Psychiatric Nursing at St. James Hospital
I’ve been a little hesitant to write a blog about some of my experiences in a psychiatric hospital in 1980s Britain for a number of reasons. I am aware that those who suffer mental illnesses are some of the most vulnerable members of society. This was definitely true in the mid-1980s in Britain. I write this with the utmost respect for the patients I came into contact with and the nursing staff charged with their care.
During the mid-1980s, I was a young student nurse at the beginning of my final year of training and was assigned to the local psychiatric hospital in Portsmouth. I had grown up in the area and heard St. James’ Hospital called many unflattering names and the patients even worse. In 1983, Parliament passed a Mental Health Act aimed at “reforming” the law that had given family members the legal right to place “mentally disordered” relatives in institutions like St. James’. As a Thatcherite policy it also aimed at saving money. Former patients were placed in group homes or sent to live on their own in the community. Many patients, who had been institutionalized for the majority of their lives under the former law, were suddenly thrust into a very alien world where they were not welcome. Those patients deemed too violent, too psychotic, or without the abilities thought necessary for living in the “community” (a euphemism for a different set of walls in an unfamiliar location) remained in one of the Victorian “Villas” built on the grounds of St. James’ hospital.
After a week of psychiatric nurse training, I was assigned to a Villa that housed approximately twenty-eight men. Many of them had been institutionalized by the courts for “crimes of passion,” (a quaint euphemism for domestic murder) to serve their sentences. Others had been placed in St. James’ or “sectioned” by their parents for deviant or “disordered” behavior or because they could not be controlled. Before 1983, sectioning—named because it was a section of the mental health code—could be for life. After 1983, under Section 2, institutionalization and psychiatric assessment could last up to 28 days (under Section 3 this could last for up to six months). By the time I entered St. James’ as a student nurse, Section 2 and Section 3 patients were treated and observed in a separate building. All other residents lived in one of the various villas on the grounds of the hospital.
I admit I felt slightly apprehensive about my new assignment. The nursing staff welcomed me but also carefully guarded the medical records of all the men. Unlike previous assignments on medical and surgical wards, students were not permitted to read the patients’ files. In addition, we wore no uniform or badges, and the staff tended to stay in the office until there was a specific need to go into the rest of the villa. The entire villa, with the exception of the short corridor outside the medication room, could be seen from the office. All the villas had been built on a variation of Jeremy Bentham’s Panopticon model to ensure surveillance of residents at all times. Medications (mainly or even wholly anti-psychotic medications) were given on a weekly and monthly basis.
I decided to spend my time with the residents rather than in the office surrounded by chain-smokers. The staff warned me never to be alone in the corridor outside the medication room as they would not be able to see me if I needed help for any reason. With this in mind, I played checkers and card games with the residents in the lounge and quickly made friends with three of the men I will call Tom, Albert, and Harry. Tom and Harry liked to walk arm in arm with me. Harry quoted poetry and talked about the books he had read and seemed to enjoy the fact that I was genuinely interested in what he had to say. Most of the other men ignored me and continued with their routines. One man, Graham, seemed to hover on the margins of our quartet, and I tried to get him interested in the games we were playing. The result was an absolute disaster. Before I had time to figure out what was happening, Albert and Graham were shouting at each other at the top of their voices and throwing punches. All the other residents of the villa circled the two men and began rocking and making ominous noises.
Within seconds the rest of the staff were in the day room using their experience to assess the situation and calm the residents. A few minutes later the doctor arrived. This was my first “psychiatric emergency,” and it felt like the medical response to a cardiac arrest.
Albert and Graham had a history of animosity toward each other, something I was unaware of. In the privacy of the office, I was told in no uncertain terms that it was my actions that had caused the incident (as well as all the work needed to report it). I felt humiliated and confused. I didn’t know that Albert and Graham didn’t like each other. I had misread Graham’s attention to our group as interest, not hostility. I had a lot to learn.
A few days later, Harry came to me distraught. He had a headache, felt weak and was clammy. He looked pale and definitely in need of attention. I asked him if he would like to see the doctor. He did. I told the staff nurse, and the doctor arrived within an hour.
Before the doctor left he came into the office where I was having my lunch and told me that he thought there was nothing wrong with Harry, and so he had prescribed him a placebo—vitamin C. It was the same doctor who had responded to the incident a few days earlier. I wanted to ask if I should take Harry’s vital signs or any other observations but before I could, the doctor explained that Harry enjoyed attention and the daily vitamin C tablet would suffice.
The following two days I was off duty and caught up on laundry, grocery shopping, and errands. When I returned to work for an evening shift, I was asked to talk to the charge nurse on duty. He explained that Harry had died unexpectedly the previous day of a massive heart attack. I was shocked. But there was more. The nurse explained that when they had gone through Harry’s personal belongings, they found a letter that expressed Harry’s deep feelings for me. Now I was stunned and sad.
Nevertheless, the shift had started and so one of the first things I did was make tea for the residents. I went to the kitchen to start the hot water and gather the cups and saucers. Graham came to the door. None of the residents were allowed into the kitchen but he seemed to want to help, and so I let him in to push the tea cart out into the day room.
The rest of the shift seemed to go without incident. The residents seemed calm and after dinner some took advantage of the warm evening to take a walk in the grounds before getting ready for bed. It was Tuesday and Peter, a particularly garrulous resident who had never spoken to me, was due his weekly bath. I had never been asked to assist Peter before. He hated the bath, especially taking off his clothes, because he believed the staff was trying to steal from him. The charge nurse explained that my job was to make sure Peter used soap in the bath and to make sure that I got out his clean clothes before putting the dirty clothes into the hamper. It seemed simple enough. I ran the bath, Peter took off his clothes and went into the bathroom, albeit reluctantly. I followed with soap and a towel and offered to wash his back. He shouted no, and so I decided to go to the dormitory and get his clean clothes ready. I placed the dirty clothes in the hamper and opened Peter’s closet. The next thing I knew, I was thrown face first onto the bed and Peter was shouting at me as he leaned on my back. He demanded his clothes back and said he was going to report me for theft. How dare I go through his personal things? I agreed to get his dirty clothes out of the hamper if he would just let me get off the bed. He agreed. I got the dirty clothes for him and he put them on again.
The following day was the first of the month and so was medication day. My job was to get the patients to go to the medication room. As I went through the day room I asked the residents to go to the medication room. It was such a routine part of life for the residents that they began making their way to the other side of the villa. Before I realized that I was in the corridor where I could not be seen by the staff in the office, Graham shoved me against the wall and stood with his face inches from mine. I was scared. The other residents in the corridor started rocking and making noises. I looked over at Tom and Albert and asked them to get help. They didn’t move. I asked again and still they made no move. Graham moved even closer, took hold of my neck with one hand and held a knife in the other and told me that he was going to kill me. Desperately I tried to think of anything in my training that might help. I remembered one instructor telling the class that sometimes the least logical idea obtains the most logical response in a patient with a psychiatric disorder.
As Graham hissed that he was going to kill me again, I asked him if he would like to have his medication first. He said yes, loosened his grasp, dropped the knife and walked toward the medication room. I picked up the knife—a kitchen knife—and walked swiftly in the opposite direction and decided to stay in the office for the rest of the shift. This time I knew I was to blame.
I learned some hard lessons at St. James’ Hospital. I learned that people with psychiatric diseases also suffer from physical disease. I learned that it is better to speak up than to keep quiet no matter how ridiculous it made me look in front of others. I learned to listen and pay attention to more experienced staff members. I learned that I had a lot to learn about people and life. More importantly, I learned that nursing was a complicated profession, but one that I loved, passionately.
[Editor's Note: May is Mental Health Awareness Month. The National Institute for Mental Health (NIMH) is a wonderful resource if you or a loved one is struggling with mental illness and need support or information.]