I am a psych nurse currently working a night shift in Sydney AMA!

Do you ever feel down about patients being kicked out because they are "better" (good enough to give up the bed, that is sorely needed)?

All the time. Sometimes people come in with a very acute and severe episode of whatever illness they're suffering from, stay with us for longer than our usual turnover of 5~7-days and get transferred to a less acute ward. It feels at times that what we do is just make sure no one else gets hurt and miss out on the opportunity to build therapeutic relationships

I worked briefly as a chaplain on the inpatient psych ward of a hospital near the downtown of a large city. Can confirm this feeling. It's common and it sucks. Much of my work was with people who had been involuntarily committed as suicidal risks, and they would only be there a few days...nowhere near enough time to get them the help they needed, but, I prayed, enough time to show them that they were, and are, loved.

There is a great deal more we could be doing to help those who suffer from mental illness. Thank you so, so much for what you do.

Indeed, with the bed pressure in psych wards, we can only hope community services are doing their best for their clients.

What drugs make people the most violent and difficult to subdue?

Meth. Hands down. People who use methamphetamine regularly and end up using 5 or 6 points in one go are absolute beasts.

What about amphetamines, I take Vyvanse, has there ever been problems with prescribed ADHD medication? Because I know that they're similar when it comes chemical structure.

Not that I'm aware of...

Most ADHD medication, dexamphetamine etc, come in very very, very low doses. Unless you're taking a whole bottle at a time, you'll be fine.

What kind of training do they give you to deal with this kind of setting? Is it above and beyond normal RN training, or does everyone learn it in nursing school?

We used to go through a 5-day physical restraint training called Critical Incident, Positive Outcome where they cover manoeuvres to restraint aggressive patients during our orientation. This is something detached from regular RN training and exclusive to front-line mental health nursing.

Nowadays we have a system called VPM (Violence Prevention and Management), a 3-day training session, which covers verbal de-escalation, breakaways (for holds and grips) and also restraint manoeuvres.

Do they provide karate training as well?

Nope, anyone with martial arts backgrounds are strictly prohibited to practice them on patients unless absolutely necessary (life threatening situations)

Can anyone fix crazy?

Depends on what you mean by crazy. Most of what we do in an acute psych ward is symptom management A.K.A.: Make sure they're less violent when they leave us to another ward or home. As for long-term treatment, its definitely possible with the right combination of medication and social supports

Ah. You can suppress crazy but it can't be fixed.

I like to think of residual symptoms like perceptual disturbances or thought disorder as scar tissue that remain after a successful surgery or procedure. We have someone who works in the service that's a past patient. He states that despite the symptoms of his illness, he's surviving and coping and making something of it rather than the negative experience he has in the past.

I am in Canada and I had a few nurses in your position that really helped me while I stayed in a psych ward. Thank you for your compassion and understanding.

What brought you to want to be in this field?

You're welcome. Although it's rare on my ward, it's always great to see people leave happy with the care they received.

As for why, I started off thinking that it'll help me understand some of my mental health issues, but then became aware that people in public wards are so far beyond a depressive episode or anxiety disorders that I just wanted to help. I felt like if a mild and short depressive episode made me feel so terrible, people with more severe mental health issues must be going through hell. And so I stayed.

You have the heart of an angel. Thanks for doing what you do.

You're most definitely welcomed.

Thanks for the AMA.

Working in an acute psych ward must be anxiety filled experience, and where you always have to be on your toes for anything abnormal/violent/out-of-the-blue crazy. Does this seep into the real world, where you are shifty and jumpy all the time? If so, what do you do to relax or unwind?

You are very welcomed. I think I carry more of my observation and verbal de-escalation skills with me. When I'm in risky places like bars and clubs or bad neighbourhoods I'm always assessing the situation in and being aware of the surrounding - weapons, dangers, exits. The job's taught me that you can talk your way out of most sticky situations.

However, like you said, the 8 hours, sometimes 15 hours at work can be mentally exhausting. Having a supportive network of colleagues, family and friends definitely help. I live close to a river so long silent walks help, psych wards are loud...

Thank you for an insightful response. Just had a quick follow-up question.

Since most of us will probably not work in a psych ward, but are often confronted with risky and sticky situations you mention above, what are some things from your individual perspective could help us be more aware? Also, could you give us an example where you talked your way out of such a situation?

To the first question: If you expect there to be an incident, know your exits. If you get cornered, make as much noise as you can to get attention. Learn some basic self-defence techniques especially breakaways. Have speed dial/favourites set up on your phone to people who can help you out.

If you're worried about "crazy people" randomly assaulting you, I can honestly say that its very unlikely that someone who is not drug-affected will assault random pedestrians. However, if someone who's suffering from Schizophrenia incorporate you into their delusions, there's not much left to do but avoid them as much as possible. If you're talking to that specific person, try to see if they can maintain eye contact. If you think something is wrong with them and they have trouble maintaining eye contact, it means they're receiving stimuli from another source. Time to back away from them.

2nd question: Was at a bar once and a security guard stood over me because I was smoking in a non-smoking area. Mind you this guy was about 6'5" and 120KGs, would have destroyed me. He seemed to no be happy with me saying I'll walk towards the smoking area, couple of metres away, with my cigarette in my hand and wanted me to put it out. When I refused and started walking he grabbed me by the shoulder and stood me in front of him. Started making threats to harm me if I don't put my cigarette out. Thinking that this guy was obviously getting way too worked up about the issue and definitely not being professional I put my cigarette out and tried to start a conversation with him which he did not want to take part in and walked away. 5 Minutes later he got a couple more of his colleagues to come and tried to throw me out. I didn't want to embarrass him in front of his colleagues so I followed. Had a nice long chat with him right outside the door. Being respectful of him and his decision I questioned his intentions. Turns out he's been working since the morning and just snapped when I wouldn't do as he says. He then apologised and let me back in and even bought me a drink thanking me for listening.

As a nurse, why do you smoke cigarettes?

Because I am a slave to addiction.

Do all hospitals have psych wards?

Are they floors of their own or just sectioned (no pun intended) off?

At least in Australia, there's a movement to move mental health facilities closer to general hospitals so that medical emergencies that our patients can have are dealt with promptly. Most facilities I know of are separate buildings completely.

I have heard that's where Elvis is residing. Any other notable guests? Someone who identifies as an attack helicopter perhaps?

Not that I'm aware of. Most celebrities would go to private facilities.

We did one time get a patient who's child is kidnapped and his story was all over the news though... That's about it unfortunately

I might have misunderstood but i think the poster asked if you have patients who think they are someone else, eg. Elvis or Jesus

Right, didn't read the second question. Not on our ward, but we have someone in a recovery ward who believes himself to be Kurt Cobain.. Besides the similarity that they're both blond, they share nothing in common. He just sits there strumming a guitar on open strings and keeps talking about his new album being released.

I once knew a Nurse who works in the ER and could not deal with the emotional ups and downs and ended up quitting. How do you deal with people getting to you emotionally day after day?

Talking. People underestimate the value of just talking and letting things go. Clinical supervision, post-incident debriefs work wonders for us.

However, people have very different tolerances for emotional turbulence so I think your friend made the right choice by removing him/herself from an environment that's too traumatic for him/her.

Are most the patients in your facility Mentally troubled(Dealing with long-term or sudden on set mental issues) or Mentally disabled(inbalances/birth defects/etc)?

Mostly patients with a dual diagnosis. On the occasion someone who's mentally disabled and have been violent recently.

Are these people who "snapped", or more eloquently stated: Met a life event/medication that caused events leading to hospitalization? Or most of these people plagued for long periods of time before being treated?

We have two kinds of schedules in Australia, mentally ill and mentally disordered.

Mentally ill patients tend to stay longer and have a diagnosis. This usually mean a longer length of stay. Mentally disordered patients can range from someone who's drunk and disorderly to someone who's attempted suicide. As long as a psychiatrist deems this patient safe to return, they may very well only spend the night.

That actually seems like a more friendly system than what the US has... course that's being said about most things now. Anyway, I was just wondering because I have a sibling who is in jail. He's a large man, built like linebacker, with the traits for a 12 year old. I was curious as the state system doesn't want to classify those types of mentally ill people. They assume them sane and ship them off for more tax dollars.

From what I know jails in the U.S. are mostly privatised so there's a incentive for legislature to lean towards sending people to jail to make these organizations more profitable I suppose.

Have you ever been physically injured on the job?

Multiple times. I have a regular physiotherapist because of my job.

Have you tried to learn any self-defense/karate-type strategies for the more violent patients? Have you ever had to deal with them?

I personally have been learning muy thai and jiu-jitsu since I was 19. Anyone with martial arts background have been strictly told that they're not allowed use these skills at work.

That said, getting hurt is less of an issue because enough of that happens in the gym.

If you find yourself in a psych ward against your will, how would you convince others that you're not really crazy?

First of all, you need at least 2 psychiatrists' opinions to be held against your will in a hospital. If the second disagrees with the first, a third is called to tie-break. The chances of two experts getting your case wrong is quite low...

Furthermore, in Australia, family members/carers can actually help you overwrite a schedule. Not forgetting that within a week, every patient will see a panel of experts (Lawyer, Psychiatrist, Clinician) that are not hired by the hospital to review your case and can discharge you.

My dad is schizophrenic and hates most medicines and his insurance no longer pays for the one he likes. He is probably going to end up permanently in an asylum. Is there a way he can refuse medicines without being forced to take it?

check your state laws on outpatient commitments and forced medications.

I would agree with this statement, I'm sorry but I'm not very familiar with mental health laws in other countries. If you're in Australia, I would liaise with the community mental health team for a plan

I have a few questions actually and hope you don't mind sharing with us. What motivates you to work as a nurse in an acute psych ward? Can you share with us your most terrifying experience while working there? And can you give us one rule/tip when dealing with patients with acute or severe psychiatric illnesses? Thanks for the AMA!

Hiya,

Very good question. To be honest, initially I got into mental health because of my own issues and thought it would be a good idea for both introspection and well helping others. Soon I realize that mental health nowadays isn't always so straight forward. People with a dual diagnosis meaning that they both have an actual mental illness and a poly-substance abuse history are the most prevalent and dangerous (to themselves and others). My motivation as of this moment is to make sure that the least amount of people get hurt due to either their illness or their drug habit.

My most terrifying experience working there is when I got put in a choke hold by someone and my consciousness fading. Because it was so unexpected, none of the training mattered and I just struggled while slowly losing consciousness. A colleague of mine saw me and came out to help. Injured my back and went to the emergency department to check if I've suffered any brain damage, which I didn't.

The best tip I can give is to build rapport. Get to know them as well as you can, help them identify their triggers and hopefully they don't target you when they become aggressive. I've once had a patient going through a very acute episode of psychosis while being tackled and restrained say my name and "help me".

Thanks for the answer! Glad that you are all fine now. I'm also very curious. Do most of the patients realize that they have psychological disorders? And will they get more depressed if they know there won't be any cure for it? How do they cope with themselves?

Some of them do. Others eventually do when they get better. Having insight can sometimes make people quite unhappy or remorseful. Most of them are stunned by disbelief when they realize what's happened.

People who experience a psychotic/manic/depressive episode for the first time don't end up on my ward unless they've assaulted someone in the general public. But as you implied, its distressing to go through an ordeal like that. Most patients are referred to a community mental health service on discharge which will help them through this period and the responsibility falls mostly on them to deal with the aftermath of an episode.

Hi thanks for the ama! I'm not sure if this practice is still being performed but do you still do lobotomy? I saw that in a movie(Sucker Punch) I watched years ago and it looks terrifying. What exactly happens during and after lobotomy? And how do you typically decide if a patient needs it?

Lobotomy is a very out-dated practice and I've actually never see it performed. http://www.bbc.com/news/magazine-15629160 has some interesting information if you want to read about it. SOrry I can't be more help on the topic.

Do you see your work environment as a positive or negative place?

Hard to say for sure... So I'll list the positives and negatives.

Positives: People do get better. No uniforms. Working with people, actually getting to know everything about them. More autonomous than a general nurse.

Negatives: So much meth... So much. We have to set a lot of limits on our patients. The recent smoking ban in Australian hospitals have not been helpful with that. I've been injured multiple times. People with Antisocial Personality Disorders (formerly known as Psychopaths).

Hi! I just graduated from university with a psych BS and got a job at a similar facility- doing nights at an acute psychiatric inpatient treatment facility at a local hospital. I've never actually had experience in patient care or with the severely mentally ill and was wondering what advice you would give to someone just starting out in the field?

Welcome to the field.

Depending on what acute means in your area, I would say keep in mind that the patients are unwell. What they say or do isn't a reflection of who they are (most of the time) but a reflection of their illness/disorder. Don't take it to heart the abuse you get, and definitely talk to loved ones if you're struggling with things at work.

Get into this thing called clinical supervision. It helps get an outside perspective on a lot of internal things that happen at work.

Canadian ICU nurse here who might be interested in moving. How are working conditions ? Are jobs readily available? Any nurse shortages ?

Couple of my colleagues are from Toronto. According to them, working conditions here are worse due to the clientele. Australian people in general feel more entitled and demanding to them and they swear a LOT. Jobs are readily available in mental health due to the shortage and people's disinterest in working in the field.

As someone with quite a few psychiatric hospitalizations under my belt, I have utmost respect for the people who work those units. From the cleaners to doctors, I know it must be a stressful job.

That being said, what made you decide to choose psychiatry? Do you plan on becoming a doctor?

Sorry if this was asked already.

No need to be sorry. I usually don't bother scrolling through a whole AMA as well.

I started off thinking that it'll help me understand some of my mental health issues, but then became aware that people in public wards are so far beyond a depressive episode or anxiety disorders that I just wanted to help. I felt like if a mild and short depressive episode made me feel so terrible, people with more severe mental health issues must be going through hell. And so I stayed.

I don't plan on becoming a doctor, I feel like I actually get less patient contact as one and they're definitely more result and medically focused. I am considering becoming a clinical psychologist though.

I'm about to enter the wonderful world of psych nursing. Why do you think psych greys such a bad wrap? I've been told (and read) numerous times that you should always,do med-surg first and psych has no upward mobility, both which are false. How do you handle these ignorant views? Any advice for a new comer in the field?

Not aware that there are such negative views. But then again I love what I do and could care less about them.

As for advice, I would say keep in mind that the patients are unwell. What they say or do isn't a reflection of who they are (most of the time) but a reflection of their illness/disorder. Don't take it to heart the abuse you get, and definitely talk to loved ones if you're struggling with things at work.

Get into this thing called clinical supervision. It helps get an outside perspective on a lot of internal things that happen at work.

Hi! Awesome to see this here. Last year i graduated with a bachelor's in Psychology. I'm going through the application process with a new college to get my bachelor's in nursing. I'm wondering what schooling you did to specialize as a Psych Nurse. My hopes are to become a Psychiatric Nurse Practitioner. I'm trying to map out a good route to achieve that goal. Also do you love doing what you do? I feel like it would be an intense, yet rewarding job.

To work as a psych nurse in Sydney, NSW, Australia, you need a BA in Nursing, then a 1 year transition period in which you get sent to different wards for experience. I'm currently studying for a MA in mental health nursing and the entry level for Mental Health Nurse Practitioner in Australia at least is the same - BA Nursing and work experience.

Have you ever seen/had a patient with Cotard Syndrome? Also are you ever frightened by your job?

No I have not. The most interesting thing I've experienced is someone with severe Korsakoff's who almost literally, has about a 20 minute memory. Had to write cards to keep with him to remind him of important things.

Wouldn't say I'm frightened. There's a great support network and I can trust the people I work with to have my back. I'd say the job is stressful more than frightening.

How do the RT staff work on your floor? Do they go through the same kind of training you do to deal with difficult patients, or do you guys do the respiratory care stuff?

RT staff

Not sure what that means... We're qualified RNs, so anything they would know about respiratory care, we do.

This is the career path I really want to take. What steps should I take to get there? Does work "follow you home?"

Again, with limited knowledge of how other countries work, you need a Bachelor's degree in Nursing to work as a mental health nurse in Australia. After you graduate, you need to be registered and then look for a job, which is easy as there's quite a shortage for MH nurses. Then a 1 year transition period where you'll get sent to different facilities in the district. Then voila, you're a mental health nurse.

Work definitely follows me home. Keeping to date with recent changes in treatment plans and new research making old practices obsolete is one part. Traumatic events happen at work constantly so you need to have a good support network. The job itself is stressful so you need to have a good unwinding plan.

Good luck in your pursuit of this career though :)

How do you defend yourself when sick people attack on you?

You stay vigilant and not let people sneak up on you.

Run...

We also have to wear this thing called a duress alarm. Which goes off and alerts all staff when you press it, or when it falls and the gyroscope is out of position for a certain period of time. At least you know people are coming if in the event you're cornered or knocked down.

Wow. Interesting. Thank you.

No worries.

Thanks for the AMA. My SO was recently diagnosed with Bipolar II. It is so scary to see the disorder take over. Do you have any advice for someone thrust into the caregiver role? I feel completely overwhelmed.

You're most welcomed. First of all I'd like to say that the most important thing is to take care of yourself. If things become too overwhelming there should be plenty of support for carers as well as those with the illness. Here are some websites that I recommend that'll help you get a better grasp of the illness and what to expect. http://www.blackdoginstitute.org.au/ https://www.verywell.com/what-is-bipolar-2-disorder-378811

With that said, I personally believe that a management plan needs to occur between the you and your SO. Some suggestions on things that need to be discussed are: What keeps him/her well. What can help regulate his/her mood. (Hobbies, etc) What are some triggers that may cause a deterioration? What are the signs of deterioration? What if she/he refuses to take medication? When is it time to seek an admission? (List behaviours that will cause both of your to be concerned etc.)

How many fingers am I holding up behind my back?

Trick question? Your hands are obviously on the keyboard.

Have you ever been crazy in love?

No to the extent where some patients attempt suicide and lose functionality over a relationship breakdown...