Let’s say June 2010

(although technically October) (Definitely) Issue #54

Hello and welcome to breakthroughs, joys, particular a second

what, after a long period
of newsletter drought,
is an ocean of fabulous
accounts of outstanding
inpatient care. More of
a magazine than a
newsletter. Huge thanks
to all of our
contributors for
generously sharing their
stories of
frustrations and
challenges. And many
thanks to all of you for
your patience (again!)
with the long gap in
newsletters. I‟ve been
immersed, occasionally
submerged, in lots of
really exciting Star
Wards‟ developments, in
edition of TalkWell.
I hope you‟re enjoying
the summery days, and
look forward to hearing
about, 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 inpatient
academic 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 longer
need to be more than a few taps of the
finger away from Star Wards 2 and
TalkWell (er, if you‟ve got an iPhone). Cool!

1
WELCOME BAGS

The idea for the activity group one of our placed a written
Welcome Bags came patients asked if they information leaflet
about from the could make their own about the ward, a kind
information we received bags to give to new word greeting card, a
for the Star Wards patients on their ward timetable for on/off
Festival Celebration to help them feel more ward activities. Some
Bags which we actively welcome and dispel their patients would also put
took part in. A group own fears about being ill in a small sachet of hand
was formed whereby the and away from home. cream, shampoo and hair
Festival Bags were made The idea for „Welcome conditioner, etc, thus
by service users from Bags‟ was adopted. It making the bag a more
the East and West was suggested that we personal item. The idea
Willows wards and were could scale down the for the „Welcome Bags‟
sent away to London. original festival bag. were created.
During the festival bag Inside the bag would be

2
These bags are given to to pour in from patients else who has just
new patients from as to what could be put arrived on the ward.
existing patients into the bags. Important During one of our groups
forming a patient‟s telephone numbers, i.e. one of our patients had
mutual support system. PALS, Carers Support finished their bag and
This has helped with the Groups, and appointment was so happy and proud
well-being of patients cards. of her achievement that
who have been attending it was suggested she
the welcome bag activity Since starting this keep the bag for
group. From the welcome bag activity herself. “No she
feedback that has been group we have had replied, I‟ve made this
received they feel they patients approach us for someone else to help
are contributing not only who have received a them feel better”.
to their own well-being welcome bag and have
but are showing the new requested to participate The message we are
patient that they care. in creating their own simply saying from these
Many new ideas continue bag to give to someone bags is WELCOME!

TalkWell Wristbands

Exciting developments produced glam

at Highgate Mental wristbands for staff
Health Unit have who have completed the
featured in Star Wards‟ TalkWell training –
newsletters since our which they have
earliest days, thanks to designed and are
their dynamic and implementing. Here‟s a
energetic modern psychologist and national pic of Buddy modelling
matron, Jo Spencer. advocate for psychology, the wristbands which
(Their leadership team and the fab Geoff will surely be auctioned
is also blessed with the Brennan – nurse for vast amounts on
amazing John Hanna, specialist, author, ebay in years to come.
humourist…) Their (The wristbands, not the
latest innovation is photo.)
wonderful!! They‟ve

3
Lagan Valley Hospital, County Antrim
By Angela Mc Shane

In November 1979 when farming, gardening and The introduction of

I started my career in cooking as part of their „New Thinking‟ that
Mental Health Nursing, daily routine. The these tasks demeaned
patient activity was patient‟s day was patients and indeed
integral to the care structured with these exploited their
offered to all inpatients. simple activities which vulnerability led to the
Social, recreational and provided a temporary demise of all activities.
occupational therapies escape from the outside Now with another new
were very much a hustle and bustle and set of themes
structured part of the were also used as a developing for recovery
patient‟s day. Indeed, method of developing models of care it is
my then older colleagues new coping and problem deemed that activities
regaled us „young‟ nurses solving skills. are a valid method of
with stories of patients aiding recovery.
Thanks to Wotton Lawn Hospital for photo

In 2006 Marion Janner experienced a very that staff and patients

set up Star Wards healing and beneficial are under, inpatient
following her own time time she found that stays tend to be
spent in St Ann‟s unfortunately while characterised by an
Hospital in North talking to other absence of therapeutic,
London as a detained patients, they had not or even recreational
patient, on a locked gained the same engagement.
ward and under Special experience due to the
Observations. While she numerous pressures

4
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 this
extending 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 right
and 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 different
therapies 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 the
internet on activities I made contact with George Nish (Charge Nurse) in Ayr in
Scotland who was very helpful and informative re setting up Star Wards in our
hospital. His guidance and support was very gratefully appreciated.

I don’t know if this is one of their new games, but

we highly recommend it as a perfect ward activity.

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 no
access 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 books
on the ward at all times.

5
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, the
questionnaire was designed using broad headed themes suggesting various social,
recreational, therapeutic and educational activities with the additional option of
further 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 gave
patients 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 the
activity 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 this
was 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 varied
range of future activities that would become part of the weekly timetable. Interests
included 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 their
skills. 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.

6
Some of the staff OT activities, nurse indoor soccer ball and
expressed concerns activities and joint table tennis bats were
regarding their own lack activities to take place, purchased to facilitate
of experience in taking thus providing a more our new activities.
discussion and structured, creative,
educational groups. This interactive and fun day Further sporting
issue is being addressed for all the patients. activities were also
with further training in Through time we made available through
group work being furthered developed our Caroline Mc Grath and
provided by Beeches resources. The use of Sports Development
Management Centre. the Day Hospital which allows W12
facilities were approved patients to participate
by senior management in variety of different
My initial meetings with and made available to us sports in the
our Occupational for use in the evenings recreational hall for 2
Therapist Anna were and at weekends. The hours every week. To
very positive but there Recreational Hall was date these include
were blurred boundary also secured and made bocca, velcro archery,
lines evident. We looked available for every curling and badminton.
at Star Wards and the Saturday and also two In the coming weeks I
benefits of, we also evenings per week. This anticipate the
looked at the results of further developed our introduction of more
the patients‟ range of activities to sports.
questionnaire and now include basketball,
through this we indoor soccer,
negotiated our working badminton, table tennis,
roles. We discussed a Wii and pool. Badminton
timetable that allowed racquets, basketball,

7
I also sourced with their programme of
community links. I summer sample sessions
visited the Leisureplex and we have chosen
and found that patients activities for patients to
on request can have an attend.
individual exercise plan
devised with one of
their trainers. Our main
community link has been Staff have also benefited from
with Atlas (Adult the activities programme. They
Learning & Support in have improved their skills and
Lisburn).
their confidence is growing in
the running of most activities
The benefits of all
these activities have
been enormous for
patients and staff alike.
New patients to our
ward believe these
They are a community activities always
group who deliver a wide happened. With re-
range of courses. They admitted patients there
are funded by the has been a mix of
Lottery, International responses. Some think
Fund for Ireland and these changes are for
Children in Need. They the better while a small
have been an invaluable proportion of patients
source providing tutors just want to do what
twice a week for they always did on
educational and previous admissions, i.e.
therapeutic activities.
lie in bed.
They have provided us
8
Staff have also
benefited from the
activities programme.
They have improved
their skills and their
confidence is growing in
the running of most
activities.
At the outset this
seemed an
enormous task and
I felt like I was
standing at the
foot of Mount
Everest. Like any
expedition it took
determination, team
work and support to
start climbing the
mountain. Ruth my ward
manager provided a lot
of the support in terms
of helping and guiding
me and in also directing
and encouraging the
nursing team to get
involved.
While this project
is still very much
under development
I believe it has all
been worthwhile.
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‟ impressive 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.

9
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.

 There‟s a strong not only makes of positive

team of them readily identity and
volunteers, called identifiable as groupness.
Robins and volunteers, but Visitors for the
inspiredly, they I‟d imagine is also visitor less is a
wear bright red great for the potential role for
polo shirts. This volunteers‟ sense the Robins.

10
 Loads of aware of who will Tai Chi, Yoga, in-
community groups be providing them door bowls, belly
come into the unit with individual dancing and
as guest speakers time that day. outside activities
 Computers and  The family and in the summer.
the internet are carer liaison  OT also regularly
available via Coleg workers are organise unit
Harlech who based in the in events eg Well
provide taster patient unit and Being Wednesday
sessions within they provide which celebrated
the unit support for family World Mental
 The unit has had members and Health Day, and
an artist in carers whilst also a unit stress-
residence and a their loved one down day
ceramics project receives a service  The unit has a
through the from the acute large and lovely
fabulous Museums setting. family visitors
for Mental Health  The pharmacist room Service
 All wards have holds group and users and staff
exercise bikes individual sessions have donated
and wii consoles. for patients and various toys and
 One to one is available for books including a
trackers are family/carer TV and Video
devised each discussions. player.
morning and put  Occupational
on display so that therapy facilitate
patients are exercise sessions,

11
Buddy and I visited action. Twix‟s repertoire movingly, Twix
recently to meet the includes twirling on her repeatedly and
fantastic staff team back legs, putting her unsolicitedly returned
and present them with paw over her face in the toy to her and the
their award. It was mock guilt, and jumping patient did indeed
fascinating and inspiring through her human respond. Buddy was well
to see the quality of the Sally‟s arms,(they were impressed with Twix and
service, the staff linked like a hoop, it this had the unexpected
morale and the wasn‟t some paranormal and hilarious effect of
relationship between experience). One of the Buddy getting a bit too
staff and patients. A big patients in the room was up close and personal
bonus of visit was seeing very withdrawn, silent with the bewildered
the gorgeous Pets as and apparently talent artiste.
Therapy dog Twix in unresponsive. Very

12
Information from the Ablett Unit

Changing Rooms!

The OT art work to be put on

activity the walls. The new
room and activity room has
the become a relaxed
children‟s environment with a
room was dedicated resource area
As part of Star Wards swopped with patient information
we looked at the use of making the activity room and resources.
rooms within the Ablett more accessible to all which includes mind,
Unit. With the patients. journeys, healthy
development of the Patients were actively lifestyle and community
patients coffee bar it involved in the process resources information.
was highlighted that and in doing so feel they The room also has a
patients who had visits have more of an onus on dedicated multi faith
from children where both rooms. The activity area which is work in
unable to access the room has been painted progress.
coffee bar due to its and patients have
location. started to undertake

13
The Feelings Tree

Healthcare support up the tree as the

worker Louise person gets better. It is
Williams has green hoped that newly
fingers not because admitted patients can
she likes gardening see from other patient‟s
but due to the comments higher up the
painting of a feelings tree that there is light
tree. The tree is at the end of the tunnel!
enthusiastically used The tree was painted by
by patients to add patients and staff of
their feelings on leaf Dinas female ward.
shape paper with the
aim of the leaf moving

Bett’s coffee Bar

Bett‟s Bar was initially with other patients and way to prepare those
opened as a place where staff in a different who are intend on
patients could take their environment. In the returning to or starting
visitors for a chat and a future we are going to work when they leave us.
cuppa. Now most be giving patients a There is a donation only
patients are encouraged chance to „run‟ Betts scheme with suggested
to visit, it provides a Bar, by serving drinks donation ideas, eg. Tea
change of scenery from and snacks which will 20p.
the ward and an hopefully give a sense of
opportunity to socialise pride and help in some

14
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 usually 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 have Releasing Time to Care the influence and

recently been addressed
at a national level and a
number of publications
and initiatives have been
put into place to
increase the positive
practice in inpatient
settings. Schemes such
as Star Wards,
and „Improving the
Inpatient Therapeutic
Experience‟, highlight
the need for protected
engagement time with
inpatients and
psychological
interventions to be more
readily available. With
backing from important
initiatives such as these,
the role of the
„Therapeutic Liaison
Worker‟ (TLW) has been
borne and created on
Ashby Ward at the
Bradgate Mental Health
Unit in Leicester.

15
Nic Higham, who was the last few years has independence. Working
previously a Healthcare obtained qualifications alongside the team on
Support Worker in various therapies Ashby Ward, Nic has
(HCSW) for about 6 including Person-centred created and devised a
years, recognised the Psychotherapy and Life full programme of
need for such a role on Coaching. therapeutic activities
the acute wards to help and groups on the ward,
create, enhance and all of which are
promote a therapeutic purposeful, provide
environment and to also structure, aim to
seek to embed this counteract boredom and
ethos on the ward frustration and increase
environment. “It makes motivation. Most of the
sense to me for us to be interventions are geared
offering service users a around psycho-education
more complete and and psychological
holistic package of care wellbeing, specifically,
whilst in hospital which groups such as and the
meets their diverse „Stress Less‟ Anxiety
Nic sees the role of the
needs,” says Nic, “The Management group and
TLW as a facilitator in
interventions which can the „Stop and Think!‟
motivating and
go into this package problem solving group.
encouraging patients to
seem to be making a Patients from the other
engage in constructive
considerable and wards in the unit are
and purposeful daily
positive difference to also able to attend the
activities whilst on the
individuals who find Stop and Think! group,
ward, supporting
themselves on these and Nic liaises with
patients with exploring
wards.” Nic is a well these wards regularly.
ways of coping and
established HCSW on
recovering whilst
Ashby Ward and over
promoting autonomy and

16
It is felt that the TLW very much in support of “Overcoming” series of
role improves TLW role and depend on self-help books. Patients
communication with it to help them organise are given the
other wards, teams and this intervention. opportunity to learn
services, which again more about their mental
reinforces a more health conditions and
comprehensive package problems and discover
of care. As part of the ways to alleviate them.
TLW role, Nic is a link In a feedback
to other services, one of questionnaire a patient
these is the pharmacy expressed,” I want to
department who are now understand the reasons
running a weekly I‟m in hospital – not just
medication education the diagnosis they think
group. From feedback I have.” Additional time
from service-users, is now provided for
medication information patients to discuss their
is a very valuable Nic has also formed a illnesses and symptoms
intervention and self-help library which with other patients and
evidence has shown that patients can access, allocated members of
medication knowledge which includes the staff.
aids compliance. The widely recommended
pharmacists who MIND publications and
facilitate the group are the CBT-based

17
The „Therapeutic Liaison are clearly benefiting has been the catalyst
Worker‟ role also from the increased which is gradually
includes liaising with the input is a reward in changing the ward
nursing team and itself. Nic insists that, culture in a positive way.
bringing together a core “Whilst this initiative is For years I have heard
of staff that co- backed by nationwide service users asking for
facilitate the ward- mental health service ward-based therapeutic
based groups. This has improvement schemes, it groups and psychological
taken careful planning, has been the support, and it‟s very
hard work and commitment and the refreshing to now see
dedication, but being fresh thinking of the these requests being
able to see that patients Ashby Ward staff that put into action.”

These new their professional very mindful of. In a

enhancements empower development. Having a recent community
both the service users member of staff on the meeting one patient
and staff. The ward ward who has a suggested that, “Getting
team as a whole have protected role to to the root causes might
very much embraced coordinate and facilitate help reduce future
these changes which are these therapeutic admissions to hospital”
making the ward a more activities is crucial if we and another stated,
healing and therapeutic are to work towards “Previously I‟ve been on
place to recover. The cutting down boredom the ward and came out
TLW role has ignited an and aggression levels on feeling no better. We
interest in therapeutic the wards. Also, need to go out with ways
activity from other reducing readmission to cope.”
staff and potentially and relapse is something
contributes towards we as a team are always

18
The additional have now been put cope post discharge.
interventions now together which patients The TLW role provides a
offered can be part of a are able to take away member of staff with
care pathway to be with them when they the capacity to
followed post-discharge. leave hospital. It is research, create and
To coincide with this, a hoped that these source these resources.
good range of self-help resources will teach
handouts and leaflets patients healthy ways to
hospital grounds with “The community
To help establish a points of interest such meetings are good
greater sense of as nearest cash point, because they help new
community and peer coffee shop and other admissions feel a bit
support on the ward a such facilities. more settled on the
weekly community Suggestions as to how to ward as they get a
meeting now takes place. improve the current chance to feel included
As mentioned previously, ways of administering and to meet other
the introduction of medication show that patients. There‟s often a
initiatives such as Star patients are unhappy good mix of new
Wards and Releasing with queuing for their patients and those who
Time to Care have tablets and would prefer are at their end of their
highlighted the a more time in hospital – this
importance of enhancing „personable‟ approach to seems like a healthy
the acute ward dynamic because there‟s
environment by listening definite sense of peer
to what it is the support.” A comment on
patients want on their a feedback
ward. The meetings give questionnaire reflected
patients a chance to this, “It was very
share both positive and helpful to meet other
negative experiences of patients, and to find out
their time in hospital, as about what ward
well as any thoughts and activities there are.” So
ideas of how the ward far there‟s been a very
might be improved. administration of good attendance rate
Already a number of medicines which has led for the group and a
ideas and suggestions to the introduction of considerable amount of
have been put forward Protected Therapeutic enthusiasm for it.
by patients, including a Medication rounds. One
map of the unit and member of staff said,

19
A weekly „Current and autonomy, enabling their time in hospital.
Affairs‟ group has also patients to build on Louise says, “The
proved very popular and their already acquired purpose of the PRF is to
encourages healthy skills and helping ensure help enable the service
debate and social a smooth, stress-free user to feel valued as a
interaction amongst discharge from hospital. human being. Its aim is
patients and staff. Working along side not to collect clinically
Other groups are based Louise Short, one of the significant information,
around health promotion ward‟s deputy ward but to provide an
and healthy managers, Nic is also appreciation of the
living/wellbeing. We are working towards utilising person, what is
working towards the „Personal Recovery important to the
providing a smoking File‟ (PRF) idea which individual in terms of
cessation workshop was highlighted in the recovery, and to
which will offer support Star Ward publications. promote greater
and advice for patients autonomy and
in their journey towards empowerment.” It is
quitting smoking. The hoped that these files
Wellbeing Clinics, held will provide patients
on a Saturday with a pack of resources
afternoon, aim to for them to build up and
monitor patients access once they are
physical health and discharged. Patients will
offer advice on living a be encouraged to add
healthier lifestyle and whatever they like to
the „Healthy Living‟ this pack to aid their
group held on a Friday The PRF will also double- recovery, including: self
morning offers to up as an induction pack help resources, creative
promote the importance and will include the ward work, religious and
of exercise by walking, Information booklets as spiritual resources,
swimming etc. well as, contact cards, a photographs and
notebook, recovery postcards etc, as well as
Groups such as the resources and a blank copies of care plans and
„Personal Recovery activity timetable for treatment plans.
Group‟ are essential in patients to plan out
promoting empowerment

20
And of course, some
groups and interventions
are designed to not only
teach patients essential
life skills but also having
some fun! Weekly
takeaways, DVD nights,
Wii fit groups,
pampering sessions and
games of bingo are all
part of people‟s
everyday routine when
at home. Creating a
sense of „normality‟ in
what can sometimes be a
very „alien‟ environment
is vital in promoting
recovery and wellness.
Weekend cookery
sessions have proved to
be very popular amongst
patients. With guidance
and supervision patients
can cook and bake and
share with the whole
ward, again creating a
sense of unity and
community. We also
have access to the unit
minibus and forthcoming
trips out will be on the
agenda during the
summer months. In
addition to all this, the
21
ward now has dedicated input, support and
volunteers who provide assistance from
regular complementary management, key
therapy sessions, personnel and fellow
offering therapies such Trust departments. One
as manicures, pedicures of these is the
and massages. Again, the „Improving the Inpatient
Liaison Worker role Therapeutic Experience‟
provides a point of initiative which has been
contact and support for a steadfast source of
these highly appreciated guidance throughout the
volunteers. setting up of the TLW
role and has formed a
very constructive
foundation and a lasting
legacy. The Department
of Spiritual and Pastoral
Care have also given a
big helping hand in
establishing groups and
humanistic interventions
on the ward and
offering valuable
assistance and advice.
Furthermore, Therapy
Services for people with
Personality Disorder
have provided
unprecedented support
Of course, all these new and commitment with
enhancements and providing specialist
improvements to the supervision and
ward couldn‟t have been consultancy.
achieved without the
Since the introduction some of the other It is important to
of Nic‟s role as positive comments remember that patients
Therapeutic Liaison received from patients. come into hospital with
Worker, the energy and complex needs. The new
enthusiasm of both ways of working on
staff and patients is Ashby ward is helping to
noticeably improving. ensure that the package
Positive feedback from of care reflects this
patients means that with new modern ways
they are reaping the of working. Hopefully
benefits from the added with the continuation of
input, activity, structure It is encouraging that Nic‟s role, Ashby ward
and therapeutic alliance other wards in the can endeavour to
and finding it wholly Trust are also actively continue to build on
valuable. All groups and working towards what‟s been achieved
sessions are evaluated establishing the TLW thus far and continually
and feedback is heartily role. Hopefully this will aim at improving
encouraged. “I can now also contribute to patient‟s experiences
increase my ability to enhancing the whilst on the acute
cope with my illness” and therapeutic environment wards and facilitating a
“It is encouraging that of these respective smoother and supportive
groups are set up on wards and create robust transition from hospital
recovery/wellness links with the wider to home.
rather than focusing on service.
your illness,” are just

Thanks to St Ann‟s Hospital, Dorset, for photo

22
Talking with very ill patients
Authors: 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 movement considerably instructing, abusing, or

people present their
conversational partners
with a perplexing range
of behaviours and
challenges to normal
social 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 spun
stone skips over water.
Or they might be deeply
depressed, full of
thoughts of guilt and
painful emotions, with
both speech and
slowed. Alternatively all
their emotions might be
flattened, dampened,
unresponsive or
incongruous. They might
be obsessed with
strange ideas and
interpretations of the
world and what is going
on around them, with
these beliefs often
about a hostile world.
Coupled with these
delusional beliefs may
be auditory or other
hallucinations,
commenting on what is
going on around them,
generally interfering
with their ability to
think. In addition to the
distraction caused by
hallucinations, their
thinking processes and
verbal abilities might
also be directly
affected by a variety of
thought disorders. They
may be irritable,
incongruous,
unpredictable, and
perilous conversational
partners until their
illness stabilises.

23
Research on nurse- disordered,
patient interaction on Training in agitated/overactive,
inpatient wards has not communication skills, the upset/distressed or
been uniformly positive. nursing process, nursing irritable/aggressive,
Although the work of models and primary seems to be missing.
the nurses is generally nursing have all been What literature there is
highly regarded by seen as ways to improve over emphasises dealing
patients (Rogers, and increase nurse- with those patients who
Pilgrim, & Lacey 1993), patient interaction. are comparatively well,
and nurses can relate However there seems to and certainly those that
many critical incidents be little guidance on are co-operative,
where their interaction specific skills for insightful, and friendly.
with patients has been dealing with the acutely However many acutely
highly valuable (Cormack mentally ill. Generic psychotic patients on
1983;Flanagan & Clarke communication skills are wards can be deeply
2003), many research well covered, and are unwell, severely deluded,
studies have found low clearly applicable. suspicious, hostile and
rates of interaction, However specific advice aggressive, and
with only 8-21% of on how to spend time incredibly challenging to
nurses time being spent with and respond to spend time with, let
this way (Altschul people who are alone provide care to
1972;Sanson-Fisher, apathetic and and treat. Here the
Poole, & Thompson withdrawn, actively literature and previous
1979). hallucinating, thought work seems to be silent.

24
We therefore decided previously formulated, psychotic patients. We
to undertake a piece of and to draw upon then interviewed them,
research to discover if expertise gained also asking them to
there were untaught, through experience. We nominate others whom
traditional or self- worked with the they knew and thought
developed skills amongst managers and nursing of as particularly
nurses identified as leadership of three expert, a strategy
being highly skilled with London mental health known as snowball
acutely psychotic NHS trusts to initially sampling. The nurses
patients. We were identify a few practicing identified were
looking for traditional qualified psychiatric currently working in
practice learnt perhaps nurses who were community and inpatient
from watching others, acknowledged experts in posts, and we collected
tacit knowledge not working with acute 28 in total.

Analysis of these download from the communication,

interviews took a lot of internet, are covered in vocabulary and timing;
work and consultation seven chapters: moral emotional regulation;
over many months. The foundations; preparation getting things done; and
results, recently for interaction and its talking about symptoms.
published as a context; being with the
monograph available for patient; nonverbal

25
The moral foundations wide consultation of rather than on their
incorporated a complex records and other symptoms, using props,
mix of sometimes people who knew the the local environment or
countervailing patient concerned, what was happening on
imperatives, such as careful observation, the ward as topics, and
notice and do not ignore consideration of the engaging in a joint
the patient, best time and location activity, spiced with
nevertheless avoid to initiate interaction appropriate humour.
intruding and respect and choosing the right Where the patient was
their privacy. Also nurse to make the apathetic and
included were values approach. withdrawn, interviewees
emphasising warmth, talked about developing
care coupled with a high Simply being with a comfortable silence,
degree of respect and acutely psychotic or engaging in a one-
an absence of harshness patients was shown to sided conversation. If
even under the most be a complex activity the patient was
challenging that could require a hallucinating, this had to
circumstances. Honesty considerable number of be tolerated and made
was seen as important, different adjustments, allowance for in the
particularly in relation approaches or conversation, and
to restrictions on interactive techniques. simpler topics chosen; if
patients‟ liberty and the The basic spine of these thought disordered
quality of the service included simply sitting themes could be named,
they received. with the patient or reminders and prompts
spending time with to the topic given,
Interactions were shown them, whilst offering clarifications sought,
to commence prior to light normal things kept simple or
meeting the patient, as conversation, the patient could be
careful preparation was supplemented by the asked to communicate
deemed to increase the nurse introducing him or through writing.
chance of success. Such herself, focusing on the
preparations included patient as a person

26
 a topic in which the useful alternative
patient was an expert communication media.
was judged a wise move, Particular care was
whilst at the same time recommended with
getting them sat down aggressive and irritable
and maintaining clarity. patients, with a non-
threatening nonverbal
There was a perhaps stance being required
surprising quantity of and a cautious choice of
new recommendations the language used.
Robin Williams‟ doodle. about nonverbal
Simple is great. communication, Whilst communicating,
vocabulary and the or in order to do so
timing of interactions. A effectively, nurses had
slow pace, slow speech, to regulate their own
For the agitated or short sentences, simple emotional responses to
overactive patient vocabulary and what patients were
reducing stimulation, repetition within and doing and saying. They
setting interaction across interactions were deemed it most
limits and giving positive recommended. Tone of important not to display
feedback were voice should be both any anxiety in the face
considered to be caring and quiet, of acute psychotic
helpful. When patients interactions being short symptoms, patients‟
were upset or and frequent, with psychological distress or
distressed, normal persistence shown in their overt hostility and
conversation was efforts to communicate. aggression. Being calm
generally felt to be There were times and and receptive in the
inappropriate, similarly occasions when touch face of such patient
in some cases it was and greater use of behaviours was deemed
judged best to avoid gesticulation were more likely to reduce
patients who were judged appropriate, and them – becoming anxious
currently irritable or times when they were more likely to amplify
aggressive. However in not. Writing and drawing them.
the latter case choosing were acknowledged as

27
Similar rendering assistance, symptoms. Following
recommendations were and in some this, for apathetic or
given about becoming circumstances being withdrawn patients, it
frustrated or irritable assertive and forceful. was judged helpful to
with patients When resistance was mutually explore causes,
uncooperativeness, lack based upon delusions, a agree a care plan,
of progress or degree of collusion was develop a routine and
resistance to actions allowed by some nurses purpose, and then take a
which would benefit if balanced by the step by step approach.
them. Finally an patient‟s needs for care. For hallucinating
optimistic outlook was For thought disorder, patients, stress
considered valuable and using gestures as a management,
motivating for patients means of communicating distraction, bolstering
(as well as fellow what was to be done was coping and in some cases
nurses). considered helpful. casting doubt or
challenging the
Attempting to get Talking about symptoms hallucinatory content
things done with with patients was the were considered good
patients (e.g. get them single largest domain in approaches. Gentle
to get up or go to bed, the interviews. questioning or direct
eat, drink, wash, take Absolutely fundamental challenge were also
their medication etc.) to all symptom areas was sometimes deemed
required a whole range the need for nurses to appropriate for the
of additional and hear what patients‟ deluded patient.
different interaction experiences were, Collusion was not
techniques, including accept them, and seek recommended, however
making suggestions to enter and understand sometimes it was
rather than ordering their effect on patients considered appropriate
patients to do things, with caring and respect. to ignore the delusions
giving reasons for the This was clearly a or find workarounds so
task, being flexible, foundation for nursing that patients‟ needs
maximising choice, practice, and was the could be met.
prompting, encouraging, starting point for all
giving positive feedback, other interactions about

28
In the case of upset and collaboration between and violence might be
distressed patients, nurses and patients. If reduced, either through
interviewees talked so the delivery of the easier
about staying calm, medication, accuracy of accomplishment of
keeping patients talking, assessments, and necessary tasks with
persisting to find out physical health status of patients, or through
the cause, and taking patients might all be more effective and
action to relieve the improved. rapid de-escalation with
cause or exploring other irritable, agitated and
solutions with the aggressive patients.
patient. Responses on
agitation, overactivity, As the risk of suicide
irritability and The expert nurses amongst inpatients is as
aggression were not recommended much of a problem with
clearly distinguishable psychotic patients as it
exercise,
and were therefore is with those who are
distraction,
considered together. depressed (Bowers,
The expert nurses relaxation, avoidance Nijman, & Banda 2009)
recommended exercise, of confrontation, it is a possibility that
distraction, relaxation, explaining the better communication
avoidance of reasons for actions would reduce social
confrontation, explaining isolation and hence risk.
and rules,
the reasons for actions Finally it might be
and rules, negotiating
negotiating advance supposed that patients
advance directives and directives and who are in receipt of
forceful containment. forceful such a highly skilled
containment. approach might have a
What would be the greater satisfaction
outcome if all nurse- with the care they
patient interaction was receive and potentially
informed by and applied be more willing to be
the techniques reported admitted to hospital on
by this study? They subsequent occasions,
would certainly seem to without the use of legal
enhance the possibility It also seems logical to detention.
of cooperation and conclude that aggression

29
What is described here
could also be widely
useful to other
professionals who have
to deal with acutely
mentally ill people
(police, ambulance
personnel, social
workers, general
practitioners and
psychiatrists), and to
family and friends of
the mentally ill, many of
whom have few sources
of concrete advice on
how to deal with the
situations they face in
their daily contact with
people who suffer
psychotic disorders.

The identified expert responses is the understanding of

group were able to
identify a positive range
of balanced behaviours,
attitudes and techniques
they utilise to reach
people suffering from
psychotic symptoms.
What also seemed to be
a feature of the
creative flexibility the
group took in any given
situation. As
researchers and fellow
practitioners it is
gratifying to be in the
position of sharing
these in an attempt to
further expand our
something so crucial to
the care of people with
mental health problems.
We offer the results of
the research as food
for reflection,
discussion and debate.

References
Altschul, A. T. Patient-Nurse Interaction A Study of Interaction Patterns in Acute
Psychaitric 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.

30