What Psychiatric Nurses Do (Part Eight – Managing Self-Harm and Suicide)

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This is part eight of my series on what psychiatric nurses do. You can read the other parts of the series here.

Self-harm is an unfortunate reality of mental health care. Many of the patients on psychiatric inpatient wards self-harm in one way or another, despite the efforts of all the staff to prevent it. Cutting, burning, scalding, swallowing dangerous substances, inserting objects under the skin, taking numerous small overdoses, head-banging, etc. Patients will find ways to self-harm no matter what you do.

I remember the first time I had to deal with a serious self-inflicted injury. A male patient had cut his wrist in his sink using a razor blade. There was blood all over the floor, in the sink, on the bed, up the walls, and his arm was covered and pumping ever more blood out. I never thought I’d be squeamish in this long-anticipated situation, but I was surprised by how freaked out I was! I panicked and asked a more experienced nurse to deal with him while I cleaned up his bedroom.

Dealing with self-harm is also challenging on a personal level. With the above incident, I found it incredibly difficult not to get angry with the patient for causing so much trouble for me and my colleagues and for putting himself and others at risk in this way. It’s hard when the same people self harm over and over and you have to deal with the consequences when you’re already very busy. Especially when they said they wouldn’t and you gave them your trust. There was a patient on the ward I was on a short while ago who would take small Paracetamol overdoses virtually every time she went off the ward, despite assuring you she wouldn’t. Each time we knew it wasn’t enough to be seriously harmful, but we still had all the extra work of ringing doctors, hospital visits, paperwork, etc. It’s hard to be patient sometimes.

When a patient self-harms it’s basically the psyche nurse’s job to pick up the pieces. Call an ambulance or doctor, clean up the wound, put on a temporary dressing, escort the patient to A&E if necessary, and do the reams of paperwork it causes. It’s difficult – psyche nurses, bizarrely, are not trained in dressing wounds, stitching or anything like that. Other than a lesson in very basic wound care and aseptic technique at uni, I never had any sort of tutelage in wound care or dressing. Wound care tends to be left to the junior doctors, who instruct nurses on when to change the dressings and how.

There tends to be a dispute among psyche nurses about the proper way to deal with self-harming. Balancing risk and promoting responsibility is a balancing act and all nurses have different opinions. Some argue that self-harm is a coping strategy, albeit a maladaptive one, and that patients should be allowed to utilise it in a safe manner. Others take the opposite view and believe self-harm should be prevented at all costs and every single possible risk should be eliminated. Actual practice tends to fall somewhere in the middle. Obvious risks are eliminated as much as practicable. Known cutters are supervised when shaving and searched for sharp objects when returning from leave; burners aren’t allowed cigarette lighters and supervised when smoking, etc. But risks can never be completely eliminated and at some point the patients have to take responsibility for themselves. It all comes down to care-planning and risk assessment. For example, a well-known patient to the ward I was on would self-harm by inserting staples and metal pins under their skin. There was no way we could stop them without massively infringing on their right to autonomy and it being a massive drain on staff resources. So they were given access to dressings and a doctor would periodically check their wounds for signs of infection.

Suicide attempts are one of the most challenging parts of the job of a psyche nurse. They’re not common, and most are not serious attempts, but are often made to sabotage care, make a point, etc. It’s unfortunate but true that some patients will use the threat of suicide as a way to get what they want, even making serious attempts but at times that they know someone will find them. Again, dealing with this sort of behaviour is very challenging, and is a major reason so many nurses become cynical (myself included). However very occasionally someone will make a genuine, real attempt to commit suicide, usually when off the ward. It’s never happened to me. In fact I only ever knew one patient who successfully committed suicide after being discharged, and I was a student. He drowned himself in a lake after convincing the whole team he was well enough to go home.

The job of the nurse is obviously to prevent suicide as much as possible. Hourly checks of the ward are done by all staff in turn, but those patients who are perceived to be a high suicide risk can be monitored more frequently, to the point where a member of staff can be within arms reach. They will be monitored until staff are satisfied the risk has decreased, and as a team the nurses and sometimes doctors will decide to reduce the observation levels. It’s a lot of responsibility and sometimes we will be wrong. The media love to vilify us for getting it wrong when someone manages to commit suicide under our care, but we’re not faultless and we’re not psychic.

Next time I’ll discuss the AWOL procedure and observations in more detail.

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What Psychiatric Nurses Do (Part Seven – Managing Violence and Aggression)

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This is part seven of my series on what psychiatric nurses do. You can read the other parts of the series here.

I distinctly remember the first time I had to participate in the restraint of a patient. Student nurses are not allowed to lay ‘hands on’ patients, so it was after I had qualified and soon after I had started working on the ward I recently left. A male patient had started to become agitated and needed medication to calm him. A team was assembled and under the guidance of an experienced nurse, I drew up the medication in a syringe and took it to where he was being pinned on the bed. I remember being terrified and standing there immobile. I said I didn’t feel ready to give an injection under these circumstances. And Maria, a brilliant nurse who I highly respect (then and now), told me in her straight-to-the-point, no nonsense way, that this is what nursing is like and I needed to get over it. I gave the injection, my hand shaking, feeling terrified and embarrassed at my anxiety and fear.

That was the first of many incidents I was involved in. And though my fear eventually left me and I developed a fairly strong stomach and cool head in difficult circumstances, I still felt that heart-pounding anxiety each and every time those alarms sounded.

Managing violence and aggression is an unfortunate but necessary part of the psyche nurse’s job. Fortunately I was never injured, but I’m a rarity. In the four years I worked as a nurse I saw colleagues beaten, bitten, strangled… dislocated shoulders, beaten and bruised bodies, damaged tendons, broken feet… It’s a truly dangerous job. Psychiatric patients can be unpredictable, and though 99% are only a danger to themselves if anyone at all, there is always that 1% that will present a risk.

Throughout the training to become a psyche nurse, and periodically once you’re qualified, you undertake intense training on how to manage violence and aggression. You’re taught, in detail, the laws regarding self-defence and appropriate reactions to threats to your safety. You’re taught de-escalation techniques. And finally you’re taught self-defence and how to restrain a patient safely. It’s all a lot of fun when you’re training with your colleagues on the crash mats in your trainers, but when it comes to the real thing knowing this stuff is vital.

During your day to day tasks as a nurse, occasionally you see situations escalating. A patient may be distressed and wish to leave. They may be hallucinating and agitated. Or they may have taken a dislike to a fellow patient or staff member. As a nurse, it’s your job to step in and de-escalate the situation. You may offer medication, listen to the patient’s concerns, or intervene in an argument. Usually you will be able to calm the situation, and laying ‘hands on’ is always a last resort. But occasionally the situation will reach a tipping point where you need assistance. This is why all members of staff carry an alarm, or pin-point.

When you pull the pin-point the alarm sounds throughout your ward and the neighbouring wards. All staff on the ward will stop what they are doing and run to the location specified on the wall display. A member of staff from each of the neighbouring wards will also answer. Often simply the presence of more people will be enough to diffuse the situation, but sometimes the noise and sudden influx of staff can escalate things. The patient may attempt to attack you or others.

This is when your training kicks in and as a team you restrain the patient. They may be taken to their bedroom, pinned and given medication to calm them, held until they’re calm, or even taken into seclusion. Each situation is different and will be assessed on a case-by-case basis by you and the team. This is when injuries can occur. Patients will often struggle, may bite or kick, and will often spit at you. It’s not a nice thing to be involved in. Restraint can also be dangerous for the patient. People have died being restrained. One member of staff will be responsible for monitoring the patient’s vital signs and ensuring they are conscious and safe.

Once the incident is over and has been managed; everything is calm, it’s your job to acquire medical attention for the patient and maybe even colleagues if they’ve been hurt. All restraints can be dangerous for the patient and they should see a doctor as soon as possible. The nurse then has incident forms, restraint records and other bits of paperwork to complete. There should be a debriefing for all the staff involved, and the patient once they’re in a suitable condition. Sometimes, after discussion among the nursing team, the police might be called. But this is not usually the case: it depends on the circumstances.

Managing aggression and violence is not the only type of incident-management nurses are involved in. Next time I’ll discuss self-harm and suicide.

What Psychiatric Nurses Do (Part Six – Admininstering Medication)

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This is part six of my series on what psychiatric nurses do. You can read the other parts here.

One of the major roles of the psyche nurse is to administer medication. But far from being the simple job of dishing out tablets that it might seem, it’s actually an extremely complicated and responsible job. The trust I worked for will not even allow newly employed nurses to give medication until they have passed an extra assessment of their capability. Psychiatric medication can be very very dangerous.

You’ll often hear all nurses joke that they know more about medication than the doctors prescribing it. Well actually, that’s not far from the truth. The moment you give a patient a medicine, you are responsible for ensuring it’s the correct medication, correct dose, correct route, etc… If the doctor has made a prescribing error it is your responsibility to notice it. If you do not notice it and give the medication, it’s you who will be held accountable, not the doctor! Consequently, nurses need a comprehensive knowledge of all the doses and indications of all the medications they’re administering.

It’s amazing how much of this stuff you pick up. When I was a student I would spend hours trying to memorise all the regularly-used medications, the doses, the side-effects, etc, all in vain. It’s just too much information to memorise like that! You learn simply by giving it over and over, reading from the British National Formulary (BNF) as you go.

So when you’re allocated to give medication during a shift, you’re responsible for the big set of keys with the medicine keys on. Different wards do things differently, but on the ward I worked on there was one set of keys and you were responsible for it until you handed it over. (Accidentally taking the keys home is something virtually every nurse has done at least once, including myself, having to travel back the 30 minutes after a night shift!). The nurse has to go through all the prescription charts before each medication time, checking which patients need them, and forming a list for a colleague to work from and call patients for you. Then the nurse goes into the clinic, prepares medicine pots, water, etc and calls each patient into the room to give them medication.

The prescription charts are daunting to read at first, but you soon get the hang of them. For each medicine you’re giving you need to know what it’s for (and if you don’t know, look it up!), that the dose is correct, that the start and stop dates are on the card, the correct route, time, and that it’s signed by a doctor. Once you’re sure each of these is correct you give the tablets to the patient. Morning and evening medication rounds can take well over an hour, as they’re the popular times to give psychiatric medicines.

Some psychiatric patients obviously won’t want the medication you’re giving them, and you may have some convincing to do. I remember once spending nearly an hour trying to give a confused and suspicious elderly lady some tablets when she was convinced it was poison. Some patients may also try to secrete the tablets, hiding them in their cheek or under their tongue. You tend to know which patients to watch our for, and need to be vigilant.

It’s also your job to ask the patients whether they’re experiencing any side-effects and assess these. You can choose to give PRN or ‘when required’ medications that have been pre-prescribed, at your discretion. For example, if the patient is agitated you could choose to give a sedative to calm them, or if they have a headache you could give painkillers.

Once the medication round is over, it’s your job to check the stocks and order anything from Pharmacy that’s needed. You also need to inform a doctor of any prescribing mistakes, or request further prescriptions.

As well as tablets, nurses also give injections: subcutaneous injections such as insulin, and intramuscular depot injections. Depot injections are long-lasting anti-psychotics given into the muscle, usually in the bottom. Again, the nurse is responsible for ensuring the prescription is correct and monitoring any side-effects. Giving depots is always a nerve-racking task. If you make a mistake, such as hitting a vein or a nerve, it can have dangerous consequences.

Nurses also shoulder a large responsibility when it comes to educating patients about the medicines they’re on. Some medications are quite toxic and can have dangerous, even fatal, side-effects. Patients need to be informed of these and told what to look out for.

So that’s medication, which leads me onto managing violence and aggression, in which medication can play a large part.

What Psychiatric Nurses Do (Part Five – The Mental Health Act and Tribunals)

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This is part five of my series on what psychiatric nurses do. Here are parts one, two, three and four.

To be a ward-based psyche nurse, you need a really good grasp of the Mental Health Act. Ward-based nurses are the only ones who actually have the power to section patients, though only for 6 hours until a doctor can arrive. I’ll just explain a little about the Mental Health Act to give some context.

So the MHA is a really long and complicated legal act that specifies which people can be detained in hospital and other places, for how long and in what circumstances. It’s made up of lots of ‘sections’, and when one of these sections is applied to someone, they’re colloquially referred to as ‘sectioned’. Not all the sections are relevant to ward-based psyche nurses. Some give police the power to enter someone’s home and assess their mental state. Some apply to patients in the criminal justice system. Generally the ones nurses like myself would deal with are sections 2, 3, 4, 5(2) and 5(4). I won’t go into the boring details of what each section involves, they’re all just sections that are regularly used in hospital.

Other than generally knowing this stuff in detail, psyche nurses are the ones responsible for scrutinising and accepting the legal documents involved in sectioning someone. It’s our job to check all the paperwork is correct and identify any errors. Nurses are also responsible for informing patients of their rights, and ensuring they get access to legal advice, advocacy and the complaints procedure. And it’s also our job to ensure the doctors keep up-to-date with certain forms that need to be completed and reviews that should be done.

Then there’s section 5(4) which is the nurse’s holding power, as I’ve already mentioned. I’ve only had to use it once in my career. If a voluntary patient wants to leave and a nurse has concerns about their safety and wellbeing, but the patient is not willing to wait to see a doctor, the nurse can legally detain the patient for up to 6 hours until a doctor can arrive to assess them. (Usually patients are willing to wait). Basically, once you’ve assessed the patient you inform them of your intention to detain them, explain their rights to them, and then complete an official document. Once the doctor has arrived, you would interview the patient together, discuss what the action should be, and the doctor will decide whether to let them leave or detain them under section 5(2) (the former rarely happens!). It will quite often be the case that you’ll disagree with the doctor about whether or not detention is appropriate – junior doctors are extremely reluctant to allow patients to leave, regardless of what the opinion of the nurses is. I’ve literally had to argue with a doctor before, demanding an appropriate reason for detention if I’m to accept the section, when they didn’t want the patient to leave ‘just because’. It’s our job to advocate for the patients and to uphold the legalities of the MHA.

Once someone is detained under section 2 or 3, the long-term detention sections, they have the right to an appeal. They can complete forms, with a nurse’s assistance, applying first to a Tribunal and then to the hospital managers. The nurse is responsible for ensuring the patient gets access to a solicitor to represent them at the hearing/s and an advocate if they wish. Once the appeal forms have been submitted, the primary nurse for the patient will be required to write a report about the patient’s progress and presentation, and scrutinise all of the case-notes since admission to check for third-party information and things that should not be revealed to the patient and solicitor (as the solicitor will be reading the case-notes in preparation for the appeal hearing/s).

The appeal hearings themselves are really stressful, and no one enjoys doing them. They’re legal meetings, similar to an official court, that take place in the ward meeting room. A judge will lead the hearing and the solicitor scrutinises your evidence. Fortunately they’re not something that happen often: most hospital patients aren’t detained, and not all detained patients choose to appeal. On the ward I worked on there would maybe be 2-3 hearings per month, and with a large team of nurses, the chance of you being the allocated nurse to attend was small. I think I’ve probably only been in about 6 hearings in my career.

The nurse’s role in a Tribunal (I’ll just call them both Tribunals, as they’re basically the same thing, just with different people hearing them) is the same as the Consultant’s and social worker’s. We all have to present our case for whether or not the section is appropriate and should be upheld. The hearing panel will first speak to the Consultant, who will state why the patient has been detained and should remain detained. The panel members will ask the doctor to defend their decision, scrutinising their evidence and questioning their reasoning. Then the solicitor will pull apart their argument. Then it’s the social worker’s turn, and then your turn. Some panels are nice and will go easy on you, asking simple questions about what the opinion of the nurses is and whether you agree with the Consultant (you don’t have to!). But others will ask difficult questions, put you on the spot, and occasionally ask you questions that are not really appropriate, such as asking you to speculate on what might happen in the future. I’ve had to be quite firm before in stating that’s not for me to say, receiving harsh criticism from the judge. Then the solicitor will pull apart all you’ve said, asking you to back up your statements. It’s hard work!

Once the panel has heard the evidence, they deliberate and announce the decision. They may choose to uphold the section, and might offer strong suggestions to the Consultant, or they may choose to remove the section and allow the patient to leave. It’s the nurse’s job to receive this decision (the Consultant and social worker don’t have to stay for the decision), and take the patient back to the ward.

Tribunal’s can drag on, sometimes lasting for over 2 hours. But they’re an important part of the job and important in upholding the rights of patients.

Next time I’ll discuss medication.

What Psychiatric Nurses Do (Part Four – Ward Rounds)

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This is part four of the series on what psychiatric nurses do. Here are parts one, two and three.

Ward rounds… I never liked doing them. Before I explain why, let me just explain a little about the general dynamic of an acute psychiatric ward.

Unlike medical wards where a medical-model is focus and the nurses do as they’re told by doctors, psychiatric wards are very much more nurse-led. Nurses make the decisions about admissions, day-to-day care plans, and are involved in every decision on the ward. The doctors come and go, and usually follow the advice and guidance of the nursing teams. Junior doctors especially tend to do what they’re told by nurses. Doctors are not held in high esteem by psyche nurses – they’re just another team member, often with no real idea about what the ward is really like or how everything works.

The only power the doctors have on the ward that the nurses don’t is when it comes to two things: medication and the Mental Health Act. And it’s here where they can clash with the nurses over decisions made. Because no matter what the nurses think, advise or know based on working with the patients 24/7, the doctor has the final word and will make what decision they think is right or safest, and the nurses have no choice but to do what the doctor says.

So that leads me onto ward rounds, and I’ll get to why I hated them so much shortly.

So the nurse allocated by the shift-leader checks the diary and team allocation board to devise a list of appointments for the doctor. Some will be arranged meetings in the diary, which community nurses and others, including family members, may be attending. But on top of that all the patients are arranged into teams and each patient on the ward needs to see the doctor at least once per week. So the nurse fits the patients in the designated team around the scheduled appointments.

Once that’s done, the nurse then needs to read-up on each of the patients who will be seen, in order to hand this information over to the doctor. This can take a while if you’ve been off, on nights, or you have a lot of patients to see. And of course you have to try to remember everything you’ve read: how the patients have been, whether they’ve slept or eaten, whether they’ve been going out and how it’s gone, details of incidents… basically everything that’s happened since the doctor last saw them. And if it sounds impossible, believe me it is!

Then the next job is to prepare everything needed for ward round: the medication cards, Mental Health Act paperwork, etc. Once this is all done, you wait… And wait… Until the doctor arrives. In fairness on the ward I worked on the Consultant was fairly punctual, but that’s not the case on all wards. Generally you’ll have a little discussion with the doctor about the upcoming appointments, may need to adjust the times a little if they have other things to nip off for that cannot be rescheduled, and listen to the doctor’s complaints about too many appointments, too many admissions or anything else they feel like moaning about that’s nothing to do with you.

Then you and the Consultant and junior doctor (if there is one) go off to a meeting room and start on the first patient. The doctor will want you to explain how the patient has been, whether they’ve had leave, what sort of symptoms they’re exhibiting, etc, and will often ask your professional opinion on the course of action, medication changes, etc. Once all that’s done, you go off and get the patient.

Which leads me onto why I hated ward rounds. Apart from the fact I’d spend most of my time struggling to recall everything I’d read about the patient, and looking like I knew nothing about them, constantly saying ‘I don’t know’ to all the questions I was asked; I also hated the fact that once you’d done this little bit, you might as well not be there! Because quite often the Consultant chooses to completely disregard everything you have advised and do what they want to do anyway. And you have to sit there in front of the patient and agree, whether you agree or not.

You would tell the doctor the patient had been settled and bright with no evidence of depression and low mood; that they’d been utilising leave ok and had made no attempts to abscond or harm themselves. You’d recommend a period of overnight leave followed by discharge within the next few days. And then the patient would come in, tell the doctor how low they felt and how suicidal they were, and the doctor would go ahead and put them on extra medication and agree to another week on the ward. You’d be left thinking what the point was in you being there, and completely frustrated and undermined. Fair enough the doctor has to make a responsible decision as it’s them in the Coroner’s court if the patient goes and kills themselves, but it’s very irritating to be asked what the opinion of the nursing team is based on round the clock care, and then be overridden by someone who has met the patient for all of 10 minutes!

Anyway; basically the nurse’s job once the patient is there, is to record the outcome of the ward round and what the plans are, in order to later inform the shift-leader. Sometimes nurses speak up and join in the discussion along with the doctor, sometimes you might sit silent and let the doctor lead. When the patient leaves you have another little discussion about what the patient said and whether you agree or disagree with the decisions taken by the doctor. Then it’s onto the next one.

Ward rounds go on and on, and you often have to nip in and out to handover little jobs to the other nurses or check things out with colleagues. As I said, I never liked them.

Next time I’ll discuss the Mental Health Act, and what role psyche nurses take in this, as well as Tribunals.

What Psychiatric Nurses Do (Part Three – Handovers and Shift-leading)

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This is part three of the series on What Psychiatric Nurses Do. Here are part one and part two.

Every shift needs a leader – someone to plan what will be done and generally take charge. On the ward I worked on nurses would take turns to lead the shift. It’s one of the most difficult aspects of the job, with lots of responsibility, and demands a lot of work on the part of the nurse. Needless to say, shift-leading isn’t popular, and I have spent many many hours complaining about having to do it too often, or coming back from annual leave or sickness to have to lead a shift.

Shift-leading begins with the handover from the previous shift-leader to the on-coming team. In theory hand-overs are supposed to be quick and concise, but as it’s often the only time nurses get to sit down together and discuss care, they also end up being care-planning sessions, time for rants and receiving support, and general gossip sessions ;).

So in theory the handing-over nurse goes through the printed sheet of patients, discussing how the patients have been over the last shift or two. They’ll identify any changes to the plan of care, the outcome of any meetings, any incidents or issues, and any outstanding jobs. As you can imagine, with 22+ patients on the books, hand-overs can be lengthy, especially if there have been a few admissions or a serious incident. The job of the on-coming shift-leader is to record all this information, quickly and in a legible form, on the sheet for future reference, and formulate a list of outstanding jobs.

Once handover is over, the new shift-leader allocates jobs to the other members of the team (usually made up of 5 staff – usually 3 nurses and 2 support workers), and basically plans the shift. It can be a tricky business trying to delegate tasks around everything that needs to be organised. For example, you have 5 staff and need to organise who will do the hourly observations at each time period, who will do medication, who will do ward round, who will be on-duty in the dining room at meal times, who will respond to the alarm (can’t be the same person who does medication or ward round), who will answer the fire alarm (can’t be the same person who does medication or the dining room or ward round), etc… Sometimes it’s a nightmare.

Once all this has been organised, the shift-leader then has dozens of miscellaneous little jobs to do, such as figuring out the number of patients in beds and whether there are upcoming transfers or discharges, allocating breaks around everything else, handing over to the Occupational Therapy team, discussing upcoming patient movements with the Crisis Team, speaking to the Pharmacist about medications that will need to be ordered, etc. It can be well over an hour into the shift before you actually get to check the diary and make a list of jobs that need to be done for the day. There are always inevitably plenty of phone calls, referrals, medication changes and other general tasks to be done. The shift-leader tends to make a long list of jobs, and the staff work through them, ticking them off as they go.

But I guess the hardest part of being shift-leader is that you’re generally in charge of the ward for those few hours. Whether a patient can or cannot go out is your decision. Admissions are agreed by you. Patient and family complaints are directed at you. All enquiries about everything are directed at you. If an incident occurs, it’s you who is expected to make the quick decisions and take the lead in any action. You have to know what is going on at all times. Sometimes you get it right and you feel on top of everything – like keeping a dozen plates spinning perfectly. But sometimes it will overwhelm you, and everything will come crashing down!!! It’s a lot of responsibility and a lot of stress. And shift-leading if you’ve been off for a few days is very difficult.

Of course, once the shift is over it’s your turn to hand-over to the next leader, and try to recall every single thing that has happened. Any outstanding jobs can be communicated to the next team.

So that’s shift-leading, the most difficult job a Band 5 nurse does. Next time I’ll discuss ward rounds; the second most difficult job.