Psychiatric-Mental Health Nursing: From Suffering to Hope

JOURNAL EXERCISE 1 Introduction Harrison and Fopma-Loy (2010) developed and pilot-tested journal prompts with students of psychiatric–mental health nursing. The prompts were based on Goleman’s domains of emotional intelligence and the competencies associated with those domains. The authors noted that the prompts, used progressively over the duration of the course, were an effective tool with which to introduce and stimulate growth of the student’s emotional intelligence. The authors also noted that students found completing a response to the prompt to take considerable time and emotional energy, as did faculty in providing feedback to the student responses. The students needed time to integrate and comment on the experience as well as time and a “safe” environment with the faculty member in order to explore thoughts and feelings identified in the response. In this chapter and on the companion website, journal prompts are provided that can be used or modified for use by students and faculty. For some prompts, sample journal entries for Julie are provided in text or on the website; sample entries for Steve are provided on the companion website. Each sample entry comes with critical thinking questions for use in classroom discussions. Julie and Steve, Journal Exercise 1 Julie and Steve are nursing students who have been assigned, on different days, to the same clinical placement for their psychiatric mental health–nursing rotation – the day hospital of the crisis center affiliated with the local community mental health center. The day hospital offers patients a safe environment, medication adjustment and monitoring, and an opportunity to participate in intensive individual and group therapies until the crisis is resolved. Peer counselors play an active role at the day hospital, which is also staffed by an Advanced Practice Registered Nurse, primary nurses, a psychologist, social worker, occupational therapist, and clinical mental health counselors. Julie and Steve will “shadow” Kelly, one of the primary nurses, and be assigned to patients in her caseload. Their clinical instructor is Shawn Wilson, APRN, a Naval Reserve officer who recently returned from a reactivation tour in Afghanistan. In addition to the journal prompts that are standard for each clinical experience, students are asked to begin a self-reflective journal, starting with the direction to “think about your self – what defines you and makes you an individual? How would your best friends or family describe you? How do you imagine who you are will have an impact on the patient with whom you work? Julie’s Entry: I’m Julie. I think I’m mostly defined as a single parent, a part-time nursing assistant, and a full-time student. I‘m a returning senior but should have graduated this past spring. I’m in the top of my class, but I had to withdraw for a semester because my pregnancy got very complicated. Ben is 18 months old now, and we are both healthy, although I haven’t lost my pregnancy weight. I am renting a room in my parents’ house until I graduate and get a full-time nursing job. Ben stays with my parents while I’m at school and work; my mom says she enjoys being a stay at home grandmother even more than she enjoyed being a stay at home mom, but she needs to get a part-time job. My dad is disabled and my mom and I both need to work at least part time to cover our bills while I am in school. My younger brother is in the Army and is going to Iraq next month. My school friends all graduated last year, but my current classmates would probably describe me as “driven” because I don’t join in their activities. I just don’t have a minute to relax. My instructors have always said I excel at critical thinking, but may not be as comfortable “connecting “ with patients. I believe that a patient would rather have a nurse who knows what to do than one who just knows how to hold hands. I already have my preceptorship for next semester in an emergency department. The ED Manager said he might have a job for me after graduation “…if you survive your psych rotation.” I am a little worried about that comment, but I only have to get through fourteen clinical days. My brother’s friends say that some of their buddies go “psycho” when they get back from combat. My dad’s been in AA for years and always makes a point of saying that an alcoholic can stop drinking but “a crazy person can’t stop being crazy.” All I know about mental illness is what I’ve read about in the newspaper or seen in movies and heard in class. I have to say I’m not really looking forward to spending time with people who are unpredictable and sometimes dangerous. Critical Thinking Questions What aspects of self does Julie reveal in her initial entry? What similarities do you see between yourself and Julie? What differences? Steve’s entry may be found on the student resource site. Answers Julie first describes herself in terms of roles as she defines them – single parent, part-time nursing assistant, full-time student. She indicates she doesn’t “have a minute to relax.” Julie reveals that she may have difficulty connecting with patients and that she is not looking forward to her psych rotation and “spending time with people who are unpredictable and sometimes dangerous.” She admits to not having any real experience with people with mental illness and views this as a separate thing than her father’s experiences with alcohol abuse and going to Alcoholics Anonymous. Answers will vary. Journal Exercise 2 Julie – Focus on Judgment Julie is given the assignment to journal about a situation she encounters in clinical, in which she is to focus on judgment. She is asked to detail a situation in which she felt she was being judged and a situation in which she judged someone else. She is to journal about her feelings, how the judging may have impacted her or the other person’s sense of self, and how it affected her subsequent behavior. Perceptions, Thoughts, and Feelings A Patient with Schizophrenia Dan Porter is a 42-year-old man who was diagnosed with schizophrenia, paranoid type at age 26. He hasn’t been hospitalized since 2000 and is stable on a combination of olanzapine, an antipsychotic, and depakote, a mood stabilizer. He sees his advanced practice nurse once every three months, or more often if needed. He is tall and thin (BMI=19), and today is dressed in wrinkled but clean-looking clothes and worn sneakers. He is clean-shaven, with several small cuts on his jaw and neck that have been blotted with bits of toilet paper; his hair is long and wet and pulled back into a ponytail. He comes to the clinic once each week to participate in a group program in which members discuss their individual wellness plans. Dan has been working on being more careful with his grooming so that he again will be permitted to spend long hours at the public library. He had been asked to leave because his body odor and general appearance was disturbing to the library’s other members. Perceptions Thoughts Feelings Action Standing, shifting weight from foot to foot, in front of appointment desk. Sign on appointment desk says “I’ll be back in five minutes, please take a seat.” Is he having akathisia? Does he know how to read the sign? Is he confused about what to do or is he ambivalent about whether to sit down or remain standing? Mildly anxious Eager to establish a therapeutic relationship with him Approach patient, introduce myself, smile and attempt to make eye contact. “Hi. I’m Julie, a nursing student. Would you like to talk with me for a bit?” Turns slightly to look at me, makes brief eye contact, says “Hi,” then turns away. Able to focus, not responding to auditory hallucinations at this time. Less anxious “Can we meet each Tuesday that I am here, at 10 a.m. in this lobby? We can sit in that corner.” (I pointed out the area designated as the “quiet conversation” corner “You’re a student?” Attending to the here and now experience, seeking orientation. Is he having disorganized thoughts? I need to orient D.P. to my role “Yes, I am a nursing student. I’ll be here every Tuesday for the next seven weeks and I’d like to plan to meet with you each Tuesday at 10 a.m. Is that OK?” (Elements of therapeutic contract) “What college?” Is he too disorganized in his thinking to keep track of all the pieces of information that I was giving him? Concerned about boundaries “I go to State, like my badge says. So, can we plan to meet each week?” (OK to disclose personal information that is not private) Staring off into space, not, making eye contact “State .... hmm. There are fifty states and only one nation, nation – did you know I’m in the national library of Congress?” Attending to internal stimuli Is he having delusions? His comments are tangential Mildly anxious Continue to need to orient D.P. to reality Started to remind him that we were talking about setting up a meeting time. “Would you like to meet each Tuesday at 10:00 am?” Looks down, no eye contact, turns away “Sure. I gotta go.” Turns and leaves the room. Later I see him outside on the porch, sitting and rocking in the chair. Established contract, but D.P. is very ambivalent. Not sure he will be there to meet me next week. Mildly anxious Wonder if he will be able to tolerate a therapeutic relationship. “OK, bye. See you next week.” Julie’s Journal Entry: When I spoke with Kelly, the primary nurse, about working with D.P., I told her my concerns about boundaries and that I thought D.P. was experiencing delusions. She said that D.P. had a doctoral degree in history and wrote a book which was indeed catalogued in the Library of Congress. Then we talked about the difference between concrete thinking and delusions. She also mentioned that D.P. tends to bring up his book as a self-esteem boost. When she said that I wondered if she thought I had not been attentive to this need when I was talking with D.P. I actually felt sick to my stomach that she would think that of me. Later I went back to her and apologized for not doing a better job with D.P. She looked a little surprised and said that she respected my using her to help figure things out and that she enjoys working with students. I thought she was judging me, but maybe she wasn’t. Even thinking she was felt awful. As I read over my process recording, I think I might have been judging D.P., too. I thought I understood what symptoms he was having and judged his comments to be part of his illness, rather than meaningful information. Critical Thinking Questions Consider Maslow’s Hierarchy of needs. What need does Julie express in this journal entry? How do you think engaging in self-reflection is helping Julie in her growth as a nurse? What emotion is she able to recognize in her patient? Herself? Answers Julie expresses a need to have others think well of her. This expresses both a need to belong as well as a self-esteem need, two different steps in Maslow’s hierarchy. In her journal entry, Julie reflects on her communications with her patient and with her supervisor, Kelly. This allows her to validate the interaction she had with her patient and learn that she made some incorrect assumptions about her patient’s behaviors. It also shows her effort to follow up with her supervisor and validate her perspective on what Kelly thinks of her. Julie expresses fear of being judged by others and how it felt “awful” when she thought Kelly was judging her. Box 7-2 Motivation and Perception Emily, a 60-year-old executive director of an investment firm, has been struggling with the symptoms of a major depressive episode for the past month and is considered to be at risk for suicide. Her husband Cliff, a retired civil engineer, has accompanied her each week as she checks in with Susan, an Advance Practice Registered Nurse, and attends a cognitive–behavioral group session. Emily’s med check is delayed, and it is her husband that first notices Susan as she enters the waiting room. Cliff greets Susan with a smile and pulls her aside to report that Emily is “back to reading her finance journals all day already. I think she probably doesn’t even need that medication.” Susan observes that Emily is neatly dressed and groomed. The finance magazine that she is holding that completely blocks her face from view is upside down. Critical Thinking Questions What is Cliff motivated to see? What is Emily’s APRN motivated to see? What strategies might you use in order to improve your ‘sight’? Answers Cliff is motivated to see that his wife is improving, that she is engaging in normal activities that occupied her before the depression set in. Susan is motivated to see Emily’s real progress and observes that Emily is not really reading her finance magazine, which is upside down. One strategy is for nurses to use is mindfulness – awareness of the present moment without making judgment or reacting automatically. By staying in the moment and carefully observing Emily and not simply reacting to Cliff’s statement, Susan was able to observe an important clue that contradicted Cliff’s hopeful observation. JOURNAL EXERCISE 3 Julie (self-awareness and self-management domains) (Harrison & Fopma-Loy, 2010, p. 647.) Prompt Experience: Describe a situation in which you did not meet your personal expectations for your clinical performance. Reflection: Thinking about it now, were your expectations realistic or unrealistic? Explain. Were your expectations healthy or unhealthy? Explain. How might you respond to a peer who voiced these expectations for himself or herself? What are the similarities and differences between how you might respond to a peer and the way in which you responded to yourself (your self-talk)? Implications: What might be the overall health implications for you if you repeatedly engage in the self-talk you described so it becomes a pattern? Julie’s Journal Entry I had to use my process recording with D.P. (Dan Porter; see patient description in Journal Exercise 2) because I realized that I was thinking about it a lot, actually losing sleep over it. I kept thinking about how far off I was with him. I expected that by doing the reading and analyzing what he said that I would show that I understood psychiatric-mental health nursing concepts. But I felt like I completely failed at understanding my patient. I’ve never “failed” like that. I also realized that I was the only one calling it failure. It’s interesting to think about how I would react to one of my classmates, because I think of myself as the “mom” of the group. I give pep talks and try to help out – I’d never call anyone a failure if they did what I did. It may not be like irrigating g-tubes, but this is definitely something that takes learning. Feeling like a failure isn’t healthy, but I sure don’t feel successful here. Critical Thinking Questions What roles does Julie assume? What changes to her EQ does she experience? Answers Julie assumes the role of “mom” to her group of classmates, in addition to the roles she described earlier of parent, nursing assistant, and student. Julie realizes that she is not a failure and learns that feeling like a failure isn’t healthy and that she can reframe how she examines situations. She also learns that the emotional context of working with patients requires learning.