I got an email this morning, congratulating me on being accepted as a Care Maker – a voluntary role working as an ambassador for compassion and caring in the NHS, in recognition of my efforts to promote the 6Cs, inspire the nursing community, and promote compassion and caring. I was absolutely delighted, of course, though that I found out this week is ironic in a way, as something I’ve been thinking about that happened on placement the weekend just gone is really affecting me emotionally.
On Sunday evening, I spent some 1-1 time with a patient, to discuss their various symptoms so that I could complete a Brief Psychiatric Rating Scale for their file. As I was listening to them describe their beliefs and thoughts about their admission to the unit, I began to realise that I had no idea how to help them, and the more I thought about it over the next few days, the more upset I became.
This particular patient is extremely delusional; they have fixated beliefs about the world around them, with evidence to back it up that, on the face of it, is completely ridiculous – and yet mostly impossible to argue against. On the few occasions I was able to point out a flaw in their reasoning, they had a counter-argument that I couldn’t defend. The patient asked me: “Can you prove to me that I’m mentally ill? When you can prove that, I’ll take your medicines.”
But we can’t. Their beliefs are actually almost convincing. They stopped taking their medication (which was mandatory under a Community Treatment Order) because they became so convinced by their truth that they are not mentally ill, the logical extension of which is that, if someone is not mentally ill, they don’t need treatment for such. The CTO got revoked when the patient’s care co-ordinator realised that although the patient was no longer fully compliant (attending the depot clinic, but not taking oral medication) and they’re now under a Section 3, which permits the MDT to detain them for treatment. At some point, the patient will either have to accept medication, or have it administered to them against their will, possibly under restraint. That thought saddens me.
And worse, I feel sure that if we manage to administer enough medication to this patient that they start to recover, eventually they may consent to further treatment, and sometime after that, they may be discharged, potentially under a CTO. Which, don’t get me wrong, is potentially great, but if it’s happened before, it can happen again: the patient somehow becomes non-concordant with their meds, they become unwell again, which distresses those around them, and they find themselves back on an acute ward, asking questions like “Why am I here, when I wasn’t doing anybody any harm?”
At first, I was just upset because I came into this career wanting to help people recover from mental health issues. Not completely, necessarily, but at least help them to start on that path. And I know that I can’t help everyone – my own personal experience, whilst a part of what makes me special, won’t be useful to all patients – but this was the first time it had occurred to me that a patient could present such a difficult case that even a consultant who’s been practising longer than I’ve been alive is stumped for ideas.
On Monday morning, I asked my mentor if I could have a chat with him about it, but our shifts only intersected by an hour, and handover took too long, and then someone came to visit him, so he told me he would talk to me the next day, as he was going to be supernumerary and would easily find time for me. But when I arrived, I found that he’d had to alter his shifts because his childcare had gone up the spout, and again, we only had an hour, and a long handover, and then his shift was over.
Of the two nurses on duty for my shift, one is a bit too lighthearted to have a serious conversation with, and the other was snowed under with work and I knew it would be pointless even asking her. Two shifts without someone to talk to when something is troubling you is a long time to dwell. I hid in the darkened sluice and cried, twice.
Here’s the thing: I don’t want to be a superhero. I know there will be people I can’t help during my career, and I can deal with that, because I know that for each of those patients I can’t help, there will be many more I can. I know that sometimes, like now, discharge won’t be goodbye, but goodbye-for-now. That’s OK.
It isn’t not being able to help people that upsets me. I’m just scared that it will never get easier. And I know that nobody will berate me for feeling emotional at knowing we can’t help this patient, that this is part of why we do so much practice and (at least theoretically) have supervision time to discuss the aspects we’re finding difficult. I don’t expect to be able to cope already.
But I am scared that it will never get easier, that it will build up and up and up, and that my emotional resilience is not strong enough. I am scared that I will not be able to cope with the sheer number of patients I will fail during my career, and I am scared of the effect that may have on those who form my support network.
Logically, I know it should get easier. I know that each time it happens, it should bother me less.
And that scares me, too: what if it does get easier, but becoming hardened to it changes me? Makes me lose my compassion and all the wonderful things that make me who I am?
My partner tried to reassure me; I had to carefully tell him, “I don’t think anyone but a nurse with years and years of experience can reassure me on this”. And then I added: “and even they may not be able to, because they’re not me.”
How does anyone know if I can cope, until I don’t?
And so, the day that I become an ambassador for compassion in care, I find myself doubting that I can (or should) do this job, if I can cope with the tougher aspects of it without changing my core, changing the person I am, the things I love about myself.
Above all else, right now, I am scared because I don’t know if I can do this without either losing my compassion, or being so compassionate that it overwhelms and breaks me.
“Compassion hurts. When you feel connected to everything, you also feel responsible for everything. And you cannot turn away. Your destiny is bound with the destinies of others. You must either learn to carry the Universe or be crushed by it. You must grow strong enough to love the world, yet empty enough to sit down at the same table with its worst horrors.” – Andrew Boyd