BACKGROUND: Despite increasing changes within mental health services, time spent with patients is still an issue of concern. A protected time initiative was introduced in a mental health acute care unit with an agreed protocol to enable nursing staff to spend more time with patients.
AIM: To investigate the implementation of protected time in the unit.
METHOD: Patients and nurses in four wards were invited to complete questionnaires.
RESULTS: Sixteen nurses and 17 patients responded. The results suggest a variety of reasons why nurses do not spend sufficient one-to-one time with patients. Patient responses were inconsistent and at times contradictory and the findings suggest nurse supervision needs to be more readily available.
CONCLUSION: A clearer understanding of protected time and a consistent approach are required, as well as venues that allow patients to discuss sensitive issues without being disrupted.
Edwards, K. et al (2008) Evaluating protected time in mental health acute care. This is an extended version of the article published in Nursing Times; 104: 36, 28-29.
Keith Edwards, PhD, MA, BA, Cert Ed, RMN, RNT, FHEA, is principal lecturer, Faculty of Society and Health, Buckinghamshire New University and West London Mental Health NHS Trust; Ajay Dhoopnarain, MSc, RMN, is CPN team leader; Jennifer Fellows, Dip HEd, RN (MH), is lead nurse; Michael Griffith, BA, RMN, RGN, is ward manager; Declan Ferguson, RMN, is ward manager; Lungi Moyo, Dip HEd, RN (MH), is lead nurse; Nicola Adamson, Dip HEd, RN (MH), is ward manager; Archibold Chaurura, Dip HEd, RN (MH), CertEd, is ward manager; all at Lakeside Unit, West London Mental Health NHS Trust, Hounslow, Middlesex.
There has been much criticism and concern regarding how mental health patients spend their time on hospital wards.
For example, Edwards (2000) suggested that nurses do not spend sufficient time with clients on a one-to-one basis to explore their mental health problems and needs. Similarly, the Department of Health (2002) called for improvements to ‘ensure adequate clinical and support inputs to inpatient wards and to maximise the time spent by staff therapeutically engaged with service users’.
Later research, also by Edwards (2005), suggested that not much had changed and Yawar (2008) reported that only 16% of patients’ time was spent in ‘what can loosely be termed therapeutic interaction’. The remaining 84% was spent aimlessly either pacing up and down the ward or sitting around doing very little.
The Mental Health Act Commission (MHAC) (2008) reported that ‘nurses frequently complain of being too busy to develop therapeutic rapport with patients’.
The MHAC (2008) recommended the following:
- All hospital wards caring for detained patients should instigate ‘patient protected time’ schemes, where patients are guaranteed time with nursing staff apart from all other distractions;
- Ward managers should audit the performance of protected time schemes, keeping records of problems in observing protected time and taking account of patient experience.
Introducing protected time
A team of nurses involved in this project acknowledged that spending productive time with patients is probably the most difficult job for nurses. The majority of their time was seen as ‘firefighting’, that is, time is completely taken up dealing with current problems with insufficient time left to prevent future ones. This becomes a cycle that is difficult to break as new problems constantly replace the old ones.
These issues were discussed within the trust and we introduced ‘protected time’ as a way of working in our own areas. This was defined as a designated period when only ward-based staff would be present, to ensure they were not constantly interrupted by other people’s demands.
Two periods in the week were initially identified. These were Tuesday and Thursday afternoons (3-5pm). These times would be spent offering one-to-one sessions, although it is important to stress this did not preclude individual sessions outside this time. The designated time could also be used to provide supervision for staff to enable them to be more effective in the sessions as we realised some staff lacked confidence or experience in such interventions.
This initiative had already been introduced in other parts of the trust; we hoped patients could receive uninterrupted one-to-one sessions and promote positive change to enhance standards and overall quality of care. We accept the ideal situation would be one whereby there is no need for protected time and the practice of one-to-one sessions with nurses becomes the norm.
The notion of protected time is not new and such initiatives are supported in the Chief Nursing Officer’s review of mental health nursing (DH, 2006). Other trusts (for example, in Derwen, Oxfordshire and Pembrokeshire) have introduced such practices but the extent to which they are successful and have been evaluated is unknown.
Hence, a year on from its introduction, we felt it was important to evaluate and reflect on the initiative’s progress. We also aimed to identify what needs to be done to consolidate the practice of one-to-one sessions.
This was the agreed protocol for protected time:
- Protected time takes place at 3pm-5pm every Tuesday and Thursday;
- During this time ward staff will not be expecting any visits from relatives or carers or any member of the multidisciplinary team;
- Visiting hours on Tuesdays and Thursdays will be at 5pm-8.30pm;
- Meetings between relatives and doctors will be arranged outside protected time;
- The response nurse system for all emergency alarms will need to continue during these hours;
- During protected time the ward will remain open for all emergency admissions via community teams.
Protected time will involve the following tasks for staff:
- A one-to-one session with nurses’ allocated patients;
- Inpatient care coordinators to meet patients and complete assessments during their sessions;
- Care coordinator to review nursing care plans, and give copies of weekly ward round sheets to patients;
- All staff including healthcare assistants to be able to offer a time when they can speak to allocated patients and be able to commit to this;
- Ward diaries to be used to arrange individual sessions;
- Attendance at planned occupational therapy activities will not be interrupted.
During protected time:
- Nursing staff will not answer ward phones;
- All phones will be diverted to an answerphone and any messages left will be responded to after 5pm;
- Callers are encouraged to leave only urgent messages and general enquiries should be made outside these hours;
- The unit coordinator can still be contacted during protected time via the bleep system.
Aim and method
This study aimed to evaluate the implementation of the protected time initiative. A nurse research interest group had been set up. Meeting monthly, it has a wide remit that includes promoting the best available evidence and strengthening nurses’ capacity to undertake research.
After much discussion this group took on the task of devising questionnaires to seek nurses’ and patients’ views about protected time. In keeping with the trust’s protocol, I submitted a proposal for ethical approval and the audit department gave permission to carry out the evaluation.
The unit has four wards and all nursing staff and patients were invited to complete the questionnaires. A timescale was set and information sheets and questionnaires were made available from a box on each ward. A sealed box was provided for participants to return them, thus ensuring anonymity.
The nurses’ questionnaire comprised 14 questions with 10 Likert-scale questions that asked respondents to tick the relevant box:
1=agree completely; 2=mostly agree; 3=it depends; 4=mostly disagree; 5=completely disagree. A column asked for comments in relation to each question.
The four remaining were open-ended and sought qualitative data. The patient questionnaire was similar, with a combination of questions on a Likert scale with space for adding comments.
The response rate was 16 nurses and 17 patients. The following findings are presented to convey participants’ verbatim accounts, as we felt this would be left to readers to interpret. However, some interpretation and meaning is also offered in the discussion.
Table 1 presents nursing staff responses to the 10 Likert-scale questions. Responses to the open-ended questions are outlined below.
One open-ended question asked nurses how they perceived their responsibilities and role in patient protected time. The written responses were almost unanimous in recognising they had responsibilities to engage with patients and welcomed the opportunity to do this without other demands.
Comments included: ‘Being able to talk to patients in depth about their feelings, listening to them and allowing them to ventilate their feelings’ and ‘One-to-one quality time with allocated patient and not to answer telephones or be in the office but to be with patients in a place of their choice’.
One comment suggested certain reservations: ‘Better if staffing levels increase during those days, my responsibilities increase with not enough staff and a fear of things going wrong with difficult patients on the ward.’
The questionnaire also asked nurses how often they received supervision and from whom. Overall, responses suggested that supervision is inconsistent and does not focus on enhancing skills for one-to-one sessions. The majority of comments indicated that supervision takes place monthly, two said ‘as required’ and three suggested ‘none really’, ‘never’ and ‘not as often as I would like’. Nurses did not indicate who their supervision was from, other than a couple of comments suggesting the ward manager.
Nurses were also asked what changes they would like to see to the protected time system. They mentioned the need for more regular staff as staffing levels determine the amount of time that can be protected.
Two respondents suggested the day needs to be changed. These two comments gave opposing views: ‘One hour is not enough for staff to utilise with protected time as well as writing in the patients’notes’ and ‘Shorten the time because patients don’t want to spend a lot of time speaking to us.’
The last question asked nurses to make any other comments on protected time. Responses included:
‘Need to be flexible when the ward is unsettled, may need to postpone PT.’
‘Some of the time to be used on our paperwork.’
‘The protected time gives nurses more opportunity to be able to have more quality time with patients and also to give them relevant information about their care.’
‘Places good emphasis on patients and staff spending time together.’
‘Most of the patients don’t want to participate; they don’t want to talk even after explaining to them what it is for. Mostly they say they have nothing to talk about.’
‘Currently it is pretty much a waste of time. Patients seem to actively avoid it, by going out of the ward or retiring to their bedrooms, probably because there is nothing interesting going on. It is a good time for nurses to have one-to-ones with their patients but healthcare assistants don’t really know what to do to use the time in a beneficial way.’
Question 1 asked patients how long they had been admitted to the ward (Table 2). This reflects a diverse range of lengths of admission and therefore the opportunity to have participated in the protected time initiative.
Table 2. Length of stay on the ward
|< one week||1|
|2 - 4 weeks||6|
|> 1 month||3|
|> 2 months||1|
|> 3 months||2|
|> 1 year||3|
Two questions asked patients whether they had had two sessions a week of protected time with their allocated nurse in the last month, and how long these had usually lasted. Eight said they had had two sessions a week, eight said they had not, and one said they did not know (Fig 1). Patients reported a range of different lengths of sessions, from over two hours to less than 30 minutes (Fig 2).
Patients were also asked to rate the environment in which sessions took place. Three said it was excellent and three said good, while five said alright, two said there were some problems and two said it was poor (Fig 3).
Additional comments included:
‘In a room where everyone can see you, very frustrating.’
‘It was in my room, everything went really well.’
‘Like a fish in a bowl.’
‘My nurse only talks to me when I have been bad.’
When asked what they normally discussed, patient comments included:
‘About welfare and medication.’
‘About my needs.’
‘Nurse only talks when I have been bad.’
‘Bad things I have done.’
‘Talk about children and when I can go home.’
‘About my health and progress.’
‘How to cope with situations at the moment’.
The questionnaire sought patients’ views on how useful the sessions were. Three said they were very useful, seven said useful, two said it depended, two said they were not usually useful and one said never useful (Fig 4).
Additional comments were:
‘Only get negative attention.’
‘They are very helpful and good.’
‘Depends on mood and who you are talking to.’
‘Sessions are good.’
‘Named nurse should come and speak to me; they are usually too busy speaking amongst themselves. Are they office staff or are they there for the patients, they make me feel very frustrated.’
When asked how they would like to use this time with their allocated nurse, patient responses included:
‘Find the right treatment and praise when I have not hurt myself.’
‘In a group with other patients.’
‘Anything that you want to talk about, but there are people hanging about and frustrating when you want to talk.’
‘Talk about what I need in hospital.’
‘One-to-one sessions at a convenient time and not hurried.’
‘To see how I am progressing and finding out when I’ll be getting out.’
Patients were asked whether there had been any problems with their sessions in the past month (Table 3).
Table 3. Problems with session in the past month
|Time not suitable||1||1|
|Day not suitable||3|
|Lack of privacy||2|
Two additional comments suggested ‘there was insufficient time to discuss issues’ and ‘if staff were more approachable it would be better’.
One question explored whether the sessions helped patients to feel good about their treatment, their care and/or their relationship with staff (Table 4).
Table 4. Impact of sessions on patients’ feelings
|Yes, a lot||2|
|Yes, in some ways||7|
|No not much||4|
|No not at all||1|
Additional comments included: ‘Always tell me things that I have done wrong, never how to improve them’, ‘If staff were more approachable’ and ‘Having a timetable, sometimes the nurses are patronising and have not been through what I have been through.’
Patients were also asked how the sessions could be improved. Comments included:
‘Okay for now.’
‘By staff listening to my opinion and give advice on issues.’
‘Spend more time with our allocated nurse.’
‘Keep it to half an hour and talk about important things.’
‘Daunting to approach staff hanging around the office, it would be better if they came to your room.’
‘More nurses, female.’
‘By letting patients know that it is happening.’
Other general comments included:
‘A timetable on times when one could help and staff should be more prepared to talk to patients as I feel they often cannot be bothered or do not really want to talk. They often seem like they are in a rush to get on and do something else.’
‘I think it is a waste of time and I take more notice of my partner than staff as staff don’t listen or do anything they say they do, you don’t get treatment, on this ward you get drugged up.’
‘I like doing gardening, shopping and nurses are busy and helpful.’
‘Could have been helpful if I had known about it.’
Overall nurses’ responses (Table 1) recognise the potential and advantages of such a system. The greatest concern tends to be about staffing levels and how this affects the continuity and consistency of the protected time initiative.
The open-ended questions also identified a number of positive aspects but, again, the issue of staffing appears to be of concern. The RCN’s (2007) survey of mental health nurses showed 66% of respondents considered staffing numbers were insufficient and 42% reported that low staffing levels compromised patient care at least once every week.
Other comments suggested patients did not want to participate. This last point may reflect the ambivalence of some nurses.
While the number of available staff does play an important part in enabling nurses to spend more time engaging in one-to-one relationships with patients, it could be argued the issue is more to do with how staff prioritise their work.
Administrative tasks are cited as a reason for not being able to spend much time with patients.
However, Menzies (1960) suggested nurses create systems as a defence against anxiety about engaging with patients’ distresses and disorders. This may be difficult for some nurses because some of these issues may also be concerns and traumas of individual staff. Clarke (2008) suggested that nurses can be affected by vicarious trauma and it may leave them emotionally overwhelmed. This is where supervision should play its part and this study suggests its availability is inconsistent. This research demonstrates that nurses can acknowledge positive aspects as well as shortcomings, both within themselves and in the service.
Patients’ responses are equally inconsistent and at times contradictory. Respondents’ length of stay varied, which meant they could give an informed view of protected time. Periods of admission varied from under one week to over one year. Not all patients appeared to receive regular one-to-one sessions but those who did said they were satisfied and sessions were useful.
The environment in which the sessions take place is an issue that requires monitoring as some patients expressed concern regarding privacy and confidentiality, as well as timing.
The responses above show certain ambiguities but also opportunities to take things forward. Within the context of recovery-orientated practice, Borg and Kristianson (2004) concluded that ‘the key characteristics were openness, collaboration as equals, a focus on the individual’s inner resources, reciprocity and a willingness to go that extra mile’. Regular one-to-one sessions can certainly be a vehicle for promoting such a culture but this can only be achieved by nurses who feel supported, skilled and up to date with developments in mental health nursing.
The type of service that patients want is a client-centred one. Many government and trust initiatives are promoting changes in culture towards helping people to build meaningful lives. The relationship between clinicians and patients should be one of partnership to achieve this.
Protected time can be a way of helping to promote nurses’ therapeutic role but, without adequate supervision, they may well withdraw into a custodial role as a defence against their own vulnerability and lack of expertise. As has been acknowledged, mental health nursing is not a straightforward or easy task. However, nurses have to try to make sense of the difficulties and complexities in patients’ lives.
Recommendations and implications for practice
This project has found much variation in practice. These recommendations bring together the study’s main findings with the aim of improving services.
- The findings should be shared at ward level and discussed with relevant senior managers.
Some nurses feel they do not have sufficient opportunities to express their concerns and sharing the findings can serve as a point of reference to bring many issues out into an open forum for discussion. It is important that the discussion is focused not only on staff at ward level but also with senior managers in terms of support and effective leadership.
- Supervision needs to be monitored and made available regularly so all staff are able to share difficulties and concerns.
Unfortunately, there appears to be some confusion over what supervision should entail as well as its regularity. Proctor (1988) defined three tasks of supervision: normative, that is, taking responsibility for standards and ethics; formative - sharing responsibility for developing professionals’ skills, knowledge and understanding; and restorative - providing opportunities for recharging emotional batteries.
- There is a need for regular and consistent protected time sessions, as well as one-to-one sessions outside these times.
Unfortunately, the dominant culture is not one in which one-to-one sessions are seen as a vital and regular part of the working day. This needs to change, with protected time a vehicle to ensure it occurs.
- A clearer understanding of the purpose of protected time should be established for all nurses and patients involved.
If nurses are unsure of what is expected of them, they will be set up to fail. Hence it is important that the concept of protected time is analysed and digested to develop a thorough understanding by all involved.
- The role/ability of HCAs needs to be clarified regarding their possible involvement.
Some HCAs are able graduates and could take on more responsibility, with supervision. It was reported that some already spend one-to-one time with patients on an informal basis.
- The venue should allow more psychological safety for patients to be able to discuss sensitive issues.
Both patients and nurses can experience a variety of emotions during one-to-one sessions, so a private and comfortable environment without constant interruption is essential. The nursing office or a corner of a lounge is simply not good enough.
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