Put some Concrete in your Breakfast: Tales from Contemporary Nursing: Building Resilience, Empathy and Confidence within a Challenging Profession 3031243927, 9783031243929

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Put some Concrete in your Breakfast: Tales from Contemporary Nursing Building Resilience, Empathy and Confidence within a Challenging Profession Rasa Kabaila

Put some Concrete in your Breakfast: Tales from Contemporary Nursing

Rasa Kabaila

Put some Concrete in your Breakfast: Tales from Contemporary Nursing Building Resilience, Empathy and Confidence within a Challenging Profession

Rasa Kabaila Nurse Practitioner and Researcher School of Rural Medicine University of New South Wales Port Macquarie, NSW, Australia

ISBN 978-3-031-24392-9    ISBN 978-3-031-24393-6 (eBook) https://doi.org/10.1007/978-3-031-24393-6 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

‘Just a Nurse’. By Suzanne Gordon. I'm just a nurse. I just make the difference between life and death. I'm just a nurse. I just have the educated eyes that prevent medical errors, injuries and other catastrophes. I'm just a nurse. I just make the difference between healing, coping and despair. I'm just a nurse. I just make the difference between pain and comfort. I'm just a nurse. I’m just a nurse researcher who helps nurses and doctors give better, safer and more effective care. I'm just a nurse. I’m just a professor of nursing who educates future generations of nurses. I'm just a nurse. I just work in a major teaching hospital managing and monitoring patients who are involved in cutting-edge experimental research. I'm just a nurse. I just educate patients and families about how to maintain their health. I'm just a nurse. I’m just a geriatric nurse practitioner. I just make the difference between staying in their own home and going to a nursing home. I'm just a nurse. I just make the difference between dying in agony and dying in comfort and with dignity. I'm just a nurse. I'm just central to the real bottom line in healthcare. Don't you want to join us and be just a nurse too? Poem by Suzanne Gordon retrieved from: Gordon, S., & Buresh, B. (2006). From Silence to Voice: What Nurses Know and Must Communicate to the Public. New York: Cornell University Press. I hope you enjoy reading these insights into the world of a nurse.

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Foreword

Stories present us with more than merely a way to organise a series of events or communicate a set of ideas; they offer a way of making meaning of what we do and who we are. Nurses tell and listen to stories every day as a part of their work, attempting to bring coherence to often chaotic situations. Stories also provide a vehicle that we can use to think about our experiences. For nurses, stories are a reflective tool that help us to communicate information and make sense of the way we work, the way we react and the way we learn. They provide a means of connecting with others in the profession. The stories in this collection represent Rasa’s reflection of her work as a registered nurse (RN). Reflecting on challenging situations is often confronting, but also essential. New nurses regularly manage challenging circumstances alone while trying to make sense of the workplace, the work itself and their role as nurses. In this way, this book offers honest and heartfelt reflections from a registered nurse who has faced, and continues to face, the hurdles associated with being a nurse. This book offers a candid insight for those considering a career in nursing as well as nursing students. It also presents a connection to those already working as nurses. It has been a privilege to work as a registered nurse. While there have been difficult times during my career, I have never regretted the decision to become a nurse. The people I have cared for, and with whom I have worked, have brought richness and a grounding humility to my life. One of the most rewarding experiences of my career has been the opportunity to work with undergraduate nursing students, observing their learning path and transition from student to nurse. This transition is not a comfortable journey; facing challenges, and steep learning curves is part of the ongoing development of a nurse. Learning requires critical reflection on experience and engagement in dialogue when alternative methods for approaching situations are imagined. Nurses must also be mindful of the respect and trust bestowed upon them by the communities they serve. For nurses, respect and trust are accompanied by an immense responsibility to protect and advocate for patients, clients and their communities. I first met Rasa when she was an undergraduate nursing student. I have been her lecturer, her workplace facilitator and a mentor during her early career. I now consider Rasa a nursing colleague and friend. She possesses a breadth of experience and knowledge, particularly in the field of mental health nursing. Her commitment to further study and lifelong learning are commendable and show how seriously she vii

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views her role. Rasa demonstrates a profoundly reflective and considered approach to life, education and work, making her a sound advocate for those in her care. Through this collection of stories, Rasa reveals how nurses advocate for others, including other nurses. Nursing is a profession steeped in story but difficult to define due to its essential diversity, and it is heartening to see nurses sharing tales from the field. In her collection of stories, Rasa shares her accounts of being an RN, adding another lens to the greater narrative that is nursing. In this way, she connects nurses and the broader community, capturing snapshots of history along the way.



Jane Douglas, PhD Registered Nurse, Doctor of Philosophy University of Wollongong https://ro.uow.edu.au/theses1/564/

Acknowledgements

• First and foremost, thank you to all my patients/clients who I have met throughout my nursing career; these are your stories too. Though being able to walk alongside you, for even a small part of your tremendous journey, you have taught me to be patient, to be kind, to be strong and to be grateful. • Thank you to head editor Marie-Elia Come Garry at Springer Nature for having faith in me and for publishing this book. It’s an honour to be one of Marie’s authors. Marie advocates for nurses strongly and appreciates the work of health professionals. From the minute I met Marie, I have always received  from her encouragement, support and warmth. It’s no easy gig to write a book, let alone have it published. I’m so grateful to have met you, Marie. Thank you for supporting me to make my dream a reality. • For the purposes of not turning this acknowledgement list into another book (which it would be if I listed all the wonderful people in my life), I want to say a huge thank you to all of my beautiful friends for continuously supporting me. You know who you are. Friends are ‘forever cheerleaders’ who ask, ‘When does your book get published?’ before even reading a page. And an added shout out to every person who allowed me to read my stories out aloud to them and who provided me with helpful feedback accordingly. • Thank you to all my family, past and present, for being just that: my loving family. • A special thank you to one family member in particular, my doting dad, the talented author, Dr Peter Rimas Kabaila, who taught me everything that he knows about writing a book. Dad, who started off saying, ‘No one will be interested in reading a book about a nurse that is neither a celebrity nor an incredibly traumatised person from some strange event that has made the press’, and then shifted his stance to, ‘Hey, I think you can do something with this’ and then supported me all the way through. Thank you, Dad—and to all other authors—for helping me appreciate the blood, sweat and tears that must be shed to write a book. To hold the passion and dedication to write a book is one thing, however, being willing to undertake the forever-long process of taking criticism on board, editing and then re-editing, takes true determination, patience and courage. Writers have no guarantee of any sort of reward or success from their projects—so being still willing to write for the love of it, I believe, is admirable. • Thank you to my cousin, Dana Kabaila, who has always been a huge support to me and the most special friend in every possible way. Dana, an amazing writer ix

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Acknowledgements

herself, happily did an initial proofread and edit of the entire book—as I did with her book. It has been a beautiful thing to be on this journey together. Thank you to my talented cousin Matt Garrick, ABC journalist and author, for all his valuable advice about writing, and encouragement to persevere with this book. Thank you to my other writer cousin, Louis Garrick (brother of Matt), for appreciating my journey as a writer himself and never doubting my ability to write this book. Thank you to all the good people in my life who have had an important part in the development and production of this book. A special mention in this regard to Amy Lewandowski, Marek Cmero, Bree Evans, Adam Bahar, Tilly Bell, Ghazal Diani and Dean Groth. Thank you to my college English teacher for creative writing: Warrick Richmond. Warrick gave me the confidence and foundation to pursue writing, which has led me to publishing nursing articles, writing, publishing, and performing poetry, as well as writing this book. Thank you to Vanessa Leong (otherwise known as Small Gojira) the talented self-taught artist and graphic designer who created the beautiful illustrations in this book. No task is too big for Vanessa, and she does her work with ease and grace. Thank you, Vanessa, for working off my photo story board and producing such beautiful art for the book with such a quick turnaround. Thank you to the professionals who have supported me in the journey of my health and well-being. You know who you are, and you are wonderful. Thank you to Dr Jane Douglas, a nursing mentor of mine, who has become a dear friend. Jane, I might not have stuck out my nursing undergraduate degree if it wasn’t for you. Thank you for always being in my corner and for encouraging me to persevere, despite the obstacles I faced as an undergraduate nurse. Thank you to Alan Merritt, my undergraduate nursing lecturer at the University of Canberra, as well as Dr Phil Maude, my postgraduate nursing lecturer at RMIT, who have taught me so much about writing, and being a nursing leader. Thank you to Dr Richard Tranter, his wife Siobhan and their beautiful family who supported me and treated me like family when I started my new role as a Nurse Practitioner in a town I had never been to before in which I knew no one. Richard, I cannot express how much your support in my role has meant to me. You are a unicorn in this world, and I will be forever grateful to you being my clinical supervisor, and an advocate for nurses. Thank you to Dr Adrian Vasko, for teaching me all that you know and for again, advocating for nurses and the work that I do. Your support is invaluable. Thank you to all my nurse and multidisciplinary team colleagues (past and present) who so bravely contributed their raw and personal clinical stories to this book. On another level, I thank my colleagues for just generally being supportive. Nurses would be stuffed if they didn’t have good colleagues to turn to in tough times. Thank you to Dr Peter Ragg, one of the greatest GPs to walk this earth. Thank you for everything you have given me and everyone who is fortunate enough to meet you. You are not allowed to retire, ever.

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• Thank you to Jerzy Beaumont for his helpful and practical advice in all things writing. His advice was always delivered with enthusiasm, encouragement and warmth. • Thank you to my editors, Phillip Berrie and David Adams, who gave brutally honest, yet invaluable, advice about how to make this book the best version of itself that it could be. Words like ‘stay strong Rasa’ following a book’s worth of edits did actually help me not to lose faith, and to persevere with the writing process. Thank you for placing your faith and energy into my writing.

Contents

1

Nurses and Beginnings������������������������������������������������������������������������������   1

2

Nurses and Crime��������������������������������������������������������������������������������������   7

3

Nurses and Death ��������������������������������������������������������������������������������������  13 3.1 Anesu’s Story��������������������������������������������������������������������������������������  14 3.2 Back to Rasa ��������������������������������������������������������������������������������������  17

4

Nurses and Bodily Fluids��������������������������������������������������������������������������  21

5

Nurses and the Emergency Department or General Practitioner��������  25

6

Nurses and Love Bites�������������������������������������������������������������������������������  29

7

Nurses and Spirituality������������������������������������������������������������������������������  33

8

Nurses and Instincts����������������������������������������������������������������������������������  39

9

Nurses and Doctors������������������������������������������������������������������������������������  45

10 Nurses and Suicidality ������������������������������������������������������������������������������  51 10.1 Step 1: Mental Health Phone Triage (Louise Speaking)������������������  52 10.2 Step 2: The Home Visit (Achara Speaking)��������������������������������������  54 10.3 Louise’s Reflections��������������������������������������������������������������������������  55 10.4 Achara’s Reflections ������������������������������������������������������������������������  56 10.5 Rasa Again����������������������������������������������������������������������������������������  56 11 Nurses and Epic Fails��������������������������������������������������������������������������������  59 12 Nurses and Contagious Diseases��������������������������������������������������������������  65 13 Nurses  and Puzzling Presentations����������������������������������������������������������  69 13.1 The Handover and the Missing Glass Eye (Rasa)����������������������������  70 13.2 The Handover and Subsequent Home Visit to Victor (Henry)����������  71 13.3 The Handover and the Black Bananas (Rasa Speaking)������������������  74 13.4 Visit to Olivia and Luke��������������������������������������������������������������������  75 14 Nurses and Burnout����������������������������������������������������������������������������������  77 14.1 Emergency Call to Help Taylor (Belle Speaking)����������������������������  82 14.2 Back to Rasa ������������������������������������������������������������������������������������  84 xiii

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15 Nurses and Associated Talk����������������������������������������������������������������������  85 15.1 Nurses and the Turning Point������������������������������������������������������������  88 16 Nurses and Blame��������������������������������������������������������������������������������������  93 17 Nurses and Being the Patient��������������������������������������������������������������������  97 18 Nurses and Magic Medications���������������������������������������������������������������� 105 19 Nurses  and the Unexplainable������������������������������������������������������������������ 111 19.1 Annie and the Case of the Mysterious Blue Hands (Wendy Speaking)���������������������������������������������������������������������������� 112 19.2 Patients Presenting to Hospital with Objects Stuck in Different Holes (Bill Speaking)���������������������������������������������������� 113 20 Nurses and Working with Youth�������������������������������������������������������������� 117 21 Nurses and Dodging Punches�������������������������������������������������������������������� 127 22 Nurses and Strange Encounters �������������������������������������������������������������� 133 23 Nurses and Confronting Situations���������������������������������������������������������� 137 24 Nurses and Psychosis, Part 1�������������������������������������������������������������������� 143 25 Nurses and Psychosis, Part 2�������������������������������������������������������������������� 149 26 Nurses and Missing People������������������������������������������������������������������������ 157 27 Nurses and the Psychiatric Ward ������������������������������������������������������������ 163 28 Nurses and Diverse Populations �������������������������������������������������������������� 169 29 Nurses and Faraway Places���������������������������������������������������������������������� 177 30 Nurses and Disabilities������������������������������������������������������������������������������ 185 31 Nurses and Suggestions for Living Well�������������������������������������������������� 191 32 Nurses and Career Prospects�������������������������������������������������������������������� 195 33 Nurses and Saying Thank You������������������������������������������������������������������ 203 Conclusion���������������������������������������������������������������������������������������������������������� 207 Discussion Questions������������������������������������������������������������������������������������������ 211 Glossary of Terms���������������������������������������������������������������������������������������������� 213

About the Author

Rasa Kabaila  Rasa began working as a personal carer at age 16. She was the youngest personal carer that the nursing home had ever employed. This started her career in nursing. Rasa graduated as a Registered Nurse in 2011 after completing her Bachelor of Nursing degree. Rasa has completed numerous postgraduate qualifications including a Master of Mental Health Nursing degree and Graduate Certificate in Palliative Care. In xv

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2019, Rasa completed a Master of Nurse Practitioner degree, and in 2020 she commenced work in an acute mental health team in rural, coastal Australia as a Nurse Practitioner, Researcher and Lecturer with the University of New South Wales Rural Medical School. Rasa is the leading Practitioner and Researcher for a depression clinic (OptiMA2 and OptiMA3 trials). She is a Credentialed Mental Health Nurse through the Australian College of Mental Health Nurses and is an Accredited Dialectical Behavioural Therapist. She is a member of the Australian College of Mental Health Nurses and is both a delegate and member of the Australian Nursing and Midwifery Federation. Rasa has published over ten articles in various scientific and academic journals. She has also published and performed poetry in various magazines, blogs, anthologies and poetry slams. Although she has always loved writing, Rasa had no idea that her nursing stories could easily fill an entire book. In 2022, Rasa began a new chapter in her career, starting her own practice as a Nurse Practitioner specialising in mental health. Rasa is passionate about nursing and believes in the value of people trying to be altruistic and caring towards humans, animals and nature, in whatever small way they can be. Outside of nursing and writing, Rasa likes to spend time with family and friends, practice martial arts, run, surf, volunteer, travel and be among nature and animals. She strives to challenge herself in every way, but also takes daily naps and laughs wherever possible. Rasa lives with her three-legged rescue cat: Boy.

Introduction

The good nurse has a weird sense of humour, is an ace multitasker, and is likely to have abused chocolate, wine and/or chips at least one point in their career. ‘We’ll need to put some concrete in your breakfast’. is a phrase which inspired the title of this book. I heard a sweet nurse say this once, with both humour and empathy, to a patient who had been in hospital for a long time because of chronic gastrointestinal and pain issues. Both nurses and patients have to put a bit of concrete in their breakfast to get through the day. This expression does not dismiss the pain or the struggle that people endure. Rather, this phrase is a way of reminding people that they will need to be brave to get through their hardships and that they are capable of resilience throughout turmoil. This book is a collection of stories that concentrate on nursing. I am a nurse, and in my opinion, nursing is not just a profession, it is a calling. There is a high rate of burnout among nurses in their first years. This is because of the high demands placed on them by the healthcare system; hospital administrations; the expectations of management, patients, families and carers; and the sheer size of the patient loads with complex needs these days. If I had read a book full of stories about nursing like this one before I decided to study nursing, then I would have likely had second thoughts about entering the field in the first place. Such a book would have either prevented me from wasting my time, or it would have better prepared me for what I was likely to face in the clinical environment. For this reason, this book is targeted at young people considering a career in nursing who would like to get some honest insights into the life of a nurse. Although nurses have many interesting stories to share, I have met a nurse who has written about her experience extensively in the format of a book. The truth is, while nursing—especially if a person is both studying nursing and working in a nursing field—one’s world is, naturally, largely consumed with all things nursing. Insightful nurses will debrief with colleagues and, outside of that, will do what they can to look after themselves and find a way to ‘switch off’, so as to achieve some balance in their lives. Finding this balance can be done through healthy avenues: spending time with loved ones, physical exercise, and mindfulness. Other ways of switching off can be more harmful, if used excessively. For example, drinking alcohol and eating chips while spending time inside alone watching a TV series all day. I feel that all these ways of finding peace can be appropriate, at times, in the right quantities. xvii

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The point I am making here is that nurses are often exhausted at the end of the day working. When they are not working, nurses are usually trying to find ways to decompress. Generally, this means the last thing that a nurse wants to do at the end of a hectic shift is to write a story about ‘a day in the life of a nurse’. When I began to think about writing this book, I found myself at an age where a lot of my friends were partnering up, having babies and settling down. At that point, I made a decision to resign from my job and travel for 4 months before seeing where life would take me next. This time of unemployment, travel, excitement and uncertainty also gave me—for the first time I could remember—a meaningful amount of time to calmly reflect and write about nursing. The tales that I have written in this book, I feel, shed important light on the crazy and beautiful work that nurses do. The reality of a nurse is different to a lot of other people; a concept that I struggled a lot with as a new graduate nurse. In the first year after I completed my nursing degree, I felt very disconnected from life outside of work because of what I was seeing and experiencing in the hospital. I also felt angry that no one else could seem to understand the nitty gritty of the things that I had to deal with during my day as a nurse, and I started to refer to people who worked in other business sectors as ‘not living in reality’. When I talked to my dad about this disconnection and the frustration I was feeling, he told me something that, somehow, felt reassuring: ‘All people live in their own reality. It does not mean that one type of work is more valuable or less “real” than another, it’s just different. However, the work that you are undertaking as a nurse is a different reality than what most people have the opportunity to see or understand’. People outside of nursing often say how they think it would be hard to be a nurse. They ask me what was the most challenging experience as a nurse. I then ask them to choose a subcategory: the goriest? the most upsetting? the most confusing? I’m not sure what people are expecting to hear when they ask these questions, but when I answer honestly, I think people are taken aback. I’ve learned that most people are not prepared for the answers given to them and my nursing stories can either make great party conversation or can leave everyone looking a little bewildered. In my career as a nurse to date, I have borne witness to many deaths as well as some intense spiritual experiences. I have been able to help people in the most joyous of ways and I have also seen a lot of trauma, both physical and emotional. I have had to keep a straight face in the most strange and hilarious circumstances, and I have also seen many, many, naked bodies. I don’t think the general public understands the high amount of responsibility and the complex skill set which nurses need to have in their clinical roles. Some nursing tasks are simple, and can be enjoyable, but these tasks are typically only achieved with a great deal of compassion, patience and people skills. Elderly people, for example, can have a very different concept of time to the nurse that is helping them in a hospital. The elderly person is generally in no rush to get out of bed. The nurses, however, are always looking at their watch, as they are aware of how many things they need to do before the medication round at 8:00 am. The elderly person will be telling a rambling story to the nurse while the nurse will be trying to

Introduction

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find a way to get them dressed and showered in record time; breaking a sweat and yet finding a way to not appear harried. The old-fashioned notion that nurses are just employed to keep patients’ company and do simple tasks is totally inaccurate and outdated. In my first year of nursing, I attended an advanced mechanical ventilation (colloquially known as life support) course to learn how to understand shockable and non-shockable cardiac rhythms and how to run a resuscitation team (see Glossary for words in bold type). The above examples show the contrast between two important, yet completely different, nursing tasks: assisting an elderly person to shower and dress and knowing how to run a resuscitation team. The stories of modern nurses are unique. They discuss humanity in its ultimate grit. Yet these stories are rarely documented; perhaps because nurses are just too tired to fathom the idea of using any more brain power to formally document nursing tales in their off time. This, I totally appreciate. As I mentioned earlier, most nurses want or need to find ways to leave these stories at work and tend to immerse themselves in other areas of their life, as a distraction, when the day is finished. This is important, and I fully support these rituals. However, I don’t want my stories, and the stories of other nurses (particularly modern nurses), to be left unheard. My aim in documenting these stories is to provide a different view of the nursing world. These views are mine, and perhaps, at times, my perspectives will not be shared by other nurses or the public. It is not my intention to throw anyone (patient or colleague) under the bus, but I also need to allow these stories to be honest, which can—at times—also mean ‘raw’. In this current day and age of political correctness, we can often spend a lot of time giving the version of a story that does not offend anyone. No one wants to get their feelings hurt, and for this reason it is appropriate to ‘put a sock in it’ sometimes. However, at other times it is a breath of fresh air to just hear things straight. This book is honest: straight from the nurse’s mouth. The author wishes to thank the interviewees who provided permission for excerpts of what they said to be reproduced among these stories. Their courage in allowing themselves to be made vulnerable, through sharing their voice and perspectives, is greatly appreciated. These stories are a gift and are an invaluable contribution to this book. The names of the interviewees, as well patients/clients and all other persons discussed within the chapters of this book, have been changed to protect confidentiality. I have made deliberate efforts to avoid, or at least explain in simple terms, nursing and medical jargon. However, where a simple explanation is not possible, terms in bold have also been explained in a glossary at the end of the book. These are real stories that I have highlighted during my time working as a nurse for the last years. In this time, I have worked across a wide range of clinical areas, which have given me a plethora of rich experiences. Many of my stories revolve around mental health nursing as this became an area of specialisation for me. Nursing is a profession that, at times, I have questioned and nearly given up on, but which I continue to be passionate about. In this book, I relate stories containing both the fun and challenging aspects of being a nurse. I’m going to be real here:

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Introduction

being a nurse is tough. There are definitely other career paths out there which provide easier ways of getting paid and provide far better working conditions. You may ask: ‘Why am I still nursing?’ Nursing has forced me to face some of the most challenging and stressful situations that I have ever encountered. Nursing has also given me the opportunity to help people find some healing on the worst day of their life. In the tough times, and the good times, my experiences in the nursing profession have added more meaning to my existence than any other job has done. Becoming a nurse is the most life-changing decision I ever made. A date-ordered list of the areas of nursing in which I have worked along with the qualifications I have obtained along the way are listed below in chronological order. 2004: School work experience in a paediatric ward in a rural hospital (Griffith). 2005: School work experience in a nursing home. Employment commenced as a personal carer in this nursing home following the work experience placement. Graduated from Grade 12. 2006: Commenced Bachelor of Nursing at university. Continued employment as a personal carer in a nursing home. 2007: Commenced employment as personal carer in the community for an agency. (In people’s homes and various nursing homes.) 2008: Continued employment as personal carer in the community for an agency. (In people’s homes and various nursing homes.) 2009: Exchange semester in Bachelor of Nursing studies in Canada. Employment commenced as a medical room assistant and phlebotomist at a medical centre. Certificate III in Aged Care achieved. 2010: Self-organised volunteer work as a nursing aid in the ASSADE medical clinic in Guatemala. Employment continued as a medical room assistant and phlebotomist at a medical centre. Bachelor of Nursing achieved. 2011: New Graduate Registered Nurse Program: intensive care unit, medical and surgical nursing, palliative care. Level: registered nurse. 2012: Volunteer work to provide medical clinic advice (as well as helping to run activities for orphaned children) in Vietnam for the Friends of Vietnam Orphanages (my father being the founder of this organisation). Relief nursing: medical and surgical nursing inclusive of the following specialities: endocrinology, respiratory, maternity, cardiology, pre-operative care, cardiothoracic surgical unit, neurovascular, urology, orthopaedics, infectious diseases and stroke and neurology unit. Charge nursing at a nursing home. Level: registered nurse. 2013: Casual and agency nursing in a variety of clinical settings as listed for 2012. Rural placement in a major trauma hospital with a large Indigenous population. Experience inclusive of surgical and medical ward nursing including neurology, oncology and rehabilitation. Four-week contract at a community mental health team for adults with moderate to severe mental illness, which led to 2 years of contracts (working with that same team). Certificate IV in Training and Assessment achieved. Graduate Certificate in Palliative Care achieved. Level: registered nurse and clinical nurse specialist.

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2014: Continued employment in a community mental health team for adults with moderate to severe mental illness. Graduate Diploma in Mental Health achieved (with Distinction). Level: clinical nurse specialist. 2015: Continued employment in a community mental health team for adults with moderate to severe mental illness. Commenced employment as the clinical nurse consultant in a youth recovery residential program. Level: clinical nurse specialist and clinical nurse consultant. 2016: Continued employment as the clinical nurse consultant in a youth recovery residential program. A Master’s of Mental Health Nursing achieved. Level: clinical nurse consultant. 2017: Continued employment as the clinical nurse consultant in a youth recovery residential program. Quarter-life crisis halfway through the year—resigned from my job and took 4 months to travel and volunteer. Self-organised volunteer work to help run activities in a mental health day program at ‘El Cribo’ in Lanzarote, Canary Islands. Upon returning from overseas, commenced casual work as an emergency department consultation nurse and as a senior nurse with a mental health crisis response team. Level: clinical nurse consultant. 2018: Contracted as a senior nurse with a mental health crisis team. An additional role within this team included working with police to provide assistance with assessments and care plans for clients who came into police contact and who presented with a mental health concern. Level 3 registered nurse position achieved. Commenced employment with a community mental health team for complex individuals with mental illness who are treatment resistant and difficult to engage. Level: clinical nurse consultant. 2019: Continued employment with a community mental health team for complex individuals with mental illness who are treatment resistant and difficult to engage. Commenced employment as a clinical nurse consultant helping clients to improve their metabolic health as part of a large research study. A Master’s of Nurse Practitioner achieved (with Distinction). Endorsed as a nurse practitioner. Level: clinical nurse consultant. 2020–2022: Continued employment as a clinical nurse consultant helping clients with their metabolic health as part of a large research study. Commenced employment as a mental health nurse practitioner in a rural, coastal town in Australia. Level: Endorsed Nurse Practitioner. Accredited Dialectical Behavioural Therapist. 2022–present: Commencement of independent clinical practice as a Nurse Practitioner specialising in mental health. There are not enough books out there which promote the amazing work that nurses do to help society. The global pandemic erupting has now pushed a healthcare service that was already under pressure now to be in complete crisis. The world now knows that we need more nurses employed to be able to move forward from this calamity. I hope that this book being read may help close that gap, in that it encourages people to consider a career in nursing while also positively promoting the incredible work that nurses do.

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Thank you for taking the time to read this book. I secretly hope that some aspiring nurses, or people feeling a bit lost as to where to go in their careers, might read this and consider a career in nursing. This book also brings about a great opportunity to break some nursing stereotypes that we have in our culture and allow people to appreciate what the modern nurse contributes to the world. And then, of course, this is a nice chance to properly talk about all those gnarly nursing stories that I’ve had to downplay at parties and family dinners. I’d like to finish my introduction with a poem by writer Suzanne Gordon. Suzanne is an award-winning journalist and author with special expertise in healthcare systems, teamwork, patient safety and nursing. My lecturers gave this poem to me and my fellow students when we were undergraduate nurses. At the time, I glued it into the front of my nursing portfolio, and I’ve kept it in that same place ever since. I use Suzanne’s poem as a reference point and read it when I need to be reinspired when clinical scenarios are tough and I am consumed with self-doubt. Every nurse needs a reminder—in times of chaos or tragedy or hopelessness—as to why they chose their profession, so that they won’t forget the important contribution that they do, in fact, make.

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Nurses and Beginnings

Nurses and Beginnings

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_1

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The good nurse will ponder an easier career choice at least once, but still chooses nursing. The good nurse understands the meaning of a hard day’s work. Every person has a journey that has led them to where they are today. My parents have a cute photo of me as a youngster dressed in medical attire, so it was clear at a young age that I wanted to be a nurse. One of the above statements is not true. I’ve always been a bit jealous of people who knew early on what they wanted to do in life, recreationally, and as a career. Anyone who knows me appreciates that I need change and spontaneity in the different aspects of my life. I’ve never really felt like I’ve been the kind of person who followed one single path continuously, and this certainly applied when choosing a career. In my teen years—from about age 15—I was obnoxious and rebellious. I was also capable of a lot more than what I let on (like a lot of teenagers, I think). My friends and I partied a lot and would deliberately get ourselves into risky situations. Vomiting from too much alcohol on a monthly basis had become the usual state of affairs by age 18. By that time, my friends and I had worked out that Wednesday, Thursday and Saturday nights were optimal partying nights, due to the offers of cheap drinks; some of these offers involved dangerously generous drink deals, which have now been made illegal where I lived. The ‘hour of power’ at one particular club allowed the patrons to buy four-dollar jugs of vodka mixed with any kind of soft drink, and one person could buy two jugs at a time. Unreal, hey? With all this partying, I still cared about other people, but as the self-centred teen years can be, I focused more on how I could get my next temporary high and how I appeared to others. In year 12, I realised that I hadn’t done as much study as I should have and had no idea what I wanted to do as a career. I therefore ventured out to do every kind of work experience under the sun, desperately trying to find something that would be my ‘calling’. Today, I still recommend to young (and older) people to experiment with a variety of work, hobbies and experiences. It’s a load of bull to expect that anyone in their teen years should ‘know’ what they want to do. A person can drastically change career paths at any point. It will likely involve sacrifice, hard work and the fear that often accompanies change, but I still strongly encourage it. In high school, I undertook work experience in the following units: furniture restoration, assistant nursing (at a paediatric ward in rural NSW) and personal caring (at a war veterans’ nursing home). I also obtained a variety of jobs, including meat patty flipper at McDonald’s, kid’s party entertainer, babysitter, house painter (and other random jobs) for my dad, community carer, personal carer at a nursing home (which stemmed from my work experience at the same war veterans’ home), doctor’s assistance and pathology assistant at a medical centre, promotional model, kennel hand and veterinarian’s assistant, carnival vendor and a retail worker at a grog shop. At the nursing home, I learned the value of hard work, how one can break a sweat dressing a person who cannot move their limbs as a result of a stroke. The humility and the privilege of being able to help someone in this situation is profound. I also

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began to appreciate the challenge of trying to decipher whether or not the water was warm enough for a resident’s shower when they cannot communicate verbally with you, or even clearly consent to your helping them. In due course, I began to learn the stories of the residents and I realised that for one resident—who had dementia—what I thought were incomprehensible verbal sounds ‘dee, dee, doo, doo’ were actually more likely to be her deciphering Morse code, as this had been her professional role in the war. This same woman, who could never make full words, once touched my arm to gain my attention after I had opened her curtains to let the sunlight in. She brushed her hand gently down the side of my face and said clearly, ‘It’s a beautiful day.’ Whether or not a person is religious, these experiences can make a person feel as though they have experienced the presence of God. My work experience placement at this war veterans’ home resulted in a part-time job for 2 years, where I was one of the youngest personal carers ever employed in the role. In college, I majored in the subjects of media and English. I was also into sport, as I had been from an early age. During college, I had enrolled in far more classes than what I had needed too. If I was being strategic, I should have enrolled in the minimum number of academic classes required—then I would have had left over time to spend studying for those particular subjects, to get the best grades possible. But I wanted to get my hands on every kind of experience (I still do). Therefore, on top of all of my academic classes, I enrolled in every kind of outdoor education unit as well as a basketball extension unit and a hospitality unit. Towards the end of college, my teachers from my hospitality unit awarded me a scholarship to study at a prestigious hotel management school in Sydney, but I didn’t even apply for the scholarship. Don’t get me wrong, I was a good student, but I feel I was considered a golden student in comparison to the other attendees of the class. Honestly, I think I got the scholarship because I was one of the few students who (a) showed up and (b) completed the basic assignments that we were expected to do to either pass or fail. With such a variety of interests in my life at the time, you can probably understand why I had conflicting ideas about which direction I wanted to take with regard to a career. Although I could see myself as being ‘alright’ working in hospitality, my heart was not in it. So at the end of year 12—with a suboptimal university entrance score thanks to the parties and the fun times—I applied to my local university with the following course selections in mind. Nursing: Because the employers in the nursing environments that I had worked in recommended it. Journalism: Because I loved writing and talking—I used to work at both my school and community radio stations—and I really felt that this was where I would go, because I hoped to be an honest journalist. One who would be at the forefront of difficult situations and would tell the stories with integrity. Media production/film studies: As I said to Mum as a kid: ‘I want the job that the movie reviewers, Margaret and David, have on SBS’s The Movie Show. How do I get that job?’

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My parents pushed for me to do nursing, and the positive feedback that I had received from the supervisors on my nursing placements was an added encouragement. I was also told that employment opportunities for nurses were abundant, which I logically justified as another reason to seriously consider nursing as a career path. Still, I struggled to see the ‘fun’ in doing nursing. I was turning 18: I partied hard through the week with my friends, and I loved making out with different boys, and just having a good time in whichever way I could find it. Nursing, by comparison, seemed like a lot of responsibility, and I just wasn’t sure if a high responsibility job was what I wanted. I had also fallen into the trap of undermining the role of nurses by comparing them to doctors in a way that labelled them as ‘beneath’ other professionals. This was probably because I associated nursing with dirty work and didn’t fully understand the role of a nurse. I also felt that nursing would block my creative pursuits. During the Christmas break of my final year of high school, I undertook some retail work at a liquor store. I think I had been secretly hoping that through trying out other jobs, I would find another ‘easier’ calling than nursing. However, I really struggled to find meaning in selling alcohol after my experiences at the war veterans’ home—I just didn’t feel needed or important in that role. I am in no way demeaning the people who work in retail: the work is demanding and poorly paid and one has to be polite and courteous to shoppers, even when the customer is being an arsehole. The point I’m trying to make is that every kind of employment has its own set of highs and lows. What’s important is that the work itself is somewhat meaningful for the individual. Most people have to spend more time at work than the time they spend doing anything else in their life, including the time they spend with family and friends. With this in mind—to make the most of employment and to be an effective employee—I feel it’s important to care about what you do for work. While still in the process of wondering which career path I would steer myself along, I applied for a role in the public service. Hundreds of people applied for seven positions and I made it to the final round. But on the last day of testing, I had a chance to speak to some people already employed in the department. These employees told me that I would essentially be making people coffee and photocopying things, but that the pay was great. I was confused as to why the application process for this job involved a full day of testing numeracy, accuracy and literacy, as well as a group interview and a one-on-one interview for a role that appeared to carry very little responsibility. I, like everyone else in that final round, was dressed in business attire—the public service camouflage—and in my high heels, tights, navy skirt, blouse and jacket I looked important, but I felt dreadfully uncomfortable, like a con artist really. I was also told that employees were given sausage rolls for morning tea, which the staff loved. It was at this point that I started to develop grave concerns about whether my professional duties in such a job would be a fit for my inner need of wanting to meaningfully help other people.

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In my one-on-one interview, I was asked to talk about a challenging situation at work that I had had to find a way through. I told them about my experience of looking after a dying resident that I really cared about at the war veterans’ home. The panel didn’t know what to say, but I got top marks in the interview and was considered suitable for the position. However, the absurdity of how different my working life would be as a public servant versus being a nurse was now clear to me. If I had become a public servant, I think that my life would have been easier. I would have been given great working conditions with excellent pay—plus sausage rolls for morning tea. At the time, I imagined that, in this kind of role, I would eventually get promoted based on a good written application, but not necessarily merit based on hard work, life experience, knowledge or wisdom gained from my dedication to study and training. I saw a stable career in front of me, but not a satisfying one, and it became clear that if my worst day consisted of having too much paperwork to file, I would never be happy in the public service. I was later accepted into a nursing course under a bridging program at my local university. Ultimately, when I took a step aside to contemplate a career path in nursing, I realised that I genuinely valued the work of a nurse and I could also not deny it any longer: the harder path, the nursing path, was the one for me.

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Nurses and Crime

Nurses and Crime

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_2

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The good nurse recognises that people are complicated. Before becoming a nurse, whenever I watched any murder trials on the news, I would wonder whether it was nature or nurture which led a person to commit an act of crime. However, it wasn’t until studying nursing that I was forced to grapple with these concepts in real life. As an elective part of my undergraduate degree, my university asked nursing students to volunteer for clinical placements within the justice health sector (in a prison). The prison placement was run in conjunction with an alcohol and drug clinical placement. As self-election for these clinical areas was unpopular, there were only two of us who put our hands up for this opportunity. I have never considered myself to be a judgmental person; however, as I later realised, humans don’t always know that they have preconceived ideas until those ideas are confronted or challenged. I expected that the inmates in the prison would be really rough. I also thought that I would be able to separate the inmates who were ‘cold-hearted’ criminals, from those who were not, based on their appearance and demeanour. I was wrong. From the first day of my clinical placement, the nurses in the prison told me that it is best not to know an inmate’s personal history and crimes, so that your values and ethics don’t interfere with your ability to stay unbiased and provide care. However, I discovered very quickly that either the prison staff or the inmates themselves would soon tell me all the details anyway. For example, one of the inmates struck up a conversation with me as he was mopping the floors of the prison. I quickly found out that he was nearing the end of his sentence and that he had earned the position of being an unpaid cleaner. Later, I found out that the opportunity of working in a role such as a cleaner or a kitchen hand was not given to every inmate. These roles carried responsibility and were considered a reward for good behaviour as it gave inmates more purpose and autonomy as well as work experience to prepare them for the outside world. At the time, I was quite shy and also not wanting to be intrusive by asking inmates too much about their personal lives. However, this guy was so friendly and incredibly keen to tell me his life story, including all the information about his convictions. Within minutes of being introduced, he was drawing a map on a piece of paper of how he had once conducted a ‘break and enter’ into a retail shop in the community. He also told me about where it went wrong and how he got caught, which consequently led to his current imprisonment. I had not asked him for his story and I would have been happy just to chat about the weather. It was just how things were in the environment of that prison system— you found out all the details even when you were not seeking them out. Another example—of how bias can interfere with your responsibilities in such an environment—occurred later on, that same shift when we were doing an observation round. My logical brain and emotional heart became conflicted when the staff informed me that one of the lovely elderly inmates who I was chatting to—an ex-priest—was also a convicted paedophile. I would have preferred not to have known. A different aspect of the prison environment showed itself at lunchtime on my first day when I took my phone out of my bag to text a friend. A fellow nurse asked

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me how I managed to get my phone in, as this was contraband, and they advised me to inform security so that prison staff did not assume I was trying to sneak suspicious items in. I duly went to security and showed them my opaque black bag with an opaque drink bottle (bags and bottles are supposed to be transparent). In my bag, I also had a glass jar filled with pesto, metal cutlery, my phone, my phone charger, my camera, a USB and my camera adapter. I had basically ticked the box for every contraband item possible, excluding injectable drugs. The security staff got annoyed and gruffly told me: ‘You knew this was contraband’. In my defence, I reminded them that I had, in fact, given them my bag to inspect, and that it had then gone through an X-ray machine, and that they had still let me through. Security at this relatively new complex was known to be inconsistent. In its early stages, there was also unregulated Internet use in the area where the sex offenders were located, which continued for a period of time until prison staff had realised the problem. Security and Internet use were not the only difficulties that the prison faced in its early days. Short staffing of nurses and security guards was also an issue. And one day, when I was off shift, a riot even broke out in the facility because of this. At the time, the inmates were protesting because they were not able to exercise outside for the last 2 days as they normally would. On those 2 days, there had not been enough security guards on shift to facilitate the safety monitoring required for the inmates to be able to go outside and exercise. It was all over the news and the prison nurse that I worked with felt that the publicising of the riot in the media was a good thing, as hopefully the government would then allocate additional funding for more guards, nurses and resources. The riot in the prison made me reflect on my undergraduate nursing degree, where I had been taught about a famous historic nurse strike in Australia. Several factors had paved the way for the nurses’ decision to take strike action. The first—under the leadership of the late Barbara Carson—was the Royal Australian Nursing Federation’s (RANF) vote in 1984 to remove the no-strike clause from its rules. Then, in that same year, the Victorian Government’s cuts to its health budget were, in the RANF’s words, ‘the straw that broke the camel’s back’. This fomented a campaign of industrial action in which members banned non-nursing duties. Working out of uniform and bans on the use of agency staff followed, and, despite the government’s offer to recruit 700 new non-nursing staff within a year, in September of 1985, nurses and midwives were still working for low wages, as well as being burdened by non-nursing duties and high patient loads. Many nurses and midwives had left the profession because of these conditions and so, on the 17th of October 1985, Victorian nurses and midwives used their powerful new industrial tool for the first time—they walked off the job and stayed out for 5 days. John Kotsifas, an industrial officer for the RANF at the time, later stated that he believed that it was the then Cain Government’s failure to honour the undertakings made in the early 1980s around workloads and career structures that led to the much longer 1986 strike where Victorian nurses and midwives refused to work for 50 days. With this in mind, I had some sympathies for the prison inmates. I feel it’s such a terrible thing, that historically—and even now—our powerful players and

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governments cannot fully understand how under-resourced healthcare and other such facilities can be until something goes wrong or a person takes extreme action as a way of demanding to be heard. On a different note, psychology plays out in funny ways in an environment like a prison. An inmate once asked me for some paracetamol, which I had to get for him from a low cabinet. Another nurse told me that he had probably just asked for the paracetamol to see me bend over so he could have a good look at my arse. It is hard to know who and what to believe in a place like that. However, the psychological ploys work both ways. For example, each day we would buy lunch in the cafeteria—complete with plastic knives and forks—and be served by the inmates. Initially, I thought it was positive that there was an emphasis on helping people in the prison so that they could prepare for life outside. But, asking for lunch from an inmate wearing a shower cap, when you are the one supposedly caring for them, felt a bit like a power imbalance, and perhaps that’s what was intended. Another vivid memory that I hold about my clinical placement at the prison was the methadone round. This process usually took about two-and-a-half hours because most of the inmates had been heroin users and subsequently, while in prison, they were on methadone. One nurse who I worked with at the prison showed me on her GPS watch that she walked about 10 kilometres a day each shift. A lot of this distance was made up from the methadone round. I learnt from the psychiatrist in the facility that heroin causes little systemic damage to the body. However, it is illegal and highly addictive. People addicted to heroin will go to any length to obtain and use the drug, often resulting in criminal behaviour and accidental deaths from overdose. One day while I was there, an error was made with the medication round; a nurse accidentally gave an inmate his methadone dose twice. The inmate had also said that he had not been given his dose, which added to the confusion. This inmate was on the highest dose of methadone possible (a fraction of that dose would have killed any non-heroin user very quickly). It was fortunate that this inmate was a big boy. His body weight protected him and prevented him from dying; he just felt high for a while instead. Unfortunately, the nurses had to suffer, as again, the local newspaper had a great opportunity to talk about a prison fuck-up. In contrast, a relative of another inmate wanted to tell the newspaper about her good news story: of how well the nursing staff had taken care of her son during his stay in prison and how the staff had personally organised to drive her home when one of the only buses to the facility hadn’t turned up. The nurses had gone above and beyond what they needed to do. However, the newspaper had refused to publish anything positive in this regard, as their political views were that our lovely city was tainted simply by even having a prison. Very soon I realised the human side of working in the prison; people are just people, of course. While I was working in the prison, I learnt that inmates would often fake or become melodramatic about medical symptoms in order to have time to speak with a nurse or a doctor; they were simply seeking some company, counselling and kindness. I also saw people finish their prison sentences and give lingering

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hugs to the nurses before they left. Sadly, I also learnt that some people made efforts to get back into prison because it was a safer, more-caring environment than their life at home. Another positive example was when I sat in on an appointment with an inmate who was soon to finish his sentence. With guidance from the doctor, he had made a big decision—to have a naltrexone implant. This was demonstrative of his commitment to abstain from heroin. This inmate had been able to graduate off the methadone program, which many people are not able to do, due to its addictiveness and withdrawal effects. A naltrexone implant is an opioid antagonist that blocks the effects of opioids and alcohol in the brain at a receptor level. Opioid antagonists such as naltrexone help to curb abuse, prevent relapse and sustain recovery from opioid addiction and alcoholism. If a person takes heroin while a naltrexone implant is in place, the risk of dying from an overdose is incredibly high. This is because, if a person with a naltrexone implant chooses to use heroin simultaneously, they may be inclined to take a large dose of heroin, to try and get the effects of the heroin that the naltrexone is blocking. Because of the significant risks involved, the use of naltrexone implants is controversial. This inmate’s decision gave me goosebumps. An addiction can throw a person’s life upside down, and it is incredibly tough for people to make changes, even when they want to. This man showed that he was willing to do anything to try to recover. From memory, it seemed that I learnt the story of most of the inmates I dealt with. The majority had had little education, and many had come from fractured households and had significant, emotion-based trauma, which they had used drugs to cope with. This experience made me realise that, if I had had any of these risk factors, it would be unlikely that I would be in the same place that I am in my life now. It’s harder to succeed in life and get where you want if there is not much keeping you afloat. Later in life, I asked a forensic psychiatrist what causes people to commit crimes—especially violent ones. I asked the psychiatrist what percentage of people fell into the categories of ‘mad, bad or sad’, and I was told that criminals are usually a mixture of all three categories, which is why it is so hard for people to make sense of this behaviour. It’s much easier not to have empathy for people who have engaged in criminal behaviour because then we can make things black or white, good and bad. However, it’s rare that anything is that straightforward.

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Nurses and Death

Nurses and Death © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_3

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The good nurse bears witness to suffering and to dying. To be a nurse means to become more familiar with death and, with that, some of the philosophy around death, dying and spirituality. It’s unavoidable. Sometimes, bearing witness to the death of a close family member or friend is what leads a person to a career in nursing. One of these beautiful tales (retold in my own words) is about my nurse friend, Anesu, who was born in a country far, far away from Australia. Anesu’s story is based within a country in Africa—where nursing practices were—and continue to be, not as advanced as in Australia, due to both cultural and socioeconomic hardship.

3.1 Anesu’s Story I’m not sure if nursing was initially some sort of ‘healing pathway’ for me. In high school, I did some work experience at one of the hospitals in my country. The matron nurse I worked with was impressed to have such a young woman (me) interested in working in the hospital. When I received my grades for the year, I did really well, and I told the matron that I wanted to be a nurse. I was surprised when the matron tried to discourage me from considering nursing as a career path. The matron encouraged me to look at other professions: ones that required higher school grades and would pay better, such as radiography. It was sad for me, because I had my heart set on nursing, but I was only 16 and I was easily influenced. The subjects I picked to do in years 11 and 12 were geography, religion and English. Religion, in terms of ‘divinity and spirituality’, was a real interest for me, and I considered that journalism could be a good pathway for me too, as I also loved researching and reading literature. However, one day I peeked into another class and saw my friends studying biology. They looked like they were learning so much and having a lot of fun. But because of what the matron said to me, I steered clear of studies in that kind of science field. Anything that I related with nursing at that point I thought of as unworthy and dirty work. My mum was always a strong woman, strong in her culture and in herself, very different to who I was as a teenager. I was often fighting against our culture. I didn’t like how women were looked at as subordinates. However, Mum was always at peace with everything in the world and I loved her dearly. Several years later, when I had finished my high school studies and had been working as a primary school teacher, Mum told me that she was preparing for some sort of surgical procedure. I didn’t know what this was for, and I feel that children, even adult children, are often left in the dark as to what is truly happening in the lives of their parents. One night, Mum made me and my siblings a big cake and a beautiful homemade dinner. It was wonderful but I didn’t know what the special occasion was. A week later, Mum entered the hospital for the planned surgery. I didn’t even know that Mum had a set surgery date until she was admitted, as she hadn’t told me or any of my siblings. When I went to visit Mum in hospital, she explained to me that the lovely dinner was so she could see us all happy as a family

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together, in case something happened to her in surgery. I was upset that she hadn’t told me that she had a major operation booked. However, I also admired her in that she had made such a heartfelt gesture to her family; she always had us in her thoughts. Not long after Mum had her surgery, she developed a sore throat and her voice became hoarse. She worked in an industry where they dealt with a lot of harmful dyes and print work. This was pretty normal for a lot of women in my country who didn’t have a lot of education. Mum did everything she could to care for her family; she was an industrious and creative woman. I wondered if the fumes from the factory were making her ill. On a Thursday, Mum explained to me that the doctor had told her that she had inflammation in her tonsils and that her tonsils needed to be removed. I wasn’t able to visit Mum in hospital on the Friday, but I came in to see her on the Saturday. Mum was really unwell. I was surprised and thought to myself, ‘Mum only has tonsillitis, so why on earth does she look this sick?’ I went to see Mum again on the Sunday and she had deteriorated to a point where she couldn’t even speak. I remember at the time seeing on her table a small tablet of two colours—what I think now was an antibiotic like amoxicillin. It’s hard for me, because now—as an experienced nurse—I cannot believe that my mother was only on oral tablets rather than something stronger like an intravenous medication when she was so sick. Mum’s throat was so inflamed that she couldn’t swallow, so she wouldn’t have even been able to take the oral medication. She should have been on intravenous antibiotics. No one seemed to care or notice that my mum couldn’t even take her medication, even when her health was obviously going downhill rapidly. To this day, I still don’t know if Mum had become septic or what was happening to her. Within a 48-hour period, Mum went from being a patient walking into hospital with a sore throat to being barely conscious. When I was teaching at school the next day, I received a call saying that I had to come to the hospital quickly. I didn’t go to the hospital; I went home instead. I was avoiding going there, I think, because it was too scary to face what the reality might be. When I arrived home, all my family were quiet and acting strange. Mum had died. At that point, I think I may have been dissociating; I didn’t believe that it was real. I can’t describe to you what I felt at that time. Saying that I felt grief would have implied that I knew and had processed what had happened. I felt so isolated and lonely through all of this. My mum was my rock; she was my guidance in life. I felt I would actually die from heartbreak. That evening, I went by the hospital to pick up my mother’s belongings. I remember so vividly walking into her hospital room and seeing my mum’s bed, empty. I was so angry. I asked my dad if he could request a post-mortem investigation to find out what happened to Mum. Dad denied this proposal and wouldn’t even let me request this from the hospital. My fucking people can be so stubborn when it comes to trying to look more into unanswered questions with health. Everything about my mum’s death was then a mystery. I wondered if she had throat cancer and if it was genetic. No one wanted to know, and no one wanted me to push the case further. I

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3  Nurses and Death

was the only one who approached this differently. It made me want to go into medical records and find out what happened to Mum. The only way I would be able to maybe understand what happened would be if I worked in the industry, in a role like a nurse. All of my focus until my mother’s death had been leading me towards different career choices, such as teaching. And I did love teaching. But, when Mum died, it changed my life, including my career choice. I started applying to become a nurse instead and I realised that it was at age 16 that I had first wanted to be a nurse and that feeling had never left me. I started off by enrolling in a nursing diploma where we were called ‘post basic students’ (PBS) and were hospital trained. In those days, our initial theory incorporated a plethora of broad nursing fundamentals, from how to assist patients to use bedpans, bed making and learning how to give patients bed baths, through to urine dipstick analysis, anatomy and physiology and then moving to physical examinations. Finally, we learnt how to give people their last official rights when they were dying. I loved it all. As nursing students, we came to a point on our clinical placements where we would conduct after-death care for patients who had passed away. Instantly, all the vivid memories of my Mum’s traumatic death came back. It was all too much. I remember seeing the same black hospital clinical waste bags that they had set up around the room when my mother had died (these same bags were used to hold deceased people’s personal belongings for relatives to pick up). Those fucking black bags, they made me feel physically sick. In the middle of the placement, I had to run out of the room. I was overcome with distress and I ran home to check that my brothers and sister were okay. Looking back on this now, I think that this emotional response was a grief or trauma reaction as it triggered memories of my mother’s death. I had to work through those kinds of feelings for over a year while I was studying before I could feel at peace with Mum’s death. I found a path of healing through strengthening my bonds with my siblings, who were also struggling with our mother’s abrupt passing. We had counsellors available, but I chose not to see one. I was more focused on trying to support my siblings in their grief, and I decided to invoke my Mum and become the rock of the family, like how she had been for all of us. Things started to change for me when we started our other practicals (i.e. our clinical placements). My strongest memory is of looking after a man with pancreatic cancer. His prognosis was poor and he could barely talk, because he was in so much pain. At that point, I still didn’t have much understanding of the pathophysiology of his disease, but I knew what he needed was decent, loving care. I thought of my Mum and I thought of the basic, important care that my Mum had needed when she had been in hospital. In that respect, I knew what to do, it came naturally, and it was not a challenge. It felt right. That was my first shift on that particular clinical placement. The patient died that shift, but he looked peaceful at the end. When the curtains closed, I remained standing there with this empty shell of a man, who was never going to wake again. All I

3.2  Back to Rasa

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could see was my Mum, but I guess it was a healing moment because caring for this man helped me accept that my mother had died. I helped another nurse wash the man’s body, one component of the man’s after-death care, and I gave him the same love and respect that I would have given to my Mum. It’s actually an amazing thing to be present with a person and to be able to help them in that way. At that time, I realised how important it is to pay your last respects to a person; it is humbling. It was a moment for me to understand my existential being and purpose; I had evolved into a different human being. I thought differently in every way: I was stronger, I viewed culture differently, and I changed the way that I treated people, all for the better. I’ve learned that whatever or whoever you are passionate about, you need to give it your all. Nursing has become a huge part of my life. I still find working in areas of nursing that work directly with death, like palliative care, very challenging because of the history of my Mum’s illness. It is a beautiful and important area of nursing but it’s not for me. Mum’s death really shaped the career paths that I chose within nursing. The best thing that I have ever done in nursing is to work in mental health. I’ve learnt different therapies that actually help people. I have cared for many clients with severe mental illness who have told me: ‘I’m totally fucked up and I know I will never get better’. Working together, we have found ways for them to recover. Working now towards being a nurse practitioner is wonderful. I’m at peace with myself and my career choice. It’s great to get back into more of a biomedical/scientific aspect of nursing. I live and breathe nursing. I’m doing postgraduate study now, not to get a fancy title or a pay rise, but I’m doing more study because I want to be a better nurse so my patients will benefit from the skills that I have.

3.2 Back to Rasa Unlike Anesu, I didn’t have someone close to me die when I was young. I also grew up differently: in a white, middle-class family in a privileged country. For me, nursing was what opened up a new world, one that included having to try to make sense of death very quickly. Entering this world is a bit like walking into a room, locking yourself in and throwing away the key. You cannot go back through the door and un-see what you have witnessed. Close encounters with death form an important part of the journey of nursing, but the process can be tough and it can make you feel disconnected from others. While a friend is watching TV with a beer, you might be giving a wash to someone who is slowly taking their final breaths. It’s a beautiful world, and it is an honour to be with a person when they are departing it, but it can also feel surreal and overwhelming. When I was working as a carer at the war veterans’ nursing home—before I had even considered studying nursing—I had my first intimate encounter with death. (The one that baffled my interviewers for the public service desk job I never took). I was 17 years old at the time and I was working with a nurse, Suzie, who I found to have a really difficult personality. Suzie was so great with all the residents of the

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nursing home. She was kind and professional, but she always seemed to be very short with me and many of the other personal carers. I thought she was a bit of a bitch really, and I wondered what I had done to be treated this way; Suzie intimidated me. Lars was one of my favourite residents at the nursing home. I know that he annoyed a lot of people, because he was messy, but at the same time, he was very particular about how other people would keep his room. Lars was also incredibly talkative and eccentric in his manner, which can be hard for busy and tired nurses to manage. I really liked Lars though, as he was always so friendly and in such good spirits. He once gave me a train driver hat of his as a sweet gift because I always admired it whenever he wore it. Lars was in a wheelchair, despite being one of the youngest residents at the nursing home. Physically and cognitively, he was the healthiest, the most robust. So, it was a surprise when, one winter, Lars got pneumonia that worsened very quickly. Before I knew it, Lars was being palliated. Witnessing dying and death teaches people that things can change very quickly and can take one by surprise. I used to spend a lot of time trying to understand why people die when they do, in terms of the timing. I know a lot of people get upset when they try to understand why young people die, as they ‘don’t deserve it’. Personally, I don’t believe that death and illness are given to people as a punishment. Rather, I think we are randomly given a set of cards to play with, the dealing with which might include illness and death. What people manage to do with their set of cards, regardless of how good or bad they are, will vary from person to person. It was Suzie who helped me look after Lars. She had experienced death hundreds of times before, but this was the first time for me and I couldn’t stop myself from sobbing. Lars lay there gasping, pale and unconscious; I could barely recognise him. Hollywood films don’t accurately show what people look like when they are dying. Dying and death is much scarier and more shocking in real life. Suzie showed me how to keep Lars’s mouth moist, which gave him some comfort as he was breathing through his mouth so heavily. When we were out of Lars’ room, Suzie put her arm around me and validated how I was feeling. She appreciated how this was all really difficult for me. I had never seen this side of Suzie. With some time to ourselves, Suzie talked to me about how her dad had died suddenly of a heart attack when she was young, and how her brother had suffered with schizophrenia and eventually ended his life through shooting himself. I couldn’t believe how much death Suzie had had to deal with when she was so young, and I developed a greater respect and understanding for Suzie as she told me her story. It was at this point that I came to appreciate that people behave a particular way because of their experiences. Suzie also told me that she had not talked about her early encounters with death for years and that she felt relieved to be able to share it with me. My relationship with Suzie was never the same again and was for the better. Sometime later, I remember meeting with a nursing student friend of mine, Nancy, during our first year of undergraduate nursing. We’d taken a long stroll together around the lake, as we usually did. The sun was setting, and we were

3.2  Back to Rasa

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preparing to give each other a hug goodbye. However, this time, we faltered, and as we both didn’t seem ready to part, we sat on the grass in silence. After a while, Nancy said, ‘This is going to sound strange, but I have been thinking about death a lot.’ ‘Me too,’ I responded quietly. ‘It’s scary,’ Nancy then said, ‘and it makes me feel a bit crazy.’ I agreed with Nancy and it gave me some relief to know that I was not alone in this thinking. Nancy went on and spoke about washing a patient who had died, and how their eyes had abruptly opened due to rigor mortis (caused by the hardening of the muscular tissues after death). Nancy had cried out in shock and then experienced immense guilt. She felt she had disrespected a person who had passed away by breaking the peaceful ambience with her involuntary squeal. The whole thing had been really confronting for her. We both agreed that we wished we didn’t have to think about death. But, as we were in training to be nurses, we had to accept that it was inevitable. However, it’s hard not to contemplate your own death when you are caring for people who are sick or dying. We sat on the grass for a long time watching the sun creep away and the sky turned black before we finally felt able to process these feelings alone again. Having to work so closely with death scared me, but it’s also what kept me in nursing. I have the ability to help someone in a vulnerable state, to treat them as I would want to be treated, if I too were dying. My sense of reality prior to nursing, although simpler, now seems strangely dull and unrecognisable. Even if I wanted to go back through that door to the world that I knew before—a time where I did not have to grapple with concepts of mortality—I can’t.

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Nurses and Bodily Fluids

Nurses and Bodily Fluids

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_4

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The good nurse probably has a major aversion to at least one bodily fluid, but has learned to deal with it. As I mentioned earlier, people often ask: ‘What’s the hardest thing that you have had to deal with as a nurse?’ When this happens, I have to pick one category from a range of difficult scenarios. The hardest things that one will encounter as a nurse will be difficult for different reasons. I feel that most nursing stories will fall under the following subcategories: the grossest, the weirdest, the saddest, the most heart-­ warming, the funniest and the most challenging. This chapter is dedicated to ‘the grossest’. Let’s start with gore—blood and guts. I’m okay with that. Some people think that nurses must be desensitised to, and not affected by, any body part, function or fluid. In my experience, that is not true. Every nurse has their weakness and a lot of the nurses I speak to say that their weakness is sputum. I have no major problem with sputum. But I am not okay with poo. As a nurse, it’s hard to avoid facing this weakness when poo is a very regular and necessary by-product of the body. I identified my own vulnerability early on, during my time working at the war veteran’s home. At age 16, I did the Saturday and Sunday shifts (starting at 7 am), as that is when I was needed for staffing purposes; the penalty rates were also very motivating. The problem was that I was also partying every weekend, and through the week, even during peak study times at college. I thought that none of my colleagues would be able to tell that I regularly partied until 4  am on Friday or Saturday night, right before shift, as I never told anyone. However, I realised that this was not the case on one particular weekend when I behaved myself and didn’t party. I didn’t drink, went to bed early and made it to my shift in the morning. When one of the other carers commented: ‘Hey Rasa, you are not hungover.’ I was pretty embarrassed. It was during one particular shift that I finally cemented my understanding that it was not realistic for me to party and then do the morning shift as I found out that being hungover and sleep deprived really compounded my struggles with interacting with poo. While helping a man who had soiled himself in bed, I had to leave the room to dry retch. One of the personal carers then pointed out that you can party, or deal with the poo, but you cannot have your cake and eat it too. That metaphor also made me feel a little nauseous. Therefore, if I avoided mixing hangovers with poo encounters, I would cope fine, right? Wrong. I was confronted by poo again as a ‘baby nurse’ graduate. At this stage in my career, I was behaving much more like a professional. By that, I mean that I was not getting too drunk, and I was going to bed on time (as much as that is possible when you work a 24-hour rotating roster). The situation occurred when another nurse and I were helping a patient in the emergency department to use a bedpan because we couldn’t get him to the toilet in time. More on this later. Some poo is worse than others, and that be the truth. As you might imagine, your poo can often indicate what is happening in your body, as well as what you have eaten, and your general state of health. However, despite all the best intentions, conditioning one’s self to not react to bodily fluids doesn’t always work, even for

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experienced staff members who work in health. When a wardsman who has worked for 15 years in a hospital starts to dry retch when they are changing a patient’s soiled pants, I feel sorry for them. Yet, I also feel selfishly validated that I’m not alone in my very physical and emotive reaction to poo. As nurses, we need to try to hide or manage our weaknesses—that’s what being a professional is. A nurse never wants to gag in front of a patient and show disgust, as one can imagine how shameful for the patient this would be. It is not the patient’s fault that their poo is smelly. It’s also a really powerless position for a patient to be in, not being able to take themselves to the toilet on their own, for whatever reason. Now, back to my baby nurse ‘poo-nami’ scenario. I had psychologically prepared myself to deal with the poo, and I was trying to work out how other nurses, like the one I was working with on that particular shift, dealt with it so well. This occasion of poo was bad. It was a never-ending continuum of a brown, runny, soft-­ serve ice cream. It also had strong notes of rotten vegetables that virtually punched you in the face, and as there were not many windows in this hospital, ventilation wasn’t really a thing. I felt really unwell, and I was trying to meditate my way through it. I thought I had my ‘game face’ on but I soon found that I couldn’t manage, and again I had to make up an excuse to find an escape and jog to the next room, out of the vicinity of any poo. Sadly, the room next door was the bedpan room, which made me feel even sicker and I doubled over, heaving, trying my best not to vomit, as I knew I wouldn’t be able to stop if I started. When I had recovered, I rushed back to help the other nurse. However, the patient had already been attended to. He had been washed and his pants were done up. I was shocked, but pleasantly surprised that the job—my job—of managing the dreadful faeces had been taken care of. The nurse I was working with admitted to me later that she knew that I wasn’t coping the minute that I excused myself, and she subsequently enlisted the aid of a different nurse to help her in my absence. Nurses tend to build up that kind of intuition with this kind of thing, like grabbing a bucket before someone spews, that kind of sixth sense stuff. So, to summarise, the grossest scenario, for me, still always comes back to poo, especially when someone is being given lactulose for encephalopathy and is completely bedridden. The doctors prescribe the medication, a nurse gives the medication, and then other nurses have to deal with the aftermath.

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Nurses and the Emergency Department or General Practitioner

Nurses and the Emergency Department or General Practitioner

The good nurse may have less sympathy for smaller problems; they have seen far worse. It can be difficult for a person to know how sick they really are and where they need to go to get appropriate help. A lot of the most intense clinical cases that I have seen—in terms of severity— were patients who came in to see a general practitioner (GP) at the medical centre where I spent 2 years as a nursing assistant. I also found that a lot of people who presented at emergency departments (ED) should have gone to a GP, and vice versa.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_5

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I’ve found that people who come into the ED, only to be told that they have a cold and need to rest up, have a hard time dealing with that. The father of a friend of mine once had a whinge to me when I was visiting them at their coast house. He told me a story of how once he had been waiting to be seen in the ED while enduring the pain of a splinter. I was told that he had had to wait for hours and how he had gotten tired of waiting, left the ED without being seen and then removed the splinter himself. I’m not dismissing the fact that more money needs to be placed into healthcare so that we can employ more nurses to reduce wait times. However, I did ask my friend’s father: ‘Did the fact that you managed to leave the ED independently and remove the splinter yourself make you think that perhaps you didn’t need to go to the ED in the first place?’ My nurse friend, Harry—who works in an ED—once informed me that he will routinely tell every person who comes in with a sore finger that he can still triage them, but the reality is that they will probably be seen in about 5 hours as the sore finger generally doesn’t compete with the guy who has just had a heart attack. ‘This usually makes people go home,’ Harry stated. He then added, ‘and that’s a good thing’. A group of my co-workers and I agreed that people seem to have forgotten that they could see their GP instead of going straight into the ED. It’s not anyone’s fault. We have all had times where we believe and feel that we are much sicker than we are. Conversely, at other times, we can be a lot more unwell than we think we are. As nurses, we get used to having patients chronically overstating the severity of their symptoms when nothing is found to be wrong later. In addition, nurses can often find themselves caring for patients who always seem to be in physical or emotional crisis, but just keep chuffing along. The problem with this is that nurses can often become a little bit desensitised to it all. In mental health, nurses get used to some people calling in every day saying that they are suicidal but then not actually taking their life. We know from research that people who continuously state that they will end their life—but who have not yet made a serious attempt to do so—are not actually at any less risk of ending their life. Regardless, nurses can still become a little complacent, because hearing these statements constantly becomes emotionally draining, frustrating and tiresome. Unfortunately, this complacency among nurses can lead to a ‘boy who cried wolf’ scenario. Nurse Harry, who I mentioned earlier, has gotten so used to many people overstating their injuries and illnesses, that he too needs to remind himself of the importance of following routine examinations, to make sure that nothing is missed. Harry knows that he has to take every patient’s story and health concerns seriously. There is one particular story that he told me that reminds him why nurses need to take this kind of approach in their work. Harry told me about a patient who would always present to the ED with gastrointestinal pain, but there was never any source of the pain found, even with extensive testing such as abdominal scans, physical examinations, observations and blood tests. After numerous hospital presentations, it was assumed that this girl must have

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psychosomatic symptoms. After all, when people are anxious, they often experience stomach pain. As the physical tests for this girl had, to date, showed no physical cause for her abdominal pain, it altered the way that she was treated the next time (the final time) she presented to the ED. The staff, who were very busy, decided not to waste their time in doing any scans when they had all come back clear previously. The girl was provided with some verbal reassurance, some pain relief, and was sent home. She later died at home and the coroner’s investigation revealed that she was found to have an ischaemic bowel, caused by a lack of blood supply to that organ—something that could have been picked up if she had had another abdominal scan. As an undergraduate nurse, I worked at a medical centre. At times, the medical centre felt more like an ED than the actual ED, and I was often running a treatment room on my own while the doctors ran their appointments. I did phlebotomy (blood taking for pathology), all the wound dressings, and assisted the doctors with different medical procedures. Our facility was not set up like an ED because it wasn’t meant to function as one; we didn’t even have any oxygen handy. One day, I had a guy come into the medical centre who had a known allergy to marijuana. He had decided to smoke some cones with a friend because it was their shared birthday and a ‘one off’. While he was in the centre, he vomited so much that we had to call an ambulance. He begged me not to call the ambulance because he had no private health insurance, but the anti-nausea injection that was injected into his bum did nothing for him and so I was left with no choice. On a different occasion, I had another guy sit in the waiting room for an hour with his Mum. When I called out his number, he told me that he had had a seizure and fallen on a heater. He also told me that he was unsure how long he had lain on the heater as he had been unconscious and the fall was unwitnessed. When he peeled off his shirt, he revealed the worst burn I had ever seen. The burn covered most of his back and had scorched through every layer of the skin. I couldn’t believe that he had sat in the waiting room without telling anyone. We sent him straight to the ED. So, if you have waited for 5 hours in an ED, were not seen and went to bed feeling better, perhaps the GP would have been the better option. However, if you are vomiting blood for 3 days straight, perhaps the ED is more appropriate. But hey, we are nurses, just show up and we’ll try to get you on the right path either way.

6

Nurses and Love Bites

Nurses and Love Bites

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_6

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The good nurse must act normal when they see weird things. Every nurse has some funny stories to tell. Some of the weirdest situations I have encountered happened while working at the medical centre as an undergraduate nurse. One of my many roles there was as a phlebotomist. While wearing my phlebotomist ‘hat’, I was to check the patient’s details on the pathology form, take the blood, place the blood in the centrifuge after letting it sit for the appropriate amount of time and, when labelled cross checked and ready, send it off to pathology for testing. On the pathology form, the doctor would write a note about their clinical reason for performing the test; without a reason for conducting a blood test, Medicare would not cover the cost. It wasn’t my job to enquire further with the patient about the clinical reasons for the test, nor did the patient have to tell me why they were having blood taken, but sometimes they did anyway. At times, this led to oversharing. Herpes man 1: ‘My girlfriend gave me herpes’. Nurse assistant: ‘Umm, jeez. That’s no good’. Herpes man 1: ‘I can’t believe it, she cheated on me!’ Nurse assistant (awkwardly): ‘Gee, yeah, that really is not good’. Herpes man 1: ‘Can you tell from this blood test at what stage my girlfriend cheated on me?’ Nurse assistant: ‘Unfortunately no, blood tests don’t work like that’. Herpes man 1: ‘I can show you if you like (getting ready to take off his pants)’. Nurse assistant (hurriedly): ‘No really, that’s okay. You don’t need to do that, I believe you’. (The nurse assistant knows that this man had taken off his pants only a few minutes earlier to consult with the doctor about his ‘issue’ and has no idea why this man feels so compelled to take his pants off a second time.)

At other times, patients provide information that reveals their lack of understanding of diseases. Herpes man 2: ‘I’m really worried I have herpes’. (This man is in his 30s and is getting a general blood set done, not a sexually transmitted disease screen.) Nurse assistant: ‘Oh, okay, that’s no good. Have you talked to the doctor about it?’ Herpes man 2 (stressing out): ‘How do I know if I have herpes?’ Nurse assistant: ‘What kind of symptoms are you experiencing?’ Herpes man 2: ‘Well, I made out with a girl and now I have a rash on my finger’. Nurse assistant: ‘Okay, so you didn’t … Umm, have sex or anything? Like, more than just kissing on the lips?’ (Nurse assistant points to the lips on her own face to avoid any confusion about which lips she is referring to.) Herpes man 2: ‘No’. Nurse assistant: ‘And your rash is only on your finger?’ Herpes man 2: ‘Yes’. Nurse assistant: ‘Well, if that’s the case, I think you can pretty safely say that you don’t have herpes’. (Nurse assistant is a bit confused at this point.) Herpes man 2 (with enormous relief): ‘Thank goodness!’ Nurse assistant: ‘Umm, no worries’.

No matter how unglamorous the job can be, how challenging, sad, or underpaid, being a nurse is never boring. When I saw the words ‘human bite’ written as the clinical reason for investigation on one blood test sheet, I was, of course, curious to

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know the story. However, as I mentioned before, it wasn’t my business to ask about why people were having a blood test; I was just there to take the blood, so I resisted asking about the human bite comment. As per the usual phlebotomist routine, I pulled up the young man’s shirt-sleeve to apply the tourniquet to prepare for the blood-taking procedure. There were numerous, deep, puncture wounds in the precise shape of a vampire’s bite all up his arm. At this point, I just had to say something: ‘Buddy, it’s not my place to ask, but what happened?’ This young man—a young indie rocker by appearance, but quiet in demeanour— sheepishly told me the story. He had met a girl in the city and they ‘got it on’. Very quickly it had become clear that there was an intense, lustful attraction between them and that they would be going home together to continue the fun. When they arrived home to ‘get jiggy’, the girl asked him if she could bite him. The guy told me that he had interpreted this request with the expectation that a few play bites were in order, maybe some hickeys. He went on to tell me that he had expected something mildly kinky but still relatively innocent and that he was down for this because she was hot, and he was keen on her, and because he felt that, no matter what he agreed to do, it was likely to eventuate in the ultimate reward: sex. She totally chomped him. I had never seen anything like this before. I could not fathom how he managed to withstand this kind of pain with bites that clearly broke the skin, in depth, multiple times. The doctor had informed him that, if the red inflammation progressed past the giant cross tattoo on his inner arm, he would need to go on antibiotics. I told him to make sure that he wore long sleeves when his Mum was around, because there was no way she was going to understand what had happened to him. The young guy agreed that, even in the middle of the intense heat of an Australian summer, he would be committing to shirts that completely covered his arms. Love bites and herpes, all a part of the nurse’s world.

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Nurses and Spirituality

Nurses and Spirituality

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The good nurse will question their faith at least once. Many nurses will be able to tell of an experience that they couldn’t understand, alluding to a force or a greater power being present at the time. I used to be a lot more cynical about the idea of encounters with spirits, but, as time has gone on— especially while working as a nurse—I have come to respect the notion that we really don’t know much about the afterlife. In general, I think people often choose to see things in black and white—we consider things to be either real or fake, with nothing in between. I believe that this way of thinking provides comfort by giving us the feeling that we have it all figured out, so that we feel less afraid about what comes after death. A few colleagues of mine—who are mentally stable, I must add—have reported vivid stories to me that have sounded supernatural in their nature. Interestingly enough, many of these stories are from healthcare workers who say that they are not religious. For example, a hospice receptionist, Sally (a self-confessed atheist), who I used to work with, once told me that she felt that she had had an experience with a greater presence. At that particular time in her life, Sally had been stressed out. She was between houses and was having a hard time managing her own photography business on the side as well as her position as hospice receptionist. In addition, she had the demands of day-to-day caring responsibilities for her young children. I’ve always found that Australians who live in areas without much rainfall do not cope well with practical tasks when it finally does rain. There are always more accidents on the road as people are not used to driving in wet conditions—drivers become impatient as they are not in the practice of giving themselves extra time to allow for driving more slowly and safely. On the day of her experience, it was raining, and Sally needed to get to work to start her shift. She was driving to work and cursing herself for not leaving the house earlier. She was also becoming anxious that her colleagues would respond negatively when she arrived late. At the time of the experience, she told me that she was imagining herself walking into work in her wet clothes with windswept hair (she hadn’t brought an umbrella) and that her colleagues were all staring at her with solemn expressions and thinking to themselves ‘Well that’s unprofessional’. Suddenly, out of the blue, she heard a loud voice say clearly the word: ‘Stop’. Sally had been alone in the car at the time, but she was confident that what she heard was not a voice in her head (nor was she influenced by hallucinogenic drugs). She was sure that the voice had been God, or some other higher presence, telling her to slow down. The voice had brought Sally back to the present moment and she had stopped her car on the side of the road and took a chance to breathe, at which point the rain—that had been falling in a light continuous pitter patter—all at once began pounding down in a fierce storm. Surprisingly, Sally also said she suddenly felt at peace with the world. Sally’s experience has led me to think about the ways that we, as humans, are connected to intense feelings, thoughts and events and what that all means. The idea of the supernatural, or a greater presence, resonates the most with me in the context of dreams.

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I’ve always been a vivid dreamer. In my experience, dreams are sometimes meaningful but at other times they are not. My dreams, at times, have involved a mix of my fears and insecurities that have arisen in times of stress. At other times, they are a comical jumble of random words and objects pulled from my subconscious— words and objects that I have encountered somewhere in the past week, or further back in my life. However, I also sometimes dream about things before they happen. I have dreamt about the family members of two different friends passing away the day before they died. The people who died were known to be sick, but the trajectory of their illness and the estimation of their time of death were not clear at the time. But in my dreams, it was. I have also had dreams about people I have not seen or thought about in years and then encountered them the next day. For example, one time I dreamt about the brother of a friend of mine, Jim (someone I had not been close to and had had nothing to do with in years). The next day, when I had a shift at the war veterans’ home, I clicked on the TV—as requested by one of the residents—and a segment about Jim’s band was playing on the news. In another dream, I saw a guy, Andy, who I had a crush on in high school. I hadn’t seen Andy since we caught the bus together when I was in grade 10, but the following day after my dream, he turned up in my drive-through lane when I was working a shift at McDonald’s. I wonder: is this all coincidence? Or is this part and parcel of intuition (something that nurses need to tap into for their work)? Or does it mean something more? It’s not only in dreams where I have felt connected to a feeling or presence that I cannot fully explain. These kinds of feelings and experiences are present in the day-­ to-­day lives of nurses in their work, particularly in clinical settings like a hospice. Jill, a patient at the hospice where I worked, was a special woman who particularly comes to mind when I think of how hard it is to say goodbye to someone. I connected with Jill the first time we met. She was not a relative of mine, but it felt like we had known each other in a past life. We could talk about anything when together, and during the time I spent with Jill, I also came to understand and appreciate her family and her friends on a deeper level too. Jill had been diagnosed with cancer very young (in her early 50s). Her husband had died unexpectedly from a heart attack, and her son had also died; I think from suicide. Essentially, Jill and her daughter, Alice (a successful, attractive, hard-­ working and confident businesswoman in her 20s), were the only ones left in Jill’s immediate family. I was always in awe of how Jill maintained a good sense of humour; she was so damn strong. One afternoon after her health had begun deteriorating, she was apparently sleeping heavily when a friend, Gina, told Alice that she thought that Jill might be taking her last breaths. Jill immediately woke up and groggily said, ‘I fooled you all, didn’t I?’ Jill’s loved ones could only laugh and cry at what they were witnessing. Jill was adored by everyone around her, people who were equally as kind, intelligent, funny and lovable as she was. She was not trying to fight the inevitable; she also did not believe in life after death and was at peace with that too. What Jill told me she found most difficult to come to terms with was imagining how Alice would

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cope without her when she died. I knew from conversations with Alice that she was also on her own journey, trying to navigate her emotions while her mother was dying. Alice had told me with some annoyance that the social worker at the hospice had wanted to talk about grief processes with her. The social worker had expressed some concern that Alice was spending too much time trying to be strong, which might interfere with working through the stages of grief. It nearly killed me when Alice told me, while holding back tears, ‘Can’t people realise that the death of a family member is not a new concept for me?’ She then added assertively, ‘I’ve already buried my dad and my brother. I know what is involved here, and I am okay.’ I didn’t say anything; I just nodded silently while keeping eye contact with just the tiniest crack of a smile, which I hoped would demonstrate my empathy towards her position. Nothing that I could have said to Alice at the time would have been of any consolation to her. However, Jill’s friend, Gina, and her sister, Eve, had promised her that they would always look after Alice. I knew that they would and I was able to console Jill with those reassuring promises. In Alice’s case, while nothing would be able to fill the gap in her life after her mother’s passing, both Jill and I truly felt that, in time, she would be okay through her own strength, and the love of those around her. Although I knew that I was not meant to have favourite patients as a nurse, I cared for Jill like I would have a family member or friend. Everybody will have people that they are naturally drawn to and connect with. That’s okay for nurses, as long as they are self-aware enough so as to ensure that they treat all patients with equal compassion and care. As expected, each time I saw Jill, she had deteriorated a little more. One day on shift, the weekend volunteer clerk at the hospice called my name on the loudspeaker, requesting I come to the front counter. I’d never been abruptly requested to come to reception in the middle of a shift like that before and I was worried. I thought that perhaps someone in my family had died or had something serious happen. When I walked up to reception, Audrey, one of Jill’s friends that I hadn’t met before, greeted me. Audrey wanted to thank me for everything that I was doing for Jill. She told me that this meant everything to Jill, her family and friends. I felt immeasurably warm and blessed knowing that I was able to help them through such a difficult stage of Jill’s life. I knew that Jill was declining quickly in her health, and, while I had borne witness to many people dying at the hospice and the war veterans’ home, this time it felt different. Caring for Jill was becoming hard for me to manage personally, and I felt out of control and was wondering if what I was feeling made me unprofessional. Was it normal and okay for me to care this much for a person that I didn’t know, beyond them being my patient? I spoke to my sister, asking what I should do for myself, and for Jill. She suggested that I write Jill a letter telling her about these feelings. I took up the idea and also decided to give Jill some seashells to pray with. My parents are Catholic. However, from my teenage years onwards, I have identified as being spiritual without any particular denomination. Through this journey,

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I have learned and moulded tools for prayer that have been helpful for me. The idea of using shells came from a counsellor who I had consulted with when I was doing an exchange semester of study for nursing in Canada. At the time, I had been stressed, overwhelmed and afraid that I was going to fail one of my subjects. I was preparing for my exams using the study techniques prescribed by my lecturers (which should have maximised my chances in doing well in the exams).However, I still felt anxious. I lacked self-belief and hope, and my sleep and appetite were being disrupted as a result. After delving into practical strategies for study and exam preparation, the counsellor also gave me a stone to pray with. They told me that the object I used to guide my prayer—a stone, a shell, a pendant or whatever I chose— was actually not important. The object used just provided a vessel to channel the prayer. I was told to hold the stone when I felt vulnerable, to remind myself that all of my study and my self-belief was held in the stone. The stone was to be a reminder that I had done everything that I could that was within my control and that regardless of the outcome, I would still be okay. With some hesitation, and almost embarrassment, I gave Jill the shells and the letter I had written the next time I saw her. I felt a bit stupid giving her the shells, but I wasn’t sure what else I could do. I couldn’t take away Jill’s illness, or the fact that she was dying, but I wanted to help Jill however I could. Anyone can appreciate the feeling of powerlessness when someone they care about is suffering and they are wanting to do something, anything, to help. Jill was still speaking, but her rate of speech had slowed and she was sleeping a lot. I did not expect Jill to live past the next couple of days—when I would be off shift. And I actually prayed that she would pass away when I was off shift. I know that sounds selfish, but I just wasn’t sure how I would manage myself emotionally if Jill passed away in my presence; doctors don’t want patients to die on their operating tables and nurses don’t want patients to die on their shift, even when it is inevitable. When I returned to work, I saw Jill’s name on the handover sheet and I sighed wearily. I now felt it was destiny for me to be there with Jill when she died. However, I was then informed that I had been allocated to another wing; Jill was on Wing A, and I had been rostered to work on Wing B. I—guiltily—felt some relief because another nurse would be caring for Jill, and I wouldn’t have to deal with her death. Even though Jill was not my patient that day, I still greeted her and her family before the shift began and explained to them that I would be working in the other wing that day. Jill looked terrible. Her breathing was laboured, and each breath was followed by a long pause. Like many people who are dying, if one could—hypothetically—lower the volume of their breathing they often appear peaceful, like they are in a deep sleep. Turn the volume back up and the breathing doesn’t even sound human anymore. Normally, the nurse allocated to a particular wing of the hospice would attend to all the needs of the patients. This gives all staff predictability and structure in knowing who they need to care for and what they need to do. However, shortly after I started my shift on Wing B, the nurse working on Wing A requested that I please call Jill’s family to let them know that her departure was looking quite imminent. ‘You know them well, Rasa’, she said. ‘They’ll want to hear it from you.’

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With shaking hands, I made the call to Eve, surprising myself that I could somehow maintain composure as I communicated this news. ‘Hey Eve,’ I began, ‘I think you had better come around. I don’t expect that Jill will live for much longer. I think it’s time’. ‘We’ll be right over’, said Eve. ‘Thank you for letting us know. Will you be there when we arrive?’ I explained to Eve that Jill was technically not my patient that day, but that I would be there. As I said this, I had conflicted feelings. A part of me truly wanted to avoid witnessing Jill dying, as I did not know how I would deal with my intense emotions. The other part of me felt both honoured to be invited and that I needed to be there. Closer to the time of her passing, I went to Jill’s room and watched her gasping, slowly and loudly, with the others. My heart was racing because I knew that this was it. Within what felt like a couple of minutes, Jill took her last breath. Everyone in the room hugged each other and they also embraced me as one of them. I kissed Jill on the forehead and then left Jill with her friends and family; they were all crying. About 2 weeks after Jill passed away, the hospice staff and I wrote a card to give to the family. The hospice had a routine of sending a card to families of those who had passed away (while under care of the hospice staff) within a few weeks of someone’s passing and then a few months later, and then again, about a year later. With these cards, there was an invitation for the families to make contact with the hospice if they found it healing or helpful. However, aside from the cards, the hospice would not make any other contact with the families, unless it was initiated by them, personally. I wondered if I would ever see Jill’s family again. The senior staff at the hospice explained to me that it wasn’t normal to hear from families after someone passes away, even when they were happy with the care that their loved one had been given. This makes sense to me now. Most people want to distance themselves from the place where an extremely difficult chapter of their life occurred. At the time, however, I found it hard to comprehend. I had been involved so intensely with the care of Jill as a patient, and then she was just gone and so were her family and the friends who I had come to know so well and cared about. A few nights later, I saw Jill in my dreams. I’m not sure what she was telling me, and I don’t think that I was meant to hear what she was saying. There was a warm glow around her, a swirl of oranges and yellow. She looked relaxed. She was no longer sick, and she was at peace. Later, I spoke with my dad about this. Had I seen a ghost? I don’t think so, but this kind of spiritual connection did not feel like a ‘made up’ experience either.

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Nurses and Instincts

Nurses and Instincts

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_8

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The good nurse will know when something just doesn’t feel right. Being able to follow instinct appropriately in life, and especially in nursing, is important. In one of my final subjects of undergraduate nursing, a wonderful lecturer of mine, Betty, talked with us about how our intuition is formed and strengthened. Betty’s hope for us, as nurses, was to be able to recognise our intuition and learn to trust when to follow it. Betty talked about how, over time, nurses can use their sharpened intuition to identify when patients are deteriorating before it is visibly noticeable. While conducting physical observations to detect illness and abnormalities is crucial, they are not the only thing that can lead nurses to know when they should be concerned. Through nursing, and also personal experiences (like romantic relationships), I’ve learned that the brain tries to be logical, the heart feels the weight of your emotions, and the stomach is the ‘middleman’. Emotional intuition is what most of us recognise as a ‘gut feeling’, which often tells us when something is not right. This has certainly been the case for me in determining if a romantic relationship is right for me to continue with. My brain tells me what it thinks I should be feeling based on what is happening around me, while my heart remains loyal to the person I am with, leaving me to feel guilt-ridden and confused by the doubt in my brain. But, if my gut feels uncertain for long enough, then I know that it is time to call it quits. In one of our tutorials, Betty discussed the context of emotional intuition in nursing and compared it to people spending time in a nightclub; the patrons of a nightclub can either trust, or ignore their intuition when evaluating if they are at the peak of the fun of a party, or if they should go home. She then talked about how choosing the time to go home will change depending on the city or town you are in, and the culture of that particular place. Discussion continued about how, in our home city, the fun in the clubs lasts until about 1  am. Although the urge might be there to keep partying, the emotionally intelligent people know that the best part of the night is over. This cohort of people have noticed that after 1 am, there is a psychological shift on the dance floor; the way people look at each other has changed to be more of a leer than a friendly acknowledgment and people dance and move in different and noticeable ways. Before 1 am, if BOY 1 bumps into BOY 2 accidentally on his way from the bar and BOY 1’s alcohol is spilled onto BOY 2, both people laugh jovially and give each other a little cuddle to show apology. Over time, however, all of the rum and sugar will turn the fun times into a deadly mix of bravado and lost inhibitions for the boys. After 1 am, if BOY 1 bumps into BOY 2 on the way from the bar, spilled drinks lead to profanities and escalating tension, and when BOY 2 punches BOY 1 in the face, an ambulance needs to be called. In a similar manner, two girls who start off their fun ‘girl’s night out’ with a pact to spend the night hanging out and being there for each other. They agree that they would both ideally like to leave the bar before the clock strikes one. However, when they are still there at 1 am, GIRL 1 is ready to go home—but GIRL 2 has met a guy she likes at the bar and has convinced GIRL 1 to stay. GIRL 1 has now become the

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reluctant ‘wing woman’ and as a result becomes a bit bored and lonely and decides to do a few more shots to keep things moving. It is soon well after 1 am and the girls have lost track of each other. GIRL 2 then goes home with the seedy Casanova from the dance floor while just around the corner GIRL 1 is vomiting into the toilet, after making a decision to drunk-dial her ex-boyfriend. I like this imagery of chaos at a bar. It shows how ignoring our intuition (often because other people tell us not to follow it or not to worry) can lead to unfavourable consequences. A person is likely to become unpopular in those moments when they beg for the group to go home rather than keep partying. The same often applies to a nurse who states their difference in opinion with regard to a diagnosis, treatment or care plan. Nursing as a newbie is tough because of the limited amount of clinical knowledge and experience that one has, and it doesn’t take long for a nurse to realise that they will be learning new things every day for the rest of their career. If a nurse truly believes that they know everything, they become a dangerous practitioner. The other side of the coin is that newbie nurses tend to know more than older nurses and clinicians assume. New nurses are generally keen to learn and carry a lot of enthusiasm but can often behave like a deer in the headlights. Being the deer in the headlights is not fun because it makes one feel just like that: a fearful animal, stunned, unsure of what to do and struggling to get past feeling blinded by the intimidating things in front of them. The advantage of being a deer in the headlights is that one looks at everything with a new set of wide eyes. This can bring a fresh perspective to a situation, which others, who have been around a long time, might lack. In my first nursing placement, I had one particular experience that taught me to trust my intuition. I was looking after a middle-aged man, called Ben, who used to be a professional basketballer and was now a husband, teacher and father. As it is for many basketballers—who spend their time jumping up and down on hard surfaces and ruining their joints—Ben now had knees that needed replacing. Ben was otherwise in good health and was not expected to have any post-operative care complications because of that. However, he would likely lose a significant amount of blood in the process of having both his right and left knees replaced at the same time (a procedure otherwise known as a bilateral knee replacement). As per the normal protocol for this kind of operation, after the procedure, Ben was placed in the intensive care unit (a critical care unit otherwise known as ICU) where I was on shift. In the beginning he was doing well, as anticipated. We both spoke a little bit of Spanish, so we were practicing the language with each other. And because, at the time, I played basketball, we also talked about that topic as I attended to his usual post-operative care. Towards the end of the shift, Ben was okay—not excellent—but okay. He was lucid, but he was taking a little longer to respond to things and just didn’t seem as bright or as energetic as before. I alerted my clinical facilitator and explained to her the subtle changes that I had observed in Ben. Based on this, my clinical facilitator wondered whether the change in him could be caused by the effects of his pain relief, in conjunction with recovering from the effects of the anaesthetic. We

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double-checked how much pain relief he had received. It had been 8 hours since Ben’s operation, and he had hardly used any of his pain relief, so it seemed unlikely that his slight change in consciousness was because of this. My clinical facilitator encouraged me to inform the medical team of my concerns, which I did. According to the Glasgow Coma Scale (otherwise referred to as a GCS Scale, which is an assessment of a person’s consciousness level), Ben was still sitting at 15. This translated to Ben being fully conscious with no abnormalities. Ben was alert and oriented to time, place and person and his vital signs (i.e. heart rate, temperature, respiratory rate and blood pressure) were good, and so my concerns did not result in any direct clinical interventions. I had told the doctors and they didn’t feel there was anything to worry about. I didn’t know what was wrong, but I still felt that there was a problem, and I wrote about that gut feeling in my journal that night, recording that I was worried for Ben and his family. When I came back to work in the morning, the night shift nurse gave me the handover notes; Ben’s GCS had dropped significantly. When I saw him, he couldn’t speak and, when I gave him a piece of paper, all he could write were squiggles. Sometime between my shift finishing and the start of the morning shift, Ben endured a stroke. What I had witnessed the day before, when I felt that something was wrong, was Ben experiencing the early signs of that stroke. Ben’s wife was crying when she came in later to ask in disbelief: ‘How the hell did this happen? He came in to get his knees done’. Post-operative stroke can happen from time to time, even for healthy people like Ben—who are considered to be in the low-risk category. Even so, I found it all hard to digest and I had to ask a senior nurse to speak with Ben’s wife. Later, I followed up on Ben’s progress when he left the intensive care unit. (I had no need to do this in my role, I just wanted to know.) With a lot of physical rehabilitation, Ben was expected to make a full recovery (thank goodness). No one had fucked up here, but as a baby nurse, I learned that, even with my flaws and inexperience, I had to place more trust in my intuition. Trusting one’s intuition can take time, and it’s often from adverse experiences that one learns this lesson. The nurse that I was at the end of my graduate year was unrecognisable from who I was at the start of that year and my greatest learning came with the decision to be assertive when it mattered, and to trust my gut. In the year following my graduate year, I had a stand-off with a doctor when I asked her to review Andrew, a patient of mine, more frequently. Andrew’s blood pressure kept dropping and his physical state was congruent with the blood pressure reading. He was ghostly white and lethargic, and he told me himself that he did not feel well. The doctor said that Andrew was being seen regularly enough and that she was not worried about him. She also told me that his normal systolic blood pressure was about 90. Still concerned, I pulled out Andrew’s observation charts from a few days prior that showed his normal systolic blood pressure to be 130—his blood pressure had dropped drastically. At the time, we were waiting for a blood transfusion for Andrew, which seemed to be prolonged. He was only being reviewed once an hour and I told the doctor that I did not feel that he was safe considering how infrequently he was being reviewed

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by the medical team. I also suggested that if Andrew was not able to be seen more regularly by the medical team, then he would be safer being transferred to the intensive care unit. I knew that through being stepped up to intensive care, Andrew would be under a one-to-one or a one-to-two nurse-to-patient ratio and would have his vital signs and physical health monitored more closely. The doctor told me that that was not appropriate, and although I repeatedly expressed my concern and clinical reasoning to them, there was no change in their stance. I finally stated that if Andrew’s blood pressure dropped further, or if I had any other medical concerns about him, and they still refused to see him, then I would make a medical emergency team (MET) call. The doctor responded by saying that I would be laughed at if I made a MET call for this patient, as he did not fit the intensive care criteria; she smirked at me while she said this. The fact of the matter was that I had many unwell patients that day, and I didn’t want Andrew to slip away while I was caring for someone else; I didn’t want to wait until he crashed (deteriorated to the point of emergency) before we intervened assertively. I may have been conservative in my approach, but I didn’t want to take any chances. So, in the middle of the ward, I told the doctor (with some force) that I did not need her permission to make a MET call. I told her that, if I made a MET call and was laughed at, it wouldn’t matter. I would never regret making a decision like that if it meant keeping a patient safe. After the event, I thought, ‘Jeez, Rasa, where did that come from?’ No way would I have been capable of being that assertive in my new-graduate year. Fortunately, I didn’t have to make the MET call, as the medical team agreed it was appropriate to review my patient every 15 minutes while he was waiting for his blood transfusion to arrive. The doctor I had the discussion/stand-off with also apologised to me. (Well, kind of. She apologised to a colleague of mine on the shift and asked them to pass the message on to me.) It’s hard. Doctors and nurses are all busy and we all want to think that we know what’s best for our patients. The doctor is the clinical lead. Nurses should follow the direction of doctors, as long as the clinical decision is justified and is in the best interest of the patient. And, if it’s not, nurses need to speak up. On another occasion in this same year, I had a student nurse, Jenny, working alongside me. We were caring for a man named Tony, who had severe abdominal pain. He needed a lot of pain relief, more than most people, which was confusing to the nurses. Tony had been asked when he entered the hospital if he had a history of drug use, and he had said no. Later, when his pain was not being managed adequately by nursing staff, he admitted that, in the past, he had been a frequent heroin user. Many of the staff judged him harshly and treated him poorly after he revealed this. One can understand why people addicted to drugs are not forthright in telling others this, when they know that they will be badly stigmatised if they are actually honest about it. A few days into his hospital admission, and after revealing his history of heroin use, Tony told the staff that his pain was getting worse. The tiny amount of oral morphine that staff had been giving him wasn’t doing anything to ease his pain. And how could it?

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A doctor reviewed him and wrote him up for a dose of intramuscular (IM) morphine to be delivered stat. Following the drug order, I informed Jenny that we would give Tony the IM morphine. In reply, Jenny said, ‘But Cindy (the other nurse) told me that we shouldn’t give the morphine to him because he is a drug addict and he is only saying he is in pain to get more pain relief’. If I had been told this kind of thing a year before by a nurse like Cindy, I may have just nodded my head, remaining passive and unsure of what was best for Tony. Times had changed though. I now had a year of experience under my belt, which had strengthened both my clinical knowledge and my intuition. Frankly, Cindy’s advice was bullshit. It wasn’t based on any evidence, it was based on her pre-­ judgment, and it was unethical. I was outraged and gave the following explanation to Jenny: ‘We are not helping this man by not giving him pain relief. By denying him pain relief, we will not fix his drug addiction; we will purely be punishing a man, who, for all we know, has legitimate pain’. I then added, ‘He has used heroin in the past, so his tolerance to pain relief is high and he therefore needs a higher amount of pain relief to manage his discomfort. Not to mention’, I said, continuing, ‘this is an order from the doctor. It is not our duty to deny someone pain relief just because we feel they don’t deserve it’. I then told Jenny that I would be giving Tony the pain relief and that Cindy could speak directly to me if she had a problem with it. Nurses need to speak up and challenge each other and the medical team when something does not seem right. Our patients depend on us to have thoroughly brainstormed, and often questioned, our reasoning before making a concrete clinical decision. Trust your gut, sister.

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Nurses and Doctors

Nurses and Doctors

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_9

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The good nurse will be taken for granted but knows their own importance. I’ve had a lot of people ask me if I have ever considered studying medicine to become a doctor. During the whole time that I studied nursing, and even when I started work as a nurse, I questioned my choice of profession. I worried about the lack of glamour in the role and the limitations regarding pay and working conditions. Also, the comments other people made about how they viewed nurses always seemed unbalanced and played on my mind. For example, I’ll always remember getting a comment from my friend’s boyfriend at a party in college: ‘You work in an old person’s home; you must love wiping people’s arses’. ‘Cheers, buddy’, I thought. What a way to summarise the humble, difficult, compassionate, important and exhausting work of a nurse—someone who provides vital care and socialisation for a vulnerable, elderly person. The roles of nurses and doctors are completely different. Doctors are the clinical lead, they are highly intelligent and have studied very hard, and they continue to study very hard to stay where they are. Doctors can also, at times, make nurses feel unworthy or stupid. However, the inaccurate portrayal of nurses in the media and in film and television also adds to a tarnished view of what a nurse is. I actually used to love the idea of dating a doctor. I thought that the experience would be in equal parts sexy and sweet. My theory soon changed. After dating a couple of doctors, I appreciated even more that the role of doctors is tough and full of pressures, more than what many people imagine. It’s not all sunshine and roses; it’s a role of extreme responsibility with very little forgiveness for mistakes. What I have found sad though is that not everyone gets into medicine for the right reasons. “Book-smart intelligence”, family pressures and cultural expectations should not be the only driving factor for becoming a doctor. But for some people, this is often the case. Indeed, I found this to be the case with one of the doctors that I dated. We were having dessert somewhere and he asked me, ‘Do you love being a nurse?’ I smiled and confirmed that I did. He then tried to reassure me that I could be brutally honest with him. ‘It’s okay, nobody is listening’, ‘ he added before asking me what I liked about nursing, as though it was baffling as to how it would be possible for me to enjoy the profession. I told him that—as a nurse—every day was exciting, and I felt grateful to be able to work so closely with my patients and to be able to help somehow. I then asked him if he liked being a doctor. He answered, ‘Not really. But I had the marks to get into medicine and all of my family are doctors’. He then admitted that the money was good, as was the lifestyle that accompanied it; he liked being able to afford the rent of a fancy apartment and enjoyed being paid to travel for work-related training. Then he confessed that he actually didn’t get the time for sightseeing when he was training abroad; he would be cooped up in a conference room the whole time and then have to fly straight home again. This was all very saddening to me. The other doctor I dated also didn’t know if he really wanted to continue on with the profession, but he had obviously worked so hard to get where he was that he didn’t think that he could justify exiting. Perhaps I’ve just dated unhappy doctors.

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During my nursing studies, countless people assumed that I was in nursing as a consolation prize for not getting into medicine or that maybe nursing was simply my pathway into a medicine degree. At one point, I was even led to think that if I was a doctor, my life would be complete. I could be rich and accomplished, and who wouldn’t want that? So, what changed my mind? I remember speaking to Wendy, a clinical facilitator and lecturer in my undergraduate nursing program, shortly before completing my nursing degree. I had gone to talk to her about possible pathways of getting into medicine after nursing. Wendy told me that she would talk to me about the pathways into medicine but encouraged me to at least try being a nurse for a year to see if I enjoyed the role. She also said that I would be surprised about what the role of a nurse actually involves, in practice. She then talked about how great doctors are important, but great nurses are equally as important. Wendy was right. In my new-graduate year, I realised that the responsibility that one holds as a nurse was far greater than I had ever imagined. In the old days, nurses used to be there primarily to assist doctors, but now nurses have more of a say in hospitals and the community. Yes, nurses follow the doctor’s lead, but there are more nurses than doctors. The roles of nurses are evolving, so it makes sense for nurses to take on more leadership roles. People still ask me, ‘What’s it like working with doctors?’ When one is a newbie nurse in a big hospital (actually, any hospital), you feel bound to the hierarchy. And not just with doctors, but amongst nurses also. The hierarchy is there for a reason and clinicians with greater amounts of experience need to be placed in positions of leadership. This hierarchy facilitates the huge number of staff and the processes that are involved in the day-to-day running of a hospital. If there is one break in the chain, the whole operation could fall to pieces. The problem, however, is that clinicians can spend too much time flattering their egos because they have people below them. People sometimes forget that those who are working ‘underneath’ them are actually invaluable—it’s often the people on the bottom of the ladder who are doing the brunt of the work that makes the person on the top look good. Most nurses will, at one point, experience doctors who come into a ward and ask if their patient has had some particular medication but won’t ask your name or even make eye contact with you. Doctor or not, if someone approaches me like that (unless it is an emergency), I deliberately get them to slow down and explain who they are and what their role is, and then force them to acknowledge myself and those around them. Doctors are overstretched. The field of medicine is extremely competitive, and at times I think that doctors can be blinded by this. As a result, a doctors’ ability to appreciate and utilise common courtesy with other staff, as well as their bedside manners with patients, can sometimes go on the back burner. That’s not to say that there aren’t nurses around who act similarly. And, just because a person is a nurse, does not mean they have intrinsically developed good people skills.

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When I first started work as a nurse in the hospital, I did not automatically understand the hierarchy system for doctors. In layman’s terms, in a hospital—as well as in the community—the consultant doctor is the head honcho of the treating team. The consultant has completed years of specialist training and has ultimate responsibility over clinical decisions for their patients. Nurses don’t often see the consultant, as they are often insanely busy. The consultants swoop in, assess the patient, write a plan and then leave. The registrar is the middleman, someone who is hoping to be the boss one day but who has not yet had enough training and experience to fulfil that role. The resident doctor is the newbie; they contribute, but their primary role is to learn and take orders. On one occasion, my quest to find a doctor to help me cannulate a patient made the hospital food chain become more obvious. I asked a consultant doctor if she could cannulate my patient. A nursing colleague approached me on the side and whispered in haste, ‘Hey, what are you doing asking her that, she’s a consultant doctor.’ The doctor, looking confused, reiterated her position to me: ‘I am a consultant’. I then clarified my need to her: ‘So, you are a consultant, which means you are a doctor, and therefore you know how to cannulate, yes?’ I wasn’t meaning to be rude; I just couldn’t at the time understand why it was taboo to ask a senior doctor to perform a clinical task that any doctor was capable of. I think that the consultant was a little dumbfounded as to how to react or what to do. She maintained a perplexed expression while taking steps to insert the cannula. My nursing colleague was amazed that I was able to get a consultant doctor to do such a basic clinical task. On another occasion, I innocently asked another doctor to explain the X-ray result of a patient of mine. This doctor went on to comprehensively teach me about these particular X-ray results for about 20 minutes in the most nurturing way. I was not made to feel stupid for asking and I later found out that this doctor was also a consultant, and the person who the X-ray belonged to wasn’t even his patient. This consultant soon became one of my favourite doctors. He was, in fact, a favourite of every nurse at that hospital because he was so personable and down to earth. Later, I realised that it does make more sense to ask a more junior doctor to place a cannula before asking the ‘big boss’. However, I also learned from all this that some people are more willing to leave their egos and hierarchical position behind to help someone less senior than themselves and build on the relationship. It is, after all, in the best interest of a doctor to be nice to nurses. Not only do nurses outnumber doctors, but nurses are often the first point of call when doctors need help. A doctor that I once worked with at the hospice also worked as a GP in a general practice. We’ll call him Dr. Care Bear. He heard me coughing one day at work and expressed concern about my cough. I discussed with this doctor about the diagnosis that had been given to me. (I had previously been told I was at the tail end of whooping cough and a throat swab had confirmed that I had, in fact, had whooping cough.) Dr. Care Bear wasn’t so sure that whooping cough was my only problem, and he offered to set up an extensive investigation and a clinical plan for me to find out for sure what was happening. He then told me that he didn’t want me to feel pressured into being ‘converted’ to one of his patients. After having lost sleep for 6 months due to this relentless cough, I figured that I had nothing to lose and was

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welcoming of any help I could receive to hopefully recover. After a few different tests, Dr. Care Bear decided to treat me as though I had asthma, as a trial. With the use of various asthma medications, I stopped coughing completely after 2 days, and I returned to this doctor with a card, chocolates and a bottle of wine. Needless to say, Dr. Care Bear did convert me; over 10 years later, he is still my GP. Dr. Care Bear has also helped me with my mental health during difficult times at work and in my own personal life. He will take calls from patients in between appointments without complaint; in fact, he encourages this. The medical clinic that he works at is a private practice, but patients are bulk billed when they are financially compromised. Dr. Care Bear goes above and beyond to help all of his patients. My GP is a gem, in every way. My faith and respect in doctors have been further strengthened by the many wonderful psychiatrists that I have worked with in mental health. These doctors have impeccable people skills; they are kind, hardworking, intelligent, precise, practical and strong. It is an honour for me to work alongside these doctors and I am grateful to be able to learn from them. Still, to sum it up: nurses’ rule, and doctors drool—I’m kidding. I’m a professional.

Nurses and Suicidality

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Nurses and Suicidality

The good nurse hopes for the best and prepares for the worst. Working in an area of acute mental health results in nurses becoming accustomed to people telling them that they have serious thoughts about ending their own life (suicidality). Nurses in this field also get used to working with a group of people who are taking deliberate steps to self-harm, as well as those who are actively trying to take their own lives.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_10

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For cases of suicidality, nurses follow an assessment protocol to gain guidance as to which kinds of intervention and support we should provide for a person, depending on their suicide risk. It’s a guide we need to follow; otherwise, nurses would end up hospitalising every person who had some sort of suicidal ideation, which is not appropriate—or even possible—with the resources we have. Many people experience suicidal thoughts at one time or another in their life. These thoughts can be just one’s brain trying to escape from an awful experience, and they don’t necessarily mean that someone actually intends to end their life. In my suicide prevention training, I got a little tired of hearing that all of us, as clinicians, would experience, firsthand, some sign that someone was going to take their own life. It’s a theory that can make clinicians feel entirely responsible for a person’s death, as it is very easy to say in hindsight that something was a sign. It also engenders the idea that nurses have more control than they actually have. In my opinion, any person who experiences depression has the potential to feel suicidal, even if it is just for a brief period. Nurses, and the general public, should be trying to help, or get help for, people who are depressed and/or feeling helpless. Although, we must also always remember that people have free will. To give you an example of this, let me tell you the story of two nurses I know: Louise and Achara. We worked together in a mental health crisis response team, and a few years ago, they faced a particular situation that demonstrates what I mean. Years later, they are still working in the same team and Louise and Achara continue to be energetic, positive, kind and highly skilled mental health nurses. They have bravely both allowed me to tell this story because they found it healing to reflect on their difficult situation. They also feel, like me, that it is important to talk about the complexities of suicide and assessing risk. This is their story. One day, Louise received a call from Belinda (a mental health client), who she triaged over the phone. Achara and another clinician, Silvia, then drove out to assess Belinda in the community.

10.1 Step 1: Mental Health Phone Triage (Louise Speaking) I tell this story when I provide mental health triage training for new staff on our team, especially when we discuss adverse outcomes that can occur when trying to triage and assess risk. What we know is that a person’s presentation, and how it is perceived by clinicians, can be very different to what is actually happening internally with the person. During the day on shift in our team, there are two mental health triage clinicians who take calls from all members of the community who are seeking mental health crisis assistance. The triage clinicians aim to conduct a succinct mental state examination and risk assessment and make an appropriate care plan based on that assessment. The triage clinician may refer the client to a GP, or other support agency, if they do not fit the acuity criteria for mental health crisis team intervention. At other times, the triage clinician may deem that the client at hand requires two clinicians to go out into the community to see the client and conduct a more comprehensive, follow-up assessment. This may result in medication

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being administered (in conjunction with a holistic care plan) and/or the client being taken to hospital voluntarily, or involuntarily, depending on the assessment. There are often multiple calls coming in through the triage line at once, so it can be a lot of pressure for the person taking the calls. Nurses have procedures for doing suicide risk assessments, but they also have to use their intuition (their gut feeling) with any assessment. The first contact with a mental health client on a mental health triage line is really important. The case here concerns a woman called Belinda in her mid-50s. Belinda was a relatively new client to our service and had had minimal contact with the crisis team. About a month prior, Belinda had been taken to the emergency department by her son after she reported to him that she had taken what she thought was a deliberate and lethal medication overdose. Our team was asked to touch base with Belinda, which we did. We found out that it was only two temazepam tablets that Belinda had consumed prior to her being taken to the emergency department. Temazepam is a medication from a class of drugs called benzodiazepines, which are sedating medications used for a variety of conditions such as insomnia, convulsions, alcohol withdrawal and anxiety. I knew that an overdose of this amount, in terms of medication toxicity and the harmful effects it would have on Belinda’s body, was not significant. But what is important for clinicians to note is the person’s intent when they take a particular action. Belinda had obviously been feeling low enough to deliberately take more than a prescribed dose of her medication. Thankfully, Belinda was able to see the psychiatric registrar at the hospital, who assessed her, developed a care plan with her and discharged her home. Belinda had reported that her depression had largely been triggered by workplace-related issues and that she had been having time off from her job for this. Based on this reasoning, Belinda was recommended to follow up with her GP, as well as access work-based counselling for extra support. Our team was also going to make phone calls to Belinda as an additional measure to try to help her. During the Christmas period, a lot of services—including health services such as GPs and counselling clinics—are shut down for the holidays. On New Year’s Day, Belinda called up our triage line. We had already been trying to get in touch with her for the last few days with no success, and when Belinda rang, she was pretty despondent. Because of the Christmas shutdown period, she had been unable to see her GP and had not been able to access a counsellor. She also had to return to work soon and was not feeling positive about this. With most clients, no matter how complex their issues, I am usually able to develop some sort of rapport with them. However, when Belinda rang, I really struggled to make a connection. She wasn’t giving me much meaningful information about how she was going, and she shut down any suggestions I made about things that might be able to help her. I sensed a real negativity from Belinda: a hopelessness about her outlook for the future. She spoke of her struggles in not being able to access support and her anxiety about returning to work. She specifically stated: ‘Things have not changed for me’.

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At this point, I felt quite confused. Most people will call the triage line because they are seeking help. Belinda was calling up and stating that she was struggling but didn’t seem to want the help that was being offered. I suggested to her that our team could drive out to visit her, but Belinda said that she would manage okay without a visit. I didn’t feel like I was going to be able to gain any traction helping her over the phone, and Belinda was also not fitting our triage criteria for an unannounced (emergency) home visit as she was not stating that she wanted to kill herself, or anyone else. Still, I had a gut feeling that Belinda was in trouble, even though she didn’t say directly that she was, and I therefore felt it would be best to send some clinicians out to see her. It was quiet that day at work, so we had capacity to see Belinda quickly and, when I told her that we would send some clinicians from our team to see her, Belinda actually pepped up. She began sounding much more positive and agreed to the home visit happily and then asked me to tell the clinicians to come around the back of the house. I was unsure why Belinda wanted us to go to the back of the house, but I got a bad gut feeling about it and told her that the clinicians would come to the front of the house (to ensure maximum safety for the clinicians) and that she would need to open the front door for them. That was how we left the conversation and Achara and another clinician spoke to Belinda about 15–20 minutes later to inform her that they would be at her house in about another 20 minutes.

10.2 Step 2: The Home Visit (Achara Speaking) I was working at the time with another nurse, Silvia, who was a senior clinician who had been working in the crisis team for a long time. I was a lot more junior at the time and it was Silvia who had spoken with Belinda prior to our home visit. It took us about 20 minutes to drive to Belinda’s house as she lived on the other side of town. We arrived at Belinda’s house and knocked on the door. There was no answer. It all seemed very weird, because we had just spoken to her and she had said she would be happy to see us. Concerned, Silvia initially tried calling Belinda’s son (her listed next of kin) to see if he could open the house for us. We couldn’t get through to him and so we decided to have a look around the house to try to find Belinda. Our team generally tries to avoid searching around the back of the house as we would prefer not to be invasive and we also want to minimise potential risks to ourselves. In this instance, we did a more comprehensive search given our concerns. Belinda was in her 50s, single, and she had issues with work that she felt might lead to unemployment. Furthermore, she had stated that she wasn’t getting along with her son—who she loved dearly. So, we proceeded with a thorough search and began walking around to the back of the house where we found a gate, which was closed. Without opening the gate, I peered into the backyard and could see a person sitting on the balcony of the house.

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I could see that the person was not sitting upright, and their torso was leaning backwards. Silvia didn’t have great eyesight and couldn’t see what I could. She began to undo the latch on the gate so that we could enter the backyard, but I had a much clearer view and I saw there was a rifle sitting in between the knees of the person sitting on the balcony. At first, I couldn’t comprehend exactly what I was seeing but I immediately panicked. ‘Please don’t open the gate’, I pleaded hastily to Silvia, ‘I see a rifle’. Silvia immediately moved away and called 000. Within 15 minutes, an ambulance arrived at the house along with the police. Because it was a suspected crime scene, we had been directed by police not to go into the house, and also not to leave the house until they had arrived. We therefore sat in our car out the front of the house, waiting for the police. It is hard to describe what I was feeling at the time, while sitting in the car, and I think I may have actually laughed. Obviously, I was shocked and confused as to what I may have seen, and I was truly overwhelmed by the implications. Logically, I was all out of sorts and by the time help arrived, I had convinced myself that the worst-case scenario was just me over-exaggerating the situation. I was too terrified to consider that my worst fears could be true. Later, it was determined that Belinda had ended her life by shooting herself in the head with the rifle. She had even videotaped the event so that police would know what had happened; I think she did this so that no one else would be blamed for her death. Because of that video, the mental health nurses did not need to be involved in the coroner’s investigation. Louise felt that Belinda had planned for the crisis team to visit her in the first instance, so that her family would not be the ones to find her body. It was a blessing that her son hadn’t answered his phone and opened the door. Finding Belinda in the way that I did was confronting for me— and I was a first responder in a professional role. I cannot imagine how distressing this scenario would have been for a family member to have found her in such circumstances.

10.3 Louise’s Reflections It took me a few weeks to start to process what had actually happened. These sorts of situations in our job tend to take me a fair amount of time to properly comprehend the whole situation and to try to understand how it has affected me. What happened to Belinda really changed the way that I thought about triage and I truly empathised with the nurses who went out to see Belinda. I can’t imagine how it must have been for them. What happened to Belinda made me a lot more mindful about the kind of jobs that the triage clinician sends their colleagues out to: the risks and what they might have to bear witness to. It opened my eyes. With our team, we get used to speaking with people who are in crisis but who often don’t make genuine attempts to end their lives. I like to think that a situation like this has made me a little bit more aware.

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10.4 Achara’s Reflections When you first interviewed me about this, I started to cry. Which felt like a strange reaction because this happened years ago, and I have moved on from the situation. However, I really appreciate being given the opportunity to be interviewed about Belinda. It’s a positive thing to be able to reflect on a past experience as significant as this one. With time, I have thought about what we could have done differently. In particular, I have wondered what nurses can do differently to prevent suicide. I have asked myself if we could have saved Belinda. At the time of her death, my brain froze up. I went into some sort of adrenaline response and my only focus was what could I do to help the situation? It wasn’t until much later that I had an opportunity to think about how Belinda’s death had actually affected me. Her death led me to feel very sad. I was saddened to think about how alone and helpless a person must be feeling at that time to take their own life. That feeling is beyond my comprehension. Further, I reflected about how we had had concerns for Belinda but had not anticipated her death by suicide. What happened to Belinda taught me to try to improve my practice. When people tell me that they are struggling, it reminds me to stay empathetic. I am reminded to take every call seriously, no matter how many calls are coming in. I don’t want any nurse to have to encounter the distressing scenario that I experienced with Belinda. Over time, I think that what happened that day, although it was dreadful, has made me a better nurse. It has further developed my growth as a professional as I have become a better listener, instead of just focusing on giving people advice. Before Belinda’s death, I had become quite desensitised and complacent, because of the high volume of similar clinical presentations. Now I think, if people are calling our service, it is because they are experiencing desperation and I assess them more holistically: taking into account people’s cultures, their histories, their weaknesses, their strengths and their resilience. I think that nurses can assess risk to some degree, but for a nurse to know who will actually take their life can be harder to predict. I wonder if we can actually predict it at all.

10.5 Rasa Again When I reflect on Louise and Achara’s experiences with trying to understand suicide, I have to also reflect on self-harm, which is a frequent clinical presentation that we see as mental health clinicians. Self-harm, like suicide, is an act of desperation brought on when feeling unable to cope with an emotional crisis. One morning, during my time working in the youth mental health sector, I was asked by the case manager of a young girl I knew, Jamie, to come and dress some self-inflicted harm wounds on her arm. Apparently, Jamie would not show them to anyone but me, as I was the nurse that she knew best from my administering of her monthly antipsychotic injection. Jamie was a girl who had a severe psychotic illness and, when she became sick, she would go downhill quickly. Before coming to us, Jamie had spent 2 years in a psychiatric ward in another city, after breaking

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many bones in her body from jumping off the balcony at her home (she nearly died). When Jamie was not unwell, anyone could see the incredibly sweet, bright and resilient young woman that she was. Jamie really was an inspiration to me, but I always worried that one day she might take her life on impulse as she was so high risk when she was unwell. At the centre where I was based, we didn’t have many dressings on hand. So, before I left to see Jamie, I had to go to a nearby medical clinic to see what they could give me. Since commencing in mental health, I hadn’t been doing any dressings, and when nurses are out of practice with particular clinical techniques, they need to think a lot more about what they are doing. Nurses even do a bit of research to refresh their memory—they don’t exactly forget their other sets of clinical skills, but it’s like revisiting another language you haven’t used for some time. One needs to dust off a part of the brain that has been inactive for a while—which makes you feel a bit rusty. I had also gotten pretty used to seeing many superficial self-harm wounds, but no major inflictions. So, I was a little out of practice in that department too. The nurses at the clinic asked me what kind of dressings I needed. I told them that I was not sure and explained that it had been reported over the phone that Jamie had self-harmed and that no one had witnessed it. In response, they offered me a range of lotions, potions and dressings. Technology advances quickly in the medical field. That, with not having done a dressing for a long time and not knowing the severity of Jamie’s wounds, led me to say ‘yes’ to every kind of supply that was offered. At the time, I felt that this was overkill, but better to be safe than sorry. So, equipped with my giant bag of medical supplies, I travelled out to the day program where Jamie was a client. Jamie was psychotic when I saw her, and I had to spend about 20 minutes trying to reassure her and coax her into even showing me her lacerations. Eventually, she consented and pulled up her long sleeves. It was the worst case of self-harm I had ever seen on a young person. I was so shocked that I wanted to cry. There were about ten incisions on both arms, ranging from 1 to 2 cm in width and 10 to 15 cm in length, and, as Jamie had not let anyone see the wounds for days, they were very infected and I was now grateful that I had brought my giant bag of dressings, saline, antiseptic and bandages—I was going to need all of it. After a lot more reassurance and convincing, Jamie also reluctantly agreed for a doctor to have a look at the wounds, but only on the condition that I wouldn’t tell her dad. Although I then informed Jamie that I would have to notify her dad about the self-harm, as part of my duty of care—fortunately—she eventually agreed. The doctor looked at Jamie’s wounds and said that she needed antibiotics to treat the infection. I then spent about an hour dressing the wounds, trying to maintain focus as I cut all the dressings to shape while also keeping everything aseptic (clean). The day program facility where Jamie was at the time was not set up for what I was doing, which made the procedure even more difficult. Applying the dressings took a great deal of time and precision and by the end my neck ached and my hands

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were shaking. The whole time that I was applying the dressings, I was also keeping Jamie informed about what I was doing to try to help her to relax. At the same time, I was also upset about how significant her self-harm was. My priority had to be to keep my care centred on making things easier for this young woman in distress. Jamie had previously told me that she wanted to be a nurse, so I had her be my ‘nursing assistant’, holding things for me when I needed her too. I also talked through the whole procedure, discussing every step and the reasoning behind it. Jamie responded really well to this, and I think it became a positive distraction for me too. When I had finished applying Jamie’s dressings, we had an impromptu psychiatrist appointment. We talked about the best ways to explain to her dad what had happened and how he would be able to support her. Although she was fearful of how her dad would react, Jamie thanked me for helping her and I gave her praise for her courage in letting me help her. Finally finished, I then drove back to my office, tired and hungry. My colleagues were eating lunch together and chatting cheerily, but I just felt stunned. One colleague, snacking on a muffin, asked me casually how my visit with Jamie had gone and I told her it was confronting. I didn’t want to upset anyone, so I gave them a watered-down version of my experience. However, facial expressions and a general demeanour give a lot away and so my colleagues responded with supportive sentiment. They understood that my experience with Jamie had thrown me more than I had anticipated. I gently admitted that yes, I had been affected. However, I knew that my colleagues would have also faced their own hardships that day and already I was starting to think about the huge number of clients that I had to follow­up with, and the piles of paperwork that would accompany this. So, I ate my sandwich by the computer as I wrote up my clinical notes for Jamie. There is quite often no time for nurses to dwell on clinical experiences that shock or upset us. We just push on. I appreciate that it is hard for those who have never felt suicidal or had thoughts of self-harm to appreciate that kind of extreme emotional pain. Self-harm and suicide are often seen as being ‘selfish’. However, selfish or not, if a person is willing to take their own life—or cause deliberate harm to themselves—I don’t think that anyone can deny that that person is truly suffering. A lot of people genuinely believe that the world, and everyone who cares about them, would be better off without them. What I say to these people is that ending their life would leave a hole that could never be filled for those around them. Then I pray that they can somehow believe it too.

Nurses and Epic Fails

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Nurses and Epic Fails

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_11

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The good nurse will screw up, will feel bad about it and then will grow from it. When learning skills in any complex area, or when under huge amounts of pressure, people are bound to make mistakes. I feel very nostalgic when I look back on what nursing meant to me when I was a new graduate: what an optimistic view of the world I had. I started off with such a Florence Nightingale image of the ‘best kind of nurse’: innovative, intelligent, caring and a pioneer. I know that I have ‘hardened up’ a fair bit since then, or at least I have become more realistic with what I am able to deliver as a nurse. Often, what a nurse is given in terms of time and resources versus the expectations of the kind of care they would like to deliver is unbalanced. Despite all of this, I hope that I have somehow retained some of those idealist approaches to nursing that I held early in my career, despite my hardening up. What I also reflect on (from my first year of nursing) is how—at the time—I managed to shine a positive light on the difficulties that I faced. I kept a journal in my new-graduate year, writing down all of my experiences: the good, the bad, the ugly and everything in between. At the time, I found it therapeutic to reflect on what aspects of my nursing day went to plan, what things didn’t and how I could do things differently. Still, when my new-graduate year was over, I threw my journal in the bin to celebrate that I was no longer at the bottom of the ladder. At the time, I had wanted to leave that year behind entirely. While it had been a year of fantastic experiences, it had also been incredibly tough. Now, years later and feeling much more confident in my nursing practice, I wish I could salvage that journal from out of the recycling bin. I’d love to be able to read about how I experienced everything back then. Now, I feel that I would be far better placed to understand some of the shame and fear that I felt during that year. Despite now wanting to recover my old journal, I know there was another reason why I did not hold on to it at the time. Reading challenging feelings from my past is something that makes me feel a little uncomfortable. If one rustled through the boxes of belongings in my shed, you wouldn’t find any love letters from past boyfriends—they have all been thrown away. That is just how I try to deal with things: let it go and move forward. I always try to gently acknowledge the past while staying focused on where I am now. This is often easier said than done, of course. In my first year out nursing, I failed a lot, and it hurt. Now, I’ve come to appreciate that nurses will continue to make mistakes all the way along their career path. Those who are self-aware, and can let go of their pride, can find ways to learn from those experiences to better themselves as nurses. Failures in all areas of life are inevitable, and a nurse can never fully master their profession or know ‘enough’— it’s just not possible. I’ve now embraced the fact that I will be learning every day for the rest of my life as a nurse, and that’s a good thing. I no longer feel silly about asking questions. Failure is also a totally subjective term, so it means different things to different people. I know that, as nurses, we have all had our different failures, but some try to hide those failures. Many nurses don’t want people to think that they are incompetent because of their mistakes, particularly if they are already viewed, or led to feel inferior, to doctors.

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I used to think that reflective practice was a useless textbook invention. The reality though is that nurses have to be reflective and philosophical to be able to learn from experiences. It’s scary to be reflective, as it means that one has to revisit stressful situations where they may have made some mistakes. Then comes the challenging stage of trying to step away from the situation and take an objective stance, regardless of how emotional the experience was. Maturity is required in reflection because it often involves admitting that your actions or judgement may have led to a mistake or a suboptimal outcome. Nurses need to learn to reflect on their experiences and realise how that can support personal growth for them as a clinician. Some failures can be funny, because the consequences are not so serious. A nursing friend once told me—laughing in hindsight—a story of when she first started work at a hospice. A patient commented that the medication she had given him ‘tasted a bit weird’. When she later checked the packet, she realised she had accidentally given him an enema medication as an oral drug. Totally embarrassed, she told the patient and they were very forgiving of the mix-up, which helped her get over her embarrassment. During my undergraduate nursing days, one of my clinical placements was on an orthopaedic ward in a particular hospital. This ward was a specialist unit that provides joint replacement surgery, trauma surgery and assistance for patients in treating and managing musculoskeletal injuries. On one occasion during this placement, I was caring for an injured motorcyclist. There was an attractive young woman at his bedside and I assumed, because she was about half his age, that she was a child of his. ‘Is this your lovely daughter?’ I asked. They both laughed and explained that they were a couple. Never again have I assumed how patients know each other. Another time, when I was working in an emergency department, I had a male patient who had come in because of rectal bleeding—the common medical term for which is ‘frank blood’. This patient was attractive and it was an early shift, so my brain was both a bit distracted and tired at the same time. All that was listed on the handover sheet was the patient’s name and the words ‘frank blood’. I told a nurse I was working with that I nearly called him ‘Frank’ about six times throughout the consultation. ‘Christ!’ the nurse exclaimed, and then she laughed and added, ‘Please don’t call him Frank’. I grabbed a pen and underlined the patient’s name three times with prominent black lines to be sure I wouldn’t call the patient ‘Frank’ by mistake. I still can’t remember what his name was but that patient will forever be referred to as ‘Frank’ in my mind (attractive Frank). Generally, by the end of night shift on a medical ward, my brain would always be turned to mush from exhaustion. Typically, we would each work four night shifts in a row (once set every month), where the shifts would be ten-and-a-half hours in length. For some reason, there would also always be fewer nurses rostered on for night shifts: usually a ratio of one nurse to eight patients. However, sometimes, each nurse would carry a patient load of as many as ten. I think that what some of the general public assume is that patients sleep through the night quietly in a hospital. Newsflash: they don’t. If you ever want to pick a time when you would expect patients to have chest pain or have their blood pressure

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drop, many nurses will tell you that this will happen at 4 am, right when the nurses are probably at their crappiest performance level, physically and emotionally. While I was working in this ward, we would have to start the medication and observation rounds at roughly 4  am, even though the medication administration time was 6 am. Starting the medication and observation round at 4 am meant that we would still be working quickly. At this pace, and if no patient became more unwell, we would be through all the nursing duties by about 6:30 am. After this, it would be a quick scramble to write up the patient notes for the handover to the morning nurses’ shift, which commenced at 7 am. A good example of how my brain turned mushy on one night shift too many was when I once sent off a sputum sample for a patient. This patient, as it turned out, had two pre-labelled, sterile specimen containers, one to collect a sputum sample and one to collect a urine sample. I checked the pathology request form against the sample before I sent it off. Later, when I read the handover to the morning staff, I stated my confusion as to why a second sputum sample request was needed, as I had already sent one off. One of the other nurses kindly touched my arm and said, ‘My dear, you sent off a sputum sample, but you sent it off in the specimen container that was labelled as urine so they couldn’t process it’. Whoops! In fairness, if you are tired, this is not hard to do, as both urine and sputum specimen bottle lids are yellow. In healthcare, clinical environments are generally very busy and under-resourced and are therefore pressured. That is why there is great potential for things to go wrong. Errors, where no individual received major injury as a result and when the nurse’s ego is not totally smashed (such as the sputum sample example above), are easy to shrug off. However, a nurse friend of mine once accidentally gave a patient in a hospice hydromorphone (a drug roughly six times more potent than morphine) instead of his actual prescribed pain relief. Naturally, she was worried that he might die from a decreased respiratory rate due to the overdose. Instead, he just felt very chilled, was completely pain-free, and reported that he had had the best night’s sleep of his whole life. This situation could have ended much worse. Realising when you have made a serious mistake is not a pleasant feeling. My biggest fail to date was while working in my first graduate nurse placement in critical care. While I take full accountability for my actions, I also believe many new graduate nurses are set up to fail placements. Older nurses are often nurturing but, at times, have been known to eat young nurses alive, metaphorically speaking. I loved my critical care placement in so many ways, and a lot of my colleagues supported me. But some did not. I had no confidence and that was obvious to everyone. I was so stressed and so focused on wanting to do a great job, that I couldn’t process much information. That’s the thing about excess stress; it doesn’t help one’s brain to function logically. When a person is overly stressed, all the oxygen moves away from their frontal lobe, which in turn hinders the ability to work through a situation calmly and with sound reasoning. At the time, it seemed like I was always running behind. I was struggling and it took me a long time to realise that asking questions when one does not know the answer is actually a good thing. But what I was taught by the reactions and attitudes of many of the staff in this particular placement was that it was better to pretend that

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you knew what you were doing so as to stay out of the limelight. The benefit of this is that one does not look like a fool. The downside is that more medical errors tend to be made. One day, I gave a diabetic patient too much insulin—a potentially lethal dose. I just couldn’t get the drug calculation right. I felt rushed and stressed and I was too scared to ask anyone. It is also mandatory to have injectable medications double-­ checked by another nurse. This is how overwhelmed I was; I couldn’t get past my own stress to do a basic safety procedure. It could have been lethal; this patient could have died. He didn’t, and I was lucky. I failed this placement and I couldn’t forgive myself for making such a huge mistake; what’s more, I didn’t believe that I deserved to be a nurse anymore and I genuinely considered quitting. Even as I write about this huge clinical error, I feel uncomfortable and afraid of judgement. But I am going to include it here because I think we need to own our mistakes so as to remind ourselves that we are only human. Following my error, and as a condition of my now ‘provisional’ contract, I had to have all of my medications double signed, including even paracetamol. Of course, my facilitators were wanting to make sure that I didn’t make any more mistakes, but can you imagine how shameful this new routine was for me? Every nurse I worked with asked why I needed to have paracetamol double signed. Humans, in my experience, never respond easily to shame and I was being made to feel both dangerous and useless—I was utterly humiliated. I found out later that I was one of many newly graduated nurses who failed placement in that critical care unit. One of those nurses was even the dux of our course, and she was then considering taking a different career path as a result of how destroyed she felt after failing. She told me that she wanted to focus on being a fitness model, which seemed to me a way to channel her perfectionistic tendencies into a way to succeed again. I’m glad that she stuck it out in nursing after all of that. However, I would also understand—firsthand from all the difficult feelings which arose from my failure in the same placement—if she had chosen not to. I will be forever grateful to Linda, who was assigned to support me as a clinical facilitator after my medication error. She met with me initially and told me that she was aware of what had happened. I burst into tears. I felt so ashamed and incompetent. She told me that I was not a bad nurse. She told me that I was a good nurse but that I needed some support and I needed to slow down and gain confidence. She also told me that she didn’t want me to float through my next placement, that she wanted me to rise beyond my mistake with flying colours. Later, reflecting on Linda’s talk, I took the initiative and bought a comprehensive drug textbook. I began studying it each night after work and on my lunch break, determined to get on top of my game and maximise my chance of success. I also began taking my time through the medication rounds, specifically avoiding distractions and especially not getting involved in casual conversation with people as I prepared basic medications, not a ‘Hello’ or a ‘How are you?’—not a peep. I am so grateful that I had someone like Linda believing in me. I’m happy to say that by my third and final new-graduate placement, I was assessed as exceeding all competencies. In addition, I agreed to disclose the story of my medication error,

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which contributed to qualitative research in a PhD study, written by my mentor Wendy. The thesis topic was an exploration of critical events that nurses experience in their early career that make them question their wanting to stay in the profession; the thesis also investigated people’s reasons for staying. Before I started explaining what had happened in my story regarding the medication error, I felt confident that I know longer held raw emotions about it. So I surprised myself when I began crying as I disclosed the details of the event in my interview. Even though I knew that my story would be de-identified, all my feelings of shame came back to me as I revisited that story. I feared that Wendy would judge me harshly and doubt my competence as a nurse. However, having my narrative documented in Wendy’s PhD was also quite cathartic. I was able to see how far I had come and recognise that I was not a failure as a person, despite making big errors. The important thing here is that I got to a point where I could own my mistake instead of hiding it and that in doing so, I found a way to better myself. I get really angry about how the media constantly highlights the errors made by nurses and doctors. Negligence is one thing, but human error is inevitable. As clinicians, we work in difficult jobs that are never straightforward. Good news stories seem to be rarely publicised for nurses; if a story is not controversial, or does not cause a lot of hype, it does not seem to be worth noting in the media. One evening, I stayed back all night with a client I had just met while she waited for a bed in the emergency department. She was agitated, but I could also see that, essentially, she was just very scared. As the waiting grew longer and longer, her distress and agitation built to a point where she began throwing things around the room and yelling. Finally, when the attention of most of the waiting room was on her, a wardsman was called to help me out, but I still stayed with her until 10 pm, when she could finally be seen by the doctors. I held her hand as she cried, and the doctors immediately gave her oxygen because she was so emotionally and physically distressed. Most nurses that I have worked with would do the same thing. Staying back, or skipping a lunch break—to go the extra mile for a patient—usually doesn’t reward nurses with extra pay or recognition. Nurses go that extra mile because they care, but hey, that’s a boring news headline, isn’t it? Epic fails, for a nurse, are inevitable. Nurses, and those around them, need to understand and recognise all the amazing things they do and learn from the screw ups.

Nurses and Contagious Diseases

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The good nurse would prefer to know you have gastro before they go to shake your hand. Working with sick people all the time pretty much guarantees that health professionals catch a lot of illnesses. The first few years working in a hospital usually result in nurses contracting every strain of cold and flu until they build up some sort of hard-core immunity. As an undergraduate nurse, I approached my GP and told him that I thought that there must be something seriously wrong with me as I was getting sick all the time. I also asked if I should be buying multivitamins to strengthen my immunity. He told me that while both working and studying it already meant that, like many others, I was probably burning the candle at both ends. That, in conjunction with treating patients who weren’t cleaning their hands and were then rubbing their grubby paws all over me, meant that I was just going to get sick a lot. This GP shared his own experience of no longer getting sick because he had been constantly sick for the first 20 years working as a doctor and subsequently now had an immune system made of steel. He added that people would be surprised if they saw how few medications that he, as a doctor, had in his house. He continued, remarking that all the person would find would be a bowl of apples in the kitchen and a packet of paracetamol in the cupboard. He empathised with me and then stated, ‘I’m afraid there are no magic medications to get better. You will just have to accept that you are going to keep on getting sick for a long time, until one day, you won’t’. A physiotherapist in the hospital where I worked once told me that she expected to get hit hard with one major hospital-acquired lurgy annually. This prediction certainly seems to have been echoed by my experience as a nurse. The minimal sleep, and the subsequent exhaustion brought on by shift work, in an environment where infectious patients touch you and sneeze everywhere increases your chance of catching a disease by about a million per cent. Hospitals are a place where people recover and then perhaps take home a little party bag (another bug). In my first year of nursing, the Infection Control Team for where I was working brought around a special infrared scanner, which was used to reveal how clean all the nurses’ hands were—the colour pink under the scanner indicated active germs. A scary truth was revealed when the scanner was run over our hands. Even as nurses—people who wash and sanitise their hands regularly—most of us saw our hands glowing pink in significant patches. The pink-hand realisation was a bit spooky. When I later started to think about all the surfaces that staff and patients touch with their grubby hands, the hospital started to feel more like a cesspool than an area of hygiene. On one occasion, a hospital I was working in had a terrible outbreak of norovirus—a highly contagious airborne gastroenteritis (gastro) virus. Airborne is the key word here. Whether or not your hands came up pink under the scanner doesn’t mean much if you can still breathe in infectious vomit particles. In unison please: ‘Gross, just gross’. Do you know the movie Contagion? In the film, lots of people get seriously ill one after another (and die) very quickly. Without all the death, but with all the vomiting and diarrhoea, the outbreak of norovirus in our hospital felt just like that movie.

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In the medical ward, a few of the patients came down with the disease, and within hours all of the other patients started to show gastro symptoms. One of the patients, bless him, was vomiting and had diarrhoea. He also had dementia. As a result, he was wandering around the hospital leaving diarrhoea- and vomit-soaked clothes everywhere. Naturally, a man who randomly leaves soiled clothes on the floor due to confusion is probably not going to clean his hands. It was a gastro war zone. ‘We’re not getting out of here okay, are we?’ I asked one doctor while all our patients were vomiting and running to the toilet. I was, in fact, seeking reassurance and hoping the doctor would allay my concerns. The doctor just looked at me, said nothing and took a deep breath, sucking his lips tightly inwards while gazing forward. I feel like this was the kind of expression that Captain Sullenberger would have made before telling his passengers to brace for impact and landing his plane in the Hudson River back in 2009. I got through the shift, which was my seventh shift in a row, but I was exhausted and anticipated that I would end up sick too, for sure. I slept like a log and woke up the next day feeling like a million bucks. However, about a minute later, out of the blue and with no prior nausea, I urgently needed to vomit. I ran to the dunny, just making it to the bowl and vomited with similar intensity to the girl in The Exorcist. This vomiting extravaganza was repeated on seven different occasions within the next 2 hours. I called up the hospital 2 days later, when I was due to work again, to tell them I was sick. The shift coordinator said ‘oh no’ and then asked me what kind of symptoms I was experiencing. I told her that I was firing out both ends and that I had to take sick leave. In reply, she told me I was the 75th staff member to report having the virus. And that was only the beginning. The virus spread from one hospital to another due to doctors and nurses working across both hospitals. Patients became so ill in two of the wards (one of them being the medical ward I worked on and another a maternity ward) that they had to move all the patients out to give the ward a ‘terminal clean’. When I returned to work, I asked the doctor from my last shift how he had pulled up. We had both been working the series of shifts that saw the majority of our patients vomit and poo in a Mexican wave style over a series of days. I wondered if he had been fortunate enough not to catch the virus. He said that the next day, following our last shift together, he had felt fine and then abruptly passed out during a surgery he was performing. He had then also began making regular trips to the toilet to empty his bowel contents too. Lesson for today, kids: If you work in a hospital, you will catch funky diseases. So, wash those hands, then wash them again and respect the fact that everything around you is dirty. Since this chapter was written, COVID-19 occurred, but I’ll leave that story, or book for that matter, for another day.

Nurses and Puzzling Presentations

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The good nurse will forever ask: ‘What in the heck?’ One of the most fun and equally frustrating parts of nursing is the investigative work. Nurses are constantly trying to figure out what is going on with a patient and how to help. However, it can be tricky for nurses to make sense of what I call ‘colourful handovers’ from other staff members. Handing over a client is the process of informing another clinician about a patient’s clinical presentation, either verbally or in written form. The handover should include any actions that have been taken regarding the care of the patient. A good handover will include a list of steps or actions that the next clinician must do regarding patient care (the care plan). Sometimes, the handover is crystal clear. While at other times, the handover provides minimal information which may as well be communicated as ‘Hey, here is this weird situation, now go make sense of it and sort it out’. To add another complexity to the problemsolving process, sometimes what nurses see in the flesh is often very different to what has been ‘handed over’ to them. When I asked my nurse mentor, Wendy, what the strangest cases were in which she had been handed over in her career, the following brief anecdotes are just a few that she offered: • The guy who had a pica (abnormal eating addiction) for metal and returned to theatre about 18 times for laparotomies. The objects he had swallowed included knives, steak knives, forks, razor blades, coat hangers and even the wire shelving from a fridge. • The patients who would come in pretending to have overdosed and then would fake being unconscious and then would have pretend epileptic fits. Some patients were very good at this, able to lie unflinching during the application of the painful stimuli tests. Often, it was only the element of surprise that would catch them out. • The woman, and her ‘partner’, who arrived in the ED late one night. The woman was complaining of vaginal tenderness and pain. The partner sat in while the doctor conducted an internal examination, which led to the discovery and subsequent extraction of a foil packet, which the doctor placed on the table. At that point, the partner grabbed the package and legged it from the ED. The woman calmly got dressed, called a cab and left also. You get the picture. Nurses become accustomed to clinical handovers and presentations that would make most people raise their eyebrows, as well as a lot of questions and intrigue. Here are a few stories that contain the latter.

13.1 The Handover and the Missing Glass Eye (Rasa) As a new-graduate nurse in a hospital, I arrived at the shift handover to have the previous nurse ask me to try to locate a glass eye that belonged to our patient: Rob. ‘I didn’t even know that glass eyes were still a thing’, I responded, before then adding, ‘I thought that glass eyes were just for villains in fairy tales. And how do

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you even lose a glass eye? Like… For what reason would you take it out and where would you leave it?’ ‘They actually cost a lot of money’, responded the other nurse, with genuine concern. The nurses all across the hospital were scurrying about and flicking through notes, trying to find out when and how this glass eye had gone missing. In the end, the case got taken to the director of the hospital because a complaint was lodged by the patient, blaming the hospital for losing his glass eye. After a thorough investigation, it was revealed that Rob did not bring his glass eye to the hospital; it had been left at home.

13.2 The Handover and Subsequent Home Visit to Victor (Henry) My nurse friend, Henry, from a mental health emergency response team, tells the story of a vague handover that was given to him for a community-based client called Victor. Henry, and another mental health clinician, Ellie, travelled out into the community to assess Victor and find out how they could help him. What follows is the story in Henry’s own words. We received a referral for this middle-aged Eastern European man named Victor, who was behaving oddly. We didn’t have much information to go off. Victor had been referred to us because he was self-detoxing from methamphetamine and was drinking methylated spirits as a coping mechanism with queried suicidal ideation. We arrived at the front of his house and found ourselves surrounded by beautiful green and lush plants; watered, healthy and well cared for. Victor greeted us at the door and invited us in—he was malodorous and had long, unkempt, dishevelled hair—a significant contrast to how well kempt his plants were. We introduced ourselves and our role. He appeared calm and expressed his gratitude for our coming. We asked if we could sit at Victor’s table to talk to him about what had been going on and how we might be able to help. Once we sat at the table, Victor’s behaviour changed from relaxed to distressed in an instant. He placed his head in his hands and started to cry. He also told us that he felt suicidal at times and was experiencing issues with his thoughts overwhelming him. He went on to tell us that his son, Gregor, had been a methamphetamine addict and that he had had to kick Gregor out of the house because he could not manage having him at home. While Gregor had been living with Victor, Gregor had had his own section of the house as Victor did not want methamphetamines being used in any part of the house he used. Victor’s belief was that the walls, carpets and the furniture in his part of the house had absorbed methamphetamines because the smoke had crept in under the door. He was also of the belief that he had absorbed some of the meth through smoke transference. In actual fact, Victor had a history of methamphetamine use himself, but at the time, he didn’t include this detail. Victor truly believed that his current presentation was a direct result of his body absorbing the methamphetamine used by his son.

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There could have been some validity in what Victor was saying. A person can absorb methamphetamine if another person smokes it close to them, and it is breathed in. But it is unlikely that second-hand inhalation of methamphetamine would make a person this paranoid and agitated—and Victor was. Victor went on to tell us that he was drinking methylated spirits (metho) as a way of managing his symptoms. We immediately thought that drinking methylated spirits was probably not the healthiest way to detox from methamphetamines. However, we tried to hold back with our judgements, so that we could hear the full story and offer the best help possible. We asked Victor to tell us a little bit more about his metho-drinking habits. From previous experience working in a rural setting, I had grown accustomed to people drinking metho, and I was of the understanding that the least harmful way to drink this (very poisonous) substance was to filter it down through bread. To better assess what kind of harm he was doing to his body, we asked Victor to show us how he would filter down the methylated spirits. Victor promptly invited us to go to his kitchen where he proceeded to pour straight methylated spirits into a cup and then cheerfully stated: ‘I just drink it like this’. He then added, ‘And then, if I don’t like the taste, I just mix it with water. Then, if I still don’t like the taste, I eat toothpaste’. He then picked up the cup and said, ‘I’m just gonna have some now’. Instantly, we jumped in—totally alarmed—saying, ‘No, no, no! Don’t do that! Please don’t drink that!’ After we had made sure that Victor wasn’t going to drink the methylated spirits, we looked around the house and saw that every room was closed off. We also saw that bed sheets had been stapled to the windows to cover them up and had been covered with two coats of aluminium foil. The environment Victor was living in suggested that there were some complex events and behaviours happening in his life. Our mission continued as we tried to find a place to interview him outside of the kitchen, away from the methylated spirits. We figured that we could only do this on one side of the house because he felt that Gregor’s old bedroom was contaminated with meth and therefore dangerous. So, we proceeded to the lounge room and it was only when we went to sit on the sofa that we realised that this was actually his bed; Victor had been sleeping on the couch to keep some distance from Gregor’s old bedroom. It was also unclear how often Victor was showering, but we guessed that it was infrequently, and now we were sitting on his bed, which felt as sticky and as dirty to sit on as it appeared. After we had created a safety plan with Victor, he told us that he wanted to show us ‘the drug den’. Internally we were thinking, ‘Fuck yeah, that will be super interesting!’ Externally, of course, we behaved professionally and calmly as we consented to a tour of the house, to better assess how he was living. It looked like a cliché drug den: with graffiti all over the walls and no natural light. However, we only got to see the room for about 5 seconds before Victor slammed the door shut. ‘We can’t keep this room open for too long’, he said at a fast rate, clearly panicked. We then continued our way through the house, and he showed us his garage where there were pictures of marijuana leaves framed on the walls and bongs all over the place. Victor then added with some urgency and dismay, ‘This is

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the drug den, keep going!’ He then pushed us through the garage to exit the area. Once out of the garage, we learned that Victor was a landscape architect and he showed us his work, which was actually really beautiful. Victor appeared to be both a talented gardener and architect. As he talked about his creative and professional pursuits, his affect changed from sad and paranoid to happy and calm. Following the tour of the drug den and Victor’s work and garden, we returned to the lounge room. This time I saw a large crystal, which I looked at with caution, not knowing if it was a big chunk of crystal meth or something else. Victor told us that it was a crystal for positive energy and tapped it on the floor to demonstrate its “positive effects”. He had a bit of a laugh at this, as did we. Underneath where the crystal had been sitting was a piece of paper with the words ‘Robin Williams’ (the deceased Hollywood actor) written on it. There were lots of circles darkly outlined around his name. With a gentle curiosity we asked, ‘So, why have you got Robin Williams’ name circled on that paper?’ Victor responded, saying, ‘Because he hung himself and I’ve been contemplating doing that’. Victor then pulled a bed sheet from the bed and added, ‘Do you want me to show you how?’ He then began to wrap the sheet around his neck. We jumped in again with ‘No, no! Please don’t do that’. Victor then stated calmly ‘I could never do it. The pain hurts too much anyway’. Naturally, we were left feeling uncomfortable and concerned. The conversation was then deliberately shifted to other things: discussing how we could support Victor’s management of his mental health, encouraging him to see his GP, etc. Some of the discussion included asking him about strategies that he was familiar with for winding down and relaxing. He replied that he had a lot of nice movies that he enjoyed watching. Victor then insisted that he go to his room to retrieve some of his favourite movies. A variety of intense horror movies were brought back, including Hostel and The Midnight Meat Train. Victor then told us that those movies relaxed him and that they were the only things that calmed him down. We began wondering if Victor had anti-social personality traits, and so, following the normal assessment strategy, we began to ask him more questions, which we hoped would provide a clearer picture regarding his suicide risk. The aim of our questioning was to find out if Victor had any future plans that would help him want to stay alive. He told us that he was hoping to sell his property and relocate further north where the climate was balmier. It did indeed appear as though Victor had been preparing his house somewhat for the move, as we had seen packed boxes around the house. We asked Victor how long he had been preparing his house for the move. He replied nonchalantly, stating that he had been preparing for 15 years. We shot each other a quick look, one of those expressions that simultaneously and silently says ‘eek!’ and ‘for reals?’ Exchanging these kinds of shared expressions is about the only thing which clinicians are able to do to appreciate a quirky situation in the midst of a serious assessment. The interview with Victor was bizarre, but we had gathered as much meaningful information from him as we thought possible at that time. Our assessment concluded that Victor had some paranoia and agitation, likely provoked by drug use. However, he did not appear to be acutely psychotic nor was he at any immediate risk

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of suicide. We also now had a plan for Victor to see his GP for ongoing support and management, as he had a good rapport with him. Victor also knew that he could call our team as needed, and, in addition, he was looking a lot calmer and happier than at the start of the interview, which was reassuring. We were about to leave when Victor abruptly excused himself. ‘I need to go pee’, he said. But then he went out the front door. We waited, not really knowing what was going on, and Victor returned shortly after. He apologised for peeing outside, but then added that he did this because it was good for the plants. We could see the reasoning for this, as urine is good for some plants. He added that he usually put out empty milk cartons to collect rain and would mix his urine with the rain water to dilute it for the garden. However, when it had not been raining, he just peed straight onto the plants. I was thinking to myself, that it was all logical—but slightly odd—social behaviour. But what he had said definitely made me not want to touch him, or to touch anything in his house. As we were leaving, Victor walked through with us and wanted to express his thanks. He asked if he could hug me and at the same time, he was virtually lunging at me in preparation for a big bear hug. I pulled back and almost ducked as though I was dodging someone swinging a punch at me. In an awkward fashion, I apologised—explaining that in our professional roles, we were unable to hug patients. It was the first thing I could think of to avoid having to touch this man while still protecting his feelings. Ellie, being the kind-hearted Good Samaritan that she was, offered Victor a handshake, which he accepted. Meanwhile, I just stood there cringing. On the drive back to our base, Ellie explained that she felt really sorry for Victor. Meanwhile, I was throwing hand sanitiser at her and reminding her that he just touched her with his dirty pee hands. Ellie wailed: the reality had sunk in.

13.3 The Handover and the Black Bananas (Rasa Speaking) Henry had found it difficult to make sense of Victor’s presentation when he had assessed him face to face, so one can only imagine how difficult it would have been for the original clinician to make sense of the situation over the phone and provide a meaningful handover. To me, a meaningful nursing handover provides relevant information about what is happening clinically with a person. A good handover will acknowledge gaps in information and will discuss efforts that have been made to close those gaps. In addition, a solid handover should state what has been done so far and what needs to be done. Hurdles arise when handovers are minimal, where the receiving clinician is not even sure what is being asked of them. Clinicians learn to appreciate that they will always be trying to seek more information to help put together the complicated pieces of the clinical jigsaw that is a person’s life. The next story led to some of my friends arguing that the title of this book should have been ‘Black Bananas’. When working in a community mental health team, it was my job to triage all incoming phone calls. Background information was always helpful, if I was lucky enough to get any.

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Clinicians depend on each other to write clear notes so that they can follow on with a plan smoothly. One day, a message was left for me to call back to a hotel manager, Andrew, where a client, Olivia, and her partner Luke owned an apartment. The hotel manager had concerns about odd behaviour occurring in the apartment. As I read through past clinical notes on Olivia’s file, I saw that prior to this call, her most recent behaviour had involved witches’ hats being thrown off a balcony that had been partitioned off with tape until repairs could be made to it. At the time, no definitive claim could be made that Olivia and Luke were involved, as nothing had been filmed on camera. However, multiple residents had reported that they had seen Luke and Olivia throwing the witches’ hats. This time, the high-wattage cords for a treadmill in the gym had been deliberately moved and placed under the machine itself, which was an electrocution risk. Again, no definitive claim could be put against Olivia and Luke, but other residents had reported they had seen them walking out of the gym just before management noted the issue. Marijuana smoke had also been observed wafting out of Olivia and Luke’s apartment, which they both denied. I advised Andrew that if he had any further concerns like the last one, that he should call the police. While on the call, I looked back at the last assessment on Olivia from a clinician in our community mental health team, which read something like the following.

13.4 Visit to Olivia and Luke I was let into Olivia and Luke’s apartment through the back door by Luke. Olivia was on her bed covered with a blanket. However, I could see no clothing. Olivia spoke with me; however, she didn’t open her eyes. She just lay on her bed and didn’t move her arms or legs. I could see old fruit in a pot plant—very black bananas. There was a large bowl of white powder on her table. Art powder? There were cigarette butts in a cup of water on her table. Olivia reported feeling ‘unsafe’ in the hotel. She declined the pathway hospital—didn’t feel this would help. Would prefer to remain at home, despite feeling unsafe. No thoughts to harm herself or others—unable to expand on what she felt unsafe about.

I discussed the list of issues raised by management and requested she cease moving the safety bollards and stop using other’s property for art. I was able to impress on her that the importance of the concerns raised were for her safety, plus the safety and comfort of other residents (bearing in mind that they live in a shared space and must obey the apartment’s rules and regulations). FIN Okay, ‘FIN’ wasn’t actually written, but this is where the notes ended. There were many question marks resulting from this assessment. What on earth was the clinical impression here? What we needed was for the information to be

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synthesised into some sort of impression or conclusion. I informed Andrew that I would touch base with him the following week to check how things were going. When I called the hotel the next week, I spoke to a different hotel manager: Cindy. She informed me that the strange behaviour of Luke and Olivia had stopped and that everything had settled. I asked Cindy to get Andrew to call me if he had anything else he wanted to talk about, but there were no calls from the hotel for the remainder of the morning. ‘Brilliant!’ I thought. ‘Now I can cross this ridiculous job off my list’. However, Andrew called me back later that afternoon. ‘Things have gotten worse’, he said. ‘Yesterday, Olivia was found wearing only a turban and said that she was “looking for ghosts”’. And so, with each shift, the puzzling presentations and colourful handovers in nursing continue. Nurses have to be continuously expecting the unexpected, despite the system of handing over.

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The good nurse tries to have a life outside of work, sneaking in joys and comforts during the odd hours of the day they have off. Due to the nature of the work, burnout is prevalent for nurses. I want to talk briefly about exhaustion. Anyone who has done nursing shift work on a 24-hour rotating roster will appreciate how tired they can feel most of the time. Nurses who work irregular shifts often don’t even know what day or time it is. Early on in my career, I consulted with my ED nursing friend, Harry (who the reader met in Chap. 7), before I started work as a new-graduate nurse. Harry was a few years ahead of me in his career and I asked him if shift work became easier to manage with time and experience. Harry responded pragmatically, saying, ‘You never stop feeling tired, you just get used to feeling tired’. Finishing a shift at 10 pm and then starting work again at 7 am really takes its toll on a person. On morning shifts such as these, it is often the case that another nurse can tell you on three separate occasions what they need you to do, and yet you’ll keep asking: ‘What?’; the brain and body need sleep to function properly. When getting ready for work on many a morning shift, I often found myself doing something strange, like pouring orange juice over my cereal. Stranger still, I would only register what was happening after the bowl was half full. I have even vomited after having breakfast before a morning shift because my stomach was too churned up from exhaustion. Another time, I found myself crying on the way to work for no particular reason; I was just so tired. I am not a coffee drinker. I don’t like the taste of it, nor the amphetamine-like effect it seems to have on me. But on a night shift, a nurse will go to any lengths to summon up extra energy. I have trialled energy drinks and drunk triple shots of coffee at midnight. Sadly, all that the caffeine ended up doing was induce a feeling of hyper alertness for about an hour. This feeling was accompanied by heart palpitations and shaky hands. Then the caffeine rush would begin to falter and I would just feel exhausted and hungover. This kind of exhaustion, coupled with having to keep working on through the night, results in strange behaviour and conversation among nurses. Wendy, my nurse mentor, told me how at 4 am during a night shift she once felt the need to roll around on the floor and pretend to be a cockroach, and she still cannot recall why she did this. I know there was no logical reason for her to act like this; however—as a nurse—I can appreciate how, while being sleep deprived, she had felt compelled to perform this cockroach re-enactment. Although I have not—to date—rolled around on the floor like a cockroach (or any other insect) while on shift in the early hours of the morning, I’ve certainly had my share of weird conversations and experiences during those hours. On one occasion, I was working the night shift on the critical care unit and in the wee hours of the morning, I was approached by another nurse who wanted to do an ‘experiment’ with me. He described an imaginary sphere and then asked me what the sphere looked like in my mind. From my description of the sphere, the nurse then told me the significance this had, metaphorically, in my life. I feel now that this nurse was probably a bit eccentric in his character and working the night shift brought out more of the off-centred side of his personality at full throttle. Honestly,

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for me, this conversation would have been odd at any time of the day, but in the middle of a night shift, it was even stranger. If odd conversations can get nurses through the night shift, then that’s a bonus. But it’s really tough when one nurse is struggling to keep awake and another nurse falls asleep at the desk. I remember this happening on a night shift in the ED. A nurse had fallen asleep sitting upright at the nurses’ station, with her head propped up on her hands. At the time, I was so tired that I did not believe that anyone could feel as shitty as I did. Consequently, I was almost angry with her that I was somehow stopping myself from falling asleep and she just couldn’t. It took me forever to wake her and I ended up shaking her quite violently. I pleaded with her to wake up—saying that it was time for us to do rounds. She eventually woke, groaning as though she had just been chemically restrained. Remembering the incident now makes me giggle, but at the time, I felt as though I was in a bad dream. It was as though I was being tortured with sleep deprivation in an army resilience-training camp and was then being told to complete unrealistic and painstaking exercises, like pushing a truck up a steep hill through muddy and uneven terrain during a storm. This sounds melodramatic, but one doesn’t know how important sleep is to proper functioning until they are forced to stay awake and work in already stressful environments. The compounding issue is that patients always seem to get chest pain or start to go downhill in the ungodly hours of the early morning. Meanwhile, the nurses—who are tired beyond belief—have to find a way to stay awake to work from 9 pm–7:30 am to care for those patients. Eventually, I realised how affected I was becoming from working the night shift when I found myself bargaining illogically with the heavens. I would silently pray that I could trade places with any of the patients, no matter how sick they were, just so I could sleep. Exhaustion takes a physical and emotional toll on nurses, but I don’t think it is the only contributor to burnout. I used to think that post-traumatic stress disorder (PTSD) and burnout were terms defining the most acute state of emotions in response to devastating experiences. I thought that PTSD was something that people experienced because of something war-like that pushed them over the edge. And burnout, I thought, was a once-only event that only some unlucky nurses have to endure. However, with experience, I have come to understand that PTSD and burnout look quite different in nursing. Burnout and PTSD are terms that I believe can often go hand in hand. A person who has experienced PTSD, and who has not taken care of themselves or been taken care of, is much more at risk of burnout. PTSD, in itself, is complex. One person may witness something horrendous and walk away unscathed. Another person will have the same horrendous experience and have it leave them debilitated and needing time off work along with needing professional help to recover. We all process things differently. Trying to define or separate the meaning of objective and subjective trauma is difficult, as each individual will have their own unique emotional reaction to a particular experience. For example, much research has explored how birth trauma lies in the eye of the beholder. Mothers, who were the subjects of this research, perceived that their traumatic births were often viewed as routine by clinicians.

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With regard to burnout in nursing: as nurses, we spend so much time pretending we are okay so as to be strong for our patients that, as a result, our own wellbeing often gets pushed to the back of a dark and dusty cupboard that no one uses anymore. No nurse wants to feel weak by admitting they are not okay. Nurses are not allowed to be weak; it screws up the perfect image of a resilient and professional leader in healthcare. The requirements of the workday also often don’t give nurses the time to stop, reflect, self-soothe and recover. Also, nurses are not routinely offered a great amount of support and instead we are encouraged to look after ourselves. However, the reality is that nurses tend to put the needs of everyone else before themselves. Vicarious trauma is not well advertised as a legitimate thing, even though emotional trauma often accumulates over time, not from just one particular event. I have found this to be the case for me as well as many other nurses. The stress from both day-to-day scenarios and bearing witness to constant trauma does build up and fester if it has no way to be released. Self-care is particularly crucial when working in mental health; having people tell you all day that they want to end their lives takes a toll. In my case, my fitness continues to prosper through my years of working as a nurse, as this is my coping strategy for managing stress. Running up a mountain is a saving grace, a way to relieve my mind and body after constantly having to listen to emotionally traumatic stories. When I started work as the clinical nurse consultant in a youth recovery residential program, I would, whenever possible, try to make it to my daily 6 pm kickboxing class. This was a regular commitment for me to look after myself, so you can imagine the predicament that I would get caught in when, for example, a teenager walked into my office at 5:50 pm with the words ‘end me’ self-carved into their arm. The thing is nurses who leave on time to make such efforts for self-care are often left feeling—or are made to feel—conflicted and guilty for doing so. I also cannot stress the importance of nurses having supportive colleagues and management to debrief with. Frankly, as a nurse, you are screwed if you don’t have people that you work with who are there for you. No one else can ever understand exactly what you are going through, but the person with the best shot is someone who works in the same field and has experienced similar things. Moreover, a colleague who will listen attentively to your woes is invaluable. At the very least, having another nurse or clinician to be able to joke with to lighten the mood in a particularly dark time can also provide some ease. But having a colleague who knows and respects the sometimes-awful situations that nurses have to deal with can also help provide some light and hope through a stressful period of time. These are the kinds of situations where the nurse is praying for help, some empathy and a solution to a problem, when the latter seems impossible to find. People say that nurses have a brutal sense of humour, and they do. I used to be appalled when I heard what nurses would say to each other when I was an undergraduate nurse. What I later realised is that this humour is a way to cope with really difficult situations. I came to this realisation myself one day when I worked at the

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hospice and was in conversation with another nurse as we were preparing pain relief in the medication room. The other nurse asked how I was going and I replied, frankly, that I was so busy that I hadn’t had the time to eat, drink or use the toilet that shift. I would have been in tears because I felt so helpless, but I also knew that crying would just slow me down and I had patients waiting on me—all with high needs— and, no matter how quickly I worked, there would still be people waiting for my help. At the time, I felt as though I was letting my patients down, simply because I didn’t have enough time or anyone to help me. So, in response to the other nurse’s question, I added something highly inappropriate: ‘If my patients are all dead in the morning, it’s not because I smothered them all with a pillow’. The other nurse just laughed; she knew I was joking (she understood that I didn’t actually want to kill my patients). Before this, I wouldn’t have believed that I was capable of making such a spooky joke in a place like a hospice, where I cared so much about all of my terminally ill patients. However, humour— no matter how off it may be—is a way to make light of a situation that would otherwise seem very depressing. Throughout the different roles of my nursing career, I have sometimes had to justify my case—to management, and to others—as to why I prefer to work just 4 days a week. I don’t have kids and I don’t study anymore, so my reason for cutting back my hours often seems a big mystery to other people. The truth is a lot of nurses work part-time to save a part of their own soul. Nursing is consuming and you don’t want to get to a point where you cannot listen to the problems of your friends and family because you have been dealing with so many other people’s problems during the day. People also ask what I do on my day off and I tell them that it depends on the day. I might do errands, like go to the post office, or do cleaning and go shopping. I am also into do-it-yourself projects around the house (e.g. painting, re-grouting tiles and gardening). And, even though by the second coat of paint you might be regretting that you undertook the project, painted walls always smile back at you in glossy white. Freshly painted walls also don’t tell you their problems. They are not in crisis and they do not criticise you. The task also has a clear start and a finish and, most of the time, an improvement has taken place. I am also into physical fitness and when I run up a mountain or around a lake, the sun warms my body, as do the endorphins. The trees are also lush and green, and the leaves sing in the wind. At times like this, I am reminded that there is peace in the world. When I am not working, I can also play my favourite music for as long and as loud as I want, and I sleep in the afternoon uninterrupted. It’s these kinds of activities that allow me to decompress enough to face the new nursing week. In regard to self-care efforts, I also don’t watch the news, because I cannot bear to hear any more problems that I cannot fix at the end of the day; I face enough of those already. This might make me sound like I am ignorant of current affairs, but I know a lot of people in the healthcare field who are the same, including my cousin, Aiste, who is a speech pathologist. I’m not ignorant. I understand that there are devastating problems in the world. The issue is not that I don’t care. The issue is that I care too much.

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For longer breaks, I travel. I do this because I love to see the world and experience how different people live in other countries. For these reasons, I go on regular overseas holidays to keep my sanity and prevent burnout. With every bitch of a nurse you have encountered, aside from some of them who have poor people skills, I will bet that a lot of them are burnt out. This burnout will usually be due to a mixture of their management and colleagues not supporting them when they needed it, and their lacking the insight to know when they needed a break—or when they needed to leave. Burnout and PTSD are experienced by nurses, so I feel it’s important that we talk about it here. My New Zealand nurse friend, Belle, spoke beautifully in our email correspondences about her journey working through what she later identified as PTSD.  This journey began with Belle being called upon to try to help a patient called Taylor.

14.1 Emergency Call to Help Taylor (Belle Speaking) There was a young patient called Taylor, a woman in her mid-20s (the same age bracket as myself at the time), who had been in the intensive care unit (ICU) for poorly managed diabetes. As a result of this, she ended up having an operation to have a limb amputated. After the limb amputation, Taylor developed a methicillin-­ resistant Staphylococcus aureus (MRSA, a strain of bacteria) infection in the wound. When Taylor started to recover, she was stepped down (in care) to the medical ward to prepare for being discharged into the community once her infection had cleared. I was working a night shift on ICU at the time, on call as the part of the resuscitation team for any emergencies across the hospital that night. All of my resuscitations to date had been pretty straight forward, and generally well managed. So, when my emergency pager went off, I proceeded with my colleague down to the ward where the alarm had sounded. There I found Taylor, the girl I had been looking after for the past few days in ICU, in a very bad state. She had been given diazepam (a benzodiazepine class of drug with a sedating effect) in an attempt to help her sleep, which would have worked if her body had not already been under extreme stress from her multiple comorbidities as well as fighting the MRSA infection and processing a polypharmacy of other drugs. Unfortunately, as a result of all these factors, Taylor had been overdosed with the medication and had gone into cardiac arrest. She was now flat on her back and vomit was pouring out of her mouth and flowing all over her face and into her open, vacant, eyes. The duty manager (the head nurse), who was meant to be leading the resuscitation, froze up. Someone else had to take the lead, and that person was me, along with the resuscitation team. I jumped straight in, without gloves (a huge infection risk for both patients and nurses) because I just had to help her, and she was going downhill quickly. We weren’t able to get a breathing tube down her airway for quite some time and Taylor was aspirating a lot (breathing a lot of the vomit into her lungs). We then began performing numerous rounds of cardiopulmonary resuscitation (CPR) and applying defibrillation shocks.

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On a previous placement, I had worked with a needleless system for administering intravenous medications, but this hospital had not yet updated its practices. The anaesthetist on the team was asking me for medications that I didn’t have the needles ready for, which once more slowed everything down. We were poorly organised and the ward nurses were all panicked. We asked them to get a nasogastric tube to help create an airway for Taylor but they couldn’t find one. Basically, anything that could have gone wrong went wrong. Then, in the middle of it all, my shift supervisor came in and told me that I needed to go on my break (while I was performing chest compressions for Taylor). I looked at her, confused and flustered, and with short words—while I was still doing chest compressions—I tried to clarify that she was actually trying to get me to go on my lunch break in the middle of CPR. The shift supervisor confirmed that I had to go on my break. I had wanted to stay but I was made to leave and so I went back up to the ICU staff room. From there, I was able to see two floors down into the ward where Taylor was. I couldn’t see her, but I could see the steel IV pole at the end of the bed moving rhythmically with every chest compression. I couldn’t stomach any food, as I was consumed with adrenaline and panic. Instead, I watched on, unable to look away. I could see all the clinicians pausing to assess the cardiac rhythm and I was just waiting for it all to stop. I was waiting for the clinicians to stop the cycles of CPR and pronounce Taylor dead, which they eventually did and it was horrible. I had a lot of unresolved issues after that, always wondering what could have been done better in Taylor’s resuscitation. The staff involved with Taylor’s care that day were asked directly after the event if they were okay and everyone said ‘yes’, probably because they felt too afraid or ashamed to admit how they actually felt or because they had not had time to process what had happened. However, we were never given an invitation or safe opportunity to debrief about Taylor’s death, and I felt like I had abandoned Taylor because I had had to leave in the middle of her resuscitation. The situation was confusing for me. I wondered if I should have been bolder at the time and demanded that I stay with her. I know now that, either way, the outcome would not have been good for Taylor; she would have died regardless. It was just a horrible situation. Finally, weeks later, I approached my team leader and told her how I was feeling and that I was having nightmares about Taylor’s resuscitation. My team leader didn’t do much to comfort me or help me and I was referred to employee assistance (counselling for employees) through the human resources department. What I had really wanted at the time was some genuine reassurance and empathy from management. What I also wanted was to attend a refresher course in advanced life support, to see if I could learn how to manage things better in the future in a complicated resuscitation like Taylor’s. At the time, I thought that I must not have been very resilient for feeling the way that I did and for being so significantly affected. This was until I talked to other colleagues involved in Taylor’s resuscitation, who were all experiencing similar PTSD symptoms. We had all been having nightmares and had similar feelings of depression and guilt. Everyone assumed that the others involved were coping, when in fact, everyone was struggling.

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14.2 Back to Rasa Belle’s story is a true demonstration of the kind of situations that nurses may have to face in their work and the toll it can take. Realistically, I think that we as nurses accumulate PTSD, and at numerous times in our career, or even during the working year, could be classified as ‘burnt out’. It is therefore crucial for nurses to be aware of the signs of burnout and PTSD, to know when things are building up and how to take a break to alleviate the pressure. The people around nurses also need to be mindful in supporting us. As a society, we are now starting to ask others if they are okay, but we are not quite there yet. The trick is to not just ask if someone is okay at the time of a potentially traumatic event; we need to follow up with people once they have had time to process what actually happened.

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Nurses and Associated Talk

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The good nurse probably swears while debriefing with other nurses in the tearoom. Nurses have their own way to describe situations, people and concepts. Here are some of my favourite nursing quotes that I have heard during my career. 1. Nurse: ‘Frequent flyer’. Context: A term used when a patient frequently re-presents to hospital. 2. Nurse: ‘Courtesy flush’. Context: Words used by a nurse to their patient to lighten the mood when a patient is too immobile to use and flush the toilet independently and the nurse steps in to help. 3. Nurse: ‘You guys give out painkillers as if they were lollies’. Context: An English nurse giving her perspective about how pain relief is given to patients in Australia in comparison to the UK. 4. Nurse: ‘Eventually, everyone says something that throws themselves under the bus’. Context: A mental health colleague of mine talking about one particular client, who clearly needed involuntary treatment and who was facing the Mental Health Tribunal. Everyone can appear to be insightful and well for a while, but most people will eventually say something that will reveal themselves to be psychotic or particularly unwell. This client appeared quite logical until the tribunal asked him why he yelled at his Mum so much at home. ‘She wants me to yell at her’, he responded. ‘How did you form that conclusion?’ the tribunal asked. To which the client responded, ‘Because the voices told me that she wants me to yell at her’. 5. Nurse: ‘I used to accept hot drinks from the clients I visited in the community, but after getting wobbly walking back to the car from the strength of the last coffee, I decided to no longer say yes’. Context: A client places a bit of whiskey in the community nurse’s coffee as a special treat to say ‘thank you’. 6. Nurse: ‘You need to keep being their cheerleader’. Context: Advice for the role that the nurse has to play to help a patient—especially for people who feel helpless. 7. Nurse: ‘An overdose of 30 paracetamol is not that significant for a lot of people; people take much larger amounts and still walk around unharmed’. Context: Words from a mental health nurse who has seen everything and is no longer shocked by much at all. 8. Nurse: ‘When someone tells you how much alcohol they drink in an admission assessment in the emergency department, double it to obtain the more likely truth’. Context: A senior nurse’s advice to me about the reality of patients generally understating their alcohol use upon entry to hospital. 9. Nurse: ‘The hand on the doorknob comment’. Context: Anything that a patient says in desperation to stop you from leaving when they know you have to wrap up a counselling session.

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10. Nurse: ‘Maybe we should talk about this again, once you’ve had a good sleep’. Context: Generally good advice for all humans, all of the time. 11. Nurse: ‘We have a situation here’. Context: When I was in the Canary Islands doing a language exchange with one of the Spanish locals. he asked me a question: ‘In English, people say both “We have a situation” and “We have a problem”, what is the difference?’ This is the explanation that I gave him. The word ‘situation’ inspires people to feel that something can be mended, whereas the words ‘disaster’ or ‘crisis’ makes the circumstance seem harder to fix. The situation might in fact be a disaster or a crisis; however, a different language is used to make a chaotic situation seem easier to manage. There is no point in nurses using language that will alarm their colleagues further. 12. Patient: ‘Will this needle hurt?’ Nurse: ‘The needle will need to break your skin and enter your muscle, so I cannot say that it will not hurt, but let’s get this done as quickly as possible’. Context: What most patients ask the nurse when they fear receiving a needle, and the response is what I usually give. I’ve heard nurses say, ‘This will be like a little scratch’, which I feel is slightly inaccurate. 13. Nurse: ‘At the end of the day, no one died from not having a shower’. Context: Comments from a nurse manager on a busy medical ward where we just didn’t have enough time to shower people daily. 14. Nurse: ‘Many people do have heart attacks on the toilet; it’s actually very common’. Context: Learning fun new facts on a surgical ward from a senior nurse. 15. Patient: (slowly and suspiciously eating custard): ‘Did you crush up my medication and sneak it into my food?’ Nurse: “Umm… Yes”. Context: Getting caught out by a patient who was otherwise refusing important medications. 16. Nurse: ‘She won’t drink water but will always say yes to tea’. Context: Pretty much every elderly person who has entered hospital. 17. Nurse: ‘That ship is not ready to depart yet’. Context: A nurse empathising with a palliated patient when he asked if he can die now, as he felt he was ready, but was not actively dying. 18. Nurse: ‘You are going into the deep end, but you will be okay’. Context: What the 16-year-old girl (me) was told by the nurse manager of a nursing home before commencing work as a personal carer in a high-needs, dementia wing.

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19. Nurse: ‘When things are at their busiest in a shift, you need to take time to make a cup of tea. This will give you a chance to reorganise your priorities for when you have finished your tea. You also need to make sure that you have allowed enough time for the tea to cool and drink it entirely before you go back out on the ward’. Context: Wise advice from a senior nurse about the importance of taking 5 minutes out of the workday for a breather when I was struggling on an extremely busy and stressful shift on a surgical ward. 20. Nurse: ‘Someone needs to ask the doctor to review the laxative dose for that patient’. Context: What every nurse says when the amount of poo is just too much to manage. 21. Nurse: ‘Why is everyone’s blood sugar level here so damn high?’ Context: Me, before realising that the lovely Greek wife of the patient in Room 14 had divvied up a full box of delicious donuts to a room full of diabetic patients. 22. Patient: ‘I sat on it’. Context: Every patient’s lie when a toy car can be seen on the X-ray of their rectum. Patient: ‘After vomiting blood for 3 days, I thought it might be time to get medical help’. 23. Nurse: ‘You didn’t think to try to seek help when you vomited blood the first time?’ Context: People often put off getting medical help for as long as they can, or just don’t understand how serious their symptoms might be. 24. Patient: ‘If I was your age, I’d follow you all over the world’. Nurse: ‘I bet you say this to all the ladies!’ Context: When a sweet elderly man that you are caring for gently flirts with you with his oldfashioned charm. 25. Patient: ‘I think this is my diagnosis, because I read a forum on the Internet’. Nurse: ‘Not everything published on the Internet is reputable’. Patient: ‘But a guy on the forum said that he had the same symptoms, and he found out that he had cancer’. Context: That bloody Internet has made a lot of the public think that cold symptoms automatically equate to cancer and that the role of a health professional is now obsolete. 26. Patient: ‘Can you please trim my nose hairs?’ Nurse: ‘No’. Context: When a patient has been in hospital for too long and starts to think that the nurse might also want to become a beauty therapist.

15.1 Nurses and the Turning Point With so much to learn, every day, it’s normal that nurses can often doubt their abilities. Therefore, to be fair for the readers here who are considering or currently undergoing a pathway in nursing, I feel it’s important for me to talk about a moment

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in which I had a turning point in my career— when I felt everything come together and I could see, first hand, my skills and experience paying off. If you are reading this book and don’t feel you have reached that point in your career yet, just wait, the time will come. In 2020, I commenced a new role in my nursing career, that of a ‘nurse practitioner’. Nurse practitioners have the authority to be able to diagnose clients and also prescribe medications within their scope of clinical practice. When I moved interstate to a rural area to take up this nurse practitioner position, as part of this role, I had to determine how I would best use my skills and my time. The three key domains for the nurse practitioner role in Australia are leadership, education and research. So I was keen as mustard to find out that I had been recruited to help lead a depression clinic that would also be a part of research. In mental health, if a person is very unwell, they can be admitted to a hospital or be managed by a mental health crisis team. However, if a person is not on the brink of ending their life, or if they are not acutely psychotic, they are often not considered ‘unwell enough’ to be a fit for such public services. What is left for these clients—the ones who may still be moderately to severely depressed, for example—isn’t a whole lot. Accessible public services are minimal, and as a result, such people will need to have money to pay for private psychologists and psychiatrists, which also typically means long wait lists, even if you do have the money. Research has shown that early remission is crucial in treating depression. People who do not have a significant decrease in depressive symptoms in the first 2 weeks are unlikely to reach remission from their depression within 3  months. Hence, early and timely access to specialist mental healthcare is crucial. Lack of access to specialist mental healthcare often results in people being misdiagnosed, and therefore they do not receive the correct treatment. It is estimated that roughly 20 per cent of people who present to primary care with depressive symptoms actually have bipolar affective disorder. These clients are also often misdiagnosed because of a lack of mental health specialist assessment and therefore do not receive the correct treatment and do not therefore reach the point of remission. With the above information in mind, and with support from one of my clinical supervisors, Dr. Addington, I decided that my scope of practice would be centred on creating a mental healthcare pathway for people with moderate to severe depression and anxiety. This pathway would allow clients to be referred by their GP to see me and, as a result, have a specialist nurse practitioner in mental health helping them optimise their treatment for anxiety and depression, and thereby, ideally, achieving remission. This pathway is part of a research study and has therefore been ethics approved. This means that, although my work is clinical (i.e. leading a depression clinic), it is also part of a larger research study involving research clinicians and academics in mental healthcare. The benefit of having this pathway as a study means that there is both qualitative and quantitative evidence to demonstrate the effectiveness of a nurse practitioner operated depression clinic supported by an online mental health assessment program. A summary of my role is listed below:

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The pathway is led by the nurse practitioner and is supported by an online program where the client does a baseline assessment and then follow-up assessments to monitor their mental health and the effectiveness of the treatment prescribed by the nurse practitioner. The treatment is inclusive of medication and talking therapies according to evidence-based clinical guidelines. Of course, nurse practitioners assess and treat clients holistically, so within the treatment plan, I would always be incorporating the individual goals of the client as well as non-­ pharmacological therapies such as ways to improve sleep, exercise, nutrition and mindfulness as well as ways to enhance general meaning and enjoyment in life. The course of treatment is not just based on the online assessment, but it is supported by an extensive and holistic nurse practitioner evaluation. The nurse practitioner assesses and accommodates all of the mental health needs of the client. This pathway is comprehensive, cost-effective, innovative and evidence-­ based—it also bridges the gap between primary and acute care. This is a leading-­ edge study and clinical approach and I’m so grateful to be able to be a part of it. Alongside Dr. Addington and myself, there is a research team that includes a peer support worker (a person with lived experience of mental illness who is trained and employed to support mental health clients) and a medical student. Dr. Addington has been really supportive of me in my role. He has worked with a lot of nurse practitioners before, and he knows their worth and ability. I, however, was new to this role and it was a new position for the health service too. In a lot of ways, I felt that I was starting from scratch all over again. Having the ability to be able to diagnose and prescribe requires a lot of expertise and holds a lot of responsibility. For the first few months in my role, I was primarily setting up my scope of practice as well as working with the research team to set up the depression clinic. At one point, I spoke to Dr. Addington earnestly as we were walking across the road together to get a coffee while undergoing clinical supervision. I told Dr. Addington that I felt like a fraud and that I didn’t believe that I knew enough to do my job well. Dr. Addington replied, saying, ‘I’ve felt like a fraud every day of my working career’. Okay, I thought, I’m not the only person here who feels like they are bluffing. However, a turning point came for me when one particular client, George, was referred to the depression clinic by their GP. The referral said that the client was in his late 50s and had experienced depressive symptoms for a couple of years, which had not lifted even when his GP had recently prescribed him an antidepressant. George was also noted to be drinking alcohol as a means to cope and the referral stated that he had also lost his brother recently, who he had been close to. As I read the referral, I wondered if I could help this man. What if George’s primary problem was alcoholism and he didn’t want to stop? What if George was not depressed and, in fact, was just grieving the loss of his brother? Regardless, when I spoke with George, he said that he was keen to come to the depression clinic. He completed his baseline mental health assessment online—as per the defined pathway—which showed red flags for potential bipolar affective

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disorder. When I interviewed George and started asking him my own questions as part of a detailed and holistic nurse practitioner assessment, he again indicated potential bipolarity, but I wasn’t entirely confident at this stage if this was his diagnosis. As suggested by Dr. Addington in clinical supervision, I asked George if he would give me consent to speak to his partner, Lucy, for collateral information to see what her impression was of his condition. George said that he would have a think about that, but, in the meantime, I noted that the antidepressant that George had been prescribed (a selective serotonin reuptake (reabsorption) inhibitor, otherwise known as an SSRI) was only at a sub-therapeutic dose level. So, with his permission, I increased the dose to be at the therapeutic level. Later, George gave me permission to speak with Lucy, who felt strongly that he did have sustained patterns of marked elevation in his mood for about 5 days at a time (indicative of hypomania in bipolar affective disorder II) as well as marked and sustained episodes of depression with similar duration to the elevation episodes. In my next review with George, I reviewed his online follow-up assessment and could see that, even with his increased dose of antidepressant, his depressive symptoms had not decreased and that his anxiety had shot through the roof—another potential indicator of mania. Once again, I spoke with Dr. Addington in clinical supervision and I told him that I now felt pretty confident that George did not have depression or anxiety; rather, his likely diagnosis was of bipolar affective disorder II. When George and I met for our next review, I discussed with him what I felt was his likely diagnosis and my rationale behind this. He was open to slowly ceasing the SSRI and was happy to be commenced on a mood stabiliser medication to test the theory. After 2 weeks on a small dose of a mood stabiliser, George reported on his follow-up assessment that he had a significant decrease in depressive symptoms; he also said that he felt the best that he had in years. Again, with George’s permission, I increased the mood stabiliser medication and he reached remission for both his depressive and anxiety symptoms. For the past 20 years, George had been suffering through periods of hypomania and depression and had come to a point where he felt this was just a part of his life and things would never improve. Now, however, George reported that he had never felt better. He was relieved and amazed and he had never imagined that life could be this good. George’s case made me realise the amazing skills that I had developed through all my years of nursing. And now, as both a senior nurse and a nurse practitioner, I know that I am no longer an imposter, that I am able to heal and help a lot of people—to potentially change the course of their life.

Nurses and Blame

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Nurses and Blame

The good nurse knows that they will be told ‘it’s all your fault’, but will persevere to try to help. I’ve always found it interesting to watch how people manage distress and upsetting situations. Do they take a deep breath, realise what control they have in the situation and then find a way to solve the problem? Or do they blame everyone else for what has happened to them?

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I once case managed a woman called Daisy in community mental health. Daisy was a transgender client who reported that she was experiencing anxiety, depression and poor self-esteem. However, in my time getting to know Daisy, I realised that she also had particular personality traits, one of which impacted her ability to manage distress effectively on her own. She had a supportive partner who worked during the day while Daisy stayed at home. For months on end, I tried different talking therapy approaches with Daisy to try to help her move forward. She didn’t want to find employment or create a routine in her life. She also didn’t want to work on her sleeping patterns or talk about her problems. Daisy enjoyed talking about the birds that we saw when we would go for a walk and she appeared happy and content when she was with her partner. In her partner’s company, she would play video games with him and they would go out to a shooting range or go to the movies together. Amongst having poor distress tolerance skills as well as being dependent on others to ease her distress, Daisy also had an avoidant personality. People who have avoidant personality traits typically report experiencing feelings of extreme social inhibition, inadequacy and a sensitivity to negative criticism and rejection. Daisy did seem to enjoy my company, but she didn’t want to work on her problems. However, I couldn’t just be Daisy’s friend. In one psychiatrist appointment, I asked Daisy what she thought had been helpful for her in her time being case managed. She responded casually that she didn’t know. I then asked her if having a case manager was of benefit to her. Daisy replied, somewhat apathetically, that she didn’t know. Assertively, I then informed her that I needed a bit more than ‘I don’t know’ to justify being able to work with her. I then explained that I didn’t want to be investing time with her if she was not even sure if it was helping. (This was after a year of working with her.) We then talked about the different stages of motivation and that everyone has a different timing for when they might be ready for change in their life. Daisy agreed in principle and so I asked her to have a think about how we could structure our time to be more goal oriented. I also encouraged Daisy to think about what I could do differently to support her in a way that would be more helpful. After the appointment, Daisy spoke with her community support worker and told them that the psychiatrist and I were blaming her for not moving forward with her recovery. Later, I spoke with the psychiatrist about Daisy’s comment, which had been reported to us by the support worker. The psychiatrist responded by asking me who else was Daisy able to blame but herself, as it was in fact, her life. The psychiatrist then added empathetically that it is actually pretty scary for a person to decide to be accountable and accept that they actually have a lot of control in the direction their life takes them. She used an example from her own life, when she had decided not to come in for the orientation day of our new health centre. At the time, she had declined the invitation because she had too much clinical paperwork to complete. However, when she had come into work a few days after the orientation, she had become angry and impatient. She didn’t know where anything was and blamed others for her being inconvenienced when she couldn’t work the new fax machine. She finished up by telling me that she now realised that while she had had legitimate reasons not to go to the orientation, and had chosen not to go, the consequences for her decision were all on her.

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After waiting some days to let Daisy cool off, I called her up and asked her if she felt ready to work with me to make some changes in her life. Daisy responded calmly and honestly, without any perceived anger or blame towards me, and said, ‘I’m not ready’. We are all human. Blame is a coping mechanism that, at times, many people use, often unconsciously, as a way to try to make sense of things. When a person dies in an accident, we need to know who was ‘at fault’, as if knowing this conjures up a magical ability to bring a loved one back from the dead. Nurses do it too; they blame each other during tough times. Many nursing teams criticise each other for the shortcomings. Yet, the reality is that every team is trying their best to piece together some complicated puzzle, often with very few resources. Working in a number of different clinical areas is a blessing because you soon realise that everyone is working hard and is enduring their own (varying) struggle and trying their best to make things work. One time, when I had just started as a new graduate in critical care, we looked after a teenage boy called Angus. Angus’ story started off pretty innocently. The series of incidents began when he and his friends were playing around with lighters and deodorant cans; Angus’ legs got burned superficially as a result. He saw a community nurse to have his burns dressed and the wounds had been healing fine and otherwise, physically, he seemed to be in good nick. Then, on the following weekend, after sneaking out to the fireworks with his friends, Angus returned home in a bad state. While he was out, Angus had started vomiting and became quickly fatigued. Angus’ family were very worried about him, especially because they hadn’t known anything about what he was doing when he was out that evening. The ambulance had been called and, after the paramedics had conducted a physical assessment, they suspected that Angus had been drinking with his friends and was subsequently dehydrated. The paramedics then instructed the family as to how much fluid they should be giving Angus and how often to check on him. Later in the night, Angus’ little brother went in to see him and found him unconscious and blue. Angus was septic and consequently had endured a heart attack. The ambulance was called a second time and the paramedics revived Angus on site and then proceeded to take him to a bigger, better-equipped hospital rather than our local one, but Angus had a second heart attack on route. Angus was too physically unstable to transport to the bigger hospital (the journey to which would have taken more time), so he was returned to the smaller, local hospital and placed on life support in a critical care unit full of nurses and doctors doing everything they could to help. But it was not enough. Angus was soon declared brain dead and I’ve never seen so many staff cry in one day. Before Angus could be taken off life support, it needed to be established if he would be an organ donor. Naturally, because he was young and the circumstances of his deterioration so unexpected, this was not a decision that Angus and his parents had ever discussed, nor thought they would ever have to. In the end, Angus’ parents made the courageous decision for him to be an organ donor. I feel it is important to mention their bravery in responding to this tragedy with a generosity of spirit. Through Angus becoming an organ donor, he saved four people’s lives.

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In the lead up to Angus’ death—when he was deteriorating rapidly—we had to have a special meeting at work. Angus’ family had been initially grateful for the support that he received from his friends on his Facebook page, but then the police had to become involved to remove his account. What had started as warm, heartfelt messages from Angus’ friends soon turned to blame and hatred for all the health professionals who had treated him. This was really upsetting for his family, and for all of us at the hospital and I too found myself joining in with the blame game. The way Angus’ story was told to me by some of the nurses at the hospital made it sound as though the paramedics had brushed over their physical assessment of Angus and had therefore under-treated him. Meanwhile, other clinicians began blaming the community nurses, making direct statements against the nurses, claiming: ‘they must not have attended to his dressings properly’. In the middle of one such conversation, where we were all blaming each other for this tragedy, one nurse made an important point. She said that even though everyone had done their best at the time to help Angus, he had declined quickly and unexpectedly and that this was just a really unusual and tragic case that no one could have predicted. She then went on to say that no one was to blame; everyone was simply reacting to feelings of sadness because this little boy had died. In retrospect, I now know that if I had been able to distance myself from all the emotive opinions of the nurses, I would have understood that the paramedics had simply assessed and treated Angus as he had presented to them—as a boy who was dehydrated. And, if I had maintained my objectivity, I would also have appreciated that the paramedics could not have known, when they assessed him that he was going to go downhill so quickly. Blame is a natural response to difficult situations. To be able to move forward, we need to understand where the blame is coming from and how we deal with it.

Nurses and Being the Patient

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Nurses and Being the Patient

The good nurse will try to put themselves in other’s shoes, whether or not they fit into size 6 stilettos. Empathy is the idea of putting yourself in another person’s shoes to gain an understanding about what life might be like for them. I begin this chapter by

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reflecting on how one experience—when I was giving a regular blood donation— led me to later become a volunteer stem cell donor. While I was sitting in the Red Cross clinic waiting to give my usual blood donation, I read a pamphlet of information for people who were considering placing themselves on the bone marrow donor register. I placed my name on the register after being told by the staff: ‘Don’t ever expect that you will be chosen to donate in your lifetime, as it’s nearly impossible to be a tissue match for someone needing the transplant’. Six months later, I received an email while I was on holiday, sitting in a hostel in Japan. I had to double-check that it wasn’t spam, because the email informed me that someone was in need of a bone marrow transplant, and I was their match. When I returned to Australia in March 2015, I had the blood testing redone to double-check that I was the best tissue match available for the patient in need. ‘We don’t get to do this test very often’, the nurse doing the procedure told me, smiling, while taking numerous vials of blood in various-coloured tubes. It was confirmed, I was definitely a match. However, I was later informed that I wasn’t needed to go ahead with the transplant. It may have been that a person with an even closer tissue match had been chosen to do the donation instead, or perhaps the recipient had passed away or for whatever reason could not go ahead with receiving the donation at that time. It might seem strange, but I was a bit disappointed. I had been looking forward to having this kind of unique experience, of being the patient instead of the nurse. (What a great story to write about, I had thought.) Of course, I had also been looking forward to helping another person in great need through the magic of modern medicine. Psychologically, I closed the door on the idea that I would be a donor and I got back to day-to-day life. About a year later, I was re-contacted by the bone marrow transplant centre to ask if I was still available to donate bone marrow. I couldn’t help but wonder whether this was for the same recipient. Did they need a second donation? Did the first donor pull out or fail the medical examination? I knew I would never find out, as it was not relevant information for me to know, but I was still curious. In fact, when choosing to be a donor, one knows virtually nothing about the recipient. A donor can assume that the recipient is likely to have a disease, like leukaemia or cancer, but that’s all that can be concluded. At the time, when I anticipated that I would be the chosen donor, I tried to visualise the recipient: what their diagnosis was, what condition their health would be in at the time of the donation and what they were like as a person. I couldn’t not help but wonder. Some of the reactions I received from people around me when I told them that I had opted to be a donor were actually surprisingly negative. Many people seemed horrified by the nature of the procedure and struggled to understand why I would undergo it for someone that I didn’t know. This sent me into a whirlwind of emotions, and at first I felt quite unsupported and upset. I couldn’t understand why other people wouldn’t consider doing the same thing; imagine if you, or a loved one, needed a donor. After further discussion on the subject, I realised that most people’s responses were a result of their misconceptions about what the procedure involved. They had the idea that the procedure would be horrifically painful, dangerous and even life impairing. This is a myth. And even when they were told what was involved

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in the procedure, those around me still imagined my hips being butchered open with a drill or something. What I felt at the time, and still feel now, is that for me to be inconvenienced for a few days by a medical procedure is a small cost for something that is so valuable to another person’s life. About a month prior to the stem cell donation, I was flown to Sydney with my brother (my companion carer) for a full day of medical testing. It was a big day. I felt a bit like James Bond when we were met by Nancy, the brusque but professional cancer nurse. In the week prior, Nancy had provided me with my flight details and taxi vouchers, and when we met on the day, she gave me a list of special instructions: who to meet, who to call and where and how the day would progress. From the 8:30 am hospital arrival until 4:30 pm, the day was full on, involving a series of blood tests; an electrocardiogram, otherwise known as an ECG (a test to monitor my heart); a chest X-ray; a physical examination; and a counselling session. There was a lot to fit in and I had to follow a strict schedule, practically running from one appointment to the next. Even over the lunch break, I was to have a meeting with one of the donor coordinators to talk more about the donation process. As part of the pre-procedure questionnaire, I was asked if I consented for my leftover stem cells to be used for medical research instead of being thrown out— being my frugal and practical self, naturally, I said yes (waste not, want not). Also, as I was a nurse, Nancy provided me with another list of instructions on how to self-administer the growth hormone injections in the days leading up to the actual procedure. While waiting for the different tests, my brother amused himself by observing, with interest, the other patients moving in and out of the hospital. There were various outpatients with fractures coming in for X-rays and others coming in to have their wounds re-dressed. There certainly were a lot of different people entering the hospital, all with different needs. At one point, while we were going down the escalators, a transgender, South East Asian man—possibly manic or psychotic—began speaking to us excitedly in an unidentifiable language. I felt immediately at home, being in the colourful public healthcare system, but this time as a patient, not as a nurse. When I met with the bone marrow coordinator for lunch, I asked her how likely it was to find a bone marrow tissue match. She told me that if everyone in Australia had no choice but to be on the register (an ‘opt-out only’ system), the recipient in need would have a 1 in 40,000 chance of finding a tissue match. As it stands, however, people in Australia needing a transplant have a one in a million chance of finding a match. I’d been forewarned by the coordinator that the whole process of being a donor can be emotional for people, and for me, I found this to be true. I couldn’t help thinking about the recipient: how sick were they; was this their last chance at life? Choosing to be a donor had also made me think about my own existence and reflect about people in my life who had passed away. I was angry too. I felt then, and continue to feel, that we should have an opt-out system for organ and tissue donation. This way, everyone would be registered to be a donor, unless they made efforts to opt out.

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With both the recipient’s consent and mine, the recipient had the opportunity (if they wanted) to write to the donor (me), anonymously, to tell me how they were going 2 years post the procedure. I’d been told to be prepared to potentially never receive any correspondence from the recipient for such situations as the recipient being too sick to be able to receive the stem cell donation in the first place, or the recipient passing away. Of course, each recipient may also have other personal reasons as to why they may not want to write to the donor. However, for me, the most emotional part of this journey had been finding out just how few people had placed themselves on the bone marrow register. It’s not my place to judge, but I just can’t understand why people don’t consider it. A person volunteering themselves to be a potential organ and tissue donor can say with confidence that they have done a selfless thing for another person. It is an act of pure altruism. Or, at the least, consider it as an all-expense holiday with a side of growth hormone injections. Towards the end of the day, Nancy and I met again for some final debriefing. She enquired if I had any further questions. So, I asked Nancy why people in society thought the bone marrow and stem cell transplant procedure was so aggressive, and if it previously had been a more difficult ordeal to donate bone marrow or stem cells. Nancy assured me that the procedure had always been safe and straightforward and that somehow word had gotten around in the general community that the procedure was something rather gruelling. To educate me further, Nancy went through the range of likely side effects involved, which are mainly bone pain and potential moodiness from the growth hormone injections. She also informed me that there are no known long-term side effects from the use of growth hormone injections for stem cell or bone marrow donors. Nancy also provided me with more information about what I might expect with the procedure based on this recipient’s individual circumstances. She told me that, while I might still be needed to donate bone marrow in the future, this time my recipient’s needs were just for stem cells. To donate bone marrow, a donor needs to be under a general anaesthetic while a series of samples, similar to a punch biopsy, are taken from the hip bone. However, for a stem cell donation, I would just be set up as for a plasma donation, but with needles in both arms. While the required number of stem cells was being removed, the remainder of my blood would be filtered back into me over a period of 4–6 hours. To be honest, I preferred the idea of the bone marrow transplant, as I would be asleep and would not have the need to urinate. And again, as a nurse, I had wanted to get the full shebang of a proper operation, bells, whistles and all. For the stem cell procedure, I was assured that I could use a bedpan, if I needed to urinate (the ultimate patient experience) or I could use the toilet. However, using the toilet instead of the bedpan would lengthen the procedure—due to needing to be disconnected and reconnected to tubes. Therefore, to my dismay, the bedpan was the recommended option. At the end of the day of testing and counselling, my brother and I had about 20 minutes left to stroll through Kings Cross and get a drink from a juice bar with a distinct 70s vibe before flying back to my city where we tucked ourselves into bed early because we were exhausted.

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At that point, I was ready to donate—every checkbox had been ticked. The dates were booked and my hormone injections were sitting in the fridge waiting for me. My sister would also be flown to Sydney to be with me for the two nights of the donation, which was to be at the beginning of March. It had been recommended by the cancer unit staff that I have plenty of entertainment, like DVDs, ready to take with me, but I was also hoping to do some study as I was in the process of finishing my master’s degree in Mental Health Nursing. However, when I mentioned this, I was told that studying would prove to be difficult as I wouldn’t have the use of my hands during the period of the donation. I was also told that, for the same reason, someone would have to feed me with sandwiches, because feeding myself would also be difficult. In the days leading up to the procedure, I said a little prayer for the staff and the universe to look after me. Of course, I didn’t need luck; I just required good hospital care, but I was still nervous, hence my prayer. The night before the procedure, I was preparing for the big day ahead. My sister and I had both just landed in Sydney. The following day at 8:15 am, I would be having needles stuck in my arms as part of the stem cell donation procedure. I had one more lot of growth hormone injections to take the night before, and an extra dose was also ready to go the next day, which would prepare me for a subsequent bone marrow transplant operation, if my stem cell count was not high enough after the initial retrieval. It was day 4 of the injections and I was once more experiencing the intense growing pains of my teen years. My energy levels were switching between being overactive and feeling really tired and spaced out. I knew to anticipate bone pain to some degree; at times it felt like an acute stabbing or radiating pain, and at other times more of an achy flu-like feeling. I had been told that the pain is usually managed by paracetamol, but I ended up asking for Panadeine Forte as the pain was getting a bit hard to manage. Normally, I have a good pain threshold and I wondered if I was feeling like this because I was a bit nervous, or perhaps because my body was sensitive to the growth hormones. In the days leading up to the procedure, I had continued to exercise as I would normally, but the pace and intensity of how I had been doing things, like running and walking, had certainly decreased while on growth hormone injections. I was uncomfortable. Still, I knew that what I was experiencing was absolutely nothing compared to the side effects that people endure from cancer treatments, which put everything back into perspective. On the day of the procedure, I was set up in my patient gown, sitting on a hospital bed, arms bent—with needles inserted in both veins to retrieve the stem cells. The nurse and the volunteer who looked after me in hospital were very kind and had good senses of humour. Meanwhile, in the background, there was also a woman from a tech company monitoring the new, beeping, stem cell machine; the hospital had had a recent change in the medical appliances used for this kind of procedure. The sounds and sights of that day are still so vivid to me and the hardest thing for me during the procedure was not being able to move my arms. My sister and the nurses fed me food and gave me water. Together they taped together a few plastic straws to create a mega straw for me to be able to scratch my face. As one would

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expect, people tend to feel a lot itchier when they know that they can’t scratch. To pass the time, I watched a couple of movies and had a little snooze. It was great having my sister with me for support; it would have been a lot more daunting and lonelier without her. Given my previous experience of being both a regular blood and plasma donor, the procedure itself did not feel too out of the ordinary. So, to me, the procedure really did feel just like a very long (8 hours total) plasma donation, without the use of my arms. As I was finishing up the procedure, I heard an elderly man in the bed next to me (a hanging sheet divided our beds) vomiting violently as a result of his cancer treatment. This once more made me appreciate that feeling ill for a few days in order to do a stem cell transplant was really nothing compared to what the recipients were going through when they needed a donation. The stem cell donation was a success. Apparently, my stem cell count was huge (a good thing), which also explained why I had had a lot of pain in the days leading up. Subsequently, I didn’t need to take any more growth hormone injections or have to go in for a bone marrow harvest the following day. I was also told that I’d continue to have joint pain for a few more days and that would be the end of it. It was a strange experience to have the procedure completed and go back to normal life again. Being a stem cell donor really was a once-in-a-lifetime experience— a very positive one—and I hope that through sharing this story more people will consider placing themselves on the bone marrow register. My stance on this issue is: ‘Just do it, who knows, maybe one day you will need a donation too?’ For more information about how to be on the bone marrow register, please see the Australian Bone Marrow Donor Registry website: http://www.abmdr. org.au/. Nothing teaches a nurse more about the way you should treat others than having the patient experience firsthand. Of course, most of the time, unlike the example of choosing to be a bone marrow donor, we do not choose to be patients. Becoming a patient, in most circumstances, carries more elements of uncertainty and surprise. Most of us have accidents or become ill when we least expect it. Being in a hospital is a scary place. The white walls, the strange smells and being confined to a bed can lead a person to feel trapped and powerless. The saving grace is the care you are given by others, the way you are treated and how well you are informed by the care staff about what they are doing. I didn’t realise this myself until I needed treatment for an unexpected knee injury and autoimmune diagnosis; health professionals need to tell you every little thing. Nurses need to tell you what they are doing and why they are doing it. Nurses also need to tell you why they are leaving and when you can roughly expect them back. And finally, nurses should comfort you when you panic and validate what a difficult position you are in. Even if you, as a nurse, are fed up with your patient (me), yet again, asking for the bedpan, you need to pretend not to be annoyed about it, even if you are busy and stressed. As nurses, we say that we can appreciate the embarrassment that a patient experiences when they need help going to the toilet. Really though, it’s not until you

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have another person take your pants down for you—to be able to perform a simple bodily function—that a nurse can really appreciate the loss of control and vulnerability that takes hold in such a situation. I first experienced this feeling of helplessness at age 14 after I had a severe knee dislocation during a basketball game, which also tore multiple ligaments in my leg. I’ve always been a sporty person who loves exercise. However, I never really appreciated how important exercise was in my life until I had a knee realignment that caused me to hobble around in a leg brace for months in constant pain. Before my operation, I had been used to running up and down a basketball court effortlessly. With the leg brace, it would take me 10 minutes to make the very short distance from the disability car park to the entrance of the cinema, and I would be shaking and sweating by the time I arrived, ready to collapse in a heap. In the end, I had to resign myself to having my friends push me through the shopping mall in a trolley, as I would be in so much pain. Everywhere I went, I felt self-conscious about what people thought of me dragging around my bionic-looking leg. It’s very hard to try to hide a thick and bulky leg brace that keeps the leg completely straight at all times. I also remember some of the grade 8 high school boys stealing my crutches and running off with them as a joke one day when I was hobbling to science class. I knew this was meant to be a playful prank, but it was not funny. I was left clutching a steel pole in an attempt to stop the huge stampede of students knocking me over as they rushed to class in every direction. There were some bonuses though. Sometimes, the boys in the older years that I crushed on—but who I would never have had the confidence to talk to—kindly offered to carry me up the stairs. I would be blushing fiercely as the strong boy, warrior-like, carried me up the stairs like I was their damsel in distress. Years later, I had to endure that bloody leg brace again when I needed subsequent surgery because my knee had become worse over the years. Now, my knees feel a little arthritic as my patella cartilage was never the same after the initial injury and also worsened over time. Nonetheless, I still get to do everything that I want to do, with some modifications and restrictions. Fortunately, that particular injury, and the rehabilitation with the leg brace, was acute but short term. My heart goes out to people who must endure a lifetime of that kind of injury, or worse. On a different note, a few years ago, I was diagnosed with a non-life-threatening but chronic autoimmune disease. What made this illness a bit more bearable was the generosity and care of the staff at the clinic where I was diagnosed. Having to lie on your side on a bed while a doctor lubricates a gloved hand and inserts it into your rectum has got to be one of the most demoralising situations to be in. I still clearly remember lying in the foetal position, with my ego and dignity having been left at the doorway of the examination room. However, more importantly, I remember how kind that doctor was to me and I wondered why she would ever want the job of a gastrointestinal specialist doctor. Sticking her finger up bottoms would be routine in her nine-to-five day and I must have been patient number one million and three who she had had to perform that procedure for. Still, she was genuine in acknowledging how uncomfortable I must be in that situation. After the examination, we talked about the ins and outs of the

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endoscopy procedure (excuse the pun)—a clinical investigation I would require due to the symptoms I was experiencing. She then asked me how things were going in my life in general. I believe that this question was raised as a part of a holistic assessment, but also I think she asked me this so that she could connect with me on a human level. After having to endure a rectal exam, I appreciated this. I told her that I had just broken up with my boyfriend, that my grandmother was sick with cancer and that I worked as a mental health nurse. She then talked with me about the importance of self-care, as she could appreciate the difficulty of the stressors I had in my life at the time. She also empathised in how important, yet demanding, my job was as a mental health nurse. Stress is not considered a causative factor to inflammation (as causative factors are difficult to fully prove, given all the confounding factors). However, stress is correlated to inflammation. With this in mind, the doctor had clinical reasons for asking me the questions that she did. Still, regardless, the way in which she asked those questions demonstrated sincere compassion which I appreciated gratefully. I wanted to give her a hug. It’s not easy being a patient. Nurses, in particular, really struggle being in that role. They know too much about what can go wrong, so they typically make very difficult patients to care for. However, all people—to one degree or another—will at some point endure a kind of illness or injury (or multiple) and will need to be cared for by health professionals. It’s disempowering and scary, but for healthcare professionals, it’s also work experience at its best. It provides an opportunity where nurses can learn firsthand the empathy they need to care for patients in the best way possible.

Nurses and Magic Medications

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Nurses and Magic Medications

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The good nurse has seen a lot of people stoned from medication. When a person is virtually incapacitated as a result of broken bones, and then undergoes surgery and requires post-operative care, you can only imagine how many painkillers and antibiotics a nurse is popping out of the pill packet. On one hand, some people deliberately overstate the pain in order to get pain relief like opioids, while other people refuse paracetamol as they are scared they might become addicted somehow. The management of pain relief is a central theme of nursing. Working in an orthopaedic ward as a second-year undergraduate student nearly broke me (pun intended). I spent my days running around like a headless chook, not knowing what on earth was going on. That type of ward is insanely busy with medication rounds and involves a lot of heavy lifting. Helping shower a person who is covered in wound dressings and casts can make even the fittest nurse break a sweat. In one of my mid-week debriefing sessions with my mentor, Wendy, I was feeling so overwhelmed and disheartened that I told her that if day-to-day nursing was the same as in that orthopaedic ward, then I didn’t believe I would survive in the profession. Wendy was above and beyond supportive and told me to take the next day off. She further assured me that not every clinical area was the same as the orthopaedic ward and that I did not have to become an orthopaedics nurse. After a week or two on the orthopaedic ward, I became accustomed to the madness of the environment and let myself learn and enjoy what I could. It was the first time in my life I witnessed how patients can become genuinely and acutely loopy from painkillers. It is amazing to see how differently people can respond to anaesthetics, opioids and sedative medications. Of course, a lot of people benefit from (and enjoy) the effects of these medications. As people, we are generally powerless to fight the effects of a medication—whether that be good or bad, while at other times, the result can just be a placebo effect. The causes of pain, and the way people experience pain, are too complex for me to summarise here. What I will note for certain is that people experience greater amounts of pain if they are not relaxed. I once cared for a man who complained of generalised body pain. He was also highly anxious, so I told him that I would start off by giving him some ibuprofen and paracetamol. I gave the man his medication and 20 minutes later I could hear him telling his family with pure joy—that whatever the nurse had given him was a miracle drug and that he hadn’t felt that good in years. Now, it could be the case that the ibuprofen and paracetamol had worked well for him and had subsequently removed all his pain, but what I feel actually happened was that the patient hadn’t heard me when I said the name of the medications. Instead, I suspect that he thought that I had given him something stronger like an opioid, such as morphine. The patient was now so relaxed and at ease that I didn’t have the heart to tell him that what I had given him was simply over-the-counter drugs. If he had asked me again what I had given him, I would have told him, but at the time, this placebo was working wonders. Different medications will be used in different clinical areas. For example, for certain medical procedures where anaesthetic is not necessary, different types of sedation are sometimes used. In the endoscopy ward, patients will undergo a day

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procedure under sedation where a camera is inserted into their body, either through their mouth to examine their throat and stomach (a gastroscopy) or through their rear end to examine their large bowel (a colonoscopy). Nursing in the recovery room of an endoscopy ward is surprisingly satisfying because of how jolly the patients are when they wake up after the procedure. To reduce the discomfort of a gastroscopy or endoscopy, patients are given a particular sedative medication that gives them pleasant chemical side effects. Patients go to sleep and then they wake up and they feel glorious. They can’t remember what happened between going to sleep and waking up; they just know that they feel like a million bucks. Also, when a patient wakes up from this kind of sedation, the nurse is considered the best thing since sliced bread. And the actual bread from the hospital-­supplied sandwich, which is normally mediocre, is the best sliced bread they have tasted. Patients often also ask if they can sleep a bit more as they say they have had the most wonderful slumber of their lives while under sedation. I secretly hoped that, because I had pre knowledge of how the drug was likely to make me behave, that I would be someone who could rationally observe but not partake in the ridiculously euphoric effects of the drug. However, when it was my turn to have a colonoscopy that required sedation, I woke up and I couldn’t stop myself from being overly familiar with strangers. Everything I said was compulsive—I had no control. I needed to share my immense love for the world and everyone in it, so I stopped a nurse I had never met before and touched his arm because I needed to show him my gratitude. His arm felt so warm and soft, and I suddenly had an absolute fondness for him. So, I told him that he was a great nurse. My adoration for the world could not be deterred, and yep, that normally bland hospital sandwich tasted awesome. Another example of how medications can have different effects with different people was with Panadeine Forte (a mix of paracetamol and codeine); I never thought it could hit someone so hard until I was looking after a sweet, middle-aged woman called Julie, who had endured a hip replacement and was subsequently residing in the orthopaedic ward. I had given Julie two Panadeine Forte tablets to prepare for the pain she would face when moving to the shower for the first time after her operation. When the time came for her shower, Julie and I chatted about the weather, families and hobbies—common patient and nurse banter. She seemed fine, so I set her up with her sponge and soap in a shower chair so that she could wash herself and then reminded her to use the call bell if she needed me. Sometime later, I realised that I had not heard from Julie for a while, so I thought I’d check in to see how she was going. As I approached, I could see she was washing herself calmly, but that the shower floor was covered in blood because her cannula had been removed. While applying pressure with a towel to the cannula site on her arm, which was pissing out blood, I asked, ‘What happened to your cannula?’ Throughout this entire process, Julie did not seem at all phased. It was as though the shower filling up with blood was a part of her daily routine. ‘Oh’, she responded with a chuckle. ‘I pulled it out’. ‘Why did you do that?’ I asked, puzzled. ‘I don’t know’, said Julie calmly

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before gently laughing again. ‘Something was not right’, I thought to myself. I suspected that Julie must have been a bit high from the Panadeine Forte, but I couldn’t believe that she could be acting this out of character after having only two tablets (the standard dose). As I helped her out of the shower to get dry and dressed in her day clothes, Julie seemed lucid and mentally coherent, and I felt that perhaps Julie was returning back to her baseline behaviour. We went back to talking about our plans for the day, but then Julie said, right out of the blue, ‘I just don’t like that man’. ‘What man?’ I asked. ‘The man with the scarecrow face’, she replied, pointing at thin air. Following that incident, and after a discussion with the treating doctors, Julie’s usual Panadeine Forte dose was halved. Her pain seemed to be adequately controlled with the lower dose and she also stopped pulling cannulas out of her arms. Furthermore, Julie was no longer bothered by scarecrow men. Like Julie, I’ve had my own vivid experiences of pain and have been given magic medications to cope. The most extreme physical pain that I have experienced in my life was when I had my initial knee dislocation during a basketball game at age 14. When I fell to the ground at the time of the injury, I straight away knew that something out of the ordinary had happened as I felt my stomach rising into my mouth; my body was telling me that I might either vomit or pass out. But I didn’t, and seconds later an excruciating out-of-body experience of pain occurred. I felt like I could not breathe and the world around me started to spin. My suspicions that something was wrong were solidified when a teammate came over to check why I couldn’t get up after my fall. She took one look at me, and then she screamed and ran off. When I looked down at my leg, my kneecap was not where it was meant to be—that part of my knee was now flat and the kneecap itself had been twisted to the left side of my leg. When I talk about this story with my Mum—who was there at the time—I recall having to wait forever for the ambulance to arrive; however, Mum says they came in 10 minutes. She is probably right, but with the amount of pain I was experiencing, it felt like an eternity. When the paramedics arrived, they gave me a medication they said would make me feel better. They said that the first one (morphine) would ease the pain but may make me feel nauseated. As the paramedics had predicted, the pain instantly started to ease, and then I felt butterflies launching from my stomach towards my throat. As soon as I told them that my tummy felt weird, they injected another drug—an anti-­ nausea drug (otherwise known as an antiemetic) called ondansetron. With these two medications working, the paramedics were then able to straighten my leg and reset my knee, after which I could physically and mentally ‘return’ to my body. As expected with that kind of injury, I endured about a year of rehabilitation and even more years of issues with my knee to follow, which included surgical intervention. Still, the day of the injury is as clear to me now as it was at the time and the fact that those medications allowed me to be treated and brought back to some state of ‘normal’ still amazes me.

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I’ve been told by women who have had children that childbirth is a kind of pain that nothing else compares to, and I’ll believe it. But at least there is the end goal of having a baby at the end of it—it’s a pain that has a reward. As nurses, we rely on patients self-reporting their pain, in conjunction with our own observations, to try to make an assessment of a patient’s condition—and it’s not easy. Then, we need to try to treat the pain, which is also not straightforward. With this in mind, and in terms of the most excruciating physical pain that I feel I have witnessed in my nursing career to date, I generally think of a lot of end-stage cancer patients. But then there was the jockey I met in the orthopaedic ward who had come off his horse. This jockey had to lie flat on his back in a full body brace for weeks because numerous bones in his body had been broken in the fall. To be raised up to be washed and use a bedpan, his whole body had to be raised by an electric lifter. Every single, tiny movement would, understandably, lead to him clenching his teeth and squinting his eyes in pain and discomfort. He was so brave; I could see he was fighting back tears. I didn’t think about it at the time, but now I appreciate that the mental strain from not being able to move at all, especially for such an active person, could make a person both depressed and a bit crazy. Seeing this jockey in the state he was in, as well as men of various ages who have had broken legs from hitting trees while skiing or coming off motorbikes, I would have expected that a person with such injuries would have been turned off of going back to those extreme sports. However, every single patient I spoke to was keen to get back to the snow or back out on the road. Even the jockey, while having no movement in his body, still told me that he was keen to recover and get back on a horse. He also never requested any pain relief while he was in that complicated brace. From placebos to hallucinations, the effects of painkillers on patients and ourselves is always fascinating.

Nurses and the Unexplainable

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Nurses and the Unexplainable

The good nurse will have to question themselves, and the world around them. Many nurses have one or more stories of where they have come across very strange clinical presentations with an unknown cause. As a new-graduate nurse, I once cared for a woman called Grace. She was a retired nurse and was under a great deal of stress. Her husband had recently been © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_19

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diagnosed with terminal cancer, which was naturally taking a huge emotional toll on the both of them. And, as a consequence of her husband no longer being able to work, they were also under financial stress. Grace appeared to be experiencing some kind of delirium. She was a patient, but she told me—and seemed to believe—that she was a nurse on shift in the hospital, along with the rest of us. Subsequently, Grace would follow the other nurses into the medication room, eyes wide, but with no clear reason as to why it was so imperative to go there. One of the nursing assistants lost a bit of self-awareness at one point when verbalising the nursing handover for Grace. He said loudly in front of Grace that she was really confused. Grace defended herself, saying that she was not crazy and, while holding an intense and desperate gaze, she asked not to be treated as though she was. I smiled weakly at Grace and said, ‘I know you aren’t crazy; we just need to find out what is happening to you right now’. Then I asked, almost rhetorically, ‘Something isn’t right, is it?’ Grace just nodded, silently. Grace’s legs were swollen and she had lost a lot of weight with no known cause. Her brain and heart scans also came back clear, as did her blood tests and we were all scratching our heads over the mystery. After a week of caring for Grace on the ward, I went on annual leave, and by the time I returned from my break, Grace had gone from the ward. I had no idea what happened to her and, as is the way in a hospital, a new patient had taken her bed the minute she had left, with barely enough time to change the sheets. My focus shifted to my current cohort of patients. It wasn’t until months later, when I was working at the hospice, that I saw Grace again. She was not a patient this time, but she was crying, perched on a bed surrounded by family and cuddling her father who had just died. She was mourning, but lucid, and looking perfectly healthy. It was not the time to ask her what had gone wrong with her medically and how she had recovered, so in my memories, Grace remains a phoenix risen from the ashes. Usually, the cause for a clinical presentation is discovered but sometimes we are surprised that the reason isn’t medical at all. My nurse mentor, Wendy, can relate to this, and below she tells the story in her words of a patient called Annie who presented with mysterious blue hands.

19.1 Annie and the Case of the Mysterious Blue Hands (Wendy Speaking) I remember the case we had of a woman, Annie, coming into the ED. She was panicking wildly because the palms of her hands had turned blue. Annie didn’t know what was happening to her and was very impatient and agitated, becoming more so by the minute and fearing that her hands might well fall off due to a decreased blood supply; she thought that her life was about to end. We all noted in our initial assessment that her hands felt warm and had complete range of motion. Annie also had no problems breathing and certainly no problems talking—well shouting, actually.

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We told her we wanted to try a treatment before she was seen by the doctor and took her over to the washbasin and asked her to wash her hands. She wasn’t pleased with this suggestion but cooperated reluctantly and, after a few moments of washing with soap and water, her hands pinked up and miraculously returned to normal. During the assessment process, we noticed her denim skirt, which she told us was new. Apparently, she had been wiping her hands down the skirt denim and the dye had rubbed off onto the palms of her hands. We then sent Annie home with instructions to wash the skirt in cold salty water and added that her problem would be solved and that the condition shouldn’t return. A nurse can often suspect the likely chain of events that have led to a particular hospital presentation, but the patient will often tell the nurse a very different version of events. There are a lot of reasons why patients will avoid being honest about what has led to them being in a hospital. Usually, patients are not forthcoming because they feel embarrassed or are fearful of being judged. For example, a lot of patients who have used illicit drugs will be afraid that they may get into legal trouble or that they will be stigmatised as a ‘junkie’. Whatever the root cause of the hospital presentation, nurses essentially just want to know the truth about what has happened, so they are able to treat the patient more quickly and effectively. However, as you might appreciate, many patients are a bit coy when it comes to explaining why they have a foreign object stuck up their bottom. I have a nurse friend, Bill, who works in the ED. Bill told me that he could write a whole chapter about all the different people who have turned up to the ED with things stuck up their bottom, or other orifice. What follows is Bill speaking in his own words about being a nurse and caring for this special cohort of patients.

19.2 Patients Presenting to Hospital with Objects Stuck in Different Holes (Bill Speaking) People seem to have a fascination with shoving things in holes where the hole probably can’t accommodate the size or structure of what is being placed there. Or perhaps the object does fit in the hole, but there are good reasons why it’s not a good idea to place it there either. In the ED, we have had a number of cases where people have placed objects of varying sizes into a specific orifice. I feel these habits start with young kids placing pieces of Lego and beads up their nose or little polystyrene foam balls into their ears. As children turn into adults, I guess they get a little more adventurous with what they decide to stick in their holes. Of course, adults often have different needs and reasoning compared to children for what leads them to make this kind of decision. However, we could also argue that perhaps children and adults are alike in their actions in that they do it out of curiosity—a test to see if something actually will fit. I would therefore like to talk about my nine most memorable cases of people presenting to hospital with objects stuck in places where the sun doesn’t shine.

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1. A 30-year-old man presented to the ED via ambulance. This patient was an IT worker and I was working the ED triage at the time. It was really busy that day, so this patient was sitting in the patient ‘overflow’ area and I was a little bit ­confused as to why he was there. This man was young and fit, and he didn’t appear ill. All I could think was: ‘You are too healthy to be here’. I then received a handover from the ambulance that said the man had a giant cucumber stuck up his rear end. When I asked the gentleman what had happened, he said that he had been camping and had gotten a tick (an insect) in his bottom. He said that he had been using the cucumber to try to remove the tick. I was unsure how a cucumber could assist a person to remove a tick from their rectum, but that wasn’t the pressing issue at the time. I looked at the doctor who was interviewing the patient with me and we exchanged the same troubled expression. We were both wondering how on earth we were going to remove the cucumber from the patient’s anus. The cucumber was lodged so far up inside the patient he was unable to pass the cucumber out naturally like a poo, and if we left the cucumber there, it would end up rotting in his bottom. It ended up that the poor gentleman had to go to the operating theatre to have the cucumber surgically removed. I saw the man the day after his surgery outside in a wheelchair having a cigarette. Cheekily, I joked with him that I guessed he wouldn’t be eating vegetables for a while. The man chuckled. As a nurse, I can sometimes get away with using a bit of humour to try to help patients relax after experiencing a bit of an upsetting event, and I am glad that he could see the funny side of it all. I also hope that in the future he will be a little bit more careful about placing objects in the ‘the point of no return’ or, as we call it in the ED, ‘the one-way valve’. 2. A different (and older) gentleman presented to the ED. He quietly proceeded to the triage desk, but was too embarrassed to admit the reason for needing medical treatment. He had told the female nurse at triage that he was experiencing chest pain, so I took the gentleman into one of the consultation rooms to conduct an electrocardiogram (ECG). As I was setting up for the ECG, the man realised that he probably had to tell the truth and he revealed to me that he had a carrot stuck up his bottom. This man was about 65 and he told me later that his daughter was about the same age as the female nurse at triage, which had made him feel uncomfortable about revealing the truth about his carrot-induced medical complication. I called the gastrointestinal specialist team for assistance and—as a team—by placing the patient in a variety of gymnast-like positions, we managed to remove the carrot with a pair of forceps, lots of lubricant and a great deal of effort. He was lucky that he hadn’t needed surgery and we were able to discharge him home. I wonder if that gentleman looks at carrots in the same way that he used to. I also wonder if he still eats carrots or had ever eaten carrots before presenting to ED with one stuck in his bottom. 3. Another older patient presented to the ED. She was 72 years old and she had a vibrator stuck up her bottom. Poor woman, she was so embarrassed. She claimed

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that she didn’t know how to work the vibrator properly and then, with major gaps in her story, told us that somehow the vibrator had got stuck up her bottom. Those old forceps came in handy once again for this woman, and we were lucky that the vibrator was only very small and that we could remove it easily. 4. On a different occasion, a 17-year-old girl came to the ED looking sheepish. She admitted that she had been experimenting with her sexual desires at home using various toys and objects. She had waited a week to seek medical treatment while the lid of a spray deodorant bottle was lodged deep in her vagina. A female doctor was, again, able to remove the lid with some forceps, and the young girl went home, happy to no longer be carrying an ‘impulse’ bottle lid inside her. 5. A 35-year-old Asian woman presented to the ED with a 350 ml glass soft drink bottle stuck in her vagina. She, unfortunately, had to go to the theatre to have this surgically removed. In this case, the forceps—that had helped so many other clients—could not be used because of the risk of breaking the glass bottle while it was inside her. This, of course, was traumatic for the woman, both physically and emotionally. In the operating theatre, she not only had to be anaesthetised but also had to be given a range of different sedatives to relax her body so that her vagina would ‘let go’ of the bottle safely. 6. Another bloke presented to the ED with a big black dildo stuck in his rectum. The female nurse who removed it for him told me she was just blown away with how big the damn thing was. As a man, and a nurse, I just don’t believe that a dildo that size could ever be a realistic replica of a penis, not even the biggest human penis on record. The nurse had been so amazed at the sheer size of the thing that she took a photo of it sitting in the infectious waste bin. She showed it to me and there it was—lying amongst a few bloody swabs from previous patient procedures—a giant black dildo, so huge and heavy that the hardy, yellow, infectious waste bin liner had crinkled and sagged all around the big cock, defeated by the dildo’s density. 7. When I was working in an intensive care unit, an elderly gentleman was admitted with unknown sepsis. His urine specimen came back clear and the treating clinical team ordered an abdominal X-ray, in which we found a biro casing stuck in his bladder. The patient told us that before insertion, he had removed the ink part from inside the biro. He had then used the hard biro cover to maintain an erection while having sex by sticking the biro into his urethra; he was a wealthy old man with a young wife. 8. Another case was a young university student who was making money as a sex worker. A car racing event had been on that weekend and it had been a good opportunity to meet some clients. The young woman presented after the weekend because she had some small sponges stuck in her vagina. She revealed that she had self-inserted the sponges prior to the weekend to stop the blood of her period interfering with her work. Again, the forceps were put back into use to remove the sponges.

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9. A 21-year-old girl came into the ED by ambulance. She told me that she couldn’t hear in her left ear. Of course, we were wondering: ‘What has happened to this girl? Did she have an ear infection? Had she been physically assaulted?’ She reported that she had been giving her boyfriend a blow job and, as he came, she had turned her head and he had come in her ear by accident and she then hadn’t been able to get the semen out of her ear. I couldn’t believe that she called an ambulance for this and that the ambulance had gone out to see her and then brought her into hospital. We told her to wash her ear out, which she did, and as a result her ear was no longer blocked and she could then go on her merry way back home. From ears and noses to vaginas and penises, it’s amazing how creative people are with what they stick inside their bodies. As this chapter suggests, the spectrum of unusual cases that are presented to nurses are indeed, never ending.

Nurses and Working with Youth

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Nurses and Working with Youth

The good nurse knows how to balance compassion with tough love to help some people move forward. For a couple of years, I worked in a child and adolescent mental health team. My main role in this position was working as a clinical nurse consultant in a youth recovery residential program. Another role in this position was to assist in © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6_20

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conducting mental health assessments for young people. Each week, I would work with other clinicians to conduct assessments for children, teenagers and their families where mental health concerns had been raised. The problems presented were on a wide spectrum of severity and complexity. For example, some parents would report that their child was anxious and had performance anxiety at school, which was compounded by perfectionist tendencies. A saving factor in a case like this—or any case, for that matter—is something that clinicians identify as a ‘protective factor’. Protective factors are things that help support people in times of hardship and mental distress. These factors can include, but are not exclusive to, having events to look forward to, hobbies (finding meaning in life) and importantly, support from family. Families who were insightful and supportive of their children, and where there was no unresolved trauma background, made for cases where solutions and recovery were possible. Other cases, where the child had experienced significant trauma and lacked appropriate support from family, were more difficult. These latter cases could be further complicated by parents who were either completely neglectful or anxiously overprotective. Our mental health team would, at times, interview children as young as 8 years old, where it would be too difficult to conduct the assessment with both the parents and the child present. The concern was that the language being used would not be appropriate and understood or could be potentially re-traumatising for the child. In assessments like these, one clinician would speak with the parents and the other would spend time in a separate, organised playroom with the child. The playroom was brightly painted and filled with various toys and furnishings. Naturally, instead of having to assess often highly anxious and/or unaccountable parents, I preferred to spend time with the child in the playroom. I have seen countless films filled with clichéd scenes of a psychologist using the Rorschach test as a way to conduct a part of a mental health assessment with a child. The Rorschach test, in my understanding, is a psychological test in which subjects’ perceptions of inkblots are recorded and then analysed using psychological interpretation, complex algorithms or both. In these films that I saw, the psychologist would be seen holding up an abstract print of a butterfly-like image and would be asking a child what it meant to them. The child would then respond saying something like: ‘It’s a car accident’. This scene was supposed to demonstrate a child’s view of the world as a result of their particular traumatic experiences. Prior to working in the mental health field, I used to be cynical of these kinds of portrayals of trauma. I’m not a psychologist, so I’m also unsure if these films have demonstrated the use and function of the Rorschach test accurately. However, after working in the mental health field as a nurse, I do now believe these films have hit the nail on the head in showing the intricacies of young people and what can affect their development, in particular, the complexities of how young people sometimes respond when they have lived through something very upsetting and frightening. One time I remember sitting on the floor—feeling like a child myself—next to an 8-year-old boy, Tommy, while his parents were being interviewed in the other room. I suggested to Tommy that we could make a village out of building blocks, and while we did this, I asked him a few questions to try to tap into his mood and gain

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an understanding of why he was there that day. His eyes stayed fixed on the building blocks as he just gave me a variety of short answers to the sum of: ‘I don’t know’. I knew not to push against such resistance, so I kept the conversation focused on the house that we were building with the Lego kit and just kept my gaze, like Tommy’s, focused on the square and rectangle bricks that we were detaching from half-­ completed assemblies to turn into new constructions. My fingertips looked like that of an ogre in comparison to Tommy’s delicate fingers, which were practically the same size as the Lego. We soon completed our little town. There were houses, a town centre, some trees and a big, random wall, which I didn’t know the purpose of, but which Tommy felt needed to be there. I gave Tommy praise for the beautiful town that he had constructed. He then walked over and removed some of the little figurines from a doll’s house that was also in the room. Tommy then placed these dolls in the town and took a little toy car and pushed it through the wall, crushing the village and running over the little dollies. ‘Why did the car do that?’ I asked. ‘That’s me and mum, and that’s my stepdad driving the car,’ Tommy answered. I later found out that Tommy’s stepfather had been violent towards both Tommy and his mother. Another part of my role in this team, as I mentioned before, was working as the nurse consultant for a youth residential program for teenagers experiencing moderate to severe mental illness. Many of the teens in the house were experiencing one, or a number, of the following risk factors: depression, suicidal ideation, self-harm, poor or non-existent school attendance, drug and alcohol use, poor self-esteem, getting involved in conflicts at school or being bullied, eating disorders, a history of trauma (which could include physical abuse, sexual abuse or emotional abuse), anxiety… the list went on. The common theme was that there was a lot of conflict at home, so severe that the young person and their parent(s) often couldn’t be in the same room for more than a minute without erupting into an argument. Basically, teens came to our program to stay for a few months when things really weren’t working out at home. I immediately feel a little guilty and hypocritical labelling some of the families that I worked with as ‘complicated’. All families are complicated. However, at times, after working in this youth program, I would think: ‘Hey, my family is a lot more functional than others’. When working with these young people and their families, I soon realised that, despite the conflict, if the parent was still willing to work on things with their kid, there was a place for growth and repair. Sometimes, though, that love seemed hard for everyone to find. In our youth residential support program, we aimed to support families to find a bridge back together, help the young person improve both their self-esteem and routines and get them back to school or start employment. We also tried to help them build their resilience with different coping strategies. As one can imagine, having a house full of teenagers with various mental health issues, while also working with their families, made for some colourful ups and downs. Having survived my teen years, I can now appreciate how shit it can be to be an adolescent. My primary school had been small, Catholic and innocent. To give you an image of this kind of innocence, at school discos, the girls would stand on the

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opposite side of the hall to the boys. We had one ‘couple’ in grade 6, who cried when a group of kids told them to kiss, and they didn’t want to. They never kissed, yet they were our school’s most exclusive romance. Graduating to high school from this kind of environment was a rude introduction to the ‘adult world’. I went from being a tall lanky girl, who was agile and fit, to having double-D boobs within a couple of months; I was also covered in pimples. Every month I experienced crippling period pain that not only made me feel nauseated and gave me migraines but also made me feel incredibly depressed. Also, in high school, many of my fellow pupils talked about having had sex. I had not even danced with a boy at a disco, let alone kissed someone. The girls also hiked up their skirts and wore makeup and fake tan, and the guys called the girls sluts, no matter what they did—long gone were the days of innocence of primary school. Being able to run and play netball seemed so much harder in my new body. I ended up becoming a competitive runner purely to avoid lunchtimes after my friendship group no longer wanted to talk to me, with no explanation as to why. What was this new world I was in? Don’t get me wrong, the teen years had their place. I took a lot of risks and I learned a lot. I also had some beautiful friendships with people and I’ve probably never laughed so much in my life. But I sure as hell wouldn’t go back and relive that chapter of my life if I had a choice. With this background, working as a nurse with adolescents was somewhat surreal. In some ways, I still felt like a teenager—as though my high school days were just yesterday—and in other ways, I felt totally removed. A lot of the residents in the program thought that I was 18 years old (because 18 is very old in the eyes of a 13-year-old), and I found myself often feeling somewhat like a bossy sister, or an aunty (the assertive yet cool one, I would like to think). I think some of the following notable conversations capture the nurse–adolescent and nurse–parent relationship quite well. Context: Picking a suitable film to watch in the house. Billy (teenager): ‘I want to watch the film Texas Chainsaw Massacre’. Nurse (Rasa): ‘It’s the birthday of one of the other people in the house, not yours. So, it’s fair that she can pick tonight’s film, one that is suitable for everyone to watch’. Billy: ‘So, we can watch Texas Chainsaw Massacre when it’s my birthday then?’ Nurse: ‘If Texas Chainsaw Massacre is deemed as an appropriate film choice by all staff and residents in the house on the night of your birthday, then sure’. Billy: ‘But I want to watch it tonight’. (Billy was a sweet, but spoiled, only child who was used to getting his needs met if he kept nagging his parents until they caved in.) Nurse: ‘Don’t bullshit me, Billy. I know that you have already had this conversation with one of the support workers today and that they gave you the same answer as me. It’s not your movie choice tonight. End of story’. All teenagers in the house in unison: ‘Woah Rasa. I never thought I would hear you swear’. Context: Trying to get a resident, Talia, to have a shower. Youth worker: ‘Can you please have a conversation with Talia, she’s not showering or washing her clothes and I can’t handle the smell’. Nurse (Rasa): ‘Has anyone had a conversation with Talia about it?’ Youth worker: ‘I feel awkward talking about it with her’. Nurse: ‘That’s because it’s an awkward conversation’.

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Youth worker: (says nothing) Nurse (sighing): ‘Fine, I’ll do it’. Nurse: ‘Hey Talia, can we have a chat?’ Talia (cheerfully): ‘Sure come in’ (into a room smelling of hard-core body odour). Nurse (does not breathe through nose): ‘Just wanted to check how often you are showering and washing your clothes?’ Talia: ‘Often, why?’ Nurse: ‘How often is often?’ Talia: ‘You know. Often’. Nurse: ‘Often is a subjective term that means something different to each person. Are you showering daily and washing your clothes regularly?’ Talia: ‘Mostly’. Nurse: ‘Hmmm, the thing is… When people hit puberty, there are many hormones going through their body. This means that showering and washing clothes is really important… So that people… smell good’. Talia (nodding but looking vacant): ‘Okay’. Staff member: ‘Right, let’s go wash your clothes now; I’ll give you a hand’. (Starts picking up Talia’s clothes mid-sentence and placing them in the basket while Talia insists that they are clean.) Context: Applying some tough love to get a resident to go to school. Nurse (Rasa; overhearing a conversation): ‘Anthea, I just heard you tell Felicity (another resident in the house) that you are not going to school tomorrow. Why is that?’ Anthea: ‘Because no one else is going to school tomorrow’. Nurse (realising she has become her mother): ‘I don’t care about who else isn’t going to school tomorrow, you are going’. Anthea (approaching the nurse at ten minutes to five.): ‘But I’ve had such a bad week, you don’t understand’. Nurse: ‘I know you’ve had a bad week; no one doubts that. But not going to school won’t help you feel better. Go on and pack your things for tomorrow, we will work out a support plan before you go to school, and you will be okay’. Context: Realising how much teenagers influence each other: the need to impress. Female teenager (laughing at something on YouTube): ‘Hey Rasa, come and have a look at this video, it’s hilarious’. Nurse (Rasa): ‘Is this going to be like the video you showed me before of the horse not making it over a jump and probably injuring itself? Am I going to be upset by this one too?’ Group of teenagers: ‘Just come and have a look!’ Nurse (reluctantly and with a degree of caution): ‘Err, okay’. Female teenager (revealing that they are watching unsuccessful acts from American Idol): ‘Isn’t it so funny?’ Nurse: ‘I feel a bit sorry for those people taking part in a serious performance and then being made fun of publicly’. Female teenager: ‘Oh Rasa, we knew you wouldn’t like it. You’re too nice’. Male teenager: ‘Actually, I don’t really like it either; I was just watching it because the others were’. Nurse: (Cracking a satisfied small smile and not saying anything in case it spoils the moment)

Although I was not employed as a family therapist, at times I felt like one (albeit, winging it a lot of the time). From the 4-day intensive family therapy training that I self-funded to assist my knowledge in this role, I learned that a lot of family therapy comes down to basics: trying to stay impartial—which is super difficult—and aiming to give different people in the family some perspective. Conversations with

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teenagers are often a little like: ‘So, how do you think Mum feels when you slam the door on her and tell her to fuck off?’ Conversations with parents can be a bit like: ‘So, you decided to film your child with your phone when they were angry, and what kind of effect did you think that had for their anger?’; Or, ‘So, he kept getting angry with you until you ended up giving him a cigarette that you fished out of the bin. The same cigarettes that you threw out because you said he couldn’t smoke them?’ Predictably, our job as clinicians was to expect parents and their children to, at first, come into the program blaming each other. Then they would both begin to blame us—the clinicians. Finally (hopefully), the child and their parents would be able to self-reflect and both see what they could personally improve and work on in the relationship. At other times, the therapeutic work was downright chaotic and messy. Such was the case with one notorious family meeting. The support workers at the house always knew that this meeting for the resident, Kanya, was going to be difficult; she did not want to move back in with her family after being in our program. Normally, we would be encouraging of families living under the same roof, unless it was completely inappropriate. Kanya’s situation fell into the second category. Kanya’s father had strong religious views that she was not in sync with, and he had a temper. One time they had gotten into an argument at a local restaurant, where he had physically beaten her up, and the incident had been so bad that it had got on the news. Kanya was of an age where she was able to make her own decisions about where she wanted to live, so a big focus of this meeting was for Kanya to be supported when she broke the news to her family, who would not be happy about her decision. Restricted availability of the program manager, myself and Kanya’s family meant that the meeting had to be organised for a day when I wasn’t working. It wasn’t ideal that I was unable to make the meeting, but the manager of the program was able to, so I figured that this would be sufficient (on condition that the manager and I organised an agenda together prior to the meeting). In the days leading up to the meeting, as planned we set a written agenda. It was organised in such a way that everyone in the family could have a chance to give their view and feel heard. Then, at the end of the meeting, we would talk about Kanya’s wishes for her living arrangements. I advised Kanya’s father about the meeting and the agenda prior to the said meeting day and he seemed to be happy with the plan. However, I came back to work to hear that the whole thing had gone up in flames. On the day of the meeting, Kanya’s family had brought a legal representative with them, who was certainly not one of the invited attendees on our list. Also, we had organised an interpreter as Kanya’s mother spoke very little English. By chance, the interpreter knew the family and Kanya’s father went ballistic because of that. The legal representative started screaming at our support team for being ‘culturally insensitive’ because we had not checked if the interpreter would know the family personally. In response, our team tried to explain that the interpreter had been booked through a service that was independent of our own. When Kanya’s wishes to not return home were mentioned, Kanya’s mother started experiencing chest pain (probably from stress), and an ambulance was called

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because people thought she might be having a heart attack. Meanwhile, the manager had to leave the room as Kanya’s dad had started screaming at her and she felt threatened. Due to leaving the room under duress, the manager subsequently left her bag which held her phone, wallet and other personal belongings in the room where Kanya’s father was; but she was too afraid to try and retrieve it. The family also said that they would be seeking legal action against our team for trying to separate Kanya from her family. I put this down to a meeting where nothing could have actually gone more wrong, even if we had tried. Having five teenagers in a house always meant that some residents would adopt a stronger fondness to particular individuals than others, as is the way for adults. With one particular cohort, we had two residents—Kylie and Will—who seemed to take a bit of a shine to each other. Crushes are fine in a recovery program when they are ‘innocent’, but they can also get complicated, quickly. We had a rule in the house that no resident was allowed in another’s room; girls and boys were also kept in different wings. On one occasion, Will was spotted hovering around Kylie’s room and was told by staff why he couldn’t do that. We explained that each resident needed to have their privacy and boundaries respected. Will said that he understood this and would not bend the rules again. The next day, as I walked through the lounge room, out of the corner of my eye I thought I saw Will with his hand on Kylie’s leg. I wasn’t sure if I had seen it or not, and I wanted to give Will the benefit of the doubt, so I said, ‘I hope everyone is keeping appropriate boundaries’. Both of them nodded but had guilty expressions plastered on their faces. As I felt that I had no evidence to push the matter further, I smiled weakly and walked away. As I walked back later, I saw it again. Will moved his hand away in a flash. ‘What did I say about boundaries?’ I scolded, and then asked them to sit on different pieces of furniture. Will and Kylie seemed to have gotten the message. A day later, I received a request to call Kylie’s parents. They had seen a photo on Facebook of Kylie wearing Will’s jumper, and with a hickey on her neck. I could have died. At times like these, I felt like palming my job off onto someone else, but I couldn’t, so I sat down with Will and Kylie, both of them holding their gaze directed towards the ground. ‘How on earth do I explain this to your parents?’ I demanded. They couldn’t say anything to me, and I again realised I was becoming more and more like my parents each day. As I discussed, like the uncomfortable situation with Will and Kylie, there were certainly times in that role where I wanted someone else to step in take-over (when things got hairy). On the flipside, with other tough situations, there were times when I just wanted to take the kids home as a way to rescue them. We had one boy in the program, Oscar, who towered over me and was a handsome young chap, lanky and awkward, incredibly polite and his face would glow bright red when he was embarrassed. Oscar was a true example of someone lacking the protective factors that he needed. I could not count how many problems he had with his family. Dad had left. Mum had a drug addiction, so did his sister (which was complicated by a degenerative medical condition). Oscar also had his own issues with drug use and would get into fights at school. He had been expelled from

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one and then stopped attending another and neither his mother nor the school had made any assertive follow-up—or even plans—to get him to go back. As a consequence, he had not been to school in a year and by the time that he entered my program, Oscar’s confidence was pretty smashed. Amazingly, he had the perseverance to stop using drugs immediately, purely of his own accord and determination. Being in a new environment, where no one else was using drugs, probably helped too. While he was in the program, his coping strategy to deal with his anxiety and depression was to focus his energy on mountain walks and swimming. He also got back to school with support from our residential facility staff and his teachers. On one walk up the mountain together, he opened up to me about his feelings of abandonment from when his father had left the family. I also learned how the craziness of his world was very normal for him: his mother offering all of her underage children alcohol at Christmas time, that sort of thing. Oscar was a good person with many positive skills and attributes; he just needed to be in an environment where he wasn’t surrounded by chaos: everyone in his family needed help, so they weren’t able to help him. While he was with us, Oscar completed his year 10 certificate, which was a phenomenal achievement given his long absence from school. However, this now meant we had to prepare for Oscar to leave our program as he had been given an extension of his stay so that he could finish his schooling. We all wanted to keep him with us in the program, for fear of how he would cope without the support we gave him, but we also knew we had to let Oscar go home at some stage. I organised a meeting with Oscar’s mother, but on that day, Oscar ran late coming home from school. So, I started the meeting with just his Mum by acknowledging everything that Oscar had been through, with a focus on his resilience. Oscar’s Mum agreed and talked about how he had been through a lot, especially when her sister had sexually assaulted him. Blood rushed from my head to my boots and I had to ask Oscar’s Mum to confirm what she had said, as no one had mentioned this important detail before. To be absolutely certain, I specifically asked if Oscar had been sexually assaulted by his aunty—his mother’s sister. Blandly, she confirmed that this was indeed the case. I think Oscar’s Mum had grown so accustomed to trauma in her life and the lives of her kids that she had lost track of the magnitude of what each individual event signified. Feeling shaky, I stated that the kind of incident described was a significant life event in the context of trauma. With my heart beating quickly, I enquired if Oscar had talked to anyone about the assault. She admitted that she didn’t believe that Oscar was even aware of her knowing the assault had occurred. It was deeply saddening to hear this, because I realised then that some of the family knew about the assault, but it was doubtful that anyone had ever spoken to Oscar about it after the event. After learning this, I spoke with Oscar’s case manager and asked her to bring this up in counselling with him. However, she didn’t feel comfortable doing so, as he had not brought up the event with her personally. It was coming up to the end of Oscar’s time with us and I didn’t want to reopen another wound for him when he

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was doing so well. Secretly, I also didn’t want to have to be the person to potentially see him upset and have to deal with the aftermath, but the queasy feeling in my gut remained. The issue would always be left unaddressed if I didn’t bring it up with him, and I couldn’t let this boy continue with the next chapter of his life without him being given a chance to at least talk about what he had been through. I arranged with my co-worker to sit with me and Oscar when we talked about it. Oscar looked so happy and then suddenly very scared when I said that we needed to talk. I felt awkward, but I needed to find a way through it. There is no easy way to address assault. ‘Oscar’, I began. ‘Your Mum told me something yesterday, and I wanted to bring it up. It’s not an easy topic to talk about’. Oscar looked confused but said, ‘Okay’. ‘Your Mum told me about something that happened, something involving her sister and sexual assault… towards you’. Oscar pulled his hooded jumper over his face and burst into tears before burying his face into his hands. My heart broke in two. I had never before met a young boy who had been sexually assaulted by a woman. The world was so unfair. How could this happen to Oscar? Oscar couldn’t make eye contact. Through huge sobs, he told me that he hadn’t told anyone and that he didn’t even know that his mother knew. I asked Oscar if he wanted to talk about it and he said he didn’t, so I then made it clear that we were there if he ever wanted to talk about it and emphasised what a strong person he was. He looked up slowly and said, ‘You guys are really kind; do you know that?’ I had felt maternal previously when I was in Vietnam working at an orphanage where I was surrounded by sweet parentless children. I had wanted to take all of the children home, because I knew that I could take care of them. And in that moment with Oscar, I felt those feelings again. I wanted to try and save him (unrealistically) from having him face another awful event in his life. At the youth residential program, we weren’t always caring for young people who were traumatised. Sometimes, those in our care just needed a bit of help to get through that crappy point in life that is being a teenager. All that stuff about trying to find your identity as a person will come and go at different points in your life. However, teenagers experience this all while their hormones are going nuts. They are outgrowing their clothes and their shoes and eating their way out of house and home and yet still being hungry and needing to sleep all the time. Also, in many ways, they are outgrowing their emotional selves at an accelerated pace. I once cared for a young man, Phil, who was prone to getting angry and not knowing why. I tried to explore what some of the triggers to his anger might be, but Phil found it hard to communicate his distress. He was a perfectionist and was really hard on himself in every way, from the way he appeared to others to the grades he would receive at school. By the time Phil was ready to graduate from the residential program, he had made significant progress. Phil and his family had found ways to communicate more effectively, and he had gained part-time employment, which he enjoyed. However, his sporadic outbursts of anger were still there.

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A few months after he left us, Phil dropped by to return a book that he had borrowed from one of the support workers. He told me that he had been looking forward to returning the book as it gave him a chance to see me and all the staff members to say thank you. I couldn’t believe how different Phil looked; he was confident, he had good posture, and he spoke with gusto with a big smile planted on his face. He was now sporting skinny leg jeans, a smart, fitted, checked shirt, an earring and a hipster haircut. Phil looked great because he was now confident in his own skin. Looking back at the conversations that I had with Phil’s family during his time at the residential program, they seemed to think that Phil was struggling to come to terms with his sexuality, in which they wondered that he might be gay. His family were supportive of him no matter what his sexual orientation; they didn’t want him to suffer and they just wanted him to be happy. It appeared that now, he looked at ease. Yet I didn’t feel that I needed to start enquiring with him about what had changed for him. I told Phil that what I could see was a young man who had come out of his shell, the vision of good health and wellbeing. Phil thanked me for hanging in there with him while he was being a ‘brat’ and I told Phil that he had himself to thank and that I was really proud of him. To be able to help our youth, we, as nurses, have to somehow remember our journey of being a teenager. Can you remember how many pairs of shoes you went through while growing up as a teenager? As soon as you had a pair that started to feel comfy, your toes would start rubbing on the end; it would be painful and you would have to annoyingly find new shoes that would hurt to break in—and the cycle would continue. Anyway, whether or not we can step into the shoes of others, we need to imagine what it might be like if we did.

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The good nurse should wear comfy shoes and clothes that double-up as martial arts apparel. My disclaimer for this chapter is that I understand that many of the people who take a physical swipe at nurses, or throw things deliberately in their direction, are

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often experiencing an impairment or malfunction of the brain. This malfunction could be something like acute delirium caused by dehydration or an infection, for example. Or it could be the result of a gradual deterioration of the brain, such as with Alzheimer’s disease or dementia. Also, people who are highly emotionally dysregulated may do something impulsive they would not have done if they were in a calmer state. I’m not trying to understate the seriousness of any of these conditions, or how they affect the people who have them and their loved ones. However, as a nurse, one needs to make light of things to be able to deal with these sorts of difficult situations. Otherwise you would not get through the day. My first experience of learning to move quickly came in my first job during high school—working at McDonald’s—where part of my role was operating the drive-­ through as a cashier to distribute food orders to customers. I was taught to hand out the food order through the window as quickly as possible. Adopting this strategy meant that, if an angry customer started going ballistic, you could shut the window before they had a chance to harm you in any way. We all followed the unofficial protocol: think ahead and slam the window shut. I never had anything thrown at me, but unfortunately one of my work mates, Chris, did. At the time, Chris was trying to console an unhappy customer—who was angry with him for being given the wrong order. The customer was making physical and verbal insinuations that he may throw something at Chris, and then subsequently hurled a soft serve at him. As he had been trained, Chris slammed the window shut before the ice cream could hit him. As a result, the soft serve plugged itself to the window like a creamy dart. The ice cream then melted down the glass slowly while Chris—on the other side of the window—was both hyperventilating and laughing, which I feel was Chris trying to emotionally regulate himself after a pretty shocking experience. Working at McDonald’s was the first time in my life where I truly witnessed how irrational people can be when they are upset. On that note, I’m sure as hell not saying that it is okay to throw your ice cream at the 15-year-old cashier when they accidentally give you a cheeseburger instead of a big mac. The fast reflexes that I learned at McDonald’s came into play when I was working as a personal carer in a nursing home while I was studying nursing in 2007. I was working on a shift in a high-needs dementia wing where there was only one other nurse on duty. In hindsight, we should have had a lot more carers on shift that day to protect the residents and each other. However, the staffing of nurses in those days was never adequate enough for the high-level needs and the number of patients needed to be dealt with. (Unfortunately, I feel this is still the case today.) Something I learned working at that nursing home that I never would have believed was that elderly people do not necessarily lose their physical strength (or their sex drive for that matter). One of the residents, Stuart, was a really big fellow and an ex competitive boxer. On this day, he was clearly stressed about something, but I could not decipher exactly what it was. He abruptly approached another resident, who was about a third of his size and was silently watching television. Stuart pushed the woman right out of her wheelchair. After consoling the woman, checking her for injuries, and lifting

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her back into her wheelchair, the other nurse and I tried to coax Stuart into his room in an effort to help him de-escalate. Deep down, I felt that our attempts would be futile, but we had no choice but to try. Everything was happening very quickly, and we were not getting much time to think. Stuart became even more frustrated and began throwing furniture around the room, so the other nurse—who was growing desperate—injected him with a dose of sedative to try to take the edge off his behaviour. However, due to Stuart’s wrestler-­ like stature, the medication didn’t touch him. By this time, security had been called, but they were taking a long time to get to us. Meanwhile, we had been trying to get Stuart to sit down so as to restrain him because, at this point, we had no choice. Abruptly, Stuart then grabbed my wrist and dug his fingernails in so hard that it broke the skin. He then began to turn my wrist around at a 180-degree angle. In response, I squealed involuntarily and twisted my torso in an effort to reduce the injury I would sustain to my wrist—I genuinely felt that the force and angle of Stuart’s grip would result in my arm being fractured. Then, as quickly as it had happened with me, Stuart took the same handhold with the other nurse, who also yelled and then cried. I was really scared, and situations like this have taught me that when the captain is panicking, the crew have no hope. Security eventually arrived and were able to restrain Stuart. Despite the shock I was feeling, I told Stuart genuinely, that I was sorry that this had to happen. He just stared at me with wide, glassy eyes as his arms were roped to a chair. Then, in an effort to try to release himself from the restraint, he pushed his head forward, wriggled and shouted: ‘Fuck you!’ Nurses often get a lot of flak from others when they have to restrain someone, and I have never met a nurse who has not found restraining someone to be an upsetting and demoralising experience for them. If nursing workplaces were adequately staffed, I feel that a lot of situations where restraints are required could be prevented. However, the reality is that nursing workplaces are typically poorly staffed. In addition, nurses are often confronted with aggressive patients who are three times their size, which can leave them with very few options as to how to protect themselves. With time away from such a situation, it is easy to be logical and recognise that Stuart had dementia, and the way that he was behaving while being restrained was not necessarily a reflection of his true character. Stuart, in that moment, would have likely felt frightened, confused and threatened and it made sense for him to swear at me. I had empathy for Stuart, but I also felt so damn powerless. My lack of nursing experience at that time, in combination with feeling so overwhelmed by the whole scenario, led me to start crying in front of this man; the way his gaze was directed at me made me feel like a villain. At the time, I couldn’t separate Stuart’s illness from the frightening experience of having a person intentionally hurt me, and my stomach continues to turn every time I see a person who has to be restrained, even when I understand that it is the last hope for the safety of that person and those around them. Experiencing aggression or injury from a patient is never easy or pleasant. I once read in a nursing journal, a story about a psychiatric nurse who needed time off for

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a concussion when a patient threw a toaster at her head. The article then went on to say that this nurse was having a hard time returning to work because she was experiencing PTSD symptoms. The article also told how that nurse’s manager had told her (clearly with no compassion or empathy and more of a focus on keeping the roster filled) that as she had wanted to be a psychiatric nurse, she should expect that this kind of thing would happen. However, even if people expect some danger and aggression from others as a part of a job (be it as a nurse or a drive-through attendant at McDonald’s), it doesn’t mean that they will not be affected by it when it happens. Nurses and McDonald’s staff also generally don’t sign work contracts that say that they should expect toasters (or ice creams) to be thrown at their heads. Regardless, nurses, like McDonald’s staff members, have to accept the risks that they face in their job and also learn to master the unofficial on-the-job training—to duck and weave. At a different nursing home, I once had this lovely resident beam at me with a wide smile and then suddenly give me an uppercut to my nostrils, right out of the blue like a jack-in-the-box. In this regard, the same principles apply to nursing as they do in boxing. One needs to keep adequate range and always have their guard up. You never know when someone might fling their fist your way. I’ve never been seriously hurt. However, in my experience, I’ve found that every hit to the face has left me feeling a bit stunned. When I played basketball in my 20s, I played on a mixed team with boys who were much bigger than me. In one particular match, I was hanging around the basket ready to try for a rebound if this guy on my team missed his shot. Instead, he faked it, jumped in the air and launched the ball down at me at full speed—as a pass—so I could take the shot instead. The ball hit me in the face, hard. At that time in my life, I was trying to avoid any unwanted attention, so I didn’t want to make an issue about getting knocked in the face. My face was a bit numb and I was also still a little shocked about what had happened, but, in order to appear ‘cool’, I said I was fine when my teammate asked me if I was okay. In response, he pointed out that my lip was, in fact, bleeding. It is much harder to act cool when your lip is gushing blood; however, this injury did not make me cry. And, even in my Muay Thai training, where I had been told that most people will shed a tear during sparring at one point, I rarely did, as the blows I received were just part of the sparring. Intent, however, can bring with it an enhanced emotional effect. When one person is deliberately trying to hurt another person, without provocation or warning, it is an awful experience. I make it sound as though nurses can stay unaffected by aggression if they can compartmentalise the medical or psychological cause of the behaviour and ignore any intent. However, as I discussed in the incident with Stuart at the nursing home, that’s not always easy to do. In my case, I have always been taken by surprise when someone hits me—even if I suspected it might happen. While working on a psychiatric ward where I was filling in, I was asked to do a medication round and went to give a gentleman his paracetamol. He was watching television and I couldn’t get his attention, so I gently touched his hand. I was successful in gaining his attention but then he turned around and clocked me in the face.

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I told one of the permanent nurses what had happened. ‘Oh yes’, she responded. ‘He can get a bit punchy sometimes’. ‘Nursey,’ I thought. ‘That information might be good for the fill-ins to know before the medication round’. Another time, while working in the emergency department, I found my colleague, Allan, in a wet uniform, patiently and calmly sweeping up tuna as a patient was being taken down the hall screaming at the top of her lungs. He told me that the patient had thrown the tuna at him and then went on to explain that the patient’s change in behaviour was to be expected, given that her blood sugar levels had skyrocketed. Changes in blood sugar level can affect a person’s mood and mental status, and when their blood sugar returns to a normal range, these symptoms often resolve themselves. With this knowledge in mind, Allan was confident that the patient’s behaviour would be back to normal once her sugars were controlled. I asked him how he was going and he told me that he was fine. And I think he genuinely was, whistling away as he swept the fishy floor in preparation for mopping it. Allan then smiled and added that he appreciated that the patient had opened the can and threw the contents, instead of the actual can, at his head. I’ve also had a cup of coffee thrown at me, which I only realised was cold after it hit me (thank the lord). It was thrown by a community mental health client of mine while he was particularly unwell at the time—and therefore residing in a psychiatric ward. He was acutely manic, and I think that he genuinely thought that throwing a cup of coffee at me was a playful and fun thing to do. After the initial shock (and realising that I had not been scalded), I saw the funny side of the event, despite my coffee-covered dress. Note readers that this was at the start of my working day and I had nothing else to change into. I, personally, have never had poo thrown at me, but I know of others who have when dealing with patients who are psychotic and distressed. I think it would be funny for everyone else, but less funny for the person having the poo thrown at them. So, junior nurses, when you go to work, make sure you bring your lunch, wear your comfy shoes and also keep your hands up and bounce.

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The good nurse has witnessed more than other people will in a lifetime, naked bodies included. Nurses become accustomed to some pretty odd conversations and strange interactions with patients. When I think of these kinds of peculiar interactions, one particular patient, named Igor, comes to mind. Igor was a patient residing on a medical ward. He had a thick Slavic accent and held a lot of conspiracy theories, and he also had a touch of dementia. It was never hard to spot Igor: walking around with his glasses on, one lens shattered and stuck together solely with sticky tape. Often, Igor would approach the desk at the nurses’ station to ask for the yellow pages to call someone. While maintaining a serious expression, Igor would inform the nurses that he had an ‘urgency’ to call a person—whose identity he could not disclose, as it was a big secret. On top of that, Igor was incontinent and refused to shower; this was one of the most significant issues that the nurses had in caring for him. When asked why he wouldn’t shower, Igor would never provide a reason. He straight up stated that he didn’t want to wash himself or be washed. Even when his pants were completely soaked with urine, he was adamant about his wishes to remain shower-free. Igor refusing to shower was a major hygiene concern and resulted in a very offensive aroma. Still, I had to admit I admired Igor’s resistance. I also had to remind myself that, as I had been told by the nurse manager, if a patient doesn’t have a shower every day, it’s not going to be life threatening. However, after not showering for days—and with his wearing soiled pants—showering starts to move from the category of less important to more of a priority. I have learned in life that charm can sometimes be a useful tool, and it certainly applies in nursing. So, on one particular shift, when Igor had been allocated as one of my patients, I entered his room with a smile carrying some towels. However, before I even had a chance to greet him, Igor stated firmly: ‘I am not having a shower’. I made my best efforts to try and make the shower sound more appealing than it was, through taking on a bit of a used car salesman approach. ‘Igor’, I started, ‘you don’t look very comfortable in those old pyjamas’. Then I added, ‘You know, it might be nice to feel some warm water on your skin, and you’ll have some fluffy, white towels and brand new pyjamas on your bed waiting for you when you get out. Doesn’t that sound great?’ Then, before he could respond, I said with a hopeful smile, ‘It doesn’t need to be a lengthy shower, and you would make me very happy if you did this for me’. Igor contemplated my offer for a moment, grunted and then reluctantly agreed to have a shower. I couldn’t believe my luck and felt like running a victory lap to the Rocky theme music. Leaving Igor to have his shower in peace, I snuck off to proudly tell the clinical nurse consultant (CNC) of the ward that Igor was having a shower. As a nurse, you will get excited about these kinds of little wins, as they can be huge achievements. The CNC congratulated me, remarking that I was the first person to be able to get Igor to shower in nearly a week. She then asked me what I did to get

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him to shower. I told her that I just asked him persuasively to do me a favour and sold the shower to him like it was a Turkish bath or something exotic. A little while later, Igor’s call bell for the shower buzzed, so I went to check in on him. I found him sitting on a shower chair with the water running. Through the hot vapoury mist, Igor murmured huskily, ‘Come here’. I edged closer, slowly, with apprehension. ‘Come closer’, he repeated creepily. With hesitation, I crouched a little closer to be more at his level while deliberately keeping some distance. He moved to the end of his seat and reached his head up towards my ear so that he could (loudly) whisper, ‘Would you like to shower with me?’ ‘Igor, I am your nurse’, I responded, in case he had become confused because of his dementia. ‘I know’, he said, as his lips morphed into a provocative grin. Igor is a great example of a person who can have muddled thought patterns much of the time but be capable of saying something lucid in the most surprising ways. I love that in all of the confused conversations that Igor had with the nursing staff, he managed to pull it together when he wanted to hit on me midway through his first shower of the week. This man, Igor, became pretty famous in our ward. On another shift, my nursing friend, Jenny, had to report at handover time that Igor had gone missing. The CNC exclaimed in wonderment how in hell Jenny had managed to lose Igor. Meekly, Jenny replied that she didn’t know how she had lost him—she was stressed out of her brain, and feeling understandably hopeless about the situation. As it turned out, Igor, with the same assertiveness that he had had with his shower refusal, had decided that he didn’t want to be in hospital anymore and wanted to go home instead. So, while wearing his backless patient apron, Igor had simply sashayed out through the security doors while the kitchen lady, who had been moving through them, was preoccupied with her food trolley. Not one person thought to stop this half-naked man with his broken glasses. In fact, Igor managed to take his briefcase, walk out the door and across the street (with his bum in the sun and patient ID band on his wrist) and catch a bus home. You can imagine how many people would have eyeballed Igor during his great escape: visitors at the hospital, pedestrians… The bus driver would have even had to sell him a ticket. I laughed when I heard about Igor’s ‘prison break’, imagining him making a quick beeline for the door. It was only when Igor got home that his daughter stopped him in his tracks and drove him back to the ward. I get it Igor; it sucks to be in hospital. The other thing that Igor liked to do was wear his hospital pyjamas with a belt underneath, which meant there was nothing available for his pants to actually anchor to. One day, again when Jenny was on shift, she got down on the floor to help Igor tie his shoelaces. Due to the belt underneath the pants’ arrangement, Igor’s pants fell straight down while he was standing in the middle of the corridor. Jenny did all she could not to laugh, so as to not embarrass Igor, but unfortunately a doctor nearby saw what happened and burst into cackles involuntarily. The contagious effect that laughing can have affected Jenny, who—still crouched on the floor—could no

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longer stop herself from cracking up. She told me later that, at the time, she felt ashamed about laughing at Igor. However, that was about to change because about 15 minutes later Igor, with a triumphant countenance on his face, walked up to the doctor who had seen his pants fall down. Cocking his head sharply at Jenny he stated: ‘You see that nurse over there, she tried to hit on me. But I’m not interested’. That rejection helped relieve Jenny’s guilt. Nurses need strange encounters with clients like Igor to keep the shift interesting.

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The good nurse will appear strong and will then cry on the way home. When no one has been forewarned that a storm is approaching, it is hard to know how to prepare for it. Nurses are often blindsided when they experience something that causes extreme stress or trauma. It is not always easy for nurses to be able to predict what will affect them so intensely. The way that an individual reacts to a situation is often dependent on the person as well as their previous experiences and conceptions. One of the first significant times in my life I recall being surprised by a fearful response to a situation was outside of nursing: it was during my time on the Young Endeavour when I was a teenager. The Young Endeavour is an Australian Navy tall ship staffed by navy crew who teach young people how to sail and to lead. I thought that I was okay with heights until I had to climb to the top mast (otherwise known as the topgallant), when I virtually had a panic attack. Only at that point did I realise how confronted I was by such extreme height exposure—I had never been so scared in my life. I was crying and swearing, and I nearly lost all bowel control (not exaggerating). With practice, climbing to the top became easier and finally, actually enjoyable. But I was really thrown the first time though, and I never would have anticipated that the brave, outgoing girl that I thought I was would be the one who found climbing to the top the most difficult. I’ve always found it interesting to hear what people say they would do, hypothetically, if they encountered a stressful or adverse situation. I’ve had friends who have previously stated that they would never stay with partners who have cheated on them (if it ever happened). Then it did happen, and they stayed. Many people have also told me that they would not pursue active treatment if they got cancer, and then—by chance—later be diagnosed with cancer and push for treatment to start the very day they got the news. One of the more interesting examples of this was with a friend called David, who was about to enter a security-type role arresting illegal immigrants to be deported back to their countries. David never believed that the stories of the people he was arresting would mess with the way he approached and felt about his work, and he always referred to his dad’s history in the police force. David’s father always spoke in black and white terms about how people who have done the wrong thing ‘needed to pay the price’. I felt that David had simplified the role to himself, and others, as a way to protect himself, or perhaps he just had no idea what the job would actually be like. With time, David ended up becoming deeply affected. The reality was that, no matter how tough he acted, the traumatic stories of these immigrants were still upsetting. He began to question the ethics behind his role. These immigrants, as they had been described in the public service job description, shifted from being two-dimensional fictional characters to being actual people. And, no matter how hard he tried to brush their humanity aside, David had to accept that these people had feelings, needs and wants, hardships and complications. He ended up undergoing a lot of counselling to come to terms with what he had witnessed and heard and was soon making tracks to leave that job.

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People often think that death is the most confronting thing to face as a nurse, but that’s not always the case. My journey into nursing really began when working in an aged care home as a carer so, by the time I started working in hospitals, death was not a new concept for me. On my first shift as a new-graduate nurse on a medical ward, I was briefed by one of the clinical facilitators about my plan for the morning with my patients. One of my patients, John, had methicillin-resistant Staphylococcus aureus (MRSA), which is a bacterium that causes infections in different parts of the body and is resistant to the antibiotic methicillin, which is normally used against this type of bacteria because it is also resistant to penicillin (i.e. it is one of the antibiotic-resistant superbugs). When patients have MRSA, they need to stay in isolation, and nurses need to wear special protective clothing when entering their room. The protective clothing also needs to be correctly disposed of each time the nurse leaves the room, to avoid spreading MRSA through the hospital; this is a time-consuming process. In this medical ward, I would normally start the shift by saying good morning to all four of my patients, introducing myself and asking them individually if they needed anything. After this, I would then commence the medication and observation round. I informed my clinical facilitator of my plan. However, she suggested that, on this occasion, it would be better if I said hello to the first three patients and then go and see John with my protective clothing on, with his medication ready to go. This would save time and also reduce the number of occasions of me going in and out of the room and, in turn, help reduce the risk of infection spreading. This plan made sense. My clinical facilitator left and I got on with the morning. After seeing my first three patients as per the plan, I got ready to see John. With my gown, gloves, apron and mask on, and a giant multivitamin pill to administer, I walked into his room. I was still partly asleep myself, which was normal for me on an early shift, so I said hello on automatic pilot. However, when I received no reply from John, I realised that he didn’t look alive. As I was tired, I was not sure if I was imagining this, so I went to touch him to make sure. He was cold and blue; he had clearly been dead for a while, so I called down the corridor for help. When I had gotten the attention of another nurse, I said (awkwardly), ‘My patient is not responsive’. The nurse came to see him and, with some confusion, sought clarification. ‘Rasa, he is not unresponsive. He is dead’, she said. I responded (once again awkwardly, and at this point feeling a bit silly), ‘Yes, I know he is dead; I just didn’t quite know what to say as this has not happened to me before’. Calling down the corridor, ‘Can someone please come here, as my patient is dead’, had seemed like it would alarm people at the time. Saying that John was ‘unresponsive’, when he was in fact dead, was a weird thing to say, but it also made sense because of my level of experience at that time. I’ll never forget how ridiculous I looked, sweating profusely, donned head to toe in non-breathable yellow protective gear with a giant multivitamin tablet in my hand. The most difficult thing to face in this situation was not John dying, but how the other nurses managed the situation. One nurse looked frantically in John’s notes to

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see if he was to be resuscitated should such a situation arise. She could find nothing, and so, in the absence of a ‘do not resuscitate’ medical order, a second nurse suggested we call the emergency medical team for John. These other nurses then explained that the emergency medical team needed to assess John, not because there was any hope of resuscitating him, but to cover themselves legally. One of the head nurses said that we should at least look as though we were doing CPR. It blew my mind, and I was not going to take part in it—it was unethical. I refused to pretend to do CPR on a man who could not be revived. I stepped away and started to write up my notes, explaining just exactly how I had found John. Another nurse then said to me, ‘It might be best that you don’t mention that his nasal oxygen prongs were dislodged when you found him’, and she also went on to suggest, ‘If you document less information, that is better’. I was appalled at the way the other nurses were reacting. John had not been neglected by the nursing staff, so why were we behaving as though we had to cover things up and had things to hide? I explained to the nurse that, if the coroner wanted to interview me about John’s death, I would be completely honest about how I found him, so I may as well write it down as I had seen it. Later, I had a different clinical facilitator come to debrief with me and see how I was going, given that John had died on my shift. My feelings remained the same: I was not affected at all by John’s death. John had had a lot of comorbidities, so his death was not completely unexpected. He would have been alive when the night shift staff had last seen him between 6 and 7 am. The shift handover was at 7 am and my shift started at 7:30 am, so he would have died sometime in that small gap. I had done nothing wrong with regard to the care that I had given him, and I had not known John as a person, seeing as I had just met him. Of course, I felt for his family, but it was not confronting for me. He had been loved and he looked peaceful after he had passed away. Whenever a patient dies, other clinicians will routinely check in just after the event to see how you are going, but sometimes it’s the things people don’t check up on that can be the most upsetting. For a period of time during 2012, I worked as a relief nurse. I chose this professional avenue to obtain a variety of different experiences in the nursing field because, typically, relief nurses are placed in a different ward or nursing area every shift. One day, I was filling in on a medical ward and I was given the handover for a patient whose name was Andrew. This man had lived a pretty hard life; he had a fractured family, had experienced homelessness at different points and had become addicted to opioids amid all of that chaos. Andrew had a lump on his face, which he had sought medical help for. Initially, the medical professionals who had seen him did not believe that the lump was cancerous. It wasn’t clear to me what kind of additional assessments or treatments had been provided for Andrew in those early stages of him asking for help. Regardless, over time, the lump hadn’t gone away and instead had increased in size. Eventually, a biopsy of the mass had been conducted and the lump was found to be a malignant tumour that had grown very quickly. Andrew was only about 30 years of age, and at the time of his diagnosis, he was told that he most likely only had 6 months left to live. Soon after that, Andrew began treatment at the hospital, primarily palliative treatment for pain relief.

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Because of a drug addiction, Andrew would ask for a lot of pain medication— more than what most people would ask for due to his body’s tolerance for pain relief medication. The nurse that handed over to me on the day that I met Andrew gave emphatic directions for me to just give Andrew as much pain relief as he asked for. Her justification for this approach was that Andrew was suffering, and because of his drug addiction history, he seemed to have a high threshold for the effects of opioid medication. With hindsight, I think it should be expected that anyone with a huge tumour on their face would want a lot of pain relief, regardless if they had a history of opioid dependence. As I went about my duties with Andrew, I found myself being prepped with warnings from other staff: ‘You will need to change Andrew’s facial dressing; it will take about an hour to do the procedure and the wound is grotesque’. Because of this, I was mentally preparing myself for the sight of this ghastly wound all shift. I gave Andrew his pain relief about half an hour before the procedure to give it enough time to kick in. And then, when it came time to do the dressing, I gently pulled away the extensive amount of gauze and padding on his face to find most of his nose was missing and there was just a huge cavity there instead. I had to take some deep breaths to steady myself. Anyone would think that seeing a man missing a significant portion of his face would have been the most upsetting thing here. It was confronting, but what was worse was how Andrew just continued to talk to me so kindly during the procedure; that and the added knowledge that this man had only 6 months to live. He spoke with shame and remorse while he winced from the pain of me swabbing his wound. ‘I’m so sorry that you have to do this’, he said. ‘This must be really awful for you’. I have tears in my eyes as I write this, and I still cannot believe that a man—so young—whose life was being cut short due to cancer and who was in tremendous amounts of pain was apologising to me. At the time, I felt deeply embarrassed. It was not the wound that was confronting me; it was this man’s suffering and his shame. At that moment, I wanted to cry, but instead I pretended that seeing the wound had no effect on me. I acted strong and I told Andrew that all I wanted was for him to be as comfortable as he could be; I also said that I could not imagine how hard it was for him to have to go through all of this. Andrew was incredibly brave. I told him this, and I meant it. My heart truly broke for him. The shift was busy—as it always is on a hospital ward—and afterwards I had to rush around until the end of the day without giving myself time to process my dealings with Andrew. That evening, in need of comforting, I went to the house of my boyfriend at the time. He was in the shower and the front door to the house had been locked (accidentally) so I couldn’t get in. I lost my mind and became angry at him. How could he be so mindless as to lock me out of the house? Of course, my reaction was an emotional projection of the events with Andrew. I cried and cried. How could he endure that kind of pain? The look in his eyes and his apologetic words have stayed with me ever since. Rest in peace, Andrew. What you will find confronting will surprise you.

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The good nurse will do whatever they can to get someone help, even if the person doesn’t think they need it. Our world—what is real and what is imagined—is really all in a person’s perceptions. It’s possible for any of us to wake up one day and have someone tell us that our reality is different than how we believe it to be. Even when people are psychologically ‘well’, it can still be difficult for us to find the truth through the illusions. I was working in a community mental health team when I was informed that a client, called Lily, was going to be allocated to me for case management. I understood through the handover that Lily had admitted herself for the first time to hospital for psychiatric reasons (an admission that was strongly encouraged by her husband, Colin). To try and learn more about Lily and better understand her situation, I read up on her clinical notes. In her hospital admission summary, Lily had stated that she was experiencing a mental breakdown caused by stress. She reported that her employment (she worked as an IT worker) was busy and demanding, and she also felt added pressure from parenting her two small children. Furthermore, Lily reported that she had lost a lot of sleep and was feeling extremely anxious—she definitely wasn’t herself and she felt as though she wasn’t coping. With regard to her admitting herself to hospital, Lily hadn’t felt it was necessary at the time and had been reluctant to go ahead, but Colin had been worried about her so she had agreed to do it. I became Lily’s case manager when she was discharged from the hospital to go back into the community. Looking through Lily’s inpatient clinical notes before my first meeting with her, I noticed that her behaviour while she was in hospital had puzzled the clinicians. She was reported as being very anxious and guarded in all her conversations, but she had not shown any other signs of paranoia or delusions, which are often key characteristics in psychotic illnesses. Subsequently, upon discharge, Lily’s treating team had not been confident with her primary diagnosis, but it was suspected she had experienced an episode of psychosis. Lily hadn’t agreed with this diagnosis and had simply told the staff at the hospital: ‘I think that my brain stopped working for a period of time’. Fair enough, I thought. Amongst her other qualities and roles in life, Lily was a dedicated wife, a mother and a professional. She just wanted to live a ‘normal’ stable and happy life. Don’t most people? Despite how much Australia has progressed in its views and approach to people experiencing mental illness, a lot of stigma remains in this area. Many people in our community still regard people with mental illness as being ‘crazy’, and I feel that the people who make these stigmatising comments do not realise how common episodes of moderate to severe mental illness are in the general population. One in five, my friends. One in five. Psychiatric stigma is also prevalent and severe in many Asian cultures. Lily and her husband were of Chinese-Australian descent. And I think that Lily was very aware of this stigma. A nurse can’t always tell that someone is psychotic straight away and it’s only with questioning that things become clearer. As planned, I started seeing Lily shortly after she returned to the community after her first admission to hospital. She had gone straight back to work while continuing her usual parenting responsibilities with the support of Colin. As time went on, she began experiencing high amounts of

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anxiety regarding some asbestos that had been found in the walls of her house. This was a real thing—her anxiety was legitimate—but these high levels of anxiety began crossing over into other parts of her life. In one of our meetings together, Lily reported that her boss and her other colleagues were plotting against her. I questioned this, wondering if Lily was experiencing paranoia. Saying that, most of us can relate to Lily, having had similar experiences—when we have felt judged or disliked by others, feelings that become magnified if we are highly anxious. The reality is that not everyone likes each other. Workplaces in particular can force people to spend time with others who personally drive them up the wall. However, it’s not culturally acceptable for a person to say to someone, straight up, that they don’t like them. In workplaces, this can lead employees to gossip and talk behind one another’s backs (or find ways to exclude or avoid the person that they dislike). I’m sure most people have experienced a situation where they feel like they are being talked about. Those around you can say that you are being paranoid, but they cannot truly confirm or deny the truth, which leaves you with the original suspicion: that someone is against you. After Lily was discharged back into the community, she said that she felt it was unnecessary to be under the treatment of a community mental health team. Subsequently, she tried to avoid seeing healthcare professionals, including me, whenever she could. She didn’t want to be considered a person with a mental illness. She especially did not want to be a person identified as having a psychotic illness, and if I were ever in Lily’s position, I think I would be the same. Lily was very good at hiding the way she felt and the things she was experiencing internally and instead she focused herself on getting on with daily life, working like a horse no matter what. A few weeks down the track at work, Colin phoned me. It was the day before Lily’s next appointment with her psychiatrist (an appointment that I would be sitting in on). Colin was worried that Lily wasn’t sleeping well and that she had virus-like symptoms, perhaps the common cold. She was also irritable and was withdrawing from Colin and her children. Not wanting to lose the opportunity for seeing her, I suggested that, if Lily was resisting coming to the appointment 30 minutes prior, he should call me and I would drive to their house to help bring her to the appointment. I felt it was crucial that Lily made it to see the doctor. In addition, I passed on Colin’s concerns to the psychiatrist as forewarning of possible complications regarding Lily’s upcoming consult. I also called Colin at 8:30 am the next day to make sure that Lily was coming to the appointment. Thankfully, Lily and Colin both turned up as scheduled without any additional help required. Physically, Lily looked under the weather: pale, lethargic—her eyes were red and looking downward. She told us that she might have the flu and for about 10 minutes, Lily answered the assessment questions from the psychiatrist in a logical manner. However, as soon the psychiatrist and I were beginning to believe that she was traveling okay mentally, Lily abruptly requested for Colin to leave the room. After Colin left and the consultation room door had closed, Lily revealed that she had one other thing that she wanted to talk about. She wanted someone to remove the recording devices that she said had been planted within her body. My stomach

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dropped but I maintained a calm expression while I shot a quick look at the psychiatrist. Our gaze met for just a second, but our shared understanding was clear: Lily’s statement demonstrated acute psychosis and a need for urgent treatment. Delusions and auditory hallucinations that centre on surveillance, persecution and/or grandeur are common for people experiencing psychosis. One nurse that I used to work with in community mental health told me about an elderly client of his who was psychotic at one point and who thought that he had a recording device inside his penis. As a result, he attempted to use a pair of scissors to remove it himself. A client of mine in his 20s also experienced an episode of psychosis, which led to him attempting to jump off a bridge because he thought that he was Superman and could fly. These kinds of delusions and hallucinations have the potential to make those experiencing them feel incredibly frightened, as well as putting them in particularly dangerous or life-threatening situations. Acute psychosis is a mental health crisis. However, even when a nurse knows that a person—like Lily—is acutely delusional, it’s not always wise to tell them your opinion directly. A person who is experiencing psychosis is likely to be extremely confused and challenging them head on does not always help. If I was certain that my beliefs were true and another person told me that they were incorrect—that I was imagining things—I think that I would become defensive and frightened as well. Wouldn’t you? The psychiatrist and I talked with Lily about how we thought it would be beneficial to escort her to the hospital for the doctors to ‘inspect’ the recording devices. I felt guilty lying to Lily. I knew that the recording devices were not real, but it was all very real for Lily. It’s a tricky thing to play these games when someone is in a psychotic state, but sometimes a nurse needs to do whatever they can to get someone help. Fortunately, Lily consented to come to the hospital with me. As she did seem to be affected by some sort of flu-like illness—as well as being delusional—I thought it best to get Lily a full medical ‘work up’ (a medical examination with further tests and investigations if warranted) in the ED. This would be conducted before having Lily assessed at the mental health assessment unit, which was next door to the ED. However, it was busy in the ED—as always—and we had to wait for hours. Lily became agitated and I begged the nurses and doctors to see her as quickly as they could, because I didn’t trust how much longer she would stay with me voluntarily in that state. Then Lily began asking me if she was going to be admitted to hospital and was telling me adamantly that she would not stay if she was asked to. I knew that Lily would need a psychiatric admission, but I didn’t want to tell her this as I was certain that she would try to run away if I did. Finally, the ED team completed Lily’s medical examination, including her blood tests. I then took her to the mental health assessment unit to wait for a psychiatric doctor to see her. The treating team and I agreed that for Lily’s safety, if she tried to do a runner, then it would be appropriate to have an order in place for Lily to receive psychiatric involuntary treatment. While waiting to be seen by the psychiatric doctor, Lily asked me again if someone was going to remove the recording devices and I told her that the doctors would attend to this shortly. Lily then asked if she could go home. After a pause, I awkwardly admitted that technically she could try to leave, but that the hospital staff had the right to keep her at the unit against her will.

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Lily immediately tried to run out the door and had to be restrained by the nursing staff to prevent her running out onto the street. She began screaming at me and the staff to let her go and became so distressed that she needed to be given a sedative. At that point, I told Lily that I would come and see her soon and then sheepishly exited the hospital. My choice to leave the hospital at that point was because I felt there was no longer any benefit in my being with Lily; in her eyes, I had both lied and betrayed her—which I had. Lily was involuntarily admitted to the psychiatric hospital, and a message was later passed on to me through the psychiatric administrative tribunal officer to say that Lily was very angry with me. I went to visit Lily a couple of days later in the psychiatric unit, when she was no longer psychotic, and we took a stroll outside to take a break from the white walls and the other unwell patients. While on our walk, she thanked me for taking her to the hospital, and I felt relieved that my rapport had not been broken with her. However, my heart also felt heavy, as her words showed that Lily was starting to recognise how significant her illness was. I can, and will always, appreciate how difficult it was for Lily, or anyone, to accept that they have an illness through no fault of their own. Despite treatment, psychosis can become a chronic illness that the affected person can always relapse into, despite their hard efforts to stay well. On this occasion, while Lily was not acutely psychotic, she was able to acknowledge why she needed to be admitted to the hospital, at the time in which I took her there. In addition, Lily also revealed to me that the day before I had taken her to the hospital, she had taken 30 paracetamol tablets, as she had had pain from the flu and in her then state of mind, had taken all the pills in an effort to make the flu go away. Hearing of Lily’s potential overdose was both a shock and saddening. It also made me recognise that choosing to have Lily medically examined at the hospital had been a wise idea. Sincerely, I told Lily that I was sorry I had put her through such a traumatic ordeal and that I had been seriously worried about her. I also told her that, if I hadn’t taken her to the hospital, I would have been limited with my options for being able to help her. Gently, I began a conversation with her about the nature of psychotic illnesses— how they present and how they are treated and managed. Then, to be completely honest with her, I talked about how people with this kind of mental illness can relapse even when they have the right treatment. I also validated Lily’s position by stating that she had not done anything wrong to cause this illness, and then—with an aim to instil some hope—I spoke about how many people in the community live with psychotic illnesses and have good lives. Lily nodded—I think she was starting to accept that her life was going to be different after this. She was still a mother, a wife and a competent professional as well as being a good person, but she also had an illness that she would have to manage as a part of that life. We stayed silent for a while, sitting side by side on the park bench in the courtyard of the psychiatric unit looking at the blossoming trees in the garden as the sun gently warmed our skin— silence is needed sometimes. I hope someone will be kind to me if my perception of reality changes too.

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The good nurse will be open to being questioned by others. You may wonder why there are multiple chapters in this book that deal with psychotic illnesses and mental health nursing. This is because mental health nursing became my specialty practice over time, and, subsequently, I have many stories from this particular clinical field. The vast majority of the clients I have cared for in mental health have had psychotic illnesses, and my heart goes out to all people with a mental illness, especially those who have experienced psychosis. In the previous chapter, I told of how I spoke with Lily about the nature of psychotic illnesses—how people who have been diagnosed can engage in treatment and still become unwell. Each episode of relapse can turn a person’s world upside down and total recovery is not typically easy. I also spoke of how people will sometimes question the intentions of others. Providing verbal reassurances—laying out one’s agenda and intentions—is often insufficient for the psychologically ‘well’ person who is suspicious. So, I hope you can appreciate that this same kind of verbal reassurance is even less sufficient for someone like James, a previous client of mine, who had a psychotic illness. James was one of those people who got some small benefit from antipsychotic medication. However overall, James had very chronic delusions and paranoia that were treatment resistant. In his teens and early 20s, James had lived a pretty chaotic life. He had frequently used illicit drugs and taken lots of risks, including walking the streets in cross-dressing attire while being intoxicated. Naturally, James had stood out and been vulnerable and subsequently often badly bullied by people that he knew personally, as well as strangers. On multiple occasions, bystanders had to phone police for assistance when things had gotten bad. By the time police arrived, James would typically be severely beaten up and curled up in a ball on the side of the road. Another time, James tried to end his life by jumping in front of a car. He survived the incident, but the event consequently resulted in a permanent limp in his left leg and associated chronic pain. I’d never met anyone before with such fixed delusions who was quite as reclusive as James. To his credit, while I knew him, he did manage to stop drinking alcohol and using drugs on his own, but he did continue to chain smoke cigarettes. At the time, the Australian Government had recently increased the price of cigarettes to nearly a dollar per cigarette. On one hand, this initiative was a positive thing because it lowered the number of people who smoked cigarettes, as there was now an increased financial incentive to quit. However, mental health clients are often without an income because of significant disabilities. They are also one of the highest populations of consumers addicted to cigarettes, which they often smoke as a coping strategy. This results in many people within this cohort of clients, being dependent on cigarettes while simultaneously not actually being able to afford them. James knew cigarettes were bad for him and he wanted to quit, but he was addicted and became even poorer than he already was because of the cost of the cigarettes. I can remember James saying to me once: ‘I got addicted to cigarettes when we didn’t know they were bad for us—now we know they are actually killing us—but I’m addicted… I can’t afford them, but I can’t stop smoking them either. People like me are now paying the price’.

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When I took over case management for James, he told me from the get-go that he didn’t need my assistance and that seeing a psychiatrist was a waste of time for him. He felt that psychiatrists didn’t actually want to help; they just wanted to brainwash their patients because of their own secret agendas. I had James previously described to me, by his psychiatrist, as being a ‘revolving door patient’. This statement suggested that James was a person who continually assessed treatment but never seemed to get better. His psychiatrist had also added, while admitting that he was using a very cruel expression, that James was a burnt-out schizophrenic. I made the mistake early on in questioning James’ delusions. The severity of his illness meant that he was past the point of being able to see his delusions as anything other than the truth. For example, early on in our working relationship, James asked me straight up if I thought that the National Aeronautics and Space Administration (NASA) was filming him. At the time, I said that his concerns about NASA were just delusions and were a part of his illness. When I returned to work the next week, I found two voicemails from James. The first message had been recorded in the early hours of the morning and consisted of James yelling angrily, stating that I had accused him of lying about NASA. In this particular message, I could hear loud heavy metal music playing in the background. The second message was James apologising and attempting to explain his frustration towards me as a side effect of a lack of sleep. James, being a music lover, had the tempo, style and volume of the music playing in the background adjusted to suit the tone of the apology message; he had selected a track underpinned by chilled-out acoustic guitar. This particular sequence of messages from James (an ‘angry’ one followed by a ‘sorry’ one) would become part of my Monday morning routine. I would be sitting in the office, trying to wake up while drinking my tea and scrolling through the staff bulletin and boring emails about IT shutdown periods and then, bang, up would pop a voicemail from James. This cycle of James feeling that I was conspiring against him—ignoring me as a result and leaving angry voicemails followed by apologetic ones, and then consenting for me to visit him—became our regular pattern of contact. It took me a long time to even get to meet James in person; he was a difficult one to catch. James often slept through the day—hence the angry voicemails in the wee hours of the morning—and if he was upset with you, or thought you were trying to manipulate him, he would not answer the phone or the door. James also asked me to always phone him before I drove out to visit. The problem was that, because he often didn’t answer his phone and didn’t call me back, I had no real way of knowing if he was happy for me to visit him or even if he was okay. I truly expected that one day I might find James on the floor, having been dead for days without anyone being aware. Therefore, I became really thankful of his pharmacist for making contact with me and sharing these same concerns. The pharmacist began calling me if James had not picked up his medication from where it had been left at his front door, and they would even make extra trips after hours to make sure that James had picked up the medication. Health professionals like this pharmacist are people who go the extra mile to help and are worth their weight in gold.

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In time, I learned that talking about music was the middle ground for engaging with James. To be honest, music was probably the only thing that we could connect on. James loved so many different genres of music: pop, rock and death metal. He even made his own music and believed that he would be famous one day. Once, he even gave me a copy of his music to listen to; I can’t say that I enjoyed it. Frankly, it was bizarre and very hard to listen to. But I am glad that James felt able to share something with me that was so special to him. We all need interests to love and to hold on to. James’ mother, Cristina, was this lovely little Spanish lady who only got to see James from time to time due to his hermit lifestyle. Cristina told me that she thought it was not healthy for anyone to sleep and smoke cigarettes all day and she wanted James to get out and about. She was right, but James was set in his ways. He was also, despite his poor lifestyle habits, surprisingly physically and emotionally sturdy. Both James’ psychiatrist and I agreed that James might be one of those people with nine lives. Sometimes people get lung cancer when they have lived the healthiest lifestyles they can, while other people destroy their bodies through their lifestyle habits and never even get a cold. We felt that James might fall into the second category and would outlive all of us; whenever James had a full set of blood tests done, his levels would always come back in the healthy ranges, for everything. Cristina grieved for the son she had had before the illness. She often told me about how James used to be so bright; he’d had a job at the shopping centre, had a great sense of humour and was a family man. Everything changed when he had started experiencing extreme paranoia. With modern technology, James didn’t really have a reason to leave the house. As I mentioned before, his medications were delivered to him by the pharmacist. Following suit, James also had an arrangement for his groceries to be hand delivered to his house. I’ll always remember meeting James at his house for the first time. He lived on this lovely, tidy, expensive street, lined with well-kept gardens and freshly painted houses. James’ house was the only subsidised, government-owned residence in the street and it looked totally different from the rest. James’ brown-brick house was tucked away on a corner and looked barren compared to the rest. On his windows were giant signs on which he had written ‘posties are the best!’ and ‘Jehovah’s witnesses go to hell’. The blinds were always shut, and the back garden was overgrown with weeds. The overall appearance was of a house that no one had lived in for years. Seeing James’ house and then meeting him in person made you feel as though Edward Scissorhands had started a new life in Australia. James looked exactly as I expected him to. With long, dark, scraggly hair and a head-to-toe ensemble of black clothing—including a particularly tired looking fitted t-shirt, skinny leg jeans and boots—he was the image of a weathered rock star who had lived the party life much longer than they should have. He would even sit in the way you would expect one of the Rolling Stones band members to. James would be perched on a seat outside, his hand resting over the side of the chair holding a cigarette, occasionally flicking his head to the side to move his lengthy and wild hair out of his face. James also had

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one eye that moved in such a way that you didn’t know where he was looking. This did no favours for him, as even without his unusual eye, he looked a tad spooky. James’ lifestyle and behaviour had mellowed since his 20s—quitting drugs and alcohol had played a key part in this change. Regardless, I still had to play things safe in the way that I managed our interactions. Cristina had told me that—5 years prior to me being allocated as his case manager—James had once struck her at a time when he was highly paranoid and agitated. She hadn’t been seriously hurt but had been very emotionally shaken by it. She also had never gone to visit him on her own again after that. Naturally, I really felt for Cristina. I imagine it would feel very strange to have to put up those kinds of boundaries with your son, someone you care about dearly. During my direct interactions with James, I would try to see if I could coax him into going for a walk with me to get some exercise. He was insistent that he did weights regularly, which I doubted, given that he was about the most inactive person I had ever met. His skin was also as pale as you would expect a person to look when they spent twenty-three-and-a-half hours a day locked up in a house with all the windows and blinds closed. I was therefore happy that we sat outside when I visited, so we could both have some fresh air. It also added an extra safety precaution for me. This judgement may seem unfair, and I am certainly not trying to paint everyone who has a psychotic illness as being a dangerous person. However, my rule in life stays the same no matter where I am: you should always avoid putting yourself in a situation where no one can hear you scream. James knew that I didn’t smoke, and I knew that he felt self-conscious about the strong scent of smoke that stuck to his clothes, but his attempts to mask the smell with cheap cologne made it all so much worse. One day, I went to visit James shortly after I had been injected with the yellow fever vaccine for an upcoming trip to South America. The vaccine had already made me queasy, but the smell of cigarettes and Lynx deodorant was all a bit too much. Whenever I smell Lynx, which thank goodness is not often, I still associate it with sweaty teenage boys from my high school days who overused it in the vain attempt of attracting a girl in the way the commercial suggested. Contrary to what the Lynx advertisement had suggested, the smell of it (compounded by the cigarette smoke and my nausea from the vaccine) pushed me over the edge and for a moment, made me question if I may pass out. James began telling me a long story about conspiracy theories, and all the while I was trying to meditate through my nausea. I was trying to disguise how unwell I was feeling, as I didn’t want him to feel more self-conscious about the smell than he already did, but I soon began to feel dizzy and started perspiring. James stopped, mid-sentence, and asked if I was okay. I reassured him that I was fine and was just feeling a bit under the weather from the injection. As anticipated, he started to stress out, and with genuine concern (bless him), James said that he knew I was feeling sick because of his cigarette smoke. I told him that that wasn’t the case and not to worry. I love these nurse and client encounters, when both parties are telling white lies, trying to protect the other person from feeling shame or discomfort.

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Following this, James refused to see the psychiatrist for his next appointment. This was a concern, as the psychiatrist had not seen him for at least 6 months. He said he would be happy to see the psychiatrist, but only if they visited him at home. This psychiatrist worked part-time and had a full client load; he really had no time for home visits. Still, by looking at his calendar, he worked out that if we left the office at 8 am on a Wednesday (outside of paid work hours), we would be able to visit James at home. What a great doctor. As we drove out to see James, we hoped that all this effort would not be wasted and that James would be awake and would also open the door for us. Fortunately, he did and the psychiatrist was impressed when I asked if we could have a look inside the house, and that James actually consented. The psychiatrist later told me that James had never let him inside before and I had to admit this was my debut tour of James’ house too. Up until this home visit, I had not been game to enter James’ house on my own but having the psychiatrist with me provided a unique opportunity. Through seeing the inside of a person’s house, a lot can be told about their living conditions and how they are tracking mentally. In films, people with psychotic illness are often portrayed as killers, which is totally inaccurate and unfair. However, the one thing that Hollywood films often do get right is the decor of a person’s house who lives as a recluse. Walking through James’ house was like going through a time machine. I saw dusty photos of James and his family from when he was a teenager, and he was unrecognisable. In these photos, James looked young, fresh, happy and vibrant. In one photo—the one in which James looked the healthiest—he was at the beach, smiling, with wind in his hair and a deep orange sunset glowing behind him. Sometimes, it is not until you look back at old photos that you can really believe how different a person’s life can become over time, because of malady. James was now living in total squalor. The house looked as though it had not been cleaned in about 10 years. The blinds were so dusty; it was as though they had never been opened. The walls were covered with posters of heavy metal musicians and sexy pop singers from 20 years ago. The whole house was messy, eclectic and just a little odd-looking. Following James’ home visit, Cristina called and asked if we had made any progress in convincing James to incorporate some exercise or community engagement in his routine. I told Cristina that I had been trying to convince James to engage in these kinds of activities for months, but that he didn’t want a bar of it. The most progress I had made with James was when he once offered me a compromise. He had offered to leave his house, but only if he could get a lift in my work car to get takeaway coffee from McDonald’s and then be driven straight back home. James felt that this was community engagement and demonstrated a worthy demonstration of him getting out of the house. At the time, I had explained to James that a drive-­ through trip at McDonald’s probably did not have quite the same therapeutic significance as going for a walk or attending a men’s support group. I told Cristina that the psychiatrist and I had come to the same conclusion: James was a recluse; he wanted to continue living that way and was unlikely to change his lifestyle. Then I added that James was not unhappy, and that that was the most important thing.

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These types of conversations are not easy to have. In most clinical cases, I believe that there is scope for things to change. However, in some circumstances, behaviour or illness is harder to transform. I think that nurses owe it to the affected person’s loved ones to be realistic with expectations regarding health goals and outcomes. Still, I knew that this honest discussion about expectations would be a hard thing for Cristina’s family to accept, especially as they would always remember and miss how James was before the illness. A couple of weeks after the psychiatrist and I visited James’ house, I spoke to him on the phone. My time working with him had taught me that I would cause him less distress and less confusion if I did not contest the validity—but also not reinforce—his delusional beliefs. In this conversation, James talked at length about one of his conspiracy theories concerning the Australian Security Intelligence Organisation (ASIO). As I listened, I acknowledged everything that he was saying but kept my eye on the time. I routinely would listen to these delusional stories for 15 minutes before changing the subject, so that James would not start to go in circles. So, when I got the chance, I asked James if he had been up to anything much on the weekend. He responded by saying that he had gone on a hike with his family in the bush. My ears pricked and I sat up erect in my chair. Then, with excited curiosity, I asked James if he had enjoyed the walk. He replied, saying that the hike had been enjoyable, but that he had had to stop after 6 kilometres as his ‘bung leg’ had started hurting. Later, I fact checked with James’ Mum and found out the hike had actually happened. This client, who was the biggest recluse I had ever met, had gone on a 6-kilometre hike through the bush with his family. The psychiatrist, when I told him, was equally amazed. James going on this hike with his family may seem to others like an insignificant event. It wasn’t. For this family, being able to do something like this, together, was significant in mammoth proportions. Also, knowing that James had felt able to undertake that hike led to the rekindling of my hope for mental illness recovery in other people who seemed stuck in their lives. James had provided me with a lesson on the importance of staying open minded and in keeping faith that change is possible for everyone. Ask me my agenda, and I’ll tell you, my truth.

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The good nurse knows that some things are out of their control. I never used to believe that people could go missing so easily: that was until a nurse friend of mine told me about one of her patients in a psychiatric ward who had managed to scale a huge fence without anyone noticing. They then just disappeared and no one has been able to locate them since. An additional role that I chose to pursue while working on a mental health crisis team had me working with police—to assist them with mental health assessments and care plans for clients who came into contact with their department. The police stations were filled with posters of people who have mysteriously disappeared, and no matter how many times I looked at the posters, I was always left with the same questions. How does a person just go missing and not be found again? Have these people been murdered or kidnapped and taken away from their homes forever, or have they chosen to vanish from the life that they once had? The rewards offered for meaningful information about these missing persons cases are often in the region of half-a-million dollars. Is it really the case that no one knows what has happened to these people? Or are the people who have the information the same people who have something to hide? When I asked a policeman these questions, he shared a theory: Australia is a massive continent with dense and seemingly endless bushland. It is an easy place for a person to disappear in, either by accident or on purpose. Here is one story about a girl named Amber who went missing. Amber was allocated to me as a client who was to be case managed while I was in a community mental health team—she was a woman who was sweet and lovable in character. Amber had schizophrenia, had a history of epilepsy and had survived a stroke that had resulted in permanent damage to her brain. Her comorbidities were compounded by ongoing illicit drug use. Amber had also gained a lot of weight from her antipsychotic medications, as is typically the case for clients on this kind of treatment. Amber was almost childlike in nature, both because of her personality and her varying brain conditions. When I met her, she was nearly 40, but she dressed and behaved like a young girl. Despite her often very incapacitating conditions, Amber was always very creative in her crafting pursuits. On one occasion, her treating psychiatrist had written in his appointment notes ‘query delusions’ because Amber had spoken about the ‘stuffed teeth’ that she had made. I explained to the psychiatrist that Amber did in fact create handmade toy animals and characters from felt, including giant teeth with cute little faces on them; she had a car boot filled with these felt creatures. As a gift, Amber once gave me a darling little bird made from black felt that sat on my work desk ever since. On one of my shifts, I was alerted by other staff that Amber was in the psychiatric unit. As I was Amber’s case manager in the community, I arranged a time to come and visit her in the hospital. She had used marijuana on that particular day, which—with the delicate state of her brain—had thrown her off the edge of mental stability. She had been taken into the psychiatric ward involuntarily by police because a member of the public had called them, worried about her; Amber had been yelling, distressed and disoriented when she was found by the police. When I

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visited Amber in the ward, she genuinely believed that she was on the ship Titanic and she was screaming in terror because she thought that she was going down with the ship. A week had passed and Amber remained in the ward. She had not recovered from her episode of psychosis but there had been a marked improvement in her mental state. As a result, Amber was given permission by the hospital to have escorted leave. When I was given that update, I arranged to take Amber out for a coffee, which she was really pleased about. At the café, as I was handing over the money to the cashier, Amber told me that she would be back in a minute. Before I knew it, she was gone and I was amazed at how quickly she disappeared. Luckily, the shopping complex was small, so I was able to find her quickly in a nearby stationary shop. The term ‘hoarder’ tends to be overused in society. I often hear people use this word whenever an individual is solely having a hard time getting rid of their junk. The term is used without recognising that hoarding can be a legitimate, and serious, mental health condition. It makes me think of when someone says that they have a phobia of something. Many of us have fears, but phobias are on the extreme end of the spectrum, just like the extreme nature of true pathological hoarding. I had previously been told that Amber had hoarding habits, and for the first time, I saw what this really looked like. Within the space of about a minute, Amber had collected several boxes of identical coloured pencils and about 12 rolls of Contact, which is used for covering books. I knew that Amber’s only income was a disability pension from the government, so she could not afford all of this stuff and likely had no practical purpose for buying the items that she placed on the counter. Not wanting to embarrass Amber in front of the shopkeeper, I quietly reminded her that the hospital had all the craft supplies that she needed; I didn’t want Amber to buy any of this stuff unnecessarily. My suggestion overloaded Amber’s hoarding compulsion, and a look of panic spread across her face. I swiftly compromised by suggesting that she only buy one roll of Contact, as this was the cheapest item in the big bundle. I figured that reducing the number of items might be a more successful approach than an all-or-nothing battle. The man at the counter started putting away the other items and gave us both a simultaneously sad and empathic facial expression—something between a grimace and a smile, which said: ‘You don’t need to explain’. Later, after a 6-week hospital admission, Amber had recovered from her psychotic episodes, but there was uncertainty as to where she would go. Amber’s family cared about her but, at the time of her discharge, no one felt able to take her home. She had been living with her grandmother prior to this admission. However, while Amber’s grandmother loved her dearly, she was getting frail and was having a hard enough time being able to look after herself, let alone her granddaughter. The hospital psychiatrist, Dr. Moss, arranged a family meeting that I would be attending, to look at Amber’s discharge options. I had been forewarned about some of the complex personalities and situations in Amber’s family. Apparently, Amber’s brother had been claiming a carer’s allowance for her for a number of years, even when he was not living with her and was not her primary carer; this payment was subsequently ceased upon government investigation. Amber’s parents had also

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broken up and re-partnered and her father, Jerry, had issues with his anger and had extreme and unusual religious views. It also seemed that no one felt ready to take Amber home—everyone was worn out by carers’ fatigue. Naturally, for a situation like this where everyone feels stuck and there is no obvious solution, the nurses’ hearts bleed for all the family members. During the meeting, Jerry became quite aggressive towards the psychiatrist and gave a list of reasons why he felt that Amber’s medication was actually making her sicker. Jerry had printed out some information on the side effects of the medication from a public forum on the Internet and demanded that the psychiatrist read the information to everyone at the meeting. The situation escalated further when Dr. Moss refused to read out the printed material. Instead, she suggested that Jerry could pass the information around to family members in the group should they express a wish to read it. Furthermore, Dr. Moss told the group that she was very familiar with the medication and that she did not feel comfortable reading the information that Jerry had given her because the source of the information was not reputable. The rest of the family sat silently with their eyes to the floor, while Amber’s father carried on yelling and swearing; they were obviously quite used to these kinds of outbursts from him. Within only a few minutes, I gained the impression that Jerry was an intimidating man with a commanding temper and strong preconceptions that could not be challenged. He would also not be consoled by his partner, who was trying to calm him down, and continued screaming at the group in general now, demanding that Amber has an exorcism. When this didn’t achieve the desired result, he became apoplectic, saying that the meeting was a waste of time and that he was ‘done’. Finally, he threw his hands up in the air and proceeded to storm out of the meeting and did not return. Amber’s boyfriend then said that she could live with him, but that his rules of the house would be to restrict Amber’s hoarding to one room that contained a large cupboard, which could be used to contain her many keepsakes. The boyfriend then reiterated that he loved her but that he also felt burnt out and had his own mental health issues to deal with. Still, discharging Amber home to her boyfriend’s house was the best plan we could come up with, given our limited options. However, I can’t say I was totally surprised when, about a week after Amber’s discharge, I was informed by her boyfriend that he couldn’t deal with the hoarding and that Amber was now staying with her father, Jerry. The second part of that sentence was the bit that worried me: a person who screams at a psychiatrist and says that their daughter needs an exorcism rings alarm bells. When I called Amber, she said she was safe, but she sounded uneasy on the phone. I then spoke to her father. He said that they were both doing okay and that they had enough medication for Amber to last a month and that they also had extra prescriptions. I took Jerry’s address down, but I was a little perplexed as the address that he gave me was not in the usual format that I was accustomed to. Jerry told me that he lived on a property, interstate and near the coast, hence the reason for the address sounding odd.

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After this call, I called the appropriate interstate mental health team and they said that they would try to contact Amber. Later that day, I received a phone call from them and they told me that, when they had tried to call Amber, Jerry had answered the phone instead and had been hostile. He had told them that he didn’t want anything to do with their team and, if he needed anything, he would call my mental health team instead. Then, when they had asked to speak to Amber, he wouldn’t put her on and had hung up on them. The interstate team then told me that, without Amber’s consent, they weren’t able to continue trying to make contact with her. This response is a reflection of some of the politics of public mental health services. As mental health teams are typically under-resourced, closing a client’s referral when the service can’t get in contact with them means that the high volume of referrals they receive can be more easily managed. When a service has attempted contact with the client, and the client has not engaged, this is a legitimate reason for closure. However, every service seems to have a different approach as to how much assertive contact they attempt with clients before they close them. Naturally, services that are the most poorly resourced will offer less assertive contact with a client before closing a referral. As a result, a lot of people who really need help often fall through the cracks. I insisted that it was imperative that the interstate mental health team try to assertively make contact with Amber and I informed them about her vulnerabilities and how her dad seemed both unpredictable and aggressive. I also described how Amber had diminished consent-making capacity due to her multiple brain conditions and pointed out that Amber had not even been given an opportunity to consent as Jerry had not put the initial call through to her. After I had made this history clear, the interstate team said they would try again to make contact with Amber because of the high level of risk. Theoretically, my job was done. Amber was no longer in our catchment area and I had handed over my concerns to another mental health team. However, ethical conscience does not work like that, and I was really worried for Amber at this point. I spoke about the case with one of our psychiatrists and we agreed that if the interstate team had not been able to contact Amber in 2 days that I should call the police. Two days passed without a call and so I opened Amber’s file on my computer to find the phone number of the interstate team so that I could follow up with them. What I found was a red flashing alert on the page showing that Amber was now a missing person. The alert also prompted anyone who may have useful information regarding her case to call the detectives, and their phone number was listed. Immediately, I contacted the detectives on Amber’s case. I provided them with a collateral history based on my time working with her. The detectives said that the address in which Jerry had given me was incomplete. While they were trying to locate Jerry’s property, all their initial enquiries regarding Amber had had to be made over the phone. Apparently, not long after the local mental health team had spoken to Jerry, he had made a police report saying that Amber had left the property without his knowing and that she had not returned. She had apparently left her wallet and phone behind but the weird thing was that the debit card was still being used. When the detectives questioned Jerry about this, he admitted to using Amber’s debit

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card. It also seemed that since Amber’s disappearance, she had not made her regular contact with Centrelink. To be able to receive her fortnightly payment, Amber would have had to log in online or be seen by a Centrelink worker, face to face in one of their offices to receive her fortnightly payment. This meant that she had no obvious means of accessing money, so how was she surviving? A week had passed and when I made further enquiries regarding the investigation, I was told that Amber was still missing. The detective I spoke to told me that a thorough search of Jerry’s property (now located) had been conducted, as well as a helicopter search of the nearby area. They had had to cover a lot of ground as Jerry’s property was in the middle of nowhere. Receiving this information was both dark and troubling to me. The detective also told me that he had found some unsettling shrines in the house and that Jerry had talked at length about his extremist beliefs on religion and the world. The detective then confided to me that it was his personal gut reaction that Jerry had murdered Amber, but that there was no proof of this. The detective felt that the gruesome reality was that Amber’s remains may have been fed to the pigs that Jerry kept on his property; in which case, no evidence would be found—their stomachs are able to digest bones. I hate to say it, but as awful as that sounds, it was what my gut suggested too. Two years later, Amber had still not been found and Jerry asked police to reissue a missing person’s search request for her. No further information regarding Amber’s whereabouts emerged, which did not surprise me. However, I maintain hope that an answer will at some time come to light to explain Amber’s disappearance. If she were found to be dead, it would be devastating for those in her life who cared about her. However, they would at least have an opportunity to grieve her loss and gain some closure. As it is, Amber’s loved ones continue to live with the uncertainty of what happened to her. As I write this, there has still been no progress made as to Amber’s whereabouts; she is assumed to be dead but her remains have not been found.

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The good nurse will enter the unknown. With regard to psychiatric nursing, one could definitely argue that the psychiatric ward of a hospital is at the pointy end of care. Early in my career, people told me horror stories about the psychiatric ward. I was told that patients who were acutely psychotic would sometimes throw their own poo at nurses and could somehow manage to smash the thick glass windows of the ward in a manic rage. And that was a typical Monday, it seemed. The psychiatric ward is indeed an area of nursing that few nurses have a desire to work in, because of the intensity of working with clients who are acutely unwell. Clients under care in the psychiatric ward are typically psychotic, manic, suicidal and intoxicated by drugs and/or alcohol, and some clients are hospitalised with a mixture of different diagnoses. Still, when a local psychiatric ward was short on staff and a message was sent out to all senior mental health nurses to see if they could work extra shifts to help, I put up my hand to do some shifts. I knew it would be difficult, but I saw it as an opportunity to learn and to grow. I remember shyly walking through the unit corridor on my first day, not knowing if I should keep my head down or greet the patients as I wandered through. I had not said a word, when one patient paced towards me speedily and began speaking to me at a rate of speech on par with his walk. ‘Are you married?’ he asked and then he told me that he had a fiancé and went into details about his girl—the love of his life—and their wedding plans. Another patient then spoke up and said, ‘Don’t trust any of the staff here; they are all trying to trick you’. Funnily enough, the staff had just told me the same thing about the patients. It was a strange place to work. At times, one patient would be screaming at another, while a nearby patient—dressed in Mickey Mouse pyjamas—would seemingly be oblivious to the disturbance. Some patients would be sitting on a sofa, looking somewhat catatonic, while slowly scooping jelly into their mouth while their eyes were glued to the television. Other patients would be quietly drawing or crying (or both), looking terrified or confused. Some patients didn’t seem to know why they were there. On the flipside, other patients knew exactly why they were in the ward, which may have been an even scarier realisation for them. No one is admitted to a psychiatric unit when life is going swimmingly. During my first shift, a patient approached me while I was preparing medications. He was short and had an impressive 70s afro. ‘I’m going out now, okay?’, the patient stated sweetly and confidently; it was more a statement than a question. ‘I’m with the walking group’, he added, as he trailed off behind a group of patients going out for their supervised stroll. His actions were a little like how a teenager would approach their Mum about a party they knew their mother wouldn’t want them to go to: ‘I’m going to the party that I told you about, Mum’, the teen would likely say as they left the house to get into their friend’s car, trying to get away before their Mum has a chance to say ‘no’. And I was the Mum in this situation, flustered and distracted, with no time to work out what was happening. I smiled meekly and said replied, ‘Um, okay’. A few hours later, someone asked where a patient called ‘Jimmy’ was; apparently the clinical staff had called the police to look for him. With rising

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apprehension, I sought clarification from another nurse on the ward: ‘Please tell me that Jimmy is not the short guy with the giant afro?’ I asked, a pleading expression plastered onto my face. The nurse confirmed that the dude with the afro was indeed Jimmy. ‘Fuck’, I responded and then confessed with embarrassment that Jimmy may have gone missing because of me. My hands rifled quickly through Jimmy’s clinical file to see if there was any information to show my fears were mistaken. But the file note for Jimmy read clearly, in giant, underlined capital letters: ‘NOT PERMITTED FOR LEAVE FROM THE WARD UNDER ANY CIRCUMSTANCES, HUGE ABSCONDING RISK’. I had assumed that Jimmy was a part of the therapy walking group—I had been royally duped. I returned a few days later for my second shift and Jimmy had been returned to the ward after being found by the police. Jimmy apologised and said he hoped I hadn’t gotten into trouble because of him. With some added sassiness to my voice, I jokingly replied, saying, ‘Jimmy, you are not sorry; you knew exactly what you were doing. You tricked me’. Jimmy just smiled knowingly. Later, Jimmy asked if he could come with me to reception to look for a coffee mug of his that had gone missing. ‘Nice try, buddy’, I replied. ‘You can fool me once, but you can’t fool me twice’. Before doing these shifts on the psychiatric ward, I used to give the nurses who worked there a bad rap. In the past, when I had been a community case manager and one of my clients had been admitted to the psychiatric unit, I had often visited them on the ward. During these visits, I had obtained a pretty vivid impression of the poorly designed layout. The unit itself had a ‘fishbowl’ arrangement—with the nurses’ office on one side of a half-dome-shaped glass wall and the patients on the other side able to look in. On the nurses’ side of the fishbowl (inside), nurses would be scurrying around, writing notes or popping out pills. Meanwhile, the patients on the outside side of the fishbowl would be staring in with vacant expressions, and knocking on the glass persistently to try to get the nurses’ attention. Most of the knocking on the glass would be patients asking for a cigarette or enquiring if they could go home. The fishbowl setup gave nurses and patients an opportunity to see each other, but also meant that the nurses could maintain their own safety. A side effect of having such a fishbowl setup was that the patients very much looked—and I’m sure felt— as though they were in a very separate world to the nurses. In addition to these initial poor impressions of the actual setup, I also thought that the psychiatric ward nurses didn’t want to spend time with their patients—or were not making the time. I have always maintained the stance that meaningful human contact is essential for patients to feel more reassured and cared for. However, when I commenced work on the ward, I quickly realised that there was no time to get anything but the essentials done. When people are acutely ill and in a psychiatric ward, the combination of medication and a secure environment is what is most important for them to get better. Unfortunately, the nurses in this psychiatric ward were under-resourced and run off their feet. There were many nurses in that ward who were dedicated, caring and willing to give the patients the right sort of attention, but unfortunately, they were

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not given the privilege of time to be able to offer such a thing, which I thought was very sad for everyone. When a nurse begins employment in a new area, they bring a fresh set of eyes to the situation. Everything is colourful; it’s new, it’s interesting, and it’s strange. As a newbie nurse in the psychiatric environment, I had not yet become institutionalised, and my experience in community health had also taught me how to work autonomously while also being a part of a tightly knit team. I had forgotten the old hospital hierarchy and structural rigidity, which meant I had a different approach than a lot of the psychiatric ward nurses. Early on during my time in the psychiatric unit, one of my patients, Judy, was looking anxious and asked if I would take her for a walk. I checked Judy’s file and she was able to leave for short accompanied walks (I had learned to always check people’s files after the Jimmy incident) and told her that I would take her for a walk when I found the time. Nurses need to be extremely careful not to make empty promises to patients and I certainly did not want this to be the case with Judy. However, on that particular shift, every time I thought I could take Judy for a walk, another thing would happen that would prevent me from doing so. Patients were constantly asking me for medication or requesting particular belongings of theirs that had been locked away. I was also receiving multiple requests from patients asking if they could call a loved one or wanting to know when they would see the doctor about a plan for going home. These are not difficult tasks, but the endless number of requests can become quite demanding and, before I knew it, hours had past and I only had a short time left on my shift. I told Judy that I would walk with her after the 8 pm medication round and informed the other nurses of the same plan. Eventually, I escorted Judy out for a walk and she lit up a cigarette the minute we strolled out the main entrance. I knew that most of the hospital had become ‘smoke-­ free’, but I thought there was still one area remaining where patients and staff could light up a ciggy. We walked to this special area, only to learn that it too was now closed to smoking. I was now in the position where I had to choose whether or not to snag a fag off an agitated woman, whose walk had been delayed for hours on my account. However, as I felt it would give her some small amount of relief, I chose to let Judy smoke her cigarette while we discreetly walked around the empty hospital campus. When we returned to the psychiatric unit, the team leader nurse proceeded to yell at me in front of all the other staff. Apparently, I was not meant to take out any patients for walks after 8 pm, as it was a safety issue. I was also informed, scornfully, that the fact that my patient had smoked a cigarette while we were out together could result in me losing my nursing registration. Disbelieving, I thought to myself: ‘There are doctors who have concealed medical records, or had affairs with patients, who have not lost their registration’. This was such a small thing, I couldn’t for the life of me work out why she was so het up. I had been placed in a difficult situation with Judy, but sometimes nurses need to weigh out the burdens and benefits and use their own common sense for the better of the patient. Think about that time that someone chose to bend the rules a bit for you, and how no one got hurt, and the world of difference that this act made for you.

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In a health system filled with bureaucracy and red tape (some of which is helpful and necessary), there are still times where it is appropriate for nurses to not hold on too rigidly to the rules to provide the best care for a patient. On another shift, I had an encounter with a patient called Grace, who was intoxicated and acutely psychotic from the consumption of methamphetamine, or as we now commonly call it: ‘meth’. Whatever people tell you about how scary people look when they have taken meth, believe it. I’ve never taken meth and, even in my risk-taking teen years, I was never tempted to do so. Out of all the recreational drugs, I just can’t believe that people are actually enjoying themselves when they are taking this particular substance. In this incident, Grace was crying hysterically while wandering around aimlessly and shoving sandwiches violently into her mouth. With bread crusts being scattered everywhere, Grace started to walk towards me, but once she was in speaking range, her demeanour changed dramatically. Grace stated excitedly: ‘Did you know that exit mould gets rid of the mould in your bathroom?’ She repeated this fact several times and then started crying again. I really detest using stigmatising language for mental health conditions, but the words that best describe how Grace was acting at this moment are ‘crazy’ and ‘a total mess’. (Sorry Grace.) I saw Grace again the following week and she looked completely different. The first time in which I saw Grace and she was intoxicated by meth, I was quite distracted by the behaviour and appearance that the effects of the drug had given her. However now, in her calmer state, while Grace was no longer becoming emotional about the effects of exit mould all the while with bread hanging out of her mouth, I could better appreciate that she was an attractive woman. She looked well-kept and was behaving like a sweet and articulate young lady. However, she couldn’t even remember meeting me. Another drug-related incident occurred when I was asked to do one-on-one care in the high dependency unit on the psychiatric unit for a young woman called Clare, who had murdered her mother while under the influence of drugs. I first met Clare with much trepidation because of what had been handed over to me about her case by the other nursing staff. Clare was a vulnerable person and awaiting a lengthy court process. The nurse at handover had told me, ‘Don’t believe anything she says; she is a cold-blooded killer’. My clinical supervisor told me that the nurses on the psychiatric ward were quite traumatised, as Clare had been telling them in detail how she had murdered her Mum. However, I had learned—from my past student placement in a prison—that to be able to deliver good care, nurses need to withhold judgement and stay neutral in their opinions of patients. The focus needs to be on the treatment and care of the patient, regardless of their personal situation. Oddly, I think this was the best shift for me working in the psychiatric unit, as the shift was quiet. As a result, I actually had time to bond with Clare and the other patients. We watched a movie and talked about hobbies and jobs, and I even braided everyone’s hair. Clare was my age, but where she had ended up with her life was completely unrecognisable to me. Her situation stemmed from a complicated life: a mood disorder, drug use and a history of trauma and prostitution; realistically, it would take

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years for the courts to reach a verdict for her charge because of her complicated history. How can anyone make sense of a case like that? Clare told me she was scared about going to prison and asked me what the prison environment would be like, and I had to admit that I couldn’t determine what the future would hold for her. She didn’t quite sigh, but she elicited a disappointed sound of ‘oh’ as she lowered her head—I think the reality of how different her life was going to be was sinking in. We then exchanged looks as we both recognised that there were no easy answers, or any way to fix Clare’s life at this point. It’s with these experiences that I can better appreciate the care which inpatient psychiatric nurses provide for this complex patient group. It’s hard for a nurse not to feel for these patients, because despite their backstory, the nurse knows that they are in hospital because they are in the midst of potentially the worst day or period of their life. And do you know who is called upon then? The nurse. So it’s good to care.

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The good nurse will respect the differences between themselves and others. In essence, my first experiences of practical nursing—as well as being exposed to a culturally different patient demographic—occurred in a rural town in New South Wales called Griffith. At the time, I was 15 years old and had been offered a work experience placement at the hospital there. My dad knew a South African family who lived in the town, and they kindly offered to host me during my placement. The mother of this family, Maria, was a nurse in the hospital’s paediatric ward. Dad had advertised me to this family as an outgoing and confident girl, but the reality was that I was a teenager who felt very nervous about entering an unfamiliar environment and was challenged by the distance from my usual social circle. Griffith is a small town with a diverse population, including significant numbers of Indigenous Australians and Italian migrants. To my young eyes, the Italian migrants appeared wealthy, cruising around in their shiny cars, and I couldn’t help but wonder how many of them were in the mafia. Conversely, on a Monday night, you would see Indigenous teenagers roaming the dark alleyways, glass bottles filled with rum. A social worker friend of mine who was born and raised in that town has often told me that you’ll never find a place in Australia quite like Griffith. On my first day of placement, which was in the paediatric ward, I vividly remember meeting an Indigenous family who had come into the unit with a baby. The biological mother was about the same age as I was at the time and she was accompanied by about six family members. I learned quickly the cultural significance of this baby having five or six people who identified as being a caregiver for the child. Although only one woman was the baby’s biological mother, all the women in this family contributed to the parenting role, and it became clear to me then that family is central for Indigenous families, what a great thing to have so many mothers supporting each other. At the time, I had no skills or qualifications in nursing—so the main purpose of my placement was for me to essentially observe what was happening in the hospital. I therefore watched on while the treating nurse, Steph, conducted a general medical questionnaire with the baby’s family. When it came to the dietary intake for the baby, it was discovered that the baby was, at times, being given Coca Cola to drink. Steph spoke to them of the nutritional and health reasons why the baby shouldn’t drink Coca Cola. This was all explained patiently, and without judgement, and it seemed as though the family genuinely didn’t have any understanding (prior to Steph’s advice) about the issues involved with feeding the baby soft drink. To me, this was a clear demonstration of the health problems caused by white colonisation in Australia. White Australians have introduced all this cheap and accessible processed and sugary food, and the rate of diabetes in the Indigenous Australian population has skyrocketed; diabetes had never been an issue in this population before this. Steph later told me about her own personal struggles; her baby daughter had a rare neurological disorder and high-care needs and was unlikely to live past the age of 3. I can’t imagine how hard it must have been for Steph, caring for all these other children on the ward while she was worried about the welfare of her own child. Steph also told me about how many people turned a blind eye to her and her

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daughter’s hardship and gave the example of struggling to walk across the road with a stroller full of bulky medical supplies—including devices for breathing assistance for her baby—that was so heavy and awkward that she could barely push the stroller. Bystanders, more often than not, would just gawk at her without making any offer to help. I think of this scenario now and it reminds me of a mandatory lifesaving course I did to become a swimming instructor, which I undertook while I was studying nursing. The video that we watched about child deaths in swimming pools showed that many children could have been resuscitated after a drowning incident if their parents had been taught CPR. But the parents didn’t do CPR as they were scared that they would do more harm than good. I feel that this happens a lot in life: people do nothing because they think that the situation at hand is either none of their business or, if it is, they feel that they are not skilled enough to possibly help. What I have learned as a nurse, which can be applied to everyday life, is that all people are able to ask another person if they need help and every person is capable of some degree of help-giving. While in Griffith, I was able to spend a few days with the aboriginal liaison worker. She was a vital employee in the hospital as she could, on many levels, understand and cater to the cultural beliefs and needs of Indigenous patients. The timing of my clinical placement aligned with the NAIDOC (National Aborigines and Islanders Day Observance Committee) Week. To commemorate this event, the aboriginal liaison worker and I walked around the hospital together one day to visit all the Indigenous clients in the ward. On this day, we gave out native flowers to commemorate the week, and supportive counselling was offered by the aboriginal liaison. I said nothing and just watched and listened as a quiet and solemn Indigenous patient in a wheelchair had wildflowers pinned to her jacket. While on one of my shifts with her, the aboriginal liaison worker got a call from a friend saying that two Indigenous boys had set a nearby building on fire the night before. She told me that, no matter what hurt people had experienced, this kind of behaviour was not acceptable and that it made her ashamed to be Indigenous. I began to appreciate how many different responses there were regarding the complex issues around the effects of trans-generational trauma and I continued to learn that solutions are rarely straightforward in this area of nursing. My work experience placement in Griffith will always stay in my memory as one which opened my eyes, when I never even knew that they had been shut. Years later, as an undergraduate nurse, I was fortunate to be able to gain additional, rural work experience through a clinical placement in Townsville, North Queensland. There is definitely a different lifestyle and culture in Townsville from what I was familiar with in my hometown. During this clinical placement, I became accustomed to a unique set of health complaints and illnesses among the patients in that region. For example, in this clinical placement, I often cared for patients who had had to travel to the hospital from Magnetic Island (or as the locals refer to it: ‘Maggie Island’), as Townsville was the closest place they could receive any medical care. Divers would also often be treated in the hospital’s hyperbaric chambers, where air pressure can be increased to treat decompression sickness.

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Another example is tropical diseases. Australia has a varied climate, but generally, the further north you go, the warmer it gets. Due to the hotter climate in the northern states, unique mosquito-borne diseases are present. The most common mosquito-borne diseases in Queensland are Ross River virus, Barmah Forest virus and dengue fever. My brother worked in Townsville during his 20s, when he was in the army, and later received inconclusive blood results for Ross River fever. These kinds of illnesses are not present in my hometown—so my brother potentially contracting Ross River fever seemed wild and foreign to me at the time. In June 2013, with 2-year graduate nursing experience under my belt, I undertook a locum, rural nursing placement at the Royal Darwin Hospital in the Northern Territory, and, as was my approach to the Townsville student placement, I was keen to open myself up to a different side of nursing. My hometown, where the winter nights reach minus five degrees centigrade fairly consistently, is on the other side of the country from Darwin, which is in the tropics. My hometown is also surrounded by mountains with the nearest beach a 2-hour car trip away. Darwin, on the other hand, is on the coast but is essentially in a desert. And, while there are beautiful beaches at your doorstep, you can’t swim because the crocodiles are there waiting for their next meal. It was without a doubt, very different to what I was used to. As an example of just how different it was, one day soon after I arrived in Darwin, I made my way to the local nude beach where I saw some nudists. They didn’t seem to be too worried about the signs that said ‘crocodiles—do not swim’ and were diving straight into the water. Meanwhile, just down the beach, there were a group of aboriginal people setting up a fire in the sand near some smashed glass bottles. Seeing these sorts of things was so unfamiliar to me and it really felt like I was in another country. I also thought it was sweet when another nurse at the Darwin Hospital—someone who had never been outside of the Northern Territory—enquired about my home town one day while we were preparing medications. ‘Your city must be the same as Darwin, yeah?’, she asked. When I responded assertively, ‘No!’ She then asked with curiosity ‘What’s different about Darwin from where you live?’ ‘Everything’, I responded. My time in Darwin was definitely colourful. I stayed with some of my brother’s friends, an army family (there is a big defence population there). Sometimes, when I was not at work, we would eat delicious ice creams from an amazing local business while sitting on the scorching hot beach with their kids. We would then have dinner while watching the sunset over the ocean, which was always enriched with vibrant purples and oranges. My friends at home couldn’t believe that the photos I took were not edited. The official and unofficial rules differ in the Northern Territory compared to the rest of Australia. For example, the speed limits are not the same; you can also buy particular types of scooters without needing a motorbike license; and it is considered unsafe to be out walking after the sun goes down. My rude introduction to some of the rougher culture in Darwin occurred when I went for a jog around the suburb where I was staying. It’s blisteringly hot in the

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Northern Territory, so my army friend gave me a CamelBak (a water supply backpack). Off I went, with my feet pounding the black and squishy asphalt in the 37-degree heat. It’s illegal in my home city to train a dog as a guard dog. Whether or not this is legal in the Northern Territory, there are tons of guard dogs throughout the neighbourhoods. I ran past one person’s house and a guard dog launched itself at me on the other side of the fence. The dog couldn’t get over the fence, but I got a huge shock and I’m fairly sure that dog would have attacked me if the fence hadn’t been there. On the way back from my jog, the dog jumped up again at the fence, barking and snarling. I was pretty fed up by this point, having been almost scared to death twice by this dog, so I squirted some water from the CamelBak onto its nose (as a disclaimer, I would like to say that I am an absolute animal lover). The dog ran off sulking, behaving as though it had been attacked, and I kept jogging. About 5 minutes later, a woman exited her car in front of me and began speaking to me, but I couldn’t hear anything because I had my earphones in, listening to my music as I often do when I am running. I pulled out my earphones and gently asked, ‘Sorry, did you say something?’ The woman—with a striking resemblance to the guard dog—barked at me: ‘What did you squirt at my dog?’ ‘Water’, I replied meekly, with the sinking realisation that this woman must have been watching me through her window. ‘It better have just been water!’, she yelled with both confrontational and threatening intent. ‘Christ’, I thought. ‘Does this lady think that a runner’s CamelBak is full of acid or something? What else would I be carrying other than water in this stinking hot weather?’ ‘Why did you do that?’, the woman demanded. I was becoming a little frightened at this point. ‘Um’, I stammered, and I now cannot believe I gave this next response. ‘I thought your dog was thirsty’, I said, almost laughing. I knew it was the most unbelievable answer to her question but at the time, I didn’t know what else to say. ‘No, you didn’t!’, the woman yelled while glaring at me. And then she added, ‘You stay away from my dog’. I sure as hell did. The relationship between white Australians and Indigenous Australians in Northern Australia is varied. While I was there, I heard a lot of people referring to the Indigenous people—those who chose to live traditionally—as ‘long-grassers’. In one sense, this term could be seen as a simple description for Indigenous people who chose to live on the land—specifically in the long grass. However, the way it was used was never in a particularly kind manner. ‘Lock your doors’, people would say. ‘You have to watch out for the long-grassers’. I was told by a dance teacher in Darwin that the white people were afraid of being robbed by the long-grassers, and that’s why a lot of white people have guard dogs. For many reasons, I was perplexed by this statement. I was left wondering if Darwin really was as dangerous and divided as people were making it to be. Darwin is closer to Bali than any other capital city in Australia, and the Royal Darwin Hospital, a large and extensive facility, is Australia’s National Critical Care and Trauma Response Centre. Given its location, capacity and clinical specialisation, it has therefore been of significant assistance in a number of regional disasters and won international recognition for its role in the retrieval, treatment and transfer

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of victims after the 2002 Bali bombings. Within 62 hours of the blasts, medical staff at the Royal Darwin Hospital had resuscitated 61 patients. In addition, an extra 68 patients were triaged and transferred to burns speciality units across Australia. The facility also treated more than 20 victims who were evacuated following the second Bali bombings in October 2005. This hospital has also treated victims evacuated from the war in East Timor in 2006. Needless to say, the Royal Darwin Hospital is a pretty remarkable place. On my first day working in this hospital, I came across a patient smoking a bong outside the front doors at 7 am. Nearby, an aboriginal man and a white man with a big beard—who were wearing matching hospital pyjamas—were sitting on milk crates and sharing a cigarette. It seemed their hospital admission had brought on a friendship, or at least an understanding of shared hardship. Also, the wards that I worked on had security guards at the entrance; I had never seen this kind of setup in a public hospital before. On one particular shift, I was caring for an Indigenous Australian woman who had been flown in from a remote community. When I lifted the sheet on her stretcher to check the name label on her wrist, several cockroaches fled out from underneath her and I had to stop myself from squealing. To even begin to work out what was happening with this woman, we first had to be able to communicate with her. So, some of the staff began running around trying to find a person who spoke her language; there are many different languages among the Indigenous people. However, what we found out in due course was that this woman was actually deaf. As unique as the nursing was in that hospital, the day-to-day clinical incidents with patients that I was accustomed to in my hometown still took place in Darwin. On the same shift, the patient next door to the deaf woman pulled out his cannula and began gushing blood. ‘Why did you do that?’, I asked with annoyance as I applied pressure to the cannula site. ‘I got sick of it, so I figured I could just take it out myself’, the man responded, pragmatically. ‘It’s a portal to your vein’, I reminded the man crossly, ‘You can’t just pull it out willy-nilly’. Another man I cared for in Darwin (an aboriginal man) was deaf-mute with a seizure disorder affected by schizophrenia, drug and alcohol use. He was also a recent amputee due to diabetes. This man was already a complex patient and adding cultural considerations to the formula made the equation extra tricky. I watched the local nurses closely to see how they cared for a man with such a complex illness trajectory. And, as it is often the way with nursing, I realised that, if in doubt as to how to manage a situation, love and compassion will always be received well by patients. Australia is clearly a country made up of many different people. My cousin, Aiste, used to live in a Melbourne suburb made up of mostly Italians and Greeks, and I could have sworn that Aiste and her husband were the only non-­Mediterranean’s living there. Like me, Aiste was born in Australia, but our grandparents are Lithuanian; they came to Australia as refugees during the Second World War. Aiste’s husband was also born in Australia but his parents are Slovakian. So, it seemed that the only non-Mediterranean people in that suburb were actually part Australian and part Slavic and Baltic. I really loved visiting Aiste because we were able to eat

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inexpensive, but delicious, Greek and Italian cuisine in the local park, made and served by passionate and traditional family-owned businesses. When there are big groups of particular populations in one area, people organically band together. My father was born in Australia but started school not knowing any English. Even though Lithuania is a small country, the small pockets of Lithuanians within Australia form a strong community. I consider myself to be half-­ Lithuanian, as my father spoke the language to us when we were growing up and we were raised with Lithuanian traditions. Even my mother, a seventh-generation Australian, has learned the Lithuanian language and is just as involved with Lithuanian traditions as my father’s side of the family. I’ll never pretend that my family, or I, is perfect, but something that I always take pride in is how our family has always made efforts to be kind and hospitable to others in the community, especially new migrants and people just generally needing some tender loving care. This approach, I feel, has stemmed heavily from the background of my grandparents, who were once people in need, trying to find a haven and solace in a time of despair and hardship. Before working in a hospital, I would never have believed that people could live in a country and avoid learning the local language for 20 years. I think I hold equal amounts of respect and frustration about this. Firsthand, from my travels, I know how hard it is to learn another language and grow accustomed to new cultures in a place that is unfamiliar to you. Australians who do not have languages in their family other than English can lack a lot of understanding in this regard. I further admire people that can manage to stay in tightly knit and supportive communities no matter where they are in the world. However, frustrations tend to arise in nursing for me when non-English-speaking people are needing emergency services and physical or emotional treatment. When these situations arise, it becomes very difficult to communicate. When working once on a medical ward, I had a really sweet Chinese patient called Ying, whose only English words were ‘hello’ and ‘toilet’. When Ying wanted something, she would smile and wave her hands frantically while yelling out, ‘Hello! Hello! Hello! Hello!’ We were heavily reliant on Ying’s son, who would often visit her in the hospital in order to translate for her. For the sake of Ying’s family and the nurses, it would have been helpful for Ying to have learned a few more words in English instead of just ‘hello’ and ‘toilet’. On another occasion, I was in a critical care unit caring for a Greek woman, Rhea, who had been taken off life support and was slowly dying. Rhea had so many family members (bless them) that, in order for them to fit into the room with all the hospital machinery and the treating staff, they had to arrange their visits in shifts of five people at a time. Rhea did not speak any English, and one of the nurses that was handing over to me complained, ‘How could she have lived here for this long without learning a word of English?’ I immediately thought of Ying, and the similar frustrations that I had experienced. (Rhea’s situation was a little different, as she was being palliated.) ‘I understand’, I told the nurse. ‘But if Rhea hasn’t learned English before now, she isn’t going to learn it while she is dying, so you had better learn some Greek, sister’; interpreters just aren’t available to provide translations

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for 24-hour, around-the-clock care. To live up to my own words, I worked with Rhea’s family during my shift to learn a few essential prompts in Greek, such as ‘open your eyes’, ‘water’, ‘toilet’, ‘pain’ and so on. It’s amazing what incidental skills and strategies nurses are forced to pick up to be able to help their patients. What I have learned from caring for a diverse population is that we all have our own unique cultural and spiritual needs. We need to nurture these needs within ourselves and respect those of others. We also don’t need to pretend to understand another culture when we just don’t get it. But, in nursing, and in day-to-day life, appreciating what is important to a person, where they have come from and what has led them here today is what empathy is all about.

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The good nurse will go on adventures and get out of their comfort zone. As the reader has probably gathered from reading this book, I believe that studying, working, volunteering and travelling in a variety of environments open new doors to learning and broaden your horizons. Having the opportunity to work in developing countries, such as Guatemala, as well as other places I knew nothing about until I hopped off the plane (e.g., the Canary Islands), has certainly been both eye opening and rewarding. During my final year of undergraduate nursing, I had my first significant relationship breakup while simultaneously recovering from orthopaedic surgery to my knee. I felt like a bit of a train wreck, both emotionally and physically, and what better remedy was there than a wild trip to South America with my friend Rebecca? It was just what the doctor ordered to help heal a broken heart. My sister and parents both warned me: if you get kidnapped, we cannot afford to pay the ransom. Roger that family I said and off we went, starting our trip in Mexico. With regard to my knee: I still had a way to go building up the strength that I had had previously, but I had been given a green light from the surgeon to start returning to my usual activities (with some exceptions, such as high-impact sport). So, Rebecca and I took note of the surgeon’s advice and in Mexico we did everything that you must do: tons of trekking, exploring many a ruin, swimming, partying with the locals and heaps of scuba diving. However, I was still struggling with break-up blues. Rebecca and I were sitting at the top of Chichen Itza one day when I suddenly found myself crying. Essentially, I think I felt guilty that I could be in a place so beautiful and still feel so sad. Most of the time while travelling, I had been able to distract myself with the beautiful world around me, but, at that moment, I felt like I had lost a lot of meaning and direction in my life. Guatemala was the next country on our list that we were due to explore, but that was when disaster hit the country. A sinkhole occurred in a major city for a combination of reasons—Tropical Storm Agatha, the Pacaya Volcano eruption and a consequent leakage from sewer pipes. As a result of the sewer damage, the water in that area became heavily polluted. So, aside from the deaths and infrastructure damage caused by the sinkhole (and an already poverty-stricken area), respiratory and gastrointestinal illnesses, especially amongst children, reached alarming rates. Rebecca was in the same situation as myself—she was also studying to be a nurse. And, given what was happening in Guatemala and our plan to travel there, it seemed like volunteering our time was the right thing to do. I also couldn’t help but think that, at last, my mind would be able to properly switch off from my own problems. Nursing has always been very comforting for me in that way. Nurses are forced to focus on the task at hand, when another person needs their care. There was a friend, called Juan who Rebecca had met, called Jose on the CouchSurfing website, an online site where hosts and travellers have the ability to meet up and arrange stays with each other. Jose put us in touch with a not-for-profit medical clinic called ASSADE in San Andrés Itzapa and off we went to volunteer. The staff at the ASSADE clinic are made up of public health professionals and women from the local community, who all choose to volunteer their time. When we

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were there, there were a total of five employees, including two doctors and a pharmacist. When we reached Guatemala, Rebecca and I found a place to live in a fun party hostel, where we may have been the only 21-year-olds who went to bed at 9 pm and scolded the other guests when they woke us up. We also rose each day with the sun to catch our rickety bus to the edge of the volcano in San Andrés where ASSADE is situated. My first image of the town of San Andrés will always stay with me. It was strange to see entire farming families set up and living on a volcano that had recently erupted; truthfully, I thought it was bloody dangerous. I still remember chickens pecking around the fallen volcanic matter at my feet as I made my way to use the outdoor toilet, which Tropical Storm Agatha had blown the roof off. I also remember sitting on the bog, with my pants around my ankles, and looking up at the overcast sky while thinking pensively: ‘Where am I and what the hell is anyone doing here?’ Rebecca’s Spanish was good, and I knew a little bit as well, but the languages spoken in this area of Guatemala were Mayan dialects, so our Spanish-speaking ability meant diddly-squat. Fortunately, there was an American girl studying public health at the ASSADE clinic who spoke the local indigenous language (What a girl!), and she became our translator. On my first day at the clinic, I learned how different the clinical presentations were here back home in Australia. My first medical consultation was with a man, dressed in muddy farming clothes, and his wife, who was dressed in traditional ‘traje’ (Mayan clothing, which, in this case, was a long-striped skirt with a sash and square cut blouse). The farmer was enquiring about symptoms that his wife was experiencing and the doctor informed him that his wife likely had the human immunodeficiency virus (HIV). I watched the man and his wife nod in response; they did not appear frightened by the news—perhaps they were in shock? This was the first time I had been present for a HIV diagnosis, and this was the first appointment of my first day at ASSADE. Rebecca and I were given fairly straightforward tasks. We did a lot of cleaning, and I was happy to do whatever I could to be useful. One such day was spent rummaging through boxes of medications donated by pharmacies in America. Most of the medications were out of date and I felt so angry. Was donating expired medications to a country in need really the best that the rich pharmaceutical companies could do? My time at ASSADE demonstrated to me that the staff there knew what to do and had a handle on things. What ASSADE really needed, like many such organisations, was more money to be able to extend their practice and have better resources. So, when we returned home to Australia, Rebecca and I ran a fundraising project for ASSADE where we organised a group hike up Mount Kosciuszko. Later, I also spoke about ASSADE at our nursing graduation ball, and—while the students were drunk and feeling generous (and also relieved to have finished their studies)—we were able to raise about $1500 for ASSADE.  If you would like to volunteer or

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donate to ASSADE, please contact the program director through the contact email listed on the ASSADE website at http://www.mmex.org/missionrecords/assade-­clinic. In 2017, years into my nursing career and as part of a quarter-life crisis, I decided to quit my current nursing role and take off on a 5-month adventure in Europe; this holiday also brought about the birth of this book. My Europe trip included visiting friends, studying language and culture in Lithuania and completing an 800 km trek/ cycle on the pilgrimage trail El Camino De Santiago. This holiday gave me the opportunity to spend a significant amount of time in Lithuania, as well as a few different Spanish-speaking countries, and so I continued to practice my Lithuanian and Spanish language skills. I wanted to make the most of that trip because, indeed, you only live once. A friend of mine had told me all about their home in the Canary Islands. These islands hold a Spanish, or should I say ‘Canarian’, culture, but are located geographically close to West Africa. I therefore decided to spend a month living in Lanzarote, one of the Canary Islands, at the invitation of a host called Diego from the CouchSurfing website. My couch-surfing host, Diego, wanted to work on his English, and I wanted to work on my Spanish, so it became an ‘intercambio’ (a language exchange). I was initially worried (as were my friends and family in Australia) that I had consented to live with a stranger for a month in another country a long way from home. Diego did hit on me once, but aside from that awkward evening (that we both never spoke about again), the arrangement was otherwise perfect. Diego welcomed me into his life. His friends and family became my own and the care and hospitality I received were impeccable. While I was there, I spent my mornings venturing out surfing in the wild waves with the hot, red dust of the Sahara Desert brushing up against my face. And the afternoons and evenings typically involved eating, drinking and socialising for hours—as Spanish people do so well. My day-to-day itinerary made for a wicked contrast of landscape and culture. For those interested, the Canary Islands were one of the filming locations for one of the Star Wars films—and I actually guessed this before that information was revealed to me. The richly combined textures of the sienna and crimson-coloured volcanic rock in the Canary Islands make you feel as though you are no longer on planet Earth. During my month in Lanzarote, I intended to continue speaking Spanish and surfing, but I also wanted to contribute to the community, to feel more connected and to give back. In my experience, it can be difficult finding volunteer work that is both legitimate and easily accessible. I had emailed a lot of different volunteer organisations, who either didn’t get back to me or said they didn’t need me. I think that care agencies are sometimes suspicious of people who are willing to work for free. Other agencies were available, but they involved lengthy courses and mountains of paperwork, and they requested that volunteers work for them for 8 weeks or more. I wanted to hit the ground running within the time frame that I had available. Fortunately, I met a lovely Canarian woman, Aitana, at a language exchange group in Lanzarote. I told her that I was hoping to do some volunteering but was

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having trouble finding anyone who wanted my help. Aitana told me that she would take me for an interview at a centre where I would be needed—and where they would be predominantly speaking Spanish, which would be good practice for me. She told me that the place was called ‘El Cribo’ and that it was a healthcare centre that ran different recovery programs for people with mental illness. The night before I went for my interview for El Cribo, Aitana asked me if I really wanted to spend my free time volunteering at the centre. As an alternative, she suggested that we could just chill on the beach, eat chips and chat. I told her that, although I could just happily lie on the beach each day, I definitely wanted to volunteer. It’s a funny thing. At work, nurses often complain about feeling exhausted and stressed, and about needing a break. However, when nurses have time off, you’ll often hear them talk about missing work. This is certainly the case for me, and a lot of people in the Canary Islands found that surprising. At El Cribo, the director asked me many questions about my reasons for wanting to volunteer and the implications. She started off by asking me if volunteering at a centre like El Cribo was a required component of the clinical placement hours of my study. I replied that it was not and added that I was already a nurse and had no study requirements to fill. She then reminded me that I would not be getting paid and checked again that I would be okay with this. There was an uneasiness in her voice that hinted she felt that I might cease the interview at this point. Instead, I responded happily saying that I knew I wouldn’t be paid and that I was absolutely fine with this arrangement. The director seemed pleasantly surprised at this and suggested that I could start on Monday, if I was happy with that, which I was. The entire interview had been in Spanish and the director then went through a huge book outlining the ins and outs of the El Cribo program. I was impressed with how organised the program was, but I also felt a little overwhelmed. The night before starting, I felt sick at the thought of what tomorrow might bring. I didn’t know what I was in for and was afraid of failing, and I was genuinely thinking about backing out. It had been years since I had worked with clients with intellectual disabilities, and this would be a large cohort of the clients at El Cribo. I was also concerned that my Spanish would not be adequate. However, I stayed the course and Aitana drove me to El Cribo the next day reassuring me that I would do just fine, as did the director when I arrived. I’m so happy that I chose to go ahead with my volunteering, despite my nerves and insecurities. The ethos of El Cribo is a testimony to what the staff deliver, and I loved it so much that I chose to volunteer every day. The way the programs run at El Cribo, and the therapeutic effectiveness of this program, was everything that I had been trying to develop in the youth residential program where I last worked. To create a positive work culture, everyone needs to share the same vision and be committed to working hard to provide the care that they promise. At El Cribo, the aim is to reduce the stigma of mental illness in the community and promote awareness of it. They do this by giving their clients every opportunity to have the same life skills and community involvement as anyone else would—to be treated as equals. By the end of my first day, all of the clients had learned my name and had checked that I would be coming back the following day, which made me feel very special.

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El Cribo doesn’t just have one activity for their clients. They can choose from many different activities that run concurrently every day. Here are just a few of the activities that were running during my time volunteering there: –– –– –– –– –– –– –– –– –– –– –– ––

Gardening Floristry Graphic design A conversation group about sexuality and relationships A meal-planning and healthy eating group A music group (through which the clients of El Cribo participate in Carnivale annually) A sports group A debating group A conversation group about budgeting and cleaning A group that went on cycling trips to the beach And A psychoeducation group

My favourite group was the gardening/greenhouse group. El Cribo owns a greenhouse where all of the plants and produce grown are solely the work of their clients, and I had the amazing experience of being taught by the clients—who are proficient in these skills—how to harvest wheat and prepare organic tea. Not only that, but these foodstuffs are then given to the community in return for a donation, a process that helps create ongoing and long-term benefits and rewards for the whole program. This gardening group was truly invaluable. Sarah Rayner, a self-help novelist based in the UK, summarised in Psychology Today that gardening is therapeutic because looking after plants gives people a sense of responsibility and allows them to be nurturers. She goes on to say that gardening keeps people connected to other living things—it is a mindful activity, and it is also exercise that assists in the body releasing ‘happy hormones’. In addition, gardening provides an opportunity to be outdoors amongst nature and soak up some sun. And, on a deeper level, gardening can teach people about the cycle of life in a nurturing way. While I was at El Cribo, I learned that many of the staff had worked there for over 10 years and that they still maintained the same enthusiasm they had when they started. I also saw that the clients who attended the different programs at El Cribo had a good rapport with the staff and that they kept saying how helpful the Centre was for them. They reported benefits such as having more meaning in their life, learning new skills, establishing routines, increased motivation, receiving support as well as feeling like a part of a family. The last of these benefits was an important one because a lot of the clients were estranged from their families, which still makes me very sad as they were all really sweet and beautiful people. Never knew the reasons why they were estranged from their families. However, I imagine a lot of these situations are impacted by the effects of stigma regarding those with mental illness and other disabilities.

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The therapeutic benefit of the kinds of activities held at El Cribo cannot be understated. One client even told me that the activities at the program were the most important thing helping him stay well and happy, more so than medication and seeing the doctor. This is not to dismiss the value of healthcare professionals and medicine, but the kinds of activities that El Cribo provided, I believe, are equally as important in mental health recovery as the medicines, treatment and counselling from health professionals. Unfortunately, these kinds of recovery programs seem to be typically undervalued in many health systems in the world. I felt honoured to be a part of El Cribo and, similar to my experience at ASSADE, my time there felt too short and I wanted to do more. While at the Centre, I had noticed that many of the furnishings were heavily worn, damaged or broken but were still being used due to funding limitations. This inspired me to undertake a fundraising project when I returned to Australia to improve the furnishings in the Centre. My fundraising goal was achieved, thanks to the generosity of my friends, family and colleagues, and subsequently the furniture has been replaced with good quality, stylish and comfortable items. Everyone at El Cribo was very grateful and the director sent me photos of the clients smiling and enjoying the new décor while holding up signs to say thank you. The whole experience at El Cribo—from being recruited to the completion of a fundraising project—leads me to reflect on how different my workplace in Australia is. Some bureaucracy is needed in healthcare for clinical practice to be fair, transparent, strategic and organised. However, sometimes our healthcare system can get a little strangled by red tape. Nurses in Australia are taught to live in constant fear of ‘doing the wrong thing’ because of the assumed risk involved. This can prevent clinicians from being creative in the ways that they provide evidence-based therapy. In a direct contrast to El Cribo, the last nursing role I had before quitting and heading overseas in 2017 did not even allow me to order an exercise ball (for use in a physical exercise group) because of the risk of someone falling off it. None of the young people in that program had any physical or intellectual disabilities and many were taking drugs and alcohol and already undertaking dangerous activities on their own accord. Strangely enough, it was deemed okay for me to take the young people for walks up the nearby mountain, which I felt was a little more dangerous than using an exercise ball. The bureaucracy that I had had to contend with had felt overly restrictive and also a little ironic. El Cribo has reminded me that, in terms of mental health, one of the best things that we, as clinicians, can do is support people in practical, fun and creative ways so that, despite their hardships, they can have meaning in their lives and regain confidence in themselves. Recovery doesn’t just come in the form of medication or seeing a health profession—it also comes through community involvement. If you would like to volunteer or donate to El Cribo, please contact the program director through the contact email listed on the El Cribo website at http://elcribo.org/.

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Traveling enables a person to broaden their horizons. Nursing in faraway places extended me as a person through the experience of being in another part of the world and seeing how people live—and also how healthcare can be delivered despite limited resources and funding. It also led me to appreciate how fortunate we are in Australia with our healthcare system, but also how we have the ability to do so much more.

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The good nurse knows that strength and determination can triumph over hardship. As a nurse, I find it important to talk about the struggles that both patients and nurses face. However, it is with equal necessity that I want to share some good news stories; I would hate for the examples of triumph over adversity to be forgotten. It was in grade 6 that I felt I developed my first true appreciation of what people can overcome while having a disability. When I was 13 years old, our primary school was lucky enough to be taken to the Paralympic Games. It was free for us to go and watch these athletes. I found it disappointing that spectator tickets needed to be free in order to encourage people to support Paralympians. On the other hand, when a person wishes to watch Olympians compete, they pay huge amounts of money. To this day, I will never understand why this is the case. The amount of dedication and strength needed to overcome a disability and then achieve outstanding sporting achievements is unbelievable. The most mesmerising event at the games for me was goalball, a sport which was invented in 1946 by an Austrian, Hanz Lorenzen, and a German, Sepp Reindle, in an effort to help the rehabilitation of war veterans who had been blinded. In goalball, participants compete in teams of three and endeavour to throw a ball (that has bells embedded in it) into the opponent’s goal. Teams alternate throwing or rolling the ball from one end of the playing area to the other, and players remain in the area of their own goal in both defence and attack. Players must use the sound of the bell to judge the position and movement of the ball, and blindfolds allow partially sighted players to compete on an equal footing with blind players. I could never imagine trying to do anything athletic blindfolded, so watching this game really blew my mind. After my exposure to the Paralympic Games, I developed a huge interest and admiration for the achievements of people who live with a disability. As a nurse, I’ve met a blind patient who could play the piano beautifully, and a paraplegic man who could move himself around the room all on his own with the use of his superior upper-body strength. These are just two of the many patients I have met who have shown me what it looks like to make the most of what you have. Before I tell you an inspiring story about a client of mine, Brian, who was diagnosed with schizophrenia, I thought that I might briefly share how I started working in mental health as a nurse. I began working for an adult community mental health team virtually by accident. But, as is the way with many things in my life, I am surprised as to how ‘accidentally’ walking into that role has been extremely fulfilling for me in many ways. After spending several years working at two of the major hospitals in my city, I commenced working with a nursing agency so as to get a broader range of nursing experience. As one of my assignments, the agency asked if I wanted to fill in as a clinical case manager for a month at an adult community mental health team. Despite having virtually no experience in this field, I agreed. In the beginning, I really did feel like I might have gone in a bit too deep. Of course, with every new work area, there are the usual difficulties: ‘Where are the toilets?’, ‘How do I use this computer program?’ and so on. But the biggest challenge was trying to learn how to approach and care for people with a mental illness.

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Before this placement, I would not have known what to do or say if a person had told me that they wanted to end their life; and these were the kinds of scenarios that I was having to deal with. All the staff members that I worked with had so much more experience in the field compared to me. However, my colleagues helped me to fit right in, teaching, encouraging and supporting me through every step of the way. And, for the first time in my nursing career, I was actually given the time to attend all of the training that would help develop me as a nurse in this field, something that my previous workplaces in the general hospital system never seemed to have the budget or time for. In community mental health, I was also given the chance to have a clinical supervisor to support me along the way. Again, this was a valuable resource that I was not familiar with from the hospital. At the end of my first month, I had fallen in love with the work. At last I felt like I may have found my true calling in nursing. I loved learning about the journeys of my clients, forming a close rapport with them and being able to help them stay in recovery in the community. I also learned that this role required a creative and individual approach to how one helps care for each person, and each recovery plan really did need to be tailor-made and require a great deal of collaboration. At first, I found it to be a difficult adjustment to using creativity in my role. I was used to working in the hospital, where observations, medications and personal care were all done routinely. However, caring for someone with a mental illness cannot be done using a textbook approach. Shift work in a hospital can be easier in some respects because you know that difficult or upsetting clinical cases can be handed over to someone else at the end of the shift. However, as a community clinical case manager, this isn’t possible as you have a list of clients who are allocated solely to you. The benefit of having your own continuous caseload means that you really get to know your clients well, you can see their progress and you are also able to work with more autonomy. However, this didn’t mean that this new way of doing things wasn’t without specific stressors. Seeing someone in a psychotic state can be really upsetting and scary, and it always broke my heart to see people chronically depressed or in a generally difficult place in their life. A lot of my clients had also had awful upbringings with drugs in the family, violence and homelessness. Facing the gritty side of life in a role like this shows you how important it is to be able to apply self-care, as well as the importance of having supportive colleagues, which I was very blessed to have in that team. Working as a clinical case manager also reminded me not to take my own life for granted, and it also taught me to stay empathetic with my clients. Who knows where my life would be if my family had been abusive and addicted to drugs, or I had been denied—for whatever reason—the privilege of being able to go to school? Now, back to Brian and his story. Sometime after Brian had been diagnosed with schizophrenia, I was allocated to be his clinical case manager to provide him with some additional support. In many aspects, things had not been easy for Brian—he was treatment resistant to many of the antipsychotic medications he had trialled,

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and as a result, he had to be treated with the last-line schizophrenia medication: clozapine. It helped him in many ways, but it also gave him a variety of side effects, including seizures, which meant that he could no longer drive a motor vehicle. Brian was the same age as I was (21 at the time), and initially I had concerns about being in a professional role for someone who had lived on this earth for the same time as myself. Later, I felt that being the same age helped with our rapport and the ease with which we learned to relate to each other. We were both in a similar point in our life, the constantly changing, exciting and scary 20s. Furthermore, Brian and I both enjoyed artistic endeavours (although Brian’s work was his profession and mine was just a hobby). At the time, I loved dancing and enjoyed drawing and craft, and Brian was—and I’m sure still is—a very talented graphic designer and musician. I was awarded the luxury of time to get to know Brian, his family and his girlfriend, Tania, in a meaningful way, and it became quickly apparent that the support that Brian had meant that he was able to stay in recovery for longer and have a better quality of life. Brian’s loved ones had a very good understanding of how schizophrenia manifested for him, his higher-risk times for potential relapses and how to help him stay in recovery. The conversations between myself, Brian and his supporters were also always upfront and pragmatic; we didn’t have to tiptoe around difficult topics regarding his illness or care. Brian also knew to seek help when he needed it, which is really helpful in recovery from a mental illness. He kept me informed as to when he felt that things were going downhill and we continually re-evaluated his care plans in response to this. Tania was a memorable person too. She was studying primary school teaching and, at the young age of 22, was beautiful both on the outside and the inside. Tania and Brian explained to me that when they had first met, Brian had told Tania that he had been diagnosed with schizophrenia and Tania had told him: ‘That doesn’t worry me’. In writing about his illness, Brian wrote the following: It is still really hard for me to deal with this illness, especially when there are sometimes no signs of when I’m getting sick, and how quickly things turn from bad to much worse, e.g. when I was last hospitalised, I started off with really bad paranoia and was very delusional. But things turned worse in a week or two when I started to have visual and auditory hallucinations, etc. Recovering from an episode like this takes lots of time and usually means months of time spent in the wards; and the more they occur, the more they are likely to recur and even worsen. After being in and out of psychiatric wards for the last several years, I now accept this and understand that it may stay like this; but I keep a positive outlook on it all, hoping that the psychotic episodes will eventually diminish and my quality of life will stay consistently better. Fortunately, Brian’s artwork was a significant motivator for him to move forward with his life. His art was beautiful, colourful, imaginative and precise. When I knew Brian, he was selling his artwork on canvas and he also owned a clothing label. He sourced blank garments from an interstate company and would send his designs to a printing factory. Brian sold his work online, as well as in shops around Australia, and had even had some interest from Japan. Since meeting Brian, I have encouraged

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him to enter two art competitions. In one competition, he was a finalist, and in the other competition, called ‘The Mindscapes Festival’, he won first place. The aim of the Mindscapes Festival is to act as a platform for bringing people with mental illness into the heart of community events. At an individual level, this can improve the general wellbeing of people living with a mental illness, while at the broader community level, it can increase public understanding of mental health issues and reduce the stigma surrounding what is a relatively common problem. With a safety plan in place, and with guidance and support from the medical team and myself, Brian—despite having many road bumps along the way—was gradually able to reduce the doses of all of his antipsychotic medication. Unfortunately, his psychotic symptoms then increased. However, the side effects from the antipsychotic medication decreased and Brian felt that this was both a manageable and a fair trade off, as he was able to get more of his quality of life back. I was proud of Brian’s hard efforts to stay in recovery and I admired the love and dedication of his loved ones, who stuck by him. I know that Brian will continue to go far in his life and it was a privilege for me to get to know him and his support network. This chapter, I hope, is an example that mental and physical illness is not always a curse. Adversity can bring hardship, but people can still live great lives despite this.

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The good nurse gives pragmatic suggestions. You, dear reader, are not my patient. But I would like to give you some health suggestions anyway. Nursing suggestion (NS) 1: Before you race off to get a blood test, check in with your sleep, nutrition, exercise and stress management practices. NS 2: All things are more manageable with a good night’s sleep as well as time to chill and relax. NS 3: Following on from the previous suggestion—have a nap, or a quiet lie down, every day if possible. NS 4: Ignore diets and aim for a balanced diet instead. P.S. moderate amounts of wine and ice cream can be included in a healthy diet. What your body can do is more important than how it looks to others. NS 5: Conversely, how well one is generally coping in life can also be monitored by the amount of ice cream and wine consumed in a given week. NS 6: However, with regard to aiming for a nutritional and lifestyle balance, if you choose to bypass healthy foods and go straight to taking multivitamin tablets, there is a problem. NS 7: Exercise every day, if possible. No matter how sad you feel, think back to a type of exercise you enjoy. Doing it is almost guaranteed to make you feel a little better. NS 8: Some people need medication. However, a ‘natural medication’ that is both cost-effective and has no side effects can be found in sunshine (sun protection still required), laughter, exercise, hobbies, being social and contributing to society. NS 9: More times than not, headaches are a result of exhaustion or stress (or at times, for coffee lovers, withdrawal from caffeine). NS 10: Screaming at someone and telling them that they are useless (even if they are) probably won’t make you feel better in the long run. NS 11: A hug a day helps keep the nurse (or doctor) away. NS 12: It takes courage to ask for help. We all need to ask for help at different times. NS 13: As we are human, we are all flawed. Accept yourself, flaws included. NS 14: It’s important to have good support, but the individual has the greatest amount of power to create positive changes for themselves. NS 15: A diagnosis is only helpful if it leads to some sort of support, healing or resolution. NS 16: Don’t be surprised when nurses and doctors get the odd thing wrong. The human body is incredibly complex. Forming a diagnosis often only occurs over time, through continuous investigations—and also, a lot of trial and error. NS 17: Pain is not always a bad thing, nor is it necessarily an indicator that your body is seriously damaged.

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NS 18: To be alive means that you will experience illness and suffering, even if you try to play it safe. So, undertake some worthwhile risks. NS 19: Unless you abuse drugs or alcohol, or have a liver that is totally screwed, for God’s sake, you can take two paracetamol tablets if you have pain or a fever. It’s hard to get addicted to paracetamol. NS 20: On a generally clean floor or surface, you can drop food and pick it up and eat it again. NS 21: One-week-old pizza is fine to eat if you have lived in a student house and your stomach is conditioned accordingly. (NS 20 and NS 21 are not really advice from a nurse: it is more my anecdotal experience from living in lots of poor student homes while studying nursing.) NS 22: Unless they are vicious, wild, frightened or full of diseases, cuddle all of the animals.

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The good nurse will never be without a job. One of the incentives put to me when I was considering nursing as a career was the concept of guaranteed employment; numerous people told me: ‘As a nurse, you will always have a job’. This is a fairly blanket statement, and I don’t believe the reality is that straightforward. I’ve worked in permanent positions and done casual work across many clinical areas, and every working arrangement has its own set of advantages as well as disadvantages or complications. For example, personal injury can make employment options quite scarce for nurses, particularly if you want to work in a hospital. When I sustained a back injury in my new-graduate year, I had to have reduced hours for a period while I was recovering. At the time, I was working as a relief nurse and one day the shift lead had not been made aware of my injury. The only places that needed me on that shift were wards that required the lifting of patients. A special meeting had to be called to work out how my situation would be handled, as otherwise I’d be forced to take unpaid leave. Working in a hospital if you have an injury can be very difficult. In the television series Nurse Jackie, the lead actress, in one particular scene, says in a dark comedic way, ‘What do you call a nurse with a bad back? Unemployed’. Again, this reiterates the importance of nurses taking care of their bodies (as well as their workplace). As a teenager—and even in my early 20s—questioning whether or not I’d have guaranteed employment didn’t really seem important. Sure, I wanted money, but I figured that some people just got by in life through picking up all kinds of odd jobs. Although I could see this approach as being somewhat disruptive and unpredictable, I also saw it as being quite liberating and fun. Having followed that kind of employment trajectory while I was studying nursing, I would personally confirm that it was the latter. As a junior nurse, if you are happy to work in different clinical areas (and work at a less senior level with less pay), you can find employment just about anywhere. One barrier that can stop some nurses from working in new clinical areas is the discomfort of having to learn the ropes again. But nurses are capable of working in any clinical area; it just takes time to practice and become confident in using a new, or less-familiar, set of tools or skills. Other barriers that can prevent nurses from working in different areas are the rostered working hours and the pay. Once a nurse becomes a specialist in one clinical area, they can move up the ladder and get paid more. However, if a nurse moves to an area that is vastly different from their speciality, they will typically be employed as a more junior staff member, which means less pay. On the other hand, some nursing roles have different working hours and nurses can either enjoy or dislike shift work because the hours fit, or don’t fit, with their lifestyle. Shift work generally impacts on social scheduling and, typically, sleep, but it pays much more than working normal business hours. Working shifts also entitles those nurses to receive around 7 week’s annual leave a year, instead of the usual 4. I know a lot of nurses who will not give up their shift work gig (regardless of if they are exhausted or are sick of the work), purely because of the big pay cut they would have to take if they went back to normal hours.

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During my early days of nursing, I met a few ‘agency nurses’—someone who finds casual healthcare employment through an agency. Hospitals and health centres in cosmopolitan areas often employ agency nurses when they are short staffed; the nurse gets paid casual rates (or even a bit more)—with added penalty rates for shift work—for which the agency takes a commission. In a cosmopolitan area, the pay for such agency nurses is pretty good but it’s essentially casual work, and there are no set working hours. Agency nurses need to be ready to work when they are called—either the night before a shift or on the day itself. Such work also involves potentially working in a different place each day. The agency nurses in cosmopolitan areas that I knew told me that they had both busy periods and quiet periods, so they typically worked more during the busier periods to compensate for the loss of income in the quieter times. Overall, the agency nurse arrangement in my city seemed pretty appealing to me, so in 2013 I quit my permanent job to become an agency nurse. However, when I quit, I found myself to be in an unforeseen quiet period. On top of that, I got really sick with pertussis (otherwise known as whooping cough). Historically, it seems I have always seemed to get very sick the minute I resigned from a permanent nursing job while subsequently losing all of my personal/sick leave entitlements. Regardless, I worked wherever the agency told me to go and I had a lot of great and varied nursing experiences because of it. Agency work taught me to be both flexible and adaptable and I was able to learn an abundance of different skills. One benefit of working as an agency nurse in a cosmopolitan area is the appreciation you would receive from the usual staff on the ward, who would generally be very grateful for your help. However, the usual staff would also typically try, wherever they could, to palm off the most difficult work to the agency nurses—to give themselves a break. Hell, if I was in their position, I’d probably do the same. Working for the agency gave me the added bonus of not being in one workplace long enough to get involved in staff politics. However, I also found it to be quite a lonely time. I had no home turf, as it were. While many of the normal staff in the wards were friendly and welcoming, some of them wouldn’t even bother to ask your name as they knew you probably wouldn’t be there the next day. When the agency shifts were not coming my way as much as I was hoping, my parents began paying me to do some practical jobs around the house for them. However, after a while, they began to run out of ideas. It was an anxiety-provoking and unsettling time for me, but fortunately, the agency finally called and offered me a month’s worth of work in a community mental health centre to work as a clinical case manager. The job on offer would also be in normal hours, which was a relief given that I had only recently recovered from whooping cough and was not enjoying the unpredictable nature of shift work. With some hesitancy, I told the agency that I was keen to accept the position, but I wanted to make sure that the team I would be working with understood that I had very limited experience working in mental health (a few days filling in on psychiatric units). The agency confirmed that the team knew and were still happy to take me on.

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I was only meant to work in the centre for a month, but at the end of my time, they couldn’t find someone suitable to fill the position. As a result of this, I was promoted and worked in that role under continuous 6-monthly contracts for 2 years. During this time, I also completed some postgraduate study in mental health nursing. Honestly, it was great. I loved the work (mental health has become my specialty), and I had better hours and was paid more because I was working in a more senior position than what I had been in the hospital. Also, because I had contracted work, I was able to take significant breaks in between contracts for travel, which I’ve learned is much harder to pull off with a permanent job. My discussion about agency nursing is a great example of how, as a nurse, you can get away with not having permanent work. There will always be ways to do as many shifts as you want (if you are flexible). And the funny thing about that whole experience is that I never even planned to work in mental health. I also did not anticipate that, through my time working as an agency nurse, I would then be led into a nursing position within mental health that I subsequently worked in for 2 years. The way in which I landed that gig, and the continuous employment that it gave me, taught me that, as a nurse, if you are happy to work in places that no one wants to work, the career prospects are endless. However, in the beginning, the main reason that I had wanted to try agency nursing was to have the flexibility to work in rural placements, which are usually offered at the last minute. Rural nursing placements typically pay agency rates and the accommodation and flights are also paid for. What I didn’t realise was that because I was a junior nurse who had worked across many clinical areas, I wasn’t considered to be a nurse with a specialty (rather, I was a jack of all trades) and therefore not very employable for rural work. I did get a few offers to do some placements in some less-desirable areas of rural New South Wales, where I would be expected to ‘hit the ground running’ and manage a ward without any assistance. But that just didn’t seem like a great deal. Fortunately, by this time, I had already been offered the month-long agency placement in the mental health team, so I didn’t take any of them up. But, when I was offered my first 6-month contract with the mental health team, I realised that I had never actually gone on a rural placement as a registered nurse. As I’d quit my permanent job with the aim of trying a rural placement, I figured I had better make it happen before I got settled into a new job. So, of my own accord (and with support from the team leader of the mental health team to have a break before starting my 6-month contract), I elected to do some work in Darwin as a casual staff member through a different nursing agency. However, due to my being a jack of all trades, I was employed as a casual staff member and not as an agency nurse, which meant that I paid for my own flights and sorted out my own accommodation. Also, there had been some sort of miscommunication between the agency and the hospital in Darwin, and when I arrived for my first shift wearing scrubs, they told me I needed an agency uniform and that I couldn’t work until the agency mailed me a uniform from the other side of the country. As I was only going to be in Darwin for a couple of weeks, I felt this was a lot

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of wasted time and money, but, as I was desperate to have a rural placement as a registered nurse at the time, I made it happen and I don’t regret it. Agency nurses who are experienced in a clinical speciality and who choose to work in rural and remote areas can have a pretty damn good gig. As rural and remote health facilities have a difficult time attracting nurses to live and work there, the incentives provided for nurses who do are great. For rural and remote agency nurses on contract, their shifts are set in stone, as long as the nurses are happy to commit to 3 months or more at the one location. For example, a nursing friend of mine, Anya, has worked as an agency nurse for years. It has led to her living and travelling in lots of different areas in Australia. She also gets paid a decent hourly (casual) rate so she has saved a lot of money. Anya also often goes traveling in between contracts, as she has the flexibility to do so. With each placement, Anya is also provided with lovely furnished accommodation and is sometimes even able to negotiate for the agency to provide her with a work car. In her recent agency placement, she was even able to negotiate for the agency to provide her with a work car. As rural and remote hospitals and health centres are so desperate for staff, her contracts keep rolling over for as long as she is happy to keep working there. I’m at a point in my career with nursing that I have enough experience to say that I specialise in a particular field (mental health). There are opportunities within rural and remote agency nursing and international placements with organisations like Médecins Sans Frontières (Doctors Without Borders) that seemed so attractive to me in my early career days as a nurse. Unfortunately, back then, when I wanted those positions, I didn’t have the experience to be considered suitable to fill the roles. However, now that I do have the required experience, I feel like I want more stability in my life, so those positions seem less appealing. It’s been a bit of a catch 22. Now that I am a little older, I can better appreciate why stability and continuity in employment is something that people desire more, and even need with age, especially if they have significant caring or financial responsibilities. The plus side of a permanent nursing position is that employment is guaranteed. The downside is that permanent positions in nursing are fairly inflexible with regard to providing time off. For me, as a nurse, 4 weeks of leave a year is just not enough. The rigidity of permanent nursing roles has often led me to eventually resign from these positions to be able to travel more. I suppose I would not have been so easily inclined to resign from these permanent roles if it wasn’t so easy to be re-employed in other nursing work, or if my personal circumstances were different. In Chap. 1, the reader can see that throughout my nursing career, I have changed nursing roles every year or two. At times, I changed roles even more frequently, because I could. My nursing work is important to me. Still, flexibility, opportunities to learn and grow and work– life balance are equally, if not more, important. And choosing to become a nurse practitioner has changed my career prospects again. A nurse practitioner is a nurse who has the training (usually a Master’s of Nurse Practitioner) and at least 5 years of experience working in a particular clinical speciality in a senior role. The nurse practitioner qualification is the highest qualification, in terms of seniority, that a nurse can achieve, and it is recognised through the

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Australian Health Practitioner Regulation Agency (AHPRA). Within their decided scope of practice, nurse practitioners have the authority to be able to diagnose and prescribe medications. The salary of a nurse practitioner is considered substantial in the nursing field. However, the pay gap between nurses and doctors is disproportionate and, in the eyes of many—including me—very unfair. Nurses are at the frontline of healthcare and they carry a huge amount of responsibility. Doctors would not be able to do their jobs without nurses, so why is this not recognised in pay equality? Nurse practitioner roles in Australia are still an emerging field, and we definitely need more of them. In some parts of the world, like North America and the UK, nurse practitioners are widely used, and they are effective in closing gaps in healthcare. I believe that enrolled and registered nurses generally have more ability and knowledge than their professional scope allows them to use and becoming a nurse practitioner has allowed me to broaden my scope significantly. Because our healthcare system is, unfortunately, medically driven, nurse practitioner positions in Australia are generally only created if positions cannot be filled by medical staff (doctors). Aside from closing gaps in healthcare, nurse practitioners are also much more cost-effective than doctors. Still, in our current healthcare system in Australia, if the taxpayer’s money continues to primarily fund the enormous salaries of senior doctors, we will not see more nurse practitioner positions being made available. Out of the four of us studying the Master of Nurse Practitioner course in 2018–2019, only one person had a nurse practitioner opportunity available in the public healthcare sector of our hometown. The rest of us had to move to other parts of Australia to find available positions. I travelled nearly 700 kilometres to relocate to a rural, coastal town to accept a nurse practitioner position, and this position was created because the area in which it is based is rural and consequently has a significant shortage of doctors and nurses. Now that I am working as a nurse practitioner, I am a lot fussier with the jobs that come my way. I would not discount applying for a nursing position that is under my level of qualification, but I am reluctant to. This is for a few reasons. Firstly, I don’t want to get paid less and have to do the same, or even harder work, than I am already doing; and secondly, as a nurse practitioner, I am now able to work in positions with more autonomy, which I find satisfying and fulfilling. There aren’t too many nurse practitioner positions available at the present time in Australia. If I left my current position, I’m not sure what my plan B would look like. It may be a thing that I take the leap into private practice. However, Medicare billing rates for nurse practitioners are not that high, so I would need to get my business hat on. Most nurses that I know find the concept of charging a patient for care, uncomfortable. Of course, the other downsides/compromises of private practice are the uncertainty with regard to income. Working for the public healthcare system means that you have guaranteed pay, no matter whether your patients turn up for their appointment or not; with private practice, this is not the case. Naturally, like any business, working in private practice holds a lot of risk and paperwork and requires a clear business strategy. Also, working privately, you don’t have a team to rely on; you only have yourself, which is a huge amount of responsibility.

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With all of this in mind, I won’t exclude the idea of moving to private practice. When I have gained more experience as a nurse practitioner, I’d like to be able to deliver holistic nursing care, in the way that I want to, without all the red tape and politics. And, if I do make the leap to private practice, it won’t be because of the nature of the work with the clients in the public system—I love this aspect of working in healthcare—but because the bureaucracy of the public health system is a constant grind. I know that I am not alone with my feelings about this. I was born into a middle-class family in a privileged country. Still, nothing about the work that I have done through my years as a nurse has been easy. I’ve done shift work on and off in nursing and non-nursing roles since I was 14 and I have done everything that has been asked of me. As a nurse, sometimes you feel like a leader, while at other times you feel like a physiotherapist, a cleaner, a mother, a counsellor or even a security guard. I have worked in clinical areas that were backbreaking, heartbreaking and full of poo. Now, with many years of nursing experience—as well as two masters degrees—it is my belief that I should work in positions where I can use what I’ve learned and be properly compensated for it. On that note, as I stated before, nurses—in many ways—generate a lot of revenue for doctors. As nurses, we have to accept that fact, but it still hurts. Doctors should get paid well. However, with the amount of responsibility that nurses hold, anyone should be able to appreciate that the pay discrepancy between nurses and doctors is unbelievable. On a different note, it was in 2020 amidst the coronavirus pandemic that I finally began appreciating that, as a nurse, I really am never going to be without work. When COVID-19 hit, many nurses were forced to—or were told to be prepared to—be deployed to other clinical areas to assist with staff shortages. These arrangements were put in place so as to boost staffing levels in particular clinical areas if coronavirus mortality rates reached alarming levels. This was unsettling for all nurses. But hey, this is what we are trained for and this is what we are paid for. At the time, nurses were on the frontline, but at least they had a job, while so many others became unemployed because of the financial downturn that came with the virus. So, are there plenty of career prospects in nursing? Yes. Can you do easier work for more money rather than nursing? One hundred per cent. Is it still worthwhile considering studying nursing? Absolutely—just be sure to ask me that question at a time when I’m well slept and my workday has not been too crazy.

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The good nurse does not expect praise or gratitude but appreciates the ‘thank you’ that they do receive from time to time. In nursing, and in everyday life, people appreciate positive feedback. When someone takes the opportunity to tell us what they value about us, we feel encouraged. I feel there is a big gap in society as far as praise is concerned and many of us are walking around constantly criticising ourselves. Other people might be in awe of what we are doing, and admire us, but if no one says anything about it, we can’t imagine it to be true. I’ve been caught out a lot assuming that people do not appreciate or care about me as a person and later finding out, through a third person, that my perceptions were wrong. Giving a genuine compliment to another person gives them an opportunity to positively alter their thinking patterns. If you feel jealous of an attractive person, tell them that they look good and you’ll be surprised at how your jealousy can turn into admiration. In nursing, you get used to a lot of clients complaining when you are trying to help them. As unpleasant as it is to hear this kind of feedback, it is important to stay objective and think about what can be gained from such comments. A lot of complaints from clients are either directly or indirectly highlighting the fact that nurses are under-resourced. It’s very difficult for nurses to give the best care possible when there is a shortage of staff and many demands being placed upon them. One would hope that, with a proper complaints process in place, this would prompt the government to consider putting more funding into healthcare. However, this has not really been my experience. What is also annoying is when clients verbally complain but don’t bother to fill out a feedback form which provides an opportunity to list practical suggestions to try to improve the situation. On the other hand, when clients have a positive experience in healthcare, the simple phrase ‘Thank you’ is one that nurses hold onto dearly. With my annual clean-out of my belongings (and believe me I can be pretty cut-throat when I want to be), I still never let go of thank you cards that I have been given by clients. Nurses don’t receive very many notes of thanks, so we keep them as a reminder of the good work that we try to do and as a form of self-soothing amid the high volume of complaints. On a different wavelength, another nurse I knew, Julie, told me the story of a somewhat bizarre and stressful thank you she received. Julie ran a dialectical behavioural therapy (DBT) group. DBT is an intensive program that aims to help people with extreme emotional dysregulation and suicidal ideation, where other therapies have not been particularly helpful. The intensiveness of a DBT program means that clients have an opportunity to form solid trust, and a rapport, with their treating clinician. This particular DBT program was coming to an end, and Julie was going to be moving on to other employment. A lot of the clients in the DBT program naturally expressed their stress and apprehension about the group finishing, and a lot of preparation had to be done by the nurses and therapists of the program to help the clients prepare for the change. One of the female clients in the group, Kristie, was pretty scared about Julie moving on, and, when the final DBT session was coming to an end, Kristie, looking

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both a bit nervous and a little wobbly, revealed a heart-shaped box full of chocolates for Julie. Kristie was about to give Julie the box but then she suddenly vomited, violently all over the pretty pink present. It turned out that Kristie had overdosed on painkillers—in an attempt to end her life—just before the group started. Julie had to call an ambulance. It is reassuring for nurses that a patient’s thank you does not always have to come in the form of a heart-shaped box dripping with vomit. When I worked in a medical ward during my new-graduate nurse year, I looked after a sweet, elderly Spanish man called José, who had Parkinson’s disease. I got to know José, his doting wife and loving children so well. José would sometimes walk around at night confused and one night he walked into a woman’s bedroom thinking she was his wife. The woman was so gentle and understanding and led him back to his own room, explaining calmly to me what the mix-up had been. Some of the other nurses found José’s behaviour frustrating and time consuming (due to him repeatedly going wandering). He was also an English as a second language patient, which made communicating with him quite tricky. However, I was always happy to be his nurse—it gave me the opportunity to practice my Spanish. To me, Jose was just a sweet, elderly man whose disease had really shaken him. He needed a lot of redirection and reassurance, and I was always happy to give that. After José had been discharged from the hospital, I arrived one day for a shift to find a gold envelope with my name on it sitting on the nurses’ station. Inside was a voucher to get my hair done at a fancy hair salon that José’s daughter owned and ran. It nearly brought me to tears. Never before had I had my hair done in a nice salon—the gesture had me feeling so special. Another nurse saw me gushing; my cheeks were flushed. It must have been clear that I didn’t know exactly what to say—I was fearful that I would appear as if I was bragging if I told my colleagues about the gift. She just smiled at me warmly and said that I had earned it. Smiling back, I was still stuck for words, though her reaction made me realise that the other nurses must have been curious and peeked inside the envelope. I booked to have my hair done on the Saturday of my next weekend off, and on the day, I was given chocolates and tea and had three hairdressers fussing over me. In order to celebrate my new-found confidence as a nurse, I decided to cut off the long hair that I had had all my life and made a change to a funky, short haircut. Boy, did I feel good. On another occasion while I was an undergraduate nurse, a woman needing a blood test came into the medical clinic where I worked. She told me that she was needle phobic. The woman gave me a history of her dreadful experiences of having blood taken. Historically, most times she had needed to have blood taken, the nurse/ doctor/paramedic/phlebotomist had had great trouble finding her vein. As a result, the procedure had generally been a stressful and painful experience for her. She went on to tell me that she had only had one occasion that had been a relatively painless experience when a paramedic had taken her blood. To say thank you, she had bought the paramedic a chocolate bar. I told her that I could not promise that I had the ‘magic touch’ but would try my best to get the procedure over with quickly, and

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with as few dramas (and needle jab attempts) as possible. Fortunately, I was able to hit her vein and retrieve blood on my first attempt and so she said thank you and left with everything seeming to have gone okay. Five minutes later, she came back in. ‘Rasa’, she announced, revealing a chocolatey treat from behind her back: ‘A Snickers bar for you’. With any gift, the receiver should be grateful, especially when the gift comes from a client who has been undergoing some difficulties, either financially, emotionally, physically or a mixture of all three (and they usually are). Even so, we’ve all had times that we have been given something that we probably have no use for. I was once given some children’s toys by a client and, as I don’t have any kids, it was a bit confusing. On another occasion, I was given what looked like a pretty, glass, angel sculpture, which I thought was beautiful. However, I soon realised that it was actually an ashtray that had already been used. However, I didn’t point that out to the client because it was still a very sweet gesture. Recently, a nursing colleague of mine, Georgina, said that she saw one of her previous mental health clients, Laurie, when she was in the community. At the time, Laurie was working at a checkout at the supermarket where Georgina was doing her shopping. Georgina holds the same understanding as myself, that—as nurses—we should never outwardly acknowledge a patient if we see them outside of a clinical setting, unless that person chooses to acknowledge us first. So, Georgina pretended that she hadn’t seen Laurie. The line which Georgina was standing in to purchase her groceries was long, and she could see out of the corner of her eye that Laurie had just closed his checkout, presumably to go on a break or finish his shift. While waiting in the line, Georgina looked around nonchalantly and saw Laurie acknowledge her presence. She smiled back meekly, not wanting to draw attention to the interaction. And then, without saying anything—and as though he were opening an invisible door for her—Laurie signalled Georgina to move into his checkout line. He had opened it just for her, which caused Georgina to smile and blush. This small act led Georgina to feel valued in astronomical proportions and she told me that, just talking about the event, nearly brought her to tears of happiness and gratitude. At the end of the day, a thank you to a nurse does not need to be shown in gifts; it can be shown in words. One of my favourite cards was written by a 16-year-old boy that I cared for in a residential mental healthcare facility. For all I know, his Mum made him write the card, because he blushed when he gave it to me and couldn’t make eye contact. It was a beautiful pop-up card that simply read: ‘Dear Rasa, thank you for guiding me through this, from MJ’.

Conclusion

And did you enjoy your nursing breakfast? My wish is that you have tasted and felt a pleasant mix of the smooth milk and the sweet grains, amongst the chunky concrete. If you have made it to the end of this book, I hope that some of the myths of modern-day nurses below have been broken:

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6

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1. Nurses are purely assistants to the doctor. 2. All nurses are secretly wishing they were doctors. 3. The uniform of the nurse is a short white dress with G-string underneath. 4. Nurses who appear tough don’t care about others. 5. The role of the nurse is easy, basic and straightforward. Ideally, dear reader I have: 1. Made you cry, or at least well up 2. Made you laugh 3. Surprised you 4. Disgusted you 5. Made you contemplate how on earth McDonald’s can be talked about so many times in a book that is centred on nursing stories 6. Inspired you to consider or continue taking the courageous pathway of becoming a nurse, even after reading this book. So where to now for me? Hopefully, I’ll continue to enjoy nursing and helping people however I can. And ideally, I’ll be having a nap on all my days off, because sleep is like crack for nurses.

 he Good Nurse’ by Rasa Kabaila: Inspired by the poem ‘Just T a Nurse’ by Suzanne Gordon The good nurse has a weird sense of humour, is an ace multitasker and is likely to have abused chocolate, wine and/or chips at least one point in their career. The good nurse will ponder an easier career choice at least once, but still chooses nursing. The good nurse understands the meaning of a hard day’s work. The good nurse recognises that people are complicated. The good nurse bears witness to suffering and to dying. The good nurse probably has a major aversion to at least one bodily fluid, but has learned to deal with it. The good nurse may have less sympathy for smaller problems; they have seen far worse. The good nurse must act normal when they see weird things. The good nurse will question their faith at least once. The good nurse will know when something just doesn’t feel right. The good nurse will be taken for granted but knows their own importance. The good nurse hopes for the best and prepares for the worst. The good nurse will screw up, will feel bad about it and then will grow from it. The good nurse would prefer to know you have gastro before they go to shake your hand. The good nurse will forever ask: ‘What in the heck?’

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The good nurse tries to have a life outside of work, sneaking in joys and comforts during the odd hours of the day they have off. The good nurse probably swears while debriefing with other nurses in the tearoom. The good nurse will enter the unknown. The good nurse will respect the differences between themselves and others. The good nurse will go on adventures and get out of their comfort zone. The good nurse knows that strength and determination can triumph over hardship. The good nurse gives pragmatic suggestions. The good nurse does not expect praise or gratitude but appreciates the ‘thank you’ that they do receive from time to time. The good nurse will never be without a job. This nurse thanks you for taking the time to walk in my shoes, and the shoes of many other nurses. My warmest wishes, Rasa Nurse Practitioner

Discussion Questions

1. The author talks about the challenges that the nursing profession has held for her and her choice to stay in the profession despite these challenges. What challenges have you faced in your career and what has led you to continue to also stay in your profession despite these hardships? 2. Nurses will encounter scenarios which force them to reflect on their own ethical and moral beliefs. Has this happened to you so far in your career? How did you manage it? 3. The author talks about getting her head around life and death scenarios in nursing with the application of spiritual awareness and philosophy. What does spirituality and philosophy look like for you in your work? 4. The author discusses some of her experiences of some of the more ‘bizarre’ sides of nursing. What kind of experiences have you had in your nursing practice that would seem a little ‘off centre’ for those who don’t work as nurses. Is any kind of situation considered ‘weird’ for a nurse? 5. The author talks about the importance of ‘trusting your gut’. Can you reflect on a time in your work where your instincts led you to make an important decision? 6. The author reflects on the fact that nurses work in a difficult profession and will make mistakes and grow from the mistakes. Would you be happy to share a time where you made a mistake, how it made you feel at the time and how you grew from this? 7. Due to the multi-faceted challenges of nursing, nurses are prone to burnout. Can you think of a time in which you felt burnt out? What was happening at the time? What were your signs or burnout? How did you recover? Reflect further on the concepts of resilience, self-care and comradery and how these concepts are applied to recovery from burnout. 8. In your experience, what kind of phrases do you find are common in the language of nurses? 9. The author talks about the concept of blame in the healthcare field. What are the factors that contribute to nurses and healthcare professionals being blamed for different things? Is the blame warranted? How can blame be better directed? Are ‘good news’ stories for nurses and health professionals highlighted in the media? © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6

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10. The author talks about how nurses often encounter situations that are puzzling and difficult to explain. Can you reflect on a scenario like this that you have encountered in your profession? Did it feel strange? Did it scare you? Did it make you laugh? 11. Nurses care for people who are in every kind of mental state, including people who are aggressive, for a range of reasons. How do you make sense of and manage aggressive behaviour in your work? 12. The author specialises in mental health. Mental health issues are prevalent in our society. Can you talk about a situation when you were involved in caring for someone with their mental health? What was difficult about this? What do you think was important in being able to help them? 13. What kind of opportunities do you feel the nursing profession can bring for caring for different cultural demographics and to be able to travel? 14. What kind of special ways have you been thanked in your career and outside of your profession? What does the gesture of saying thank you do for us as professionals and as people? 15. The author reflects on the different kinds of career prospects that nursing provides. Can you think of any other career prospects that the nursing profession can facilitate?

Glossary of Terms

Affect  In the context of a mental state examination, an affect represents an immediately expressed and observed emotion (e.g. the patient’s facial expression or overall demeanour). Antipsychotic medication  A type of medication primarily used to pharmaceutically treat psychosis. Bipolar affective disorder  Bipolar affective disorder (BPAD) is a psychological illness that involves severe mood swings. These mood swings take the form of depression or mania (a significantly elevated mood) and may last for several weeks or more at a time. During the time of depression, people with BPAD often have great sadness, guilt, no appetite and poor sleep and cannot enjoy themselves. Mania is the opposite of this with patients experiencing erratic and excited behaviour. During mania, patients often have increased libido, require less sleep, have excessive energy and can sometimes engage in risky behaviour, for example, spending excessive amounts of money. Hypomania is a less extreme form of mania and while the symptoms are similar, they are less intense. Some patients may also have a mixed episode that involves the symptoms of both manic and depressed episodes during a short period of time (less than 1 week).There are two commonly recognised types. BPAD and the experience and duration of symptoms are dependent on the individual and not easy to generalise:Type I: Patients have marked manic periods and depressive episodes, which usually last for at least 1 week or more.Type II: Patients have severe depression but only mild manic (hypomanic) episodes, which are shorter lasting (for as little as 4 days or more). Cannula  A tube that can be inserted into the body, often for the delivery or removal of fluid, but which can also be used for the gathering of samples. It can also be referred to as an intravenous (IV) cannula. Cannulate  The procedure of inserting a cannula or thin tube into a vein. A needle guides the insertion of the tube by making an entry into the vein. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. Kabaila, Put some Concrete in your Breakfast: Tales from Contemporary Nursing, https://doi.org/10.1007/978-3-031-24393-6

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Clinical Facilitator  A registered nurse, involved in a current nursing practice, who is engaged to facilitate student and new-graduate learning in an off-campus clinical setting and/or an on-campus setting. Clinical Nurse Consultant  An advanced-practice nurse who can provide expert advice related to specific conditions or treatment pathways. This role title can differ between states in Australia. Clinical placement  Clinical placement units are core units in a Bachelor of Nursing degree. Typically, clinical placements are in hospital wards or a community health setting. Clinical placements are conducted to allow nursing students to observe and practice (under supervision) clinical skills related to nursing. Clinical presentation  The collection of physical signs or symptoms associated with how well, or unwell, a person is (mentally or physically), the interpretation of which contributes to a specific diagnosis. Clinical supervisor  A professional who assists nurses in developing their practice through regular discussion that encourages a reflective experience within the nurse. This process is referred to as clinical supervision. Clinicians  In this book, and some other texts, clinicians are defined as healthcare providers who deal directly with patients. However, in other texts, clinicians are just defined as doctors. Comorbidities  A comorbidity refers to a medical condition existing simultaneously, but independently, with another condition of a patient. If there is more than one comorbidity, the term used is ‘comorbidities’. Consultant (doctor)  A consultant doctor or ‘physician’ is a senior doctor who holds advanced training in one of the medical specialties. Once specialty training has been completed, doctors are able to apply for consultant positions. Defibrillation  The stopping of the fibrillation of the heart by the administering of a controlled electric shock to restore its normal rhythm. Delirium  Delirium (or acute confusion) is an acute medical condition whereby a person’s mental ability is affected. It develops over a short period of time (usually within hours or days) and symptoms tend to fluctuate throughout the day. Delirium is most commonly due to a medical cause such as severe illness, constipation, dehydration, infection, pain, a drug effect or drug withdrawal (especially from alcohol and sedative drugs). However, causes of delirium are numerous, complex and often mixed (multifactorial) and in some people the cause cannot be identified.

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Detoxing  The process of ceasing the use of drugs of dependence or alcohol so as to expel the substance and other toxins from the body. Some people may choose to do this on their own at home. Public and private health facilities offer ‘detoxification’ or ‘detox’ clinics to help people manage potential withdrawal symptoms that they may experience while detoxing. Withdrawal symptoms while detoxing is a result of the stopping or reducing the use of alcohol or a drug of dependence. Withdrawal symptoms can differ depending on whether the person is withdrawing from alcohol or drugs. Different types of drugs can also have particular withdrawal effects. Withdrawal symptoms can include anxiety, gastrointestinal upsets, difficulty sleeping, headaches, irritability, tremors and seizures. Discharged  The process of being exited from care at a hospital. A hospital discharge will take place when a patient is deemed to no longer need inpatient care and can go home. Unless a patient is mandated to receive care (admitted as an involuntary patient), patients can also self-discharge against medical advice, if they choose. ‘Do not resuscitate’ medical order  Do not resuscitate orders (otherwise known as ‘not for resuscitation orders’) are a medical order used to prevent the use of resuscitation measures when they are considered to be futile or unwanted. A do not resuscitate order is issued by a doctor in consultation with the patient, their agent or guardian (if applicable), as well as senior medical and nursing staff. Where a do not resuscitate order does not exist, doctors assess whether the patient has the capacity to make such a decision, and if not, who is authorised to participate in the making of such decisions on the patient’s behalf. Electrocardiogram (ECG)  A non-invasive medical assessment where electrodes are placed on the skin of the chest and connected in a specific order to a machine that, when turned on, measures the electrical activity of the heart. Handover (nursing handover)  A nursing handover occurs when one nurse hands over the responsibility of care for a patient to another nurse. This can occur at the end of a nursing shift, when a patient has been transferred to a different ward, or when a patient has been allocated to a case manager for follow-up care in the community. Nursing handovers are present in both hospital and community settings. In the hospital setting, nursing handovers occur three times a day, on average, for each patient. Hyperbaric chamber  A room that allows an individual to breathe 100% pure oxygen at greater than 1 standard atmosphere of pressure. Hyperbaric chambers are used to deliver hyperbaric oxygen therapy (HBOT). HBOT was developed to treat underwater divers suffering from decompression sickness (the bends). It has since been approved by the Undersea and Hyperbaric Medical Society for 13 conditions including air or gas embolisms, carbon monoxide (CO) poison-

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Glossary of Terms

ing, smoke inhalation, gas gangrene caused by certain bacteria, decompression sickness, radiation tissue damage, thermal burns, non-healing skin grafts, crush injuries, wounds that fail to heal through conventional treatment, serious blood loss and intracranial abscesses. ICU  Abbreviation for intensive care unit, a critical care unit in hospitals where patients requiring close monitoring and intensive care are kept. Infection Control Team  A team of health professionals who provide the following services regarding infection control: multi-disciplinary education programs, clinical visits and audits, assistance with establishing and facilitating infection control programs, infection surveillance, outbreak monitoring and response as well as assistance with the redevelopment and refurbishment of buildings. Involuntary treatment  In Australia, there are circumstances where a person can be legally hospitalised for a mental illness without their consent. A person can also be legally compelled to receive treatment—medication and/or therapy— without their consent. The laws covering involuntary hospitalisation vary from state to state, but generally, a person can only be hospitalised involuntarily if they are judged to meet all of the following criteria: they have a mental illness, they need treatment, and they can’t make a decision about their own care. The person must also meet one, or both, of the next two criteria: they are considered to be a danger to their own safety, or they are considered to be a danger to someone else’s safety. Knee realignment  A type of knee surgery that aims to take the stress off the worn part of the knee and move it to an area that is not worn. In the knee realignment procedure, the bone is cut 80% of the way across and then bent by a predetermined amount and fixed in place with a metal plate and screws. Sometimes bone is used to fill in the gap created by the cutting and bending of the bone. Laparotomies (plural of laparotomy)  A laparotomy is a surgical incision into the abdominal cavity, either for diagnosis or in preparation for major surgery. Mechanical ventilation (life support)  Mechanical ventilation, often regarded as ‘life support’, is where mechanical means are used to assist or replace spontaneous breathing. This may involve a machine called a ventilator, or the breathing can be assisted manually. The need for mechanical ventilation is indicated when the patient’s spontaneous breathing is inadequate to maintain life. It is also indicated as prophylaxis for the imminent collapse of other physiologic functions, or ineffective gas exchange in the lungs. Mental Health Review Tribunal  The Mental Health Review Tribunal is a specialist, quasi-judicial body constituted under the Mental Health Act 2007  in Australia. It has a wide range of powers that enable it to conduct mental health inquiries, make and review orders and hear some appeals about the treatment and care of people with a mental illness.

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Mental state  The state/position that a person is assessed as being in regarding their mental health, functioning and behaviour. Methamphetamine  A synthetic drug with more rapid and longer-lasting effects than amphetamine; used illegally as a stimulant. Methadone round  A ‘nursing round’ is a broad term that describes the act of the nurse performing a clinical task or assessment where more than one patient will be seen for the same thing. For example, in a hospital setting, at 8 am there are typically medication and observation rounds during which all patients due for medications and observations will be seen by the nurse. When I was undertaking my clinical placement at the prison, there were so many inmates there on methadone, that methadone rounds were required. Naltrexone implant  A small pellet that is inserted into the lower abdominal wall under local anaesthetic. Depending on the type of implant, it can be effective for 3–6 months and releases a controlled amount of naltrexone into the body, which blocks the effects of opiate drugs. Nasal oxygen prongs: (nasal cannula)  A device used to deliver supplemental oxygen, or an increased airflow, to a patient or person in need of respiratory help. This device consists of a lightweight tube that splits into two prongs on one end, which is placed in the nostrils and delivers a mixture of normal air and oxygen. Nasogastric tube  A thin polyurethane, silicone or rubber tube that is inserted into a patient’s stomach through the nasal or oral passage to administer (gavage) or remove (lavage) substances in the stomach. Norovirus  A type of airborne virus that causes gastroenteritis, the symptoms of which are vomiting and diarrhoea. It is highly infectious and may cause outbreaks in settings such as schools, childcare centres, aged-care facilities, cruise ships, restaurants and hospitals. Opioid antagonist  An opioid antagonist, or opioid receptor antagonist, blocks the effects of opioids on one or more of the body’s opioid receptors. The medications naloxone and naltrexone are commonly used opioid antagonist drugs. They are competitive antagonists that bind to the body’s opioid receptors with a higher affinity than opioids, but in doing so do not activate the receptors. Palliated  The process of palliating aims to ease the symptoms, pain and suffering of a disease without curing the underlying disease. For example, a patient who has advanced cancer and is unresponsive to treatment may receive palliative treatment. Phlebotomist  Phlebotomy is the procedure of drawing blood from a patient (mostly from veins) for clinical or medical testing, transfusions, donations or research. Phlebotomists collect blood primarily by performing venipuncture.

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Placebo effect  A beneficial effect produced by a drug or treatment that cannot be attributed to the treatment or drug itself and must therefore be due to the patient’s belief in the effectiveness of the drug or treatment. Polypharmacy  Polypharmacy is the concurrent use of multiple medications by a patient. Polypharmacy is most common in the elderly. Post-operative care  Care that is provided to a patient in the period following a surgical operation. Post-traumatic stress disorder (PTSD)  Post-traumatic stress disorder (PTSD) is a mental health condition that’s triggered by a terrifying event—either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.Most people who go through traumatic events may have temporary difficulty adjusting and coping, but with time and good self-care, they usually get better. If the symptoms get worse, last for months or even years and interfere with your day-to-day functioning, the person may have PTSD. Psychoeducation  An evidence-based therapeutic intervention for patients and their loved ones that provides information and support to better understand and cope with illness. Psychoeducation is most often associated with serious mental illnesses such as dementia, schizophrenia, clinical depression, anxiety disorders, psychotic illnesses, eating disorders, personality disorders and autism, although the term has also been used for programs that address physical illnesses, such as cancer. Psychoeducation offered to patients and family members teaches problem-solving and communication skills and provides education and resources in an empathetic and supportive environment. Psychosis  The word psychosis is used to describe mental conditions where there has been some loss of contact with reality. When someone becomes ill in this way, it is called a psychotic episode. During a period of psychosis, a person’s thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not. Symptoms of psychosis include delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear). Other symptoms include incoherent or nonsense speech, and behaviour that is inappropriate for the situation. A person in a psychotic episode may also experience depression, anxiety, sleep problems, social withdrawal, lack of motivation and difficulty functioning overall. Psychotic  Relating to, denoting, or suffering from an episode of psychosis. Psychotic illness  A mental illness characterised by a primary presentation of psychosis. Examples of some psychotic illnesses are schizophrenia and schizoaffective disorder.

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Recovery room  A hospital room equipped with apparatus for meeting post-­ operative emergencies and in which surgical patients are kept during the immediate post-operative period for care and recovery from anaesthesia and sedation Registrar (doctor)  A doctor with at least 3 years’ experience in a public hospital, who supervises more junior doctors and is training to be a specialist. Reflective practice  A process that nurses should use as an opportunity for learning to improve their practice. There are some evidence-based reflective models available, such as the ‘Gibbs Reflective Cycle’, that provide a structure for the nurse to discuss their feelings about a situation and then prompt themselves to evaluate, analyse and form a conclusion and an action plan accordingly. Resident (doctor)  A qualified, junior doctor who has not had enough experience or training to become a registrar. Resuscitation team  A resuscitation team is a team of nurses and doctors who are in place to respond to cardiac arrests and resuscitations in a hospital. The team may take the form of a traditional cardiac arrest team, which is only called when a cardiac arrest is recognised. Alternatively, hospitals may have strategies in place to recognise patients at risk of cardiac arrest and be able to summon a team, such as a medical emergency team (MET), who attend patients who are at risk of a cardiac arrest, as well as those in direct cardiac arrest. Rigor mortis  Otherwise known as post-mortem rigidity, is the third stage of death. It is one of the recognisable signs of death and is characterised by a stiffening of the limbs, post-mortem, and is caused by chemical changes in the muscles. In humans, rigor mortis can occur as soon as 4 hours after death. Septic (septic shock)  A severe medical condition caused by the process of sepsis that has not been treated. Sepsis is a potentially life-threatening condition caused by the body’s response to an infection. The body normally releases chemicals into the bloodstream to fight an infection. Sepsis occurs when the body’s response to these chemicals is out of balance, triggering changes that can damage multiple organ systems. Shockable and non-shockable cardiac rhythms  Some cardiac rhythms are able to be ‘shocked’ with a portable automatic cardiopulmonary resuscitation machine. The two ‘shockable’ rhythms are ventricular fibrillation and pulseless ventricular tachycardia. The two ‘non-shockable’ rhythms are asystole and pulseless electrical activity. Sputum  A mixture of saliva and mucus coughed up from the respiratory tract, typically as a result of infection or other disease, which is often examined microscopically to aid medical diagnosis.

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Stepped down (in care)  In a stepped-care approach, an individual will be supported to transition up (stepped up to higher intensity health services) or stepped down to lower intensity health services as their needs change. Stigmatising language  Language that, when used, gives a mark of disgrace associated with a particular circumstance, quality or person. Stimuli tests  These tests primarily focus on testing the patient’s mental status, cranial nerves, sensory input, motor responses and reflexes. In comatose patients, the test consists of observing the patient closely and eliciting a reflex response to assess the level of cerebral input. Suicidal ideation  Thinking about, or planning, suicide. Thoughts can range from a detailed plan to a fleeting consideration. It does not include the final act of suicide. Suicidality  The noun form of suicidal. The tendency of a person to commit suicide. Systolic blood pressure  Systolic blood pressure refers to the amount of pressure in a person’s arteries during the contraction of the heart muscle and is the top number written in a blood pressure score. The bottom number refers to the blood pressure when the heart muscle is between beats. This is called the diastolic pressure. Throat swab  A throat swab culture, or throat culture, is a test commonly used to diagnose bacterial infections in the throat. These infections can include strep throat, pneumonia, tonsillitis, whooping cough and meningitis. Tourniquet  A tourniquet is a device that applies pressure to a limb or extremity so as to limit—but not stop—the flow of blood. It may be used during venipuncture, as well as in emergencies to limit blood loss. It is also used in surgery and in post-operative rehabilitation. A simple tourniquet can be made from a stick and a rope, but tourniquets found in the medical setting are usually made from some stretchable material that can be tightened and fastened with a detachable clip. Triage  In the medical and mental health setting, triage is the assessment of degrees of urgency of wounds/illnesses/crisis episodes to decide the order of treatment of a large number of patients or casualties. Urethra  In anatomy, the urethra is a tube that connects the bladder to the urinary meatus for the removal of urine from the body. In males, the urethra travels through the penis and also carries semen.

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Vicarious trauma  The negative transformation in the helper that results (across time) from empathic engagement with trauma survivors and their traumatic material, combined with a commitment or responsibility to help them. People who work in services in which people with traumatic histories present seeking help, or who work with traumatic material are at particular risk.