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Making peace with imperfection

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By: Nina Solis, BSN, RN, OCN

Working as a nurse with OCD

Takeaways:

  • Undiagnosed obsessive compulsive disorder can create challenges in daily functioning, including in the workplace.
  • Accurate diagnosis, treatment, and continued support can help nurses with this condition thrive in their careers.

Author’s note: Although I’m someone who suffers with obsessive compulsive disorder (OCD), I’m not a mental health professional. Ultimately, I can’t speak for everyone’s experience—I can speak only my own. If you believe you might have OCD based on anything you read in this article, please consult an OCD specialist for an accurate diagnosis and treatment.

Those of us who work in healthcare devote our careers to caring for sick and injured people day in and day out. However, when it comes to caring for ourselves, especially our mental health, things can get more complicated. When I started my career as a nurse, I quickly recognized a lack of support and representation for healthcare professionals who struggle with chronic mental illness. Although we had in-services and wellness events talking about meditation, self-care, and skills to reduce burnout, I’d never experienced a formal conversation about practicing nurses who struggle with anxiety, depression, post-traumatic stress disorder, or any other of a wide range of diagnoses.

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I can’t deny that I’ve felt fear and even shame at the idea of my colleagues knowing that I’ve struggled with my mental health for as long as I can remember. How would they react if they knew the reality of what I’ve gone through? I’ve lived in constant fear that I’ll never be able to live up to my own perfect standards. I’ve lost sleep for fear of causing harm. Some days, I’ve battled uncontrolled anxiety over the idea of making even the smallest mistake.

This is my reality as an RN with obsessive compulsive disorder (OCD). I’ve long felt isolated and misunderstood because of my diagnosis, but I know now that countless other healthcare workers thrive at their jobs despite the mental health obstacles they face. I’ve developed daily strategies to ensure I can perform my job to the best of my abilities. Although I still find it difficult to talk about my mental health, I know that sharing my experience will allow others to feel seen, understood, and respected for the amazing healthcare workers they are.

What is OCD?

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, OCD is a mental health disorder defined by unwanted and sometimes frightening obsessions (thoughts, urges, mental images) frequently accompanied by a strong desire to suppress them with compulsions (repetitive behaviors or mental acts). Diagnostic criteria for OCD include the presence of obsessions and/or compulsions that cause significant distress and are performed more than 1 hour per day. The time it takes to engage in these compulsions, paired with consequential avoidance of situations and places, can prove debilitating. While compulsions feel like a necessary act for someone with OCD, they don’t feel good or enjoyable.

Due to widespread media tropes, misinformation, and cultural conditioning, many of us recognize OCD as a disorder that simply involves a love of cleanliness and tidying. In reality, OCD remains vastly misunderstood, and, according to a 2021 study by Stahnke, is classified as one of the most debilitating mental health disorders. After I received an official diagnosis of OCD in adulthood, my psychologist determined that I could have been diagnosed as young as 7 years old based on a review of past and current symptoms. I couldn’t help but wonder how I could have gone this long without knowing. What factors prevented my diagnosis before adulthood?

According to Stahnke, providers frequently misdiagnose OCD because of a lack of knowledge. For patients who face the consequences of general misunderstanding and stigma associated with OCD, late diagnosis can result in years of unnecessary suffering without proper treatment. Some patients may even be at risk for psychosis or suicide if they go long enough without help. I’m grateful that I never reached that point, but I can’t help but wonder what my life might have looked like if I had received a diagnosis earlier, and how it might have changed my experience as a struggling new nurse.

How was I diagnosed?

The stress I experienced as a new-to-practice nurse triggered my official diagnosis and associated symptoms. Although I’ve experienced a few different OCD subtypes throughout my life, the most prevalent has been responsibility OCD. Des Marais describes this subtype as revolving around an inflated sense of responsibility, which can include excessive worry about causing mental or physical harm to another person or feeling at fault for adverse events outside of one’s control.

As a healthcare provider, I know what kind of pressure we face to complete our work efficiently, based on evidence and according to organization policy. Historically, I thrived with those kinds of motivators in place, but I developed a kind of terror when I started work as an RN. Suddenly, I was in charge of other human lives, not simply my own. Although I was well prepared to work as a nurse, I felt consumed by the fear of making a mistake. Empathy and concern with the well-being of others is a positive trait when working in healthcare, but responsibility OCD takes these attributes to an unhealthy level.

When preparing medications, I’d check drug labels and expiration dates multiple times, far exceeding the standard of practice. I’d spend so much time assessing central lines that I fell behind on my daily tasks. I’d ask multiple coworkers the same question to ensure I performed a procedure exactly right, even though I’d done the procedure correctly in the past. If I thought I’d made even a small mistake, I’d feel the need to immediately confess it to my patients and coworkers. When my OCD worsened, I would leave a patient’s room after properly administering medications, then suddenly feel intense fear wash over me that something was wrong. Even though I always checked the five rights of medication administration and scanned each individual medication, I would convince myself to go back into the room and dig in the trash for recently discarded labels to confirm I gave the correct medications.

Not only did these actions impact efficiency, but they also led to intense shame and embarrassment, which fueled a desire to correct my actions. I found it hard to sleep at night because I’d replay every perceived error or conversation misstep from the prior shift with resulting feelings of guilt. I believed that the more I reviewed these errors and missteps, the more I’d learn from them and prevent a future mistake. Like many other people who suffer from OCD, I knew how baseless these anxieties were. However, when you’re stuck in an obsession/compulsion cycle, you can feel terror at imagining what would happen if you stopped. It left me unable to trust myself and my abilities and afraid to perform my job without supervision. Outwardly, I appeared a caring and competent nurse, but I felt only helplessness and fear on the inside.

Eventually, I realized that I was obsessively seeking feelings of rightness and certainty in aspects of my life outside of work. If I couldn’t confirm that a situation felt right, “good,” or moral enough, I would fall into a spiral of compulsive thoughts and actions to seek clarity. These thoughts kept me up all night and even appeared in my dreams. Once, I wrote down every time my brain became fixated on an obsession throughout the day, and I logged over 8 hours of rumination on a single topic. That’s a full-time job on top of my actual full-time job. All of this information flipped a light switch for my therapist, who finally said, “I don’t think you’re experiencing generalized anxiety. I think you might have OCD.”

What are the treatment options?

Exposure and response therapy (ERP), which aims to reduce OCD symptoms by confronting symptoms at the source, proved a game changer in my OCD treatment. Using ERP, I learned how to identify triggers for my obsessions and choose not to engage in the compulsions I used to minimize anxiety. For example, if I had just given medications to a patient and knew I’d thoroughly checked the five rights of medication administration, I would first identify my obsessive thought: “What if I made a mistake?” Then, to combat my compulsions, I would consciously avoid looking for discarded labels or asking other people for reassurance.

My therapist explained to me that the goal of ERP is to push yourself to the point of peak anxiety, and then watch yourself come back down, repeatedly. You start out feeling like you can’t possibly take any more distress, and then your body eventually learns that it can re-regulate itself and calm down without needing to complete any compulsions.

I experienced a great deal of discomfort at the start of this therapy, and a few times I nearly stopped. I would convince myself that it wasn’t helping or that avoiding my compulsions could put me or others in danger. OCD obsessions can feel like very real warning signs from your brain, so you believe that you’re being irresponsible by not acting on them. However, the more I practiced ERP, the easier it became to feel confident that I could trust myself and my actions as a nurse.

Using ERP, in addition to mindfulness and medication, played a huge part in my healing. It allowed me to identify when something triggered my OCD and plan out how I could handle it. This helped to create more time in my workday, contributed to lower levels of anxiety, and most important of all, it allowed me to show compassion to myself. I didn’t have these worries because secretly I was a horrible, harmful nurse. I had them because I truly care so much about each patient I encounter and always want the best for them.

Recovery and connection

Since I received my OCD diagnosis, I’ve sought out stories of other healthcare pro­viders who’ve also dealt with OCD and found career success. I’ve also slowly grown more comfortable with educating my coworkers about the impact of OCD in the nursing profession. I respectfully call them out when they’re unknowingly insensitive. I can’t count the number of times I’ve heard a colleague say “I’m just so OCD” when referring to keeping a clean workspace or setting up patient supplies. Not only is OCD something undesirable and uncomfortable, it’s also not a casual personality trait that someone can claim whenever they want. I’m not “so OCD” because I’m excited about order or cleanliness—I’m someone who suffers with a disorder I wish I didn’t have to live with.

My personal experience with OCD has been an enlightening and ongoing journey. Many times I’ve felt completely hopeless, but increasingly I’ve felt proud of myself for how hard I’ve worked to overcome my disorder. I’m lucky to have a supportive community, kind coworkers, and patient mental health specialists to guide me along the way. I want to let others in my situation know we aren’t inadequate or careless just because OCD makes us believe that we are. Healthcare workers are brave, hardworking, and smart, but we’re also human beings. Nothing about me, my life, or job performance will ever be perfect, and for the first time, I’m making peace with that.

Nina Solis is a clinical research and hematology-oncology nurse based in Los Angeles, California.

American Nurse Journal. 2024; 19(6). Doi: 10.51256/ANJ062457

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, Text Revision (DSM-5-TR). Washington, DC: American Psychiatric Association Publishing; 2022.

Des Marais SN. Responsibility OCD: Everything is my fault. Impulse Therapy. March 10, 2021. impulsetherapy.com/responsibility-ocd-everything-is-my-fault

Stahnke B. A systematic review of misdiagnosis in those with obsessive-compulsive disorder. J Affect Disord Rep. 2021:6;100231. doi:10.1016/j.jadr.2021.100231

Yan J, Cui L, Wang M, Cui Y, Li Y. The efficacy and neural correlates of ERP-based therapy for OCD & TS: A systematic review and meta-analysis. J Integr Neurosci. 2022: 21(3);97. doi:10.31083/j.jin2103097

Key words: obsessive compulsive disorder, OCD, mental health, new nurse

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