Let’s start with depression.
One of the worst cases of depression I saw was a poor man who, unknowingly, had been suffering a MDE for perhaps a year. His relationship had broken down, over time he’d retreated to a bedroom. The ex wanted him to move out so they could get on with their life. The guy didn’t have the energy to get up off his bed and brush his teeth, never mind move out. He’d have topped himself but that takes effort, focus and will. MDD takes all of those away. He was thin as a rake. The ex wasn’t hard hearted but knew nothing about depression and just didn’t get what was happening. The relationship had long broken down and they weren’t speaking. Eventually someone clicked and brought him in (can’t remember exactly how it happened) to be assessed. He grasped the help, agreed to be admitted but he’d absolutely have been sectioned if he’d refused.
Now, the ever present risk with patients like these isn’t when they come in. Then, they are like petrified statues, except lying down. Nurses have to help them shower, dress, eat and drink. But later, when they are just that little bit better, feel that slight lift in energy and get-up-and-go, that’s what we call ‘smiling depression’. It takes experience and/or to be taught to spot it by a wise old head. Yet another thing you cannot learn from a book or lecture. The poor patient still has the hopelessness, the my-life-is-never-getting-any-better, this is as shit as it gets for the rest of my life; the anti-depressant hasn’t yet lifted his mood. But now he has that little bit of energy to escape from hell-on-earth. That’s the danger period. Get him through that and give the anti-depressants the time they need to start working on his mood.
But remember, this is the state of play you are paying for right now. The nursing staff are not allowed to fully concentrate on preventing the patient seizing his opportunity to tie their neck up or store up their tablets. Oh, no. They have to take their eye half off the ball to avoid getting a complaint because managers (& HR) are ever watchful for breaches of least restrictive, coercive practice (they get to decide what constitutes this, not a normal person) and – I’m educatedly guessing here – if they discipline some underling for breaching these policies it provides evidence to the CQC that they are obediently following least-restrictive procedures.
So, at this point, imagine the patient is on 1:1 observations. The staff has to actively distrust the patient – for a while – and expect them to try and kill themselves. There aren’t that many suicide methods available in modern mental hospitals. (*a) That’s one good thing going for the patient. There used to be far more, they’ve been steadily reduced. Shower rails just strong enough to support a magnetically attached curtain. Cone shaped taps with no protuberances. But you still have to be hard hearted and coercive. You still have to tell those patients what to do and make them do it. E.g. observing them in the shower, on the toilet, searching them, confiscating items, making them take their tablets – that’s another post or two.
*a) That explains why the numbers of successful suicides of patients on grounds leave have gone up.
How long does the courageous ward manager – a silly headed young woman who suspects she got the job solely for her skill in memorising and regurgitating management’s favourite policies and eagerness to police them – hold off the least restrictive committee nagging her to get the section taken off and improve their stats?
When the patient uses the Trust’s weaponised complaints procedure to pressure her to take them off 1:1 obs, to dress and shower without being watched etc, does the manager stand firm or give in?
There’s a straightforward solution – or so it seems to this unreconstructed old dinosaur.
Repeal (publicised by a huge fanfare and cascades of memos, emails, posters, compulsory management visits to the sharp end to verbally deliver the news) those least restrictive policies this afternoon.
Return to nurses the full power to use their discretion, clinical judgment, experience and so on to treat the patients.
Gut the weaponised power of HR to use the disciplinary process to enforce hospital laws whoops, policies written by unaccountable managers who magically escape the consequences when they write short-sighted, virtue signalling, cleft stick, double-bind, impossible to actually follow, guaranteed to produce foreseeable harms etc rules, policies and procedures.
NB I’m going to write a series of posts on the Darlington nurses case and this issue was a major factor in that one.
In one swoop, doing that could remove nurses’ anxiety and fear about doing the right thing for the patient – and free us up to do it. Don’t hold your breath.
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