The Re-Adjustment of the Hospital In-Patient How the Nurse Can Help
- Author:
DAY
Night Charge Nurse, St. James’ Hospital, Portsmouth; Winner, ” Lord ” Memorial Essay Competition, 1949
To those nurses who have grown grey in the service, any consideration of the patient’s readjustment to life, on discharge from hospital, must inevitably recall the distance we have travelled in the field of Mental Health over the past quarter of a century and the changes in the nursing approach to mental illness during that period.
Many of us can remember?for it was not so long ago, really?when the best that we could offer our patients was a refuge from the world and such care and comfort as it was in our power to give; theirs to appreciate. We longed to do more?but could not. As time went on, progress, ” the shining light that shineth more and more unto the perfect day”, made it possible for us to think more in terms of relief and recovery, less of asylum. To-day, psychological medicine has a place in social service which few of us could have imagined possible twenty-five years ago; the question of reconditioning the patient, so that after recovery and discharge there shall be no recurrence of the trouble, is becoming increasingly vital as a nursing problem. It is a most heartening development.
Let us seek an analogy from the recent war. It will be remembered that long before the cessation of hostilities, wise men were giving thought to the building of the post-war world. It was not enough, they said, that peace should be merely an uneasy breathing space between two wars; they wanted to find a way to create a world of smiling, happy childhood, of men and women who could live and work together in friendliness and security; a state of society in which war could never happen again. So with the mentally ill. What is the lasting . avail if, on recovery and discharge, patients return to the same environment, have the same attitude towards that environment and are subject to the same stresses that combined to produce former difficulties. Is it altogether surprising, if, under such conditions, the old troubles sooner or later reassert themselves and they suffer another breakdown ?
If we had attained the ultimate Utopia, it might be possible to readjust to an unsuitable environment. But under our existing economic structure, such a thing is very rarely accomplishable. The housewife, anxious and depressed as a consequence of the strain of coping with post-war domesticity, must live where her husband’s work is. Queues ! Rations ! Shortages ! Trying to fill a quart pot of expenses with a pint of income ! These are the problems of her contemporaries everywhere. When a man has been a bank clerk for twenty years he cannot, as a rule, switch to house decoration or landscape gardening at a moment’s notice; nor, in a competitive, striving world, can he avoid those frustrations and setbacks which are the common lot of man, merely by changing his occupation. Nor can thousands of workers of either sex avoid the deadly monotony of repetition work which, in an age of machine-watching and mass production, is the cause of so much neurosis in industry. ” The mind is its own place, and in itself Can make a heaven of hell, a hell of heaven said Milton, and in the vast majority of cases of people at odds with their environment (the maladjusted child apart) it is not so much the environment that is the cause of the difficulty as the person’s attitude towards it. The object then, of treating for readjustment to commercial and social life, must be so to change the patient’s outlook that he may be able, more courageously, to grapple with the old environment when he returns to it?to meet it with a different approach, a less jaundiced eye. And this end must be in view even while physical treatments for obliterating the exciting cause of the trouble are still being carried out; in fact it must be the goal from the moment of entering hospital. Two methods suggest themselves. The first is psychotherapy, the second the group of treatments which may be broadly classified under the head of occupational therapy.
Psychotherapy, which aims, by psychoanalytical methods, to probe the root cause of the problem is, of course, largely the doctor’s function. The nurse has, nevertheless, considerable opportunity. A careful study of the patient’s social history and domestic background is well worth the trouble involved. A thorough grasp of the doctor’s plan of treatment is essential.’ Thus armed?and helped by the closer, day-to-day relationship which a nurse has with the patients?factors may be uprooted from which a sense of frustration, of inadequacy, ?f inferiority have arisen. By precept, by example, by conversation in the course of the day’s normal round, the patient could be helped on the road to overcoming some of the ways by which he has, in the past, failed to come to terms with his environment. The ambitionthwarted, for example, whose ambitions are beyond the range of their capabilities, may be helped, through doctor and nurse in combination, to realize their limitations and adjust their outlook. The square-peg may similarly be removed from the round hole. Indeed, the art of wise talking?and that includes the art ?f knowing when not to talk?can be a very Potent weapon in the mental nurse’s armoury. Occupational and the companion therapies, Play therapy, recreation therapy, bibliotherapy, are very much the nurse’s line of country. Let it be at once emphasized that occupational therapy does not merely mean making baskets, rugs and table-centres which are .subsequently sold at a handsome profit. It is curative, not commercial. It has the immediate effect of avoiding boredom and unhealthy thinking during the intervals between treatments and during convalescence. It gives the patient something with which to occupy hands and thoughts. More than that, however, it aims, by stimulating the creative urge, to restore lost self-confidence and above all to widen the range of interests. In general?though this must not be accepted as an axiom?the more varied a person’s hobbies and tastes, the more cultural reserves he has to fall back upon and the greater his depth of understanding of men and matters, so the more tolerant is likely to be his attitude towards an uncongenial environment and the less likely is he to break down under the stresses and strains of life.
The nurse’s job here is to encourage the patient to the top of his or her bent; to awaken dormant or untapped interests in handicrafts, music, art, literature, sport, dancing, gardening, collecting and the hundred and one other means by which humanity diverts itself, stimulates itself or seeks mental and spiritual solace. This is by no means easy; it involves infinite patience, the risk of rebuffs and many possible false starts before discovering where an interest is likely to be developed. It can range from physical activity to, in quiet mood, advice and discussion over the choice of books. But it is fascinating and tremendously worth-while and it affords a nurse almost unlimited scope. Obviously, the more varied a nurse’s own’ interests the greater his or her potentialities in this direction. But virtuosity and versatility are not essential. The great thing is to be able to encourage; to have the art of awakening enthusiasm in others.
Inter-hospital, inter-departmental, inter-ward and inter-patient activities and competitions is another effective nursing job in this medium. The patients themselves should be encouraged to take a full share in their organization and administration, the nurse holding a watching? and watchful?brief. Who knows what latent talents may emerge; talents which may afterwards become buffers against the slings and arrows of outrageous fortune ! Have you ever re-visited, after long absence, a place once familiar, but now, in the process of time, much changed and, stepping back into the past?as it were into another world? sought well-remembered land marks, hoped to recognize a few faces ? Only to find, instead, that demolition and re-building and the decay which the years must bring, have changed the face of the district and that gone are all the old familiar faces. You are a stranger in a land where once you were at home: a poor, lonely ghost, longing to be remembered, wandering among the ruins of a once happier day.
Something akin to these emotions must so often, long years ago, have been experienced, on facing the world again, by those patients who were fortunate enough to recover after perhaps years under certificate. And something akin to them could, as easily, be felt to-day, though a great slice has now been cut out of the average period of hospitalization. The tendency, even in an up-to-date hospital where there is greater contact with the outside world, for life to become monastic, ” the world forgetting “, can be very real. The patient is still, metaphorically, very much shut in behind high walls and bars.
The’ nurse, in close daily association, can become a sort of liaison-officer between the patient and the life beyond the hospital gates. The responsibility for creating a friendly, homely atmosphere in the ward, as opposed to bare, barrack-room-like institution frigidity, rests almost entirely with the nursing staff. Those small touches, acts of courtesy and consideration for the feelings of others, that ” indefinable something ” which makes up the pattern of home life, need never be entirely absent from life in hospital. They are for the nurse to give and encourage; they smooth the way. Newspapers, periodicals and discussions help to keep patients ” in touch “. Where suitable, walks and visits to entertainments in the district, patient and nurse together?not a group of patients, which can invariably only mean embarrassment to the sensitive person?help to ward off a sense of remoteness from the world. By these and other means a nurse can do much to ensure that the patient is never entirely cut off from ordinary life and so avoid, as far as possible, the risk, on discharge, of his being haunted with a feeling of being ” not wanted “, not fitting in, of that sickening loneliness of the spirit which could so easily undo in a short time all that the hospital has done.
It is good that legislation and science should so admirably have combined to reduce the length of a patient’s stay in hospital, but there is a danger lurking behind even this inestimable boon. Let us take the hypothetical case? by no means an unusual one?of the housewife referred to earlier and who has, shall we say, left home and children to the care of an elderly mother, a kindly, but already overworked neighbour, or to a husband faced with this addition to his normal job. It is perfectly understandable if, on recovery from physical treatment and ” feeling much better in myself “, as she might put it, she should wish to return home at once and relieve others of the burden they have been carrying for her. The doctor will undoubtedly advise a policy of festina lente, pointing out the necessity for preparing her mind to tackle the future; for a period of quiet convalescence. The nurse who will endorse this advice and supplement it with details of others who have insisted on premature departure, only to return in a short while, acknowledge their error and remain to complete the treatment, may, if successful in persuasion, be helping to contribute more that she knows to human happiness.
The peculiarly intimate nature of the nurse/ patient relationship has been much stressed here and with reason, for on it hangs the whole art of mental nursing. To gain the patient’s confidence, that is the beginning of all success and a good start in the relationship is half the battle. The nurse who can strike up this happy association from the first, so that the patient feels at once that he (or she) is in sympathetic and understanding care, is already on the high road. No light task this, and there can be no rule of thumb to determine how to set about it. We are dealing with human minds, delicately balanced as a watch spring; some enter hospital on the defensive?aggressive, non-co-operative; others come without hope; others still obsessed by the ” Lunatic Asylum ” attitude towards mental illness. Each category, each person within each. category, requires a different, an individual approach. Resourcefulness is the keynote.
The routine of nursing; the general duties in connection with physical treatments; the careful observation of the patient under domestic conditions, his eating and drinking, his waking, his sleeping, may secure data?perhaps some almost infinitesimal detail?which will help to explain a maladjustment.
We seek divine guidance in our way of life. Is it not of a piece, then, that in asking for blessing on our work we should think, too, of those who are entrusted to our care, remembering, with Tennyson, that ” more things are wrought by prayer than this world dreams of What is the secret ? Winning confidence. Keeping eyes, ears and brain alert. Being tactful, resourceful and versatile. Doing one’s duty?just that. That is the beginning and the end of ” helping to permanent recovery of all mental nursing?the alpha and the omega.
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