How to Coach Yourself and Others Coaching and Counseling in Difficult Circumstances | Page 98

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Thus having uninterrupted time to sit down with a patient and respectfully listen to their experience, is at a
premium. Such times are more likely to occur on night duty when demands are reduced because many patients
are asleep, or at weekends because of reduced demands to service other professionals visiting the ward.
Opportunities at other times are a scarce resource. The reality of interactions between patients and staff is that
they tend to be brief, and conducted on the fly in the midst of other activities. This can be an asset in certain
circumstances, and our interviewees did point out that joint activities were ways to develop conversation with
patients, and that some patients mental state did require interactions to be short and to the point. However
interactions are conducted by those with minimal or incomplete training far more frequently than with a
qualified nurse – a situation that causes considerable frustration to those who have assiduously trained for three
years to practice as a skilled and qualified psychiatric nurse. This is not to say that no time is ever available, nor
that there are some wards and teams where the time that is available is wasted in doing nothing or staff making
social conversations with each other. An efficiently managed and hardworking staff team can make the best of
those opportunities which are available. And the fact that our expert nurses could talk about a wide range of
techniques and skills demonstrated that they had acquired these in practice and they were feasible.
The environment of the ward can also provide obstacles. If quiet privacy was the best location for meaningful
conversation, then appropriate rooms had to be available. Yet many wards in outdated buildings would find such
provision a challenge. And even if such rooms were available, for a nurse to go with a patient into such a room
removed one person from general supervision of the ward and patients – an important task to be able to provide
instant support to patients with fluctuating and unpredictable mental states, to prevent aggression, bullying, selfharm and absconding. Trying to converse within the ward day room or public areas meant that passers by could
overhear what was being said, making both parties self-conscious and guarded. Meanwhile the nurse was open
to being approached and interrupted by other patients with requests and demands.
Another way of regarding these competing pressures is to consider the nurses’ tasks. Their first priority was to
keep patients safe, and this meant keeping them on the ward when necessary, and keeping a constant
supervisory eye over every patient and every area of the ward. That observation enabled them to complete the
second task of assessment – monitoring the condition and behaviour of patients to inform other members of the
team, enabling correct treatment and diagnosis. The third task, that of giving treatment, centres currently mainly
around giving medication, involving four lengthy medication rounds each day, inlcuding persuading reluctant
patients to take their medication, checking that they have been taken, answering questions and assessing for side
effects, plus a lot of communications with doctors and pharmacy about medication changes, discharge
medications, leave medications, etc. Lastly comes making sure that patients eat and drink sufficient for their
health, have clean clothes to wear, take baths, shave, cut their nails, etc. Interaction takes place alongside these
tasks, but not a great deal of time is left over for general conversation to build relationships. Structured
therapeutic interactions are possibly amongst the last in a long line of priorities.
It also needs to be recognised that the psychotic experience itself represents a very real barrier to
effective communication. It is an alien, abnormal and private experience, thus accessing it from
outside and understanding it are problematic. Cognitive processing is compromised: the patient’s
concentration, memory and ability to understand are adversely affected, thus acquiring or giving
information is difficult. Inpatients are frequently hostile, mistrustful and angry because of their
confinement on the ward, the restrictions placed on them, close living with other people, mood
changes, delusions and hallucinations; all of which pose challenges to nurses’ efforts to establish
and maintain a supportive relationship. Strange, bizarre and frankly funny beliefs, talk and actions
by patients mean that ma