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.

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

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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)

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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

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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.