Since 2003 I have
been employed by the NHS on the strength of my ‘lived experience.’ An essential
criteria of the role was an acute admission, a fact in my life which at the
time felt like a barrier to ever working again. The Mental Health Trust in
Leeds was forward thinking and my peer worker style role was really quite
revolutionary. There were 12 of us who started together and we called Service
User Development Workers, each of us was allocated to an acute ward. My role is now much broader but I am still privileged to work with people within acute wards and I facilitate a group within which people can discuss their experiences and beliefs in a non-judgmental environment.
When I was admitted
in 2001, I was told, tomorrow you will see the psychiatrist. Naively this conjured
up an image of a leather sofa, a highly trained listening ear with time to hear
my story and help to confirm my theory about how a traumatic event early in my
life had left me broken. No, that wasn’t what happened, I spent about 5 minutes
in the company of this man, he handed me haloperidol and said I would be better
if I took this. I asked what would happen if I did not and was told I would be
restrained and forcibly medicated. Within only a few days I was experiencing
the extreme end of too much haloperidol and no words can describe the terror of
that. A state in which it is hard to speak let alone engage with the challenge to unravel your mystery. Simply put I was re-traumatised by the very service which claimed to be
helping me. Everything I did or spoke about became a symptom.
In truth it was a symptom! A symptom of a broken system
I had hoped that
people would have time to talk to me, help me work out the mysteries life had
hidden in the hand dealt to me, to unpick my metaphors and paradoxes, but what
we find is a lack of Therapeutic Engagement which is widely acknowledged and
documented. In 2011 Edwards said
What do we already know from published literature
- In
2008 the Mental Health Act Commission (MHAC) recommended that all units with
patients detained under the Mental Health Act 1983 should implement a system of
patient –protected time (MHAC 2008)
- Research
shows persistently that patients in mental health wards are deprived of
therapeutic interaction (Sharac et al 2010) and this situation was highlighted
by England’s chief nursing officer (CNO) (Dept. of Health 2006)
- Moyle (2003) found a discrepancy between friendly relationships
wanted by patients and the detached stance of nurses; while the patients
expected psychiatrists to focus in illness and symptoms, they did not want this
from nurses.
- Peplau (1952) states that the general
conditions that are likely to lead to health always include the interpersonal
environment
- According to a review of patient’s
experiences on MH wards (Quirk and Lelliot 2001) the desired characteristics of
nurses are empathy, listening, tolerance and knowing individual needs. However
patients in the review often perceived custodial or punitive attitudes in
nurses; patients also observed nurses lingering in the office.
- Importantly they note, ‘the mental health
system often diverts nurses from individualised care towards procedural
priorities and maintaining order and safety. A major issue for nurses therefore
is role conflict between their dual responsibilities for care and control. ‘
Barriers
- Goffman (1961) observed that nurses maintain a social distance from their
‘stigmatised’ patients
- Peplau
(1952) acknowledges that in general personal relationships with patients are
taboo in nursing.
- Menzies (1960) identified unconscious defence mechanisms in
nurses who protect themselves from anxiety by denying involvement in their
work.
- Handy (1991) found despite potential
satisfaction from interaction with patients, MH nurses derive comfort from order and thereby they maintain an impersonal
regime that ultimately causes job dissatisfaction.
- Bowers et al 2009, Johnson et al 2011
recognise good morale among nursing staff in acute MH units but contributory
factors for lack of nurse-patient contact are not difficult to find and include high acuity, an increasing proportion of patients detained under
the mental health act 1983, understaffing and bureaucratic burden.
- Quirk and Elliot (2001) argue that the rapid
patient through put in acute psychiatric units has an adverse effect on quality
of care. Reduced hospital provision
has led to a higher proportion of
detained patients and reliance on pharmacological rather than interpersonal
therapeutic interventions. Patients are not always amenable to
therapeutic interaction because of their condition or of the medication they
receive.
- Edwards et
al (2008) examined a PET scheme and found while nurses acknowledged their
responsibilities in providing time for individual patients, staff shortages and other issues made
it difficult to fulfil this expectation. Nurses observed some patients did not want one-to-one
sessions, and there was a lack of
supervision to support the practice.
Next Steps
- A
first step would be to define Patient Engagement Time, purpose and scope Nolan (2013)
- An
important stage is defining who within the nursing team are appropriate for
delivering patient engagement time. I.e. Peer Support Workers, Nurses, Health Support Workers,
Occupational Therapists
- The
Productive Ward project also known as Releasing
Time to Care, focused on improving ward processes and environments to help
nurses and therapists spend more time on patient care. Perhaps it is an ideal
time to rerun the process.
- Guidance
should be produced for therapeutic engagement sessions based on empirical
evidence. Nolan (2013)
- Access
to training and supervision. Nolan (2013)
- Staff supervision needs to be consistent, supportive and carried out by
appropriately trained, competent and experienced staff. Edwards (2011)
- Likely
to fail if it becomes another task in the daily routine and if nurses and
patients are insufficiently motivated to embrace the opportunity for better
engagement. Nolan (2013)
- Mental
Health Nursing lacks a distinct theoretical framework. Formulated by Hildegard Peplau in 1948,
published in 1952.
John Thorpe - Recoveryleeds.blogspot
References
Department of Health (2006) From values to action: The chief nursing officer’s review
of mental health nursing. DH, London
Edwards K, Dhoopnarain. A Fellows J et al (2008)
Evaluating protected time in mental health acute care. Nursing Times 104, 36,
28-29
Edwards K (2011). What
prevents one to one care? Mental Health
Nurses 10 January, 2011
Goffman. E 1961
Asylums: Essays on the social situation on mental patients and other inmates.
Doubleday, New York NY.
Handy J (1991)
Stress and contradiction in psychiatric nursing. Human Relations. 44, 1, 39-53.
Menzies IEP (1960)
The functioning of social systems as a defence against anxiety. Tavistock,
London
Moyle W (2003)
Nurse-patient relationship: a dichotomy of expectations. International journal
of mental health nursing
Nolan F, An
evaluation of protected engagement time on staff and patient outcomes in acute
mental health inpatient wards in England. Presented at the 19th
International Network for psychiatric nursing research. Royal College of
nursing, Warwick
Peplau. H. (1988).
Interpersonal Relations in Nursing.
The Macmillan Press. London. First published 1952
Quirk A and
Lelliot P (2001) What do we know about life on acute psychiatric wards in the
UK? A review of the research evidence.
Social Science and medicine. 53, 1565 – 1574.
Sharac J, McCrone
P, Sabes-Figuera R et al (2010) Nurse and patient activities and interaction on
psychiatric inpatient wards: A literature review, International Journal of
nursing studies, 47, 909-917