Removing barriers between nurses and patients: adopting a new model of patient care has empowered mental health nurses at Timaru Hospital to focus on patients' achievements rather than their problems.

NURSES IN the central office looking out from the glassed-in station, down corridors via cunningly angled fish-eye mirrors, looking out like fish from a bowl. This separation, physical and emotional, once characterised the setting in Timaru Hospital's acute inpatient mental health ward.

Before I was appointed clinical coordinator in 2000, the glass was taken out in an effort to overcome the separation and staff retreated to a small office. The "fish bowl" counter remained, along with shelves of books and folders, like a lawyer's office, the trappings of professionals.

This attempt at progress, at removing the barrier between nurses and patients at a physical level, largely failed at a more important one. It did not help nurses establish the truly reciprocal relations with patients that make an important difference to recovery. (1) What it did was simply drive them into a smaller, more cramped office to await the next task in the daily routine. What was missing was a way for staff to survive out of the fish bowl. Without the tools to survive in an environment of power sharing, reciprocity and relationship-building, they were left to flounder.

Why was this the case? Surely nurses have the tools to work in the modern day psychiatric setting? Surely principles of psychosocial rehabilitation have been around for half a century and nurses are well versed in these methods? Surely the new teaching in polytechnics prepares nurses to work intimately with people to plan treatment and recovery? Maybe the knowledge was there--it was with most I but the institutionalised environment was a product more of individual personalities and perspectives than a team-led process.

Prior to my joining the team, a colleague had warned me I would find the Kensington Centre ten years behind the times. In fact, what I found was a group of caring, dedicated staff with wonderful resilience who had weathered many changes and who overcame their reservations to accept yet another co-ordinator into their midst. Staffing was a problem, with four vacancies, and management had just repaired some unpopular roster changes. What more would staff be expected to do?

An initial assessment over three months revealed a system of working with clients that was primarily focused on problem resolution. If problems were resolved, then there was nothing more to do. This could mean that some patients whose problems were less obvious missed out on staff time, with input directed more to those who disrupted the environment with their behaviour. The squeaky wheel gets the grease. What was required was a model of care that would reach all people no matter how "noisy" they were and would give the staff a way of surviving outside the fish bowl.

In my previous job in a community organisation I had come across the "strengths model". (2) This was developed at the University of Kansas in the early 1980s and has gained popularity as a recovery model for people with severe, persistent mental illness. Used in New Zealand mainly among some non-government organisations for the past four years, this model of case management offered opportunities to meet the needs of patients and staff. The manager of mental health services had the vision to recognise this model could make a significant difference to the people we supported. Research suggests the model reduces hospitalisations, length of stay, family burden, and results in fewer crisis contacts. (2) These outcomes are all measures of a successful mental health programme.

The model was developed at the University of Kansas' School of Social Welfare in response to a project to case manage a group of high-need, long-term clients with psychiatric diagnoses. When looking at existing models, the researchers realised that their main focus was on the deficits of individuals, with very little attention given to their strengths and those of the community. This meant a huge number of opportunities were missed to help a person grow beyond their difficulty and reinforced instead a sense of hopelessness and disability.

Recognising that focusing on deficits may actually make people worse or at best no better than before they became unwell, six key principles of an alternative model emerged:

* The focus is on strengths, not weaknesses, deficits and problems.

* The person is in charge no matter what, and nothing is done without their approval.

* People continue to grow and to change, no matter what their disability.

* The community is considered an oasis of resources and opportunities, full of understanding and helpful people.

* The relationship between the person and their key worker is primary and essential.

* Assertive outreach is the preferred means of intervention. (3)

In early 2001, management at Timaru Hospital's mental health service began a discussion with staff about embracing a recovery model of care. The Mental Health Commission's 1998 Blueprint for Mental Health Services talked about the need for services to operate in this manner (4) and in due course a training guide was released. (5) With general acceptance by all staff that we needed to "bite the bullet" and undergo yet another change, we decided to proceed. The strengths model was chosen as the best available recovery model, as it was relatively simple to understand, contained practical, easily taught tools, focused on empowerment and personal responsibility, and recognised the importance of family and community in a person's ongoing recovery and well being.

Teaching the new model

In June 2001, we embarked on a training programme to teach all mental health workers in South Canterbury the principles and tools of the strengths model. After three months, we were ready to begin and ward staff led the way by introducing the model's tools, strengths assessment and goal planning in their work with clients. This was a first for an acute setting in New Zealand. Issues of acuity and safety were paramount in understanding there is a time in recovery when the strengths model can truly be honoured in principle and practice. Guidelines to assist staff in making this judgement have been developed in-house. (6)

To say there was no resistance to the new approach would be exaggerating, but it did surprise us how little there was. Some staff found the notion of change tiresome and unattractive, others struggled initially with the change of focus to strengths rather than problems and deficits, as they had spent so much of their career immersed in exploring the breadth and depth of people's pathology. What they struggled to understand was that, rather than ignoring problems, the model provided a way of helping people beyond their difficulties through the strength of their personal and community resources.

We spread the initial training over three months to enable a gradual change of attitude and perspective and to give staff time to ask questions and challenge what they were being taught. We also introduced a process of group supervision to continue the process of education, sharing ideas and support, and encouragement from peers. (2)

Nurses now became "key workers" with a job description based on strengths' principles. Their responsibility was to work closely with their clients to uncover individual and community strengths, to bring these together in a goal directed manner, and to spend time achieving steps that would bring them ever closer to their aspirations. With the tools to teach and guide each client, staff became empowered to work more effectively outside "the fish bowl" and to share the journey of recovery. They became enabled to celebrate and enjoy their clients' everyday achievements and to adopt an even more hopeful, healthful attitude.

Laughter became the norm. People who had not visited the ward for some time remarked on the relaxed and happy atmosphere. A visiting nursing tutor remarked that, when she visited two years ago, everyone had been so formal and uptight. This time she had staff coming up to her asking if she was being attended to and sharing a smile and some conversation. Clients who had experienced the old treatment approach, once they got used to the change in focus, were mostly positive and excited about the strengths' approach. The few who had difficulty were unable or unwilling to take responsibility for their behaviours and so it became very obvious where they were stuck.

Staffing shortages disappeared, with no unfilled vacancies for the past year. The incidence of people going "AWOL" from this open ward reduced. Clients reported that the emphasis on personal control helped them view staff as helpful rather than controlling. Staff stated they couldn't imagine working "the old way". The "fish bowl" was abandoned. Even the counter has gone now. All that will be left, once the carpentry work is completed, will be a large tropical fish tank in the lobby, with sofas and armchairs and staff and clients relaxing together, watching the graceful movements of impossibly beautiful creatures.

With a change of focus and an injection of enthusiasm, staff have turned their practice inside out and made major gains in professional development. Staff have learnt what it means to walk beside people in the helping relationship, understanding the importance of reciprocity and therapeutic self-disclosure. They know recovery is a journey that takes many turns and that hope is crucial. Working in a recovery-orientated manner, they are able to enjoy the superior outcomes this produces for the people they support.

Some early results

Since the introduction of the strengths model, the re-admission rate has dropped by 20 percent. The average stay has gone down by 25 percent from 12 days in 2000 to nine days over recent months. Admissions for 2002 were 27 percent down on 2001. This reduction in admissions is in the main a product of the community mental health teams and other support agencies (Richmond Fellowship, Timaru Mental Health Support Trust, Caroline House, Victoria Trust) also using a strengths' approach. Together we are helping the people who were once the greatest users of our services find better ways of coping. For instance in 2001, there were 250 inpatient admissions, representing 195 individuals and accounting for 4010 patient-stay days. Of those 195 people, 29 or 15 percent were identified as frequent users of our inpatient services. They accounted for 1423 (35 percent) of the total patient-stay days. They also accounted for 84 of the 250 admissions, ie 34 percent. By helping these people find better ways of living and maintaining their wellness, the service is able to free up a third of inpatient resources.

Our unit has capacity for 15 residents and takes people from the south and mid Canterbury regions, with a population of around 75,000. Due to lower than usual occupancy rates, the unit has accepted patients from Christchurch (and even Auckland on one occasion) for periods of time, to help alleviate pressure on those services. Those particular admissions are not represented in the figures. For two consecutive months last year, the average occupancy was four, an historical low.

REFERENCES

(1) Mead, S. and Copeland, M.E. (2000) What recovery means to us: consumers' perspectives. Community Mental Health Journal; 36: 3, 315-328.

(2) Rapp, C. A. (1998) The Strengths Model: Case Management with People Suffering from Severe and Persistent Mental Illness. New York: Oxford University Press.

(3) Saleeby, D. (1997) The Strengths Perspective in Social Work Practice. 2nd ed. New York: Longman.

(4) Mental Health Commission. (1998) Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington: Author.

(5) Mental Health Commission. (2001) Mental Health Recovery Competencies: teaching resource kit. Wellington: Author.

(6) Mosley, B. and Liddy, P. (2002) Guidelines for the use of the Strengths Model in an In-Patient Unit. Timaru Mental Health Services.

--Paul Liddy, RPN, BA (SocSc), is clinical coordinator at Timaru Hospital's acute inpatient mental health unit, the Kensington Centre.