My first night shift on a Mental Health rehab unit

Night Shift on a rehab unit

I was working a bank shift which means I am on the Trust’s bank of staff who are available to cover shifts on the various wards if they don’t have enough staff. Because I was a student I could only work as a nursing assistant (N/A).

In comes Ayo with her big bag and her big blanket, tutting as per usual before slumping down into a chair, moaning, “Oh Lord, I don’t need this, I worked early bank shift on Jasmin (ward).”

Working a night shift then a late shift is not standard practice. Long hours, fatigue and lack of rest breaks or time to recuperate between shifts are associated with an increased risk of errors. However it’s very difficult for Ward Managers to keep track of, if staff members do extra bank shifts on another ward, which many of them do. Is it any wonder they’re tired and burnt out when they’re working three to four bank shifts a week elsewhere?

Handover

Lisa arrived just in time as Clare was about to start handover at nine pm “Mandy’s not coping with the titration of her Diazepam and continues to scream at medication time. Sasha remains bright in mood and went out with her nurse to buy new underwear today. She asked when Nancy was working next……..” and this made me smile as I’d taken a shine to her too. “Elsa messed herself again today and her clothes were found in the shower floor.” Clare briefly covered all patients on the unit and said her goodbyes. That left left Lisa, Ayo and me working as a support worker.

Ayo was coordinating this shift but before she could even allocate patients and any tasks Mandy was banging on the office door “I need my medication. I need my medication……” and as I went to speak to her Ayo cried out “No. Let her wait. Everyone have to wait.”

“Ayo, I just want to let her know that she will get her medication soon. It’s not nice that she’s crying and upset. I ………..”

“No!” muttered Ayo and she kissed her teeth. Ayo then allocated four patients to me, including Mandy and Elsa. As much as I loved working with all the patients, cos they each brought their own joys with them, I noted how I was always given the more difficult patients to work with. Unfortunately, lots of staff did this but, by rights, they ought to have taken these patients because they were trained and qualified.

Lisa would be doing medication this night and I was to prepare supper of toast and hot chocolate; no coffee or tea because patients weren’t allowed caffeine before bedtime. Mandy was given her medication first then she tottered through to the kitchen, wringing her hands and muttering to herself. “Hello Nancy. It’s nice to see you again. I’ve had my medication but they’ve cut it down and I can’t cope Nancy. Honest, I can’t. Can I have three slices of toast nurse and will you cut it into quarters for me?” before shuffling over to the large table. I took her hot chocolate over as she was trembling and I could see her ending up with half a cup if she was to carry it.

Edward was next at the counter and he too shuffled away happily with his toast and jam and cup of chocolate. Edward was forty years old but could have passed for fifty plus as he was always unshaven, his face was weatherbeaten and his grey hair had receded. Edward had a diagnosis of schizophrenia and since he was seventeen he heard many voices and saw people who were not visible to others. Unless you saw him at mealtimes, you wouldn’t know he was there; he was so quiet. I had to seek him out each week for games night and he came along willingly, as he was actually really good at scrabble and we both enjoyed the challenge.

Bedtime

With medication and supper over I went to check on my four allocated patients. All bar Edward were in their rooms and in various states of undress. Mandy wore a long floral flannelette nightgown and ancient slippers and I watched as she carefully folded the clothes she’s just taken off into neat piles. Her room was spotless if not a little cluttered as she collected china tea pots of all size. and colours. “Night, night nurse. Will you close my door for me?”

Sasha was in bed and snoring lightly. Elsa was struggling with her bra straps so I offered to help. “Fuck off me, you. I don’t need you.” she spat and turned her back on me. “Go on, fuck off.” Then she gave me another of her toothless grins. I think she just liked to test the nurses’ responses. She always made me smile and I told her I’d be back in five to see she was okay. I did go back because if you say you will, then you must. So many patients are left waiting when nurses tell them they’ll come back and I think it’s cruel. That left Edward. He was watching a film in the shared living area, chuckling away to himself. I wasn’t sure if he was laughing at the television or the voices he heard but he looked happy enough. I was going to go over to sit with him for a while when Ayo called “Bedtime Edward.” and switched the lights out.

I said “He’s watching this film, let him see the end. It’s over in twenty minutes.”

“It’s eleven o’clock and it time for bed. Come Edward. Come now.” Totally ignoring me, she watched as Edward struggled to get out of the chair and shuffle over to the door. Once everyone was in bed Lisa checked all the downstairs doors and windows then returned to the office. I asked why Ayo wouldn’t let Edward finish watching the film and she said “Eleven o’clock, lights out.” I couldn’t believe it because I’m sure everyone has a different body clock and bedtime and had Edward been at home, he would have watched the end before going to bed. I was going to make sure that I documented this in Edwards notes and flag it up at the next team meeting.

Staff bedtime too

It was eerily quiet, pitch black and unnerving as I went to the kitchen to get drinks for myself and Lisa. On my way back to the office, all I could see in the living area was a pair of eyes peering out at me from underneath a blanket. I whispered “Hello,” but got no response. I crept forward so as not to startle what I thought was a patient but Ayo shrieked “My Lord. Girl, what you doing? You frightened the life out of me.” There she was, feet up with her slippers lying on the floor, curled up on the sofa. “I havin’ my break. Go. Foolish girl,” and she kissed her teeth.

Off I went with the drinks, shaking my head, stunned. I asked Lisa whether this was normal practice, for staff to sleep while on duty and was told that we each get two hours break but Ayo just sleeps all night. “So that would leave one of us on the floor?” I enquired. If both Ayo and Lisa were on a break that would leave me, an N/A, to be responsible for the unit. “Yes, that’s what we do. It’s okay, Ayo always sleeps” she smiled.

“I’m sorry Lisa but I don’t feel comfortable with that. I’m working as an N/A and I’m not qualified if there’s any emergency.”

“Nancy, she’s done it for years. Even our manager knows.” said Lisa sighing and shrugging her shoulders. However, that night neither she nor I had a sleeping break. We both sat in the office, Lisa looking at holidays online and me reading through my patients’ notes. I really enjoyed finding out more about the patients and while it was quiet I could help update their care plans, number the pages in their files and generally complete paperwork that’s often difficult to do during a busy shift.

The time went quickly and I was so immersed I didn’t hear Ayo coming into the office. However, I heard her loud yawning and watched as she stretched upwards before dropping herself into the spare chair next to me. I caught a whiff of her stale morning breath and body odour! Offering to make us drinks allowed me to make a swift exit and by the time I’d returned Ayo had rolled her chair to another desk.

Six fifty five and the morning staff were starting to arrive. “Nancy, Lisa, you go on the floor, I do handover.” Which is normal for the coordinating nurse to stay in the office to give the handover, while the rest were outside attending to patients. However I couldn’t help but wonder how a nurse who’d slept all night and hadn’t asked her colleagues about the shift’s events could possibly give an adequate handover. Again, I asked Lisa who tutted and said “Nancy, you’re just a student. It really won’t do you any good to keep questioning your colleagues practices now. They won’t thank you and you’ll fall out.”

“I don’t want to fall out with them but as I’m a student, working as a nursing assistant surely I have an opinion? And I don’t think it’s safe for patients or staff if others are not doing their job.”

“Nancy, it’s just how it is, how’s it’s been for years and you can’t change it.”

The Nursing & Midwifery Council’s (NMC) Code of Conduct 2015, sets out professional standards of practice and behaviour for nurses, midwives and nursing associates. Point 3.4 states: act as an advocate for the vulnerable, challenging poor practice and discriminatory attitudes and behaviour relating to their care. Both Ayo and Lisa had completely ignored all the rules!

Would you be able to highlight where they’d gone wrong?

Would you have reported them?

I would later talk this through with the unit Manager.

Note to self: “Folks who never do any more than they get paid for, never get paid for any more than they do”― Elbert Hubbard

Shocked at seeing a mental health patient being dragged to the floor by nurses

My first few days………

Just five minutes, a quick coffee and a ciggie then back to the ward where I was able to let myself in as I’d been given keys and a swipe card for the downstairs door. Derry had gone into Management Round which, I was informed, happens each Monday morning. Apparently, this is where the Doctors plan ward round allocation of patients, who are normally seen on a weekly basis.

The phone was ringing off the hook and there was no one else around to answer it so I gingerly picked it up, saying ‘Good morning, Lavender ….’ A female interrupted and spoke urgently “Why is my brother off the ward? He’s banging on my front door and all the bloody neighbours are out on their doorsteps. What’s going on?”

“Uumm, good morning. I’m a student nurse. Do you know who you want to speak to, which nurse?”

“Someone who knows what they’re fucking doing would be good.”

“Ok, what’s your name and your brother’s name …..”

“It’s Pauline Kennedy calling and my brother is John. He’s screaming through the letterbox now, can you hear him? Fucking arse”

“Pauline, hold on a second.”

“Not you, him, sorry.” I’m glad she clarified that cos I’ve been called some names in my time, but that was a new one. “Ok, Pauline, give me a second, would you like to hold on or shall I call you back?”

“No, I’ll hold…” she tutted. I dashed up the corridor, knocked the door to the meeting room and popped my head in to tell Derry and the Doctors. “For fuck sake.” Derry’s Irish brogue rang out and “Has she called the police?” enquired one Doctor, the elder out of two. But Derry was out the door, heading for the office and I followed.

“How’d he get out?” Derry muttered to no one in particular. “Hello Pauline, it’s Derry here. Is he still there? Have you called the police? Aye, I know but okay, I’ll do that. You just keep yourself safe and I’ll call you back in a wee minute.”

“Jesus, we’re in trouble now. This guy used to live with his sister and he’s paranoid about men wanting her, that they want to have sex with her. He’s already done time for smashing the electricity man in the face with a brick after the poor man went to check the meter. John’s on a Restriction Order (1) so he is.”

“Here, you call the police on this number and let them know what’s going on. Pauline’s address is there,” urged Derry, pointing out a page in John’s file. Alison had just come into the office and I could hear Derry filling her in while I spoke with the police. I was a bit nervous, having never been in a situation like this before, but I was able to give all the necessary details to the police.

Derry, bless him, winked and gave me the thumbs up while he was on the other line to Pauline, letting her know the police were on their way. At the same time, she’d told Derry that John was quietening down a bit. The two doctors; the Consultant Psychiatrist and an SHO (2) appeared at the office door. “Everything alright Derry, Nancy? Oh, hello Nancy. Sorry, I’m Doctor Shand and this is Doctor Wiles. Do we know what’s happening? Let me know when he’s back on the ward please.” he smiled and left.

“Good job there Nancy. Will you just write in his notes; what happened?” Derry asked.

It wasn’t long before the ward door opened and I could see John being led in by the police and half a dozen people who, it turns out, are part of the Hospital Rapid Response Team (RRT), called to assist in emergencies like this. John shuffled in, head down, looking shame-faced and went to the smoking-room while a police officer spent a moment with Derry then led his team away.

The RRT was a team made up of six-seven people, mainly men it seemed, one from each of the wards, who responded when a bleep and the radio sounded, telling them where to go. On this occasion, they’d been called to the hospital entrance when the police arrived with John to escort him back to the ward. The Team had now followed Derry into that tiny office and, being a bit nosey, I went to the smoking-room where I offered John a ciggie. I’d cottoned on that ciggies were the currency used if you wanted to engage a patient and this time was no exception.

However, sitting between John and another patient, who’d introduced himself, with a cut-glass English accent, as James and asked for a ciggie, I felt decidedly uncomfortable. John was muttering he wanted to kill someone and James was bouncing back and forth in his chair, fists balled tight. I was wondering how I could finish my freshly lit ciggie and make my exit back to the relative safety of the kitchen without bringing too much attention to myself. Just at that, the door opened and Derry said “Come on John, you need to take your meds.”

“Nope!” John had no sooner hurled back at him when the RRT burst in and launched at him, grabbing him by his elbows and wrists, pulling him up out of the chair and on an authoritative command “Down!” to the floor. John was yelling “Fucking bastards. You fucking wait.” and struggling among the fag butts and drink slops, battling against the five staff holding on to him; one on each arm, one on each leg and one at his head. The person at his head was talking to John, calmly telling him what was happening, that it was for his own good and that he was okay. “Keep still. You’re safe.”

Hell, this didn’t look okay to me. Alison came in with a small cardboard tray holding two half-filled syringes and waited while someone pulled John’s jeans and boxers down about six inches. My heart was pounding and my eyes felt like they were on sticks as Alison swabbed an area of John’s right buttock, then said “A sharp pinch John.” she calmly popped one needle in and squeezed followed by another.

I would later learn that the intramuscular injections they’d administered was what nurses called ten and two; ten mg of Haloperidol (3), and two mg of Lorazepam (4) which, together create sedation quickly. This combination of drugs is normally used in the management of acutely disturbed patients? However, a patient unknown to the hospital or a smaller person i.e. a female, would be given a reduced dose of 5 mg of Haloperidol and 1 mg of Lorazepam in the first instance.

RRT held onto John for a few minutes and he eventually stopped struggling. Derry said “You good John? Come on now. We’ll let you up. Easy now.” They helped him to his feet and one by one, limbs were let go and the team dispersed. “Into the office boys and girls,” Derry continued, as if nothing had happened.

There was a quick debrief, where I learned that no one was taking responsibility for letting John out. I’d only been given the keys prior to my ciggie break and he certainly didn’t leave with me, despite the knowing glances I was getting from the ward team. However, the team agreed that the Control and Restraint (C&R) had gone well and no one got hurt, so the RRT left the ward.

Derry and Alison were both busy documenting the incident in various forms, so when I heard that someone had to complete an incident form, I happily offered. They chatted away, telling me that John had missed his morning medication which included ten milligrams (mg) of Diazepam, known to have a sedative effect, hence the paranoia and visit to his sister’s.

Alison held her hands up as she’d done medication that morning and she’d missed this. She insisted I document this on the incident form but I showed them both my documentation where I’d written, “John was seen on the CCTV leaving the ward at 08.10, just as medication was being administered and therefore did not have his medication.”

“Well done Nancy. You checked that yourself, did ye?” I grinned from ear to ear when he half-joked “You’ve got the job.”

(1) A Restriction Order is when Criminal courts can use section 37 if they think you should be in hospital, instead of prison. Section 41 is a restriction order. The Crown Court can add this order to a section 37 if they think you are a risk to the public – Section 37/41

A section 41 Restriction Order can be added to a section 37. It is then called a section 37/41. Only a judge in a Crown Court can do this. They will do this if they think you are a risk to the public.6 The restriction order means that there are restrictions on both you and your Responsible Clinician (RC). One restriction is that your RC needs to get permission from the Secretary of State for Justice to discharge you.

(2) SHO – A senior house officer (SHO) is a non-consultant hospital doctor in the UK. SHO’s are supervised in their work by consultants and registrars. In training posts these registrars and consultants oversee training and are usually their designated clinical supervisors.

(3) Haloperidol helps you to think more clearly, feel less nervous, and take part in everyday life. It works in the brain to treat schizophrenia and has a sedative effect within ten minutes It can also help prevent suicide in people who are likely to harm themselves. It also reduces aggression and the desire to hurt others. It can decrease negative thoughts and hallucinations. https://www.webmd.com/

(4) This medication is used to treat anxiety. Lorazepam belongs to a class of drugs known as benzodiazepines which act on the brain and nerves (central nervous system) to produce a calming effect. This drug works by enhancing the effects of a certain natural chemical in the body (GABA). https://www.webmd.com/

Note to self: “Empathy is seeing with the eyes of another, listening with the ears of another and feeling with the heart of another.” Author unknown.