Changing cultures on psychiatric wards
Posted Monday 26 April 2010
A post on the excellent Wife of a Schizophrenic blog describes two psychiatric wards with wildly varying attitudes from the nursing staff:
Things were so different in the psychiatric hospital than they were in the psychiatric ward in the general hospital. It was like stepping into another world. On the psychiatric ward where Mr Man had been for his first 3 weeks, the staff mixed freely with the patients. They chatted, they drank coffee together, they went for walks in the grounds, and they played board games.
In the psychiatric hospital the staff always seemed to be cooped up in the staff room, engrossed in conversation with other staff members, and not in any mood to be disturbed. Don’t be mistaken; I don’t mean that they were busier, or that they took their role more seriously, far from it. They were engrossed in conversation about their own concerns - laughing, joking, and playing computer games. Whether you were a patient or a visitor, you were met at the staff room door with the same level of contempt.
Two wards, both staffed by the same mix of mental health nurses and healthcare assistants. One with a good culture of nurses engaging with patients, and one with the staff all locked up in the office. I've worked on wards that resembled the former, and others that were more like the latter. Why do some wards get it right where others don't, and how does one change a bad ward culture into a good one?
As for the first question, it isn't a matter of training. Yes, yes, we've all seen those Daily Mail editorials about how nurse training has been taken over by politically-correct sociology-babble, churning out nurses who are too clever to care, too posh to wash (What's the psych equivalent?
Too posh to play pool?) and so forth.
But the nurses on the "good" ward in the above quote had undergone the exact same training as those on the "bad" one. Besides, when I was a student nurse my nursing lecturers repeatedly exhorted us to engage with our patients, work to build therapeutic relationships, and so on. It was certainly made clear to us that we shouldn't be hiding in the office avoiding our patients.
Some have suggested that the problem is that too much of nurses' time is taken up with paperwork and "firefighting". There's a degree of validity to this. It's certainly true that nurses, along with so many other public services (see also the police, social work, teaching etc) have become bureaucratised and forced to spend more time form-filling and less time doing their jobs.
It's also true that on a hectic acute ward nurses' time can inevitably be distracted into dealing with the more challenging patients at the expense of everyone else. Even so, I can't help notice that those nurses who claim most forcefully that this is the problem often seem to be the ones who've just spent the past ten minutes sat in the office discussing the esoteric mysteries of The X Factor. Besides, even if the staff nurses have a mound of paperwork to complete, there's no reason for the HCAs (Health Care Assistants) to be sat with them.
Quality of leadership comes into it. The personality of the ward manager can have a big effect. So too can whichever staff nurse happens to be coordinating the shift at that particular time. Good ward leadership involves leading by example, showing that you value engaging with patients and expect others to the same. It also involves occasionally being willing to crack the whip and start shooing staff out of the office.
The calibre of healthcare assistants matters a great deal too, as they're usually the people who have the most contact with patients. Attitude can often be far more valuable than experience. A HCA who's young, inexperienced but keen as mustard is much better than one who's been there for 20 years and stopped giving a toss 10 years ago.
Physical design of the ward can have a surprisingly high influence. If the ward office is large and comfortable then nurses have a tendency to gravitate towards it. If it's small and cramped then they're more likely to be on the ward floor with the patients. I once knew a ward manager who was closely involved in the design of a new psychiatric unit. He went to great lengths to ensure the office was as nasty, uncomfortable and impractical as possible. If he could have put razor blades on the seats, he would have done so.
As for the second question, can ward cultures be changed? Certainly attempts have been made to do so. Perhaps the most well-known of these is the Star Wards initiative, which focuses on staff-patient interaction, promoting therapeutic activities and combating boredom. There's also the Productive Ward scheme, which aims to improve efficiency on wards to release time for direct patient care.
Others have called for a radical change in the ethos of mental health nursing. Phil Barker's Tidal Model claims to provide "a philosophical approach to the discovery of mental health" enabling people to "reclaim the personal story of mental distress, by recovering their voice". Some of my colleagues regard it as a sincere attempt to base mental health nursing on humanistic principles. Others dismiss it as "beardy-weirdy, New Age hippy bollocks". Feel free to make your own decision.
As for myself, a while back I was coordinating the shift on a ward, and I discovered an anorexic patient, supposedly on 15 minute observations, who had spent the past half hour surreptitiously exercising in the toilets.
Meanwhile the bulk of the staff had been sat gossipping in the office. I considered the lessons from Productive Ward, weighed up the philosophical values of the Tidal Model, thought back to my university lectures on the Force Field model of change management...then stomped into the office and threw a massive tantrum in front of the entire team.
Two minutes later, the office was empty and all the staff were on the ward floor, looking slightly afraid.
Crude, but it worked. Maybe I should market it.
Zarathustra, from Mental Nurse
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