As nurses in behavioral health, we were not well-versed in the field. After 33 years in ICU nursing, I left the unit expecting behavioral health to be an easier transition. However, the comparison between the two was like comparing apples to oranges. There was no real comparison between the two.

One day, we admitted a 33-year-old female patient who was constantly angry and had outbursts, hitting patients and staff members without apparent reason. On the first day, she informed us that she was a female, even though she dressed in typical male attire with a short-cropped haircut and demanded to be called Lisa. The next day, she became a male and changed her name to Tommy. By the third day, she identified as “they/them.” This constant change in pronoun use was confusing for the staff, so we decided to call the patient by their last name for safety reasons. The outbursts continued, leading to the patient being placed in isolation to protect others.

We had a mandatory Zoom meeting with the social workers who felt the staff needed to be educated on the subject. The meeting almost felt like a reprimand, considering our unit was already busy with high-acuity patients diagnosed with conditions such as schizophrenia, paranoid schizophrenia, bipolar, and psychotics. These patients often did not comply with their medications or attend therapy, leading to a revolving door of admissions and discharges.

During the Zoom meeting, the social workers emphasized the importance of using a patient’s perceived pronouns, but it was a daily challenge with our patient, Lisa. There was no pattern to her pronoun usage, and we struggled to keep up. I pointed out to the social workers that we had patients insisting on being called “Your Majesty, the Queen of England,” “Jesus,” and even “pregnant with the baby Jesus.” How do we determine when to use a patient’s pronoun versus their delusional title?

The social workers agreed that titles such as “Jesus” and “The Queen of England” were delusional thoughts, but there was still confusion over whether a patient who changed their pronoun usage every day was also experiencing delusional ideations. In the end, it was decided that we would not acknowledge delusional thoughts but would acknowledge a patient’s pronouns even if they changed daily.

It became clear that there was a lot of confusion surrounding gender identity, but it was unclear when it started or what caused it. With all due respect, it was decided that the best course of action was to call the patient by their last name to maintain a level of calmness in the volatile behavioral health unit.

The lesson learned was that, while ICU patients were complex and challenging, there was often an algorithm that could be followed to match their disease process. In behavioral health, there was no such algorithm or finite answer.

Debbie Moore-Black is a nurse who blogs at Do Not Resuscitate.