by Jody Alaine Lacson

One day I worked in a unit for substance-induced psychotic and traditional psychiatric patients. I arrived at 7:45 AM. Suffering from insomnia the night before, I was sure I would be late. I felt like a zombie.

Mrs. Bland, the instructor, paraphrased directly from the textbook in her southern accent, “Ya’ll gotta remember, for prevention of nosocomial infection, you must clean in one direction: from the vagina down to the anus.” The lesson was perineal care, the third week of training to become a nurse’s assistant. Mrs. Bland was slowly reviewing the procedure on a mannequin. She stressed every step so that the process wouldn’t seem as complicated when it was our turn to practice on the dummy.

Looking for a little distraction from the uncomfortable lesson, I glanced out my ninth-floor classroom window. People were walking the Queens streets in slow motion as if they were trying to conserve energy. It was one of those humid August days. The air, thick and sticky, made breathing an exhausting undertaking. Even though it was summer, I didn’t mind sitting in a classroom if it meant a refuge from the heat. Mrs. Bland finished her lesson with some advice from the textbook: “Now, this may be a little embarrassing for the resident, so don’t forget to act professionally, handle the person gently, and be polite throughout the procedure.” She asked for volunteers.

Tentatively my classmates raised their hands. Even though practicing the procedure for the first time would be unnerving, they needed the skill to pass the practical exam for certification. She wanted us to say each step out loud as we were doing it. This was her teaching technique to help us memorize. I was one of the last ones to go, and by then, the steps were repeated so many times, that I didn’t need to think in order to articulate what I was doing.

“First, you have to knock politely and introduce yourself to the patient, making sure that you inform her of your duty and that she is comfortable with the situation. Then you must lower the bed rails and the bed level for good body mechanics. Next, put on gloves to promote safety and infection control.” These words flew out of my mouth effortlessly as I began to carry out the task. “After you position your patient on her back, you flex her knees and spread her legs. And, making sure the chux is underneath her, you wet and soap the washcloth.” While the first volunteers’ voices were meek, mine projected loudly almost to say “as a matter of fact”. “Make a mitten out of the washcloth and separate the labia with one hand while using the washcloth mitt to cleanse between the labia with a downward stroke.” I spoke in monotone like someone reciting the pledge of allegiance or a prayer that’s been heard so many times that the words have lost their meaning. “After cleaning her with the soapy washcloth, you rinse her in the same way with a different wet washcloth.” I was on auto-pilot. “Once you’re finished cleaning the front, help the patient to her side and proceed with cleaning the buttocks in the same technique.” The whole process had become robotic for me, lacking any thought and feeling.

As I reflect back on that day, I think to myself: how can someone deal with a situation where he or she is required to get so uncomfortably close to a person and yet still be able keep his or her distance? This “close-professionalism” seems paradoxical.

Perhaps the task seemed really easy because we were only dealing with an inanimate prop. The mannequin, which we called “Mrs. Jones”, did not present aversion to any of the procedures we performed on her. She did not feel embarrassed when we asked her to spread her legs. Mrs. Jones didn’t cause any trouble when we transferred her to a wheelchair. She didn’t complain about how terrible the food tasted when we fed her. Mrs. Jones didn’t cry when she felt loneliness or pain. She never refused her medication. After explaining the duties we were about to carry out, we were trained to ask the patients: “Is that okay with you?” Mrs. Jones would always look at us with a smile and a blank stare. She was always okay with it.

By the end of the summer, I was certified. At eighteen, I was the youngest student in my class to finish the course. Before long, my mother helped me apply to the White Glove Nursing Agency. Then, I obtained a position in the psychiatric department at the hospital where my parents worked.

I don’t have a permanent unit. My placement depends on which psyche unit needs the most staff at a given day. I jump around according to the demands of the hospital, which gives me a few doses of experience within each unit. Because of ethical reasons, hospital policy does not allow relatives to work in the same unit. I never worked with my parents, so they would never be able to watch over me as I work. Their hearty “Congratulations!” about my first job was coupled with, “You better be careful. The hospital setting is unpredictable.” Before this, I never had a job, and they worried that I might become overwhelmed and wouldn’t be able to handle what might happen when dealing with mentally disturbed people. I had confidence, however, that I could do the job. I wouldn’t have gotten certified if I wasn’t capable. “Thanks, but I can handle it,” was my response.

As I began working, I gradually realized that it wasn’t my skills that caused my parents’ concern, it was my age. In the course, most of my classmates were middle-aged adults who decided to change their career path. I, on the other hand, was only eighteen, fresh out of high school and hadn’t even started college yet. They were married with children and had experienced so much of the world, while I had barely stepped foot into it. The eventual clash between my youth, optimism, and inexperience and the actual workings of the hospital would acquaint me with the realities of patient-nurse relationships.

One day I worked in a unit for substance-induced psychotic and traditional psychiatric patients. I arrived at 7:45 AM. Suffering from insomnia the night before, I was sure I would be late. I felt like a zombie. My gelatin legs brought me up to the nurse’s station to greet the staff and receive my assignments. According to the nursing care plan, I had to monitor the halls, take vital signs, make the rounds, and serve meals and snacks. These psychiatric patients are high functioning, so much of my job description didn’t require me to do more intensive care giving. Many of the patients have a high potential for “elopement” (the hospital term for breaking out of the unit), aggressive behavior, self injury, and sexual misbehavior. Monitoring the halls and making rounds every fifteen minutes to record patient activities were essential to prevent any dangerous incidences. My role, therefore, allotted me with frequent patient interaction. In contrast, the nurses dealt with patients minimally. They worked mostly behind the desk to give medication, handle paperwork, and evaluate patients’ progress.

At 8:15 AM, a man in a blue uniform rolled a cart full of breakfast trays. I yelled out, “Breakfast!” and the patients gradually came out of their rooms. In their loosely fitted powder blue pajamas, they slowly treaded into the day area like sheep being herded into an enclosure. Each person has a particular nutrition plan, so I made sure to call out the names labeled on each tray assigned for a specific person. “Mr. S.” was the first name I called. A tall, older-looking man with thinning, disheveled, silver hair came to receive it.

He said, “You don’t look familiar. Are you new?”

I nodded.

He smiled and asked, “What’s your name, my dear?”

I answered politely, “Jody.”

“Well then, Jody, thank you for breakfast,” he said with a wink and sat down to eat.

After breakfast, I went around the unit to make my rounds, checking off the people on the list and making sure all was well. I sat in the end of the hallway to guard the door and watch over the day area activities when I finished. Mr. S. was pacing in the hallway in front of where my chair was stationed. Mid-pace, he stopped and turned to me saying, “Are you Filipino?”

I quickly answered, “Yes! How’d you know that?” I didn’t recognize that my tone was more “friendly” instead of “professional” and incited more conversation out of him.

“I knew you were Asian. I judged from your bone structure that you were somewhere from the South Pacific.”

Oblivious to what the conversation might lead to, I continued on, “Wow, you are really good at recognizing that.”

“Yeah, I know. I have a talent for it. How old are you?” he asked.

“I’m eighteen,” I responded.

“So young! You remind me of a beautiful flower,” he said as he grinned to show his deteriorated teeth browner than his complexion.

Suddenly, a voice came from behind the nursing station: “Jody, can I talk to you for a moment?” It belonged to the nurse in charge, Leslie. She was in her late 20s early 30s, and being slightly taller than five feet, her petite frame did little to demonstrate her authority. Her face, however, displayed an expression that didn’t read “disapproving” as much as “concerned”. Without words she relayed a message to me in a way that only an authority figure, with more experience, could.

“You don’t need to engage in a conversation with any of the patients. You’re so young, and you might not realize that they are put in here for a reason. You could put yourself in danger if you give them the opportunity. Just leave them alone; they’ll be fine on their own.” She spoke in that low voice people use when talking about something confidential.

I nodded and sat back down.

Inching towards my direction, Mr. S. asked, “Did she get mad at you?”

“She told me not to talk to you.” I answered, looking at the door to avoid eye contact.

“Bah! They never want us to talk to them except when we need medication or something. Other than that, we can only have conversations with other patients—not with normal people. It’s making me crazier than I already am!” he said emphatically throwing his arms up in the air.

Perhaps Leslie was merely looking out for my best interest. I knew very little about Mr. S. I knew that a lot of patients with mental conditions are very volatile. There was a possibility that he was dangerous. Still, dealing mostly with paperwork, she saw Mr. S. as a manifestation of medical terms and charts. Her duties behind the nursing station provided little opportunity for understanding him beyond that. She could have been wrong in thinking that her patient’s friendly behavior was a guile to hide misconduct. According to healthcare consultant Kathy Malloch’s medical article “Nurse-Patient Relationships: Essential Skills for Expert Nursing Practice,” “The essence of a nurse-patient relationship [is] the humanizing processes that translate robotic, mechanical tasks into personalized services.” By distancing themselves to prevent a potentially dangerous incident, maybe they are neglecting a key ingredient for patient progress and recovery.

I had little consciousness about how big of a factor my age was. Leslie and my parents had been working so much longer than I had. Surely, their concern was coming from experience. Sometimes, though, all those years of seeing bad real-life scenarios can harden a person’s trust of patients.

“I have seen things you only saw on TV. It’s no joke,” my dad would say. My parents would often speak about their workday when the family gathered to eat. They’d say, “This patient did this to so-and-so” or “I can’t believe this person did that to this patient.” My sister and I always felt excluded.

When I started working in the hospital, I became a part of their circle. Instead of me silently chewing as they discussed work, I’d be the one to start a conversation. Despite this, I still felt like I hadn’t been initiated into the club of seasoned caregivers without seeing some crazy episodes for myself.

I wanted to be a realist instead of an optimist. I wanted them to prove that their insight and advice came from somewhere real. My dad took it as a challenge to prove that he was right and began, “Well, if you want a real story, I should tell you what happened to Sue.” I worked with Sue, a nurse, a number of times, including that day with Mr. S. She was a sweet lady who always made it a point to ask how I was doing in school every time she saw me. “She worked as the medication nurse that day. A tough-looking Hispanic guy asked for more Klonopin (a narcotic), and she told him that she gave him the prescribed amount. Any more, and he would’ve gotten high, which is probably the reason why he wanted it. Well, the guy held a grudge against her. He went to sleep, angry. In the middle of the night, he woke up and started having hallucinations,” my dad said pointing to his head as he illustrated with his hands. “Sue was on break. She was resting in the treatment room lying on a stretcher. The guy came to the nursing station asking me where the ‘medication lady’ was. I told him that she was on break. I dunno, I guess he realized she was in the treatment room, and the next thing I heard was her screaming, ‘Help!’ When I got there, he was reaching for her shirt but grabbed the bed sheet instead.” My dad let out a “hah!” as if saying how inconceivable the situation seemed in retrospect, but how fortunate he was to get there on time.

“She was like ‘I didn’t do anything wrong to him.’ He was cursing her out like: ‘You ugly bitch. I’ll change your face!’ The guy was as big as me and I wrestled with him until the hospital police came. I didn’t hurt him; I only restrained him. The police held him down and I gave him a strong sedative. Heh! He eventually slept in the observation room.”

After hearing this, it is no wonder why they had such a huge concern for my well being. “This is why we tell you never to get too close to a patient. You never know what they will do,” my father warned with his stern “father” voice, “I don’t want you to find yourself in those kinds of situations.”

“Yeah, I see that,” I contended, “But, do you think that it can be counter-progressive when the only interaction between you and your patient is giving them medication and enforcing constraints?”

My mother answered, “As a nurse you need to play different roles. Sometimes you need to be a gentle, comforting figure to help ease the patient’s sufferings. Other times, you need to be like a friend to them, ready to listen to their problems and be a medium to release their anxieties. And sometimes, you need to act like a parent or a disciplinarian. You need to assert your authority and refraining from being too close. I keep away because, if I do, I can take better care of my patients. You can’t always just be their ‘friend’ when you know that they really need someone to administer or enforce something they don’t like.” She pointed to my dad saying, “The guy in Papa’s story needed someone to set rules and stop him from being a hazard to himself and others. We need to be away to preserve ourselves and in turn, help them.”

I wondered why being “friends” might blur a nurse’s ability to do what’s best for the patient and even hinder her from carrying out her duties. My primary responsibility was to keep patients and staff safe. A sacrificed conversation is a small price to pay to keep order in a unit prone to chaos.

With this in mind, I was still bothered by the idea that I couldn’t help patients the way I wanted. How could I help someone if I couldn’t even get close to them? When I was younger, I thought that healing someone meant having a strong connection with someone who is suffering. The healer had to be vulnerable to bring strength to another who is more vulnerable than herself. Perhaps it was my naiveté that made me believe that Mr. S. did not have bad intentions and that I could bring him some relief simply by talking to him. I didn’t want to think that giving him a chance to interact with me might also be give him a window to take advantage of me. After my parents told me stories about staff members who were assaulted by patients prone to violent behavior because of their mental instability, I felt confused. I took a cautious attitude, and because of it, I felt a wall build up, which prevented me from opening myself up. While this wall prevented me from falling into a risky situation with someone whose condition possibly affected his moral judgment, it may also have deterred me from providing the kind of care and emotional support that he, as a psyche patient, needed.

I sought advice from my mother. “I get frustrated that maybe what I do is wrong. I think that some nurses think I’m not capable of fulfilling my assignments because I still don’t know the kind of role I have to take. Sometimes I think that I’m being too friendly, and other times, patients won’t even respond to me because they don’t see me as ‘approachable.’ How did you find a happy medium?”

“It is hard to judge how to balance the degree of closeness you should have with a patient. With some patients, it is very easy to make a bond. Other times, you can’t forge a relationship as easily. But you have to remember that the word ‘relationship’ means two people are involved. Your problem is that you always think about what’s best for the patient. It’s good to have that. But, you gotta think about yourself too and how a relationship affects you. Your father told me about an old woman that he became fond of in his old job at the nursing home. He used to clean the ulcer on her foot from her diabetes. And he liked her because she was a sweet and complacent patient. Did you know he cried when she died because of septic shock from that ulcer? He didn’t realize that she had an impact on him just as he had on her.”

My mom continued, “I don’t know how you get so worked up over this. You learned more about patient and nurse relationships than I did when I was studying nursing at your age. In the Philippines, we weren’t taught a lot about the psychology of care giving. I never dealt with ‘emotions’ until I came to the States. Back then, we just dealt with the technical stuff and nothing else. We can help suture people up like pros, but we weren’t good at consoling people. As a student we were used as substitutes for real staff in a hospital. There were not a lot of patients’ rights policies then, so there were no regulations against students working in hospitals. The general consensus about people in the medical field was that they were professional and they knew the best way to care of a patient. The patients had little input. I know that sounds bad, but our country had huge faith in our medical professionals.”

My father jumped in saying, “In America, the nurses are afraid to touch the patients. I studied nursing here. The nursing curriculum for Mama is not the same as in Hostos Community College. As nursing students, we’re taught to think about a patient more holistically. You know that a guy got in trouble because a crazy patient said he raped her? People take allegations here seriously, you know. That guy is so nice. He’s harmless, but they can’t ignore her claims. He was probably just talking to her, and she made up some story about rape. He was trying to show a little compassion for her but ended up getting in trouble for it. So you see, you have to take care of them physically and emotionally, while looking out for yourself too. It’s a hard balance. There are so many policies and regulations we need to follow, that a nurse can just be paralyzed! Sometimes it’s best to just leave patients alone and just do what you gotta do.”

These issues are like the balls in a tennis game. Each whizzes back and forth trying to determine a point to favor one side. Just when one side seems to establish a point, the other side has easily gained back the ground it lost. There may never be a definitive “winner” in this patient-care giver relationship tennis match, so I don’t know if I have reached a real resolution. Yet, I’ve learned that patients are to be handled with care and caution. Perhaps the realization of this duality is the key to taking the right attitude towards this delicate dilemma.

So why go into this field? Why subject myself to professional ambiguity? The answer is simple (and perhaps a little cliché). It’s because I want to help people. Growing up in a poor country, I understood the importance of caring for others at an early age. Not everything was easily attainable, especially health-care. Our government didn’t have programs like Medicaid that brought health-care to the needy. The already impoverished people needed to pay out of pocket to be cared for or treated for their ailments. The profession of caregiving may require me to take physical risks, I may have to put myself in uncomfortable circumstances where I could be antagonized. These patients might even take away a part of me every time I get involved—wearing me down emotionally. Nevertheless, I still want to do this. I’ve been exposed to a lot of suffering in the Philippines, but I was lucky enough to experience a life with abundant opportunities in America. I wanted to do my share in providing opportunities for others, and by being a part of the medical field, I can offer people a fundamental opportunity—good health.

***

Jody Alaine Lacson lived in the Philippines until the age of six when her family immigrated to New York. She is a junior at Lehman College in the Bronx, where she is majoring in nursing and double-minoring in French and nutrition. She works in the Department of Supplemental Instruction at the Lehman Campus as a study group leader for anatomy and physiology students. She also works per diem as an nurse’s assistant in a city hospital. She currently resides in Yonkers, New York with her parents and sister. She plans to become a nurse practitioner and work for the Red Cross in its relief efforts and to promote community health among people of countries in need.