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