What Psychiatric Nurses Do (Part Two – Assessment and Care Planning)

This is part two of the series on What Psychiatric Nurses Do. You can read Part One here.

A significant part of the training to be a psyche nurse involves learning to assess needs and plan care. It’s a tricky thing. In theory (and what you learn in training), a nurse is supposed to assess all aspects of a patient’s needs, including social needs, spiritual needs, physical needs, etc… In reality that rarely happens. There simply isn’t the time to go into so much detail, and ward-based nurses don’t have the time or resources to address things like social needs. These would be the remit of community psychiatric nurses (CPNs).

Assessment tends to be a fairly ad-hoc thing. Assessment tools are available, to assess things like depression, anxiety, withdrawal symptoms, medication side-effects, etc, but on a ward they’re rarely used. Again, there simply isn’t the time. Nurses (and support workers) simply use their knowledge and experience from day-to-day interactions with patients to assess what’s happening for the patient and what their needs are. Every interaction with a patient is a mini-assessment. To a casual observer it may seem like a nurse discussing with a patient what’s on the TV is just that, but in fact that nurse will be assessing the patient’s alertness, cognition, signs of depression or anxiety, signs of psychosis, any confusion, the presence of pressured-speech, thought disorder, etc.

In addition to these general conversations, the nurse will aim to spend dedicated 1:1 time with the patients they are assigned as primary nurse for. These sessions will be an opportunity to discuss what the patient’s needs are, how they feel about their treatment and progress, any issues they have, any symptoms they are experiencing. There is rarely time to explore issues in depth, and in truth most nurses have very little training in therapy and counselling. We can take courses on counselling and the like, but these tend to be available to more experienced nurses on the higher grades. Band 5 nurses (what I was) don’t tend to be trained in therapies.

Care-planning is supposed to take place together with the patient, based on what needs have been identified and assessed. And in an ideal world, that would happen. But when targets to have care plans completed within 72 hours of admission were brought in, this pretty much went out the window! Care-planning became a paper exercise, based on little, rarely with involvement from the patient, and simply to have them completed so it looks good on the ward stats. Nurses try to make the care plans as tailored to the patient’s needs as possible, but when you have to have the care plan completed before you’ve even sat down with the patient or you get hassle from managers, it makes it difficult.

Either way, care planning basically involves just that – planning the care. They’re all done on a computer form now, where you identify a need, decide what interventions you are choosing to address that need, and review the plan weekly to amend the interventions, close them if needs have been resolved, etc. So let’s say for example someone is suffering from a manic episode. Their needs would be to get some sleep, experience a reduction in symptoms, get some time out, etc. Interventions would be things like education on sleep-hygiene, administration of medication, addressing agitated states through de-escalation techniques, PRN (when required) medication, etc. Once the care plan has been devised, it can be discussed in review with the doctor where interventions will be decided by the Consultant and nursing team, and the nurse can put things like referral to community teams, therapies, etc, into action.

Assessment is a significant part of the role of a psyche nurse. The Consultant and other professionals rely on the day-to-day assessments of the nursing team. Discussions amongst the nurses about the presentations of the patients take place at staff hand-overs, where there won’t always be agreement about what’s going on for a patient and what the plan of action should be. Which leads me onto my next subject…. hand-overs and shift-leading.

What Psychiatric Nurses Do (Part One – Admissions)

My nursing-related posts have always been popular, including the one I had to delete from my old blog. So as I’ve just left the profession, I thought I’d pay kudos to the hard work of my ex-colleagues and just explain to anyone interested what psychiatric nurses actually do. This will be a little series of posts about the profession, with details of all the aspects of a nurse’s job.

When I registered on the course to train to be a psyche nurse, I honestly had no idea what it actually involved. And if you asked anyone not in the profession, they would probably have some misconceptions about the role, and in truth no real idea of what the job involves. Psyche nursing is completely different to any other type of nursing. And the role is about as diverse a job as you can get. I don’t think even my friends and family genuinely understand what the job involves. There are whole books on the subject, trying to pin down what exactly a psychiatric nurse does. I myself started (and WILL one day finish!) a book based on a psychiatric ward.

So here I’ll try to describe what a psyche nurse actually does…

Well firstly, nurses work on lots of different areas. During my training I was mostly ward-based, because that’s what I preferred, but I also did placements on elderly wards, community teams, rehabilitation and a day-centre. In the UK, people in mental health services (let’s call them patients :P) usually enter mental health services for the first time through a ward. They’ll go to A&E, be picked up by the police or go to their GP (general practice doctor). The ward will assess them and either send them home, refer them to a community team who will support them at home, or perhaps send them onto rehabilitation or to attend day centres. It all depends what level of support is needed.

As I’ve pretty much always worked on a ward, I can only really speak from the perspective of a ward-based psyche nurse. So that’s what I’ll do.

So yeh, most of the patients referred to the type of ward I worked on, come through A&E or the police. We’d occasionally have people referred from a GP, but not very often. Most admissions are people who have either attempted or threatened suicide, and have been picked up by an ambulance and taken to A&E. There they are assessed by the Crisis Team (a specialised team of psyche nurses and Psychiatrists), who are the ‘gate-keepers’ to the wards.

The other way patients are usually admitted is being picked up in the street by the police, usually for acting strangely, or if the police have to go their home after a disturbance. The police bring the patient to a special unit called the 136 Suite, where they can be assessed by a nurse and a doctor, who will decide if they should be sent home, admitted and if necessary sectioned.

So once the patient has either agreed to come into hospital voluntarily (informal) or has been sectioned, the nurse in charge of the ward (i.e. this was me) gets the call from the Crisis Team. I would take a history, find out why the patient is being admitted and what the assessing practitioner wants from the admission. It may be further assessment, treatment, detox (although officially detox isn’t an appropriate reason for admission to an acute ward it does happen, A LOT) or to maintain their safety until further support can be put in place at home. I would then find out when the patient is coming, how they’re arriving, what sort of state they’re in, any risk issues, etc.

Once the call is over I would find the patient on the computer system, do a bit of reading, inform my colleagues and the on-call doctor of the admission, make sure a room is made up, allocate someone to do the admission (which could be me), and start the paperwork. It may be many hours before the patient actually gets to the ward.

Once the patient comes, if I was admitting, I would welcome them to the ward, explain what is going to happen, and then sit down with them and complete their admission paperwork. They may be extremely distressed, in which case I would risk-assess the situation, may ask other members of staff to sit in with them, or simply leave all the admission stuff until a later time. The doctor would attend, and together we would take a history if we could. Then I would show the patient around, explain the ward rules, and generally settle them in. If they were distressed, at that point I would leave them with colleagues and myself and the doctor would discuss medication to help calm them.

Once the doctor has done his stuff, including blood tests, a physical and other little jobs, I would then sit down to complete care plans for the patient, risk assessments, and other bits of paperwork, all of which can take as long as three hours. That’s right… THREE HOURS!!!

Admissions are generally easy but time-consuming, but they can be risky. Most admissions are patients who are known to services and have been in hospital many, many times (which is partly what makes the job so soul-destroying), but occasionally a patient who is completely unknown will be admitted. In truth, when you enter that room with them, you don’t know what you’re walking into. Part of the training to be a nurse is teaching you to recognise dangerous situations and prepare for them. For example, before entering a room with a patient a psyche nurse knows to inform other colleagues where they are, ensure their attack alarm is working and easily grabbed, where the exit to the room is, and where the best place to sit for the quickest exit is. But even with all that, occasionally things can go wrong. It’s never happened to me, but there have been times where the assessing nurse is attacked. A few years ago on the ward next to the one I worked on, when assessing a patient with puerperal psychosis, a member of staff was severely beaten, requiring many weeks in hospital.

So that’s admission. Next time I’ll discuss assessment and care planning.

Recipe: Chocolate and Orange Fudge

It’s been ages since I posted a recipe, though I’ve been doing loads of baking. And I’ve been experimenting with fudge, among other things. I LOVE fudge. And it’s surprisingly easy to make. People are put off making it, thinking it’s very complicated, but in fact it has very few ingredients and with a bit of practice it’s a cheap and simple treat that can be made in loads of different flavours. Here is the recipe for a delicious chocolate and orange fudge, made by myself for my little bro’s birthday last week. It’s really scrumptious!

Ingredients:

• 115g unsalted butter
• 300ml full-fat milk
• 150g milk chocolate (broken into pieces)
• 450g granulated sugar
• rind of 1 orange
• juice of 1/2 orange

Method:

Grease a shallow 18cm/7 inch square tin.

Pour the milk into a large saucepan with the chocolate, butter and sugar. (To make fudge you need as large a pan as you can get, as the fudge will travel up the sides as it boils. I use a jam-making pan, which is huge. A large saucepan will do, but it’ll take much longer to cook).

Heat the mixture in the saucepan gently, stirring constantly, until the chocolate and butter have melted and the sugar has completely dissolved.

Bring the mixture to the boil. Simmer, stirring occasionally, ensuring you scoop the mix from the bottom of the pan so it doesn’t stick.

As the mixture turns into fudge you will notice a change in smell, and it will look thicker. To check whether the fudge is ready, you can use a sugar thermometer (the temperature should reach 116C – soft ball stage), but I prefer to test with a bowl of cold water. Drop a small amount of the mixture into the water and then roll it into a ball. If it forms a soft and squidgy ball that doesn’t disintegrate in your fingers, it’s ready. This can take anywhere from 10 minutes to as much as 40 minutes, depending on the size of your pan, how quickly it was simmered, etc.

Remove the pan from the heat and stir in the orange rind and juice, stirring quickly. Leave to cool for 5 minutes. (This is the part where fudge can be ruined if you leave it to sit too long. It’ll start to solidify and crack. Don’t leave it any longer than 5 minutes.)

Using a wooden spoon, beat the fudge until it begins to lose its shine and becomes thick and creamy. (This can take a long time and it’s hard work, but don’t be tempted to stop before it’s done. You will definitely notice the difference when the fudge has changed.)

Immediately turn the fudge into the tin and leave it to cool. When it is cool, mark the surface into 1 inch squares and leave it to set for a few hours. When it’s set, cut it into squares with a sharp knife.