FOREWORD
The problems and challenges faced by service users and staff in acute psychiatric in-patient units today have been well documented. The Tidal Model is a nursing response to these challenges. The model uses water as a metaphor for human experience and provides a conceptual tool for structuring and implementing appropriate nursing responses to prevent both service users and staff from being 'engulfed' by the tide of thoughts and emotions and consequent behavioural and cognitive problems which are so much a feature of acute mental illness.
The model is firmly based in the establishment and management of human relationships, which has always been the particular territory of mental health nursing, but which has tended to be lost in more recent years with advances in psychopharmacology, increasing focus on evidence-based interventions grounded in psychology and profound changes in available nursing expertise and skills in in-patient areas.
Changes in the delivery of mental health services to people with acute mental health problems has taken the focus away from in-patient care and moved it towards community care. Whilst this has had many positive benefits for service users and their families, in-patient units have languished in the shadow of community services and have lost both medical and nursing leadership and the relationship knowledge base of experienced mental health nurses.
Paradoxically, the needs of those people who require admission to hospital have become more complex and severe as a result of available community treatment. This has been exacerbated by changes in nursing education, which have affected staffing, and skill mix in many areas. The result has been that those who most need a high level of mental health nursing expertise have been, in some circumstances, the least likely to receive it.
The Tidal Model project focuses on the introduction of the Tidal Model into one acute admission ward in the Queen Elizabeth Psychiatric Hospital, Birmingham & Solihull Mental Health Trust. The ward (Tolkien Ward) is in many ways no different to many other acute admission wards serving inner-city populations. It has 22 beds, 5 admitting consultants, and experiences the usual staffing problems, workload pressures and bed shortages.
Nursing staff complained of little time to engage with patients or to carry out their work to the standards they thought they should achieve. They lacked understanding of nursing models and structures for delivering and organising care and had little perceived control over their work. Therefore a decision was made to try and alter the way nursing care was delivered on the ward and the Tidal Model was chosen as a way to change nursing practice so that it would be more in-line with perceived professional standards, deliver care that was service user focussed and based on nursing approaches and values rather than those which were more associated with the medical field of psychiatry.
The Tidal Model project had 8 distinct phases:
1. A multi-disciplinary literature review was undertaken
2. The aims and objectives of acute admission wards as understood by nurses at the QEPH was then ascertained and examined
3. Nurses’ perceptions of the quality of their relationship with patients on acute wards at the QEPH was then established and examined
4. Current nursing practices on QEPH acute admission wards as perceived by nurses was elicited and examined
5. Specific problems and difficulties that nursing staff were experiencing in their day-to-day work on acute wards were identified and examined
6. The Tidal Model was then implemented on Tolkien Ward in an attempt to address some of the problems and difficulties that have been identified
7. The Tidal Model implementation was evaluated by way of interviews with service users, staff evaluations and by means of statistical data obtained with the help of the Trust’s Research Department
8. Preparation and publication of this report
The stages are described in detail in the report. The Tidal Model project has challenged the perceptions of nursing staff that there was no time to talk to patients. It has shown that structuring nursing care in different ways, for example by working collaboratively with service users from assessment through to care planning and evaluation, and making time to engage with and talk to patients, can improve service users' experiences of their care and improve nurses' perceptions of their contribution to a person's care. The Tidal Model implementation has also been associated with a significant reduction in untoward incidents, a shorter length of stay and a reduction in complaints from service users about nursing care and staff attitude. Some service users found that their care was much more focused than previously and that staff had more time to talk to them.
One of the most important features of the Tidal Model Project has been that it has been carried out on a normal ward, with the usual staffing problems and workload challenges. There have been times when the Tidal Model has not worked perfectly and times when it has felt too difficult to structure in the time for daily care planning. There have been occasions when service users have not wanted to or felt able to participate in their care. There have been challenges in relation to the skill set of staff and its compatibility with the Tidal Model. Despite this, the team have persevered, learnt by doing and have been able to see the benefits of using the Tidal Model. Service user evaluation, both formally through the Project and through other routes, has been positive.
There is still work to do. The Tidal Model Project has exposed a clear deficit in therapeutic relationship skills and knowledge amongst nursing staff. Currently significant amounts of time are spent on training staff to deal with violence and aggression that might be better spent in part learning how to reduce such incidents by better knowledge and awareness of service user needs.
This would be in-line with what service users have been saying to us for many years. The Tidal Model has yet to make an impact on some other professionals’ perceptions of what nurses do and how they contribute to the wider multi-disciplinary team. Bed shortages and workload pressure remain. However, the tide seems to have turned in the right direction and staff are more skilled in negotiating the ebbs and flows of patient experience and the reality of working in acute admission units than they were previously.
The staff on Tolkien Ward, and Graham Brooks and Bill Gordon especially, have achieved what many thought was impossible – to change the focus of nursing care on an acute admission ward to enable therapeutic engagement with patients, structured nursing care, a safer environment and improved service user and staff satisfaction – whilst still doing 'the day job'. They have proved that it is possible to 'wave' rather than 'drown' in acute inpatient wards. I hope that other areas will read this report and be encouraged and enthused by the achievements of the project, the potential for mental health nursing and the experiences of service users.
Chris Halek
Deputy Director of Nursing & In-patient Programme Director
June 2004
ACKNOWLEDGEMENTS
We would like to thank the following people for their on-going help, support and contributions to this project.
Many thanks and with much appreciation:
§ To the service users who gave honest and helpful feedback on their view of the Tidal Model and how it has helped them towards recovery
§ To Becky Arlan, former Tolkien Ward Manager QEPH, who first helped get the project underway and offered constant encouragement
§ To all Tolkien Ward staff for their hard work ‘swimming against current’ and for their contributions and insights on how nursing practice on an acute ward can be improved
§ To Peter Nolan, Professor of Mental Health Nursing, Staffordshire University, Faculty of Health and Sciences for his guidance, advice and encouragement
§ To Phil Barker, former Professor of Psychiatric Nursing Practice, University of Newcastle UK, presently visiting Professor at Trinity College, Dublin, Ireland and his colleagues, Elaine Fletcher, former Research/Practitioner, Psychiatry Research Unit, University of Newcastle-upon-Tyne, and Chris Stevenson, former Lecturer in Psychiatric Nursing Practice, Department of Psychiatry, University of Newcastle upon Tyne, for their assistance, training and counsel as the project has unfolded
§ To the Consultant Psychiatrists Hugh Rickards, Brian Dalal, Patrick O’Brien and R Ismail for their helpful feedback, especially during the early days of the Tidal Model implementation on Tolkien Ward
§ To all the members (regular and occasional) of the Tolkien Project Steering Group who helped keep the project focused, on the road and going in the right direction, specifically: Mark Harvey, former Clinical Nurse Specialists Adult In-patient Service QEPH, Chris Halek, Deputy Director of Nursing, BSMHT, Liz Parry, Assistant to the Medical Director, BSMHT, Cath Gilliver, Modern Matron For the Adult In-patient Service QEPH, and Tina Elcock, In-patient Service Manager, QEPH
TABLE OF CONTENTS
CHAPTER ONE: INTRODUCTION
1.1 Background to this study ______________________________________________________ 7
1.2 Looking inside the black box____________________________________________________________ 8
1.3 Tolkien Ward ______________________________________________________________ 9
CHAPTER TWO: LITERATURE REVIEW________________________________________ 10______
2.1 The state we're in _____________________________________________________ 10______
2.2 Childhood abuse, psychosis & the dynamics of containment, control and milieu toxicity____ 13
2.3 Why don't nurses talk to patients any more?______________________________________ 18
2.4 The dislocation of appearance and reality on acute wards___________________________ 20
2.5 Conflicting perspectives on the appropriate focus of nursing care_____________________ 21
2.6 Contradictions within current mental health nursing theory___________________________ 22
2.7 Impact of the psychiatric medical model on current nursing care______________________ 25
2.8 The starting point of research and the problem of bias______________________________ 28
2.9 A commitment to basic principles of action research________________________________ 29______
2.10 Abductive reasoning _____________________________________________________ 30
2.11 Qualitative and quantitative (statistical) evidence_________________________________ 31
2.12 Conclusion: In search of a non-reductive science of care___________________________ 33______
CHAPTER THREE: METHODOLOGY___________________________________________ 36______
3.1 Study design ______________________________________________________________ 36
3.2 Qualitative and quantitative methods of inquiry used in this study_____________________ 36______
3.3 Five questions which have needed an answer3____________________________________ 37
3.4 Six stages of action research implementation_____________________________________ 37______
CHAPTER FOUR: THE QEPH NURSING STAFF INTERVIEWS ____________________ 38
4.1 Thematic analysis of interviews_________________________________________________ 38______
4.1.1 Nurses' perceptions of their role on acute in-patient wards_____________________ 38
4.1.2 Perceptions of the purposes of acute wards_________________________________ 39
4.1.3 Perceptions of patients' expectations of care________________________________ 40
4.1.4 Perceptions of the quality of nursing care planning___________________________ 41______
4.1.5 Perceptions of the amount of time spent talking to patients____________________ 42
4.1.6 Nurses' knowledge of models of nursing care_______________________________ 42
4.1.7 Teamwork issues _____________________________________________________ 42______
4.1.8 How, in your opinion, can nursing care be improved?_________________________ 43
4.2 Concluding remarks _____________________________________________________ 43
CHAPTER FIVE: WHY THE TIDAL MODEL?_____________________________________ 45______
5.1 Recent developments in nursing science_________________________________________ 45
5.2 Time as a commodity _____________________________________________________ 46
5.3 Use of the Tidal Model as a means to reforming nursing practice______________________ 46
5.4 Origins of the Tidal Model _____________________________________________________ 47
5.5 The theoretical basis of the Tidal Model - a thumb-nail sketch________________________ 48
5.6 Introducing the holistic nursing asessment of patients needs_________________________ 48
5.6.1 Holistic assessments and other types of professional assessments_________________ 48______
5.7 Daily care plans _____________________________________________________ 49
5.8 Evidence of clinic effectiveness of the Tidal Model from other pilot sites________________ 49
CHAPTER SIX: NARRATIVES OF CHANGE______________________________________ 52______
6.1 How the Tidal Model was implemented on Tolkien Ward_____________________________ 52______
6.1.1 Implementation strategy________________________________________________ 52
6.1.2 Tidal Model Induction Day_______________________________________________ 52______
6.1.3 Preparing the ground___________________________________________________ 53______
6.1.4 Nursing attitudes to training_____________________________________________ 53______
6.1.5 Redesigning the nursing documentation____________________________________ 53
6.1.6 Changes in management________________________________________________ 54______
6.1.7 "T DAY' _____________________________________________________ 54______
6.1.8 Bed management issues________________________________________________ 54______
6.1.9 The Tidal Nurse _____________________________________________________ 55______
6.1.10 Budgetary constraints_________________________________________________ 56______
6.1.11 A temporary reprieve for the Tidal Nurse__________________________________ 56______
6.1.12 Challenging the previous nursing culture__________________________________ 57______
6.1.13 Accountability and work delegation_______________________________________ 57
6.1.14 The use of Bank Nursing Staff___________________________________________ 58
6.1.15 Observation versus "engagement"?______________________________________ 58
6.1 16 Care planning and observations_________________________________________ 59
6.1.17 Hitting rock-bottom: June 2003__________________________________________ 60
6.1.18 Future developments on Tolkien Ward____________________________________ 60
6.1.18.1 Group supervision______________________________________________ 60______
6.1.18.2 Staff training__________________________________________________ 60______
6.1.18.3 Group work____________________________________________________________ 61
6.1.18.4 Environment___________________________________________________ 61______
6.1.18 .5 User's Voice__________________________________________________ 61______
6.2 The perceptions of Nurse Managers_____________________________________________ 61______
6.2.1 Testimony of previous Ward Manager of Tolkien Ward________________________ 61______
6.2.2 Testimony of Cinical Nurse Specialist Adult in-Patient Services QEPH____________ 62
6.2.3 Testimony of Modern Matron for the Adult In-Patient Services QEPH_____________ 63______
CHAPTER SEVEN: EVALUATION OF THE TIDAL MODEL____________________________ 65
7.1 QUALITATIVE EVIDENCE _____________________________________________________ 65
7.1.1 Service user (in-patient) evaluation_______________________________________ 65
7.1.1.1 Overall service user evaluation of the Tidal Model_____________________ 66
7.1.1.2 Comparison with previous in-patient expereince_______________________ 66
7.1.1.3 Holistic assessment and care plan aspect of the Tidal Model_____________ 66
7.1.1.4 Most helpful aspects of the Model___________________________________ 67______
7.1.1.5 Least helpful aspects of the Model__________________________________ 67
7.1.2 Tolkien Ward staff evaluation questionnaires________________________________ 68
7.1.2.1 Qualified nursing staff____________________________________________ 68______
7.1.2.1.1 Satisfaction with the Tidal Model___________________________ 68
7.1.2.1.2 Training, supervision and staff handovers between shifts_______ 70
7.1.2.1 3 Comparison with other nursing models______________________ 70
7.1.2.2 Nursing Assistants_______________________________________________ 72______
7.1.2.3 Medical Staff____________________________________________________________ 72
7.1.2.3.1 Communications________________________________________ 73
7.1.2.3 Concluding Remarks_____________________________________________ 73
7.1.3 Nursing Staff away day: applying the EFQM Excellence Model__________________ 74
7.1.3.1 Benefits for the staff team________________________________________ 74
7.1.3.2 Perceived benefits for service users________________________________ 74
7.1.3.3 Staff training and education_______________________________________ 75
7.1.3.4 Documenting of the nursing process________________________________ 75
7.1.3.5 Leadership _____________________________________________________ 75
7.1.3.6 Resources _____________________________________________________ 75
7.1.3.7 Nursing policy issues_____________________________________________ 75
7.1.3.8 Where are we, right now, concerning Tidal Model implementation?________ 76
7.1.4 Four-month Tolkien Ward documentation audit______________________________ 76
7.1.4.1 Daily care plans_________________________________________________ 77______
7.1.4.1.1 Audit result____________________________________________ 77______
7.1.4.1.2 Quality of nurse-patient engagement_______________________ 77
7.1.4.1.3 Daily care plan implementation____________________________ 78
7.1.4.1.4 Cultural issues__________________________________________ 78
7.1.4.1.5 Identifying staff training/education deficits___________________ 79______
7.1.4.1.6 Staffing levels and skill mix_______________________________ 79______
7.1.4.1.7 Initial 72-Hour assessment and care plan____________________ 79
7.1.4.1.8 Audit results___________________________________________ 79______
7.1.4.2 Nursing holistic assessment_______________________________________ 80______
7.1.4.3 Discussion and concluding remarks_________________________________ 80______
7.2 QUANTITATIVE EVIDENCE _____________________________________________________ 83
7.2.1 Untoward incidents______________________________________________________________ 83
7.2.1.1 The concept of milieu toxicity______________________________________ 83______
7.2.1.2 Serious versus minor incidents on Tolkien Ward_______________________ 83
7.2.1.3 Untoward incidents on all four QEPH acute admission wards_____________ 84
7.2.1.4 Untoward incidents on Tolkien Ward_________________________________ 87
7.2.2 Characteristics of patients admitted to Tolkien Ward__________________________ 90
7.2.2.1 Number of admissions____________________________________________ 90______
7.2.2.2 Source of admissions____________________________________________ 90______
7.2.2.3 Patient age ______ 91
7.2.2.4 Medical diagnosis________________________________________________ 91______
7.2.2.5 Patient ethnicity_________________________________________________ 94______
7.2.2.6 Methods of discharge_____________________________________________ 94______
7.2.3 Complaints _____________________________________________________ 95______
7.2.3.1 Number of complaints relating to nursing care________________________ 95
7.2.3.2 Analysis of complaints on Tolkien Ward______________________________ 95
7.2.4 Concluding remarks_____________________________________________________________ 97
CHAPTER EIGHT: DISCUSSION AND CONCLUSION_______________________________ 98
8.1 Discussion: _____________________________________________________ 98
8.1.1 Interpreting the significance of the results of untoward incidents________________ 98
8.1.1.1 Other plausible reasons for the reduction of incidents__________________ 99
8.1.1.2 Rigorous proof or 'inference to the best explanation'?_________________ 101
8.1.2 What this study confirms in terms of other studies__________________________ 102
8.1.3 What this study adds to other studies_____________________________________ 104
8.1.3.1 The relational nature of empowerment_____________________________ 104
8.1.3.2 Nursing perceptions of time______________________________________ 104______
8.2 Conclusion ____________________________________________________ 105
8.2.1 Creating negative and positive communication feedback loops________________ 105
CHAPTER NINE: RECOMMENDATIONS_______________________________________ 107
9.1 General recomendations for the BSMHT_________________________________________ 107
9.2 Recommendations for staff training and development______________________________ 107
APPENDICIES _____________________________________________ 108
10.1 Historical and theoretical background to the Tidal Model___________________________ 108
10.2 Nursing holistic assessment form_____________________________________________ 114______
10.3 Nursing guidance to the use of the holistic assessment form_______________________ 121
10.4 Initial 72-hour assessment and care plan_______________________________________ 124
10.5 Daily care plan record ____________________________________________________ 126
10.6 Nursing guidance for use of daily care planning form_____________________________ 128
10.7 Patient ward round plan ____________________________________________________ 130
10.8 Patient observations/engagement care plan_____________________________________ 131
10.9 Initial staff interview letter of consent__________________________________________ 133
10.10 Initial staff interview schedule_______________________________________________ 134
10.11 Verbatim summary of initial nursing interviews_________________________________ 135
10.12 Qualified nurses' questionnaire______________________________________________ 141______
10.13 Multi-disciplinary team questionnaire_________________________________________ 144
10.14 Patient information sheet_____________________________________________________________ 146
10.15 Patient consent form ____________________________________________________ 148
10.16 Patient interview schedule__________________________________________________ 149
TABLES AND FIGURES ________________________________________________
Table 1: The dynamics of abuse ______________________________________________________________ 14
Table 2: The dynamics of in-patient care on acute wards______________________________________________ 15
Table 3: Dynamics of psychosis ______________________________________________________________ 15
Table 4; Cure Model of Control versus Care Model of Compassion________________________________________ 18________
Table 5: Average rating of Tidal Model by Tolkien nursing staff on 'satisfaction'____________________________ 68
Table 6: Average rating of Tidal Model in comparision with other models_________________________________ 71
Figure 1: Number of incidents within each category for all acute wards at the QEPH 2001-2002________________ 85
Table 7: Percentage of incidents within each category for all acute wards 2001-2002________________________ 85
Figure 2: Number of untoward incidents recorded for each admission ward for the two time periods____________ 86
Table 8: Number of incidents recorded for each acute ward during the two time periods_____________________ 86
Figure 3: Number of incidents for all acute wards 2002-2003___________________________________________ 87
Table 9: Percentage of incidents within each category for all acute wards 2002-2003________________________ 87
Table 10: Number of incidents on Tolkien Ward before/after introduction of the Tidal Model__________________ 88
Figure 4: Comparison of the number/type of incident for the two periods on Tolkien Ward___________________ 89
Table 11: Number of admissions/repeated admissions before and after introduction of the Tidal Model_________ 90
Table 12: Percentage of patients admitted to Tolkien Ward via different sources for the two time periods_______ 90
Tabel 13: Age of patients admitted to Tolkien Ward for the two time periods______________________________ 91
Figure 5: Medical diagnosis of patients admitted to Tolkien Ward 2001-2002______________________________ 92
Figure 6: Medical diagnosis of patients admitted to Tolkien Ward 2002-2003______________________________ 93
Table 14: Ethnic groups of patients admitted to Tolkien Ward for the two time periods______________________ 94
Table 15: Methods of discharge for the two time periods______________________________________________ 94
Table 16: Number of total complaints regarding nursing care for the two time periods_______________________ 95
Figure 7: Specific issues raised as complaints on Tolkien Ward for the two time periods_____________________ 96
Table 17: Percentage of decrease of untoward incidents following implementation of the Model_______________ 99
CHAPTER ONE: INTRODUCTION
1.1 Background to this study
Over the past few years, policy documents from the Department of Health as well as empirical research studies suggest that acute psychiatric admission wards are experiencing difficulties in managing clients in their care. Amongst these difficulties is an increasing reduction of in-patient beds nationally and the increasingly complex problems that clients present on admission.
The acute admission wards in the Queen Elizabeth Psychiatric Hospital (QEPH) are clearly experiencing the same type of problems as other facilities nationally.
Bowers and Park (2001) state that one of the unfortunate and unintended consequences of the deinstitutionalizing of mental health care by shifting care out of the old Victorian asylums into the community [1], has been the relegation of acute in-patient care from the centre to the margins of mental health services. In their view economic and philosophical objections to hospital care have resulted in great uncertainty about the contemporary purpose of in-patient services and thus of the role of psychiatric and mental health nursing within that context.
On the other hand, they assert that adequate alternatives to in-patient services have not been developed. The result is that psychiatric hospitals are now paradoxically almost entirely associated with containment. The assumption that they can be appropriate places of refuge has virtually disappeared.
According to a recent Sainsbury report (1998) [2], patients [3] tend to experience their stay in acute wards as non-therapeutic. There is little individual care planning and the environment tends to be custodial in nature with little quality. In addition to this, working on acute in-patient admission wards 15-20 years ago was a relatively high status position for psychiatric nurses who worked with patients considered to be amenable to both intervention and care. This is no longer the case.
What used to be the jewel in the crown of psychiatric services has become the rump. According to Quirk & Lelliot (2001), acute wards are now places of risk, violence, restraint and custodial care where the quality of care has been compromised or is under threat. They are perceived to be relatively low status or dead-end work environments. Nurses who work on acute wards in comparison to their community colleagues are paid less, tend to be less well educated professionally and have fewer opportunities for career advancement. The result is that the least able and the least experienced nursing staff care for the most acutely distressed patients[4] . According to Quirk & Lelliot (2001) –
“Nurse patient contact has declined; and patients are critical of conditions on the ward and view life there as both boring and unsafe”.
In addition to this, they state that acute wards are characterised by rapid staff turnover, extensive use of bank and agency staff and low staff morale. The improvement of the quality of care on acute admission wards is thus a major on-going concern for the Department of Health (1999, 2002, 2003), which, in a recent Policy Implementation Guide (2002), openly admits that:
“In-patient services are not working to anyone’s satisfaction”
According to Allen & Jones (2002), with acute mental health care in such a crisis we should consider every mental health nurse who works in the acute in-patient setting as a key resource for change. Until this view is adopted, many nurses who see themselves as seriously ill-equipped for the strenuous demands placed upon them in the acute setting, or undervalued because of a lack of relevant training and support as well as underpaid, will continue to leave acute in-patient work for less stressful, more prestigious and better rewarded jobs in the community.
As a result of this state of affairs, this study seeks to give a wide-ranging picture of the full context in which these problems have developed, in order to more effectively identify those nursing practices, and the theory underlying them, which will substantially improve the therapeutic experience of clients. By doing so it seeks to examine, in depth, a current issue of great concern to the Department of Health and to the nursing profession, an issue that has important implications for all the acute in-patient facilities at the QEPH and the way in which these impact on in-patient service users.
1.2 Looking inside the black box
Quirk & Leliott (2001), in their discussion of previous studies on the nature of current psychiatric in-patient care, point out that there is actually very little known about the quality of care being provided on UK admission wards. Despite various studies about daily life on acute wards, what is left is a patchy, inconsistent picture and a very opaque window looking in on how in-patient care is currently experienced by its recipients and by the nurses who work on acute wards. In the authors’ words:-
“There is a sense that hospital care is a black box, with people being admitted and discharged, but with little known about what happens to them while they are there”.
According to Higgins et al. (1999) patients report feeling bored, filling in time by sitting on their own doing nothing, watching television or talking with other patients. 40% of patients according to national survey undertaken by the Sainsbury Centre for Mental Health (1998) reported having undertaken no social or recreational activity while on the ward. Another survey undertaken by Ford et al. (1998) reported that most patients had little to do all day and the nursing staff took little interest in them unless they were making a disturbance.
This study seeks to take a look inside at least one black box in the hope that by obtaining data as well as testimonies on the way things actually are on the acute wards at the QEPH, a real transformation of nursing practice can begin to impact on the wider vision for building and nurturing organisational change and developments already underway within the Birmingham and Solihull Mental Health NHS Trust (BSMHT).
1.3 Tolkien Ward
Tolkien Ward is one of four adult acute in-patient wards at the Queen Elizabeth Psychiatric Hospital (QEPH), which is in Edgbaston, Birmingham, United Kingdom, serving a population of approximately 450K. The QEPH provides in-patient care for the South of the city. In addition to the four acute wards the hospital contains an Intensive Care Unit, three Speciality Wards, three Elderly Care Wards and offers other services such as Neuropsychiatry, Psychology, Psychotherapy and Day Service Care. The QEPH has 93 acute in-patient beds within the four adult wards plus 10 on the ICU.
Tolkien Ward has 22 beds and its catchment area covers the Bourneville, Kings Norton, Cotteridge, Kings Heath, Billesley, Brandwood, Hall Green, Fox Hollies and Acocks Green areas of the city of Birmingham.
At the time of the implementation of the Tidal Model there were four area-based Consultant Psychiatrists whose patients were on Tolkien ward. There was also a Neuropsychiatry Consultant who had the use of two-three of the beds.
The nursing establishment for the ward during the project was:
One x ward manager (Grade G)
Two x deputy ward managers (Grade F)
11 x qualified nurses (Grades D/E)
11 x nursing assistants - mixture of full and part-time (Grade A)
CHAPTER TWO: LITERATURE REVIEW
2.1 The state we’re in
According to the report Acute Problems by the Sainsbury Centre for Mental Health (1998), acute admission work in England is in great difficulty today. This is due to a number of inter-related reasons. Some of these are historical and economic and are directly related to a lack of investment in in-patient services over several decades, as both policy focus and resources have been re-allocated to the community. In addition to this, there has arisen a correspondingly inadequate system for training and educating nurses in ways appropriate to the very specialised nature of acute care at a time where there is an ever-increasing pressure on the in-patient system due to bed shortages [5].
Not surprisingly, under such circumstances, service users tend to experience their stay on busy acute wards as anxiety provoking and non-therapeutic. This is, in part, related to the fact that there is little skilled therapeutic involvement of nurses with patients on acute admission wards. The reason given for this by nurses is that they are just too busy doing other things like administration, answering the phone, writing up notes, attending meetings and dispensing medication. Much of the current literature into acute psychiatric care highlights a system under increasing stress [6].
Although acute admission wards are not currently in fashion within the NHS, a body of evidence is emerging that they are not only needed, but can potentially be a very effective type of intervention for some people under some circumstances. Nevertheless, according to Priebe and Turner (2003), skilled nurses[7] and planners are attracted away from acute in-patient work to community-based work because that is where the resources are and where nursing career opportunities lie. This leaves fewer resources to create and develop effective in-patient services.
In addition to this, nursing as a profession has developed a degree of autonomy and respect within the community that it does not have within more medically dominated and poorly resourced NHS hospital settings. This tends to place acute in-patient nursing staff on the defensive. They tend to see their nursing role as subordinate and ancillary to that of the medical staff in the context of what is, often, a custodial environment.
According to Forrest (1994), one of the biggest problems in attempting to study or to improve acute in-patient services is how best to measure, understand and to work within their very complex dynamics in order to transform nursing practice. In reviewing the therapeutic day, Ehlert and Griffiths (1996) looked at the social environment and social activities on acute wards and found that many were poor and had little to engage anyone undergoing a severe mental health crisis. They also found that both nurses and patients held unfavourable views about the ward. They complained about inadequate staffing levels, the lack of support for staff and patients, the lack of patients’ involvement in their own care, and the lack of therapeutic activities available for patients during the course of a day. Some patients stated they were unable even to have a cup of tea when they wished; others said they were bored most of the time and that there was little or nothing for them to do or read, and a few stated that they had no opportunities to involve themselves in activities that would enrich them spiritually.
Consistent with the Sainsbury report are the findings of the Standing Nursing & Midwifery Advisory Group in Mental Health Nursing: Addressing Acute Concerns (June 1999). The SNMAC also highlights the severe problems acute in-patient services are experiencing nationally. For effective reform of the acute in-patient system to take place, according to the report, what is clearly needed is a 'change in therapeutic culture' within the acute in-patient setting [8].
But, such a change is clearly dependant on broader systemic and institutional changes within the mental health system as a whole, such as those recommended by the NHS Modernisation Agency booklets on developing and nurturing an ‘improvement culture’ within the NHS as an organisation [9]. It must become more collaborative and facilitative in its way of operating if it is going to deliver a more client-centred type of care. The way in which decisions are actually made at the management and operational levels will also need to change if a genuine transformation in therapeutic culture is to take place.
Quirk & Lettiot (2002), after looking closely at the available in both historical and sociological context have come to the conclusion that:
- Despite the development of community care and associated processes of de-institutionalisation, the hospital remains the hub of mental health services in the UK
- However, previous quantitative and survey research indicates that quality of care in acute psychiatric admission wards has been compromised or is under threat and points to a bleak experience for people who are admitted. Indicators of this include that there have been increases in admission rates, the proportion of compulsory admissions, and bed occupancy rates
- There is also evidence of violence, sexual harassment and substance misuse in this setting, accompanied by rapid staff turnover, low staff morale, and an increasing proportion of 'difficult patients’ (especially young men with schizophrenia)
The authors, both nationally respected researchers, emphasise the fact that although nurse/patient relationships are perceived to be one of the most important aspects of care, yet nurse/patient contact has declined dramatically on acute in-patient wards over the last decades; and patients are now critical of conditions on acute wards and tend to view life there as both boring and unsafe.
2.2 Childhood abuse, psychosis, & the dynamics of containment, control and milieu toxicity
Complicating the issue of ‘why’ managing care on acute in-patient words is now so dangerous and difficult are three interconnected factors, which often, according to Davenport (2002), tend to converge and support each other on acute wards:
- The relational dynamics of ‘adult’ survivors of childhood sexual and physical abuse
- The nature of custodial in-patient care on acute wards
- The dynamics of psychotic mental states
Along with Davenport (2002), Wurr & Partridge (1996) also maintain that there is a high incidence of people on acute wards today, with various medical psychiatric diagnoses, who have experienced sexual and physical abuse in their childhood. More recently, Hammersley et al. (2004) have highlighted the growing clinical evidence that there is a strong link between childhood abuse and subsequent psychosis in later life [10].
Typical relational dynamics associated with a history of childhood sexual and/or physical abuse would include post-traumatic stress disorder (PTSD), psychological dissociation (‘splitting’), drug and alcohol abuse, a pattern of re-victimisation and re-traumatisation, difficulties within relationships in which there is an imbalance of power and the over sexualisation of relationships in general.
According to Davenport (2002), the relationship between patients, many of whom have this history, living together on an acute admission ward in an intimate, but unsafe environment where there are outbreaks of violence and verbal abuse is easily sexualised and vulnerable to exploitation. This dynamic has a confusing impact upon nursing staff, who are normally not trained to deal with these phenomena and who thus get caught up in situations with little if any insight into what is happening. Relationships on the ward are thus easily subverted within a victim/perpetuator dynamic. According to Hammersley (2004) [11]
Some patients become powerless, while others are seen as predatory. Women patients are most often adversely affected. Staff find it particularly challenging to handle these difficulties with sensitivity; they can contribute to poor outcome, characterised by treatment dropouts, lack of meaningful therapeutic relationships and acting-out behaviour. For staff, the outcome is equally poor, with lack of job satisfaction, a high staff turnover and high sickness rates.
According to the now classic paper by Menzies Lyth (1988), a recognised feature of many hospital wards are institutionalised nursing practices and management attitudes that strengthen nursing staff’s psychological defences against the experience of anxiety. One aspect of these defences is the avoidance of patient contact under plausible pretexts.
The Menzies Lyth study concerned general nursing, but Davenport (2002) convincingly applies the findings to acute psychiatric wards. Within this context, at any given time, a number of patients on the ward will be in the midst of a psychotic episode. Aspects of their behaviour and the way they relate to staff and others will be driven by the dynamics typically underlying psychotic states.
Davenport’s (2002) thesis is that the dynamics of past abuse in individual patients when brought together with a custodial style of nursing care built upon nursing defences against anxiety, as well as the bizarre behaviour of some psychotic patients, makes the development of a therapeutic culture on acute wards exceedingly difficult. These three dynamics tend to work powerfully together to create a toxic or anti-therapeutic milieu based on denial rather than on trusting therapeutic relationships open to feelings, insight and new learning. The three tables below illustrate how these three dynamics often interact within acute in-patient settings:
Table 1: The dynamics of abuse
IN THE PRESENT | DYSFUNCTIONAL DYNAMIC |
Difficulties in establishing trusting relationships with staff. | Manipulation of an unequal power relationship between parent and child for adult gratification leads to long-term difficulties in negotiating trusting relationships. |
Poor personal boundaries | Violation of the child through a sexual act may lead to long-term difficulties recognising and maintaining personal boundaries |
Re-victimisation syndrome | Early experience creates a strong on-going expectation of repeating the cycle of abuse in the present. |
Low self-esteem, self-disgust and self-loathing | The original experience of abuse instils a sense of abuse, both past and present, being deserved |
Sexualisation of therapeutic relationships | Early experience of a sexual relationship with a care giver creates the on-going expectation that future care giving relationships will also be sexual or become sexualised |
Transference and counter-transference difficulties between staff and patients | Working with survivors of sexual abuse may evoke powerful feelings of rage, disgust and hatred, which may be displaced by the patient and experienced as disabling, confusing or frightening by staff. |
After Davenport (2002) adapted |
Table 2: The dynamics of in-patient care on acute wards
IN THE PRESENT ON THE WARD | DYSFUNCTIONAL DYNAMIC |
Ritual nursing tasks and procedures performed each day | Ward routine lends stability and consistency to nursing task performance and avoids excessive decision-making, but the progression to compulsive anxiety avoidance-ritual can depersonalise care, reinforce depersonalised ways of relating to patients and to the avoidance of engagement with them. |
Resistance to change | Familiar ways of thinking and working are adhered to even when they are dysfunctional, making both patients and staff feel peripheral to and powerless within the routine process of institutional care. |
Nursing detachment and denial of feelings | The necessary professional detachment and maintenance of personal boundaries becomes extreme and is characterised by therapeutic withdrawal, poor handovers, rapid staff turnover, failure to follow through care plans and the avoidance of difficult patients. |
Collusive redistribution of social roles, e.g. scapegoating | Specific individuals are unconsciously chosen to fulfill a role for the ward and then act upon that role as assigned. |
After Menzies Lyth, 1988 adapted |
Table 3: Dynamics of psychosis
THE INDIVIDUAL PATIENT | IMPACT ON WARD DYNAMICS |
Psychological splitting | Nursing staff and patient groups are artificially split into good v. bad, us v. them, or victim v. perpetrator |
Grandiose omnipotence | Patients (or staff) feel entitled to act as if they are all-powerful or all-knowing |
Pathological projective identification | Parts of the self are experienced as intolerable and are projected out into others; others unconsciously respond in accordance with this projection. As patients often project intolerable aggression or rage, staff may be perceived as dangerous. |
Persecutory states | Potentially good or popular figures are regarded with intense suspicion. |
Inhibition of symbolisation (failure of verbal linking) | The use of pathological projective identification may disrupt rational thinking and good decision making and lead to disordered interpersonal behaviour. |
After Davenport (2002) adapted |
The three dynamics described in the above tables can be aptly described as ‘toxic’ rather than healing or recovery-oriented. Stated briefly, the metaphor of relationship toxicity alludes to any interpersonal context within which verbal or physical violence/abuse (either as a perpetuator, victim or silent witness [12]) takes place on a regular basis, as well as to those institutional environments where relationships are characterized by denial, lack of trust, manipulation, defensiveness, poor personal boundaries, and depersonalisation [13].
By way of contrast, genuinely therapeutic dynamics are characterised by the core conditions necessary for personal growth, originally identified by Rogers (1951,1961 and 1980), such as mutual positive regard, trust and respect, clear boundaries, openness and honesty, willingness to learn and congruity of thought, feeling and behaviour [14].
The metaphor of relational toxicity has been used for a number of decades in the addictions-recovery movement pioneered by Alcoholics Anonymous in the 1930’s (See Kurtz 1979) [15]. It has facilitated a worldwide self-help movement, which has developed very clear concepts about the kinds of relationships, thinking and behaviours that tend to promote recovery from both addiction and relationship disorders and those that do not. The mental health service user/survivor/recovery movement employs similar perspectives on personal growth in conjunction with a hard-won practical wisdom that has many analogues within the self-help addiction and co-dependency recovery movement.
These analogues are instructive and are gradually transforming our understanding of mental health issues, but also the role of service users in developing health-care policy and models of recovery absent from the conventional psychiatric model, which has tended to think primarily in terms of disease/cure in which the helping professional is in charge of the whole process.
However, the weight of the responsibility of the ‘cure model’ in the mental health field is, according to Olthuis (2001), absolutely immense [16]. In reality, this responsibility is just impossible to bear. It also tends to support a dependency and victim mentality in service users by undermining the need for people to take personal responsibility for their own lives, actions and recovery. Over-burdened by their sense of total responsibility for both the behaviour and the recovery of those they seek to cure, many helping professionals tend to see their role primarily in terms of controlling their clients and not in terms of sharing responsibility equally with them in a spirit of collaborative problem solving.
Within this ‘control-cure paradigm’, according to Olthius (2001), helping professionals naturally tend to interpret situations in such a way that if things go wrong (as they often do), the professional offering the service or ‘cure’ cannot be blamed. Blame will then be shifted on to colleagues or to the service user and to his or her intransigence. Applied to nursing within this paradigm, one-to-one sessions with patients often become battles of will between the nurse and the patient in which the nurse seeks to ease his or her conscience by pointing at the service users bad behaviour, and failure to co-operate.
And for their part, service users – saddled with the feeling that it is their duty to get better in order to save the nurses’ ego – can end up over-complying with whatever help is offered as treatment, by saying and doing exactly those things designed to win the approval of the nursing and medical staff. This is how a ‘good patient’ should behave. Service users, especially those who have a history of childhood abuse, can thus be profoundly patronised and intimidated by the acute in-patient treatment setting, causing them, in turn, to either close down emotionally or to ‘act out’ in protest.
So, for Olthius (2001), if we are to overcome such non-therapeutic relationships and treatment environments, the premise is clear. The ‘cure paradigm’ of control should be replaced with a ‘care paradigm’ of caring-with. Olthius thus advocates a recovery-oriented and client-centred model based on a partnership between the person in need and those offering help. In addition to this, the responsibility for recovery lies ultimately with the service user not with the helping professional.
Table 4, following, Olthius (2001), contrasts two models or paradigms: the cure paradigm of control-over service users in contrast with the partnership paradigm of caring-with service users. In terms of the discussion above, it is clear that what Rogers (1951 and 1968) first identified as the core personal characteristics necessary to form therapeutic relationships (congruence or genuineness, unconditional positive regard and accurate empathic understanding) are most likely to flourish within the caring-with paradigm based on partnership than it is within the more dictatorial cure-control paradigm.
Table 4: Cure Model of Control versus Care Model of Compassion
CURE PARADIGM OF CONTROL | CARE PARADIGM OF COMPASSION |
Power Over | Power With (Mutual Empowerment) |
Cure | Caring-with |
The Expert | The Helper |
Technique | Personal- interaction |
Detachment | Involvement/Engagement |
Impersonal | Personal |
One-Directional | Multi-directional |
Instrumental Reason | Imagination/Empathy |
Dictative/Dictatorial | Collaborative/Partnership |
Compliance | Empowerment |
Uni-Vocal (Only One Voice Heard) | Multi-Vocal (Many Voices Heard) |
Institution-centred | Client-centred |
When I Feel Responsible For Others, I…….. | When I Feel Responsible With Others, I…….. |
Talk a lot | Listen a Lot |
Tell People What to do | Invite |
Fix Things/ Withdraw | Attune and Stay With |
Protect | Encourage |
Rescue | Share |
Control | Go With the Flow |
Carry Other Peoples Feelings | Show Understanding |
Interpret Others Thoughts and Feelings | Encourage Self-Understanding |
Make Decisions For Others | Encourage Responsible Decision-Making |
After Olthius (adapted) |
2.3 Why don’t nurses talk to patients any more?
Davenport’s (2002) thesis concerning how the inter-relationship between childhood abuse, psychosis and the dynamics of containment impacts nursing practice on acute wards, when brought together with Olthius’ (2001) contrast between a ‘cure’ versus a ‘caring-with’ model of interpersonal relations helps explain why nurses tend to avoid patient contact on acute wards even though they may be unaware that they are doing this.
Peter Cambell, a long-term survivor of the mental health system, gives a personal account of the frustration and anger many service users feel as in-patients, because of the fact that nurses claim not to have enough time to talk to them. His testimony is consistent with the current literature. According to Cambell (1999):
People with a mental illness diagnosis often say that they value relationships more than psychiatric drugs.
This coincides with nurses saying how much they value their relationships with their patients. Yet nurses also express frustration and anger as they explain how there is not enough time for them to talk to their patients or to establish meaningful therapeutic relationships with them on acute wards.
Part of this general frustration is compounded, according to the available research, by many nurses’ acute awareness of the large gap that exists between, on the one hand, the stated values of their profession and personal vocation to be a caring person, and, on the other hand, the harsh reality of poor care experienced by both patients and their relatives [17]. The Department of Health's (1994) mental health nursing review declared:
'The work of mental health nurses rests upon the relationship they have with people who use services. Our recommendations for future action start and finish with this relationship'
But, one could ask, what is the real possibility for developing this kind of partnership between nurse and patient within present acute in-patient settings when nurses do not spend quality time with their patients or talk to them except in summary ways?
According to Cambell (1999), the professional and research consensus is that interactions between service users and nurses have generally improved in the community over the past few decades. The barriers that power imbalances (between those who deliver mental health services and those who use them) used to place along the pathway of therapeutic relations in the past are now generally understood today.
In the more distant past, the role of psychiatric nurse was, according to Sainsbury (1974), clearly defined in terms of a rigid institutional hierarchy in which the patient had the lowest place. Orders were passed down the line. According to Sainsbury (1974)
There was a relationship of authority-submission between nurses and patients, and nurses were expected to direct and manage patients in all their activities. The criterion of the nurse’s efficiency was the quietness and tidiness of the ward, rather than the therapeutic atmosphere and the quality of their relationship with their patients.
Cambell reminds us that things have improved considerably since then. Service users are much more powerful today than they were during the high Victorian era and more powerful then they were in the 1960s and 70s. Nevertheless, serious problems and dilemmas still remain within the hospital setting today. According to Cambell (1999)
One of them is why mental health nurses in in-patent settings will not talk to us. Service users clearly expect nurses to talk to them – we may get diagnostic interviews from psychiatrists and group therapy from psychologists, but we expect nurses to talk to us. Ostensibly, that is also what mental health nurses intend to provide. Professor Altschul (1972) has written of the importance of interaction, saying: 'it has meaning, is mutually beneficial and has purpose', but how much of such interaction do we get and is it becoming more or less common? Unfortunately, patient contact is not a significant priority in the traditional psychiatric hospital.
2.4 The dislocation of appearance and reality on acute wards
Sociological research into the nature of knowledge has demonstrated the many ways in which our knowledge and perception of reality is, in the words of Berger and Luckmann (1966) ‘socially constructed’. This has enabled a more self-aware and self-critical appraisal by nurses today of their role within the mental health system of both the past and present and the historical and ideological factors which have influenced both the theory and practice of nursing as well as the theory and practice of psychiatric medicine, counselling and psychotherapy. There is, according to Lynch G (1998),
…..an increasing recognition that the cultural and intellectual world that we now inhabit is very different to the one in which therapy originated
The discrepancy between the stated values of client-centred care and service user involvement within the nursing profession and the present reality of nursing care on acute wards is thus one of the first painful issues that needs to be faced in any serious effort to change nursing practice on acute wards. Contemporary psychiatric nursing in particular is fraught with many dislocations of reality and appearance, which reflect the inner tension between the Victorian and early 20th century origins of psychiatric nursing and its present very different historical context. Contemporary mental health care nursing is thus rife with often unacknowledged philosophical disagreements over the proper focus of mental care, and thus ethical strife.[18]
Ethical strife, according to Lakeman and Curzon (1998) is generated when nurses strive towards understanding the individual in our care rather than simply relying on psychiatric or diagnostic labels. Philosophical conflicts (say, over what it means to be a human being) surface where there are sharp disagreements over the proper focus of nursing care. This is especially the case when nurses see their nursing practice compromised or undermined by institutional and administrative practices which they see are clearly disempowering both patients and themselves, practices that are extremely resistive to change or reform. In the literature consulted [19], nurse clinicians and academics as well as service users complain that the gap between nursing theory and practice has never been greater than it is today.
There are complex reasons for this. Peters and Chiverton (2003) observed that where there was focus on a patient’s progress this tends to be conceptualised primarily in medical terms. In other words, it tends to be constructed in terms of purely medical treatments, new medication or referral to other medical specialities. The result is that doctors tend to dominate decision-making on acute in-patient wards and patients have few opportunities to say how they really feel about things except within formal medical ward rounds lasting about 10 minutes or less. During those few minutes patients must face their psychiatrist, junior medical staff, medical students, the nurse (and often nursing students), the social worker, occupational therapist and other helping professionals in a meeting which can involve up to eight to 10 people. Nursing practice, in such a context, tends to subordinate itself to medical interpretations of the patient and the patient’s problems. Often the result is the loss of a uniquely nursing perspective.
According to Morrey (1998) Davidson (1998) and Berke (1989), nurses working on hospital acute wards tend to view and talk about the patient as if the person was a passive host of mysterious mental disease processes to be looked after by experts who 'always know best'. They also tend to assume that the patient's own interpretation of his or her experience and symptoms has no or little relevance to their treatment and that ‘insight’ means agreeing with the doctor or the nurse about the meaning of the patient’s symptoms and diagnosis. It is then the job of the nurse to help control or suppress the patient’s symptoms of distress, often whilst ignoring the patient’s own interpretations or version of events [20].
According to Jourard (1971), much of the professional expertise of psychiatric nurses working in hospitals tends to involve the nurse’s
….ability to get patients to conform to the prescribed roles they are supposed to play within the social system of the hospital, so that the system will work as smoothly as possible
Although Jourard was writing over 30 years ago the situation he describes is still current within many hospital settings today, as evidenced by Moorey (1998), Nolan (1999), Hall (1996), Horsfall (1997), Barker et al. (1997) and others. Within a ‘containment’ or custodial style of care the emphasis falls primarily on the management of risk rather than on the recovery of the person in care. Nursing practice in this context tends to value various methods of suppressing symptoms and controlling disturbed behaviour more than learning from the patient about the patient and the nature and meaning of this patient/person’s distress from the patient’s perspective.
In such an environment, according to both Bray (1998) and Horsfall (1997) the uniqueness of each person receiving care tends to disappear behind diagnostic labels. The person’s own voice is easily silenced under such conditions by the authority of professional or bureaucratic language. When that happens, it is more or less inevitable that the relationship between nurse and patient will be a depersonalised one, a relationship which follows a predictable, institutionalised, stereotyped, pattern, not conducive to therapeutic relationships or to genuinely therapeutic conversations.
2.5 Conflicting perspectives on the appropriate focus of nursing care.
Having raised the difficult issue of the ‘social construction of reality’, it is appropriate for this study to examine briefly those philosophical perspectives which impact on contemporary nursing practice at ward level and on the way in which patients are actually understood and treated. The institutional dislocation between appearance and reality on acute in-patient wards tends, in the view of many clinicians, researchers and academics involved in the mental health field, to recapitulate at the institutional level incompatible conceptions of what it means to be a person as well as conflicting views about the appropriate focus of compassionate care and thus of the nursing task. The literature discussing this issue is extensive [21].
The problem can be expressed in the form of a series of related questions. Should nursing be understood primarily as a reflection of, or an auxiliary to, psychiatric medicine, and work within the parameters of the ‘hard sciences’? Or should nursing develop its own methodology and make its own unique contribution to care outside of (but working alongside) the natural sciences? Should mental health nurses be working more (but not exclusively) within the parameters of the social sciences? Although some nurses still prefer to work within the categories of traditional psychiatric medicine, others are seeking to pioneer a more humanistic and collaborative approach to care which privileges the patient's narrative, concerns and problems (as perceived by the patient) over any professionally constructed ‘diagnosis’. According to Barker et al. (1997) nursing care should be located within the context of everyday life and thus be focused on the person’s relationship with self and others within the context of their interpersonal world. Nursing practice should be focused on helping people address their human responses to psychiatric disorder, rather than the disorders themselves, which are, by definition, professional constructs.
But, in order for people to do this, nurses must begin to learn to trust the capacity of persons in their care to explore and understand their own troubles, and mental health problems and to resolve these in a climate of warmth, acceptance and understanding. In the absence of such a climate, genuinely therapeutic conversations are, of course, unlikely to happen.
2.6 Contradictions within current mental health nursing theory
Epistemology [22] is that branch of philosophy that deals with the theory of knowledge. In terms of the present debate going on within the theory of nursing, epistemology is the study of our right (or lack of right) to the beliefs we have as nurses about what constitutes good nursing practice. Ethics, particularly, the ethics of belief, involves the rules used in evaluating different kinds of beliefs, in this case, beliefs about the nature of human beings and the nature of care.
According to both Horsfall (1997) and the various contributors to Psychiatric Nursing Ethical Strife (1998) [23] incoherence in nursing theory arises when the nursing emphasis on care in which the nurse and patient are seen to be ‘interdependent’ and to be working in collaboration with each other in the context of a personal relationship runs at cross-purposes to materialist epistemologies which see the ideal knowledge situation as depersonalised and entirely objective. When medical understandings of the mind and mental health problems become reductive in this sense (which is not always the case) and are then incorporated uncritically within nursing theory and practice these become riddled with deep epistemological and ethical contradictions, contradictions that have been identified and discussed within the philosophy of mind for over 50 years [24].
In point of fact, Michael Polanyi (1958), the Scottish philosopher John Macmurray (1957 and 1961) and the philosopher of science Thomas Kuhn (1962) have all shown in different ways how the conflict between personal and impersonal forms of knowledge remains counter-productive and is no longer supported within the history of science itself [25]. In its broadest terms it can be seen as a conflict between two irreconcilable life and world-views, that of a basic humanism which is holistically and deeply integrated with basic human ethical values versus a science, which claims complete value and ethical ‘neutrality’. This claim can be traced back to the legacy of a particular 19th century philosophical movement called positivism.
Positivism is historically associated with the philosophy of Auguste Comte (1798-1857) [26] who said that the highest form of knowledge is simple description of sensory data and that all that is worth knowing can be reduced to such descriptions [27]. Positivism, in its bio-medical form, seeks a complete account of mental events and human behaviour, including mental health or illness [28], in terms of purely physiological bio-chemical events. However, it is easily shown that a general deterministic theory of the physiological causation of human consciousness is philosophically inconsistent as a theory as well as unsuitable as a foundation for an ethical belief system, which could provide a controlling framework for nursing practice as a science of care [29].
Firstly, according to Clouser (1991), who is a philosopher of science, as a scientific general theory all such reductionist explanations are self-referentially incoherent. In the specific case of bio-medical reductionism, the inconsistency is due to the fact that purely biomedical explanations of human cognition do not and cannot explain the origins and nature of the theory itself. In other words, those who hold to such a theory are normally unwilling to say that the theory itself is simply the product of the electrical and chemical functioning of their own brains. This would clearly undermine and reduce to absurdity the entire basis of the theory itself, as a credible general scientific theory [30]. And yet logical coherency would require that they say exactly that.
Secondly, in terms of the ethics of belief, one cannot posit the physical brain as the exclusive locus and cause (without remainder) [31] of human consciousness, self-awareness and insight and thus of, non-organic mental health problems and at the same time advocate genuinely 'humanistic' person centred solutions to care and to the resolution of those functional problems.
Or at least one cannot do so without great inconsistency and without demonstrating a profoundly split and contradictory view of reality, the nature of human being and mental health. Of course this in no way minimises the usefulness of psychiatric medication in the treatment of some conditions or as useful tool to be used in the control or self-management of distressing symptoms of mental disorder (whatever the cause) but that is a different issue.
2.7 Impact of the psychiatric medical model on current nursing practice
According to Clouser (1991) no theory, practice, or institution is neutral with respect to core beliefs. Descending from theory to practice it is clear that what we as individuals believe about human beings will determine to a large extent how we will behave towards ourselves and other people and how, as helping professionals, we will conceptualise the nature of the care we offer to others. Several papers address this issue, especially the need for nursing to establish itself as a form of knowledge (embodying its own values, theory-base and methodology) in its own right alongside other types of knowledge [32] so that nursing practice is informed by its own conception of the meaning of care and is not side-tracked or distracted away from its proper focus within the domain of compassionate care.
In their attempt to formulate standards of good practice psychiatric nurses have often been impeded by the beliefs, assumptions and conceptual parameters of medical psychiatry in ways that have, until recently, evaded conscious awareness. For example, Hall (1996) argues that nursing still uncritically incorporates assumptions of the psychiatric medical model into its own understanding of the human person and care. The medical model, although appropriate for doctors, is not appropriate for nurses and has not, to date, resulted in any effective nursing approaches to the care of people with mental health problems.
Horsfall (1997) also reminds us that modern psychiatric nursing emerged historically under the patronage of Victorian psychiatry in a pre-existing organisational hierarchy in which the medical profession wielded ultimate power and authority over the patient’s treatment (Wilson and Kneisl 1992). Thus, a materialist medical epistemology was absorbed uncritically by the nursing profession in its formative stages and became the foundation for much of modern psychiatric training and education. In fact, until recently, psychiatric nursing has, according to Horsfall (1997) more than any other mental health profession, been in thrall to mainstream medical theory. According to Horsfall
As the importance of objectivity, the mind-body split, and a material understanding of the person increased, the values of caring, holism, and self-expertise (of patients and nurses) diminished.
To this day, mainstream bio-medical epistemology proceeds on the philosophical assumption that the psychiatric patient has a disordered mind arising from a damaged or diseased physiology [33]. The aetiological sites of this malfunction are understood to be lie within aetiological neurotransmitter imbalance, possibly partially genetic in origin, which is to be corrected by means of a specific recourse to chemotherapy. Horsfall draws out several logical and practical consequences of this belief-
Such an orientation ultimately mitigates against the agency of both the psychiatric nurse and the psychiatric service user. What is a consumer to do about his or her terrifying experiences if his or her body is faulty and only medical prescription is offered? What is the nurse to do if mental illness is caused by neurotransmitter excess or depletion and the medication is meant to rectify the uptake at the receptor site? Materialist psychiatric epistemology has profound consequences for psychiatric users and nurses, beyond that of diagnosis and treatment by medication. A focus on the physical indicates a narrow view of patients and of oneself as a person and a nurse. The medical model seriously limits the patient’s sense of competence, control, and responsibility. It also excludes or displaces the centrality of the nurse’s interpersonal skills in supporting and improving patient resourcefulness and well-being.
Hall (1996) identifies several assumptions underlying the psychiatric medical model and questions these from a more humanistic perspective. She shows how using purely diagnostic medical explanations of the patient’s 'problem' is inconsistent with good nursing practice. The author describes the process of her own awakening to how conventional psychiatric thinking was undermining her relationships with patients.
She then offers suggestions for more appropriate nursing practices and strategies as does Evans (2001) who warns that the adoption of chemical therapies should not be employed in place of or at the expense of the holistic approach which is valued so highly by patients, carers and nurses.
The issue raised in different forms by these papers share an over-riding concern with the very real problem of dehumanising treatments and represent what could be called a search for the ‘whole person’ in care. They are therefore not anti-medical model in tone. As Barker (2003) says, returning to the pioneering work of Hildegard Peplau, medical psychiatric diagnosis represents a useful way of talking about groups of people with similar problems of living, but…
It is largely irrelevant to the consideration of what any individual might need, now, in the name of nursing care. We can answer that only be exploring the widest possible personal context, which will allow us to gain some insight into what is meaningful for this particular person, as opposed to what might be considered ‘appropriate; for a group of ‘patients’.
Barker (2003) goes on to say that for the past two decades in both the USA and in the UK mental health nurses have started to move away from the strict use of a medical-diagnostic model. Barker continues:
The voice of the nursing process movement urged all nurses to show concern for the person behind the patient label, reminding us to look for ‘worth’ amid what might seem like insurmountable problems…..
but, he warns:
-There is a grave risk [today] that nursing might drift back into a reductionist approach to care delivery, using medical diagnosis as the primary determinant for the design of care.
On a somewhat different track, Hummelvoll and Steverinson (2001) look at the source of some of the tensions and pressures nurses are experiencing on acute in-patient wards. Their analysis describes in more detail how the high-pressure and unpredictable environment of acute wards in combination with short hospital stays is impacting nursing practice. Nursing practice in such contexts tends to be tentative and summary. Nursing care under such circumstances is characterised by great 'therapeutic superficiality'. This constitutes a serious hindrance to nurses encountering the patient as a person. It also prohibits genuinely therapeutic conversations developing between nurses and their patients.
The proper focus of nursing care is distorted, Parse (1999) argues, when the medical specialty of psychiatry is practically and ideologically dominant in relation to nursing care. To conceptualise nursing theory and practice in terms of an applied science model, one that combines biology, physiology, and psychiatry but, strangely enough, has no specific knowledge base of its own, is to fail to grasp the true focus and domain of nursing care. Parse is not alone [34] in taking issue with the idea that an applied natural science model should be the template of choice for nursing theory and practice. Although the nurse needs to be informed by medical, biological, pharmacological and other kinds of knowledge these forms of knowledge do not and cannot in and of themselves define the heart or unique focus of care.
The preferred alternative is that nursing should be seen as a basic human science with its own unique conceptualisation and contributions to make, one focused on the whole person in relationship to others, to health and to illness. The key concept for Parse is that of 'human becoming' and the fact that people are always in a process of change. The significant structures relevant for nursing are the lived experiences of patents as described by the patients themselves.
Finally, Barker et al. (1997) seek to define the focus of nursing practice in such a way that it is fully outside the perimeters of medical psychiatry. Nurses should acknowledge that the phenomena dealt with by them in the act of care are human responses to various life problems. Nurses do not deal with now, and have never dealt with at any point in history, mental illness per se, as that has always been the psychiatrist’s role.
2.8 The starting point of research and the problem of bias.
Although the research methodology of this study will be discussed in Chapter Three, the principles and rationale underlying the methodology will be discussed at this point in the literature review.
It has been an essential part of this study to ask the following questions:
Þ How is this study connected to learning, to institutional change, and to nursing theory?
Þ How has the project been effected by on-going operational difficulties within the QEPH acute in-patient service?
Þ How has it been related to present Department of Health guidelines and directives?
Þ How has it been related to the personalities, and experience of nurses in senior management, clinical or teaching positions who have welcomed the initiative?
Þ How does this study relate to the personal bias of the authors of this paper and to their personal beliefs and past experiences of what works and does not work?
Such questions, once asked, according to Mark Fenton (2003), raise critical issues about the very nature of research itself and the evidence base, which should inform good nursing practice. This is especially true for any human science, which seeks to be reflexively self-aware of its commitment to keep its focus on care. Connected with this is the need for a kind of nurse training and education that keeps this focus clear and does not lose it.
One problem that besets conventional research as well as present nursing training and education is their relevance to the real world in which people actually live and work. Thompson and Dowding (2001) found that one of the most influential factors impacting nursing practice is the opinion, recommendations and practices of nursing peers and colleagues, rather than theory or research. In addition to that, nursing practice on acute wards tends to be dictated by what service users are prepared to accept, by the hospital’s management and operational policies, by the local ‘nursing culture” and by what a hospital is willing to pay for.
Simmons (1995) questions the following three assumptions
- That decisions about research methods are ever purely objective (in the way usually claimed) or
- Are ever informed exclusively by the pristine or ‘scientific’ nature of the research question itself or
- That research questions ever automatically indicate in and of themselves what approach to use
These three assumptions vastly over-simplify the historical, social, and economic contexts within which all human enquiry and decision-making are embedded. This being the case, Simmons 'grasps the nettle' and recommends that research bias is always inevitable, not necessarily a bad thing, and should be harnessed in the cause of doing effective research [35].
One problem that besets nursing research in particular, according to Simmons, is that it usually has no impact at all on actual nursing practice. This is because most nursing research does not set out to create change in the settings studied. Researchers usually 'leave the field' unaffected by the research process itself, and this leaves nurses working in the clinical setting seeing little relevance to most research findings, and with little guidance on how to implement the findings even if they wanted to. Therefore Simmons recommends action research as the best way to address this particular problem.
2.9 A commitment to basic principles of action research
This study began as and remains an exercise in action research and grounded theory [36]. According to Newman (2000) and Reason and Bradbury (2001) a basic assumption of action research is that research cannot be divorced from real life. Action research searches for and questions the validity of different types of knowledge, institutional structures and practices, ways of relating and forms of existence. Action research can be applied to establishing and examining why when working in the helping professions, people can become so easily trapped in unhelpful and un-therapeutic contexts or ‘negative circles’ of relating and decision-making.
Action research initiates a focused well-informed course of action into such contexts and begins to reflect on the experience of whatever happens next. This process involves developing a spirit of co-operative inquiry in which all of those involved (nursing staff, managers, patients and service users) become co-researchers whose thinking and experience contribute to the emergence of solutions to the problems, which arise during the project’s implementation. Co-operative inquiry is thus a form of research as well as a way of working and learning with others in the same organisation who have similar concerns and who, according to Haig (1995):
- Seek to understand what is a shared world in order to make sense of life and to develop new creative ways of looking at things and to learn from experience rather than just recycling all the old problems and explanations
- Want to learn how to act collaboratively with others in order to change things that need changing and to find out how to do things better
2.10 Abductive reasoning
The pragmatic American philosopher Charles Peirce (1839-1914) [37] talks of ‘abductive reasoning’ [38]. This is a type of reasoning that is prepared to accept a conclusion purely on the grounds that it appears to satisfactorily explain what evidence is available at the time. It is the pattern of reasoning most commonly used by ordinary people day by day and is used in both action research and grounded theory [39]. It does not seek to prove that (a) ‘causes’ (b) in the way typical of the natural sciences and in fact insists that the complexity of some situations prohibits ‘proof’ of this type.
Peirce calls this kind of ordinary reasoning ‘inference to the best explanation available at the time’. This type of reasoning is judged to be adequate to most of our purposes in life [40] including, it could be argued those mental health nursing practices, which facilitate good care. But, what would constitute an adequate ‘theory’ or explanation and justification of these practices? Glaser (1992) gives two basic criteria for judging the adequacy of any theory (or explanation) emerging from such reasoning: firstly that it fits the situation; and that it works –and secondly that it helps the people in the situation to make sense of their experience and to manage the situation better.
One question which arises in such a discussion is: What is adequate evidence and evidence for what purpose? For example, Williams and Garner (2002), two doctors, discuss the host of problems, which are generated when RCT (Random Controlled Trials) becomes the only 'gold standard' for what is considered 'good evidence-based practice' in medicine. Many medical practices just do not yield to RCT methodology, but should not, on that basis, be deemed ineffective, irrational or not evidence-based at all. The authors conclude that an exclusive emphasis on narrowly defined evidenced-based criteria drastically oversimplifies and undervalues the complex and interpersonal nature of effective care [41].
Abductive reasoning recognises that a distinction should be made between hypothesis testing (testing some big theory made in advance) and an emergent theory or understanding of a situation involving people in relationship which develops by increments over time. According to Dick (2002) the key to effective research is remaining open to what is actually emerging (in a very global way) once a project such as this gets underway, with a willingness to change course and adapt creatively to whatever does in fact happen within the larger institution as a consequence of undertaking the project.
The danger or temptation is always to move directly to ‘premature closure’ by forcing some theory on to the evidence generated by the study before any explanation is really warranted or justified at any level of inquiry. In order to remain open to what is actually emerging in the situation one needs, as a researcher, to learn to tolerate:
Ø A high level of confusion
Ø Feelings of powerlessness and inadequacy to the job at hand and so on
2.11 Qualitative and quantitative (statistical) evidence
This study seeks to examine different types of evidence, generated as part of an action research project undertaken at the QEPH in order to come to a number of conclusions and judgements about those nursing practices which clearly improve the therapeutic experience of patients in contrast with those that do not. So it is important to clarify the nature of this study and the nature of its conclusions and recommendations. According to Stevenson et al. (2002)-
Research into clinical effectiveness in health care is complicated and cannot mirror the processes of the natural sciences. Consequently, it is important to treat evaluation tentatively……... Although the Tidal Model has theoretical justification and fits with the recommendations of the National Services framework (DoH 1999), it nevertheless has to be subjected to an evaluation process in order to be classified as evidence-based practice [42].
Bonell (1999) recommends that ideally both qualitative and quantitative methods should be used together in designing any research study. He seeks to dispel the myth that qualitative research methods (such as action research, grounded theory, the use of interviews and focus groups) and quantitative research methods (statistical number crunching) are necessarily opposed.
Whether or not they are in conflict depends entirely on the assumptions and philosophies of the researchers [43]. Therefore the evidence base for this study includes of a mixture of quantitative and qualitative data such as QEPH nursing interviews, audits of nursing documentation of the Tidal Model following its implementation, and the personal testimonies of key people, including service users involved in the project as the process of implementing the Tidal Model on Tolkien unfolded. This evidence has then been examined in the light of the known literature and other studies, which addresses the same or similar issues [44].
2.12 Conclusion: In search of a non-reductive science of care
According to a number of authors, especially Barker (1999), Sullivan (1998) and Nolan (1999), alternative more humanistic approaches to mental health nursing need to be pioneered in the 21st Century or the problems currently facing NHS Mental Health acute in-patient services will continue to get worse. An essential feature of a balanced model of care is that it will be genuinely holistic, non-reductive, truly collaborative and respectful of the whole person in care and of that person’s voice in the context of that person’s life-narrative.
The meaning of the stories different people tell about themselves cannot be reduced to the way in which they are functioning (well or poorly) within the different aspects of their lives. The focus of nursing, it is argued, should thus be upon these stories and upon caring interpersonal relationships located uniquely within the context of everyday life [45]. But, as all the above authors point out, to re-focus nursing care in this kind of way will require a redefinition of what it means to be a mental health nurse. Such a change will also require major redefinitions of what it means to provide good care within the context of acute in-patient services. Thus, more rigorous attention will need to be given, argues Barker (1999), to nurse training and education for the development of –
a ‘critical and informed’ self knowledge with more sensitivity and compassionate awareness of the nurse being a fellow human traveller with her or his patients on life's sometimes strenuous, dangerous, but exciting journey into the unknown.
But, in order for this to happen, according to May (1990), nursing, as a profession, will need to make a more robust commitment to the reformation of the institutional context within which nurses are educated and trained and seek to practice if they are to provide a therapeutic environment of nursing care. This is not an easy task.[46] Root and branch reform is necessary to bring present institutional and professional practices in line with basic human values, human rights, and human duties/responsibilities.
One theme that stands out clearly in the papers reviewed above is that the nursing profession is seeking to extricate itself from the medical model not by being ‘anti-medical model’, but by insisting that nursing is not medicine and should be concerned with fundamentally different issues and practices than medicine. Nursing, in its central focus, is not concerned with ‘cure’ or medical treatments per se (as these are the concern of the medical profession) but with the person’s relationship to health and illness.
According to Olthuis (2001) to dwell exclusively on ‘cure’ can focus the nurse so much on solutions, answers, and performance that there is little room for the listening, attending, and caring that is required for inner healing, which lies at the heart of therapy. Success in implementing real change in acute in-patient care, according to Griffiths (2002) as well as Rix and Shepherd (2003) requires working in a genuinely collaborative way with commitment at all levels of the organisation including clinical leadership, management support and a wide range of stakeholder input. According to Griffiths:
The problems facing many acute wards may seem utterly daunting, but there does seem to be something in a systematic collaborative approach that can lead to rapid and significant improvements. It requires planning, enthusiasm and commitments. I know the solutions are out there because I have seen them.
Horsfall (1997), however, is not so upbeat:
Humanistic nursing care cannot apply revolutionary leverage to an ossified system. But, it can assist with changing nursing ideas, practices, and workplace cultures at the grassroots level for the benefit of psychiatric service users and nurses. Before humanistic nursing practice can be implemented, contradictory theoretical assumptions need to be uncovered.
Humanistic nursing remains committed to holistic conceptions of nursing care, which, in turn, are based historically on non-reductive views of the human person where the emphasis is on the importance of personal relationships, personal growth and development as well as spirituality and ordinary everyday life as the appropriate context of care [47]
CHAPTER THREE: METHODOLOGY
3.1 Study design
There have been eight distinct, but complimentary dimensions to this study:
- A multi-disciplinary literature review was undertaken to determine the state of psychiatric acute admission wards today, the difficulties mental health nurses are facing in this context in their attempt to provide good care, and current nursing opinion on the best way to overcome these problems so that the therapeutic experience of patients on acute wards can be substantially improved.
- The aims and objectives of acute admission wards as understood by nurses at the QEPH was then ascertained and examined.
- Nurses’ perceptions of the quality of their relationship with patients on acute wards at the QEPH was then established and examined.
- Current nursing practices on QEPH acute admission wards as discerned by nurses was elicited and examined.
- Specific problems and difficulties that nursing staff were experiencing in their day-to-day work on acute wards has been identified and examined.
- The Tidal Model has been implemented on Tolkien Ward in an attempt to address some of the problems and difficulties that have been identified.
- The Tidal Model has been evaluated by way of interviews with service users, staff evaluations and by means of statistical data obtained with the help of the Trust’s Research Department.
- On the basis of the information and learning generated by the above process, a report has been written with specific recommendations to Birmingham and Solihull Mental Health NHS Trust (BSMHT) as to how the therapeutic environment and the running of acute wards at the QEPH can be substantially improved, thus leading to an improvement in patient care and to a substantial improvement in the therapeutic experience of service users.
3.2 Qualitative and quantitative methods of enquiry used in this study
The qualitative methods used by this study have included:
- QEPH recorded interviews of nurses’ perception of the quality of care they are providing on the acute wards
- Tolkien Ward nursing staff and MDT evaluations of the Tidal Model
- Tolkien Ward ‘away day’ nursing staff reflections on the changes in nursing practice on Tolkien Ward which had taken place through use of the Tidal Model
- A Documentation Audit of Tolkien Ward nursing notes.
- Tolkien Ward service user evaluations of the Tidal Model
- Tolkien Ward Manager’s testimonial narrative of the process of change management required for successful implementation of the Tidal Model
- Testimonies of senior nurse managers
The quantitative methods used by this study have included:
- Analysis of data from the Risk Management Department
- Analysis of data from the Information Management and Technology (IMT) Department
- Analysis of data from the Complaints Department
3.3 Five questions which have needed an answer
This two-year study has sought to answer five basic questions:
- What is the nature of the work currently taking place on acute admission wards at the QEPH according to the testimony of the nurses who actually work there?
- How can the services that nurses provide to patients and their carers within the acute in-patient setting be substantially improved?
- What kinds of nursing-practices generate a therapeutic (or healthy) as opposed to an anti-therapeutic (or toxic) ward environment?
- What kinds of continuing education and training/re-training do nurses actually need to ensure that their practices are evidenced-based, client-centred, outcome-effective, and in-line with current protocols of good practice?
- What kind of policy and management changes need to take place at the QEPH and within the Trust in order to facilitate appropriate changes in nursing practice as well as that of the nursing culture so as to substantially improve the quality of in-patient care?
3.4 Six stages of action research implementation
The carrying out of this project has therefore involved six distinct stages:
- Undertaking the literature review (Chapter Two)
- Carrying out individual recorded interviews with nurses (Grades A-G) who are normally working as part of a duty rota on acute in-patient admission wards at the Queen Elizabeth Psychiatric Hospital (Chapter Four)
- Introducing a new therapeutic nursing model called the Tidal Model on Tolkien Ward (Chapters Five & Six)
- Assessing and evaluating the implementation of the Tidal Model on Tolkien Ward (Chapters Seven & Eight)
- Writing a report, based on that evaluation, which includes specific recommendations to BSMHT on how best to reform current nursing practice (Chapter Nine) in the light of the evidence provided by this study
- Disseminating the report with its recommendations widely within the Birmingham and Solihull Mental Health NHS Trust and beyond
CHAPTER FOUR:
THE QEPH NURSING STAFF INTERVIEWS
During May and June of 2002, nurses employed within the acute admission wards at the Queen Elizabeth Psychiatric Hospital (QEPH) were approached to participate in recorded interviews regarding their views of their current role and the care they provide. A total of ten qualified nurses participated (Grades D-F). All four acute in-patient wards (Tennyson, Bronte, Owen and Tolkien) were represented. The interview schedule (see Appendix 10.10), was designed to elicit:
q Nurses’ understanding of the aims of acute in-patient admission wards
q Their perception of the type and quality of nursing practice on the wards
q Specific problems and difficulties experienced in their day-to-day work
4.1 Thematic analysis of QEPH nursing staff interviews
Following is a thematic analysis of the recorded nurse interviews. The interview schedule and a complete verbatim summary of the transcripts to these interviews may be found in Appendix 10:10 and 10:11.
4.1.1 Nurses’ perceptions of their role on acute in-patient wards
The nurses were asked what it was like for them working on an acute in-patient ward at the present time. The consensus view was that the wards were extremely hectic and busy with little therapeutic focus. What made them feel most frustrated was that there just was “not enough time to do the job properly”:
“I spend most of my time just running around a lot, but at the end of the day what have I actually done?”
There was thus not enough time spent with patients. One reason given for this was the amount of administrative work nurses are required to undertake:
“The paper work I have to do takes me away from the patients. I don’t like that.”
Only one person said that they enjoyed working within this hectic environment, whilst three felt it was “very stressful”. High staff turnover, resulting in “only a few experienced nurses to carry the ward” contributed to the nurses’ general feelings of dissatisfaction.
When asked to describe what their actual work entailed, most responses were task-orientated bearing little relation to therapeutic engagement with patients, such as:
Ø giving out medication
Ø counting the benzodiazepines
Ø doing administration
Ø ward rounds
Ø doing observations
Ø checking the staff alarms
Ø order the meals
Ø getting information from the Ward Clerk
Ø most of the time I spend in the office dealing with the doctors and staff issues
Ø admissions
Ø dealing with doctors
Only one nurse mentioned patient care plans. Some nurses said a large proportion of their time was taken up with “checking up on bank and agency staff to make sure they are doing their job” and allocating staff to specific duties such as undertaking patient observations. An F grade also said their role was to give support to the nursing team.
It was clear, however, that the nurses, despite this, felt that their primary role should be to “care for patients”:
“To listen to them, to be a go-between the patient and the medical staff. To speak for the patient.”
“The most important aspect of my job is patient care. But, this means having a well-run ward which is not in chaos so much of the time with only fire-fighting and crisis management the main way of working.”
“All the other things I have to do defeats the purpose for why I am here, which is to spend time with and to help patients. That’s very frustrating.”
Indeed, it was a lack of quality patient contact that most of the nurses said was the part of the job they liked least. The majority cited spending time with patients as the part they liked the most. It was particularly satisfying “watching patients get better” when that happened. Some also saw the variety and unique challenges posed on the ward in a positive light: as one nurse said, “no two days are the same”.
4.1.2 Perceptions of the purpose of acute wards
The nurses were asked what they saw as the purpose of the acute admission ward on which they worked. Many felt the ward should be providing a safe environment for people in crisis, to help them get better. This was seen to involve service users having “someone to talk to” and “getting their medications sorted out”. One person additionally commented that the purpose of the ward appeared to be “dealing with anything that comes through the door”.
However, in the opinion of the nurses interviewed, not everyone who ‘comes through the door’ has a serious mental health problem. Although most appear to come in the midst of some kind of “psychiatric breakdown”, or, for example, to have their medication reviewed, a large number are seen to be admitted for other reasons:
“In reality it seems like the real reason many are admitted is that they are just not coping with their personal circumstances and relationships.”
“We get a lot of patients who are basically in crisis for one reason or another who are not really mentally ill.”
Such crises were cited as including drug and alcohol problems, or “even just accommodation problems”.
Concern was expressed that some people are admitted to the ward at the expense of others:
“We get a lot of personality disorders. These are the ones who tend to keep being readmitted over and over again, not the people who are genuinely mentally ill.”
4.1.3 Perceptions of patients’ expectations of care
The nurses shared the opinion that patients’ main expectation of in-patient care was to be discharged as soon as possible, “get back out there”, but “in a state where they can look after themselves”. It was noted that some patients do not appear to know what to expect, especially if it is their first admission. Others, on the other hand, described as the “revolving door” patients, know what to expect and tend to “settle right in” quickly. Two nurses expressed the view that most “patients feel they should be having more contact time with nurses”, and yet “often time is not available to them when they need it the most”. However, one nurse also commented that:
“Sometimes they expect staff to do everything and sometimes they get resentful and get angry at the idea that they need to take a few steps themselves.”
It was noted that there was often very little for the patients to do to occupy themselves on the ward, and it was felt that the restrictions placed on patients, including “being confined to the ward”, was an aspect of in-patient care the patients liked least. Despite this, the nurses thought the social aspect of the ward was what patients liked most about their in-patient stay:
“They tend to like socialising with other patients and tend to spend most of their time sitting in the smoking room socialising with other patients.”
It was also felt that patients liked “being helped by nurses”, and that they sometimes complained when they did not have enough contact with staff. Indeed, as one nurse pointed out, lack of staff contact left patients feeling “angry and neglected”:
“One patient said to me that she had been on our ward for a month and not a single nurse had spoken with her about her problems. She said that this had happened on her previous admission as well.”
Despite the lack of nurse-patient contact, and the negative feelings that appear to arise from this, all the nurses described their relationships with patients as good or very good.
“I get to like them over a period of time and I would hope they would get to like me.”
One nurse defined the roles that they adopted in building relationships with patients:
“Sometimes I take on a parental role because of the state they are in. I like to act as a distant friend or encourager.”
4.1.4 Perceptions of the quality of nursing care planning
The nursing staff were asked how well they thought individual care plans worked on their ward. The consensus was that they didn’t work very well at all. One nurse commented, “Staff on our ward are too busy to do proper care plans on a regular basis”. However, nurses on other wards said that care plans were written, but rarely consulted “except in the case of very difficult patients”. Care plans tended to be “more or less the same for each patient”, “not really individualised”. When they were individualised they tended to be “so long and complicated that nobody bothers to reads them”. It was further suggested that:
“Not everyone on the team will agree with the plan a nurse has made because people have different opinions on how to manage things like self-harm and so on. So what’s the point?”
It was said that disagreements about the content of individual care plans was often not confined to the clinical team:
“There tends to be a real mismatch between the patients’ views of things and the nursing and medical views. So it would not be a good idea to show patients their care plans.”
“I know that if I showed patients the care plan I had written for them, many would get angry and upset, so you don’t want to upset the applecart.”
It appeared that these conflicts were not the only reason why patients were not involved in the development and review of their own care plans. Some nurses felt that “most patients are just not interested”, whilst others “are not well enough to set their own goals so we have to step in and do that for them”. Once again, lack of time was raised as a key issue justifying the lack of client-centred care planning on the wards.
“We struggle just to do basic nursing care and written care plans just do not feature in that kind of basic nursing at all. There is just not enough time to sit down with patients for 20 minutes or so to do a care plan or review a care plan with them.”
The time factor not only hindered patient involvement: it was felt that the wards were too “hectic” or “chaotic” for staff to ensure that the planned care was implemented at all. Care plans were therefore generally seen as merely a paper exercise with little benefit to either staff or patients.
4.1.5 Perceptions of the amount of time spent talking to patients
All of the nurses interviewed commented on how difficult it was for them to organise any regular or structured time with patients on their wards. This was another reason given for not doing regular care plans:
“There is no point in making an appointment to meet up with a patient because often when the time comes you are busy elsewhere doing other things, so what’s the point? You just let the patient down.”
They did, however, try to find time to spend with individual patients on an ad-hoc basis, for general encouragement or to sort out a crisis, but this tended to be just 15 minutes per shift.
“The longest time I spend with patients is during the ward round in a group setting led by the doctor. That’s a shame, but that is the truth.”
Unsurprisingly, therefore, none of the nurses spent time with patients in planned structured group settings:
“Groups do start up now and again on our ward through the initiative of one or more nurses, but is soon discontinued because there is not enough time or staff and other activities and duties tend to make running groups impossible.”
4.1.6 Nurses’ knowledge of models of nursing care
None of the wards appeared to implement any specific model of nursing care:
“Everyone works in his or her own way”.
“We joke and say ‘eclectic’, but in reality we do not have one.”
“We are dictated to by the medical model. This is because of the way the hospital is actually run and the way decisions affecting the patient are actually made on the ward by the consultants.”
“We do not operate any specific nursing model. There are too many consultants on the ward. Sometimes the ward feels like a busy Accident and Emergency ward.”
The nurses were not forthcoming with their knowledge of different models of nursing care, and none could suggest any model that might help improve patient care.
4.1.7 Teamwork issues
Teamwork was considered to be very important, and the nurses felt that the members of their nursing teams worked well together, especially when under pressure which was most of the time. They also recognised situations that caused a breakdown in teamwork:
“When we don’t work well it is usually because of poor communications and everyone being under such stress all the time.”
4.1.8 How, in your opinion, can nursing care be improved?
Many suggestions were made about how the wards could be improved in order to provide better patient care:
q less bank and agency staff
q more qualified staff
q less patients (so more time can be spent with each)
q a better physical environment
q more interview rooms
q time for more one-to-one patient care
q more organised activities
q less ‘fire-fighting’
q less paper work
q reduce the number of tasks that do not directly relate to patient care (e.g. answering the telephone, dealing with doctors)
4.2 Concluding remarks
A thematic analysis above has established that in the opinion of the nurses interviewed the nursing care on acute in-patient wards where they work does not reflect, on the whole, principles of good nursing practice. They realise this, but feel there is little or nothing they can do about it because of the busy and often chaotic nature of the ward, lack of time, the way in which in-patient treatment is dominated by medics, and because of nursing administrative activities which keep them away from meaningful patient contact. The predominant feeling is one of frustration and powerlessness to change things. All of these factors, when brought together, appear to preclude genuinely therapeutic conversations developing between nurses and their patients on any kind of regular or structured basis.
On the other hand, nurses agreed that the main way of making improvements for both patients and staff was to free up the nurses’ time to allow them to work more closely and collaboratively with patients in a structured manner. It was also suggested that training, for example in counselling skills, would facilitate better engagement with patients further still. But, all were pessimistic about any of this ever happening.
Increased patient contact would have the additional benefit of allowing the nurses to spend less time on the tasks that currently cause frustration: administrative work, “constantly answering the telephone”, “being available on demand to doctors” and to other members of the multidisciplinary team and constantly “checking up on bank and agency staff”. The nurses also believed that this would result in less tension and aggression on the ward, leading to a more therapeutic environment generally.
Throughout the interviews, there was also a very strong sense of the nurses wanting to reduce the chaotic nature of the wards, which left them feeling so stressed that at times they felt unable to do their jobs properly. But, there seemed to be no way of doing this. This affected their morale negatively. As one nurse suggested, the first thing that would need to take place before the ward could be improved would be “a morale boost” for the nursing team.
CHAPTER FIVE: WHY THE TIDAL MODEL?
5.1 Recent developments in nursing science
The relatively recent development of involving mental health clients in their own care, especially those in in-patients settings, has become, not without controversy [48], a central tenet of DoH recommendations and directives [49] as well as a central tenet within the contemporary mental health nursing profession itself.
There is a growing body of evidence [50] that the therapeutic experience of patients is enhanced greatly when nurses spend quality time with their patients and where genuinely collaborative client-centred care is adopted as the fundamental principle underlying nursing practice and nursing interventions.
Goodwin et al. (1999) concluded that it is the users of the services themselves who are the best judges of the effectiveness of mental health services. They are the people who are in the best position to identify those factors that promote or block recovery from mental health problems. They recommended that service providers pay much closer attention to the experience of service users and to use the experiences of service users and ‘survivors’ of the mental health system as the bedrock for future developments.
Recent studies have shown that in-patient clients who do well are those who relate well to nursing staff, are engaged with, kept informed about their condition, have their therapies explained to them and sense a hopeful attitude on the part of the nursing staff. Clients describe the significance of the ward environment during their stay in hospital and its impact not only on their progress in recovery, but also on the nursing staff who work within it.
Primai et al. (1998) found that it is the attitudes of the nursing staff that have the greatest impact on the ward atmosphere and this impact is what influences the extent to which nurses engage with clients [51]. These researchers also found that the quality of the nursing involvement with clients was what clients considered most helpful. High levels of engagement were also influenced by the composition of the care team, but more importantly, according to Mohr (1999) by the characteristics of the dominant nursing culture that prevails within the hospital itself and on the ward. Eklund and Hallberg (2000) report that in an environment where interpersonal skills and engagement with clients is highly valued, job satisfaction tends to be high, as does the level of communication and co-operation between team members and managerial feedback. In such therapeutic environments, all staff regularly have clinical supervision, to which they attribute the success of their ward.
5.2 Time as a commodity
Available evidence according to Jackson & Stevenson (1998) also suggests that nursing perceptions of time, especially ‘lack of time to speak to patients’ depends mostly on the attitudes of the staff team and the nursing culture in terms of what is considered to be the highest priority. The amount of time spent talking to patients is also closely related to the degree to which nurses actually value interpersonal helping skills and to whether or not there is regular clinical or non-managerial supervision of the staff team.
It is these factors more than any other types of constraints that determine nursing perceptions about how much time is available to engage with patients therapeutically. According to Jackson & Stevenson (1998)
‘Time is not absolute and perceptions [of how much time there is to give] are constructed on the basis of many information sources.’
The initial findings of a large study into the ‘need for nursing’ by Barker et al. concur with a number of other studies [52]. According to Jackson & Stevenson (1998):
“What makes nursing different from any other discipline of the health care team is the time spent with clients both in social, ordinary relationships, as well as with more therapeutic agendas. What users of mental health services most need from psychiatric and mental health nurses is time to form relationships and to talk.”
5.3 Use of the Tidal Model as a means to reforming nursing practice
A decision was made to introduce the Tidal Model on Tolkien Ward in an attempt to significantly increase the frequency and quality of therapeutic nurse-patient contact on the ward, to ensure that care plans were being done on a more consistent basis according to genuinely client-centred principles in the hope of reducing the often chaotic atmosphere of the ward. It was felt that the use of the Tidal Model nursing manual [53] in conjunction with appropriate re-training would supply the necessary tools and structure for this to begin to happen, even though a number of staff were pessimistic about the possibility of any significant changes taking place.
It was clear that the following changes were necessary if nursing practice was going to improve on Tolkien Ward.
v Nurses on Tolkien Ward needed to spend more quality time with their patients in order to engage therapeutically with them
v Appropriate nursing holistic assessment and care planning tools needed to be in place to facilitate this
v Nurses needed to be properly educated and trained to work in a truly collaborative spirit with their patients and in an appropriate client-centred way. Some nurses working on the ward appeared to lack basic counselling and interviewing skills [54]
v All of these changes, it was agreed, were inter-related and thus required the kind of integrated evidenced-based holistic approach to nursing care and practice exemplified by the Tidal Model
5.4 Origins of the Tidal Model
The Tidal Model was originally developed from a Newcastle University 5-year study of the ‘need for nursing’ by Barker, Jackson and Stevenson (1999). Using grounded theory methodology, a substantive theory of nursing practice emerged based on the perceived need for mental health nursing care. This study involved six sites from England, Eire and Northern Ireland and discovered a consensus across both the receivers and providers of mental health care that the essential feature of mental health nursing (the core category) involved a complex set of personal relationships: “knowing you, knowing me”. The emergent theory confirmed present understandings of the centrality of good interpersonal relationships in the healing of persons with mental health problems and confirmed that this understanding should inform nursing care and practice.
As a theory-based approach to psychiatric and mental health nursing the Tidal Model emphasises the central importance of:
q Developing an understanding of the person’s nursing needs through collaborative, client-centred nursing practices
q Developing therapeutic relationships through discrete methods of active empowerment
q Establishing nursing as an educative element at the very heart of interdisciplinary intervention
A key mental health nursing task, according to the Tidal Model, is to focus on the personal experience of the patient in the current moment of time. By maintaining that focus, according to Barker and Reynolds (1997) the nurse gains an appreciation of ‘Who this person is’ as well as that person’s human needs and what needs to be done to address them.
To first find and then keep this focus involves listening carefully and respectfully to patient’s unique story, which then becomes the context of care planning. The patient’s needs and wishes are the heart of the caring process. This means nursing assessments and care planning with the patient avoid professional jargon or medical constructions of the person’s problem preferring, instead, the use of ordinary everyday language.
One purpose of nursing care planning is to help patients to identify their own problems and needs. This is undertaken by way of an initial formal holistic nursing assessment which is completed with the nurse, but written in the patient’s own words.
5.5 The theoretical basis of the Tidal Model – a thumb-nail sketch
Briefly stated, the Tidal Model draws on five overlapping theoretical frameworks.
- The theory of psychiatric and mental health nursing developed by Barker, Jackson and Stevenson from the ‘Need for Psychiatric Nursing Study’ (1998)
- The interpersonal paradigm of nursing developed by Hildegard Peplau (1952/1988)
- The various theories of empowerment within interpersonal relationships and educational environments
- An empowering-interactions model of mental health nursing developed by Barker et al. (2000) in the context of community mental health work
- Chaos theory, where the unpredictable – yet bounded – nature of human behaviour and experience can be compared to the flow and power of water provides the core metaphor of the Tidal Model. See Barker (2000)
5.6 Introducing the holistic nursing assessment of patients’ needs
The holistic assessment, according to Barker (2003:74) involves:
….dipping into a complex bag of tools in search of the one tool (or combination of tools) that will unlock our understanding of the person’s problems – or shared understanding with the person of ‘what is really going on, and what might be done in response to this’. We might assess people:
- To find out who they are – as in the life profile
- To describe and measure specific ‘problems of living’ – as in the problem-oriented interview; or
- To describe their assets and personal and social resources – as in the strengths assessment
5.6.1 Holistic assessments and other types of professional assessments
Traditional professional assessments (medical, psychological, or social work) are designed to break down the ‘whole’ person into different aspects of functioning, and into constituent ‘sub-problems’ in terms of psychiatric diagnosis, psychological functioning, social functioning and so on. The assessment is usually written in the professional terminology of the discipline to which the assessor belongs and within which she or he has been trained. In addition to this, traditional assessments tend to be based on a highly professional relationship in which the assessor, not the client, is seen to be ‘the expert’ and the authority on the patient’s problem. The Tidal Model nursing holistic assessment differs from these in the following important ways:
- The nursing holistic assessment is focused on the person’s experience of their problems and needs, health or distress right here and now [55].
- The nursing assessment of need seeks to draw together, as far as possible, the person’s whole experience and seeks to produce a representation of the person’s problems in ways that seem real to the person and reflect accurately the person’s understanding of ‘the problem’.
- The results of the nursing holistic assessment are thus presented in the person’s own words or ‘voice’ and not in a professional language.
- The nursing assessment emphasises collaboration and dialogue, and recognises that the person in care is the ‘expert’ on their own problems and needs. To this extent the nursing assessment does not seek to be a ‘professional construction’ of the problem (in the same way that a psychiatrist or psychologist would seek to do that) but seeks an understanding of the patient’s world in terms of the lived experience of the patient and seeks to expresses this in ordinary language that makes room for both mutual learning with the client and collaborative problem resolution.
5.7 Daily care plans
The task is then for nurses to sit down with patients on a daily basis to review and to construct with them practical plans which accurately reflect the person’s own understanding of their present, medium or long-term goals. The purpose of good care planning is to work on problems, which are of concern to the patient especially in those areas where the person’s mental health and human functioning are at issue.
The holistic assessment and daily care plans, with supporting documentation, are just two of a number of practical tools provided in the Tidal Model nursing manual. Key to implementing the Tidal Model is ensuring that every nurse has a copy of the manual, which by teaching and example is specifically designed to empower nurses to foster:
Ø Engagement with the client vs. distanced and merely custodial ‘observation’
Ø Collaboration with the client vs. a dictative or authoritarian approach
Ø Empowerment of the client through privileging the client’s self-narrative and self-description as the primary locus of engagement within which solutions to problems are discovered and worked through
Ø A way of working with clients that avoids and resists the imposition of professional constructions and interpretations of the clients’ problems
5.8 Evidence of clinical effectiveness of the Tidal Model from other pilot sites.
Fletcher & Stevenson (2001) give the results of a pilot study on the introduction of the Tidal Model on two wards in the acute health services in Newcastle City Health Trust. This was followed by introduction of the model into all nine adult acute wards in the service. One ward was evaluated for six months before and after introducing the model. Nurses’ perceptions of the model were then assessed using questionnaires. Initial results indicate that after implementing the Tidal Model:
- There was an increase in the number of people admitted on an informal basis
- A reduction in the number of people subject to sections of the MHA
- The number of admission for the post-test period doubled
- The length of stay decreased by 24%
- The number of violent incidents decreased by 40%
- Episodes of self-harm decreased by 6%
- The use of restraint decreased by 67%
- The interval between admission and full initial assessment was reduced to an average of 1.3 days (from 3 days)
Staff questionnaires elicited the following responses:
- I enjoy working within the Tidal Model. It gives me as a nurse a unique way of working – it gives nurses more power
- I think the Tidal Model has improved standards of care because it makes nurses listen and talk with the patients. Some people used to shy away from this
- It gives the empowerment to the patient by planning their own care with support from staff. It appears to work with all types of mental health problems
- The model allows truly patient-centred care, rather than just rhetoric about it
- The model helps us formally access the suicide risk. Before, it was just nurses’ and doctors’ intuition
Stevenson et al. (2002) report in even more detail on this project and ends by saying:
After a two-year pilot phase the Tidal Model was introduced in May 2000 across the whole Adult Mental Health Programme in Newcastle and North Tyneside, comprising eight admission wards, a ‘step down’ sub-acute unit based in the community, and all associated community support teams. A number of supplementary pilot sites have been established in several countries – Australia, Ireland, Japan, New Zealand, Scotland and Wales – across a wide range of clinical settings; from a rural mental health service in Adelaide, Australia, and a Maori forensic mental health service in Porirua, New Zealand, to a rehabilitation service in Glamorgan, Wales. These additional pilot sites (numbering 15 at the time of writing) will allow a degree of cross-national as well as cross-cultural evaluations of the model in action.
Finally, Cook at al. (2003) report on an evaluation of the Tidal Model within a Maori forensic unit based in Rangupapa, New Zealand. The outcomes of this study suggest that the implementation of the Tidal Model has resulted in positive experiences for both nurses and patients, as well as other identifiable beneficial outcomes. The Tidal model, according to this report:
….supported the nurse’s ability to provide nursing that was directed from the patient’s narrative as well as other factors for the person concerned. The themes that arose from this research project show that the impact of the model was empowering for the patients, their families and thus nurses.
The participant patients were supported and encouraged to take an active part in the direction and implementation of their nursing care. The patient’s experience was realised through mutual discussion. Their ability to identify their own needs and co-create their care goals with the nurse supporting them is consistent with a recovery approach. This enabled the nurse to focus on the kind of care the patient needed as they took steps on their own recovery processes. The researchers intend to undertake further analysis in relation to a recovery approach and report their findings separately”
CHAPTER SIX: NARRATIVES OF CHANGE
6.1 How the Tidal Model was implemented on Tolkien Ward
By Graham Brooks – Ward Manager
This narrative section has been written by the Ward Manager of Tolkien Ward who describes how the Tidal Model was implemented on Tolkien Ward, what decisions were made, why they were made and the effects on the care delivered on the ward. In addition to this, he gives an analysis of what worked and what didn’t, the successes and the mistakes, the hurdles that had to be overcome, the mountains the staff team had to go round and how they slayed a few ‘dragons’ on the way.
6.1.1 Implementation strategy
The choice of Tolkien Ward as the pilot project site for implementation of the Tidal Model at the QEPH was made prior to my coming to the ward as Deputy Ward Manager in May 2002. When I arrived on the ward the plan was for the Ward Manger, myself and the other Deputy Ward Manager to receive training in the basic Tidal Model principles of nursing practice. From there, decisions would be made about how the Model would be implemented.
In order to do this, there was an away day for the three of us with the Lead Project Nurse to provide this training and make decisions on how best to begin and then carry through implementation. We agreed on a number of things that would have to be in place if the model was to be implemented successfully on the ward.
6.1.2 Tidal Model Induction Day
Various aspects of how the model would be implemented were discussed, but it was agreed that for the model to be implemented successfully on the ward then Nursing Assistants would have to be much more involved in the nursing process than they had traditionally been. This included engaging with patients in a structured manner, being involved in and able to contribute to aspects of care planning and regularly writing in the nursing notes. We did not want the Tidal Model to be seen purely as yet another domain of the Qualified Nurses, but something that could be ‘owned’ by all the staff on the ward. Therefore, we felt it was vital that Nursing Assistants would carry out some of the daily care plan assessments. Secondly, all clinical grades of staff working regularly on the ward would be involved in a full training day. The purpose of these ‘Tidal Model Induction Days’, which were facilitated by the Project Nurse, was to provide a basic introduction to both the theory and the practice of the Tidal Model for all staff.
The day involved a PowerPoint presentation on the historical background and theory of the Tidal Model, with opportunities for staff to ask questions and a video presentation of a nursing holistic assessment. Participants were then given an opportunity to construct a core care plan based on the video example of the holistic assessment and to reflect on their present practice. This was followed in the afternoon by a role-play session where participants had the opportunity to use the holistic assessment form by experiencing interviewing, being interviewed by other participants and observing the process.
It was recognised that this one-day training did not cover all of the training needs of the nursing staff, but it would be sufficient to start implementing the model and it remains a basic feature of the training of new staff who come to work on the ward. It was also felt that it was necessary for Nursing Assistants to receive the same basic training in the Tidal Model as Qualified Nurses.
6.1.3 Preparing the ground
The training of the whole staff team was carried out over a six-week period (one day per week) from July 2002 through to September 2002 by way of allowing a study day for staff to attend and sending approximately six staff per day. A mix of graded staff were sent on each day to ensure that there was not a problem with staffing the ward. This also included Student Nurses who were on placement on the ward at that time.
6.1.4 Nursing attitudes to training
This was not an easy or straightforward task. A number of staff on the ward at that time had a record of not attending training days when nominated to go and expressed negative views about such days. Non-attendance was usually due to sickness or to avoidance, such as claiming they had forgotten that they had to attend on that day, attending on the wrong day etc. Training courses were seen as an inconvenience, an interruption to the normal routine and not held in very high regard. The situation was compounded by the systems in place at the time, which made it difficult to monitor attendance of training courses, such as little or no feedback about attendance.
To combat this negativity and to avoid ‘confusion’ all staff were informed in writing when they were expected to attend. This was verbally confirmed when they were given the letter and it was made clear on the off-duty what staff were meant to be doing on that day. In addition, I requested feedback on attendance from the Project Nurse. These steps proved to be successful. Out of a total of 29 staff and students, 24 attended as nominated, three had to attend a later session due to non-attendance (various reasons) and two, who had been on long term sickness, attended the next training day after the launch of the model on the ward. Also included in these training days was the Ward Clerk to help facilitate the administration of the project.
6.1.5 Redesigning the nursing documentation
The next part of the project was to redesign the nursing process and its documentation. It had been some while since the existing process and documentation had been formally reviewed. Forms had changed over a period of years. There was no cohesion to the documentation and the presentation looked shabby.
It was immediately obvious that the forms used on the ward were not suitable for the assessments and care planning aspects of the Tidal Model. In addition to this, it was felt that there were deficiencies in the existing admission documentation. For example, there was no place for recording necessary relevant information or contact details of others involved in a patient’s care, which was therefore very time consuming to find when needed. This contributed to inefficiency. So the opportunity was taken to revamp the entire nursing process documentation.
We felt it important to make the new forms, based on Tidal Model principles, as adaptable as possible so that it would be easy to make changes based on observations whilst it was being used. As a starting point, the examples of the documentation included in the Tidal Model book were used as a template. However, there were no copies of the forms on computer disc and scanning them proved problematic so they had to be re-designed from scratch. Other forms, examples of which are included in the Appendix to this report, were created in a similar style. It was also decided to use different colour paper for different categories of forms to make them easier to locate.
This was completed and circulated to all interested parties for approval, which was granted with a few minor alterations for legal reasons.
6.1.6 Changes in management
It was at about this time that the Ward Manager decided to take one year’s sabbatical leave. I applied for the temporary Ward Manager’s post and was successful in obtaining the position. From the perspective of continuity for the project this was beneficial, as I had been at the centre of the decision process with Bill Gordon and the Project’s Steering Committee from when I first arrived on the ward. I was also aware of the many difficult changes in working practice that would be needed to create the time for the nursing assessments and care planning to take place and I had ideas of how they could be made.
6.1.7 “T DAY“
The next step was to agree on a day when the ward would officially ‘convert’ to the Tidal Model. By now all the paperwork was ready, the majority of the staff had been trained and the patients on the ward at the time had been made aware of what was happening and how it would affect them. This was done by way of the weekly Community Meeting, which had been set up on the ward. We agreed that there would always be a reason not to implement it, such as staff on holiday or high clinical activity, so we set a date and stuck to it. The date we chose was 5th October 2002 and this became known as ‘T Day’. We decided to make ‘T Day’ a Saturday as the weekend tended to be quieter than weekdays and would make it easier to change over to the new nursing process documentation.
Initially, we put all new admissions from the community onto the Tidal Model when they came in. We also put patients who had been admitted to different wards, but came within our catchment area onto the Tidal Model when they were transferred to Tolkien Ward.
6.1.8 Bed management issues
Implementing the Tidal Modal on Tolkien Ward has been an uphill struggle because, at times, the needs of the project have been in conflict with the hospital’s administrative and bed management policies. The bed management policy for the QEPH at the time was to admit to the ‘host’ ward and to transfer out a patient was deemed more settled in order to free up a bed.
As the only ward operating the Tidal Model we all had some concerns about this. This policy meant that patients who had been initially admitted and started on the Tidal Model and benefiting from that were suddenly transferred to another ward when their bed was needed for a new admission, possibly losing the benefit they had gained.
Our bed occupancy ran at about 110-120% so this happened very frequently. It took a lot of negotiating with the Duty Nurse (who all admissions came through) to keep the problem to a minimum. However, this was one of the ‘dragons’ we came across where hospital policies had priority over the needs of the pilot project.
This led to a constant ‘watering down’ of what we were trying to do. It also led to increasing patient dissatisfaction, as they did not get the same level of structured nursing intervention on the other acute wards. The policy was eventually changed, about six months after ‘T Day’, although not due to the problems we had identified. There was a consensus between medical and nursing staff that the policy was creating a poor experience for patients throughout the hospital. From then on the policy was to admit to where the bed was and to repatriate when possible in a controlled way. This has helped maintain the consistency of the project, but the staff on the ward have had to be watchful that the new policy is upheld.
We discussed, as a team, what we should do when patients who come under the catchment area of other wards are admitted to Tolkien Ward, as this happens regularly. The concept of nursing them under the ‘old’ system was rejected as unworkable. It is not felt to be possible to run the old and the new nursing process together side by side on the same ward. Generally, patients from other catchment areas who have been admitted to Tolkien Ward tend to stay on Tolkien Ward rather than being transferred to their host ward.
We also explored the possibility of patients from our own catchment area who were being nursed on the Intensive Care Unit (ICU) being nursed under the Tidal Model. However, this was soon discounted as impractical due to the different systems being operated on the two wards and to the limitations of the staffing establishment.
6.1.9 The Tidal Nurse
To help the project get fully underway and to reinforce and consolidate the training that the staff had already received, we decided that every member of staff, including A Graders, should have the experience of working one week as the lead ‘Tidal Nurse’ on a rotational basis. During that week the member designated ‘Tidal Nurse’ would be supernumerary and responsible for ensuring that the initial Tidal holistic nursing assessments and daily care plans were being carried out on a daily basis. The plan was not for them to do all the assessments and care planning, but to facilitate that process.
In practice, the Tidal Nurse would, on occasion, go back into the official numbers to free up another member of staff to come out so that other staff could carry out the care plans, engage with patients in-line with the new nursing process and gain valuable experience. This was never planned to be a permanent feature, but as a key aspect of staff training that would last about six months whilst the Tidal Model became embedded into the culture of the ward. On the whole, this system worked very well for a while and gave everyone increasing confidence in carrying out the assessments and care planning.
Unfortunately, this process became diluted on occasion due to staffing shortfalls when it was necessary to include the Tidal Nurse in the numbers when it was not possible to provide additional staff to cover. It was further complicated by budgetary constraints.
6.1.10 Budgetary constraints
The acute wards at the QEPH are perceived to be constantly running over their budgets. This had a negative impact on the work we were trying to do as a pilot project. We did all we could to operate in as cost effective way as possible. On the other hand we had no extra budget or resources over and beyond the input of the Project Nurse to implement the changes. We were running at a comparative level to the other acute wards who were not undertaking a major reform of nursing practice. Consequently, a lot of questions were asked about the viability of the ‘Tidal Nurse’ concept and despite explaining what we were trying to achieve by doing this, after negotiation with Senior Management, we reluctantly agreed that we would stop the practice of having a supernumerary nurse.
6.1.11 A temporary reprieve for the Tidal Nurse
Shortly afterwards there was an unexpected need within the hospital to temporarily re-deploy a senior nurse from another area. Senior Management decided to place her on Tolkien Ward to assist us with Tidal Model implementation. The original plan was that she would be supernumerary and would not be included in the numbers. This was possible because her salary was not linked to Tolkien Ward’s budget. It was also felt that because of her experience she could act as the ‘Tidal Nurse’ whilst she was based on the ward.
We all had misgivings about this as we felt that our regular staff would not be gaining the experience they needed from adopting that role themselves. But, I decided to proceed on this basis. Fortunately, our concerns proved to be unfounded and this proved to be a very beneficial thing. The staff team learnt a lot about engagement and working with patients from the new nurse and after a while she spent more time coming into the numbers than being supernumerary. This ‘Tidal Nurse’ process therefore continued until a permanent post was found elsewhere for the nurse. By this time Tidal had become firmly embedded into the fabric of the ward.
On reflection, we all feel that using the original ‘Tidal Nurse’ concept (all staff having the experience on a rotational basis) was a very helpful and effective approach to staff training and development and I would recommend that this approach be used should the Tidal Model be implemented elsewhere within the Trust. Obviously it does have temporary cost implications, but the benefit to the staff and to the task of initial Tidal implementation far outweighs this.
6.1.12 Challenging the previous nursing culture
The Tidal Model has not been popular with all staff. However, as highlighted elsewhere in the report, the general reaction has been very positive. This is reflected in the staff interviews and was the consensus of the staff away day (see Chapter 7.1.2 –7.1.3). Nevertheless, for various reasons, some staff have not been in favour of it. During the first year of the project, there has continued to be a high turnover of staff on the ward. In most cases they have gone on to ‘more responsible’ posts.
From talking to staff on other wards and in different Trusts it appears that there is often a misconception of what the Tidal Model is actually about. Apart from the expected resistance to change, some staff are worried that the Tidal Model asks them to work harder than they already do at present at a time when they feel they are already working too hard in a very stressed environment. There are also those staff who like the status quo, who don’t want to do the job in a more professional way or in a way that is different from the way they have always worked in the past. There is also the issue of lack of confidence in carrying out the assessments and care plans. And there are also those who seem to thrive in the chaos that used to be, and on occasion still is, prevalent on the ward.
6.1.13 Accountability and work delegation
One of the biggest problems that I encountered when I first began to work on the ward as a Deputy Ward Manager was a lack of accountability within the staff team. Tasks were delegated to staff, but these were often not done and there appeared to be little in the way of monitoring performance. I felt strongly that this needed addressing so that the Tidal Model could be successfully launched.
The main way this was dealt with was to get organised at the beginning of each shift. This meant properly and officially nominating who would be responsible for various tasks, when work-breaks would be taken, designating who would carry out observations and when. The issue was making sure this was obvious to everyone. This was generally adhered to, but was not popular with some staff who were used to a more ad-hoc approach. We also introduced a Tidal Diary which was an up-to-date record of which patients had had their daily care plans completed, when they were done and who did it. This kind of approach soon made it obvious who was shirking their responsibilities. I believe that this was a factor in why some staff asked for a transfer to other wards and why others moved on.
Over time, the effect of this has been that most of the staff on the ward now want to be there and are happy to be working with the Tidal Model. The last four months have seen a period of stability in the staffing on the ward. However, I feel that this pattern and the issues it raises will be repeated anywhere the Tidal Model and a structured way of working is implemented. It is thus imperative that all staff should be involved with the decision of when and how to roll it out.
6.1.14 The use of Bank Nursing Staff
The other main issue of concern is the use of Bank staff. During periods of staffing instability and also at times of high observation levels, it has been necessary to use Bank Nurses. We worked hard to ensure our skill mix was as robust as possible with the resources available and that wherever possible we minimised the use of bank staff. However, the Project Nurse and myself anticipated that this would be an issue and we agreed that we should do our best to train the Bank Nurses we used on a regular basis.
This was arranged and carried out at the ward’s expense. However, we soon discovered that the Bank staff we had trained were working on other wards at the same time that we were being sent Bank staff who had not been trained in the Tidal Model. When I spoke to the staff concerned they reassured me that they had wanted to work on Tolkien Ward, but that the Resource Department had arranged this.
I brought this up with the Resource Department and it was explained to me that vacancies were filled by allocating the staff who declared themselves available for work on a ‘first come, first served basis’. I explained the rationale behind what we had done and tried to negotiate for us to have first use of those Bank nurses we had trained and who had indicated that, if given the choice, they would prefer to work on Tolkien Ward, ,but without success. Again, it appeared that the needs of the hospital had priority over the needs of the pilot project. We eventually did solve this problem by anticipating and predicting when our staffing shortfalls would be and by block booking the Bank staff we used, thereby minimising the problem.
However, I feel that it is not cost effective to train people in a particular skill and then not utilise them when staff are needed to carry out that task. I also feel that this has seriously delayed the process of implementing the Tidal Model on Tolkien Ward. The situation went on for many months and put unnecessary strain on the regular staff team and on the ward by making them have to ’carry’ untrained staff every shift. This meant the care planning and patient contact suffered. On reflection, we should have considered building in some safeguards to ensure that bank staff who were ‘Tidal Trained’ were obliged to work on the ward and that Resource had no option to send them here, thereby solving the problem ourselves. Whether this will be a problem in the future will depend on how the Tidal Model is expanded to other areas of the Trust. If that happens, the training of Bank Nurses should be a high priority once all regular staff are trained.
6.1.15 Observation versus “Engagement”?
Tolkien Ward has 22 beds. The establishment staffing levels for the ward are as follows.
EARLY | LATE | NIGHT |
5 | 5 | 4 |
When there are Level 3-4 (1:1) observations on the ward the establishment changes to:
EARLY | LATE | NIGHT | |
1st LEVEL 3-4 | 5 | 5 | 4 |
2nd LEVEL 3-4 | 6 | 6 | 5 |
3rd LEVEL 3-4 | 7 | 7 | 6 |
The Observation Policy states that each ward should have no more than three Level 3/4 observations. However, high clinical activity can sometimes dictate that we go above that level.
Over the period of running the Tidal Model we have had fluctuating observation levels. It is noticeable that the number of daily care plans completed drops dramatically when we have three Level 3 observations. We have tried to analyse why this happens and have come to the following conclusion.
6.1.16 Care planning and observations
We operate the Shift Co-ordinator system where one Nurse operates as the focus of all that is happening on the ward. This seems to work best in terms of communication amongst the team and disseminating information. This means that when we have three Level 3 observations there are 6 staff to carry out the three observations and the Level 1 (General or hourly observations) and Level 2 (Timed) observations.
In practice staff have an hour carrying out Level 3 observations and then an hour doing other tasks, such as Level 1/2 observations, assisting in-patient care, escorting etc. When you factor in work-breaks you have a situation where for most of the shift there is only 1 Nurse each hour not carrying out observations.
With up to two Level 3 observations you can have between four and two staff available as staff do not usually have the ‘hour on, hour off’ schedule, therefore they can more easily fit in the normal routine of the ward and are left free to carry out other tasks, such as the Tidal assessments and daily care plans. We have tried various ways of managing the situation, but with minimal success. I do not feel that having more staff would necessarily be the solution to the problem as this brings up issues such as managing them and the cost.
However, I feel serious consideration should be given to limiting the number of Level 3 observations to two per ward should the Tidal Model be implemented throughout the hospital. We have already done a lot of work on the ward with the medical staff to make the observation levels realistic and to keep them under more regular review, but there is still scope for more to be done. If this work is carried forward in the right kind of way then it is feasible.
I feel a lot of this is due to the growing ‘engagement’ ethos of the ward rather than the ‘observation’ mentality of the old system. Experience has taught us as a team that for many Nurses, ‘observation’ still means just that, sitting looking at someone, rather than an opportunity to spend time with someone, getting to know them. To help combat this we are now promoting the use of the term ‘engagement’ instead of ‘observation’ and our nursing process documentation now reflects this.
6.1.17 Hitting rock bottom: June, 2003
In June 2003, there were four separate serious clinical incidents on Tolkien Ward in the space of about 10 days [56]. As staff came to terms with one, then another one happened. Investigations showed that they were all unrelated, involved different staff and patients and that they would have been difficult to predict. This had a profound effect on the staff team and consequently the Tidal Model took a back seat.
As the month wore on the ward became more like it was before the introduction of the Tidal Model. Holistic assessments and daily care plans were being completed very infrequently, the ‘Those Who Shout the Loudest Getting the Most Nurse Attention’ syndrome had set in once again. We discussed how to stop the stream of serious incidents as a team. I also spoke to my peers and to Senior Nurse Management asking for advice.
However, it was only when I discussed the situation in clinical supervision that it became obvious to me that it was the Tidal Model that had originally solved the problems for the ward and it was likely to do the same again. So the team started to do the holistic assessments and the daily care plans regularly again and the ward soon returned to what it had become since the launch of the Tidal Model.
On reflection it is now obvious that this is what was needed, but it has been a very useful lesson to learn.
6.1.18 Future developments on Tolkien ward
The Project Nurse and myself have discussed how we would like to take things forward from here and feel the following would be appropriate and necessary.
6.1.18.1 Group Supervision - We have been running a weekly supervision session for staff on the ward in conjunction with the Psychology Department. It has been a tremendous success and is popular with staff. However, clinical activity initially impacted on this and meant that the sessions did not happen. They were also not seen as a priority by staff who were unfamiliar with what they could potentially gain from it. Over time it has become a regular occurrence and is well attended. However, it is difficult to free up staff from their normal working day and we have had to be innovative with how we organise it. In addition, as it is staff who are on duty when it happens who attend there is no organised approach to ensure that all staff receive supervision. We plan to keep a register of who attends and ensure that the off duty offers all staff the opportunity to attend.
6.1.18.2 Staff training – We feel that there are further training needs that staff require to supplement the experience they have gained since working with the Tidal Model. Firstly, they need training in engagement and how to get the most from the time they spend working collaboratively with the patients. Secondly, they require additional training in working with diverse cultures. They also require guidance in how to work with groups so that the remaining part of the Tidal Model can be launched. The intention is to provide this in conjunction with the Psychotherapy Department who are keen to provide input into the Adult in-patient service. A pilot course has been devised and will shortly be up and running. We also feel that it is necessary to provide training in the new Nursing documentation. Staff have adapted well without much in the way of formal training, but to enable them to make full use of the potential that the documentation offers they need to build on their experiences.
6.1.18.3 Group Work – Once sufficient staff have been through the training in Group Work then groups will start to be run on a regular basis, taking into account what is recommended by the Tidal Model manual and also by what the patients on the ward would like.
6.1.18.4 Environment – Unfortunately, Tolkien Ward only has two rooms where the patient interviews can be carried out. In lieu of more available space, we have created two areas that can be used for therapeutic interaction. One of these was created by virtue of a kind and sizeable donation from the WRVS who purchased a large fish tank for the ward. This has now become the main area for patients to congregate on the ward. In addition, as previously mentioned, there was a pool table on the ward, which due to incidents has now been removed. We now use this area as a quiet space and it is used for a variety of things including daily care planning.
6.1.18.5 User Voice – We have forged strong links with User Voice and they now hold a fortnightly closed (to Nursing Staff) meeting on the ward alongside the regular Community Meeting. This initiative has been very productive and is appreciated by both service users and staff. A lot of the recommendations from these meetings have been implemented and have had a positive effect on the Ward environment.
With these changes I feel certain that we will have an environment that is therapeutic and of benefit to the patients that spend time there. It will also be somewhere where the staff can be proud to work.
6.2 The Perceptions of Nurse Managers
6.2.1 Testimony of previous Ward Manager of Tolkien Ward
“I was Tolkien Ward Manager when this project was first initiated and I gave it my full support because I felt the Tidal Model offered a way forward for us on the Ward.
When Bill first joined the nursing team on Ward 5 it was at a time when there was a new interest being shown in the acute in-patient service from government and at different organisation levels at the QEPH. This included Clinical In-patient Specialist, and our Operational Manager who was the Deputy Head of Nursing, as well as the Resource Manager.
It felt like the services were being supported economically and developmentally and we were being supported and encouraged to take the time to explore nursing initiatives.
What I hoped we would get out of the Tidal Model was a positive way of re-engaging with our patients, a way that empowered both the patients and the nursing staff.
I felt the Tidal Model could be the vehicle to get nurses back to what out training had taught us, to learn from our experiences of interacting and communicating with patients and to develop new skills and positive experiences for both nursing staff and for patients.”
6.2.2 Testimony of the Clinical Nurse Specialist Adult In-patient Services QEPH
“…Bump bump, bump, on the back of his head, behind Christopher Robin. It is as far as he knows the only way of coming downstairs, ,but sometimes he feels there really is another way, if only he could stop bumping for a moment and think of it.”
Bump, Bump, Bump
During my three-year period working as a Clinical Nurse Specialist on the four busy acute in-patient wards at the QEPH, I often thought of the above intelligent words of a very wise bear. Words, which rang so true for the situation both staff and patients found themselves in on those wards.
The situation of always being too busy to think, too busy to do anything different or to change things was part of a continual negative circle we found ourselves in. Words like “we have tried that before, we are too busy, we do not have the staff” were all too familiar. The questions we kept asking ourselves were:
What are the experiences of patients/service users on the acute wards?
What do they get from the service we are providing?
What is it they get from being an in-patient on our wards?
We could not always answer these questions. It sometimes felt that people got better despite what we did! The staff wanted to make a difference. They did care, but they felt frustrated by things that were out of their control and influence, but affected their working practise. There was a constant pressure on beds, complaints, unsatisfactory ward environments, on-going staffing problems, untoward incidents and a general lack of recognition for what was really positive and good work going on under those conditions.
From a personal point of view I returned to the adult acute environment after a considerable period of time working in the forensic service. What was obvious to me, but difficult for me to understand was how busy everyone was on the acute wards! Staff were governed by tasks rather than interventions. They often talked of wanting to spend more time with patients, but the tasks always took over. We needed to find a way of moving out of this negative circle of events. What we had to help us was the fact that the staff wanted to do things differently and wanted to work smarter, not harder.
So we took time away from the ward to reflect together on ways in which to move forward in a positive manner and support and encourage the teams on the ward. We tried to capture the motivation and commitment of staff and utilize this as a key tool in making a difference on the acute wards. We had very positive support from the service user groups as well.
The Tidal Model
We were in the fortunate position that where staff were reflecting on their practice and when Bill was looking at the Tidal Model we all felt we had the makings of a structure that would enable us to take things forward. On reflection now, the old problems still exist. However, the important point is that they are now less overwhelming for those working on Tolkien Ward since the introduction of the Tidal Model. The staff feel that they now have a clear plan and a structure to work to. Having that structure has enabled staff to engage more often with patients and to implement better nursing interventions as well as doing the fire- fighting.
I was personally involved from the start of this project and feel fortunate to have taken part in it. Within a short period of time change began to happen on Tolkien Ward, and with other important developments within the service I believe that we have made good progress.
Looking Ahead
Having moved on from the adult acute service, I am extremely proud that the developments have continued. Now, through the research and reflection on how the Tidal Model has improved the service, I am keen that we role out the model onto the other acute wards and within BSMHT. I am aware that there are already plans to involve the forensic directorate in implementing the model.
There is clear evidence that the model is making a difference. It has enabled the work on Tolkien Ward to improve. In my opinion it is the staff and service users within the service which are the main reasons why it has been successful.
We have been able to stop bumping for a while and to think of other ways of doing things. Problems still remain and the outside influences beyond our control are still there, including bed pressures. So it is important that the progress achieved on Tolkien be built upon and extended. We must persevere to continue to improve engagement with our patients within the in-patient service. We should be offering service users a positive experience of care and an acute in-patient service, which makes a positive difference to their lives and enables their recovery.“
6.2.3 Testimony of the Modern Matron for Adult In-Patient Services QEPH
“I have to admit to some initial scepticism about the Tidal Model; - I wasn’t convinced that the time and resources needed to implement it would be a worthwhile investment when there were so many pressures on the QEPH acute wards and their environments often seemed chaotic.
15 months on I feel thoroughly converted. The Tidal Model has provided Tolkien ward with a robust framework both to improve patient care and to give staff a sense of order and purpose. In addition, the atmosphere on the ward is generally calmer, as the statistics for untoward demonstrate.
Valuable lessons have been learnt for the Adult In-patient Service; (for example, staff training needs in the area of therapeutic engagement and group work skills have been highlighted) and Tolkien ward has often been at the forefront of developing and piloting new documentation and working practices which have then been adopted by the other acute wards.
In the light of these positive changes, I feel we should work towards implementing the Tidal model on the rest of the Adult In-patient wards. I would like to thank Bill, Graham, and the staff team for all their hard work.”
CHAPTER SEVEN:
EVALUATION OF THE TIDAL MODEL
This evaluation of Tidal Model brings together both qualitative and quantitative evidence and interprets these within an action-research paradigm.
7.1 Qualitative evidence
Central to this evaluation has been the personal testimonies and opinions of in-patient service users, which have been assessed by means of a questionnaire. One assumption of this evaluation is that service users are the best judges of the quality of the care they have been receiving. Another key source of evaluation has been the opinions and testimonies of nurses and psychiatrists. These were assessed by questionnaires as well as by a nursing staff away day in which the model was discussed and evaluated by all grades of nursing staff working on Tolkien Ward. This section concludes with a documentation audit of the nursing processes associated with Tidal Model implementation.
7.1.1 Service user (in-patient) evaluation
Four in-patient service users were interviewed on Tolkien Ward and asked about their view of the Tidal Model. The interview schedule (see Appendix 10.16) was designed to reflect the principles of the nursing holistic assessment. In other words, the answers given to the questions where written down verbatim and the wording checked with the patient to ensure that it accurately expressed their view and opinion. All four persons had been in-patients on at least one occasion in the past.
7.1.1.1 Overall service user evaluation of the Tidal Model
All four persons interviewed said that:
Ø Their own story was given full attention by the nursing staff
Ø Their own views were respected by the nursing staff
Ø Their words were recorded (in both the holistic assessment and care plans) verbatim
Ø The care plans were focused on their actual needs/wishes
Ø The nurses helped them to be more clear about their personal goals
Ø All found the ‘daily activity programme’ adequate
Ø The nurses helped them to move towards discharge from hospital.
However, one patient said that there was often a lack of consistency and regularity doing care plans, especially during a two-month period around Christmas, which had an adverse effect on her and some of the other patients because:
“For some reason the nurses just did not talk to us very much anymore. But, things seem to have improved a bit since then.” [57]
Three of those interviewed claimed that their experience with the Tidal Model was dramatically different and much better than the way they had been treated in hospital before as psychiatric in-patients.
7.1.1.2 Comparison with previous in-patient experience
All four patients interviewed said they greatly appreciated the Tidal Model emphasis on collaborative care planning and said that this was very different from the kind of nursing they had received previously at the QEPH or elsewhere. One patient said:
“When I was here before the nurses never talked to me, but only the doctor. I think (the Tidal Model) is a lot better. The communication is a lot better.”
Another said:
“I was here five years ago. Nothing was in place then. It was all just a fog for me. This time the fog cleared up quickly by meeting up with the nurses and talking about specific things.”
Another said:
“I think the Tidal Model is more organised and focused than what I had before. I feel better treated this time around (it’s my 5th admission).”
7.1.1.3 Holistic assessment and care plan aspect of the Tidal Model
Three of those interviewed said they found these aspects very helpful and attributed much of their recovery to the process of therapeutic engagement with the nursing staff. The one person who found it less helpful said:
“I am not sure how helpful anything was. I was just glad I have gotten through this. I found the holistic assessment dreadful because I did not like the person I saw myself to be when I was saying the things I was saying. It made me feel all mixed up inside. For two months I was ‘numb’, but I am now a lot better. I don’t know why I am better. But, the nurse did respect my views which I appreciated. I am not sure how much the care plans helped, but I am really glad that discharge from hospital is in sight.”
The positive comments from the other three were as follows:
“The care plans helped to pinpoint the areas that need to be discussed, as opposed to just rambling on. They provide the skeleton to put the meat on. They help to bring up areas of concern so you’ve objectives to work towards and you know how to achieve them because you have talked about it.”
“The nurses have more time for you and MAKE more time. It was really helpful to be able to talk out my problems and the nurses really listened to me. That didn’t happen before.”
“They helped me to see when I was ready to get out of here. The nurses heard MY version of things. I feel the nurses really understand me (I am difficult to understand).”
“The nurses really helped me with my goals so I knew what to do in order to get out of here. We went step by step. Talking to the nurses and having them listen to me was the best support.”
7.1.1.4 Most helpful aspects of the Model
The most helpful aspect was seen to be the opportunity to meet up with nurses on a regular basis in order to construct relevant, practical care plans that were recovery-focused. This process sometimes resulted in the bringing up of personal issues for the patient, which, although painful, were seen to help facilitate recovery.
“I feel I have been helped properly this time. What I have requested I know will be done. I was able to see for myself the problem areas. I broke down and cried because I could see where I have been going wrong, being so selfish towards my wife.”
“I feel very supported by the nurses. It (the care plans) gives me the opportunity to go back and to look at the previous agreement and to see if things happened or not. If they have not happened I can then make sure it does happen.”
“We are able to make a personal plan together.”
“This time I was picked up from the depths of despair…but in stages, step by step. I think that was due to the regular care plans. I think the whole thing is really excellent.”
“What was most helpful was just the nurses talking to me and having a laugh and a joke sometimes. I now realise how the miscarriage I had when I was 15 made me ill. I never told anybody about that not even the doctors. When I told them (the nurses) about my past they just listened to me. I found that a lot of help.”
7.1.1.5 Least helpful aspects of the Model
One criticism made about the Tidal Model was lack of nursing consistency in doing it. One person said:
“It seems logical to me and I like it in principle. But, the main problems with the Tidal Model are that it is sometimes not done or done consistently.”
“One of my problems is that I am distrusting and disbelieving about most things. I think being clear about things and my own goals is down to me and not the nurses or the doctors.”
7.1.2 Tolkien Ward staff evaluation questionnaires
The Tidal Model was launched on Tolkien Ward on the 5th of October 2002. Questionnaires were sent to all clinicians on Tolkien Ward in order to obtain their views of the Tidal Model, 6 months after Tidal Model implementation
7.1.2.1 Qualified Nursing Staff
Questionnaires were sent to the eleven qualified nurses. Seven were returned, a high response rate of 64%. Of the seven who completed them, one was an F Grade (Deputy Ward Manager) four were E Grade staff nurses and two were D Grades.
7.1.2.1.1 Satisfaction with the Tidal Model
This section consisted of seven questions, and the nurses were asked to give a rating in response to each using a scale where 1 = much worse, 2 = worse, 3 = about the same, 4 = better and 5 = much better. The following table shows the average rating of the seven nurses for each of the questions.
Table 5: average rating of the Tidal Model by Tolkien nursing staff in terms of ‘satisfaction with the Model of care’
QUESTION: | Average rating |
To what extent does the Tidal Model enhance your professional practice? My sense of professional nursing competence is now… | 3.86 |
To what extent does the Tidal Model help you to focus more clearly on the patient’s need for nursing care? My sense of focus is now… | 4.14 |
To what extent does the Tidal Model help you develop a helping relationship with the person in your care? My ability is now … | 4 |
To what extent does the Tidal Model help you to develop an understanding of the person in your care? My understanding is now… | 4.57 |
To what extent does the Tidal Model help you to construct collaborative nursing care plans, which express the views of the patient? My opportunity and ability to do this is now… | 4.14 |
To what extent does the care plan element of the Tidal Model enhance your sense of job satisfaction? My job satisfaction in this area is now… | 4.14 |
To what extent does the Nursing Holistic Assessment element of the Tidal Model enhance your assessment skills? My skills in this area are now… | 4 |
Using the rating scale above rate the overall quality of the nursing care on Tolkien Ward, as you perceive that, in comparison to the way you worked before using the Tidal Model. In your opinion the care is now… | 4.8 |
According to the above, the qualified nursing staff rated the Tidal Model as Better (4) >> Much Better (5) than their previous way of working in terms of professional satisfaction.
Additional comments made concerning the overall quality of nursing care on Tolkien Ward were:
“Patients say they are listened to. They feel they can approach staff to talk to when they are feeling low or anxious etc. They also feel that their care is better over all because the nurse sits down with them on a daily basis to listen to their problems.”
“The number of violent incidents has decreased. Patients feel usually more involved in their care. Referrals to OT and Dentists are completed more readily.”
The nurses were asked how they thought the Tidal Model could be improved and their nursing practice brought more in harmony with the therapeutic principles of engagement, collaboration and empowerment. The wide range of suggestions fell broadly into five categories:
- Nursing team working
- To pull together more as a team
- Regular clinical meetings for nursing teams
- “When an admission comes in it is important to fully complete the admission process even if the patient is not allocated to the team you are working with and hand the client over”
- “Working with Bank/Agency staff is not good enough – too much pressure is then put on regular staff to do TM”
- “More support from Bank Agency Mangers to ensure that those who have completed the TD Training are booked on Tolkien Ward to ensure consistency of care”
- Multidisciplinary team working
- Doctors should visit the ward at appropriate times during the day
- “Tolkien Ward can be very busy. This does not necessarily have to do with the amount of patients, but the amount of Consultants. Less Consultants means less SHO means fewer ward rounds and fewer Doctors on the ward wanting nurses’ time”
- Multi-disciplinary notes
- Service user activity
- Re-design of the ward to give the client a pro-active role
- Specific ward-based groups and more co-ordination in this area
- More staff to escort patients off the ward
- Time pressures
- Inability to complete Tidal Care Plans due to time constraints
- “Not to feel pressured to spend so much time with paper work”
- The ward environment
- “More interview rooms available”
7.1.2.1.2 Training, supervision and staff handovers between shifts
Five nurses (71%) felt that further training; support or supervision would be valuable in using and developing the model fully.
“For the TM to work effectively all staff need to be trained before implementation.”
One respondent suggested that any type of further training would be helpful as shift patterns had prevented them from attending any training other than the away day. Others felt that further training would enhance the staff’s confidence in facilitating group sessions and implementing care plans and that unqualified staff would benefit from training in counselling skills. Two nurses also wanted to explore the Tidal Model further as they felt that that the model had not yet been fully implemented:
“The Tidal Model needs to be deepened as it becomes more of a philosophy not just another model of nursing.”
All of the staff stated that there were, normally, no a) staff clinical supervision sessions or b) care support groups outside daily handovers. There was no appropriate context within which to discuss, at depth, current nursing care and staff team issues. This was, it was felt, detrimental to the quality of the nursing care on the ward.
The majority (71%) also felt that the daily staff handovers were inadequate to deal effectively with the often difficult, personal, managerial and care issues that arose during the course of each shift. The main reason given for this was lack of time due to ward activity. There was a consensus that regular structured care team meetings would be beneficial.
7.1.2.1.3 Comparison with other nursing models
There appeared to be a lack of clarity concerning what, if any, nursing models staff had used prior to using the Tidal Model on Tolkien Ward. Models given were: Roper, Logan and Tierney; Orem’s self-care deficiency model; the medical model and an eclectic approach. It was also stated that “there appeared to be no obvious nursing model employed” on other acute in-patient wards at the QEPH. The nurses were again asked to give a rating in response six questions comparing the Tidal Model with other models using the scale between 1 (much worse) and 5 (much better):
Table 6: Average rating of the Tidal Model in comparison with other models or ‘no nursing model’.
QUESTION: | Average Rating |
In general, how does the Tidal Model compare with the nursing model you were using before? | 4.29 |
In terms of the initial nursing assessment of the patient on admission, how does the Tidal Model Holistic Assessment compare with the kind of assessment you were using before? | 4.57 |
How does the Tidal Model care planning element compare with the way in which you did care plans before? | 4.29 |
In terms of time, to what extent is the Tidal Model more or less efficient that the one it has replaced, or the one you have used before? | 4.5 |
In terms of communication with nursing colleagues, how does the Tidal Model compare with the one you used before? | 4.17 |
In terms of communicating with the MDT (Multi-disciplinary team) how does the Tidal Model compare with the one you have used before | 4.29 |
The Tidal Model was generally viewed as far superior, that is, rated Better (4) >>> Much Better (5) to the nursing models or lack of any nursing model they had been involved with previously at the QEPH or elsewhere.
“One of the main strengths of the Tidal Model seems to be its simplicity, and I think that this helps facilitate its implementation in different areas with suitable adjustments.”
The main reason for the popularity of the model was that it facilitated engagement with individual patients and the entire patient group and that all members of the nursing team had a role in this. As one nurse stated:
“With the Tidal Model people are aware of issues in regard to all clients.”
One respondent, who felt that the environment on Tolkien Ward was “chaotic”, as a result of a low staff-patient ratio, saw this as particularly important. There was agreement that the increased knowledge of all the patients also facilitated communication with the rest of the multi-disciplinary team.
The care planning element of the Tidal Model was viewed extremely positively, resulting in care plans that were generally more relevant and up to date. Its particular strength was seen to be its emphasis on collaboration with patients and the fact that it encourages engagement with individual patients every shift. It was felt that this increased satisfaction for both service users and staff.
“I think the Tidal Model is good with patients who are withdrawn as it engages them. Patients have often commented that they like having an opportunity to discuss their care plan more frequently and it gets them more involved in their own care.”
“I think it is great and satisfying to work in collaboration with clients instead of the old system fighting to access the computer to print off a prepared care plan off a template. Which means care was not individualised and with the Tidal it is now.”
“It looks at the clients in collaboration with their care and this feels like what I came into nursing for.”
The Tidal Model was seen to be more efficient than previously used models, and not having to spend so much time at the computer was also seen as beneficial. One nurse added that it improved assessments, as “the questions [in the initial assessment] are different from those asked by the doctor”. It was also felt that the model provided a more structured approach to patient care. It was noted, however, that “It can be time consuming, but that depends on organisational skills of staff to get the job done.”
7.1.2.2 Nursing Assistants
Questionnaires were sent to the 10 Nursing Assistants attached to the ward. This time the response rate was very low (10%) with only one questionnaire being returned. This one evaluation was, however, very positive. The Model was rated ‘better’ than the previous way of working and the respondent rated the overall quality of care as ‘better’ than before, concluding:
“Having the Tidal Model has helped the ward extremely. Patients feel more comfortable with staff, & staff feel they are now aware of patients’ problems more. The ward could be better, but it has definitely improved.”
7.1.2.3 Medical Staff
All 10 medical staff attached to the ward were asked to complete questionnaires. Three were returned, a low response rate of only 30%.
The medical staff were asked to compare the nursing care being provided following the introduction of the Tidal Model with the nursing care previously provided on Tolkien Ward or on other wards. Two of the doctors stated that this question was not applicable, and one said they felt the nursing care was “about the same”:
“When it works, it is excellent. But, my experience is that it does not work enough of the time so I do not think it has a massive effect yet.”
When asked how satisfied they were with the information they had received regarding the Tidal Model and its implementation on Tolkien Ward, the three respondents’ replies ranged from satisfied to not satisfied.
One doctor said that they thought they understood the principles underlying the Tidal Model well, although a second doctor said they did not understand the principles very well. When asked what they believed the principles to be, the responses were:
“Every patient offered time each day to discuss their concerns and come up with some goals and management plan as desired by the patient.”
“Engaging with patients. Exploring patient’s symptoms/consensus/wishes.”
“Concentrating on the patient’s narrative.”
“Getting nursing staff to talk to patient’s more.”
None of the medical staff felt that a half-day’s training in the Tidal Model would be of interest or of use to them. However, one did perceive the need for information provision:
“I think as doctors we do need information given formally, but perhaps not as much as a 1/2 day.”
7.1.2.3.1 Communications
The doctors were asked to rate the communications and contributions of the nursing team within the MDT on a scale from 1 to 5, where 1 was very poor and 5 was excellent. The average score was 2.7, indicating an overall view of poor-OK. Rationale for this low rating was the lack of consistency, with communication varying greatly depending on which nurses were on duty. One respondent further suggested that:
“Nurses know what has been going on with patients, but do not tell us. Nurses need to take more initiative as they do have an important role in the MDT.”
Despite the very low response rate from the medical team, the comments that were received were generally very encouraging and supportive of the Tidal Model. The medical staff also appeared to recognise some of the difficulties faced by the nursing team in implementing the Tidal Model:
“Unfortunately, nurses seem to have to spend most of their time on administration and paper work or patient observations and spend very little time in building relationships with patients. The Tidal Model goes some way towards ensuring that nurses spend time with patients in a therapeutic setting.”
“I really like and agree with the Tidal Model. It needs commitment and money from the Trust to make it work in the interest of patients.”
7.1.2.4 Concluding remarks
Although the response rate for the medical team and the nursing assistants was disappointing, the response rate for the qualified nursing staff was high. The important point is that the responses that were obtained by all grades of staff showed overwhelming support for the Tidal Model, mainly because it was felt to empower both service users and the nursing team. There were also many useful suggestions for improving the use of the Tidal Model in the future, including further training, improved staffing and the introduction of structured team meetings.
7.1.3 Nursing staff away day: applying the EFQM Excellence model
Sue Phillips facilitated the day in the context of the EFQM Excellence Model, which seeks to provide a self-assessment tool that can empower continuous improvement. Staff were encouraged to
q Identify their strengths
q Identify areas needing improvement
q Identify an adequate benchmark to assist the measurement of progress
q Assess improvement in the clarification of priorities
q Identify a framework for sharing best practice
A consensus emerged during the day that the Tidal Model provided a good framework for shared practice. During the day participants broke down into groups for sharing and discussion over specific issues, and comments were written down on a flip chart for further discussion. The following comments were taken verbatim from the flip-chart and notes of the day. According to the staff team, benefits of the Tidal Model included:
7.1.3.1 Benefits for the staff team
- The Tidal Model is more a philosophy of care than it is a ‘model’
- The TM patient/nurse relationship fostered by the Tidal Model improves communication
- The TM increases staff and patient rapport
- Improves quality of information
- Makes you feel like your part of something bigger than just Tolkien Ward practising worldwide
- Makes staff MORE pro-active
- A-Graders (Care Assistants) now do more one-to-one work with patients
- Helps us do the job we are paid and trained to do
- The whole approach
7.1.3.2 Perceived benefits for service users
- It is patient-led rather than nurse-led
- It allows patients to set their own goals that are real and achievable by them
- It enables staff to be constantly updated with information from patients
- It facilitates engagement with ‘quieter’ patients
- The quieter patient doesn’t get neglected because of the more vocal patients
- Talking to and involving patients – getting to know them as individuals
- To make the patient’s feel valued and respected
- Improves communication
· Benefits for the wider organisation
- Increases continuity of care and consistency
- Reduces frustration, violence or risk
- Reduces the ‘revolving door’
- Staff coming from different Trusts are interested in working on Tolkien Ward
- Allows more time for patients to express their feelings
- Helps prevent violent incidents occurring on the ward
The Tidal Model also presented a number of challenges and difficulties for the staff team, which were openly discussed. These were identified as:
7.1.3.3 Staff training and education
- There is a lack of staff training for Bank staff
- Time constraints make doing the TM difficult
- Lack of experienced staff
- Unfamiliarity with staff and patients due to bank/agency staff supplying cover
- Staff who do not know the ward (Bank and Agency) are not Tidal trained
7.1.3.4 Documentation of the nursing process
- Extra cost and paper wasted (organisational)
- An awful lot of paper work
- Administration documentation can be wordy and difficult to understand
- Other non-Tidal jobs omitted (organisational)
- Storage problems due to continual paperwork
7.1.3.5 Leadership
- Other tasks (not directly related to patient care) take priority (medics, problems on ward high level of clinical activity)
7.1.3.6 Resources
- Can put strain on staffing levels
- Low staffing levels affect your time with patients
- Not enough private space on the ward
- Doing holistic assessment and daily care plans is time consuming (for staff)
- Can be repetitive
- Pressure to do it everyday, but staff do it only and when or as it is required
7.1.3.7 Nursing policy issues
- Daily care plans can be repetitive (patient)
- Language barriers and cultural awareness
- Problems engaging with some patients i.e. lack of insight, paranoia etc
- Needs to be done over 24 hours
- Lack of patient motivation
- Patients sometimes refuse to engage on a daily basis stating that everything is the same as yesterday
- Problems with delegation – primary named nurses aren’t always given their patients to do
At the conclusion of the day the feedback concerning “where are we, right now, concerning Tidal Model implementation?” was as follows:
7.1.3.8 Where are we, right now, concerning Tidal Model implementation?
- We still need a deeper understanding of the model to build a more thorough relationship with patients
- I am new to the Tidal Model, but have reviewed the theory and am glad to be involved with it. Pleased with what I’ve seen
- We need to establish the need…for this
- I think we are doing well and have implemented the model well. Sometimes there is a lack of communication
- Things are going well. Feel that some patients do not need daily care plans
- Sometimes a patient has had a Tidal done on the night shift and then has it redone first thing on the early shift. I feel this is sometimes too much
- Positive approach, more time spent with patients
- Some improvement, but not 100%
- Feel Tidal is going well, but need more feedback from Bill
- All staff should be Tidal trained, not just left up to a few people to do
- I think there are problems with all the Tidal paperwork
- Proceeding, but we need more practice
- The team has made tremendous steeps and their hard work has made it a success in the short term
- I don’t know much about it, but hope to learn and apply it throughout my placement
- Encourages staff to spend time with patients, is a positive thing
- Care plans are improving the additional elements need more work and understanding
- Can’t comment
- Needs some tweaking, fine-tuning, particularly with regard to admission assessments
- It definitively ensures that more time is spent with patients. You can get to their main issues more effectively
- I feel we’re getting to grips with the Tidal Model more, spending more time with patients
7.1.4 Four-Month Tolkien Ward Documentation Audit
The Tidal Model was launched on Tolkien Ward on the 5th of October 2002.
On January 14th 2003, four months after Tidal Model implementation, using the following format, 22 patient files were audited from Tolkien Ward:
NAME | |||
Date | Complete/Incomplete? | Poor/OK/Good | |
Admission Form | |||
Admission Checklist | |||
72 Hour Care Plan | |||
Holistic Assessment | |||
Risk Assessment | |||
Daily Care Plan (last completed) | |||
Today’s Date |
Gap between PRESENT CARE PLAN and LAST CARE PLAN? | Number of days: |
Reason for Gap? |
General comments on Tidal Documentation: |
7.1.4.1 Daily Care Plans
With a few exceptions, all Tolkien Ward patients are now being seen daily, or almost daily by members of the nursing staff team for a period of interpersonal engagement, care plan review and care planning. Where this is not happening there are identifiable reasons why not, such as serious ‘engagement’ difficulties because of the nature of the patient’s mental health problem or because the patient has issues about being in hospital and/or resentment about being detained under a section of the Mental Health Act.
7.1.4.1.1 Audit results
On the day of the audit of those 18 patients not on leave:
9 | Patients had been seen either that day and/or the day before. |
6 | Patients, had gaps ranging from 2-6 days. |
1 | Patient had not been seen (or constructively engaged with) for 11 days |
1 | Patient had not been seen (or constructively engaged with) for 12 days |
1 | Patient had not been seen (or constructively engaged with) for 20 days. |
Two of these had returned from leave on the day of the audit (which was done in the morning) or the day before and one (not seen for 12 days) had serious engagement difficulties because of severe chronic mental health problems. The remaining three patients: with two week, three week and two week gaps respectfully were on leave.
It was not possible to determine from one patient’s documentation when the admission had taken place, as the information was not available. A home phone number was attached to the front sheet, but there were no other details
Overall, daily care plans, with a few exceptions, are now being done daily or almost daily with, on occasion, no more than two-three days gap appearing between plans.
Anecdotal testimony from nurses on Tolkien Ward suggests that patients are responding positively to these changes and value the increased nurse/patient contact, feel their needs are being ‘heard’ and acted upon and that their views are being more respected. Patients are thus more willing to co-operate with and value their care plan.
7.1.4.1.2 Quality of nurse-patient engagement
It is difficult to determine the quality of the patient/nurse engagement or improvements in meeting patients real needs from the paper documentation alone, although this documentation is an improvement on the system it has replaced because it makes clear what is not clear in the other system, namely, the frequency of nurse-patient engagement in a collaborative care planning process.
By their nature, the descriptive powers of nursing notes are very ‘thin’ and an entire one-to-one session with a patient may well be summarised by way of a few “bullet points” and not as a coherent case-history This, however, is entirely appropriate and recording one-to-one sessions in detail would not be practical within an acute in-patient setting. So, it is difficult to discern to what extent and depth Tidal principles of holistic, collaborative, empowering client-centred care have been understood by nurses working on the ward or penetrated into the ward culture as a whole.
With the above observations in mind, I now turn to some specific problem areas this audit has highlighted along with some recommendations on how these problems might be resolved.
7.1.4.1.3 Daily care plan implementation
Documentation indicates (even by its absence) as well as anecdotal evidence indicates from both nurses and patients that there remain difficulties with care plan implementation. Care plans are sometimes not completed or the nurse does not carry out his or her part of the agreed plan. This, understandably, creates tension and resentment on the part of patients, especially when they trust the nurse to ‘sort something out’ or to do something for them as part of an agreed care plan and nothing happens. This failure may be connected with staffing problems and, on occasion, lack of qualified OR regular staff that know the ward and patients well enough to do these tasks.
The solution to this problem is threefold:
Ø Staffing levels and skill mix need to be brought up to an adequate standard
Ø There should be proper delegation of work at the beginning of each shift and
Ø The primary or named nurse should be the person to both plan and carry out care with the help of the associate nurse or a care assistant by way of clear delegation of the tasks required
7.1.4.1.4 Cultural issues
One reason care plans do get followed through is that care plans have not been delegated properly to another nurse at the beginning of each shift or, if it has been delegated, it is not carried out. This appears not to be a problem of ‘lack of time’, but a problem within the ward and hospital nursing culture itself. Some nurses appear to resent being told what to do by other nurses and there is a lack of accountability and consequences for failure to carry through work, which has been delegated. Some nurses appear to be reluctant to take responsibility for their actions within the context of a staff team. Others clearly resent ‘the added work’ which client-centred care seems to ‘add’ to an already busy ward.
In addition to this, high levels of clinical activity on the ward, high staff turnover, lack of regular qualified staff and over dependency on the Nurse Bank and on Agency nurses (not trained in Tidal principles) continue to frustrate progress in implementation and place added pressure on the staff team. However, the staff seem to be rising to this challenge rather than getting discouraged and appear to be well motivated to get the Tidal Model to work
7.1.4.1.5 Identifying staff training/education deficits
Implementing the Tidal is revealing a serious lack of the most basic “interviewing/listening/counselling” skills within much of the nursing team, many of whom have little experience in engaging at depth with people in emotional or mental distress in a structured therapeutic way. This makes the undertaking of proper nursing holistic assessments as well as genuinely collaborative care planning difficult. The provision of regular, on-going courses in basic helping, interviewing, counselling, problem solving and listening skills are not considered to be a priority by the Trust as it is simply assumed that nursing staff working on acute wards already possess these skills, when, in fact, many do not.
7.1.4.1.6 Staffing levels and skill mix
On Tolkien Ward chronic staff shortages and/or inadequate ‘skill mix’ also continue to create serious logistic problems for ward management and to a large extent have been doing so for several years now. This includes areas of chronic staff sickness, staff suspensions, and a steady stream of newly qualified ,but relatively inexperienced staff nurses who tend to ‘move on’ after six months as well as over-reliance on Bank and Agency staff who know little or nothing about the Tidal Model or of the pilot project underway.
Despite this regular Tolkien staff that have undertaken Tidal Model training have been coping very well under difficult circumstances and have achieved a much higher standard of care nonetheless.
7.1.4.1.7 Initial 72-hour assessment and care plan
This is the ‘holding’ care plan we have designed on Tolkien Ward to bridge the period from admission until the holistic assessment has been completed. It is accepted that this ‘Initial 72 Hour Assessment and Care Plan (72CP)” will often be initially constructed on the basis of incomplete information and on first impressions of the patient. The 72CP has been designed so that an initial assessment can be undertaken non-collaboratively (if so required) to ensure a safe environment and other basic issues, especially for patients who are very emotionally or cognitively disturbed or who are hostile or uncooperative. But, ideally, it should be undertaken collaboratively with the patient on admission. It should be completed at the same time as the admission and seen as part of the admission procedure.
7.1.4.1.8 Audit results
Of 22 patients, 13 had a completed 72CP for the day of their admission, four patients had a completed 72CP within three days of their admission. Of the five who had no 72CP, clearly in three of these, the patient had been admitted elsewhere OR before the Tidal implementation. This left only two patients with no 72CP and with no reason being given or evident from the notes why not
7.1.4.2 Nursing holistic assessment
According to this audit only nine (out of 22 patients) on the day of the audit had received a Nursing Holistic Assessment, even though daily care plans were in operation for the remaining 13.
The question needs to be asked: “What is the basis of these care plans if no documented nursing assessment has taken place?”
Of the nine who had been assessed, the gap between the days of admission ranged from ‘the same day’ to three weeks, with an average of just over four and half days.
Of the 13 who did not have a Holistic Assessment, one long-term in-patient (with serious chronic mental health problems) was clearly not yet capable of usefully benefiting from a collaborative assessment. Yet, perhaps one could be undertaken with her mother and brother? A creative use of the Tidal tools should be considered in difficult cases. Of the 12 remaining, for two patients admission information was very ‘thin’ and incomplete (see below) and no admission date was given although many weeks had gone by. Of the 10 remaining, two had been admitted within the previous week. Of the eight remaining patients who had not received a Holistic Assessment, the admission dates are as follows:
Date of this audit: 14/1/03
10/12/02
29/12/02
12/10/02
31/12/02
24/12/02
18/12/02
28/10/02
18/12/02
7.1.4.3 Discussion and concluding remarks
In the light of this initial audit of Tidal Model implementation three observations are in order:
First of all, patients who may be highly distressed or mentally disturbed on admission, or initially hostile and uncooperative about being admitted against their will to hospital on a Section of the MHA, may be initially unwilling or unable to engage with a nurse sufficiently for a collaborative holistic interview to be done within the first three days following admission. Ideally, the holistic assessment should be undertaken within the first three days, or as soon as possible after that. On occasion this may take a number of weeks or longer.
Secondly, when engagement with the patient is proving to be very difficult so that both the holistic assessment and collaborative care planning are not taking place the three nursing goals
- To therapeutically engage with the patient, and
- To do holistic assessment
- To do the risk assessment (*)
should be the primary on-going nursing goals until such time as the holistic assessment has been completed. Only after a therapeutic alliance between nurse and patient has been established is it realistic and practical for genuinely collaborative care planning to begin.
(*) The new full Risk Assessment procedure and documentation is not yet in place on Tolkien Ward. It is anticipated that it will be within a few months time
It is understood that in rare circumstances genuinely collaborative care planning may never take place at any depth with some patients, especially in the case of inappropriate admissions where the person is not mentally ill. The attempt to make such an assessment, and the refusal of the patient to take it seriously, and other factors may help identify more quickly inappropriate admissions.
Failure to undertake a genuinely collaborative holistic assessment within the first three days of admission is therefore not a serious issue if good reasons can be given why, for this patient, an assessment of this type has not been possible or even desirable. Nevertheless, degrees of collaborative care planning can still take place.
On the other hand, with patient transfers to and from other wards it is sometimes possible to have a patient occupying a bed on the ward who is on permanent leave from another ward, a patient one has never met and for whom both the relevant notes and documentation are sometimes temporarily missing or very incomplete etc.
However, if the patient is known, and has been resident on the ward for many weeks, but is still refusing or ‘unable’ to engage, and a holistic assessment has still not been completed and there is no recurring daily care plan for a) engagement or b) to do the holistic assessment, a potentially dangerous situation is being generated which could erupt into a serious untoward incident.
This is especially the case if the patient is deluded, isolated, hostile and prone to violence or unpredictable behaviour. At the very least it should be documented, as part of the daily care plan that “patient is not engaging with the nurses” with a clear daily plan for that engagement to happen, as above.
Thirdly, there are several aspects of the Tidal Model we are not doing which we need to develop to a good standard over the next year. These include
- Weekly Group Work. The Tidal Model Manuel suggests three main types of Tidal focused groups, A Solutions Group, A Recovery Group, and An Information Group. These would be in addition to the present Patient Meeting Group
- Use of the patient security plan
- Use of the BSMHT Risk Assessment Tool
- Regular clinical supervision of all staff using TM
In conclusion, considering that we are in the early stages of Tidal Model implementation the results of this audit are very encouraging although, predictably, the implementation of the Tidal Modal has exposed a number of problems, which will need to be addressed as part of the implementation process.
- On the positive side:
Ø All ‘regular staff’ have undertaken a day’s training in the basic principles and practice of the Tidal Model
Ø Each new admission is, in principle, receiving a Nursing Holistic Assessment
Ø Daily care plans, with regular reviews, are being implemented for all patients
Ø New Documentation forms have been devised to facilitate accurate recording of the Tidal Nursing Process. These are under regular review
Ø A new admission front sheet and checklist has been designed so that all Tolkien Ward nursing documentation is now consistent in basic design and typographical appearance
Ø A ‘Tidal Nurse’ with a clear job description has been introduced to work on a 9-5 basis to help implement the process and to keep nursing care ‘focused’ and its documentation accurate and up to date. The Tidal Nurse is drawn from all existing regular staff, including A-Graders who work ‘on rotation’ to fulfil this role
Ø All 22 patients are now officially on the Tidal Model
Ø New nursing notes folders have been introduced
- On the negative side:
The introduction of the Tidal Model and this audit has highlighted various problem areas related to staffing levels, management issues as well as educational and training deficits within the staff team. For example, problems related to the old pre-Tidal Model nursing culture include:
Ø A nursing culture in which work does not tend to get properly delegated or, if delegated properly, it is not carried through
Ø The absence of any explanation or consequences for this
Ø The lack of regular opportunities for staff to meet together, to discuss staff team issues in an environment suitable for open and honest sharing of issues
Ø Handovers ‘between shifts’ on a busy ward do not normally provide this opportunity
Ø In addition to this, high numbers of agency staff, transient bank staff not trained to a ward’s therapeutic ethos and a high regular staff turnover are clearly detrimental to the delivery of any quality service
These are difficulties that, I hope, will be resolved over time, as there seems to be a positive attitude and a will to overcome these problems at both the clinical and management levels.
It is hoped that continued, effective implementation of the Tidal Model will help to both recruit and ‘keep’ a well-motivated, highly trained and good quality staff to work in this demanding specialist work within the acute in-patient facilities of the Birmingham and Solihull Mental Health NHS Trust.
7.2 Quantitative evidence
7.2.1 Untoward Incidents
7.2.1.1 The concept of milieu toxicity
The metaphor of relational toxicity, as described in section 2.2 can be used to describe those ways of relating which do not promote trust, mutual respect, openness, honesty and learning from experience, but are typified by defensiveness, manipulation, scapegoating, blame, insecurity, and resistance to change. Such relational contexts are, it has been suggested, non-therapeutic to the degree that they cause insecurity and anxiety, and put people at risk. Such environments cannot, when these features predominate, promote the recovery of clients or the personal growth and professional development of staff.
With these issues in mind it is essential to look at acute in-patient wards where care has become compromised or is under constant threat because of institutional and administrative practices that tend to disempower both patients and nursing staff and unnecessarily limit choice (See Barker and Davidson 1998). Of special concern are the rates of patient self-harm, patient’s absconding, ‘acting out’ behaviour and the need for physical restraint as well as other indicators of toxicity such as low staff morale, the number of staff suspensions, a high staff turnover, and a constant ‘crisis management’ style of operations on acute wards and within the hospital.
Therefore an analysis of untoward incidents was undertaken for the year prior to the introduction of the Tidal Model on Tolkien Ward and these compared with the untoward incidents for the year following Tidal Model implementation. It was also decided to determine how the number and nature of such incidents compared with those on the other three acute admission wards at the QEPH, Tennyson, Bronte and Owen Wards for the same two periods. Data for this purpose was obtained from the Trust’s Safecode database of untoward incidents.
7.2.1.2 Serious versus minor incidents on Tolkien Ward.
For the sake of this evaluation some untoward incidents reported on the IRIS forms have been deemed more significant than others as indicators of the relative ‘toxicity’ of the ward environment as defined above. On the whole, most serious incidents come under the category of Violence/Abuse/Harassment, but others, such as patient self-harm, reported physical restraint and absconding/AWOL come under the Clinical Incidents and Security Incident categories.
Categories such as staff ill health, fire incidents and personal incidents have been excluded. Clinical incidents such as minor medication errors (those with no adverse outcome) or things like “needle-stick injury” or “Box found in doctor’s office open” or administration errors like “papers not receipted on admission” have also been excluded from the more detailed Tolkien Ward evaluation. On more than one occasion an Incident Report has included two incidents i.e. Patient attempts to abscond AND is restrained. This has been taken into account.
The serious incident types for measuring the level of toxicity were considered to be the frequency and type reported
- Serious Clinical Incidents (such as patient self-harm or suicide)
- Serious Security Incidents (absconding/AWOL)
- Violence/Abuse/Harassment
For the purpose of the Tolkien Ward evaluation the following categories of untoward incidents have been used:
- Intended or actual self-harm
- Abscond/AWOL
- Physical Restraint
- Threat of physical violence
- Actual physical assault
· Sexual assault
- Verbal abuse
- Disorder/Intimidation
- Sexual harassment
- Racial harassment
- Other
7.2.1.3 Untoward incidents on all four QEPH acute admission wards
In the year prior to the launch of the Tidal Model (1st October 2001 – 30th September 2002), a total of 308 untoward incidents were reported to have taken place on Tolkien Ward. This compared with 258 on Owen Ward, 215 on Tennyson Ward and 180 on Bronte Ward.
Tolkien Ward therefore accounted for 32% of the 961 incidents that were recorded on the four QEPH acute admission wards, the highest percentage.
Of the 961 incidents across the four acute admission wards, 403 were categorised on the Safecode database as clinical incidents, 145 as security incidents and 413 as violence/abuse/harassment. Figure 1 below shows the number of incidents within each category that occurred on the four wards, and Table 7 shows the percentage of the total number of incidents within these categories that occurred on each of the four wards.
Figure 1: Number of incidents that were reported within each category on all QEPH acute admission wards, October 2001 – September 2002
Table 7: Percentage of untoward incidents occurring on each of the QEPH admission wards, October 2001 – September 2002
Category of incidents | Percentage (%) of the total number of incidents in each category | Total | |||
Tennyson | Bronte | Owen | Tolkien | ||
Clinical Incident | 29 | 15 | 28 | 28 | 100% |
Security Incident | 14 | 27 | 20 | 39 | 100% |
Violence/Abuse/Harassment | 19 | 19 | 28 | 34 | 100% |
In the twelve months following the introduction of the Tidal Model (1st October 2002-30th September 2003) the total number of untoward incidents reported for Tolkien Ward reduced from 308 to 140, a decrease of 55%.
This decrease in untoward incidents on Tolkien Ward, when compared with the rise in untoward incidents on both Tennyson and Bronte Wards (and a slight decrease on Owen Ward), is significant. Tolkien Ward, in the year 2002-2003 accounted for only 14% of the 990 untoward incidents reported across all the acute admission wards, now significantly the lowest percentage. This means Tolkien Ward, which had the highest number of untoward incidents in the hospital in the first year, had the lowest number in the second year.
When the two years (pre and post-Tidal Model implementation) are compared, this amounts to a decrease from 32% to 14% of the total number of untoward incidents reported on all acute wards. Table 8 below gives the figures for this and Figure 2 gives a bar graph representation. Figure 3 then gives a bar graph representation of the total number of incidents that were reported within each category of incident for all acute wards during that second year from October 2002 – September 2003.
Table 8: Number of untoward incidents recorded for each admission ward during the two time periods
Ward | Total Number of incidents | |
2001-2002 | 2002-2003 | |
Tennyson | 215 | 423 |
Bronte | 180 | 191 |
Owen | 258 | 236 |
Tolkien | 308 | 140 |
Total | 961 | 990 |
Figure 2: Number of untoward incidents recorded for each admission ward during the two time periods
Figure 3: Number of incidents that were reported within each category of incident for all the acute wards October 2002 – September 2003
Of the 990 incidents recorded for the year 1st October 2002 - 30th September 2003, 375 were categorised as clinical incidents, 269 as security incidents and 346 as violence/abuse/harassment. The percentage of incidents within these categories that occurred on each of the four wards is shown in Table 9.
Table 9: Percentage of untoward incidents occurring on each of the admission wards, October 2002 – September 2003
Category of incidents | Percentage (%) of the total number of incidents in each category | Total | |||
Tennyson | Bronte | Owen | Tolkien | ||
Clinical Incident | 56 | 9 | 20 | 15 | 100% |
Security Incident | 34 | 28 | 24 | 14 | 100% |
Violence/Abuse/Harassment | 35 | 23 | 28 | 14 | 100% |
7.2.1.4 Untoward incidents on Tolkien Ward
An essential aspect of this evaluation has been to look at Tolkien Ward not in comparison with the other acute wards at the QEPH, but in relation to itself prior to and following the introduction of the Tidal Model to see if there were any significant changes between the two periods. The data obtained from the Safecode database was therefore analysed in more detail to determine the exact nature of these incidents. For example, the ‘clinical incident’ category was subdivided into what was considered to be ‘serious’ in contrast with minor incidents. This allowed the incidents to be placed in more specific and meaningful categories (see Table 10, below).
It was found that some incidents were not relevant to the issue of ‘milieu toxicity’ as defined above and they have therefore been excluded. Thus, the total number of incidents for both years shown in Table 10 is lower than the totals given above.
Table 10: Number of incidents of each type before and after the introduction of the Tidal Model on Tolkien Ward
Nature of incident | Number of incidents | |
2001-2002 | 2002-2003 | |
Intended or actual self-harm | 31 | 14 |
Absconsion/AWOL | 58 | 26 |
Physical restraint | 13 | 7 |
Threat of physical violence | 25 | 12 |
Actual physical assault | 43 | 26 |
Sexual assault | 1 | 0 |
Verbal abuse | 28 | 8 |
Disorder/intimidation | 15 | 5 |
Sexual harassment | 1 | 2 |
Racial harassment | 2 | 1 |
Other | 23 | 2 |
Total | 240 | 103 |
As both Table 10 above and Figure 4 (following page) indicate, the numbers of incidents of all types were reduced dramatically following the introduction of the Tidal Model, with the exception of sexual harassment where the increase was minimal.
Figure 4: Comparison of the number of each type of incident on Tolkien Ward in the twelve months before and after the introduction of the Tidal Model.
7.2.2 Characteristics of Patients Admitted to Tolkien Ward
Data was then obtained from the Trust’s electronic patient information system (ePEX) in order to obtain an overview of the admissions, discharges and characteristics of patients admitted to Tolkien Ward before and after the implementation of the Tidal Model.
7.2.2.1 Number of Admissions
In the year prior to the introduction of the Tidal Model (1st October 2001 - 30th September 2002) there were a total of 308 admissions to Tolkien Ward, including transfers from other wards. This comprised 267 individual patients. As Table 11 below indicates, 27 patients were admitted twice during that period, four patients were admitted on three occasions and two patients were admitted four times. Patients who were admitted to Tolkien, transferred to another ward, and then subsequently transferred back to Tolkien are counted as a single admission.
The number of admissions to Tolkien Ward after the introduction of the Tidal Model (1st October 2002 - 30th September 2003) was slightly lower than during the previous year. The 277 admissions comprised 252 individual patients, of which 23 were admitted twice and one patient was admitted on three occasions.
Table 11: Number of admissions and repeated admissions to Tolkien Ward before and after the introduction of the Tidal Model
Number of Admissions | Number of Service Users | |
Oct 01 - Sept 02 | Oct 02 - Sept 03 | |
1 | 234 | 228 |
2 | 27 | 23 |
3 | 4 | 1 |
4 | 2 | 0 |
Total Number of Admissions | 308 | 277 |
The mean length of in-patient stay for patients admitted during the period 1st October 2001- 30th September 2002 was 33 days. This ranged from a single day to 482 days. Following the introduction of the Tidal Model the mean stay was 35 days. However the range was lower: from a single day to 314 days.
7.2.2.2 Source of Admissions
Table 12: Percentage of patients admitted to Tolkien Ward via different sources before and after the introduction of the Tidal Model
Source of Admission | Percentage (%) of Service Users | |
Oct 01 - Sept 02 | Oct 02 - Sept 03 | |
QEPH Ward Transfer | 23.7 | 28.2 |
Emergency Domiciliary Visit | 18.8 | 15.2 |
Emergency GP | 14.6 | 7.2 |
NHS Accident & Emergency Department | 9.0 | 15.6 |
Out Patients Clinic | 8.4 | 8.3 |
Police Station | 6.8 | 7.2 |
NHS General Hospital | 5.8 | 1.8 |
Emergency CPN | 3.6 | 5.4 |
Self-Referral | 2.9 | 2.9 |
Planned Admission | 2.6 | 1.1 |
Emergency Social Worker | 2.3 | 4.3 |
Court | 0.9 | 0 |
Usual Place of Residence | 0.4 | 0.7 |
Other NHS Psychiatric Hospital | 0.3 | 1.1 |
NHS Maternity Hospital | 0 | 0.4 |
Day Hospital | 0 | 0.4 |
Not Known (No Fixed Abode) | 0 | 0.4 |
Total | 100 | 100 |
7.2.2.3 Patient Age
The age ranges of patients admitted to Tolkien Ward during the time periods were very similar. In October 2001 – September 2002, the range was 16-67 years, and in October 2002 – September 2003 the range was 17-73 years. The mean age for both time periods was 39 years.
Table 13: Age of patients admitted to Tolkien Ward before and after the introduction of the Tidal Model
Age Group | Percentage (%) of Service Users | |
Oct 01 - Sept 02 | Oct 02 - Sept 03 | |
<18 | 1.1 | 0.4 |
18-24 | 15.7 | 14.3 |
25-34 | 24.3 | 24.6 |
35-44 | 26.2 | 27.0 |
45-54 | 18.7 | 21.4 |
55-64 | 12.0 | 9.9 |
65+ | 1.9 | 2.4 |
Total | 100 | 100 |
7.2.2.4 Medical diagnosis
Figures 5 and 6 following show the diagnoses for patients admitted to Tolkien Ward during the two time periods under study. There is no significant difference in the medical diagnosis of patients over the two year period indicating that changes in the number of untoward incidents was not related to any significant changes in the patient population in terms of diagnosis.
Figure 5: Medical diagnoses of patients admitted to Tolkien Ward prior to the introduction of the Tidal Model
Figure 6: Medical Diagnoses of patients admitted to Tolkien Ward following the introduction of the Tidal Model
7.2.2.5 Patient Ethnicity
Table 14: Ethnic groups of patients admitted to Tolkien Ward
Ethnic Group | Percentage (%) of Service Users | |
Oct 01 - Sept 02 | Oct 02 - Sept 03 | |
Asian/Asian British Bangladeshi | 5.5 | 1.4 |
Asian/Asian British Indian | 0.7 | 2.4 |
Asian/Asian British Pakistani | 0.7 | 2.4 |
Asian British Other | 0.4 | 0 |
Black/Black British African | ||