Gathering Nuts While in May
My month in an acute psych unit is over. This one has proved to be more intellectually and emotionally draining than the last. I’m not ultimately surprised at that, because it’s minds and emotions that we’ve been dealing with so much more than bodies, but still a noticeable thing. This isn’t to say that problematic interfaces between minds and bodies have been present either, such as the physical or cognitive side-effects of medications; with patients complaining of everything from feeling slower or stupefied to hyper-salivation and neuroleptic malignant syndrome. The more I read about the side-effects of high-dose or long-term antipsychotics such as tardive dyskinesia, the more cautious I feel about their use.
Interestingly, those concerns, linked with the current approaches to smoking reduction or cessation, have born some fruit during discussions with patients about cutting back. I’ve spoken to two or three newly admitted people who were unaware that dropping the number of cigarettes each day may (among many other useful things) facilitate a drop in the strength of their medication, and therefore a potential drop in the side-effects they experience. That approach has been a useful discovery, and one to keep in mind when performing health promotion and education tasks in whatever field of nursing I wind up in, integrating a few of the ANMC competencies, and learning objectives I set previously.
In some areas, such as knowledge development, I feel I lived up to that plan well. I read further into the DSM IV, looking at various aspects such as the personality disorders on Axis II, driven in part by the patients I was dealing with, but also the experience of finding that staff were unable to answer my questions and supply a ‘quick fix’. One of the things I’ve really come to appreciate is the blurred borders between one disorder or diagnostic category and another. When people are broadly described as having Cluster B traits, it’s not necessarily a lack of precision on the describer’s part, but that a person might have traits generally associated with a number of different personality disorders. Developing my understanding of other concepts or tools such as the Health of the Nation Outcome Scale (HoNOS) rating system has also firmly reminded me that there is a wide variety of individual knowledge, interpretation, and skill in use, and that leads to variability in even supposedly reliable tools. There are many moments when psychiatry, psychology, and mental health nursing have all seemed pretty murky as a result of experiences like these.
While my theoretical knowledge has increased, there were moments when I wasn’t so sure about my interpersonal skills. A few patients left me doubting my abilities to handle them (or even three year old children) well. I found learning how to deal with acutely manic patients particularly difficult in terms of what to (or not to) say or do sometimes. Setting limits and maintaining them, when they were continually being pushed was a challenge, especially for a person who’s default inclination is to want to help or say ‘yes’. I learned to be very careful, but it wasn’t an easy or quick process. When discussing this with one of my preceptors he did helpfully remind me that the patients were “far better at the crazy game than I was”, having had more experience and were likely to run rings around me as a result. Comforting, but still the aspect of the placement that I found most frustrating and difficult, and one to be wary of and work more on in the future.
Despite those experiences I found communicating and building therapeutic relationships with the majority of patients relatively easy and enjoyable. I utilised the principles I’ve learned over the course of this degree and previous employment (the fundamental one being to do what I said I would, or explain why I was unable to) to good effect, and generally managed to consider before speaking. I had some positive effects on patients as a result, I think. I also collaborated increasingly smoothly with other staff over the course of the month, and eventually did get to sit in on more ward rounds with the registrar and consultant psychiatrists. The shifts in the intensive care section were better for that as there were less patients, less distractions, and less physical space to get lost in. I was also happy with my documentation and handovers by the end of it all too, with much practice writing notes and participating in handovers.
I remain as aware of the medical focus on the unit as I was in the first week. Sadly, I didn’t get to spend any time with the psychologist on the ward, but did get to discuss additional therapeutic approaches while out with a community mental health nurse for a day. I remain startled that modalities such as Cognitive Behavioural Therapy or Acceptance and Commitment Therapy are not included in ‘basic training’ for mental health nurses, or utilised more on the ward. It’s seems to be an area for personal pursuit and development, should I wish to work in mental health at some stage, rather than a mandated or institutionally-facilitated one.
This placement has been a broadening experience, and demystified acute psychiatric care for me. I built upon previous employment and university experiences of caring for mentally ill people in the community, and understand the relationships between community care and acute care better as a result. I’ve gained further knowledge of pathology, treatment, and legislation; consolidated some skills; and clarified a few personal aspects that need consideration and development. I suspect I could slot into a nursing position in the unit at short notice if I needed to, and that’s a satisfying realisation, but there’s still an awful lot to learn in order to better than just competent.
Interestingly, those concerns, linked with the current approaches to smoking reduction or cessation, have born some fruit during discussions with patients about cutting back. I’ve spoken to two or three newly admitted people who were unaware that dropping the number of cigarettes each day may (among many other useful things) facilitate a drop in the strength of their medication, and therefore a potential drop in the side-effects they experience. That approach has been a useful discovery, and one to keep in mind when performing health promotion and education tasks in whatever field of nursing I wind up in, integrating a few of the ANMC competencies, and learning objectives I set previously.
In some areas, such as knowledge development, I feel I lived up to that plan well. I read further into the DSM IV, looking at various aspects such as the personality disorders on Axis II, driven in part by the patients I was dealing with, but also the experience of finding that staff were unable to answer my questions and supply a ‘quick fix’. One of the things I’ve really come to appreciate is the blurred borders between one disorder or diagnostic category and another. When people are broadly described as having Cluster B traits, it’s not necessarily a lack of precision on the describer’s part, but that a person might have traits generally associated with a number of different personality disorders. Developing my understanding of other concepts or tools such as the Health of the Nation Outcome Scale (HoNOS) rating system has also firmly reminded me that there is a wide variety of individual knowledge, interpretation, and skill in use, and that leads to variability in even supposedly reliable tools. There are many moments when psychiatry, psychology, and mental health nursing have all seemed pretty murky as a result of experiences like these.
While my theoretical knowledge has increased, there were moments when I wasn’t so sure about my interpersonal skills. A few patients left me doubting my abilities to handle them (or even three year old children) well. I found learning how to deal with acutely manic patients particularly difficult in terms of what to (or not to) say or do sometimes. Setting limits and maintaining them, when they were continually being pushed was a challenge, especially for a person who’s default inclination is to want to help or say ‘yes’. I learned to be very careful, but it wasn’t an easy or quick process. When discussing this with one of my preceptors he did helpfully remind me that the patients were “far better at the crazy game than I was”, having had more experience and were likely to run rings around me as a result. Comforting, but still the aspect of the placement that I found most frustrating and difficult, and one to be wary of and work more on in the future.
Despite those experiences I found communicating and building therapeutic relationships with the majority of patients relatively easy and enjoyable. I utilised the principles I’ve learned over the course of this degree and previous employment (the fundamental one being to do what I said I would, or explain why I was unable to) to good effect, and generally managed to consider before speaking. I had some positive effects on patients as a result, I think. I also collaborated increasingly smoothly with other staff over the course of the month, and eventually did get to sit in on more ward rounds with the registrar and consultant psychiatrists. The shifts in the intensive care section were better for that as there were less patients, less distractions, and less physical space to get lost in. I was also happy with my documentation and handovers by the end of it all too, with much practice writing notes and participating in handovers.
I remain as aware of the medical focus on the unit as I was in the first week. Sadly, I didn’t get to spend any time with the psychologist on the ward, but did get to discuss additional therapeutic approaches while out with a community mental health nurse for a day. I remain startled that modalities such as Cognitive Behavioural Therapy or Acceptance and Commitment Therapy are not included in ‘basic training’ for mental health nurses, or utilised more on the ward. It’s seems to be an area for personal pursuit and development, should I wish to work in mental health at some stage, rather than a mandated or institutionally-facilitated one.
This placement has been a broadening experience, and demystified acute psychiatric care for me. I built upon previous employment and university experiences of caring for mentally ill people in the community, and understand the relationships between community care and acute care better as a result. I’ve gained further knowledge of pathology, treatment, and legislation; consolidated some skills; and clarified a few personal aspects that need consideration and development. I suspect I could slot into a nursing position in the unit at short notice if I needed to, and that’s a satisfying realisation, but there’s still an awful lot to learn in order to better than just competent.