Feature Story: Caring for Amy
Salim Pabani, R.P.N. - Edmonton, Canada
I have been a Registered Psychiatric Nurse since 1995. I worked at a psychiatric facility in Edmonton Alberta where I had the opportunity to work with a young client who left a lasting impression on me as a caregiver and changed my career from that point on.
This story is about Amy (pseudonym), who joined the youth program I was working in. Amy was a likeable 15-year-old who was admitted to the youth program because her behaviour was becoming unmanageable in the group home she was living in at the time. The staff on our unit were provided with Amy’s care history in the various facilities in which she was placed ever since she was an 8-year-old child. She had a history of unproven sexual abuse and physical abuse as a child, as well as many conflicting accounts of the same from various social workers and from the client herself, who was a poor historian. Her various care facilities gave an extensive account of unmanageable behaviours from the client over the years.
In view of the history provided, most of my colleagues on the unit, including myself, expected a very different person than the one we encountered. We met a young lady who was polite, approachable and pleasant to talk to, with a very good sense of humour. She instantly became everybody’s favourite client – someone we all wanted to take care of and provide with the best care we could offer. There was a general feeling on the unit that the people who took care of Amy in the community probably had little knowledge of behaviour management and lacked the knowledge and skills to take care of someone like Amy – that finally she was in a facility where she would receive the care she needed and deserved.
Layers of truth
Amy was happy and compliant as long as she received the attention she seemed to crave. Gradually, staff noticed that when the initial attention Amy received was no longer provided, she began to get restless and appeared to seek more and more attention from staff on the unit. When this attention was not forthcoming, Amy started exhibiting behaviours we did not encounter before. For example, Amy would walk into an empty cupboard and pull the door shut from inside. This forced the staff to search for Amy and engage in a dialogue with her about why she did what she did, and about what unit expectations were of clients if they wanted to avoid any negative consequences like the loss of privileges.
Staff observed that when Amy spent time in common areas of the unit where both male and female clients socialized, she got into conflict with her female peers over her relationships that developed with male peers. Amy also lacked social etiquette and often said things to her peers which resulted in conflict, as a result of which Amy often ended up being restrained and placed in seclusion. In the process of restraining Amy, she kicked and spat on staff, and also swore at them. She was no longer perceived by staff on the unit as ‘a sweet little miss’. Her behaviour was now perceived as ‘attention-seeking’ behaviour which we were not to give into since that would be considered as ‘feeding into her negative behaviour’. Her negative behaviours were now labelled as ‘unmanageable’ and, by this point, our staff were no different than all the caregivers Amy encountered in the past.
The unit started having special conferences with multidisciplinary staff in order to come up with a care plan which would enable the staff on the unit to manage Amy’s behaviour more effectively. Dr. K (pseudonym) came up with a care plan which was based on behaviour management. He wanted all staff to implement this plan consistently and document all behaviours from Amy, as well as the interventions that followed.
This care plan included providing a reward for positive behaviours from Amy and a loss of privileges for negative behaviours. Amy loved herbal tea so after a positive behaviour, herbal tea was one of the rewards she received to encourage more of the same behaviour. Amy loved going on escorted walks throughout the hospital grounds, so this became one of the privileges she lost if she engaged in negative behaviours. Amy also loved playing UNO (card game) and enjoyed spending hours making necklaces out of beads. Some days, she would ask me to make herbal tea for her first thing in the morning. I encouraged Amy to engage in a positive activity like playing UNO with me so she would earn the privilege of having the herbal tea afterwards. She responded well to this care plan. At times, Amy perceived her positive behaviour as a bribe she offered to staff in exchange for rewards and required an explanation of how the reward and loss of privileges operated as part of her care plan.
The majority of nursing staff and aides had become accustomed to engaging with clients as little as possible so that they could socialize more with each other in the nursing station. The care plan devised for Amy was therefore considered ‘a pain in the butt’ for these nurses and aides - and any staff members who were willing to cooperate with this care plan made the rest of the staff ‘look bad’.
Bad to worse
Amy received increasingly less attention from staff and her negative behaviour escalated. As a result, she increasingly ended up in seclusion. There was one morning when Amy was placed in and out of seclusion four times. Her behaviour while in seclusion also went from bad to worse. She attempted to strangle herself with her clothing including using her underwear to harm herself. She also tore sheets and blankets into shreds and tried to use this to strangle herself. For this reason, Amy was often placed in seclusion naked. When Amy made a request to visit the washroom, she was escorted back and forth by a battery of staff in case her behaviour went out of control and she ended up harming herself, others or the property. This kind of behaviour became so frequent that staff chose to ignore Amy’s request to use the washroom to void or to defecate. As a result, Amy both voided and defecated in the seclusion room and later would spread it all over the floor, and slide on it, making an unsightly and foul smelling mess on the floor. Eventually, a second seclusion was created so that staff could transfer Amy there while the first seclusion room was cleaned.
When Amy lacked attention, she engaged in negative behaviours like opening an old wound on her left arm with a screw and causing it to bleed. Later, she would push staples into the same open wound, preventing it from healing. She also pushed screws and medication cups into her vagina which often required medical attention from resident doctors. When Amy engaged in these negative behaviours, the majority of staff considered them as ‘attention-seeking’ behaviours not worthy of any attention. They were of the opinion that by paying attention to Amy’s negative behaviours, they would encourage more of the same. I was one of the few nurses who chose to have a one-to-one with Amy in order to understand why she engaged in this negative behaviour, in an attempt to help her address her needs more appropriately.
Amy told me her biological father used to sleep naked with her when she was a 4-year-old child and that social services suspected she was sexually abused by her dad. This was not conclusively proved but her dad was forced to live away from the family. She talked about how her mom spent time drinking alcohol with her boyfriend in their living room in plain view of all of the children in the house. Amy told me she was the eldest child in the family and was having to look after her siblings. She felt that she also had to look after her mom since she was not capable of looking after herself.
Amy told me that one day she wanted to void desperately and knocked on the washroom door but her mom did not open the door for a long time. Eventually, Amy pushed hard on the washroom door and it opened. She became witness to her mom having sex with her boyfriend in the tub. Her mom placed a burning cigarette butt on Amy’s left arm and, at this point in the story, Amy placed her finger on the wound on her left arm, which was perpetually healing. Amy told me she would rather be punished than be ignored because this was her way of knowing that she was ‘alive’.
My eyes filled with tears listening to her sad story and for the first time, I understood why Amy always behaved negatively when ignored, and also why she perpetually opened the wound on her left arm, never allowing it to heal. My peers did not buy into my theory and were bent on punishing her in order to reduce her negative behaviour. They deliberately sabotaged Amy’s care plan, failing to cooperate with Dr. K. Eventually, Dr. K handed in his resignation and moved on to another position in the city. Dr. R, who worked with Dr. K, also resigned at about the same time and moved on to work on a new assignment in another psychiatric facility.
A new plan
Dr. D, who came to replace Dr. K, implemented a new care plan for Amy. Dr. K relied more on information provided by the treatment team and less on information provided by Amy herself. In contrast, Dr. D gave greater weight to information provided by Amy and took what the staff told him with a pinch of salt. My account of events in Amy’s case was similar to that of the client for the most part. Dr. D devised most of Amy’s care plan himself and invited very little feedback from the staff. Each day, Dr. D got an account of events of the previous day from both Amy and the staff. If there was a discrepancy between the information provided by Amy and the staff, he confronted both parties to clarify what happened.
Staff started engaging more actively with Amy and provided greater cooperation for Dr. D’s care plan than ever before, knowing that Dr. D had little tolerance for any attempt to sabotage this care plan. Amy’s behaviour gradually improved and she changed from being the most difficult client in the hospital to being the best. The original plan was to provide 1 year of treatment to Amy and discharge her back to the facility she came from. However, after about 2 years of treatment, Amy was ready for discharge. Since Amy’s discharge, our staff received feedback from her present facility that apart from an occasional slip-up back into her negative behaviour, Amy is doing fairly well and is now able to receive more frequent visits from her biological dad, which Amy appears to be very happy about.
Amy’s case touched my heart more than any I have encountered during my nursing career. I am more convinced than ever before of how important it is to know how my patients feel so that I can understand why they think and behave in the ways they do, and how this can shape their lives. If by engaging in an empathetic and caring approach, we are able to know how one thinks, then we can identify the fault in their thinking and help them change their inappropriate behaviours to more appropriate behaviours, providing them with hope for a brighter future.
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