Lawrence Ward

Non-compliance was discussed by staff frequently with the need to improve medication adherence emphasised. Risk was discussed in relation to service users’ vulnerability and the risk of the person to others. A number of admissions of new patients took place during the period of observations. Notes regarding the situation when people were admitted highlight not taking medication and concerns over specific hazards such as level of aggression were identified in the handovers between staff. Levels of distress were also noted by some. Organisational changes were discussed between staff including introduction of payment by results. The introduction of a locked ward was debated.

Extract from Field Notes, Day Two, Early Shift

Daisy – was put on observations following hitting two other

service users the night before. She attempted to leave the ward unescorted that morning. The nurse stopped her and explained that the observations were introduced to protect others as they have a duty to protect others. Daisy was encouraged to take responsibility for her actions, with the nurse suggesting if she did the observations wouldn’t be necessary. When Daisy emerged from her room that morning (prior to this exchange) she was greeted by the HCA with “You won’t be causing any trouble today, I’m not having it”.

131 Interview Summaries

Natalie, Nurse Band 5

Qualified 7 years, HCA 12 years prior to this

Natalie highlighted that it is concerns identified by staff regarding patients that will prompt discussion; leading to action and a decision. Different structures for decision making on the ward were discussed. These included ward rounds but decisions were also made informally when people come together. Team decision making deals with escalation of concerns as the situation develops. This takes place through handovers, office discussions and ward rounds. Within formal structures the consultant holds the power for decision making. The role of acute wards was described as to manage risk. Natalie explained that confidence and experience as a professional influenced practice around risk. Management of risk was linked with

consultants’ role and a fear of blame. She suggested that patients

should have involvement in decision making but that they don’t tend

to be.

“She is here in tears, had some time with her …went into a room with her tried to persuade her to take some medication ,

thought it might help calm her down but she wouldn’t have

it. She wanted to go for a walk, we said well if things were OK for the next half an hour then we‘ll look at going out for a walk, we’ll respect your wishes. So it’s kind of a joint care between the patients and staff and everybody involved in the persons care, it doesn’t always work like that.”

Emma, Nurse Band 6 Charge Nurse

Qualified 8.5 years

The process of decision making was described as hierarchical, she perceived disagreement as being between doctors and nurses though did briefly discuss a lack of consensus between nurses. Emma highlighted a paucity of patient involvement in decision making. Risk

132 was identified as a key factor in whether someone is discharged from the acute ward. Decisions are deferred to doctors when risk is greater. Emma related decision making to back covering and fear of blame, particularly from the organisation. She had experience of being

involved with an inquiry and coroner’s court. Examples of dilemmas

relating to observations, including the role of gut instinct influencing perceptions of possible risk.

“I still think it’s very much the consultant; I think they keep saying they want to work away from that, from institutional ward rounds where the consultant kind of leads it. But I still

think it’s very much consultant lead care in general so that

guides your major decisions.”

Zoe, Nurse Band 5

Qualified 10 months

The process of decision making on the ward means that riskier, bigger decisions involve medical staff. These included reducing level of observations and discharge. Zoe suggested an escalation to the decision making process which was related to fear of the consequences. This was linked with the NMC and media coverage.

She highlights difficulty in getting the balance between individuals’

independence and service interventions. Sharing decision making with other professionals and team working was highlighted as important particularly with her level of experience.

“I think it depends on what the decision was as to how important it was, if it was for a minor decision then you might discuss it among the people on the shift or just make that

decision on your own then disseminate it. If it’s a bigger

decision with more impact you definitely would discuss it with your colleagues and also the MDT as well, certainly get the input of the SHO and consultants even just in a general chat in the office.”

133

Kimberley, Nurse Band 5

Qualified 21 months

Kimberley discussed sharing decision making with the team and talking with others; though recognised her confidence in making decisions has increased with experience. An attempt to involve people in decision making was recently introduced through recovery sheets used in ward round but she highlighted that in reality people

aren’t involved. Kimberley brought up that there are some issues of

power in decision making and expressed difficulty when doctors

don’t agree. Kimberley was due to attend coroner’s court soon. She highlighted she didn’t feel responsible for the death and she feels

everything that should have been done was. Kimberley discussed

concerns about service users ‘doing something’ (to themselves) and

linked this with fear of losing her registration. Examples of

therapeutic risk taking and consequences when didn’t go according to

plan were discussed.

“One example could be when I was in ward round, I was the only qualified present, obviously there was myself the patient, the consultant and crisis. I felt the patient was ready to be discharged but the consultant disagreed so I was in the ward

round and it’s hard sometimes you get so frustrated because

the patient wanted to go, he had his heart set on going and I thought he was ready to be discharged and the crisis team were happy to visit him and to try and support him in the

community but the consultant was like no…He staid another

week but wasn’t really given a rationale as to why… so that’s annoying. Sometimes I do think you know you are on the ward 24 hours a day and you see what this patient is like,

consultants will come once a week for an hour and it’s

frustrating.”

NB Kimberley had spent 3 months working on Lawrence ward but at the time the interview took place had just rotated to the locked ward.

134

Edward, Consultant Psychiatrist

He suggested that decisions are largely consensual and team based

though later highlighted that the role of consultant can be to ‘enable’

decisions to be made when there is a lack of clarity or struggle for resolution. Edward highlighted that doctors are often involved where there are concerns or a need to consider medication. However, he

feels this mirrors a ‘real’ role around taking managing risk,

medication can be used as code for bringing these concerns to the

doctor. Edward identifies the role of society in perpetuating doctors’

responsibilities for maintaining social order, which was linked with status and expense of psychiatrists. He also suggests that the organisation seems to want to share decision making but focus on the

doctor when “things go wrong”. Currently requested to appear at two

coroners cases but not that involved with the service users that the cases were about.

“Some months later he went missing and was eventually found dead, so I am not quite sure why I have been asked to attend the coroners hearing. The other was somebody that I had seen for the last time about nine months before he killed

himself and again why am I you know? I’ll do it, its fine,

perfectly comfortable with what happened. But why am I

being asked to go along at all? There’s something about

being the psychiatrists who was identified with that particular person; immediately says to the coroner I must see that

doctor.”

Charlotte, Nurse Band 5

Qualified 6 years 3 months

Where risk and dilemmas are concerned team working and sharing decision making in the team is important. Patients are involved

through 1:1’s and presenting views in ward round, though ultimately

135 is difficult to make decisions about observations, particularly reducing observations. Described herself as cautious person and this has influence on decision making. Has attended coroners court

following a patient’s suicide, experience was unpleasant and she was

very aware of how this influences decisions currently, though considered the process as a fact finding mission.

“Usually the patient is discussed in their absence and then they are brought into ward round and then their points of view are put across - their own point of view rather than ours. Sometimes a decision is made before the patient is actually seen but then when the patient is actually seen decisions made might change, it depends on what the patient

wants or how the patients presenting.”

Key words

Following are the keywords consistently identified within the data

from the in –patient setting.

 Risk  Power

 Structure of decision making  Blame

 Roles and responsibilities  Relationships

 Dilemmas discussed related to these areas; observations,

admissions, nurses holding powers, non-compliance, restraint, gaps between ideal and possible, medication, safeguarding

4.1.6.2 Assertive Outreach