The Student Psychiatric Nurse on Placement in a General Hospital: What am I Doing Here?

Ben Davidson,
Maudsley Hospital, London

At 4.30 am on my third night shift, having just cleared away faeces-stained sheets of an old man recovering from heart surgery, too tired to read any more psych-literature and no longer needing to dip into poetry by Buckowski to remind me how miserable and grim it all is, I find myself pondering that very question.

ENTERING PATIENTS' EXPERIENTIAL WORLD

Mr de Clerk in bed 6 belches, voluminously and at length, as he sits on the edge of his bed. They've opened him up, tinkered with his heart and lungs and then put it all back together again. He is looking down at his chest, puzzled and confused. I wonder if he will get up and wander off again. He needs reorientation so that he goes to the toilet to urinate and not the cleaner's cupboard. Three days now it has felt like he was on the edge, building up to something.

Big Jim down the far end calls out in his sleep. Last night he was up at 4.00 am with strange dreams of Sister Joanne organising him here and there, pills being offered, things being sorted out, somewhere just outside of his control. They took out the deep tension sutures which hold his chest together this morning, and for the second time the wound split open. We've talked about his fears of death and the episode, on recovery from the last anaesthetic, when it took three nurses to hold all twenty stone of him down, thrashing around, gasping for breath. He knows his feelings well enough. A sixty year old docker, forty years of fifty cigarettes and at times fifteen pints of beer a day. He's kind of resigned to ill-health now. He could see it coming a year back and just packed in the drink and smoke. 'I just fucked them off,' he says. Too late. They still had to open up his chest twice to replumb the blood supply to his heart. Now he enjoys himself and forces desperate humour out of the situation, slapping our backs with his rich voice and cheering everyone up as if they were the ones standing on the brink, maybe never to come back: and him still drunk ...terrified...

I've only two shifts left on this placement. I've been here nearly three months. Coming back from the second bay where Steve fell out of bed earlier I noted how natural it had seemed to grab the sphygmomanometer with only minimal prompting, measure his blood pressure and pulse, hardly even noticing I was doing it, and be aware of other things all the while, in particular aware of Steve himself, his anxiety. The cuff still took a bit of gentle fumbling to get on. I had to feel in three different places across the crook of his arm to find his brachial pulse before placing the stethoscope. But there was just so much more confidence this time. And get this ...I managed to listen to what he was saying and respond with some genuine, calm reassurance at the same time as I pumped up the cuff, gently let out the air and noted with satisfaction that first click, ...thump, ...thump, descent of mercury a little fast ...slightly seal off the air, slower ...thump; last one at 70 mm Hg ...is it? yes; no more thumps, as air now hisses out of the fully open tap; cuff off, remember the numbers: 140, 70; and yes but its understandable with the sedatives and listen, Steve, if you want to take it easy and lie back you'll get off to sleep again, again. Don't worry. No need to feel guilty. Just lie back ...there.

No more time to write ...sudden flurry of activity, 5.30am and Antonio pushes his buzzer by mistake; as I pass him on my way back Mr Armitage asks for a jug of cold water and ice; still up reading: two nights no sleep - I must see if he needs to talk; Louise grabs me to help out with Mr Browning in the side room; stink hits me as I go in, some awful discharge from a bladder infection where his catheter is irritating; that smell; not for 233*; is that one of the smells of death? He too had a coronary artery by-pass graft (Desai & Jayakrishnam, 1991) two months back, followed by a stroke, followed by a lung collapse, tracheotomy, now he cannot speak; gunk, like custard splurting out of his tracheotomy tube whenever he coughs, which is all the time. At first, I saw him as a mechanism and series of operations. I had to; it is less frightening, less terrifying to do so (Menzies, 1960). Then I decided I mustn't. Yesterday I made myself talk to him. I forced myself to sit through the awful feeling of impotence before his outrageous suffering, the humiliating inability to understand even what he wanted to communicate, all the time experiencing a sickening dread, just not wanting to be there. Mostly, he wanted to communicate where he was in pain. All over, apparently. I've syringed bile out of his stomach via a naso-gastric tube. I haven't yet suctioned the custard out of his lungs though. And he also wanted to communicate this: holds two fingers to his head like a gun and fires. I'd rather be dead

*233 is the number of the emergency resuscitation team. "Not for 233" is therefore a euphemism meaning that the patient in question is not to be actively resuscitated in the event of heart failure.

Final Word

There he was in that room
beached under that white sheet
blind
legs amputated:
again and
again,
they kept chopping away
at him.
all the operations, it
was all they knew
to
do.

he talked about various
things, mostly about a
subject we had both been
imbued with
and that he was still
strangely
interested in

the nurse came in,
indicated to me
that
he needed
rest.

I told him that
I must
leave.

"there is something
terrible
that finally comes to most
people," he said

Then he whispered what it was

we said
goodbye

on that long drive back
into town
on the
freeway

I saw it
everywhere

it shouted and it
flailed and it
wailed

it hung there
in the
sky
as

the fat belly
of heaven
laughed:

"bitterness,"

(Buchowski, 1991; p 175)

THE ROLE OF THE PSYCHIATRIC NURSE

I have argued elsewhere (Davidson, 1992) that I believe the role and function of the psychiatric nurse to be twofold: to provide demystification (Laing, 1965, 1967; Smail, 1984, 1988) in order to help someone who is 'mentally ill' accept that however bizarre their experience and incomprehensible and overwhelming their emotions, their 'illness' is the reasonable upshot of their life history; as Egan (1990) puts it, to help them accept and tell their story. Secondly to offer friendship (Strang, 1982) and comfort (Smail, 1984, 1988) to provide a sense of solidarity and belonging which may help someone survive their crises and eventually tackle aspects of their predicament which are genuinely amenable. to change.

In a sense, taking care of other people in this way is how humans might, in an ideal word, be expected to behave reciprocally in any relationship (Smail, 1988). My view of mental health nursing skills, therefore, is such that in principle they are transferable from a psychiatric hospital to a surgical ward in a general hospital without any great difficulty.

My opening sketches, above, are offered byway of an attempt to convey how I feel I implemented these skills in practice on the general ward.

Of course I didn't exercise an exclusively therapeutic influence, and when I did it was often not such a formal undertaking as it sounds. Sometimes I joined with Big Jim laughing off his terror of death, colluded with him in joking away that fear of a gaping hole opening up in the again in his chest if he coughed too hard. As I mentioned, I tended not to enter into the experience of Mr Browning in his misery. And I found Steve's demanding whine and incessant fretting as irritating and off-putting as anyone else. But it seems to me that to the extent I did try to enter into their experience, and in being willing to undertake the experiential shift involved therein, I could at times provide a space in which patients were able to unburden themselves a little and offer them a genuine sense of solidarity in facing their situation. Put simply, I enabled a few people to say how bloody awful the whole terrible business was for them, and not feel so alone.

But I didn't do it straight away.

OBSTACLES AND DIFFICULTIES

Patricia Benner (1982) has adopted a skills acquisition and development model originally developed by Dreyfus & Dreyfus (1980) to explain the process of becoming a nurse. The model was developed in studies of chess players and pilots, but Benner has adapted it to suit general nursing, and in the paper 'From Novice to Expert' (Benner, 1982) she elaborates five stages that one passes through:

• novice
• advanced beginner
• competent
• proficient
• expert

There are two guiding principles to one's transformation through each of these stages.

‘One is a movement from reliance on abstract principles to the use of [one's own] past concrete experience as paradigms. The other is a change in the perception and understanding of a demand situation so that situation is seen less as a compilation of equally relevant bits and more as a complete whole in which only certain parts are relevant.'
(Benner, 1982; p. 402)

Early in my placement on Lonsdale ward, this entire new world of sickness, surgery, care and death seemed so foreign that I spent much of the time in a state of experiential paralysis. Its odd, but I have never experienced such unfamiliarity and terror in psychiatry. My response was very much in keeping with the novice stage described by Benner. I retreated into the security and familiarity of thought and abstract principles; I studied at length the procedures and operations patients were undergoing, and plagued staff nurses with endless questions, often enough involving matters of some technical detail barely relevant to the job in hand.

Meanwhile, understanding how to deal with a cardiac arrest and learning how to share the task of making a bed efficiently with another nurse were, in a bizarre way, of equal importance - they were both Just items from a vast mountam of unfamiliar tasks which I simply had to try to master. 'Getting my head round' them seemed to be the first step. And just how do you wash the face of a fifty year old woman who has been doing it for herself all these years? Which bit of her face do you apply the flannel to first? How do you support her head while you do it? And what about the rest of her? In the first week, simply trying to master the measurement of blood pressure and getting someone off the commode seemed almost unbearably taxing, and I recall clearly the almost perpetual state of anxiety I was in, so that just reaching over to get a thermometer for a patient seemed to result in my elbowing over cups of coffee, or other such blunders, with embarrassing regularity.

Counselling skills at this time were not a priority. They were not even a possibility. This left me feeling even more deskilled.

ACQUIRING GENERAL NURSING SKILLS

According to Benner, the advanced beginner notes, on the basis of real experience,'the recurrent meaningful situational components' (Benner, 1982; p. 403). To translate, this is to say that a transformation takes place wherein the nurse begins to recognise aspects of situations that indicate, or demand from her a particular response. This recognition comes from her own experience and familiarity with the situation, rather than from a book.

When Steve fell out of bed I recognised immediately the need for a set of observations, the need to watch out for a spine or head injury, the need to get him back to bed, reassure him, make sure there were no neurological problems, call a doctor, complete an accident report form and so on. But as a respondent of Benner's describing nurses at this stage, puts it, I was like 'a mule between two piles of hay' (Benner, 1982; p 404) when it came to prioritising these activities, and I required the proficiency of the staff nurse Louise, who was on duty at the time, to direct me.

Being able to prioritise and plan one's actions efficiently in terms of long range goals is what Benner calls competence. In the above situation, for example, to have known intuitively what to do first about Steve's fall, immediately recognising not only the demands of the situation, but also discriminating the relative importance of each item on that checklist have constituted competence. In other areas, however, where I was guided by a clearer idea of the appropriate objective, some competence was in evidence by the end of the placement. For example, after I had cleaned and redressed Vincent's huge arterial leg ulcers several times under supervision, I simply knew on one occasion, from the state of his bandages, to put more sachets of saline on a trolley the bank nurse had prepared. There was going to be a lot of mess. Only a small example, but one which indicates the extent to which, as the placement progressed, I achieved a sense of command over certain areas of activity.

I worked with Vincent throughout the placement and the change in my care from him exemplifies these stages well.

Encouraging Vincent to straighten his leg was initially, as a novice, an unintelligible task I had been , something to do with physiotherapy.

After three weeks, as an advanced beginner, I recognised that whenever his hip was abducted I should encourage him to straighten it. Bending it as he did was an indication of and response to his being in pain. Nevertheless, it had to be straight because it was an obstacle to rehabilitation following the graft of a new femoral artery to his left leg. Abducting the hip constricted the blood vessel, reducing the blood supply to his limb and risking muscle contracture.

At six weeks, as a competent, I understood all of the above, but was able also to recognise the need to talk to Vincent about his attitude to pain relief and encourage him to have some P.R.N. (as required) distalgesia. I also perceived from his responses a deficiency in his understanding of his condition (in particular he did not understand the risk of further deterioration of blood supply and subsequent complications if he did not take seriously our prescriptions regarding pain management and leg-straightening). I therefore made a mental note to educate him further about his condition when the distalgesia had taken effect and he was better able to concentrate. Meanwhile I put his splint back on and went to get the medication.

SYNTHESIZING PSYCHIATRIC AND GENERAL NURSING SKILLS

At the level of proficiency, Benner describes skills which, interestingly enough, start to sound more familiar to a psychiatric nursing ear. 'There is a web of perspectives (Benner, 1982; p 405) from which one may, as a proficient, understand, predict and plan. One has the ability to modify one's perspective m response to changes which would seem to the mere novice or competent 'unintelligible nuances in the situation'. (Benner, op cit.)

When other nurses were still insisting to Vincent, recently, that he should agree to an amputation, I felt just about able to provide an alternative response. The cardiovascular professor had stated quite categorically to Vincent that the advised amputation was only to a small extent because of the danger of septicaemia from the rotting tissues, as we had mistakenly understood and informed him. There was no imminent danger of gangrene or septicaemia, and that did not concern him (the prof) at the moment. The more pressing concern was that the recent femoral arterial graft had not been successful. Although arterial blood now suffused his foot beautifully, the arteries and capillaries between knee and ankle had apparently deteriorated to an extent where blood was not able to backfill them from the new, artificially plumbed supply to the ankle. These capillaries just were not there any more. The muscle was dying or dead. There was no power in it and the whole lower leg was thus a useless limb. Go home, said the prof, and see how much you can use the leg; then make your decision. A prosthetic limb is better than an unusable, decaying one, and that is why I advise amputation.

On Vincent's return he was walking, for the first time in months, on both legs. Within days he had worked at the task to an extent where he could walk the length of the ward several times without a stick and apparently with little or no pain. Sister Joanne echoed the prof's sentiments: she had never seen a leg so deteriorated get better, and she retained some scepticism as to whether it would. Interestingly, however, she did not feel the need to repeat the prof's advice to Vincent, or persuade him accept it, as some less experienced nurses, even a senior staff nurse, did. She was able and ready to adopt a new perspective, if necessary

For my part I told Vincent that in the light of the professor's advice and subsequent developments in his mobility, I completely understood his inclination (and subsequent decision) not to have the amputation, and wished him well insisting only he made certain to act as soon as he had the .slightest suspicion ,the leg was deteriorating or he was going septicaemic: Empowering .and offering support to. Vincent seemed, from the point of view of this new perspective, the right thing to do.

At this level it seems that self-awareness is increasingly important, particularly when the situation demands assertiveness on the part of the proficient to challenge the group perspective and adopt her or his own. The sort of sensitivity to one's own intuitions and experience required at this level may be analogous to what I have argued is so important in mental health nursing, the sensitivity to someone else's experience and willingness to facilitate its articulation.

The level of expert is a development beyond proficiency where, for example, it is no longer a struggle to deploy new perspectives. Indeed, all of the above from the most prosaic task to the most creative reframing exercise is like second nature and takes place at an increasingly preconscious level, freeing one to attend to whatever other agendas are important.

THE SKILLS ACQUISITION CONTINUUM

Of course, these stages are not an all or nothing affair. Whilst one may be novice in some activities or areas of work, one may be considerably advanced in others. And again, they are perhaps not so much discrete stages as tendencies along a continuum of skill acquisition and personal development. Nevertheless, the model provides a way of understanding the processes involved in becoming a nurse and it has been particularly I useful tome. As I progressed in certain areas of activity, learnt the ward routine and developed an overview of what happens to patients under- going coronary artery by pass graft surgery, aortic valve replacements and other standard operations, I found I was increasingly at ease and able to implement the mental health nursing skills mentioned earlier. (These areas of competence did not have to be - and were not - extensive, as I was supernumerary for the entire placement.)

Furthermore, acquiring competence in a few basic areas led to my no longer having to concentrate so hard on learning the tasks, processes and routine of the ward, and freed my mind to attend to other matters. It was only after reaching this stage of competence that my general state of anxiety decreased to a level where I came to understand some of the reasons for my dread of this placement and my terror regarding sickness and death. I shall say a little more about this in a moment, but the point for now is that Benner's model helped me to give shape and structure to these experiences, as I believe it is likely to be of help to anyone in a similar situation.

BRINGING NEW SKILLS AND UNDERSTANDING BACK TO PSYCHIATRY

I have indicated above a number of general nursing skills I have acquired, ranging from bed baths to wound care, measurement of blood pressure to semi-specialist areas of health education. These are likely to come in useful from time to time in psychiatry. In contrast to this, I do not imagine the need will arise for me to remove a chest drain or neckline, or suction a tracheotomy tube again. Similarly, there are many areas of knowledge of a generally applicable nature which, not having studied biology at school, I have learnt about for the first time and should be able to use and pass on: the different systems in the body - the cardiovascular system, respiration, nutrition, the relevance of basic physical observations and so on. And again, in contrast to this, many areas of knowledge I have acquired are quite specialist and likely to be redundant back in mental health nursing. (But if any of my psychiatric patients do need coronary artery by-pass graft surgery, for example, I shall certainly be able to explain it to them, help to prepare them psychologically, and if they are particularly into horror and gore, even go into the gruesome details of what it looks like, as I watched one!)

More than all this, however, I have noted a change in my attitude to sickness, physical disease and death. I had never before confronted these issues except by way of a terrifying experience when I was six and was taken to see my eighteen year old brother in hospital, following a motorcycle accident. His leg was broken in some fifteen places and amputation was on the cards. His ruptured liver had leaked some four pints of blood into his abdomen by then (although they did not know this at the time), and he was semi-conscious and yellow. It was a Nightingale ward and smelt of antiseptic and sick, There was traction equipment attached to the bed, and weights hanging from the end. Everything echoed. I felt sick and faint, and ran out crying and terrified. I learnt that seeing me so upset had, in turn, upset John all the more. I felt guilty about that, but could not go back to the ward.

As a child I could physically run away from the horror of that situation. Ar. adults, particularly as nurses, however, that option is no longer so straightforward.

COPING MALADAPTIVELY WITH SICKNESS AND DEATH

Menzies (1960) study of nursing services in a general hospital is well known, an describes many ways in which nurses do deal with the intense and complex anxieties arising from their work.

Nurse are in constant contact with people who are physically ill or injured, often seriously. The recovery of patients is not certain and will not always be complete. Nursing patients who have incurable diseases is one of the nurse's most distressing tasks. Nurses are confronted with the threat and the reality of suffering and death as few lay people are. Their work involves carrying out tasks which, by ordinary standards, are distasteful, disgusting, and frightening. Intimate physical contact with patients arouses strong libidinal and erotic wishes and impulses that may be difficult to control. The work situation arouses very strong and mixed feelings in the nurse: pity, compassion and love; guilt and anxiety; hatred and resentment of the patients who arouse these strong feelings; envy of the care given the patient.
(Menzies, 1960; p III)

Menzies characterises the techniques which nurses used for dealing with these issues as essentially defensive and maladaptive. For example, splitting up the nurse-patient relationship by preoccupation with tasks, depersonalisation, categorisation and denial of the significance of the individual ('the liver in bed 10', 'the pneumonia in bed 15') and so on. In all, nine aspects of the nurses' and the hospital's social defence system are described, 'the characteristic feature [of all of which is their] orientation to helping the individual avoid the experience of anxiety, guilt, doubt and uncertainty. (Menzies, 1960 p XIV). There are also aspects of the organisation of staff which Menzies acknowledges induce still more anxiety and detract from job satisfaction, but which I would argue are further examples of the social defence system in practice, in that they serve mainly to disorientate staff even more from their purpose and thus obscure the defences already mentioned, resulting not only in evasion of anxiety, but mystification (Laing, 1965) as to what has happened. This social defence system as a whole, Menzies concludes, 'represented the institutionalisation of very primitive psychic defence mechanisms, a main characteristic of which is that they facilitate the evasion of anxiety, but contribute little to its true modification and reduction. (Menzies, 1960; XXII)

COPING CREATIVELY WITH SICKNESS AND DEATH

By entering into the experience of patients who are sick or dying in the way described above and developing a therapeutic nurse-patient relationship, I believe that general nurses can, and do, overcome the failings described by Menzies. To the extent that I was able myself to do this, I not only helped patients a little, but I began to disentangle my own I confused experience of sickness and death, and started to modify and reduce, rather than evade, the anxiety associated with it. It would be ridiculous to say I have resolved, or was now comfortable with these issues, but it certainly feels as if I now have some familiarity with creative (as well as defensive) strategies in facing them. In particular it seems to me that my attitude to sickness and death is characteristically more tolerant and accepting, rather than terrified and evasive, as it was before. This change is the main thing I believe I shall take away from this placement and back to psychiatry.

CONCLUSION

In the foregoing pages I have sketched some of the ways in which I have brought my mental health nursing skills to general nursing, hopefully passing some of them on in the process, and ways in which I have failed to do so. I have also tried to show how general nursing skills and knowledge, and particularly a willingness to respond authentically to the painful experience of working with the sick and dying is likely to aid my practice as a mental health nurse. Reasons enough, it seems to me, for my having been sent into a general hospital on the placement which I dreaded most and was convinced was of least use or relevance for me.

Meanwhile, now on my last day, Big Jim is preparing to go home. 'So long, Benny Boy' he booms down the ward. 'You layoff that drink boy'. Vincent is hobbling around at home I expect, distracted by pain and uncertainty as to whether his ulcers are really getting better and how useful the leg really is. But the church is praying for him and the prof is ready with his Black and Decker if things do not workout. He accepts he might have to lose it but it will be hard. As Vincent says, "I'd grown kind of attached to that leg". The lady whose coronary artery by-pass graft and aortic and mitral valve replacement operations I watched is dead. Her heart just packed up in the end. She's gone. May she rest in peace.

I've got to go and see Sister now, for my final report. (It seems odd that someone who I like and respect so much should have seemed so menacing on my first day, when it appeared as if she was angry with me for calling her Joanne and not Sister). And then I'm out of here.

I'm relieved its over,

but then

again,

it never is...

REFERENCES

Benner, P (1982) From Novice to Expert American Journal of Nursing Vol 82.

Buckowski, C (1991) Septuagenarian Stew: Stories and Poems Black Sparrow Press, Santa Rosa.

Davidson, B (1992) What can be the relevance of the psychiatric nurse to the life of a person who is mentally ill? Journal of Clinical Nursing Vol. 1 pp. 199-205.

Jayakrishnam, A, & Desai J, (1991) Coronary Artery by-pass Grafting. Nursing Standard Vol 5 No 18 pp 52-53 Jan 23rd 1991.

Dreyfus, S and Dreyfus, H (1980) A five stage model of mental activities involved in direct skill acquisition quoted in Benner (1982) From Novice to Expert.

Egan, G (1990) The skilled Helper - a systematic approach to effective helping 4th edition, Brooks Cole publishing, California.

Laing, R D (1967) Mystification, Confusion and Conflict in Intensive Family Therapy Boszormeny-Nagi, I and Framo, T L eds.

Laing, R D (1967) The Politics of Experience Ballantine, London.

Menzies, I C P (1960) A case study in the functioning of social systems as a defence against anxiety Human Relations Vol 13.

Smail, D (1984) Illusion and Reality: The meaning of anxiety Dent, London

Smail, D (1988) Taking Care: an alternative to therapy Dent, London.

Strang, J (1982) Psychotherapy by nurses -some special characteristics Journal of Advanced Nursing Vol 7 pp167-171

"Final Word" ©1990 by Charles Buckowski
reprinted from Septuagenarian Stew: Stories and Poems
with the permission of Black Sparrow Press

© The Author

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Ben Davidson, 95 Enys Road, Eastbourne, East Sussex BN21 2ED., England.