Saturday, 13 February 2010

Tackling The Mental Health Minefield Part 9 - The Nurses: Carers Or Prison Warders

(This post continues the story from Tackling The Mental Health Minefield Part 8 - OT? What OT?)

The people that patients have most interaction with while in hospital (apart from other patients) are the nurses. Although in these days of tight budgets the number of nurses on a ward is supplemented with the addition of unqualified staff and in the hospital that I was in these members of staff are known as Care Support Workers. When in an ordinary hospital you have a reasonable idea of who is staff (they wear a uniform) and who is a patient (they will generally be lying in a bed or wearing night clothes and a dressing gown. In a mental hospital it is often far more difficult to make the differentiation. The nurses don't wear uniform and the patients are usually wearing normal every day clothes.

The funny side of all this is that on more than one occasion I had both patients and staff speak to me thinking that I was a member of staff. I'm not sure why this should have happened; whether it was because I didn't look like a mental patient or because I looked as though I knew what I was doing, I'm not sure.

This post will be broken down into several sections and cover areas and say things that I am sure may be upsetting to some mental nurses. Any criticisms that I make are directed at the staff that I had interaction with during my stay in hospital and not to all mental nurses, so those professionals who read this please do not think too harshly of me for I am only reporting it as it was during my incarceration.

Named Nurses

Okay, we all know about named nurses. They are the one's who you can go to when you have problems and they are supposed to be your first port of call if you are having problems. That's fine if the nurses work some sort of regular shifts, but the nurses on the two wards that I was on seemed to work a fair amount of double shifts so you would see a nurse for a couple of days and then you might well not see them again during your stay on the ward. On the first ward I was on I was assigned a male nurse 'M' as my named nurse and I can report that at no time while I was on the ward, and he worked at least four of the eight days that I was on the ward, did he ever introduce himself to me or even talk to me. This defeats the object of having a named nurse, doesn't it?

On the second ward that I was on, my named nurse introduced herself to me on my second day on the ward, and then told me that she was going to be off for the next week. At no time during my three weeks on the ward did she make any effort to actually talk to me, and I am afraid that I have to say that she was the nurse who ran around like a headless chicken when I had my angina attack and wouldn't give me my GTN spray until she had found a second nurse to be with her while she opened the drug trolley.

As far as I can see the named nurse is a good idea in theory but it is rarely going to work properly because of shift patterns and the fact that the nurses rarely seem to leave the office.

The Office

From reading other blogs it is apparent that those of us who have been inpatients in a mental hospital all have the same opinion that the nurses spend far too much time in the office writing reports about the patients and nowhere near enough time actually interacting with the patients that they are writing reports on.

My first ward had a large office that was big enough for most of the nurses and care support workers to spend much of their shift in there. Sometimes the only member of staff who was not in the office was the one going round doing the hourly checks on where the patients were. the office on the second ward I was on wasn't large enough to swing a cat in and yet at most times of the day all the members of staff would be locked away in there except for the person going round the ward doing the hourly checks and the person sat outside the office keeping an eye on one of the patients, J.

J would walk up and down the main corridor of the ward for hours. She wasn't allowed any leave and rarely had visitors; the only time that she left the ward was to go to the meeting room where ward rounds were held. J also ate constantly if she could get her hands on food. Any food. She would go into the kitchen area and take handfuls of sugar and eat it. The result was that the staff stopped putting sugar out for us to use in hot drinks except in sachets. this didn't stop J, because she would just take a handful of them and eat the sugar, throwing the packets down wherever she happened to be at the time. She would also take the little containers of jam, marmalade and honey that we had at breakfast and supper by the handful and lick the contents out of the containers while walking up and down the corridor. All that the staff ever did was to tell her not to eat the sugar or the jam. She was not told to pick up the rubbish that she would leave lying around. It was the patients who decided that something needed to be done because we were sick of finding half-eaten containers of jam in the box in which the jam and butter were stored. By watching J, and every time she threw rubbish on the floor or put empty containers anywhere other than in the bin, one of the patients would tell her to pick up the rubbish and put it in the bin, likewise with the jam containers. After a week or so of this J started to put the rubbish in the bin automatically. Because the staff spoke to her in such weak tones, and the patients used authoritative voices as one would with a naughty child, so J learnt what was acceptable and what was not. If the member of staff who was assigned to watch her walk up and down the corridor for hours during the day had been used to engage her in some meaningful activity then I am sure that it would not have been long before it was no longer necessary to have a member of staff monitoring her all the time.

My question is, why do so many of the staff need to spend so much time in the office ostensibly writing reports on the patients? Because they spend so much time in there and so little time with the patients, anything that they write must be a fairytale anyway.

Protected Time

Protected times are something that seem to exist in all mental hospitals. They are useful because it means that certain things can be done on the ward without unnecessary people (and that does include visitors) being around. This means that mealtimes were protected times and each morning the hour between 11am and midday, was protected time. There were notices to this effect at the entrance to the wards and they made it quite clear that the hour of protected time before lunch was for the nurses and patients to interact.

The problem was that this never seemed to happen. This hour each morning when nothing was happening (no OT, no psychotherapy group, nobody allowed to use the gym) was, except for Monday mornings when a ward meeting was held, were just an excuse for all the staff to congregate in the office.

It was near the end of my stay in the hospital that I was asked to take part in the group psychology session. Four patients, including myself, one of the nurses, the ward psychologist (who is the psychologist that I see for psychotherapy now) and his trainee were sat in a room with the aim of doing some talking. The other three patients had been present at the group session the previous week so the had done all the introductory stuff and their input was to talk about how things had been since that last session. I, however, was new to this and I was expected to do a bit more talking, which somewhat surprisingly I did, about why I was in hospital and about how long I had suffered from depression. After having done this, the psychologist asked if there was anything else that we wanted to talk about, or to raise for the group to discuss.

I'm not sure how it happened because I am not naturally someone who would speak up in these circumstances, but I found myself talking about how little interaction had taken place between me and the nurses. I said that I had been in hospital for nearly a month and during that time only two nurses had taken the time to actually sit down and talk with me, to find out whether there was anything that they could do for me, and to generally put me at my ease. I questioned the point of the hour of protected time in the morning if the nurses were just going to sit in the office as they did for the rest of the day and ignore the patients. At this point, the other patients at the session also joined in and made similar comments all of which left the nurse, who had decided to come to the session to see what went on, somewhat red-faced.

I think that what I said struck home because the next day on the stroke of 11am, the office emptied and the nurses went in search of a patient with whom they could interact. This practice continued after I had left the ward, but I would question whether they have gone back to their bad habits now we are a few more months down the line.


It is important that anyone reading this should recognize that the views expressed here are my own based on my experience of a month in a mental hospital. I don't wish to offend anyone but I am telling it how it was in the hospital that I was in; I am sure that things are not as bad everywhere, and it is possible that there may be some hospitals that are even worse.

I have been on surgical wards with as many patients as there were in the wards in the mental hospital that I was in, which operated with a similar number of nurses, where the patients were not as mobile as they tend to be in a mental hospital, and yet where I would have regular periods of interaction with the nurses. And on the surgical ward the nurses had to do proper nursing things like changing dressings and helping the patients with their ablutions. So why do mental nurses consistently fail to interact with the patients?

One thing that concerned me greatly was the number of coloured nurses on the ward and the difference in their attitudes to the coloured patients and those who were white. It is bad enough to suffer discrimination because you have a mental illness, it is appalling when the discrimination is actually being shown by the people who are supposed to be helping you, not only because you have a mental illness but also because you are white. Another bad practice that was common among a particular group of nurses was their having conversations in front of the patients in a foreign language. The Nigerian staff were the offenders here, breaking Mental Health Trust policy by so doing.

I found, and have mentioned this in various of the posts in this series, that the nurses seemed to have little respect for the consultant psychiatrists and had no qualms about contradicting their (the consultant's) decisions or arguing with the consultants over what had been said. To have done this is bad enough, to have done it in front of a patient is unprofessional.

So all in all, I do not have a high opinion of the mental nurses (and care support workers) that I came in contact with. Yes, there were a few very good nurses and I was thankful when they were on duty, but the majority of them left a lot to be desired. I was left with the feeling of being discriminated against because I was not schizophrenic or a drug addict, because I was white, and as another patient said of me, because I was probably more intelligent than most of them.

To be continued.


Danni said...

I guess I'm lucky, in that the ward I've been on several times is pretty good these days, with most of the nurses spending time in one of the television rooms rather than the staff room, so there was always someone to talk to. I was mistaken for staff more than once, which amuses me because I'm very "odd" in appearance, especially when I'm unwell.

The ward wasn't perfect, but over the years it has improved, and there was daily OT and stuff available. It's a shame that other wards appear to be even worse (including in the same unit, according to some of the patients). I was last admitted a year ago, and though it's not nice, it wasn't terrible either.

Anonymous said...

i usually find your posts very interesting and look forward to reading them. however i have to say that i found there were aspects of your last post that i found rather insulting. Firstly, the treatment of the patient named "J". The comment "the patients used authoritative voices as one would with a naughty child, so J learnt what was acceptable and what was not" made me cringe. Surely it is not for the patients to choose to treat another patient as a "naughty child", no matter how irritating you found her behviour to be. Concerns about the effect it was having on other individual patients should have been addressed with nursing staff / the ward manager. Secondly, your comments regarding "coloured" staff.Not only is this term offensive but it is also used as a derogitory sweeping statement about all such staff.
I hope that by drawing your attention to these comments i have not upset you. I did debate whether to leave a comment but decided that by writing a blog, you are opening up the arena for debate. Having spent a year on an NHS mental health ward i too am aware of some appaling practise by a minority of nurses but choose to give the majority the benefit of doubt and believe that they are simply trying to do the best they can with the little resources and great demands on their time that they have.

madsadgirl said...


I take on board what you are saying but you are perhaps getting the wrong end of the stick here. The problems with J were that both patients and staff had concerns about her behaviour, but the staff seemed incapable of doing anything about it, while the patients, who were perhaps the ones who suffered most from her behaviour, did something and it was effective. I have to say that I have seen J in the last couple of weeks (she is still in hospital) and she still throws things on the ground, but if you suggest that she picks it up and puts it in the bin, she will. This is not a naughty child, but a young woman of 23 who is almost feral in some of her behaviour which I have no doubt could be improved if only the staff stopped sitting on their backsides and actually did some work with her.

On the subject of the coloured nurses, I stand by what I said. There were significant differences in the way that the white patients (who actually represented the majority on the ward most of the time) were treated by these nurses than the way that they treated the coloured patients. Before you try to suggest that I am a racist, I most definitely am not. However, it is not unknown for there to be significant racism shown against white people in large parts of London. There were only two coloured nurses who even came close to the standard of most of the white nurses that were on the wards that I was on. And the comment made by one of the patients about my being more intelligent than the nurses and that being one of the reasons that they were discriminatory towards me was actually made by a male West Indian schizophrenic who was one of the nicest people that I met while in hospital and who was very caring and looked after me when I was having a couple of very low periods.

As I said in the post, it was my view of what happened to me on the wards that I was on and I knew that the post would undoubtedly upset some but I wrote anyway.

Anonymous said...

Well as you say, we are all entitled to our opinions and your post clearly decribes your own personal veiw of your time on a psychiatric ward. I would encourage you however to reflect on some of the language you have chosen to use and perhaps channel some of your unhappiness with the service you recieved through the proper channels of complaint. As your experience has so obviously upset you then i can only suggest that this would be ther best way of affecting permanent change.

Anonymous said...

from my perspective, there are some really valid points in this post.
after about a week on my first placement (adult acute admissions)i was surprised that there didnt seem to be a great deal of patient-staff interaction.
I know there is a lot of paperwork involved in nursing, but I thought then, and I still think now that there is opportunity for this contact that isn't used.

Also, in 7 months, I will be a qualified nurse and I think that posts such as these will shape my practice.

Susie said...

It almost sounds like we have been in the same hospital, although i have been assured by my psych that in the 3 and a half years since i was there last, a lot has changed and improved.

Forgive me but i'll reserve my judgement on that one until i am forced to experience it again (which i truely hope i never will!)

I hope many more students can read posts like this, and learn from our experiences.

take care.


I tended to find there were a handful who genuinely cared and wanted to help - that would be those who broke the rules and gave me the odd hug now and again (or whenever i needed it, and after being there 6 months on one occassion......) However they were always the people who had no power within the nursing system - 2 wonderful HCAs who of course would not be listened to by those higher up as they were only HCAs. Or on another occassion there was a charge nurse who would dearly have loved to help me with my eating issues, having worked in that area before, but as she was not on my psychs team, she could do nothing but make suggestions to the charge nurse on my team. Thus my eating issue was left untouched and resulted in full blown anorexia and malnutrition when i left the hospital.

But i think on of the most memorable comments came from a student who a was on constant obs with me, a fellow student asked her if she was going with them somewhere or another. her reply (clearly within earshot)? "When i've finished babysitting..." Fortunately my tears were noticed by the lovely charge nurse mentioned above, and she had words which resulted in the student being ultra nice to me from then on.

The best interaction i had was on the PICU, but with a 10 bed ward and about 5 staff, constant supervision, a smaller one room sitting area - i would hope so too! Just a shame that i wasn't well enough for any interaction for most of the time, and of course when i was, i was moved back up to the acute ward.

Zarathustra said...

My own experience is that paperwork can be something of an excuse. When nurses say they're too deluged with admin to get out on to ward floor, I generally find myself asking them why it is that they've been sitting in the office talking about Strictly Come Dancing for the last half hour.

Also, the paperwork is nearly all done by the staff nurses, so even if the staff nurses are stuck with a big pile of forms, there's no excuse for the HCAs being in there with them.

Whether or not nurses on a psych ward are hanging around the office or getting out on the ward floor talking to people often has more to do with the culture of that particular ward, and often with the personality of the ward manager and whoever's coordinating the shift at any one particular time.

Physical design of the building comes into it too. If the ward office is large and comfortable then nurses will start congregating in it. If it's small and uncomfortable then they're more likely to avoid the office and get out on the ward floor. A while back I was talking to a ward manager who was involved in the design of a new ward. He went to great lengths to ensure the office was as poky and unpleasant as possible.

Anonymous said...

My named nurse was K and she never officially introduced herself to me either, in my three week stay on the ward I only spoke to two nurses. One was on my first night J who I think took me into a side office to eliminate any fears I had about being admitted, by this point it was around 10pm at night, I was exhausted and still waiting officially for the doctor to do what he needed to do before I could go to bed!

The second I spoke to was B when I was getting distressed after not sleeping about 4 nights in a row and threatening to leave! I spent most of the time speaking with the HCA or the 1st year student nurses on the placements, one who I of course had the immense pleasure of seeing again the other week at the university when I went for my own interview! :)

I pretty much recall the same experience, I seem to recall most of the staff spending their time sitting in the office and when they seemed to be in dining area they were reading the papers at the table rather that spending time with the patients. I really hope that when I start my own training I’ll remember from my own experiences that if I have ‘spare time’ to be reading magazines it would be spent talking to a patient who might actually appreciate having someone to talk to.

The way you refer to the patient J reminds me of a similar patient we had who obviously had clear mental health problems and learning disabilities. She was a long term patients with most definitely a mood disorder of some kind but how the staff acted to her behaviour to me was really neglectful. She would dress up provocatively and attempt to sexually get involved with other patients – at one point she developed her love for me! The she would become aggressive and start to throw things around, but the staff would just stand around and let her get on with it, when she was out of the room they would laugh and joke about it as though it was funny when to me it was obvious she was ill, the last thing staff on the ward should have been doing was laughing about her.

Sadly I witnessed this all to similar happening on wards that are not mental health wards, staff who prefer to sit in the office doing admin rather than attending to the patients needs. I recall one incident where a patient wanted to use a commode in the middle of the night because they couldn’t get to the toilet on their own. The nurse on duty refused and said there was none on the ward and didn’t even assist the patient to the toilet. Eventually they assisted them, left them in a cold toilet without a dressing gown, where they fell to the floor and were there for over an hour and couldn’t reach the emergency pull cord to get help. More the likely she wanted to continue reading her weekly copy of ‘Hello’ than help the patient onto a commode, ironically there are always about 5 commodes on this particular ward.

As for how you have worded your post, don’t feel the need to change anything. Your opinion is your opinion. The world and especially this country is all to PC these days, it should not matter what words you choose, often the older generation (sorry if I cause offence) use different terms than the younger generation. For instance the nurse who refused to provide the commode for the lady in the night was African, Nigerian, or some other ethnic minority I cannot be sure for certain I was not there at the time, but she was pointed out to me two days later when she was on a day shift. However equally I have witnessed poor care for white nurses on wards as well. In fact thinking back to the care I witnessed this time last year it appals me that I let the staff who inflicted such harm on someone I loved and that I allowed it to go on as long as I did. I feel guilty every time I think that I didn’t step in and do something about it.

Lily said...

I know I've heard these stories before but it still shocks me. My pet hate is when I see staff in the hospital speaking any other language than English.

This isn't some kind of jealousy as my parents aren't English and from a young age at home I spoke a different language at times. I just think it's so rude.

It's even worse in the context of mental health where patients may feel paranoid already or just need a little more comforting.

Having been placed in the same hospital trust that Madsadgirl spent her stay in hospital with, I can completely back up what she said.

It might be unPC but in this trust it's the african nurses who speak to each other in different languages. In a different trust I was on placement in it was eastern european HCAs who were always being told off for it. This isn't anything racist towards these groups of people, I'm sure in a different country the English staff talk to each other in English, but it is something people should be aware of without taking offence so they can change their behaviours. Noone minds you talking in your mother tongue on you breaks in the staff room, but in front of patients it's only polite to speak in English, as the hospital trust rules clearly state.

I've been really interested to read other people's similar experiences in the comments. :)

Anonymous said...

Even though there is an ocean between us we must have been in the same hospital...

I would be hard-pressed to choose my favorite staff experience from this past summer but it would be a toss up between the staff member who refused to open a bathroom for an incontinent patient because "you go too much", the med nurse who did not know that fluoxetine=prozac, and the night the nurses absconded with the patient-only boombox and took it back to the office and threw themselves party (no lie, patients were at the desk answering the phones).

One of the nurses at this place actually did not speak English. I do not mean their accent was heavy. I mean they did not speak the language. Another routinely asked patients out on dates. Another took apparent pleasure in denying patients their PRN pain and/or anxiety meds FOR HOURS. One PROMISED a patient that she would fax documents to court for him so he'd be excused from appearing and then just didn't do it (meaning he faced an arrest warrant upon discharge from the hospital). One very religious nurse went through all the patient DVDs and videos one night and removed all that he thought were "inappropriate"; a unit full of adults was left with two disney movies to watch.

I could go on, but you get the point. When I got out I wrote about all this just to get it off my chest. I helped a surprising amount, so I'm glad to see you are saying what you need to say. I enjoy your columns a lot.

DeeDee Ramona said...

I've learned to be the demanding annoying patient. If I want to talk to a nurse, I bang on the office door until they have to pay attention, and so on. I'm not suggesting you should have done the same - I am lucky that both depression and mania make me bolshie as HELL so I am able to do this.

Ultimately, the squeaky wheel gets the grease.

Anonymous said...

Where I was Dee, if you banged on the door, you'd find yourself in seclusion.

cb said...

Thanks for posting this. I think it's very important that your voice is heard.

DeeDee Ramona said...

On the subject of languages, I remember once turning the tables on the doc that way - I and my mum were in talking to the psychiatrist and he was being a pain in the arse so my mum and I discussed in Irish Gaelic how best to get him to see things our way!

I think he found these 2 ladies speaking a language he had no hope of understanding a bit off-putting...'d be amazed how many people on the Tube can speak it though!

Anonymous said...

I guess I was lucky in that on my ward, there always seemed to be someone around to talk to, although this may have been due to the fact that I spent half of my time on close observation with a nurse following me everywhere, they didn't really have any choice but to talk to me!

I found that the HCA's were actually a lot more helpful and considerate than the nurses, and that a quick word with the consultant if you were unhappy with any off the staff was a sure fire way to get them to change their behaviour!

I did at one point have to spend the night on the downstairs ward, though, and that was more like your experience - I thought there would be MORE staff interaction because their office was behind a glass wall so they could see & talk to you whenever you walked past, but this was not the case. At one point, when I needed to see a doctor, I had to wait about half an hour for someone to come out from behind that glass screen and do something about it.