Student Nurse Blog Year 3 - Week 21

January 24th 2007

24/01/2007

I started the second week, and final part, of my mental health/psychiatry EU Directives placement on Monday 22nd January 2007. The first shift was an 8am – 4pm stint. The placement was on the same acute psychiatric admissions ward that I had done my first weeks mental health EU Directives.

Although I was still familiar with the ward, the shift started with a tour around, showing me where everything was. I was then issued with my personal alarm. After that I was given a quick overview of the ward philosophy and policies. Since I had last worked on the ward a new strategy had been brought in known as ‘Refocusing’.

Refocusing aims to improve the standard of care and patient satisfaction. This means that the patient receives a more focused admission based on their needs. They will be given an opportunity to express their opinion about their care on the ward and will be provided with a structured day that will engage them with nursing staff. This will happen by providing predictable, well-managed and clear structures on the ward. By introducing and maintaining appropriate ward boundaries. Developing the means to provide high levels of therapeutic engagement and to promote respectful, joint relationships between staff and service users and their significant others and to ensure that service users and those who advocate for them work together with staff towards a common aim extended within the refocusing project.

Everyone I have spoken to, both patients and staff have found the ward boundaries and expectations very fair and reasonable. I think that the idea of refocusing is fantastic. Especially from my previous experience of acute psychiatric admissions wards. I have worked for a very short time on two other such wards prior to my nurse training (around 2001) and found that – at that time – patient and nurse interaction was very limited with no real structured day for the patients (please note that these two psychiatric wards were not in this area and were in two locations much further south of my current location).

If anyone wishes to see a copy of the ward boundaries and expectations please feel free to ask and I can post them on this blog, or email them.

I was then given time to walk around the ward on my own and talk to some of the patients. Three of the patients on the ward had been on the ward during my first week’s mental health/psychiatry placement over a year ago. However, these three particular patients each suffer from long term mental health conditions which means that they occasionally relapse and become non-compliant with their medication, or they get better and again become non-compliant with their medication (because they feel that they no longer require it because they are better). This then means that they need to be admitted to an acute psychiatric admissions ward so they can be mentally stabilized and recommenced on their medication.

I spent a lot of the first day talking with the patients and getting to know them. Some of them were more engaging in conversation than others, depending upon why they had been admitted to the ward. Mid-morning I met up with the nurses again and they went through the weekly activities timetable with me. There was a newspaper group held each morning. This basically involved one of the nurses sitting with some of the patients in the dining room and talking about the contents of the newspapers. I joined in with that morning’s newspaper meeting, which lasted until lunchtime. I spent lunchtime reading through the notes for a couple of the patients that I had talked to that morning (the one’s that I had not known from my previous time on the ward). After lunch I spent some more time talking with some of the patients. Most of the conversation involved asking the patients how they were feeling, how long they had been on the ward for, why they had been admitted to the ward, past psychiatric history, any concerns that the patients had and how they felt they were coping. The responses I got from a large amount of the patients I spoke to were quite positive. A lot of the patients were happy to talk about their psychiatric illnesses or psychological conditions. Of those patients who had no insight into their illness, they were still happy to engage in conversation regarding their delusions or psychosis, which allowed me to gain equally beneficial information into their conditions.

At 3pm there was a scheduled ‘stress busters’ session, which was one of three weekly afternoon sessions run by the Occupational Therapist. However, she was off sick this week, so the session was run by one of the nurses. There are two acute psychiatric admissions wards that are joined together and share the same dining facilities. They also share the same planned activity sessions, such as ‘stress busters’. A total of six patients attended the afternoon session from both the wards. The nurse read out information on anxiety from an information pack, covering what anxiety was, what triggered it, the physical symptoms resulting from anxiety and then a question and answer session. I was able to give some advice at the end regarding the benefit of identifying ‘triggers’ for anxiety and learning and rehearsing relaxation techniques so they became a conditioned response in order to allow people to cope with anxiety provoking situations. I was only able to do this due to my psychology diploma and other previous training in counselling.

I found the first day very useful and extremely good. It allowed me to build good relationships with around half of the patients on the ward, as well as learn about the new techniques used in psychiatric wards regarding patient care and treatment planning.

My second shift was on the Tuesday, where I worked a 9am – 5pm shift. I was also supposed to have my intermediate and final placement interview for my clinical placement. This was due at 11am. I started the shift by joining in with the morning drug rounds again and talking with the nurse about some of the medication. I then spent most of the morning talking to several of the patients and expanding on the conversations I had with some of them the previous day. At 1050am I left the ward to go over to the medical rehab ward (also in the same hospital) for my intermediate and final placement interview with my mentor and ward manager. When I arrived at the ward it was absolute chaos (no change there for the NHS!). The first thing I saw as I walked onto the ward was the Matron running with an ECG machine. Whilst I waited for my mentor I revised some medications for my interview and helped out on the ward by answering the phones. At 1120am I started to become a little concerned, wondering whether my mentor was delayed because she was trying to find somewhere to park, or had forgotten about it or was unable to make it due to other clinical commitments. At 1140am I decided that I would go back to the psychiatric ward, to save wasting anymore time. I left a message with the ward clerk and one of the staff nurses asking my mentor to radio page me or phone the psychiatric ward when she came in for the late shift. Then I left my radio page number on the front of my practice placement competencies folder. I went back to the psychiatric ward and read up some more in the office on assessment rating scales.

During lunch time I read up some more on the assessment scales and then ate my sandwiches in the dining room, whilst talking with some of the patients. In the afternoon I spent more time talking with some of the patients. There was one particular patient who had been admitted as being psychotic and suicidal. He was in a particularly low mood and I spent a good time over the two days talking with him. On several occasions I had managed to raise the mood (if not only slightly) with three of the patients I had talked with during my time on the ward. I spent a good fifteen minutes talking with this male patient and, as with every other patient I talked with, I explained that I was a student nurse and was not trained to the same level as the psychiatric nurses on the ward. At the end of the conversation with this male patient, he thanked me for our conversation and said that it had helped him greatly, his mood had certainly improved. After that I attended the weekly ‘community meeting’, which is the same as the old style weekly ward meetings, but developed more around the new ‘refocusing’ philosophy.

Things started to get a bit more exciting after the meeting. One of the patients, who wanted desperately to be home by Thursday and was sectioned on the ward, started to loiter around the main entrance, watching the main doors. Three other nurses and myself were in the dining room area, where we could see the main entrance. We were keeping an eye on this particular patient, as she had tried to leave the ward before during prior admissions. Things then started to take a turn for the worst. The nurses had to attend to another patient and asked me to keep an eye on this other patient by the main entrance. A couple of the nurses from the other ward were in the dining room area, but didn’t have a completely clear view of the main entrance and ofcourse, they had their own patients to watch. After successfully deterring the patient from attempting to leave the ward on a number of occasions, it finally happened. A visitor was leaving the ward and I saw this patient turn towards the main doors. I went after her and called out her name as she got to the doors. She slipped through the doors after the visitor and suddenly my heart started pounding. She had made it off the ward. Adrenaline kicked in and I just ran, calling after her. She ran past the visitor and towards the stairs. I burst out of the ward doors and chased after her, running down the stairs. I could hear two nurses running behind me, I was pleased to hear I had backup with me. On the second flight of stairs I caught up with the young female patient and grabbed her arm, but she shook free. Not wanting to cause her to fall down the stairs I decided not to grab her again until we were off the stairs. I jumped down the last five steps and chased after the patient. Ten feet away were the first set of automatic doors. This slowed the patient down and gave me chance to close the distance. As she passed through the first set of double doors I grabbed her around the waist with both my arms. She was powerful and obviously determined to escape, but I was able to prevent her from going through the external set of automatic doors. By this time the two other nurses had caught up with us and were restraining the patient.

I was relieved for the support and backed off as the two nurses took over. I stayed behind the patient, in place and ready to assist if she broke free. The hospital manager was also there to assist, if required. We took her to the lift and then back up to the ward, where she was given some sedatives and put on close observations. I have worked with psychiatric patients a lot, both before and during my nurse training, but I have never had one try to escape on my shift before. I certainly reflected on this incident in my professional reflective journal. I learnt a lot from this incident, the first being, why didn’t I activate my personal alarm before chasing after the patient? What would have happened if I hadn’t been seen chasing after the patient by the two other nurses? Why didn’t I atleast call out for assistance when I engaged on the chase? Even though I called out the patient’s name, without calling for assistance I could have ended up persuing her on my own with no back up support once I had caught her.

After that we had more excitement on the ward as a new patient was admitted. This male patient had spent the last month abroad and was being admitted following a ‘manic’ episode, which had resulted in him being detained by the police where he was then detained under section 3 of the mental health act. When he was brought onto the ward he was extremely manic and under the influence of alcohol. After an assessment with the on-call psychiatrist he then came back onto the ward area. He was verbally abusive, demanding that he speak to his private psychiatrist or he would sue the hospital, demanding that he phone his solicitor, accountant and anyone else he could think of. At times he was that worked up that his speech was incomprehensible. It was such an interesting case that I stayed on after 5pm, although only by ten minutes, but enough time for me to see the nurses calm the patient down slightly and talk him into taking some of his medication. It was certainly a very interesting and educational shift. However, it also reminds you just how much suffering people can experience who have psychiatric or psychological illnesses or disorders. It is such an unfortunate situation for anyone to find themselves in. Then you try to compare medicine non-compliance for a patient with insulin dependence diabetes against a patient who has schizophrenia. It makes you wonder if some non-compliance management strategies used in psychiatry could be successfully adapted and transferred to manage non-compliance in some medical patients. See you, Matt.

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Day three – Semester 5 EU Directive Mental Health placement. 

Today I worked an early shift on the psychiatric ward, starting at 7am and finishing at 3pm. We started the shift with handover. The new patient who had been admitted yesterday late afternoon had apparently calmed down considerably during the evening and had had a peaceful night. Handover finished at half seven. I then joined the nursing auxiliary who was sitting in one of the comfortable seating areas on the ward. There were a handful of patients who were already up and a couple of them were sitting in this area. We sat chatting with them. I asked the nursing auxiliary what the routine was for an early shift (as I had previously started after 8am on my first two days). She explained that there wasn’t much to do until around 830am when we would go round and wake up any patients still asleep so they could have their breakfast and medication.

My mentor saw me and asked if I’d like to have my own patients today. I jumped at the chance and she assigned me four patients. The four patients she had assigned to me where those whom I had spoken to and engaged with the most, except for one of the patients, whom I knew and had spoken to only briefly. She explained that for two of the patients I would have to do a one to one with them during my shift. This is where you sit down with the patient and talk to them or engage in an activity with them of their choice. The patient gets to choose the content of the one to one sessions.

Just after 830am the nurse auxiliary and myself went round the three dormitories and all the side rooms, waking up those patients who were still asleep. At 9am the morning drugs were started and I went round reminding those patients who were still in bed about their medication. We finished the drug round at 920am and I returned to the office to get ready for one of the morning ward rounds. At 930am I went down to the resource room (where ward rounds and other meetings are held) along with the staff nurse, a pharmacist and a psychiatrist to do the morning ward round. It was quite interesting sitting in on the ward round because two of the patients on the round were patients I had had quite a bit of contact with during my first two days on the ward. This meant that I knew quite a bit about them and their conditions and was able to expand on that by sitting in with the psychiatrist. The other two patients were patients I wasn’t so familiar with. One had Huntingtons’ disease and I had not really engaged with this patient, as she tended to isolate herself a lot. The other patient had suffered a form of dementia caused by Korsakoff’s disease. This is an illness in which damage to a small area of the brain results in disorientation and absolute loss of recent memory, often caused by alcoholism. In this patient’s case it was caused by alcoholism and she had lost most of her short-term memory capacity. This meant that she was being referred to alternative suitable long-term accommodation. In most cases this would probably be a residential home of some kind. However, in this patient’s case the psychiatrist had been able to find a specialist unit which dealt purely with patients who had Korsakoff’s disease.

The ward round was an interesting and educational experience. We finished the round at just before 11am. One of the patients’s I was due to do a one to one with approached me and asked if I was doing the one to one with him. I told him I was and asked him what he would like to do during the one to one session. He told me that he just wanted to talk. I checked with my mentor who told me it was fine for me to do the one to one session with the patient before lunch. I went back to see the patient and asked him if he wanted to have his one to one. He agreed and we went into the lounge to have a chat. I let him lead the session. He started by talking to me about his delusions of threats against his life by various organisations and how he felt there was also a new threat from another organisation. We continued to talk about his delusions and I tried to lead him onto the issue of safety and whether he felt any safer since he had been admitted to the ward. He told me that he felt much safer now that he was on the ward. I then asked him about his level of mood, which he responded by telling me he was reasonably happy. I asked him about activities and whether there were any activities that he would like to take part in, which he wasn’t currently involved with. He seemed to be involved in a couple of regular activities and didn’t wish to be involved in any more. I finished the session by asking the patient if there was anything else he wished to discuss. There wasn’t, and he was happy to finish the session, so I informed him that if he wanted to talk about anything else later, just to come and find me. The session lasted around half an hour. After the session I returned to the office and documented the session in the patient’s notes. I then asked my mentor to read the entry and counter-sign it for me. My mentor told me that the entry was fine and that she was happy with the way I had conducted the session with the patient.

Whilst I was doing a one to one session with a patient another ward round was taking place. This was in the form of a review with a psychiatrist reviewing the patient who tried to escape from the ward yesterday. Obviously the psychiatrist explained that there was no way possible that he could even consider discharging the patient. She became upset about this, however, the psychiatrist explained that if he discharged her and she went home and killed herself intentionally or by accident he would be accountable. A compromise was reached and the psychiatrist put the patient on 30 minutes observations for the rest of the day and overnight. He told the patient that if she could show she could behave for the rest of the day and overnight, she could have a days leave tomorrow for her birthday and then weekend leave thereafter, until the psychiatrist was happy she could cope fully at home with her parents.

Not surprisingly, giving the nature of this patient’s condition, the young patient started to loiter around the main entrance area. We all knew what was going to come next. She would try her best to escape from the ward again, proving that she really didn’t want to go on leave, or even get discharged from the ward. When a patient suffers from a combination of a type of personality disorder and behavioural problems it can make it so much more difficult to help them. This young patient has already appealed against her section and now that her psychiatrist has refused to discharge her, the appeal will go ahead and is scheduled for Friday morning. It would be really good if I am able to sit in on the appeal. However, I am not sure if this will be possible, due to the age of the patient and the nature of her personality and behaviour. I will ask my mentor tomorrow sometime and see what she says.

After writing up the notes from the one to one session I took half an hour off for lunch, so I could go over to the Education centre and library and print off some things I’d got off the internet around mental health patient assessments. I got back to the ward around 1240pm. I spent the rest of my time chatting to some of the patients on the ward. At around 130pm I wrote up in the notes of the four patients that I had been assigned to that day. One of the patients I had been assigned to was also in the morning ward round that I had attended. During the ward round provisional discharge arrangements had been made for this patient and I documented these details in this patient’s notes.

I really did enjoy the shift today and can’t wait until my next shift. I am working early shifts for the last two days of my placement. With regard to my intermediate and final interview, I still haven’t heard anymore from my mentor. I phoned the clinical facilitator manager again today, who has now told me that the final interview form is not due for submission until 4pm on the 6th February, so this gives me an extra week at least. Matt

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25th January

Well today I experienced first hand that the mental health NHS Trusts are in just as much crisis as the Acute NHS Trusts, its dangerous, unacceptable, and down right disgraceful that healthcare professionals such have to work under such conditions! No matter where you work, it seems that if you are a nurse working within the NHS you are putting your PIN on the line every time you go into work. The senior managers, chief executives, NHS and Government are incompetent and need to sort it out.

I am sorry that I seem to be so disillusioned with the NHS but every nurse I have spoken with has raised their concerns and fears over the current working conditions. If anyone every came to me and told me they were thinking of doing their nurse training I would quite simply tell them to forget about it and look at a career in some other profession.

I was on the early shift, working from 7am – 3pm. When I got to work there was one trained nurse and one nurse auxiliary on the same shift as me, that was it. We had one level one patient (which means they have to be specialed the whole time) and nine level two patients (who are under observations)! All this and just two members of staff on. Obviously I was there, but if it hadn’t been for the fact that I was there this week for my mental health placement, it would have just been two members of staff. They had put an ‘A’ grade post out to NHS professionals yesterday morning, but the agency had been unable to fill the post. We were unable to borrow any staff from the ward adjoined to ours, as they were also dangerously short staffed.

We had handover. The patient who tried to escape from the ward the previous day tried to escape from the ward again last night. Only this time she made it out of the hospital and was apparently dodging traffic on the main road before nursing staff were able to catch her. So she was on 5-minute observations. Another patient was on 10-minute observations, four patients were on 15-minute observations and three patients were on 30-minute observations. They had three discharges and three new admissions last night, and we still had a patient in a ‘leave’ bed (where the patient was away on leave). However, this patient was due to return from leave today. If she had done well on leave then we would be okay because we could send her out on leave again. However if she hadn’t coped so well it would mean that we would then have two patients assigned to one bed. But then if the NHS will close all these acute admission psychiatric wards, its bound to place a strain on the remaining wards that are still open.

After hand over the nurse auxiliary went to take over on the special with the level one patient. I joined her and chatted to her about level one observations. It was something that general student nurses were not allowed to do. However, when I had done my first week’s mental health placement on the ward I had done the level two observations. I went back to the nursing office and saw my mentor. I asked her if she wanted me to do the level two observations. She told me that she was going to ask me to do this, but needed to go round the ward and count all the patients for the start of the shift and carry out the first full set of level two observations herself first. So twenty minutes into the shift and I did level two observations for an hour. At 830am I started to go round the ward, waking up the patients who required morning medications. Luckily at 8am another nurse auxiliary and staff nurse turned up to work, so we had a few more numbers on the ward.

The whole shift was busy from start to finish. I had two turns at doing level two observations (which I was put down to do and involved one hour each turn), but ended up doing around four hours of level two observations because the nursing staff were so busy. I was also allowed to witness first hand and see section 5(4) of the mental health act (nurses holding power to keep a patient on the ward for six hours) and section 5(2) of the mental health act (doctors holding power to keep a patient on the ward for a further 72 hours). This was due to one of the emergency admissions that came in last night wanting to leave the ward. The staff felt that if this patient did leave the ward they would end up killing themselves. After contacting the patient’s psychiatrist it was arranged that the patient would be put on a section 3 of the mental health act, where they could be detained for up to six months. The patient’s GP and social worker were contacted, as a patient can only be put on a section 2 (up to 28 days) or section 3 by a psychiatrist, adequately approved social worker and a doctor. No one wanted to section the patient, but felt it had to be done for her own safety.

Obviously this took up a lot of the nurses time, plus we had a morning ward round as well, which one nurse had to be present at. In addition to this, the nursing staff also had to arrange the review for the patient who had returned from leave. This meant she had to see the psychiatrist at the ward round and one of the nurses had to contact the community psychiatric team to get a report on how the patient had been doing whilst on leave.

I had been given four of my own patients again; two of which were due for a one to one. Unfortunately I was only able to do a one to one for one of the patients, as I did not have enough time to do two. Out of all the one to ones required for the patients on the ward, I think only half of these were done. This was due to lack of time, staff shortages, and a very high workload. Even one of psychiatrists I was talking to commented on how the NHS was no longer coping and did not have anywhere near the resources required to allow staff to meet some of the national guidelines for best practice.

None of us got to have a lunch break. I ate my sandwiches in the dining room, whilst writing up the notes for the four patients I had been assigned that day. They allowed me to leave half an hour early, as I did not have a lunch break. All the nursing staff, especially my mentor, were disappointed and apologetic that the shift had been the way it was and that I had – at times – been used as an extra pair of hands. However, they were all very grateful for the work I’d done during the shift and thanked me for my help. My mentor had described the whole situation as being ‘total sh@*@’. She had written out an incident form reporting the dangerous situation due to being short staffed. However, my mentor explained that it wouldn’t do much good, as none of the other incident forms had made any difference. Never mind, it seems that the early shift tomorrow could also be just as short staffed. I am on the early tomorrow, so I will let you know how it goes.

I have just been up to the rehab ward where my placement is. My two mentors (the two ward sisters) have done my final interview form for me. When I spoke to the clinical facilitator about having problems fitting in the final interview, she told me that if my mentor was positive I would pass, she could complete the final interview form for me first, and then later arrange the final interview. I had left my practice placement book with both my mentors on Friday, so they were both able to have a look through and see the compentencies I have to achieve. The assessor’s comments part of the form was brilliant. They have really given me a fantastic write up and they have passed me with merit. That will be the third placement I have passed now with a merit, which is good sign into my ability and professional conduct as a nurse.

I finish my mental health placement tomorrow and go back to the rehab/care of the elderly placement on Monday. I have two weeks left of that placement, but will have my intermediate/final interview next week, just to ’tick all the boxes’ in my practice placement book (which we now no longer have to submit) and to enable two way feedback regarding my time on the ward and the compentencies I have achieved. Matt

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26th Jan

Today was my last day on my mental health placement. In many ways I felt disappointed, as I had enjoyed the last week and would have liked to have spent more time on this placement. I had built up some good therapeutic relationships with some of the patients and had been able to gain an insight into several mental illnesses, as well as gaining an insight into patients’ experiences with living with such illnesses.

As a third year student I had definitely noticed the difference between this week’s experience on the psychiatric ward compared to my first week’s experience during my first year of training. However, in many ways I still feel that during the first year of adult nurse training, we should have atleast three to four weeks’ learning disability, mental health and paediatrics/midwifery, as opposed to just one to two weeks.

My shift today was an early shift starting at 7am and finishing at 3pm. The shift was just as busy as usual. I had a great last shift and took part in several level two observations as well as engaging with several of the patients on the ward. Many of the patients with whom I had interacted and engaged with during the week knew that today was my last day. A few of them had thanked me for the small difference I had made by talking with them during the week. Where I had felt confident I had used a brief form of solution-focused therapy during conversations with some of the patients. Under the new ‘Refocusing’ strategy for acute admissions psychiatric wards solution-focused therapy should form the structure of therapeutic conversations with the patients. It is a very useful form of therapy, where there is no real need to focus on, or explore, the problem. Instead it looks at solutions. What the patient would like to see happening to improve their situation, how they see the future when they are better, coping strategies and mechanisms, etc.. It is a very useful form of therapy that can be used in any situation.

I was able to spend a little bit of time on the office computer and searched for articles on Solution-Focused Therapy, which is the type of conversational engagement strategy that is used on the ward with psychiatric nurses engaging with patients’. It is similar to the humanistic psychology approach, where the idea is to focus on solutions as opposed to the problem, and trying to encourage the patient/client to arrive at their own solutions, rather than directing them.

Near the end of the shift many of the nurses thanked me for all the hard work I had contributed during my time on ward. My mentor thanked me and informed me that I was the keenest general student she had seen on a mental health placement. I think this is because a lot of general students’ can be slightly afraid due to the nature of some of the patients’. I explained that I was just a keen student with an interest in psychology, psychiatry, counselling, and general medicine. I am keen in every area I come into contact with within the health care industry. Matt

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