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super7577

Poor nurse performance. What would you do?

48 posts in this topic

A 30 year was referred to the Crisis Team by the GP about 3 months postnatally with obvious symtoms of moderate postnatal depression. The Crisis Team decided to mange the case themselves without getting a doctor involved.

A nurse kept seeing the patient for 6 weeks doing nothing apart from 'chatting' to her weekly. She kept focussing on her 'distress' related to difficult childhood for which she referred her for psychotherapy assessment. Depressive symptoms were never elicited neither any proper treatment offered.

The patient's GP finally prescribed her an antidepressant at 4 months that resulted in rather emarkable and quick recovery. I saw her at 4 and half months when the symptoms had almost resolved but she had never been told what was wrong with her and how it could be treated.

Sad state of affairs that maks you feel rather sorry for the New Ways of Working by incompetent people. This happens so often. No one bats an eyelid and patients continue to receive shoddy care.

Would anyone in my position have taken any action? I'm not sure what I should do? Any thoughts? (please don't say 'Talk to your consultant'...increasing medic impotence!)

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What is important is not how it appears to you, but how it appears to her.

Was she asking for more? Was she unhappy with what she got? If she has had a shi*ty childhood and she's feeling happy 4 months after having a child of her own, without anyone telling her she has a chemical problem in her brain- I'd call that a result. It's not the medical model, but medical explanations are not the best relief to all, in all circumstances...

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I work in a Crisis Team and i am speaking from experience.

Incidents like this can happen to anyone but definitely more with colleagues with less experience.

In regard to your case i believe it all boils down to having medical input within a Crisis Team and the necessity to reiterate that every new patient seen by nurses or SW be seen asap by medical personnel.

An important question to ask is who is the RMO even when the patient is under the Crisis Team. There should be a Consultant who is responsible for every patient taken on by the Team.

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Excuse me- trying to understand a patient's distress is NOT poor nurse performance. Try and think outside the medical model.

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Ros - are you being tongue-in-cheek?

Letting another human being suffer for four months only for a rapid recovery after the prescription of appropriate treatment is not 'understanding a client's distress'.

It is poor quality care.

The medical model has its place - do not underestimate OUR skills.

F_S

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Would she have naturally recovered if the antidepressants were not started by the GP?.

she already had few weeks of 'regular support' from the nurse which might have caused improvement in her symtoms,may be its chance that she improved when medication have been added.

in postnatal period-may be she was breastfeeding the baby,and might have thought not to take any medication which might have side effects on baby.

Have you talked with the nurse whether she discussed the option of medication with service user

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Sure- I would not have started this thread if any treatment had been offered to her earlier.

The question is not what led to her recovery eventually-could be a combination of several factors.

The question is why the patient's illness was not diagnosed timely(even someone with an IQ of 50 can feel someone else's distress!) and why was medication or proper psychological treatment not offered. Is 'chatting about distress' fo 6 weeks an evidence based treatment for depression?

This concept of medical and psychosocial model is the most nonsensical thing I've heard. The basic issue is to offer a treatment (medication, psychotherapy, even blackmagic if of proven usefulness) that has a higher chance of working as shown by research or experience.

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My experience with nurses has been different. They are brilliant and the future of psychiatry is in their hands. I have seen more incompitent doctors than nurses.

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I think it is extremely difficult at times to make out the difference between an adjustment disorder or major depression...

Moreover, even in chatting, we use a lot of cognitive and behavioural strategies inadvertantly...

I suspect the nurse would have had a reason for taking the decision...

With the new ways of workign coming up, each person is responsible for their patient... so if a patient has not been seen by the consultant, it is not his/her responsibility... and thats what the GMC says I guess...

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I believe that there are those good nurses who go on to become efficient nurse practitioners but there are quite a few bad nurse practitioners as well. I am not sure about the training in ICD and pharmacology they receive as we are char grilled in the Mrc Psych exams . They however have a natural flair for CBT techniques as they often tend to know the patient as a person very well which can be therapeutic.

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If the patient's mental health had deteriorated to an extreme level ie suicide and homicide! Who is ultimately responsible? The buck stops at the Consultant in most places.

It would be great if doctors are not solely responsible for the care of their patients . I dont think it has reached that stage as yet , thankfully. :o

I believe the Nurse is too blame. Hence the reason for saying patients need to be soon asap when referred to such Teams.

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An important question to ask is who is the RMO even when the patient is under the Crisis Team. There should be a Consultant who is responsible for every patient taken on by  the Team.

patients who are not detained under the MHA do not have an RMO. Consultants (and other docs) are not responsible for the care of patients they have not seen nor are the responsible for the care of patients they have seen, but they are responsible for what they do (or do not do).

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Excuse me- trying to understand a patient's distress is NOT poor nurse performance. Try and think outside the medical model.

i agree with the first part, but i wonder what the second part means.

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I can not find some of the pieces of the jigsaw here. Can u tell me how the patient went to the GP after a few months? Was she asked to go there by herself by the nursing team, or the patient herself went to her GP for whatever reasons? Plus how did she then come to be in your OP clinic? Through the GP? crisis team?

Finding out this information would be valuable in this case. :) :) ;)

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Excuse me- trying to understand a patient's distress is NOT poor nurse performance. Try and think outside the medical model.

Are doctors necessary ??????????????????????????????????????????. If nurses can do everything? I have absolutely nothing against them but their forte is [highlight]nursing[/highlight] and that is what they should be doing. It seems like they are doing everything but these days. And why should wwe think outside the medical model. May be if we start doing that we shd give up our GMC regustration. It is useless to pay 395 pounds ayear to think outside the medical model. I am just fed up with the way the role of the doctor is being undermined. We have speccialised knowledge and skills and we and others shd acknowledge that.

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Sore point with me, guys. I had PND myself. Don't underestimate the power of psychosocial support and depathologising which as doctors we are NOT good at generally, but which is often an important part of different psychotherapies, particularly systemic. Fair enough if she needed antidepressants, but there is nothing wrong with a stepped care model.

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If some one who is supposed to cannot differentiate mild from moderate depression then this speaks for itself. I was reading through a patients past records yesterday and found that this 66 yr old lady(frail, socially isolated, living alone for past 20 yrs, no children, estranged from her brother and mother, memory problems) was seen by a mental health practitioner in the A&E following an OD of her antihypertensive tablets, and her management plan said' Advised to join a gym to build up social contacts'. I am still chuckling away.!!!!!!!!

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Nurses have competency training. I haven't signed one assessment form. Also they need to have 360 degree appraisal. Again I have not filled any forms for any nursing tudents or nurses yet. maybe I am not around much?!!

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My experience with nurses has been different. They are brilliant and the future of psychiatry is in their hands. I have seen more incompitent doctors than nurses.

Freud I am surprised. Doctor bashing seems to be the new mantra nowadays. Condemn doctors and praise nurses and u will be seen as progressive and elite. I know a few rubbish doctors too but that doesn't make the nurses doctors. they are what they are ie good nurses, period, full stop. Nursing is a completely different skill.

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What is everyone's understanding of what nurses should be doing? What are their skills? Their role has changed significantly over the last 5-10 years, it is not clear what we should be expecting from their discipline. These may be some obvious questions but it may be useful to clarify these points to continue with this debate.

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My understanding is that nurses are good at offering friendly support and filling in forms for various assessments. However, their understanding of illnesses and the treatments is almost non-existent. A layperson can also tell whether someone is 'mad' or 'sad' but secondary care should be more sophisticated that this. It should be about excellence rather than providing informal support. The ability to analyse clinical problems takes years to develop and does not come easily without a theoretical foundation. Nowhere in the world (I mean NOWHERE) have nurses been asked to be clinicians in areas where there is no deficiency of doctors.

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What is important is not how it appears to you, but how it appears to her.

Was she asking for more? Was she unhappy with what she got? If she has had a shi*ty childhood and she's feeling happy 4 months after having a child of her own, without anyone telling her she has a chemical problem in her brain- I'd call that a result. It's not the medical model, but medical explanations are not the best relief to all, in all circumstances...

hear hear..  ;)

im working with the NWW model.. and one of the disadvantaegs of it is just what you (not you ros. the OP) spoke of..

i.e. nurses not referring to doctors when its necessary..

on the flip side.. nurses are under pressure to refer to doctors only when necessary.. and she might not have felt it necessary at the time..

its what she felt at the time.. if she felt she was bad enough to require antideps then she wouldve asked the GP / Psych doc to prescribe one..

looks like she didnt.. maybe she made a bad judgement call..

but on the flip side.. kudos to her for not taking the knee jerk reaction most of us as doctors take..

i.e. patient unwell.. now which pill can i give her?

crisis resolution teams are much maligned.. they take the most difficult patients and its a fricking thankless job..

what about poor doctor performance?

and poor consultant doctor performance..

the same consultants who prescribe olanzapine by the bucketload..

who say.. prescribe the patient lithium.. if she gets hypothyroid.. give her a thyroid replacement pill..

who focus on risk but dont give a rats ass about the patient..

ahh.. id better stop.. before i really get started..   :)

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Asking nurses to be clinicians is a typical politically motivated stopgap measure and there might be several reasons for this, one of these might be monetary, doctors expect more. But these will have serious repercussions. Even with nurse prescribers, docotrs are still asked to prescribe even simple things like paracetamol and gaviscon. It seems nurses as a profession and other professions as well eg social workers etc want greater power which they have got but dont want the responsiblity that comes with it.

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[highlight]kudos to her for not taking the knee jerk reaction most of us as doctors take..

i.e. patient unwell.. now which pill can i give her?[/highlight]

[highli[highlight]ght]the same consultants who prescribe olanzapine by the bucketload..

[highlight]who say.. prescribe the patient lithium.. if she gets hypothyroid.. give her a thyroid replacement pill..[/highlight]

who focus on risk but dont give a rats ass about the patient..[/highlight][/highlight]

ahh.. id better stop.. before i really get started..   :)

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My experience with nurses has been different. They are brilliant and the future of psychiatry is in their hands. I have seen more incompitent doctors than nurses.

Another recent scenario,

I get called by a nurse on an elderly ward, Doctor the patient is trying to leave the ward, pleas ecome and put him under 5(2). I go there, patient is 84, depressed, psychomotor retardation, took 5 min to get out of the chair. I speak to him and he says he wants to go home, because he wants to get a change of clothes, his daughter who was supposed to visit has not visited him. I spend 10 min explaining that he cannot go, staff will get in touch with daughter, situation resolved.

While I am there I decide to check upon another patient I had seen few days ago and get told he is absolutely fine, has some blood results just come back. I look at the results Na 123, Have you told anyone about this I ask. I get the reply no.PANIC PANIC, I immediately ask to see the patient.

Future of Psychiatry???????? GOD SAVE.

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