Mental Health Team

Views of a Mental Health Nurse

A view from a Mental Health Nurse

My name is Emma.  I am a Band 5 Staff Nurse in a community hospital in NHS Forth Valley in a ward which provides mental health care for older adults with dementia.  I have spent most of my 19-year nursing career caring for patients with dementia, a condition which can present many challenges not only for the patient but also to those who provide their care.

When Covid-19 first hit the news I have to admit that I really didn’t pay it much more than passing attention - it was terrible of course but it was all happening so far away - though, as the weeks progressed and the year turned, it became increasingly evident that this was going to affect us.  In our spare moments at work my colleagues and I would find ourselves gravitating towards the ward sitting room where the television would be on and we might catch an update on infection rates and deaths.  We shook our heads in silent sympathy when we watched reports about the devastating situation in Italy... and then Spain... and we debated amongst ourselves how we thought we might keep ourselves, our families and our patients safe.  It didn’t matter what we talked about, the conversation would inevitably return to coronavirus. We felt anxious and frightened.  We felt stressed.  We would resume work after days off with an unsettling feeling of not knowing what situation we would be returning to. 

NHS Forth Valley were sending out Covid-19 bulletins and updates on a frequent, almost daily, basis at first and the changes seemed to be coming so quickly that, sometimes, I wouldn’t even read them as I fully expected the situation to very quickly change again.  Guidelines for reporting covid related deaths, guidelines for non covid-related deaths, videos about how to carry out testing, videos on how to don and doff PPE, what PPE to use and when – it felt never-ending and, at times, I wished I could close my eyes and it would go away.  At other times I felt a fierce sense of duty and pride for myself and my colleagues. We would do this, we would keep our patients safe and we would show everyone what stern stuff the NHS is made of.  A rollercoaster of emotions and, thankfully, the latter has endured!

Our usual remit for the ward is to admit patients with a moderate to severe level of dementia who have already undergone a period of assessment and who require a further period of inpatient care before they might be ready to go to a nursing home or other long-term care arrangement.  Our remit now was to admit patients with a milder level of dementia, perhaps with more physical or medical concerns than we were used to, in order to free up beds in Forth Valley Royal Hospital to allow them greater capacity to care for the expected influx of patients with Covid-19.  We would not be admitting patients with Covid-19 but we would be instrumental in relieving the pressure on those who were.  A flurry of activity seemed to follow over the succeeding days and weeks, speeding up discharges for those who were ready and admitting those who weren’t.  All but essential visiting stopped as the country went into lockdown.

 It soon became policy that we wear masks throughout our shift.  Of course this was the only right course of action but this was also a difficult transition for us.  The therapeutic relationship between mental health nurse and patient relies heavily on non-verbal communication and the ability to appear non-threatening towards patients with severe cognitive impairment who may be confused, disorientated and frightened, and a smile goes a long way towards helping build this relationship.  How would our patients react to not seeing our smiles and other facial expressions?  How would they react to being approached by a masked figure in the semi-darkness of their bedroom at night as the nurses carried out their checks?  Would the incidence of aggression rise?  Would we see an increase in the levels of stress and distress in our patients?  Our relationship with our patients felt especially important now as they would not be able to receive regular visits from family and friends for some time.  We began to smile more, making sure this was reflected in the visible parts of our faces. We softened the tone of our voices and opened our postures. We used touch more, a reassuring hand on a patient’s arm or shoulder, and we endeavoured to bring more into our conversations with them.  Occasionally a patient might pass comment on our masks but it seemed that our efforts paid off and there did not appear to be an increase in any of the behaviours about which we had been concerned.

Another concern was how we would contain the virus if there was an outbreak on the ward.  A notable feature of all the dementia wards in which I have worked is the number of patients who wander around the ward.  They might be looking for something, perhaps seeking an exit, or their condition may cause the kind of restlessness which only the ability to be continually active can alleviate.  Providing the patient isn’t distressed this wouldn’t normally be a concern but allowing them to wander unhindered would be inappropriate in the event of any confirmed Covid-19 cases in the ward.  Our patients generally have little concept of infection prevention and control procedures and physical distancing is unfeasible in dementia wards for a variety of reasons but how could we enforce isolation on a patient who was infected but who felt too well to be nursed in bed and who would not understand why their movements must be restricted? Could we reasonably isolate infected patients within their rooms and expect our therapeutic relationship to be unaffected and their sense of mental well-being to be maintained?

We asked these questions as mental health nurses-putting the mental health and well-being of our disorientated and vulnerable patients to the forefront, this perspective is in our nature.  We are in the fortunate and most-likely uncommon position of not having identified (to date) a single case of Covid-19 in the ward but we remain on our guard.  We have begun to gravitate back to the sitting room and the television again to hear updates how the virus is being managed amidst concerns about a potential second way. But we are okay, we are increasingly aware of our strengths and weaknesses and of those in our work environment and we are quietly preparing ourselves for what the coming months may present.

This is my own personal account. I am not presuming to speak for my colleagues, but I have used the word “we” in many cases here because our team effort has endured, and we have supported each other throughout.