ABC: D to F

D to F in my somewhat tongue-in-cheek guide to secure MH services…

Originally posted here.

D is for….

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

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)

 

E is for…

 

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.

 

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.

God, I can’t half waffle…

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