Sunday, February 8, 2009

Resistance is Futile

The tipping point came for me while observing the facility’s interdisciplinary work session. The head nurse, a social worker and a psychiatrist were having their regular meeting where they went through the patients cases and discussed plans of care. In the middle of the presentations, the social worker brought up the issue of a request for transportation from one of the patients. She had a court date today. She was trying not to lose custody of her children. She had missed a previous court date because she had been in this facility. If she missed this one, that would be it.

Less than five minutes were spent on the issue. The first reaction was that it would be a headache to arrange for transport. The psychiatrist then asked the social worker about what she thought the patient’s capacity to care for her children was. The patient was challenged just to take care of herself, “She does not need those kids.” And that was it. No transportation would be provided. Next case please.

When the meeting concluded I sought out my clinical instructor. I told her what had happened. She told me I had misunderstood. She would arrange for me to meet with the social worker so that I could ask her about it. I flatly refused. I was sure I had not misunderstood and did not think the social worker would appreciate being called out by a nursing student. I saw it as an attempt by the instructor to put me in my place. No, I would not do it. I did not agree. I told the other students about it at the group meeting at the end of the day. It raised a couple of eyebrows, but no one seemed particularly concerned.

I was without support. I spoke with my nursing school advisor. She seemed to be somewhat sympathetic, but was not really open to hearing about my concerns. As a nursing student, I had no standing. I had no training or experience that qualified me to evaluate or comment on the workings of a mental institution.

I did not expect to change anything at the mental hospital. I just wanted to find someone I could talk with about it. Someone who could accommodate what I was seeing and talk with me about how to get through it all.

I could not contain the urge to resist. I was not getting any traction on the issues, so I fought against a grade on a paper that had been assigned as part of the clinical coursework. This way I would at least have a voice. The very premise of the assignment had offended me. I already had a BA with a major in psychology. In all the time I had spent in psyc undergraduate courses, I had not had any contact with patients of any sort. The reason was clear; qualification to offer counseling came on the level of graduate study. As nursing students, we had one psychology class and one clinical during the entire program. On the first day at the mental institution, I had been sent alone into a room with two inpatients and told that I should have a therapeutic interaction with them. I decided that it would be most therapeutic if I did not allow either of them to come between me and the door to the room.

The paper assignment was to transcribe a therapeutic interaction we had had with a patient and evaluate it according to the therapeutic principles we were learning. I wrote the paper on my own terms. I expected a C, but I got an F. I complained to my advisor. Maybe I was being punished for making trouble. My advisor was not very enthusiastic about the whole thing, but she set up a meeting with the director of the nursing program at the university.

I liked the director of the program. She was friendly to me. Her background was in pediatrics and I had sought her advice several times on how to care for my recently born son. My fantasy was that she would ask me privately what all this was about. She would listen and understand and would take steps to somehow at least make the psyc nursing program more appropriate. I was more emboldened when I heard from other students that my clinical instructor had once been the director’s teacher and had told her she would never amount to anything. ‘I am offering a good service to the nursing program and the director will be pleased with me,’ I told myself.

It did not quite go that way. In the meeting, my advisor was asked if she thought the grade was appropriate. “Yes, definitely,” she replied. If she had only told me beforehand she was going to say that, there would have been no need for the meeting. I saw it was hopeless. I accepted the grade. I was again offered the opportunity to rewrite my paper and I again declined. No one could understand why. It seemed lazy-crazy. There was no opportunity to explain myself. All of my anguish about the facility was totally irrelevant. I lost the respect of the director and never recovered it. I moved to the back rows for the rest of my nursing education and kept a chip on my shoulder. It was pedestrian versus SUV, just like I thought it would be.


Christian Sinclair, MD said...

Excellent demonstration of moral stress that occurs for learners when they are hindered by the hierarchy of teaching.

At least you have the blog to find some sympathetic ears.

BTW here is a post about an article studying moral distress in medical students.

Jay said...

It rarely pays to be a squeaky wheel, does it? My squeaking hasn't necessarily served me well over the years. Yet I'm dismayed at the complacency I see, not just in healthcare or higher ed, but in my children's elementary and middle schools, in the legal system, all over the place.

Kudos for staying your ground. Your courage may not always be appreciated, but your fellow "mavericks" (forget that Palin used the the word) applaud you for having the guts to ask "why?"