Eskdale Ward

Student Welcome Pack 2015/16

Eskdale Ward, Edenfield Centre

PrestwichM25 3BL

Contact number: 0161 772 9280/9278

Welcome to Eskdale The aim of this welcome pack is to provide you with some useful information in order to alleviate some of the practical concerns you may have about this placement.

The team values the input of students whilst on placement and they are looking forward to you joining and contributing towards the team.

The Edenfield Site

Edenfield offers a medium secure, forensic assessment and treatment service. The majority of

patients are subject to sections of the Mental Health Act (1983), and very occasionally informal.

Patients are admitted from a number of areas including Prisons, Special Hospitals, internal

transfers from other wards within the Service, low secure hospitals and occasionally patients who

are recalled from the community as part of the function of their restriction order.

The aim of the ward is to provide individualised care, using the appropriate skills and expertise of

the staff group to:

Assist the individual to regain the best level of mental health

Assess the risk to the patient and others

Offer input to patients with particular specialist needs

Reduce the risk of repeat offending

Assist the individual to move to the most appropriate placement in the

future

Patients and, whenever appropriate, their families and significant others, are very much involved

in their programme of care. The maintenance and development of appropriate links outside of

the unit are promoted whenever possible.

Service Philosophy The philosophy of care is based on the Health Care Recovery Model and aims to provide high quality care in a safe and therapeutic environment.

The staff on these wards will offer patients and their significant carers information about mental health, recovery and the choices/resources available to them.

We operate a structured approach to daily life. Designated times will be set for various needs to be met throughout the course of the day, ensuring that all patients have equal access to these events.

We believe that patients should have the opportunity of achieving their maximum potential. The patients will be supported to relate to each other in a manner that is free from violence, bullying, coercion and oppression of any kind.

We will provide holistic, collaborative care for our patients, their families and carers, that is based on comprehensive assessments and the best evidence currently available.

All patients and staff on the acute wards can expect to be treated without judgement and with dignity and respect, by a positive and motivated team using helpful relational boundaries. We will respect the diversity of all individuals on the ward and accept that everyone has a right to have their views and opinions heard.

The acute ward staff will work in line with the ‘The Ten essential Shared Capabilities ’. Developed through ‘Skills for Health’, the 10 ESC provide, in one overarching statement, the essential capabilities required to achieve best practice for education and training of all staff who work in mental health services.

The Model of care:

The Model of Care used on the active treatment & recovery wards will guide staff in their work and is based on the principles of recovery:

The Health Care Recovery Model will guide staff to:

Recognise and support the personal resourcefulness of our patients.

Encourage active participation and a collaborative approach to care. Patients are encouraged to view themselves as capable of recovery rather than passive recipients of professional interventions.

Create an environment of HOPE for our patients.

Create relationships that encourage the growth of self-confidence, self-esteem and self-acceptance.

Validate current coping strategies and experiences.

Combat discrimination and social exclusion.

The Model aims to demonstrate a commitment to recovery, evidence based care and life-long learning.

The Model incorporates an understanding and implementation of physical, procedural and relational security to maintain a balance between public safety and the recovery of the patient.

Staff profile

Ward Manager: Alan ShepleyMentors: Pete Johnson, Jennifer Hodgkiss, Natasha Meredith, Janet Derbyshire.,

Trust Educational Link Practice Education Facilitator Debbie Barry debra.barry@gmw.nhs.uk 0161 358 1657

Placement Orientation Check List

Must be completed within the first week of starting the placement

Aspect Yes initial /Date

No

Fire Regulations and emergency procedure

Issues surrounding confidentiality are discussed

Health and Safety policies/lone working policy/ complete emergency contact sheet

Uniform policy/ standards of dress discussed

Informed of shift pattern

Placement philosophy discussed

Introductions to staff and environment

Student to inform mentor personal tutors name and contact details

Informed of Practice Education lead for placement

Sickness and Absence procedures discussed

Student aware of resource file and notice board

Induction completed in practice placement Document

When all these have been achieved

Mentors Signature: Date Students Signature: Date

You will be allocated a member of the ward, who will be responsible in guiding and facilitating your learning. We hope to work in collaboration with you to create optimum opportunities of learning in an open and supportive atmosphere.

Induction

All students will receive a local orientation/induction to the service by your mentor or another member of team within the first 48 hours of placement. This coincides with the induction you should find in your practice placement documentation.

What you can expect from us:

A minimum of 3 formal meetings with your mentor where your progress can be evaluated and documented

Respect for your learning needs and capacity

Openness and honestly regarding your progress both professionally and personally

Help and time to facilitate your learning needs through other members of the multi-disciplinary team

Assistance in identifying and securing spoke placements

Time with your mentor where you can learn and improve on nursing skills and practice

Your opinion will be valued and your views will be welcomed

What we expect from you:

To treat all its patients with respect and dignity

To work as a team with other staff members and students

To be punctual

To complete your university assignments in your own time

To remain aware of your own boundaries and limitations

To take responsibility for keeping patient information confidential

To demonstrate a willingness to learn

Responsibility for own learning

To understand the needs of patients and the pressures of a forensic service

Health and Safety The ward has a variety of health and safety information regarding policies, fire documentation and so forth. It is important that you read and understand and familiarise yourself with this documentation

Dress Code

All staff are expected to maintain high standards of personal cleanliness and hygiene when undertaking Trust business. This includes clothing and footwear, which should be clean, conservative, well presented and suitable for the job being undertaken. Trust identity badges must be worn at all times on Trust premises and be available to confirm identify to member of the public or other services when in the community. Lanyards must meet the trust health and safety requirements and be laundered regularly or replaced if soiled.Hair should be clean, neat, and tidy; extreme hairstyles or colourings are not permitted. Use of make up and nail varnish (for non clinical staff) should be discrete and maintained appropriately e.g. chipped nail varnish is not acceptable.

Jewellery should be discrete and appropriate and kept to a minimum. Simple stud earings are acceptable anything other than this present a safety risk. Facial/body piercings are not acceptable and should be removed whilst at work. Staff wearing facial piercings for cultural reasons should ensure that these are covered if they are unable to remove them.

Visible tattoos should be covered where practical/possible, and offensive tattoos must be covered.

Footwear should be practical and relevant to: the task undertaken; equipment used; and the environment the tasks and equipment are used in. Consideration should always be given to health and safety with regard to footwear choices e.g. flip flops are not acceptable footwear in any Trust environment. Managers need to locally determine appropriate footwear following a health and safety risk assessment.

To ensure effective communication clothing which covers the face (veil/niqab) is not permitted for any staff in contact with patients, carers or visitors, or for staff in other roles where clear face to face communication is essential, e.g. training. The wearing of headscarves needs to be risk assessed to ensure that any fastenings do not pose a health and safety risk.Staff who wish to wear a veil/niqab when they are not working-such as in breaks, during their lunch, or walking around buildings/sites are allowed to do so. They must however be prepared to remove their veil/niqab if their identity is asked to be checked against their ID badge.

Anybody in inappropriate dress will be sent home immediately on arrival to change.

Hours of Operation It is expected that you will adopt the working pattern of your Mentor and work at least 50% of your time with them. You are expected to work a mixture of early, lates long days and night shifts which incorporates some weekend exposure (typically 2 weekends in 4). The standard shift pattern at Edenfield is two long days, and two shorter ones ( which can be either early or late)

Whilst you are supernumerary in status, you are encouraged to get involved in the ward activities, taking responsibility for tasks and so on. Eskdale is an environment which offers night shifts, therefore it is a good opportunity to work some nights as part of your 24 hour cycle of care.

Shift PatternsThe service provides a 24 hour service 365 days a year.

Early: 7.00 – 3.00Late: 1.00 – 21.00Long Day 7.00 - 19.15Nights 19.00 – 7.00

Handovers take place whenever somebody starts a shift, these will usually follow the pattern above. Two larger handovers take place, at 7.00-7.15 and 19.00-19.15 respectively.

Sickness/Absence or Lateness In the event of sickness or sudden unexpected circumstances please contact the team and the university immediately. The practice educational lead will then e-mail your details to the university. If you don’t contact the placement this will be logged as an unauthorised absence which may impact on your practice hour requirements.

Please inform us if you are going to be late or delayed so the staff can act accordingly.

Travelling Expenses and Car Use You may claim your mileage through the university if it is over and above the miles you would usually travel to the university. This however is not available to seconded students. You canIf you are using your car to meet the community nurse at a clients home you must have business insurance.

Car parking & Travel At your Greater Manchester West Service induction you should be asked whether you have a car, as they will be able to arrange barrier passes for you. If you have not done this, if you contact reception, they should be able to, find out how to arrange this for you.

Other Travel alternatives

Bus: There is a bus stop at the top of the site, which serves bus services coming from around Manchester.

Tram: Prestwich is part of the Manchester tram service.

Transport for Greater Manchester contains a list of public transport links, and they have a journey planner which contains information about public transport in general

http://www.tfgm.com/Pages/default.aspx

At certain points in the day, a shuttle service operates between the Edenfield centre, and the top of the site. Details regarding this service are advertised on bus shelters on the site.

Refreshments and food

There is an on-site café which has a variety of light options (jacket potatoes, salads, sandwiches, soup and so on). At the top of the Prestwich hospital site there is the Waterdale Café which has a variety of more filling options, and a changing daily menu.

The Eskdale has a staff room on site on the second storey of the ward. This contains facilities for making hot drinks, and microwaves for heating food.

Smoking

This is a non-smoking Trust across the whole site. There are no facilities for staff or patient smoking.

Mentors Role and Responsibilities

You will be assigned a qualified mentor at the start of the placement and will be encouraged to work with all the team during your stay In the event your mentor being unavailable due to sickness or annual leave, alternative arrangements will be made by your mentor to support you in their absence.

Identifies experiences for students to meet their learning needs Acts as a role model Offers ongoing and constructive feedback Integrates learning from practice and educational settings Undertakes assessment and completes the relevant documentation

Student Roles and Responsibilities

You are seen as an equal partner in learning and assessment process. With your mentors guidance you should be able to take responsibility for personal learning by: Identifying specific learning needs and factors which may affect learning Identifying specific learning opportunities as they arise Participate appropriately in giving care Produce the required documents Undertake self assessment where / when relevant Discuss your progress with your mentor and give you some feedback about the placement and

your experiences. Please maintain confidentiality at all times.

Student TimetableYou are encouraged to organise a timetable of activities under the guidance of your mentor for example attending spokes, in house training, e-learning and working with other members of the multidisciplinary team. For a list of Spokes, and contact information, please consult Appendix 1

Opportunities

Edenfield is a diverse site, where you will have many opportunities for learning, and practicing your skills. Below is a list of things to think about or get involved in, The list is not intended as exhaustive, if you feel any amendments could be made, please note this on your feedback form

Take a look at the policies on the intranet and see what policies you think are particularly relevant to your placement.

Ensure you identify where seclusion facilities exist, and the policies that govern use oif seclusion/ INS

Reviews are carried out fortnightly. Ask your mentor if you can observe them/assist completing their patients review, taking the opportunity to present these to the team

Take a look at the Mental Health Act 1983 and research into the forensic sections, patients’ rights and how they affect patients

Take a look on ICIS at some reviews and risk assessments that have been carried out, taking the opportunity to write care plans and assessments

Are your clinical skills up to date? Can you perform basic observations i.e. blood pressure, temperature.

Give depot medications and dispense medication and PRN medication

Practice handovers

Observe and conduct a 1:1 session

Write daily nursing notes

Recording incidents on ICIS/ DATIX

Take part in assessments/ transfers/ escorts

Participated in a major review (when available)

Attend high risk escorts/ court appearances

Working with a complex & challenging client group

Personal SecurityEveryone is responsible for his or her own personal security and also for assisting and observing others. Upon entering the unit each member of staff or students are allocated an alarm known as a P.I.T, each member of staff checks their alarm is working by testing it in the testing station (please ask your mentor if you are unsure), it only takes a few seconds and it is important it may not be for your own sake that you pull your alarm – think of others too.

On each ward there is a designated security nurse for each shift, they will have received an induction and be aware of that wards security procedures (each ward has slight differences i.e. Ullswater patients use metal cutlery but Eskdale use plastic etc)

Personal security is important in any mental health setting and you can aim to reduce any situations by…..

Always informing others where you are going

Do not go down corridors alone

Always sit nearest to a door when in a room

Be aware of your surroundings

Ensure you have had a handover at the start of every shift BEFORE you go onto the ward, you do not know what might have changed since your last shift

Ensure you report to the nurse in charge upon entering any other wards so that they know you are there

Continually risk assess situations and areas

Use your skills and your gut feeling! If you are not comfortable with a situation then remove yourself from it and inform someone

Boundaries & Boundary setting

In any psychiatric setting staff, including students must be aware of and display disciplined and professional boundary setting. This is not always easy as we are all human after all !!

You should start to be aware of how you set your own boundaries as a student and continue this through your nursing career. It is good practice to continually look at yourself and check that your boundaries are still in place.

Have a go at this self -assessment questionnaire, it is private to you but if you have any issues, concerns or questions you can discuss them with your mentor.

1) Have you felt that you were responsible for the clients behaviours and that his or hers misconduct was a reflection of your professional competence?

2) Have you arrived early or stayed late to be with your client for a longer period of time?

3) Have you felt that other staff members were to critical of ‘your client’?

4) Have you felt that you were the only one who understands the client?

5) Have you had difficulty in setting limits with your client?

6) Have you found yourself relating to a client as you might a family member?

7) Have you received any feedback about your behaviour being over friendly or involved with clients and/or their families?

8) Have you experienced sexual feelings towards a client?

9) Have you derived great satisfaction from a clients praise, appreciation or affection?

10) Have you kept secrets or felt that there were things about a client that cannot be shared with other staff? (a very slippery slope!)

11) Have you felt that other staff members were jealous of your relationship with a client?

12) Have you tried to ‘match-make’ a client with one of your friends?

13) Have you found it difficult to handle client unreasonable requests for assistance, verbal abuse, or sexual language?

14) Does this client or situation remind you of a similar person or situation? If so , is there anything that you feel you need to resolve about the person, or situation before you can work with this client?

15) Do you feel uncomfortable in approaching your supervisor or colleagues to discuss your feelings about a certain client?

PERSONALITY DISORDER

Common personality traits [characteristics] Inflexible and maladaptive responses to stress Difficulty in working / loving relationships

Ability to evoke interpersonal conflict in others Capacity to have an intense effect on others

Cluster A [odd / eccentric]

PARANOID PERSONALITY DISORDER Suspicious / paranoid / mistrusting Unforgiving [bear grudges] Difficulty establishing close relationships Perceived as cold / unemotional / detachment Lacking sense of humour Overcritical of others [difficulty accepting criticism]

SCHIZOID PERSONALITY DISORDER No desire re close relationships Little interest in sexual activity Isolative Perceived as cold / unemotional / detachment

SCHIZOTYPAL PERSONALITY DISORDER Withdrawn [as schizoid] Aloof Ideas of reference / unusual perceptions [schizophrenic symptoms] Social anxiety [paranoid] Eccentric [behaviour / appearance]

Cluster B [dramatic / erratic / emotional]

ANTISOCIAL PERSONALITY DISORDER [psychopath] Antisocial / criminal behaviour [animal cruelty] Manipulative / deceitful / exploitation Irresponsibility [fail to honour obligations] Aggression / violence Lack of remorse or empathy Alcohol / substance abuse

BORDERLINE PERSONALITY DISORDER Intense / unstable relationships Dependant and rejecting / avoid abandonment Impulsive / reckless activities [self damaging] Mood swings Self harm / suicide Lack of satisfaction [boredom / emptiness] Weak sense of identity Intense affect [anger / depression / anxiety] Extreme sarcasm / bitterness Manipulation

HISTRIONIC PERSONALITY DISORDER Self centred [attention seeking] crave gratification Crave excitement Fickle / flirty Over exaggerate

Easily influenced Smothering / destructive / lack empathy Increased [over] emotional

NARCISSTIC PERSONALITY DISORDER Exploit others Arrogant / grandiosity / over inflated self Lack empathy Fantasist / attention seeking Begrudge other [feel more deserving] Controlling / disruptive [provoking]

Cluster C [anxious / fearful]

DEPENDANT PERSONALITY DISORDER Overfriendly Submissive [agreeable] Overwhelming fear of separation Require nurture / support Poor decision making

OBSESSIVE COMPULSIVE PERSONALITY DISORDER Inflexible / rigid Over control Perfectionist [cannot delegate] / unrealistic expectations Overemphasis on work Highly critical [self / other] Preoccupied [lists / rules] Depression / social phobia

AVOIDANT PERSONALITY DISORDER Social phobia Inadequacy / feel inferior Fear rejection / criticism Isolative

If you think that you need further support in this area then please do speak with your mentor who will be happy to discuss this further with you.

Reasonable Adjustments Please confide in your mentor if you have any specific learning or health needs so that the mentor can make plans for (individual) reasonable adjustments to support you in the placement setting. Failure to do so may inhibit your learning when supportive measures could have supported you. Complaints and ConcernsShould you have any complaints or have concerns during you placement please speak to your mentor or to the manager. We want your stay to be a positive experience and respect your

honesty so that we can address anything untoward immediately rather than wait for feedback from the university. Further support can be accessed from the Practice Education Facilitator.

Notice Board Students are actively encouraged to add information to the notice board, articles they have read, interesting spokes etc.

Information TechnologyIf you do not already have appropriate IT access, you will be able to arrange this through the ward administrator, who will provide the appropriate forms.

In House Training SessionsThere are a variety of in house training sessions, e-learning packages which allow students to attend or complete if they are not filled by qualified staff. Please access staffnet webpage and/or the practice placement website.

Hub and spoke opportunities We have a good range of Practice learning opportunities available whilst you are on placement (appendix 1) which can be discussed with your mentor. We would like you to complete the spoke feedback sheet as evidence for your portfolio, and for you to have a short discussion with the mentor about your experience on your return(appendix 2). This helps the team to evaluate whether the spoke was appropriate and that you accessing a valuable learning experience that compliments you’re leaning needs.

Placement feedback We actively encourage students to complete the placement feed back sheet at the back of this pack. We appreciate honest comments so that we actively maintain or improve student’s experiences in the future (appendix 3).

LibrariesThe Trust library has recently been refurbished and is situated in Harrop House at the Prestwich site and is open daily during the week. Wi-Fi is available and computer access. The library team are very resourceful and are willing to support students in their studies.Monday to Friday 8-30am – 5pm Contact no. 0161 772 3618

Looking after your OWN mental healthWe understand that working in a forensic unit can be often be daunting and that it can be hard to know how to understand our own emotions when nursing this particular client base. Therefore, all students will be closely monitored and encouraged to ensure that not only are they are getting the most out of their placement, but that they are also supported emotionally and professionally.

Appendices

1. Spoke Placements/ Opportunities2. Spoke feedback sheet 3. Student development checklist4. Reflective questions5. Medication & Adminsitration6. Physical Health

7. Common mental health sections

Appendix 1 –Spoke Placements/ Opportunities

Environment/ Ward Contact ext Speciality/ SettingM

ens

Med

ium

Sec

ure

Dovedale 3030 Mens Acute

Rydal 4622 Mens Acute

Ferndale 3975 Mens Long Term

Silverdale 3968 Mens Treatment

Borrowdale 3181 Mens Treatment

Conniston 4360 Mens Treatment

Ullswater 3280 Mens Rehabilitation

Keswick 3303 Mens Rehabilitation

Wom

ens

Ser

vice

Hayswater 4364 Womens Theraputic Enhanced Medium Secure Services

Loweswater 4692 Womens Step Down

Derwent 3402 Womens Rehabilitation

Buttermere 3690 Womens Acute

Low

Sec

ure

Wentworth House 707 7366 Low Secure

Rockley 772 4440 Low Secure

Newlands 3634 Mens Step Down

Lowry 3553 Low Secure

Kingsley 3552 Low Secure

Junction 17 3678 Adolescent Psychiatry Unit

Gardner Unit 3425 Adolescent Secure Inpatient Unit

John Denmark Unit 3400 National Deaf & Mental Health CentreOccupational Therapists 3190 Occupational Therapists

Oth

er o

n-si

te F

acili

ties Patterdale/ Gym 3170 Therapy

CPN's 3582 CPN's

Diabetes Clinic 3956 Diabetes clinic

Clozaril Clinic 3956 Clozaril Clinic

Practice Nurse 3956 Practice Nurse

First Step Trust 3961 On-site service user-led shop

Appendix 2

Student Spoke Placement Feedback

Student Name:

Mentor:

Date(s) of Spoke:

Spoke:

Spoke supervisor:

What learning outcomes do I want to achieve on this spoke?

What have I learnt from this spoke experience?

Student and Mentor Discussion of experience

Appendix 3Student Nurse

Role DevelopmentTopics

You may find this following checklist a useful tool to use in conjunction with the list of outcomes in your PDP and/or practice based assessment

Learning activities / researching topics (world model)

Student nurses will spend time exploring a variety of information sources. These learning activities / research topics will be planned and relevant to your placement here on Eskdale enabling you to develop a structured plan of learning opportunities.

These activities will be negotiated with your mentor to ensure that you are meeting your learning needs / action plans, and will be used as evidence for your student placement document. Over the course of a week you will be able to utilise resources as a means of completing a learning activity / research topic. As it is not always possible for you to work with your mentor, this time will allow you research and collect evidence regarding the selected learning activity / research topic, before presenting / feeding back to your mentor.

1) Medication card activity achieved on_________________witnessed by_____________

Demonstrate the ability to safely dispense oral medication, display good knowledge of 4 drugs routinely used and identification of effects / side effects.

Consent to treatment [3 month rule, form 38, form39] Once only medicines PRN Regular medicines [form, route, times, dose, start / stop date] Signature / codes Discretionary medicines Depot injections

2) IM Depot injection activity achieved on______________witnessed by_______________ Demonstrate the ability to safely dispense medication by injection including:

Discuss a IM depot medication, Demonstrate practical technique of drawing up medication Calculation dose Discuss sight / technique Demonstrate practical technique of IM depot administration If possible administer IM depot [this may or may not always be possible]. Complete Lunsers [assessment tool]

3) Mental Health Act [2007] activity achieved on____________witnessed by______________

Demonstrate the ability to present legal aspects relative to mental health according to the Mental Health Act [1983] and Code of Professional Conduct, display good knowledge of section 3, section 37, section 41 and section 47/49 which are routinely used on Eskdale ward.

Function / purpose of section Duration Appeal rights Discharge

4) Therapeutic relationship activity achieved on______________ witnessed by___________

Demonstrate the ability to initiate, maintain and disengage in therapeutic relationships, show understanding of the components of therapeutic relationships.

5) Ward handover activity achieved on ___________witnessed by______________

You are expected to communicate the ward handovers over the course of 1 week, you will be supported to:

Accept ward handover from previous shift Document as relevant in ward handover book Present [verbal] ward handovers to oncoming staff and o/t staff Summarize re: patients mood / behaviours / interactions Risk Physical health Medication Leave Activities Visitors

6) x 2 weekly reviews activity achieved on____________witnessed by______________

Demonstrate a working knowledge of the Care Programme Approach in relation to providing and presenting to the Multi Disciplinary Team a written report for a CPA meeting / x 2 weekly review.

7) Assessment tool activity achieved on ____________witnessed by______________

Demonstrate the ability to utilise a formal assessment tool, eg, LUNSERS, Becks depression inventory, KGV, , PIPS.

8) Care planning activity achieved on____________ witnessed by________________

Demonstrate the ability to formulate research based care plans utilising the process of assessment, planning, implementation and evaluation.

9) Patient presentation activity achieved on______________witnessed by______________

Choose a specific patient and discuss [as per global nursing assessment] re:

Social / Psychiatric history Diagnosis / symptoms Index offence Section of mental health act [1983] Interpersonal skills Treatment Care plans

10) Management of violence and aggression

activity achieved on______________witnessed by ______________

Ability to demonstrate verbally your knowledge of de-escalation techniques, discussing the importance of communication skills, body language and the effect of these on actual / potential violent incidents. To discuss the rational for treatment strategies, and show understanding of Nice guidelines for dealing with violence and aggression.

Appendix 4

Reflective questions

Below is a list of a few reflective questions, you may well find it useful to complete some or all of them. They may well be useful in writing your learning diary, or for informing discussions with your mentor.

A PATIENT ASKS YOU IF THEY CAN TELL YOU A SECRET – WHAT WOULD YOU SAY?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

WHAT WOULD YOU SAY IF A PATIENT ASKS YOU WHERE YOU LIVE?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

HOW WOULD YOU TELL A PATIENT THAT IT WAS TIME TO GO TO BED?

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

SOMEONE RINGS THE OFFICE AND SAYS THAT THEY ARE PATIENT X’S SOLICITOR AND ASKS ABOUT THEIR CARE, WHAT WOULD YOU DO?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

A FRIEND ASKS YOU ABOUT A HIGH PROFILE PATIENT, WHAT WOULD YOU TELL THEM?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

A PATIENT COMES TO YOU AND SAYS THAT ANOTHER PATIENT IS BULLYING THEM – HOW WOULD YOU HANDLE IT?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

YOU ARE DISTRIBUTING MEDICATION AND THERE IS A MEDICATION THAT YOU HAVE NEVER HEARD OF, WHAT WOULD YOU DO NEXT?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

A PRESCRIPTION CARD IS HARD TO READ AND YOU ARE UNSURE OF THE DOSE, WHAT WOULD YOU DO?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

A PATIENT TELLS YOU THAT THEY HAVE THE LEAVE TO GO OUT IN THE GROUNDS BUT YOU ARE UNSURE, WHAT WOULD YOU DO?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

A PATIENT REFUSES THEIR MEDICATION HOW WOULD YOU HANDLE TO SITUATION?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

A PATIENT ASKS YOU TO LEND THEM SOME MONEY, WHAT WOULD YOU DO?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

AFTER A SHIFT YOU FIND THAT YOU CAN’T STOP THINKING ABOUT WORK AND/OR A CERTAIN PATIENT, HOW WOULD YOU HANDLE THIS?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

A PATIENT ASKS YOU HOW ANOTHER PATIENT – WHO IS ON ANOTHER WARD IS DOING, WHAT DO YOU SAY?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

A PATIENT STARTS TO ‘FLIRT’ WITH YOU, HOW DO YOU HANDLE THE SITUATION?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

A MEMBER OF STAFF ASKS YOU TO COUNTERSIGN FOR SOME MEDICATION BUT YOU DIDN’T SEE THEM DISTRIBUTE IT? WHAT WOULD YOU SAY?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

A SENIOR STAFF MEMBER ASKS YOU TO CARRY OUT A TASK THAT YOU DO NOT THINK IS CORRECT, WOULD YOU QUESTION THEM? WHAT WOULD YOU SAY?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Appendix 5

Medication

1) Reading the prescription card:

The way in which prescription cards look may vary from placement to placement but they should all contain the same information. You must check each section before you distribute the medication.

Check the name on the card Check the date of birth Check for allergies Can you clearly read the medication (yes the stories are true about Doctors hand

writing !!) Check the time Check the stop date Check the dose Are there any contraindications ie over BNF limits Check the PRN section Is there a depot due Do you know the possible side effects for the drug you are giving?

For PRN medication

Assess the mental or physical state of the patient Read the card to see what other medication they have requested and when Take the physical obs if deemed necessary Use your skills when assessing, is there another way that this patient can cope ie

relaxation, taking a walk etc

NOTE: Even if a Doctor has prescribed the medication it is the nurse who dispenses it therefore he/she is accountable, therefore they must ensure that all checks are made.

It is not possible for a nurse to remember every medication there is but it is important that they know what they are dispensing which is why it’s a good idea to regularly refer to the BNF (British National Formulary)

Its good practice to look up any drugs that you are unsure about. Qualified and experienced nurses do this too - not just students!

2) Common Medications

Below is a list (non exhaustive) of some of the common medications encountered in Mental Health. NB trade names of drugs always start with a capital letter; generic names do not. Different drug companies will give different names to the same generic drugs, so some drugs are known by several different names.

Abilify – aripiprazole Used for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

amisulprideUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

amitriptyline HClUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

aripiprazole

Used for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Arpicolin - procyclidineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Benzatropine - mesilateUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Benzhexol HCl - trihexyphenidylUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Buspar - buspironeUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Camcolit - lithiumUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Carbagen - carbamazepineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

CarbamazepineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Chloral hydrateUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

chlordiazepoxideUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

chlorpromazineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Cipramil - citalopramUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Clopixol Acuphase - zuclopenthixol acetateUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

clozapineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Depakote - valproic acidUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Depixol -flupentixolUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

diazepamUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Dozic - haloperidolUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Efexor - venlafaxineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Epilim - valproate; sodium valproateUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

fluoxetineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

lamotrigineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

chlorpromazineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

lithiumUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

lorazepamUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

NitrazepamUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

nitrazepamUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

olanzapineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

paroxetine HClUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

procyclidine HClUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

promazine HClUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

propranololUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

prozac - fIuoxetineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

quetiapine   Used for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

Risperdal - risperidoneUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

venlafaxineUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

zopicloneUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

zuclopenthixol acetateUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: ……………………………………………………………………………………

zuclopenthixol decanoateUsed for/indications: ……………………………………………………………Common side effects: …………………………………………………………Dose: …………………………………………………………

Appendix 6

Physical Observations

Physical care is equally important in a mental health setting as it is in a general setting especially as many patients take large doses of anti psychotic medication.

Most students have at some point ‘done’ someone’s physical obs but what is it you do with that information, can you interpret it? Consider the following questions

Can you take a patient’s blood pressure using both electronic and manual machines and read, interpret and record the results?

Do you know how to take a patients temperature and read interpret and record the results?

Do you know how to weigh a patient and check their BMI? How do you check a patients pulse? What’s the best way to observe a patients respiratory rate?

What do the oxygen saturation readings mean? How do you check a patients blood sugar levels? What other questions would you ask a patient when asking about their physical health?

We have to remember that patients will not automatically tell staff how they are physically feeling and what is going on with their physical health. They may think that some things are ‘normal’ or are just too embarrassed to approach staff and tell them. Nurses should regularly ask about patients bowel habits, urine output and sleeping etc as this can help get the full picture of a patients physical health which can in turn effect their mental well being

Appendix 7

Patients concerned in Criminal Proceedings or under Sentence. Section 35 Remand to hospital for report on accused's mental condition.

Section 36 Remand of accused person to hospital for treatment.

Section 37 Powers of courts to order hospital admission or guardianship.

Section 38 Interim hospital orders.

Section 39 Information as to hospitals.

Section 39a Information to facilitate guardianship orders.

Section 40 Effect of hospital orders, guardianship orders and interim hospital orders.

Section 41 Power of higher courts to restrict discharge from hospital.

Section 42 Powers of Secretary of State in respect of patients subject to restriction

orders.

Section 43 Power of magistrates' courts to commit for restriction order.

Section 44 Committal to hospital under section 43.

Section 45 Appeals from magistrates courts.

Section 46 Persons ordered to be kept in custody during Her Majesty's pleasure.

Section 47 Removal to hospital of persons serving sentences of imprisonment, etc.

Section 48 Removal to hospital of other prisoners.

Section 49 Restriction on discharge of prisoners removed to hospital.

Section 50 Further provisions as to prisoners under sentence.

Section 51 Further provisions as to detained persons.

Section 52 Further provisions as to persons remanded by magistrates' courts.

Section 53 Further provisions as to civil prisoners and persons detained under the

Immigration Act 1971.

Section 54 Requirements as to medical evidence.

Section 54a Reduction of period for making hospital orders.

Section 55 Interpretation of Part I

PART 2: USEFUL INFORMATION

Health Career Model

The Health Career Model is essentially concerned with the person in a social context. The notion of career derives from the intervention of the nurse being future orientated, increasing the health choices, health chances or health prospects of individuals or groups (including families) taking cognisance of the biography of the person or persons being helped.

The nature and activity of nursing involves different kinds of knowledge, some of which is impersonal and mechanical, objective in nature – from physiology to procedures and decision making - whilst other aspects of the nurses role requires more personal knowledge of such things as an appreciation of feelings, development of self-esteem or personal growth.Figure 1 highlights the different attributes on intersecting continuance between individual and group and humanistic and mechanistic interventions

Interpersonal Individual Science

[psychological]

Mood grief – bereavementOther Loss Loneliness Insecurity

Sleep disturbance Fear AnxietyAgitation Communication Memory

Low self-esteem / confidenceProblem solving Cognition

[biological]

Stroke Heart DiseasePoor Mobility Risk of Falls

Disturbance from FamilyCannot go out

Humanistic Mechanistic

[social]

Family structure RelationshipsFriends Dependency on othersConflict Socialising HygieneActivities Shopping Home

Community environment

Housing provision FinancesBenefits Legal issues Advocacy

Social / Health Agencies CostsDecision making FreedomAutonomy Rights Power

Sociology Group Political

There are four distinct but overlapping quadrants of the health career model relating to science (physical aspects), interpersonal (psychological aspects), sociological and political facets of a person’s health career (Figure 1).

ROLE OF THE NURSE RE MDT WORKING

CONSULTANT

OCCUPATIONAL THERAPIST SOCIAL WORKER

FINANCE SOTP

FST CAB Nurse

FINANCE PHARMACY

PRACTISE NURSE FAMILY

MINISTRY OF JUSTICE

CARE PROGRAMME APPROACH / CPA

Initially introduced in 1990 and revised in 1999, the integrated Care Programme Approach [CPA]

is a framework / delivery system underpinning mental health care for all service users,

highlighting the importance of health and social services working together with the involvement of

the patient / carers, providing an intergrated service, a recovery based approach. Armstrong

[1999].

Services are required to deliver the CPA according to two levels:

Standard CPA for patients likely to: require low level support from one agency / discipline

self management of their mental health needs

have active informal support networks

pose little danger to themselves / others

maintain contact with services.

Enhanced CPA for patients likely to: have complex / multiple care / social needs

be difficult to engage / disengage

require contact with several agencies [including the criminal justice system]

intensive / frequent interventions

present a risk to themselves / others

be at risk of serious self neglect / vulnerability

Due to having multiple care needs and a serious and enduring mental illness all patients care at

the Edenfield centre is managed via enhanced CPA.

The four essential elements of the Care Programme Approach are:

systematic assessment of the patient’s health and social care needs,

the formulation of a care plan to address those needs

the appointment of a care co-ordinator to monitor the delivery of care

regular reviews

This assessment involves all members of the MDT gathering information and data that reflects

the patients health, in relation to biological, psychological, social and political dimensions, as

Hodges health career model.

Sainsbury centre [2005] suggest effective implementation of the CARE PROGRAMME

APPROACH is vital to ensure appropriate services are planned and delivered to patients under

the mental health act [1983]. Staff from all agencies / disciplines should work together to provide

a seamless service between hospital and community services.

Standards relating to patient involvement state that the patients CPA care plan is required to

included psychological, physical and social functioning, and patients are to have a written copy of

their CPA care plan, which is to include a crisis plan, and an aftercare plan detailing care to be

provided, naming his care co ordinator, and action to be taken in a crisis.

The National Service Framework [NSF] [DoH 1999] for mental health, set out standard four:

suggesting that all mental health service users on the CPA should receive care which optimizes

engagement, prevents or anticipates crisis and reduces risk. DoH [1999]

The role of Care co-ordinator is undertaken the patients Consultant Psychiatrist [qualified

professional [health or social], who is an experienced mental health worker and is from the local

team / district of origin] whose role is to ensure care is effectively co ordinated within the service,

from admission to discharge.

Patients are assigned to one multi disciplinary team [case manager], and the team have a fixed

case load and a high staff / patient ratio, delivering all services where and when needed, 24 hr a

day, 7 days per week.

CPA admission review’s are held within 8 weeks of the patients admission, ongoing CPA reviews are 2 weekly, and CARE PROGRAMME APPROACH major reviews are held on a 6 monthly

basis [maximum].

Handover / ICIS prompt

Biological

Physical wellbeing? Physical observations? Weight? Blood sugars? Diet and fluids? Medication? Compliance? Side effects? Depot? Changes to prescription card? Sleep pattern?

Out patients appointments? Clozaril clinic?

Psychological

Mental state? Presentation? Behaviours? Mood? Depressed? Elated? PRN medication? Psychotic? Positive symptoms? Negative symptoms? Delusional ideation? Anxiety? Concentration? Assessment tools?

Social

Engagement? 1:1 Sessions? O/T Sessions? Sociable? Isolative? Intrusive? Behaviours? Leave? Rec? Shop? ARC? FST? Grounds? Waterdale? Family contact? Approved visit? Professional visits? Disinhibited?

Risk

Level of observations? Risk relapse signatures? Incidents? Hostility? Behaviours? De esculation? Self harm? BMI? Sexually inappropriate? Illicit drugs? Alcohol? Room search? C&R risk? Absconsion? Secure escort? Handcuffs?

NICE guidelines MANAGEMENT OF VIOLENCE AND AGGRESSION

HOSTILE / AGGRESSIVE PATIENT

VERBAL DE-ESCULATION

RETURN TO WARD

ORAL / IM MEDICATION

VERBAL DE ESCULATION

RETURN TO WARD

CONTROL AND RESTRAINT

VERBAL DE ESCULATION

RETURN TO WARD SECLUSION

Violence

ASSESSING POTENTIAL VOILENCE History of violence Psychotic features [paranoia / hallucinations / delusions] Intoxicated / alcohol / drugs Personality disorder [antisocial / borderline / narcissistic] Poor impulse control Chronic physical illness

SIGNS AND SYMPTOMS Hyperactivity / pacing / restlessness Increased anxiety Posture / tension

Eye contact [intense / avoidance] Verbal abuse / threats Silence Property damage Weapon

MILIEU CONDUCTIVE TO VIOLENCE Overcrowding Staff inexperience Provocation Over controlling Poor limit setting Loss of privileges

Positive Symptoms Negative Symptoms

Positive symptoms refer to thoughts, perceptions, and behaviours that are ordinarily absent in people in the general population, but are present in persons with schizoaffective disorder. These symptoms often vary over time in their severity, and may be absent for long periods in some patients.

Hallucinations. Hallucinations are "false perceptions"; that is, hearing, seeing, feeling, or smelling things that are not actually there. The most common type of hallucinations are auditory hallucinations. Patients sometimes report hearing voices talking to them or about them, often saying insulting things, such as calling them names. These voices are usually heard through the ears and sound like other

Negative symptoms are the opposite of positive symptoms. They are the absence of thoughts, perceptions, or behaviours that are ordinarily present in people in the general population. These symptoms are often stable throughout much of the patient's life.

Blunted Affect. The expressiveness of the patient's face, voice tone, and gestures is diminished or restricted. However, this does not mean that the person is not reacting to his or her environment or having feelings.

Apathy. The patient does not feel motivated to pursue goals and activities. The patient may feel lethargic or sleepy, and have trouble following through on even simple plans.

human voices.

Delusions. Delusions are "false beliefs"; that is, a belief which the patient holds, but which others can clearly see is not true. Some patients have paranoid delusions, believing that others want to hurt them. Delusions of reference are common, in which the patient believes that something in the environment is referring to him or her when it is not (such as the television talking to the patient). Delusions of control are beliefs that others can control one's actions. Patients hold these beliefs strongly and cannot usually be "talked out" of them.

Thinking Disturbances. The patient talks in a manner that is difficult to follow, an indication that he or she has a disturbance in thinking. For example, the patient may jump from one topic to the next, stop in the middle of the sentence, make up new words, or simply be difficult to understand.

Patients with apathy often have little sense of purpose in their lives and have few interests.

Anhedonia. The patient experiences little or no pleasure from activities that he or she used to enjoy or that others enjoy. For example, the person may not enjoy watching a sunset, going to the movies, or a close relationship with another person.

Poverty of Speech or Content of Speech. The patient says very little, or when he or she talks, it does not amount to much. Sometimes conversing with the patient can be unrewarding.

Inattention. The patient has difficulty attending and is easily distracted. This can interfere with activities such as work, interacting with others, and personal care skills.

Stress vulnerability model

What is the stress vulnerability model?

The stress vulnerability model first defined by (Zubin and Spring 1977), this model proposes that individuals with a vulnerability to psychosis, such as those with first degree relatives with a diagnosis of mental illness are at a proportionate risk of developing a psychosis as their stress levels increase. Put simply the Stress vulnerability model is an idea that people become ill when the stress they face becomes more than they can deal with.This model also looks at how people deal with stress differently i.e. some people may be able to take a particular problems in their stride as opposed to someone else who faced with the same problem may not be able to cope and subsequently become psychotic, mentally un well or experience a relapse of an existing mental illness.The model also attempts to give an explanation of why some people experience psychosis and other people do not.Can you think of a time in your life when you may of experienced an increase of stress in your life?What is stress?

There are numerous definitions of stress. One definition by (Lazarus & Folkman 1984) describes stress as the occurrence of significant life events that are interpreted by the person as undesirable. Health professionals have also categorised these events into major and minor.

Implementing change

Discuss a practice development initiative / implementing a changeDiscuss:

Leadership styles Autocratic / democratic Transformational Motivation of others delegation Life long learning / education Lewin / force field analysis [frozen / unfrezze / refreeze] Kotters Change Model NHS Change Model

Clozapine Quiz

CLOZAPINE IS BEING USED MORE AND MORE IN PSYCHIATRY AND THERE ARE PATIENTS ON ESKDALE WARD WHO TAKE CLOZAPINE, SEE

HOW MUCH YOU KNOW……..

FOR EACH STATEMENT DECIDE WHETHER EACH STATEMENT IS TRUE OR FALSE

DON’T WORRY IF YOU DON’T KNOW ALL THE ANSWERS TRY TO LOOK THEM UP

Q1: Why do patients need regular blood tests whilst taking clozapine? a) To check that they are taking it b) To check that it is effective c) To check for toxicity

Q2: The regular blood tests measure: a) Level of clozapine in the blood b) Red blood cell count to check for anaemia c) White blood cell count to check for neutropenia

Q3: Patients who are prescribed Clozapine must: a) Have a history of non-compliance with other drugs b) Have failed to respond to at least two other drugs c) Have a diagnosis of Schizophrenia

Q4: The following drugs can be safely administered with clozapine without additional monitoring: a) Diazepam b) Haloperidol c) Carbamazepine d) Amisulpiride e) Antibiotics

Q5: The following are common side effects of clozapine: a) Skin rash b) Hypersalivation c) Constipation d) Insomnia

Q6: The following tests should be undertaken before a patient starts Clozapine: a) ECG b) EEG c) LFT’s d) WBC

Q7: Patients starting on clozapine must: a) Start on 12.5 and have their dose increased over several weeks b) Be an inpatient c) Have regular monitoring of pulse, temperature and blood pressure

Q8: Clozapine must: a) Must always be prescribed by a pstchiatrist b) Can only be dispensed by registered pharmacies c) Can only be prescribed to registered patients d) Is only available from one supplier in the UK

Q9: Patient who have a red result should: a) Continue taking clozapine with daily blood tests b) Stop taking clozapine until blood tests improve c) Stop taking clozapine immediately and cannot restart

Q10: A patient who has neutropenia must: a) Be admitted to a mental health unit b) Be admitted to a medical ward and barrier nursed c) Be monitored for signs of infection and may need antibiotics

Q11: A safest antipstchotic to prescribe for a patient who has a red result is: a) Olanzapine b) Risperidone c) Chlorpromazine d) Haloperidol

Q12: Patients who are taking clozapine need regular compliance checks because: a) They must not be allowed to hoard tablets as they are dangerous in overdose b) It is important not to run out of tablets and they must remember to collect their medication at the right time. c) If they stop taking clozapine for more than 48 hours, they need to be reinitiated at 12.5mg

Q13: A patients compliance can be checked by plasma levels: a) They are performed regularly using samples that are sent to the lab for the WBC b) They can be ordered separately from any hospital lab c) The sample must be taken around 12 hours after the last dose is

taken

Q14: Which of the following side effects are dose related: a) Neutropenia b) Sedation c) Hypotension d) Hypersalivation

Q15: Dietary advice is necessary for taking clozapine because: a) It can cause constipation – adequate fibre and fluid intake is important to prevent it b) It can cause weight gain can be minimised by healthy eating c) Certain foods need to be avoided as they can cause a dangerous rise in blood pressure

IF YOUR NOT SURE OF ANY OF THE ANSWERS THEN HAVE A GO AT LOOKING THEM UP! ONCE YOU’VE DONE THAT CHECK IT WITH THE ANSWERS BELOW TO SEE HOW YOU DID !!

CLOZAPINE QUIZ- ANSWERS`

Q1: a) FALSE - Regular blood tests do not measure the amount of clozapine in the blood so cannot be used to monitor compliance.

b) FALSE - As a) above

c) TRUE - Regular blood tests measure toxicity relating to the ………………………………………………………………………………………...

Q2: a) FALSE - As Q1 a) above

b) FALSE - Red blood cells are not checked

c) TRUE - The different types of white blood cells are counted and compared to normal values i.e. white cell differential ………………………………………………………………………………………...

Q3: a) FALSE - Clozapine is only available as a tablet and must be taken regularly: It is not the ideal choice if the patient has a history of poor compliance. b) TRUE - Clozapine is the only licensed drug for treatment resistant schizophrenia NICE guidelines recommend its use in patients who fail to respond to two antipsychotics. c) TRUE - Clozapine is licenced for treatment-resistant schizophrenia but it can also be used in very small doses to treat psychosis in Parkinsons disease.

………………………………………………………………………………………...

Q4: a) FALSE - All benzodiazepines carry a risk of respiratory depression when used with Clozapine.

b) TRUE - Haloperidol is one of the safest antipsychotic to use whilst increasing the dose of Clozapine.

c) FALSE - Carbamazepine must NEVER be given to a patient who is on Clozapine as it too can cause neutropenia.

d) TRUE - There is evidence to support the prescribing of amisulpride or sulpride in addition to Clozapine to improve symptom control.

e) FALSE - Some antibiotics e.g trimethoprim, cannot be given to patients on Clozapine. It is very important to check

which antibiotics are safe to use.

………………………………………………………………………………………...

Q5: a) FALSE - Skin rashes are not a common side effect

b) TRUE - Hypersalivation is very common, especially at night and can be treated by hyoscine hydrobromide.

c) TRUE - Constipation is very common and many patients need regular laxatives and dietary advice. It can lead to intestinal obstruction on rare occasions and can lead to changing blood levels of Clozapine.

d) FALSE - Clozapine often causes sedation and patients affected prefer to take most of their daily dose at night. ………………………………………………………………………………………..

Q6: a) TRUE - Clozapine can be cardiotoxic and a baseline ECG is recommended.

b) FALSE - An EEG is only needed if a patient has fits on Clozapine and further investigations are indicated. Doses over 600mg (total once day dose) have a higher risk of fitting.

c) FALSE - These are not needed.

d) TRUE – This is needed to register patient with the monitoring service before commencing clozapine. A different white blood cell count is required as a base line: the neutrophils and platelets must lie in a specific range.………………………………………………………………………………………..

Q7: a) TRUE - The standard regime increases slowly however, if retitrating after a short break, the dosage can be increased faster.

b) FALSE - Recent licence changes now allow home initiation but monitoring must be regularly undertaken.

c) TRUE - Regular ‘obs’ are vital to monitor physical side effects.

………………………………………………………………………………………...

Q8: a) TRUE - GP’s in this trust area cannot prescribe Clozapine: only registered consultant psychiatrists can initiate new patients (and those registered for treating psychosis in Parkinsons disease).

b) TRUE - Pharmacies also need to be registered: in this trust area there are no registered community pharmacies. Supplies come from a hospital pharmacy or HomeLife.

c) TRUE - All patients must be registered with CPMS or equivalent. One patients Clozapine must never be used to treat another patient.

d) FALSE - Three companies now produce Clozapine: Denfleet (Denzapine, Ivax (Zaponex and Novartis (Clozaril). Each has its own database for recording blood test results.

………………………………………………………………………………………... Q9: a) FALSE - Clozapine must be stopped immediately

b) FALSE - Clozapine cannot be restarted even when blood tests improve.

c) TRUE - Only in exceptional circumstances can a patient be rechallenged after a red result. This use is unlicensed and the consultant would have to take full clinical responsibility

………………………………………………………………………………………...

Q10: a) FALSE - Depends on patients mental state: he/she may be better managed at home.

b) FALSE - Depends on neutrophil count, temperature and other signs of infection.

c) TRUE - Mouthwashes and antifungals are also usedQ11: d) Haloperidol - Safest to use as it doesn’t affect white blood cells.

………………………………………………………………………………………...

Q12: a) TRUE - Clozapine is dangerous in overdose: Patients with a

history of self harm need close monitoring and might need weekly supplies.

b) TRUE - Robust arrangements must be in place c) TRUE - Retitration is necessary if this occurs

………………………………………………………………………………………...

Q13: a) FALSE - No, a separate sample is required b) FALSE - They must be sent to the Toxicology Unit as Guys hospital.

c) TRUE - If the sample is taken shortly after a dose is taken, this will not give a true plasma level

………………………………………………………………………………………...

Q14: a) FALSE - Can happen even at small doses, at any time but most likely to occur in first 6 months.

b) TRUE - Night time dose is usually larger because of sedative effect

c) TRUE - Minimised by slow titration of dose

d) TRUE - Hyoscine can reduce secretions and is often added to regime.

………………………………………………………………………………………...

Q15: a) TRUE - Constipation can lead to fatal obstruction: laxatives should be offered

b) TRUE - Weight gain is common but not inevitable

c) FALSE - MAOI’s are the drugs that require dietary restriction

Student Placement Evaluation

Please could you complete this short questionnaire to give your feed back about your recent placement. We value your honest and frank opinions and aim to use the feedback to enhance and develop the learning environment and experience for all future students. Your feedback is very important to us.

1. What did you like best about the placement?

2. What did you like least from the placement?

3. What changes could be made to facilitate your learning experience?

4. Could anything extra be added to this document?

5. Any Other Comments?

Acknowledgements This welcome pack was put together by Samuel Fowler (Student Nurse) and Jennifer Hodgkiss with the help from Alan Shepley and Kate Tasker Please comment if you would like anything else included that would be helpful to students in the future.

Thank you