Feature Art & science |
The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
Protected engagement time in mental health inpatient units Niall McCrae explores barriers to one-to-one patient contact and how these might be overcome by allowing space for skilled nurses to offer therapeutic interventions Correspondence [email protected] Niall McCrae leads the postgraduate diploma in mental health nursing programme, at the Florence Nightingale School of Nursing and Midwifery, King’s College London Date of submission January 2 2014 Date of acceptance February 26 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nm.rcnpublishing.com
Abstract Protected engagement time in mental health inpatient units is a fixed period each day during which administrative activities and visiting are suspended so that nurses can focus on individual patient contact. However, there are a number of barriers to implementing this strategy effectively, which include high workloads, staff shortages and lack of supervision to support therapeutic interventions. This article discusses some of these barriers and suggests that managers of acute psychiatric units should ensure that patients have appropriate emotional support, and that skilled mental health nurses should be supported to devote time to therapeutic interventions. Keywords Patient contact, engagement, mental health, inpatients, acute psychiatric unit ASCENDING THE staircase to a triage ward in a psychiatric hospital in inner London, I faced a large handwritten sign stating, ‘Protected engagement time 4-5pm. No visitors.’ I thought of the families of patients and how this message might be interpreted: did this relate to safety, or perhaps a therapeutic programme with patients locked in a room to discuss their problems with a budding psychoanalyst? We should not presume that people understand the meaning of ‘engagement’, which can have many connotations from military to romantic. For the uninitiated, protected engagement time (PET) is a response to persistent criticism that patients in acute mental health wards receive little attention from nurses beyond instrumental activities.
28 April 2014 | Volume 21 | Number 1
Dedicating time for nurse-patient contact is a strategy that can result in major improvements in patient care – which will be discussed in this article – but PET is not always applied in an optimal way. Now that several years have passed since its introduction, it might be useful to consider whether PET is achieving its goal.
Therapeutic activity In the past, nursing in mental health hospitals was dominated by rules and routine. A therapeutic role for nurses was first formulated by Hildegard Peplau in 1952 (Peplau 1952), but studies of UK psychiatric hospitals showed that nurses spent only one tenth of their shift talking to patients (John 1961). The reason for this could be as much psychological as practical. Goffman (1961) observed that nurses maintain a social distance from their ‘stigmatised’ patients, while psychoanalyst Menzies (1960) identified unconscious defence mechanisms in nurses who protect themselves from anxiety by denying emotional involvement in their work. More recently, Handy (1991) found that despite the potential satisfaction from interaction with patients, mental health nurses derive comfort from order, and thereby they maintain an impersonal regime that ultimately causes job dissatisfaction. Most mental health care is now provided in the community, but inpatient units remain an essential component of NHS provision. For many patients, hospital admission is their first contact with mental health services, and their distress can often be compounded by ward environments they may perceive as chaotic and intimidating. However, a common experience among patients is boredom. A study across acute wards of one mental health trust found that at any time during the day an NURSING MANAGEMENT
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average of 84% of patients were socially disengaged (Radcliffe and Smith 2007). Research shows persistently that patients in mental health wards are deprived of therapeutic interaction (Sharac et al 2010), and this situation has been highlighted by England’s chief nursing officer (CNO) (Department of Health (DH) 2006). Yawar (2008) warns of the implications of this neglect: ‘There are countless humane, imaginative and gifted clinicians working in psychiatric hospitals. But below certain levels of funding, staffing, stability and expertise, psychiatric hospitals come to embody the opposite of their aim, becoming dingy and brutal, and fostering permanent disability and stigma.’ In a study of inpatients with depression, Moyle (2003) found a discrepancy between friendly relationships wanted by patients and the detached stance of nurses; while the patients expected psychiatrists to focus on illness and symptoms, they did not want this from nurses. According to a review of patients’ experiences on mental health wards (Quirk and Lelliott 2001), the desired characteristics of nurses are empathy, listening, tolerance and knowing individual needs. However, the patients in the review often perceived custodial or punitive attitudes in nurses; patients also observed nurses ‘lingering’ in the office. It should be acknowledged, however, that the mental health system often diverts nurses from individualised care towards procedural priorities and maintaining order and safety. A major issue for nurses, therefore, is role conflict between their dual responsibilities for care and control. Workload is high in inpatient units, but nurses have more contact with patients than other clinicians. According to Bowers et al (2005), ‘the close proximity of staff and patients within acute psychiatry enables staff to develop positive and warm relationships with patients’. However, while each patient is allocated a named nurse, this does not necessarily ensure supportive and constructive engagement. Examining activity diaries in psychiatric wards, Ryrie et al (1998) found that, while almost half of overall staff time was spent on patient contact, this inversely correlated with professional grade: patients had most interaction with the least qualified workers. Studies suggest there is good morale among nursing staff in acute mental health units (Bowers et al 2009, Johnson et al 2011) but contributory factors for lack of nurse-patient contact are not difficult to find and include high acuity, an increasing proportion of patients detained under the Mental Health Act 1983, understaffing and bureaucratic burden. NURSING MANAGEMENT
Quirk and Lelliott (2001) argue that the rapid patient throughput in acute psychiatric units has an adverse effect on quality of care. Reduced hospital provision has led to a higher proportion of detained patients and reliance on pharmacological rather than interpersonal therapeutic interventions. Patients are not always amenable to therapeutic interaction because of the effects of their condition or of the medication they receive. Bed capacity has continued to fall, leading to acute mental health units being used for brief episodes of treatment; for example, patients are in general initially admitted to a triage unit for a maximum stay of one week before discharge to a home treatment team or to longer-term care. Despite reported benefits of triage in the wider mental health system (Inglis and Baggaley 2005), there is little time for nurses to develop meaningful relationships with patients in the acute phase of mental disorder. As services evolve, structured therapy may be withheld until the acute phase has passed, and after discharge. Nurses have a major role in helping patients to return home as soon as possible, where they will have access to further psychotherapeutic support from practitioners in the community. A report by the thinktank, Centre for Social Justice (2011), argues: ‘Acute inpatient psychiatric wards should become psychiatric intensive care units which have higher status, better defined models of care and work more intensively with the patient, so their care can be “stepped down” to a community setting at the earliest, most therapeutically appropriate point.’
Protected engagement time In 2008, the Mental Health Act Commission (MHAC) recommended that all units with patients detained under the Mental Health Act 1983 should implement a system of patient-protected time (MHAC 2008). This means that for a fixed period each day administrative activities and visiting are suspended so that nurses can focus on individual patient contact. Promoted by the DH, this initiative has been widely applied to mental health inpatient settings, but evidence is needed on both the content and outcomes of PET. Early reports are equivocal. Edwards et al (2008) examined a PET scheme in one acute mental health unit comprising four wards and found that, while nurses acknowledged their responsibilities in providing time for individual patients, staff shortages and other issues made it difficult to fulfil this expectation. Additionally, nurses observed that some patients did not want one-to-one sessions, and there was a lack of supervision to support the practice. April 2014 | Volume 21 | Number 1 29
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Art & science | mental health For three years, Fiona Nolan led a DH-funded controlled trial of PET. The study had three components: national mapping of acute wards that implement PET and a telephone survey; evaluation of the effects of PET on patients and staff by comparing 12 wards that have implemented the scheme and 12 that have not; and intensive, qualitative case studies on three wards that use PET. Of 446 acute mental health wards identified in England, 210 had introduced PET, of which 194 participated in the telephone survey, and from which a total of 346 patients and 424 staff participated in the trial. Preliminary data (Nolan et al 2011) reveal similar obstacles to those found by Edwards et al (2008). The final results will be published soon but, in a presentation at the RCN mental health nursing conference in September 2013, Nolan (2013) reported no significant differences between intervention and control wards on a wide range of outcome variables, including patient satisfaction and staff morale. However, a significant difference was found in nurse-patient contact, and according to patients’ reports their needs were satisfied. Having been immersed in this concept in research and in her role as a senior nursing manager, Nolan thinks that PET is a promising strategy for improving patient contact, but that it has been applied in an unstructured way. Implementation of PET in the trial was inconsistent, and varied from a structured to an ad hoc approach. For further research, the fidelity of PET must be determined and assessed. In practice, nurses need clarity on the purpose and scope of these sessions. Guidance should be produced for therapeutic engagement sessions based on empirical evidence. Further, we should learn more about patients’ individual and collective expectations of PET because only through shared meaning can productive relationships develop. Improved access to training and supervision may be required to support PET to fulfil its potential, but there may be other underlying issues to address; for example, PET is likely to fail if it becomes another task in the daily routine, and if nurses and patients are insufficiently motivated to embrace the opportunity for better engagement. Further, there is risk of unintended consequences, so that, for example, PET could be regarded as the only time that nurses talk to patients. According to nursing students I work with, one ward that has PET does not involve nurses at all, but uses groups run by associate practitioners. In this ward, PET may have relieved some nurses from talking to patients. 30 April 2014 | Volume 21 | Number 1
Therapeutic engagement The shortfall in nurse-patient contact is a problem not only of quantity, but also of quality. Are nurses expected to use PET to work with patients psychologically, or should it be restricted to supportive interaction? Nurses themselves are not always able to articulate a purpose for their engagement with patients, as observed by Altschul (1972): ‘It has proved impossible to obtain any picture of the treatment ideologies which prevail among nurses, or any theoretical basis upon which nurses act in their dyadic interactions with patients.’ In other words, instead of coming together as a dyad, nurses and patients may remain detached, with different if not conflicting goals. Altschul’s work was a major influence on mental health nurse training, boosting the emphasis on interpersonal skills in the syllabus. However, therapeutic ability is highly variable among nurses. In the 1990s, after the shift from an institutional regime to care in the community, many nurses developed their therapeutic repertoire by training in counselling skills. In primary care settings, nurses applied the person-centred, non-directive approach of humanistic psychologist Carl Rogers (1951), and Gerard Egan’s (1975) problem-solving ‘skilled helper’ model. However, counselling activity declined partly due to a policy response to community care scandals including killings by disturbed patients, which led to reorientation of mental health nursing to patients with severe mental disorder (Hewitt 2008). Additionally, the effectiveness of counselling offered by nurses was called into question (Gournay and Brooking 1994). By contrast, cognitive behaviour therapy (CBT) has been established as a standardised and consistently effective treatment (Clark 2011). Despite overlapping roles in multidisciplinary teams, formal therapy tends to be delivered by psychologists. Nurses, meanwhile, have limited opportunities to develop their role in therapy. The paucity of evidence for therapeutic interventions by nurses (Curran and Brooker 2007) is unsurprising given the disadvantaged position of nursing in research infrastructure and funding (Mantzoukas 2007). There is also a simplistic notion that nursing is ‘care’ but not ‘treatment’: in my experience, when a patient recovers from depression, the discharge summary is likely to attribute this primarily to an antidepressant prescribed by the psychiatrist. Perhaps PET would work better if nurses had a clearer therapeutic role. A problem here is that mental health nursing lacks a distinct theoretical framework. Various models of nursing have been devised since the 1960s, but without much success NURSING MANAGEMENT
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(McCrae 2011). One model specifically for mental health nurses is Barker’s Tidal Model (Barker and Buchanan-Barker 2010). Applying this to inpatient care, Barker and Buchanan-Barker suggest daily one-to-one sessions, discovery groups and solution-finding groups facilitated by nurses. This collaborative model lacks supporting evidence but, as with PET, this might be due to inadequate implementation (Lloyd-Evans et al 2010); nurses might not be inclined to work in genuine partnership with patients. A systematic review of 132 empirical studies of patients’ experiences of mental health nurses in the UK (Bee et al 2008) found sparse evidence of nurse-patient collaboration. Arguably, another reason could be that mental health nurses have limited autonomy to determine their practice in the medico-managerial hierarchy of the hospital than in the more level playing field of community teams. As noted in the CNO review (DH 2006), principles of psychological therapy are inherent to mental health nursing, if not always applied. Bee et al (2008), however, suggest nurses need better training in therapeutic engagement. Focusing on emotional
intelligence in nurse training, Hurley and Rankin (2008) criticise an exaggerated faith in CBT, urging a broader range of talking therapies in mental health care. Therapeutic provision should be presented more inclusively and cover methods that can be applied by mental health nurses, including motivational interviewing. Sadly, nurses who gain qualifications in therapeutic interventions do not always have the opportunity to practise their skills, and the necessary clinical supervision for dealing with challenging patients is not always available (Crowhurst and Bowers 2002).
Conclusion To improve nurse-patient engagement, there must be more focus on what is done rather than how much. Whatever strategy is applied, managers of acute mental health units must ensure that patients have appropriate emotional support, while the more highly skilled nurses in the team should be enabled to devote time to therapeutic interventions. With the will and direction of nursing leaders and practitioners, meaningful engagement is an achievable goal.
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
References Altschul AT (1972) Patient-Nurse Interaction: A Study of Interaction Patterns in Acute Psychiatric Wards. Churchill Livingstone, Edinburgh.
Curran J, Brooker C (2007) Systematic review of interventions delivered by UK mental health nurses. International Journal of Nursing Studies. 44, 3, 479-509.
Barker P, Buchanan-Barker P (2010) The Tidal Model of mental health recovery and reclamation: application in acute care settings. Issues in Mental Health Nursing. 31, 3, 171-180.
Department of Health (2006) From Values to Action: The Chief Nursing Officer’s Review of Mental Health Nursing. DH, London.
Bee P, Playle J, Lovell K et al (2008) Service user views and expectations of UK-registered mental health nurses: a systematic review of empirical research. International Journal of Nursing Studies. 45, 442-458. Bowers L, Simpson A, Alexander J et al (2005) The nature and purpose of acute psychiatric wards: the Tompkins Acute Ward Study. Journal of Mental Health. 14, 6, 625-635. Bowers L, Allan T, Simpson A et al (2009) Morale is high in acute inpatient psychiatry. Social Psychiatry and Psychiatric Epidemiology. 44, 1, 39-46. Centre for Social Justice (2011) Completing the Revolution: Transforming Mental Health and Tackling Poverty. tinyurl.com/km34r8o (Last accessed: March 3 2014.) Clark DM (2011) Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. International Review of Psychiatry. 23, 4, 318-327. Crowhurst N, Bowers L (2002) Philosophy, care and treatment on the psychiatric intensive care unit: themes, trends and future practice. Journal of Psychiatric and Mental Health Nursing. 9, 6, 689-695.
NURSING MANAGEMENT
Edwards K, Dhoopnarain A, Fellows J et al (2008) Evaluating protected time in mental health acute care. Nursing Times. 104, 36, 28-29. Egan G (1975) The Skilled Helper: A Model for Systematic Helping and Interpersonal Relating. Brooks/Cole-Thomson, Monterey CA. Goffman E (1961) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Doubleday, New York NY. Gournay KJM, Brooking JI (1994) Community psychiatric nurses in primary health care. British Journal of Psychiatry. 165, 231-238. Handy J (1991) Stress and contradiction in psychiatric nursing. Human Relations. 44, 1, 39-53. Hewitt JL (2008) Dangerousness and mental health. Journal of Psychiatric and Mental Health Nursing. 15, 3, 186-194. Hurley J, Rankin R (2008) As mental health nursing roles expand, is education expanding mental health nurses? An emotionally intelligent view towards preparation for psychological therapies and relatedness. Nursing Inquiry. 15, 3, 199-205. Inglis G, Baggaley M (2005) Triage in mental health – a new model for acute in-patient psychiatry. Psychiatric Bulletin. 29, 255-258.
John AL (1961) A Study of the Psychiatric Nurse. E&S Livingstone, Edinburgh. Johnson S, Wood S, Paul M et al (2011) Inpatient Mental Health Staff Morale: a National Investigation. Final Report. tinyurl.com/k4rvcew (Last accessed: March 3 2014.) Lloyd-Evans B, Johnson S, Morant N et al (2010) Alternatives to standard acute in-patient care in England: differences in content of care and staff. British Journal of Psychiatry. 197, S46-S51. Mantzoukas S (2007) A review of evidencebased practice, nursing research and reflection: levelling the hierarchy. Journal of Clinical Nursing, 17, 2, 214-223. McCrae N (2011) Whither nursing models? The value of nursing theory in the context of evidence-based practice and multidisciplinary health care. Journal of Advanced Nursing. 68, 1, 222-229. Mental Health Act Commission (2008) Risk, Rights and Recovery: The Mental Health Act Commission Twelfth Biennial Report 2005-2007. MHAC, London. Menzies IEP (1960) The Functioning of Social Systems as a Defence against Anxiety. Tavistock, London.
engagement time, with other wards delivering standard care alone. Psychiatrische Praxis. 38, P48. Nolan F (2013) An Evaluation of Protected Engagement Time on Staff and Patient Outcomes in Acute Mental Health Inpatient Wards in England. Presented at the 19th International Network for Psychiatric Nursing Research – Royal College of Nursing, Warwick. September 7 2013. Peplau H (1952) Interpersonal Relations in Nursing. Macmillan, London. Quirk A, Lelliott P (2001) What do we know about life on acute psychiatric wards in the UK? A review of the research evidence. Social Science and Medicine. 53, 1565-1574. Radcliffe J, Smith R (2007) Acute in-patient psychiatry: how patients spend their time on acute psychiatric wards. Psychiatric Bulletin. 31, 167-170. Rogers C (1951) Client-Centred Therapy. Houghton Mifflin, Boston MA. Ryrie I, Agunbiade D, Brannock L et al (1998) A survey of psychiatric nursing practice in two inner city acute admission wards. Journal of Advanced Nursing. 27, 848-854.
Moyle W (2003) Nurse-patient relationship: a dichotomy of expectations. International Journal of Mental Health Nursing. 12, 2, 103-109.
Sharac J, McCrone P, Sabes-Figuera R et al (2010) Nurse and patient activities and interactions on psychiatric inpatient wards: a literature review. International Journal of Nursing Studies. 47, 909-917.
Nolan F, Johnson S, Lloyd-Evans B et al (2011) A preliminary comparison of acute mental health inpatient wards which use protected
Yawar A (2008) Time and humanity on psychiatric wards. The Lancet. 371, 9609, 285-286.
April 2014 | Volume 21 | Number 1 31
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The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
Protected engagement time in mental health inpatient units Niall McCrae explores barriers to one-to-one patient contact and how these might be overcome by allowing space for skilled nurses to offer therapeutic interventions Correspondence [email protected] Niall McCrae leads the postgraduate diploma in mental health nursing programme, at the Florence Nightingale School of Nursing and Midwifery, King’s College London Date of submission January 2 2014 Date of acceptance February 26 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nm.rcnpublishing.com
Abstract Protected engagement time in mental health inpatient units is a fixed period each day during which administrative activities and visiting are suspended so that nurses can focus on individual patient contact. However, there are a number of barriers to implementing this strategy effectively, which include high workloads, staff shortages and lack of supervision to support therapeutic interventions. This article discusses some of these barriers and suggests that managers of acute psychiatric units should ensure that patients have appropriate emotional support, and that skilled mental health nurses should be supported to devote time to therapeutic interventions. Keywords Patient contact, engagement, mental health, inpatients, acute psychiatric unit ASCENDING THE staircase to a triage ward in a psychiatric hospital in inner London, I faced a large handwritten sign stating, ‘Protected engagement time 4-5pm. No visitors.’ I thought of the families of patients and how this message might be interpreted: did this relate to safety, or perhaps a therapeutic programme with patients locked in a room to discuss their problems with a budding psychoanalyst? We should not presume that people understand the meaning of ‘engagement’, which can have many connotations from military to romantic. For the uninitiated, protected engagement time (PET) is a response to persistent criticism that patients in acute mental health wards receive little attention from nurses beyond instrumental activities.
28 April 2014 | Volume 21 | Number 1
Dedicating time for nurse-patient contact is a strategy that can result in major improvements in patient care – which will be discussed in this article – but PET is not always applied in an optimal way. Now that several years have passed since its introduction, it might be useful to consider whether PET is achieving its goal.
Therapeutic activity In the past, nursing in mental health hospitals was dominated by rules and routine. A therapeutic role for nurses was first formulated by Hildegard Peplau in 1952 (Peplau 1952), but studies of UK psychiatric hospitals showed that nurses spent only one tenth of their shift talking to patients (John 1961). The reason for this could be as much psychological as practical. Goffman (1961) observed that nurses maintain a social distance from their ‘stigmatised’ patients, while psychoanalyst Menzies (1960) identified unconscious defence mechanisms in nurses who protect themselves from anxiety by denying emotional involvement in their work. More recently, Handy (1991) found that despite the potential satisfaction from interaction with patients, mental health nurses derive comfort from order, and thereby they maintain an impersonal regime that ultimately causes job dissatisfaction. Most mental health care is now provided in the community, but inpatient units remain an essential component of NHS provision. For many patients, hospital admission is their first contact with mental health services, and their distress can often be compounded by ward environments they may perceive as chaotic and intimidating. However, a common experience among patients is boredom. A study across acute wards of one mental health trust found that at any time during the day an NURSING MANAGEMENT
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
average of 84% of patients were socially disengaged (Radcliffe and Smith 2007). Research shows persistently that patients in mental health wards are deprived of therapeutic interaction (Sharac et al 2010), and this situation has been highlighted by England’s chief nursing officer (CNO) (Department of Health (DH) 2006). Yawar (2008) warns of the implications of this neglect: ‘There are countless humane, imaginative and gifted clinicians working in psychiatric hospitals. But below certain levels of funding, staffing, stability and expertise, psychiatric hospitals come to embody the opposite of their aim, becoming dingy and brutal, and fostering permanent disability and stigma.’ In a study of inpatients with depression, Moyle (2003) found a discrepancy between friendly relationships wanted by patients and the detached stance of nurses; while the patients expected psychiatrists to focus on illness and symptoms, they did not want this from nurses. According to a review of patients’ experiences on mental health wards (Quirk and Lelliott 2001), the desired characteristics of nurses are empathy, listening, tolerance and knowing individual needs. However, the patients in the review often perceived custodial or punitive attitudes in nurses; patients also observed nurses ‘lingering’ in the office. It should be acknowledged, however, that the mental health system often diverts nurses from individualised care towards procedural priorities and maintaining order and safety. A major issue for nurses, therefore, is role conflict between their dual responsibilities for care and control. Workload is high in inpatient units, but nurses have more contact with patients than other clinicians. According to Bowers et al (2005), ‘the close proximity of staff and patients within acute psychiatry enables staff to develop positive and warm relationships with patients’. However, while each patient is allocated a named nurse, this does not necessarily ensure supportive and constructive engagement. Examining activity diaries in psychiatric wards, Ryrie et al (1998) found that, while almost half of overall staff time was spent on patient contact, this inversely correlated with professional grade: patients had most interaction with the least qualified workers. Studies suggest there is good morale among nursing staff in acute mental health units (Bowers et al 2009, Johnson et al 2011) but contributory factors for lack of nurse-patient contact are not difficult to find and include high acuity, an increasing proportion of patients detained under the Mental Health Act 1983, understaffing and bureaucratic burden. NURSING MANAGEMENT
Quirk and Lelliott (2001) argue that the rapid patient throughput in acute psychiatric units has an adverse effect on quality of care. Reduced hospital provision has led to a higher proportion of detained patients and reliance on pharmacological rather than interpersonal therapeutic interventions. Patients are not always amenable to therapeutic interaction because of the effects of their condition or of the medication they receive. Bed capacity has continued to fall, leading to acute mental health units being used for brief episodes of treatment; for example, patients are in general initially admitted to a triage unit for a maximum stay of one week before discharge to a home treatment team or to longer-term care. Despite reported benefits of triage in the wider mental health system (Inglis and Baggaley 2005), there is little time for nurses to develop meaningful relationships with patients in the acute phase of mental disorder. As services evolve, structured therapy may be withheld until the acute phase has passed, and after discharge. Nurses have a major role in helping patients to return home as soon as possible, where they will have access to further psychotherapeutic support from practitioners in the community. A report by the thinktank, Centre for Social Justice (2011), argues: ‘Acute inpatient psychiatric wards should become psychiatric intensive care units which have higher status, better defined models of care and work more intensively with the patient, so their care can be “stepped down” to a community setting at the earliest, most therapeutically appropriate point.’
Protected engagement time In 2008, the Mental Health Act Commission (MHAC) recommended that all units with patients detained under the Mental Health Act 1983 should implement a system of patient-protected time (MHAC 2008). This means that for a fixed period each day administrative activities and visiting are suspended so that nurses can focus on individual patient contact. Promoted by the DH, this initiative has been widely applied to mental health inpatient settings, but evidence is needed on both the content and outcomes of PET. Early reports are equivocal. Edwards et al (2008) examined a PET scheme in one acute mental health unit comprising four wards and found that, while nurses acknowledged their responsibilities in providing time for individual patients, staff shortages and other issues made it difficult to fulfil this expectation. Additionally, nurses observed that some patients did not want one-to-one sessions, and there was a lack of supervision to support the practice. April 2014 | Volume 21 | Number 1 29
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Art & science | mental health For three years, Fiona Nolan led a DH-funded controlled trial of PET. The study had three components: national mapping of acute wards that implement PET and a telephone survey; evaluation of the effects of PET on patients and staff by comparing 12 wards that have implemented the scheme and 12 that have not; and intensive, qualitative case studies on three wards that use PET. Of 446 acute mental health wards identified in England, 210 had introduced PET, of which 194 participated in the telephone survey, and from which a total of 346 patients and 424 staff participated in the trial. Preliminary data (Nolan et al 2011) reveal similar obstacles to those found by Edwards et al (2008). The final results will be published soon but, in a presentation at the RCN mental health nursing conference in September 2013, Nolan (2013) reported no significant differences between intervention and control wards on a wide range of outcome variables, including patient satisfaction and staff morale. However, a significant difference was found in nurse-patient contact, and according to patients’ reports their needs were satisfied. Having been immersed in this concept in research and in her role as a senior nursing manager, Nolan thinks that PET is a promising strategy for improving patient contact, but that it has been applied in an unstructured way. Implementation of PET in the trial was inconsistent, and varied from a structured to an ad hoc approach. For further research, the fidelity of PET must be determined and assessed. In practice, nurses need clarity on the purpose and scope of these sessions. Guidance should be produced for therapeutic engagement sessions based on empirical evidence. Further, we should learn more about patients’ individual and collective expectations of PET because only through shared meaning can productive relationships develop. Improved access to training and supervision may be required to support PET to fulfil its potential, but there may be other underlying issues to address; for example, PET is likely to fail if it becomes another task in the daily routine, and if nurses and patients are insufficiently motivated to embrace the opportunity for better engagement. Further, there is risk of unintended consequences, so that, for example, PET could be regarded as the only time that nurses talk to patients. According to nursing students I work with, one ward that has PET does not involve nurses at all, but uses groups run by associate practitioners. In this ward, PET may have relieved some nurses from talking to patients. 30 April 2014 | Volume 21 | Number 1
Therapeutic engagement The shortfall in nurse-patient contact is a problem not only of quantity, but also of quality. Are nurses expected to use PET to work with patients psychologically, or should it be restricted to supportive interaction? Nurses themselves are not always able to articulate a purpose for their engagement with patients, as observed by Altschul (1972): ‘It has proved impossible to obtain any picture of the treatment ideologies which prevail among nurses, or any theoretical basis upon which nurses act in their dyadic interactions with patients.’ In other words, instead of coming together as a dyad, nurses and patients may remain detached, with different if not conflicting goals. Altschul’s work was a major influence on mental health nurse training, boosting the emphasis on interpersonal skills in the syllabus. However, therapeutic ability is highly variable among nurses. In the 1990s, after the shift from an institutional regime to care in the community, many nurses developed their therapeutic repertoire by training in counselling skills. In primary care settings, nurses applied the person-centred, non-directive approach of humanistic psychologist Carl Rogers (1951), and Gerard Egan’s (1975) problem-solving ‘skilled helper’ model. However, counselling activity declined partly due to a policy response to community care scandals including killings by disturbed patients, which led to reorientation of mental health nursing to patients with severe mental disorder (Hewitt 2008). Additionally, the effectiveness of counselling offered by nurses was called into question (Gournay and Brooking 1994). By contrast, cognitive behaviour therapy (CBT) has been established as a standardised and consistently effective treatment (Clark 2011). Despite overlapping roles in multidisciplinary teams, formal therapy tends to be delivered by psychologists. Nurses, meanwhile, have limited opportunities to develop their role in therapy. The paucity of evidence for therapeutic interventions by nurses (Curran and Brooker 2007) is unsurprising given the disadvantaged position of nursing in research infrastructure and funding (Mantzoukas 2007). There is also a simplistic notion that nursing is ‘care’ but not ‘treatment’: in my experience, when a patient recovers from depression, the discharge summary is likely to attribute this primarily to an antidepressant prescribed by the psychiatrist. Perhaps PET would work better if nurses had a clearer therapeutic role. A problem here is that mental health nursing lacks a distinct theoretical framework. Various models of nursing have been devised since the 1960s, but without much success NURSING MANAGEMENT
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
(McCrae 2011). One model specifically for mental health nurses is Barker’s Tidal Model (Barker and Buchanan-Barker 2010). Applying this to inpatient care, Barker and Buchanan-Barker suggest daily one-to-one sessions, discovery groups and solution-finding groups facilitated by nurses. This collaborative model lacks supporting evidence but, as with PET, this might be due to inadequate implementation (Lloyd-Evans et al 2010); nurses might not be inclined to work in genuine partnership with patients. A systematic review of 132 empirical studies of patients’ experiences of mental health nurses in the UK (Bee et al 2008) found sparse evidence of nurse-patient collaboration. Arguably, another reason could be that mental health nurses have limited autonomy to determine their practice in the medico-managerial hierarchy of the hospital than in the more level playing field of community teams. As noted in the CNO review (DH 2006), principles of psychological therapy are inherent to mental health nursing, if not always applied. Bee et al (2008), however, suggest nurses need better training in therapeutic engagement. Focusing on emotional
intelligence in nurse training, Hurley and Rankin (2008) criticise an exaggerated faith in CBT, urging a broader range of talking therapies in mental health care. Therapeutic provision should be presented more inclusively and cover methods that can be applied by mental health nurses, including motivational interviewing. Sadly, nurses who gain qualifications in therapeutic interventions do not always have the opportunity to practise their skills, and the necessary clinical supervision for dealing with challenging patients is not always available (Crowhurst and Bowers 2002).
Conclusion To improve nurse-patient engagement, there must be more focus on what is done rather than how much. Whatever strategy is applied, managers of acute mental health units must ensure that patients have appropriate emotional support, while the more highly skilled nurses in the team should be enabled to devote time to therapeutic interventions. With the will and direction of nursing leaders and practitioners, meaningful engagement is an achievable goal.
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
References Altschul AT (1972) Patient-Nurse Interaction: A Study of Interaction Patterns in Acute Psychiatric Wards. Churchill Livingstone, Edinburgh.
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