Tag Archives: nursing

Unrealistic deadlines & nurses feeling guilty

We nurses aren’t perfect. We generally spend our time trying to sort out problems that we didn’t cause. That’s more than most people do. It’s more than the majority of our critics.

But no matter how hard we try, sometimes we fail. Sometimes we don’t fail but people place such unrealistic expectations on our practice, make such unrealistic demands of us that we face criticism, insults, even threats of violence for not living up to the demands of others.

People can disregard our efforts, they can slander us on social media and dismiss us as incompetent, callous fools if they like. That’s their right…

But we don’t have to agree with them!

Labelling, recovery and therapeutic optimism

 Back in 1963, researcher David L. Rosenhan masterminded an elaborate hoax. It was a scam designed to study the effects of labelling upon clinical practice and to determine whether psychiatric diagnosis is based upon professional skill or simple expectation and prejudice. It was a bold experiment with profound implications for clinical practice even now almost half a century later.

The idea was simple enough. Rosenhan persuaded a group of confederates to approach state hospitals in America and request a consultation. Each told the psychiatrist who assessed them that they had begun to hear a voice which said “Empty”, “Hollow” or “Thud”. That was enough to secure them a bed in the local psychiatric hospital. But that wasn’t all, bad though that low threshold for admission might be, in itself.

Once admitted on to the ward Rosenhan’s confederates ceased any pretence of voice-hearing. They behaved perfectly normally and showed no symptoms of mental disorder at all. At this point we might expect the staff running the ward to smell a rat but that’s not what happened. Whilst the fellow patients could tell very quickly that their fellow patients weren’t actually ill, the staff apparently could not.

Even perfectly ordinary activities such as writing was seen as pathological. Pacing up and down through boredom in this secure, low-stimulus environment was interpreted as a sign of illness. It seems that once the label of ‘mentally ill patient’ was applied everything the confederate did was interpreted by those lights.

The staff saw precisely what they expected to see.

This mirrors an earlier study by Rosenhan and his colleague, Jacobson who examined teachers’ attitudes to students who had arbitrarily been tagged either as ‘bright’ or ‘not bright’ by the researchers. The school, known as ‘Oak school’ to protect the identities of all concerned, also lived up to expectations of labelling theory. Not only did teachers interact with children in accordance with the labels they had been assigned, but the children also began to live up or down to the expectations of the teachers – even though their actual test scores had been ignored when they were randomly assigned ‘bright’ or ‘not bright’ status. Each child took on the behaviours and traits of the label, regardless of their actual abilities and achievements.

This is why it is so important that we understand labelling in our work with people who have mental disorders. Whatever we believe and expect is likely to come true.

If you want the people you work with to recover you need to start believing that they can, and you need to act upon that belief. Remember that recovery is built upon lots of little steps in the right direction and we can encourage that simply and effectively by doing relatively simple things, things like offering praise, acknowledgement, recognition and practical help, repeatedly and well.

That’s hardly rocket science, is it?

Complete the contact form below to arrange training for your staff.

Don’t let yourself off the hook so easily

This short video talks about the dangers of allowing ourselves this luxury too soon.

It’s OK to find a way to feel good about ourselves but sometimes we need to think things through honestly and without any excuses first. From reflective, professional practice to dealing with disappointment in our personal lives we cannot grow unless we are first prepared to take a long, hard and critical look at ourselves and our own role in creating misfortune and disappointment for ourselves and for others.

Empty platitudes about how “It wasn’t meant to be” aren’t only vaccuous, they’re inherently damaging too.

If you’d like to arrange training for your staff please fill in the form here…

Expressed emotion: New video tutorial

Is ‘Expressed emotion’ really a thing in mental health care?

To arrange training for your staff please complete the contact form below…

The fight continues

I’ve neglected my blog over the past few weeks and months. It’s easy to be distracted by other things as life’s hectic pace continues unabated. But this week I’ve seen things, some positive and some not so good, that inevitably have brought my attention back to my roots and the reasons why I got into mental health care in the first place.

I didn’t always want to be a nurse. As a young man my dream was to act. I planned to tread the boards throughout the world to the delight of my adoring fans. Unfortunately for me the world had other ideas.

By my early twenties I found myself unemployed and homeless. I’d taken the advice of Thatcher’s government to ‘get on my bike’ in search of work. I didn’t have a bike so I hitchhiked instead, seeking my fortune in a country where working-class lads like me could never do well. There’d be no pot of gold at the end of Thatcher’s rainbow no matter how hard I searched.

Those weren’t the happiest times in my life but they may well have been the most instrumental. During those days I met some extremely troubled people. I became pretty ‘troubled’ myself for a while. I learned to let go of social prejudice as the most unlikely of my associates showed immense kindness whilst those my society had always taught me to respect displayed a callousness and indifference that seemed almost beyond belief. I made some good friends and I learned a lot about human frailty.

Lincoln YMCANo single incident made me decide to become a mental health nurse but there are a few ‘front-runners’. One or two of the people I met in hostels left a permanent impression upon me. Several of my old friends from those days are dead, long before their time because of a lifestyle that was more about drug-induced psychological ‘anaesthesia’ than anything else. And I saw a woman jump to her death from a multi-storey car park not far from my accommodation in Lincoln YMCA.

I was the first to reach her. She whimpered softly as I knelt beside her, shouting to the office workers in the building across the road to call an ambulance but it was no good. She died in Lincoln hospital a little while later. I felt helpless and I felt ashamed.

It seemed clear to me that my society had driven her to this drastic course of action. I didn’t know her story. I still don’t. Looking back I have no idea what led her to this tragic decision but at the time it all seemed so clear. Society was indifferent to suffering and I wanted to do something to change all that.

In those days I was misguided, I was overly-simplistic, I was unrealistically ideological and I had a ‘saviour fantasy’. I thought I could make everything alright for everyone I ever met just by being me. I was heading for burnout before my mental health career had even begun.

These days I have a more seasoned view of what I do. Twenty-one years as a qualified mental health nurse will do that for you. I’m only one man and I’m not all-powerful. I can’t change everything… but I can help.

The paternalism of my early career has gone now. I no longer see my role as the all-knowing saviour come to ‘bless’ the patient with my charitable assistance. Now I’m a fellow traveller trying to find individual answers to individual problems in a system that still likes to put people in boxes and pretend that’s enough. The pigeon-holing culture of psychiatric diagnosis still remains but things are getting better. I’d like to think that my generation of nurses have been instrumental in that. God knows – we’ve tried.

mh-recovery-nothing-mysticalToday, 20 years on, recovery is seen as a reality. Inter-agency working has become so ingrained that it’s often hard to know which worker has which training in the community teams I work with. Diagnosis is giving way to formulation. Generalised assumptions about faulty biology are giving way to more evidence-based ideas that are just as likely to include the effects of social inequality and cognitive style.

Society at large is slowly waking up to its own role both in creating and maintaining mental disorders through exclusion, prejudice and marginalisation of those who don’t fit the required stereotypes of ‘acceptable culture’. There’s still work to be done and the fight against stigma and dehumanising assumptions goes on, but I’m proud to say that I’ve been part of that struggle and will continue to be for a good few years yet.

20 years from now though, the newly qualified nurses of 2036 will look back at my generation of nurses, at the class of ’92 and throw their hands up in horror at the way we used to treat people. At least I hope they will.

If the nurses of the future don’t criticise the nurses of today then we won’t have done our work properly. Each generation should have reason to criticise the one that went before. I hope they’ll also understand though that had we not fought against the injustice of our own time they would still be perpetuating it in theirs.

The fight continues…

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Privileged glimpses 24: The clinician’s illusion

This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.

The clinician’s illusion sounds as though it would only apply to clinical, therapeutic situations but that’s not the case at all. This is one of the most widespread examples of faulty thinking and we are all susceptible to it. Essentially it’s one of several logical errors that are based upon the false idea that ‘my experience is all there is’.

There are very good reasons why human beings are so vulnerable to the clinician’s illusion. Many would argue that it’s inevitable because we base our judgements upon our experience of the world. In evolutionary terms that’s one of the main reasons why our species has survived at all. This is probably as ‘hard-wired’ into consciousness as any human trait could ever be. We all learn from experience.

Unfortunately that experience can be misleading as we shall see.

To make sense of the clinician’s illusion I want to tell you a little about my own experience as a mental health nurse on acute psychiatric wards. Then, having made the point we’ll widen the scope a little to show how the clinician’s illusion is both applicable to all of us. We’ll also show how our vulnerability to it is used by cynical persuaders from private citizens to politicians who manipulate our understanding to gain agreement or endorsement of their views.

When I worked on the wards my colleagues and used a familiar expression – a cliche if you will. It went like this:

“We don’t have much money but we do see life.”

It was, as much as anything a relatively light-hearted way to acknowledge amongst ourselves that sometimes we witnessed and were involved in situations that were distressing, unpleasant and occasionally harmful. What we saw on a fairly routine basis had the potential to cause very real psychological trauma in its own right and I have known many mental health nurses who have been unable to bear its weight. The use of clichés such as this is more than just a way to acknowledge that ‘shit happens’ – it’s also a way to demonstrate mutual awareness and support. Like the ‘gallows humour’ so often heard on ward nights out (and so often criticised by the uninitiated) it’s part of an arsenal of psychological defence mechanisms that nurses at the front line employ to keep themselves sane.

But there’s a major problem with this. It’s not true. Well – the not having much money part might be but not the rest. Acute nurses do not see life – at least they don’t see very much of life. They see the worst of life but not the best.

By definition patients in acute psychiatric wards are distressed and they are not coping well. If they were then they’d be somewhere else getting on with their lives. Acute nurses meet people at their most unwell – and only at their most unwell. And many of them return repeatedly to the wards as their mental health breaks down.

Our experience then, as ward based nurses was that everyone with a diagnosis of serious and enduring mental disorder comes back to us sooner or later. We see them come back every working day and that experience of working with relapsing patients is what we used to form our opinions. That’s why, when I was an acute nurse I didn’t believe in recovery from mental disorders such as schizophrenia. I had no experience of it. Everybody I met at work had relapsed (or I expected that they would one day based upon my past experience of other people).

But not everyone comes back.

According to the Royal College of Psychiatrists own figures only about a third of people diagnosed with schizophrenia experience lifelong deterioration and another third (give or take) get beyond their problems altogether. We didn’t see those people on the wards because they never needed us again. We only saw the people who did relapse.

Not everybody relapses

The clinician’s illusion is the illusion that comes from limited experience. Clinicians see ill people and so they come to believe that everybody is ill – or at least likely to become so.

The clinician’s illusion is what happens when we place too much weight upon our own limited experience and ignore the wider experience of others. It’s the fatal flaw that underlies the statement so beloved of many that..

“I speak as I find”

It’s laudable, of course to learn from our own experience but not to the exclusion of everything else. If we really want to make sense of the world we need to be prepared to look beyond our own experience and take account of the experiences of others.

Oscar Wilde once remarked that only a fool learns from his experience. The wise man learns from the experience of other people. Perhaps Wilde would have called the Clinician’s illusion the ‘fool’s illusion’ for precisely that reason.

But it’s not enough just to say ‘learn from everyone’. It’s necessary to have some means of judging the reported experiences of others too – otherwise we’re open to all sorts of abuses and misrepresentations. My own view is that ‘evidence is the thing’.

Don’t worry too much about anecdote – that can be misleading. Follow the evidence. Otherwise we end up making just as many mistakes.

For example there is a narrative in UK about people with disabilities and those who need to rely upon state benefits to survive. The narrative is that disabled people are workshy scroungers and that honest hard-working people should not be asked to support them. This narrative has proven to be very persuasive and many people (largely those who do not work with disabled people) believe it. Let’s look at why..

Ever since the ConDem government came into power back in 2010 UK citizens have repeatedly been told that benefits claimants are predominantly abusing the system. Government ministers have repeatedly made that claim and the real evidence about claimants and their circumstances has repeatedly been suppressed.

Right wing media articles repeatedly publish stories about people ‘swinging the lead’ and even ‘fly on the wall’ television shows present benefits cheats to the nation on a very regular basis. For the majority of people (who don’t regularly come into contact with severely disabled citizens) this constant procession of fraudsters becomes the only experience they have of disabled benefits claimants. And cynical politicians know this all too well.

So the clinician’s illusion (my experience is all there is) means that the population is easily swayed by arguments about benefits fraudsters because they believe that it’s a real problem when in fact official figures (the evidence from a range of experiences) show that only a tiny proportion of claimants are ‘swinging the lead’. But that’s not what our political leaders want us to believe. So that’s not what we are shown.

Unless we become alert to the notion of the clinician’s illusion in our own lives we will remain susceptible to persuasion by any Tom, Dick or Harry who wants to manipulate our opinions for their own cynical ends.

For example, if your only experience of someone you meet is what they tell you about themselves it pays to look a little deeper before you jump in and support their endeavours. You might just be being played.

I’ll end with another cliche.

“Self praise is no recommendation”

Privileged glimpses 23: “It’s just behavioural”

This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.

The young woman sat hunched in her chair, not making eye contact with any of the half dozen or so people seated around the little room. It was hot, stiflingly so with so many bodies in such a small space. All eyes seemed to be upon her as a moon-faced man, dressed in an immaculate suit, began to speak.

“How do you feel this afternoon?”

The young woman didn’t answer as she picked imaginary lint from her blouse.

“Have you been taking the tablets?”

The man in the suit, a consultant psychiatrist, seemed to be addressing his patient but his attention had already shifted elsewhere. He had given up waiting for a response even before he’d finished speaking to her. Now, along with everyone else in the room (except the patient herself) he was looking at me, her primary nurse.

“Everything’s been given as prescribed.” I said. “No problem.”

The psychiatrist nodded and half-smiled his approval. My patient, all but forgotten now, stared at the floor in silence.

A few minutes more discussion between the various members of the team followed about the relative merits of antidepressants ensued. Then, again looking directly at me, the psychiatrist asked:

“Do you think you’re getting any better?”

I waited for her to answer, shifting my own gazer toward her in the hope that others would try to include her also. Perhaps this would help her to feel noticed again. Then the psychiatrist spoke again:

“Is she improving, Stuart?”

There was no response from the patient so I explained that she had indeed made progress, she was sleeping and eating normally and had begun interacting with other people on the ward too.

“No evidence of that here, is there?” The psychiatrist quipped, eliciting tiny, almost imperceptible smiles from one or two of the others in the little room.

I explained (again) that these team meetings were intimidating for her and that her presentation on the ward was far more relaxed. I explained again about the work we’d done on the ward and how she was able to talk about her problems with us and her depression was lifting every day. I also pointed out that she specifically asked that I explain this precisely because she lacks confidence in this setting.

“It’s just that she feels much more ‘on show’ during the ward round”.

The young woman raised her head a little and grunted her agreement, albeit rather timidly.

“So you can speak.” Said the psychiatrist. “You just choose not to speak to me.”

Once again the woman’s gaze dropped to the floor in front of her. She said nothing more in the ward round although she did begin sobbing quietly to herself upon learning that she would be discharged home that day.

After she left the room (it’s strange how readily people accept the decisions of psychiatrists and just go) I made the point that although she was improving she wasn’t well enough for discharge yet. I believed, the whole nursing team believed, that another week or so would make all the difference. I pointed out that her lack of confidence in the meeting was evidence that her former high self-esteem had not yet returned.

“That’s only behavioural.” Said the psychiatrist as he completed the discharge forms.

I’m always interested to know just what people mean when they describe a person’s actions as ‘behavioural’. Actually I’d be interested to know of any action that isn’t ‘behavioural’.

In the health and social care context (including psychiatry) what ‘behavioural’ usually means is that we feel powerless to change the behaviour or that we are at a loss to understand it. Actually the two meanings often go hand in hand as a little understanding does tend to point the way to the solution anyway.

It’s not difficult to understand why this young woman was so quiet (elective mutism we call it in the trade). It’s not difficult to see the solution either – a smaller group meeting, perhaps with only one or two people present and some attempt to engage with her as a person rather than as a set of symptoms would probably have worked wonders. It certainly helped in my one to one sessions with her on the ward.

However, such understanding would require a little thought, flexibility and even compassion. It’s much easier to write the situation off as ‘behavioural’, all the time pretending that the word actually means something clinical and isn’t just an excuse for our own lack of imagination.

A fundamental premise of this series and of care provision in general must be that everything we do is behavioural but that nothing is ‘just’ behavioural. If we want to be effective we need to stop hiding our own inadequacies behind this meaningless term and take the time to understand the individual instead.

Everything happens for a reason and effective work with people whose behaviours can be challenging must begin with that ‘cause and effect’ principle clearly understood.

Privileged glimpses 16: Support is meaningless all by itself

This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.

SupportThe word ‘support’ is meaningless in and of itself. Not the activity – just the word. It’s meaningless for care providers to talk about support unless they then go on to say what they will actually do – what ‘support’ means in this context. Does it mean sending a letter of approval to the local paper, clapping or simply smiling benignly? Or does it mean something more tangible?

In my training I often ban the word altogether. That gets people actually to think instead of just trotting out tired old cliches. It’s sad to see how many people will confidently state that they’ll offer support as though that solves the problem but when pressed have no idea about what is really required.

Support is a nice, warm, fluffy word but in itself it doesn’t really mean anything more than good intent.

If you work in social care or health care then let me make a suggestion. Stop saying ‘support’ because it lulls us into a false sense of competence and when other people use the word immediately stop them and ask them just what that support will be.

Oh yes – and be prepared for some very experienced and knowledgeable looking people to be unable to answer you.

Sad isn’t it?

Privileged glimpses 3: People do the best they can with what they’ve got

This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.

sweet shopImagine a small child in a very large sweetshop. The lights are off and it’s completely dark except for a single spotlight illuminating a tiny piece of shelving. On the shelf, visible in the little pool of light are three bars of chocolate. One bar is milk chocolate, another dark while the third is white chocolate. That is all the child can see.

The child has one simple instruction…

Take your pick…

Obviously the child will choose one of the three chocolate bars he can see. It doesn’t matter what other treats might be in the shop because he can’t see them – he doesn’t know that they are available options.

This little post isn’t really about chocolate bars and children in sweetshops though. It’s about social care service users and the options they have available.

The sweets in the shop represent coping strategies. They’re behaviours. Choices about what to do in different situations. And just like the child in the sweetshop service users (along with everybody else) only choose the options, the behaviours that they know about.

So if someone you work with makes poor choices that’s not necessarily because they don’t want to do better. It’s more likely because they either don’t know what else to do or because they don’t think that other options will work for them. Many people understand intellectually about good coping skills, socially acceptable behaviours but don’t believe that they will be given the opportunity to make different choices work for them. If they’re used to being treated with mistrust they won’t believe that the truth will work for them. If they’re used to being ignored they won’t believe that not drawing attention to themselves will meet their need for human contact. And they may well be right.

So, just like the child in the sweetshop they take the best option available to them.

They do the best they can with what they’ve got.