Have you ever come across bad mannered colleagues? Unfortunately, it’s almost a given for a lot of nurses working in Acute Mental Health wards. Perhaps they’re too long in the job and need to get out? I met many bad mannered nurses and doctors but for now, I’ll just mention two nurses with whom I worked during my first six months as a newly qualified nurse.
The first I will call Chief because when I asked him a question about about a patient he hissed “Do you know, in my country I am chief of my clan and people respect me?” and as I backed away from him, confused, he continued “Men are to be respected. You hear me?” As he was way up in my face, of course I could hear him – loud and clear.
“But what has that to do with whether Silvio has a Ward Round appointment today?” I asked and, with his forefinger almost poking my nose he retorted “Because he has no ward round and that, as his primary nurse, is my decision. He was rude to me yesterday and this is not allowed. He must be more respectful.” Ah! So it wasn’t me he was having a go at, which I’d initially thought. He was so angry with the patient for disrespecting him that he cancelled the patient’s ward round!
I picked the phone receiver up from the table, where I’d unwittingly left it, and was about to inform the caller that Silvio didn’t have an appointment, when the Consultant Psychiatrist on the end of the line said “Put him back on the list please and put Chief on the line immediately.” I smiled sweetly at Chief as I handed him the handset and left the office.
The arrogance of the man. As a newly qualified nurse, I didn’t feel able to tell him exactly what I was thinking but I’m so glad our Consultant Psychiatrist heard the whole conversation and no doubt he gave Chief and earful. I had a few more substantially worse run-ins with Chief during my time on this ward, but that’s a tale for another day.
Adam’s inability to cope
Adam was a tiny, white, middle-class posh boy amongst the bigger lads of many different races on the acute wards and I happened to be on night-shift with him and Ama, a support worker. After medication, most patients had gone to bed and Peter was in the office so I was ‘on the floor’ checking the bedrooms and dorms. The third member of staff always sat on the corner of the dorm area so that they could see both the male and female areas.
The ward was eerily dark and quiet and, truth be known, I was more than a little anxious. In the early hours, when Ama was on his break, I rounded a corner and was confronted by Sabina, a young black female, growling and hissing and making clawing movements towards my face. I jumped back in fright but she continued towards me, on her tiptoes, still clawing and hissing. I quickly regained my composure and asked if I could help, as I tried to walk to one side of her to guide her down the corridor, towards the office.
It was a natural instinct not to walk ahead as I wasn’t sure what she might do behind me. I desperately needed Adam’s help because I didn’t know how to handle the situation and, to be honest, I was afraid. We were taught about the various mental health disorders and symptoms in Uni but only now, I realised they hadn’t taught us how to manage them, other than with medication that is.
The twenty or so metres down that corridor felt like a kilometre because, despite my calm words of encouragement, Sabina’s behaviour continued and I felt increasingly nervous. We got to the office where I appealed to Peter with my eyes, like “Help!” as I very quietly explained. Peering over the top of his glasses, he smirked at me and said “She’s okay, don’t you worry your pretty little head.” and he laughed. “She’s in her first year of studying to be a lawyer. Looks like schizophrenia and she’ll be seen in ward round this Thursday” (where she’d be assessed by the whole multi-disciplinary team). This really wasn’t helping me, or Sabina and despite my anxiety, I felt for her.
By this time, outside the office, Sabina was hissing loudly, howling and clawing at the perspex window, her nails dragging like chalk on a blackboard. Adam said just to observe her for now and write it down in her notes “This is what you signed up for – just talk to her.” Talk to her? She was screaming like a banshee, her face was contorted, as were her arms and fingers, and her eyes looked glazed.
“Ward round is three days away” I insisted “so what do we do in the meantime? Does she have any medication prescribed and does she need some now?” I simpered and wondered whether this was the job for me after all. Adam explained that Sabina was on Section 2 of the Mental Health Act 1983 (1), and that she was only only being observed for the moment – no medication prescribed.
“Go on.” he said and shooed me out. I took a deep breath, opened the office door and went to walk out when Sabina launched herself at me. Somehow, I was quicker than her and managed to get past her unharmed. Instead, she flew at Adam and gouged chunks out of his face until he was able to grab her by the wrists. Still, she fought, and given his slight frame, she managed to pull him down to his knees and grabbed at his eye with one loose hand, causing a stream of blood. In the meantime, I called 2222 “Rapid Response (2) to Lavender Ward.” Within about fifteen seconds, at least three team members; large burly men, had burst through the doors where I was ready to direct them to the office.
It took all three of them remove her fingers from Adam’s hair and to restrain her. While some might disagree with it, the C&R techniques (3) we were taught always had patient safety at the forefront.
Sabina now looked confused, pitiful and absolutely defeated. The standard intramuscular (IM) medication (4), 10mg Haloperidol and 2mg Lorazepam (known by nurses as 10 & 2) was prescribed by the Doctor and administered by a female nurse.
As the medication took effect, Sabina relaxed and was escorted back to her bed. The RRT left and Adam turned to me, still with the blood on his cheek, furious. “Why did you call RRT? We could have dealt with it on our own!” I waited as he paused for a moment, as if considering his next words, then he added “If you’d de-escalated the situation adequately in the first place, we wouldn’t have needed RRT. She’s normally okay you know.” He tutted and sighed heavily “Now we have to do an incident report AND write it all in her notes. Well, you’ll have to do it and I’ll sign it off.”
I said to him “It didn’t look like we were managing it effectively, Sabina was clearly unwell and responding to voices. I’d asked you for support but you (a) let it escalate. You must have heard the commotion in the corridor,” He ignored me, so I continued – “and (b) I haven’t been C&R trained either so I’m not sure how I could have helped. This office is tiny and we could all have been hurt. I thought calling for RRT was the best option available.” Peering over his glasses again, he just looked at me with disdain.
I did document everything in her notes and completed an electronic incident report, typing exactly as it happened. However, Adam refused to sign it off as he didn’t like what I’d written so I clicked send anyway and off the form went to Head Office. He remained furious and barely spoke to me throughout the rest of the shift.
- Of course, I wished I was more skilled in talking to someone with with psychotic symptoms. I’d had them myself so perhaps I ought to have known what to do. But other than offering support, telling her she’d be okay and trying to remain calm throughout, I didn’t know what else to do.
- I know I wasn’t C&R trained but wondered whether I ought to have attempted to pull Sabina off Adam, to help my colleague. However, the nurse’s office is tiny with lots of sharp corners on tables, filing cabinets etc so any of us could have been badly hurt and things could have been made worse.
- However, because Adam was more qualified, together with the fact I’d only just met her, and he had more knowledge about her admission and presenting symptoms, I thought he could have intervened sooner and supported me. I know if I was the more senior staff member, I would have done things differently.
- I was impressed, on this occasion, by the way the three male RRT members restrained and held Sabina’s arms firmly but lightly, and they didn’t think it necessary to put her on the floor. They kept talking to her calmly and quietly, telling her she’s safe and would be okay. I would later see some terrible techniques and staff attitudes.
- I wondered whether the IM medication had been given too soon – perhaps we should have offered oral medication first, rather than have her go through the undignified process of pulling down her clothing (5) to inject medication into her bare buttocks.
- I knew that I’d have to become more confident in preparing the medication (while under stressful situations) and in actually administering the injections. It’s quite easy to give injections when a patient is sitting or standing peacefully but if they’re wriggling about and fighting, it’s more difficult.
- Next, I wanted to speak with colleagues I’m quite close to and my supervisor to see how they would have addressed the incident.
- Finally, I thought about how I would approach Adam the next time we worked together to ask if we could discuss this incident to see exactly what we could have done differently. Now wasn’t the time because he was still angry but I definitely wouldn’t ignore this issue. I would also let him know that his shouting at me was inappropriate, whatever he thought I’d done wrong.
How do you think the incident could have been handled differently?
- Section 2 of the Mental Health Act 1983, (provides for someone to be detained in hospital under a legal framework for assessment and treatment of their mental disorder for a period of up to 28 days).
- 2222 is the number dialed to request Rapid Response Team (RRT) and 3333 is used for Cardiac arrest on the ward. The RRT consists of one member of staff from each ward so there ought to be eight team members plus the staff on the ward. A doctor would normally attend too, but wouldn’t be involved in restraint.
- Control and restraint techniques are used to intervene quickly to ensure the safety of the patient and those nearby. Control and Restraint is generally safe for the patient as the nurses take all the knocks and bruises when and if the patient is restrained down to the floor.
- Haloperidol can be used to treat acute psychosis and has proven efficacy for agitation and Lorazepam can decrease acute agitation and have efficacy similar to haloperidol, but with more sedation. A combination of lorazepam and haloperidol is thought to be superior to either medication alone. Lorazepam helps maintain sedation and decreases potential side effects caused by haloperidol. Consensus guidelines from 2001 and 2005 recommend combined haloperidol and lorazepam for first-line treatment of acute agitation. Hannah Brown MD, Current Psychiatry. 2012 December;11 (12):10-16.
- Being physically held down and having your clothes pulled out of place, often in front of others, can be an extremely humiliating, as well as frightening, experience. Not only that, but restraint on females is often carried out by male nurses, another factor that compounds the fear and trauma of those women and girls who have histories of abuse and violence at the hands of men. Katherine Sacks-Jones, The Guardian, 2017.