A few months ago I was working a night shift and I was allocated the care of an 11 year old boy who was currently in A&E awaiting the arrival of an RMN. The reason for admission was that he was suicidal and had made attempts on his life that day.
We didn't really feel that our ward was the most appropriate place for this young man, usually we try to put these children into cubicles for some privacy and peace and quiet, unforutnatly the only cubicles on our ward are too far away from the nurses station and out of sight to be able to closely observe him. We decided to allocate him in our second bay in a bed opposite the nurses station. Not ideal as there were 4 other young children in that bay.
I tried to ready the bed space removing an items which could be used to harm himself, not an easy talk considering every bed space has a suction unit with lengths of plastic tubing and the child next door was an on IV infusion with long power cables coming out of his machine and plugging into the socket right next to this child's bed. I made the space as safe as possible, got a not-too-comfy chair for the RMN, pulled back the curtains and waited for the call.
When I got downstairs to the A&E department I was told that he was with his mother and the RMN in a room just out in the corridor. Then ursing staff weren't able to give me a very good history as he had been seen by the on-call psychiatry team almost immediately and they had had little to do with him. The story was that the boy had twice that day tried to run out in front of a car but had been stopped on both occasions. His mother had brought him into hospital because she was concnered abotu this and his recent behaviour. He has recently lsot a friend, and relative a little while ago and he dad was currently in prison.
I took the paperwork and joined the young man, his mother and RMN in the side room. I introduced myself and explained I was there to take him up to the ward. At this point he completely refused to come with me, said he wanted to go home, that he didn't need to come into hospital, that his mother had tricked him there.
So began an hour of negotiation. I explained to him that he wasn't in any trouble, but that his mum had been worried about him and that's why she had brought him in, and that we just wanted to keep an eye on him overnight.
He told me that he was fine, there was nothing wrong and that he didn't need to be there. Now his mother joined in, at times being constructive and helpful and at other times frustration getting the better of her and she would lose her temper with him.
She tried being the authorative parent, saying she had made the decision as his parent that he needed to be there and he would do as he was told. She tried explaining that she was concerned about him and about what he had done today. She got angry and told him how he was upsetting her.
I watched a lot of this, intervened when I felt it would be helpful, tried to placate mum when she got angry. Simon (not his real name) became increasingly frustrated, saying that he wouldn't do it again, that he didn't need to be here, said no one would believe him when he said he was okay. He slammed his fists into his lap, got up and banged his fists against the wall then sat in the corner of the room.
I tried to explain that it wasn't that we didn't believe him or thought he was lying, but because of what happened to day it was my job to make sure that he was okay, and that whilst he might feel okay at the moment and feeling one particular way sometimes this can change and we needed to make sure he was safe overnight.
Between angry outbursts and protestation he would become withdrawn and tearful refusing to make eyecontact with anyone in the room and not registering when someone spoke to him.
Every now and then the RMN would chime in with helpful comments such as "You're wasting time down here" and an inappropriate moments (e.g. mid conversation) "Let's go up to bed". I did my best to ignore this and manage to refrain from telling her to be quiet or giving her the "evil eye".
Simon was convinced that his uncle was going to come in and take him away, he kept telling us this and his mother explained that this wasn't the case and that his uncle would say he had to stay.
Almost an hour after arriving in the department I left the room to give him a few moments with his family (oh an the lovely RMN) whilst I had a discussion with the A&E nursing staff.
"You're still here?!"
"Yes, and I can see what you mean about the RMN" (They earler had described her a bit "odd")
"You know she came out of the room before you arrived asking for us to sedate him as he was upset?"
"I'd probably need sedating if I had her looking after me."
Although the child was upset, it was "normal" upset in my eyes, I would probably feel exactly the same way in his situation. He wasn't violent or aggressive, jsut very frustrated and did calm down. I felt that I had been making progress with him and that he was becoming more resigned to being admitted, however I now didn't feel the bedspace we'd allocated him was appropriate and that he needed a more private space.
We contacted the bed manager and reallocated him to a cubicle on our adolscent ward close to the nurses station. Although he was below the age the unit would usually accept we felt it would be better for him and they would be able to provide better care there.
I went back to explain to Simon and his family that he would be going to a different ward with a nice private room of his own where he could get a better night's sleep. His uncle had by now arrived and was whispering in his ear, he didn't stop when I entered the room or after I stood there for a few moment (which I found a little odd). I said goodbye to Simon without a glance or acknowledgement that I had spoken and hoped on my way upstairs that I hadn't traumatised the child too much.
He was admitted to the adolscent unit next door where I was told he had a good night's sleep, was seen by CAMHS the next morning and discharged. I don't know if he had any follow-up in the community.
6 comments:
Ok... now remember, you asked for me to be opinionated! So I will... :o)
I read some of the later comments in the previous post to this one also and thought better to repost them in here along with some other gibberish of my own.
"Z, regarding your last comment I totally agree! I think some people see it as easy money, especially at night (more money for less work)."
Now, having worked as an agency nurse myself for just over a year, I agree there are -some- like that. There are those who do and those who don't. I'm a -er.. I'm a good one. Honest.
Unfortunately, it is true there are a few lazy useless ones; I've booked them myself by mistake (only ever once tho).
However, the result is, those good agency nurses now all get treated like they're crap before they even walk in the door. A&E beg for an RMN to come cover specialist work that needs to be done - yet when they get there, they're treated like a leper. No one talks to them, no one is sociable and no one seems to realise that this person just cancelled all their plans to get their butt across town to help sort out your problems with you.
My experiences of being a RMN agency nurse (and not just working cover in general units) are not altogether pleasant either.
Firstly, a lone RMN specialling is like asking you to deal with an RTA (or MVA) on your way home from work. You are away from your 'tools' (pool table) and in a strange environment (still no pool table) and with people you've probably never worked with before (& probably can't play pool). RMN's have very little basic knowledge of general health care (compared to our general/adult nursing cousins) and are probably not much good at knowing what a pneumothorax is - but we can tell how good or bad it makes you feel for having one.
So when the RMN turns up, don't expect them to have any idea about that piece of tube or the meaning of some of those machines that go ping, and don't expect them to come in all full of gusto and confidence. They have no back up team or lines of communication - you are their only back up and it would be nice to have a little handover time to get to know you an d about the patient first too.
"We always make sure we don't put out too comfy a chair for them to sit on, otherwise we find them snoring when we go in to to do our obs!"
I could poke you with a stick. You're one of those that gave me a bad back from doing night shifts in a hard chair for 14 hours. When a patient sleeps, what does the RMN do? There's not even 4 hourly obs; you can only write about a night spent asleep in so many words and the whole bloody bay is dark so the patients can sleep. Personally, I used to slap myself at about 4am, repeatedly.
Another post tells (sorry, I forgot who posted):
"On the subject of RMNs watching over patients on non-psychiatric wards: I required medical treatment when I was an inpatient in the adolescent unit, and the nurses on the general ward were obviously not used to patients having a psychiatric nurse with them - they were scared of me, and got very upset whenever my RMN went to the loo and they had to watch me for a minute!"
Not only was I left in a hard chair for 14 hours, no one offered me a drink or showed me where the toilet was. No one came in and said; "You want to get a 5 minute break? I'll sit here for a bit" - I spent 14 hours sitting on my own, in darkness, in a hard chair, and when I dared to go for a toilet break the nurse came up to me and said "where are you going? you can't leave your special" - yet never once offered me a pee-break.
"(They earler had described her a bit "odd")"
So when your agency RMN walks in and sees "the hard chair" already in place for him/her, you can imagine what other joyous 'collegial care' s/he is looking forward to for the rest of the night.
Having said all that, doesn't mean your RMN was any good. Tho from what you say, it might not be she was all bad either. Sometimes us RMN's work in weird ways - asking him to relocate upstairs might mean that RMN has noticed how he is being agitated by mum and perhaps all the attention; removing that might help. Sedating him? Possibly she just wants a quiet night shift, but when you're the lone RMN with little or no back up - what else can you do? I don't advocate for patients being sedated in advance of good counseling skills tho, but sometimes it's a good adjunct.
You said it was night shift, so I'm guessing late evening or early hours of the morning - sleep is a useful tool and things look different in the morning. Tho what mum was doing bringing him that late to A&E unless he'd just done it or they'd been sat waiting to be seen 4+ hours. I can't judge too much as I wasn't there.
Re 'inappropriate comments mid conversation': The RMN may well have been able to assess that this was likely to drag on if left as it was - and when you say you spent an hour negotiating, that's a fair amount of a shift to spend on one person in one go.
"Now his mother joined in, at times being constructive and helpful and at other times frustration getting the better of her and she would lose her temper with him"
This may have been what the RMN was trying to avoid by moving him upstairs?
Ok, so maybe I'm stretching things to defend the RMN who in all likelihood was there for as peaceful a night as possible (tho, isn't that the idea of having the RMN?) and she might perhaps have handled things better by using some other 'tools' she should have in her repertoire.
I did my agency for variety, experience and flexibility - the big money was useful bonus but helped with the 'flexibility' side of needing to do only 3-4 shifts a week rather than amassing me huge bankrolls.
In defence of many agency RMNs who perhaps aren't so bad, I'd ask for these comments to perhaps be considered when you get your next RMN special, and maybe introduce them to some team members, even offer them a comfy chair and perhaps a strong caffeine to keep them awake or a 5-10 minute sanity break every two hours.
Or even better, if you have a pool table lying around somewhere...
:o)
Mr Ian, thank you for your comments, I appreciate the "other" viewpoint and someone speaking from experience. My turn to get opinionated ;)
I agree with what you are saying: The good agencies nurses get lumped along with the bad ones and assumptions are made before they even step onto the ward. However, I would not say that personally I have never treated anyone like "crap" regardless of whether they are actually crap or not(!), it isn't in my nature.
I do talk to the agency nurses I work with and do try to make them feel welcome, though the majority we see are regulars for us.
"No one seems to realise that this person has just cancelled all thier plans to get their butt across town to help sort out your problems with you". Whilst I see your point and I will bear that in mind when we next call someone in at short notice, they *choose* to work in this manner. Agency nursing, accepting a job and dropping all else is a choice. If you don't like doing it then don't do it. Nothing is worse than working with someone who doesn't want to be there. However that does not excuse treating another professional badly.
Now the next point you make is very valid and perhaps I will take it up with my ward manager. A pool table, and as it happens I do play pool. Not very well. But I can hit the balls at least. Well usually. Sometimes I even pot a ball. And sometimes that isn't the white ball. However, I digress.
I understand that an RMN does not have the same experience as a paediatric or adult nurse when it comes to general health care and I wouldn't expect them to (unless they were adult or paed trained initially) just like I have limited knowledge/experience when it comes to assessing someones state of mind and counselling them.
There are probably a lot of paediatric and adult nurses who wouldn't know what a penumothorax is either. Or how good or bad it's making the person feel.
Ouch. That stick hurt. Now I shall give an definition of a "not-too-comfy chair". A padded one, not one of those horrible plastic ones, but not one of those big, padded comfy arm chairs that are likely to make the most alert person feel comfortable and sleepy.
Yes, your'e right, there's very little for you to do whilst the patient is asleep. That's why we're not giving you a big comfy armchair and I'm happy for you to do my 4 hourly obs if you would like.
However, if I were working a night shift with an RMN and the patient was asleep, I would happily have the cubicle door open and the RMN outside where they can observe the patient and still have chat with myself, if they're still talking to me after that hard chair I've given them.
I happily sat in with mypatient whilst my RMN went off for a ciggerette/loo break, or my colleague sat in whilst she had her lunch. I think the unit I work on are quite good for that.
The RMN described as a bit "odd" actually had a very comfortable chair. Which perhaps explains the oddness, the comfy chair was completely unexpected and beyond the realms of her experience?
You make some very interesting points with regards to the bahviour of the RMN that night and what she *might* have been trying to achieve and I have considred them (honestly!). However as you say you weren't there and you have only what I say here to form your opinions on, and this is a post written months after the event. I still stand by what I said. This lady had some of the worst communication skills I have encountered, not just in what she said but how she said it. However I'm sure at times my communication skills leave something to be desired so in future I will endeavour to be less judgemental and more supportive of my colleagues.
The RMN I talked about in my pervious post I actually spent a lot of time talking with, discussing our patient as well as the weather. She had breaks and I even offered her a doughnut and a cup of tea (which she refused)!
I will rememeber your comments next time I have the pleasure of working with an RMN and endeavour to make him/her feel more welcome and appreciated. I can't always promise a comfortable chair (we have limited chair resources) but I will ensure they at least get to use the toilet when needed during their shift.
No pool table, but we do have table football.
Eek. Got to run, work. Sorry if some of this doesn't make sense or is rather abrupt, I was working against the clock!
Thank you again for your comments, I appreciate the time you took to post.
I meant to add, if the suggestions to go upstairs hadn't been interspersed with "You're wasting time" I might have agreed with your suggestions.
Hi Angela
I've given you a link from our weekly blogs digest, as promised.
That poor boy. I can't imagine how he must have felt, to have three people he loves taken away from him in a short space of time. And then being at the hospital, receiving mixed messages from the people "caring" for him - I can't help but wonder how he will remember this time and how it will affect his attitude towards his mother and MH services later in life.
And I'd love to know what his uncle was saying to him.
Hi Z, thanks for the link. At interesting week's round up there, I shall be adding your blog to the list of blogs I run out if time to read ;)
MMW: I was also intrigued as to what his uncle was saying to him. It seemed that he was a calming influence and perhaps someone he looked up to. That's just the impression it gave me, without hearing what was said I couldn't be sure.
Post a Comment