What Psychiatric Nurses Do (Part Twelve – Mentoring and Supervision)

This is part twelve (the final part!) of my series on what psychiatric nurses do. You can read the other parts of the series here.

Teaching and mentoring students and newly qualified nurses was my favourite part of psychiatric nursing. I loved when we had students on the ward, especially first-years. Their bright-eyed, naive, blank-slate approach, and the opportunity ahead of them… It was exciting helping them through their journey. 

Basically, all the staff on the ward are responsible for guiding and teaching students and new nurses. There’s so much they need to learn, and students will spend time with various members of the team, getting experience in all the aspects of running and working on a ward. But each student and preceptor (a newly qualified nurse on their initial introduction to the job) will be allocated a mentor and co-mentor who are responsible for overseeing their learning and ensuring they’re meeting all their learning objectives. 

Becoming a mentor is a complicated business. I undertook the training as soon as I was able to. You have to enrol at university to complete the mentorship training, which is paid for by your employer. Then you attend university one day per week for a number of months, or some people do an intense course of a few days a week for just a few weeks. You attend lectures and have to do coursework, as well as working with a student, under supervision, at work. Once you’ve passed your course, you then have to co-mentor three students before you can be signed off as a mentor and have your own students. You have to complete top-up training every year, and maintain a portfolio of your work with students. 

To be a mentor to preceptors is more complicated, and at the place where I worked only Band 6 nurses (most nurses are Band 5) could mentor preceptors. 

Unfortunately, despite passing my training I only had the opportunity to co-mentor one student, as soon after I left university I went on maternity leave. But I had the pleasure of working closely with lots of students and preceptors throughout my short career. I would let them shadow me, teach them about writing care plans and doing assessments, observe them giving injections and taking physical measurements, and talk to them about their experiences and issues they were having. It was very rewarding and interesting. 

Not all nurses are so interested in students and preceptors. I had some awful experiences as a student myself, with disinterested staff who couldn’t care less about teaching students and were sometimes downright hostile! And I guess that’s one of the reasons I was always so keen to be there for students when I was a nurse myself. But overall, all nurses are professionally obliged to assist students and preceptors with their learning and most do. 

Mentors basically work closely with their allocated students, working with them directly ideally a couple of times a week, matching shifts. Each student will have different learning objectives based on where they are in their training. First years generally need to focus on basic things like interpersonal skills, taking physical measurements, and general learning about healthcare, whereas third years need to focus on the more advanced aspects of nursing like shift leading, assessment and staff management. The mentor will closely monitor what the student is learning, meet with them regularly to identify learning opportunities, and assess their progress throughout the placement. The mentor is also responsible for noticing and addressing any issues with the student, such as areas they’re struggling, problems with attendance, etc. Sometimes it may be necessary to inform the university if the student is not meeting their obligations, and mentors can refuse to give the student a pass for the placement if serious issues arise. Mentors are basically teachers and assessors, working in tune with the university, for the duration of the student’s time with them. It’s a lot of responsibility. 

The final part of the job of a psychiatric nurse I just want to touch on is supervision. All nurses, as part of their professional development, are supposed to access supervision. Supervision is basically a form of informal counselling with a more experienced nurse who you get along with. Soon after commencing employment you have to approach a nurse you’re comfortable with and ask them to provide supervision. It shouldn’t be a nurse who works in the same place you do. It could be a nearby ward nurse or community nurse or lower manager. The supervisor/supervisee relationship is confidential and you’re supposed to meet at least once per year. Supervision is basically intended to discuss any issues that have arisen for you at work or even in your personal life, and get support. The supervisor might listen to problems you’re having, suggest things you could do or places you could access services to assist you, or help you work through issues you’re having. Supervision is protected time which you’re allowed to take whenever you need it, fully paid. 

In practice, in my experience, supervision wasn’t accessed nearly as often as necessary. I myself rarely accessed it. There just wasn’t time, and trying to match schedules with someone on a another ward was a logistical nightmare! However you are professionally obliged to have supervision, as it’s part of professional development criteria. 

…

So that’s it. Twelve sections of description of what exactly psychiatric nurses do. Told you it was a diverse job! It’s a hard, stressful job with little reward and high-risks. Those that do it need a medal! Kudos to all my ex-colleagues. I couldn’t do it anymore, but they’re still there, day after day, putting their heart and energy into helping others. I take my hat off to you. X

What Psychiatric Nurses Do (Part Eleven – Discharges and Training)

This is part eleven of my series on what psychiatric nurses do. You can read the other parts of the series here.

When patients are coming to the end of their stay on a ward, a number of things will happen. The nursing team will start to make plans for the patient’s transition back home days or even weeks before discharge. Community teams will be spoken to and invited to meetings. Family members may be consulted. For some patients, arrangements for housing may need to be made by referral to housing agencies or places at rehabilitation centres may need to be found. It all depends on the patient. For some patients who are in hospital for a matter of days, transition home may be simple: speak to the family, arrange community follow-up, order medication, done! But for some patients who have been in hospital many months and who will need significant community support, it may take weeks of planning to put everything in place. 

Between them the Consultant, community team (if there is one) and nursing team will coordinate the discharge. All patients have to receive at least 7 days of follow-up post-discharge from an inpatient psychiatric ward. This is a legal requirement. For those patients who do not have a designated community nurse, follow-up is undertaken by the Crisis Team, Discharge Liaison Team or something like it, depending on the area. A nurse will meet the patient prior to discharge and arrange a time/day for a home visit, support phone call, etc. 

A day or two before discharge a nurse will need to ensure medication has been ordered. Then there will usually be a ward review where the doctor agrees to the discharge. If the patient is sectioned, the Consultant needs to complete a form officially discharging them from the section. Then it’s a whole stack of paperwork and little jobs for the nurse to look forward to. 

Discharging patients on the ward I was on started off as a simple paper exercise. But as the computer system replaced the paper one, the number of clerical tasks multiplied to the point where discharges became a very time-consuming procedure. Prior to discharge the nurse needs to weigh the patient, complete a discharge paper and give it to the patient, ask them to complete a satisfaction survey and give them their medication. Then they need to complete a discharge risk assessment, discharge the care plans, complete numerous other little forms, cross the patient off numerous boards, remove the patient from the bed on the computer system, make a case-note entry…. you get the idea! A huge long actual printed list of little tasks you need to do, and if you miss anything you get a telling off from management. If you have two or three discharges in a shift (not unusual), these discharges can end up taking half your day up!

Voluntary patients can, of course, also discharge themselves against medical advice if a doctor or nurse has seen them and are satisfied they’re not risky enough to be detained. The patient has to sign a form agreeing that they are leaving against the advice of the ward staff. This is fairly unusual in these risk-averse, compensation-culture times, but it does happen occasionally.  

In addition to doing the actual job of a psychiatric nurse, there is always mandatory training to be complicated. It gets to be a bit of a pain. Things like fire training have to be done every year – a computer program or short lecture. Managing violence and aggression refreshers need to be done every 18 months or so – a 2 day course which, if you miss, you have to do the 5 day full training all over again. Some things like accepting mental health act papers only need to be completed once. But on top of these there are always little updates to knowledge to be completed, most of which is on the computer. It’s very hard to keep up with these around all the other work that needs doing. And management nag about people completing them all the time, as they themselves are getting ear-ache from their managers about staff keeping their training up-to-date. 

As part of a nurse’s professional development we can also choose to undertake further training. University courses are available and fully paid-for by the employer. You have to go through a fair amount of paperwork to get onto these courses, and the employer has to be satisfied it’s worthwhile them paying for it, but they will. Instead of working you will spend so many of your work days at university. Unsurprisingly nurses like doing this! Courses are generally things like psychotherapy, counselling skills, managing medication, specialism in acute ward nursing, mentorship – which is one I did at the nearby university one day per week. The courses nurses do can add to their professional qualification – for example if you have a diploma like I have, you can add up the ‘points’ from extra training, over time, to top-up to a degree. 

Which leads me onto my final discussion: teaching and mentoring students and new nurses. 

What Psychiatric Nurses Do (Part Ten – Personal Physical Care and Clerical Duties)

This is part ten of my series on what psychiatric nurses do. You can read the other parts of the series here.

Personal physical care has got to one of the least popular aspects of a psychiatric nurse’s job, and the one that is most frequently delegated to healthcare support workers. It’s not supposed to be, but in reality it is. I personally found the personal physical care of patients awkward and embarrassing and avoided doing it if I could. (That’s not to say all nurses are as cowardly as me!)

On adult inpatient wards, physical care is not common, and you get out of the hang of doing it (which is why I always found it so awkward). But occasionally there are elderly or infirm patients; disabled people who might need some assistance with some aspects of personal care; patients with dementia or other cognitive difficulties; or patients who are catatonic. Staff might have to bathe patients, assist them with dressing or the toilet, give bed-baths, help with feeding, etc. It requires patience, professionalism and sensitivity to assist patients with personal care. It also requires experience, which is where I and other nurses struggle. The older, more experienced nurses and healthcare support workers have done this stuff for years and could dress a patient with their eyes closed. I, on the other hand, had little experience and felt nervous about it. Regardless, personal physical care is a part of the job and something all nurses have to do at some point.

It can be especially difficult with patients with cognitive difficulties who may resist attempts to help them. There is a duty of care to patients to maintain their physical health, and sometimes it may be necessary to restrain a patient in order to care for their physical state. This is very difficult and risky for everyone involved.

As well as personal care, nurses have numerous other physical health tasks to perform when required such as weighing patients, taking blood pressures, monitoring blood sugars, taking ECGs, etc. These are part of plethora of daily tasks that need doing. Psychiatric patients are at a very high risk of physical health issues such as obesity, high blood pressure, diabetes, etc: partly due to psychiatric medication and partly because of the poor lifestyle choices most psychiatric patients make. Nurses have to monitor physical health and refer any issues to the doctors.

(Are you getting to understand just what a diverse and busy job it is yet?)

Clerical duties take up a significant part of a psychiatric nurse’s working day. At the end of every shift an entry needs to be made in the case-notes of every patient on the books. The case-notes are mostly on computers now, which was a great development to those speedy typers like me, but many of the other staff struggled with this change and typing these entries takes an age for them. The entry made needs to give a description of how the patient has been throughout the shift; how their mental state has been, whether they’ve eaten, been off the ward, done anything risky, etc. Most of the decisions about care are based on these entries so they’re very important and need to be thorough. However… there are a number of problems with this. Firstly, not all staff make great entries. In fact some are downright illegible and say nothing useful. Secondly, it’s quite likely that the member of staff writing the entry hasn’t even laid eyes on their patients for the whole shift, being too busy. And thirdly, for some patients there is nothing at all to say as they’ve been exactly the same every single day for weeks. You might as well copy and paste the same thing day after day.

As well as making an entry at the end of every shift, staff are supposed to make an entry in these notes as soon as possible after any significant event. Someone rings about the patient, make an entry. The patient does something risky, make an entry. You spend some 1:1 time with a patient, make an entry. With 22 patients on the ward I was on and 5 staff per shift, I bet you can see that writing in case-notes takes up a lot of time, especially if you’re not very fast at typing.

The ward I worked on had a fantastic ward clerk. Without her the place would have fallen apart. But despite that, there was still a lot of clerical work to do, especially if it was her day off (usually falling to the shift leader). Numerous phone calls, filing, referral forms, etc. At least an hour of most days will be spent on purely clerical duties (not including the case-notes entries I just talked about). Just the general day-to-day things that need doing to keep the ward running smoothly.

Next time I’ll discuss the discharging of patients and mandatory training.

What Psychiatric Nurses Do (Part Nine – Observations and AWOL Patients )

This is part nine of my series on what psychiatric nurses do. You can read the other parts of the series here.

As I described in my last post, hourly observations are a mandatory part of the running of a psychiatric inpatient ward. In truth the job tends to fall to healthcare support workers as the nurses are often too busy, but all staff on the shift are supposed to do them. The shift leader devises a schedule of who will do the observations at certain times, and the staff then try to stick to it.

The staff member on the observations carries a board that has all the patient’s names, what room they’re in, and then 24 little boxes for each hour of the day alongside the name. Each hour you go around, locate the patients, and add a little code to each box to say where they are. Then you add up how many patients there are on the ward each hour. The board can also be used as a fire register if the fire alarms go off, and is it the most up-to-date record of who is on the ward.

Sound simple? Well, it’s not always. Sometimes you can’t find someone. In which case you have to go around the whole ward, searching room after room. If you still can’t find them, you’ll need to speak to all the other staff to check no one has let them out without putting a note on the leave board on the wall. And if you still can’t find them, you’ll need to inform the shift leader who will decide what to do next (which I’ll discuss in a moment). The person on observations is also responsible for checking everything is ok on the ward: that the right doors are locked, that everyone is safe, etc. And unfortunately it’s often the person on observations who finds self-harm and suicide attempts. Some patients wish to be found and stopped and will deliberately wait until they know someone is about to check on them before trying to harm themselves.

As well as the routine hourly observations, it’s not unusual to have one or more patients on 15 minute observations. They may be new to the ward, have told staff they’re feeling suicidal or be agitated and at risk of violence, etc. The same staff member on the hourly observations will also do the 15 minute observations. Sometimes there may be a fair few patients on 15 minute observations so it can become a time-consuming and laborious task. This is why observations so often fall to healthcare support workers.

Then there are level 2 and level 1 observations that are only used if a situation is escalating. Level 2 means the patient needs to be within eyesight of at least one staff member (sometimes more). Level 1 means the patient needs to be within arms-length of at least one staff member. These observations aren’t often used, particularly level 1 which I think I’ve only seen used a handful of times, as they’re obviously a massive drain on staff resources and a major infringement to the patient’s rights. But if someone is agitated and has made attempts to harm someone, or is repeatedly attempting to harm themselves, then these observations can be implemented for short periods. It is difficult to sustain them long-term, and if these levels of observations are needed for prolonged periods the patient is often transferred to the Psychiatric Intensive Care Unit (PICU) where they have a much smaller number of patients and a higher staff-patient ratio.

So if a patient cannot be found anywhere, and no one has let them off the ward, the shift leader and other staff will need to do a quick assessment of the situation. Someone will try to ring them on their mobile phone. If the patient is ‘low-risk’ and it’s suspected they’ll return on their own, then often they’ll be posted as on leave for a few hours to give them chance to return. If there are some concerns over their safety or risks, the doctor will be informed as well as the ward manager if it’s day-time hours. Often it will be necessary to implement the AWOL procedure. You might ask how a patient manages to leave a ward without asking. Well, there are many ways that patients find. On the ward I was on we had patients squeeze through windows after breaking the hinges, climb over the smoking courtyard roof, wait until someone is entering the ward and push past them… lots of ways!

The AWOL (absent without leave) procedure is long and time-consuming. I’ve done it so many times I could do it in my sleep. The nurse completes a missing-person form with a description of the patient, has a quick read through the notes to highlight risk issues, acquire contact details and addresses, etc, and then rings the police to inform them we have a missing patient (they just love inpatient wards ringing them!). The police will take all this information and decide what to do. If the patient is voluntary the police aren’t obliged to do anything, but if you have identified specific risks they will usually visit the patient’s address to check on them and ask officers to keep an eye out. If they find the patient they cannot force them to return, but if they have their own concerns they can obviously detain the patient themselves. They’ll ring the ward, let us know the patient is ok, and then the ball is back in our court as to what to do next. If the patient is sectioned then the police are obliged to try to find them and bring them back to the ward, using force if necessary.

Most AWOL patients are returned quickly, either by themselves or by the police. They may have left to acquire drugs or alcohol, or simply to test boundaries or make a point. But sometimes AWOL patients harm themselves or, very rarely, other people. Sometimes they do bizarre things or get on random public transport and end up on the other side of the country. One AWOL patient that escaped from the hospital I worked at one time went to the general hospital next door, stole a nurse’s uniform and pretended to be a nurse on the ward! When these things happen risk incident forms need to be completed and sent to management who will analyse the situation and look at things that need to be done. If a serious incident occurs there will be investigations. It’s often easier if the patient escaped off their own back. If a member of staff has knowingly let the patient out and they’ve gone on to do something risky, then you’re in dodgy territory and need to make sure you’ve covered all your bases. I can’t tell you how nerve-wracking it is to have allowed a patient off the ward only for them to go out and take an overdose. It’s one of the reason shift-leading is such a stressful job!

Next time I’ll discuss physical care and clerical duties.

What Psychiatric Nurses Do (Part Eight – Managing Self-Harm and Suicide)

This is part eight of my series on what psychiatric nurses do. You can read the other parts of the series here.

Self-harm is an unfortunate reality of mental health care. Many of the patients on psychiatric inpatient wards self-harm in one way or another, despite the efforts of all the staff to prevent it. Cutting, burning, scalding, swallowing dangerous substances, inserting objects under the skin, taking numerous small overdoses, head-banging, etc. Patients will find ways to self-harm no matter what you do.

I remember the first time I had to deal with a serious self-inflicted injury. A male patient had cut his wrist in his sink using a razor blade. There was blood all over the floor, in the sink, on the bed, up the walls, and his arm was covered and pumping ever more blood out. I never thought I’d be squeamish in this long-anticipated situation, but I was surprised by how freaked out I was! I panicked and asked a more experienced nurse to deal with him while I cleaned up his bedroom.

Dealing with self-harm is also challenging on a personal level. With the above incident, I found it incredibly difficult not to get angry with the patient for causing so much trouble for me and my colleagues and for putting himself and others at risk in this way. It’s hard when the same people self harm over and over and you have to deal with the consequences when you’re already very busy. Especially when they said they wouldn’t and you gave them your trust. There was a patient on the ward I was on a short while ago who would take small Paracetamol overdoses virtually every time she went off the ward, despite assuring you she wouldn’t. Each time we knew it wasn’t enough to be seriously harmful, but we still had all the extra work of ringing doctors, hospital visits, paperwork, etc. It’s hard to be patient sometimes.

When a patient self-harms it’s basically the psyche nurse’s job to pick up the pieces. Call an ambulance or doctor, clean up the wound, put on a temporary dressing, escort the patient to A&E if necessary, and do the reams of paperwork it causes. It’s difficult – psyche nurses, bizarrely, are not trained in dressing wounds, stitching or anything like that. Other than a lesson in very basic wound care and aseptic technique at uni, I never had any sort of tutelage in wound care or dressing. Wound care tends to be left to the junior doctors, who instruct nurses on when to change the dressings and how.

There tends to be a dispute among psyche nurses about the proper way to deal with self-harming. Balancing risk and promoting responsibility is a balancing act and all nurses have different opinions. Some argue that self-harm is a coping strategy, albeit a maladaptive one, and that patients should be allowed to utilise it in a safe manner. Others take the opposite view and believe self-harm should be prevented at all costs and every single possible risk should be eliminated. Actual practice tends to fall somewhere in the middle. Obvious risks are eliminated as much as practicable. Known cutters are supervised when shaving and searched for sharp objects when returning from leave; burners aren’t allowed cigarette lighters and supervised when smoking, etc. But risks can never be completely eliminated and at some point the patients have to take responsibility for themselves. It all comes down to care-planning and risk assessment. For example, a well-known patient to the ward I was on would self-harm by inserting staples and metal pins under their skin. There was no way we could stop them without massively infringing on their right to autonomy and it being a massive drain on staff resources. So they were given access to dressings and a doctor would periodically check their wounds for signs of infection.

Suicide attempts are one of the most challenging parts of the job of a psyche nurse. They’re not common, and most are not serious attempts, but are often made to sabotage care, make a point, etc. It’s unfortunate but true that some patients will use the threat of suicide as a way to get what they want, even making serious attempts but at times that they know someone will find them. Again, dealing with this sort of behaviour is very challenging, and is a major reason so many nurses become cynical (myself included). However very occasionally someone will make a genuine, real attempt to commit suicide, usually when off the ward. It’s never happened to me. In fact I only ever knew one patient who successfully committed suicide after being discharged, and I was a student. He drowned himself in a lake after convincing the whole team he was well enough to go home.

The job of the nurse is obviously to prevent suicide as much as possible. Hourly checks of the ward are done by all staff in turn, but those patients who are perceived to be a high suicide risk can be monitored more frequently, to the point where a member of staff can be within arms reach. They will be monitored until staff are satisfied the risk has decreased, and as a team the nurses and sometimes doctors will decide to reduce the observation levels. It’s a lot of responsibility and sometimes we will be wrong. The media love to vilify us for getting it wrong when someone manages to commit suicide under our care, but we’re not faultless and we’re not psychic.

Next time I’ll discuss the AWOL procedure and observations in more detail.