2.13.2008

macropsychotic

Today was a holiday on the unit, I was lucky I remembered to come to clinical! I figured since it was a "holiday" that I wouldn't have clinical, but this was just one of those funny tricks of logistics. All the better, because of car trouble and other interfering factors, this was the first week where I got to spend two back-to-back patient contact days in the milieu.

This was a great opportunity, since all of the therapy groups were canceled. My case-study, my unit-buddy and myself settled in for a long-overdue game of RISK. Now, I haven't played this game except single-player on a very old black-and-white macintosh, while I was pre-literate (not much reading involved in the game anyway, except the rules). We selected a variant of the game that was "quick", that is, a game where one player only has to possess three particular territories to win, instead of controlling the entire board.

I enjoy strategy games, and my case-study is simply mad for them. We both agreed that you can learn a lot about someone by playing games with them that would not be explicit through use of language. I explained a bit about Go to him and he seemed interested, I'll try to bring my goban up next time and see how well he tolerates a new game. I was suprised how easy-going he was about playing, I think he enjoys that game in particular because of the involvement of dice. Pathological gambling is part of his diagnosis, and it's been a problem in the past to the point where he's excluded from Bingo. Risk offers an interesting alternative, where "bets" are taking place, but fully from within the context of the game, through weighing the probabilities of certain series of attacks' success. Tokens are moved around, exchanged and lost but they represent military power and are non-tradable outside of the game.

At lunch-time my case-study excused himself to walk down to the community cafe for lunch and a cigarette. My unit-buddy from my cohort stayed behind to work on paperwork, so I took the opportunity to walk with my case-study and learn a bit more about him. I suppose this is one of the advantages to being Male in this setting, the instructors admonitions to never be "alone" anywhere in or around the milieu don't really apply to us. I have to attend a make-up observation day, and I was actually surprised when the other student who needs to make a day up (a female) said that we both had to be on the same unit because we're not allowed to be anywhere alone. That's news to me!

Although my case-study has a level of restriction that allows him to roam the grounds unsupervised, he still can't open doors on his own. All of the doors in all of the buildings are locked. Although he could have had someone buzz him through the barriers, I figured I had nothing else to do, so I accompanied him just to get him through the doors. I wouldn't have done this if I hadn't verified his restriction level with staff! If he was on a restriction level that allowed him to traverse the grounds with an escort, I would need to find staff to accompany us.

On the walk over, he talked about his plans for relocation. He was still somewhat evasive about his expected timetable for his reentry into the community, but he mentioned a specific 24/7 community observation facility near our nursing school, where he plans to take accounting classes. Risk for Relocation Stress Syndrome definitely made an appearance in my nursing care plans. On the way we met another patient who works in the greenhouses. He was from a different unit, so I hadn't reviewed any of his information, but I was told that he and my case-study had been friends in the maximum-security unit, and that his RISK and stratego games were gifts from this person. They have been friends for about 8 years now. His friend was quiet but friendly, with gentle blue eyes and a mildly anxious affect. He "keeps up with hollywood" and knows the birthday of pretty much any celebrity I could name (which was about 2, don't ask me which ones). He also has a hobby of collecting maps, and has detailed knowledge of geography, a subject I never did very well. I told him that I used to collect maps of places that have never existed, he thought that was very odd.

The cohort made another attempt at watching a movie at the end of the day, so I excused myself again and returned to the unit. I've been enjoying the flexibility and autonomy. Patients were scares on my return, so I spent the remainder of my time with the head nurse of the unit (A different one from my orientation day).

The head nurse was practically pulling her hair out, because the state health inspection had instructed her to change some things about the way she writes care plans. For one, she can't phrase the problems in the second-person anymore. That is, she can't write "You are not compliant with medication therapy". She's not sure exactly what she should replace it with, but her best guess is replacing it with the third-person "Mr. X is not compliant with medication therapy". The second-person convention appeared...oh, I dunno, maybe 40 or 50 times throughout 8 different diagnoses. Not only that, she had to add long-term goals in addition to the short term goals and objectives, which were really a combination of short and long term goals as they stood. She made some progress on this earlier, but lost all of her work on the computer.

Watching her work, it wasn't difficult to imagine how this might have happened. I gave her some quick instruction in the finer points of copying and pasting text, and showed her the magical wonder of the CTL key, and how she can use it to highlight multiple things at once. She had been spending all day working on this, and with a few simple instructions she was zipping right along. I wonder how many nurses are wasting all day doing tasks that should really only take minutes if their word-processing software is being used properly? I suppose it creates some interesting possibilities in slacking off. What I thought was perhaps more surprising was that this seasoned nurse with multiple tracks of career experience didn't seem clear on exactly how to write a care plan, I practically did most of it for her. The interventions were unchanged, but the rest of it had to be completely reworked. I tried to stay out of it for the most part..after all..I'm not getting paid! After she asked me a few times for wording advice and suggestions for goals I decided this was actually a pretty constructive way to spend my time, compared to aimless browsing of patient charts. We plowed through all eight care plans in record time, and I got to learn a bit about how care-planning at a state institution works. We both agreed it can be maddening at times! She also expressed frustration that the whole exercise seemed somewhat pointless to her, as she wasn't sure anyone would really even be reading it except the people checking to see if she wrote it correctly.

Other things about her attitude also puzzled me..they're things that I've noticed in other people I've discussed my experiences in the milieu with. She spent a lot of time gossiping about the situations of some of the patients, and certain phrases kept coming up over and over. "He's not a nice person" "these aren't nice people" "some of these guys will never get better" and things like that. I dunno. Maybe what she was saying was true, but I'm not sure what the..erm..therapeutic rationale for phrasing it that way might be. She reflected aloud on an incident where one of the patients exposed himself to a nursing student from another school. She said that other nursing student was probably not educated about her rights, since if she reported this to the patient's parole officer, the patient would go back to jail. She seemed to view this as a positive thing..I asked her what therapeutic impact jail would provide. She shrugged and responded that the patient wasn't improving any here. Outside the milieu many people take it a step further and reason that what the people in the milieu are doing is a waste of time, that these people should all be executed or put in jail. Jail, of course, carries sentences of half the length, and executions are even more costly than life imprisonments, so I usually just chalk this up there with people who think the best way to deal with ten million illegal immigrants is to transport them physically to a border and wave good-bye. The question remains, though, not of what is necessarily just or reasonable at an individual level, but what actions can actually improve the mental health of the community at large. Tricky, tricky!

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