Difficult Conversations with Colleagues
CAMHS Self-Harm - the Nurse Pressing for Discharge
Before we begin
Welcome. This is the first colleague drill, the pressure to discharge a young person after self-harm. Not a patient in front of you, but a colleague, under pressure, asking you to do something that is not yet safe, or not yet right, and your job is to hold the line without losing them.
A teenager has come to the emergency department after an overdose, is medically cleared, and wants to go home. The busy night charge nurse, under real pressure for beds, presses you to discharge, more than once. The safe answer is firm and well-known, a young person who has self-harmed should stay overnight and be fully assessed the next day by a senior. Your task is to hold that, and to acknowledge the nurse's genuine bind while you do.
Two habits carry every colleague drill. Keep them close.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
Ready. Let us walk in.
What this drill looks like
Picture the department, late at night. A task card, near enough, this.
A young person has attended the emergency department after an overdose, is medically cleared, and the charge nurse wants to know when they can be discharged. Discuss the management plan with the charge nurse.
Here is the shape of it. Acknowledge the nurse's pressure. Explain the default, overnight admission and senior review next day. Explain why, what can only be done in working hours. Name safeguarding. Explain what the review will decide, and the follow-up if discharged. Offer the observation bed as the collaborative middle.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, acknowledge the bind first
You do not open by refusing. You open by acknowledging the pressure the nurse is under, because that keeps them with you.
Say something like this.
Thank you, and I can see how stretched you are tonight and how much you need the space. Let me talk you through what I think is safest, and let us find a way that works for the department too.
Check. Shall we meet the colleague. Let us.
Who is in front of you
In front of you is the charge nurse of a paediatric emergency department, on a night shift, kind and reasonable, and genuinely under pressure to free up beds for patients waiting for medical assessment. The young person is medically well and wants to go home, so, to the nurse, she looks like a sensible discharge.
The nurse is not being obstructive, they are managing a full department. They will come with you if you explain your reasoning clearly and show you understand their position, and they may then offer a paediatric observation bed as the answer. Meet the pressure with understanding, not defensiveness, and hold the safe plan.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - The default: overnight, then senior review
Trigger. The nurse asks when she can go home.
Decode, kept in your head. The recommended default for a young person who has self-harmed is to be admitted overnight, usually to a paediatric ward, and fully assessed the following day by a senior clinician in normal working hours.
The move. State the default plainly, as the standard, not your preference.
For a young person who has harmed themselves, the recommended plan is to keep them in overnight, on a paediatric ward, and have them fully assessed tomorrow by a senior in working hours. That is the standard, safe approach, not just my call.
Check. The default stated as the standard. Move on.
4.2 - Why: what only working hours can do
Trigger. The nurse asks why she cannot simply go home now.
Decode, kept in your head. The reason is concrete. Overnight, you cannot gather the vital collateral, family, school, the social worker, cannot get a senior review, and cannot properly assess the home. The overnight stay keeps her safe and buys the information.
The move. Give the concrete reasons, not a vague rule.
The reason is practical. Right now, at night, I cannot speak to her family, her school, or her social worker, I cannot get a senior review, and I cannot check that home is safe to go back to. The overnight stay keeps her safe and lets us get all of that tomorrow, so we do not send her back into something unsafe.
Check. The why given concretely. Move on.
4.3 - Name safeguarding
Trigger. There is a detail that raises a safeguarding question.
Decode, kept in your head. You must say the word safeguarding, and say what prompted it, here, that she was unsupervised and alone at the time of the overdose. The next-day review will consider whether local safeguarding procedures should be triggered.
The move. Name safeguarding, and the reason for it.
There is also a safeguarding question I have to flag, because she was alone and unsupervised when this happened, and the review tomorrow will need to consider whether safeguarding procedures should be started.
Check. Safeguarding named, with its trigger. This is a scored sentence. Move on.
4.4 - The bed-transfer question
Trigger. The nurse asks if she can be moved to a psychiatric ward to free the emergency bed.
Decode, kept in your head. A mental-health-bed admission is a separate, higher threshold, considered only if the risk is beyond what the community can manage. It is not a way to move her out of the department tonight. The overnight paediatric stay is the right place.
The move. Explain the difference, and why the observation ward is right for now.
A psychiatric ward admission is a bigger decision, made only if her risk is too high to manage at home, and that is exactly what tomorrow's assessment will decide. For tonight, a paediatric or observation bed is the right place, and if you can arrange one, that would be perfect.
Check. The bed-transfer distinction drawn, the observation bed accepted. Move on.
4.5 - What the review decides, and the follow-up
Trigger. The nurse asks how you will decide, and what happens if she goes home.
Decode, kept in your head. Tomorrow's senior review weighs the depression, the ongoing intent, the hopelessness, and the support at home, to decide admission or discharge. If discharged, she is referred for a community follow-up within seven days at most.
The move. Explain how the decision is made, and the safety net if she goes home.
Tomorrow the senior will weigh her mood, whether she still wants to die, and how safe home is, to decide between admission and discharge. And if she does go home, she is referred to the community team to be seen within seven days at the latest, so she is not just let go.
Check. The decision process and the follow-up explained. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Caving to the bed pressure
Agreeing to discharge a young person at two in the morning to free a bed, before collateral, senior review and safeguarding, is unsafe and fails the station. Hold the overnight plan, warmly.
5.2 - Being defensive with the nurse
Meeting the pressure with irritation or a flat no loses your colleague. Acknowledge the bind, explain the reasoning, and offer the observation bed as the shared solution.
5.3 - Forgetting the word safeguarding
Missing the safeguarding sentence, and what prompted it, is a lost mark and a clinical omission. Say it, and say why, the unsupervised overdose.
5.4 - Confusing the observation stay with a psychiatric admission
The overnight paediatric stay is for safety and assessment. A mental-health-bed admission is a separate, higher-threshold decision for tomorrow. Do not blur the two, or use a psychiatric ward to empty the department.
Check. Name the trap you avoided. That is the mark.
The close
Close in four small movements.
One. Thank them, and acknowledge the bind again.
Thank you for bearing with me, I know how hard tonight is for you.
Two. Restate the safe plan.
She stays overnight for safety and monitoring, and is fully assessed by a senior tomorrow in working hours.
Three. Confirm the shared solution.
A paediatric observation bed is ideal, and I am grateful you can sort one.
Four. Stay available.
Call me if anything changes overnight, and I will keep you posted on the plan.
The two habits, again
Carry these two out of the room.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
The thread of this drill is one line. Overnight and senior review the next day, because the night cannot get the family, the school, or the safeguarding picture, held warmly against the bed pressure.
Do those two things and this conversation with a colleague is yours to steer.
The Adult Awaiting a Bed - Pressure to Discharge
Before we begin
Welcome. This is the adult bed-pressure drill. Not a patient in front of you, but a colleague, under pressure, asking you to do something that is not yet safe, or not yet right, and your job is to hold the line without losing them.
An adult who has been assessed as at risk is waiting in the emergency department for a mental health bed, and the department, under pressure, wants them discharged, or moved up to a ward that has not yet accepted them. The failure is to let bed-flow override safety. You hold the risk-based plan, you acknowledge the department's genuine bind, and you put in place an interim safe plan, observation, an escort, the crisis team, while the bed is arranged.
Two habits carry every colleague drill. Keep them close.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
Ready. Let us walk in.
What this drill looks like
Picture the department. A task card, near enough, this.
An adult in the emergency department has been assessed as needing admission, or further assessment, and staff are pressing for them to be discharged or moved because of bed pressure. Discuss the plan with the nurse in charge.
Here is the shape of it. Acknowledge the pressure. State the risk-based position, this person is not safe to discharge. Explain that a ward move needs an accepted bed and a proper handover, not a corridor transfer. Put an interim safe plan in place. Agree how you keep them safe until the bed is ready.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, name the shared problem
You do not open by defending the patient's bed. You open by naming the shared problem, a stretched department and an at-risk patient, and putting yourself on the same side.
Say something like this.
I know the department is under real pressure, and I want to help you free up space. My difficulty is that this person is not safe to send home, so let us work out together how to keep them safe while we get the right bed sorted.
Check. Shall we meet the colleague. Let us.
Who is in front of you
In front of you is the nurse in charge, or a bed manager, doing a hard job under real strain, with patients on trolleys and no space. To them, a patient who is medically fine and waiting for a mental health bed looks like someone who could go home, or could simply be sent up to the ward.
They are not wrong to want flow, they are wrong only if flow overrides safety. The patient still has the intent, or the risk, that led to the decision to admit. Your job is to keep the person safe without dismissing the department's bind, and to offer a real interim plan rather than a flat refusal.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - Restate the risk-based position
Trigger. The nurse suggests discharge.
Decode, kept in your head. The reason for admission still stands. Restate, briefly and without a full history, why this person is not safe to leave.
The move. State the risk plainly, as the reason, not a rule.
This person still has the risk that led us to decide on admission, the ongoing thoughts and the intent, and nothing has changed to make home safe. So discharging now would not be safe, however much I wish I could help with the space.
Check. Risk-based position restated. Move on.
4.2 - A ward move needs an accepted bed
Trigger. The nurse asks to send them up to the ward now.
Decode, kept in your head. You cannot move a patient to a ward that has not accepted them, without a bed, and without a proper handover. That is unsafe and it is not a transfer, it is moving the risk to a corridor.
The move. Explain why a real transfer needs the bed and the handover first.
I would move them up gladly the moment there is an accepted bed and a nurse ready to take handover, because that is a safe transfer. Sending them to a ward that has not accepted them, without a bed, just moves the risk somewhere with less oversight, and I cannot do that safely.
Check. The difference between a transfer and a corridor move drawn. Move on.
4.3 - Put an interim safe plan in place
Trigger. The wait for the bed will take time.
Decode, kept in your head. You do not just say no, you make the waiting safe, a suitable space, enhanced observation or a dedicated nurse, removal of means, and the crisis team or bed managers actively chasing the bed.
The move. Offer the concrete interim plan.
Here is what I can do to make the wait safe and to help you, a quiet space rather than a busy cubicle, close observation or a dedicated nurse, anything they could use to harm themselves removed, and I will get the bed managers and the crisis team actively chasing a bed now.
Check. A real interim safe plan offered. Move on.
4.4 - Escalate the bed, not the discharge
Trigger. The pressure is real and the system is stuck.
Decode, kept in your head. The answer to a bed shortage is to escalate the bed problem up the system, not to escalate the patient out of the door. Name who you will involve.
The move. Commit to escalating the bed through the proper channels.
The right way to solve the bed pressure is for me to escalate it, to the on-call manager and the bed team, so this becomes their problem to expedite, rather than something we solve by taking a risk with the patient. Let me do that now.
Check. Escalation of the bed, not the patient, agreed. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Discharging to free a trolley
Letting an at-risk adult go home because the department needs the space is the exact failure the station tests. The risk that justified admission has not gone. Hold it.
5.2 - A corridor transfer
Sending a patient up to a ward that has not accepted them, with no bed and no handover, is not a transfer, it is moving risk to a less-watched place. Insist on an accepted bed and a handover.
5.3 - A flat no with no alternative
Simply refusing, without offering an interim safe plan and without helping with the flow, loses your colleague and leaves the patient unsafe in a busy cubicle. Offer the observation, the means removal, the escalation.
5.4 - Not escalating the bed
Absorbing the pressure yourself, and neither solving nor escalating the bed, leaves everyone stuck. Escalate the bed problem up the system, so it is expedited properly.
Check. Name the trap you avoided. That is the mark.
The close
Close in four small movements.
One. Acknowledge the pressure again.
I really do understand the bind you are in, and I want to help you clear the space.
Two. Restate the safe line.
But this person is not safe to discharge, and I cannot move them without an accepted bed and handover.
Three. Give the interim plan.
So, a safe space, close observation, means removed, and I will escalate the bed right now.
Four. Stay in it with them.
Keep me posted, and I will keep chasing, so we get them the right bed as fast as possible, together.
The two habits, again
Carry these two out of the room.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
The thread of this drill is one line. An at-risk adult is not discharged to free a trolley and not sent up before the bed exists, held with an interim safe plan while you escalate the bed, not the patient.
Do those two things and this conversation with a colleague is yours to steer.
Advising a Nurse Who Questions the Plan
Before we begin
Welcome. This is the advising-a-nurse drill. Not a patient in front of you, but a colleague, under pressure, asking you to do something that is not yet safe, or not yet right, and your job is to hold the line without losing them.
You are explaining a management plan to a nurse looking after a patient whose condition they do not usually treat, and they question part of it, why the tiny meals for a starving patient, why the caution. This is not a disagreement to win, it is a colleague to teach. You answer their actual question first, you explain the reasoning plainly, you cover the practicalities they need, and you keep checking they are following, because they may not know the psychiatric detail.
Two habits carry every colleague drill. Keep them close.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
Ready. Let us walk in.
What this drill looks like
Picture the medical ward. A task card, near enough, this.
A patient has been transferred to a general ward for treatment, and the nurse caring for them is unfamiliar with the condition and unsure about the plan. Discuss the management plan with the nurse and make sure they understand the key risks.
Here is the shape of it. Answer the nurse's actual question first. Explain the reasoning behind the plan, in colleague terms. Cover the monitoring and the practicalities. Address their worry about the patient leaving, capacity and detention. And check, throughout, that they are following.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, answer their question first
You do not open with a lecture on the illness. You open by answering the very thing that is puzzling them, because that earns their attention.
Say something like this.
Thank you for looking after her, and it is a really good question. Let me answer exactly what is puzzling you, the small portions, and then explain the thinking behind the whole plan.
Check. Shall we meet the colleague. Let us.
Who is in front of you
In front of you is a conscientious nurse, perhaps a junior one, caring for a patient with a condition they rarely see, an eating disorder on a medical ward for careful refeeding. They have heard of the danger but do not understand it, and they are puzzled that the dietician has advised such a small serving for someone so underweight.
They are not challenging you, they are trying to do right by the patient and want to understand. Your task is to teach them, colleague to colleague, without talking down, to answer their real question, and to make sure they leave understanding the risk they are helping to manage.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - Answer the actual question: the small portions
Trigger. Why such a small meal when she is so thin.
Decode, kept in your head. The small portion is the treatment. Feeding a starved body too fast causes a dangerous shift of minerals, the refeeding syndrome, which can be fatal. Slow, monitored feeding is what keeps her safe.
The move. Explain that the small portion is the safety, not a mistake.
The small portion is not an oversight, it is the treatment. When a body has been starved and you feed it too quickly, there is a dangerous shift in the body's salts that can affect the heart and can be fatal. So we reintroduce food slowly and carefully, and that caution is exactly what keeps her safe.
Check. The actual question answered first. Move on.
4.2 - The mechanism, in colleague terms
Trigger. The nurse wants to understand why.
Decode, kept in your head. In starvation the mineral stores, potassium, magnesium, phosphate, are depleted and insulin is suppressed. Feeding raises the blood sugar, insulin surges, and the minerals are driven into the cells, dropping the blood levels dangerously, with a risk of cardiac arrhythmia.
The move. Give the mechanism plainly, pitched to a colleague.
The reason is that starvation depletes the body's stores of potassium, magnesium and phosphate. When you feed, insulin surges and drives those minerals into the cells, so the blood levels drop sharply, and that can trigger a dangerous heart rhythm. Slow feeding lets us stay ahead of it.
Check. The mechanism explained. Move on.
4.3 - The monitoring and practicalities
Trigger. The nurse needs to know what to watch and do.
Decode, kept in your head. The practical package, an ECG and bloods including salts and bone profile, thiamine and vitamins, close dietician review, and often one-to-one nursing.
The move. Give the concrete monitoring and care.
In practice she needs an ECG and regular bloods including her salts, thiamine and vitamins started, close review by the dietician, and often a nurse with her one to one. If her salts drop or her heart tracing changes, we act quickly.
Check. Monitoring and practicalities covered. Move on.
4.4 - The worry about her leaving: capacity and detention
Trigger. The nurse asks what to do if she tries to leave.
Decode, kept in your head. The answer turns on her legal status. If she is detained under mental health legislation, she can be treated and stopped from leaving. If she is informal and there is doubt about her capacity to make that decision, a formal capacity assessment is needed.
The move. Explain the legal position clearly and what to do.
If she tries to leave, what you do depends on her legal status. If she is detained under the Mental Health Act, we can keep her and treat her. If she is here informally and you doubt she can weigh the decision to leave safely, call us for a capacity assessment before she goes, and keep her safe in the meantime.
Check. Capacity and detention explained. Move on.
4.5 - Check they are following
Trigger. You have given a lot to a colleague new to this.
Decode, kept in your head. The mark is for teaching a colleague, which means checking understanding, not delivering a monologue. Invite their questions and confirm the key points landed.
The move. Pause, check, and invite questions.
That was a fair amount, so let me check I have explained it well. What would you want to call me about, and is there anything about the plan that is still unclear.
Check. Understanding checked, questions invited. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Not answering their actual question
Launching into the illness while ignoring the thing that puzzled them, the small portions, misses the point and the mark. Answer their real question first.
5.2 - Talking down, or over their head
Either patronising a colleague or burying them in jargon fails the communication mark. Pitch it colleague to colleague, and translate the psychiatric detail they may not know.
5.3 - A monologue with no checking
Delivering everything without pausing to confirm they follow is not teaching. Check understanding and invite questions.
5.4 - Missing the capacity and detention point
Leaving the nurse without a clear answer on what to do if the patient tries to leave, which turns on detention and capacity, is a lost mark and a safety gap. Cover it explicitly.
Check. Name the trap you avoided. That is the mark.
The close
Close in four small movements.
One. Thank them.
Thank you for caring for her so carefully, and for asking rather than guessing.
Two. Recap the key risk.
So, slow feeding to avoid the dangerous mineral shift, close monitoring, and call me if her salts or heart tracing change.
Three. The safety point.
And if she tries to leave, call us about her status and capacity before she does.
Four. Stay available.
Ring me any time with anything at all, and I will come. You are not managing this alone.
The two habits, again
Carry these two out of the room.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
The thread of this drill is one line. Answer their actual question first, teach the reasoning colleague to colleague, and check they are following.
Do those two things and this conversation with a colleague is yours to steer.
Holding the Treatment Sequence - Lithium in a Dehydrated Patient
Before we begin
Welcome. This is the treatment-sequence drill. Not a patient in front of you, but a colleague, under pressure, asking you to do something that is not yet safe, or not yet right, and your job is to hold the line without losing them.
A colleague, often a nurse, wants a medication started or escalated now, and their instinct is a good one, but the timing or the sequence is wrong and, here, unsafe. The clearest example is a manic, dehydrated patient in the intensive care area, where starting lithium immediately would be dangerous, because dehydration reduces how the kidneys clear it and drives the level up towards toxicity. You honour the colleague's intention, you explain the safe sequence, and you offer what to do right now instead.
Two habits carry every colleague drill. Keep them close.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
Ready. Let us walk in.
What this drill looks like
Picture the intensive care area of the ward. A task card, near enough, this.
A patient is acutely manic and unwell, and a colleague is pressing for lithium to be started now. Discuss the plan with the colleague and explain the safe approach.
Here is the shape of it. Acknowledge the good intention, lithium is the right long-term mood stabiliser. Explain the safety problem, dehydration and lithium do not mix. Explain what must happen first, rehydration and baseline bloods. Say what to do now instead for the acute state. Then the safe sequence to start lithium, once stable and monitored.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, honour the instinct first
You do not open by telling the colleague they are wrong. You open by agreeing with their instinct, then explaining the timing.
Say something like this.
You are right that lithium is exactly the sort of thing this patient may need in the longer term, and I am glad you are thinking ahead. The issue is not whether, it is when, and right now it would not be safe. Let me explain.
Check. Shall we meet the colleague. Let us.
Who is in front of you
In front of you is a colleague, often an experienced nurse, caring for a patient who is acutely manic, overactive, agitated, sweating, not drinking, and dehydrated. They know lithium is a mood stabiliser and, wanting to help, they are keen for it to be started now.
Their instinct is sound, the patient may well need lithium. But their timing is dangerous, because in a dehydrated patient the kidneys cannot clear lithium properly, the level climbs, and toxicity, which can be lethal, follows. Your task is to honour their good intention while holding the safe sequence, and to give them something useful to do right now instead of nothing.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - The safety problem: dehydration and lithium
Trigger. The colleague wants lithium started now.
Decode, kept in your head. Lithium is cleared by the kidneys, and dehydration reduces that clearance, so the level rises towards toxicity. Starting it in a dehydrated, acutely unwell patient is unsafe.
The move. Explain the safety problem plainly, as the reason.
Here is the difficulty. Lithium is cleared by the kidneys, and when someone is dehydrated, as this patient is, the kidneys cannot clear it well, so the level in the blood climbs quickly towards a toxic, and potentially dangerous, level. Starting it now, while she is dehydrated, could tip her into lithium toxicity.
Check. The safety problem explained. Move on.
4.2 - What must happen first
Trigger. The colleague asks what needs to change.
Decode, kept in your head. Before lithium, she needs to be rehydrated and physically stable, and she needs baseline investigations, kidney function, thyroid function, a full blood count, and a heart tracing, because lithium is titrated against those.
The move. State the prerequisites clearly.
Before we could safely start it, two things. She needs to be properly rehydrated and physically stable, and we need her baseline bloods, kidney and thyroid function and a full blood count, and a heart tracing, because we start and monitor lithium against those numbers.
Check. The prerequisites, rehydration and baseline bloods, stated. Move on.
4.3 - What to do now for the acute state
Trigger. The patient is acutely manic and needs treating now.
Decode, kept in your head. The acute mania is treated now, safely, with an antipsychotic, and a benzodiazepine for agitation and sleep, alongside rehydration. That controls the episode while we prepare the ground for lithium.
The move. Offer the safe, immediate treatment, so the colleague is not left with nothing.
So here is what we do right now, which does help her. We treat the mania with an antipsychotic, and something to settle the agitation and help her sleep, and we get fluids into her. That controls the acute episode safely today, and it prepares the ground so we can add lithium properly once she is stable.
Check. The safe immediate treatment offered. Move on.
4.4 - The safe sequence to start lithium
Trigger. The colleague wants to know when lithium does start.
Decode, kept in your head. Once she is rehydrated, stable, and the baseline bloods are back and acceptable, lithium is started at a low dose and titrated, with levels checked after a few days and then regularly. Sequence and monitoring are the safety.
The move. Lay out the safe sequence.
Once she is rehydrated, physically stable, and her kidney function and the other baseline tests are back and fine, then we start lithium at a low dose and build it up, checking the blood level after a few days and regularly after that. Done in that order, it is safe and effective.
Check. The safe sequence and monitoring laid out. Move on.
The same principle, other colleagues
The sequence problem shows up in other guises too. Say the principle out loud.
5.1 - Pressing for clozapine too early
A colleague may press for clozapine, when the current antipsychotic has not yet had an adequate trial. Clozapine is reserved for illness that has not responded to at least two antipsychotics, each at an adequate dose for an adequate time. If the current drug has not been optimised, the safe next step is to optimise it, not to leap to clozapine.
5.2 - The maximum dose not yet reached
Where a colleague wants to switch or add a drug because the patient is not better, first ask whether the current medication has been given at an adequate dose for an adequate duration. Changing before that is not a failure of the drug, it is a failure to give it a fair trial. Optimise before you escalate.
5.3 - Escalating in the physically unstable patient
Any drug that needs a stable body or baseline monitoring, lithium, clozapine, and others, should not be started in someone acutely physically unwell. Stabilise the body, get the baseline tests, then start. The principle is the same, right drug, wrong moment.
Check. Name the principle, right drug, wrong moment or wrong order, and the safe sequence. That is the mark.
The close
Close in four small movements.
One. Honour the instinct again.
You are right that lithium is likely part of her longer-term treatment, and I am glad you flagged it.
Two. State the safe line.
But not while she is dehydrated, because that risks lithium toxicity. First we rehydrate and get her baseline bloods.
Three. Give the now-plan.
Right now we treat the mania with an antipsychotic, settle the agitation, and get fluids in, which helps her today.
Four. The sequence, together.
Then, once she is stable and the bloods are back, we start lithium properly and monitor it. Let us do it in that safe order, together.
The two habits, again
Carry these two out of the room.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
The thread of this drill is one line. Right drug, wrong moment. Dehydration drives lithium toward toxicity, so rehydrate, get the baseline bloods, treat the acute state first, and start lithium only once stable and monitored.
Do those two things and this conversation with a colleague is yours to steer.
Explaining Capacity to a Care Worker
Before we begin
Welcome. This is the capacity-for-a-care-worker drill. Not a patient in front of you, but a colleague, under pressure, asking you to do something that is not yet safe, or not yet right, and your job is to hold the line without losing them.
A care worker or support worker is unsure whether a patient, often someone with dementia, has the capacity to refuse care, and what they are allowed to do. Your job is to give them a usable, plain-English version of the capacity test, to remind them it is specific to this decision at this time, and that a person can make what looks like an unwise choice and still have capacity, and to set out what to do when capacity is lacking.
Two habits carry every colleague drill. Keep them close.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
Ready. Let us walk in.
What this drill looks like
Picture the care home or the ward. A task card, near enough, this.
A patient is refusing care, and the care worker looking after them is uncertain whether they have the capacity to refuse and what should be done. Explain capacity to the care worker and advise them.
Here is the shape of it. Presume capacity. Give the four-part test in plain words. Stress it is decision-specific and time-specific. Explain that an unwise choice is not incapacity. Explain what to do if capacity is lacking, best interests, and least restriction. And keep it practical and usable.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and reassurance
You do not open with the law. You open by reassuring the care worker that asking is exactly right, and making it practical.
Say something like this.
You did the right thing asking, and it is a good question. Let me give you a simple way to think about capacity that you can actually use on the floor, and then what to do either way.
Check. Shall we meet the colleague. Let us.
Who is in front of you
In front of you is a care worker, conscientious and a little anxious, looking after a patient with dementia who is refusing help with personal care. They are caught between not wanting to force someone, and not wanting to neglect them, and they are unsure what they are allowed to do.
They do not need the legal detail, they need a clear, usable rule and the confidence to apply it. Your task is to hand them the four-part test in plain words, to correct the common error that a difficult or unwise refusal means the person lacks capacity, and to tell them what to do when it genuinely is lacking.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - Presume capacity
Trigger. The patient is confused, so the worker assumes they cannot decide.
Decode, kept in your head. We start by presuming capacity. A diagnosis of dementia does not by itself remove it.
The move. Correct the assumption gently.
The first thing is that we always start by assuming a person can decide for themselves. Having dementia does not automatically mean they cannot. So we begin from yes, and only decide otherwise if we have to.
Check. Presumption of capacity established. Move on.
4.2 - The four-part test, in plain words
Trigger. The worker needs a usable test.
Decode, kept in your head. Four questions, understand, retain, weigh, communicate, put into everyday language.
The move. Give the four in plain words.
There are four simple things. Can he understand what you are offering and why. Can he hold that in mind long enough to decide. Can he weigh it up, the good and the bad of having the care or not. And can he tell you his decision in some way. If he can do all four, he can decide, even if we do not like the answer.
Check. The four-part test given plainly. Move on.
4.3 - Decision-specific and time-specific
Trigger. The worker thinks capacity is all-or-nothing.
Decode, kept in your head. Capacity is for a specific decision at a specific time. He may lack it for a complex choice and have it for a simple one, and it can change through the day.
The move. Explain that it is specific and can fluctuate.
Capacity is not all or nothing. It is about this particular decision, right now. He might be able to decide about a cup of tea but not about a big medical decision, and with dementia it can come and go through the day, so if now is a bad moment, it may be worth trying again later.
Check. Decision- and time-specific nature explained. Move on.
4.4 - An unwise choice is not incapacity
Trigger. He is refusing care, which seems foolish, so the worker assumes he cannot be capable.
Decode, kept in your head. The commonest error. A person is allowed to make what looks like an unwise decision. It is the process of deciding, not the wisdom of the outcome, that counts.
The move. Correct the error clearly.
This is the important one. Someone is allowed to make a choice we think is unwise, and still have capacity. So refusing care does not, by itself, mean he cannot decide. It is how he reaches the decision that matters, not whether we agree with it.
Check. The unwise-choice error corrected. Move on.
4.5 - What to do if capacity is lacking
Trigger. Sometimes he genuinely cannot decide.
Decode, kept in your head. If he lacks capacity for this decision, care is given in his best interests, in the least restrictive way, considering his wishes and involving those who know him, and you document it.
The move. Explain the best-interests, least-restriction approach.
If, when you go through those four things, he genuinely cannot decide, then we act in his best interests, doing what he needs in the gentlest, least restrictive way, taking account of what he would have wanted and talking to his family, and we write down our reasoning. And you can always call us to help assess it.
Check. The best-interests, least-restriction path explained. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Equating dementia with incapacity
Assuming that because he has dementia he cannot decide is wrong and disempowering. Presume capacity, and test it for the specific decision.
5.2 - Treating an unwise refusal as incapacity
The commonest error. Refusing care that he obviously needs does not prove he lacks capacity. Judge the process of deciding, not the wisdom of the choice.
5.3 - Giving the law instead of a usable tool
Reciting statute at a care worker helps no one. Give the four questions in plain, floor-ready words, so they can actually apply them.
5.4 - Forgetting least restriction
Even where capacity is lacking, care is given in the least restrictive way, taking account of his wishes. Forcing the most convenient option is not best interests.
Check. Name the trap you avoided. That is the mark.
The close
Close in four small movements.
One. Reassure the worker.
You are doing the right thing by asking and by not just forcing it.
Two. Recap the tool.
Understand, hold, weigh, and tell you, for this decision, right now. If he can, he decides, even if it is unwise.
Three. The if-not path.
If he genuinely cannot, we act in his best interests, gently and least restrictively, and involve his family.
Four. Stay available.
Call us any time to help assess it, and try again at a better moment of the day.
The two habits, again
Carry these two out of the room.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
The thread of this drill is one line. Presume capacity, test it in four plain steps for this decision now, and remember an unwise choice is not an incapable one.
Do those two things and this conversation with a colleague is yours to steer.
Advising Staff on the Agitated Dementia Patient
Before we begin
Welcome. This is the behavioural-symptoms-in-dementia drill. Not a patient in front of you, but a colleague, under pressure, asking you to do something that is not yet safe, or not yet right, and your job is to hold the line without losing them.
Care-home or ward staff are struggling with a resident with dementia who has become agitated or aggressive, and the unspoken hope is often that you will simply prescribe something to sedate them. You resist that. A change of behaviour in dementia is usually communicating something, pain, an infection, a change in the environment, an unmet need, so you hunt the cause first, you put non-drug measures first, you avoid benzodiazepines and are cautious with antipsychotics, and you never blame the behaviour on the dementia without checking the body.
Two habits carry every colleague drill. Keep them close.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
Ready. Let us walk in.
What this drill looks like
Picture the care home. A task card, near enough, this.
A resident with dementia has become increasingly agitated and has been aggressive to staff and other residents. Speak to the staff member and advise on assessment and management.
Here is the shape of it. Hear what has changed, and when. Hunt the cause, physical, environmental, unmet need. Set out non-drug measures first, and the ABC approach to find triggers. Explain the cautious, last-resort place of medication, avoiding benzodiazepines. Reassure the staff and plan review.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, hear it as communication
You do not open by reaching for a prescription. You open by reframing the behaviour as communication, and asking what has changed.
Say something like this.
Thank you for flagging this, and I know how hard it is to manage. When someone with dementia changes like this, it is very often them communicating that something is wrong, so before anything else, let us work out what has changed and why.
Check. Shall we meet the colleague. Let us.
Who is in front of you
In front of you is a care-home staff member, worn down, worried, and hoping you will prescribe something to calm the resident, because it has become hard to manage him and hard to keep others safe. There may be an unspoken pressure that if it cannot be managed, the placement is at risk.
They are not wrong to want help, but the quick sedative is usually the wrong first answer, and can be harmful. Your task is to shift them, gently, from what can we give him to what is he telling us, and to arm them with practical measures, while keeping medication as a cautious, last resort.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - What changed, and when
Trigger. The behaviour is new or worse.
Decode, kept in your head. A change from his baseline is the clue. When it started, and what changed around then, points to the cause.
The move. Ask what changed and when, in detail.
Tell me exactly what he is doing that is new, when it started, and what changed around that time, anything at all, new residents, a new member of staff, a change in routine, a family member who has stopped visiting.
Check. The change and its timing captured. Move on.
4.2 - Hunt the physical cause
Trigger. A change of behaviour in dementia is often physical.
Decode, kept in your head. Pain, infection, especially urine, constipation, dehydration, a new medication, poor sleep, all present as agitation. You must not put it down to the dementia without checking the body.
The move. Screen for the treatable physical causes first.
The first thing to rule out is a physical cause, because that is so often it. Is he in pain, could he have an infection, especially a urine infection, is he constipated, dehydrated, on any new medicine, sleeping badly. We check the body before we blame the dementia.
Check. Physical causes hunted first. Never overshadow. Move on.
4.3 - The ABC approach to triggers
Trigger. The agitation has patterns.
Decode, kept in your head. A simple record of what happened before the behaviour, the behaviour itself, and what happened after, reveals triggers and what maintains it, and points to changes that reduce it.
The move. Set up the antecedent, behaviour, consequence record.
It really helps to keep a simple chart, what was happening just before each episode, what exactly he did, and what happened afterwards. That often reveals a trigger we can remove, a noisy time, a particular task, being rushed, and it guides what to change.
Check. The ABC approach set up to find triggers. Move on.
4.4 - Non-drug measures first
Trigger. Staff want to know what to actually do.
Decode, kept in your head. The first-line treatments are non-drug, a calm predictable environment, familiar things and faces, meaningful activity, music or reminiscence, meeting needs before they escalate, a gentle unhurried approach.
The move. Give the practical non-drug measures.
The main treatments here are not tablets. A calm, predictable routine, familiar objects and faces, activity that suits him, music he likes especially around care times, and meeting his needs, the loo, food, comfort, before he gets distressed. A gentle, unhurried approach does more than any sedative.
Check. Non-drug measures given as first-line. Move on.
4.5 - Medication, cautious and last
Trigger. Sometimes, after all that, medication is needed.
Decode, kept in your head. Medication is a cautious last resort, for severe distress or risk, reviewed regularly. Benzodiazepines are avoided, they worsen confusion and falls, and antipsychotics are used sparingly, briefly, and carefully, given the real risks in dementia.
The move. Place medication honestly as the last, cautious step.
If, after the physical checks and the practical measures, he is still severely distressed or at risk, then we consider medication, but cautiously and briefly, and we review it. We avoid the sedative type, the benzodiazepines, because they worsen confusion and falls, and we use antipsychotics only sparingly and carefully, because they carry real risks in dementia.
Check. Medication placed as cautious, last resort, benzodiazepines avoided. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Reaching for a sedative first
Prescribing something to calm him as the first move, without hunting the cause, is the failure the station is built to catch. Cause first, non-drug measures first, medication last.
5.2 - Overshadowing a physical cause
Putting the behaviour down to the dementia without checking for pain, infection, constipation or a new drug misses a treatable, sometimes serious, cause. Always check the body.
5.3 - Giving a benzodiazepine
Benzodiazepines worsen confusion and falls in dementia and are avoided. Reaching for one is both a lost mark and a real harm.
5.4 - Dismissing the staff's distress
The staff are struggling and, sometimes, the placement is at risk. Acknowledge their difficulty and support them, rather than lecturing, or the practical plan will not be carried out.
Check. Name the trap you avoided. That is the mark.
The close
Close in four small movements.
One. Thank and support them.
Thank you, and I know how demanding this is for you and the team.
Two. Recap the order.
So, check the body first, keep the chart to find triggers, and the calm routine and familiar comforts, before any medication.
Three. The medication line.
Only if he is still severely distressed do we add a medicine, cautiously and briefly, and never a sedative benzodiazepine.
Four. Plan review, stay involved.
Let us review him together soon, and call me if he deteriorates or you are worried. You are not managing this alone.
The two habits, again
Carry these two out of the room.
One. Colleague to colleague, but check they are following. You pitch it at a professional level and you respect their expertise and their pressure. But you pause to make sure the reasoning has landed, because a busy nurse, a junior, or a care worker may not know the psychiatric detail, and the mark is for teaching a colleague without ever talking down to them.
Two. Hold the safe, evidence-based line, warmly, with the reason and an alternative. You never simply refuse a colleague, and you never cave to their pressure. You explain why the safe course is safe, you acknowledge their real bind, the beds, the workload, the worry, and you offer what you can do, the observation bed, the interim plan, the safe next step.
The thread of this drill is one line. A change in behaviour is communication, so hunt the cause, put non-drug measures first, avoid benzodiazepines, and never overshadow a physical cause.
Do those two things and this conversation with a colleague is yours to steer.