The ‘Nurse Special’ – Caring at Close Range

The ‘nurse special’ role is a unique one and at times can be challenging, mind numbing, exciting, dangerous, boring, difficult or tedious. It depends on the patient, the environment and the personality, skills and attitude of the nurse. The role of nurse special is to give ‘1 on 1’ nursing assistance to patients that require extra monitoring. If the patient is bed ridden the role may involve sitting there for hours and doing regular observations (obs). However if the patient has mental issues eg late stage dementia, schizophrenia etc… the role is extremely difficult and can test the patience and stamina of the nurse.

Bob is constantly moving and will not sit still. This means the nurse has to follow him wherever he goes within the ward. It is a fine line that has to be tread by the nurse as they try and engage Bob, and distract him from dangerous situations but may also put themselves in the firing line of ‘hitting out’ or verbal tirades. The nurse is usually stationed outside the room on a small desk with his medical notes on it. They have clear vision of the patient at all times and have to battle with boredom most of the time. When Bob gets up he tends to wander aimlessly and is unpredictable. The nurses are usually informed of his behaviours and are often on edge until they work out his body language and triggers. In an 8 hour shift the nurse may be walking up and down for 7 of the 8 hours which is extremely tiring.

When a new nurse special is allocated, our family usually explains the tips and tricks to looking after Bob. We teach the nurse what to look for signs of agitation and how to handle them when they do. Many of the nurses have little or no experience with dementia patients and have no idea about the ‘repetitive’ nature of the disease and the cognitive issues associated with it. There is no point in trying to argue or reason with a person with late stage dementia as they simply do not have the capacity. We explain that it is best to ‘agree’ with the patient and ‘go along’ with whatever they believe they are doing or saying. If the dementia patient does their buttons wrong on their pajamas etc it doesn’t really matter and you tend to accept a lot more things that are not normal. I tell  nurses to ‘take the blame’ for things with dementia patients as it is the best way to avoid trouble.

Many of the nurse specials are new to nursing and is why they have been allocated to the specialling role as they are essentially babysitting the patient. Sometimes you have very experienced nurses allocated and the experience shows and is evident immediately. The way the nurse interacts and handles the patient is vital. With Bob he likes to touch people and this can be really confronting for a new nurse. They also need to be aware that when agitated he may grab their wrist  or hand and squeeze it to hurt them. This makes the nursing role a very stressful one and I really do feel for them. They cannot leave Bob’s side, but also have to take action for every move that he makes.

We tend to ask a lot of questions of the nurse and always want to know when meds are given, any difficulties and be advised if there have been any ‘code blacks’ (security team restrains). Bob has been in the RAH now for just under a week and had 10 code blacks which are vital to protect the nursing staff and also the patient. Bob can take up to 45  minutes to subdue and often needs extra injected meds as required. Inexperienced nurses tend to call for ‘code blacks’ too quickly which really frustrates the family as we are trying to avoid the trauma if possible. Having said that – an early call for help can also be a safe call (and life saving). I have been with Bob when he has become violent and within 30 seconds we have gone from calm to out of control and knowing security is on it’s way can be very comforting when in the heat of battle. (refer restrain teams blog)

I like to discuss with the ‘nurse special’ the following when I first meet them:

• brief history on him and advise how nice a person he was before dementia
• interacting with Bob and understanding his speech
• encourage the nurse to read the case notes during quiet times
• how to detect mood changes (eg. the tension in his hands, an evil stare, or swearing)
• how to get Bob to take his medications (eg place tablet in his right hand then give him cup in the same hand)
• monitoring his behaviours, toileting, drowsiness and sleeping patterns and reporting things accordingly
• tips for his meal times, changing his clothes, showering and bed times
• tips for de-escalating bad behaviours (eg do not make sudden moves, do not show fear etc)
• advise them to rest when Bob sleeps as once he awakes they will be walking some serious kilometres
• letting them know they can call me 24/7 if things get out of hand
• advise them what we will be wanting to know when we turn up or call

As nurses change shifts 3-4 times per day we end up having to explain the above topics over and over again. This is taxing on the family but we believe if we can teach each nurse about dementia in the process they will become better nurses in the future. If we get a feeling the nurse is not up to the task we will contact the Ward Manager and suggest extra help for them if required or perhaps ask for a switch if they are really scared etc.(which is totally understandable). When we have the same nurse caring for Bob, it is very comforting as we can relax (to a degree) and know the nurse is fully informed and can usually handle the situation. We often create a relationship and bond with the nurses as we work together with them to deal with Bob. I have to admit that he is extremely difficult to handle and will test out each nurse.

The nursing role in a hospital environment is one which is totally valued by me and and is so vital to the patients. We like to advise the nurses of Dad’s kind nature as dementia can often mask the real person and give the nurse the false impression that the person may have been aggressive and violent all their life. We always worry that the nurse may ‘pigeon hole’ Bob as a nasty patient and treat him accordingly. By discussing his former life and nice qualities we hope they can see through the behaviours and tap into his good side where possible.

Our nurses are underpaid and are under extreme pressure and their care and understanding is greatly appreciated. Keep up the good work!