C is for...

More ABC guide to secure services. Hopefully to be taken lightheartedly...

There's some nasty swears down the bottom. Don't read if easily offended :o)


Care/Intervention plan

A document – largely considered by many patients to be mythical – that outlines their, um, plan of care. They are slightly different depending on whether you’re talking about a care plan for a CPA (Care Programme Approach) meeting or the day-to-day stuff on the wards, but basically, it documents what is going to be done, by whom, and when. Theoretically this is negotiated with the patient, who signs them and keeps a copy. Realistically, the staff write it, decide that the patient is too unwell to see it, then use it as an excuse to make them do stuff, e.g.

Q: “Why do I have to shower every day?”
A: “Because it’s in your care plan.”

Should a patient ever request to see this fabled document, the staff will immediately (a) panic and (b) quickly rewrite the plan to exclude anything that might upset the patient, such as references to the fact that they are mad as a box of frogs. They range from the complex (X will engage with Y from psychology once a week to identify appropriate methods to manage his anger and violent impulses) to the basic (‘X will refrain from eating any non-foodstuff items’).

In secure services, everyone tends to have similar care/intervention plans. One for observation/engagement (coming up soon under E), one or two for leave, one for violence and aggression, one for physical health and/or medication, and others for client-specific risks e.g. self harm.

Incidentally, our trust has done away with paper records, but still expects a patient to sign their plans. So you print one off the computer records system, get it signed, and are then technically forbidden from storing it anywhere. Clever, no?


Control and Restraint

Or Care and Response, if you are restraining the elderly*. When a patient kicks off, it’s essential that the situation is controlled quickly and safely. We get taught the right way to do this, so that when it happens the nursing team spring into action like a well oiled machine, using efficient techniques to restrain the patient in a humane and dignified manner.

I’m sorry, I need to take a second to stop laughing my ass off.

Ok. Firstly, I have worked with the people who train you in these techniques, and I have never seen any of them use them to ‘take the patient to the floor’. They just don’t work**. Once the patient is sprawled on the floor, yes, they work ok to keep them there. You hardly ever have to stand on their neck. But when you have a rampaging psychotic person they are generally not going to stand still long enough for you to position yourselves correctly in order to use the techniques; frankly, nothing short of a semi-coordinated rugby tackle will take some of them down.

Secondly, no matter what you say, there is no dignified way to pin a person to the floor. If you’ve ever experienced it, you’ll know. It’s a bit like being the ball in the middle of a rugby scrum. Only one of the players has a big needle and is trying to pull your trousers down.

I’ve been lucky enough so far to never have been the nearest nurse when a patient has been kicking off (well, luck, and the fact that I have an extremely well developed sense of danger that means I’m always just a little bit too far away) so I’ve never had to do the initial wrestling to the ground bit. Instead, I always get the legs. I end up clinging on for dear life as I get flailed all over the damn place. You usually get more bruises from the laminate floor than from anything the patient could have done in the first place. I sometimes long for mechanical restraints. For use on others, of course.

There’s tons more I could do about this, but I want to keep them kinda brief. So, onwards…


*Yes, we sometimes restrain people classed as ‘elderly’. Look at it this way; think of the evilest old person you know (the ones that try to run you down with their mobility scooters and hit you with their walking sticks) and then imagine they think you have kidnapped them and are trying to poison them. Now throw in the super-strength that pissed off mad people seem to get and you see why Care and Response is sometimes necessary. It’s that, or near lethal doses of antipsychotics.

**Has anyone else? Genuinely interested here…


Criminals

Secure units take a mix of people. Some are those on section 3 (admission for treatment order), who have never been caught committed a crime, but who for various reasons are unsuitable for ‘normal’ mental health wards. For example, they may be violent or aggressive, or prone to absconding, or are just reluctant to take their happy pills.

Others are people who have ended up there through contact with the court and prison system. Some come for assessment; a judge might want to know if they are mental before deciding what to do with them. Mostly though, these people are mainly on section 37 (similar to a section 3, but ordered by a court in place of a prison sentence) with a section 41 restriction order from the Ministry of Justice (written as a s37/41) which basically means the MoJ needs informing when these patients get leave. Unlike in prison, they have no set period they have to serve so could be in, like, forever. Some of them are a bit gutted by this when they realise their 'I’m mad not bad’ act has worked; they now have a nice cushy room…with no release date. The other common one is a section 47, which is a transfer from prison order; the patient might not have been ill at the time of the offence, but has become so in prison and is just a little too bonkers to be nursed in jail. These patients have a set sentence, however if they are in hospital when it ends, they don’t automatically get released. They also usually have restrictions orders attached, which are s49’s.

Patients also come in as a ‘step down’ from high secure services. This tends to mean that we have a lot of patients who were pretty nasty…a long time ago. A lot of the murderers have already been inside for 10+ years by the time they come to us, and are pretty much spent. Some of them committed their crimes in the ‘60s and ‘70s, and are so institutionalised that they are never getting out of services completely, despite the fact that they are unable to put on their own socks, let alone hurt anyone. Sometimes, when you take them to the park to feed the ducks, you can’t quite believe that the man next to you once bludgeoned his parents to death.


Cutlery

Is counted at the beginning of each shift and after each meal, before patients are allowed to leave the dining room. If you need to pee during lunch, a nurse will come and watch you to make sure you haven’t secreted a knife and are secretly trying to hack off your (or anyone else’s) appendages. Although given that the knives can’t even cut mash, the chance of you doing any damage to either yourself or others is minimal. Still, if you are considered to be a risk, you will be given unwieldy plastic cutlery at meals thus ensuring you will still be trying to eat your lunch an hour after everyone else has finished and gone back to bed. Possibly the theory being that eventually the patient will be so weak from hunger that they won’t have the energy to be dangerous.


Long shift today. We de-escalated the hell out of those patients. Lot's of threats, but no actual violence. Score!

EDIT:

David reminded me of another C...


Cunt

Another name for a nurse. Loses it's power after repeated exposure, causing the speaker to add increasingly desperate adjectives to achieve their desired affect. Hence:

Fat cunt
Fucking cunt
Lesbian cunt (often used during restraint, cause obviously we're restraining you because we secretly want to touch you)
Bulimic cunt (yep, got that one yesterday. So I threatened to throw up on her.)
Raping, gangbanging cunt (had that one too. Laughter is apparently not the response he was hoping for.)

Etc. On a night shift, nurses gather together and compare the abuse they have recieved in some sort of 'Top Trumps' competition. The more obscence or bizarre, the more kudos for the nurse.