Wednesday 13 February 2008


My junior doctor started last week and, today, starts on his placement.

What's he been up to over the last 7 days, then? He's been indoctrinated or inducted or instructed or something in to the Trust. Finally he's arrived, bright eyed and bushy tailed, ready to learn something about mental health work with older adults.

What did he do yesterday? Why, he did his Managing Violence and Aggression (MVA) training. What was this? He said it was mostly about running away but then there was lots of tustling around with holds and stuff that he's already forgotten as it all got quite confusing.

Medics tend to have a more cavalier attitude to this since, in truth, it's not common for patients to assult us. Fair or not, the last 2 occasions I know of when a patient seriously assaulted a psychiatrist they both ended up detained in a high security forensic hospital for the long haul . . .

. . . it's rather the opposite with in-patient nursing colleagues, sadly, since they are assaulted more often. Our incident forms show it's rare for community nurses in our corner to be assaulted. In-patient staff are open to assault when delivering personal care. Although not acceptable it is understandable - helping a confused patient undress for a bath when the patient can't appreciate why amounts to them experiencing someone tearing their clothes off them, thus they react to fend this off. Good dementia care means repeated reality orientation (speaking to the patient throughout the process rather than just explaining before care's undertaken and assuming 90 seconds later they're still retaining that) and de-escalation of risk.

So in fairness a good organic assessment ward for older adults will have patients who can be challenging to nurse if it's not care planned for and resourced adequately. I'd see this as key - high staffing levels of qualified mental health nurses are key to managing Behavioural and Psychological Symptoms of Dementia (BPSD) and reducing risk to staff and other patients.

At present none of my in-patients are on an antipsychotic at all, not even prn. It's been tried but hasn't been successful so was stopped. The management is wholly about skilled nursing care. In the last year, several patients have been admitted from EMI nursing homes as unmanageable through violence. Medication changes were tried in the community. All have been placed from the ward back into the community after admission and receipt of this skilled nursing care.

For nurses to generate stability and reduce risk without use of oodles of medication, in my corner, necessitates good staffing ratios and the right environment. Without this, the evidence shows nurses get battered.

It's frustrating. Done well, with lots of staff, units are successful with excellent patient care, turning folk from unsettled/unmanageable to content/manageable. Done badly, with poor staffing levels, units are unsuccessful, don't effect change, staff turnover is high and assaults are commonplace.

Now if only I could persuade the local acute Trust to buy in to this, so their staff aren't getting battered all the time whilst trying to care for delirious and demented folk with medical needs . . .


ditzydoctor said...

i can't imagine life without nurses. many's the time they've called up my doctor (whatever level he/she is!) and saved their arses by telling them something they've forgotten!

Disillusioned said...

Good post. Good staffing is the key to good treatment, in most (if not all) areas of mental health, I believe. Think how many problems could be prevented by good staffing levels - enough staff to talk and listen to patients, to spend time with them to prevent deterioration and / or a crisis. Like you say, "if only..."

Spirit of 1976 said...

Indeed, Disillusioned. I think levels of nurse staffing are absolutely crucial in maintaining good quality care. Which is why we keep banging on about nurse-patient ratios over on Mental Nurse.

Disillusioned said...

I wouldn't disagree with you for a moment, Z. Levels of provision have been one of the problems I have experienced. (The other focuses on narrow minded thinking and discrimination, but that's another story!)

Anonymous said...

I think there's more to the quality of care than nursing ratios. Shrink writes more about the quality of the care rather than the numbers.
I'm actually more interested in increasing the quality of nursing staff rather than quantity - if you have 4 shit nurses and then go get 4 more - you have 8 nurses who can give out shit care faster. Ratios, in this instance, makes no difference. Of course, the 'chance' factor is that 2 of those 4 extras are actually very good; but 2 will still be part of the problem. Quality before quantity

Fiona Marcella said...

Having been assaulted more than once (a lot more than once!) by a psychiatric patient (my daughter) I'd say that levels of violence definitely do reflect both quantity and quality of care - I was a crap carer with no training and little aptitude, and I was on my own. But that's what community care can boil down to.
I have noticed in my other life working with out of hours doctors and noctors that the noctors make all sorts of efforts to ensure their safety (working in curtained rooms rather than ones sealed with doors, sitting next to the exit) the doctors (GPs) happily allow themselves to be barricaded in with the patient. There have never been any real "incidents" and patients usually go away from their consultation resigned to soldier on if not hugely relieved and reassured.

Disillusioned said...

I agree that quality is vital too - but you have to have the quantity in order to provide the quality. I guess it's some kind of equation: quantity + skill + willingness = quality nursing.

Cockroach Catcher said...

Sometimes other factors come into play. Withdrawal of privileges (such as cigarettes, soft and hard drugs, visiting and so on) can provoke violence as seen in some prison riots in the past. Sometimes these things are too politicised to achieve a different end. Nowadays many staff members do not have the skill level of those who used to serve in the older style bigger mental hospitals and any show of inexperience or fear on their part will simply invite attacks. People in certain situations revert to animal behaviour that sometimes surprises even the most experienced.

The Cockroach Catcher

Calavera said...

Maybe I missed this, but what does prn mean?

It's sad that nurses have to deal with abuse from patients. You mentioned before how key they were in your department in ongoing patient care.


Anonymous said...

prn = pro re nata - as necessary/required (medication)

To respond to Am Zhang Kipperbang:
"Nowadays many staff members do not have the skill level of those who used to serve in the older style bigger mental hospitals and any show of inexperience or fear on their part will simply invite attacks"

I'd agree that many of the old style 'nursing management strategies' have gone - and fo0r bloody good reason. "showing fear" is the mental health equivalent of - show them the stick - and it just isn't meant to be that way.
I'm also intrigues why this theme was brought into a blog on elderly nursing home care... have you not ready the national strategy for introducing "Tazar use in EMI"?

The Shrink said...

Tainted Halo, quality care is the key.

With inadequate staffing levels you can not have quality care.

With adequate staffing levels you may or may not have quality care. But at least one obstacle that absolutely prevents it has been removed.