VOL: 98, ISSUE: 48, PAGE NO: 26
Nick Bowles, MA, BA, RMN, is senior lecturer, School of Health Studies, University of BradfordPeople admitted to acute psychiatric settings are among the most vulnerable and disturbed mental health patients. They require a high level of engagement, including supportive interventions, one-to-one time with a named keyworker and a range of social and therapeutic activities. Evidence shows that patients place a high value on the time that care workers spend with them (Jackson and Stevenson, 1998; Bowles et al, 2001).
People admitted to acute psychiatric settings are among the most vulnerable and disturbed mental health patients. They require a high level of engagement, including supportive interventions, one-to-one time with a named keyworker and a range of social and therapeutic activities. Evidence shows that patients place a high value on the time that care workers spend with them (Jackson and Stevenson, 1998; Bowles et al, 2001).
However, there are signs that patients rarely receive this level of service. They might receive little more than a few minutes per day with a worker (Mind, 2000). There is often a lack of structured activities (The Sainsbury Centre for Mental Health, 1998) and relationships with staff have been described as 'passing' (Higgins et al, 1999). These factors are unlikely to promote recovery or help staff to assess and plan care.
There are numerous reasons for this lack of engagement, including insufficient time and lack of trained staff. However, it may be that acute wards are not set up to provide high levels of engagement. If services valued such engagement it would be managed as rigorously as, say, risk management. Engagement would be a focus for data collection, audit, performance management and supervision. However, commonly it is not.
There may be several reasons that engagement is not treated as a priority. The most dominant practice in acute psychiatry has become formal observation, often a demanding, boring and ritualistic pastime of precious little benefit to the patient. After a few hours of carrying out 'obs', few nurses wish to spend further time with patients.
In addition, the atmosphere on acute wards can be fraught. Violence and aggression are increasingly common, and staff may sometimes feel the ward is out of control and that they have few options to deal with antisocial behaviour. This generates an adversarial climate in which staff are perceived, and perceive themselves, as custodians and are usually striving to maintain control.
The constant risk of adverse events takes its toll on nurses and may lead to distant, disengaged behaviour. Patients learn that acute wards provide little support, structure or help, other than medication. They may respond with apathy, disengagement, anger and aggression. Both staff and patients end up with low expectations, which contribute to a 'pact of apathy', with a sense of diminished personal responsibility on both sides. Staff show low engagement and low commitment to change; patients avoid engagement, become inert and more likely to act out rather than talk through their distress.
Solution-focused communication skills
The need to address this situation is recognised in the Department of Health's new policy on adult inpatient care (DoH, 2002). It acknowledges that in environments where there is a high level of therapeutic intervention and interaction, the amount of disturbance, violence and boredom is diminished. It also argues that inpatient nursing depends on relationships and that a culture of engagement should be fostered.
The approach must be perceived by patients and staff as useful, and must not make excessive demands on staff. It must be appropriate for use within the short time patients stay on acute wards and suitable for when they are at their most ill. Finally, it should require only a short period of training to make it cost-effective and to ensure that staff time spent away from practice is minimised.
Solution-focused communication skills meet these requirements. They are quickly taught and may be used in almost any context. For example, a nurse could use them to engage a patient in a brief chat over a drinks trolley or in a formal 40-minute session. There are almost no contraindications other than the usual judgements experienced workers make about patients' mental state.
Acute ward nurses as therapists?
Most ward-based staff would not describe themselves as therapists. They would probably wish for nothing more than a simple set of skills to use without significant change to the pattern of their working day. This last point is crucial - it is pointless to train staff in skills that their workload does not permit them to use, a lesson many educators, commissioners and graduates of lengthy psychological interventions courses are still learning.
Solution-focused conversation is something that all direct care workers can engage in. With a few days training they may use it to construct meaningful therapeutic dialogue even with people who are very unwell, disorganised or who have a limited attention span.
The solution-focused approach to engagement is both radical and simple. The care worker seeks to elicit, amplify and reinforce the patient's strengths and resilience, in contrast to the deficit/illness model in which most people have been socialised.
The worker begins by seeking collaboratively to develop a vision of a 'preferred future' - a picture of the patient in the near future when things are beginning to improve. This often motivates patients and reminds them that they have often taken steps towards their goal, promoting their sense of competence. One technique used to elicit this vision is the 'miracle question' (Box 1).
Patient and worker then work with this motivation in a spirit of optimism and belief that change and improvement are possible. This sort of interaction may be termed a 'constructive conversation', which is founded on the premise that solely talking about problems and deficiencies is not enough to mobilise change in the patient.
Solution-focused conversations are structured (Box 2) and make few demands on the care worker, other than the need to believe that change is possible and to maintain a collaborative spirit. Consequently, staff evaluate them positively (Bowles et al, 2001).
Staff trained in and familiar with the approach are more likely to engage with patients, experiencing a sense of worth and a reminder of their own value as therapeutic agents.
Structured, high levels of engagement make for more therapeutic, calmer and safer acute wards. However, many acute staff have become socialised to a low engagement, defensive culture or have little time or training to do anything else.
Solution-focused techniques are quick, easy and cost-effective to learn. They provide a structure for effective, brief interventions with a wide range of patients, including the very ill, and help to promote collaboration and patient responsibility without making huge demands on the care worker.
They aim to focus on positive outcomes and active change, however limited, in the context of what are usually relatively brief admissions to inpatient wards. As such they offer a different therapeutic climate for patients, allowing them to reflect on their strengths, resilience and healthy coping mechanisms, while nurses can draw upon a sense of therapeutic direction and purpose in what is undoubtedly one of the most difficult areas of nursing.