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:

 

 

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:

 

  1. The relational dynamics of ‘adult’ survivors of childhood sexual and physical abuse
  2. The nature of custodial in-patient care on acute wards
  3. 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

 

  1. That decisions about research methods are ever purely objective (in the way usually claimed) or
  2. Are ever informed exclusively by the pristine or ‘scientific’ nature of the research question itself or
  3. 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):

 

 

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:

 

  1. 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.
  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 discerned 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 has been identified and examined.
  6. The Tidal Model has been implemented on Tolkien Ward in an attempt to address some of the problems and difficulties that have been identified.
  7. 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.
  8. 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:

 

 

The quantitative methods used by this study have included:

 

 

3.3 Five questions which have needed an answer

 

This two-year study has sought to answer five basic questions:

 

  1. 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?
  2. How can the services that nurses provide to patients and their carers within the acute in-patient setting be substantially improved?
  3. What kinds of nursing-practices generate a therapeutic (or healthy) as opposed to an anti-therapeutic (or toxic) ward environment?
  4. 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?
  5. 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:

 

  1. Undertaking the literature review (Chapter Two)
  2. 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)
  3. Introducing a new therapeutic nursing model called the Tidal Model on Tolkien Ward (Chapters Five & Six)
  4. Assessing and evaluating the implementation of the Tidal Model on Tolkien Ward (Chapters Seven & Eight)
  5. 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
  6. 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