I'm in Control

I’ve been working at the psych hospital for a few months now and have come to take the first few hours of my shift very seriously.  I do not trust the night shift nurses.  Not because they are bad nurses, but they’re mostly travelers and have no problem answering what I consider key questions with, “I don’t know,” as they clock out and walk away. 

First, I skim the board for familiar names as many of these patients are in and out or stay for extended periods.  Then I’ll circle the unit and count the number of patients I have and make sure it matches the board and that they are all, in fact, breathing. I then go to each chart and read the last progress note, I actually skim the last three to see if they’re the same.  It’s common for nurses to copy and paste progress notes. 

This was upsetting to me for the first week until I appreciated how impossible it is to get your work done in the 12 allotted hours. And anyway, if a patient’s presentation has already been eloquently narrated, why go through the effort of trying to find synonyms for “labile emotional state”? Trying to do so sometimes made it seem like there were changes in behavior when there weren’t.  I’m fine with copying and pasting progress notes now as long as there is at least one additional sentence.

This small effort speaks volumes and could be something as simple as, “No additional changes noted at this time.” or “Patient verbalized, ‘I know there’s poison in this water.’”  Even if progress notes include, “Patient continues to be…” and then the note is copy and pasted this is enough for me to believe enough of an assessment was actually done.  But just copy and pasted or missing notes altogether and my chest tightens a little bit as my mind goes to the worst places of what we might be missing.

Then, I’ll look through the last set of vitals.  Many patients refuse vitals.  This is behavioral health, vitals are not the primary concern.  But because refusals are common, staff also get lazy and just don’t do it.  If there are none in three days I’ll start with those patients and see if they’ll let me get their vitals, which they usually do. 

I find I have a patient who has refused vitals for the five days since her admission when her blood pressure was 160/110.  She never should have been accepted, that is not a safe blood pressure and we are not a medical hospital.  She does have blood pressure meds prescribed to her, which she has been refusing along with her antipsychotics since her arrival. Her progress notes are so generic they essentially describe nothing beyond saying she is a human who is alive, but the notes are also not anything I would have judged was I not suddenly angry my coworkers left me with a high-risk patient and without giving me a heads up.

I stand to go find the vitals cart and my mind goes straight to finding her stroked out in bed, face drooping, drooling, unable to speak clearly. I feel my heart race as I picture this and decide to take a piss and a few deep breaths first. 

This is a big part of why I’ve concluded bedside nursing is not for me.  I take things to the worst place. I get worked up when communication isn’t dialed. It’s never going to be dialed when you have 12 patients at a time. 

I find my patient sitting on her bedroom floor, in the sun coming in from the window, legs crossed, hands on her knees palms up, meditating. She looks very peaceful and she tells me she is, that it’s hard to be in here, but she is strong and has figured out a way.

I ask if I can take her vitals and she says no. She explains that machines suck part of our soul away when we attach them to our bodies and she’s worked hard to develop the energy field around her that she’s created and doesn’t want it disrupted.

I say I understand, and that she really does look peaceful, and that the sunlight is pretty, because it is.  I ask if I can sit with her and she allows it.

I say, “I was looking at your vitals when you came in and it looks like your blood pressure was really high, is it usually high?”

She says, “Well, that’s what they tell me sometimes but it’s not.  It is, but only when they’re taking it because of the bad energy they’re putting into me.  I don’t know what they expect.  But you don’t need to worry because, as you can see, I can control my blood pressure with my mind and it’s down right now. I’m in control.”

I say, “I can see that and I believe you. I am also in a tough spot right now because my job is to make sure everyone here is medically safe, and that’s one of the numbers we look at to determine if someone is safe. I’m not allowed to chart what I think, I have to show that if a number is high or low that I look into it and re-check until it’s within a safe range.  Is there any way I could get a blood pressure?”

She says, “No, I’ve explained myself, and now you’re starting to upset me.  If you understand me, like you say, then leave me alone.”

I say Ok and go call the doctor.  He says send her to the ER.  I think this is dumb but also may be necessary.  I picture her screaming and fighting as they restrain her to the gurney, the ER nurses being annoyed that they have to take a patient not because there is even really a problem, but because there might be a problem. “This is not an emergency and not what the ER is for!” I hear the staff saying to each other.  I picture her returning, fuming, never to talk to me again, I, who said I understand and believe her. 

I decide to give it another shot and go into her room, sit on the floor, and say, “The doctor told me to send you to ER.”

She looks at me like I am evil, ”I will not go.”

I say, “I don’t want you to have to go, you do look peaceful. I don’t want to disrupt that and know that I already have.” I say, “According to the rules they use to let me keep my license as a nurse, a blood pressure of 160/110 would put a person at risk for things like a stroke, especially when it hasn’t been re-checked in 5 days so could potentially be even higher.  I need to show that I’m protecting people from things like that. I brought my manual blood pressure cuff, it's my personal cuff and stethoscope.  There are no batteries, no machines, just a cuff I squeeze air into and then listen with this stethoscope. Would you let me use this?”

Because a manual blood pressure cuff is not a soul-sucking machine she agrees.  Her blood pressure is 142/90.  She is safe. This is stroke risk over years elevated, not stroke risk this week elevated.

She says, “Told you.”

I thanked her and left. This took up too much of my morning and I am now behind. A coworker, his title “Patient Rights Person” or something that affect, comes in and asks if I am having any trouble with the patients. He’s very nice, always has a good attitude. I say, “Almost, I have a patient who’s been refusing vitals but we talked and she finally let me take them.”  

“Who?” he asks.  I tell him and he says he’ll talk to her.  I say, “OK, we’re all set though, I talked to the doctor already.” 

A few hours later she comes to me and calls me a stupid lying bitch.  She tells me that to send someone else in to threaten her has certainly gotten her blood pressure up now. She tells me she doesn’t trust me anymore and will no longer be talking to me.  She’s crying.

“This is all because you! You said you understood and believed me and wanted to protect me.” She sounds absolutely disgusted.

Sometimes, you just can’t fucking win, can you? 

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Review

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This story is profoundly human, emotionally layered, and rich with social critique, particularly around the conflicts between institutional rules, patient autonomy, and the emotional burden of caregiving. It's an honest portrayal of the moral gray areas nurses navigate daily—balancing empathy with clinical responsibility—and how bureaucracy can unintentionally deepen suffering for both patients and caregivers.

The internal battle between following protocol and honoring a patient’s sense of dignity is central here. Despite doing everything right, the narrator is left with a profound sense of failure and betrayal. The final reflection—“Sometimes, you just can’t fucking win, can you?”—perfectly encapsulates the emotional toll of caregiving in a broken system.

The tone is reflective, compassionate, and painfully honest, with a simmering undercurrent of frustration and exhaustion. There’s a quiet resignation that runs through the story, capturing the emotional weight of doing everything "by the book" only to face unintended harm.