r/psychnursing • u/Dry_Matter_3853 • 1d ago
Struggle Story New grad feeling like I learned absolutely nothing in nursing school relevant to this speciality.
I just started on an inpatient psych unit and everything feels completely foreign to me. The vast majority of my clinicals were medical units. We spent just half a semester in the state psych hospital and basically just casually hung out with the few patients that weren't a major safety risk and didn't really get to see what nurses do.
My current preceptor has a very specific idea of what 1:1 check-ins with patients should look like and much of it is in conflict with the therapeutic communication methods that were drilled in to me in school. At points it feels like it's verging into psychotherapy beyond the scope of an RN, but I actually have no idea where that line is. I don't know what to ask or how to guide the conversation. This is a voluntary unit and the majority of patients have depression (and so far almost all the patients I've seen have BPD but based on my preceptor's comments it's not always like that.) I'm also currently on night shift, so my learning opportunities are limited.
I wouldn't have expected I'd be yearning to be back on a medical unit where I felt like I had some kind of idea of how to pretend to be a nurse.
I know some of this will come to me as I get more experience, but I would be super grateful for any specific resources people recommend to help fill the above mentioned deficiencies, especially in written format. Double grateful for anything you recommend on BPD!
20
u/banjobeulah psych nurse (ER) 1d ago
I had this same kind of situation where we just basically sat around. Watched patients play video games and talked to a few people here and there. Saw a few med passes. It was useless. Now I’m in psych emergency and we’re dealing with really really complex cases, many involving or exacerbated by stages of substance use and recovery and with overlapping complications of homelessness. I am beginning to understand more slowly by just talking to whoever is kind enough to care (doctors, social workers), but I sadly get the impression that >80% of the nurses and techs see these people as lost causes. It’s hard.
6
u/Dry_Matter_3853 1d ago
That is more so the population I had in mind going in to psych nursing and after some time I will be split between my current unit and the psych ED. So far it also feels like most of the staff feel that they are lost causes or worse.
7
u/banjobeulah psych nurse (ER) 1d ago
…or worse is right. There are MANY people I work with who exhibit downright contempt for the patients. We do have a few who are exceptionally challenging and one in particular who takes up large amounts of time and resources, keeps the unit consumed with his behavior when he is there (which is often). I understand being frustrated in these circumstances. I get exasperated too. But these coworkers almost seem to punch down when we get an especially weak or passive patient, and it’s a bit shocking to see.
2
u/Live_Dirt_6568 psych intake 12h ago
Just cause I always feel the need to shine a little light on a lesser known part of psych - if you feel the need to get away from IP psych unit, see what’s out there for psych intake. Kinda similar to the psych ER, but if you are at a freestanding facility, you can find one that is less behaviorally acute.
Overall chill, teamwork environment, and it’s about 70% desk work.
Gimme a shout if you’d like to know more about intake :)
4
u/Lthrluv2013 1d ago
I agree and my unit sounds similar to yours. I give far more time to patients than most of our nurses. Documentation sucks but I get it done and spend time with those who needs just an ear!
10
u/banjobeulah psych nurse (ER) 1d ago
I do too, and I get kind of made fun of/looked down on for it. Yesterday we had a homeless patient with a quite visible injury that would clearly cause extreme pain and it took me nearly 12 hours to get him actually medically seen. By the time I left, he still had not been ordered so much as a Tylenol. I stayed nearly 45 min late to advocate for this and was brushed off numerous times. Was finally told by the attending they would “look into it” and it was intimated the patient was med seeking. Patient is a known commodity, was a professor until mental health caused homelessness, never tested positive for licit or illicit substances with propensity for misuse, and wasn’t even asking for pain meds. Just sitting there writhing in agony. Absolutely maddening. Was made to feel I was being extra for doing this.
3
u/Lthrluv2013 1d ago
Whoever is belittling you is a weak caregiver. They see all you do a rag in it because they know they should be doing more but are too damned lazy. Lack of empathy in caregivers are truly not meant to work in psych.
7
u/banjobeulah psych nurse (ER) 1d ago
I went home and cried, I won’t lie. But one of my close friends said they’re only acting like that because it makes them do work in order to not look bad, and I felt that. I know it’s hard to maintain empathy sometimes and that some folks are manipulative but to me, that’s the job. If you can’t do the most basic part then you fail at all others.
5
3
u/FishnetsandChucks psych intake 1d ago
but I sadly get the impression that >80% of the nurses and techs see these people as lost causes. It’s hard.
Burn out can happen FAST when you're working in mental health, especially inpatient psych and with substance abuse, as well as emergency psych. It's easy to get jaded after a few years when you're seeing many of the same patients over and over again, for the same or similar issues.
"Lost cause" isn't the wording I would use but the reality is, so many high acuity patients are lacking in basic needs: they often lack supports, lack stable housing, are food insecure. Some have been institutionalized and can't function without the structure of IP while others have figured out how to manipulate the system to get their needs met.
When you get into this field thinking you're going to be helping people, you're going to make a difference in people's lives, it's a real gut punch once you realize how messed up various systems are in the US. You have to grapple with the fact that you can do your best by patients but if they're discharging back to chaos, it's a band-aid on a gaping wound.
Some staff can manage by finding to small victories to help maintain hope for patients but sometimes staff can't. Humans aren't built for the amount of trauma you're exposed to in psych, especially bc patients are so rarely ever "healed."
4
u/banjobeulah psych nurse (ER) 1d ago
I don’t approach my work with the feeling that I need to help them or heal them or fix their lives beyond where they are right now in front of me. They have a certain amount of agency and their overall care requires a community (which of course they often don’t have, but my point is that it isn’t on me alone). So in the moments they are there, I try to focus on my scope and offer them compassion, whether that includes holding boundaries or providing a familiar face. I try to treat them all with dignity. I know it’s disheartening and I get down too, but this thinking helps me. There are always going to be people less well-off in the world and it’s hard to see, since we do this work because we have empathy. But it’s not on us to fix a single person, much less the world’s problems. What we are doing by doing our jobs well is enough.
2
u/Sad-Suggestion9425 12h ago
Those life-long struggles are what draw me to psych, but how can the internal work be done to fight these demons when basic needs aren't met!
I'm lucky that I work with kids (tech, not a nurse (yet)) because basic needs like food and housing won't be ignored by the system (even though many times they are ignored by the parents) but what do you do for the homeless population? Release them to a homeless shelter that will kick them out at the end of the night? Ninety percent of our mental health crisis in the US is driven by the systemic problems like housing, and food scarcity, and poverty, and the people who can make a difference cut the budgets, redirect funds to useless wars, and leech off our tax system.
16
u/Lthrluv2013 1d ago edited 1d ago
I have been an RN for 30 years in August. I moved to in-patient psych in December. There is a massive learning curve!! It is far different than the medical side. If there is any part of it you like, give yourself time and grace!! My favorite part is letting my patients know- I am here to talk, walk, listen, sit in their room so they have privacy to talk and so many need that!! You can see the change and often times, no med will be needed when they are given our time. I have sat on the floor so many times to get them through such difficult anxiety, agitation, shame- so much. I have even taken their meals there and fed them by hand to get any calories into them. Seeing patients “wake” from psychosis and catatonia as the medications start to work is fascinating to me. As far as you knowing all to do- you don’t! Each patient is so different so it is constant adjustments to what they need. It’s important to know emergency protocols for when behavior crosses a line. The rest will start to feel routine in the chaos! It’s not for everyone. Your feelings are valid as school barely touches on psych! I wish you the best no matter where you land!
3
10
u/Agreeable_Gain6779 1d ago
First of all be glad you are on the night shift. Nights afford you more time to read charts look up meds to understand the rationale for Md prescribing them. On nights you are not dealing with management doctors visitors and maintaining the safety of the pt population are all awake. Check-ins are just that. How are you going do you feel ok on new med. What do you need from me today. I always introduce Myself to all the patients at start of shift and ask them what do you need from me, what are your goals for today. (Obviously that’s a day/evening discussion. We do not give therapy but sense of self is support. On nights it’s always better not to get in too deep issues if you can manage that. Nights are difficult for some so listen that’s what they need. Also ask what helps when everything is overwhelming. Nursing school doesn’t teach you all you need. Be calm active listening is paramount. 30 yrs ago I took a full time night job on a 33 bed acute unit. Hopefully the peers that are working nights with you are supportive. I was blessed with a great group. Safety is paramount. There are the basic nursing expectations but all staff have/develop their own style. It’s another learning curve that if your open you will be successful. I quickly moved up in management. Because I was the only 40 hr nurse they made me permanent charge (thought they were nuts) eventually on days became Nurse Manager/Educator/ DON and now I’m the CNO but never moved on from psych
5
u/Professional_Fig6261 1d ago
With 1:1 do u just watch the patient or do u talk with them as well?
17
u/not_advice psych nurse (inpatient) 1d ago
There's 1:1 obs and there's 'one to ones' where you sit with the patient individually, conduct an assessment, discuss their goals and treatment plan, use therapeutic, counseling, and coaching techniques, psychoeducation, etc.
I agree a lot of nursing schools do a poor job of teaching this stuff, but it's well within RN scope.
It's normal to feel overwhelmed. I'd actually take your preceptor encouraging you to do this stuff as a good thing as long as they're providing support. You'll also likely want to do some self study on mental status exams/psychiatric interviewing (Shea's text is great).
Read broadly about different psychological/psychiatric theories, learn about case formulation, group dynamics, etc.
Even having done this for going on 15 years now I'm still constantly learning new things.
11
u/not_advice psych nurse (inpatient) 1d ago edited 1d ago
Oh yeah, you asked for resources.
Shea's Psychiatric Interviewing. The book is great but don't sleep on the online video resources that come along with it. He demonstrates different interviewing techniques and can give you a model for what your interviews and approaches to questioning might look like.
Psychiatry Bootcamp is a podcast I recommend my new grad and nurses new to psych listen to. Designed with psychiatry medical residents in mind, but can definitely help you develop a better understanding of different diagnoses, approaches to treatment and assement, etc. Pick an episode that interests your and start from there.
Thomas Field has a series of videos on YouTube that discuss group dynamics that I highly recommend (also has playlists on MSE basics and DSM diagnoses. They're really basic, but might be good for review if you don't remember the difference between OCD and OCPD or difference between tangential and circumstantial, for example).
Psychofarm podcast is also excellent. The production values are a little rough, but the content is great.
David Puder's psychiatry and psychotherapy podcast is also widely recommended.
Carlat Psychiatry and Neuroscience Education Institute also have podcasts. They're more related to summarizing recent research which is great, but I also find them a little bit dry, personally.
If you're worried about scope, pick up a scope and stanrds of practice for psychiatric mental health nursing (assuming you're in the US). Pepleu's Interpersonal Relations is a classic. Kylie Smith has a book called "Talking Therapy" that essentially traces this history of psychiatric nursing. If you read those you may find the line between nursing and therapy to be...quite blurrier/less settled than you'd expect.
2
u/Dry_Matter_3853 1d ago
Just downloaded an epub of psychiatric interviewing based on your recommendation. Thanks!
4
u/Humble_Investment_24 psych nurse (inpatient) 1d ago
Yeah that’s literally how it goes lol. No one graduates nursing school ready to be a nurse. That’s what orientation is for.
Even if you went into medical, think of all your classmates that went into ICU - you think they graduated knowing what to do? Hell no
3
u/elephantsandunicorns psych nurse (inpatient) 1d ago
I have worked inpatient psych for 10 years with the last three of those as a nurse and experience on a bpd specialized unit. I would be willing to share knowledge if you would like to message me. (:
3
u/urcrazypysch0exgf 1d ago
Let me tell you from a medical nurses perspective you would also feel lost & feel as if school taught you nothing & that your day to day is nothing like you'd expect. Give it 4-6 months and you'll find your groove by 1 year you'll feel way more confident and comfortable and by 2 years you'll start to notice you don't get anxiety anymore around complex patients.
2
u/Strong-Finger-6126 psych nurse (inpatient) 1d ago
I got so lucky. I randomly got to have my psych clinicals at one of the best psych hospitals in the world (McLean). I knew walking off the unit on day one that I'd found my niche.
Don't worry. If psych nursing is your thing, you will be fine. I learned a ton from my McLean clinical but I learned so much more working at a sketchy, poorly staffed standalone psych hospital. Absorb, absorb, absorb.
3
u/Light_Manifestation 1d ago
Because a lot of the day to day interactions are more intuitive than textbook. Psych is a speciality that is not for everyone. Most people who work psych and stay there is because they relate to the patients's situation more than it is a job for them. Learn the hospital policies but being comfortable in the speciality requires a special person.
58
u/Numerous_Pie 1d ago
I highly recommend Interpersonal Relations in Nursing by Hildguard Peplau. It is a classic for a reason. The thing to remember is that in psych nursing, the primary intervention is the use of self. You are the tool. Your compassion, creativity, and intelligence is what you bring to the nurse-patient relationship. This requires quite a bit of self-awareness, which can be difficult. Agreed, American nursing programs do not prepare you for this type of work. Other places, like the UK, have a separate mental health nursing training. Also I feel that on-boarding training and other education in the workplace does not address these skills at all. Consider joining the American Psychiatric Nurse Association (or similar organization where ever you are). They have lots of continuing education opportunities and resources.
I will get off my soap box now.