T E A C H I N G P S Y C H I A T R I C N U R S I N G IN A N

E M E R G E N C Y P S Y C H I A T R I C S E R V I C E

By Catherine- Williams, R.N., M.S.N.

HE community mental health T movement and the concomitant trend toward keeping patients out of mental hospitals has had a major im- pact on the teaching of psychiatric nurs- ing at the University of Washington. Prior to the fall of 1967, instruction in psychiatric nursing in the undergraduate program was carried out at one of the state hospitals. During the past several years owing to changes in its patient population, this hospital has focused its services on an extensive geriatric pro- gram. Because of this, the University instructors in psychiatric nursing found themselves confronted with an unsuit- able patient population and a teaching unit which no longer fit into the philos- ophy of the School of Nursing or the philosophy of the undergraduate psychi- atric nursing courses. In accordance with this philosophy, “Correlated theory and clinical experiences are offered in the care of the physically and mentally ill in the hospital and in the home; and in teach- ing, treatment, rehabilitation, prevention

and health conservation for all age groups.”

Contrary to this philosophy, the stu- dents in the psychiatric nursing courses were having most of their clinical prac- tice on wards which were specifically geriatric services. The few students who did have their clinical experience on the psychiatric service were placed on ex- tended care wards where the majority of patients were over sixty years of age and had been hospitalized for the greater part of their adult life. Since no more than two students were permitted on each of the two admission wards at one time these wards were inadequate for providing experiences for all of the forty-five to fifty students who were in the hospital each quarter. Con- sequently it seemed imperative that the faculty look elsewhere for suitable learn- ing experiences in psychiatric nursing.

The selection of the county hospital as one of the three hosiptals to be used for learning experiences brought about the need for some serious reevaluation

Perspectives in Psychiatric Care Volume VII Number 2 7969 69

and consideration of the method of teach- ing psychiatric nursing. The psychiatric unit at this hospital is set up as an emer- gency psychiatric service, and the criter- ion for hospitalization is “need for im- mediate hospitalization in the absence of other readily available resources.” The aims of the psychiatric service are to re- lieve the patient’s acute distress and, when possible, to work out some plan with him whereby he can return to his family and community, preferably with some type of follow-up care. When this is not possible the patient and the staff work out plans for further hospitaliza- tion, usually in some other facility.

The rate of patient turn-over is high on this psychiatric unit, and very few pa- tients are there long enough for the student to develop the customary inten- sive one-to-one relationship with a pa- tient. Much of the therapy is directed toward crisis intervention. This situa- tion provoked the faculty to ask: “Can psychiatric nursing be taught in terms of crisis intervention without the benefit of an intensive one-to-one student-patient relationship?” Or, more specifically, “How can we make this experience most meaningful to the students?”

In seeking an answer to these ques- tions the psychiatric nursing instructors bore in mind that the intelligence and professional potential of our nursing students are of high caliber and that the clinical experiences in psychiatric nurs- ing are provided during the senior year. We also took into consideration the basic assumptions in the Statement on Psychiatric Nursing Practice of the American Nurses’ Association. The first of these assumptions states that potential for health is an inherent capacity of life. Our students are encouraged to focus on the healthy aspects of the patient’s personality. At first they have some diffi- culty in dealing with this concept. They

come to the experience with certain pre- conceived ideas that the nurse must “help the patient with his problem.” They soon learn, however, that “helping the patient with his problem” does not always mean dwelling on the problem, and they learn to confront the patient with reality in a comfortable manner.

Take for example, the patient who re- iterated many times what a terrible per- son she was, how she used alcohol as an escape, and caused her family a good deal of anguish as a result of her drink- ing. The student responded with, “Yes, from what you have told me, it does seem that you have caused your family as well as yourself a great deal of hard- ship. You have told me this many times. Now I am wondering what we can do to change this behavior. You say you use alcohol as an escape. Escape from what?” Together they began to work out approaches in a problem-solving manner. The student gleaned information regard- ing the marriage relationship of which the doctor was not totally aware. The husband, though resistive at first, agreed to family counseling after the patient’s discharge.

Such reality orientation is also possible with patients in an acute schizophrenic break with severe personality disorgan- ization. I believe that one of the most valuable learning experiences for these students is to see these extremely dis- turbed patients demonstrating such bi- zarre behavior, yet able to respond to the approach of another person.

In contrast to the experiences at the state hospital, where patients gradually lost contact with their families, at the county hospital the student is able to observe the impact of mental illness upon the family of the patient. A mem- ber or members of the patient’s family are brought into the treatment program immediately upon the patient’s admis-

70

sion, and plans are made with them and the patient for the patient’s return to the community or further hospitalization elsewhere. On a busy admission ward, the staff often does not have time to spend with the family, and the student frequently acts as a consultant to the family. She offers information regarding available facilities and explores with the family the feasibility of the patient’s utilization of these facilities. Perhaps, even more important, she provides a source of support and reassurance to a family bewildered and frightened by the occurrence of mental illness among them.

The Statement on Psychiatric Nursing Practice includes an assumption concern- ing the mentally ill person’s inability to carry on activities of daily living and the impairment of his interpersonal re- lationships. Another assumption has to do with the patient’s need for exper- iences which will promote feelings of worth, self-esteem, and self-respect. I be- lieve that these two assumptions are very much interrelated. One of the pathways by which a patient can achieve self- esteem is through meaningful interper- sonal relationships and through taking an interest in his activities of daily living. At the same time that his self-esteem is enhanced, he will begin to take more in- terest in his daily living activities and pride in his personal appearance. He will also broaden his ability to develop re- lationships.

This concept of enhancing self-esteem was illustrated by a student’s interaction with a young woman who had made sev- eral attempts at suicide. This patient had very derogatory feelings about herself. She spent most of her day alone and was withdrawn to the point that she never initiated contacts with others. When she did communicate, much of her talk was about her feelings of unworthiness,

Perspectives in Psychiatric C a r e Volume VII

“Why do you bother with me? I am all bad. I am no good to anyone. I have never done anything good in my life. I am a failure. I have never succeeded at anything.” The student responded, “Can you bake a cake?” At first this seemed like a rather trite remark and the stu- dent was displeased with herself for say- ing it. However, the patient’s response was a positive one. One can speculate about the reasons for this response; it may not have been the content of the student’s remark so much as her attitude of sincerity. Whatever the reason, the patient reacted positively toward this student, who was sincere and concerned about her interest in such ordinary activ- ities as baking a cake. Discussions of recipes, housekeeping, fashions, and per- sonal grooming became avenues by which the student helped this patient to enhance her self-esteem and take an in- terest in her daily living activities.

In a sense, the student in this setting learns how to invite the patient back into society by helping him to cope with the various aspects of society which are threatening to him. She serves as an identification figure to the patient by helping him to participate in interper- sonal relationships and to develop a feel- ing of trust and acceptance within these relationships. The student and the pa- tient can then test out their feelings and reactions within the framework of these relationships. The student has to be at- tuned to her own feelings, attitudes, and reactions as she interacts with a variety of patients, each presenting his own in- dividuality and his own technique of coping with anxiety.

Students need support and reassur- ance from the instructor as well as guid- ance and direction, and individual con- ferences remain an essential teaching tool. Another essential element is the opportunity the students have to come

Number 2 7969 71

together and discuss their interactions. These meetings are relatively unstruc- tured, and usually the students discuss their interactions of the day openly with one another. This discussion affords them the opportunity to analyze their own feelings, attitudes, and reactions to per- sons and situations. They begin to test out their own feelings with one another and to view themselves in light of how their peers perceive them.

From our experience in utilizing an emergency psychiatric service as a teach- ing facility I believe that psychiatric nursing can be taught to undergraduate nursing students in terms of crisis inter- vention. The situations in the setting can be used to help students to develop the

kinds of abilities they are most likely to need in the future. Upon graduation very few students will be working in state institutions; the vast majority will be working in a general population cen- ter. Whether the nurse is in a com- munity mental health facility, a public health agency, an emergency service of a hospital, or any nursing unit in a gen- eral hospital, she needs to react spontan- eously and “think on her feet,” evaluat- ing the interpersonal process as she inter- acts with each person or group of per- sons. For this reason I believe that crisis intervention is a more realistic approach to the teaching of psychiatric nursing than the methods we used in the state hospital.

COMMUNITY MENTAL HEALTH PROGRAM UNIVERSITY OF CALIFORNIA

SCHOOL OF NURSING SAN FRANCISCO MEDICAL CENTER

The University of California School of Nursing is offering a two-year post-masters program in community mental health. The program is designed to prepare students to function in a variety of community settings as administrators, clinical specialists, change agents, researchers, and university faculty. There will be opportunity and freedom to pursue and develop substantive and practice areas of particular interest to the student.

A limited number of National Institute of Mental Health stipends are available. Further information and applications for admission may be obtained by writing:

COMMUNITY MENTAL HEALTH PROGRAM UNIVERSITY OF CALIFORNIA SCHOOL OF NURSING

San Francisco Medical Center San Francisco, California 94122

72