Update – Poor standards at 28 mental health units

Greyscale photo of woman sitting on a mental health asylum bench
Old mental health Asylum

This post began with an article published in The Guardian: Psychiatrists called for inquiry after report on private units, many occupied by NHS patients. Inspector discovered poor standards at 28 mental health units.

I’d written that this is great news. Not because poor standards were discovered, but because it’s been reported and it’s out there!

Update

According to the NHS

“One in four of us will experience mental health problems, and mental illness is the single largest cause of disability. Yet mental health services have for several decades been the ‘poor relation’ compared to acute hospital services for physical conditions”.

NHS, Five Year Forward View

The NHS goes on to detail — “What’s been achieved in England over the past three years?” and one particular point stood out for me:

“NHS England’s mental health taskforce has agreed a detailed improvement blueprint to 2020, in partnership with patient groups, clinicians and NHS organisations”. See Mental Health Taskforce Report, which states that

“It is therefore essential that all involved in the delivery of mental health services have the knowledge and skills required to deliver high quality care and have access to education and training.”

NHS

Mental Health Nurse training

Little white character of a man holding a large poster saying Staff training
Mental health nurse training — Clipart.com

Now, whether this all means only for NHS staff, it’s still a step in the right directions. However, when I was nursing, it was almost impossible to get staff to attend the Statutory and Mandatory, let alone any other training.

Mandatory and statutory training is undertaken by all staff and is deemed essential for safe and efficient service delivery and personal safety. It reduces organisational risks and ensures organisations are meeting their legislative duties.

The Royal College of Nursing (RCN) write that “Continuing Professional Development (CPD) is additional to any mandatory or statutory training that an organisation may provide.

While there is no universally agreed definition of CPD, there is a broad
consensus that, in a nursing context, its main purpose is to help staff to
maintain and develop the skills they need to deliver high quality, safe
and effective care
across all roles and settings”.

Nurses must stay up to date with the latest developments, continuing to update their skills and competences to meet changing future population health needs effectively and safely.

Ooh, if I had a £ for every member of staff that refuse to attend any more training courses than is necessary i.e. Statutory and Mandatory……… This still shocks and surprises me. We had access to our local University which offered so many nursing skills and knowledge courses and — all for free!

When I was a ward manager, some staff suggested I was picking on them if I suggested courses such as Verbal and written English. Once we’d ironed out that I wasn’t picking on anybody, I now had to enforce attendance on relevant courses. If staff still refused, they would be placed on what’s called Performance Management for a period of time. It would then be a job for me and the charge nurses to manage that nurse’s performance. What a performance palaver.

I really appreciated that our Trust granted me years of extra training to support some of my specialist roles. This included working with patients and their families, where the patient had schizophrenia and Cognitive Behaviour Therapy (CBT) for Schizophrenia.

Over to you

Large red question mark with little white charater of a man leaning against it
Clipart.com

Is it just me? I loved going on the courses to keep up to date with nursing practice. It made me feel more confident and competent at doing my job. Would you take the extra training if your Trust or company offered it? I look forward to your comments or thoughts and question.

Okay, back to where this first article started:

Patient’s fears about admission are real

Grey scale image female staring out of a window near to an unmade bed
Mental health patients bedroom. Design Pics Inc/REX

I’ve already mentioned some of the poor practice I’ve come across in other posts, but there’s so much more. Like the way some staff dismiss patients’ fears and anxieties. What appears to be a molehill for us may feel like mountains to patients.

When a patient expresses their fears about admission to an acute mental health ward, it’s extremely important to listen, so they feel heard and know that you care. It’s particularly difficult for patients who’ve been sectioned under the Mental Health Act 1985 (MHA) and almost dragged from their comfortable homes by well-meaning (or not) family, carers, Social Workers and a Psychiatrist.

During the admission process it’s essential to accept that patient fears are real for them, and not to dismiss them. Some patients are acutely unwell and can be chaotic on admission so again, it’s important to continue the conversation as many times as a patient might need. Nurses also ought to let patients know that they have the right to appeal against their Section and give them the correct paperwork to do so.

Patients also need to know about Patients Advice and Liaison (PALS), an important service, which will support them with almost anything. They can make an appointment with the team who will come to the ward if a patient has no leave.

Private sector mental health units

Coloured image lady sitting at lap top and on the telephone
Nursing administration —Photo by Shutterstock.com

While The Guardian reports “Inspectors have found 28 privately run mental health units to be “inadequate”, this does not detract from poor standards within the NHS. I only had one elective placement (which I chose) within a private unit and I would never go back. Most of the staff were agency and who probably couldn’t get permanent jobs if they tried. They were rude, authoritarian and antagonistic not just to patients but to families, colleagues and students.

They didn’t like me and the feeling was mutual. I asked too many questions and ‘cared too much’ when I ought to be doing some work i.e. the menial tasks they couldn’t be bothered doing. What they didn’t know, because they didn’t ask, was that I had been doing secretarial work for near on twenty years and I loved doing the admin, completing computerised care plans etc. I was quick and quite good (compared to them) at it, so I smiled throughout the shift – something that bugged colleagues when they disliked you.

Private sector treating patients badly

Overdose of medication — mental health nursing

One particular famous client (they were called clients in private units) had overdosed on illegal substances many times. She was on methadone, an opiate prescribed by doctors as a substitute for heroin, and she wanted to eat lunch before medication. However, on this particular day, when she went to get her medication, the nurse who’d been doling out meds had left the ward.

The other nurses wouldn’t give her the methadone and told her she’d have to wait, which could potentially trigger debilitating withdrawal symptoms like nausea and insomnia. The patient was agitated by this, and I was p’d off because I thought the nurses’ punitive actions were totally unacceptable.

I went to the unit Manager who was sitting in his plush office and asked whether it was standard practice to hold medication hostage. He tutted and exhaled heavily, put his muscled arms up behind his dreadlocked head and proffered an uncomfortable smile. “Mmm, Nancy is it? Look, she’s a pain. Man, she always think she can bend the rules.”

“Pfft, rules?” I asked. This is a healthcare facility isn’t it? I am in the right place?”

“Nancy, we only have enough staff to do the basics, they don’t have time to run after clients whenever they want.”

“Okay, but Molly’s totally distressed now so I’ll go and talk with her and document all this in her notes.” I said with a sarcastic smile and walked out of his office. He wasn’t long in chasing me down the corridor, apologising profusely; he was just having a bad day, he didn’t realise what staff were doing! He would get the medication now. I still documented this event in Molly’s notes and asked a nurse to co-sign it.

The nurse who’d declined to give out the medication didn’t speak to me the rest of my placement? Was I bothered? It was one less idiot to listen to as she did nothing but whinge about the job, moan about various patients and kiss her teeth throughout her shifts. She spent more time on the computers, googling hairstyles and nail art, not realising that somewhere in Head Office, the tech guys could easily follow what she was doing, see how much time she spends online and could report her for time wasting.

Did no one care?

Coloured image of black man sitting at his desk in front of a computer
Mental health nurse playing online games – Photo: Gettyimages.co.uk

Much of the time on this elective placement I felt so powerless and could totally empathise with patients. No one wanted to listen and no one cared! Staff appeared to find everything a chore and it seemed they only came in to earn money. See, nursing isn’t just a job. Being a professional nurse means the patients in your care must be able to trust you, it means being up to date with best practice, it means treating your patients  and colleagues with dignity, kindness, respect and compassion.  It means understanding the NMC code of conduct. It means being accountable. Katrina Michelle Rowan, 2010.

I was able to complete several PBA’s on this placement and learnt more about how not be be a mental health nurse. I saw how poor the team’s communication skills were, both verbal and mainly non-verbal. I saw how badly they treated people, how unprofessional they were and how they lacked empathy for anyone. As much as the staff on this placement tried to hold me back, little did they know how much I gained and how much I’d grown by watching their indifference. I always say, there’s never a bad lesson.

Why do you blog?

It’s yet another dull day in London but I have a lot to be happy about. I have an amazing partner who’s really looked after me since I was disabled by Transverse Myelitis in 2011. I’m grateful I have an amazing close-knit family and I will be going up to Scotland in November for a niece’s wedding where I’ll get to see everyone. I am delighted with my two amazing sons; one (Ricci) is currently a Research Fellow in the States and the other (Ravi) is a Physiotherapist in London.

Today I’m going to meet Ravi and his new wife for afternoon tea and I’m so excited. I haven’t seen them together since their wedding and they’re going to bring some wedding photos for me to look through.

I’ve been up for an hour now and have been going through my posts’ comments and tried to answer everyone. Somewhere along the way I’ve picked up great blog: Crushed Caramel where she’d answered an interesting set of questions posted by another blogger: Salted Caramel so I thought I’d have a go too.

Do you blog to promote your business?

No. I became disabled and regretfully medically retired from my job as a Mental Health Nurse/Ward Manager, a job I truly loved. I also had to cease running my small business where I worked as and supplied Mental Health First Aid instructors to a variety of organisations. We taught MHFA to a wide range of companies, schools and Armed Forces. I was there at the inception of MHFA England and would love to be able to carry out more training in order to raise aware of mental health issues.

Or is your blog a launching pad for your social life?

What social life? Okay, so I’m exaggerating a little ‘cos I’ve already told you I’m off out this afternoon. We went to see our grandchildren on Thursday and got to stay the night. It was sooo much fun playing games like hide and seek, where when you’re looking for a two year old an you utter to yourself “Now, where’s that Ava?” and she shouts “I’m here.” and her four year old big brother shouts crossly “Aaaava! You’re not supposed to tell her! You’ve spoiled the game now!” and off he stomps, sulking and trying not to laugh when I pretend trip and fall onto the sofa “Ouch, Ouch!”

We’re going back there this Sunday and I’m cooking stew and dumplings (a nod to my Scottish heritage) for everyone together with my brother-in-law and his girlfriends. So far my social life’s been all family but hopefully next week I’ll be able to catch up with a few friends.

Does it exist only to complement your Instagram account?

No. I’ve never had an Instagram account. I’m a complete technophobe and not very computer literate, despite having typed and used computers since the seventies. Oops, just given away my approximate age 😉 When my energy levels reach rock bottom, I sometimes find it hard enough responding to my blog comments, Twitter and my emails, let alone having another account such as Instagram. However, I love picking up my laptop and catching up with everyone’s news – it’s my little window on the world.

Is your blog making you real money (if so please let me into your secret)?

No. Unfortunately not and it never will really. I don’t intend to monetize my blog and only set it up because I wanted to make use of my fifteen years of diaries, kept from when I was nursing. Reading through them reminds me of all the good times I had, the amazing inspiring people I met; both patients and colleagues. However, I was also reminded of the poor standards of practice and that’s really what I wanted to highlight in my blog.

I want people (nursing students, nurses, doctors, social workers, occupational therapists, community psychiatric nurses, the public, MP’s, the government, patients, carers or friends) to be informed and make the necessary changes. Tell your care team you are not happy with the standards of care. Tell your boss,manager, team that standards must be raised. I want Doctors and nurses to continue with their professional development and stay up-to-date with current practices. Ooops! Rant over.

Are you blogging because you are so adept at this craft that you want to teach it to others?

No. I wish I was smart enough tho’. I loved teaching and mental health is my niche, so I’ll stick to it. I can offer lots of information, not unsolicited advice, and point people in the right direction if they are seeking support but I can’t profess to being a teacher or instructor any more.

Or are you like me : blogging just due to the urge to write?

Yes. I’m like you. Yay, we have this one in common. I love reading and also enjoy writing; releasing the pent up frustration that’s been raging inside me for so many years. As a mental health nurse I was used to writing ‘in and on reflection’, hence the lengthy notes in my old work diaries.

As I’m disabled I often have time on my hands and can’t believe how many hours I used to spend on social media i.e. Twitter and Facebook, just to see if anyone had messaged me or liked my comments. Now I’m blogging, the likes, the helpful comments and advice I get is both helpful and constructive. I only started blogging a few months ago and I’ve not even finished with my first work diary yet – so looks like I’ll be here for a few more years.

What are your reasons why you put the proverbial blood sweat tears into your blog posts?

I want people to be aware of the poor standards of practice in mental health units. I want everyone to shout it from the rooftops or from the highest mountain whenever they come across poor practice in mental health nursing and care environments. I want to increase awareness of diagnosis (right or wrong sometimes) the signs, symptoms, causes and effects of mental health disorders. And I want to reduce the stigma. I know I can’t change the world on my own but if my little blog is of use to one person and they have the confidence to speak out, it’s a start.

Bullied by mental health colleagues?

Unfortunately I came across many bullies when working in mental health environments – the very place where the staff have been trained to care for people, to provide preceptorship supervision and mentorship to their colleagues.

What is bullying?

UNISON* has defined workplace bullying as persistent offensive, intimidating, humiliating behaviour, which attempts to undermine an individual or group of employees.

Bullying at work can be broadly broken down into two different types. That which is: personal in nature – e.g. derogatory remarks about a person’s appearance or private life and work-related – e.g. questioning a person’s professional competence, allocating unachievable tasks. Many bullies will of course engage in both types.

Serial bully

During a placement in the Community Mental Health Team (CMHT), I was horrified that at the age of thirty-six I was being bullied by my supervisor Alan (an ex-policeman). I thought I’d put all that behind me when I finally left the school gates.

This vile man would constantly belittle me, talk over me and question my judgement and knowledge of patients and undermine me in front of colleagues He’d ignore my input and he’d snigger at my Cockney accent if I spoke in meetings, because he knew I hated it. He’d deliberately leave me out of ward rounds when ‘my/our’ patients were being seen saying there was no point me attending as I had nothing to add.

He smirked as he refused to sign my attendance sheets saying he didn’t know what days I turned up or didn’t – only because he came in late every day. I was lucky that his colleagues offered to take me out on patient visits or to ward rounds in the hospital. He blatantly ignored my attempts to communicate with him but still he looked furious when I said I had no option other than to speak to the CMHT Manager. His boss had to act as mediator for the rest of my placement because Alan continued to intimidate me with his passive aggressive stance. How sad that two ‘adults’ had to resort to this!

Based on research into thousands of cases of bullying at work, Tim Field** believed the serial bully’s focus is on power, control and subjugation of others. They usually operate by targeting one individual and bullying them relentlessly until they break down or leave. They then move on to their next victim. By the time organisations realise that there is a serial bully in their midst, considerable damage has already been done.

The policeman’s wife

My next placement was in a mental health rehab unit and on my first morning during ward round I noticed the Consultant’s leather holdall with her name engraved on it. She was only the serial bullying policeman’s wife – and my heart sank to my stomach. However, she was as sweet as he was sour and as warm as he was cold; she was smiley and encouraging and I liked working with her. It was during this time that she told me they were going through an acrimonious divorce. Not sure I had any sympathy for him.

Don’t rock the boat

It was also during my next placement in the rehab unit that I came across Ricky who was the Acting Manager. I told him about one particular patient, a young lad called Devlin who found it difficult wake up, to get up, showered and dressed before morning medication and breakfast. The nurses wouldn’t re-open the treatment room to give him his medication and they refused him breakfast, telling him that he should get up earlier. Ricky’s response was eyes rolling and “Tut, this is a rehab unit Nancy and patients have to learn how to get up and ready in time for medication and breakfast. This is why they’re here.”

I flippin’ knew it was rehab! Nonetheless, some patients need to be encouraged to get up on time, “get him an alarm clock or something” I suggested. More eye rolling and tutting but he did open the treatment room and give Devlin his morning medication. I made some toast and tea for Devlin but was severely criticised and told by Ricky that I shouldn’t have done this and not to do it again because other patients will expect it too.

I also spoke to Ricky with regards to the nurse who came in each night shift with her slippers and duvet and slept on the sofa once the patients had gone to bed. I highlighted the risk to our patients, myself and colleagues as we were one member of staff down when she slept. Huffing and puffing or tutting and heavy sighing, he told me that I was there and would make up the numbers. However, as students, we were there to learn by shadowing colleagues and not to be counted in the staff numbers.

First he asked “What do you want me to do Nancy?” Without allowing me time to answer, he went on to say that Ayo, the ‘sleeper’, had been there so long on night shifts because she had children so they cut her a bit of slack. More likely, he didn’t want to rock the boat; he was afraid of his long-term staff and I think he lacked the confidence to deal with them effectively.

However, he had no problem making derisory comments about my naivety and lack of lack managerial knowledge or how to deal with staff. I lost respect for him as a Manager and couldn’t even be bothered to tell him that I’d been a Human Resource Manager for almost twenty years.

I asked casually how long Ayo had been on permanent nights and was astonished when he told me twenty years. This lady had grandchildren by now and no one had ever questioned her working nights constantly, which was against Trust Policy.  Ricky refused to take action and I was berated for raising problems where there was none and told “Don’t even think of informing Human Resources. It would just mean more paperwork and aggravation.” – for him no doubt!

Ricky made it as difficult for me as possible to raise concerns about the poor practice I witnessed on the unit. However, I was able to write about it all in my Practice Based Assessments and the essay that followed this placement and felt vindicated by the Uni lecturers’ comments and high marks I received for both.

I eventually qualified as a mental health nurse and within four years I was promoted to Ward Manager (Band 7). I often bumped into the bullying policeman who was still working at Band 6 level and the Acting Manager who’d since been demoted back to Band 6 and without exception I greeted them with the same cheery smile I’d always given them.

*Tackling bullying at work, A UNISON guide for safety reps

**Tim Field, UK National Workplace Bullying Advice Line between 1996 and 2004

10 attributes of a good mental health nurse

Would you make a good mental health nurse?

Good mental health nurses need at least:

  1. Excellent Knowledge of Mental Health problems and how to apply it in practice. It’s no good just reading articles, books, leaflets or patient notes. You need to be in the thick of things, working with patients and colleagues, asking relevant questions, asking for and accepting help where necessary, putting all your theoretical knowledge safely into practice in order to support a patient. You need to use your knowledge of a patient to be able to effectively handover to and liaise with the multi-disciplinary teams, families and carers in order to provide continuity of care.
  2. Empathy and the ability to relate to people of all ages and backgrounds. Nurses need the ability to put themselves in someone else’s shoes, walk a mile in someone’s shoes, to see what they see and feel how they feel. Like when a mother smiles and her baby catches the emotion and smiles with her or when a mother is angry or stressed and the baby catches this and cries, possibly adding to the mother’s angst and negative feelings. Try not to use platitudes i.e. “Time is a great healer.” to someone who’s just lost their mum/dad or “It will all look brighter in the morning.” to someone who is depressed. Don’t offer unwanted advice. Who wants to hear “Oh my mum’s neighbour’s grandson had that and he used to ………..” or “I had depression because ……..” then go on to your own story. It’s not about you or the grandson!
  3. Be non-judgemental. “Love is the absence of judgment.” — Dalai Lama. Of course it’s in our nature to judge and it can be a good thing, it’s how we make sense of our world. We sometimes make snap decisions about patients based on their colour, sexual preferences, race, religion and even small things like how they’re dressed. However, a nurse mustn’t decide to see someone as being above or beneath them, they have to remain open to different possibilities and options. Being judgemental alienates us from others which is no good in a mental health environment. Nurses need to look beyond the presenting facade and immediate appearance of a patient where they’ll often find very human and tragic struggles. You can disagree with a patient’s choices or strong opinion but do it in a non-judgemental way. You could say something like “I hear what you’re saying and I appreciate your opinion but I see it differently. Tell me why you think …………”
  4. Communication skills. And I think you need excellent communication skills when working with sometimes confused, angry, sad, depressed or manic, chaotic, aggravated, delusional, psychotic patients and their families. Often there is so much going for a patient and they need support in many areas i.e. housing, finances, childcare, animal at home alone, emotional, physical or mental health. You need to be able to listen mindfully, to stay in the moment with the patient or family and not to immediately start preparing your answer. A patient wants to feel heard. Listen to the end of a patient’s ‘story’. The clue is often there; a small add-on for the patient but it’s actually the problem causing them the most grief. You need to be able to remain calm to speak clearly, concisely and appropriately to the patient and ask if they need further explanation or if they need more time to think. You need to be able to look; observe the patient and sometimes the family dynamics in order to gather information. Observe their facial gestures; whether they’re smiling, nodding, frowning. Observe posture; are they slumped, sagging shoulders and look at clothing appropriate for the weather. You might observe that the patient smells unclean, his teeth haven’t been brushed. You might notice that the patient is sweating or has a fever and take his temperature. The Royal College of Nursing (RCN) states that by using your eyes, ears, nose, touch and knowledge of what is ‘normal’ for the people you care for, you can identify potentially serious changes in mood and mental state and take action early on.
  5. Compassion is usefully described as a sensitivity to distress together with the commitment, courage and wisdom to do something about it (Cole-King & Gilbert, 2011). It’s a genuine sympathy for hardship or suffering. It’s kindness and the simple act of showing it can make a world of difference in a patient’s day. Nurses often come into people’s lives when they are in distress, pain and vulnerable and how they treat patients, carers and their families can leave a lasting impression. Ignoring differences and finding things in common help you relate to a patient and what they might be going through. Active listening, use of paraphrasing what the patient just said, makes them feel heard and cared for. Leaving your own world at the front door and just being there in the moment with a patient encourages openness and a mutual trust. These small acts all impact on a patient’s emotional responses and their view of the care they are to receive. Sometimes the nurse is the only person they have to listen to them and take their illness seriously, which is why compassion is key; it’s always at the forefront of what we do (www.yourworldhealthcare.com).
  6. Commitment in nursing is about providing the best care available at all times. You must commit to building positive and trusting relationships with colleagues and patients and their significant others to promote continuity of care. A nurse must be able to make the patient and families feel valued and cared for and feel safe in the nurses knowledge and skills. Therefore nurses must stay up to date with all relevant practice and be committed to lifelong learning which will enable delivery of excellent person-centred, evidence-based care. Education doesn’t stop when a nurse qualifies! Moreover, nurses must commit to taking good care of their own physical, emotional and mental health. If a nurse is not okay how can they expect to look after patientsundefined
  7. Ability to stay calm. If you can keep your head when all about you are losing theirs ………. by Rudyard Kipling comes to mind. Sometimes perhaps because they’re distressed, delusional or chaotic, patients can become angry and insistent on having their needs met immediately. It’s imperative that nurses can remain calm to deal with pressure, emotional outbursts or any other stressful situation effectively. Patience is important in helping you to effectively deal with a crisis as is being a team player skilled in the art of working well with other. Knowing how to effectively interact with different types of people will help to de-escalate or diffuse a potential risk situation and avoid having to use ‘Control and Restraint’ techniques on a patient.
  8. Emotional intelligence (EI) is how effective we are at behaving and responding in a mature manner, as well as our ability to properly process circumstances around us. As a mental health nurse, you would need to remain calm and use your EI if there was ever a ‘standoff’ situation where a patient becomes aggressive and physically threatening. You’d need to take in everything and everyone around you immediately to ensure the safety of the patient and others. Noticing, understanding, and managing one’s own and other’s emotions can be used to effectively engage the patient and bring calm to the situation. You might say to the patient “I hear what you’re saying……. I can see that your angry. What can I do to help? What would you like me to do?” “Would you like sit with me and I can listen?” What else might you say?
  9. Resilience enables nurses to cope with their work environment and to maintain healthy and stable psychological functioning. Working in mental health environments can be at best, positive and fulfilling but demanding, tiring and hectic and at worst, negative, exhausting and traumatic which can cause nurses both physical and mental problems, such as irritability, unhappiness and lack of concentration. Resilience is the ability to bounce back and it can be learned and improved upon through good supervision, preceptorship and mentorship programmes provided by the organisation.
  10. Adaptability is the ability or willingness to change in order to suit different conditions; it’s a necessary quality in an ever-changing work environment, particularly in mental health nursing. A mental health nurse will meet people who are often misunderstood by society, including their friends and family (www.yourworldhealthcare.com) and so need the ability to adapt easily to new patients, different disorders and changes in mood and emotional states together with new students, new nurses, change in Junior Doctors every six months, new procedures and policies…………… The list is infinite end ever changing as is mental health environments, so a nurse has to be flexible, to be curious, to be open minded and to see ahead and have a plan B.

The above attributes are essential though this list is not exhaustive. There are are many more personal characteristics such as being warm and engaging, considerate and so on.

I wish I could say I observed all the above in practice during three years of study and fifteen years of working within mental health.

Should we report our Mental Health colleagues?

Would you put yourself in the firing line and report a colleague’s poor practice?

My last post “Poor standards discovered at mental health units” was instigated by The Guardian’s grim report in the Private Sector. I followed on by writing about a placement I’d had, only one two-week elective placement in Private Unit and it was just as grim. However, I had many other placements and also worked within the NHS and I’m afraid it was equally as bleak in some places.

I wrote of the nurse who came in laden with pillow, slippers and big blanket every night shift and once patients were in bed she made herself comfortable on the sofa where she slept ’til around six a.m. She wasn’t the only person who slept but the majority of staff woke after an hour or two and returned to duty.

I didn’t believe anyone should sleep whilst on duty on busy acute mental health wards but, as a student, was advised by colleagues not to rock the boat when I mentioned it. There would normally be two qualified nurses and one nursing assistant on duty during the night shift, on a twenty-bedded (plus) ward and if someone was sleeping that only left two staff to deal with any admissions or any emergency that might occur.

I was no spring chicken. I’d returned to studying at the grand old age of thirty-six and was classed as an adult learner. An adult who knew what was right and wrong – so I couldn’t sit by and ignore ‘sleepers’ as it made the shift unsafe for both patients and the non-sleeping staff. The NMC Code of Conduct 2015 states ‘ work with colleagues to preserve the safety of those receiving care.’ and I would quote this to the nurse in charge and would many times hear ‘Look it’s just what we do.’ or ‘Everyone does it.’ and ‘We all take two hour breaks here and if you want to sleep, it’s okay.’

I stood my ground and told senior staff that if this continued I’d have no option but to report it. Subsequently I noticed there were no ‘sleepers’ when I was on duty but I’d later heard that I was a ‘splitter’, someone who ‘split the team’ by complaining about poor practice.

I completed a placement in the community and I hated it. I had to work with miserable burnt out nurses, those who’d left the hustle and bustle of the acute wards for quieter and easier nine-to-five jobs in the community. As I’ve previously mentioned, my Supervisor was regularly thirty to forty minutes late so I latched onto other senior nurses, asking if I could do anything to help or could I accompany them on patient visits.

I was often met with belligerence and tutting and found many of them had huge chips on their shoulder. ‘They should have got promotion.’ ‘They didn’t win any awards.’ ‘They shouldn’t have to be walking the streets at their age.’ ‘They’re fed up with students.’ Blah blah, flippin’ blah.

Their own bad moods and failures often impacted on relationships with patients as they clicked their teeth, tutted and whinged as they assessed patients in their own homes. “Tsk, George why is this flat a mess? If you can’t look after yourself you go in (to hospital).” They’d do a quick ‘how are you?, are you sleeping well? are you eating well? and are you taking your medication?’ then they’d leave.

There was never with any kind of encouragement, always with a negative or condescending comment. Oh my word, give it up. Leave the job. Change career. Retire! Ffs!

Quite often, on my days off, I would spot community staff in Tesco around three or four p.m. doing a large shop then sitting down for coffee and cakes when they should have been at someone’s home. That’s when you see in patient’s notes “Knocked two or three times and patient not in.” and you can see the same comment documented for weeks at a time!

I mentioned this during a ward round, when the Psychiatrist was discussing a patient who’d been recently admitted and looked like a homeless person; with matted dreadlocks and long, dirty nails. He was one of the patient’s who’s notes read ‘Patient not at home.’ for 6 consecutive months so he’d clearly not been seen in the community.

Later, when the visiting (Community Psychiatric Nurse) CPN had returned to her office she’d told her colleagues and boss what I’d said. I got a short, sharp, round-robin email telling me to speak with the community team manager before gossiping. Oh how I smiled as I saw that the Psychiatrist had responded before I could, stating that I had done the right thing and leave it at that.

Did they think I liked having to complain? Still, as a student learning how to become a good mental health nurse, I complained, time and time again and each time, I hated it.

Some time later and having worked on my first acute mental health ward for about six months, I was awarded the Trust’s ‘Most excellent Newcomer of the Year‘ which came with a nice cheque (donated by a local company), flowers and a lovely piece of inscribed crystal that now sits proudly in a dusty cardboard box somewhere. As I walked through my colleagues to the lecturn to receive my award I heard the whispers behind covered mouths ‘Tsk. That’s her. That’s the splitter!”

Mental Health rehab works—only if the staff do

Realkm.com

While I was a student on the rehab unit I had to complete my Practice Based Assessments (PBA’s) and I’d chosen four patients that I could work with to meet these over the twelve weeks placement. First there was Mandy who had Generalised Anxiety Disorder (GAD) and next was Sasha, Elsa and Edward who all had a diagnosis of chronic schizophrenia.

Mandy

I spent many pleasurable weeks working with Mandy, the lady who’d previously screamed for her medication several times a day. She repeatedly said that she could notice the reduction in each nought point five mg Diazepam, which was highly unlikely. However, I appreciate that for her, it was difficult, hence her continuous screeching at medication time.

From my parenting days, I knew that distraction worked well when children were upset so I hoped distraction might help Mandy too. I would offer her a cup of tea and ask what her plans were for the day or about her collection of teapots, rather than have the poor lady screaming and working herself into a panic attack.

It’s a shame that other nurses hadn’t picked this up as it would have been far easier for them in the long run and certainly better for Mandy. However following discussions with her Primary Nurse, the nurse who has overall responsibility for a patient, her care plan was updated and read “When Mandy is upset and screaming her allocated nurse must use distraction techniques.”

Example care plan
How a care plan might look

Care plans are prepared for each patient and wherever possible, are developed with the patient, rather than for the patient. The care plans are used to guide your practice with patients, to explain what care is required and how to carry it out.

As she got better, Mandy would eventually accompany me to the local Primark to get cheap knickers. Grinning cheekily, she would say the money she saved from buying these allowed her to buy her favourite yoghurts from Marks and Sparks next door. Once I’d left the unit it always cheered me up when I saw Mandy and I loved to stop for a chat.

Sasha

I had a lot of fun working with Sasha; she was witty, intelligent and was becoming much more cheerful as the weeks went on. Between us we managed to clear all the cereal boxes from her room along with the crumbs and mouldy, congealed leftovers we found in bowls under her bed.

This wasn’t my favourite task but I laughed all the way through it because Sasha was getting really cheeky. When I was busy scrubbing the floor she’d sit on her bed reading or stand at the window waving at random passersby and she’d crack up when I spotted it.

Many of Sasha’s care plans were updated or changed altogether now because she’d made great progress in several areas and some of her care plans were now outdated. One care plan read ‘Encourage Sasha to keep her bedroom tidy and work with her if necessary. If Sasha refuses, staff to advise her that they have a duty of care to ensure her environment is clean.’ It was like writing instructions for nine year olds rather than senior qualified nurses.

Another care plan read ‘Encourage Sasha to spend time off the unit and accompany her if needed.’ I loved spending time with her in the cafe, a local haunt for both patients and staff. I always took my badge off when accompanying patients outside as I wanted them to feel equal in the community. It really bugged me seeing staff wearing badges when outside with patients. It was like ‘them and us‘ and showing the staff member was in a position of authority, which I thought was unfair.

Elsa

At forty eight Elsa hadn’t aged well at all; she originally came from Greece and her face was craggy from the sun. She had short wiry grey hair which she hacked at herself, staring in the mirror taking great clumps out with almost blunt scissors. These were eventually taken from her as she’d often say to fellow-patients and staff “I will kill you.” She did this with a wicked grin so I didn’t think she was really serious but the scissors might have posed a risk to both her and others.

One of her care plan was updated and read ‘When Elsa wants to cut her hair, a staff member must be with her and remove the scissors back to the office once finished.’ I wanted to find out why Elsa chose to use her clothes as toilet paper but, despite using one of our translators, she just shrugged and grinned when asked. However, it was something we had to work on, we couldn’t just ignore it. I asked several staff nurses what has been tried in the past and what worked but was told “That’s just Elsa. She always does it and nothing works.” Elsa had been on the unit for months and nobody could tell me what had been tried.

When I was on duty as a nursing assistant (NA) or there on my student placement I tried to speak with Elsa every couple of hours to see if she needed the bathroom. I tried taking her to the toilet, getting her to sit for a while to see if she would poop, her favourite word. Sometimes it worked and I had to wait while I encouraged her to use toilet paper. “Too small.” she would grin “No enough.” and she’d try to use her skirt. Ah! Next time I accompanied her to the bathroom I took a roll of the large hand drying paper. Success!

NMC.org.uk

One of her care plans was updated to read ‘Encourage Elsa to use the toilet throughout the shift and have hand paper available.’ though I know this rarely happened as I never saw it documented. The Nursing & Midwifery Council (NMC) Code of Conduct states that ‘nurses should respect, support and document a person’s right to accept or refuse care and treatment.’ It did not say ‘if patient refuses support, just leave it at that.’

Once my placement ended I would later hear that Elsa had reverted back to using her clothing to wipe herself. I was truly mad that the nurses had allowed this to happen. It was like they’d given up caring and they were just passing time until retirement. However, I did learn how not to nurse and their disassociation made me even more determined to be a good nurse. Our patients deserved better.

Edward

Edward had long been on a medication called chlorpromazine, the first antipsychotic which was widely shown to be significantly more effective than later antipsychotics. However this drug had a range of distressing side effects, one of which Edward had was the shuffling gait known to nurses as the ‘chlorpromazine shuffle.’

He would also complain of constipation and impotence. He was prescribed a regular dose laxatives and he often requested Viagra but would talk about not being able to get rid of his erection for hours. You had to laugh with him, his tales were hilarious. He told me about one time when he was on the bus returning to the unit and the movement gave him an erection just as his stop was coming up. It was summer and he was wearing just shorts and a t-shirt so he had no way of covering the erection. He had to stay on the bus and went miles out his way.

My main task with Edward was to get him to take better care of his hygiene. He was physically fit and more than able but he really needed a ‘kick up the backside with my tiny size three’s’, I’d tell him. He also picked his nose and would later want to shake my hand. This was one habit that would have to go and I told him I would never shake his hand unless he hadn’t washed it. I also said I wouldn’t accompany him in the community if he was wearing his usual attire of stained tracksuit bottoms and a dirty old t-shirt. I often used my sons as examples, telling Edward that I wouldn’t go out with them if they weren’t clean.

One afternoon I arrived on the unit and there was Edward, spick and span. He was clean and reeking of cheap aftershave. His receding hair had been carefully dampened down and he wearing mismatched clothes but they were spotless. He’d been waiting for me since after lunch. How could I not take him out to the local snooker hall? This was his favourite outing as the voices he heard were much quieter and encouraging when he was concentrating. It became a weekly treat while I was there but I later saw him shuffling along the street, head down and miserable.

I don’t know why the nurses on the rehab unit ignored any improvement or the hard work that was done. They scoffed at his updated care plans, saying – it won’t last! Why did they think it was okay to let patients revert to their old habits.

Conclusion—Rehab does work — but only if the staff do!

*The Purpose of the Written Care Plan is to ensure continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during ward rounds. http://www.rncentral.com/nursing-library/careplans

Night shift on a Mental Health rehab unit

Night Shift on a rehab unit

I was working a bank shift which means I am on the Trust’s bank of staff who are available to cover shifts on the various wards if they don’t have enough staff. Because I was a student I could only work as a nursing assistant (N/A).

In comes Ayo with her big bag and her big blanket, tutting as per usual before slumping down into a chair, moaning, “Oh Lord, I don’t need this, I worked early bank shift on Jasmin (ward).”

Working a night shift then a late shift is not standard practice. Long hours, fatigue and lack of rest breaks or time to recuperate between shifts are associated with an increased risk of errors. However it’s very difficult for Ward Managers to keep track of, if staff members do extra bank shifts on another ward, which many of them do. Is it any wonder they’re tired and burnt out when they’re working three to four bank shifts a week elsewhere?

Handover

Lisa arrived just in time as Clare was about to start handover at nine pm “Mandy’s not coping with the titration of her Diazepam and continues to scream at medication time. Sasha remains bright in mood and went out with her nurse to buy new underwear today. She asked when Nancy was working next……..” and this made me smile as I’d taken a shine to her too. “Elsa messed herself again today and her clothes were found in the shower floor.” Clare briefly covered all patients on the unit and said her goodbyes. That left left Lisa, Ayo and me working as a support worker.

Ayo was coordinating this shift but before she could even allocate patients and any tasks Mandy was banging on the office door “I need my medication. I need my medication……” and as I went to speak to her Ayo cried out “No. Let her wait. Everyone have to wait.”

“Ayo, I just want to let her know that she will get her medication soon. It’s not nice that she’s crying and upset. I ………..”

“No!” muttered Ayo and she kissed her teeth. Ayo then allocated four patients to me, including Mandy and Elsa. As much as I loved working with all the patients, cos they each brought their own joys with them, I noted how I was always given the more difficult patients to work with. Unfortunately, lots of staff did this but, by rights, they ought to have taken these patients because they were trained and qualified.

Lisa would be doing medication this night and I was to prepare supper of toast and hot chocolate; no coffee or tea because patients weren’t allowed caffeine before bedtime. Mandy was given her medication first then she tottered through to the kitchen, wringing her hands and muttering to herself. “Hello Nancy. It’s nice to see you again. I’ve had my medication but they’ve cut it down and I can’t cope Nancy. Honest, I can’t. Can I have three slices of toast nurse and will you cut it into quarters for me?” before shuffling over to the large table. I took her hot chocolate over as she was trembling and I could see her ending up with half a cup if she was to carry it.

Edward was next at the counter and he too shuffled away happily with his toast and jam and cup of chocolate. Edward was forty years old but could have passed for fifty plus as he was always unshaven, his face was weatherbeaten and his grey hair had receded. Edward had a diagnosis of schizophrenia and since he was seventeen he heard many voices and saw people who were not visible to others. Unless you saw him at mealtimes, you wouldn’t know he was there; he was so quiet. I had to seek him out each week for games night and he came along willingly, as he was actually really good at scrabble and we both enjoyed the challenge.

Bedtime

With medication and supper over I went to check on my four allocated patients. All bar Edward were in their rooms and in various states of undress. Mandy wore a long floral flannelette nightgown and ancient slippers and I watched as she carefully folded the clothes she’s just taken off into neat piles. Her room was spotless if not a little cluttered as she collected china tea pots of all size. and colours. “Night, night nurse. Will you close my door for me?”

Sasha was in bed and snoring lightly. Elsa was struggling with her bra straps so I offered to help. “Fuck off me, you. I don’t need you.” she spat and turned her back on me. “Go on, fuck off.” Then she gave me another of her toothless grins. I think she just liked to test the nurses’ responses. She always made me smile and I told her I’d be back in five to see she was okay. I did go back because if you say you will, then you must. So many patients are left waiting when nurses tell them they’ll come back and I think it’s cruel. That left Edward. He was watching a film in the shared living area, chuckling away to himself. I wasn’t sure if he was laughing at the television or the voices he heard but he looked happy enough. I was going to go over to sit with him for a while when Ayo called “Bedtime Edward.” and switched the lights out.

I said “He’s watching this film, let him see the end. It’s over in twenty minutes.”

“It’s eleven o’clock and it time for bed. Come Edward. Come now.” Totally ignoring me, she watched as Edward struggled to get out of the chair and shuffle over to the door. Once everyone was in bed Lisa checked all the downstairs doors and windows then returned to the office. I asked why Ayo wouldn’t let Edward finish watching the film and she said “Eleven o’clock, lights out.” I couldn’t believe it because I’m sure everyone has a different body clock and bedtime and had Edward been at home, he would have watched the end before going to bed. I was going to make sure that I documented this in Edwards notes and flag it up at the next team meeting.

Staff bedtime too

It was eerily quiet, pitch black and unnerving as I went to the kitchen to get drinks for myself and Lisa. On my way back to the office, all I could see in the living area was a pair of eyes peering out at me from underneath a blanket. I whispered “Hello,” but got no response. I crept forward so as not to startle what I thought was a patient but Ayo shrieked “My Lord. Girl, what you doing? You frightened the life out of me.” There she was, feet up with her slippers lying on the floor, curled up on the sofa. “I havin’ my break. Go. Foolish girl,” and she kissed her teeth.

Off I went with the drinks, shaking my head, stunned. I asked Lisa whether this was normal practice, for staff to sleep while on duty and was told that we each get two hours break but Ayo just sleeps all night. “So that would leave one of us on the floor?” I enquired. If both Ayo and Lisa were on a break that would leave me, an N/A, to be responsible for the unit. “Yes, that’s what we do. It’s okay, Ayo always sleeps” she smiled.

“I’m sorry Lisa but I don’t feel comfortable with that. I’m working as an N/A and I’m not qualified if there’s any emergency.”

“Nancy, she’s done it for years. Even our manager knows.” said Lisa sighing and shrugging her shoulders. However, that night neither she nor I had a sleeping break. We both sat in the office, Lisa looking at holidays online and me reading through my patients’ notes. I really enjoyed finding out more about the patients and while it was quiet I could help update their care plans, number the pages in their files and generally complete paperwork that’s often difficult to do during a busy shift.

The time went quickly and I was so immersed I didn’t hear Ayo coming into the office. However, I heard her loud yawning and watched as she stretched upwards before dropping herself into the spare chair next to me. I caught a whiff of her stale morning breath and body odour! Offering to make us drinks allowed me to make a swift exit and by the time I’d returned Ayo had rolled her chair to another desk.

Six fifty five and the morning staff were starting to arrive. “Nancy, Lisa, you go on the floor, I do handover.” Which is normal for the coordinating nurse to stay in the office to give the handover, while the rest were outside attending to patients. However I couldn’t help but wonder how a nurse who’d slept all night and hadn’t asked her colleagues about the shift’s events could possibly give an adequate handover. Again, I asked Lisa who tutted and said “Nancy, you’re just a student. It really won’t do you any good to keep questioning your colleagues practices now. They won’t thank you and you’ll fall out.”

“I don’t want to fall out with them but as I’m a student, working as a nursing assistant surely I have an opinion? And I don’t think it’s safe for patients or staff if others are not doing their job.”

“Nancy, it’s just how it is, how’s it’s been for years and you can’t change it.”

The Nursing & Midwifery Council’s (NMC) Code of Conduct 2015, sets out professional standards of practice and behaviour for nurses, midwives and nursing associates. Point 3.4 states: act as an advocate for the vulnerable, challenging poor practice and discriminatory attitudes and behaviour relating to their care. Both Ayo and Lisa had completely ignored all the rules!

Would you be able to highlight where they’d gone wrong? Would you have reported them?

I would later talk this through with the unit Manager.

Note to self: “Folks who never do any more than they get paid for, never get paid for any more than they do”― Elbert Hubbard

Does Mental Health Rehabilitation really work?

Early shift

memesmonkey.com

As I parked up my first morning, even above Slade’s Noddy Holder screaming “It’s Chriiiiiistmass”, I could hear a female screeching “Medication. I want my medication. Where’s my medication? I need my medication.” The poor neighbours either side of the building must have been well p’d off. It was six forty-five, pitch black outside and the streets were eerily quiet — other than the high pitched screeching coming from the Mental Health Rehab Unit piercing the air.

Someone in the office by the front door pressed a button to let me in and I was greeted by this tiny little lady who grabbed both my hands and panted “Help me. Help me please. I need my medication. You’re new. Are you an Agency Nurse?” Will you help me? Please?”

I spoke calmly but firmly, “Listen to me, I can’t help you right now…” I was trying to placate her enough so that she could hear me and take in what I was saying. At the same time I was trying to get her to take a breath as she was panicking and was as white as a sheet. I really felt for her.

“Please, please. I’m begging you,” she continued to screech, now in my face, as I tried to disentangle myself from the tight grip she had on my wrists. The office door opened and a nurse yelled “Cindy, stop it, leave her alone. Cindy!” I’d now managed to get myself free but Cindy had grabbed the nurse and was pulling on her cardigan, all the while screeching “You’re a bitch. You’re a fucking bitch! Get my medication you fucking black bitch.”

The nurse eventually pushed me into the office and she followed, turning to slam the door in Cindy’s face with a kiss of her teeth “Oh Lordy Lord. That Cindy. She will be the death of me. I am Ayo. Who are you?”

I breathed a sigh of relief and introduced myself as the Student Nurse. “I don’t know. See how it is here. I pray to God for her sins,” humphed Ayo. “Hmmm. Take a seat. Ah! Here come the staff.” and I turned to see two females and one male puffing away outside, the ciggie smoke belching through the office window. “Tsk, Tut. I don’t know. Smokers, heh!” moaned Ayo as she reached to slam the offending window shut.

Seven o’clock on the dot the three members of staff traipsed in, throwing their coats on top of a filing cabinet. Lisa was first to introduce herself as the RMN, the shift coordinator and my supervisor, and said “That’s Lorna, she’s a qualified (RMN) and that’s Graham the NA (Nursing Assistant).” Where’s the fourth member of staff? I thought to myself.

Morning handover

“Okay.” started Ayo, above Cindy’s screeching. “The lady herself. Cindy, she slept and now she has been shouting before six thirty. Lord help me! Everybody still in bed. Only Sasha, she awakes all night but she stay in her room. Somebody needs to clear her room. I saw the mouse there.” My feet moved on their own, up off the floor as I sat on a desk, and I shuddered involuntarily when I was looking around for the said mouse.

Ayo continued and ended with “Moses needs to see a Doctor and his toenails need to be cut. It’s in the diary for this morning. Now I’m going home. Goodbye!” She pulled off her slippers and put them in her bag then huffed and puffed as she bent down to put her shoes on. She grabbed a large woollen blanket and shuffled out of the door.

Lisa went through the diary, handed out tasks to the other two and said she was doing medication and that I should shadow her. Lorna went off to wake up the other nine patients that lived in the ten bedded unit and Graham wandered off to the kitchen to prepare for breakfast.

Medication

With our coffee, Lisa and I went to the medication room, we were met with Cindy who was still gulping in great lumps of air, wringing her hands and saying “Thank you Lisa.” and “Thank you nurse.” to me. Yes, I could get quite used to being called Nurse.

“Right Cindy. You know we start titrating down your Diazepam today.”

“No, please Lisa. Not today. I can’t cope. I can’t cope!” Cindy screamed.

“Nought point five milligrams Mandy. You won’t even notice it.” Lisa tutted and turned to me. “She’s been on thirty milligrams three times a day for years and you can see it doesn’t reduce her anxiety. So we’re going to try titrating down while she’s in Rehab.” Cindy lived in a one bedroom flat and had apparently relapsed over a period of six months prior to admission to an acute ward. Once stabilised she was transferred to rehab.

Cindy had generalised anxiety disorder (GAD) which is a long-term condition that causes you to feel anxious about a wide range of situations and issues, rather than one specific event. 

People with GAD feel anxious most days and often struggle to remember the last time they felt relaxed. As soon as one anxious thought is resolved, another may appear about a different issue. Titration looked like it would go on forever, reducing her Diazepam by nought point five mg three times a day. However, Cindy eventually accepted the reduced dose and greedily swallowed down all her medication, followed by gulps of water, then scurried off to the dining room.

Breakfast

We continued until each patient had had their medication then joined everyone for breakfast in the dining room because, on rehab, we were encouraged to eat with the patients each mealtime. Lisa waffled something about nurses having a responsibility to role model table manners and eating with the patients was supposed to encourage healthy eating. I wasn’t sure that this was an evidence-based intervention but I went along with it anyway.

Coffee and toast with jam was just what I needed but as I sat to eat I was immediately struck by an offensive odour. One older lady to my left had obviously not washed or brushed her teeth, yet there was another disgusting smell.

Graham screwed his nose up and said “She’s just sat there and shit herself and carried on eating!” to nobody in particular. “That’s Elsa.” he whispered with an Aberdonian accent. “She normally goes to the toilet but she uses her clothes to wipe herself and then hides them down the back of the toilets, eh Elsa?” he now boomed. “Elsa, say hello to Nancy, she’s our new student.” Elsa’s face was buried in the huge breakfast she was picking up with her teeth. She raised her head and gave me a toothless grin.

None of the staff got up to help Elsa so I offered, but Graham told me “No. Wait til after breakfast!” And this is rehab? I wondered — does it really work?

Around the table, there was belching, farting and one young chap was trying to snort back the snot that was threatening to hit his top lip. He eventually gave up and wiped a huge glob on the sleeve of his t-shirt leaving a silvery snail-like trail.

Coffee finished and my toast in the bin, I helped clear the table and took my time in the kitchen. I was hoping someone would deal with Elsa, as I was already feeling queasy. Fortunately, she’d gone by the time it took me to do the dishes but she’d left wet poop dribbling down the chair legs. Gloves and apron on and ten minutes later the chair was scrubbed and left outside in the back garden to dry.

Activities of daily living

To the bedrooms on the first floor now where I tried encouraging patients to wash and dress before attending any appointments or activities. Oh my word! I’d knocked and opened the door to Sasha’s room and was aghast at the cereal boxes piled as high as the ceiling. At a guess I’d say there must have been over two hundred boxes and the only other floor space was filled by her bed and two or three black sacks.

“Get out of my room.” stormed Sasha as she pushed me and slammed the door. I stood for a few seconds, stunned, then knocked and called out “I’m a student nurse Sasha. Is there anything I can do? Would you like me to help you clean your room.”

“Get lost.” Sasha muttered. I went to find Lisa and asked what I could do to help Sasha. “Not a lot,” Lisa laughed. “Her room’s been like that forever. She won’t let us in.” That can’t be right. Surely we have a duty of care? I went to the office to look through Sasha’s file and her painstakingly completed but outdated care plans to see if I could find ways to engage her.

I read that she was single, had no children and had been in care since the age of eleven when her mother couldn’t cope with her chaotic behaviour. She was thirty one and was diagnosed with Schizophrenia at eighteen. Sasha heard voices and was often heard talking back to them when alone in her bedroom. Apparently Sasha had no insight and didn’t believe she had a mental health problem. She’d been on the unit for six months and was awaiting housing but it was proving difficult to find a place that would meet her needs.

I decided then that I’d be really firm with Sasha right from the start, telling her that we have a duty of care to ensure that her environment is habitable. If she wouldn’t clean it herself, then we would have to do it! It annoyed me that staff had let her live like this for months. Even if Sasha had refused to let them clean it, surely the staff could have come up with a plan between them.

It was exhausting and often thankless, but I worked hard with Sasha for the next twelve weeks, updating her care plans and engaging her in meaningful activities; things that would both interest and help her rather drum banging or painting by numbers. I appreciate that one of her care plans previously stated ‘Engage Sasha in activities.’ But, while these particular activities may help with dexterity and fine finger/hand movement, I wasn’t sure they would support her development. It was clear that certain staff had intermittently tried to push Sasha into any activities and wrote in her notes ‘Declined to attend.’ I wondered why!

I’d eventually learned more about Sasha, along with the other patients on the unit, and had managed to form a professional bond with each of them. As I got to know them better, often by engaging them in friendly banter, I was better informed about their likes and dislikes. It was easy to see they weren’t interested in particular activities and that they had their own ideas about how to spend their time.

Mark liked football so I’d have a kickabout with him in the gardens – he was quite good – so encouraged him to attend the local leisure centre where he could access different types of exercise and look out for a local football team to join.

Jenny loved knitting so we bought her knitting needles, a few patterns for baby clothes (that she requested), and some wool. She wasn’t great, dropping more than a few stitches, but that wasn’t the point. She enjoyed it. Other staff who could knit helped her unpick and start again. Eventually, with the help of staff, she started her own small weekly knitting group on the unit.

We also got a group of patients to go swimming once a week, with a member of the team. We also went to the local pub once a week so that some of the young lads could have half a pint and a game of pool. They’d never felt comfortable going into a pub previously, because they were worried about what other people thought. We quite often did get some odd looks but as a rule, the regulars were great – helping the lads with their game and showing them trick shots.

At the end of my placement I loved seeing Sasha and the others laughing, smiling, engaging and growing in self-confidence and once again, I was sad to leave.

I would later bump into some these patients in various settings i.e. in the community or on the wards and I was either saddened by their relapse or delighted by their continued improvement.

Note to self: “Public service must be more than doing a job efficiently and honestly. It must be a complete dedication to the people and to the nation.” Margaret Chase Smith.

Not proud of our Community Mental Health Teams

My first placement with a CMHT

A GP might refer an out-patient but in-patients are generally allocated to a Community Mental Health Team (CMHT), prior to hospital discharge, which is normally made up of various multi-disciplinary professionals such as:

  • Community Mental Health Nurses (CMHN) and unqualified support staff
  • Social workers and Approved Social Workers (ASW’s) – Same as social workers, but ASW’s have undergone specific training in mental health law; the Mental Health Act 1983, which enables them to carry out Mental Health Act assessments with other professionals.
  • Consultant Psychiatrist, Senior Registrar and/or SHO’s (Senior House Officers) who are Doctors undergoing their six months training in a particular area of medicine. In this case, Psychiatry.

The CMHT works with a person who may get help from one or two of the above professionals, depending on their needs.

As a Mental Health Nurse student, I was allocated to Alan, a CMHN who would be my supervisor for the duration of this placement. I was five minutes early so I had a coffee and introduced myself to a few of the team while waiting for Alan. It was eight fifty-five and their overall mood matched the weather on that stormy Monday morning. Had they not been sitting at desks, behind the flexy plastic window, I might have thought they were patients waiting to be told they’re being placed on Section 3 of the Mental Health Act 1983 (1) and are due to have medication — injected into their eyes.

I smiled as the front door opened and an older gentleman walked in. He was wearing a tatty tweed jacket, a moth-eaten jumper and a shirt so old, the collar was frayed. His well-creased trousers looked as though they’d had an argument with his ankles and his black plastic slip-ons squeaked as he walked. Still, his gappy-toothed smile was welcoming and as he stuck out his hand, he pushed open the inner door with his backside and he introduced himself as Javid, a Social Worker.

Washingtonpost.com

I explained who I was and Javid took me down to what looked and felt like a fusty old storeroom. He pointed out his desk, Alan’s desk and the one opposite that I could use and off he went.

I went through my Practice Based Assessment (PBA’s), a list of evidence-based tasks to be carried out at each placement, to see which ones I might be able to meet sooner rather than later. I always liked to get a head start and not leave the PBA’s right til the end of placements.

While thumbing through a patient file, gathering information for one of my PBA’s, I happened to look up saw a rickety old bike being chained to the railings. I watched as a pair of green wellies marched up the few steps to the front door then heard them thumping down towards the basement. The office door bashed open and there Alan stood. He pulled himself up to his full six foot plus, puffed out his chest and glared at me, demanding “What do you think you’re doing?” in a broad Scottish accent. Think Billy Connolly!

“Javid said I could look through……..”

“Is Javid your supervisor? No, he’s not. I am. Javid is an ASW and you. are. a. mental health student. Are you not?”

I almost stood to attention. Instead, I raised my eyebrows and stared back at him for what seemed like an age. He turned on his heels saying “I’ll get myself a coffee and see you when I come back!”

This was the way Alan continued over the next few weeks, barking orders at me and ignoring any questions, feeding me snippets about his patients – when he saw fit.

He told me he was married and had two children and that he was an ex-police officer, something I should have guessed. Either that or the Armed Forces. He was not a nice man. Rather, he was an egoistical, belligerent and manipulative git.

Unionmedico.com

I was surprised one morning when Alan told me I was to run his Depot Clinic (2) under his supervision. Patients come to the clinic bi-weekly or four-weekly to have their antipsychotic medication via intramuscular injection. “You do know how give give injections, I presume?” he snapped “And don’t forget to check which side. I’ll countersign the medication charts when you’ve done.” I had observed several injections during my in-patient placement but I’d never actually administered one.

My first patient was due in soon so I checked her medication chart and spotted the small letter ‘L’ underneath the signature box, which I gathered meant that was the side the last injection was given. Injections sites were alternated to stop the buildup of scar tissue on one side.

Sally, my first patient, appeared sullen and I wasn’t sure I’d be able to engage her in idle chit chat before inserting the needle, something I hoped would help take the patient’s mind off the injection. However, she chatted amiably about me being a new student and asked whether I liked football. The needle was out and I told her that I was an Arsenal fan. “Blinding. Me too. I ain’t never been myself tho’, ave you?”

“Yes, I’m lucky. I’ve been to quite a few games.” I was scribbling my signature on her meds form when she turned her head to me and said “Come on, ‘urry up girl!”

“All done Sally.” Ha! I’d given my first real injection and she didn’t even notice. Her eyebrows shot up then I got a wink and a brief smile of approval as she buckled up her jeans. “You’re alright you are. She can come ‘ere again Alan.” She gave me a knowing look and glared at him as she left the clinic. Not a word from him, just another of his withering looks as I passed him the meds chart to countersign.

Irishtimes.com

A month passed and Alan continued to arrive late every day. One morning, Javid asked if I’d like to go out and visit some of his patients with him and I jumped at the chance. We arrived at Anne’s house to see her in the front garden wearing a flimsy kaftan and barefoot. She twirled around on the grass, arms outstretched and head thrown back as she sang – Julie Andrews popped into my head. In fact, as I sit here typing, the classic film, The sound of music, has just started on t.v. and every time I see it, I remember Anne.

Anne grinned when she saw Javid and waved him in with a dramatic curtsey, telling us she was calling the children in for lunch. Four skinny under-twelves trooped into the living room and hungrily snatched up huge doorstep sandwiches. They danced, skipped and jumped all over the two mismatched sofas as they munched. They sang silly songs and clapped loudly, dropping crumbs everywhere. Their likeness to the much loved Von Trapp family didn’t go unnoticed.

They were clean, wearing all manner of clothing; some too big and some to small, all bare foot, but they looked happy and were both well spoken and well mannered.

Crazyhead comics

Anne had a diagnosis of bipolar disorder which used to be known as manic-depression, where a person has episodes of depression (feeling very low and lethargic) and mania (feeling very high and overactive). Unlike simple mood swings, each extreme episode (high or low) of bipolar disorder can last for several weeks, or even longer, and some people might not experience a normal mood very often. Bipolar disorder is treated with mood stabilisers such as Lithium or Valproate, which is actually an anticonvulsant medication (also known as antiepileptic medication), which were all originally made for treating epilepsy. Epilepsy is a neurological disorder that can cause seizures.

Once we were on our own, Javid asked Anne if it was okay for me to complete a mental health assessment, done by observation and direct questions, assessing things like:

  • mood, behaviour and appearance
  • thought form for speed and coherence
  • thought content for delusions, suicide, homicidal or violent thoughts, obsessions and perception
  • cognition for orientation to time, place and person, attention and concentration

Finally, I assessed her insight to gauge whether Anne knew her incessant chatter, thought disorder and her behaviour wasn’t normal, given the weather and both her and the children’s appearance. However, she didn’t believe she was currently unwell “This is nothing.” she chirped. “You’ve seen me worse Javid.”

Javid smiled, then stood to bid our goodbyes and I couldn’t help but giggle when Anne and the children burst into song “So long, farewell, Auf Wiedersehen, adieu. Adieu, adieu. To you and you and you.”

Sitting in his car, Javid talked me through the visit and agreed that yes, he had seen Anne worse? “Really?” I asked. He nodded and chortled. However, he said he would check to see if there was a bed so that he could plan a voluntary admission over the next few days. He said that Anne would use all kinds of delaying tactics but would eventually agree to voluntary admission. “She knows she has a chronic (long-term) diagnosis and she’s well known to services. She’s aware that if she doesn’t go voluntarily, she would be admitted under Section 3 of the MHA 1983. This means patients can undergo coercive interventions, such as enforced medication, seclusion and restraint.

After a few more less-exciting home visits Javid and I returned to the CMHT, around four fifteen. We were just in time to complete our documentation and to see Alan snap his briefcase shut, throw me a look of utter disdain and head for the door. Thank God for the weekend.

Alan’s lateness carried on, his behaviour remained erratic and his lack of interest or guidance was getting me down. There were days I was in tears, despite the admin girls telling me to ignore him and making me laugh, saying he just needs a good shag!

Every day Alan was late I went out on visits with Javid or other staff who’d asked if I’d like to accompany them. I was gaining so much experience as the team were supportive and fed back to me my strengths and small areas that I could build on.

Most of my PBA’s had been completed I and was pleased with the necessary evidence I had attached, having made sure there were no names or numbers that could identify individual patients. The staff I’d worked with wrote on my PBA’s that I was really intuitive and empathic, that I had excellent communication skills, and had been proactive in achieving the high standards I’d set myself. Over all they said they were impressed. All I needed now was for Alan to sign them off as having been completed.

Lady smirking – iStock.com

The arrogant shit refused! He hadn’t seen me complete any of the tasks listed on my PBA’s so he would not sign them! He couldn’t possibly!

Long story short, I had to involve his superior who agreed that other senior staff I’d worked with could sign them off for me!

The admin girls mychieviously phoned me to ask about my results and I boasted – I only got a huge 94% for these PBA’s. Guess who they couldn’t wait to tell!

Note to self: I might have lost a battle but I certainly won the war.

(1) Section 3 allows for a person to be admitted to hospital for treatment if their mental disorder is of a nature and/or degree that requires treatment in hospital.  In addition, it must be necessary for their health, their safety or for the protection of other people that they receive treatment in hospital.  Section 3 is used where the person is already well known to psychiatric services or following an initial assessment under Section 2. 

Under a Section 3 you can be detained for up to six months in the first instance.  This could be renewed for a further six months and then for periods of one year at a time.  Section 3 can only be renewed following an assessment by the doctor responsible for your care (Responsible Clinician or RC).  Each time the Section 3 is renewed, a review of your current care and treatment is carried out by the Mental Health Act Managers.

(2) A depot injection is a slow-release, slow-acting form of medication. It isn’t a different drug – it’s the same medication as the antipsychotic taken in tablet or liquid form. But it’s administered by injection, and it is given in a carrier liquid that releases it slowly so it lasts a lot longer.

Mental health patients being dragged to the floor

My first few days………

Just five minutes, a quick coffee and a ciggie then back to the ward where I was able to let myself in as I’d been given keys and a swipe card for the downstairs door. Derry had gone into Management Round which, I was informed, happens each Monday morning. Apparently, this is where the Doctors plan ward round allocation of patients, who are normally seen on a weekly basis.

The phone was ringing off the hook and there was no one else around to answer it so I gingerly picked it up, saying ‘Good morning, Lavender ….’ A female interrupted and spoke urgently “Why is my brother off the ward? He’s banging on my front door and all the bloody neighbours are out on their doorsteps. What’s going on?”

“Uumm, good morning. I’m a student nurse. Do you know who you want to speak to, which nurse?”

“Someone who knows what they’re fucking doing would be good.”

“Ok, what’s your name and your brother’s name …..”

“It’s Pauline Kennedy calling and my brother is John. He’s screaming through the letterbox now, can you hear him? Fucking arse”

“Pauline, hold on a second.”

“Not you, him, sorry.” I’m glad she clarified that cos I’ve been called some names in my time, but that was a new one. “Ok, Pauline, give me a second, would you like to hold on or shall I call you back?”

“No, I’ll hold…” she tutted. I dashed up the corridor, knocked the door to the meeting room and popped my head in to tell Derry and the Doctors. “For fuck sake.” Derry’s Irish brogue rang out and “Has she called the police?” enquired one Doctor, the elder out of two. But Derry was out the door, heading for the office and I followed.

“How’d he get out?” Derry muttered to no one in particular. “Hello Pauline, it’s Derry here. Is he still there? Have you called the police? Aye, I know but okay, I’ll do that. You just keep yourself safe and I’ll call you back in a wee minute.”

“Jesus, we’re in trouble now. This guy used to live with his sister and he’s paranoid about men wanting her, that they want to have sex with her. He’s already done time for smashing the electricity man in the face with a brick after the poor man went to check the meter. John’s on a Restriction Order (1) so he is.”

“Here, you call the police on this number and let them know what’s going on. Pauline’s address is there,” urged Derry, pointing out a page in John’s file. Alison had just come into the office and I could hear Derry filling her in while I spoke with the police. I was a bit nervous, having never been in a situation like this before, but I was able to give all the necessary details to the police.

Derry, bless him, winked and gave me the thumbs up while he was on the other line to Pauline, letting her know the police were on their way. At the same time, she’d told Derry that John was quietening down a bit. The two doctors; the Consultant Psychiatrist and an SHO (2) appeared at the office door. “Everything alright Derry, Nancy? Oh, hello Nancy. Sorry, I’m Doctor Shand and this is Doctor Wiles. Do we know what’s happening? Let me know when he’s back on the ward please.” he smiled and left.

“Good job there Nancy. Will you just write in his notes; what happened?” Derry asked.

It wasn’t long before the ward door opened and I could see John being led in by the police and half a dozen people who, it turns out, are part of the Hospital Rapid Response Team (RRT), called to assist in emergencies like this. John shuffled in, head down, looking shame-faced and went to the smoking-room while a police officer spent a moment with Derry then led his team away.

The RRT was a team made up of six-seven people, mainly men it seemed, one from each of the wards, who responded when a bleep and the radio sounded, telling them where to go. On this occasion, they’d been called to the hospital entrance when the police arrived with John to escort him back to the ward. The Team had now followed Derry into that tiny office and, being a bit nosey, I went to the smoking-room where I offered John a ciggie. I’d cottoned on that ciggies were the currency used if you wanted to engage a patient and this time was no exception.

However, sitting between John and another patient, who’d introduced himself, with a cut-glass English accent, as James and asked for a ciggie, I felt decidedly uncomfortable. John was muttering he wanted to kill someone and James was bouncing back and forth in his chair, fists balled tight. I was wondering how I could finish my freshly lit ciggie and make my exit back to the relative safety of the kitchen without bringing too much attention to myself. Just at that, the door opened and Derry said “Come on John, you need to take your meds.”

“Nope!” John had no sooner hurled back at him when the RRT burst in and launched at him, grabbing him by his elbows and wrists, pulling him up out of the chair and on an authoritative command “Down!” to the floor. John was yelling “Fucking bastards. You fucking wait.” and struggling among the fag butts and drink slops, battling against the five staff holding on to him; one on each arm, one on each leg and one at his head. The person at his head was talking to John, calmly telling him what was happening, that it was for his own good and that he was okay. “Keep still. You’re safe.”

Hell, this didn’t look okay to me. Alison came in with a small cardboard tray holding two half-filled syringes and waited while someone pulled John’s jeans and boxers down about six inches. My heart was pounding and my eyes felt like they were on sticks as Alison swabbed an area of John’s right buttock, then said “A sharp pinch John.” she calmly popped one needle in and squeezed followed by another.

I would later learn that the intramuscular injections they’d administered was what nurses called ten and two; ten mg of Haloperidol (3), and two mg of Lorazepam (4) which, together create sedation quickly. This combination of drugs is normally used in the management of acutely disturbed patients? However, a patient unknown to the hospital or a smaller person i.e. a female, would be given a reduced dose of 5 mg of Haloperidol and 1 mg of Lorazepam in the first instance.

RRT held onto John for a few minutes and he eventually stopped struggling. Derry said “You good John? Come on now. We’ll let you up. Easy now.” They helped him to his feet and one by one, limbs were let go and the team dispersed. “Into the office boys and girls,” Derry continued, as if nothing had happened.

There was a quick debrief, where I learned that no one was taking responsibility for letting John out. I’d only been given the keys prior to my ciggie break and he certainly didn’t leave with me, despite the knowing glances I was getting from the ward team. However, the team agreed that the Control and Restraint (C&R) had gone well and no one got hurt, so the RRT left the ward.

Derry and Alison were both busy documenting the incident in various forms, so when I heard that someone had to complete an incident form, I happily offered. They chatted away, telling me that John had missed his morning medication which included ten milligrams (mg) of Diazepam, known to have a sedative effect, hence the paranoia and visit to his sister’s.

Alison held her hands up as she’d done medication that morning and she’d missed this. She insisted I document this on the incident form but I showed them both my documentation where I’d written, “John was seen on the CCTV leaving the ward at 08.10, just as medication was being administered and therefore did not have his medication.”

“Well done Nancy. You checked that yourself, did ye?” I grinned from ear to ear when he half-joked “You’ve got the job.”

(1) A Restriction Order is when Criminal courts can use section 37 if they think you should be in hospital, instead of prison. Section 41 is a restriction order. The Crown Court can add this order to a section 37 if they think you are a risk to the public – Section 37/41

A section 41 Restriction Order can be added to a section 37. It is then called a section 37/41. Only a judge in a Crown Court can do this. They will do this if they think you are a risk to the public.6 The restriction order means that there are restrictions on both you and your Responsible Clinician (RC). One restriction is that your RC needs to get permission from the Secretary of State for Justice to discharge you.

(2) SHO – A senior house officer (SHO) is a non-consultant hospital doctor in the UK. SHO’s are supervised in their work by consultants and registrars. In training posts these registrars and consultants oversee training and are usually their designated clinical supervisors.

(3) Haloperidol helps you to think more clearly, feel less nervous, and take part in everyday life. It works in the brain to treat schizophrenia and has a sedative effect within ten minutes It can also help prevent suicide in people who are likely to harm themselves. It also reduces aggression and the desire to hurt others. It can decrease negative thoughts and hallucinations. https://www.webmd.com/

(4) This medication is used to treat anxiety. Lorazepam belongs to a class of drugs known as benzodiazepines which act on the brain and nerves (central nervous system) to produce a calming effect. This drug works by enhancing the effects of a certain natural chemical in the body (GABA). https://www.webmd.com/

Note to self: Empathy is seeing with the eyes of another, listening with the ears of another and feeling with the heart of another.” Author unknown.