Some of you might want to crucify me for mentioning ‘fake’ patients but hold on. Wait until you’ve finished reading this post.
I was still in my six month preceptorship period when Pauline was admitted to Lavender Ward, an acute inpatient mental health ward. She was neat and tidy, her hair and nails were spotless, she appeared cheerful and engaged easily with the other patients while waiting to be assessed. However, during her admission assessment she relayed that she had been living on the streets, she was paranoid, depressed, anxious and suicidal – she’d actually been seen by passers bye running across a main road several times, without looking out for traffic, according to the paramedics who brought her in.
Pauline was articulate, she maintained good eye contact with me and smiled appropriately during the assessment. She said she had no family at all and had lost her friends since becoming ‘mad’ and homeless – though she couldn’t remember for how long. Pauline reported that she slept well although she had paranoid dreams, which didn’t wake her. The paranoia she described was that someone was after her and wanted to kill her but she couldn’t be clear about when this happened or who it was that wanted to kill her.
Once seen and admitted by a nurse, the patient’s baseline observations are taken i.e. blood pressure, temperature, pulse, respirations, height, weight etc. All of which were stable. After this, the patient would be seen by the ward doctor, normally an SHO, a junior doctor who is on their six month rotation and has little psychiatric knowledge.
We had a tall, handsome and smarmy (oops, I mean polite) young chap, Dr Wellar, who looked down his nose whenever a nurse approached him. This was only his second week on the ward and I did tell him one day, “these nurses know way more than you do, and you ought to treat them with the respect they deserve.” That marked my card with him, I’m afraid.
Dr Smarmy stood to greet Pauline and, shaking her hand, he invited her to sit in ‘his’ office for a chat. She was in heaven, all smiles and giggling like a teenager. So I wasn’t sure why, when they’d finished her assessment, he announced to the team that she needs to be on close obs (There’s lots of circumstances where patients may require one to one nursing i.e. the patient is acutely physically unwell and/or requires frequent observations, the patient is acutely mentally ill and/or at immediate risk of serious self harm/suicide etc).
Depending on the level of risk, one to one nursing can be carried out by either a qualified nurse or a nursing assistant. Pauline was classed as high risk of suicide so needed to be observed by a qualified nurse 24/7, which includes when the patient goes to the loo. This takes one person from the staff numbers i.e. reducing the amount of staff by one. If you are nursing one to one, you cannot be expected to care for your five patients on top of this. Sometimes, the Trust allowed us to have an extra member of staff, more often a nursing assistant, to keep costs down.
As I’d done Pauline’s initial assessment, I was allocated as her 1:1 nurse so I spent the rest of that morning’s shift with her. We chatted about the weather, her dog and how she was worried about him – she didn’t know where he was. Pauline’s mum works “oh, I mean worked” as a teacher but she couldn’t remember the name of the school. I just kept the conversation light and said how proud she must have been of her mum etc. But something just didn’t sit right with me and I passed all this onto the afternoon shift.
On my next shift, I was allocated to Pauline, 1:1, as apparently she liked me and we’d built up a good rapport. Again we chatted amiably about her past – what she could remember of it – she said her depression was affecting her memory. Obviously I had to accompany her while she showered and went to the loo, but to give her some privacy and to maintain her dignity, I averted my eyes temporarily. However, she was inappropriate at times, dropping her towel, not able to find her knickers, could I pass her the toilet paper or her wet wipes – almost anything to keep my attention.
Let me tell you something now; it’s no fun being in a bathroom when someone else has to poop and it’s worse still when you have to get close enough to pass the toilet paper.
Towards the end of one shift, she told me how sad she was that I’d be off over the weekend as she really enjoyed out chats. At the end of my shift she really invaded my personal space when she threw her arms around me and planted a great big kiss on each cheek “Adios. Au revoir. Bye my angel nurse. I will miss you.” I kid you not.
I’d really enjoyed my days off but still looked forward to getting back to work. On my return, as I walked through the front door to the ward, I was almost past the Dr’s office when Smarmy called me in, “Can’t you even get one thing right? You only had to look after one person – how hard can it be?” he demanded and shook his head at me disdainfully. “Pauline said you left her in the shower for nearly 20 minutes and she tried to kill herself.” I shook my head back at him, I smiled and assured him that this was simply not true.
He continued berating and belittling me until he took a breath and I simply responded that I was off to see our Ward Manager. She believed and trusted me that it simply wasn’t true. He’d been ‘had’ but obviously this was the story he was re-telling the whole multi-disciplinary team, making me look incompetent. However, he took in what the ward manager said to him and conceded he might be wrong.
In the meantime, I felt like I’d been punched in the stomach. I was hurt by Pauline’s tale; I thought we’d formed a good professional bond. One of our senior nurses said not to worry, don’t take it personally and reflect on this; trust me, you will learn from it.
I had to work with Pauline a few more shifts and just kept up the banter but didn’t mention the ‘incident’ and nor did she. Had I been a bit more experienced I would have discussed it with her but right at that moment, I didn’t want to upset her – there was something going on for her? and I was still trying to work her out.
After a week, we had a phone call from her mother, asking if we had a Josephine on the ward. Yes, it turns out this is something Pauline does now and again. She frequents hospitals seeking admission because she said ‘she gets a bed and fed’. In the meantime, she saves up her benefit money while she’s in whatever hospital. Some might say that this is a mental illness in itself?
This young lad had been admitted voluntarily after he went to A&E saying he was paranoid and hearing voices. He was amiable and loved chatting with fellow patients and the staff. He could be heard asking other patients why they were in hospital and was interested in hearing about their symptoms. After a few days staff could see that he wasn’t displaying any symptoms of anxiety, paranoia or hearing voices and had hinted as much to Ronnie.
Late one night shift, we watched as he paced the long corridor outside the nursing office. He had his head cocked to one side, looking up towards the heavens’, and was saying out loud “Sorry. Say that again. I can’t hear you.” He gave the odd sideways glance towards the office to see if anyone was watching him and continued, “Don’t say that. I’m scared. You’re scaring me.”
Me and Billy, my favourite nurse, found this rather comical and went to sit outside to observe Ronnie and start a conversation with him. Billy asked “What are the voices saying to you Ronnie?” and Ronnie cocked his head to one side, looked upwards again and asked “What are you saying? Ah, ok, hold on.” and in all seriousness, he turned to Billy and said “They’re saying they don’t like you. They don’t want me to talk to you.”
I could barely keep a straight face as I probed a little further, “Okay, tell me Ronnie, how many voices are there?” He did the cocked head thing and the upward glance then cupped his ear, as though he was listening, then counting on his spare hand he looked at me and whispered, “two – and they said they like you.”
We continued in this vein for around fifteen minutes before Billy and I just laughed out loud. Ronnie’s utterances were becoming more ludicrous by the minute and Billy said as much to him, “Hey, soft lad. You look bloody stupid. You’re not hearing voices are you?” Ronnie knew the game was up and pleaded with us not to tell the doctors, “Anyway, they can’t send me home, I don’t have anywhere to go. They’ll have to find me a flat, won’t they?”
Emergency Treatment Team
I worked with the Emergency Team for a while. This was where people would come during daytime hours to be assessed and we, as nurses, would decide whether to admit someone or to refer them to another service i.e. home treatment team (HTT).
We had so many ‘fake’ patients asserting their mental illness rights, looking for admission so we could find them a home with a garden. Or they needed housing application forms completed, saying that they had a mental illness, which they hoped would put them near the top of the the already groaning housing list or benefit forms so they could access Disability Living Allowance.
Many reported being depressed but when asked to explain, some would say they’ve got a bad back and needed a ground floor flat as the stairs were difficult. Or excruciating headaches due to noisy, antisocial neighbours and it’s driving them mad so they need to move. As though getting a new home would somehow magic away their pain and depression. While I appreciate that decent housing is beneficial to everyone, admission to a mental health ward is not. Furthermore, housing lists are stretched to their limits and London now requires around 66,000 new homes a year to provide enough homes for current and future Londoners.
Given that our hospital served the local population which was approximately 52% non white-British, we had patients from nearly every country and many of them needed interpreters. When they mentioned housing or benefit forms, I always asked them via the interpreter “Do you know where you are right now?” and “Do you know this is a mental health emergency department?” And often told them “This is not a housing services.” or “This is not a benefit office.” before signposting them to the appropriate services
The thing is, we had thousands of patients with chronic mental illnesses who desperately needed our support and mental health intervention or treatment. Moreover, Mental Health is like the Cinderella service of the NHS and we don’t get lots of money so what little we do get is needed for ‘real’ patients.
Do you think I was harsh in turning patients away?