F is for...

Favourite Patients

Having 'favourite' patients is highly unprofessional. Of course, that doesn't stop it happening in just about all mental health settings. Professionals are human too, and it's very difficult to remain totally objective without becoming a robot. Robot's aren't known for their therapeutic engagement skills. The trick is not to let it interfere with how you treat everyone.

Strangely, favourite patients aren't always the ones who follow the rules and do everything they're told asked to. In fact, staff will usually have different patients they each like better; there is rarely anyone on a ward who is universally hated, no matter how difficult they are. A patient I struggle to get on with for whatever reason might get on much better with other members of staff, and similarly one of my 'favourites' is someone who everyone else rolls their eyes about a lot. You can never know how someone is going to react to you, but there are some ways to ensure you won't be anyones favourite...

1. Make malicious complaints. And I do mean malicious; valid complaints won't (usually*) get you hated, despite what you might think. If you are complaining because there weren't enough staff to take you out on leave, we won't take it personally; in fact, we will probably side with you because a complaint coming from a patient will have more oomph than one from staff. If, however, you are complaining about something that never acutally happened (and you're not delusional) which could land someone in serious shit, then yes, people may take a dislike to you.

2. Assault other patients. I'm not talking about attacks by patients who are acutely ill; I'm talking about the ones who plan it, who pick on weaker or more vulnerable targets. That pisses us off. We get quite protective of a lot of our patients.

3. Attack staff. Again, not relevent if you are acutely ill. But if you know what you're doing, and do it anyway, then eventually you're just gonna alienate everyone. Which may be what you wanted, but it will just make things harder for you in the long run. We will still (hopefully) be professional in our dealings with you, but no-one is going to go out of their way to do anything for you.

4. Make comments about our family/loved ones. I have been called a lot of names, and had some very personal remarks made about me, my body/face, my sex life etc. Fine. But when you start making comments about peoples children (eg. loudly hoping they die horribly, or worse, talking about what you are going to do to them when you get out) then that gets people's backs up. Patients on our unit know that if they really want to hurt Mr Door, then it's me they need to go for, either physically or verbally. Luckily, he's not upset anyone enough to try it. I'm pretty sure he'd kill them if they tried, so it's probably a good thinh he's trying for a career change.

Anyway, back to favourites. In forensics, things get a little weird. In order to work with this particular client group, you have to be able to detatch yourself somewhat from their crimes. You can never forget about it completely, of course, but just in order to be not only civil but actually therapeutic in your interactions requires you to put it to the back of your mind.

Through ignoring the crime, though, you end up liking people who have done some nasty stuff. Because people that do nasty stuff aren't always nasty to be around. Some of them are actually quite funny, intelligent, charismatic people. And so your favourite patient might be a killer, or a sex offender, or maybe just a plain old bank robber.

This is weird enough, but then you have the odd moment of clarity. You remember their victims, and their victims loved ones. They probably hoped their abuser/killer etc would spend the reast of his life in a dingy cell being thoroughly miserable. They were unlikely to think that they would end up on a (comparatively) comfy ward being liked (again, comparatively). I don't know about anyone else, but that doesn't sit comfortably.

One of the patients I have a particular soft spot for is a man convicted of murder. I know I'm of a similar age to one of his victims. I'm pretty sure this victims family would be devastated to think that I occasionally go out of my way to do 'nice' things fro him. In this case, the 'nice' thing is to occasionally bring him crayons and scrap paper in, because his brain is so fucked that all he does is draw the same few symbols over and over again on whatever he can egt his hands on. There is possibly some sort of karmic justice going on there. Mr Door has been known to put songs on patients mp3 players using our home computer. At the end of the day, it's not a prison and they're there for treatment, not punishment. But it's still hard to reconcile, and I sometimes wonder if I should be more 'professional'.

Ok, I'm stopping there before I get in too deep and confuse myself.

*Of course, this is based on where I work. Can't speak for other places. But I would hope patients feel able to make valid complaints without threat of retribution these days...Naive? Me?


(In)Famous Patients

Every now and again, we get a patient admitted who is 'famous', or possibly more correctly 'infamous'. This usually means they have been in the local paper under the headline 'madman goes on naked samurai sword rampage'. Occasionally, they have made the national news, and we did have one patient who got a mention in a book and never let us forget it. Of course, staff behave professionally in these situations and will make sure to take turns to go and gawp at them. There is often a memo sent out reminding us not to talk to reporters and giving the number of the Trust PR office, who are apparently better at saying 'no comment' than the rest of us. We also have to screen the newspapers before they go onto the ward, and don't usually let them on if they have stuff in about a patient. A procedure that often proves pointless when said patient's face is then splashed all overthe BBC news along with every little detail of the crime.


Fence

It's about 15 feet high. It's the bit that actually looks like it belongs on a prison. The other security methods tend to be a bit subtler; the windows are barred, but not in a particular jail-style way, and the locks aren't very imposing. All the glass is toughened and shatter-proof; neither of which, it turns out, will prevent a truly determined man from putting his head through it.


Female Services

Women get a raw deal when it comes to secure services. They are in the minority, which means that instead of having separate wards for, say, acute and chronic patients as they do for men, everyone gets lumped in together on one messed-up ward. It's not a great combination, as the acute patients inevitably require more nursing input and so there's an unfait distribution of care. The private sector appears to do better than this, seemingly they have more specialist wards. But then, we send them all of our nightmare patients anyway, so it kinda makes up for it.

I could do an essay about female servies, and in fact, have. See here for more discussion of it.


Firesetting

Often people in forensic services like to burn things. Sometimes the things are inanimate objects; sometimes the things are other people. Sometimes the things are themselves. Either way, lighters are highly restricted (each area has a ward lighter and patients can earn the privilege of having one during the day) and matches are banned. Most often, if you find a contraband lighter, the worst that was planned for it was lighting a sneaky fag in the toilets. Most patients couldn't be arsed with setting fire to anything cause they'd have to get off the sofa to evacuate.


That was F. I'm sure I had other things to include, that got deleted in the Big Format Fuckup. Hey ho.

Does anyone know...

...why I can't copy and paste into blogger from a word document (Office 2007)anymore? Cause I used to be able to. The 'paste' option is greyed out and ctrl+v isn't working.

Don't really want to copy out the 1500 word post I just wrote.

I hate computers.

We can rebuild...

Due largely to my own stupidity (and evil twats on BitTorrent), my laptop got a virus the other day. Two, in fact, according to AVG which just kinda sat there and looked at them, before whimpering a bit and slinking off in admission of defeat. One of them appeared to just give me some delightful links on my desktop (possibly of the type Aethelread was attempting to obtain here) whereas the other just decided to totally fuck everything up. Basically, it wouldn't let me do anything; change any settings, open any programs, look at my task manager, etc. I couldn't do a system restore or even start up in safe mode. So I consulted the expert - my dad. Who managed - with the best of intentions - to get it stuck in a neverending restart loop. So. We formatted the bastard.

Which has worked, but of course has left me bereft of 3 years worth of 'stuff'. Downloads, programs, assignments, pictures, music, favourite websites, blah blah blah. I still haven't remembered everything I've lost so am just hoping none of it was irreplaceable. This is also my own stupid fault, since I hadn't backed it up. My dad already shouted at me about it, don't worry.

Anyway, I also lost quite a few drafts of blog things. I will get back round to re-writing them, but I have homework from uni this week so things might be a bit quiet for a few days.

On the plus side, the stupid thing works much quicker with all the crap taken off, and I'm wondering if I can live with it being back-to-basic. Hmm.

Black Friday

Apparently, the term 'Black Friday' traditionally refers to the Friday after Thanksgiving in the US, which is one of the busiest shopping days of the year.

Where I work, we have a slightly different interpretation.

Affectionately known as "the black 'un", it is the last Friday before Christmas; the day in which the entire unit (barring the skeleton crew left at work, and a few scaredy-cats who value their dignity and, in some cases, marriages) descends on the town centre and gets completely shit-faced, leaving behind a trail of broken hearts, bloody noses and STI's. It starts as a ticketed do in a grotty room above a pub, until the management realises what the fuck they've let themselves in for and start kicking people out. This is because usually, by the time the ticketed thing starts at 7pm, most people have actually already been drinking for between 2 and 7 hours.
Basically, it is the culmination of putting up with a year of this sort of thing; a huge venting of stress.

Partners are supposed to be banned, but since me and Mr Door both work there we get an exemption.

We got our tickets yesterday* :o)


*We are numbers 100 and 101. The town isn't going to know what's hit it..

E is for...

My 'to-do' list is getting a bit ridiculous. I've managed to knock off 'get car insurance' and 'pay gas bill' and now here's 'the letter E'. Unfortunately everything else seems to get neglected in favour of 'spend untold hours looking at random crap online'. Must start prioritising...sigh.

Engagement and observation

Back in the good old days (i.e. about six months ago), we had obs. These are not to be confused with physical obs, such as proper nurses might carry out to determine BP/heart rate/respiration etc. Obs in mental health consist of (a) ascertaining that the patient is breathing and (b) determining that the patient is not doing anything they shouldn’t be engaged in meaningful activity. Basically, whichever member of staff was failing to look sufficiently busy would get handed the obs board, which had charts for each patient detailing how often you had to check on them and a little space to sign to say they were breathing when you did. Sometimes you would write a little description of what they were doing to enable you to write up your notes later without having to think too hard, e.g. 5pm; sleeping, 5.30pm; sleeping, 6pm; etc. Patients were checked on a minimum of half-hourly, with many of them being on 5 or 10 minute obs. If you have a 20 bed ward, with 5 patients on 5 mins, another 5 on 10 mins and the rest on half hourly’s, you are basically spending your entire time looking for patients. Once found, the patient will sometimes helpfully say something like ‘what?’ at which you grunt ‘obs’ and then they grunt back. Repeat x 288 times per 24 hours.

If you are doing the obs on a night shift, you must take a torch and shine it directly into the patients’ eyes until they start swearing at you, hence proving they are alive.

One of the absolute best ways to get yourself fired is to say you’ve done the obs when you haven’t; if the obs are signed for and your patient turns out to have been (a) dead for several hours or (b) absconded then you are going to get found out. This in no way stops people from leaving the obs all night then signing 12 hours worth after having a quick check about at 7am.

Also much fun are constant or special obs, which basically do what they say on the tin; the patient gets the pleasure of a staff members’ company constantly. Generally a pain in the arse for the patient, who would otherwise be able to cut up/ligature/break things in peace. Although sometimes they still can, when the observer falls asleep/gets engrossed in their magazine.

Anyway; now we don’t have observation. We have engagement. No more ticky board, no more peering at patients through their bedroom window (that is, observation window, not actual window. That would be creepy (er)). Now, we – shock, horror - have to talk to them. Or engage. Therapeutically, ideally. Constant obs still exist, but there is more emphasis on using them…therapeutically.

Of course, it’s still handy to check that your patients are still there and still alive. So now you have fire checks (as in "crap, fire! Where are the patients?! Consult the fire check board!") that are carried out once an hour, and involve peering at the patient through the obs window…and ticking it off on a fire board.

It’s a completely different system, though. Honest.

Escort

No, not a hooker. It’s something a detained patient usually has to have when they leave the building. Escort level is decided by the MDT and documented on a form called a section 17. Some patients eventually get unescorted leave, but most need one or two staff escorts. Sometimes, they need even more; one patient who wouldn’t have any leave otherwise needs to attend another hospital for appointments, and he is escorted by three male staff due to his very unsettled mental state and scary scary strength. Escort levels are also often increased when patients are taken to court for trial or sentencing, in case they decide to make a last ditch break for freedom/notoriety. It’s not unknown for them to go with a four-man response team and a driver; the court personnel are not impressed if you can’t handle your own patient.

There is a kind of progression with escorts and leaves. Patients who are a risk (either of violence, absconscion or just a risk to women in general) are usually sent everywhere with two males, possibly progressing to a male and female if they behave themselves. This is important; the chances of there being three males (two to go out, leaving one as required on the ward) on a ward at any time are incredibly slim, so you are scuppered for leave if that’s your escort level. However, male/female leaves are much easier to facilitate. After this, you might progress to one male, then one staff of any gender. Sometimes, they throw in a requirement for one of the staff to be qualified, particularly if the patient has physical health needs, e.g. a patient who has epilepsy might be escorted by a qualified nurse so diazepam can be administered if they have a seizure whilst out.

Electronic records

Basically, all patients’ notes should now be on computer in our trust. This has good and bad points. Staff can now get instant access to any patients notes as soon as they’re admitted, without waiting for them to be couriered over, which is good. However, it now takes twice as long to do your notes because (a) this is the NHS and there aren’t enough computers and (b) there’s always someone hogging them who thinks a mouse is a small furry creature that eats cheese and takes an age to type anything. Good points for patients are that staff have access to their history; they should enable better care provision and patients shouldn’t have to repeat themselves too much. Bad points are that staff have access to their history and so they can’t make shit up (e.g. “at my last hospital I had unescorted leave and used to get temazepam every night.” Oh yeah? Computer says no.)

The ‘paperless office’ idea is just bollocks, though, frankly. The Mental Health Act has so much paperwork that needs an actual hard copy keeping that we still need folders for it all. Add to this letters, scan/test results, signed copies of care plans and s17 forms, etc and patients files aren’t actually much thinner than they used to be. Still, it’s handy for sharing information between professionals, which is always something that benefits from improvement.

Mr Door is still on nights, but so far my hormones remain in check...must be saving it up for our first day off together...

Saturday lightheartedness...

A meme stolen from Aethelread

My mother once threatened to throw a woman out of a pub window. I think I know where I get my temper.

Never in my life have I seen the attraction in ‘gorn’. Saw, Hostel etc just make me sick.

When I was five I used to make my toy dinosaurs eat my sisters Barbies. I still would, too.

High school was/ is something I’m quite glad I never experienced, if TV is anything to go by.

I will never forget the sight of a man with a cold eating his used tissue. Ever.

I once met Jet and Hunter from Gladiators. Oh yes.

There’s this person I know who makes me want to hurt them every time they open their mouth.

Once, at a bar, I stole an ashtray. I don’t even smoke. What can I say, I’m a REBEL.

By noon I’m usually contemplating getting dressed. Or wishing I’d phoned in sick at work.

Last night I dreamt one of my lecturers was selling chocolates from a tent in the grounds of a local park. I got annoyed because she didn’t put enough chocolates in my box. Anyone care to interpret?

If only I had more.

Next time I go to church/ temple it will probably be whilst escorting a patient.

Terri Schiavo is my idea of a living hell.

I like sleep.

When I turn my head left, I see a wall with one of Mr Door’s pictures on it.

When I turn my head right, I see a room that is an appalling mess.

You know I’m lying when I say 'I respect what you’re saying, but…' I don’t.

In junior school I was ‘quiet and conscientious’ on every single report.

If I was a character written by Shakespeare I wouldn’t understand a word anyone was saying.

By this time next year I will be a nurse. Holy fuckin’ shit.

A better name for me would be anything other than what it is. I hate my name, much to my mothers distress. My middle one isn’t any better either.

I have a hard time understanding the motivations of my classmates. Why are you on this course?

If I ever go back to school I won’t be surprised. I quite fancy getting a PhD. Just so I can be a doctor-nurse.

You know I like you if I voluntarily make conversation with you. Sitting with me in awkward silence? Yeah, I hate you.

If I won an award the first person I’d thank would be Our Dark Lord Lucifer. Just for the entertainment value.

I hope that lots of good things happen. Although I’ll settle for an absence of bad things.

Take my advice. I dare you.

My ideal breakfast is a cup of tea and a kitkat.

A song I love but do not have is unimaginable, thanks to t’interweb.

If you visit my hometown, I suggest body armor and some sort of semi-
automatic weapon.

Tulips, character flaws, microchips and track stars, that’s what little girls are made of.

Why won’t anyone make Aethelread the supreme ruler of the universe? He’d be good at it.

If you spend the night at my house you will likely leave with pneumonia from the damp.

I’d stop my wedding as soon as my dad gets drunk and throws a punch.

The world could do without all Saturday night reality TV.

I’d rather lick the belly of a roach than watch the X Factor.

My favourite thing is Mr Door. And my TV.

Paperclips are more useful than 98.4% of everyone.

And by the way, you’re standing on my foot.

The last time I was (really) drunk I vomited yellow bile stuff.

My grandmother always laid on the best guilt trips.

D is for...

A quick note before I start D: I got my marks back, and I've officially passed my second year, yay! :o) Somehow managed to pull out a 70% average, which fantastic, but a bit scary. It kinda opens the door to the possibility that I could get a first class degree. So now there's pressure; if I knew I had no chance of getting one, it would be easy and I would be very happy with a 2:1 (thrilled, in fact). But now I, and more importantly, Mr Door and my mum, have got a glimpse of it, we'll all be wanting me to get a 1st. Which I'm really not sure I can do. I'm pretty sure I've been lucky so far, and this year gets harder. Bah. Oh well. I'll just keep doing my best and hope for kind markers.

Onwards...

Death in custody

Patients sometimes die in hospital. It is always tragic and, no matter how much of a pain in the arse they were as a patient, their death will affect the staff. Mental health tends to be a small community, and every loss is felt.

Luckily no-one has died unexpectedly where I work during the period I’ve been there; not through lack of trying, I might add*, which in some ways is testament to the skills of the staff. Whether we should actually be letting them do it is being discussed on Mental Nurse, and isn’t a subject I’m going near even with a bargepole here because I'm a coward. People have died of illness; there is a general hospital nearby where they tend to get transferred and then, when the MoJ is sure they are definitely dying and not just faking the terminal cancer, they may get taken off their section. As long as they are too ill to get out of bed, of course. If the person has been a long-time patient and has no family, the unit might send staff to sit with them as a friendly face (as opposed to a legal obligation) so they don’t die alone. This is either very nice of them or extremely cruel; you can’t even get a break from us when you’re dying...

There are very strict things that have to happen when someone dies in custody. I don’t really know much about it; the extent of my knowledge is that, when removing a ligature, we are not allowed to cut through the knot - if the patient is successful then it might be evidence. Which, frankly, is the last thing on my mind when I’m confronted with a blue-headed person** but rules are rules…

*The women’s ward is averaging an attempt a day at the minute.

**i.e. Cyanosed. Not just blue.


Drugs (that is, illicit ones; not the ones we give out like Smarties. Cause those ones are ok.)

Also banned, but easier to smuggle in than alcohol and potentially easier to avoid detection, if you choose your drug carefully (i.e. don’t come back off leave stinking of weed, since that is a smell instantly recognisable by mental health nurses everywhere who, of course, never use the stuff*). We have drug screen tests, but they are actually used less in secure than acute services, due to the theory that patients have less access to drugs than people on open wards. This is odd when you consider that the local dealers have figured that hanging around the hospital grounds is a potential goldmine; particularly once they’ve witnessed the overweight, arthritic security guards unsuccessfully trying to persuade unruly 8 years olds to leave the premises and realised they are no great threat. If you have no leave, then you are reliant on other patients smuggling stuff in for you…which often means buying stuff that has been residing in someone’s rectum for as long as it’s taken them to find a way to get it to you. Delightful.

*That actually largely true. Weed is for pussies. Mental health nurses need much stronger shit.


Discharge

In the 14 weeks I was on placement on an acute ward, almost all of the patients were discharged. New ones came in, obviously, but towards the end there were only a couple who had been in when I started. I was struggling to keep up with the pace on occasion, but then I'm atrocious with names anyway.

I’ve been working in secure services for 6 years. Around 80% of the patients who were there when I started are still there. Discharge, on the odd occasion it happens, is a very slow process. Even on our ‘short stay’ ward patients aren’t expected to be discharged in under 18 months. On the plus side, it means you get to develop some very good relationships with patients. On the down side, if you hate a particular patient, there’s a fair chance you will still be nursing them in ten years time, by which point you will be ready to be committed yourself. Some patients get so settled that rather than face discharge after that length of time, they sabotage any efforts to move them on. A patient who has been completely non-violent for years will start pulling sinks off the wall at the very mention of going to a hostel. Although frankly, having seen many hostels, I’d become violent at the thought of living in one too.

Diagnosis

A few generalisations here for you. For example, you don’t see many people with affective disorders (e.g. anxiety, depression) in secure services. The bulk of patients have schizophrenic-type illnesses, bipolar disorder (which I know might technically be affective, but I always consider alongside psychosis in my own head) or personality disorders. Depressed and anxious people are not big criminals; if you lack the motivation to get showered and dressed, you’re quite unlikely to go robbing any banks in your dressing gown. A lot of the crimes committed by those with schizophrenia are related to their delusions; lots of murders/assaults are caused by paranoid beliefs. I mean, if your mum has been replaced by a demon then killing her is actually self defence. People who are manic seem to lose impulse control and tend to get into fights quite easily, and sometimes come to the attention of police through inappropriate sexual behaviour in public places or with the people on the bus who really didn’t want to be shown your new genital piercing, thank you. Patients with PD’s characterised by emotional instability tend to lash out at others, when not lashing out at themselves. Either can get you admitted to a secure ward if severe enough.


Danger

I would argue that working on a secure unit is less dangerous than working on an open acute ward or in the A&E on a Saturday night. For example, we have lots of locked doors, a lot of people trained in C&R, and a lot of sedative drugs immediately to hand. Still, attacks on staff are common, be it being spat at (one of my pet hates), having things thrown at you (cups, tv’s, pool tables, etc) or getting properly physically or sexually assaulted. You have to watch your back, and hope everyone else is, too. It’s easy to get complacent, especially with patients who have been in a long time. One minute you can be happily playing wii golf supervising a patient activity and the next you can be rugby tackled by the little 70 year-old fella’ who missed his meds this mornings. Sometimes, you get a patient in who is very dangerous, usually towards females, and they limit women working/coming onto the ward until he is drugged into a stupor and unable to hurt anyone. I would think it was an excuse for the male staff to lie around farting, swearing and getting takeaways without anyone to nag them, except that the majority of the female staff are actually worse for that stuff. Myself included*.


*Except the farting bit. I don't do that.


More from Quacktitioner :o)

Delusions - Fixed, false beliefs, often in secure services with a paranoid theme. Although I did once walk into work to find three patients who all had religious delusions and varied beliefs of messianic missions sat around a table poring over the bible.You know it's going to be a loooong day....

Duty Rota aka the "off duty" - Move over Dan Brown, this is the most read book on the ward. It is recognisable as being the dirty, tatty old A4 binder ... the binder that was new three days ago.

(Completely agree with the off duty one; also immediately gets covered in crossings out and scribbled-in names, until it is unrecognisable from the original published rota and people have swapped about until they have the shifts they wanted in the first place)

Taking a breather

Having a short break from the ABC to have a witter about my life. If you think this will bore you then feel free to wander off to a better, less random blog. There are many of them listed off to the left.

Uni is not particularly thrilling at the minute; 3rd year seems to focus a lot on management and teaching methods and very little on actual nursing. I have a pharmacology exam next month, which is apparently very difficult, but it's only formative so if we fail it's ok. Until our poor knowledge of pharmacology kills a patients, anyway. *sigh* I know a staff nurse who's mentor on a placement refused to pass her for being, well, incompetent, but the uni let her continue the course anyway. It's pretty shocking. Also, once again, the uni has taken on more students than the have placements available for, in the hope that some drop out/more placements become available by magic. There is money involved, so who cares if some people get placed somewhere completely inappropriate? Or nowhere at all, as has happened before?

I have a couple of very, very dull essays to do, which I can avoid by changing to the degree, but until then I have to keep attending the seminars for them. Should find out in a few weeks if I can change. I really, really want to change. I'll actually cry if I can't. Some of the people on the degree course are so thick that if they come out with a degree whilst I only get a diploma then I will go on a killing rampage.

Am a bit worried about my mum at the minute. Her dentist has referred her to the big hospital cause she has a suspicious thing on her tongue. Given her 20-60 a day fag habit (depending whether she's at work or not) I'm fearing the worst. I'm trying not to think about it.

My dad, at least, is ok...he's busy spending his redundancy/pension money on constructing the worlds best home entertainment system in his council house. The amount of gear he has in his living room is impressive; am pretty sure it's actually worth more than his house. Given that he is surrounded by drug addicts and criminals, I'm also quite surprised he hasn't been burgled yet.

I fully expect to be horribly hormonal this week, luckily (for him) Mr Door is doing a ridiculous amount of night shifts so will avoid my random crying and occasional incomprehensible rages. I'm not sure being on my own will make me feel any better (actually, I know it'll make me worse), but it's just safer for our relationship this way. There's no chance of me dumping him because he didn't fold the towel on the radiator. I'm a catch, aren't I? In my defence, I never used to be like this; it's just the last 2 years I've become the PMT monster.

Ok, am off to optimistically think up dissertation topics. Any suggestions for anything interesting (e.g. nothing drug and alcohol or primary care related please) would be appreciated...

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.

B is for...

So continues the tongue-in-cheek (aka it’s all meant in good fun, please don’t shout at me) ABC guide to secure mental health services.

Today’s words are brought to you by the letter B.


Bedrooms

Most modern psych hospitals have individual rooms, whilst some of the older ones still have bays (e.g. 4 beds to a room, divided by the worlds shittiest curtains; discussing suicidal feelings whilst the person in the next bed lays there farting is very difficult). As far as I’m aware, secure units all have individual rooms; obviously volatile patients need their own space, also, they used to be locked in them on a night. We’re not allowed to lock patients in their rooms any more, and in fact can’t; the doors are all unlockable from inside. If you want to keep someone in, you have to stand outside with your foot against the door. The locks these days are mostly used to keep people out of their rooms; some of the patients on the long stay wards have completely kitted out their bedrooms with the latest 37”, high def LCD TVs, DVD players, games consoles, freeview boxes and stereos (your tax dollars at work, folks; people on some sections get £90+ a week, pay no bills and for some reason get the winter fuel allowance. Others get naff all except £16 a week off the hospital for fags.). They don’t want to come out; in fact, the doors all open outwards to prevent patients barricading themselves inside. This does mean that many an unexpecting nurse has been smacked in the face by a well-flung bedroom door whilst doing the obs, however. One of the lesser-known hazards of nursing.


Banned Items

Lots of things are banned, either for security or just for fun. I mentioned alcohol, obviously, and drugs. Some of the others are a bit odder. Chewing gum and blu-tack are verboten (can be stuck in locks, used to model keys or cover alarm sensors) as are matches, lighters (arson, obviously), mobile phones* and any bottles or packets that aren’t factory sealed (drugs, alcohol risk). Oh, and anything sharp/breakable/sniffable (razors, glass bottles, deodorant etc) needs to be handed to staff for safekeeping. Patients are only allowed to keep £20 on them at any time, to reduce the chances of them getting very far should they try and do a runner. Of course, you could argue that this just increases the chance that they’ll mug someone on their way out, but nevermind.

* The only patient phones are the payphones in the communal areas, where staff can listen in. It’s been known for patients to ring other wards to co-ordinate riots on occasion, or just arrange beatings for people that owe them money/fags. It has also been known for patients to arrange retribution for assaults against popular staff members…including against patients that have since been sent to higher security hospitals. Kinda makes you feel all warm inside knowing a patient is willing to have someone beaten up for you.


Birthdays (and Christmas)

Inpatients get an NHS birthday cake (which is actually quite nice, considering they need defrosting when they are delivered) and, usually, a special buffet tea stocked with Aldi’s finest. They get to make requests for what they want, and a sample menu might be as follows; ham/cheese sandwiches, scotch eggs, sausage rolls, beefburgers, hotdogs, nuts, pickled onions, crisps, fizzy pop. Health promotion consists of the staff keeping back half the crisps for the night shift to eat. Sometimes things get really wild and they break the Karaoke out. At Christmas, each patient gets a present to the value of £15 from the ward. Many of them, it’s the only present they get. For a substantial minority, it’s the only new set of underpants/socks they’ll get till next Christmas. They get a slightly healthier buffet, and what passes for Christmas dinner in the NHS, and some of them get phone calls from family since visits aren’t allowed on Christmas day (each ward can only accommodate 2 visits a day, and it was felt it wouldn’t be fair to allow some if they couldn’t allow all). It’s quite sad, really, but the staff usually do their best to cheer people up. How successful they are, given that they don’t want to be there either, is debatable.


Bathing

Always seems to be one of the first things to go out the window when people get ill. Wards tend to get…unpleasant…if hygiene isn’t enforced prompted. Fourteen overweight, sweaty men who don’t change their clothes (ever)* and are less than diligent with their toilet hygiene are more than a match for any housekeeper with any amount of NHS air freshener. Sometimes, threats and bribery are employed to get them to bathe. Sometimes they are physically dragged under the shower. Sometimes all it takes is a pretty young woman offering to scrub their back…then, once they’re in the tub, you send in the nursing assistant affectionately nicknamed Tiny who happens to be built like a concrete plinth. Repeat weekly/fortnightly/monthly/yearly (delete as applicable depending on how often your unit gets inspected by the Care Quality Commission).

*Incidentally, what is it with people with schizophrenia and layers? I’ve met so many who will wear multiple pairs of trousers and tops and will refuse to take their coats off even when the temperature tops 30 degrees. Mentalness is strange.


So that was B. If anyone thinks of something major I’ve missed, give me a shout. Or write a bit for it and I’ll stick it up and put my name on credit you :o)

A is for...

In the interests of attempting to post something, well, interesting, I've decided to attempt a new series. I don't know whether it will actually interest anyone, but I figure it stands a better chance of doing so than me simply whinging about my health/education/peers/family ad infinitum.

Anyway, all it really is is a slightly tongue-in-cheek ABC guide to medium secure mental health services. I'll try and do one letter per post, hence giving me 26 posts worth of material. Of course, there's a fair chance I'll get bored around the letter M or so and abandon it, but hey, lets think positively. I'll endevour to make them vaguely entertaining (as well as informative; it'll be like Sesame Street but without the drugs for inspiration), but am basically assuming that because it's an area that interests me it will interest everyone else too. I may be wrong, but it's my bloody blog, so tough.

I'll still intersperse the interesting stuff with rants and whinges, I'm sure.

(Speaking of which, I have Fresher's flu. I'm not even a Fresher, but their very presence has infected me. Not happy.)

So, onwards with A...

Abscond

Patients, for some reason, are not always entirely happy to be locked up. Sometimes, they try to run away. Occasionally, some are desperate enough to attempt to climb the 20ft fence whilst pissed-off staff cling to their ankles and try to pull them back down. More usually, however, patients escape whilst out on leave. Some patients will gradually gain the trust of the staff and consultants and obtain unescorted leave, only to hop on the next bus to Scotland (and occasionally, ferry to Amsterdam) and not come back. Others – less patient patients, who don’t want to wait the several years it can take to get unescorted leave – just decide that they can run faster than their escort and leg it when they are distracted. If said patient has been on the unit for longer than a few months, they are almost certainly much bigger than they were (antipsychotics are a bitch for weight gain) and in that time will have done no more exercise than it takes to throw a cushion at someone who tries to change the channel while the X Factor is on. They therefore usually get rugby-tackled by some now very irate staff and are hauled physically back to the unit, where they lose all their leave and are subject to much head-shaking and what the hell were you thinking?’s.

If they do escape, most are located within a few hours; usually passed out under a bush somewhere in the hospital grounds with an empty bottle of gin. Others get dobbed in after a few days by family or friends, who gradually realise that having an escaped, unmedicated, psychotic criminal kipping on your sofa is not as much fun as it sounds. Still others bring themselves back when they run out of money.

Basically, absconsions (a word that only appears to exist within NHS policies) are much more common than you might think, particularly in the summer when the weather is nice and the bushes are dry. The media isn’t usually told until a few days later, if at all.


A is also for: Alarms.

Staff and visitors to the unit have to wear personal alarms on their belt. This is pretty common on mental health units, I gather, but there are a variety of types. Some have different mechanisms: if you press the little button, it means you would appreciate some assistance with a difficult situation; if you yank the alarm apart (it’s in two joined parts, it’s not vandalism), it means you are having the shit kicked out of you and need to be rescued immediately. They all communicate your location to others in some way; either by a pager system or by flashing the info up on a panel on the wall. Newer alarms are even fancier; they go off if they come off your belt, and some go off if the mini-spirit level inside indicates that you are horizontal. So basically, if you are on the toilet and it falls off or if you forget you’re wearing it and decide to get comfy on the sofa, you might get a surprise visit from the response team. Who will either (a) laugh hysterically (if you are on the toilet) or (b) swear at you (on the sofa). Even fancier ones now come with GPS, apparently, so that you can track your staff throughout the shift. This highly specialised, very expensive bit of kit is allegedly to improve staff safety...and not at all to do with seeing who's sneaking out for a crafty fag behind the metaphorical bike sheds.

Our unit regularly used to run out of alarms to give people, simply because they break so often and are expensive to replace. I used to enjoy telling people that the bit of plastic they had just dropped in the loo was worth £200.


Alcohol

Is banned, although it doesn't stop friends and families trying to sneak it in. When a patient gets leave, it's sometimes specified whether they can drink or not. If they can, it's usually limited to a couple of units...but by that point, their tolerance is so low, you get 15 stone blokes getting pissed off 3 units. Which is funny.


Antipsychotics

Drugs used to treat...well, lots really. As wikipedia says about Chlorpromazine (the first antipsychotic); it effectively treats schizophrenia, severe mania in people with bipolar disorder, and uncontrollable hiccups. Basically, they control some of the weirdness like hallucinations, with varying success. They also have a huge range of side effects. Some people love them, many others hate them, and most find them somewhat beneficial but would rather they could remain conscious sometimes and like, poop occasionally whilst taking them. On my unit, the majority of patients are on these medications, along with mood stabilisers, antidepressants and about a million drugs to counteract the side effects of the other drugs. I have a love/hate relationship with them; I've seen them work miracles, and I've seen them do fuck all, and I've seen them do some scary shit (see: oculogyric crisis). I've also seen the way Big Pharma manipulates their usage and distribution, and it's not good.

It's worth bearing in mind that people on certain sections (eg. s3, s37) of the Mental Health Act can be forced to take medications for their mental illness. There is no more horrible feeling than restraining someone and sticking a needle in them. Unless they have just broken a chair over your colleagues head, of course, in which case it is somewhat less horrible, although not very PC to say so, so nobody tell the NMC I said that.

Ok, that's enough for A. I've probably missed something obvious, but Mr Door will be home soon and I need to cook his tea.


EDIT: Suggested by Quacktitioner...

Airlock - A term that sounds really high tech, secure and reminds you a bit of 2001 the film until you realise it's just two doors with a gap inbetween.

Anyone anymore? :o)

EDIT 2: And finally, something serious and actually useful from There and Back :o)

Advocacy

Advocacy in all its forms seeks to ensure that people are able to speak out, to express their views and defend their rights. Historically, individuals experiencing mental ill health have often not had their opinions and ideas taken seriously and have not been enabled to make their own choices.Advocates work with service users, safeguarding their rights, empowering them to make informed choices about their care and treatment and take greater control of their own lives.This can include:

· providing support if service users wish to comment or complain about a service they are not happy with
· supporting mental health service users with Mental Health Act Tribunals
· attending Care Plan meetings or other meetings with service users
· assisting service users in accessing services.

Just one of those days

I foolishly agreed to do a weekday day shift yesterday. I usually avoid them like the plague because the lack of enhancements + the presence of management usually = not worth the hassle. As it was, I saw one manager for five minutes, so wasn't too bad on that front. Unfortunately, I got shifted to the womens ward; instead of the (comparatively) quiet shift I had been hoping for, I got a day of breaking up fights and verbal abuse. Oh, and special obs. Joy.

For those that don't know, so-called special obs (or enhanced, or constant obs) are when you observe a patient on a 1:1 (or sometimes 2:1, if it's a dangerous patient) basis. Our trust has 2 types; within eyesight, where you just have to be able to see them at all times, or within arms reach, where you have to be able to physically touch them if necessary. The second one is pretty rare, but yesterday I got to do eyesight obs for about 6 hours of my shift. Supposedly, you should only do them for an hour at a time, because of the intense nature of sitting with someone who may be actively trying to kill themselves. In the end, I was doing 2.5 hour stints because it was less stress than getting involved in the rest of the shit that was going on on the ward. The patient had self harmed quite badly a few days before (some idiot had given her a razor and she'd started hacking at tendons) but was now quite settled; she was being specialled because she had an anniversary coming up that might be a trigger. She spent most of the day in her room, and luckily slept in a position that pretty much precluded her being able to SI under the covers. Some patients have been known to SI very badly whilst being specialled; if the nurse lets them put their hands under the covers, sometimes the first they know of it is when the blood starts dripping off the sheets. But this girl was ok in that respect.

She got chatty on the afternoon, and decided she was going to try to shock me. Cue much swearing, discussion of sexual and criminal behaviour and general grossness. I'm pretty unshockable by now, which I guess is a good thing. She didn't get a reaction anyway, although I felt like I needed to wash my brain a bit when she finished.

In between specialling, there was the delightful job of stopping the rest of the patients from killing each other. There is a certain subset of patients who are completely intolerant of their fellow patients illnesses; even though they themselves are ill, and behave inappropriately on occasion, as soon as they see another patient doing so they turn on them. They either can't or won't try to understand or empathise. This ward is basically full of patients like this, who hate each other, and meal times were like being in a school yard with all the bickering and arguments and threats to life and limb. Frankly, I wanted to bang their bloody heads together. One nurse did have the bright idea of getting them to stop fighting by giving them a common enemy; us. So we had a few minutes of getting ranted at by everyone before they turned on each other again, but I'm used to that.

The highlight of the day was being called a fucking cunt by a starey-eyed, screaming banshee of a woman whom I had the audacity to ask to stop shouting abuse at another patient.

And people wonder why I prefer to work nights; the patients are all asleep and I get paid nearly 50% more for it.

*Sigh.* I do actually like talking to patients, it's the whole point of the job, after all. But sometimes you just have one of those days that makes you think, what the fuck am I doing?