3.21.2008

Reorientation

I had my make-up day at the mental hospital this week. One other student from my cohort was with me, and we were joined by one additional student from another cohort who missed her orientation day.

During our customary leisurely breakfast and decompression session, I exchanged greetings with two of the patients I've met already during the observational experience. It was nice to feel appreciated and recognized there already, even though I haven't provided any care as an RN. I got some useful ideas from the instructor about what to focus on for my peer-teaching project on neuro-linguistic programming, something that's been on the back-burner because of all of the other chores I have to attend to.

On our walk over to the medium-security forensics unit that had been our clinical "home" for the first month of the semester, another familiar face made an appearance, to "break in" the newcomer through a series of bawdy jokes, as is his custom.

While the new student toured the medium-security forensic unit, my classmate and I reported to an area of the unit neither of us had been to before. This unit was different than the other ones we've been to in that no one here had a level of restriction that allowed them to traverse the grounds of the hospital unescorted.

After briefly introducing ourselves to the RNs on the unit (who were busily attending to the paperwork required for medication order renewals and doctors appointments), we were almost immediately set upon by the patient "ambassador" of the unit, someone who appeared to be self-selected as the one who talks to the students. We spent our entire time in this unit talking to this patient in the "sun porch" area of the day room. He said that the other occupants of this unit wouldn't be comfortable talking to students, but I wonder how much truth there was to this. Personally I would have liked to mingle with the unit as a whole, but this patient had a lot to say and talk about, so I settled in for a long conversation.

This patient was in a film recorded at the hospital, a film about living with schizophrenia. It's required viewing for new-hires. I found this interesting, since I've been playing around with the idea of filming similar video-content, except story driven and focused on the providers of care in addition to the consumers of health care. His commitment to the hospital had ended, but he expressed a desire to remain in the hospital. Not only that, he was not interested in decreasing his level of restriction at all. He told us about advocacy unlimited, but was somewhat cagey as to what exactly he did for that organization.

While he was talking to us, he answered a question that wasn't even asked until later. It's the same answer I hear from everyone who's a consumer of mental health services. It's the answer to the question "what can I do to be a good nurse for someone like you?" whether that's in the milieu, the community or the hospital. It's a question my classmates ask reflexively, whenever we're given the chance. The response always seems to come down to the same things:

Treat us with respect,
Be humane, and
remember to smile.

After our conversation there, we took a tour of the maximum-security forensic unit, where our instructor worked. It was an interesting tour, we saw the instructor exchange warm greetings with patients and staff, and I even ran into someone I took anatomy & physiology with back before I was accepted into the nursing program. One of the RNs there graduated from my program last year, suggesting that although they -say- you need a year of general psych experience before switching to forensics, this is not always the case.

Our first stop after the security-bubble was a restraint room, where a staff member observed a patient through a window. I snuck a peek, even though I internally chided myself for not respecting the patient's privacy. Inside the room, a very large, very fit man was lying in a bed in four-point restraints, not moving at all. One of the other students mentioned how big he was, the instructor observed that he's also very difficult to wrestle. I'll bet! It made me wonder how much more difficult it is to manage restraints for someone with a seizure disorder. The restraint room definately sent us a message that we were in a very different environment from medium-security. The most restrictive level of restraint I saw there was seclusion, in which one of the patients was given a dark, quiet room with a mattress and blankets to rest in for a while.

I think that if I were to work in that environment, I should prioritize taking Aikido lessons, something I had been mulling for a while but conflicted with my school schedule. Taking Judo as a youth gave me a good foundation of how to manage people kinetically without injuring them, something that was built upon by the "physical management techniques" training I got while working in the group home for adults with MR/Autism. The instructor told a story about a particularly violent day on the unit that resulted in about..what was it..9 staff members carried out in stretchers with various injuries. When the dust settled and order was restored, the patient was completely unharmed, save for a tear in their pants. It really spoke to the professionalism of those mental health workers. I've seen enough punitive retribution against patients (in other settings) to be impressed with their restraint and professionalism. So, Judo is good for reducing the effect of variables like speed, strength and size on physical management outcomes, but it still involves "attack" and "defense". What I like about Aikido is that it's purely defensive. Demonstrations I've seen on video are highly entertaining, and feature things like 5-7 people attacking the demonstrator, only to have all of their arms tangled together, and then gently scooped up and laid to rest on the floor.

I don't mean to belabor the physical management side of things, I just think Aikido might come in handy some day, wherever I end up. It's far more important, of course, to de-escalate situations before violence occurs. Our academic work points to setting firm limits as a key measure to take, but doesn't get too much in depth after that, I suppose more specialized training awaits in the field.

One of the patients in maximum-security exchanged greetings with our instructor, and described "some difficulty" he had been having with his sore throat. He went on to explain something (my memory is fuzzy here) about being worried about the presence (or potential presence) of police, and was concerned some harm could come to us. He seemed to deflate when he said this, leaned against the wall, and seemed for a moment to be immeasurably sad. The instructor thanked him for his concern, and commented on how nice it was of him to be concerned about us.

What I appreciate the most about having the opportunity to observe these interactions in this setting is the degree to which our instructor models "mental health". In trying to explain this to people I get a lot of resistance, most commonly in the form of the idea that "mental health" is highly subjective and can take a lot of different forms. This may be true, but perhaps the difference is easier to notice when you're around people who are severely ill. Perhaps "mental health" is too broad or loaded a term. "Adaptive behaviors" might fit the bill better. The simple power of a greeting, active listening, showing concern, rephrasing, etc are all easy to overlook when it's written down on paper, but when actually practiced leads to effective and compassionate teaching. This reminds me of the "synergistic" model of nursing education I read about briefly in preparing the NSNA resolution..on some level, the way we teach our patients is the same way we teach our students and our peers. It also reminded me once again of the relationship between nursing and psychotherapy, in that it's easier to learn it by having it done to you than it is to approach it from a purely intellectual standpoint.

I've transitioned from being actively ambivalent about working at this facility to being somewhat optimistic and excited. It's still the only place that seems to be interested in hiring me, I just need to make sure I take steps to keep my clinical skills up, regardless of which unit I get hired into.

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