Back in 1980 when (due to a clerical error!) I accidentally ended up working in a psychiatric hospital, I was, like most newbies, nervous and very green behind the ears. I landed a job as a nursing assistant in a “rehab” ward. “Rehab” was of course a euphemism for “abandon all hope”. The ward I landed in was the end of the line in a chain of rehab wards. The chain started off with “acute rehab” where your 6 weeks to 6 months revolving door punters were shunted in and out. In the middle link of the rehab chain were the 30-60 year olds who had not been cured and had failed to rejoin society despite “acute rehab” and were now permanent (but accepted) residents in a colourful and fairly lively community where the unexpected often happened and a cigarette could buy you anything. I was however, inducted into the elephant’s graveyard at the very bottom end of this chain, “the departure lounge”. A place for the elderly, institutionalized, functionally ill to sit in a circle and finally get to smoke their cigarettes in peace while awaiting the undertaker. Many of these folks had spent all their adult lives in the bin, seen cultures, modes of treatment and various regimes come and go (both inside and outside the grounds).
The “departure lounge” was not just an elephant’s graveyard for patients, it also performed the same function for staff. It was staffed mainly by elderly “burnt-out” nurses who had been dumped there by a new regime and left to get on with it. Perhaps the nursing admin of the day viewed them as embarrassing mistresses from previous sordid affairs, to be hidden away, while, like the patients, they withered, awaiting their final release. Some of the patients and staff had known each other for decades and had fell into fixed ways of coping with each other. I’m wandering away off topic here so will try and get back on line.
Looking back now, it seems crazy that a healthy young man was frightened of these frail elderly patients but frightened I was, after all they were officially “mad”, they might attack me at any moment. I was seriously impressed by the confidence of the older nurses, they showed no fear of the homicidal maniacs. I wanted to be confident and competent like them. Having no benchmarks for caring for the mentally ill, all I could do was follow the example of the professionals (if ever a line sounded like a defence plea from the guilty then that was it!). I’m not going to say it was all bad because it wasn’t. In fact, what went on was perhaps outdated but it was all well meant and for the most part quite touching and kind.
The ward was run as a therapeutic community (interpret that with a similar pinch of salt used with the word rehab) and I was told the patients had to be encouraged to participate in this community or they would withdraw into their own little disconnected worlds. All very admirable you might think. I guess it all depends on how you define “encourage” and where you draw the line between encouraging and bullying. Following examples set by staff, I’m pretty sure I sometimes bullied patients, occasionally shouting at them to “encourage” them to participate. I’m sure my behaviour was akin to that of some dreadful old style school PE teacher. I was told that if “they” didn’t respond when you spoke to them, you had to shout or they would just ignore whippersnappers like me. Similar encouragement was used to get patients up in the mornings. Worst of all was “seeing to their personal hygiene”. Fortunately/Unfortunately, most of these folks were very subservient but I remember one guy (an informal patient) in particular who absolutely hated having a bath. Once a week he was carried kicking and screaming, dunked in a bath and washed, totally against his will. The only questions asked by nurses (including myself) was “top and tail” or “a leg and a wing”. One of the saddest things in retrospect was that very few patients had any personal belongings. There were no personal clothes, just ward stock. Although you soon got familiar with the ward clothes and remembered that the green tweed trousers fitted Big Jimmy, most of the morning was often spent trying to find clothes to fit the patients. Quite apart from the lack of dignity, identity, etc, imagine not even having your own pants and everybody wearing the same ones, absolute yeuch! I still find it hard to believe that I didn’t find this appalling at the time and just merrily accepted it as the way it was. Was that really me?
The model of care could probably best be described as patriarchal containment. Patients’ rights and their ability to consent and make decisions was regarded as extremely limited. They could pick whether they wanted beef or chicken for dinner but that was about it. They were cared for on a daily basis whether they liked it or not. And I participated fully in this.
I had been honing my skills as a junior SS officer for a couple of months when a student nurse came to the ward on placement. I was immediately bowled over by her different approach, she displayed profound kindness and sensitivity towards all the patients. She had a quiet, caring, supportive manner and although she didn’t always manage to get them to wash, she certainly made them smile. I immediately knew she was doing the right thing and that I had found a role model to emulate. I wanted to learn more about doing the right thing so applied to do my RMN training. I was accepted on the condition that I survived three months in “the bowels”, a notorious psychogeriatric ward.
It was called “the bowels” for two reasons. Firstly and most obviously because of the smell which hit you once you had contorted and gained entry by mastering the three door handles that kept the unit officially “unlocked”. The second reason it was called “the bowels” was because it was on the lower floor/basement of a wing situated on a very steep hillside. The “dormitory” which was a huge mixed sex bedroom had open views (hidden behind closed curtains of course), one room looked onto a 10 foot brick wall, while the rest of the unit was underground! It felt like being in a nuclear submarine. “The bowels” was the land of the geriatric (or Buxton) chair where restless people with dementia were tipped back to almost the horizontal and then spent all day banging the table, shouting and trying to escape from underneath their dining (read that as restraining) table. Tables (screws long since worn out through constant pulling and twisting) were secured by tying them on with crepe bandages. Patients slid down until only their chin held them in place. Nurses prevented daily asphyxiations by lifting them back up using the old leg and a wing technique (wet patients usually slid easier). Incontinence was a huge, never-ending and unbeatable foe in those days before the invention of Tena pads and slips. Subsequently there was very frequent toileting, often accompanied by terrified screaming, spitting and violence as clothes were hurriedly removed from confused and anxious patients. It must have been a dreadful existence for people with dementia and it was certainly a very stressful, thankless task of hard labour for the nurses (most of whom also looked very old for their years). It was rumoured that the night staff used the tails of the split back nighties to tie patients onto commodes when seeing to them during the night so that they could safely look after all 36 without any fractures being sustained.
Despite these awful conditions nobody got upset, nobody complained, nobody protested. This was not in the Victorian era, nor in war torn Nazi Germany or in the third world. This was here in the UK only twenty odd years ago. It may all sound terrible today but hey… “we were only following orders”.
Thanks for this post. A salutary reminder of how things used to be “back in the day”. I’ve heard similar stories from older RMNs – particularly about the stench of urine and faeces that used to permeate the psychogeriatric wards.
Your point about how these wards used to be a dumping ground for burnt-out incompetent nurses is an interesting one. My experience is that elderly wards still have some burnt-out no-hopers working there, but at the same time some of the finest RMNs I’ve ever worked with have been in dementia services. There doesn’t seem to be an in-between.
I completed my training in 2006 and in reading your post am unfortunately reminded of one of my ‘rehab’ placements (a small community home filled with people who had nowhere to go when the old asylum shut and were largely unable to return to community living due to the effects of institutionalisation).
On my first day I was greeted with two ‘burnt out’ nursing assistants screeching and hauling great handfuls of linen covered in blood from a patients bedroom onto the landing outside the nursing office. My initial reaction was that there had been some sort of massacre in the room, in fact the patient had neglected to use a sanitary towel during the night! Instead of addressing this issue in a sensitive manner these two staff felt it completely acceptable to advertise the fact to all.
Following this ‘breakfast time’ commenced which entailed the staff cooking themselves bacon sandwiches and hollering at any patient who dare enter the kitchen that this was ‘staff breakfast time’! Thank goodness a new manager had just come into post and by the end of the eight weeks had sorted out this abusive behaviour making my placement a very interesting insight into the implementation of change.
It did however highlight that in some of the dark corners of ‘rehab’ that have been largely left to their own devices some of the more dodgy ‘old school’ (sorry OSB) ways of working still linger on.