Power and Humility encapsulate the test of our understanding of established principles of hope, nurture and empowerment of individuals in our care. Perhaps like no other specialty, power and humility converge in Mental Health Nursing – like tectonic plates grinding one against the other under the earths crust and bursting to the surface, there is an inevitable crisis, a complex ethical challenge. How we respond are the critical moments so familiar to us as Mental Health nurses. It’s a widely known fact that one in four of us have a mental illness at some point in our lives. Many of us are lucky to avoid the complexity and destructive impact this could have on our lives and those of family, friends and community. We know that stigma remains alive and well though we seek to eliminate and minimize its impact on those most vulnerable.
My experience as a mental health nurse invites me every day of my working life to put my practice up to scrutiny. Where is my humility in the face of the powerlessness of those in my care? How do I feel when a person with a mental illness is admitted to hospital having stopped taking their prescribed medication, choosing instead to find their own prescribed and non-prescribed medication to deal with the pain of their illness? I have to arrest my inclination to make a judgment. I for one cannot claim to have completed every course of antibiotics prescribed. I have taken for granted that the medication has done its work. And to some extent I have used alcohol as a remedy for my insecurities and social discomforts. Alcohol is an acceptable though for many a dangerous form of treatment and is not a prescribed medication! At other times I have disregarded the advice of the medical profession, and have not always been wrong in doing so!
For many with a mental illness though, treatment is foisted upon them. The decision is made and the power of the Mental Health Act takes its course. The power I have, though unwanted through the Mental Health Act, gives me a license to exercise power of those in my care- and I am sometimes overwhelmed by the responsibility of how it is to be managed. We make judgment calls every day on behalf of our patients and I believe it is the ethical dilemmas we face that bind us together.
I have a story that stays with me and comes to my consciousness when I am called to make a decision that in fact repulses me, whether it be the forced dispensing of medication or some thing more subtle. This story is one of the subtle ones. It was heart breaking for me though not an example of the clearly visible obstructions to individual liberty that we witness and participate in when we decide that all other means of persuasion have failed. This story took place in an inpatient mental health facility. These units can be highly demanding as we know, perhaps not necessarily because it’s so busy or because it is so steeped in the medical model, relying on tranquillisers and antipsychotic medication as the first line of intervention, but because of the demands on our ethical framework.
In this story I had been assigned, among other patients, a man of around 60, suffering from major depression. His illness proved to be resistant to all the usual medications and so it was decided by the medical team that he should have a course of electroconvulsive therapy. This man had been through all sorts of medical and surgical interventions. Before his admission to the mental health unit he had suffered chronic back pain and eventually underwent surgery, followed by months of physiotherapy. He had a long list of medical conditions and had an extensive number of medications to take every day. He was retired and had been a GP in India before coming to Australia. His recovery from the spinal surgery was slow and he became depressed. His physical needs were difficult for the nursing staff to manage, the pain of mental illness surrounding them demanding so much of their time. This set up an unfortunate sequence of events.
Word had been going around that this man had no respect for females or female nurses. In some way his cultural background and profession explained his apparent unwillingness to help himself. He seemed to respond more readily to the male nurse who got him to eat with out assistance and who was able to engage with him in conversation. The man’s behavior became a source of constant irritation, particularly, as expected, for the female nurses.
The electroconvulsive therapy had no measurable effect- a therapeutic seizure could not be triggered. He was brought back from the theatre suite in a wheelchair three times a week. On one occasion, the nurse who managed the patients attending and returning from ECT therapy reported that the man had been incontinent after his treatment.
Days later I had been assigned this man to my care. His family were very supportive and often brought food for him to eat. They spent time getting him to eat and drink. During my shift I saw that there were no family around and made an attempt to engage him and offer him dinner. It was difficult to know what he was thinking because he seemed barely able to answer. His responses had deteriorated to a whisper, his lower legs atrophied from lack of use. He appeared to have all but given up. His face was expressionless.
I asked if he felt like eating anything. To my surprise he indicated that he did and attempted to lean forward. As I assisted him to sit at the edge of the bed, I noticed a large ring of dried urine on the sheet where he had been lying. I was upset that he was in such a bad way and responsible, baring the weight of his situation against the power I had invested in my role to coerce him into cleaning himself up. I urged him to take a shower and that tried to reassure him that I would help him. I offered him a choice as to how he might to go about things and asked him if he would rather eat first and then shower. He indicated he would eat and I had to watch him eat his food in this state. He shook so violently he could hardly bring the fork to his mouth. Unfortunately this had been passed off at previous cross-shift reports as a plea to be fed rather than to feed himself.
I helped him as best I could to make the process easier but after a few mouthfuls he slunk back onto the bed, too exhausted to continue.
Something inside me snapped at that moment.
I felt I had to take control, to direct proceedings firmly.
I looked at him and told him that he would have a shower and that I would help him to do it. Then I would make his bed and offer him a proper pair of pajamas instead of an impersonal hospital gown. I told him that he is a dignified man and loved by his family. A nappy, heavy with urine and smears of faeces fell from his body as I helped him up. I could not tell if he knew how upset I was to see the state he was in.
He somehow managed with a frame to get to the shower.
He almost fell, reeling into my body a few times. The battle became as much mine as his. When he sat down I turned the shower chair around so that water streamed onto the back of his neck. I gave him a piece of soap and a flannel and told him quite firmly to start washing his chest while I washed his back. He tried to move the soap over his chest but he could not. As I washed his back the man lifted his head back, allowing the water to run down over the back of his head. He closed his eyes and I could see there was some dim pleasure in it. I used a cloth and soap and gently washed his head and it seemed to give him a momentary respite from his suffering.
After the shower I dried his body and stopped to catch my breath before lifting him up to the frame. His head was bowed and I felt exhausted and upset.
Then, just as I turned away to reach for another towel, he murmured. ‘Thankyou.’
It was something I did not expect.
It was the most wonderful thing to hear and I told him so.
When he finally lay semi-recumbent in his freshly made bed, I sat beside him and explained to him why I thought nursing was such a difficult job. I had to make a judgment call. I could not allow him to stay in that bed in that condition. I had to make the decision for him and proceed.
‘I hope you understand and respect the decision I made for you.’
There is a sequel here that I only learnt about when I returned to work the following week. It was an intensely personal experience for me and I was overwhelmed by the dilemma of using power in this way. Somehow this intimate scenario hit me harder than the many coercive interventions I have seen in mental health units every other day.
He continued to deteriorate and eventually the medical team saw it fit to transfer him to an intensive medical unit. His psychiatric medication had interacted with the other medications he was prescribed, resulting in a rare and severe condition.
I wanted to see him again to let him know that I really did care. He had looked so far away when I looked into his eyes that evening.
‘I know you’re in there,’ my inner voice said. ‘You have a caring and loving family, it must be worth the fight’.
When I walked into his room in the medical unit the curtains were partly drawn and I saw that his eyes were closed. But when he opened them I saw the expression of recognition in his face – it was almost disbelief. Yes, he remembered me. I asked him how things were- was he getting any better?
He looked across at me and said ‘I think so- yes’. Needless to say I could not stay long- the tears were ready to fall.
As I left him he reached out his hand and said, ‘You are so kind’
I seem to cry every time I tell this story. I hope it resonates with you too.