What Psychiatric Nurses Do (Part Four – Ward Rounds)

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.