Therapeutic Engagement within Acute Inpatient services – A personal Interest

  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

'The culture of acute wards needs to be kept under constant scrutiny so that the notion of therapy rather than containment is the philosophy of care'

Edwards ‘What prevents one to one care?  Mental Health Nurses 10 January, 2011

  We can see from published literature that the importance of Therapeutic Engagement is not new, back in 1952 Peplau stated that

 ‘…the general conditions that are likely to lead to health always include the interpersonal environment’

Given how long this has been known, why then does it still not exist within present  Patient Experience, while service users have been asking for it for so long?

I would like to share some of the research I have made and would welcome any comments you may have to aid developing the understanding of this issue from both a service user and staff perspective. This isn't intended to become a stick to hit people over the head with. I would like to share what I have found to develop the understanding of all the issues involved and see how together as staff and service users we can begin to improve this situation.

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 19^th 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