What about poor nursing in mental health?

I studied mental health nursing because I wanted to be a nurse. I wanted to help people overcome the battles that come with mental illness, to support them through crisis and recovery. I wanted to teach and educate patients and their families about mental illness, the medication, expected outcomes and how to stay well by offering them evidence based information and treatment.

I wanted to nurse and I never thought about being in management again. I’d spent almost twenty years in management, particularly Human Resources management and I was bored with it all. However, as I moved up the ranks and got to attend various meetings both within our hospital and at Head Office, I soon learnt that the higher up you went, the more you understood. Previously unaware, I now appreciated the hierarchy, the mechanics of the various departments and where, why and how systems, policies and procedures were developed.

I was first promoted from the old D Grade to E Grade within six months, then six months after that I was offered F Grade (now Band 6) within the Day Hospital and I loved it. This is where I was able to access most of my further education i.e. CBT for Schizophrenia and Thorn Nursing (after which, I was qualified to provide interventions and education for the patient and their families). I was to work on this unit for almost three years (where my then Manager was a disgrace and I had to complain) and that in itself is another post.

However, I was offered the Acting Manager post (Band 7) on Care of the Elderly (you’ll find the name changes always happen in Mental Health i.e. previously called Old People’s Ward) with no interview. I asked the Service Director, “Why me?” and he said “because I thought you’d be good at it.” Most of the original team were delighted but there remained several who weren’t quite so happy as apparently, my reputation preceded me.

Two nurses immediately requested moves to other wards and thankfully they were taken on by their previous managers (saved me the job). The two other nurses stayed but were given the opportunity to apply elsewhere – they weren’t good nurses anyway and I’d rather they just left. However, they said they’d heard good things about my management style from colleagues and decided to ‘give it a go – working with me.’ Ha, like they were doing me a favour. The Band 6, Chris (Assistant Manager) was Mauritian, he was married and had two young children and he didn’t like me at all.

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Chris went everywhere with his notepad tucked under his arm and could be seen scribbling away in every given situation, despite being asked not to. As part of his role, he was Supervisor to six qualified nurses which meant that he ought to meet with each of them to look through their patients care plans and risk assessments to ensure that they were relevant and up to date. Other things would be to ensure that all their mandatory and statutory training was up to date and if not, arrange it

During Chris’s supervision with me, it was my responsibility to ensure that he was fully supported in doing his job, that he had the training and tools necessary to carry out his role. He was immediately defensive, telling me he’d been doing this job for two years already and there was nothing he needed support with “thank you very much!” he huffed.

“That’s great Chris. So can you tell me why X, Y and Z’s supervision hasn’t been completed for two months?”

“I don’t have time. You always want me to do other things. And anyway, supervision doesn’t have to be every month,” he smirked.

“Okay, tell me what time you need and when and, as previously suggested, I’ll cover your role on the ward while you complete supervision. How does that sound?”

“Yes, but you’re always busy.”

“Chris, let me know when you have booked the supervision for X, Y and Z and I’ll put it in my diary so that I can cover for you. Yes?”

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Eye rolls “If you say so.”

“Now Chris, what is it I always have you doing?”

“Mmm. Audit patients’ paperwork.” He suggested.

“Okay. But you’re doing that while you’re carrying out supervision by ensuring that your staff have all paperwork up to date. Yes? Is there anything else you need time for?”

“Mmmm. I’ll think about that.”

“Great. You do that Chris, and get back to me with a list of things you need from me before your next supervision. Let’s put a date in the diary now. And just so we’re clear, have a quick read through the supervision policy, I think you’ll see that supervision must be done every month and if not, why not needs to be documented.”

“Sorry. Can you repeat that please. Slowly this time so that I can write it all down?”

It became clear that Chris was put out, angry even, that I’d been given the post as Acting Manager when he thought the job would be his, as next in line. Chris made it almost impossible to work with him, constantly declining tasks, ignoring any requests from myself and colleagues, generally being disruptive and spending lots of time in corners, scribbling notes. I spoke with my line manager who spoke with Chris. The upshot was that he put in a 32 double-sided typed complaint against me and I had to meet with the Human Resources Manager.

Sixty four pages of nonsensical garbage, saying anything from “She doesn’t like me typing in capitals,” (I don’t. It’s known as shouting) and “She doesn’t like me being late,” (I didn’t. Especially when he was thirty minutes late and he would walk straight past me without a word – just a smirk) to “She doesn’t tell me where she is going when she goes on holiday,” He was informed by HR that he only needed to know when I would return. Chris was given a written warning for wasting Trust time and for malicious gossip.

He eventually moved to another ward but left soon after to become a tube driver for Transport for London. I had to interview him about a year later for a Band 5 post.

Eric was from Africa but had studied to become a nurse in the UK before applying for a post on out ward. He was articulate, polite and seemed theoretically knowledgeable so he was successful and joined our ward. His first shift was an afternoon shift, starting at 1.30 pm but he didn’t arrive until almost 3 pm and just walked past my office, with no apology or reason. Okay, I gave him the benefit of the doubt, first day and all that. However, on the second day, the same thing happened so I called him in for a quick word. “Okay, that’s two days in a row Eric and you haven’t even acknowledged your lateness.”

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“Ah. I live up very far north London and it take me about two hours to travel here.”

“You knew when you came for your interview how far you’d have to travel and you need to take that into consideration when you leave for work.”

“Ah. I’m not sure how I will make it for the early shifts then if I have to leave home two hours before.”

I don’t know how he made it into work on time every shift after that. I didn’t ask.

From my office one afternoon I heard and saw a commotion in the day area so I stuck my head out and beckoned Eric. I said for him to sit and I’d be back soon then I went over to a forlorn looking Clive, on of our elderly African patients. “Clive, hey what’s wrong?” But I’d already spotted that he’d wet himself. I called over a nursing assistant to help me get Clive to the shower room and to get some clean clothes before I went back to my office.

“Okay Eric, talk me through what happened there please.”

“You saw him. Clive. He is lazy and jus’ piss ‘imself. On the chair. He raise his walking stick to me so I tell him, if you do that, I’ll hit you back.”

“Yes, I heard you shout at him Eric and why did you raise your hands to him?”

“Him have to know he can’t threaten me. Now he know and so everyone else too. Don’t threaten me.”

I asked so many questions of Eric, hoping he would see his wrongdoing; what he had done wrong, not what Clive had done, “And what would the other patients think?”, “How would Clive’s family feel if they saw that incident?” Nope – nothing! I then asked him, “What would you do if you saw a nurse raise their hands to your mother or father……” Ah! The penny dropped.

Eric got sent home and was given a written warning…………….. I got a another Bullying and Harassment complaint.

How would you manage staff like these? I’d really love to know.

Fake mental health patients

Some of you might want to crucify me for mentioning ‘fake’ patients but hold on. Wait until you’ve finished reading this post.

Pauline

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I was still in my six month preceptorship period when Pauline was admitted to Lavender Ward, an acute inpatient mental health ward. She was neat and tidy, her hair and nails were spotless, she appeared cheerful and engaged easily with the other patients while waiting to be assessed. However, during her admission assessment she relayed that she had been living on the streets, she was paranoid, depressed, anxious and suicidal – she’d actually been seen by passers bye running across a main road several times, without looking out for traffic, according to the paramedics who brought her in.

Pauline was articulate, she maintained good eye contact with me and smiled appropriately during the assessment. She said she had no family at all and had lost her friends since becoming ‘mad’ and homeless – though she couldn’t remember for how long. Pauline reported that she slept well although she had paranoid dreams, which didn’t wake her. The paranoia she described was that someone was after her and wanted to kill her but she couldn’t be clear about when this happened or who it was that wanted to kill her.

Once seen and admitted by a nurse, the patient’s baseline observations are taken i.e. blood pressure, temperature, pulse, respirations, height, weight etc. All of which were stable. After this, the patient would be seen by the ward doctor, normally an SHO, a junior doctor who is on their six month rotation and has little psychiatric knowledge.

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We had a tall, handsome and smarmy (oops, I mean polite) young chap, Dr Wellar, who looked down his nose whenever a nurse approached him. This was only his second week on the ward and I did tell him one day, “these nurses know way more than you do, and you ought to treat them with the respect they deserve.” That marked my card with him, I’m afraid.

Dr Smarmy stood to greet Pauline and, shaking her hand, he invited her to sit in ‘his’ office for a chat. She was in heaven, all smiles and giggling like a teenager. So I wasn’t sure why, when they’d finished her assessment, he announced to the team that she needs to be on close obs (There’s lots of circumstances where patients may require one to one nursing i.e. the patient is acutely physically unwell and/or requires frequent observations, the patient is acutely mentally ill and/or at immediate risk of serious self harm/suicide etc).

Depending on the level of risk, one to one nursing can be carried out by either a qualified nurse or a nursing assistant. Pauline was classed as high risk of suicide so needed to be observed by a qualified nurse 24/7, which includes when the patient goes to the loo. This takes one person from the staff numbers i.e. reducing the amount of staff by one. If you are nursing one to one, you cannot be expected to care for your five patients on top of this. Sometimes, the Trust allowed us to have an extra member of staff, more often a nursing assistant, to keep costs down.

As I’d done Pauline’s initial assessment, I was allocated as her 1:1 nurse so I spent the rest of that morning’s shift with her. We chatted about the weather, her dog and how she was worried about him – she didn’t know where he was. Pauline’s mum works “oh, I mean worked” as a teacher but she couldn’t remember the name of the school. I just kept the conversation light and said how proud she must have been of her mum etc. But something just didn’t sit right with me and I passed all this onto the afternoon shift.

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On my next shift, I was allocated to Pauline, 1:1, as apparently she liked me and we’d built up a good rapport. Again we chatted amiably about her past – what she could remember of it – she said her depression was affecting her memory. Obviously I had to accompany her while she showered and went to the loo, but to give her some privacy and to maintain her dignity, I averted my eyes temporarily. However, she was inappropriate at times, dropping her towel, not able to find her knickers, could I pass her the toilet paper or her wet wipes – almost anything to keep my attention.

Let me tell you something now; it’s no fun being in a bathroom when someone else has to poop and it’s worse still when you have to get close enough to pass the toilet paper.

Towards the end of one shift, she told me how sad she was that I’d be off over the weekend as she really enjoyed out chats. At the end of my shift she really invaded my personal space when she threw her arms around me and planted a great big kiss on each cheek “Adios. Au revoir. Bye my angel nurse. I will miss you.” I kid you not.

I’d really enjoyed my days off but still looked forward to getting back to work. On my return, as I walked through the front door to the ward, I was almost past the Dr’s office when Smarmy called me in, “Can’t you even get one thing right? You only had to look after one person – how hard can it be?” he demanded and shook his head at me disdainfully. “Pauline said you left her in the shower for nearly 20 minutes and she tried to kill herself.” I shook my head back at him, I smiled and assured him that this was simply not true.

He continued berating and belittling me until he took a breath and I simply responded that I was off to see our Ward Manager. She believed and trusted me that it simply wasn’t true. He’d been ‘had’ but obviously this was the story he was re-telling the whole multi-disciplinary team, making me look incompetent. However, he took in what the ward manager said to him and conceded he might be wrong.

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In the meantime, I felt like I’d been punched in the stomach. I was hurt by Pauline’s tale; I thought we’d formed a good professional bond. One of our senior nurses said not to worry, don’t take it personally and reflect on this; trust me, you will learn from it.

I had to work with Pauline a few more shifts and just kept up the banter but didn’t mention the ‘incident’ and nor did she. Had I been a bit more experienced I would have discussed it with her but right at that moment, I didn’t want to upset her – there was something going on for her? and I was still trying to work her out.

After a week, we had a phone call from her mother, asking if we had a Josephine on the ward. Yes, it turns out this is something Pauline does now and again. She frequents hospitals seeking admission because she said ‘she gets a bed and fed’. In the meantime, she saves up her benefit money while she’s in whatever hospital. Some might say that this is a mental illness in itself?

Ronnie

This young lad had been admitted voluntarily after he went to A&E saying he was paranoid and hearing voices. He was amiable and loved chatting with fellow patients and the staff. He could be heard asking other patients why they were in hospital and was interested in hearing about their symptoms. After a few days staff could see that he wasn’t displaying any symptoms of anxiety, paranoia or hearing voices and had hinted as much to Ronnie.

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Late one night shift, we watched as he paced the long corridor outside the nursing office. He had his head cocked to one side, looking up towards the heavens’, and was saying out loud “Sorry. Say that again. I can’t hear you.” He gave the odd sideways glance towards the office to see if anyone was watching him and continued, “Don’t say that. I’m scared. You’re scaring me.”

Me and Billy, my favourite nurse, found this rather comical and went to sit outside to observe Ronnie and start a conversation with him. Billy asked “What are the voices saying to you Ronnie?” and Ronnie cocked his head to one side, looked upwards again and asked “What are you saying? Ah, ok, hold on.” and in all seriousness, he turned to Billy and said “They’re saying they don’t like you. They don’t want me to talk to you.”

I could barely keep a straight face as I probed a little further, “Okay, tell me Ronnie, how many voices are there?” He did the cocked head thing and the upward glance then cupped his ear, as though he was listening, then counting on his spare hand he looked at me and whispered, “two – and they said they like you.”

We continued in this vein for around fifteen minutes before Billy and I just laughed out loud. Ronnie’s utterances were becoming more ludicrous by the minute and Billy said as much to him, “Hey, soft lad. You look bloody stupid. You’re not hearing voices are you?” Ronnie knew the game was up and pleaded with us not to tell the doctors, “Anyway, they can’t send me home, I don’t have anywhere to go. They’ll have to find me a flat, won’t they?”

Emergency Treatment Team

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I worked with the Emergency Team for a while. This was where people would come during daytime hours to be assessed and we, as nurses, would decide whether to admit someone or to refer them to another service i.e. home treatment team (HTT).

We had so many ‘fake’ patients asserting their mental illness rights, looking for admission so we could find them a home with a garden. Or they needed housing application forms completed, saying that they had a mental illness, which they hoped would put them near the top of the the already groaning housing list or benefit forms so they could access Disability Living Allowance.

Many reported being depressed but when asked to explain, some would say they’ve got a bad back and needed a ground floor flat as the stairs were difficult. Or excruciating headaches due to noisy, antisocial neighbours and it’s driving them mad so they need to move. As though getting a new home would somehow magic away their pain and depression. While I appreciate that decent housing is beneficial to everyone, admission to a mental health ward is not. Furthermore, housing lists are stretched to their limits and London now requires around 66,000 new homes a year to provide enough homes for current and future Londoners.

Given that our hospital served the local population which was approximately 52% non white-British, we had patients from nearly every country and many of them needed interpreters. When they mentioned housing or benefit forms, I always asked them via the interpreter “Do you know where you are right now?” and “Do you know this is a mental health emergency department?” And often told them “This is not a housing services.” or “This is not a benefit office.” before signposting them to the appropriate services

The thing is, we had thousands of patients with chronic mental illnesses who desperately needed our support and mental health intervention or treatment. Moreover, Mental Health is like the Cinderella service of the NHS and we don’t get lots of money so what little we do get is needed for ‘real’ patients.

Do you think I was harsh in turning patients away?