My mental health nurse training
I spent three arduous years at university, half of which was spent as a student on placements within various mental health settings, to become a mental health nurse. But it took me another four years of working as a mental health nurse, along with more part-time studies, to feel confident in my knowledge and skills and to become a good nurse.
I was so proud when I was offered my first nursing post on my favourite ward and looked forward to working with the team. Generally, within our Trust, on each ward for twenty patients, we had two qualified Registered Mental Health (RMN’s) nurses and two Nursing Assistants (NA’s) on each of the morning and afternoon shifts. On the night shift, we had two RMN’s and one NA. One RMN acts as shift co-ordinator and they allocate patients to each member of the team. Normally, one would allocate patients with the least clinical needs to the NA’s and patients with higher risk and needs would be allocated to qualified staff.
We also had State Enrolled Nurses SEN’s – qualified second level nurses, who had undertaken a course of preparation of at least 18 months. This title and their training course were phased out in the ’90s. By 2000, SEN’s worked in the clinical setting as part of a team usually lead by a Registered Nurse (RN’s). SEN’s were less well trained than a Registered Nurse, who had undertaken courses of three years. SEN’s wouldn’t often take charge of a ward and there were other restrictions as to what they could do.
Couldn’t care less attitude
We had three of these lovely SEN’s on our ward, I liked them as individuals and I respected their 10-20 years of experience. I learnt much from these SEN’s – more about ‘how not to be a nurse’ unfortunately. We had Marie who was from the eastern side of the world. She had a nervous tic where she blinked rapidly and wriggled her nose in time to her rapid-fire speech. You would forgive patients for not liking Marie as she was brusque and barked out orders to patients and staff like a drill sergeant on speed.
One day I popped my head in to see Connie, an elderly lady who had schizophrenia and found her sitting on her bed crying. I asked why and, in her lovely Irish lilt, she sighed “Oh, I don’t want to get anyone in trouble. I’m okay, honestly.” Knowing she wasn’t okay, I encouraged her to tell me what was wrong. She whispered “Marie’s just been in to wash me and put cream on my bottom but I’m even sorer now, She rubbed me so hard with a rough towel. But no matter, please. I’ll be fine.”
“You don’t look very fine to me Connie. Come on my lovely. Let me see what we can do to make you more comfortable.” She lay on her bed and lifted her hospital gown, legs akimbo, the poor thing. She was mortified. Actually, so was I when I saw that her bottom, her genital area, the top of her thighs and under her large breasts were all red-raw and seeping green liquid. I pulled her gown down and told her I was off to see the ward doctor and wouldn’t be too long.
Doctor Dalani, a kind but very young junior doctor was good at his job and, he loved working in Psychiatry. I caught him just as he was going for lunch and explained the problem. I giggled when his face turned puce and I pretended I hadn’t seen him retch. He came with me to assess Connie’s sores; he lifted her gown, took one look and fled from the room. I don’t think he was aware that he’d held his breath all the while he was in Connie’s room. Back in his office, he prescribed antibiotic cream and a course of antibiotics.
Later that day, with said cream, pills and non-latex gloves I popped into Connie’s room and bathed her skin with a soft cloth and warm water. Then I dabbed it dry and applied the cream as softly as possible. Connie said her thighs were painful at night as they rubbed against each other so I told her how I’d slept with a large pillow between my thighs in the past and I got her one from our store cupboard.
I was disappointed because Marie could have and should have done all this. When I went to explain what I’d done and said that a new care plan needs to be put in place, Marie yapped at me, “She’s my patient. Don’t touch!” When discussing issues like this with my supervisor, I was told: “Don’t worry, that’s just how Marie is!”
Dumb and Dumber
It was lunchtime and I could hear a commotion on the ward; chairs scraping and raised voices so I looked out from the office. Two members of staff, two third-year students and several patients were all standing, anxiously staring at each other, mouths wide open but saying nothing. Jenny, an older and very large patient, appeared from around the dining area corner. She was still in her nightdress, staggering towards the ladies, in the corridor, and clutching her throat. She was choking!
“Get the emergency trolley and call the Crash Team” I yelled at staff as I ran to Jenny. She was far too big for me to do the Heimlich manoeuvre (a first-aid procedure used to treat upper airway obstructions by foreign objects). I tried to bend her over slightly and using the heel of my hand, I thumped hard between her shoulder blades, in an attempt to dislodge the food. Nothing.
The students were now screaming at the other two members of staff, “do something Alison. Where’s the trolley Devinder? What’s the number for the crash team?” Fortunately, Judy, a large Caribbean NA came from nowhere, taking control, “You get the trolley Devinder. You, Alison, call Crash, 2222!” Then she tried to help me hold onto Jenny, who was slipping from my grasp, going blue and wheezing. Jenny had, unfortunately, wet herself, then – she was unconscious.
Our patient had no pulse
Jenny slid to the floor and I went with her, finding myself kneeling in a pool of urine. I continued to thump hard between her shoulder blades and I started to panic – there was no emergency trolly, no oxygen…….. “Get everyone away from here!” I demanded, “or get a curtain,” because other patients shouldn’t be watching this. I felt angry at the lack of support from the other two staff and the senior students and their inability to follow simple instructions. Moreover, I felt scared as Judy and I stared at Jenny’s limp body and felt her pulse weaken to zero.
The door to the ward burst open! Help had arrived. The out of breath on-call-doctor asked if she’d lost output. I foolishly replied, “Yes – she peed herself.” Then, I realised, that wasn’t what he meant. I was moved out of the way as the Cardiac team took over, and two senior nurses beamed at me, “Well done.” and ” You did well.” I was shaking like a leaf. “Take five minutes to yourself – and breathe!” One said warmly and I watched as Jenny was lifted onto a trolley and taken to the general hospital. She survived after they were able to dislodge a large piece of unchewed beef.
Post incident debrief
Immediately after the event, I rounded up the staff and students to de-brief. I asked how everyone was and also, what we could have done differently. “You could have been a bit calmer. You shouldn’t have shouted at us. You could have………….. You should have…….
I told them that what I’d actually meant was We could have:
- intervened sooner. Perhaps the observing nurse Devinder (an SEN of almost thirty years) or the senior students could have alerted us earlier
- attempted to dislodge the food immediately and
- called out for help, instead of all just standing there
- moved patients away
- put a screen up
- got the emergency trolley and oxygen sooner
- offered to help me
I was furious with the nurse in charge, an SEN who had been on this ward for eight years but still didn’t know what to do in an emergency. This wasn’t the first incident either. I spoke to our ward manager the next day and said, as much as I like Devinder, I couldn’t work with someone so incompetent and that he needed extra training. That day, he was moved to another ward!
English as a second language
I was by now acting ward manager on a ward for the elderly when I came across Mala, who was of Indian origin and spoke near-perfect English. She was an SEN of many years and appeared competent. She was always smiley, keen and efficient so I liked working with her on shift. However, I was auditing her patients’ files one morning and spotted lots of grammatical errors and spelling mistakes, one which could be misconstrued and another, well, that one was just funny.
Once, during a team meeting, Mala not only fell asleep but, she was snoring so loudly, we couldn’t hear each other speak. She was nudged several times by staff either side of her but on each occasion, she fell back into her coma. At the end of the meeting, I asked Mala to come into my office for a quick chat. Immediately defensive, she slouched on a chair with her arms folded and her chin in the air. I said I’d like to talk to her about a few things and started by asking if she was okay? “Of course I am okay. Why are you asking me? Do you have a problem with me?”
“Tell me what happened in the team meeting Mala.” I began. Her nostrils flared, she pulled herself up and snorted “Nothing, I was just resting my eyes.”
“You were sleeping Mala and it’s not appropriate in a team meeting or at any other point during a shift. Is everything okay with you? What can I do to help?”
“Nothing, I was just resting my eyes. Why are you picking on me? You don’t like me, do you?”
“Mala, let’s stick to the point. You were asleep and snoring.”
“No. Why are you writing things down? Why you don’t like me?
“I have to keep a record of our meetings Mala. I also need to speak to you regarding your notes and care plans. I noticed lots of errors; this one here,” I pointed out to her. “What does it say?”
“It says ‘patient slept all night,'” she stated.
“No Mala, it says ‘patient slipped all night'”
“Well, you know what it means. I am a good nurse. You just don’t like me.”
We were all aware that this particular patient had a habit of falling over -and as patient notes are potentially legal documents – Mala’s ‘slipping’ all night could be taken quite literally in a court of law.
Mala, let’s look at this one – what does it say?”
“It says ‘patient obese from having too much ‘coke'” she faltered.
It says “too much ‘cock’ Mala.” She had the good grace to blush and she gulped “Oh, I did not know. Sorry, I will change.”
On I went, error by error, and much to Mala’s consternation, I suggested that she attend the English course provided by the Trust. She was not happy and continued with “You just picking on me. Why you don’t like me. Tell me.”
“Mala, I’m not picking on you. I’m doing my job. Would you like it if, as a manager, I didn’t do my job properly?”
“You being racist. You don’t like my English. I will put a complaint,” she huffed.
“Okay, that’s fine Mala. Let me print out the Bullying and Harassment Policy and the Race Discrimination Policy for you. Why don’t you take them both away with you, read them and highlight anywhere that you feel I’ve been inappropriate, picking on you or being racist. When you’ve finished, come back to me and I’ll help you write your complaint in the correct grammatical and spelling format. I’ll let you have two weeks. How does this sound?”
Mala glared at me but took the policies anyway before I asked her to sign the notes I’d just typed. She refused, fuming and stormed off. They would be signed when, after two weeks, I asked her into my office. “How did you get on reading the policies Mala? Would you like me to print out a complaint form?”
“I can’t be bothered. I….. No. Just leave it at that,” she blustered.
“Okay Mala, but I still want you to attend the English course so, I’d like you to apply within the month. I also would like you to sign the notes I typed during our last meeting.”
While I appreciate that SEN’s had less formal training than we did as RMN’s, these three had many more years of experience on the wards. and it just beggars belief that they’d been allowed to get away with such incompetence for so long. Still, that’s another post.
How would you have responded to any one of these three SEN’s? I’d be interested to know your thoughts.