by Charles O'Meara, RN
Recently a pedestrian ran out in front of my car. I slammed on my brakes and the guy behind me rear-ended me. Nobody was hurt, nobody was mad. While waiting for the cops and exchanging information, the guy who hit me asked what I did for a living. I replied that I am a psychiatric nurse. And then he asked, "So...what does a psychiatric nurse do?" Before I begin, let me make it crystal clear that while I'm drawing on my own experiences here, any good psych nurse does all the same stuff. It's just that we often operate out of the public eye, on locked wards and our professional world doesn't get a lot of press. Let's see, there are lots of subspecialities you might not know about in psychiatric nursing. I started in forensic psychiatry where I worked with the 'criminally insane' (a term no forensic psychiatrist uses, by the way). Then there's child and adolescent psychiatry; geriatric psychiatry; addiction and substance abuse treatment (because if you weren't crazy to start with, the drugs will make you so - and you probably were mentally unstable to start with); there's people with developmental disorders like autism and what used to be called mental retardation (now 'intellectual disability'). That's a good list to get started. Yes but what do we do? A lot of people have badly skewed ideas of what psychiatric medicine is. Too many movies have used mental illness and psychiatric hospitals as key ingredients in horror/murder/supernatural thrillers. So most people think that 80 percent of my patients are axe-wielding maniacs like Jack Nicholson's character in "The Shining," and that the other 20 percent of my patients are the unbathed folks you see wandering around in parks and city streets talking to themselves and pushing a shopping cart full of cans and bottles. The kind of patients you deal with depends on where you work, what program you're attached to, how good their insurance is and what kind of family support they do or don't have. When I worked in forensic psychiatry, I worked solely with what are known as people found not guilty of a particular crime or crimes "by reason of mental defect." In that capacity, I didn't deal with adolescents, I didn't deal with geriatric patients and, at that time, we didn't address substance abuse as we should have or could have. Mostly we watched and talked to patients to try and figure out if they were still as dangerous as the day they came in or whether some progress had been made in terms of stabilizing them. When I moved out of forensics to a community-based mental health agency I worked with people who lived in the community, either alone or with family or in some sort of residential facility with 24-hour staffing. My job at that time was to keep folks from going back into the hospital by monitoring and assessing their mental health regularly, working with and educating the staff who cared foro them, making sure they took their meds, checking their living situation for things like weapons or making sure they had food, and staying in touch with a constellation of people involved in their care: social workers, probation officers, the pharmacy they used, their case manager, whoever managed their money, their landlord, their family and so on. When I worked in-patient, on locked psychiatric wards, I worked with people who were usually very, very unstable. They usually came to us straight from the ER and they came to the ER usually via some involvement with the police. Maybe they were happy, amusing lunatics who walked around without pants on or wore a child's Halloween costume over their clothes year round. Maybe they were massively depressed and had mutilated themselves or attempted suicide in a major way. Maybe they were bipolar people off their meds, manic, loud, agressive, angry, pushy, in your face, harassing other patients, starting fights and generally disrupting everything. Maybe they were schizophrenics, also off their meds, who were so withdrawn they barely spoke or acknowledged your - of were wildly delusional and hallucinating and hearing the voice of God or a demon telling them to do something dangerous or frightening. Like setting their mattress on fire to purify it. Which is something that happened. I never worked with kids. I avoided it intentionally. Too traumatic and depressing for me. But on in-patient wards, due to funding reductions for various programs, we began to get more and more eighteen and nineteen year-olds who were "on the spectrum," with autism or Asperger's Syndrome or intellectual disabilities. We alkso got what became known as "dually diagnosed" patients who had co-existing mental health problems as well as substance problems. Homeless schizophrenics who drank to quell the voices and paranoia. Bipolar patients who would put anything in their system in any quantity for the hell of it while manic. Depressives trying to numb their own personal pain. So over time I developed skills needed to work with addicts, whether they had mental health issues or not. But what did I actually do? I gave patients medication and monitored them for problems those medications might cause as well as trying to ascertain whether the medication was helping. Psych nurses are required to have good verbal skills and be somewhat sociable in the work place. Because there are no blood tests or imaging tests to tell us whether a patient is getting ready to harm themselves or is hearing voices, we have to rely on something very basic: talking and listening to patients. Then we write notes about what they said and discuss it with doctors and others. So psych nurses meet regularly with psychiatrists, or talk to them on the phone, or sit in on morning rounds with the doctors to give our input. (This, sadly, is an aspect of psych nursing that's all but disappeared due to increased workloads and reductions in insurance reimbursement. Too often, nobody wants to hear what the nurse has to say anymore, just give the pills and move on to the next patient). And contrary to popular opinion, psych nurses do indeed require medical skills. Psych patients generally develop all the same physical problems as anyone else: cardiac problems, high blood pressure, diabetes, kidney problems, stomach problems, skin problems, dental problems, neurological problems, etc. If my patients had diabetes, I checked their blood sugar level and gave insulin. If they had heart problems, I monitored the blood pressure and heart rate and watched them for signs of a heart attack, which I spotted on more than one occasion. I educated patients - or tried to - about their diagnoses, their meds, what we were attempting to do for them, why it's important to brush your teeth regularly and how to maintain a heart healthy diet. If the patient had self inflicted wounds or had surgery, I changed dressings, did wound assessment and skin care, addressed ostomies, listened to the lungs of people with chronic respiratory problems and all kinds of other stuff that "real" nurses do. (It's sadly not uncommon to find nurses outside of psych who think we don't know how to care for a cancer patient or a cardiac patient. But we have to know that stuff because the non-psych wards generally aren't equipped to deal with a sick and actively mentally ill patient). Like all nurses, we have to know the generic names and brand names of literally hundreds of medications, again, psych meds and other meds. We have to know how to spot a patient with a UTI and how to perform a CIWA assessment on an alcoholic in withdrawal. We have to perform the Heimlich maneuver (I've done it!) We have to be able to differentiate between patients who are probably suicidal and others who are not; patients who are hallucinating and those who are just telling you about something they saw on TV as if it happened to them. We have to be able to spot all kinds of dangerous behavior before it becomes dangerous. A patient who mentions sex or pedophilia in every conversation is not simply rude, they're giving you clues. A patient who spends an inordinate amount of time reading up on explosives is not to be taken lightly. We have to know how to perform a fall risk assessment, a skin breakdown risk assessment using the Braden scale, and a Mini Mental Status Exam to help spot early signs of dementia. We have to be able to play detective and keep an eye out for subtle things, like a patient who changes their shoes two or three times every shift, or goes into the shower and comes out 30 seconds later with only their hair dampened, or patients who try to sneak away to have sex in a closet. Or fashion weapons out of soda cans and broken coffee mugs someone put in the trash without thinking. Or stash drugs that a visitor brought them from "the outside." We have to check under their bed to see if they are storing their urine in cups (it's happened) or whether they are defecating in the laundry hamper (yup) or stockpiling food from their tray on the window sill and drawing cockroaches. We have to know how to manage patients who become angry, dangerous and threatening; how to get out of a chokehold; how to block a punch; how manage a patient holding a chair over their head and threatening to throw it (you just keep talking to them and distracting them and pretty soon their arms start shaking and they drop the chair). We have to know all sorts of things like never going into a patient's room ahead of the patient, always behind them. And that you always have to keep an arm's length away from them. Their arm's length, not yours. We have to know about their lives, their past. Were they ever in jail? For what? Were they abused or neglected as a child? Were their parents mentally ill? Did they grow up in a shelter? Did they grow up amid wealth and privilege? (you'd be surprised). At what age did they start using drugs? At what age did they start hearing voices or trying to kill themselves for the first time? We have to encourage and cajole and prod and insist and coerce them to keep their doctors' appointments, take their medication, and not to call their father and threaten to burn his house down. Again. We have to help them get hooked up with food stamps and housing and dentists and getting them new eyeglasses because the ones they have are nine years old and scratched. We try to make sure they get flu shots and dress warmly if they're going to spend winter days (and nights) wandering the streets. We try to make sure they don't wear their winter coat when they're walking around in 95 degree weather. We try to make sure they actually have a winter coat. There's more, but you're probably getting bored, so I'll leave you with this. Once, when I had been a psych nurse for about ten years, I was moaning out loud to my supervisor about how it's discouraging working with the mentally ill because so few of them get better. It feels hopeless, futile, I said. And my supervisor said to me. "Yes, but you do one thing for these patients that nobody else in their life does." "What's that?," I asked. "You listen to them," she replied. |
charles o'meara, r.n.I have worked as a registered nurse for more than two decades, ninety percent of that time as a psychiatric nurse. Archives
June 2017
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