Learning in a time of COVID

(From Left to Right: Elisa McNeilly, Sylvia Gomanda, Matt Cunningham (September 2018 Mental Health Nursing Students), Warren Stewart (Senior Lecturer in Mental Health Nursing))

Introduction

During the Covid-19 pandemic of 2020, health and social care students of all kinds played a significant role in supporting the frontline NHS workforce. Students contributed to safe and effective care in hospitals and communities, while simultaneously continuing with their studies.

This short piece of reflective text outlines some of our developmental experiences while working in a local specialist mental health unit over the summer lockdown months. We were brought together both clinically and educationally, through a weekly seminar series, led by the consultant nurse and two clinical nurse specialists. As a collective, we felt moved to reflect and write about our experiences. For some students this opportunity transpired to be their best experience on the course so far.

Matt writes about being a male student in a secure female clinical setting, conversely Elisa writes about her experience as a young-women working for the first time in male acute. Sylvia’s experience was epitomised by a relationship with a specific service-user, and myself, the experience of returning to practice.

Warren – A truly honorary contract.

Seeing my neighbour’s genuine appreciation for NHS workers and hearing some of the narratives of my practice colleagues coalesced into a drive to do some proactive during lockdown.  With a little extra time on my hands, I contacted a colleague and within a short space of time an honorary contract was arranged for the summer months. This effectively amounted to an afternoon a week on a male rehabilitation ward, supporting a couple of seminars and making a visit to another unit.

The arrangement was quite rapid, there wasn’t time undertake a full trust induction, meaning there were a number of things I couldn’t do, for example, accessing care notes. At first, I thought, what do I have to offer?  I didn’t feel like I was making much of a difference.  I felt a palpable sense of ambivalence and will confess to feeling like a spare part for a while.  I was unsure of ‘how things worked’ in the local micro-culture and worried about saying or doing the wrong thing.  I became conscious of my external impression management, as I negotiated my interested, but ‘outsider’ status.  In short, I became the embodiment of all of the processes we discuss with our students prior to placements, including the ‘cloak of competence’ which I deployed, with variable effect!

The experience gave me greater empathy for my students on their placement’s carousel.  Having cut my teeth in Victorian institutions it was lovely to be in such light and spacey, modern conditions.  Despite the increased restrictions, the staff did a perceivably brilliant job of managing the communal emotional climate. I observed some impressive de-escalation which seemed so natural but was underpinned by relational and practical expertise.

Looking back, my presence did mean something real to me and hopefully the patients. An extra pair of hands meant the patients could get outdoors and use the football courts, I did a few medication rounds, sat in on my first virtual ward and covered staff breaks. None of this sounds particularly glamorous, but did help to keep the ward ticking over, simultaneously refreshing some of my rusty skills.  I also had the chance to spend some time with the patients, which is the first thing I think of when I look back. I guess it also means if there is a second/third lockdown and support is required then I could pick up the reigns relatively quickly.

Matt – women’s medium secure forensic

In May 2020 we were given an opportunity to opt-in as ‘nurse support workers’ meaning being paid a Band 3 wage whilst gaining student nurse experience and placement hours. I was really incentivised by the prospect of greater responsibility, for example, conducting observations, doing 1:1’s and accompanying patients on grounds leave. This made me feel more useful, and part of the team.

Informed only by a Channel 4 documentary, I had some preconceptions of what a forensic placement might be like.  I expected to encounter hostility, aggression, and tough personalities; instead, I walked onto the ward to find a group of diverse, mostly shy and vulnerable people and the ‘offender’ identity soon dissipated. Invariably, themes of childhood abuse, neglect, and deprivation appeared in their case histories, and so accounts of violence, arson or gang-related crime were put into a social context. This sparked my interest in the relationship between trauma and criminality and thoughts that as a society, we should place more emphasis on rehabilitation rather than punishment.

This was also my first placement on a women’s ward, and I became hyper-aware of my identity as an unknown male entering a women’s space. Adopting a trauma informed mindset, I considered the negative association that some in this patient group may have with men, and I enquired early on whether this would be significant to anyone. There were so many points of learning specific to women’s physiological needs, for example, in relation to medication and side-effects. I was also pleased to be tasked with the care-planning of a returning patient, and having heard they liked sports, I suggested a game of badminton as an informal way of getting to know them. We sat and listened to music afterwards, enjoying the warm weather. Having covered their hobbies and interests, and some anxieties around being back, it felt natural to address the more difficult subjects and formulate a full care plan, which was verified by a registered nurse. My confidence developed in those conversations, and I was more aware of using techniques, such as Socratic questioning and motivational interviewing.

Overall, I learned the importance of working to create a sensitised, therapeutic environment, and the effect this has for a person over time. Patients can be challenging but if the whole nursing team can stand with them through difficult times then that consistency enables recovery to happen. I think I’ve added to my student mental health nurse ‘tool-kit’ of interventions and ideas, but I still see the greatest tool as one’s person or ‘self’. One of the highlights was our weekly reflective practice and teaching sessions led by two clinical nurse specialists and a nurse consultant. This made a huge difference to overall learning. It was a supportive and safe place where we could discuss complex case studies, dilemmas and key decisions. The topics were always relevant, and we were given choice over the content.

Elisa – My reflection

As the pandemic progressed, I felt that as a student nurse I had to do something. Our cohort was offered some placement options in a forensic medium-secure male ward and I immediately applied for a position. It was my first time in a forensic setting so there was a lot to get used to, for example, the key fobs, radios, airlocks and security processes. Starting any new placement usually is an adjustment, yet there was the added pressure of having to social distance and wear a mask; I never realized how much communication is delivered through facial expressions.

Working with male offenders was initially a bit intimidating; I needed to remind myself that it was part of the role to remember the risks and to be aware to not be isolated with a patient. As a ‘new person’ to the ward, there was potential to be seen as vulnerable to manipulation. There were a couple instances of aggressive behaviour during my time there, being a ‘nurse support worker’ meant I was expected to intervene, whereas as a student you can’t. This was quite a challenge, especially while wearing PPE and trying to maintain social distance.

Over time I started to feel more relaxed on the ward, but I knew that I had to maintain personal and professional boundaries at all times. This has been my favourite placement so far; due to long admissions therapeutic relationships can really develop, and the staff really had so much time for the patients. Working in forensic mental health really developed my empathy towards the patients, inclusive of their histories. Some of their cases were quite ‘high profile’, so it was interesting to see how the media portrayed them compared to how I knew them on the ward. I feel the experience helped me to become less judgmental and to have an elevated compassion for those in the criminal justice system.

I often felt out of my depth, so the weekly reflective practice was so helpful as it was a safe place to reflect, discuss and learn. We practiced some simulated scenarios and debriefed any distressing experiences. This weekly programme was so invaluable that I am using the model for my business proposal in an assignment, as a way to boost confidence and resilience for all students. All in all, it was a priceless experience both in terms of my progress as a student mental health nurse and personal growth.

Sylvia – ‘Over-riding my fears’.

I was supported to learn so many new skills during lockdown, for example, the use of Skype video conferencing to conduct recovery reviews was new to me. I was lucky enough to get to know and work with a specific service-user and I would like to illustrate my time on the unit through this relationship. For the purpose of this reflection, I will call him George; he had a complex range of intersecting mental health, social and educational needs.

George can become frustrated when he perceives his needs are not being met, when he feels his rights are violated or when he feels rejected. This can result in behaviours which I initially found intimidating and left me feeling a more than a little discombobulated.  He has a history of non-suicidal self-injurious behaviours which he says help him to manage his voices and negative thoughts. He acknowledges that his style of interaction can stretch interpersonal boundaries, however he has the ability to form positive, appropriate and therapeutic relationships with specific staff members, (as it transpired, like me). He can regulate his emotional responses especially in the context of clear goals and objectives. Regular interaction, nursing care, medication, Occupational Therapy and psychological interventions such as Dialectical Behaviour Therapy (DBT) all came together to help him to manage his emotions and behaviours. Personal boundaries are very important to discuss and maintain and I learned not to create too strong an attachment, as eventually it could be perceived as rejection.

I noticed my emotional labour in needing to develop my internal resilience and manage my fears. As I became aware of these processes, our relationships became more relaxed, it became easier to engage with him and he was more likely to listen to me and accept medication from me. Sometimes he would request for a 1-1 and express his feelings, I found I could provide reassurance and support him with his needs. Once while on section 17 leave unescorted he contacted the ward, declining to speak with the regular staff to speak to me, which I take as a real compliment. The relationship presented its challenges and did cause some stress, however, working together taught me how he could be approached and how we could communicate better. I learned from him, and we learned to work to each-other’s strengths.

Conclusion

In summary, the reflections visibilize the personal and professional learning we benefited from during the time spent at ‘the unit’ during lockdown.  The key points relate to the secure nature of the clinical area, the limitations imposed by the Covid virus and the fundamental importance of our relational nursing activities. The seminar series presented us with the structure to connect with one another and helped us to extract the learning from our immediate practice experiences.

We hope we were able to make a contribution to the community in some small way. It is our collective desire to express our thanks to the numerous staff (and patients) who helped to shape our roles and experience.