On April 22nd we had our last clinical experience for NURS 342. That morning I, along with two other students, arrived at Methodist TSP early to observe ECT. Afterwards, I was assigned to the level 1 women, along with another TLU student nurse.
If I could repeat this clinical day, I would change how I interacted with a level 1 patient, R. I had been feeling very confident in my therapeutic communication skills, but somehow everything I said to R just fed her delusions and paranoia. When I first arrived on the floor I was a little disappointed by how “normal” all the patients seemed. Two of the patients I saw looked like typical college students (and it turned out one really is a college student). The nurse, Michelle, assured me that these patients really are mentally ill, that you just have to talk to most of them for a little bit before it becomes obvious. I helped Michelle administer medications to R, who seemed pleasant albeit a little confused. R is an older woman who sat in a wheelchair that she moved with her feet. She was compliant with medications and denied any suicidal or homicidal ideation. However, after the medication administration she told me that she could tell what I was feeling—that I had pain in my hands. I told her that I didn’t actually feel any pain. She assured me that all three of us had strange sensations in our hands, legs, and faces. Then she pointed to Michelle, the nurse, and asked if I could see her skin peeling off. I told her that Michelle’s skin looked just fine to me. I didn’t think about my responses as “arguing” with a delusional patient but more of an orientation to reality, clarifying what I could see and feel. However, Michelle later warned me that R gets “crazier” the more you talk with her (which is why Michelle herself ends conversations after the direct questions related to medication) and that arguing with her delusions tends to “get her worked up.” Later R asked me when she could leave the hospital and I told her I would ask her nurse. However, the other nurse (Magda) told me that Michelle was unavailable because she was on the phone with R’s mother. Somehow I thought it would reassure R to know that her nurse was working on her case, so I reported back that I couldn’t yet get an answer to her question but that her nurse was on the phone with R’s mother. This comment provoked a response of outrage and perhaps paranoia. R asked “What?! How can she be on the phone with my mother when I don’t have a mother! Who is she talking to about me? She can’t do that!” A male nurse actually stood in the doorway and blocked it so that R couldn’t chase after me. In the midst of this another patient struggling with paranoia was pacing the hallway and the two women ended up triggering each other to ever increasing tension and suspicion. I went back into the nurses’ office and ended up not interacting with R anymore that day. I saw her interacting with other people, though, during recreational therapy, and she didn’t have any further outbursts.
This experience taught me a couple of things. In part, it reinforced our textbook’s warning not to argue with someone who is hallucinating or experiencing delusions. Now I will be much more aware of what might constitute “arguing.” The overall experience on level 1 also reinforced the importance of following narrow parameters. I should not have said anything to R that wasn’t absolutely necessary. Perhaps R’s chart warns that the mere mention of her mother triggered R’s anxiety and delusions. I don’t know, and I shouldn’t have shared any information about who her nurse was talking to. On the level 1 unit I also saw nurses trying to be kind and accommodate individual patients—with bad results. One patient (the college student) asked if she could use a different phone because of the static on the phone in the dayroom. Magda let her use one of the phones at the nurses’ station. However, this became problematic with the pacing patient with paranoia (who refuses to take any antipsychotic medication because she believes it is poison) demanded that she likewise have access to that phone and began loudly complaining “it isn’t fair!” that the other patient have this privilege. I can see that inflexible policies might be much more effective with this population. A final realization came from observing the interactions between R and the pacing patient (whose name also begins with an R). R commented that the pacing woman is “supposedly” afraid of the other patients on the unit. R asked me “if that’s true, then why am I afraid of her?” There was a kind of logic there. It suddenly made me think “who had the terrible idea of putting mentally ill patients together on one floor? Of course two people with paranoia are going to act suspiciously and frighten each other!” Clearly there is a delicate art to figuring out what patients are compatible and which patients should be kept apart. [At San Marcos Treatment Center I think they use the term “ops”—some patients have a person who is identified as their “opposite” and they are not allowed to sit next to or speak with that person.]
Overall, the biggest lesson from the day was that mentally ill people can be unpredictable. That should be obvious, and this semester it has been drilled into our heads again and again that we should not let our guard down. However, I think that even if I had exhibited perfect therapeutic communication and followed every policy, there is still a possibility that I could have “triggered” a patient to react in an unpredictable way. There are certainly things I can do to improve my own nursing practice. However, I need to remember that nothing I do can guarantee that these patients will behave in safe, appropriate or predictable ways. That’s the whole reason why these women are hospitalized: they cannot be trusted to behave safely. It would be dangerous to ever become too confident. Perhaps that applies to other areas of nursing as well. No amount of professional nursing care can guarantee that all patients will heal or even live. There is only so much we can control, and other people’s behavior is not within the realm of my control.