Staff and Service Users’ Perceptions of Acute Care: a Thematic Analysis Caroline Laker, Nurse Researcher SURE, Institute of Psychiatry This study (LIAISE) was funded by the National Institute for Health Research as the first phase in a wider applied programme grant called the PERCEIVE study.

Method Aim: To develop 2 measures capturing staff and service users’ perceptions of acute inpatient care, using a participatory research model pioneered by Dr Diana Rose (SURE, IOP). Reference Groups: Comprised senior nursing staff or representatives from mental health organisations. Identified major themes from their experiences of either delivering or receiving services. These were incorporated into a flexible topic guide for the focus groups. Focus Groups: 4 focus groups of 5-8 people (staff or service users) met twice to discuss their views and experiences. Analysis: Throughout the focus group process, data was analysed using NVIVO to identify key themes. Final Consultation: The results of the analysis were presented to 2 expert panels and the reference groups for their comments.

Secondary Analysis How staff identify with their role in promoting recovery. How the ward milieu can enhance or hinder recovery. How service users view themselves within the ward. Note: these findings represent a ‘general consensus’ amongst both sets of focus group participants (-ve).

Title here Staff d iscussed their role in maintaining the status quo. Violence, poor staffing levels (bank staff) and changing shift patterns were contributors to the ‘unstable milieu’. PROMOTING RECOVERY OR PEACEKEEPING? “And so the whole thing boils down to one thing…staffing levels…there are times you see incidents coming there’s nothing you can do to prevent it.” ENVIRONMENTAL NOT INDIVIDUAL FOCUS: “I think the burnout period is coming now for a lot of the staff that have worked there …..because the pressure is so much - in terms of therapeutic environment for the patient I think we do meet the patients needs ….. but in terms of one to ones (it’s) very difficult and also trying to keep a calm environment it’s quite difficult you’ve got 16 at a time of very unwell patients all at once”. Ward instability: staff perceptions

Ward instability: service user perceptions In many cases service user and staff views about the ward contained similar themes, but service users took a less global view. ACUITY: “I think acute wards are quite stressful places to be ….. because like you’ve got people with all different kinds of illnesses. You might have someone with depression in with someone with paranoid schizophrenia or really aggressive and the two don’t match.” A PERSON OR A PATIENT? “I mean there are so many different levels, like down from, from absolutely silent to somebody running around pissing all over the place. …I mean what can you do? Can you sift people who are sort of semi ill and then, you know that they’ve got acute wards obviously, but it’s a big wide range of things they’re covering isn’t it… So they’ve got a big wide thing right, and therefore they can only like sort of deal with patients on a sort of book, text book, in a text book way so that everybody is doing the same thing”.

Title here Ward instability caused a sense of ‘interaction anxiety’, between staff and service users. The perceived need to self protect created avoidance rather than promoting interaction. AVOIDANCE – SERVICE USERS: “if you get somebody who doesn’t want to engage and how do you get them to engage? - and that can be quite demoralising for a nurse if you just so happened to have three days of someone not wanting to and you just……” There was also an issue of staff avoiding staff interactions. AVOIDANCE – STAFF: “I think it is tough actually, because if there has been a difficulty like within the team like a tricky team dynamic I’ve been in that situation... and actually people have been like, ‘so how have you found the work?’ ‘Yeah, yeah fine’, and I know that actually in the back of my mind I’m thinking actually no its been rubbish and I just don’t feel comfortable in saying it here right now..... it’s a difficult problem....” The social milieu: staff perceptions

The social milieu: service user perceptions Service users attributed limited interaction opportunities (activities and talking therapies) to staff being unavailable or disinterested. UNAVAILABILITY: SU1: “A lot of the time you had to go to them to say ‘I need to talk’ and they’d say ‘five minutes’. And half an hour later you’re getting worse and worse and worse, you’re spiralling down, you need that person to talk to and they finally decided to turn up.” SU2: “By which time you think about cutting your wrists and f*****g off.” TALKING HELPS: “I took a massive overdose, I couldn’t have any medication. So it was …. counter- productive being in hospital. No point because no-one was talking to me.”

The effect – disempowerment/frustration STAFF EXPRESSED FEELING OVERBURDENED: “It’s kind of like a can’t do mentality isn’t and I can see where it comes from.….you have very limited time to spend one to one time with your patients … and I think that often nurses start losing some of the therapeutic skills they have because their stuck - I’m a band six nurse I’ve got loads of experience and if I’m shift coordinating I’m stuck being a telephonist. SERVICE USERS EXPRESSED FEELING ALONE: “But they wouldn’t take the trouble to come and sit, just take one of the staff to sit in your bedroom with you and maybe talk over what’s making you feel like that. Yeah rather than do that, they just sit back and just let you go over the top and then they pound on you with the needle.” Both groups seem to share a sense of powerlessness and frustration.

Feeding the negative cycle These feelings of frustration then feed into the ward environment, increasing acuity levels. Service users felt that there was a direct effect on aggression. FEELING MISUNDERSTOOD: “It’s a natural behaviour. Anybody, no matter who it is yeah, you’ve been put in somewhere where you don’t want to be, you will get a little bit angry. And when they say ‘no, you can’t go nowhere’, you would get angry. But they see that anger as sickness, you’re out of control. They don’t understand.” Staff described an increase in the negative team dynamic. BAD ATTITUDES: “I mean I’ve had an experience for example, say a nurse was standing next to saying the linen cupboard or something, right next to the linen cupboard. And then someone, a patient asks them, ‘oh, can I have something from the cupboard?’ - the nurse is standing there she has the keys but she’ll send the patient to go and find me doing something else to come and open the cupboard for her because you know that’s just not her job.”

Cycle of Acute Care Variability No voice/ frustration No participation Poor engagement Difficulty communicating Avoidance INTERA CTION DISEMPOWE RMENT INSTABI LITY

Summary In acute care the current focus is on risk – this is not a therapeutic model. Staff and service user involvement in informing service changes. What do service users want the ward to look like? streaming patients with similar diagnoses for example. individualised talking therapy. What do staff feel is feasible to deliver? should we be re-examining the nursing ‘team’