Communication Challenges

Despite the claim that developing therapeutic relationships is important, it has been difficult to define and operationalise (Clarke 2012). To try and clarify this issue Dziopa and Ahern (2008) developed a typology of the therapeutic relationship components. They divided it into nine main constructs: conveying understanding and empathy; accepting individuality; providing support, being there/being available, being genuine, promoting equality, demonstrating respect, trust, maintaining clear boundaries and having self awareness. While

Chambers (2005) emphasises the importance of trust, respect, empathy, and power issues. Although, recently in mental health there has been somewhat of a shift in focus to more recovery, equality and collaborative practices (Higgins and McBennett 2007).

Reviewing how service users experiencing acute psychosis and nurses communicate is deemed important as nurses are by far the largest professional group employed in Irish Mental Health Services, and therefore have more opportunities for them and other professionals to communicate with service users. At present there are about 5000 registered mental health nurses working in Ireland (Nursing and Midwifery Board of Ireland 2015). For example, nurses are present on in-patient units/wards twenty-four hours a day, and are very likely to visit these service users in their homes or meet them in mental health day hospitals. Therefore, how they communicate together has meaning and implications for both parties.

Service users place value on how mental health clinicians communicate and interact with them, in particular listening, talking and spending time with them (Gilburt, Rose and Slade 2008; Russo and Hamilton 2007), and appreciate when nurses help them ease their distress (Hem, Heggen and Ruyter 2008). Yet, other studies indicate that often both nurses and service users are unhappy or frustrated about their communications and interactions (Hem 2008; Koekkoek, Van Meijel and Hutschemaekers 2006; Duxbury 2002; Breeze and Repper 1998). Therefore, service users and nurses experience of communicating together will be explored from both perspectives in this study.

Peplau (1992) maintains that the purpose of the therapeutic relationship between the nurse and the patient is to investigate and gain familiarity with the patient’s understanding of his/her situation and background, and to contribute to strengthening his/her self-esteem, identity, and ability to bond with others, so as to overcome their difficulties. However, In relation to service users experiencing acute psychosis O’Brien and Cole (2003) claim that nurses often experience it as challenging, as some can be withdrawn when they are focused on their internal experiences or frequently seek contact when angry, very anxious or afraid, as well as needing assistance with sleeping, food, and hygiene. Occasionally, service users can also become verbally and physically aggressive towards nurses especially on inpatient units (Duxbury 2008, 2002).

Dual Role – Custodian and Helper

Another identified challenging aspect of nursing care that can cause tension and problems is when nurses try to develop therapeutic relationships with service users in the context of having a dual role as a helper and custodian when working on in-patient units. Deacon (2003, p.466) points to the conflict between “therapeutic nursing” and “custodial nursing”, as those working on wards/units are strongly occupied with various safety measures, like confiscation of patients’ belongings, searching patients, use of personal alarms, locking doors and regulating the patients’ activities so as to minimise risk to self and others (Bowers et al. 2002). So, an aspect of mental health nursing in this context is to monitor and enforce rules in order to set limits on in-patients’ behaviour, such as smoking, sexual appropriateness and aggressive behaviour (Alexander and Bowers 2004). Indeed, a report by the Department of Health and Children (2003) found that mental health nurses are at risk of being assaulted especially when working on an inpatient unit.

The intent of risk management from a nursing perspective is to create a safe environment against violence, aggression and self-harm (Risk Management in Mental Health Services 2011). For nurses, minimising risk and connecting with service users experiencing acute psychosis are important; yet it appears that the reduction and management of risk is considered paramount. This could be due to the various models of therapeutic relationships that nurses learn as students, as Bowers et al. (2009) maintains that these models were not designed for work with acutely disturbed people on in-patient units, and where Horsfall, Cleary and Hunt (2010) assert that chaos and danger have the potential to occur at any time. In addition to the unpredictable nature of an acute in-patient unit, it is also what nurses consider to be the unpredictable behaviour of those with acute psychosis, in particular when they respond to what is occurring for them internally, which nurses consider as delusional beliefs/paranoia/hallucinations (that nurses are unaware of). Thus, nurses are conscious of potential risks when communicating together, and often judge it safer to adhere to risk management procedures rather than focusing on developing a therapeutic relationship.

Risk and Vulnerability

Those who experience psychosis and attend mental health services can have different experiences of care. As discussed in the previous section the subjective experience of psychosis and its impact can be very difficult for service users and their families/significant others. Those who experience acute psychosis report, at times, that they have an

uncontrollable sense of self of varying degrees which includes feeling different, emotionally distressed, vulnerable and insecure, losing confidence in their judgement of others, leading to isolation and shame, as well as confusion about upsetting thoughts. This sense of loss of control can include causing harm to self or others, being controlled by outside powers, which can cause feelings of anxiety, distress, sleeplessness, anger and irritability (Koivisto et al. 2003), and are present when they interact and try and communicate with nurses. On these occasions they believe it is important that they are listened to, taken seriously, reassured and have skilled help to respond to these acute moments so things will not get worse (Living with Psychosis 2012).

With regards to the causality of aggression, a disparity was found by Duxbury and Whittington (2005) between service users and nurses’ views about the causes of service user aggression on in-patient units. Service users perceived poor communication and environmental conditions as significant issues for causing aggression, while nurses considered the service users’ mental illness to be the main reason. Another factor to be taken into account is the subjective experience of what some service users consider aggression from nurses, such as being restrained when attempting to abscond. “I was rugby tackled from behind by a six foot something male nurse”, reported one, while another service user recalled: ‘I refused medication and I was held down and injected by six staff. What I really feel strongly about is that no one gave me a choice’

(Octwell and Capital Members 2007 p.49).

These experiences of nurses enforcing hospital policy regarding keeping people deemed at risk to others or themselves in hospital, and ensuring medication compliance, can be quite traumatic for the service user. In addition, the above can occur in the context of feeling frightened, confused, experiencing strange phenomena, believing they were detained unnecessarily and powerless to change their circumstances. Within the above circumstances service users can become resistive and aggressive (Chambers et al. 2014). Other service users can develop negative perceptions of ward/in-patient unit regimes when they feel oppressed by the amount of control over their activities, and/or when rules are applied in a rigid manner, which in itself can lead to aggression (Nijman et al. 1997). Specific communication difficulties identified by some service users result in feeling disrespected as human beings, not being included in their own care, or care that has no meaning in the context of their lives; or feeling that nurses consider them inferior human beings (Olofsson and Jacobsson 2001). In

particular, service users fear and/or experience the loss of the ability to make choices and the authority to implement them (Waters and Cashin 2009), in addition to their creditability being challenged by mental health workers (Lakeman et al. 2012). This sense of loss of personal agency often occurs in the context of forced hospitalisation and being medicated, which usually happens after refusing to engage in offered treatment.

The role of nurses in ensuring psychotropic medication compliance is another potential point of tension between nurses and service users. Nurses play a pivotal role in the co-ordination of medication compliance for service users both in the community and in-patient services. At a ward/in-patient unit level it involves making certain that there are adequate supplies of medication and administering medication, in addition to ensuring its compliance. In community settings nurses are often involved in psycho-education with service users and their families about pharmaceutical services relating to mental health, problem solving as well as encouraging compliance (Duxbury et al. 2010; Cowman, Farrelly and Gilheaney 1997). The report ‘A Vision for Psychiatric/Mental Health Nursing in Ireland’ (Cusack and Killoury 2012) found that 94% of nurses were involved in medication management, 77% felt it important aspect of care planning, and 88% believed that administering medication was an extremely/very important aspect of the effective delivery of care. Hence, compliance with antipsychotic medication is considered important by most nurses in managing symptoms and reducing relapse rates and hospitalisations for those who experience psychosis (Monahan, Doyle and Keogh 2008). This is considered necessary as service users are deemed to have the potential to develop a chronic and debilitating illness, in particular if they refuse to take medication due to a lack of a significant degree of insight or acceptance of their illness (McPhilips and Sensky 1998). Thus, this strong emphasis on compliance places the nurse in a position of persuasion and control, particularly on inpatient units.

However, with regard to service users who live in the community, it appears that nurses’ engagement with them around compliance relies more on negotiation (Henderson et al. 2008). For example, Deering (2004) conducted a study on how nurses can influence service users to adhere to prescribed treatments. She found that developing therapeutic relationships was essential where the nurse and service user can connect on a human level by getting to know each other and trust the other’s opinion. This approach allows the nurse to respectfully suggest and work with service users about any issue he/she has about aspects of treatment

plans. However, the majority of nurses believe that medication is an important aspect of managing, treating and hopefully recovering from psychosis, and advocate for its compliance.

Some service user’s report that the experience of taking antipsychotic medication is the cause of a worsening of their symptoms in conjunction with the absence of an exploration into their current personal or environmental difficulties or distress (Lilja and Hellzén 2008). Other side- effects can occur when they are prescribed a combination of anti-psychotic medication which has a negative impact on their quality of life, such as feeling very sedated and physically unwell (Farrelly 2002), and/or being coerced into taking it through persuasion or force (Gault, Gallaher and Chambers 2013). Hence, experiencing side effects of medication is highly prevalent and significant in decisions not to take or continue with antipsychotic medication, as well as feeling coerced into complying (DiBonaventura 2012). This experience of taking antipsychotic medication and deciding to discontinue it can result in creating distance and distrust between service users and nurses, where each has diverse opinions on the benefits and disadvantages of medication. However, other service users felt that medication was an important aspect of their treatment, in particular when they had a good relationship with their psychiatrist or nurse (Day et al. 2005).Despite the above issues many service users continue to seek out nurses on in-patient units or allow a Community Mental Health Nurse (CMHN) into their homes to try and connect with them, in order to get information, to ease felt burdens or to try and share their worries. In addition, a study carried out by Koivisto et al. (2004) found that people trying to recover from psychosis in inpatient settings need nurses to protect them from vulnerability, which is feeling safe, being understood, respected and trusted. This can occur when a nurse verbally assures them of their safety, and is available regularly and when needed.

However, orther studies from a service user perspective found that at times mental health nurses spent insufficient time with them. A study byFord et al. (1999) of service users from a medium secure unit found that 73% found talking to nurses to be helpful, but only 57% of nurse time was spent with them. While some service users recognised that nurses had a heavy workload, they also highlighted a lack of enthusiasm from nursing staff about interacting with them, which made service users believe that they were un-deserving of inpatient care. In a similar study by Barker (2000), a user led study of 343 inpatients, 57% said that they did not have enough contact with nurses, with the majority (87%) saying they had less than 15 minutes of interaction per day. As a result, they had a superficial relationship

with their named nurse (Martin and Street 2003). In a review of nurse and service user activities and interaction on psychiatric inpatient wards Sharac et al. (2010) found that on average around 50% of nursing time was spent in contact with patients, but therapeutic time spent with them was only 4-20%, with most of their time being devoted to administrative and practical tasks. However, Bowers (2013) maintains that a lot of important conversations occur with service users while also doing the practical tasks, for example when dispensing medication: in other words informal conversations occur. He suggests that admission units are unpredictable and therefore do not lend themselves to planned one-to-one meetings, while also acknowledging that sometimes staff avoid conversing with service users as it can be emotionally draining. Furthermore, there are times when service users do not want to talk to nurses.

Alternatively, some service users reported that when trust was built up with a nurse through approachability, friendliness, and perceiving them to be personable, human and empathic (Svedberg, Jormfeltdt and Arvidsson 2003), as well as inspiring hope for the service user (Cutcliffe and Grant 2001), they considered the nurse as an ally in their struggles to reach their own sense of wellness. In other words, a relationship that is built on trust is where the patient’s values are respected; can play a large part in creating hope and fostering recovery (Moyle 2003). While a service user led study by Gilbert, Rose and Slade (2008) found that communication was an important aspect of their experiences with mental health clinicians, which was both positive and negative; positive when they felt listened to and the clinician was interested in their story, negative when ignored, dismissed or experienced coercive practices such as use of threats. Another service user led research found that the most important aspect of their care was being able to talk to staff (Russo and Hamilton 2007). Therefore, it appears that a lot of the difficulties are created and resolved through the quality and content of how both the nurse and service user communicate together.

In summary, it appears that service users and nurses can have different experiences of communicating together which can be either positive or negative. As professionals, mental health nurses have responsibility to be able to engage in therapeutic communications with all patients, yet many patients are dissatisfied about its quality and content. This can occur despite the fact that all student nurses learn a variety of communication models to interact and communicate with service users’ experiencing psychosis when attending college, both

generic and specific, and have opportunities to learn from qualified nurses when on clinical placements. Some of these communication models and approaches are outline below.