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The use of refocusing in acute psychiatric care

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VOL: 98, ISSUE: 22, PAGE NO: 44

Nick Bowles, MA, BA, RMN, is senior lecturer, School of Health Studies, University of Bradford; Peter Dodds, RMN, is senior nurse, Oakburn Ward, Lynfield Mount Hospital, Bradford

Nick Bowles, MA, BA, RMN, is senior lecturer, School of Health Studies, University of Bradford; Peter Dodds, RMN, is senior nurse, Oakburn Ward, Lynfield Mount Hospital, Bradford

Acute psychiatric wards have deteriorated into a state of chronic dysfunction over a decade or more, despite accounting for 60% of the NHS's mental health budget. Many patients report feeling unsafe and say they often receive little more than custodial care and treatment that is intended to meet only their most pressing needs. Patients receive limited therapeutic or social input and many do not have access to a daily programme of activities, are not involved in planning their care (or discharge-planning) and are often bored.

It is not uncommon for a significant proportion of patients to remain in bed for hours during the day, choosing to socialise at night instead. Substance use and drug-dealing are endemic and incidents such as self-injury or suicide, while apparently avoidable, are common.

Numerous factors have led to the poor state of acute psychiatry. Pressure on beds has risen steadily over the past 10 years, and those admitted are increasingly the most ill, vulnerable, disturbed and/or disturbing to care workers and the communities in which they live. An already complex clinical picture is often exacerbated by substance use, a lack of housing or community provision and social hardship, all of which make treatment more difficult and delay discharge.

Unsurprisingly, acute psychiatry is no longer an attractive career option for many nurses. Those that remain committed to working in acute environments are demoralised, poorly prepared for the demands they face and under considerable stress. Many leave to work in assertive outreach, home treatment and crisis teams.

The impact of home treatment and assertive outreach on activity levels in acute wards is beyond the scope of this article. However, it is ironic that such services, many of them required by the National Service Framework for Mental Health (NSF) (Department of Health, 1999), are a factor in the dilution of skill mix, clinical experience and expertise in struggling ward-based teams.

Time for change

The state of acute psychiatry was described as a neglected area of thinking and research by the Sainsbury Centre for Mental Health (1998). Since its survey, Acute Problems, things have moved on. The Department of Health launched an important strategy for acute mental health in April (DoH, 2002), which was developed by a multiprofessional group of clinicians. The Sainsbury Centre for Mental Health (2002) has also initiated an important practice development and evaluation project, In Search of Acute Solutions. Meanwhile, the Bradford approach to practice development, the subject of this article, has been tested, widely disseminated and is already being applied in other settings.

Unlike the longer-term DoH strategy and the Sainsbury Centre for Mental Health project (2002), the Bradford approach has been evaluated and described accurately enough to enable it to be applied elsewhere. We believe it is one of the most accessible and immediately available resources to staff in acute care.

Developing practice in Bradford

Oakburn is an acute psychiatric ward for men, serving a deprived inner-city area of Bradford. Three years ago the ward was chaotic, noisy and dirty. Nurse-patient relationships were poor and of little benefit to either party, partly because of the extensive use of formal observations and partly because of a lack of understanding of the value of meaningful engagement. Levels of violence, self-injury and staff absenteeism were high, documentation was poor and morale was low. For the past three years this team has been developing its practice in collaboration with the University of Bradford, which has led to the formation of a model for change described as 'refocusing acute psychiatry'.

What is refocusing?

Refocusing is a highly specific series of interventions based on psychological and organisational theories we developed (Bowles and Dodds, 2001; Bowles et al, in press).

Most important is the use of the 'job strain' model (Karasek and Theorell, 1990), which has led to better understanding of the factors that cause poor performance, absenteeism, and mental and physical ill health in the workplace. Job strain is at its greatest when staff face high psychological demands as a result of their workload. For example, they may report working very hard, working fast or not having enough time to get the job done, with little control and autonomy to make decisions that meet the demands of the job. They may therefore be unable to use their judgement and skills, or their decision-making ability may be undervalued. A third factor is the availability and quality of social support in the workplace.

Staff are at greatest risk when all three factors are present. This is called isostrain. In acute psychiatry, nurses and health care assistants face high demands in each of these areas and are at high risk. This is shown by the following:

Work strain

- The acute environment is noisy, chaotic and sometimes dangerous;

- Workload is consistently high - and likely to increase as crisis and home-treatment teams are more widely used;

- Many teams are supported by bank and agency staff, whose limited skills and clinical awareness increase the demands on permanent staff.

Little control and latitude in making decisions

- High workload is a factor in poor engagement with patients, which reduces the nurse's ability to understand, contain and report the patient's state to colleagues, potentially reducing the nurse's credibility;

- Partly as a consequence of the above, a great deal of nursing time is spent servicing observations ordered by medical staff;

- Nurses have inadequate professional development opportunities which, were these to be made available, could increase control and latitude in making decisions.

Workplace support

- Busy teams have limited opportunities for structured, social support and the poor uptake of clinical supervision is well documented.

Changing practice

Acute nurses are likely to face isostrain for much of their working week. However, this model can be applied to patients also as they face the same noisy and chaotic environment, and have less personal control and support as a consequence of admission. This can be disempowering and disorienting because it reduces their access to family and friends, limiting their opportunities for engagement. Other problems include a lack of privacy, inadequate cleanliness, poor levels of information, and limited structure and activity each day.

Practice changes that aim to reduce the strain on staff and patients are likely to be of the greatest value. These must:

- Increase the person's sense of personal control and involvement in decision-making;

- Reduce the onerous demands that the environment makes on the person;

- Increase the level of support provided to the person.

Refocusing in practice

Over three years, the Bradford team has achieved significant change in its approach to practice and clinical outcomes. The ward environment is carefully managed to minimise noise and promote a sense of calmness and safety. The ward is highly structured yet offers patients more choice and greater access to activities, events outside the ward or simply fresh air. Nurses engage patients in one-to-one sessions and groups.

Because the nurses are proactively engaged, they spend less time firefighting and more time working with patients, so the clinical team has better information on the treatment decisions that can be made. Our audit data shows that patients now have greater engagement with their named nurses; about 95% of patients take part in structured one-to-one sessions every day and are therefore better informed, better supported and more involved in their care.

Strong leadership and better teamwork have brought about clinical changes. Clinical and line management supervision are the norm, supported by planned professional development. The nurses routinely collect, manage and report audit data to the team, which ensures that the team's performance and decisions are evidence-based. Patient opinion is also sought weekly.

Increased engagement and availability of staff on the ward have enabled a reduction in the use of routine formal observation, allowing staff to be redeployed to structured individual and group activities and informal time with patients.

The results of these management changes are best expressed in terms of clinical outcomes. Readmission rates are now 4% within 90 days and the mean length of stay is about 24 days. Complaints are down by half, violence and aggression by a third, self-injury has been reduced by two-thirds, and absence without leave has been almost halved. Nursing sickness and absence rates have dropped from over 10% per whole-time equivalent to less than 1% per WTE. Consequently, bank and agency costs have fallen considerably.

Refocusing in other parts of the UK

A small funded study enabled us to develop a clear understanding of the theoretical and practical components of refocusing and to prioritise these. Consequently, it has been possible to apply the refocusing model in other clinical settings.

We are now engaged in refocusing work with two NHS trusts in Bolton and Shropshire. Early results from Bolton, where we began work last September, look promising. Having engaged in whole-team training and developed a year-long schedule for the implementation of change, Bolton acute services are demonstrating increased leadership at all levels and improved multiprofessional working.

Greater patient involvement and significant changes in practice are becoming evident. Practice changes include more structured activity, increased meaningful engagement, reduced environmental stress and noise, better induction on admission, higher patient satisfaction levels and better staff supervision.


Patients and staff in acute settings deserve change and urgently require meaningful proposals for a working model and a vision of how it may be implemented.

Refocusing meets this need. It has been proven in practice and has been developed for use in other settings. It is understandable, robust and founded on a sound research-base, which has been refined over a period of about 15 years. Crucially, the fundamental principles and some of the structural elements of refocusing are in keeping with the newly launched DoH acute strategy (2002). As such, the refocusing model provides a vehicle for planned practice change and the implementation of this strategy.

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