It’s well established that psychiatric nurses have long disregarded the physical health of people with serious, ongoing mental health problems.
Recently visiting a friend in hospital, I was reminded of the practical split in the way nurses view their patients.
It’s well established that psychiatric nurses have long disregarded the physical health of people with serious, ongoing mental health problems. This, in part, contributes to the scandal of life expectancy for people with schizophrenia being somewhere between 12 – 15 years less than the general population.
However, this has resulted in policy initiatives and hugely positive changes in practice, with most psychiatric nurses recognising the importance of understanding the intrinsic link between the patient’s physical wellbeing and their mental state.
However, the care provided to my friend confirmed that, for many of those adult nurses working in hospitals, what goes on above the neck – how patients feel, their cognitive state - are as apparently unfamiliar as the dark side of the moon.
Confined to bed, she had been very unwell with a longstanding disease. Further complications meant she was on unusually high doses of opiate analgaesia. To make matters even more difficult she was MRSA positive and thus isolated in a side cubicle.
With her family unable to visit frequently, she had little interaction with others.
Her physical care was of a high standard but, for much of her stay on the ward, she was sleeping for up to 18 hours a day and was often very disorientated.
The organic reasons for this were fully investigated and no abnormalities discovered. But it seemed there was no further curiosity about why a woman in her early 60s, who was completely oriented and alert prior to admission, might have experienced such a profound and distressing change since coming into hospital.
Moreover, going through the new ritual of ticking off routine items, or ‘rounding’, she was often noted to be ‘alert’ when that was obviously far from the case.
“she was often noted to be ‘alert’ when that was obviously far from the case”
Her analgaesia had been necessary when she was still partially mobile. However, now confined to bed it appeared that, unless some unseen hand had robbed her of her cognitive ability, high doses of opiate medication were almost certainly contributing to her confusion and drowsiness.
Despite repeated requests from the family, the medication wasn’t reduced. Of course, prescribing is a medical responsibility and this case was yet further complicated by the involvement of the palliative care doctor.
But both the nurses’ deference to his view that the medication shouldn’t be changed - based on a brief assessment – and their lack of thought about the impact this was having on her life emphasised serious flaws in nursing that are not going to be changed by checklists or directives.
As days turned to weeks, the consequences of her languishing in her confused state were far reaching. Due to an unforeseen error, she developed a pressure sore. Her carefully planned discharge home was abandoned. She was abruptly transferred to a nursing home.
“She was abruptly transferred to a nursing home”
Liaison psychiatry nurses often complain at their adult colleagues’ lack of awareness when asked about the mental state of patients they’ve referred and are familiar with the crie de couer of those on the wards, arguing they’re too busy to spend time with patients, that it is as much as they can do to carry out the myriad tasks required to meet their physical needs, let alone talk to them.
Anyone who spends 10 minutes on a ward will know how busy it is.
Nonetheless, it is interesting to consider why any nurse would see it as more important to work at remedying a wound infection than addressing someone’s confusion, or think it appropriate to prioritise washing them rather than meeting their emotional needs.
Of course, it’s ultimately a false dichotomy, as one doesn’t preclude the other. But if we are talking about nursing the person, what is it that renders the physical more important than those things that make us human?
Ward teams rightly pride themselves on reducing infection, pressure sores and falls, often displaying charts demonstrating their progress. Yet there is rarely anything that outwardly links nursing care to patients’ psychological and emotional wellbeing other than that nebulous notion of ‘patient satisfaction’.
Post-Francis, we talk endlessly of ‘compassion’. One understanding of this complex concept is that, to demonstrate compassion, we must first understand the person’s suffering, embrace it and then act in a way that will attempt to change it.
It is therefore self evident that we cannot demonstrate compassion until we embrace the whole person including, most importantly, those things that make them a person rather than a patient – their thoughts, their feelings.
As for my friend, whose overall prognosis is unchanged, post discharge her analgaesia was dramatically reduced. She experienced no increase in her pain and was completely restored to her previous level of cognitive functioning, able to enjoy the company of the family and friends who feared they had ‘lost’ her forever.
It is a tragedy of contemporary healthcare that her nurses did not see it as essential to contribute to the part of her recovery which was possible.
Chris Hart is consultant nurse in forensic and intensive care nursing, South West London & St George’s Mental Health NHS Trust and principal lecturer, Kingston & St George’s University of London.