CBT

I went to a workshop on CBT (cognitivebehavioural therapy) for psychosis this week and it was very well done. The presenter was a Dr from Britain and he was lovely-down to earth, funny, with a lot of good information. As he presented you could easily understand his perspective on mental illness/psychiatry-which was that the person with the disorder was the expert in their life and what they needed to be well-rather than the medical system telling people what they needed to improve things.
This is a perspective that I believe is sorely needed in health care and especially psychiatry. I suppose by my statement it could be presumed that *I* am the one calling the shots by telling health care providers what they need to do, but to be honest I think that ethics and ethical care are not relative theories based upon what each person deems ethical. I think that ethical care can be brought down to right/wrong, good/bad in some situations. We need to be gathering perspectives, respect different cultures, and respect individual choice, but in the case of people providing care I believe that there should not be an option in terms of whether following ethical practice. Too often in psychiatry I think that we dismiss the patient's rights/beliefs/thoughts/ choice and cover ourselves with the thought that 'oh, they can't decide that right now, they aren't capable of making that decision' and don't look for ways in which people can manage their own care. We have case conferences where everyone except the patient is there determining the course of their life. We force people to take medications that we ourselves wouldn't touch with a 10 foot pole and then wonder why they 'go off their meds'. We enforce blanket rules with little consideration for individual need and then wonder whay someone 'acts out' when getting frustrated. We certify people, taking away their right to move freely, make life impacting decisions about own health care and then wonder why they get mad at us and resist being involved in the health system.

I get frustrated when our college of nursing responds to poor ethical practice with the reply, 'well, you have to work within the system, it'll confuse the patient if you don't follow the system's way of doing things' even when the way of doing things does not fall within best practice, prudent nursing, or minimal ethical standards. Can someone explain to me how this is OK? Why is this allowed? Why aren't people fighting this?

Before you know it, I'll be the weird activist standing outside health care facilities with a sign, people giving me funny looks as they make a large circle to avoid me.

Teaching

Who knew? So, I start teaching at the university! Psychiatry clinical to 3rd year nursing students-I have no idea what it will be like. I feel like it will be a good opportunity to promote the idea that mental health nursing is 1) not scary 2) found everywhere in nursing 3) a fantastic place to work. I don't think that everyone will agree with #3, but I should be able to reinforce #'s 1 & 2 and perhaps people will believe that psychiatry is Pretty Awesome.
It feels strange to be teaching-title is Clinical Associate. Maybe I need business cards?
I don't actually start with students until mid-Oct, until then I kind of hang out-go to some meetings and try to wrap my mind around what I will be doing.
I didn't think I would be teaching at this point in nursing, but I actually am quite excited about the prospect. I think it really does have to do with wanting to promote psychiatry as a great area to work in. People get so weirded out by it and there is a lot of stigma to overcome. As mental health professionals we don't do any favours by making comments at the nursing station that reflect poorly on our clientele. Honestly, I have been thinking about how to prepare students for that-appreciating humour and using it as a release while at the same time respecting patients all the time. Also to remind myself in the future that kind of talk is not appropriate-whether I am teaching or working as a floor nurse. Hmm, I already sound like a Matron.

Private health care

So, surgery done on my knee finally and at private clinic a few days ago. There was actually no difference in care or even really how it looked, I thought. Perhaps a nicer bathrobe to wear while waiting to go into OR. And the OR had this huge bank of windows looking out on a lovely view.
Because my surgery was work related I got my surgery done quicker-I must remember to ask Dr how long it would have taken at private clinic.
I don't feel bad at all about having it done quicker as I was thoroughly sick of using crutches-but don't know if it had been coming out of my pocket if I would have paid for it. I guess considering that my wage is being paid while I am off, it didn't affect me too much but if I had to be without income it might have been another situation.I would've had to do a cost-benefit analysis. Plus I also justify that the longer I am off, the more it costs as the gov't in essence pays my wage. If I had said no, will wait in line with everyone else-wouldn't have been covered at all. Rationalizations.
Nurse who saw me preop did not help my pre-surgery anxiety. Seemed nice enough, but too high energy and said 'oh my god' 'if your finger starts going blue then it's time to cut off the ring. Your finger will swell during surgery' when looking at ring finger as I couldn't get my rings off. Thanks, I knew that. Finger is swollen because joint does this weird double jointed thing, ring is bent and finger got puffy from me trying to pull the damn thing off. My pulse remained at 113-if she thought it would go down after that reassuring discussion it didn't. As it turns out finger was fine. didn't become gangrenous. The nurse who showed me into the OR was much calmer and nice. After the 1st anxiety-provoking nurse left the room after giving Richard and I a bunch of post op instructions, Richard turned to me and said 'what do we do?'. Teaching was not absorbed.

Being a Patient

I have been crabby most of the day-feeling like I'm bored, but can't really do anything because of my knee not cooperating, don't want to read, crabby with Richard, wanting to get stuff done but can't really do much, slightly angry about that, and wanting to get out of house-though was out earlier and didn't really do much to improve my poor humour.
Which led me to think, 'so this may be on a small level what it feels like for some people who have a chronic illness'. I say on a small level because I know this will correct with surgery, I'm not really in any pain-only discomfort when I overdo it, and I have adequate resources to deal with the situation-I'm getting paid my salary, getting treatment paid for, and getting it quicker-jumping the queue because it is work related.
But..it does give me a good insight into how frustrating it is to have a condition impacting my ability to live normally-not able to do the things I used to take for granted, and seeing how it impacts my relationship with people around me. Having to ask for things that I was able to do by myself, and getting angry over having to ask. Getting used to not having things done in the time and way that I am used to. This makes me appreciate the difficulty and enormous life-changing circumstances that others deal with. What would it be like to be so depressed that I couldn't leave bed? How would it feel to live with hallucinations and paranoia that others were wanting to kill me? And to have difficulty processing information in understanding that it is an illness to begin with? How it would feel to know that others around you are tired of dealing with your illness and are questioning whether they can live with you and know that the disease is not going to go away? To deal with knowing that life will never be the same?
At a recent seminar I heard that people with a high IQ who live with schizophrenia are at higher risk of dying by suicide (and overall risk of dying by suicide if you have schizophrenia is high-according to several documents 10% of people with schizophrenia die by suicide-though some articles state that rate may be lower-5% and again several note that if living with schizophrenia-40% may attempt suicide-huge numbers) as when some people understand the entire impact that schizophrenia may have on their life-they are unable to manage the impact of this and suicide. Pretty sobering and frightening to think of how hopeless people feel when thinking of their future and what they will do in it.
How would I feel to deal with knowing that the entire way I had pictured my life was not going to happen? Of course, we all deal with life changing directions multiple times, and know that plans more often than not, will not be what we had thought. But coping with such a different direction? I think that as a nurse I have frequently not paid enough attention to the strength and resilience people demonstrate in living through and making a quality life with their diagnosis/disease/illness.

Waiting

No change in knee status-continuing to wait for WCB to approve claim or at least process it. Since surgeon is on holidays, doesn't really make much difference, since I can't have surgery anyway. I see why people get so irate at waiting for decisions etc. as I am getting so irritated with this process. Still on crutches, knee still locked. It is good to be reminded of how frustrating the process is when you are on the receiving end of healthcare. Nevermind that I'd much rather be on the other end. Sigh.
Got together to review the new protocols for monitoring patients after being secluded and having rapid tranquilisation (giving people meds to calm them down after being extremely agitated). It was a really productive session and I think that what we developed certainly will help in monitoring patients and make us accountable in our practice. The tricky part is going to be rolling it out-how will people respond to these changes?
I find it interesting how in a rapidly changing environment such as healthcare, there are so many people who resist change. I know that I don't always respond well to change, but I do try to recognize that it is inevitable in life, not to mention in an area such as healthcare. What is it that we resist? Fear of the unknown? Fear that we won't be able to adapt? Anger that the other way worked perfectly fine, why should I change? Nothing bad happened before, why change now? Complacency that it is too much work to change, the way we do it now works, why go to all the trouble to change it? Given that one of my requirements as a registered nurse is to consistently be evaluating my own practice and developing goals for myself on areas to work on, I feel I have no choice but to do that. I suppose since I have been nursing for only 2 years, maybe I'm used to always having to reflect on my work as I did it all through nursing-constantly being evaluated and constantly having to develop goals. I got tired of it, but in retrospect, it helps now as I don't mind asking for feedback on what I'm doing. Not that I am happy when I screw up, but I thinking I am finally able to see this as a learning opportunity, rather than a personal failure.
One of the great things about this committee is the positive patient focus and agreement that all the members have in working together to improve patient care, with similar ethical focus. Makes such a huge difference in committee work. Working in groups where everyone does not have the same focus or have other agendas makes group work loonnggg and painful.
My sister-in-law and brother-in-law are visiting and we were talking about my work and she said 'it's great to see how passionate you are about your work. You've really found the job you love'. It's true, I do, and I don't understand how others don't feel the same way. I think this can be a problem as I get impatient and angry with people who just 'put in their time' the whole time they are at work. I think a weakness of mine is lack of tolerance for nurses who I perceive as not putting enough effort into their job or not doing their job up to my ethical standards. This obviously is not so good when I sit in judgement because then I can't recognize that there are different ethical responses to situations. How though, do you accept something when you believe it to be against our code of ethics? And how can I maintain my ethical principles without wanting to change situations to fit within the code of ethics? How many ways can you interpret the principle of maintaining dignity and actually maintain that dignity?

Injury Prone

So, sitting on the bed today I again threw my knee out. While putting on my knee brace, turned slightly on bed, pop from the knee, can't weight bear again. So, this is an interesting situation-what is it like to be a patient? Go to GP, who kindly fits me in within 1/2 hour. Refers me to ER, as still haven't heard back from orthopedic referral-going to ER results in quicker referral process. Richard is wheeling me around in wheelchair, as other option is to hop everywhere. I go through triage process, surprisingly, I am seen by ER Dr. and out of hospital by 1 pm, after getting there at 1130. Amazing, I kind of think-given about hearing about long time spent in ER and I knew this wasn't a serious thing-as in losing a limb, heart attack kind of thing. Now I have referral to orthopedic clinic for Tues. and am on crutches. Which of course, means I can't work. On the whole, it felt like I certainly got quick, effective treatment. I have to say though, that I think people responded slightly differently knowing that I work at hospital-a bit warmer, this may be just my perception and not accurate though. Plus, having a claim makes it quicker, and I don't think it was all that busy there today. I feel kind of embarrassed about being a patient-it does feel like I am putting people out. Not to mention how I feel about being off of work-as I am supposed to work this weekend- I wish I could just go and do something there, but seeing as how even navigating the house is problematic, I don't think it is an option.
On a positive note-the previous owners of the house had a grab bar in the bathroom-for the grandpa who was living with them. This has already come in handy.

Mediocrity

Did I spell that right?
I have been thinking of the pressure there is to conform within workplaces. How it is difficult to be somewhat different in your approach and do the things that you think are best practice-even though others don't practice in that way. Not that I mean to imply that I am perfect, sadly fall far short of that, but how to continue doing things in what I believe is the right way, while still maintaining a collegial relationship. This can be a difficult thing. We all want to feel like our way is the best and it is difficult to get differing opinions. I know when someone approaches me and says 'oh, have you thought of this?' or 'oops, you missed this', I feel like defending myself, even if I think, 'yeah, you're right'. Hopefully, I don't appear defensive, but pretty sure I have-it is difficult to accept that though I want to never make a mistake dealing with people's health, I'm human = human error.
All that being said, I hope that I don't become complacent and stagnant and start coming to work on autopilot-pretty sure is kiss of death for patient care.
Yet there is a human urge to stay within the safety of the pack and not do anything to stand out, good or bad. So, you don't want to screw up and be eaten by the pack of lions, but neither do you want to come up with a new way of doing something, get the rest of the herd irritated with you, reject you, and still end up being eaten by the lions. Don't know if that analogy makes total sense, but general idea is there.
Given that I am Type A personality with job performance-my internal alarm clock goes off if I act in a way that I believe to not be 'good enough'. I end up being riddled with anxiety if I do something that isn't the right/proper way. And going home feeling that I have let down my value system is a much harder thing for me than going home feeling like I have pissed someone off because I refused to do something that I feel is wrong. Hmmm, perhaps this gives me an understanding of other people's motivation? If others find more value in being part of group, and see the emotional value of belonging as more valuable than acting according to less emotional, more idea focussed value systems, then it makes sense to be a part of group as their internal anxiety will increase when not part of it, just as my internal anxiety increases when feeling like I am not living up to being good enough.

Ow

I did some training/recertification on dealing with violent situations in the hospital and reinjured my knee that I sprained 2 winters ago skiing. Stupidly I heard it crack during 1 situation, then thought, oh well try again. Then ended up on the floor. Now I am icing it and thinking I will probably need to wear a knee splint thing tomorrow at work. Nurse, heal thyself.
We talked a lot about violence etc. Really, though people often think that in psychiatry that it is so unsafe, I hardly ever feel unsafe at work. Only if someone is being particularly difficult and that hardly ever happens. I think nurses are much more likely to get injured in long term care, with people who have dementia. Or ER, where people are coming in off the street-with who-knows-what going on.
When people go onto the psych unit, they tend to be surprised at how quiet it is. We obviously try to keep it low key for a reason, as loudness stresses people out, but I think how difficult it is for people on other units with machines beeping, call bells ringing, people rushing around. How does anyone sleep? It goes on all night. I remember when Dad was in ICU after his sugery and he got delerium and the nurses saying, oh he needs to get some sleep. Well, whenever was there, lights were on, it was loud, how does someone who is all drugged up, in pain and not in their own bed sleep through all of that?
There are many ways that in the hospital we make healing difficult for people and I think noise stress is not looked at enough. Along with about a 1000 other things.

Why do we do work?

Work went really well this week, even though we were soooo busy and short staffed. I'd much rather be busy and deal with some increased stress from that, rather than be less busy and be stressed from complaining nurses.
I was talking with a friend who also nurses and we were discussing why we like work. She talked about certain moments where you feel like you are witnessing something really amazing. Like when someone who has been so sick, takes a turn and begins to get better.
I had to work overtime for 2 hours as we were short 2 staff for the next shift. I hardly ever do it and it was my last shift, so I thought, sure why not? A family from out of town came to see a patient, and they looked so tired. I asked whether they had a place to stay, they didn't. So, I called a motel that I thought would be reasonable, clean, and close, and then drew them a little map of how to get there. They were really appreciative, though it maybe took 5 minutes to do. That is the kind of thing that keeps me feeling happy when I leave work. Naturally, the pay is good, benefits are good, and I live nice and close, so there is no commute, but honestly, it is the small things that give a sense of fullfillment. Like when patient brought me back a coffee (with cream and sugar-and I take it black), but I drank it and thought, how thoughtful is that? Someone is in the hospital and yet they gave this to me! Or a patient made me a piece of jewellery and wrote me a letter thanking me. Or holding a person's hand because they are scared. Or I see an old patient working and they remember me and we talk about how they are doing now, and I think 'they look great!'
We just got a contract extension and the gov't gave us a raise after this contract ends. Cost of living. To be honest, I think I make a lot of money already-this is not necessarily popular to say in the nursing station, and given the present economic climate, I thought we were lucky to get cost of living-again not popular. But this money wouldn't really mean anything if I didn't like my job and didn't feel happy while I was there. I don't always put in for missed breaks and stuff because I think that sometimes I can take a few more minutes on one, and I think that in the end, it all evens out. I do believe that it is OK for me to go the extra mile once in a while because it's a good job and I feel that I am appreciated at work. Happiness certainly is not contingent on the amount of money you make. I am not saying that I don't feel that I earn the money I make, because I believe that I do-it is sometimes a difficult job-but what keeps me happy there isn't the money, it is the actual work-with all its' difficult times.

Preceptor

So, the educator at work asked if I'd preceptor a nursing student for her practicum. I happily obliged. I met her for coffee yesterday and I think she will be good-seems very keen and bright and personable.
I like doing this kind of stuff though I think perhaps other seasoned nurses might think, who does she think she is? She just graduated 2 years ago and she's helping a 3rd year nursing student! But I feel that our educator wouldn't have asked me if she thought I'd not be good at it.
I hope that I do a good job. I'd really like honest feedback from this woman on how her learning experience is and what I could do to improve. Having a good preceptor can really break or make your practicum. Which leads me onto my ongoing thoughts of 'nurses eating their young', which is just another term for lateral violence. Why is it that nursing and nurses as caring professionals are often unsupportive towards their peers? I saw it as a student, where I was referred to as 'the student' and not by name, and was not always received with open arms when arriving on the floor. And working as a nurse, there have been many instances where I've seen it happen to others and towards me personally.
I think it would be an interesting research project. I've read some stuff that talks about nurses being traditionally undervalued, oppressed group and these groups will often turn in on themselves to deal with the stress and lack of power they feel. Like some immigrants to new places who form gangs to belong, but end up terrorizing other people. I've also read about healthcare being an incredibly hierarchical workplace where different levels of power are assigned depending upon your role-also leading to kicking the dog kind of behaviour. And always blamed is the stress, and high pressure work environment where as nurses we are responsible for people's lives. When doing research for a paper I wrote on nurses and addiction, some articles talked about nurses tending to be Type A personalities-perfectionist and not forgiving of mistakes-either our own or others, and there is also research reporting that nurses tend to internalize stress and their job-which would lead to higher stress and therefore presumably more irritability and taking stuff out on those around you. To be honest, I also think that a union environment adds to this-Mom, nevermind the comment you are about to make about I told you so. It can add to an us vs them atmosphere where it is someone else's fault that things aren't good-whether that's the actual management, health care system, government, patients, co-workers, the person who looked at us funny on the way to work. Blame is not helpful in dealing with healthcare-though it certainly seems to be what we do-as a society we blame the government for poor health care, as nurses we blame the doctor for poor medical decisions, the medical system blames the patients for their own poor health (if only people exercised, ate well, lowered their stress etc. they'd live longer and stop costing taxpayers money). Doctors blame nurses for under/overreporting concerns. Someone told me a Dr said she should go back to nursing school when this nurse called about a concern.
All this being said, I think it is our own responsibility to ensure that we create a safe, comfortable working place. And be aware enough of ourselves that we recognize when we are perpetuating this power imbalance-in whatever form it may be. I know that I have done this-questioning what others do and being snide about it. I do try to be positive and upbeat at work and to be supportive of others without being an unquestioning ninny, which can lead to, 'well, we've always doen it that way, why would we change it?' My big teeth-clenched, bite-my-tongue reaction honestly does happen when I feel that patient care and rights are not being respected. And if I feel that patients are not being treated with dignity and value. Not to say that I don't get annoyed when I have a personality conflict with another person-especially when dealing with someone who is in my view more rules oriented-I mean yes, rules are there for a reason, but shouldn't we consider the reason behind it? And I do like gossip. A lot. However, it is my professional responsibility to act as a professional-which means good, clear communication and thoughtfulness behind all my interactions at work.

Psych

As in it feels weird to write this weblog.

And I am thinking of writing about general nursing issues related to psychiatry.

So far, not very interesting, really. Or perhaps only interesting to me?

Though in school we talked a lot about the role of the nurse and how there is not very much accurate information about what nurses do, there is even less accurate information about what nurses in psychiatry do. Do we wander around jabbing people who act strange with needles, spending the rest of the time in the nursing station coldly plotting how to destroy people's lives per One Flew Over the Cuckoo's Nest? Do we dress all in white, peering in locked rooms at dangerous people, as in The Terminator? (where the mom is in the forensic psychiatric hospital) Do we inject people with insulin to get rid of hallucinations as in the most recent episode of House-which I might say had no clue about actual treatment of psychosis.

Sadly, even within the workplace as nurses we perpetuate these sterotypes and worse, we end up promoting stereotypes about people with mental health issues.

I've been doing research for our nursing practice committee related to psychiatric issues and I have to say that there is not enough research done on psychiatry and poor information out there for nursing practice within this area. It is frustrating when you think that (give or take depending on what research you use) 25% of the population will have a mental health issue at one time or another during their life.