Keywords

The Nursing Team

The nursing team at the Walker Unit is an ever changing body of people, with quarterly rotation in junior nurses undertaking their Transition into Mental Health Nursing development year and a generally stable group of CAMHS experienced nurses ranging from three to eight or more years. Approximately half of the regular staff have undertaken some level of post graduate training in child and adolescent mental health.

Leading the nursing team is a Nurse Unit Manager (NUM) and a Clinical Nurse Consultant (CNC), who perform two distinct functions; NUM responsibilities include management of human resources and facilities, staff performance and organisational capacity issues, while the CNC is responsible for clinical issues related to care planning, risk management of patients, organising the referral process and undertaking pre-admission assessments and supporting the milieu of the unit.

The number of staff each shift is based upon the number of patients on the unit, organised as part of the wider hospital on a shift by shift basis, so can range between two and five staff. The night shift is always staffed by two nurses, between Sunday and Thursday one staff member on the afternoon shift starts later to cover a twilight shift to support night staff settle the unit. Because some young people are granted home leave on the weekend, nursing numbers will typically be lower than during the working week. Nursing numbers can be increased to respond to the level of clinical dependency, such as requiring care level one observations to support safety of a young person. There are times when nurses from adult mental health wards are deployed to the Walker Unit to fill staffing shortages.

Supporting Young People

At the Walker Unit, there are three nursing teams of five. Each team is led by an experienced CAMHS Registered Nurse (RN8) or Clinical Nurse Specialist (CNS1). A team is responsible for two to four young people, and the staff in that team become their young person’s “Primary Nurses”. The rationale for team nursing is to foster, as far is possible, continuity of nursing care and maximise the number of shifts as possible for a young person being nursed by someone familiar with their care. Primary nurses should focus some of their time to develop effective therapeutic relationships with their primary young people; getting to know their interests, likes, dislikes and aspirations for the future. As a relationship is established, nurses can then engage a young person with collaborating in care planning and explore challenges they experience, and evaluate the effectiveness of care plan interventions attempted. Primary nurses typically attend family meetings as a support to the young person, advocate their perspective or provide feedback to family members. Within their primary nurse team there is a “Lead Primary Nurse” for each individual, this role is purposely an administrative one to ensure that care plans, required documentation and reports are kept up-to-date and are accessible.

Day-to-Day Allocation of Nursing Tasks

The allocation of staff to young people usually also considers the therapeutic relationships between staff and a young person, a young person’s level of clinical dependency, previous clinical incidents such as self-harm or verbally hostile or aggressive behaviour as well as the level of experience a staff member has in supporting young people with complex behaviours. Other considerations include staff fatigue, shift patterns worked and recent previous allocation to patients, so there is sharing of the clinical workload. It is not uncommon for young people to express dissatisfaction when they are allocated staff who they are not familiar with, or that they have had challenging experiences with, and therefore being able to explain allocation decisions, both clearly and with diplomacy is a skill required by the nurse in charge. When a young person requires supervision on care level one, within eye-sight or arms reach, additional staff are requested to support this intervention. The supervision is shared amongst all the staff on shift with a maximum two hour period on 1:1 observations. To support the allocations of patient care and other jobs on a shift by shift basis, the nurse in charge works from a diary that has reminders for role and activities required each day, they transcribe their allocations onto a white board in the nursing office visible for all staff to view and know their jobs for the shift.

Managing Safety on the Unit

Nursing staff are the guardians of the environment and undertake shift by shift safety checks. There are typically several patients on the unit who will scan the environment for opportunities and means to self-harm. As such, nurses must ensure the removal of used linen (ligature risk), cutlery and crockery removal after meals and snacks (cutting risk), ensuring musical instruments and videogames consoles are securely stored when not in use (strings and power cords provide a ligature risk). Young people being admitted or returning from periods of leave must participate in a search before entering the main unit environment to prevent contraband items being brought into the environment. The main focus is implements for self-harm, such as blades or shards of glass, but illicit substances are also “on the radar”. There are two levels of search used: PAT and GOWN search. A PAT search involves a declaration if they have contraband items, emptying pockets and bags to nursing staff and handing in any devices or restricted items to be held securely. A GOWN search is a more invasive process and is summarized in Box 6.1.

Box 6.1 Elements of a GOWN Search

  • Two staff undertake the search—of the young person’s preferred gender

  • Staff gain consent

  • Conduct in a bathroom

  • Ask young person to hand in any contraband items

  • Young person disrobes to underwear and puts on hospital gown

  • Young person removes underwear

  • Clothing searched by staff

  • Visual person search and metal detector search conducted

  • Young person dresses

The decision to use PAT or GOWN search is based on the patient’s recent risk history.

Care Planning

The primary nurse team has responsibility to engage the young person in thinking about their care plan and treatment, they have knowledge of the aims of an admission, the strengths and difficulties questionnaire and consumer wellness plans that are completed by young people to guide their understanding of what the content of care plans should be. The Walker Unit has two kinds of care plan; a multidisciplinary (MDT) care plan and specific or targeted care plan. It is the second that is usually created between nursing staff and the young people. Specific or targeted care plans typically aim to increase a young person’s skills in managing a task or situation more independently through practice or attempting different strategies. The structure of the care plan used is depicted in Fig. 6.1.

Fig. 6.1
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Example of a care plan (p. 1)

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The first page includes identification of young person; name, Medical Record Number (MRN), care plan number and a care plan title. The title of the care plan should be relatable to the young person and be written using language easily understood. An example would be “Building tolerance to my emotions and distress” rather than “Managing aggressive behaviour”. The title of a care plan is often the beginning of the “sales pitch” used by staff to persuade a young person to work in collaboration with their team. The young person or family’s observation is next and details in their own words what they see as the challenge in their situation that requires support. The team adds their observations of the same. A rationale for the care plan is given in “Identified need” section, which guides the young person as to what benefits may be achieved by working through the care plan with the team. Lastly, the “Goal” of the care plan should be linked to the overall aims of the admission. These two sections are written in “recovery focused” language, offering hope and optimism that changes can be made. Coffey et al. (Coffey et al., 2019) support the recovery focus in care planning and choice of language to support consumers.

The second page of the Care Plan (see Fig. 6.2) lists interventions that should be used to work through the presenting situation. These interventions are written in sequence and guide staff what should be done and how. Interventions take into account the wishes of a young person.

Fig. 6.2
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Example of a care plan (p. 2)

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If a young person’s behaviour raises safety concerns, decisions for interventions can be taken by nursing staff. Actions can include relocating the young person to a more contained area of the unit, increasing the level of direct observations, activating the duress system to increase staff availability, and administering PRN medication. On occasion, this may require the use of restraint. Restrictive practices are only deployed to maintain safety if less intrusive interventions have been ineffective.

Care plans are developed consistent with the principles of trauma informed care, offering choice to a young person, empowerment through self-determination, collaboration throughout the experience, developing trustworthiness and maintaining safety, both physically and psychologically. The nursing staff have a care planning resource folder that includes ten template care plans, providing them with guides as to what should be included in care plans for specific situations, so that they can discuss and individualise care plans with a young person. The template titles are listed in Table 6.1.

Table 6.1 List of care plan templates
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Motivating Young People to Engage in Care Plans

The Walker Unit runs a continuous achievement level system consisting of five different achievement levels; bronze; silver; gold; platinum and diamond. Each level has different privileges and restrictions; lower levels having increased restrictions and less privileges and higher levels less restrictions and more privileges (See Fig. 6.3). Privileges include access to mobile devices, SIM cards, attending outings, going on daily walks, kitchen access and unescorted leave off the unit. If a young person displays unsafe behaviour such as aggression towards others, damage to property or deliberate self-harm requiring medical intervention a young person is placed on bronze level for 24 hours, this has the most restricted access to privileges, if they manage the 24 hour period without repeat of the behaviours they move back to silver level.

Fig. 6.3
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Summary of level system

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This achievement level system was initially designed with the young people and acts as a positive reinforcement for the young people. A young person’s level reflects their effort in engaging in the treatment program, following their care plans and managing their safety. Movement up and down the levels provides the team, but particularly the nursing staff with a tool to reward effort, but also to provide natural consequences for behaviours displayed. There are occasions where a young person’s capacity to follow the level system requires adjustments; so, a care plan is created to specify these circumstances and adjustments.

Observations for Safety and Being Present

Physical presence on the floor requires that effective allocation of duties and sufficient staffing is maintained. Being present and engaging with young people is emotionally labour intensive (Forster & Smedley, 2019a; Forster & Smedley, 2019b) and requires staff to be interested in the young people, and be able to engage in age appropriate dialogue, or participate in light hearted fun situations such as playing games or activities. Senior nursing staff use Spence’s (Spencer, 2017) model of nursing interventions to promote active engagement and demonstrate interventions becoming more coercive or restrictive when reflecting on practice (see Fig. 6.4).

Fig. 6.4
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Hierarchy of nursing intervention. (Reproduced with permission from Spencer, S. (2017). Nursing Responses and Interventions for Episodes of Adolescent Distress in an Acute Child and Adolescent Mental Health Inpatient Unit: An Interpretive Descriptive Study. (Unpublished Doctoral Dissertation) University of Newcastle)

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At the same time as offering diversional activities, staff should be vigilant to observe for changes in behaviours of young people and be ready to intervene when a young person is “triggered” by something or someone. Young people at the Walker Unit have limited choice as to where they spend time and whom is in their vicinity, therefore negative interactions can and do occur between them. Staff need to be able to carefully manage interactions between young people, provide activities that can be inclusive such as board games, movies or card games and invite the whole group of young people to participate. For many young people simply being invited to be involved can help change their feeling within the environment. Having an allocated staff member to monitor the whereabouts of young people each hour shares the responsibility of locating all young people. Closing down the environment dependent on the ward activities is another way of simplifying this task and ensure everyone is visually accounted for, an example is at night time, the wider unit is closed and locked to bring activities for young people into the main lounge, bedroom and bathroom corridors and focus on completing the night time routines.

Clinical Supervision for Nursing Staff

There are a number of ways clinical supervision is offered at the Walker Unit for nursing staff; monthly group clinical supervision for nursing staff only, fortnightly whole team systemic clinical supervision, monthly incident review meetings, hot and cold debriefs following an incident and individual clinical supervision. Nursing group supervision is undertaken by an external supervisor and is independent of the NUM and the CNC. The nature of the young people’s presentations, managing the therapeutic milieu, engaging with the young people, the application of the level system, sitting with young people in distress, or de-escalating situational behaviours all have an impact on staffs emotional availability. Decisions made amongst team members can often spur different personal views and perspectives on treatment which ignite passionate and sometimes emotional responses between staff, clinical supervision on all levels is one way to discuss and explore these situations, identify and articulate nursing interventions and any resolutions needed (Forster & Smedley, 2019b).