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A Night In the Life of a Mental Health Nurse

The other night, a patient held a knife to my throat.

by Sarah Smith
18 December 2014, 10:30am

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I work as a nurse on an acute mental health ward. One month in every three, I'm on "nights" – 12-hour shifts that run from 7.30 PM to 7.45 AM. Sometimes I'll be there later, or earlier, depending on how complicated the handover to the day staff is.

I start by doing my rounds, doing the nurse-type things you might imagine in your head: I talk to my patients and see how they're doing, check their medication and then make a start on my paperwork. There might be need for close observations, too, where patients need to be kept within eyesight or – in the most extreme circumstances – at an arm's reach at all times. It's suicide watch, essentially, though we never call it that.

Paperwork takes up my time more than anything else. These days, as we're individually audited by our managers, we have to make sure our care plans are properly managed. Each nurse is allocated a set amount of patients and they're our responsibility – so, too, is keeping our care plans updated. My patient care definitely suffers because of the intensity of this compulsory responsibility – I can't care for someone if I am too busy writing about them.

Aside from the paperwork, no two nights are the same. It's completely unpredictable and there are often emergencies. The other night, a patient held a knife to my throat. It was only an eating knife, so not all that dramatic, but you know... alarming all the same. When incidents like this happen you have to react very quickly. I took the knife from her and she was, luckily, open to taking her medication. No hard restraint was required because other people were free to assist me. It doesn't always work out that way.

The reality of working in NHS hospitals at the moment is that night shifts are always understaffed. Mental health wards are no exception. I was fortunate with the knife incident, but in the dark hours there are usually only three professionals per ward. Sometimes, as a Band 5 Staff Nurse (23-years-old, a year into the job), I'm the most senior person in the whole building. There are times when people sound their alarms and there's just no one available. There was a rumour in the summer about introducing a Band 6 to work night duties – someone who would be there especially to navigate these incidents – but hasn't happened yet.

We are, of course, given training to handle the hazardous implications of our practice. Provisions are in place. Legally, we can do anything – within reason – to protect ourselves. If someone is punching the shit out of someone else, we don't have to be delicate about it. Obviously none of us want to do anything to harm the patients in our care – it's the precise opposite. But sometimes, situations require drastic actions that ultimately benefit patients' safety.

The level of threat of physicalrom patients can be, at times, frightening. A few weeks ago a senior member of my team was stuck in a locked room, unable to leave his shift hours after finishing, because a patient was threatening him with jugs of boiling water. This was a staff nurse who I look to for guidance – someone who's usually so calm, at ease. When he's worried, I know it's bad.

It's not just the fear of physical abuse, though. The verbal stuff is much more frequent and, often, has greater impact. I work in an inner-city London hospital that provides care for a very multicultural community. As a result, there is a lot of racism, and it's never not shocking – especially when it's thrown around in such a cavalier way. If though our patients are very unwell and many, really, don't know what they're saying, the words remain brutal. They're a shock to the system.

Some of it can be quite funny, though. A Chinese patient said she was going to chop off a male nurse's balls and turn them into chop suey the other day. I laughed and so did he. She may have been capable of doing just that, but you have to laugh. You have to get on with it.

During my last batch of night shifts we had an emergency admission where the patient had to sleep in the lounge. It was the only option available. We become fire fighters in those incidents, making the best of it until the morning, when the cavalry arrives.

For all the training in the world, though – and we do have excellent training – we are running on all cylinders, all of the time. The mental health sector and the complex level of care required remains misunderstood, hidden away. We are making progress, and I love the NHS with every fibre of my being. When we're able to do the jobs entrusted to us, I think we give the best care in the world. We have a holistic approach in the UK, tailoring care to suit and individual's needs rather than a blanket approach for each specific illness, and it's incredibly strong. I'm also incredibly proud that, in a hospital in a poor part of the country, we care for so, so many who'd be left unchecked without the NHS.

It's undoubtable that the NHS is a precarious structure right now. The foundations are shaking. But it's worth remembering that things were more more fucked up in hospitals 50 years ago. They might have had more staff, but one person I know says he trained under someone who used to just stand in a mental health ward with a bottle of liquid medicine and brazenly dish it out, with little determination for individual cases whatsoever. Things have moved on dramatically. It's not about keeping everyone quiet or sedated. We work with patients now. We build rapport and therapeutic relationships.

But things are difficult. The problems we're facing – hierarchical shake-ups, funding cuts, reorganisation on an astounding level – have a huge impact on how mental health is delivered and responded to. I think, if measures aren't put in place very soon – perhaps with this new £30 million pledge from the government emergency mental health care – there's a very real danger that we'll start slipping backwards. Sustainability is vital.

During my last batch of night shifts we had an emergency admission where the patient had to sleep in the lounge. It was the only option available. We become fire fighters in those incidents, making the best of it until the morning, when the cavalry arrives. These are very ill patients. Most are sectioned and need urgent, intensive care in the same way someone who's bleeding uncontrollably does. The mentally ill can spontaneously become psychotic; unmanageable for nurses and carers who have a ward full of other patients.

There is also the unavoidable issue of police cells and whether they are the best environment for someone who is mentally ill. On our ward, most of our admissions come through Accident and Emergency, but a fair few come from the police. I'm sure the police want to do the best for people, but there's just such a stigma surrounding the mentally ill still – so many perceptions aren't just wrong, they're dangerous. The police are trained in something entirely different to mental health workers – people who are unwell are not criminals. Even if they pose a risk to themselves or others.

Being kept in a holding cell is testing for anyone, but for those who are really vulnerable, it is terrifying. It can also have a negative effect on someone's possibility of recovery. And it's an unfortunate truth that, sometimes, mentally ill people are sometimes mistreated – intentionally, or otherwise. I've had to help patients file complaints on more than one occasion. Then again, how would the police know what to do? My friends still have no idea about what my work involves. People are shocked when I tell them I dress "smart casual" because we want to remove any impression of authority – they imagine me walking around in a white coat.

This government cash injection into emergency mental health can't come too soon. The level of care we've built so far might find itself in danger with a lack of adequate resources on the front line – the people on the ground who deal with the raw, gritty stuff, the nurses who are now working with the police to become more equipped at dealing with uncertainty and trauma.

The more staff we have, the more time we'll have to treat our patients. I've been told that it costs around £1,000 a night to keep a mentally unstable person in hospital, but if we can't offer adequate care when it's needed, the implications of readmission, etc., will, I imagine, end up costing a lot more than two extra nurse's wages. We're paid, on average, just over £25,000 a year.

When it comes to mental health, early intervention is key. If we can get to grips with problems earlier, logic suggests that there'll be fewer emergencies to react to in the future.

The name of the author has been changed to reflect the nature of her work

As told to Josh Barrie

More from VICE on mental health:

Young, British and Self Harming: Why Are So Many British Kids Hospitalising Themselves?

Why It's So Hard to Talk About Male Anorexia

This Is What Developing Acute Schizophrenia Feels Like

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