Why do you blog?

It’s yet another dull day in London but I have a lot to be happy about. I have an amazing partner who’s really looked after me since I was disabled by Transverse Myelitis in 2011. I’m grateful I have an amazing close-knit family and I will be going up to Scotland in November for a niece’s wedding where I’ll get to see everyone. I am delighted with my two amazing sons; one (Ricci) is currently a Research Fellow in the States and the other (Ravi) is a Physiotherapist in London. Today I’m going to meet Ravi and his new wife for afternoon tea and I’m so excited. I haven’t seen them together since their wedding and they’re going to bring some wedding photos for me to look through.

I’ve been up for an hour now and have been going through my posts’ comments and tried to answer everyone. Somewhere along the way I’ve picked up great blog: https://crushedcaramel.wordpress.com where she’d answered an interesting set of questions posted by another blogger: https://saltedcaramel670.wordpress.com/2019/10/07/why-do-you-blog/ so I thought I’d have a go too.

Do you blog to promote your business?

No. I became disabled and regretfully medically retired from my job as a Mental Health Nurse/Ward Manager, a job I truly loved. I also had to cease running my small business where I worked as and supplied Mental Health First Aid instructors to a variety of organisations. We taught MHFA to a wide range of companies, schools and Armed Forces. I was there at the inception of MHFA England and would love to be able to carry out more training in order to raise aware of mental health issues.

Or is your blog a launching pad for your social life?

What social life? Okay, so I’m exaggerating a little ‘cos I’ve already told you I’m off out this afternoon. We went to see our grandchildren on Thursday and got to stay the night. It was sooo much fun playing games like hide and seek, where when you’re looking for a two year old an you utter to yourself “Now, where’s that Ava?” and she shouts “I’m here.” and her four year old big brother shouts crossly “Aaaava! You’re not supposed to tell her! You’ve spoiled the game now!” and off he stomps, sulking and trying not to laugh when I pretend trip and fall onto the sofa “Ouch, Ouch!” We’re going back there this Sunday and I’m cooking stew and dumplings (a nod to my Scottish heritage) for everyone together with my brother-in-law and his girlfriends. So far my social life’s been all family but hopefully next week I’ll be able to catch up with a few friends.

Does it exist only to complement your Instagram account?

No. I’ve never had an Instagram account. I’m a complete technophobe and not very computer literate, despite having typed and used computers since the seventies. Oops, just given away my approximate age 😉 When my energy levels reach rock bottom, I sometimes find it hard enough responding to my blog comments, Twitter and my emails, let alone having another account such as Instagram. However, I love picking up my laptop and catching up with everyone’s news – it’s my little window on the world.

Is your blog making you real money (if so please let me into your secret)?

No. Unfortunately not and it never will really. I don’t intend to monetize my blog and only set it up because I wanted to make use of my fifteen years of diaries, kept from when I was nursing. Reading through them reminds me of all the good times I had, the amazing inspiring people I met; both patients and colleagues. However, I was also reminded of the poor standards of practice and that’s really what I wanted to highlight in my blog. I want people (nursing students, nurses, doctors, social workers, occupational therapists, community psychiatric nurses, the public, MP’s, the government, patients, carers or friends) to be informed and make the necessary changes. Tell your care team you are not happy with the standards of care. Tell your boss,manager, team that standards must be raised. I want Doctors and nurses to continue with their professional development and stay up-to-date with current practices. Ooops! Rant over.

Are you blogging because you are so adept at this craft that you want to teach it to others?

No. I wish I was smart enough tho’. I loved teaching and mental health is my niche, so I’ll stick to it. I can offer lots of information, not unsolicited advice, and point people in the right direction if they are seeking support but I can’t profess to being a teacher or instructor any more.

Or are you like me : blogging just due to the urge to write?

Yes. I’m like you. Yay, we have this one in common. I love reading and also enjoy writing; releasing the pent up frustration that’s been raging inside me for so many years. As a mental health nurse I was used to writing ‘in and on reflection’, hence the lengthy notes in my old work diaries. As I’m disabled I often have time on my hands and can’t believe how many hours I used to spend on social media i.e. Twitter and Facebook, just to see if anyone had messaged me or liked my comments. Now I’m blogging, the likes, the helpful comments and advice I get is both helpful and constructive. I only started blogging a few months ago and I’ve not even finished with my first work diary yet – so looks like I’ll be here for a few more years.

What are your reasons why you put the proverbial blood sweat tears into your blog posts?

I want people to be aware of the poor standards of practice in mental health units. I want everyone to shout it from the rooftops or from the highest mountain whenever they come across poor practice in mental health nursing and care environments. I want to increase awareness of diagnosis (right or wrong sometimes) the signs, symptoms, causes and effects of mental health disorders. And I want to reduce the stigma. I know I can’t change the world on my own but if my little blog is of use to one person and they have the confidence to speak out, it’s a start.

My journey through a psychotic depression – part I

The World Health Organisation recognises World Mental Health Day on 10 October every year, with the overall objective of raising awareness of mental health issues around the world and mobilizing efforts in support of mental health. This year’s theme set by the World Federation for Mental Health is suicide prevention.

Today, in recognition of World Mental Health Day I’m going to tell you my story – publicly – for the very first time and already it’s unsettling me. I didn’t realise how difficult writing it all down and seeing it in print would be. However, I want to do this in the hope that it will help others to open up and raise awareness of how mental ill health can happen to any of us at any time.

My relationship breakdown

The first time I split up with my ex, after almost nine years, I was thirty and our sons were seven and five. I was absolutely devastated as I hadn’t seen it coming. I believed we were happy and everyone thought we were the perfect couple. However, one thing always came between us. He’d regularly smoked cannabis and by this time he was taking E’s (Ecstasy)* which I totally disagreed with and I didn’t like being out with him when he was under the influence. I also detested his ‘come down’ from the E’s which could last for days. It’s said that regular ecstasy use may lead to sleep problems, lack of energy and feeling depressed or anxious and along with these he was moody and angry.

We were with friends in a bar one night and I could see his mouth twitching, his jaw muscles tightening and moving and I told him I wasn’t happy that he’d taken E’s while out with me. He laughed and said “You need to take something Babes. Come on, lighten up a bit Darlin’. I was just saying to Maggie, we should go clubbing more.” Clubbing? More? We’d never been clubbing.

Oosh! It hit me like a physical blow to my guts! I was rooted to the spot as I remembered – he’d been on the phone (landline, before mobiles) a lot recently, female workmates had called him and he’d called them all darlin’ and he’d been out at least once a week (on lads nights) wearing suits I’d had cleaned for him, the shirts I’d ironed and the aftershave I’d given him for his birthday.

Walking from one bar to the next I said “You’re seeing someone?” and Tony replied “Eh? Sorry, what did you say?” giving himself time to form an answer. I knew then that he was cheating though he denied it. With my head spinning and my heart breaking we spent the rest of the evening with friends in our local, me all the while desperately hoping that it wasn’t true. When we got home I calmly said “You’d best pack cos you’re not staying here.” More to see what he would say or do. He laughed nervously and thought I was joking. “Where will I go? I can’t leave now.”

“It’s not my problem. Go to your mum’s,”

“Babes, look, we’ll talk in the morning. Come on let’s go to bed.”

Pft. I told him I wouldn’t be sleeping with him, “You might have caught something.” I’d sleep in the one of the boys’ rooms as they were at their grandparents round the corner. The effects of his drugs were wearing off because he started yelling “Your effin’ frigid you are.” and “I ain’t going nowhere you stroppy cow. You’re an effin’ nutter. Effin’ nuts just like your mother!” he spat.

Ouch! He really knew how to hurt. I’d told him some time ago that my mum had been in Stratheden (an old asylum in Scotland) many years ago and had Electroconvulsive therapy (ECT)** as she had severe depression. The nasty imbecile, trying to detract from the real issue here, just threw this confidence right back in my face. Stomping up the stairs and banging doors he eventually went to bed and within minutes I could hearing him snoring like the damn pig he was, not a bloody care in the world!

I sat awake on the sofa unable to sleep all night, crushed and sobbing uncontrollably, thinking about what to to do next and what to say to people. My mood swung wildly from sad to angry, anxious and confused, fear and denial as I drank one coffee after another and smoked too many cigarettes.

Tony was mostly a good guy

Tony wasn’t always a monster. He was actually a good guy (without the drugs). He made me laugh, he was affectionate, kind and generous, he was popular and had lots of long-term friends who adored him. He was a great dad; he did most of the night feeds and loved playing with the boys, taking them to all their activities and to the Arsenal games. He loved a clean house and enjoyed decorating our home, he’d often wash the windows and blinds without prompting. He came from a huge loving family (Indian and Spanish) who thankfully adored me and thought I was a good influence on Tony.

We’d often go out in the summer on huge family picnics where there’d be up to fifty of us all in Regents Park, Hyde Park, Kenwood Park, at Alexander Palace or at the beach. Friends who joined us couldn’t believe how many people were there and were amazed at the range of food; tortilla’s, croquetas, paella, Russian salad, whole chickens and hams, breads, cheeses, samosas, onion bhajis.

We’d be there until it got dark, playing swingball, cricket and football with the all kids. We regularly had Christmas dinner for around twenty people where Tony would keep everyone entertained and all the New Year parties were held at out house along with the boys’ birthday parties which went on way into the night.

“Cor, it stinks down here. You been up all night?” rasped Tony as he wearily descended the stairs in the morning, still with his stupid nervous smile. I almost felt sorry for him. He made us both coffee then slumped on one of the two sofas and reached for the television controls. Too slow. I grabbed it first and put it out of his reach, behind my back on the other sofa. “Have you nothing to say?”

“Aaww, this ain’t one of them ‘we have to talk’ thingy’s is it? Anyway what do you want to talk about?”

“Last night.”

“Last night. What was we saying? I can’t remember.” To be fair, he probably couldn’t remember too much after the fog of drugs and copious pints of beer. But I didn’t believe he could remember nothing and I knew he was just playing for time. “What’s her name?” I asked. He giggled anxiously and didn’t answer me – a sure sign he was cheating. “Ah, it’s one of those girls from the office.” I said. “Which one?”

He still refused to answer so I told him to start packing, still foolishly hoping he’d tell me it wasn’t true. The fact that he went upstairs to pack, so easily, with no arguing just confirmed it was. He packed some bits saying he’d come back for the rest, then he left and I watched from the kitchen window as he walked away without a backward glance. As he disappeared from view I locked the door. I turned, slid down and with my head in my hands I cried as I’ve never cried before, snot mingling with my salty tears.

When I eventually stopped crying my thoughts turned to the boys and off I went, howling again. How on earth was I going to tell them? I couldn’t bear to think of their gorgeous little faces, big brown eyes made even wider with disbelief as the life they knew would be turned upside down – just like that. That selfish b*stard, I hated him! What was worse, I knew he’d be down the pub laughing and joking with his pals.

Aaarrgghhh! I wanted to scream from the rooftops. Instead, I called his mum and dad to tell them the news and asked them to keep the boys for another night as I couldn’t face them right now. Not with my red-rimmed piggy eyes and blotchy face. I didn’t want them to see me so upset and I honestly hoped Tony would come back and tell me he’d made a mistake.

His mum and dad didn’t believe he’d leave and thought this would just blow over, bless them. Then I cried again. The thought of not seeing all my lovely family, missing out on weddings, picnics, celebrations and family gatherings. See it’s not just the couple involved in a breakup; think – when you throw a pebble into a lake and you see the water ripple outwards – it affects the bigger family and friends circle.

Ripple Effect

It makes no sense to consider
a life where we never met.
We met and that’s it.
Whatever pebbles we disturbed
started rolling down life’s mountain,
either missing other stones altogether
or eventually triggering landslides
where I always seemed to be standing.
But these avalanches of angst,
or anxiety, never touched you,
just the anger at all my dust
drifting by, obscuring your view
of what you found most important.
Your reflection may not look like
it once did in that mirror pool.
No, age didn’t cause the change.
It’s really the ripples
of concentric circles that your
fleet of pebbles set off now that
they’ve finally come to rest
upon what might’ve always mattered
to you most.

JOSEPH HESCH, FEBRUARY 20, 2019 / 

My story, Part II will follow shortly. You’ll learn about my hell during a Psychotic Depression; symptoms, effects and recovery.

*Ecstacy makes people feel very happy – hence the name, ‘loved up’ – users often feel love and affection for the people they’re with and the strangers around them, they feel energised and alert.

**ECT is an invasive type of brain stimulation that’s sometimes recommended for severe depression if all other treatment options have failed, or when the situation is thought to be life threatening. https://www.nhs.uk/conditions/clinical-depression/treatment/

Have you ever been bullied by mental health colleagues?

Unfortunately I came across many bullies when working in mental health environments – the very place where the staff have been trained to care for people, to provide preceptorship supervision and mentorship to their colleagues.

What is bullying?

UNISON* has defined workplace bullying as persistent offensive, intimidating, humiliating behaviour, which attempts to undermine an individual or group of employees.

Bullying at work can be broadly broken down into two different types. That which is: personal in nature – e.g. derogatory remarks about a person’s appearance or private life and work-related – e.g. questioning a person’s professional competence, allocating unachievable tasks. Many bullies will of course engage in both types.

Serial bully

During a placement in the Community Mental Health Team (CMHT), I was horrified that at the age of thirty-six I was being bullied by my supervisor Alan (an ex-policeman). I thought I’d put all that behind me when I finally left the school gates. This vile man would constantly belittle me, talk over me and question my judgement and knowledge of patients and undermine me in front of colleagues He’d ignore my input and he’d snigger at my Cockney accent if I spoke in meetings, because he knew I hated it. He’d deliberately leave me out of ward rounds when ‘my/our’ patients were being seen saying there was no point me attending as I had nothing to add. He smirked as he refused to sign my attendance sheets saying he didn’t know what days I turned up or didn’t – only because he came in late every day. I was lucky that his colleagues took pity on me and took me out on patient visits or to ward rounds in the hospital. He blatantly ignored my attempts to communicate with him but still he looked furious when I said I had no option other than to speak to the CMHT Manager. His boss had to act as mediator for the rest of my placement because Alan continued to intimidate me with his passive aggressive stance. How sad that two ‘adults’ had to resort to this!

Based on research into thousands of cases of bullying at work, Tim Field** believed the serial bully’s focus is on power, control and subjugation of others. They usually operate by targeting one individual and bullying them relentlessly until they break down or leave. They then move on to their next victim. By the time organisations realise that there is a serial bully in their midst, considerable damage has already been done.

The policeman’s wife

My next placement was in a mental health rehab unit and on my first morning during ward round I noticed the Consultant’s leather holdall with her name engraved on it. She was only the serial bullying policeman’s wife – and my heart sank to my stomach. However, she was as sweet as he was sour and as warm as he was cold; she was smiley and encouraging and I liked working with her. It was during this time that she told me they were going through an acrimonious divorce. Not sure I had any sympathy for him.

Don’t rock the boat

It was also during my next placement in the rehab unit that I came across Ricky who was the Acting Manager. I told him about one particular patient, a young lad called Devlin who found it difficult wake up, to get up, showered and dressed before morning medication and breakfast. The nurses wouldn’t re-open the treatment room to give him his medication and they refused him breakfast, telling him that he should get up earlier. Ricky’s response was eyes rolling and “Tut, this is a rehab unit Nancy and patients have to learn how to get up and ready in time for medication and breakfast. This is why they’re here.” I flippin’ knew it was rehab! Nonetheless, some patients need to be encouraged to get up on time, “get him an alarm clock or something” I suggested. More eye rolling and tutting but he did open the treatment room and give Devlin his morning medication. I made some toast and tea for Devlin but was severely criticised and told by Ricky that I shouldn’t have done this and not to do it again because other patients will expect it too.

I also spoke to Ricky with regards to the nurse who came in each night shift with her slippers and duvet and slept on the sofa once the patients had gone to bed. I highlighted the risk to our patients, myself and colleagues as we were one member of staff down when she slept. Huffing and puffing or tutting and heavy sighing, he told me that I was there and would make up the numbers. However, as students, we were there to learn by shadowing colleagues and not to be counted in the staff numbers. First he said “What do you want me to do Nancy?” Without allowing me time to answer, he went on to say that Ayo, the ‘sleeper’, had been there so long on night shifts because she had children so they cut her a bit of slack. More likely, he didn’t want to rock the boat; he was afraid of his long-term staff and I think he lacked the confidence to deal with them effectively. However, he had no problem making derisory comments about my naivety and lack of lack managerial knowledge or how to deal with staff. I lost respect for him as a Manager and couldn’t even be bothered to tell him that I’d been a Human Resource Manager for almost twenty years.

I asked casually how long Ayo had been on permanent nights and was astonished when he told me twenty years. This lady had grandchildren by now and no one had ever questioned her working nights constantly, which was against Trust Policy.  Ricky refused to take action and I was berated for raising problems where there was none and told “Don’t even think of informing Human Resources. It would just mean more paperwork and aggravation.” – for him no doubt! Ricky made it as difficult for me as possible to raise concerns about the poor practice I witnessed on the unit. However, I was able to write about it all in my Practice Based Assessments and the essay that followed this placement and felt vindicated by the Uni lecturers’ comments and high marks I received for both.

I eventually qualified as a mental health nurse and within four years I was promoted to Ward Manager (Band 7). I often bumped into the bullying policeman who was still working at Band 6 level and the Acting Manager who’d since been demoted back to Band 6 and without exception I greeted them with the same cheery smile I’d always given them.

*Tackling bullying at work, A UNISON guide for safety reps

**Tim Field, UK National Workplace Bullying Advice Line between 1996 and 2004

10 attributes of a good mental health nurse

Would you make a good mental health nurse?

Good mental health nurses need at least:

  1. Excellent Knowledge of Mental Health problems and how to apply it in practice. It’s no good just reading articles, books, leaflets or patient notes. You need to be in the thick of things, working with patients and colleagues, asking relevant questions, asking for and accepting help where necessary, putting all your theoretical knowledge safely into practice in order to support a patient. You need to use your knowledge of a patient to be able to effectively handover to and liaise with the multi-disciplinary teams, families and carers in order to provide continuity of care.
  2. Empathy and the ability to relate to people of all ages and backgrounds. Nurses need the ability to put themselves in someone else’s shoes, walk a mile in someone’s shoes, to see what they see and feel how they feel. Like when a mother smiles and her baby catches the emotion and smiles with her or when a mother is angry or stressed and the baby catches this and cries, possibly adding to the mother’s angst and negative feelings. Try not to use platitudes i.e. “Time is a great healer.” to someone who’s just lost their mum/dad or “It will all look brighter in the morning.” to someone who is depressed. Don’t offer unwanted advice. Who wants to hear “Oh my mum’s neighbour’s grandson had that and he used to ………..” or “I had depression because ……..” then go on to your own story. It’s not about you or the grandson!
  3. Be non-judgemental. “Love is the absence of judgment.” — Dalai Lama. Of course it’s in our nature to judge and it can be a good thing, it’s how we make sense of our world. We sometimes make snap decisions about patients based on their colour, sexual preferences, race, religion and even small things like how they’re dressed. However, a nurse mustn’t decide to see someone as being above or beneath them, they have to remain open to different possibilities and options. Being judgemental alienates us from others which is no good in a mental health environment. Nurses need to look beyond the presenting facade and immediate appearance of a patient where they’ll often find very human and tragic struggles. You can disagree with a patient’s choices or strong opinion but do it in a non-judgemental way. You could say something like “I hear what you’re saying and I appreciate your opinion but I see it differently. Tell me why you think …………”
  4. Communication skills. And I think you need excellent communication skills when working with sometimes confused, angry, sad, depressed or manic, chaotic, aggravated, delusional, psychotic patients and their families. Often there is so much going for a patient and they need support in many areas i.e. housing, finances, childcare, animal at home alone, emotional, physical or mental health. You need to be able to listen mindfully, to stay in the moment with the patient or family and not to immediately start preparing your answer. A patient wants to feel heard. Listen to the end of a patient’s ‘story’. The clue is often there; a small add-on for the patient but it’s actually the problem causing them the most grief. You need to be able to remain calm to speak clearly, concisely and appropriately to the patient and ask if they need further explanation or if they need more time to think. You need to be able to look; observe the patient and sometimes the family dynamics in order to gather information. Observe their facial gestures; whether they’re smiling, nodding, frowning. Observe posture; are they slumped, sagging shoulders and look at clothing appropriate for the weather. You might observe that the patient smells unclean, his teeth haven’t been brushed. You might notice that the patient is sweating or has a fever and take his temperature. The Royal College of Nursing (RCN) states that by using your eyes, ears, nose, touch and knowledge of what is ‘normal’ for the people you care for, you can identify potentially serious changes in mood and mental state and take action early on.
  5. Compassion is usefully described as a sensitivity to distress together with the commitment, courage and wisdom to do something about it (Cole-King & Gilbert, 2011). It’s a genuine sympathy for hardship or suffering. It’s kindness and the simple act of showing it can make a world of difference in a patient’s day. Nurses often come into people’s lives when they are in distress, pain and vulnerable and how they treat patients, carers and their families can leave a lasting impression. Ignoring differences and finding things in common help you relate to a patient and what they might be going through. Active listening, use of paraphrasing what the patient just said, makes them feel heard and cared for. Leaving your own world at the front door and just being there in the moment with a patient encourages openness and a mutual trust. These small acts all impact on a patient’s emotional responses and their view of the care they are to receive. Sometimes the nurse is the only person they have to listen to them and take their illness seriously, which is why compassion is key; it’s always at the forefront of what we do (www.yourworldhealthcare.com).
  6. Commitment in nursing is about providing the best care available at all times. You must commit to building positive and trusting relationships with colleagues and patients and their significant others to promote continuity of care. A nurse must be able to make the patient and families feel valued and cared for and feel safe in the nurses knowledge and skills. Therefore nurses must stay up to date with all relevant practice and be committed to lifelong learning which will enable delivery of excellent person-centred, evidence-based care. Education doesn’t stop when a nurse qualifies! Moreover, nurses must commit to taking good care of their own physical, emotional and mental health. If a nurse is not okay how can they expect to look after patientsundefined
  7. Ability to stay calm. If you can keep your head when all about you are losing theirs ………. by Rudyard Kipling comes to mind. Sometimes perhaps because they’re distressed, delusional or chaotic, patients can become angry and insistent on having their needs met immediately. It’s imperative that nurses can remain calm to deal with pressure, emotional outbursts or any other stressful situation effectively. Patience is important in helping you to effectively deal with a crisis as is being a team player skilled in the art of working well with other. Knowing how to effectively interact with different types of people will help to de-escalate or diffuse a potential risk situation and avoid having to use ‘Control and Restraint’ techniques on a patient.
  8. Emotional intelligence (EI) is how effective we are at behaving and responding in a mature manner, as well as our ability to properly process circumstances around us. As a mental health nurse, you would need to remain calm and use your EI if there was ever a ‘standoff’ situation where a patient becomes aggressive and physically threatening. You’d need to take in everything and everyone around you immediately to ensure the safety of the patient and others. Noticing, understanding, and managing one’s own and other’s emotions can be used to effectively engage the patient and bring calm to the situation. You might say to the patient “I hear what you’re saying……. I can see that your angry. What can I do to help? What would you like me to do?” “Would you like sit with me and I can listen?” What else might you say?
  9. Resilience enables nurses to cope with their work environment and to maintain healthy and stable psychological functioning. Working in mental health environments can be at best, positive and fulfilling but demanding, tiring and hectic and at worst, negative, exhausting and traumatic which can cause nurses both physical and mental problems, such as irritability, unhappiness and lack of concentration. Resilience is the ability to bounce back and it can be learned and improved upon through good supervision, preceptorship and mentorship programmes provided by the organisation.
  10. Adaptability is the ability or willingness to change in order to suit different conditions; it’s a necessary quality in an ever-changing work environment, particularly in mental health nursing. A mental health nurse will meet people who are often misunderstood by society, including their friends and family (www.yourworldhealthcare.com) and so need the ability to adapt easily to new patients, different disorders and changes in mood and emotional states together with new students, new nurses, change in Junior Doctors every six months, new procedures and policies…………… The list is infinite end ever changing as is mental health environments, so a nurse has to be flexible, to be curious, to be open minded and to see ahead and have a plan B.

The above attributes are essential though this list is not exhaustive. There are are many more personal characteristics such as being warm and engaging, considerate and so on.

I wish I could say I observed all the above in practice during three years of study and fifteen years of working within mental health.

Should we report our Mental Health colleagues?

Would you put yourself in the firing line and report a colleague’s poor practice?

My last post “Poor standards discovered at mental health units” was instigated by The Guardian’s grim report https://www.theguardian.com/society/2019/sep/25/inspectors-discover-poor-standards-at-28-mental-health-units in the Private Sector. I followed on by writing about a placement I’d had, only one two-week elective placement in Private Unit and it was just as grim. However, I had many other placements and also worked within the NHS and I’m afraid it was equally as bleak in some places.

I wrote of the nurse who came in laden with pillow, slippers and big blanket every night shift and once patients were in bed she made herself comfortable on the sofa where she slept ’til around six a.m. She wasn’t the only person who slept but the majority of staff woke after an hour or two and returned to duty.

I didn’t believe anyone should sleep whilst on duty on busy acute mental health wards but, as a student, was advised by colleagues not to rock the boat when I mentioned it. There would normally be two qualified nurses and one nursing assistant on duty during the night shift, on a twenty-bedded (plus) ward and if someone was sleeping that only left two staff to deal with any admissions or any emergency that might occur.

I was no spring chicken. I’d returned to studying at the grand old age of thirty-six and was classed as an adult learner. An adult who knew what was right and wrong – so I couldn’t sit by and ignore ‘sleepers’ as it made the shift unsafe for both patients and the non-sleeping staff. The NMC Code of Conduct 2015 states ‘ work with colleagues to preserve the safety of those receiving care.’ and I would quote this to the nurse in charge and would many times hear ‘Look it’s just what we do.’ or ‘Everyone does it.’ and ‘We all take two hour breaks here and if you want to sleep, it’s okay.’

I stood my ground and told senior staff that if this continued I’d have no option but to report it. Subsequently I noticed there were no ‘sleepers’ when I was on duty but I’d later heard that I was a ‘splitter’, someone who ‘split the team’ by complaining about poor practice.

I completed a placement in the community and I hated it. I had to work with miserable burnt out nurses, those who’d left the hustle and bustle of the acute wards for quieter and easier nine-to-five jobs in the community. As I’ve previously mentioned, my Supervisor was regularly thirty to forty minutes late so I latched onto other senior nurses, asking if I could do anything to help or could I accompany them on patient visits.

I was often met with belligerence and tutting and found many of them had huge chips on their shoulder. ‘They should have got promotion.’ ‘They didn’t win any awards.’ ‘They shouldn’t have to be walking the streets at their age.’ ‘They’re fed up with students.’ Blah blah, flippin’ blah.

Their own bad moods and failures often impacted on relationships with patients as they clicked their teeth, tutted and whinged as they assessed patients in their own homes. “Tsk, George why is this flat a mess? If you can’t look after yourself you go in (to hospital).” They’d do a quick ‘how are you?, are you sleeping well? are you eating well? and are you taking your medication?’ then they’d leave. Never with any kind of encouragement, always with a negative or condescending comment. Oh my word, give it up. Leave the job. Change career. Retire!

Quite often, on my days off, I would spot community staff in Tesco around three or four p.m. doing a large shop then sitting down for coffee and cakes when they should have been at someone’s home. That’s when you see in patient’s notes “Knocked two or three times and patient not in.” and you can see the same comment documented for weeks at a time!

I mentioned this during a ward round, when the Psychiatrist was discussing a patient who’d been recently admitted and looked like a homeless person; with matted dreadlocks and long, dirty nails. He was one of the patient’s who’s notes read ‘Patient not at home.’ for 6 consecutive months so he’d clearly not been seen in the community.

Later, when the visiting (Community Psychiatric Nurse) CPN had returned to her office she’d told her colleagues and boss what I’d said. I got a short, sharp, round-robin email telling me to speak with the community team manager before gossiping. Oh how I smiled as I saw that the Psychiatrist had responded before I could, stating that I had done the right thing and leave it at that.

Did they think I liked having to complain? Still, as a student learning how to become a good mental health nurse, I complained, time and time again and each time, I hated it.

Some time later and having worked on my first acute mental health ward for about six months, I was awarded the Trust’s ‘Most excellent Newcomer of the Year’ which came with a nice cheque (donated by a local company), flowers and a lovely piece of inscribed crystal that now sits proudly in a dusty cardboard box somewhere. As I walked through my colleagues to the lecturn to receive my award I heard the whispers behind covered mouths ‘Tsk. That’s her. That’s the splitter!”

Poor standards at 28 mental health units

https://www.theguardian.com/society/2019/sep/25/inspectors-discover-poor-standards-at-28-mental-health-units

Psychiatrists call for inquiry after report on private units, many occupied by NHS patients. This is great news. Not because poor standards were discovered, but because it’s been reported and it’s out there!

Patient’s bedroom. Design Pics Inc/REX

I’ve already mentioned some of the poor practice I’ve come across in other posts but there’s so much more. Like the way some staff dismiss patients’ fears and anxieties. What appears to be a molehill for us may feel like mountains to patients. When a patient expresses their fears about admission to an acute mental health ward it’s extremely important to listen so they feel heard and know that you care. It’s particularly difficult for patients who’ve been sectioned under the Mental Health Act 1985 (MHA) and almost dragged from their comfortable homes by well-meaning (or not) family, carers, Social Workers and a Psychiatrist.

During the admission process it’s essential to accept that patient fears are real for them and not to dismiss them. Some patients are acutely unwell and can be chaotic on admission so again, it’s important to continue the conversation as many times as a patient might need. Nurses also ought to let patients know that they have the right to appeal against their Section and give them the correct paperwork to do so. Patients also need to know about Patients Advice and Liaison (PALS), a service which will support them with almost anything. They can make an appointment with the team who will come to the ward if a patient has no leave.

While The Guardian reports “Inspectors have found 28 privately run mental health units to be “inadequate” this does not detract from poor standards within the NHS. I only had one elective placement (which I chose) within a private unit and I would never go back. Most of the staff were agency who probably couldn’t get permanent jobs if they tried. They were rude, authoritarian and antagonistic not just to patients but to families, colleagues and students.

Nursing admin. Photo: Shutterstock.com

They didn’t like me and the feeling was mutual. I asked too many questions and ‘cared too much’ when I ought to be doing some work i.e. the menial tasks they couldn’t be bothered doing. What they didn’t know, because they didn’t ask, was that I had been doing secretarial work for near on twenty years and I loved doing the admin, completing computerised care plans etc; I was quick and good at it so I smiled throughout the shift – something that bugged colleagues when they disliked you.

One particular famous client (which they were called in private units) was on methadone, an opiate prescribed by doctors as a substitute for heroin, and she wanted to eat lunch before medication, which she did. However, when she went to get her medication the nurse who’d been doling out meds had left the ward.

The other nurses wouldn’t give her the methadone and told her she’d have to wait, which could potentially trigger debilitating withdrawal symptoms like nausea and insomnia and I thought the nurses’ punitive actions were totally unacceptable.

I went to the unit Manager who was sitting in his plush office and asked whether it was standard practice to hold medication hostage. He tutted and exhaled heavily, put his muscled arms up behind his dreadlocked head and proffered an uncomfortable smile. “Mmm, Nancy is it? Look, she’s a pain. Man, she always think she can bend the rules.”

“Pfft, rules?” I asked. This is a healthcare facility isn’t it? I am in the right place?”

“Nancy, we only have enough staff to do the basics, they don’t have time to run after clients whenever they want.”

“Okay, but Molly’s totally distressed now so I’ll go and talk with her and document all this in her notes.” I said with a sarcastic smile and walked out of his office. He wasn’t long in chasing me down the corridor, apologising profusely; he was just having a bad day, he didn’t realise what staff were doing! He would get the medication now. I still documented this event in Molly’s notes and asked a nurse to co-sign it.

Guess who didn’t speak to me the rest of my placement? Was I bothered? It was one less idiot to listen to as she did nothing but whinge about the job, moan about various patients and kiss her teeth throughout her shifts. She spent more time on the computers, googling hairstyles and nail art, not realising that somewhere in Head Office, the tech guys could easily follow what she was doing, see how much time she spends online and could report her for time wasting.

Busy tech guy – Photo: Gettyimages.co.uk

Much of the time on this elective placement I felt so powerless and could totally empathise with patients. No one wanted to listen and no one cared! Staff appeared to find everything a chore and it seemed they only came in to earn money. See, nursing isn’t just a job. Being a professional nurse means the patients in your care must be able to trust you, it means being up to date with best practice, it means treating your patients  and colleagues with dignity, kindness, respect and compassion.  It means understanding the NMC code of conduct. It means being accountable. Katrina Michelle Rowan, 2010. https://www.nursingtimes.net/archive/nursing-will-never-be-just-a-job-to-me-24-07-2010

I was able to complete several PBA’s on this placement and learnt more about how not be be a mental health nurse. I saw how poor the team’s communication skills were, both verbal and mainly non-verbal. I saw how badly they treated people, how unprofessional they were and how they lacked empathy for anyone. As much as the staff on this placement tried to hold me back, little did they know how much I gained and how much I’d grown by watching their indifference. I always say, there’s never a bad lesson.

Mental Health rehab works—only if the staff do

Realkm.com

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.

Mandy

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.”

Example care plan
How a care plan might look

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.

Sasha

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.

Elsa

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!

NMC.org.uk

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

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