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A day in the life of an acute hospital psychiatric nurse: trying to predict what might happen during e shift on any one day in an acute inpatient mental health unit is impossible. A nurse must be adaptable and willing to cope with e variety of unplanned events.

It is 7am, the start of the day shift on a typical day at Middlemore Hospital's 50-bed acute inpatient mental health unit Tiaho Mai. It is hand-over time and the night staff are bleary-eyed as they read out the overnight report. The morning shift staff look very different, our hair still damp from our morning showers and the air heavy with perfumes and after-shave lotions.

The changing of the guard nears its conclusion. Polite small talk is exchanged as the day staff farewell their colleagues, who look forward to the sanctuary of feather and down. Those of us remaining can only guess at what surprises await us.

A quick scan of the diary and the allocation of patients are completed. The mandatory jobs such as clinic duties, dispensing medications and morning tea are triaged, with special attention to the competency of the toast maker. By now, most of us have transformed into something approaching normal. The scene is set.

Psychiatric nursing is unique in that the day's events are impossible to predict. The best made plans are often foiled by unexpected events. Most of us are allocated four to five patients, which is not too different from the patient load in a general hospital setting. That may not sound overtaxing but the reality is very different. Those who are in in-patient acute psychiatric hospitals rarely have physical ailments; hence they are seldom confined to bed. This in itself presents numerous problems, not the least being finding them. A simple blood pressure may take ten minutes, so if you have six to do, then an hour or ten percent of your working day soon evaporates.

Doctors' hand-over is next on the agenda. The team seeks a room in which to conduct the daily hand-over. With the consultant, registrar and house officer present, the nurse assigned to the hand-over gives the team an account of the last 24 hours for each and every patient on the ward. All issues are discussed, including current presentations, noting either improvement or deterioration. Medication is adjusted, meetings are proposed, social issues discussed and accommodation post discharge considered. Details of all decisions are recorded and passed on to each client's key nurse for the day.

Organising a multi-disciplinary meeting to discuss a particular patient sounds simple. The reality is quite the opposite. It is absolutely essential to choose a time that suits the inpatient team, as without this, making any other plans is futile. Others involved may include the community support team (especially when a discharge is being discussed), family and support people, the occupational therapist and the social worker. The services of an interpreter may also be necessary. Bringing together this collection of people is a real challenge. All have their own particular schedules, multiple case loads and prior commitments. The nurse who has to organise such a meeting needs a phone, and a place devoid of the background noise of the nurses' station. Having outstanding organising ability is also an advantage. Confirmation of attendance is tentatively pencilled in. The list of attendees is growing. Just when you feet confident this meeting is actually going to happen, a key player rings with their apologies. A huge sigh is followed by a shake of the head, then it's back to the drawing board. The little hand is pointing to ten, indicating the morning break. The team assembles, the coffee poured. Noise intensifies as multiple conversations erupt. Even with the best of intentions, the talk inevitably gravitates to matters pertaining to the clientele. Nevertheless, this is a well deserved respite from the pace of the morning thus far. Ten minutes feels like two. Before we know it, it is time to return to the coalface.

The 20 metres or so separating the tea room from the nurses' station should take as many seconds to complete but seldom does. As the nurses walk down the corridor, clients approach them requesting meetings with their doctors, escorts to the shop, information on medication, a toll call to mum and dad, some clean towels. These are all reasonable requests. However, there is only so much one can do in the time available. "Ask your nurse", is the normal response. "But she is too busy," is the common reply. These interruptions can put a spanner in the works for a nurse trying to maintain some kind of time management.

By this stage, any hope of keeping to time is well and truly lost. The emphasis is now on task completion. While searching the linen cupboard for those towels, a colleague calls out, "You are wanted in court." Real athleticism is required to collect the patient's notes, medication chart, find the patient and arrive at the venue on time. The judge decides the patient needs to remain in hospital. The court is adjourned and you are left to return the patient to the ward and, on occasions, console them, provide explanations and clarify the decision.

Working on a care plan

Once back on track, with a dear outline of what needs to be done, the day continues. A b-line is made for the office to work on that all-important care plan. As I stretch out my arm towards the notes, the phone rings. It is the doctor asking me to arrange a meeting with a particular patient. Foiled again. Off I go to find the patient and secure a room, not always easy when space is at a premium. The meeting begins, the review is completed. The outcome, in this case, is a change in medication and a referral of the patient to the community providers as required. I shelve the idea of working on the care plan and give priority to ordering the medication and to the referral process. Huge chunks of the day are taken up with unplanned but not totally unexpected detours.

Lunch arrives. The patients congregate in the dining room. All hands are needed on deck during lunch time as this is potentially a time of high risk. Lunch brings together a collection of personalities, all with serious mental health conditions, often exhibiting paranoia and suspicion (common emotions in an acute setting). Supervising the meat and cleaning up afterwards takes around half an hour. Then it's time for the staff to relieve each other for their 30-minute break.

In the staff room, groups of people engage in conversation. Others prefer to read a book or catch up with the daily paper. A few appear to be catching up on a bit of shut-eye. I prefer the short walk to the hospital cafe. This may take ten of my precious 30 minutes, but I believe it worth while, as it allows me to fraternise with others who have no affinity with mental health. The coffee is gulped rather than sipped. Nevertheless the time out has given me a power charge, just enough to give me the boost I require to attack the post lunch session with increased vigour.

Arranging a family meeting

On my return from lunch, I check with colleagues that nothing untoward has happened in my absence, then it's straight back into work. A family meeting is due. Securing a room is the priority. The family arrives. I page the doctor, collect the notes, and inform my peers of my pending absence from the ward. After introductions, the business at hand is discussed. It is not uncommon for these important meetings not to go according to plan. On occasions the nurse is caught short, ill prepared for a discharge, as pressure from family to be reunited with their loved one dictates the outcome. If this is the case, the nurse must facilitate a clear and concise plan to ensure the patient's successful departure. This may include completing a vast paper trail taking up to an hour and even longer if the patient has no community support in place.

Conversely, if the family or inpatient team thinks a return home is potentially detrimental, the meeting can turn sour. Such issues need to be addressed and input from all parties is essential to ensure an acceptable plan is put in place. The psychiatric nurse is often the key to diffusing such situations, as the time the nurse has spent with the patient has built trust, enabling the nurse to be key in any de-escalation required.

Later that afternoon, the occupational therapist enters the nurse's station and requests assistance with the afternoon programme. We all agree that occupational therapy plays an essential rote within a psychiatric hospital and that the majority of the activities have a significant influence on patient outcomes. But to take a nurse off the ward to assist with the programme can be taxing. Every effort is made at the onset of the duty to allocate a nurse but, with the unpredictable nature of nursing, sometimes there is no one to send.

Responding to an emergency

Without warning, the piercing shrill of the alarms ring out. All eyes focus on the digital display, indicating the general location of the emergency. Adrenaline starts to pump as all available staff run to the locality. As a mate nurse, there is an unwritten rule that I should attend, but at 45 years of age, I am often overtaken by a younger new graduate. The crew arrives to support their peers, only to be greeted at the door by an arm-waving nurse indicating a false alarm. The panting, hall-blocking mass of nurses disperses and the nurses endeavour to return to their prior commitments, physically a little the worse for wear but grateful no injury has occurred.

At the nurses' station, it is not unusual for all the telephones to be ringing at once, nor is it uncommon for two or three incoming calls to be for the same nurse. One might be a query from a family member, another a request from the community team, a third from the pharmacy seeking clarification of a faxed medication order.

Now the rush is over, consideration needs to be given to recording the day's clinical notes. The challenge is how to write a factual account of one's patients' clinical conditions when face-to-face time is so limited. This skill develops over time. The ability to assess an individual patient using brief but to the point notes is often enough to create an overview of how well or otherwise that patient may be. Obviously, if any concerns are apparent, a comprehensive nursing review is made.

A nurse will often canvas their peers for collateral information in order to establish a comprehensive overview of a patient. I believe this is unique to psychiatry. Regardless of a nurse's experience, it is invaluable to compare observations and conclusions with others to broaden one's knowledge base. To write notes on four or five patients, you need to start early, as ten minutes per individual is optimal. All too often I see nurses writing their notes well after the end of their shifts.

The day's workload is finished, with all tasks completed or at least passed on to the following shift. Nurses on the afternoon shift begin to filter through the door. The chatter builds as colleagues catch up with one another. A senior nurse collects the hand-over sheet and the team assembles. Coffee and tea are poured as the hand-over begins. Each patient is discussed in turn, some with a simple "no change in presentation" to a comprehensive account and plan for others. The day staff appear re-energised at the thought of their departure and by 3.30pm the changing of the guard is complete. So begins a different shift with its unique issues and challenges.

This account of a day in the life of a psychiatric nurse may paint a picture of chaos and disorganisation. This is the reality and what attracts me to the profession. I enjoy multitasking and trying to bring some semblance of order to the day. I get great satisfaction from helping others, assisting those in my care to make choices and decisions about their care. Nurses are intermediaries between the medical team and the patient. We are advocates for our patients and often the only people able to support them. Such a position is a privilege. After five years' working in this acute psychiatric hospital, I remain buoyed by the daily challenges. The peer support is exceptional When a relationship between a patient and staff member is at risk of becoming sub-therapeutic, there is always some one ready and willing to take over, ensuring a safe work environment. The humour on the ward is also unique. I can think of no other place I would rather work. My only regret is that it took until I was 40 to find the perfect job.

This article was reviewed by Kai Tiaki Nursing New Zealand's editorial review committee in September 2005.

Russell Murphy, RN, now works as a crisis nurse in the community with Counties Manukau District Health Board. He left Tiaho Mai late last year to broaden his psychiatric skills and develop his career path.
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Title Annotation:PRACTICE
Author:Murphy, Russell
Publication:Kai Tiaki: Nursing New Zealand
Date:Oct 1, 2005
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