What Psychiatric Nurses Do (Part Nine – Observations and AWOL Patients )

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

As I described in my last post, hourly observations are a mandatory part of the running of a psychiatric inpatient ward. In truth the job tends to fall to healthcare support workers as the nurses are often too busy, but all staff on the shift are supposed to do them. The shift leader devises a schedule of who will do the observations at certain times, and the staff then try to stick to it.

The staff member on the observations carries a board that has all the patient’s names, what room they’re in, and then 24 little boxes for each hour of the day alongside the name. Each hour you go around, locate the patients, and add a little code to each box to say where they are. Then you add up how many patients there are on the ward each hour. The board can also be used as a fire register if the fire alarms go off, and is it the most up-to-date record of who is on the ward.

Sound simple? Well, it’s not always. Sometimes you can’t find someone. In which case you have to go around the whole ward, searching room after room. If you still can’t find them, you’ll need to speak to all the other staff to check no one has let them out without putting a note on the leave board on the wall. And if you still can’t find them, you’ll need to inform the shift leader who will decide what to do next (which I’ll discuss in a moment). The person on observations is also responsible for checking everything is ok on the ward: that the right doors are locked, that everyone is safe, etc. And unfortunately it’s often the person on observations who finds self-harm and suicide attempts. Some patients wish to be found and stopped and will deliberately wait until they know someone is about to check on them before trying to harm themselves.

As well as the routine hourly observations, it’s not unusual to have one or more patients on 15 minute observations. They may be new to the ward, have told staff they’re feeling suicidal or be agitated and at risk of violence, etc. The same staff member on the hourly observations will also do the 15 minute observations. Sometimes there may be a fair few patients on 15 minute observations so it can become a time-consuming and laborious task. This is why observations so often fall to healthcare support workers.

Then there are level 2 and level 1 observations that are only used if a situation is escalating. Level 2 means the patient needs to be within eyesight of at least one staff member (sometimes more). Level 1 means the patient needs to be within arms-length of at least one staff member. These observations aren’t often used, particularly level 1 which I think I’ve only seen used a handful of times, as they’re obviously a massive drain on staff resources and a major infringement to the patient’s rights. But if someone is agitated and has made attempts to harm someone, or is repeatedly attempting to harm themselves, then these observations can be implemented for short periods. It is difficult to sustain them long-term, and if these levels of observations are needed for prolonged periods the patient is often transferred to the Psychiatric Intensive Care Unit (PICU) where they have a much smaller number of patients and a higher staff-patient ratio.

So if a patient cannot be found anywhere, and no one has let them off the ward, the shift leader and other staff will need to do a quick assessment of the situation. Someone will try to ring them on their mobile phone. If the patient is ‘low-risk’ and it’s suspected they’ll return on their own, then often they’ll be posted as on leave for a few hours to give them chance to return. If there are some concerns over their safety or risks, the doctor will be informed as well as the ward manager if it’s day-time hours. Often it will be necessary to implement the AWOL procedure. You might ask how a patient manages to leave a ward without asking. Well, there are many ways that patients find. On the ward I was on we had patients squeeze through windows after breaking the hinges, climb over the smoking courtyard roof, wait until someone is entering the ward and push past them… lots of ways!

The AWOL (absent without leave) procedure is long and time-consuming. I’ve done it so many times I could do it in my sleep. The nurse completes a missing-person form with a description of the patient, has a quick read through the notes to highlight risk issues, acquire contact details and addresses, etc, and then rings the police to inform them we have a missing patient (they just love inpatient wards ringing them!). The police will take all this information and decide what to do. If the patient is voluntary the police aren’t obliged to do anything, but if you have identified specific risks they will usually visit the patient’s address to check on them and ask officers to keep an eye out. If they find the patient they cannot force them to return, but if they have their own concerns they can obviously detain the patient themselves. They’ll ring the ward, let us know the patient is ok, and then the ball is back in our court as to what to do next. If the patient is sectioned then the police are obliged to try to find them and bring them back to the ward, using force if necessary.

Most AWOL patients are returned quickly, either by themselves or by the police. They may have left to acquire drugs or alcohol, or simply to test boundaries or make a point. But sometimes AWOL patients harm themselves or, very rarely, other people. Sometimes they do bizarre things or get on random public transport and end up on the other side of the country. One AWOL patient that escaped from the hospital I worked at one time went to the general hospital next door, stole a nurse’s uniform and pretended to be a nurse on the ward! When these things happen risk incident forms need to be completed and sent to management who will analyse the situation and look at things that need to be done. If a serious incident occurs there will be investigations. It’s often easier if the patient escaped off their own back. If a member of staff has knowingly let the patient out and they’ve gone on to do something risky, then you’re in dodgy territory and need to make sure you’ve covered all your bases. I can’t tell you how nerve-wracking it is to have allowed a patient off the ward only for them to go out and take an overdose. It’s one of the reason shift-leading is such a stressful job!

Next time I’ll discuss physical care and clerical duties.

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.