What everyone should know about mental health nursing

Some jobs are definitely physically demanding. Some are extremely mentally demanding and some are acutely emotionally demanding. Get this — mental health nursing is all three.

But no matter how physically tiring, emotionally draining and mentally exhausting, lots of the mental health nurses I’ve had the honour of working with do an amazing job. They cared about their patients physical, emotional and mental well-being and often went way beyond the call of duty.

Boris Johnson lbc.co.uk

The government should recognise how difficult it is for nurses, working long days because someone hasn’t turned up for their shift (for whatever reason), working nights when they could be at home with their kids and families and working in difficult environments like mental health.

Local MP’s should spend a week on our wards (a day isn’t long enough), not just observing, but getting their hands dirty. Then they should shout from the rooftops of the Houses of Parliament or through Boris Johnson’s letterbox “Nurses deserve better wages!”

Current salaries for newly qualified nurses range from £22,128 to £28,746 (Band 5) with an annual 1% pay increase, NHS 2019. Our poor MP’s only receive around £79,468+, a 2.7% increase on last year. Boris Johnson’s promise of more money to the NHS, but let’s hope that includes salary increases befitting the job.

The NHS should also be thankful for these nurses, who often go short on breaks and who have to stay fifteen to thirty minutes longer most days. See, you can’t just walk out on a patient who’s upset, angry or crying, saying “that’s it, my shift’s done.” Following this interaction there’s the documentation to complete. You must document everything. I always taught nurses — if it’s not documented, it’s not done.

With regards to documentation the Nursing and Midwifery Council’s (NMC) The Code 2018; states:

10. Keep clear and accurate records relevant to your practice. This applies to the records that are relevant to your scope of practice. It includes but is not limited to patient records. To achieve this, you must:

NMC 2018

10.1 complete records at the time or as soon as possible after an event, recording if the notes are written some time after the event

10.2 identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need

10.3 complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements

10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation

10.5 take all steps to make sure that records are kept securely

10.6 collect, treat and store all data and research findings appropriately

Our documentation and patient files are potentially legal documents whereby, if there was a serious untoward incident i.e. a patient died by suicide, they would be called for and used as evidence in the following investigation. You can’t just say afterwards i.e. “the patient told me they were happy and looking forward to visitors that afternoon, so I didn’t think there was any risk of suicide”. If you didn’t document it — it didn’t happen.

Whilst the above is one reason for appropriate documentation, it also informs colleagues on the next shifts or a nurse’s return to work from time off. It lets them know about the patient’s mood and mental state, what they may or may not have done the previous shift and any interventions you undertook.

Nurses are generally allocated around five patients each shift and after handover, the first thing a good nurse does, is read the last few entries in their patient’s notes and catch up on their care plans, which may or may not have been changed or updated.

Thegaurdian.com

However, the not-so-good and the downright lazy nurses had me tearing my hair out at time. Daily entries consisted of “Patient slept most of the shift.”

A nurse worked (well, they were in the building) an eight hour shift and that’s all they have to write?

Okay, so the patient might have slept most of the shift, but what did they do the rest of the time? Did the nurse try to wake them, encourage them to get up for breakfast/lunch, to attend an activity? And while the patient slept, did the nurse audit the patient’s notes to ensure everything was in order, i.e. patient name on each page, pages were numbered, care plans were up to date?

Even if the patient had slept most of the shift, surely you’d attempt some intervention, try to engage them. Even if they do tell you to ‘fuck off’, or yell ‘leave me alone’, write that — it shows that you have at least attempted to engage them. And don’t give up at the first hurdle, try again. And again. Then document it.

I’d tell patients that I was going to sing and tap dance in my heels if they didn’t get up, they’d half-laugh and eventually drag themselves out of bed. I also told them that we, as nurses, had a duty of care and that included providing a clean environment, followed with a cheery “Now get your bum up so we can change your sheets and clean your room!” I didn’t mind if they went straight back to bed once we’d finished but usually, once they actually got out of their bedroom, they tended to eat, engage with others or watched t.v. in the day area.

online.umn.uk

It really isn’t that difficult. And it also shows the patients that you care enough to keep trying. Patients really do know the difference between the nurses who just want an easy time or are bored and the ones that care, the ones who want to help, the ones who don’t mind getting their hands dirty. They noticed and had more often than not, experienced nurses dissociation and emotional distance on a daily basis. Quite simply, patients recognised poor nursing.

Some nurses I worked with appeared devoid of the critical ability needed to assess patients, to assess any risk and to provide appropriate care and treatment — other than medication. They lacked the observation, communication and interpersonal skills to engage with patients and they showed little or no empathy. They saw patient’s distress only as a set of symptoms (not a human being in pain), often calling them ‘attention seeking’ or ‘manipulative.’

When a patient became angry (appropriate to their current situation i.e. the nurse wouldn’t let them use the telephone when they needed to contact benefits etc.) nurses saw it as ‘kicking off’, ‘taking liberties’ or generally just getting on the nurse’s nerves.

Some nurses seemed to forget or ignore all the knowledge and skills they’d acquired at uni; their compassion, empathy and understanding had all but disappeared, or they’d just burnt out from all the extra shift they worked – through choice!

Let’s get something straight!

If you don’t want all the back-breaking physical work (left by bone-idle nurses on the previous shift), the constant demanding emotional interactions, the woefully tiring verbal onslaught that greets you each shift because their needs weren’t met on the last shift or the boring whining, repetitive complaints and the teeth kissing or tutting – and all that is from your colleagues only — then mental health nursing is not for you.

NMC 2010

Nurses have a responsibility to deliver consistent high quality care. They have a duty to promote good mental health and encourage healthy behaviours by building good relationships and gaining the trust and confidence of their patients, NMC; Standards for competence for registered nurses 2010.

Many mental health nurses lack knowledge and skills

Even early on in my mental health nursing career, as a student in fact, it was clear to me that some mental health nurses needed to find another job. They won’t though. They know they have a cushy job working for the NHS. It’s notoriously difficult to dismiss staff, even if you do follow the Trust Policies exactly.

Smashing Magazine

I saw many a nurse who lacked the knowledge and skills necessary for nursing and who was totally unaware of it. They belong in the unconscious incompetence group in the square and this makes them potentially dangerous. If they’re not even aware, or have never been told that they are incompetent, they’ll continue to perform poorly and make mistakes, some of which could be fatal, in terms of nursing.

The fact that these nurses were oblivious to their incompetence is bad enough, but for this not to have been picked up by their managers is almost criminal. One major problem was that our managers were all previously nurses and 99.9% had no secretarial, admin, book-keeping, human resources or management experience. Therefore managers lacked the knowledge and skills to manage staff. That’s another post.

Some of our nurses were just plain lazy too, maybe because of their incompetence, so I’ll start off with them.

Tenor.com

The number of times I approached a nurse sitting on their lazy fat arse, watching t.v., particularly if they were on what’s called a bank shift (we had a bank of staff who covered extra shifts where needed), infuriated me. I’d suggest, if they were qualified, they go and help with medication. “Oh, but I’m just bank shift today,” they’d exclaim. I’d ask if they were getting paid a wage this week, “Yes,” they’d laugh, looking at me curiously.

“Okay, good. Now get up and go do something to earn it.” I’d smile.

Even bank nursing assistants tried the “I’m only bank today.” Somehow that translates as you don’t have to do any work on a bank shift? And “I’m just bank this morning. I’m on blah blah ward this afternoon/evening so I’ll be exhausted. Oh, and I need to leave early.”

“That’s not my problem whether you’ll be tired, nor is where you’ll be working later, you committed to a shift and I need you to carry it out.” I’d insist.

“Well you need to call my manager to tell them I can’t leave early,” they’d cry.

“No. You need to tell your manager and let them know that you booked an extra shift on our ward, knowing you were working on your own ward later.” I’d remind them.

“Evelyn never had a problem with me working double shifts, and she let me go early.” tried one nurse.

“Evelyn no longer works here. And there will be no more double shifts and leaving early from now on.” How these staff got away with all this for years, I can only guess.

However, the thing I detested most was when you said to nurses, “Put your newspaper down, spend some time with your patients, talk to them……..”

I got “I don’t know them, I’m just a bank nurse.” or “I don’t know what to say.” How hard is it to start a damn conversation? I always wondered at uni, why we had to have copious lessons in communication skills. Now I know.

Lazy Doctors

Syfy.com

Some Doctors were just as bad, particularly during the night shift. You’d call them to assess a patient in A&E and they’d say “I’m over at Rosemary ward (situated five minutes down the road from the main hospital) with a patient. I’ll be there in about an hour,” which really meant two. Hhmmm, Rosemary ward – every night you called for a Doctor – they only had eight patients.

Obviously I was aware that Doctors worked long hours and the needed breaks, but we were working with agitated and chaotic patients here, many who needed medication prescribed immediately. Without medication, patients sometimes had to be restrained, which wasn’t fair on them, or the Team – soooo a change in tactics was needed. “Okay, no problem Doc. I’ll put that in the notes. Thank y…….”

“Okay, okay. I’ll be there” and so they were, ten minutes later.

Kobi was just plain lazy

Metablog Mattadorrecords.com

We had one nurse, a lump of lard called Kobi, who was as round as he was tall and he just lumbered around the ward, stuffing his face non-stop. As part of our jobs, we are expected to carry the bleep for Rapid Response (RRT where you have to attend any emergency on A&E or another ward) and to help restrain patients when necessary. Before I joined Daffodil ward, Kobi had long since refused to do these two tasks because he said he had sore knees. His colleagues thought this was unfair as they were having to pick up the slack, and I agreed.

I appreciate that staff will be sick or in pain at times, but there are policies and systems in place to manage this i.e. assess for other underlying health problems, further training, offer Occupational Therapy or other support and plan a time frame in which to return to full duties or assess the need for more time, then review. You can’t just decide you won’t do these tasks.

When we met to discuss this issue, I gave him some options to consider and offered support. He puffed and panted “I was manager (for a private mental health hospital) for two years before, you know. I have a right to refuse to do things as I see fit. I will speak to my union, you know.”

Healthline.com

“Yes, I’m aware that you were a Manager and yes, of course, please speak to your union. Let them know what we’ve discussed, the support I’ve offered you and the three-month time frame for review. I’ll put what we’ve discussed in writing later today.” He never did go to his union and his knees got better but unfortunately, he didn’t.

Kobi was neglectful

During one morning handover, Kobi reported that Betty had fallen from her chair in the night and that she was assessed before being supported back to her chair. We could see Betty sitting in the day room and she looked rather uncomfortable, so I asked “Ah, was she bruised or anything? What did the Doctor say?”

“Pftt, she didn’t need a Doctor. She was all okay. She say her shoulder hurt, but she always complain about it.”

“Why didn’t you call the Doctor, Kobi? She always complains about her left shoulder – because. she’s. in. pain. Kobi. This time, she’s holding her right shoulder.”

“I assessed her and she was okay. I tell you. I was manager before, I can make a judgement call.”

Everybody knows that if a patient falls, a Doctor must always be called to assess for injury or pain and to prescribe any further treatment or pain relief. What on earth made him think that on this occasion, he did not need a Doctor to visit the ward?

US News Health

At that, I left the nursing office and went to speak with Betty to ask if she was in pain and at the same time, take a look at her shoulder. She didn’t have to take her cardigan off fully because as I slid the top of the sleeve towards her shoulder, she yelped and I caught sight of the almighty black and blue bruise. “Get Betty over to A&E immediately please Lauren. Kobi, when you’ve finished handover, come to see me.” I silently fumed.

“Er, no! I can’t. I have to take my grandson to school. Then I’m off ’til Monday,” he croaked and he looked quite flustered. I immediately rang my Modern Matron for advice and she agreed there wasn’t much we could do until he returned. In the meantime, the rest of the staff had to complete his paperwork, fill out the incident form and someone had to sit with Betty over at A&E.

Eventually we met again and he was given his first written warning (I would have dismissed him).

Kobi was a risk to patients

Not a month later, he let a patient into the bathroom on her own and she almost drowned in the bath. This elderly patient, Esme, couldn’t have been more than 4′ 6″ and obviously wasn’t long enough for her feet to reach the end of the bath. She was in the habit of filling the bathtub to the top and it was written in her care plan that 1) she must be supervised in the bathroom at all times, 2) she had to request the key to the bathroom door, to alert staff that she wanted to have a bath and 3) she was not to have a bath during the night.

Telegraph.co.uk

This lardy arse excuse for a man said that, despite the clear care plan, he wanted to give Esme some privacy so he just popped back and forth every minute to check on her. Yet another nurse said he sat in the office for about thirty minutes while she went round the ward to do the half hourly checks. It was this nurse who heard Esme splashing around, almost drowning, and called for help to open the door as Esme had locked it from the inside. Oh but he did real good this time; he called the Doctor!

As instructed by the Human Resources Department, he was given his second written warning, which I didn’t think was good enough so they removed him from our ward, only to be placed elsewhere – a male ward, so he would be at less risk of causing harm to a patient.

Rachel just panicked

During a restraint one day, where it took more nurses than usual to restrain a new admission patient, I was on the floor trying to engage the patient and give assurances that we were indeed trying to help him. Rachel, a ward nurse, had gone to draw up the medication and had been gone for over ten minutes; the patient was becoming more agitated and the restraint team were tiring.

Rachel eventually returned and with the patient’s underwear down, she cleaned and marked the injection site. She pressed the plunger so the needle went in slightly and pulled it back out, as is correct. She was ashen faced when she saw blood in the barrel, which means that she’d hit a blood vessel*. This isn’t a huge problem as long as you stop, remove the needle and press on the injection site to stop it bleeding. She didn’t. She pressed the plunger and the needle went in.

*A broken blood vessel can cause internal bleeding within the muscle and the patient may feel pain and stiffness in the muscle. If a blood vessel breaks, scar tissue or blood clots can form and if a blood clot starts to wander and reaches the heart or lungs, the consequences can be life-threatening.  Injections that hit an artery can be particularly dangerous.

Rachel started panicking and was tearful, so I lead her away while the rest of the team continued and someone called for the Doctor. I got Rachel a coffee and sat her in my office to calm down before joining the Doctor, who confirmed there was no real damage done and the patient would be informed later.

TheSun.co.uk

I returned to my office and downloaded an Incident Form so I wouldn’t forget to complete it later. I turned to Rachel and said not to worry as everything was fine, “Talk me through what happened,” I said kindly, as I felt bad for her. The floodgates opened and she wailed “You were rushing me and I made a mistake……….. It wasn’t my fault……”

“Hey, no one’s blaming you Rachel. Mistakes happen. I just want you to talk me through it.” We have protocols to follow with damaged injection sites and I wanted Rachel to discuss what happened, so that she would learn from it. There would be no follow up other than if she were to make the same mistake again. Only then would she be requested to attend the “Safe medication” course.

Rachel wasn’t prepared to let me explain, “If there’s nothing wrong, why am I in your office? And why have you got the incident form out?” She screamed defensively. “I don’t need this. You don’t know what’s going on in my life.”

“No, I don’t. But you can tell me……….” too late. She’s up and out the door, storming into the staff room, telling everyone on her way, “she’s picking on me.”

The long and short of it – she went off sick with work-related stress. Me, my manager and the HR department tried to contact her at regular intervals, even visiting her home, in accordance with Trust Policy, to no avail.

Almost a year later, without my knowledge or any reference request, she was back in our hospital, working on the Mother and Baby Unit.

Oh dear. Even HR make mistakes – she was still officially employed by the Trust. And who in hell thought she’s be suitable to work with newborn babies!

Who do you think ought to be responsible for incompetent and lazy staff?