A Night in Psych

I am new to psychiatric nursing. It’s not my specialty, having done mainly cardiac and corporate nursing. But I am one of those annoyingly curious individuals (aka, "potentially meddlesome") and after reading several of your stories over the past few years, I decided to switch specialties. 

Psych nursing isn't difficult, not in the traditional sense. Instead of a full physical assessment, for example, we perform assessments specific to the mind ("focused" assessments). Instead of monitoring heart rhythms, cardiac drips, and vital signs, we monitor behavior and medication compliance (among other things).

What makes psych nursing a challenge is the emotional vulnerability of the patients. This vulnerability manifests in many different ways. The patients may be angry, depressed, apathetic, labile, euphoric, or any combination of emotions and behaviors the average person would not deem appropriate to a given situation (such as laughing uncontrollably at a funeral or cutting themselves when they achieve a goal). 

I had been interested in how our facility approached the transgender issue. For a few years now, the physical assessment on other units had included questions about preferred pronouns. In fact, it’s the very first question we have to answer in our electronic charting system. 

I learned very quickly that most patients are annoyed when I ask about their preferred gender. I get a lot of "what does this have anything to do with why I'm here?" That’s a fair question when you are prepping for a colonoscopy and exploratory surgery. Actual gender is more important, given the very real sex-based disparities in health and healthcare outcomes that can be obfuscated by gender ideology (and have absolutely nothing to do with medical bias). 

I honestly worry that decades of credible research will be destroyed by this non-scientific approach to gender. After a simple Google search looking into gender disparities in healthcare, most results come up with "gender inequality" and dive into the transgender issue, or ambiguously define gender so it’s unclear which population (biological men or women) are actually referring to.

Here's a quote from Harvard med. It’s not profound by any means, but the second half of the quote throws the first half into question in such a way that women's healthcare will be inadequately addressed if the health and heath care related outcomes of trans-women are included:

"The overall prevalence of coronary artery disease is lower in women, and they tend to develop heart problems at older ages (the average age for a first heart attack in men is 65, compared with 72 in women). But gender — which refers to the social and cultural characteristics associated with being male or female — has contributed to disparities in cardiovascular care..."

When did gender become social and cultural? Many of you know this answer far better than I do. But I am trying to figure out how healthcare is being challenged by gender affirming care, and so far, it appears that every other specialty is largely unaffected except for psych (and when I say "unaffected," I'm referring to the actual practice of medicine, not just academia). 

I have found that most older medical doctors who specialize in cardiology, nephrology, and other disciplines roll their eyes and comply just enough to keep their jobs, but they honestly couldn’t care less. It’s mainly the newer docs who are embracing gender affirming care. (As a nurse, I am skeptical of their judgement and will not take my children to any doctor who embraces gender affirming care). 

But Psych? Well, I am honestly still learning about Psych. I have to be careful, for obvious reasons. Being fired for using the wrong pronoun isn't something I want on my resume. 

So here I am, learning about psychiatric nursing. The only skill we really need is situational awareness, and CPI certification, which is essentially situational awareness paired with de-escalation training and safe methods of restraining a patient physically if they attempt to attack you or others.

I prefer working the night shift. It’s harder on the body, but it also means that if you have a patient crisis, you can actually focus on it without the daily needs of other patients distracting you.

And night shifts for psych fits my preference perfectly. Those few who stay up all night are the ones who really need you. They are the detoxers, the opioid withdrawals, the schizophrenics. 

One of my patients was a fabulous young man with a vibrant personality. His grandmother, who raised him, and was his sole source of support, had died six months previously. This was his third stay since her death.

He was on estrogen. He wore hair curlers and a bathrobe. He had a boy-crush on the unit, and giggled whenever that patient was within eyesight. 

In report, I was told he had begun estrogen treatments (in the form of a cream) within the last three months. I stayed silent, but my mind wondered if anyone had suggested grief counseling instead of hormones. I was new to psych, but how hard was it to see that, in his attempt to overcome his grief, he wanted to keep grandma close by impersonating her? If the hair rollers and bathrobe manifested after her death, wasn't this something that needed to be addressed? 

But no. We were there to start him ("her") on new meds to help regulate his mood, and that he was there because he had started cutting himself. 

I wish I had been brave enough to ask if the cutting started after the estrogen, but I already knew no one would know the answer to that. Given the company's new policy on gender (affirmation over biology), we didn't dare. We were just there to give meds and prevent the patients from escalating. 

Here is an example of what affirmation on psych looks like: two hours into my shift, I was given a new admission. She had been raped several years before, and regularly came in, claiming she was experiencing "a total mental breakdown." 

We had one "female" bed left in a largely double bed unit. We were otherwise full. Make a guess who her roommate would be?

Yep. My emotionally vulnerable, biologically male, transgender patient. I swore under my breath. There was no way this could end well. I was about to have two very triggered patients on my hands for no other reason than because psychiatric healthcare had chosen to compromise what was best for each patient in the name of gender affirming care. 

Our unit has an interdisciplinary admissions process. The first specialty to see the patient is social work. The second is nursing. Our social worker that night was following facility policy and placed the female rape patient with the biologically male transgender patient.

My supervisor lost it. She called the social worker and proceeded to explain that a rape victim should not be in the same room as a human being who had the very anatomy that had assaulted her. It wasn't because my patient was violent (far from it). It was because he would trigger her, and we all knew it.

Since this was policy, my supervisor lost the argument. The director of nursing was called and gave her an ultimatum-put the female patient in with the transgender patient or risk a verbal warning.

I was so relieved I wasn't the only one to see how wrong this was, and that my supervisor was trying to advocate for both patients, as all good nurses should. I was not thrilled at what I had to do next. Should I tell the rape victim who her roommate was? Or let her find out for herself? 

I opted for the second. If a bad policy has any hope of being overturned, the patient’s natural reaction should guide that process with little to no interference on the part of staff. I may be wrong, but at least a handful of bad experiences must be played out before staff speaks up. That way the challenge comes from experience and not potential bias.

It took two minutes after I had settled her into bed before we found out just what she thought about this arrangement. I hadn't reached the nurses station yet when her hysterical expletives could be heard down the hall.  She was rejecting her roommate as loudly as she could.  

My supervisor and I acted quickly. The whole unit had just gone to bed for the night, and this woman was waking them all up. My trans patient was now extremely agitated. He had simply introduced himself and, after she made him aware of her situation, he said that he understood her reaction, and he didn't want her to feel unsafe. 

But he was also clearly as triggered as she was, despite being less vocal. As we spoke, I noticed him wringing his hands, and picking at the skin on his fingernails. He was bleeding, and it was self-inflicted. My supervisor saw it too. We both knew it could have been prevented. He had just been removed from one-to-one supervised care (reserved for actual suicide attempts, where someone needs a dedicated round the clock caregiver staying with them at all times). This could cause a regression.

While I talked down my transgender patient, my supervisor did some patient bingo. One of our rooms was shut down because the toilet didn't work. Would our rape patient be willing to use the staff bathroom down the hall instead of having a private one? She would need to ask for a key each time, but she would have her own room.

She said yes. Admissions was called, the room change was now in the system, and all seemed well. I was able to convince my transgender patient to take some medication for his agitation, and I allowed him to stay up in our common area until he had calmed down enough to go to bed.

I wish I could say that was it. But the admissions team was determined to follow our policy of making money over sensible decisions and, 90 minutes later, they accepted another female patient. 

The room with broken toilet was a single room, not a double room. And our female patient this time - she was Muslim. 

I haven't felt this unlucky in a long time. The same scenario played out, in nearly the same way. Our new admission was admitted just before midnight, and after finding out who her roommate was, she rejected him. 

But she was much calmer. Instead of yelling at him and telling him to f**k off like the other patient did, she came to me. And my supervisor and I decided a little more patient bingo was necessary.

We did what should have been done to begin with. We placed the transgender patient in the room with a single bed and broken toilet (ensuring he would get no more roommates of any gender), and we placed the last two admissions in the room he had started out in.

The medication I had given him for anxiety had left him somewhat sedated. He barely remembered having a Muslim roommate. But when he woke up before 6 am, I had to reassure him of his worth. He knew he had been rejected, and to be rejected twice in such a short amount of time was a huge blow to his self-esteem.

I'm not sharing this because I have a profound solution, or even because I am especially brave. I'm sharing this because I went home that morning and wept for him. I don't agree with gender ideology, but I also don't hate transgender individuals. It was devastating for my transgender patient to be rejected like this. It was also completely preventable had an acceptance of the scientifically based biological definition of sex been embraced, instead of the "social/cultural" definition of gender. 

Another coworker felt my supervisor and I were being intolerant, but we pointed out that in both scenarios we didn't intervene, so if anyone was intolerant, it was the rape victim and a Muslim woman. My coworker wisely left it to that.

I actually enjoy psych nursing. I enjoy the break from watching a ventilated patient slowly die. I enjoy the break from family members trying to override DNR (do not resuscitate) orders on patients whose physical condition is so dire they would have no quality of life if they were kept alive artificially. 

But this is hard, too. Three people were wronged that night. One of them much more than the other two. All in the name of gender affirming care. 

I admire all of you who have to live with this on a daily basis. I've written here before, and I just want to say it again...

You are not alone. I felt frustrated, defeated, overwhelmed, and unprepared for this experience. Only one nurse that night felt the supervisor and I were being intolerant. Two other nurses understood how very wrong it was to place a woman in a man's room and said as much. Even the transgender patient understood.

But we are all afraid of standing up to this social contagion. No one wants to lose their job. No one wants to be labeled intolerant or written up for going against company policy. We just want to do our jobs and advocate for our patients without our facility working against the best interests of both its staff and its clientele.

You may never hear our stories or know our struggles. But we are fighting, or at least we are trying to. 

I don't experience this every day but every day I dread being in a situation like this again without a sympathetic supervisor. 

You are NOT alone.