Navigating the Psych ER as a New Grad Nurse

Navigating the Psych ER as a New Grad Nurse

I sighed and looked up, the light turned green. Green means go, right? I advance on the pedal, and drive through the intersection. Only, I didn’t make it through. CRASH! I remember the event like it was yesterday. It seemed as though time stopped. Glass shattered on my clothes, my dress, through my hair…I heard the crunch and screeching of tires. The car door started jetting into my leg from the brute force of the oncoming car. I let out a blood-curdling scream.

Time immediately stopped. “Oh my God.” I thought. “This is it. This is how I am going to die.” It is true. You kind of think of everything in those milliseconds. “I should have told my parents I love them tonight. I should have told my friends how much they mean to me. I should have…” So many should haves…

The car came screeching to a halt. Was I dead? [et_bloom_inline optin_id=optin_21]

My car was facing the other way. I had been T-boned, driver’s side, by a man running a red light. They estimated his speed was at least 60 mph. Two ambulances, police officers, and many deep breaths later, I’ll never forget the police officer’s face as he looked at my mangled car, my shocked tearful face, and said, “I have no idea how you walked out of that car alive.” With that, he put his hat on, turned on his heel, and walked away.

That night, I ended up being the patient in an ED. It was eye-opening, to say the least, that the affect this reversal had on me.

Fast forward to now, and I still drive through that intersection, although now a shiver runs down my spine sometimes as I do. What is that red light runner doing now? I wonder this sometimes. How did it affect him? You see, it is this “how does the other person feel” perspective that I try and think of now when given the psychiatric rotation in the ED.

I have stared in the face of the “truly mad, or truly crazy” person. How do I know? Believe me, you know. As an ED nurse one can tell the difference between the “fake crazy” and “real crazy.” I have never been more terrified than standing face-to-face with “real crazy.” Respectfully, I try, as with the red-light runner, to understand what they must be feeling.

I was given the psychiatric assignment just the other day. As an ED nurse, it is pivotal in our department we do not let homicidal or suicidal patients leave. They are a danger to themselves and others. Sometimes I am still reminded of my parents’ drawing in our house from Alice in Wonderland—the one where the Cheshire Cat exclaims, “We’re all mad here.” “How do you know I’m mad?” said Alice. “You must be,” said the Cat, “or you wouldn’t have come here.”

Sometimes, when I am dealing with psychiatric patients I will admit I think of this drawing. Am I mad for being here? How can I care for these patients when I have no idea what on Earth they are going through?

It is then I just think of humanity’s basic principle: help one another when in need. Perhaps I cannot understand what they are seeing or hearing, but I can at least be present. And this is the fundamental advice I have for nurses with psychiatric patients: just be present. Sit there, listen. Yes, it feels uncomfortable. Despite having a black belt in Taekwondo, multiple degrees, certifications, and a license telling me I can deal with this stuff, I still feel pretty useless and helpless when confronted with mental illness. Your presence and physical company can be instrumental when no else dares to do so. Now, obviously if a patient is acting out and belligerent, then yes, due caution is in order.

Speaking of, as a new grad nurse, I have not been immune to psychiatric patients acting out. I have seen a patient spit and stood in front of a patient at arm’s length as she shouted obscenities: “YOU ARE THE DEVIL INCARNATE. YOU ARE A VICTORIA’S SECRET WHORE!” Once a patient even reached for my neck, her far-away look belying her violent mannerism. I, thankfully, acted quickly and maneuvered away.

I have been kicked in the ribs by a teen thinking I was an angel from Hell. I know a nurse who had to lock herself in a supply closet to keep from being hit, and I also know a nurse who had his ribs broken by a patient. I have assisted in numerous patients being restrained in four-points, and as a new grad nurse I have been the one shoving a needle in a psychiatric patient’s thigh—hoping against hope that the police officers can restrain the patient long enough for the medicine to take effect and knowing it is down to me to accurately and quickly sedate the violent patient.

And I’ve come out the other side. Sometimes I battle what I think is right versus what medicine dictates. And I am often reminded of Jung’s saying, “Show me a sane man and I will cure him for you.” Having attained a minor in philosophy, I often find I think of this.

Despite all—literally—bruising moments, I try to always think of what the patient feels, what the patient thinks. Will I ever really know, or understand? Probably not. But, as a new graduate ED nurse, I find I am just finding my footing, and I reflect on the Kate Millett oddity that “[t]he involuntary character of psychiatric treatment is at odds with the spirit and ethics of medicine itself.” As a new graduate nurse in the ED, here are four things I have learned when dealing with the psychiatric patient.

1. Be present.

Sometimes the best medicine is doing nothing, just being present for someone else during his or her crisis. I have heard many a patient’s plea for death, and many more regrets. Sometimes, I think it truly is beneficial to be a comforting presence.

2. Listen.

As with number one, I find silence is something I am still quite uncomfortable with. I am a nurse; I am trained to intervene, to DO something. Sometimes, however, so much more can be accomplished by just listening.

3. Stay safe.

As a new grad nurse, I find in the ED I am always watching my surroundings—one eye and one ear out, looking, listening around me. Besides observing for potential code situations, I always make sure I have an escape plan if a psychiatric patient ever does get violent. Further, I have seen psychiatric patients bolt like lightning down hallways, once time in nothing more than his skivvies (which at best were barely hanging on). It is always best to be proactive rather than reactive—a good rule for the ED in general.

4. Stay calm.

Above all, I feel patients can sense when a health care professional is anxious or nervous. Staying calm around someone who is completely unpredictable is hard—especially if the triage note says something like “homicidal ideation, tried to kill sister with a knife today”—but it is imperative.

As for me, I have been trying to see the other side since my fateful crash. Maybe I don’t always understand the psychiatric patient’s mentality, or even want to understand it, but I can care the best way I know how, one shift at a time.

I think it is important to note that not all psychiatric experiences are negative; in my day I have met many the sweet, kind, elderly—but politely—confused patient. “Dear, I cannot seem to make my sheets like I like them.” She looked at me, smiled, and beckoned me over. “I just can’t get these sheets right,” as she attempted to smile. We walked arm in arm, but I noted that she started tearing up. “Okay, we can do this. How about we try together?” I asked, smiling and offering some consolation. “Yes, yes. We will try again. I am just so confused!” She put her hands up in the air, exasperated. As I stared at this woman, I felt empathy. Okay, I thought, time to initiate some first-class bedside manner—GO!

And thus I sat down on the bed beside said confused patient and we talked, even shared a laugh. And though, bless her heart, I know she will not remember our conversation, by the end of it she looked at me with blue eyes and stated a simple but powerful “Thank you.” Then she reached up and hugged me. An actual, genuine, heartfelt, gracious hug. Is getting a hug from a psychiatric patient cause for concern? Well, it depends on the situation, and perhaps the general answer would be “yes.” But not this time. That shift, we made her bed a total of 5 times, and I don’t regret a single one. I learned having patience with patients is instrumental in their care. I gotta tell you, the way she looked into my eyes and uttered those two monumental words that every nurse longs to hear—I’ll never forget it. And it was then I understood how a patient can leave a lasting impression and teach just as much as nurses care for, teach, and affect patients. Maybe it is this reciprocity that is the gem of nursing. And my treasure chest is becoming quite full these days.