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.

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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.