While I was a student on the rehab unit I had to complete my Practice Based Assessments (PBA’s) and I’d chosen four patients that I could work with to meet these over the twelve weeks placement. First there was Mandy who had Generalised Anxiety Disorder (GAD) and next was Sasha, Elsa and Edward who all had a diagnosis of chronic schizophrenia.
I spent many pleasurable weeks working with Mandy, the lady who’d previously screamed for her medication several times a day. She repeatedly said that she could notice the reduction in each nought point five mg Diazepam, which was highly unlikely. However, I appreciate that for her, it was difficult, hence her continuous screeching at medication time. From my parenting days, I knew that distraction worked well when children were upset so I hoped distraction might help Mandy too. I would offer her a cup of tea and ask what her plans were for the day or about her collection of teapots, rather than have the poor lady screaming and working herself into a panic attack.
It’s a shame that other nurses hadn’t picked this up as it would have been far easier for them in the long run and certainly better for Mandy. However following discussions with her Primary Nurse, the nurse who has overall responsibility for a patient, her care plan was updated and read “When Mandy is upset and screaming her allocated nurse must use distraction techniques.”
Care plans are prepared for each patient and wherever possible, are developed with the patient, rather than for the patient. The care plans are used to guide your practice with patients, to explain what care is required and how to carry it out.
As she got better, Mandy would eventually accompany me to the local Primark to get cheap knickers. Grinning cheekily, she would say the money she saved from buying these allowed her to buy her favourite yoghurts from Marks and Sparks next door. Once I’d left the unit it always cheered me up when I saw Mandy and I loved to stop for a chat.
I had a lot of fun working with Sasha; she was witty, intelligent and was becoming much more cheerful as the weeks went on. Between us we managed to clear all the cereal boxes from her room along with the crumbs and mouldy, congealed leftovers we found in bowls under her bed. This wasn’t my favourite task but I laughed all the way through it because Sasha was getting really cheeky. When I was busy scrubbing the floor she’d sit on her bed reading or stand at the window waving at random passersby and she’d crack up when I spotted it.
Many of Sasha’s care plans were updated or changed altogether now because she’d made great progress in several areas and some of her care plans were now outdated. One care plan read ‘Encourage Sasha to keep her bedroom tidy and work with her if necessary. If Sasha refuses, staff to advise her that they have a duty of care to ensure her environment is clean.’ It was like writing instructions for nine year olds rather than senior qualified nurses.
Another care plan read ‘Encourage Sasha to spend time off the unit and accompany her if needed.’ I loved spending time with her in the cafe, a local haunt for both patients and staff. I always took my badge off when accompanying patients outside as I wanted them to feel equal in the community. It really bugged me seeing staff wearing badges when outside with patients. It was like ‘them and us‘ and showing the staff member was in a position of authority, which I thought was unfair.
At forty eight Elsa hadn’t aged well at all; she originally came from Greece and her face was craggy from the sun. She had short wiry grey hair which she hacked at herself, staring in the mirror taking great clumps out with almost blunt scissors. These were eventually taken from her as she’d often say to fellow-patients and staff “I will kill you.” She did this with a wicked grin so I didn’t think she was really serious but the scissors might have posed a risk to both her and others.
One of her care plan was updated and read ‘When Elsa wants to cut her hair, a staff member must be with her and remove the scissors back to the office once finished.’ I wanted to find out why Elsa chose to use her clothes as toilet paper but, despite using one of our translators, she just shrugged and grinned when asked. However, it was something we had to work on, we couldn’t just ignore it. I asked several staff nurses what has been tried in the past and what worked but was told “That’s just Elsa. She always does it and nothing works.” Elsa had been on the unit for months and nobody could tell me what had been tried.
When I was on duty as a nursing assistant (NA) or there on my student placement I tried to speak with Elsa every couple of hours to see if she needed the bathroom. I tried taking her to the toilet, getting her to sit for a while to see if she would poop, her favourite word. Sometimes it worked and I had to wait while I encouraged her to use toilet paper. “Too small.” she would grin “No enough.” and she’d try to use her skirt. Ah! Next time I accompanied her to the bathroom I took a roll of the large hand drying paper. Success!
One of her care plans was updated to read ‘Encourage Elsa to use the toilet throughout the shift and have hand paper available.’ though I know this rarely happened as I never saw it documented. The Nursing & Midwifery Council (NMC) Code of Conduct states that ‘nurses should respect, support and document a person’s right to accept or refuse care and treatment.’ It did not say ‘if patient refuses support, just leave it at that.’
Once my placement ended I would later hear that Elsa had reverted back to using her clothing to wipe herself. I was truly mad that the nurses had allowed this to happen. It was like they’d given up caring and they were just passing time until retirement. However, I did learn how not to nurse and their disassociation made me even more determined to be a good nurse. Our patients deserved better.
Edward had long been on a medication called chlorpromazine, the first antipsychotic which was widely shown to be significantly more effective than later antipsychotics. However this drug had a range of distressing side effects, one of which Edward had was the shuffling gait known to nurses as the ‘chlorpromazine shuffle.’
He would also complain of constipation and impotence. He was prescribed a regular dose laxatives and he often requested Viagra but would talk about not being able to get rid of his erection for hours. You had to laugh with him, his tales were hilarious. He told me about one time when he was on the bus returning to the unit and the movement gave him an erection just as his stop was coming up. It was summer and he was wearing just shorts and a t-shirt so he had no way of covering the erection. He had to stay on the bus and went miles out his way.
My main task with Edward was to get him to take better care of his hygiene. He was physically fit and more than able but he really needed a ‘kick up the backside with my tiny size three’s’, I’d tell him. He also picked his nose and would later want to shake my hand. This was one habit that would have to go and I told him I would never shake his hand unless he hadn’t washed it. I also said I wouldn’t accompany him in the community if he was wearing his usual attire of stained tracksuit bottoms and a dirty old t-shirt. I often used my sons as examples, telling Edward that I wouldn’t go out with them if they weren’t clean.
One afternoon I arrived on the unit and there was Edward, spick and span. He was clean and reeking of cheap aftershave. His receding hair had been carefully dampened down and he wearing mismatched clothes but they were spotless. He’d been waiting for me since after lunch. How could I not take him out to the local snooker hall? This was his favourite outing as the voices he heard were much quieter and encouraging when he was concentrating. It became a weekly treat while I was there but I later saw him shuffling along the street, head down and miserable.
I don’t know why the nurses on the rehab unit ignored any improvement or the hard work that was done. They scoffed at his updated care plans, saying – it won’t last! Why did they think it was okay to let patients revert to their old habits.
Conclusion—Rehab does work — but only if the staff do!
*The Purpose of the Written Care Plan is to ensure continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during ward rounds. http://www.rncentral.com/nursing-library/careplans