Introduction
Being in hospital is always a difficult time for patients. However, for some it can also be very distressing and emotionally traumatic. It can be hard for staff in general/acute hospitals to know what to say – what is the ‘correct thing’, how to behave, how to help relatives and also how to help yourself so you don’t go home and worry about your patients. We’ve called it Brief Encounters as this captures the intense and necessarily swift interactions ward staff have with patients continuously through a shift. Less romantic but more practical than the film. And with an s.
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Issues that are particularly difficult for staff and patients include:
- Patients who have long term conditions eg stroke, diabetes and can’t see a way out
- Patients who are anxious, frightened and distressed because they’re in hospital
- Patients with a diagnosis of a mental health disorder who find it difficult to cope in a stressful, busy environment
- Patients who are frightened of dying
- Patients who are demanding and time consuming
- Patients who are in pain and don’t know how to cope with it
- Patients who feel powerless and no one listens to them, staff ignoring them
- Disagreeing with colleagues about the best way to treat a patient
- How to keep the relationships with patients professional
- How to keep yourself sane
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Many general hospitals have a mental health liaison team who can advise and support staff and patients. Brief Encounters can provide additional ideas and information to help staff:
- have richer relationships with patients in emotional crisis
- feel more confident about the enormous skills you already have in working with very distressed or confused patients
- learn a bit more about the main psychiatric illnesses
- become more popular, charming and gorgeous and probably win the lottery.*
*Or not…May have gota bit carried away there.
Brief Encounters recognises that the two people in a caring conversation have very different current experiences and needs. The member of staff’s needs include:
- building up a relationship with the patient, so patients like and trust them, and are motivated to be honest with staff about what’s going on for them
- getting to know the patient as an individual – what their life is normally like, what they enjoy, what they find difficult, etc.
- reducing the gulf created by the power difference between staff and patients
- understanding what that person’s experience of physical and mental illness is like and how they cope with it
- assessing their current emotional state, including what is helping or slowing their recovery and their level of risk
- trying to do all the above at the same time as wash patients, give medication, ensure people are drinking enough, help relatives…
The patient’s needs include:
- wanting someone to be interested in them as an individual, not just as a patient (and not just as a diagnosis – mental or otherwise)
- feeling able to trust a member of staff so they can rely on them for emotional support, information and human contact.
- simply wanting to have a bit of a natter to relieve what can often feel like long and empty hours in hospital
Staff and patients’ needs here can be very hard to reconcile. The ferocious demands on staff time and energy, including emotional energy, can make it feel impossible or even inappropriate to spend time chatting with patients. But a few minutes invested in a chat can save many hours or days of ‘fire-fighting’ when important issues are covered, and the relationship between the member of staff and patient is bolstered.
There’s some great advice about reconciling competing demands in the wonderful book ‘If Disney ran your hospital’. At Disney there are 4 areas to focus on – these have an order of priority and when faced with conflicting demands you can use these to help you decide what is your priority. If it works for Disney it can work for the NHS.
Disney’s priorities are:
SAFETY
COURTESY
SHOW
EFFICIENCY
(‘Show’ means how the hospital appears to people using it – is it clean, well maintained, fit for purpose? For example, do staff look like NHS professionals should look to inspire confidence and trust? How informative, welcoming and reassuring is signage?)
Throughout Brief Encounters these are your priorities – we create patient safety by having a relationship with them, however brief, by knowing and connecting with our patients. This covers every aspect of care from safe drug administration to listening to their fears, hopes and anxieties.
Brief Encounters looks at how relationships between staff and emotionally vulnerable patients are nurtured through ‘caring conversation’. It’s informed by the evidence of the recovery power of conversation to help people with mental illness or in extreme distress where there is no actual diagnosed mental illness. There is considerable research showing how expressing themselves and being heard in a particular way enables patients to access thoughts, feelings and experiences and to gain new perspectives on these – even when stuck in a general hospital. This then helps them to have a greater understanding of themselves, their situation, their illness, its treatment and the recovery process.
The magical thing is that even a simple, sociable conversation can have a profound impact on someone who is in a bad emotional state. It can also increase ‘relational security’ – having someone to relate to emotionally increases feelings of safety, and therefore someone is more likely to stay on the ward and participate in their treatment.
Please don’t feel you need to use or read all of Brief Encounters. Just dip into the bits that interest you or where you feel most in need of some fresh ideas.
Mentalising
‘Mentalising’ is a slightly odd name but don’t let hat put you off! It refers to that essential life skill of being aware of what’s happening or happened in our own minds and in other people’s minds. Mentalising, or being ‘mind-aware’ is about being in touch both with what we’re thinking and feeling and what other people are thinking and feeling. Profs Bateman and Fonagy created Mentalisation Based Treatment for a group of patients whose high level of emotional needs had til this century led to them being regarded as untreatable – people with Borderline Personality Disorder. But the approach is equally valuable working with patients with any or no psychiatric diagnosis. (And indeed when wrangling at home about whose turn it is to put out the rubbish.) This is a simple and practical concept and one you and colleagues are already using hundreds of times a day.
At times of considerable stress, the ability to be aware of what is in the patient’s mind is put under great pressure. It’s hard to think straight, and even harder to tune into what other people are thinking and feeling. But it’s at exactly these times that we need to be effectively mind-aware. Let’s take a common and very tough example – when a patient is highly agitated and gentle attempts to reassure and calm them have failed, and there’s a real risk they will hurt themselves, or someone else. A non-mentalising response would be to focus only on the practicalities – noticing where the patient is, who’s near them, what staff are available to help, etc. A mentalising stance would not only take into account these important considerations, but also help you to identify what you’re feeling (e.g., scared, angry, empathetic, calm…) and, crucially, what the patient is feeling. By being aware of what’s in the patient’s mind, you will be in a much better position to see things from their perspective, and work out how best to resolve the situation. Similarly, being aware of your own thoughts and feelings is also crucial to being able to manage the situation calmly and effectively.
For example, your patient has pressed her call bell: ‘Nurse, you’re late again with my pain killers. I can see you all sitting at the nurses station chatting, it’s all hopeless on this ward’. Your immediate reaction is to want to respond defensively – you weren’t chatting, it was the nurses’ handover, there are 20 other patients on the ward, you can’t always get everything done on time….. However, using mentalising you think ‘She sounds very alone and worried, maybe she thinks the pain means she’s not getting any better. I’d be fed up if I was in this much pain and could hear others laughing.’
Anthony Bateman, co-creator of Mentalisation Based Treatment, said: “Brief Encounters enjoyably covers the many aspects of mentalising skills which ward staff successfully use throughout each shift. Working with patients in emotional crisis requires particular attention to what might be going on in their minds as well as your own. Although patients in emotional turmoil can be very demanding to care for, they are often also exceptionally appreciative of and responsive to gentle, non-judgemental support.”
Further info about mentalising in ‘Mentalizing in Clinical Practice’ by Allen, Fonagy and Bateman and at www.mentalising.com
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