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Transcript of Star Wards Oct 2010 Newsletter
8/8/2019 Star Wards Oct 2010 Newsletter
http://slidepdf.com/reader/full/star-wards-oct-2010-newsletter 1/30
Let’s say June 2010(although technically October) (Definitely) Issue #54
Hello and welcome towhat, after a long period
of newsletter drought,
is an ocean of fabulous
accounts of outstanding
inpatient care. More ofa magazine than a
newsletter. Huge thanks
to all of ourcontributors for
generously sharing their
stories of
breakthroughs, joys,frustrations and
challenges. And many
thanks to all of you for
your patience (again!)
with the long gap innewsletters. I‟ve been
immersed, occasionally
submerged, in lots ofreally exciting Star
Wards‟ developments, in
particular a secondedition of TalkWell.
I hope you‟re enjoying
the summery days, and
look forward to hearingabout, and publicly
celebrating some of the
amazing opportunities you‟re providing for
patients.
Love
and
New resources available from our website www.starwards.org.uk
Report on our Stupidly Big Members‟
Survey (written by eminent inpatientacademic Prof Alan Simpson of City
University) and Star Wards‟ Impact Review
(written by usually imminent inpatient, me)
Using TV for TalkWell training
Some great videos on our Star Wards
channel(www.youtube.com/starwardschannel)
and because Buddy is a gadget freak, we‟ve
now got….iPhone apps!! Yup, downloadable
free from the iTunes store. You no longerneed to be more than a few taps of thefinger away from Star Wards 2 andTalkWell (er, if you‟ve got an iPhone). Cool!
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WELCOME BAGS
The idea for theWelcome Bags came
about from the
information we receivedfor the Star Wards
Festival Celebration
Bags which we activelytook part in. A group
was formed whereby the
Festival Bags were madeby service users from
the East and West
Willows wards and weresent away to London.
During the festival bag
activity group one of ourpatients asked if they
could make their own
bags to give to newpatients on their ward
to help them feel more
welcome and dispel theirown fears about being ill
and away from home.
The idea for „WelcomeBags‟ was adopted. It
was suggested that we
could scale down theoriginal festival bag.
Inside the bag would be
placed a writteninformation leaflet
about the ward, a kind
word greeting card, atimetable for on/off
ward activities. Some
patients would also putin a small sachet of hand
cream, shampoo and hair
conditioner, etc, thusmaking the bag a more
personal item. The idea
for the „Welcome Bags‟
were created.
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These bags are given to
new patients from
existing patientsforming a patient‟s
mutual support system.This has helped with thewell-being of patients
who have been attending
the welcome bag activitygroup. From the
feedback that has beenreceived they feel they
are contributing not only
to their own well-beingbut are showing the new
patient that they care.
Many new ideas continue
to pour in from patients
as to what could be put
into the bags. Importanttelephone numbers, i.e.
PALS, Carers SupportGroups, and appointmentcards.
Since starting thiswelcome bag activity
group we have hadpatients approach us
who have received a
welcome bag and haverequested to participate
in creating their own
bag to give to someone
else who has just
arrived on the ward.
During one of our groupsone of our patients had
finished their bag andwas so happy and proudof her achievement that
it was suggested she
keep the bag forherself. “No she
replied, I‟ve made this
for someone else to help
them feel better”.
The message we are
simply saying from these
bags is WELCOME!
TalkWell Wristbands
Exciting developmentsat Highgate Mental
Health Unit havefeatured in Star Wards‟
newsletters since our
earliest days, thanks totheir dynamic andenergetic modern
matron, Jo Spencer.
(Their leadership teamis also blessed with the
amazing John Hanna,
psychologist and national
advocate for psychology,
and the fab GeoffBrennan – nurse
specialist, author,humourist…) Their
latest innovation iswonderful!! They‟ve
produced glamwristbands for staff
who have completed theTalkWell training – which they have
designed and areimplementing. Here‟s a
pic of Buddy modelling
the wristbands which
will surely be auctionedfor vast amounts on
ebay in years to come.(The wristbands, not the
photo.)
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Lagan Valley Hospital, County Antrim
By Angela Mc Shane
In November 1979 when
I started my career inMental Health Nursing,
patient activity was
integral to the care
offered to all inpatients.Social, recreational and
occupational therapies
were very much a
structured part of thepatient‟s day. Indeed,
my then older colleaguesregaled us „young‟ nurses
with stories of patients
farming, gardening and
cooking as part of theirdaily routine. The
patient‟s day was
structured with these
simple activities whichprovided a temporary
escape from the outside
hustle and bustle and
were also used as amethod of developing
new coping and problemsolving skills.
The introduction of
„New Thinking‟ that
these tasks demeaned
patients and indeed
exploited their
vulnerability led to thedemise of all activities.
Now with another new
set of themes
developing for recoverymodels of care it is
deemed that activitiesare a valid method of
aiding recovery.
In 2006 Marion Janner
set up Star Wardsfollowing her own time
spent in St Ann‟s
Hospital in North
London as a detainedpatient, on a locked
ward and under Special
Observations. While she
experienced a very
healing and beneficialtime she found that
unfortunately while
talking to other
patients, they had notgained the same
experience due to the
numerous pressures
that staff and patients
are under, inpatientstays tend to be
characterised by an
absence of therapeutic,
or even recreationalengagement.
ThankstoWo
ttonLawnHospitalforphoto
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Marion, along with the charity Bright, is working with partner organisations to help
animate acute wards, and its Star Wards project has collected a range of practical
ideas for substantially improving inpatient‟ daily experiences. Their vision is of acute
wards were;
* Talking therapies play as substantial a role as medication.* Patients are supported in enhancing their management of their symptoms and
treatment.
* There is a strong culture of patient mutual support, with the potential for thisextending once they leave hospital.
* A full programme of daily activities doesn‟t just eliminate boredom but actively
contributed to accelerating patients' recovery.
* Patients retain and build on their community ties.
Star Wards set out not with a list of what is wrong, but of 75 things that are rightand could very simply improve the quality of life in mental health units.
In February 2010 I commenced the post of Activities Coordinator. For me there was a
familiarity in promoting this new venture as a lot of it appeared to be based on my
experiences within nursing many years ago where the focus was based on differenttherapies being available for all inpatients. Star Wards was the main focus and
research tool on which my new working role is based. Following time researching theinternet on activities I made contact with George Nish (Charge Nurse) in Ayr inScotland who was very helpful and informative re setting up Star Wards in our
hospital. His guidance and support was very gratefully appreciated.
I began by looking at resources and activities available to the patients on our ward. As
the Occupational Department is located in a different building the patients had noaccess to board games, materials, books etc. I trawled charity shops, car boot sales
and asked family members and friends to kindly donate their unwanted items. As a
result the patients now have access to a wide and varied selection of games and bookson the ward at all times.
I don’t know if this is one of their new games, but
we highly recommend it as a perfect ward activity.
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A relaxation programme was also sourced and implemented on the ward.
I looked at devising a questionnaire to seek patient‟s opinions on activity provision on
the ward. I spoke with other staff members for their ideas on how to develop and
move forward with the activities programme. With their input and support, thequestionnaire was designed using broad headed themes suggesting various social,
recreational, therapeutic and educational activities with the additional option offurther suggestions to be added. I tested the questionnaire on a few patients who
were ready for discharge.
The questionnaire was administered and left available for all patients to complete on a
voluntary and anonymous basis. After a period of two weeks which I believe gavepatients time to complete and also to capture new patients coming into the ward I
analysed the data. It was established that patients were not satisfied with theactivity provision available to them while in hospital.
A questionnaire was also made available to all staff members. (why ask the staff?
Inclusiveness, support for the new programme, use of range of skills etc.) Again thiswas on a voluntary basis. This was to source interests and hobbies and to utilize skills
that are in addition to their nursing skills. Through this we discovered a wide variedrange of future activities that would become part of the weekly timetable. Interestsincluded aromatherapy, dance, keep fit, art and crafts, non baking groups, walking
groups, beauty classes, pampering and relaxation classes.
Most of the staff was enthuastic, keen and motivated and there was a new energy on
the ward. Some staff searched the internet to further develop the delivery of theirskills. I have met with some staff that has yet to fully embrace the concept of ward
based activities as a method of recovery. Hopefully through this programme they will
witness the benefits for themselves.
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Some of the staff
expressed concerns
regarding their own lack
of experience in takingdiscussion and
educational groups. Thisissue is being addressed
with further training in
group work beingprovided by Beeches
Management Centre.
My initial meetings withour OccupationalTherapist Anna were
very positive but therewere blurred boundary
lines evident. We looked
at Star Wards and thebenefits of, we also
looked at the results ofthe patients‟
questionnaire and
through this we
negotiated our workingroles. We discussed a
timetable that allowed
OT activities, nurse
activities and joint
activities to take place,
thus providing a morestructured, creative,
interactive and fun dayfor all the patients.
Through time we
furthered developed ourresources. The use of
the Day Hospitalfacilities were approved
by senior managementand made available to usfor use in the eveningsand at weekends. The
Recreational Hall wasalso secured and made
available for every
Saturday and also twoevenings per week. This
further developed ourrange of activities tonow include basketball,
indoor soccer,
badminton, table tennis,Wii and pool. Badminton
racquets, basketball,
indoor soccer ball and
table tennis bats were
purchased to facilitate
our new activities.
Further sportingactivities were also
made available through
Caroline Mc Grath andSports Development
which allows W12patients to participate
in variety of differentsports in therecreational hall for 2hours every week. To
date these includebocca, velcro archery,
curling and badminton.
In the coming weeks Ianticipate the
introduction of moresports.
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I also sourcedcommunity links. I
visited the Leisureplex
and found that patients
on request can have anindividual exercise plan
devised with one oftheir trainers. Our main
community link has been
with Atlas (AdultLearning & Support in
Lisburn).
They are a communitygroup who deliver a widerange of courses. They
are funded by the
Lottery, International
Fund for Ireland andChildren in Need. They
have been an invaluable
source providing tutors
twice a week foreducational and
therapeutic activities.
They have provided us
with their programme ofsummer sample sessions
and we have chosen
activities for patients to
attend.
The benefits of all
these activities havebeen enormous for
patients and staff alike.
New patients to ourward believe these
activities alwayshappened. With re-admitted patients there
has been a mix ofresponses. Some thinkthese changes are for
the better while a smallproportion of patients just want to do what
they always did onprevious admissions, i.e.
lie in bed.
Staff have alsobenefited from the
activities programme.
They have improved
their skills and theirconfidence is growing in
the running of mostactivities.
At the outset thisseemed an
enormous task andI felt like I was
standing at thefoot of MountEverest. Like any
expedition it took
determination, teamwork and support to
start climbing the
mountain. Ruth my wardmanager provided a lot
of the support in termsof helping and guidingme and in also directing
and encouraging the
nursing team to getinvolved.
While this project
is still very much
under development
I believe it has all
been worthwhile.
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Staff have also benefited fromthe activities programme. Theyhave improved their skills andtheir confidence is growing in
the running of most activities
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Buddy and I have just got back from a fascinating visit to Lagan Valley and also Downpatrick and Ulster hospitals. It was very much as Angela describes in her
fabulous article above. They have made fantastic progress in a remarkably short space
of time, very much thanks to Angela and colleagues ‟ impr essive energy, tenacity and
creativity.
One of the most striking aspects of the visit was the palpably strong relationship between patients, as well as with staff. I have to confess to some bias where Irish
people are concerned. I think that along with Cubans and Costa Ricans they are the
warmest, friendliest people on the planet. But even taking both this national quality and my unswerving adoration into account, it was evident from where patients were
sitting, how they were engaging with each other and the tone, content and generosity of their conversations, that the wards are very nurturing, healing environments. They
are certainly blessed with some visually highly attractive design features (I ‟m a sucker for curved walls), but the wards also present some challenges as some of them are a bit sprawling and must be difficult for staff to be able to „oversee‟.
They have a dazzling timetable of events, and the input of OTs is key to this. To take just one example of the thoughtfulness that goes into planning patients ‟ activities, I
learnt a lot from visiting an art room where dramatic, ambitious mosaics are made. The
young and dynamic OT described to me that mosaics are a great group activity,absorbing and satisfying whatever level of concentration or artistic ability the person
has and the results are not just stunningly beautiful, but visibly so as the large panels are proudly displayed on the hospital walls.
I was also very fortunate in spending lots of time with the service improvement manager, Pat McGreevy who organised the visit. Pat
was incredibly patient with my zillions of very „basic‟ (i.e. at best
dense at worst crass) questions about how The Troubles and the relatively recent outbreak of peace have impacted on people ‟s
mental health and on services. It also turns out that Pat has specialised in research into suicide, including traveling to America
to learn from trail-blazing services there. It was very heartening to hear about how
his expertise has translated into service improvements.
Many thanks to Angela, Pat, colleagues and patients for letting Buddy and I visit and
learn so much about the great work that ‟s happening in County Down.
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Ablett Unit, Rhyl
I‟ve begun enthusing via blog about the
incredible Ablett Unit in Rhyl: http://starwards.org.uk/newsletters/18
2-ablett-unit-wins-full-monty. Ablett achieved the Full Monty Award for
having all 75 ideas in place, but amazing patient opportunities go way beyond the 75 ideas. Information from Ablett is on
p.10, but below are some of the highlights for me.
T here‟s a strongteam of
volunteers, calledRobins and
inspiredly, theywear bright redpolo shirts. This
not only makesthem readily
identifiable asvolunteers, but
I‟d imagine is also
great for thevolunteers‟ sense
of positiveidentity and
groupness.Visitors for the
visitor less is apotential role forthe Robins.
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Loads ofcommunity groups
come into the unit
as guest speakers
Computers andthe internet are
available via ColegHarlech who
provide taster
sessions withinthe unit
The unit has hadan artist in
residence and aceramics projectthrough thefabulous Museums
for Mental Health
All wards have
exercise bikes
and wii consoles.
One to one
trackers aredevised eachmorning and put
on display so that
patients are
aware of who willbe providing them
with individual
time that day.
The family andcarer liaison
workers arebased in the in
patient unit and
they providesupport for family
members andcarers whilst
their loved onereceives a servicefrom the acutesetting.
The pharmacistholds group and
individual sessions
for patients andis available for
family/carerdiscussions.
Occupational
therapy facilitate
exercise sessions,
Tai Chi, Yoga, in-door bowls, belly
dancing and
outside activities
in the summer. OT also regularly
organise unitevents eg Well
Being Wednesday
which celebratedWorld Mental
Health Day, andalso a unit stress-
down day The unit has a
large and lovelyfamily visitors
room Serviceusers and staff
have donated
various toys andbooks including a
TV and Videoplayer.
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Buddy and I visited recently to meet the
fantastic staff team
and present them with
their award. It was fascinating and inspiring
to see the quality of the service, the staff
morale and the
relationship between staff and patients. A big
bonus of visit was seeing the gorgeous Pets as
Therapy dog Twix in
action. Twix‟s r epertoire includes twirling on her
back legs, putting her
paw over her face in
mock guilt, and jumping through her human
Sally‟s arms,(they were
linked like a hoop, it
wasn‟t some paranormal
experience). One of the patients in the room was
very withdrawn, silent and apparently
unresponsive. Very
movingly, Twix repeatedly and
unsolicitedly returned
the toy to her and the
patient did indeed respond. Buddy was well
impressed with Twix and this had the unexpected
and hilarious effect of
Buddy getting a bit too up close and personal
with the bewildered talent artiste.
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Information from the Ablett Unit
Changing Rooms!
As part of Star Wardswe looked at the use of
rooms within the AblettUnit. With thedevelopment of the
patients coffee bar it
was highlighted thatpatients who had visits
from children where
unable to access the
coffee bar due to its
location.
The OT activity
room and
thechildren‟s
room was
swoppedmaking the activity room
more accessible to allpatients.Patients were actively
involved in the processand in doing so feel theyhave more of an onus on
both rooms. The activityroom has been paintedand patients have
started to undertake
art work to be put onthe walls. The new
activity room has
become a relaxedenvironment with a
dedicated resource area
with patient informationand resources.
which includes mind, journeys, healthylifestyle and community
resources information.The room also has adedicated multi faith
area which is work inprogress.
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The Feelings Tree
Healthcare support
worker LouiseWilliams has green
fingers not because
she likes gardeningbut due to the
painting of a feelings
tree. The tree isenthusiastically used
by patients to addtheir feelings on leafshape paper with the
aim of the leaf moving
up the tree as the
person gets better. It ishoped that newly
admitted patients can
see from other patient‟s
comments higher up the
tree that there is light
at the end of the tunnel!The tree was painted by
patients and staff ofDinas female ward.
Bett’s coffee Bar
Bett‟s Bar was initially
opened as a place where
patients could take their
visitors for a chat and acuppa. Now most
patients are encouraged
to visit, it provides achange of scenery from
the ward and anopportunity to socialise
with other patients andstaff in a different
environment. In the
future we are going tobe giving patients a
chance to „run‟ Betts
Bar, by serving drinksand snacks which will
hopefully give a sense ofpride and help in some
way to prepare thosewho are intend on
returning to or starting
work when they leave us.There is a donation only
scheme with suggested
donation ideas, eg. Tea20p.
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Enhancing the therapeutic environment of Ashby Ward
Jo Lock (Staff Nurse, Ashby Ward)
The environment of an acute inpatient setting can be typically described as chaotic,
busy and at worst, untherapeutic. It is no surprise that sometimes patients find their
stays on acute wards fraught, stressful and quite frankly an experience they want to
put behind them! Boredom and lack of therapeutic activity has long been recognised as a „side effect‟ of hospital admission and something that patients frequently
complain about. One patient recently stated on a feedback questionnaire: “The
psychological elements aren‟t us ually treated on these wards – it‟s a matter of dosing
them up and sending them out” and “Some sort of weekly psychology session could have
helped me while I was ill to help me recover more quickly and reduce my time in
hospital.”
These issues haverecently been addressed
at a national level and a
number of publicationsand initiatives have been
put into place toincrease the positivepractice in inpatient
settings. Schemes suchas Star Wards,
Releasing Time to Careand „Improving the
Inpatient Therapeutic
Experience‟, highlightthe need for protected
engagement time withinpatients andpsychological
interventions to be morereadily available. With
the influence andbacking from important
initiatives such as these,
the role of the„Therapeutic Liaison
Worker‟ (TLW) has been
borne and created onAshby Ward at the
Bradgate Mental HealthUnit in Leicester.
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Nic Higham, who was
previously a Healthcare
Support Worker
(HCSW) for about 6 years, recognised the
need for such a role onthe acute wards to help
create, enhance and
promote a therapeuticenvironment and to also
seek to embed thisethos on the ward
environment. “It makessense to me for us to beoffering service users amore complete and
holistic package of carewhilst in hospital which
meets their diverse
needs,” says Nic, “The
interventions which can
go into this packageseem to be making aconsiderable and
positive difference to
individuals who findthemselves on these
wards.” Nic is a well
established HCSW onAshby Ward and over
the last few years has
obtained qualifications
in various therapies
including Person-centredPsychotherapy and Life
Coaching.
Nic sees the role of the
TLW as a facilitator in
motivating andencouraging patients to
engage in constructive
and purposeful dailyactivities whilst on the
ward, supporting
patients with exploringways of coping and
recovering whilst
promoting autonomy and
independence. Working
alongside the team on
Ashby Ward, Nic has
created and devised afull programme of
therapeutic activitiesand groups on the ward,
all of which are
purposeful, providestructure, aim to
counteract boredom andfrustration and increase
motivation. Most of theinterventions are gearedaround psycho-educationand psychological
wellbeing, specifically,groups such as and the
„Stress Less‟ Anxiety
Management group andthe „Stop and Think!‟
problem solving group.Patients from the otherwards in the unit are
also able to attend the
Stop and Think! group,and Nic liaises with
these wards regularly.
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It is felt that the TLW
role improves
communication with
other wards, teams andservices, which again
reinforces a morecomprehensive package
of care. As part of the
TLW role, Nic is a linkto other services, one of
these is the pharmacydepartment who are now
running a weeklymedication educationgroup. From feedbackfrom service-users,
medication informationis a very valuable
intervention and
evidence has shown thatmedication knowledge
aids compliance. Thepharmacists whofacilitate the group are
very much in support of
TLW role and depend on
it to help them organise
this intervention.
Nic has also formed a
self-help library whichpatients can access,
which includes the
widely recommendedMIND publications andthe CBT-based
“Overcoming” series of
self-help books. Patients
are given the
opportunity to learnmore about their mental
health conditions andproblems and discover
ways to alleviate them.
In a feedbackquestionnaire a patient
expressed,” I want to
understand the reasons
I‟m in hospital – not justthe diagnosis they thinkI have.” Additional time
is now provided for
patients to discuss theirillnesses and symptoms
with other patients and
allocated members ofstaff.
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The „Therapeutic Liaison
Worker‟ role also
includes liaising with the
nursing team and
bringing together a core
of staff that co-facilitate the ward-
based groups. This hastaken careful planning,
hard work and
dedication, but beingable to see that patients
are clearly benefiting
from the increasedinput is a reward in
itself. Nic insists that,
“Whilst this initiative is
backed by nationwidemental health service
improvement schemes, ithas been the
commitment and the
fresh thinking of theAshby Ward staff that
has been the catalyst
which is graduallychanging the ward
culture in a positive way.
For years I have heard
service users asking forward-based therapeutic
groups and psychologicalsupport, and it‟s very
refreshing to now see
these requests beingput into action.”
These new
enhancements empowerboth the service users
and staff. The ward
team as a whole havevery much embraced
these changes which are
making the ward a more
healing and therapeutic
place to recover. TheTLW role has ignited an
interest in therapeutic
activity from otherstaff and potentially
contributes towards
their professional
development. Having amember of staff on the
ward who has a
protected role tocoordinate and facilitate
these therapeutic
activities is crucial if we
are to work towards
cutting down boredomand aggression levels on
the wards. Also,
reducing readmissionand relapse is something
we as a team are always
very mindful of. In a
recent communitymeeting one patient
suggested that, “Getting
to the root causes mighthelp reduce future
admissions to hospital”
and another stated,
“Previously I‟ve been on
the ward and came outfeeling no better. We
need to go out with ways
to cope.”
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The additional
interventions now
offered can be part of a
care pathway to befollowed post-discharge.
To coincide with this, agood range of self-help
handouts and leaflets
have now been put
together which patients
are able to take away
with them when theyleave hospital. It is
hoped that theseresources will teach
patients healthy ways to
cope post discharge.
The TLW role provides a
member of staff with
the capacity toresearch, create and
source these resources.
To help establish a
greater sense ofcommunity and peer
support on the ward aweekly communitymeeting now takes place.As mentioned previously,
the introduction ofinitiatives such as Star
Wards and Releasing
Time to Care havehighlighted the
importance of enhancingthe acute wardenvironment by listening
to what it is the
patients want on their ward. The meetings give
patients a chance to
share both positive andnegative experiences of
their time in hospital, aswell as any thoughts and
ideas of how the ward
might be improved.Already a number of
ideas and suggestions
have been put forwardby patients, including a
map of the unit and
hospital grounds withpoints of interest such
as nearest cash point,coffee shop and other
such facilities.Suggestions as to how toimprove the currentways of administering
medication show thatpatients are unhappy
with queuing for their
tablets and would prefera more
„personable‟ approach to
administration ofmedicines which has led
to the introduction of
Protected TherapeuticMedication rounds. One
member of staff said,
“The community
meetings are good
because they help newadmissions feel a bit
more settled on theward as they get achance to feel includedand to meet other
patients. There‟s often a
good mix of new
patients and those who
are at their end of theirtime in hospital – this
seems like a healthydynamic because there‟s
definite sense of peer
support.” A comment on
a feedbackquestionnaire reflected
this, “It was very
helpful to meet otherpatients, and to find out
about what wardactivities there are.” So
far there‟s been a very
good attendance ratefor the group and a
considerable amount of
enthusiasm for it.
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A weekly „Current
Affairs‟ group has also
proved very popular and
encourages healthydebate and social
interaction amongstpatients and staff.
Other groups are based
around health promotionand healthy
living/wellbeing. We areworking towards
providing a smokingcessation workshopwhich will offer supportand advice for patients
in their journey towardsquitting smoking. The
Wellbeing Clinics, held
on a Saturdayafternoon, aim to
monitor patientsphysical health andoffer advice on living a
healthier lifestyle and
the „Healthy Living‟
group held on a Friday
morning offers to
promote the importanceof exercise by walking,
swimming etc.
Groups such as the
„Personal Recovery
Group‟ are essential in
promoting empowerment
and autonomy, enabling
patients to build on
their already acquired
skills and helping ensurea smooth, stress-free
discharge from hospital.Working along side
Louise Short, one of the
ward‟s deputy ward
managers, Nic is also
working towards utilisingthe „Personal Recovery
File‟ (PRF) idea whichwas highlighted in theStar Ward publications.
The PRF will also double-
up as an induction packand will include the ward
Information booklets as
well as, contact cards, anotebook, recovery
resources and a blankactivity timetable for
patients to plan out
their time in hospital.
Louise says, “The
purpose of the PRF is to
help enable the serviceuser to feel valued as a
human being. Its aim isnot to collect clinically
significant information,
but to provide anappreciation of the
person, what isimportant to the
individual in terms ofrecovery, and topromote greaterautonomy and
empowerment.” It is
hoped that these files
will provide patients
with a pack of resourcesfor them to build up and
access once they aredischarged. Patients willbe encouraged to add
whatever they like to
this pack to aid theirrecovery, including: self
help resources, creative
work, religious andspiritual resources,
photographs andpostcards etc, as well as
copies of care plans and
treatment plans.
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And of course, some
groups and interventions
are designed to not only
teach patients essentiallife skills but also having
some fun! Weeklytakeaways, DVD nights,
Wii fit groups,
pampering sessions andgames of bingo are all
part of people‟s
everyday routine when
at home. Creating asense of „normality‟ in
what can sometimes be avery „alien‟ environment
is vital in promotingrecovery and wellness.
Weekend cookery
sessions have proved tobe very popular amongst
patients. With guidanceand supervision patientscan cook and bake and
share with the whole
ward, again creating asense of unity and
community. We also
have access to the unitminibus and forthcoming
trips out will be on theagenda during the
summer months. In
addition to all this, the
ward now has dedicated
volunteers who provide
regular complementary
therapy sessions,offering therapies such
as manicures, pedicuresand massages. Again, the
Liaison Worker role
provides a point ofcontact and support for
these highly appreciatedvolunteers.
Of course, all these newenhancements and
improvements to theward couldn‟t have been
achieved without the
input, support and
assistance from
management, key
personnel and fellowTrust departments. One
of these is the„Improving the Inpatient
Therapeutic Experience‟
initiative which has beena steadfast source of
guidance throughout thesetting up of the TLW
role and has formed avery constructivefoundation and a lastinglegacy. The Department
of Spiritual and PastoralCare have also given a
big helping hand in
establishing groups andhumanistic interventions
on the ward andoffering valuableassistance and advice.
Furthermore, Therapy
Services for people withPersonality Disorder
have provided
unprecedented supportand commitment with
providing specialistsupervision and
consultancy.
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Since the introductionof Nic‟s role as
Therapeutic Liaison
Worker, the energy and
enthusiasm of bothstaff and patients is
noticeably improving.Positive feedback from
patients means that
they are reaping thebenefits from the added
input, activity, structureand therapeutic alliance
and finding it whollyvaluable. All groups andsessions are evaluatedand feedback is heartily
encouraged. “I can now
increase my ability to
cope with my illness” and
“It is encouraging that
groups are set up on
recovery/wellnessrather than focusing on your illness,” are just
some of the otherpositive comments
received from patients.
It is encouraging thatother wards in the
Trust are also activelyworking towardsestablishing the TLWrole. Hopefully this will
also contribute toenhancing thetherapeutic environment
of these respectivewards and create robust
links with the widerservice.
It is important toremember that patients
come into hospital with
complex needs. The new
ways of working onAshby ward is helping to
ensure that the packageof care reflects this
with new modern ways
of working. Hopefullywith the continuation of
Nic‟s role, Ashby ward
can endeavour to
continue to build onwhat‟s been achieved
thus far and continuallyaim at improving
patient‟s experiences
whilst on the acute
wards and facilitating a
smoother and supportivetransition from hospital
to home.
22
ThankstoStA
nn‟sHospital,Dorset,forphoto
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Talking with very ill patientsAuthors: Len Bowers, Geoff Brennan, Gary Winship, Christina Theodoridou
Many thanks to Len and colleagues for allowing us to include this article in the
newsletter. It‟s a great summary of their superb, essential reading publication Talking with Psychotic People, which is (also generously) downloadable free from:
http://citypsych.com/docs/Talking.pdf
Acutely mentally ill
people present their
conversational partners
with a perplexing rangeof behaviours and
challenges to normalsocial interaction. Their
mood might be one of
euphoria and elation,with thoughts running
through their head at
speed, skipping from
topic to topic as a spunstone skips over water.Or they might be deeply
depressed, full of
thoughts of guilt andpainful emotions, with
both speech and
movement considerably
slowed. Alternatively all
their emotions might be
flattened, dampened,unresponsive or
incongruous. They mightbe obsessed with
strange ideas and
interpretations of theworld and what is going
on around them, with
these beliefs often
about a hostile world.Coupled with thesedelusional beliefs may
be auditory or other
hallucinations,commenting on what is
going on around them,
instructing, abusing, or
generally interfering
with their ability to
think. In addition to thedistraction caused by
hallucinations, theirthinking processes and
verbal abilities might
also be directlyaffected by a variety of
thought disorders. They
may be irritable,
incongruous,unpredictable, andperilous conversational
partners until their
illness stabilises.
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Research on nurse-
patient interaction on
inpatient wards has not
been uniformly positive.Although the work of
the nurses is generallyhighly regarded by
patients (Rogers,
Pilgrim, & Lacey 1993),and nurses can relate
many critical incidentswhere their interaction
with patients has beenhighly valuable (Cormack1983;Flanagan & Clarke2003), many research
studies have found lowrates of interaction,
with only 8-21% of
nurses time being spentthis way (Altschul
1972;Sanson-Fisher,Poole, & Thompson1979).
Training in
communication skills, the
nursing process, nursingmodels and primary
nursing have all beenseen as ways to improve
and increase nurse-
patient interaction.However there seems to
be little guidance onspecific skills for
dealing with the acutelymentally ill. Genericcommunication skills arewell covered, and are
clearly applicable.However specific advice
on how to spend time
with and respond topeople who are
apathetic andwithdrawn, activelyhallucinating, thought
disordered,
agitated/overactive,
upset/distressed or
irritable/aggressive,seems to be missing.
What literature there isover emphasises dealing
with those patients who
are comparatively well,and certainly those that
are co-operative,insightful, and friendly.
However many acutelypsychotic patients onwards can be deeplyunwell, severely deluded,
suspicious, hostile andaggressive, and
incredibly challenging to
spend time with, letalone provide care to
and treat. Here theliterature and previouswork seems to be silent.
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We therefore decided
to undertake a piece of
research to discover ifthere were untaught,
traditional or self-developed skills amongst
nurses identified as
being highly skilled withacutely psychotic
patients. We werelooking for traditional
practice learnt perhapsfrom watching others,tacit knowledge not
previously formulated,
and to draw upon
expertise gainedthrough experience. We
worked with themanagers and nursing
leadership of three
London mental healthNHS trusts to initially
identify a few practicingqualified psychiatric
nurses who wereacknowledged experts inworking with acute
psychotic patients. We
then interviewed them,
also asking them tonominate others whom
they knew and thoughtof as particularly
expert, a strategy
known as snowballsampling. The nurses
identified werecurrently working in
community and inpatientposts, and we collected28 in total.
Analysis of theseinterviews took a lot of
work and consultationover many months. The
results, recentlypublished as amonograph available for
download from theinternet, are covered in
seven chapters: moralfoundations; preparation
for interaction and itscontext; being with thepatient; nonverbal
communication,vocabulary and timing;
emotional regulation;getting things done; and
talking about symptoms.
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The moral foundations
incorporated a complex
mix of sometimescountervailing
imperatives, such asnotice and do not ignore
the patient,
nevertheless avoidintruding and respect
their privacy. Alsoincluded were values
emphasising warmth,care coupled with a highdegree of respect andan absence of harshness
even under the mostchallenging
circumstances. Honesty
was seen as important,particularly in relation
to restrictions onpatients‟ liberty and thequality of the service
they received.
Interactions were shown
to commence prior to
meeting the patient, ascareful preparation was
deemed to increase thechance of success. Such
preparations included
wide consultation of
records and other
people who knew thepatient concerned,
careful observation,consideration of the
best time and location
to initiate interactionand choosing the right
nurse to make theapproach.
Simply being withacutely psychoticpatients was shown to
be a complex activitythat could require a
considerable number of
different adjustments,approaches or
interactive techniques.The basic spine of theseincluded simply sitting
with the patient or
spending time withthem, whilst offering
light normal
conversation,supplemented by the
nurse introducing him orherself, focusing on the
patient as a person
rather than on their
symptoms, using props,
the local environment orwhat was happening on
the ward as topics, andengaging in a joint
activity, spiced with
appropriate humour.Where the patient was
apathetic andwithdrawn, interviewees
talked about developinga comfortable silence,or engaging in a one-sided conversation. If
the patient washallucinating, this had to
be tolerated and made
allowance for in theconversation, and
simpler topics chosen; ifthought disorderedthemes could be named,
reminders and prompts
to the topic given,clarifications sought,
things kept simple or
the patient could beasked to communicate
through writing.
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Robin Williams‟ doodle .
Simple is great.
For the agitated oroveractive patient
reducing stimulation,setting interactionlimits and giving positive
feedback were
considered to behelpful. When patients
were upset ordistressed, normalconversation was
generally felt to beinappropriate, similarlyin some cases it was
judged best to avoidpatients who were
currently irritable or
aggressive. However inthe latter case choosing
a topic in which the
patient was an expert
was judged a wise move,
whilst at the same timegetting them sat down
and maintaining clarity.
There was a perhaps
surprising quantity ofnew recommendations
about nonverbalcommunication,
vocabulary and thetiming of interactions. Aslow pace, slow speech,short sentences, simple
vocabulary andrepetition within and
across interactions were
recommended. Tone ofvoice should be both
caring and quiet,interactions being shortand frequent, with
persistence shown in
efforts to communicate.There were times and
occasions when touch
and greater use ofgesticulation were
judged appropriate, andtimes when they were
not. Writing and drawing
were acknowledged as
useful alternative
communication media.
Particular care was
recommended withaggressive and irritable
patients, with a non-threatening nonverbal
stance being required
and a cautious choice ofthe language used.
Whilst communicating,
or in order to do soeffectively, nurses hadto regulate their ownemotional responses to
what patients weredoing and saying. They
deemed it most
important not to displayany anxiety in the face
of acute psychoticsymptoms, patients‟
psychological distress or
their overt hostility and
aggression. Being calmand receptive in the
face of such patient
behaviours was deemedmore likely to reduce
them – becoming anxiousmore likely to amplify
them.
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Similar
recommendations were
given about becoming
frustrated or irritablewith patients
uncooperativeness, lackof progress or
resistance to actions
which would benefitthem. Finally an
optimistic outlook wasconsidered valuable and
motivating for patients(as well as fellownurses).
Attempting to getthings done with
patients (e.g. get them
to get up or go to bed,eat, drink, wash, take
their medication etc.)required a whole rangeof additional and
different interaction
techniques, includingmaking suggestions
rather than ordering
patients to do things,giving reasons for the
task, being flexible,maximising choice,
prompting, encouraging,
giving positive feedback,
rendering assistance,
and in some
circumstances being
assertive and forceful.When resistance was
based upon delusions, adegree of collusion was
allowed by some nurses
if balanced by thepatient‟s needs for care.
For thought disorder,using gestures as a
means of communicatingwhat was to be done wasconsidered helpful.
Talking about symptomswith patients was the
single largest domain in
the interviews.Absolutely fundamental
to all symptom areas wasthe need for nurses tohear what patients‟
experiences were,
accept them, and seekto enter and understand
their effect on patients
with caring and respect.This was clearly a
foundation for nursingpractice, and was the
starting point for all
other interactions about
symptoms. Following
this, for apathetic or
withdrawn patients, it
was judged helpful tomutually explore causes,
agree a care plan,develop a routine and
purpose, and then take a
step by step approach.For hallucinating
patients, stressmanagement,
distraction, bolsteringcoping and in some casescasting doubt orchallenging the
hallucinatory contentwere considered good
approaches. Gentle
questioning or directchallenge were also
sometimes deemedappropriate for thedeluded patient.
Collusion was not
recommended, howeversometimes it was
considered appropriate
to ignore the delusionsor find workarounds so
that patients‟ needscould be met.
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In the case of upset and
distressed patients,
interviewees talked
about staying calm,keeping patients talking,
persisting to find outthe cause, and taking
action to relieve the
cause or exploring othersolutions with the
patient. Responses onagitation, overactivity,
irritability andaggression were notclearly distinguishableand were therefore
considered together.The expert nurses
recommended exercise,
distraction, relaxation,avoidance of
confrontation, explainingthe reasons for actionsand rules, negotiating
advance directives and
forceful containment.
What would be the
outcome if all nurse-patient interaction was
informed by and appliedthe techniques reported
by this study? They
would certainly seem toenhance the possibility
of cooperation and
collaboration between
nurses and patients. If
so the delivery of
medication, accuracy ofassessments, and
physical health status ofpatients might all be
improved.
It also seems logical to
conclude that aggression
and violence might be
reduced, either through
the easier
accomplishment ofnecessary tasks with
patients, or throughmore effective and
rapid de-escalation with
irritable, agitated andaggressive patients.
As the risk of suicide
amongst inpatients is asmuch of a problem withpsychotic patients as itis with those who are
depressed (Bowers,Nijman, & Banda 2009)
it is a possibility that
better communicationwould reduce social
isolation and hence risk.Finally it might besupposed that patients
who are in receipt of
such a highly skilledapproach might have a
greater satisfaction
with the care theyreceive and potentially
be more willing to beadmitted to hospital on
subsequent occasions,
without the use of legaldetention.
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The expert nursesrecommended
exercise,distraction,
relaxation, avoidanceof confrontation,
explaining thereasons for actions
and rules,
negotiating advancedirectives and
forceful
containment.
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What is described here
could also be widelyuseful to other
professionals who haveto deal with acutely
mentally ill people
(police, ambulance
personnel, social
workers, generalpractitioners and
psychiatrists), and tofamily and friends of
the mentally ill, many of
whom have few sources
of concrete advice on
how to deal with thesituations they face in
their daily contact withpeople who suffer
psychotic disorders.
The identified expertgroup were able to
identify a positive rangeof balanced behaviours,attitudes and techniquesthey utilise to reach
people suffering frompsychotic symptoms.
What also seemed to be
a feature of the
responses is thecreative flexibility the
group took in any givensituation. Asresearchers and fellowpractitioners it is
gratifying to be in theposition of sharing
these in an attempt to
further expand our
understanding ofsomething so crucial to
the care of people withmental health problems.We offer the results ofthe research as food
for reflection,discussion and debate.
References
Altschul, A. T. Patient-Nurse Interaction A Study of Interaction Patterns in AcutePsychaitric Wards. First Edition. 1972. Longman Group Limited 1972, Churchill
Livingstone.Bowers, L., Nijman, H., & Banda, T. 2009, Suicide inside: a literature review on inpatient suicide (http:citypsych.com/docs/LitRevSuicide.pdf) City University, London.
Cormack, D. 1983, Psychiatric Nursing Described Edinburgh: Churchill Livingstone.Flanagan, T. & Clarke, L. 2003, Institutional Breakdown APS, Salisbury, Wiltshire.
Rogers, A., Pilgrim, D., & Lacey, R. 1993, Experiencing Psychiatry: Users' Views of
Services London: Macmillan.Sanson-Fisher, R. W., Poole, A. D., & Thompson, V. 1979, "Behaviour Patterns Within a
General Hospital Psychiatric Unit: An Observational Study", Behaviour Research and
Therapy , vol. 17, pp. 317-332.
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