This study explores the barriers to effective interaction between nurses and service users in acute settings
In this article…
- Developing a therapeutic relationship with service users
- Challenging stigma and promoting client engagement
- Improving the efficacy of one to one sessions
- Helping nurses make the most of their existing skills
Keith Edwards is part time associate lecturer at the Open University and former joint appointee as a principal lecturer in mental health at Buckinghamshire New University and West London Mental Health Trust.
Edwards K (2010) What prevents one to one care? Nursing Times; 107: 1, early online publication.
Background In 2007, West London Mental Health Trust was visited by the Healthcare Commission (now the Care Quality Commission), which identified a number of issues requiring attention. One major concern was the lack of effective interaction between nurses and service users in acute care. A study was set up to investigate the reasons for this, and what could be done to improve care.
Aim To determine why mental health nurses on acute admissions wards struggle to spend one to one time with service users, and what can be done to address the problem.
Method Interviews with four senior nurses were conducted to identify any initial concerns and problems. This information was then used as a basis for semi structured interviews with all 11 acute admissions ward managers at the trust.
Results Five common themes were identified from the interviews as the major barriers to one to one care: administrative duties; understanding one to one sessions; control over workload; staff needs; and ward culture.
Conclusion The trust has started to address the issues identified by the study. Staff training and education have been improved, and policies implemented. The study is a small one, so replicating it nationally would help give a better overall picture of this issue in mental health services.
Keywords: Therapeutic engagement, Mental health, Service user, One to one
- This article has been double-blind peer reviewed
- Look at ward administrative duties to see how time can be released for one-to-one working. Implement the NHS Institute for Innovation and Improvement’s Productive Ward scheme.
- Give staff the training they need to feel capable of engaging with service users.
- Ward managers need to assert themselves and take control of everyday events.
- Staff supervision needs to be consistent, supportive and carried out by appropriately trained, competent and experienced staff.
- The culture of acute wards needs to be kept under constant scrutiny so that the notion of therapy rather than containment is the philosophy of care.
Mental health nursing is complex and demanding. A fundamental part of the role of the mental health nurse is forming a therapeutic relationship with service users, and their family or significant others.
Recent government policies, including the Department of Health’s Refocusing the Care Programme Approach (DH, 2008) and Essence of Care benchmarks for communication (DH, 2010; 2008) back this approach, as do many researchers who believe this relationship is the core of psychiatric or mental health nursing.
Nolan (1993) suggests the great strength of mental health nurses is their closeness to clients, while Wilkin (2003) says the emphasis of mental health nursing is on the development of a therapeutic relationship or alliance. Reynolds (2003) also stresses the importance of “one to one” working, believing that a therapeutic relationship is the crux of nursing. In practice, this means the nurse should seek to engage with the person in their care in a positive and collaborative manner. This empowers service users to draw on their inner resources, in addition to any other treatment they may be receiving.
The Mental Health Foundation supported greater access to talking therapies, (www.mentalhealth.org.uk/campaigns/we-need-to-talk) and the recovery approach within mental health services has become a guiding vision that promotes the need to work in partnership with service users (Chandler, 2010; Shepherd et al, 2008).
However, this is only possible if nurses spend quality time with service users. According to the NHS Institute for Innovation and Improvement (2008), ward nurses in acute settings spend around only 40% of their time on direct patient care.
This project was initiated after a 2007 visit to West London Mental Health Trust from the Healthcare Commission, (now the Care Quality Commission), which identified a number of issues that required investigation (Mental Health Act Commission, 2008). The commission questioned service users and staff at the trust, and looked at a wide range of services. This resulted in a number of further visits to monitor progress.
One major concern was that interaction between nursing staff and service user interaction needed to be more effective. Service users told the commission they often felt their care plan could apply to anyone, and was not personal to them. Achieving truly personalised services can depend on challenging stigma and stereotypes about mental illness among medical and nursing staff, and service users should be recognised as individuals, not simply categorised by legal status or diagnosis.
The commission suggested that services should provide individualised, holistic care that promoted recovery and inclusion, and that service users and carers must be involved in care planning. It also recommended that efforts should be redoubled to ensure that ward staff actively engaged with service users wherever possible.
In response to the commission’s concerns, a project was set up to investigate the discrepancy between the role of the mental health nurse described in the literature and the actual practice of mental health nursing at the trust.
A meeting was set up with four senior nurses from the trust’s acute care services to identify key concerns regarding staff spending time with service users.
The hourly meetings were conducted on an informal, one to one basis to give the nurses the opportunity to state their concerns and priorities.
Notes were taken and sent back to the nurses for confirmation. The issues identified are outlined in Box 1.
Box 1. Key concerns identified by senior nurses over time with service users
- One to one sessions with nurses and service users need to be more integral to the working routine.
- The focus of these sessions needs to be more transparent to remove confusion around the nature of the sessions. A working definition of one to one sessions needs to be developed and agreed.
- The ability to engage in therapeutic relationships is often compromised by nurses having to take on containment roles.
- Nurses need development and support to become therapeutic agents, rather than just adopting a custodial role.Regular audits should be conducted with both nurses and service users to ensure one-to-one sessions happen frequently enough.
- Sessions need a clear structure.
- Resources are needed to develop staff and ensure there are enough staff to cover for absent colleagues. The nurses felt that many bank or agency staff showed limited commitment and made little contribution while employed in a temporary capacity.
- Nurses are expected to have one to one sessions with each patient on their caseload at least twice a week. However, these fluctuate between planned sessions and taking place “on the hop”.
- Healthcare assistants also spend time with patients one to one, but often they are seen as working beyond their role with very little ongoing training. Some are very able while others are perceived as “plugging the holes in the service”.
- Bed occupancy and staffing levels are not always synchronised. This leaves nurses feeling they have little control over admissions. They also feel disempowered when others make decisions that affect their work and the time available to spend in one-to-one care with service users.
The initial meeting provided a baseline for the project. We decided that all ward managers in acute areas within the trust would be contacted as these were the people running the wards and providing leadership.
Eleven ward managers, representing all of the trust’s acute wards, were interviewed. The project used the issues identified in the first phase as the focus for semi-structured interviews with the ward managers. A combination of preset topics and follow up probes encouraged the participants to elaborate on their responses. There was no questionnaire, but a crib sheet was used to explore the initial topics identified systematically.
All the nurses had a very positive attitude towards doing their jobs effectively. Despite this, they said that one to one sessions with service users did not take place in a consistent or efficient manner. Some said that sessions only occurred at weekends or in the evenings when other professionals were not around. This suggests it was not seen as part of the core work of the nurse.
The data from the interviews was collated and subjected to a content analysis. The following five themes emerged from the study:
The nurses said there was too much administrative work, as most activities that take place during a shift had to be recorded. They said administration was taking priority over staff spending sufficient time engaging with service users on a regular, one to one basis.
Discussions focused on a whole range of administrative tasks, from making and answering phone calls to writing in the ward diary and in service users’ notes.
Employ a full time administrator for each ward could prove to be a more efficient use of resources than having nurses carry out so many office tasks. Writing in service users’ notes could be done during one to one sessions.
A clear message from the discussions was a lack of understanding of what one to one sessions should entail, or how long the sessions should be.
Although a lot of discussion takes place during interactions with service users, such as assessments or medication rounds, time was not always set aside to specifically engage with them in a therapeutic way.
It was felt that psychiatrists or psychologists were more likely to set up fixed appointments for therapeutic intervention, whereas nurses were only able offer one to one sessions when they could fit them in.
The ward managers also acknowledged that it was difficult to engage with disturbed and demanding service users. Comments indicated that staff thought some service users were seen as a “lost cause”, especially those who were regarded as “revolving door” readmissions, and those with a personality disorder diagnosis were seen as “incorrigible”.
This was frustrating for staff who felt too familiar with the service user and did not know how to engage with them in a meaningful way. Some staff did not know how to engage with these service users, while it was suggested that others “could not be bothered” and merely adopted a containment approach.
It was suggested that developing guidelines and structuring one to one sessions and interventions would help. Not all staff have the skills or confidence for effective one to one engagement, so staff training needs were also identified. Although a lot of opportunities are available for educational and personal development for staff, mandatory training had precedence over other training and education that could enhance staff ability.
Ward managers felt they had little control over their workload, and that bed management was dictating the pace of work. People were being admitted to wards without those doing the admitting having any real understanding of the staffing levels and the demands on the wards. The message appeared to be: “You are an admissions ward so must accept admissions.” Other comments included:
- “There are too many service users in seclusion.”
- “One to one observations take up too much time.”
- “Psychiatrists want many admissions immediately put on one to one observations. This depletes staff availability for more therapeutic and structured one to one sessions.”
Other concerns were that escort duties took up a lot of time and reduced staffing levels, and a lack of consistency or continuity with bank staff.
The ward managers felt it was the nurses who dealt with the real difficulties on the wards, while the other professionals just “come and go”.
Nurses said they tried to engage with service users at least twice a week regarding care plans, although this differed from ward to ward. Some suggested that more “protected time” could help with regular appointments (Edwards et al, 2008).
Staff training and supervision were major concerns; one to one sessions, when they did take place, varied depending on the level of training and support that staff had received. It was suggested that involving former service users and role modelling by senior staff could be beneficial.
Some ward managers thought some staff were “burnt out” and not truly engaging with service users. They also thought the admissions process was not well thought out with regard to staffing levels, and there was no appreciation of the psychological needs of staff. Staff sickness was seen by some ward managers as a metaphor for stress and staff wanting personal space.
Some long term staff were seen as resistant to engaging on a one to one basis with service users and quite content to function in a containment role.
Recruiting and replacing staff was also a concern as it led to a greater burden on regular ward staff. It was expressed on a number of occasions that agency or casual staff did not have the same level of commitment as regular staff.
In some areas, support from service managers was seen as very positive, with clear leadership and good teamwork. However, it was suggested that overall supervision needed to be improved.
Supervision for staff was said to occur monthly in most areas, but was not always seen as successful. When group supervision took place, it was felt that facilitators did not always have the necessary skills or confidence and were ill prepared for effective group supervision.
The ward managers felt that administrative issues, such as the recording of the number of admissions, discharges and incidents, took precedence over contact with service users. This was the dominant culture on the wards and was seen as having greater importance than valuing human contact.
Staff attitudes were also highlighted. It was felt that new members of staff could feel stifled by established staff seniority, and the negative stereotypes attached to service users with conditions such as personality disorders.
It was also suggested that some nurses found it difficult to adopt a therapeutic role and give greater priority to managing and containment. Coping or getting by was seen as the dominant cultural expectation of many nurses, rather than engaging proactively, effectively and meaningfully with service users.
There also appeared to be conflict over whether acute wards should provide therapy or containment, and it was suggested that getting the right balance could be difficult. One to one sessions were conducted on a casual basis and targets for admissions and discharges took precedence over time for compassionate care.
Nursing on acute mental health wards was seen as a high pressure job, and it was suggested that during quieter periods some nurses metaphorically put their feet up to recharge their batteries.
The benefits of working one to one with mental health service users are evident from the literature, but this study revealed many barriers to this therapeutic process.
According to the Royal College of Nursing (2007), four in 10 nurses working in mental health believe they are not able to make full use of their skills.
If service users do not receive regular therapeutic intervention from nurses, it has to be questioned whether they are actually being treated or simply contained. The extent to which mental health nursing is still rooted in its more custodial historical past requires further discussion.
However, it must be acknowledged that a lot of progress has been made at the trust since this study was conducted. Education and training to help nurses increase the amount of direct care time given to service users has improved, and the trust has also adopted Releasing Time to Care - the Productive Mental Health Ward (NHS Institute for Innovation and Improvement, 2008).
Improvements at the trust have been acknowledged by the Care Quality Commission, and work to increase the amount of one to one time service users spend with nurses continues.
This small scale study has identified some of the issues and concerns around one to one care for mental health service users and how these can be addressed.
However, as the study was only conducted at one trust it is impossible to say whether the findings would be the same elsewhere. Replicating the study nationally would enable us to see if other mental health trusts have faced similar issues, and what they did to improve practice and ensure nurses and service users can work together to facilitate therapeutic care.
Despite possible threats to healthcare spending due to the current economic climate, it is hoped the continued support and development of mental health services will remain a priority.
Care Quality Commission (2008) Mental Health Act Commission Annual Report. West London Mental HealthNHS Trust. London: CQC.
Chandler, R (2010) Making Recovery a Reality – a Lived Experience Perspective of the Sainsbury Centre for Mental Health Workshops. London: SCMH.
Department of Health (2010) Essence of Care 2010. Benchmarks for Communication. London: DH.
Department of Health (2008) Refocusing the Care Programme Approach. Policy and Positive Practice Guidance. London: DH.
Edwards K et al (2008) Evaluating protected time in mental health acute care. Nursing Times; 104: 36, 28-29.
Mental Health Foundation (2006) We Need to Talk Campaign. London: Mental Health Foundation.
NHS Institute for Innovation and Improvement (2008) Releasing Time to Care: the Productive Ward.NHS Coventry: Institute for Innovation and Improvement.
Nolan P (1993) The History of Mental Health Nursing. London: Chapman and Hall.
Reynolds B (2003) Developing therapeutic one-to-one relationships In: Barker P (ed) Psychiatric and MentalHealth Nursing: the Craft of Caring. London: Arnold
Royal College of Nursing (2007) Untapped Potential: a Survey of RCN Members Working in Mental Health. London: RCN. tinyurl.com/untapped-potential
Shepherd G et al (2008) Making Recovery a Reality. London: Sainsbury Centre for Mental Health.
Wilkin P (2003) Clinical supervision. In: Barker P (ed) Psychiatric and Mental Health Nursing: The Craft of Caring. London: Arnold