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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
13 Comments
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i am a cpn. i am ashamed to say i see my job to protect my people from an inpatient stay in our local psychiatric hospital. i am struggling just now personally cos i needed to request support very reluctantly from my inpatient facility for a very ill young woman with eating disorder of binging purging type, having visited her on a daily basis for three weeks. her illness unfortunately progressed last week to delusional and paranoid. she is voluntary, but i am shocked and ashamed at the lack of therapeutic care she is getting. I would have hoped for regular one to ones, her and me being well informed and not to hear her say she continues to binge purge, self harm. what in gods name has happened to us as a profession when the charge nurse when challenged complained about the lack of staff. thought we had a duty of care regardless of management inadequacies...thank you for this forum cos i feel distressed and angry and impotent here in this situation.
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Too often we all complain to each other - we know what it's like, but feel powerless to change things. We don't want to complain or create a fuss, worrying about how that will be viewed afterwards.
One site I've found useful has been http://www.patientopinion.org.uk It's run by an independent social enterprise. All feedback (about the good and the bad) goes, anonymously, behind the scenes directly to the people who can take actions to improve the situation. Some posts have responses from the Trusts. Friends and staff can post as well as people who use services. All mental health trusts are signed up to using it - it would be great to see more postings.
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Hi,
I'm in Australia and as someone who's been in a psych ward a number of times, the situation is as dire over here too.
The last time in, as unwell as I was, it hurt so much to have to try to keep reminding the three different 8 hr shift nurses basic life preserving requirements that I needed - every day for four weeks.
It was so torturous to deal with my extreme illness and communicate my needs to staff that each seemed to be more interested in looking 'cool' and bouncing a tennis ball up an down as I tried to find the right words to ask for a critical blood sugar test. After two weeks, I was finally able to tell them that I hadn't eaten for nearly a month and that I hadn't taken my meds for over a month.
I also get very angry when young nurses straight out of college tell people what to do in terms of their illness - I'm sorry, but what real life experience do these young kids have to be in such responsibility for say a 50 year old man with a history of abuse? It's not right.
To any MH staff reading this, please can you tell the people who run the system to help change it? You think it's working from your point of view, but that is the problem. Everything in the system is run from 'your point of view'. Thankyou.
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Great post Z, especially the anecdote at the end, that really made me smile. And Karen many thanks for that link. Of course we who know what it's like are scared to complain - mud sticks and in the MH system it's like being branded on your forehead for life.
My last inpatient stay I was unfortunately overheard quietly comforting another inmate in the corridor who was upset that on that particular shift there seemed to be lots of male staff around and she hadn't seen any women. All I did was try to reassure her that there were a couple of female nurses around and if she asked she could probably see one of them. I thought that was the end of the matter until a week after my discharge when my CPN said to me "I didn't realise you have a problem with male staff, why didn't you tell me?" and went on to explain to my complete surprise that it was in my notes that I had kicked off demanding to see female nurses and generally being Patient From Hell and uber-uncooperative with all the male staff. Ever since then, every single mental health professional I've seen has made comments on the fact that I "get distressed" around male staff and it's regularly - often contemptually - pointed out to me that demanding to see certain people or being Difficult In General won't do me any favours. I've tried and tried to explain to any number of people 'til I'm blue in the face but like I said mud sticks and I'll probably have this following me around for life.
So with an innocent "there there" in the corridor making me patient from hell, is it any wonder I dare not complain when stuff really does go wrong? We rely on the staff to treat us with respect - it's not as if I want people to be superhuman, just to do their job, that's all.
If I've said it once I've said it a hundred times: I'm deaf to protests of lack of training, funding, resources, staffing and all the rest of the excuses that get bleated at us whenever we wonder why the MH ward is such a dire place to be - it doesn't take training or money to just treat people like human beings. -
I work at SLAM not on ward but go into wards as a therapist and find the the ward very difficult place to be on. Wards run a on they own systems and if you don't fit into them then you don't get seen or helped.
I find the whole environment unrelaxing, unwelcoming and generally not a very nice place to be on and I'm a member of staff i can't begin to think what it's life is like for patients.
I think it may be the number of bank patients on the ward to make up number. If a football manager, the Local PM or local council wasn;t providing the service promised then we say something or the person ends up getting sacked. What I can understand from the NHS is that we employ poor staff who struggle to speck english or communicate with staff. I often have telephone conversations with staff from wards who I can;t understand or they understand me so how are patients meant to cope.
I recommended get good quality staff who are checked and checked again re the quality of care by management.
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Great post. A friend of mine suggested I take a look.
I posted about my experiences in a psychiatric hospital on my site: http://www.mindparts.org/2010/04/grouphealing.html
My experience has been that at the hospital I goto, that the staff is quite engaged with the patients. It's a trauma and dissociative disorders speciality unit, so there is general agreement that trauma survivors do well with caring staff.
However, I suggest that also the dynamics on any ward, whether it be a psych hospital or general hospital, can change depending on the population. My experience is that in a general hospital, there is such a broad range of mental illness that the environment can feel toxic. Also, I have been on the trauma specialty ward when there has been one or two patients who drastically change the dynamics too.
Thank you for the post. I'll be sure to check out your site now that I know about it!
Paul
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Thanks so much for a fascinating and enjoyable post, Zarathustra. As a fan of your blogs and therefore your approach as well as your writing, I'd love to be a patient on your ward - at least on your shifts! To digress slightly, I've just done a stand-up comedy course and most of the others are now busy gigging. One realisation is that the same venue is a very different experience from one week to the next, depending mainly on the (sobriety levels of the) audience but also due to running order etc.
Part of the conundrum of raising ward standards to those of the best are that patients need staff to be as human, normal and themselves as possible. This in itself creates instant variations. There can be systems or attempts to constrain disparities, notably through policies, imposed standards etc. But these tend to have the effect of paralysing staff confidence in their ability and at best confuse the extent to which they are ‘allowed’ to use their initiative and individuality.
From Star Wards’ experience, the most important factors in creating and sustaining great wards are staff motivation and morale. Consideration of policies, structures, standards, edicts, working conditions and, crucially, staff support should always include the simple question of whether they will make staff feel better or worse about themselves and their work. Henry Stewart of Happy Ltd wrote a fascinating piece about making mental health wards great places to work – http://tinyurl.com/starwardsoriginal
Cheers
marion
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Very interesting read, thanks all.
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I do feel sorry for nurses who are constrained by their working conditions and prevailing models that many are just wasted by the services they work within. However Marion, when I come across one of the many wonderful wards you want to be on I'll let you know.
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I've been on two wards in two different towns in the last two years.
The first had a small army of personable and approachable staff, who didn't cram into the tiny staff offices but instead roamed the corridors, arranging a host of activities. They would bring in a guitar and sit and strum, or start a knitting circle, or just make a tea and chat with us patients. I improved a great deal within a week, and can still remember certain staff interactions two years on.
My last stay on a ward up north was one where there was never a nurse or assistant to talk, frequently staff sat in the large set of offices, being aggressive and rude when approached by patients. It took me much longer to recover to a point where I was discharged.
It seems kindness is not something that can put in a job description, which is a shame.
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Hi Marion
Thanks for your thoughts on what makes for a good ward. I've heard a lot of good things about the Star Wards initiative, though sadly I've yet to see it in action round our way.
I like your comment about how "patients need staff to be as human, normal and themselves as possible." Every good RMN (or HCA in a mental health setting) I've ever worked with has exemplified those qualities.
I'm afraid you won't be able to be a patient on my ward, though, as I've recently moved to a CPN post.
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people can have all the qualifications in the world,but you cannot teach compassion.
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i couldn't agree more with what you say about compassion, carol. how do you foster it? one thing for certain, you cannot be compassionate if you are not prepared to talk to in-patients. on the acute ward i experienced recently, the nurses were talking allright but only to each other or their mobile phones. depressing.
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