Bad-mannered nurses on 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!

123RF.com

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.

First time seeing a patient being restrained – ‘for his own good’

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 but 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* so he is.”

“Here, you call the police on this number and let them know what’s going on. Pauline’s address is there,” said 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 stunned, 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** 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, probably 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 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 the wrist, 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. He was safe. Hell, it didn’t look okay to me. Alison then 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 for more than one reason and my eyes felt like they were on sticks as Alison swabbed an area of John’s right buttock then saying “A sharp pinch John.” she calmly popped one needle in and squeezed followed by another.

RRT held onto John for a minute or so and Derry said “You good John? We’ll let you up. Easy now.” One by one limbs were let go and the team dispersed. “Into the office boys and girls.” Derry continued, as if this hadn’t just happened, so I thought it best to leave too. There was a quick debrief where I learned that John had obviously managed to sneak out and no one was taking responsibility for letting him go. I felt safe in the knowledge that 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. The team agreed that the situation had gone well, no one got hurt and the RRT left the ward, leaving me, Derry and Alison. I observed as they documented the incident in various places and heard that someone had to complete an incident form. They chatted away, telling me that John hadn’t taken 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.

The intramuscular injections they’d given John was what the team called ‘ten and two’; ten mg of Haloperidol which has a sedative effect within ten minutes and two mg of Lorazepam which creates sedation within thirty to forty minutes. These drugs are normally used in the management of acutely disturbed patients?

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.