Mental Health Nurse - Mental health 360°

What happens in a Community Mental Health Team?

What is a Community Mental Health Team (CMHT)?

Community Mental Health Teams are multi-disciplinary — Community Mental Health Teams are made up of multi-disciplinary professionals

Have you ever wondered what happens in a Community Mental Health Team (CMHT)? Let’s take a look.

They were developed in the UK to deliver Care in the Community in the late 1980s. This was a British policy of deinstitutionalisation; treating and caring for physically and mentally disabled people in their homes rather than in institutions.

A GP might refer an out-patient, but in-patients are generally allocated to a CMHT prior to hospital discharge. These CMHTs are made up of various multi-disciplinary professionals such as:

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

Once referred to the CMHT, an assessment would be completed to build up an accurate picture of a person’s needs. The patient might get help from either one or two of the above professionals, depending on their needs.

My first placement at a Community Mental Health Team

How a basement CMHT might look — Image by Washingtonpost.com

As a Mental Health Nurse student, I was allocated to Alan, a CPN who would be my supervisor during this placement. I arrived 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 the team’s overall mood matched the weather that stormy Monday morning. Had they not been sitting at desks, behind the flexy-plastic window, I might have thought they were patients with depression — just staring blankly into oblivion.

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 creased trousers looked as though they’d had an argument with his ankles and his black plastic slip-on shoes squeaked as he walked.

Still, his gappy-toothed smile was welcoming. He stuck out his hand, pushed open the inner door with his backside and introduced himself as Javid, a Social Worker.

I explained who I was and he took me down to what looked 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.

Student nurse Practice Based Assessments

I went through my Practice Based Assessment (PBAs) to see which ones I might be able to meet — sooner rather than later. Students have a list of evidence-based tasks, to be carried during placements, which are assessed for competency by their supervisor. This was a lengthy process so I always liked to get a head start and not leave the PBA’s right ’til the end of placements.

While idly thumbing through a patient file, I happened to look up and saw a rickety old bike being chained to the railings outside. I watched from the basement window as a pair of green wellies marched up to the front door. The wellies stomped about a bit before thundering down towards the basement.

The office door crashed open and there stood Alan! He pulled himself up to his full six-foot-plus, puffed out his chest and glared at me. “What on earth do you think you’re doing?” a broad Glaswegian accent rasped. 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?” He turned on his heels saying “I’ll get a coffee and see you when I come back!”

And this was how Alan continued over the next few weeks; barking orders at me and ignoring any questions, or feeding me wee snippets about his patients.

Depot injections by Community Mental Health Team

Intramuscular depot injection administered by Community Mental Health Team

I was surprised one morning when Alan told me I was to run the weekly Depot Clinic under his supervision. This is where patients come every 1-4 weeks to have antipsychotic medication via intramuscular injection.

Some patients prefer this as they tend to forget or refuse to take their daily tablets. Other patients must have medication by injection under a Section of the Mental Health Act 1983. If a patient is known to be non-compliant with medication, Depot injections are often recommended during Multi-disciplinary team (MDT) meetings.

“You know how to administer injections, I presume?” snapped Alan. And without waiting for an answer, “don’t forget to check which side they had their last injection. I’ll countersign the medication charts when you’ve done.” I’d observed several injections during my in-patient placement but I’d never actually administered one. I told Alan and all he did was nod; indicating me to just get on with it.

My first patient was due in soon so I checked her medication chart and spotted the small letter ‘L’ underneath the signature box. I gathered this meant that their last injection was on the left buttock so this time it would be on the right. Injections sites were alternated to stop the buildup of scar tissue on one side.

Administering my first depot injection

Preparing depot injection — image by Pixabay

Sally, a 36-year-old female, appeared sullen and I wasn’t sure I’d be able to engage her in idle chit chat before stabbing her with the needle.

However, she chatted amiably about me being a new student and asked whether I liked football. The needle was out — and I told her I was an Arsenal fan. “Blinding. Me too. But I ain’t never been to a game.”

I did take her along to a match some years later, but that’s another tale. Anyway, there I was, scribbling my signature on her medication chart when she turned her head to me and chirped “Come on, ‘urry up mate!”

“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 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 chart to countersign.

My first Community Mental Health home visit

Community Mental Health Teams work with patients in their own homes — Image by Pexels

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 barefoot and wearing a flimsy but colourful kaftan. She twirled around on the grass, head back and arms outstretched as she sang. Julie Andrews popped into my head and I fondly remember Anne whenever I hear “The sound of music”.

Anne grinned when she saw Javid and waved him in with a dramatic curtsey, then called the children in for lunch. Four skinny under-twelves trooped into the living room and hungrily snatched up huge doorstep sandwiches.

The kids 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 too small, all barefoot, but they looked happy and were both well-spoken and well mannered.

Bipolar disorder

Anne had a diagnosis of Bipolar disorder which used to be known as manic-depression. Someone with Bipolar has episodes of mania (feeling very high and overactive) and periods of depression (feeling very low and lethargic).

Unlike simple mood swings, each extreme episode (high or low) of bipolar disorder can last for several weeks, or even longer. Bipolar disorder is treated with mood stabilisers such as Lithium or Valproate, which were all originally made for treating epilepsy.

Community Mental Health Assessment

Javid asked Anne if it was okay for me to complete a mental health assessment, done by observation and direct questioning, 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 we 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’d check to see if there was a bed so that he could plan a voluntary hospital admission over the next few days.

Javid 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’d be admitted under Section 3 of the MHA 1983”. This means patients can undergo coercive interventions, such as enforced medication, seclusion and restraint.

Mental Health documentation to be completed

CPNs have to complete lots of documentation — image from Pexels

After a few more less-exciting home visits Javid and I returned to the CMHT around four-fifteen, just in time to complete our documentation.

Alan threw me a look of utter disdain as he snapped his briefcase shut and headed 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.

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 some staff were supportive and fed back to me my strengths and small areas that I could build on.

My Practice Based Assessment

Most of my PBA’s had been completed I and was pleased with the evidence I’d attached. I’d 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. Overall they said they were impressed. All I needed now was for Alan to sign them off as having been completed.

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! Aaarrgghh!

Over to you

But it got worse……….. I’ll do a short follow-up. But in the meantime, I’m happy to answer any questions and look forward to hearing what you think about care in the community. Does it work? Or even, just say “Hi.”

Do you experience anxiety while studying

Have you ever felt anxiety while you were studying?

Anxiety while studying nursing — Anxiety while studying -Photo by Alexander Dummer

The feeling of anxiety is often in response to stress, like anxiety while studying hard for end of year exams. A recent conversation with a good friend, who’s struggling with anxiety during her final nursing exams, made me reflect and repost this old article.

Many people have these anxious feelings during their lives and fortunately, these feelings normally pass once the pressure has subsided.. However, having an anxiety disorder is more than feeling anxious or stressed. It’s when the anxious feelings don’t pass, they occur frequently and stop you doing what you want to do. Moreover, people with an anxiety disorder often find it very difficult to manage their symptoms.

I felt stuck in the vicious circle that was anxiety and my life. And it was getting worse. Some days (and nights) of constant anxiety left me feeling drained, fatigued, and unable to focus or concentrate. Struggling with what felt like a scrambled brain, I couldn’t take in or retain the information I needed to study.

My anxiety was crippling while I was studying

Anxiety and studying — Photo by Eternal Happiness

I just wasn’t getting this studying and revising lark. And how foolish was I? I thought I’d be learning about mental health nursing. So I couldn’t understand why we had so many lectures about all the oligies i.e. sociology, biology, physiology and psychology.

These lectures were normally trotted out by bored lecturers using big words, which was a major bugbear of mine. By the time I’d figured out how to spell sternocleidomastoid* the lecturer had moved on. And my notes then had more holes than Swiss cheese.

Another bugbear was how many communication and interpersonal skills classes we had to attend each week. I mean, everyone has these skills. Right? Doh! I should’ve realised that the shoving and pushing brigade, together with the teeth clicker and tutters, didn’t. Not forgetting the newspaper rattlers and chair scrapers, the talkers and the snorers, along with the class disruptors.

While it wasn’t anyone’s fault I was plagued with anxiety, it was certainly my classmates’ lack of consideration that made it go through the roof. I think I spent the first half hour of each class wound up like a coiled spring. Just waiting for all the commotion to die down so the lecturer could begin.

There’s no such thing as a stupid question, or so it’s been said. Well, I beg to differ, because some students really did ask stupid questions. And with disturbing regularity. Just kill me already! “It says here to write my name in black ink, does that mean I can’t use a blue pen?” or “We’ve been told we had to arrive on time for classes. Does that mean we can’t be 5-10 minutes late?”

And these same students managed to interrupt and disrupt lessons with their stupid questions, so much so, that the topics were cut short. This meant we had to go through the whole bloody lesson all over again the following week.

I wish I’d known how to reduce my anxiety while studying

Studying and taking notes — Study and writing notes — Photo by Victoria Borodinova

Three months in and just before Christmas, we were given an essay to complete over the festive period. It was something like ‘How my life is different since starting Uni.’ Okay. Sounded simple enough. Until I got it home and read how I had to write in an ‘academic’ manner? Using references and to use ‘reflection in and on action.’ I’d only passed a few low-grade GSCSs some twenty years previously, for crying out loud. And, as far as I can remember, we didn’t use referencing, and no one ever mentioned ‘reflection’ or ‘academic writing’.

Let me tell you, pre-computers, I re-wrote this essay so many times, wanting to sound clever and knowledgeable. That didn’t work. It just left me feeling even more stupid than I’d first thought, and my anxiety was sky high. The more anxious I got , the less I could concentrate on my essay, and the deadline was looming. What, with this and the class disruptors, boredom, big words and stupid people, I wondered if uni was for me.

However, what example would I have set for my sons had I not completed the essay and got a whopping seventy eight per cent as a result?

Before you go any further, stop!

Body can't be tense and relaxed at the same time — Body can’t be tense AND relaxed at the same time — Photo by La Miko

A little tip for you. Let out that big breath you’re probably holding in right now. That’s right — let it out with a big huff. Let your shoulders drop down from your ears. Unclench your teeth and jaw, go on, give it a little wiggle and let your whole face relax. Now drop your shoulders, unclench your fist (s) and lay them (or one of them if you’re on your mobile now) flat on the table or your lap. Uncurl/uncross your legs, give your toes a wiggle and let me explain quickly.

Your body physically can not be tense and relaxed at the same time. So — if you’re hunched up, fists in tight balls, jaws clenched — you’re effectively telling your brain you’re on alert, tensed and ready to fight or flee. The brain is constantly receiving signals from the body, registering what is going on inside of us. So it makes sense, if you follow the tips above, your relaxed body is telling your brain you’re calm and relaxed.

Now you might try this and think “Huh, that didn’t work,” and you might be right, the first time. But if you practice it enough — waiting for the bus, sitting on the train, in the lift, in the shower or standing in that always slow queue at the Post Office where the person in front is paying all their bills with pennies.

Practice, practice, practice. And just when you do need to relax quickly ie before an interview, exam etc, you’ll have practised so often, you can do it immediately, with ease.

What is an anxiety disorder?

Anxiety disorders and counselling — Anxiety disorder and counselling

Anxiety is your body’s natural response to stress. It’s a feeling of fear or apprehension about what’s to come. But if your feelings of anxiety are extreme, last for longer than six months, and are interfering with your life, you may have an anxiety disorder and you should contact your GP, access counselling, seek professional help.

Some symptoms of anxiety

Tense muscles
Irritation
Excessive worrying
Restlessness, pacing, fidgeting
Agitation, quick to anger
Snappy
Fatigued – changes to previous sleep pattern
Changes to previous eating pattern
Changes in libido

Repeat the technique as above — breathe, relax your jaw…….. Go back up the page, remind yourself of the technique and practice, practise, practise.

Now take a look at this model for anxiety. Then read about coping skills to relieve anxiety, panic attacks and stress.

Anxiety can be debilitating, so it’s important to seek professional help if your symptoms are severe. If you feel anxious on the majority of days and experience one or more of the symptoms listed above for at least six months, it may be a sign of an anxiety disorder.

Regardless of how long you have been experiencing symptoms if you ever feel like your emotions are interfering with your life, work or relationships you should seek professional help.

Although anxiety is a medical condition in its own right, there can sometimes be a physical reason for your symptoms – and treating it can bring the anxious feelings to an end. See your GP to rule out any other causes and do not self-diagnose.

Are you still practicing unclenching your teeth and jaw? If not, go back up the page and remind yourself of the techniques.

Over to you

So you have anxiety? I hope you’ve found this post useful and if not, I’m happy to answer any questions and accept any suggestions. Let us know your tips to control your anxiety, and I look forward to your comments.

*Sternocleidomastoid — One of two thick muscles running from the sternum and clavicle to the mastoid and occipital bone; turns head obliquely to the opposite side; when acting together they flex the neck and extend the head

Bullied by work colleagues

Have you ever been bullied by work colleagues?

I was bullied by several work colleagues in various mental health environments over the years. Bullied in the very place where the staff had trained to care for people! Bullied by nurses who’d studied to provide preceptorship supervision and mentorship to their fellow-nurses? To the bullies, “I wonder if you know what it feels like to be bullied?” Let me tell you here.

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.

If you’re being harassed or bullied by work colleagues, and their behaviours are something you don’t want, the law calls this ‘unwanted conduct’. If you wanted to complain, you would need to show that the person who harassed you meant to make you feel a certain way. Otherwise, that you felt that way even though it wasn’t their intention. This is called ‘purpose or effect’. If the person didn’t mean to make you feel this way, it also has to be ‘reasonable’ that you felt that way.

The serial bully

The word Bully. The word Bully is written in red with orange words about bullying — Bullied by work colleagues — Image by John Hain @ Pixabay

During a placement in the Community Mental Health Team (CMHT), I was horrified that I was being bullied by my supervisor Alan (an ex-policeman). Oh, my word, 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
always tried to undermine me in front of colleagues
ignore my input and he’d snigger at my Cockney accent if I spoke in meetings, because he knew I hated it
deliberately leave me out of ward rounds when ‘my/our’ patients were being seen, as I had nothing useful to add.
smirked when refusing to sign my attendance sheets saying he didn’t know what days I turned up or didn’t – only because he was late every day. I was lucky that his colleagues offered took me out on patient visits or to ward rounds in the hospital because
he blatantly ignored my attempts to communicate with him

Still, he was furious when I said I had no option other than to speak to the CMHT Manager. His boss then had to act as mediator for the rest of my placement because Alan continued with his passive aggressive stance. How sad that ‘adults’ had to resort to this!

How it feels to be bullied

Coloured image of young female with face looking sad or sick with anxiety. — Sick with anxiety — Image by Aleksandr Davydov @ Stocklib.jpg

That man made my working life a misery. I felt sick with anxiety each morning; my stomach churned, my mouth was dry and my fingers were tingling. I was drowning in quicksand and I couldn’t breathe — until the kind Social worker brought me coffee and helped me calm down. The admin team were great too and they hated what was happening to me. Why didn’t anyone else say something about it, tell the manager?

Imagine waking up each morning knowing you’ll be facing yet another nightmare. Perhaps you’re afraid of spiders, and one day someone drops a box of them on your head — and they tell you they’ll do this every day! Or you don’t like lifts and you’re stuck in one all day! That’s what it feels like when you know you have to face your bully again and again. You wake up wondering what he’ll do today, what he’ll say, how much worse can he make me feel?

How bullying affected my self-esteem

My confidence was shaky, and my self-esteem plummeted even though it was someone else’s actions that contributed towards those feelings. These days, now my mental state is more stable, I wouldn’t let anyone’s else’s actions affect me like that. Now, I can attribute the cause to external factors i.e. that certain someone else, the bullies, leaving my self-esteem perfectly intact. You can also read My self-esteem building blocks on my blogging friend Ashley’s (Mental Health at Home) post, here.

However, at the time, imagine the shame of it. Being bullied at the age of thirty-six! I felt so alone and isolated, despite the good intentions of the rest of the team. While they were ever so kind to me, they didn’t help to stop it — of course, they didn’t want to be involved. But, they ought to have realised that, because no one wanted to be involved, he’d do it again and get away with it.

Still, I was determined that arse wouldn’t break me or make me leave my placement.

Power and control

Bullied by work colleagues —Image by Gordon Johnson @ Pixabay

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 rehab unit and on my first morning I noticed the Consultant’s leather holdall, engraved with gaudy gold initials. 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. Although I had no sympathy for him, I never told her what he’d done to me.

Don’t rock the boat

It was also during that placement in the rehab unit that I came across Ricky, the Acting Manager. I told him about a particular patient, Devlin, who found it difficult 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 he should get up earlier.

Ricky’s response was eyes rolling and “Tut, this is a rehab unit and patients have to learn how to get up and ready in time for medication and breakfast. That’s why they’re here.” I flippin’ knew it was rehab, and why they were there!

Nonetheless, some patients needed to be encouraged to get up on time, I suggested we get Devlin an alarm clock. More eye rolling and tutting, but Alan did open the treatment room and gave Devlin his morning medication. I made some tea and toast for Devlin, but Ricky said that I shouldn’t have and not to do it again because other patients will expect it too.

Nurse sleeping on night shift duty

I also mentioned the nurse who came in each night shift with her slippers and duvet and slept on the sofa once 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, he’d retort that I was there on duty too, and that I would make up the staff numbers. I argued that as students, we were there to learn by shadowing colleagues and not to be counted in the staff numbers.

“What do you want me to do?” he sighed. Ayomi, the ‘sleeper’, had been on night shifts for years, and because she had children, they cut her some slack. More likely, he didn’t want to rock the boat; he was afraid of his staff and 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. In truth, he was shutting me up and bullying me for speaking up about the poor practices. I lost respect for him as a Manager. Additionally I couldn’t even be bothered to tell him that I’d been a Human Resource Manager for almost twenty years.

Poor practice being ignored

Black and white image of two palm facing up with words Speak and Out on each palm - About being bullied in the work place — Don’t ignore bullying in the workplace

I asked 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 constant nights. This was against Trust Policy. Ricky refused to take action and I was berated for raising problems where there was none. They told me “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. He wouldn’t allow me 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. Additionally I reported it in the essay that followed this placement. I felt vindicated by the Uni lecturers’ comments and high marks I received for both.

It truly feels awful to be bullied. But there is always hope. Stay strong, find yourself a good support system. For me help came from colleagues who validated the experience and my feelings. You should always speak up!

In my next post, we’ll take a closer look at bullying and how to stop it!

Over to you

Yes, I’ve been updating some of my older posts. Those of you who’ve been with me for a while might recognise this earlier work. But needless to say, bullying is still around and there’s a certain stigma about being bullied when you’re an adult. What do you think? What would you do or say if you were being bullied by a colleague, and would you report them?

Related: Research shows that bullying is corrosive to mental health and well being (1). Bullying and toxic shame (2).

10 attributes of a good mental health nurse

What makes an excellent mental health nurse?

Coloured image of several pairs of hands up in the air, holding uni caps and certificates — Mental health nursing graduation

A fellow-blogger is considering a career in mental health nursing and asked what skills they would need in order to become a good mental health nurse. Forget skills for a moment, I’d suggest that certain attributes are required of good mental health nurses (RMN’s).

Perhaps you are or you’ve been a patient and you’re not sure what to expect of RMN’s? Whether or not you’re engaged in the mental health field, wouldn’t it be amazing if everyone had these attributes? Okay, that’s a big ask. But having these attributes can help make a difference; even in your own lives and relationships. ..

MH nursing is the most rewarding job ever, trust me. It’s a highly respected career and there’s always a demand for skilled RMN’s. It’s often demanding, challenging, stressful, and exhausting, but it’s never boring. If you’re considering a career in this exciting, ever-growing area of nursing, you’ll need to think about the attributes needed for mental health nursing.

Attributes of a good mental health nurse

Words of Angela Mayou - People might not remember your name but they will never forget how you made them feel.

It’s a given that RMN’s need a sound knowledge of the theories of mental health and illness. They also need to understand and apply current legislation, paying attention to the protection of those who are vulnerable. Furthermore, nurses must use their knowledge of patients to handover to multidisciplinary teams effectively, to ensure continuity of care.

However, there’s so much more needed to nurse patients who experience mental illness, and who are often distressed or confused. So now it’s time to put the knowledge books aside and think about the attributes of a good RMN.

Empathy helps patients with mental illness

Coloured image of lady with big afro hair smiling - writing about empathy — Empathy

Good RMN’s must have the ability to put themselves in someone else’s shoes, walk a mile in their shoes. Imagine the single parent being admitted to hospital and her children having to be fostered out? Or the married man whose wife leaves him — because of his clinical depression. What about the man who dresses as a female and everyone laughs at him? Try putting yourself in any of their shoes.

Try not to use platitudes like “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’s depressed. At best you’ll sound insincere and at worst, condescending.

Don’t offer unwanted or ill-informed advice either. Who wants to hear “Oh my mum’s neighbour’s grandson had that and he used to ………..” Or “When my friend had depression, she ……..” then go on telling your own story. This isn’t empathy. It’s not about you, or your friend! It’s for and about the patient, or the person standing in front of you.

Being Non-judgmental is essential

Black image writing You are not alone on this journey, about judgement — Non-judgemental

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. Sometimes we all make snap decisions about a person; based on their colour, race, religion and even small things like how they’re dressed. But doing so is not an attribute of a good mental health nurse.

Being judgemental alienates us from others, which is no good in a mental health environment because patients need to be able to trust that you’ll do your very best for them, regardless.

Good mental health nurses, and indeed people, need to look beyond the presenting facade and immediate appearance, behind which they’ll often find very human and tragic struggles.

You can help your patients by providing kind, nonjudgmental care that acknowledges all aspects of their makeup. Nonjudgmental, holistic care affirms the dignity of your patients and helps them have a voice in their healthcare, (Arkansas University, 2017).

You can disagree with a patient’s or friend’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 …………”

Communication skills are a key requirement for every good mental health nurse

Slide talking about an effective communication process — Want to brush up on your Communication skills

Excellent communication skills are a must when working with confused, maybe angry, depressed, manic, or psychotic patients and their families. In fact, I think we can all learn about better communication skills.

We all, especially mental health nurses, need to be able to actively listen, to stay in the moment with the patient or their families. So, don’t immediately start preparing your answer to their questions — listen to the end of their ‘story’. The clue is often there; a small add-on from the patient —right at the end — but it may actually be the problem causing them the most grief.

Remember, there is so much going on for say a newly admitted patient, and their needs may be complex, often requiring support in several areas. They may be too fatigued to deal with things like finances and bills or pets, so you’ll need to communicate these needs to the multidisciplinary team.

Speak Clearly

You must be able to speak clearly and concisely to the patient, asking if they need clarification or more time to think about what you’ve just said. Active listening and paraphrasing what the patient just said, makes them feel heard, understood and cared for. This is crucial attribute of a mental health nurse.

You need to be able to look, to see the patient, and sometimes the family dynamics, in order to gather information.

Observe facial gestures to see whether they’re smiling, nodding, frowning. Observe their posture; are they slumped, sagging shoulders, dressed appropriately for the weather. You might observe that the patient smells unclean and his teeth haven’t been brushed. You might notice that the patient is sweating or has a fever, and understand that you have to take action.

“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.”
The Royal College of Nursing (RCN)

Compassion

“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. RMN’s come into people’s lives when they are in distress and vulnerable, and how they treat patients, and their families can leave a lasting impression.

Accepting differences and finding things in common help you relate to a patient/person, and what they might be going through. You’ll be showing them a kindness they might not get elsewhere, and despite them being mentally unwell, they will appreciate and remember it.

Leaving your own world at the front door, and just being there in the moment with a patient encourages openness and mutual trust. These small acts impact on a patient’s emotional responses and their view of the care they are to receive.

Sometimes mental health nurses are 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 nurses do.

Treating yourself and your colleagues compassionately goes a long way too. If we can’t look after ourselves, how then do we look after patients?

If you are a nurse commitment must be on your list

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 a good mental health nurses must stay up to date with all relevant practice and be committed to lifelong learning.

Continuing professional development that focuses on compassion will enable delivery of excellent patient-centered and evidence-based care. Moreover, good mental health 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 their patients

How a good mental health nurse must have the ability to stay calm in a crisis

If you can keep your head when all about you are losing theirs ………. by Rudyard Kipling comes to mind. It’s imperative that qualified mental health nurses have the ability to remain calm when dealing with emotional outbursts or challenging behaviour.

Being calm will be beneficial to both you and the patient. If you’re panicking or flapping about, the patient will feel it and they too might become distressed.

Knowing how to interact effectively 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.

Emotional intelligence: A mental health nurse must have the ability to understand her patient’s emotions

Coloured image of female sitting on edge of mountain - Understand and manage your own emotions — Understanding your emotions

Emotional Intelligence (EI) is described by two researchers (Peter Salavoy and John Mayer) as the ability to

recognize, understand and manage our own emotions
recognize, understand and influence the emotions of others

In practical terms, this means being aware that emotions can drive our behaviour and impact people (positively and negatively), and learning how to manage those emotions – both our own and others – especially when we are under pressure.

An RMN, must remain calm and use their EI if there’s ever a challenging situation where a patient becomes aggressive or 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 you’re angry. What can I do to help? What would you like me to do?” “Would you like to sit with me and I can listen?” What else might you say?

Adaptability – Nursing in a fast paced environment

Adaptability or willingness to change in order to suit different conditions is necessary in an ever-changing work environment, particularly in nursing. An RMN will meet people who are often misunderstood by society, including their friends and family. Therefore, RMN’s need to adapt quickly and easily to new patients, different disorders and changes in moods.

There’s also new students, new mental health nurses, change in Junior Doctors every six months, new procedures and policies…………… The list is infinite end ever-changing, as is mental health environment. RMN’s must be flexible, be curious, be open-minded, and able 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, engaging, and considerate.

Over to you

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. What do you think? I’d be interested to hear your thoughts and I’m happy to answer any questions.

Related: How to care for the mental health of the nurses in your life in these trying times (1). This was me: My mental health nursing career (2)

Update – Poor standards at 28 mental health units

Neglect is one of the consequences of poor standards at 28 mental health units — 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 ought to be 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.

What does Continuing Professional Development really mean?

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.

Refusing to attend training courses is a reason for poor standards in mental health units

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 p~~erformance~~ 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

What do you think about poor mental health standards? — 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; an increase in poor standards in mental health units is observed at a national level

Patients are more depressed because of poor mental health standards. — Mental health patients bedroom. Design Pics Inc/REX

I’ve already mentioned some of the poor practices on mental health units I’ve come across in other posts. But there is 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. This way 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). Some are almost dragged from their comfortable homes by well-meaning (or not) family, carers, Social Workers and a Psychiatrist.

Patient fears are real for them

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. This means it’s important to continue the conversation as many times as a patient might need. Nurses that work on mental health units also ought to better communicate with their patients. They should know they have the right to appeal against their Section. And they should be provided with the correct paperwork to do so.

Patients experience low standards in mental health units first hand. They should 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

The Guardian reports “Inspectors have found 28 privately run mental health units to be “inadequate”. Regardless, 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. They were referring to i.e. the menial tasks they couldn’t be bothered doing. What they didn’t know was that I had been doing secretarial work for near on twenty years. I loved doing the admin, completing computerised care plans etc. Being quick and quite good (compared to them) at it, I smiled throughout the shift – something that bugged colleagues when they disliked you.

Private sector treating patients badly

Poor standards in mental health causes incidents — 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. Today she wanted to eat lunch before medication. 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. When a methadone user doesn’t receive a dose on time, it will trigger debilitating withdrawal symptoms like nausea and insomnia. The patient was agitated by this. I was p’d off because I thought the nurses’ punitive actions were totally unacceptable.

How I dealt with it

I went to the unit Manager who was sitting in his plush office. I then asked him 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. Our staff doesn’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; therefore 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.

A typical example of an employee with low standards

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. She would moan about various patients and kiss her teeth throughout her shifts. Spending more time on the computers, googling hairstyles and nail art. She must have not realised that somewhere in Head Office, the tech guys could easily follow what she was doing. They could see exactly how much time she’d spent online, and they could report her for time wasting.

Did no one care about low standards at mental health units?

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. Always treat 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 I also 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. 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.

Related posts: Clapped out: Mental Illnesses, abuse by services and #ClapForCarers (1). Acute care facilities and mental health facilities are below modern design standards (2).

The curse of ward managers in mental health

What do ward managers do on mental health wards

Ah, here’s the rub

Coloured image of female asleep at her desk — Ward Manager asleep at her desk —
Image from Pexel.com

Each ward had a manager who worked 9-5 and was expected to split their role 50% managerial and 50% clinical. What p’d me was the fact that most managers sat in their office 99% of their day. Tho’ they did pop their smug faces around the nursing office on their way out to get coffee or lunch.

Crikey, like most nurses, I’d forgotten what a lunch break was.

And heaven forbid, Managers might get their hands dirty. Or their neatly pressed shiny trousers, if they dared to sit with patients at mealtimes. Managers should have been out there on the floor, supporting nursing staff to do their jobs effectively.

What could managers do?

Coloured image of elderly lady walking with walking stick — Elderly patient had walking stick
snapped in two — Wolfgang
Eckhert from Pixabay.com

They might have noticed the patient with false teeth who was choking on a large chunk of beef and nearly died. Or that a nurse really did break an elderly patient’s walking stick over her knee then hid it behind the filing cabinet. Why believe the lady with psychosis, eh?

A manager on the floor might have spotted (when a nurse didn’t) an elderly patient sneaking out with the lunch trolley. They’d be contacted at home later to be told that this poor man died. The next day it would be all about filling in paperwork for the impending investigation. Never mind the poor patient or his family.

Oh, and the manager would be looking for someone to blame. Why did nobody notice? What were all the staff doing? Where was everyone? Who opened the door and let Archie out? He actually snuck out. The video footage from security didn’t detect him behind the lunch trolley either.

Perhaps they could’ve stopped the gullible junior doctor unlocking a side door to let a patient out. She was yelling through the door that she was a visitor and had got locked in. He didn’t think to check. And he didn’t notice her slippers as she shuffled out? She was found, safe but causing pandemonium in the local market, throwing wet fish from a stall at anyone who went near her. The not too friendly police stank of rotten prawns when they returned her to the ward.

How Managers could sit on their fat lardy arses in their back office with the door shut was beyond me.

What managers should do

The following is a shortened version from my previous Job Specification for Ward Manager. In it, it states that a Ward manager must:

Coloured image of black man with wild hair painting — The provision of Art therapy —Image by andrea Piacquadio from Pexels

promote a therapeutic environment that is conducive to recovery and the development of independence.
lead and be responsible for the clinical management of a ward, where patients may present with complex behaviour that challenges services.
allocate and support individuals with delegated work
coordinate and monitor the delivery of evidence-based person-centred healthcare.
be accountable for the provision of appropriate physical care to support the general health needs of service users.
be responsible for ensuring that services are responsive to individual customs and beliefs, age ………. and that service users and staff are supported to fulfil these.
be responsible for the provision of and access to a range of therapeutic activities, emotional support and stability to clients to ensure effective engagement.
support and supervise staff to ensure the maintenance of professional boundaries.
create, develop and maintain professional supportive relationships with all members of staff to enhance service delivery and recovery.
ensure that all documentation is robust and that audit is undertaken to evidence this.

Job spec doesn’t apply to management

Image white shredded paper with Job specification no longer needed

That all seems clear enough to me. However, I get the feeling that once managers have the job, the job spec’s shredded, never to be referred to again. I think all managers should have this framed, or at least laminated, and displayed in their office. And just for good measure, they could add a great big arrow pointing to this “Please let me know how I’m doing.” and stick it their office door. That way nurses, patients and family or carers can pull them up when they’re not doing their job.

Love your enemies

While perhaps I didn’t call my managers out directly, I would let them know when I was unhappy with their suggestion or directives that went against Trust policies. As a Band 6 Charge Nurse (assistant manager), my manager would tell me to have staff plan the dates for their entire year’s annual leave, including me.

Er Errr, the policy says no. Staff didn’t have to do this and many couldn’t or didn’t want to. Mostly, as our rotas were distributed each month, I would plan my holidays prior to the following month’s rota.

When I relayed this back to my manager, he whined: “I’m going to have to tell Miranda (our local nursing director).”

“Ooh, scary. Tell Miranda,” I’d grin.

Nope, he wasn’t best pleased, “Oh come on. Don’t make me do this. Miranda won’t be happy.”

“Tell Miranda to speak to me then. I’m not pushing staff to do this.” And he did tell her. She came up to his office, arms folded and grimacing, “What’s all this nonsense about? Who the hell do you think you are?” without letting me answer she raged on, “I’m your boss and I’m telling you………”

Colour picture of an NHS lanyard — NHS Staff identification holder

With my hand up, “Let me stop you there Miranda. If we take our badges off, we’re just the same, me and you. We’re both human and I’d appreciate it if you treated me so.” As I watched her eyes bulging and the fumes flaming from her nose I continued, “The Trust Policy states that staff can plan their holidays whenever they like, so I’m not going to do as you ask. I can’t plan for a year so I don’t expect twenty-eight other staff to be able to either.”

“Do you know what. Just bloody leave it,” she snapped, “Mark will do it,” nodding at him before storming off the ward. She absolutely hated me. She’d ignore me in corridors or in meetings, even though I’d always smile at her and say “good morning Miranda.”

“Love your enemies, it will drive them crazy.”
Anon

I won’t even start on about our Modern Matrons, I’ll leave that for another post.

You might be interested in the following articles:

The ugly truth about mental health nurses here
Poor nursing in mental health here
Bad manned nurses on mental health wards here
Should we report our mental health colleagues here

Over to you

Have you ever worked with ineffective and impossible managers? Would you have called your manager out? I’m interested in your thoughts and I look forward to any comments or questions.

This is a true account from my perspective and all names have been changed to protect the lardy arsed, ineffective and impossible managers — and save them from any embarrassment.

The ugly truths about mental health nurses

Shocking ugly truths about our Mental Health Nurses

Coloured image of the Nursing & midwifery Council's The Code — Ugly truths about our mental health
nurses who neither meet nor maintain
expected standards

I discovered many shocking ugly truths about some of our mental health nurses. What was more appalling however, was the response (or lack of) of their managers and modern matrons. I wasn’t a patient. I was a nurse, and a ward manager.

Have you ever been an inpatient on a mental health ward? Have you come across washed out nurses who’ve either lost the ability to care, or they never cared in the first place?

Our Nursing and Midwifery Council’s (NMC) The Code (2018) contains the professional standards that registered nurses must uphold. This is a nurse’s bible, whatever your faith or religion, and all standards ought to be reached by the end of your three years pre-reg training. Moreover, you should be committed to upholding these standards throughout your nursing career. Essentially, through revalidation, nurses provide evidence of their continued ability to practice safely and effectively.

“The Code provides a clear, consistent and positive message to patients, service users and colleagues about what they can expect of those who provide nursing care.”
NMC, 2018

Who oversees our mental health nursing standards?

Black and white image of man with hands on a wall, head down — Patient experiencing mental illness —
ugly truths about our Mental Health Nurses

Now, I’m not sure the above-mentioned patients and services users ever get to see this Code; it’s not given to them on admission. Therefore, I don’t believe they do know what to expect. Okay, imagine for a second that they’ve seen The Code and the standards of care provided don’t match up.

Do you think patients are in any fit state to ensure nursing staff uphold these standards? No? Me neither and I think it’s up to the profession itself to effect, maintain and monitor these standards.

While I agree patients ought to be able to expect certain standards, they’re often too unwell to notice. Many of our inpatients suffer from a wide range of mental illnesses including bipolar, schizophrenia psychosis, personality disorders, and depression. They might be confused, drowsy due to the effects of medication and sometimes angry because they’ve been detained. Expecting anything might be too much!

Most inpatients are on a section of the Mental Health Act (MHA 1985). This is a law that requires patients to remain on the ward for assessment and also treatment. Some patients are informal, which means they gave consent for admission and can come and go as they please.

Nurses should be doing more

As a new nurse I was excited and couldn’t wait to uphold the standards and expected the very same from my colleagues. Patient care and safety were, as expected, my (our) main concern. It was up to me (us) to ensure patients’ needs were recognised and assessed. However, how can patient needs be recognised if staff don’t actually spend any time with them?

While well aware that our wards were often oversubscribed and our patients could be chaotic, it p’d me off seeing how little time nurses spent with their allocated patients. Moreover, their half-hearted attempts at engaging with patients were sadly reduced to the odd casual nod or fake smile.

It wound me up no end when I shared my concerns with my managers and they’d just say “Oh, that’s just how they are.” Or “Don’t report it, you’ll just cause problems for yourself.”

No wiggle room to meet everyone’s every need

Coloured image of lady in jeans and blue jumper taking notes. Female with pae trousers sitting with her hands on her lap — Mental health nurses — Image from Medpagetoday.com

Each shift, we’d be allocated five patients to look after, on top of which, one nurse would coordinate that shift. One nurse might be in Ward Round and one nursing assistant (NA) would hold the Rapid Response radio (attending to crises elsewhere). The fourth member of staff, an NA, would be on the floor, and completing the hourly checks (ensuring patients are safe).

This didn’t make it easy for nursing staff to spend long periods of time with their patients. However, we were fortunate when we had good nursing students to help out. They had the time to spend chatting with patients and feeding back to nursing staff. Or they’d help coordinate the shift, releasing the coordinating nurse to spend time with their patients. Students would be answering telephones and constantly unlocking the door to let people in or out of the ward. Patients loved having good students on the ward because they usually had the time to chat.

Nurses could work smarter

Staff ought to have allocated tasks to students which would then free them up. They could have used that time to spend with a patient and to document more than a line or two in their notes.

Still, even with time to spare, we’d see staff flicking through patient’s magazines or settling themself in front of the t.v. Then you’d see a one line entry in patients’ notes saying “Mary had a quiet day. Stayed in her room throughout the shift.” Did this nurse speak to Mary? Had they asked if she wanted breakfast or lunch? Did they ask Mary how she felt or whether she needed any support? Who knows, because if it’s not documented, it didn’t happen. So — not only did they not speak to that patient, they obviously didn’t ~~give any~~ care either.

Not every day you get to see such sights

Coloured image of lady at her computer — Ugly truth about mental health
nurses — planning holidays

I think because I was older than your average new nurse, I got away with tongue in cheek remarks directed at lazy staff. “Are you on shift today Monica?” when caught organising her whole year’s holidays on the only nurse computer we had.

Or “There’s beds to be changed if you’re bored Ade?” I’d say with a grin. That got them of their backsides, and their tutting or heavy sighing never deterred me..”…….. and Sidney needs support with his toileting when you’re done,” I’d chuckle.

Harsh? Maybe, but like I said to my colleagues, if I’m cleaning up sh*t, so are you! I wouldn’t expect staff to do anything I’m not prepared to do myself. And for the nurse who said of a patient who’d spent her night rolling around in her own excrement, “No, she didn’t do it deliberately.”

And, “Just to get attention and pee us off?” Duh! Evie had faeces up her nose, in her ears, dangling from her eyelashes and under her nails. Safe to say, she was covered poo. I’m certain this unfortunate young female would have been horrified to know she’d been rolling around in her own mess.

“No, I’d never seen a sight like it either but you didn’t have to yell at her. The girl didn’t know who or where she was. Yes, I also gagged as I donned plastic bags over my feet and hands before rolling Evie onto a sheet. My back hurt too as we dragged her out of the bedroom, into the shower room. But I didn’t make it obvious by heaving dramatically in her face every five seconds.”

As for managers

And to our manager “Nice of you to retch theatrically then walk on by when you came in late that morning, for the millionth time.” Ha! Now that’s another post — what’s the point of ward managers?

Over to you

Large red question mark with little white character leaning against it - pondering — Clipart.com

As a new nurse, what would you have said or done? Would you feel able to call out your colleagues? What might a new nurse learn from this post? I look forward to hearing what you think and any questions are welcome.

This is a true account from my perspective and all names have been changed to protect the lardy arsed staff and save them from any embarrassment.

Testimonial

“If you’re looking for a hard-hitting evaluation of the mental health profession with a sharp wit, please stop by Caz’ blog. She writes pieces revealing the challenges and problems in mental hospitals from first-hand experience as well as examining different mental health diagnoses and taking on the myths around them. Not the kind of myths I cover, the kind that hurt. Thank you, Caz. You are an amazing, courageous person.”
Kindly written by Ceridwen at Illuminating the fools mirror, 2020.

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.

No need to explain

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?

Blood, sweat and tears
The balance careers photo

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.

The way to change the world is through individual responsibility and taking local action in your own community. Jeff Bridges

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

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!

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

What is a Community Mental Health Team (CMHT)?

My first placement at a Community Mental Health Team

Student nurse Practice Based Assessments

Depot injections by Community Mental Health Team

Administering my first depot injection

My first Community Mental Health home visit

Bipolar disorder

Community Mental Health Assessment

Mental Health documentation to be completed

My Practice Based Assessment

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Have you ever felt anxiety while you were studying?

My anxiety was crippling while I was studying

I wish I’d known how to reduce my anxiety while studying

Before you go any further, stop!

What is an anxiety disorder?

Some symptoms of anxiety

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Have you ever been bullied by work colleagues?

What is bullying?

The serial bully

How it feels to be bullied

How bullying affected my self-esteem

Power and control

The policeman’s wife

Don’t rock the boat

Nurse sleeping on night shift duty

Poor practice being ignored

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What makes an excellent mental health nurse?

Attributes of a good mental health nurse

Empathy helps patients with mental illness

Being Non-judgmental is essential

Communication skills are a key requirement for every good mental health nurse

Speak Clearly

Compassion

If you are a nurse commitment must be on your list

How a good mental health nurse must have the ability to stay calm in a crisis

Emotional intelligence: A mental health nurse must have the ability to understand her patient’s emotions

Adaptability – Nursing in a fast paced environment

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Update

Mental Health Nurse training

What does Continuing Professional Development really mean?

Refusing to attend training courses is a reason for poor standards in mental health units

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Patient’s fears about admission are real; an increase in poor standards in mental health units is observed at a national level

Patient fears are real for them

Private sector mental health units

Private sector treating patients badly

How I dealt with it

A typical example of an employee with low standards

Did no one care about low standards at mental health units?

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What do ward managers do on mental health wards

Ah, here’s the rub

What could managers do?

What managers should do

Job spec doesn’t apply to management

Love your enemies

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Shocking ugly truths about our Mental Health Nurses

Who oversees our mental health nursing standards?

Nurses should be doing more

No wiggle room to meet everyone’s every need

Nurses could work smarter

Not every day you get to see such sights

As for managers

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