Anxiety and panic attacks on honeymoon

My journey through anxiety, panic attacks, depression and psychosis – Part X

Black and white photo young woman in tears - everything is fragile
Anxiety and depression made me feel so fragile

This is the 10th in a series of “My journey through Anxiety, panic attacks, depression and psychosis. Please click here for Parts I, II, III, IV, V , VI, VII, VIII and IX if you wish to read the backstory (It might make more sense).

For those of you who don’t know, I started writing about my journey six months ago and only ever intended to write it in four posts. However, it’s become clear that my journey through anxiety and panic attacks was a lot longer and more painful than I remembered. That’s made it difficult to get the words down on paper at times. I’ve taken many breaks and written lots of other posts in between, giving me time to reflect and bounce back a bit stronger each time.

It’s not what you’d expect on honeymoon, is it? I mean, married for one day, in Sunny Corfu with my new hubby, I should be in heaven, right? Oh no, not me! I had anxiety and several panic attacks throughout our first night. And not for reasons you might have thought. If you read my last post “Done with anxiety and Panic Attacks” here, you might remember……

Home from honeymoon

The young women in sun hats and summer dresses, laughing
No anxiety here
Ben White @ Unsplash.com

He continued as he started, creating merry hell. He was legless and chatting up anyone under 30, thinking I’d be jealous — I wasn’t. Oh, I forgot to tell you, he was ten years younger than me. Ha, not so anyone would notice.

So, after honeymoon-gate, did it get any better? Once we got inside my house, my eldest son greeted us both warmly, and welcomed us home. He laughed, telling Ian to get the kettle on, saying “You live here now,” which he did indeed. It was the first time I’d thought about the fact that he was now moving in with us. I had that sinking feeling in my stomach and it didn’t feel right.

After dinner drugs

After a chatty takeaway dinner the boys went off to their rooms to study, leaving Ian and me in the sitting room. He cracked open yet another beer can and began rolling a joint. “Oh no you don’t, not in this house and certainly not in front of the boys,” I cautioned. I knew he’d smoked the odd joint at a party, but there was no way I’d have cannabis in our home.

“Man, I f*cking live here as well, don’t I? Ye’ve never stopped us before like, and you’re not stopping us now,” he retorted. Attempting to cajole him, cos I didn’t want a row, I suggested he go out to the garden. He stormed out, huffing and puffing, almost taking the door off its hinges then allowing it to slam shut.

“It’s alright, the wind caught the door”, I lied to the boys who were peering down over the landing. My heart was hammering, and I could feel the anxiety engulfing me, rapidly. Christ! Then I remembered, I’ve got to take this damn idiot with me, in my car to work tomorrow. Urgh! The thought of having to be in the same building all day, every day.

Panic attacked me

Black and white photo of young woman, head down - what do you know about anxiety
Anxiety and panic attacks

The words “what the hell have I done?” were already screaming at me, as panic attacked me. Yet I still had to get through bedtime, and that was as appealing as having a wisdom tooth out.

However, after more beer and spliffs, he was barely even fit enough to get up the stairs. He stumbled his way to bed and, despite his man sweat, the smell of beer and cannabis, I managed to sleep.

Early shift next morning, we were showered and out the door before the boys got up for school. Ian asked if he could drive my practically new, one year old car but was stared down by the withering look that said “Yeah, right! And if you get stopped by the police!” So he curled his six foot self into my tiny car, tutting and cursing. Huh, like he’d fit his lanky legs beneath the steering column anyway.

When we got to work and were going through the front doors he leant in, “Give us a kiss then.” As I’d turned to stare at him in shock, he caught me unawares, smack on the lips. People milling around reception “oohed and “aahed” and I realised it was done for their benefit.

Back at work as mental health nurses

Three men wearing red t-shirts and navy trousers - Rapid Response Team
Rapid Response Team might be dealing with a patient who has Psychosis

Back at work the days got better and the weeks flew by and by being on opposite shifts, I could avoid Ian for a lot of the time. However, being on the Rapid Response Team (one person from each mental health ward who would attend to emergencies around the unit) meant we’d occasionally bump into each other at work. Like most of the men on Rapid Response, but particularly cos I was there, the macho in Ian emerged, which both irritated and sickened me.

This wasn’t how you approached patients when they were psychotic, possibly responding to voices and already terrified. However, male staff would pull themselves up to their full height, head back, arms crossed and staring down the patient, almost goading them into a fight. As the Team coordinator, I’d advise staff to stand back while I spoke quietly and calmly to the patient, asking what the problem was and how could we help.

Despite being psychotic or manic, patients would generally relax slightly, enough to state their need; which was often just a cigarette, a hot drink or some fresh air. Even if they were unhappy about having to take medication, they could usually be encouraged to take it, without a fight that was unwinnable anyway.

Soggy Christmas Crackers

Things weren’t fantastic at home because Ian continued to drink beer and smoke weed on a daily basis, only now he confined himself to the bedroom. He’d lie there in a stupor, watching all kinds of scifi over and again, waiting for me to return, when he’d start name-calling and trying to provoke me. He’d want to know which men were on shift, was I screwing him/them, which one did I fancy or was I having it away in the store cupboard!

Red and white photo of Christmas table
No anxiety at Christmas, please
Image by Styleestate.com

Fast forward — Christmas, and we all went to my brother’s for lunch, where there would a huge gathering of various families. No guesses who was pissed before lunch, was laughing too loudly at unfunny comments and telling inappropriate jokes to people he didn’t even know.

Then, as we sat for lunch on a makeshift bench he lurched backward, kicking the dinner table almost into the air, throwing the rest of us off kilter. Glasses shattered, the spilled wine ruined the Christmas crackers, cutlery rattled onto the new dinner service as, wide-eyed, we all tried to catch bits and pieces. “Outside. Now!” I hissed.

“Why, what’s up like?” he laughed. The upshot was that I took him home and left him, while the rest of us had yet another fantastic family Christmas.

Tale of the strange makeup bag

As usual, I was going out with my girlfriends for my January birthday drinks and Ian wasn’t best pleased, even tho’ he hadn’t planned anything. A girl’s night out was just what I needed and of course, we all had a ball, dancing until the early hours. We got into our taxis and giggled most of the way home, not a care in the world.

My best pal was staying with me thankfully cos in the morning Ian had come across a strange makeup bag on the kitchen worktop. He wanted to know why I’d taken makeup out with me, what did I need it for and who was I chatting up this time. At least Anj could vouch for me that it wasn’t mine. Nonetheless, it was another interrogation that lasted weeks. He never did believe that we found it in the back of the taxi and took it home, just for devilment.

Oh, how I loved to flirt

Swimming pool oasis
Anxiety and panic attacks need a
holiday

That summer, I booked us a holiday to Egypt with the boys and one of their best friends. We had three rooms on the ground floor, right by the swimming pool and we were all excited. Not two days in and Ian started! I was flirting with the boys’ friend; lying with my legs wide open. Now, lying on a sunbed in a bikini, legs akimbo is not a good look. Not for me. Not for anyone. And me — flirting, with a thirteen year old boy? un-bloody-believable!

We had one of those harsh but whispered arguments so the boys couldn’t hear in the next rooms. But there was no doubting that Ian didn’t hear or get the message. He was almost in tears and apologising, blaming the drink and the heat. Oh my God, not only the sickening accusations, but his pitiful begging turned my stomach.

I made it through our first anniversary but the following morning he was at the blame game again and who was I shagging this time. He knew it was a woman and he was okay with that, he just wanted to know who it was. He then went on to how I was flirting with my dad at the family gathering the night before! Enough

That was it. I’d had enough! I’d tried and put up with his constant bullying, patronising and manipulative behaviour for a year now. I told him to pack his things and leave before I got home from night shift the next morning.

Over to you

Large red question mark with little white character leaning against it, pondering
Clipart.com

It’s late and having spent the last week with two little imps, our gorgeous grandchildren, I’m exhausted. I’ll finish here for now and hope you’ll stay with me for the next part. In the meantime, I’d love to hear your thoughts and please feel free to ask any questions.

You can read text chapter here.

Should we use restraint on mental health wards?

What would you think if you were visiting a family member or friend on a mental health ward and you saw someone being physically restrained?

Latest guidance from the Department of Health (DH)

Positive and Proactive Care places an increasing focus on the use of preventive approaches and de-escalation for managing behaviour that services may find challenging. All restrictive interventions should be for the shortest time possible and use the least restrictive means to meet the immediate need based on the fundamental principles in Positive and Proactive Care.

Nursing staff should act within the principles set out in Positive and Proactive Care, and use all restrictive interventions in line with the MHA Code of Practice 2015, Mental Capacity Act 2005, Human Rights Act 1998 and the common law.

What is restraint

Restraint is used by trained healthcare staff to stop or limit a patient’s movement. Restraint may be used without the patient’s consent.

Restraint might be needed if a patient is violent or agitated – so that he doesn’t harm himself or others.

Three types of restraint

Unknown
  • Physical restraint limits specific parts of the patient’s body, such as arms, legs. or head.
  • Chemical restraint is medicines used to quickly sedate a violent patient. This might be given as oral medication (a tablet) or intramuscular (an injection).
  • Seclusion is placing the patient in a room by himself. The room is locked and kept free of items that could cause injury. The walls are padded and there is normally a large rubber bed to reduce risk of harm to the patient. A member of the team will watch him at all times when he is in seclusion.

Control and Restraint training (C&R)

Seated restraint – Twitter.com

As mental health nurses and nursing assistants, we have a full week (9-5pm) of Control and Restraint (C&R) training and let me tell you, it’s exhausting – when you’re only 5′ 4″ and you’re trying to restrain your 6′ 6″ colleague. As well as our mental health nurse training, we are taught de-escalation skills during C&R. You always attempt de-escalation techniques first. You might offer the patient some oral medication to reduce his/her agitation, to stop the violence, stop the voices, bring them down from an extreme high or calm them down enough to speak to them clearly and rationally etc.

De-escalation

While working in any specific area, nurses ought to be visible and taking in what’s going on around the ward, the bathrooms and bedrooms. They should be discreetly observing patients, mindful of any signs of agitation or conflict between patients. It’s always much easier to verbally de-escalate if you intervene quickly; either distract the patients, possibly asking one to move away from the area. Your colleagues should be made aware of possible escalation so that they can help and support you if necessary. Humour is quite useful sometimes – I used to tell the big lads “If you were one of my boys, you’d get my wee size three’s up your backside,” and they’d laugh.

If an incident starts to escalate out of control, someone calls Rapid Response (RRT) to the ward and a team of 7-8 members of staff (one from each ward, and normally men?) will come running. There will a Lead RRT member who ought to take control by first finding out who or what the problem is, if it’s not already visible i.e. two patients fighting.

The health.com

The RRT will be in the nursing office deciding the plan of action. First might be just to speak to the patient(s) involved. I can understand how the patient might ‘give in easily’ when they see such a big team of people, practically surrounding them, and comply with what’s asked of them i.e. accept some oral medication.

Sometimes a male patient sees this big team as a threat and might challenge them – some male patients have said “I know I can’t get them all, but I’ll effin’ hurt one of them.”

Jason was admitted as a voluntary patient

I was manager on Lilly Ward, a mixed sex acute in-patient ward and a tall and handsome young lad was admitted informally late one afternoon. He came up to the ward with his dad, a Rastafarian who told me that Jason had been smoking cannabis and he’d been hearing voices for a few weeks. “I take the stuff myself. I know the weed. But no. Its no good for him. I don’t want to leave him here but I want him to learn. Its bad, smoking all the days with his new friends.” I told dad to go, Jason would be fine with me.

I took Jason into the nursing office to explain his admission was voluntary and that he would be under observation for a few days to see what’s happening for him. He said he hadn’t slept for three days as the voices wouldn’t let him. The voiced scared him and I could see he was hallucinating as we were speaking. I asked whether he wanted some medication to help him sleep which he declined. As we chatted, I learned that he had a close family who he loved dearly and his mum was his hero. “You’re a bit like her you know. Calm and friendly and smiling. Just like my mum.” He said shyly, which endeared him to me.

I could see the panic rising in Jason and as I’d already explained to him, I’d hate to see him ending up a Section of the Mental Health Act but if he was unwilling to comply, this is what would happen. I’d seen so many young lads come through the system saying that all their friends smoked cannabis and it did them no harm. However, it was my job to explain that while cannabis doesn’t cause Schizophrenia, if you are already vulnerable to mental health problems, the cannabis might trigger it.

Twitter.com

By now he was losing focus and I knew he needed medication. Offering oral meds first and an explanation of what they do may help a patient feel more in control of the situation, but I’d tried for over an hour with Jason. I’d also explained that if wouldn’t accept it, we’d have no choice but to give him medication by injection. He was becoming increasingly agitated, banging his head on the wall, and my colleagues were becoming concerned that I was cornered in the office. I wasn’t worried for myself at that point, I felt sure that, following our lengthy discussion, he wouldn’t harm me.

Rapid Response Team to Lilly Ward, please

The noise of his head cracking the wall was unbearable and RRT were called as this boy was going to really hurt himself. Jason saw them running in and jumped to his feet. I told him needed to leave the office as the Team would be coming in, so he let me past. As soon as I’d left the office three of the Team went in to restrain Jason. It was awful because it was such a tiny space and as they all went down to the floor, I could hear Jason calling out for me, crying and apologising. I was distraught for him, but I still had to get the medication drawn up quickly and to inject Jason, for his own safety. He was given 2 mg Lorazepam which has a sedative effect and 5 mg Haloperidol, an antipsychotic.

Once the medication took effect, after a couple of minutes, the Team helped Jason up and walked him to his bedroom, where he’d sleep for some hours. The Team met to debrief, to ensure nobody was injured and to discuss whether there was anything we could have done differently. We believed we had done the right things and that there was no need for seclusion on this occasion. The ward Doctor placed Jason on Section 2 of the MHA (1983) which meant he would detained for up to twenty eight days and could be treated without his agreement.

Face down restraint – BBC.co.uk

To restrain someone, you would initially use three members of the Team; one to take each arm and one to direct the patient’s head. If the patient cannot be held like this, the next step would be to go down to your knees then onto the floor where two other Team members would hold the legs. The patient’s safety is always uppermost in your mind. Really and truthfully, if anyone gets hurt during a restraint, it’s generally staff as your knees and elbows hit the floor.

Risks of restraint

There are risks, of course. Patients often struggle against physical restraint, which could cause skin wounds or block the blood flow. It can also increase the patient’s heart rate and breathing rate which again, can be life-threatening. Medication could cause low blood pressure, shallow breathing or heart rhythm problems. Some antipsychotics can also cause side effects like stiffness and shakiness, restlessness (akathisia), movements of the jaw, lips and tongue (tardive dyskinesia), slowness and sleepiness.

Nursing staff have to regularly assess for side effects as well as:

  • vital signs, such as heart rate, breathing rate, and blood pressure
  • patient’s physical comfort
  • patient’s skin for injury
  • monitor patient’s behavior
  • allow the patient to leave seclusion (if used) as soon as he is calm and cooperative

All necessary paperwork and an incident form must be completed and a care plan put in place.

It’s good practice if the nursing team on the ward go round checking on other patients to see how they are if they’d witnessed the restraint. It can be really frightening and assurances might need to be given.

Mental Health Act (1983)

Telegraph.co.uk

More often than not, the patient will feel quiet groggy when they wake but will still feel a little calmer. The nursing team will then try to engage the patient and let them know of their Rights under the MHA (1983), letting them know they can appeal against this Section and give them the appropriate paperwork to do so.

Patients would frequently be brought into A&E on Section 136 of the MHA (1983) by the police and RRT would be called to assist if the patient was violent or agitated. This means a restraint may have to take place there instead of on the ward and the patient would then, once sedated, be moved to Seclusion for a period of time.

Most nurses don’t like having to restrain patients – male or female. Just think how a patient who’s been physically or sexually assaulted in the past must feel. They’re already confused, distressed, experiencing delusions or hallucinations or mania then they’re being restrained, having their underwear pulled down and having injections forced upon them.

There have been some unusual restraint situations too. When the RRT arrived at the dining area on our ward, the patient was standing on a table, naked and masturbating. Another young man knew that RRT were on their way to see him, he ran to the bathroom, got naked and smothered himself in shampoo so that the Team wouldn’t be able to get hold of him.

The restraint I hated most, was when we had to get a baby from his mother’s arms; she was psychotic and at risk of hurting her child. I’ll never forget her blood curdling screams as we took the baby away from her.

I always found the females the most difficult to restrain. With the men, you know they’ll punch, kick or headbut, but the women – they’ll do that and kick, scratch, nip, pull hair, spit and bite…… Thankfully, I didn’t have to do many.

Do you think patients should be restrained? Or is there another way?

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?

Bad-mannered nurses working on NHS mental health wards

Have you ever come across bad mannered colleagues? Unfortunately, it’s almost a given for a lot of nurses working in Acute Mental Health wards. Perhaps they’re too long in the job and need to get out? I met many bad mannered nurses and doctors but for now, I’ll just mention two nurses with whom I worked during my first six months as a newly qualified nurse.

Chief‘s arrogance

The first I will call Chief because when I asked him a question about about a patient he hissed “Do you know, in my country I am chief of my clan and people respect me?” and as I backed away from him, confused, he continued “Men are to be respected. You hear me?” As he was way up in my face, of course I could hear him – loud and clear.

“But what has that to do with whether Silvio has a Ward Round appointment today?” I asked and, with his forefinger almost poking my nose he retorted “Because he has no ward round and that, as his primary nurse, is my decision. He was rude to me yesterday and this is not allowed. He must be more respectful.” Ah! So it wasn’t me he was having a go at, which I’d initially thought. He was so angry with the patient for disrespecting him that he cancelled the patient’s ward round!

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I picked the phone receiver up from the table, where I’d unwittingly left it, and was about to inform the caller that Silvio didn’t have an appointment, when the Consultant Psychiatrist on the end of the line said “Put him back on the list please and put Chief on the line immediately.” I smiled sweetly at Chief as I handed him the handset and left the office.

The arrogance of the man. As a newly qualified nurse, I didn’t feel able to tell him exactly what I was thinking but I’m so glad our Consultant Psychiatrist heard the whole conversation and no doubt he gave Chief and earful. I had a few more substantially worse run-ins with Chief during my time on this ward, but that’s a tale for another day.

Adam’s inability to cope

Adam was a tiny, white, middle-class posh boy amongst the bigger lads of many different races on the acute wards and I happened to be on night-shift with him and Ama, a support worker. After medication, most patients had gone to bed and Peter was in the office so I was ‘on the floor’ checking the bedrooms and dorms. The third member of staff always sat on the corner of the dorm area so that they could see both the male and female areas.

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The ward was eerily dark and quiet and, truth be known, I was more than a little anxious. In the early hours, when Ama was on his break, I rounded a corner and was confronted by Sabina, a young black female, growling and hissing and making clawing movements towards my face. I jumped back in fright but she continued towards me, on her tiptoes, still clawing and hissing. I quickly regained my composure and asked if I could help, as I tried to walk to one side of her to guide her down the corridor, towards the office.

It was a natural instinct not to walk ahead as I wasn’t sure what she might do behind me. I desperately needed Adam’s help because I didn’t know how to handle the situation and, to be honest, I was afraid. We were taught about the various mental health disorders and symptoms in Uni but only now, I realised they hadn’t taught us how to manage them, other than with medication that is.

Ward round. Photo – University of Nottingham

The twenty or so metres down that corridor felt like a kilometre because, despite my calm words of encouragement, Sabina’s behaviour continued and I felt increasingly nervous. We got to the office where I appealed to Peter with my eyes, like “Help!” as I very quietly explained. Peering over the top of his glasses, he smirked at me and said “She’s okay, don’t you worry your pretty little head.” and he laughed. “She’s in her first year of studying to be a lawyer. Looks like schizophrenia and she’ll be seen in ward round this Thursday” (where she’d be assessed by the whole multi-disciplinary team). This really wasn’t helping me, or Sabina and despite my anxiety, I felt for her.

By this time, outside the office, Sabina was hissing loudly, howling and clawing at the perspex window, her nails dragging like chalk on a blackboard. Adam said just to observe her for now and write it down in her notes “This is what you signed up for – just talk to her.” Talk to her? She was screaming like a banshee, her face was contorted, as were her arms and fingers, and her eyes looked glazed.

“Ward round is three days away” I insisted “so what do we do in the meantime? Does she have any medication prescribed and does she need some now?” I simpered and wondered whether this was the job for me after all. Adam explained that Sabina was on Section 2 of the Mental Health Act 1983 (1), and that she was only only being observed for the moment – no medication prescribed.

“Go on.” he said and shooed me out. I took a deep breath, opened the office door and went to walk out when Sabina launched herself at me. Somehow, I was quicker than her and managed to get past her unharmed. Instead, she flew at Adam and gouged chunks out of his face until he was able to grab her by the wrists. Still, she fought, and given his slight frame, she managed to pull him down to his knees and grabbed at his eye with one loose hand, causing a stream of blood. In the meantime, I called 2222 “Rapid Response (2) to Lavender Ward.” Within about fifteen seconds, at least three team members; large burly men, had burst through the doors where I was ready to direct them to the office.

Control & restraint – youtube

It took all three of them remove her fingers from Adam’s hair and to restrain her. While some might disagree with it, the C&R techniques (3) we were taught always had patient safety at the forefront.

Sabina now looked confused, pitiful and absolutely defeated. The standard intramuscular (IM) medication (4), 10mg Haloperidol and 2mg Lorazepam (known by nurses as 10 & 2) was prescribed by the Doctor and administered by a female nurse.

As the medication took effect, Sabina relaxed and was escorted back to her bed. The RRT left and Adam turned to me, still with the blood on his cheek, furious. “Why did you call RRT? We could have dealt with it on our own!” I waited as he paused for a moment, as if considering his next words, then he added “If you’d de-escalated the situation adequately in the first place, we wouldn’t have needed RRT. She’s normally okay you know.” He tutted and sighed heavily “Now we have to do an incident report AND write it all in her notes. Well, you’ll have to do it and I’ll sign it off.”

PMVA Control & Restraint

I said to him “It didn’t look like we were managing it effectively, Sabina was clearly unwell and responding to voices. I’d asked you for support but you (a) let it escalate. You must have heard the commotion in the corridor,” He ignored me, so I continued – “and (b) I haven’t been C&R trained either so I’m not sure how I could have helped. This office is tiny and we could all have been hurt. I thought calling for RRT was the best option available.” Peering over his glasses again, he just looked at me with disdain.

I did document everything in her notes and completed an electronic incident report, typing exactly as it happened. However, Adam refused to sign it off as he didn’t like what I’d written so I clicked send anyway and off the form went to Head Office. He remained furious and barely spoke to me throughout the rest of the shift.

On reflection

  • Of course, I wished I was more skilled in talking to someone with with psychotic symptoms. I’d had them myself so perhaps I ought to have known what to do. But other than offering support, telling her she’d be okay and trying to remain calm throughout, I didn’t know what else to do.
  • I know I wasn’t C&R trained but wondered whether I ought to have attempted to pull Sabina off Adam, to help my colleague. However, the nurse’s office is tiny with lots of sharp corners on tables, filing cabinets etc so any of us could have been badly hurt and things could have been made worse.
  • However, because Adam was more qualified, together with the fact I’d only just met her, and he had more knowledge about her admission and presenting symptoms, I thought he could have intervened sooner and supported me. I know if I was the more senior staff member, I would have done things differently.
  • I was impressed, on this occasion, by the way the three male RRT members restrained and held Sabina’s arms firmly but lightly, and they didn’t think it necessary to put her on the floor. They kept talking to her calmly and quietly, telling her she’s safe and would be okay. I would later see some terrible techniques and staff attitudes.
  • I wondered whether the IM medication had been given too soon – perhaps we should have offered oral medication first, rather than have her go through the undignified process of pulling down her clothing (5) to inject medication into her bare buttocks.
  • I knew that I’d have to become more confident in preparing the medication (while under stressful situations) and in actually administering the injections. It’s quite easy to give injections when a patient is sitting or standing peacefully but if they’re wriggling about and fighting, it’s more difficult.
  • Next, I wanted to speak with colleagues I’m quite close to and my supervisor to see how they would have addressed the incident.
  • Finally, I thought about how I would approach Adam the next time we worked together to ask if we could discuss this incident to see exactly what we could have done differently. Now wasn’t the time because he was still angry but I definitely wouldn’t ignore this issue. I would also let him know that his shouting at me was inappropriate, whatever he thought I’d done wrong.

How do you think the incident could have been handled differently?

  1. Section 2 of the Mental Health Act 1983, (provides for someone to be detained in hospital under a legal framework for assessment and treatment of their mental disorder for a period of up to 28 days).
  2. 2222 is the number dialed to request Rapid Response Team (RRT) and 3333 is used for Cardiac arrest on the ward. The RRT consists of one member of staff from each ward so there ought to be eight team members plus the staff on the ward. A doctor would normally attend too, but wouldn’t be involved in restraint.
  3. Control and restraint techniques are used to intervene quickly to ensure the safety of the patient and those nearby. Control and Restraint is generally safe for the patient as the nurses take all the knocks and bruises when and if the patient is restrained down to the floor.
  4. Haloperidol can be used to treat acute psychosis and has proven efficacy for agitation and Lorazepam can decrease acute agitation and have efficacy similar to haloperidol, but with more sedation. A combination of lorazepam and haloperidol is thought to be superior to either medication alone. Lorazepam helps maintain sedation and decreases potential side effects caused by haloperidol. Consensus guidelines from 2001 and 2005 recommend combined haloperidol and lorazepam for first-line treatment of acute agitation. Hannah Brown MD, Current Psychiatry. 2012 December;11 (12):10-16.
  5. Being physically held down and having your clothes pulled out of place, often in front of others, can be an extremely humiliating, as well as frightening, experience. Not only that, but restraint on females is often carried out by male nurses, another factor that compounds the fear and trauma of those women and girls who have histories of abuse and violence at the hands of men. Katherine Sacks-Jones, The Guardian, 2017.