Hey fine folks, feel free to ask me anything regarding the NSW Mental Health Act (2007) and what to expect if you, a loved one, or a friend are *scheduled by police, ambulance officers, or mental health professional. Please keep in mind that I am unable to comment on your personal experiences, the suitability of the medications you have been prescribed, or your diagnosis.
*Scheduled - detained as an involuntary patient under the NSW Mental Health Act (2007)
Is it because you misspelt you're? :P
I'm not shaw
What's the weirdest thing you've seen a patient do?
That's hard to quantify. I've seen some very strange behaviours over the years. I've witnessed a few particularly unwell patients over the years consume their own faeces. That's always tough to deal with.
Yesterday I watched a guy on Hay St, Perth, stage a concert. Im sure he was there. He had the microphone, the stage, the crowd….. he hit the high notes…. what a performance.
Shame he was just some meth head really.
Is this known as a 'code brown'?
Had a feeling that I shouldn't have read this thread during lunch break. :)
Any savants?
No savants. To be scheduled under the NSW MH Act you must pose a danger to yourself or others. Having a mental illness or intellectual disability does not in itself mean you are a danger to yourself or others.
Every tried triple integrals? or fourier transforms?
I'm pretty sure I was a danger to myself at that point during uni.
I have a mate who is a Mental health nurse in Adelaide and the stories he tells are traumatic to say the least. I am not sure they could pay me enough.
He is constantly spat at, abused both verbally and physically, and is mindful of his personal safety each and every shift. He said they prefer males nurses at the secure unit because of the intimidating nature with some of the patients. Its mostly a high proportion of drug and alcohol related problems with many patients getting younger and younger. These days he chooses to work shifts presumably when most are all asleep…
Mental Health nurses are regularly verbally abused and physically assualted by psychotic patients. While this is completely unacceptable, patients who are psychotic are not able to distinguish reality from their delusion. In NSW, the overwhelming majority of mental health nurses are female. There is a policy that every unit must have at least one male and one female nurse on duty. Male and female patients have the right to be cared for by a nurse of their own gender if possible and practical.
patients are regularly verbally abused and physically assualted by Mental Health nurses across Australia.
no-one working within the system breaks the code of silence.
You must love 10 + 10
Hey Harley, how's the Joker doing?
For violent patients, How do you deal with the fine line of defending yourself vs misconduct?
Nurses can only defend themselves in a defensive capacity. That means we are not allowed to assault a patient in our own defence. We must take evasive action and retreat to the nurses station whenever possible. We carry duress alarms which are activated by throwing them on the floor or pressing the button on them. This initiates a "code black" emergency which gets relayed to hospital security guards and all other nursing staff on duty in the unit.
"That means we are not allowed to assault a patient in our own defence."
Yes we are to a reasonable degree and in defence. As with all other human beings. You think those 2 dead mental health nurses in Orange did not have that right?
Nurses are never allowed to assault patients. We can restrain a patient who poses an imminent danger to themselves or us, nothing more. Do any more than that and AHPRA will call you in to explain why your registration should not be revoked.
@[Deactivated]: Alrighty then, if someone is literally stabbing your colleague multiple times lets just wait for the code team or police to arrive.
@Jaystea: No I am not. Check the legal definition of assault. Also check the law on defence of self and others. In no way is one or two or even three nurses or staff is going to be able to effectively “restrain” someone who has deadly intent. What then are you going to do if someone is already actively trying to killing someone?
The example I gave is a concrete one and occurred in Orange NSW in 2011. One mental health nurse dead and one gravely injured. Do you honestly believe that they never had that right to use reasonable force to defend themselves?
@pao2x: I think you're splitting hairs about the definition of assault - I'm fairly sure that the use of force, even deadly force if warranted, is allowed in cases of self-defence, even if such actions would be legally classified as "assault".
@pao2x: Oh right, yeah I'm saying OP actually agrees with you, but is just using a different definition of "assault" (i.e. the criminally culpable with no legal defence kind).
@HighAndDry: Not entirely, restrain is a technical term and if all we are allowed to do is restrain then that limits reasonable defensive use of force.
@pao2x: Yeah - no I get what you're saying, I'm actually not sure whether OP is just slightly misspeaking (because I honestly can't imagine their only recourse being attempts to restrain a patient if the patient is presenting a threat), or if their internal policies are actually that boneheaded.
@HighAndDry: HighAndDry is right - pao2x is using hospital terminology - they can defend themselves until they can get to safety. What that looks like is different depending on the situation, but it's all about intent. If the intent is to defend and restrain it's not assault, even if it looks like it on CCTV (that said there is a line).
@MessyG: & @pao2x Defend and restrain is legal. Assault is not something you would say nurses and medical officers do. Restraints are physical or chemical. However you wouldn’t consider this assault as the intent is not to cause harm but to prevent harm from self and staff. @MissG If I recall you are a medical officer. You would have seen this in your career. As a CNE there has been many times we have had to chemically sedate patients due to risk of harm to self and to staff. Problem is if it’s a repeated occurence the scheduled act allows the use of force to be used. If not scheduled the limitations are generally restricted to evade patients
@maverickjohn: I think this is still just a matter of terminology. For example, if a patient is being violent and rushing a nurse, pushing them away would be both "defend" but also "assault" by the legal definition - just a case where the assault has a valid legal defense.
What do you love and hate most about your job?
The best part of my job is seeing patients leave the unit healthy and well. The worst part is dealing with drug and alcohol patients who game the mental health system to avoid criminal charges or pending court cases.
Do you think of these people as mentally unwell due to the sociopathy related to gaming the system and faking emotions to get places. Ulitmately there lives are not better off having done this even if it relieves them of more serious consequences. Putting yourself first and foremost anyway you can is human even if it is poor.
The worst part is dealing with drug and alcohol patients who game the mental health system to avoid criminal charges or pending court cases.
That's a pretty sweeping statement you've made there, and it's not clear to me you're in a position to make it - you don't necessarily know what goes on in court, and you're not an expert in court process.
I'd much sooner be convicted and do a little time and know i'll get out, than try to get scheduled whereby i could be confined forever.
There is a real incentive for some people to be classed as psychotic than not if they have committed a felony. If a psychiatrist makes the judgement that a patient is not in capacity then they will be committed to another facility instead of prison, or perhaps be given a lesser charge altogether. That said, I don't believe that any drug and alcohol patients are looking to game the mental health system. Usually drug patients present with substance induced psychosis and the alcoholics with suicidal ideation on the background of an adjustment disorder or something with underlying personality structure. All that resolves pretty quickly after a crisis admit.
@D0NALDTRUMP: Many people with drug and alcohol addictions are homeless and need a bed for a night or two. Those in the know present to ED and claim to be having suicidal thoughts for example. They can't be turned away.
@[Deactivated]: I suppose the point I was communicating poorly was that there was nothing inherent to alcohol or drugs that make/cause those patients to game the system for court cases or whatever. I see the wider point you are making and I agree. Sometimes you don't have to admit suicidal patients. If they have a history of presentations where they've been admitted yet continue to present frequently as if nothing's changed, you can say that a hospital stay is detrimental to their mental health / fails to contain risk and is counterproductive. Discharge to community. Make the onus on them to engage supports.
@D0NALDTRUMP: We regularly have patients present to ED a day or two before their court dates and claim to be unwell. Again, we can't turn them away. In this day and age there are serious consequences for turning someone away who does then go off and hurt themselves. Only a very experienced psychiatrist would have the confidence to turn away someone from ED who is claiming to be suicidal.
@[Deactivated]: I agree with the gaming the system part. My point wasn't meant to be contrary to yours. re: discharge… It's a rare thing and doesn't happen for new presentations, only in circumstances I specified and again, rarely.
@D0NALDTRUMP: Sorry, I misinterpreted your reply. Look, I don't begrudge anyone a bed really, it's the cost to the system and the taking of a bed away from a patient in real need that gets up my nose. The whole drug and alcohol rehab system needs to be overhauled and given a massive funding boost. It's a shambles.
We regularly have patients present to ED a day or two before their court dates and claim to be unwell.
Well if my court date was coming up i'd probably be more vulnerable as well.
The narrative that people 'game' the system can be very easily weaponised to argue a reduction in overall funding in mental health. I'm not sure that's where you want to go…
@[Deactivated]: I’m also a Psych Nurse. People definitely play the system. I see it every day. I work both in Private and public. The public hospital I am at is treat like a hotel for some of the patients. I’ve been told by patients personally that they AirBnB their apartments out when they come in for admission.
@digitalbath: Can’t edit my post. But that should be Private patients treating our facility as a hotel.
@digitalbath: I should say i have no inside or personal knowledge of what goes on inside one of these units, but i do have a bit of an idea of the legal framework and how policy arguments play out when it comes to funding decisions. I see some parallels between what i'm reading and hard-line arguments surrounding refugee policy.
Hey, thanks for doing this - just wondering what strategies for developing insight in consumers? and can you tell me more about seclusion rooms and how they're used?
cheers
My apologies for the slow reply, I missed your good question. Insight comes with wellness so we can only usefully employ strategies for maintaining that insight towards the end of a patients admission. Patients suffering schizoaffective disorders will generally never be able to maintain a sufficient level of insight to prevent relapse. When a patient is nearing discharge they will have sessions with our psychologist who will tailor individual strategies to develop and maintain insight.
We seclude patients for their own safety and the safety of staff if they become violent or acutely suicidal and need to be chemically restrained [injected with sedating medications]. Seclusion is a last resort and NSW Health is currently reviewing seclusion practices in mental health units and has set a seclusion reduction target of 25% for all units, however this is somewhat impractical because of the fluid nature of the acuity levels in high dependency mental health units. On average, my unit secludes one or two patients a month.
thanks for the reply shenanigan. I'd be interested to know why you hold such a pessimistic view about schizoaffective disorder. I wonder if it's the mood component that adds to the challenge of preventing relapse (ie the need to take both an antipsych and a mood stabaliser).
re seclusion rooms, glad to hear about the reduction target!
Nurses are human and they make mistakes. We pay a heavy price for our mistakes.
There should be systems in place to prevent this happening, like doctors must sign off on every check out, or an interview being required before a checkout, or not making nurses or doctors have to work such long shifts. The sector needs more funding.
Doctors and psychiatrists are not generally stationed in mental health units, they visit the unit to conduct mental state examinations and patient reviews. It is during these reviews that doctors and nurses discuss patients suitability for leave. Only nurses can sign patients out of the unit. We have the authority to cease a patients leave if we feel they are not well enough. I agree that nurses and doctors are overworked and fatigue leads to errors which can have disastrous consequences. And yes, we desperately need more funding.
Checking her for what? Was she supposed to ask 'are you going to go kill yourself?' and also expect an honest answer? Sounds like you're laying blame in the wrong place.
It is akin to a doctor disconnecting someone from a breathing machine or cutting off the wrong limb.
Don't be absurd, this is nothing alike.
If you check yourself in as a voluntary patient, do you lose the right to leave?
@Baysew: Yes you can - you get checked by a doctor on arrival have an order made out. In her case she could detect the suicidal feelings getting higher and higher and made sure to get herself in before they got too much to escape. This tended to happen every couple of months and she would usually have to stay 2-3 days before the doctor would say she was safe to return to her supported accommodation. If she didn't get better in that time she would be transferred to a long stay facility in the other hospital where there was access to a wider variety of treatment (the Canberra Hospital only has very limited emergency mental health services).
@Quantumcat: I'm sorry to what happened to your friend, the difficult part is that sometimes people can think they are doing well and doing better and the moment they step out, the world comes crashing. It's not the doctors or the nurses job to sit there and read minds to understand if they are telling the truth or not and even so, at times you cant watch someone 100% of the time to understand whether they are safe or not.
It's not the doctors or the nurses job to sit there and read minds
Actually it is, it's their job. People seem to think that mental health illnessed are not real illnesses. If a doctor makes a mistake in a physical illness and the patient died everyone would be up in arms. Just because the mistake caused the patient to bleed out instead of killing themselves doesn't make it any different. You can't just tell the haemorrhaging person "well you should have kept your blood in". This is the same as telling someone with a mental illness "just stop feeling and acting that way".
@Baysew: Voluntary patients are not automatically afforded leave. Voluntary patients are vetted for leave in the same way that involuntary patients are. Further to this, voluntary patients do not have the right to discharge themselves. This is a huge unknown in the community. Voluntary patients will often be scheduled by the nurse-in-charge [NiC] (if they demand to be discharged) until the patient can be reviewed by a psychiatrist. If a NiC schedules a voluntary patient that patient must be reviewed by a psychiatrist within two hours and the involuntary schedule is usually upheld by the assessing psychiatrist.
I see where you're coming from.
They certainly do have a DOC, and because of that there's a certain standard of care that they need to satisfy, and if they don't meet that standard then they have been negligent and can be held to account for that negligence.
There's a bit of a history of compounding failures in mental health cases, especially in NSW. They get ventilated with inquests and families suing in negligence.
Fact is though a lot of the issues are probably less to do with the nursing itself, and more to do with systemic issues and state funding certainly is a big factor in that.
Fact is though a lot of the issues are probably less to do with the nursing itself, and more to do with systemic issues and state funding certainly is a big factor in that.
That's exactly what I think. It probably comes from people believing that an illness they can't see doesn't exist, so doesn't deserve funding like an illness you can see the effects of like cancer. Sadly this is an opinion held by most people - until they experience a mental illness or have a loved one that develops one.
@Quantumcat: sorry to hear about your experience and your friend. The truth is that we have very poor methods of detecting suicidal risk. I agree more should have been done. The questions is.. more of what?
a common misconception is that hospital is always good for the mentally ill. This is not always true. A hospital can actually increase your risk. Long hospital stays can become non-therapeutic. very little 'getting better' happens in the hospital. the real work is done by the patient outside of the hospital and in the community. the hospital can only contain the risk if it's an acute exacerbation of suicidal ideation. it won't make it go away.
we have very poor methods of detecting suicidal risk.
Maybe in the general case but not here. She had had bipolar depression for many years and they had a long history. They knew exactly what was going on, it was very well documented in her files and the doctor that triaged her documented that she needed to stay under observation and not be allowed to leave.
If you don't have any experience of being treated for mental illness yourself or of loved ones you aren't qualified to spout platitudes. This is a clear failure of the medical system. Whether the nurse at the desk was overworked and tired because they didn't have enough staff, or they misplaced her files, or they read someone else's instead of hers, I don't know. But it was a failure.
@D0NALDTRUMP: its very revealing all the negs being thrown at Quantumcat for having their say about an avoidable tragedy. I wonder what this thread is really about, the 2 hander, nsw mental health etc.
no-one cares much about anything anymore let alone the mentally ill. they are more vulnerable than children and have far fewer protections.
@petry: I think quantum is right to be upset that their friend passed away and it's probably true that if the friend wasn't detained then they might not have passed away. Mental illness is hard to understand and not even psychiatrists can be expected to read someone's suicidality accurately.
@petry: I object to the fact that Quantumcat is blaming the nurse as though she knows for a fact that the nurse did something wrong, when the fact is she wasn't there, don't have all the facts, and mental illness is still badly understood and hardly an exact science.
If you don't have any experience of being treated for mental illness yourself or of loved ones you aren't qualified to spout platitudes.
I'd say if you didn't have any mental health qualifications, you aren't qualified to spout platitudes - for example, being a cancer patient doesn't make you an oncologist. I get that you're emotional about your friend, but you obviously weren't there - only your friend, the nurse, and whoever the treating physician was (if they were there) are really in a position to comment.
@Quantumcat: Don’t start blaming the staff for this. If she was allowed to leave there would have been a medical clearance granting her discharge. People are very quick to blame staff particularly nursing staff for not managing appropriately. You don’t know the amount of stress staff undergo each day. How many assaults they have to be subjected to, how much stress from senior management and how much patient flow is a priority for hospitals in general. I can almost guarantee it with 99% certainty that nurse would not have discharged your friend without being reviewed by a medical officer and granting clearance for discharge.
Just because a doctor doesn’t see them on discharge doesn’t mean they hadn’t seen your friend earlier.
@maverickjohn: Me:
The sector needs more funding.
You:
Don’t start blaming the staff for this.
I am blaming the system not the staff. The nurse that let her out was probably on the tail end of a 12 hour shift and doing 3 people's work.
If she was allowed to leave there would have been a medical clearance granting her discharge.
There was not. I went through all this at the time (well her mother did mostly and I did some further research with the information she gave me from talking to the staff and doctors). She was detained and was supposed to be checked every hour by a doctor at the time. Under no circumstances should she have been allowed out without supervision.
@Quantumcat: your quote exactly ' My best friend died because the psychiatric nurse in the mental health unit of the Canberra Hospital let her sign out without checking her at all ' so yes you are blaming the psychiatric nurse in this case. when you have mentally ill patients as you mentioned there could have been bipolar behaviours, especially if this is something that had happened a few times. she could have been saying to the doctors i'm doing better my mind is in a good headspace for them to have let her out and the moment she stepped out that could have crumbled. unless there is a doctor there 24/7 which they have other patients then perhaps they would be able to detect a sudden and sporadic change in their behaviour which could have been odd.. you also mentioned 'If you don't have any experience of being treated for mental illness yourself or of loved ones you aren't qualified to spout platitudes' each patient is treated differently and i would hardly say that because you are the loved one that makes you qualified to spout platitudes, you unfortunately do not know what was going through your friends mind at the time.
Last comment was too harsh. Let me try again: I feel she died because she was mentally unwell and threw herself off a bridge.
To blame the nurse would be akin to blaming yourself because you were her best friend - nurses are people too, and there's only so much anyone can do when someone is set on self-harm. Consider that she voluntarily walked out of the psych ward - she obviously no longer thought she was suicidal, and if she didn't, she would not have reported herself as feeling suicidal to the doctors or nurses there.
In my experience, when someone has true intent to harm themselves or take their own life, it is almost impossible to stop them. Human willpower is incredibly powerful and people generally find a way to do what they want - it just so happens sometimes we are lucky enough to stop them.
I've seen a patient who took their own life in a hospital; it is sad, but it does happen.
In my experience, when someone has true intent to harm themselves or take their own life, it is almost impossible to stop them.
The desire in this case was caused by a chemical imbalance in her brain, that needed treatment. If she had received the treatment she would have lost this desire, and lived another 50 years (assuming subsequent attacks were also treated).
This is very different from someone making an objective decision to end their life because of chronic pain or the state of their life (divorce, death of child, loss of job etc). Her life was going really well - honours in her grade 6 piano exam, distinctions in her university classes, video games she was looking forward to coming out, and supportive family and friends. She was happy in between her attacks. This failure of the medical system cut short a bright and beautiful life.
@Quantumcat: I respect and understand what you're trying to say, but medicine and also life in general is not that black and white.
Yes, we treat depression with medications to help influence or correct imbalances in neurotransmitters but we also do things like encourage lifestyle modification, counselling and behavioural therapy - and this just proves that many mental health conditions are multifactorial and cannot be attributed to one single thing.
I am so sorry for your loss, and I cannot imagine the pain and suffering not only she, but those close to her have felt.
We are lucky to live in a country with a robust health service - some countries don't even recognize mental illness or have provisions/capacity to treat it. It is not fair (except in proven cases of negligence or intentional harm) to blame the medical system and those who serve within it.
This is very different from someone making an objective decision to end their life because of chronic pain or the state of their life (divorce, death of child, loss of job etc).
I can't believe you'd support those with mental health issues on one hand, and say absolute drivel like this on the other. Suicide is never a reasonable option - to say that "oh yeah, divorce, death of child, loss of job are objectively okay reasons to commit suicide" is f'ing nuts.
This failure of the medical system cut short a bright and beautiful life.
You keep saying mental illnesses are like other illnesses such as cancer, etc. But if someone passes away from cancer, we don't say the medical system "cut short their life", we would say that they passed away due to cancer. Likewise here - short of proven medical negligence, which isn't the case here, the medical system can only do so much.
As much as I agree, coroners and the people that decide don't always agree Ive known a MH nurse who had to sit through this issue and cop the blame because the family needed that to grieve. If I remember correctly they stopped just short of blaming the nurse and being able to be sued by the family. Still not 100% finalised.
What do you think would reduce cases of mental illness in society?
What is the most important thing you have learned in all of your experience in the field?
Eradicating methamphetamine would halve the admissions to mental health units. The most important thing I've learned is that affording mental health patients respect and dignity fast tracks their recovery.
Thank you. Sharing your experiences helps all of us.
There's no doubt there are people who are using them reading this or people who read this and know people are using them. But still nothing will be done by anyone, should we just secretly record them and threaten them to share with police? or even the cops won't do jack? Lol
If they know they will be reported when they seek help, they won't stop the drugs, they just won't seek help. If the people they trust are threatening to get police involved, they're not going to feel like they can trust them anymore. Actually getting them sent to prison won't help because there's drugs in prison.
Getting police involved at the dealer level would probably work better, but they're not going to be eradicated, and you probably don't want it to be linked to you. Or getting an individual into rehab, but there's no point if that's not what they want and it's far from a guarantee even if it is what they want.
legal methamphetamine and all rec drugs would allow better quality drugs, much more tax that could be spent on more mental health and drug programs. In some instances it has been shown to reduce overall use. It also lowers crime significantly in many areas as black markets incentivize criminal activity.
I just want to say that an often overlooked issue among the general public is the long-term concurrent abuse of prescription medications (e.g. benzos like Xanax) and alcohol. Recreational drugs are more expensive and harder to obtain, but aren't the only drug-fuelled road to suicidal ideation, mania and disinhibition.
Dan Murphy's and a friend or family member faking symptoms to get you a hit has been a great contributor to many social issues that stay under the radar.
There's a lot of discussion in both the public sphere, including the media and in politics, about how best to solve the homeless problem and the related mental health problem - with some claims that many homeless (or otherwise) people who suffer from mental health problems can become contributing members of society if they're just taken off the street and given proper treatment.
In your experience, what's the proportion of people who have an actually realistic chance of becoming productive members of society - and by this I mean able to hold a job, not just not a danger to society - even with the best treatment reasonably available?
Good question. A major issue for a sustained recovery is medication compliance. This is overwhelmingly the reason we see regular readmissions - we call them frequent flyers. People who have a psychiatric condition such as schizophrenia are far more likely to be homeless and they have almost no insight into their condition. This is compounded by the side effects of psychotropic drugs which are intolerable for many patients. Why would you wilfully take medications that makes you fat and lethargic if you don't believe you are mentally unwell?
Question,
Is the reason you call them Frequenct Fliers because they're high?
I didn't notice that connection when I read it at all! I thought it was just a reference to them being repeat customers.
@HighAndDry: I doubt that's what they meant at all.
Jokes about mental illness tends to trivialise the whole show, so i'm not into them myself.
@[Deactivated]: I don't think it was a joke, just an informal term. And I personally don't think anything is out of bounds for comedy. But I guess everyone has a different sense of humour.
It's not just nurses who use this term, many people who work in hospitals knows what this means. And it does not refer to a state of 'high'-ness, it refers to the frequency they keep coming back, usually for the same reasons, sometimes with trivial differences.
Just means they regularly use a service.
Does working around the mentally unstable make you feel saner?
Do you ever catch yourself agreeing with them or thinking 'thats an interesting way of looking at it' when they share their delusions?
No, it doesn't. It does however highlight the very thin line that separates society's definition of mentally well and mentally unwell. I've seen many admission that could have been me in my wilder younger years. Many delusions are fascinating but we never validate their delusions.
Interested to know how you respond to patients delusions? Do you challenge them?
It would be counter-productive to challenge some who is in the grip of a paranoid delusion. Delusions are often what we call 'fixed state', meaning that nothing you can say will convince the patient that they are delusional. They can't be reasoned with. We do tell them that they are currently unwell and that they are not thinking logically but this is generally only when they are distressed in the context of their delusion. If we observe a patient becoming distressed, aggressive, or responding to non-apparent stimuli [visual and auditory hallucinations] we will offer them an oral antipsychotic medication. If the patient refuses to take the oral medication the Nurse-in-Charge will make a decision whether to enforce the patient's compliance. The patient will again be offered oral medications and told that if they do not accept it they will be given an intramuscular injection of the same medication. This usually compels their compliance with the oral medication.
@[Deactivated]: As someone with a family member who suffers from schizophrenia, I am so grateful to you for sharing your insight with people who don’t have first hand experience.
Thank you so much!
I keep pressing this buzzer but your not coming.. where are you!?