Star Wards Oct 2010 Newsletter

8/8/2019 Star Wards Oct 2010 Newsletter

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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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http://www.starwards.org.uk/

http://www.starwards.org.uk/



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



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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http://starwards.org.uk/newsletters/182-ablett-unit-wins-full-monty






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.

21



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



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.

23





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.

24



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.

25



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.

26



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.

27



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.

28



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.

29

The expert nursesrecommended

exercise,distraction,

relaxation, avoidanceof confrontation,

explaining thereasons for actions

and rules,

negotiating advancedirectives and

forceful

containment.



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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Star Wards Oct 2010 Newsletter

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