Case study 5: Cambridge University Hospitals NHS Foundation Trust (Mental Health / Substance Misuse)

Background

case5The individual is a 38-year-old female. She has a personality disorder of the antisocial and impulsive type and a heavy substance misuse problem. She has some forensic history, having being detained in a secure forensic unit, and has also been in prison for burglary. She has been treated under the Mental Health Act three times in the last eight years and has one admission to a Psychiatric Intensive Care Unit (PICU).

Her mother died of a drug overdose when she was 8 years old. Her father, an alcoholic, died 3 years ago; they had lost touch but were briefly reunited before he died. She has one sibling, a professional, although she has no contact with them. She was born in London and had a very difficult childhood. She was sent to special school for behavioural disturbance, was bullied by other local children and called “stupid” and worse. Her poor reading and writing abilities indicate that she is dyslexic. Her father physically abused her and she hid in a cupboard frequently to avoid him. She left home at 14 years of age to live with travellers; her mother had also been a traveller. She has a heavy drug habit (less so now as has come off crack cocaine by herself and heroin) and misuses alcohol.

For her current admission, she went to the emergency department saying she was suicidal, however she was deemed at low risk and discharged. Following discharge, she jumped 20 feet and fractured both ankles.

Her challenging behaviour followed admission to a busy orthopaedic ward and she was placed in a single room to try and manage the disruption. She shouted abuse at nurses from the room saying she needed painkillers. Because of this, the nurses found it difficult to care for her as she was very intimidating. The nurses also found it difficult to develop a rapport with her. She would lower herself from the bed and shuffle into the corridor on her bottom and shout verbal abuse at the nurses, ignoring all other patients. Security was frequently called to get her back into her room. She was closely observed by a nurse outside her room providing one- to-one care.

A nurse specialist was called in after a weekend when security had been with her six times just on the Sunday. The patient had an intimidating manner when the nurse arrived.

Personalised interventions

1.  Engagement 

The nurse worked by treating the patient as politely as possible at all times with a calm voice and low expressed emotion, introducing herself and sitting down to demonstrate that  she was willing to spend time with the patient. The patient was asked what she would like and the nurse tried to fulfil her wishes if at all possible, or else gave a clear explanation as to why not.

The patient wanted to go out for a break from the ward, which they did. This was an opportunity to begin engaging the patient by asking them what had happened (getting the patient’s narrative of recent events rather than reading medical and nursing notes). This is when she spoke about her abusive past history (corroborated by medical notes). She talked about her challenging behaviour and she said she was in pain and no one would give her painkillers.

2.  Aims of care

The aim is to enable staff to see her as a person with individual needs; and to reduce her verbal aggression and the need for security.

3.  Nursing care plan

Staff negotiated with her so she understood what the nurses were trying to do and she could see how she could benefit from it. The aim of the plan was to ensure her needs were met so she did not have to exhibit challenging behaviour to be noticed.

Staff instigated a Positive Behaviour Programme (positive behaviour for the nurses not the patient) where they were to go into her room every hour, ask if she wanted anything and have a chat. When drawing up the plan it was made quite clear what kinds of requests were appropriate e.g. requests for painkillers, drinks, breaks from the ward etc.

A record of these visits was kept on the patient’s wall where she could see it and also outside (thinking about confidentiality and minimal information) on her door to remind the nurses to do them.

The nurses discussed her difficult past history so they could see that she had no pattern of her needs being met.  The only way she knew how to function in an institution was to be aggressive, as in that way some needs would be met. They were very sympathetic as they had no knowledge of her past history and so had been frightened of her. She was regretful about some of her behaviour and said that she was aware that she had frightened an old lady when she was swearing in the corridor, which demonstrated that she had some control over her behaviour.

4.  Daily evaluation

On the first night after the start of the intervention the patient had one verbally aggressive outburst at 3.00am but there was no need for security. Since then, she has had no verbal aggression, no shuffling into the corridor, and there has been no need for security or for close observations. Initially nurses spent up to 3 hours a day with her at various times but that went down to 1 hour within 4 days.

At the time of writing, the programme had been in place for a week and she was currently awaiting surgery.

Source: Dr Joy Bray – Mental Health Specialist Nurse, Cambridge University Hospitals NHS Foundation Trust