clinical experiences are known to be the most anxiety producing. They have historically been minimally interactive. Students are typically only observing behaviors or staff duties on the unit. This encourages students to continue to feel afraid and worried to attempt to interact with the patients. By limiting the learning experiences of students, educators and healthcare facilities continue to not only encourage the stigma of mental health nursing as "not real nursing", but also perpetuate the stigma that mental health patients are not deserving of "real care". Historically, Mental Health nursing has been an undervalued profession. Mental Health nurses were seen as wardens or custodians. Mental health patients were viewed as in need of containment or being locked away. Although treatment options for mental health patients are changing and care is becoming more deinstitutionalized, mental health nursing still remains an undervalued profession. Recruitment and retention are at extremely low levels when compared to other areas of nursing. Mental Health nursing is not regarded as a desired career option by most students or as a desired career option by most seasoned nurses. A look at the NCLEX distribution plan for 2014 shows that content for Psychosocial Integrity contributes for approximately 11% of the exam. On the contrary, nursing programs do not reflect the significance of this within their mental health courses. Changes in mental health nursing education/clinical rotations to improve the perceptions, attitudes, and overall experiences of the student nurse are needed. Ongoing plans to develop and implement an intensive mental health clinical experience for nursing students that focus on increased student participation and therapeutic interactions are necessary. Efforts to ultimately improve the student's knowledge and understanding of the mental health patient while reducing the stigma of mental health nursing as a profession should include: a thorough conduction of a pre-assessment of student's fears and anxieties as well as mental health knowledge base prior to the first clinical experience, implementation of various education sessions with regards to topics such as Therapeutic Communication Techniques, Practice Patient 1-1 Interview Sessions, and Simulation Lab Sessions for Substance Withdrawal and Delirium, integration of guest speakers from various community mental health treatment sources throughout the semester during the theory course, additional educational sessions such as crisis intervention, group training, medication administration, etc. throughout clinical rotation, and follow- up with post clinical conferences to reevaluate the student's attitudes/ perceptions/concerns daily as well as learning needs. By changing the way we present mental health nursing to students, we can expect the following projected outcomes: Increased student/patient interaction on the mental health unit-increased positive care outcomes/patient satisfaction, Improved results of post education/clinical experience assessments- decreased fear and anxiety, Improved knowledge base and attitudes of students as it pertains to mental health patients and nursing, Eliminating stereotypes of mental health nursing, and Advancement towards long term goals of improved nursing recruitment in the area of mental health to ensure adequate care for patients. When we focus on Intensive Education while providing ongoing support and feedback to students; Attitudes can change for the positive, Perceptions can change for the realistic, and experiences can change for the better. Jessica S. Quigley RN, DNP References Grouthro,T. (2009). Recognizing and addressing the stigma associated with mental health nursing: a critical perspective. Issues in Mental Health Nursing, 30(11):669-76. Happell,B., Platania-Phung,C., Harris,S., & Bradshaw, J. (2014). It's the Anxiety: Facilitators and Inhibitors to Nursing Students' Career Interests in Mental Health Nursing. Issues in Mental Health Nursing, 35(1):50-7. Happell, B., Welch,T., Moxham,L., & Byme,L. (2013). Keeping the flame alight: understanding and enhancing interest in mental health nursing as a career. Archives of Psychiatric Nursing, 27(4):161-5. O'Brien,L., Buxton, M., & Gillies,D. (2008). Improving the undergraduate clinical placement experience in mental health nursing. Issues in Mental Health Nursing, 29(5):505-22.