As a registered nurse, I worked in a big (urban) psychiatric emergency department which is known for its humanistic philosophy, policies and practices. The work was getting increasingly harder. We had complex cases, a very high workload and a growing number of patients even if our emergency room remained the same size. Patients were put in the corridor and other open spaces to sleep. There was no privacy. Doing our evaluation and intervention was becoming more and more difficult. When we were talking about our workplace, we would often joke that we were lucky to work in a “loft style” psychiatric emergency.
Unfortunately, things were not funny for many of us.
I realized how violent our job was when I became the assistant head nurse on another psychiatric department. Here, I want to emphasize that I’m not talking about patient violence, but rather about administrative violence toward nurses. More specifically, I want to emphasize the problematic use of the “caring discourse” to pressure nurses into silence, inaction, and acceptance of unbearable working conditions, and to blame or shame them in situations when they are being “good nurses”.
One thing I learned about this position is that I not only had to advocate for our patients, but I also had to do the exact same thing for my colleagues who experienced administrative violence every day. It is, in fact, always strange to observe that in a psychiatric environment, in which “caring” is such a prevalent discourse, subtle forms of violence are never far from it. In saying that, I realize that this is a complex (and paradoxical) situation which is quite difficult to grasp so let me give you an example:
It was a Friday afternoon. That day, we had a high number of high-risk patients who needed constant supervision. I had a call from my superior, who was asking me to admit three new patients from the emergency room. One hour remained before the next shift. The only nurse available to welcome them on the unit was tired. She had a hard day and did everything in her power to ensure that every patient received the best nursing care possible. She also made the necessary effort to help patients who had additional needs. For example, one of the patients wanted to leave for the weekend but we did not have medical authorization to approve this request. Despite this, she made sure everything was organized in order to make it possible for the patient to leave. I was myself unavailable to accept more patients on my caseload due to the change of shift and the weekend preparation.
I told my superior that the admission of three more patients would have to wait until the next shift. I justified this decision by the fact that my colleagues were overloaded with work to finish before the weekend and that the level of surveillance required was already at its highest. He said: “Ok, I will think about it”. Five minutes after, when I came out of an improvised meeting with one of the psychiatrists (you know, for the weekend leave), my superior was on the unit and was talking directly to my colleague. She gave the same answer I gave my superior a few minutes before, but he then said: “Well, Suzy (fictional name), you should not think about you but about what is best for your patients”.
Words can hurt, even if they are compassionate. And if this is what we mean by “caring”, I don’t want to be a part of such conception of what it means to “take care” of people. I was angry, I openly and publicly opposed myself to my superior while emphasizing that we had already talked about the situation and that my position was clear. A quite uncomfortable silence was present in the room and I knew the “flag was on my head”.
On the next Monday, my superior asked me to meet him in his office. His statement was clear: “Any further opposition to administrative decisions will not be tolerated”. I didn’t say anything, but before leaving is office, this is what I said this: “You hired me in this position because I had a good clinical judgement and because you thought I would be a good team leader. I did my job. I think I demonstrated both my clinical judgement and my leadership in this situation and I beg you to prove me the opposite. When you called me to have my clinical appreciation about the situation, I thought you really wanted it. You just showed me that I am only a good assistant head nurse when I obey to orders, even if I find them dangerous.”
Days passed and I waited for the kind of punishment nurses have to endure when they voice their opposition to their superiors: an administrative blame, a suspension or worse. What came instead were excuses for my superior, who thought about the situation and realized I may have done the good thing when I reported how violent is words were.
Nurses have to stop thinking it is necessary to forget themselves in order to care for patients. It is only if you know your values, but also your limits, that you can provide good nursing care. You have to stay true to yourself. Sometimes, that means you have to voice your opposition to situations that are unbearable to you, your colleagues, and the patients you care for. I am a nurse and I am proud of who I am. I want to advocate for patients I care for every day, but also for nurses like me who struggle to fight for what is right. I want to be a “good nurse”. Because fighting for what is right is what being a “good nurse” is all about.