Safwards

Resistance to Know Each other.

Why are some staff reluctant to complete Know Each Other profiles? Here are a few thoughts.

1) Are we surprised?.
No. There are staff who will be reluctant to complete. There was in the pilot, there was in the trial and there are in implementation wards.
There will also be staff that will have no problem in completing. Ditto pilot, trial and after.
Is one set a “good “bunch of Nurses and one “bad”? No. The ones who resist have “an issue”. The issue seems to take a number of forms, but we will come to that later.

2) If they have an issue, should we allow them to abstain?
No. The intervention may bring up stuff and it may be uncomfortable, but it is designed to stop conflict and has been tested with a range of other things and has contributed to reduction. Saying people don’t have to do it would be like saying we don’t care about creating conflict. You may have an issue, but you have to deal with it. That’s what nursing is all about.

3) So what are the issues?
There seem to be two major ones.

a) “ I don’t want to share as it will make me vulnerable. They might use it against me in some way”
Some people seem to feel that ANY information will be used against them by patients. For some of these nurses it is because they feel they have been “burned” in the past – i.e. that a patient abused or misused a personal piece of information. I guess here the problem is working out what happened – if there is an incident that needs to be worked through in supervision or some supportive forum – and learning to take the “I am trusting you” risks again. It is inevitable that patients and staff will come into dispute (look at the Safewards model!) and trusting people is always a risk – but you do need to develop a way of coping with this. Simply not trusting patients comes across to them and, paradoxically may make you MORE vulnerable. It’s easy to have a go at someone perceived as a “poe faced jobs worth” than someone you perceive as friendly. Also, we can say goodbye to the notion of patients trusting us if we are not prepared to reciprocate. Trust is a two way street

b) ”I don’t want to share as I need to maintain my professional distance”.
Nonsense. Sorry, but it is. I have had many a GP in my time, but the one that sticks out for me as clearly the best was the one who I trusted. He never invited me to his house, we never had a pint together and he was always professional, but in the short time he looked after me I got to know little bits and pieces in passing. He noticed a football top once and disclosed he was an Arsenal season ticket holder. He once told me he would not be around for a while and, when I asked if it was a holiday, said “No – paternity leave.” before telling me who I could get treatment from if I needed. Later he told me he had two kids. He also always called me by my name and, after looking at the notes, could remember things that we had talked about before. I always saw him as a professional, but never as distant. As a consequence I can honestly say I was really happy to be treated by him and wish he was still my GP.

What all this seems to boil down to is that we have to admit that there are nurses among us who don’t trust patients, for one reason or another. While we need to help them to work through this, we also need to be firm that they need to work nit though. Their inability is the wards vulnerability.

4) Any practical tips?
I must admit I did like James Wright’s idea of getting patients to interview staff. I like it because it cuts right across the issues – Can you say no to an actual patient? The other thing is a like the symbolism of asking the patients to help us with a problem of ours. I am sure some of them are better at this than us. If staff are really resistive, they can choose the patient! You could have variations of this theme – put out the name of a nurse on a blank sheet and get the patients to write “know each other” items they think they might already know. We might be surprised at what they do already know. Anyway, including pts seems like an inspired idea to me.

Any other brilliant thoughts from out there? You lot are bigger experts now as you’ve implemented more than we were able to!!

But please, don’t give up on KEO because nurses find it difficult. Remember as well that the true sign it is being effective is if patients want to also do theirs and make a whole community. After all, if we really want to stop conflict, we can only do it together.

Hi Geoff and everyone,

I am not so sure that there has always been an incident of some sort in someone's past that makes them wary about sharing any information, anything at all. There might be other things behind this, including:

They heard about someone else who shared too much and got burned. Or there is some mythic story floating in the gossip circuits of their hospital about what happened once to someone, or what somebody heard once happened to someone at 'another' hospital.

The emphasis on maintaining boundaries with patients during training is so intense, that they have adopted a simple black and white rule to protect themselves from any potential criticism of 'inappropriate' relationships with patients - don't share anything! So a genuine wish to do the right thing coupled with uncertainty about the limits of what is allowed results in actions which are counter productive.

Similar ambiguities and complex rules surround confidentiality, and what you can and can't say publicly about your work. These rules are not straightforward, they are hard to learn, and they are interpreted differently by different people, and people do get burned, disciplined, criticised for breaches. Best therefore to say nothing, and this generalises to the ward situation and what they are willing to say about themselves.

Generalised anxiety about patients and what patients might do. Not necessarily based on experience of having shared too much and experienced harm from so doing. More the type of experience we have all had, being assaulted or verbally abused by a patient we have invested time in building a relationship with. Therefore to protect themselves from hurt, they erect barriers and draw themselves inwards. Hence the intensity of the objection to KEO.

Anybody else have any ideas about this?

Len

Yes, Len, I agree. A generalised sense of anxiety or a focus on negative experience. You reminded me of one area that talked about staff reluctant to have their surnames on their badges as there had “been an incident of a nurse being stalked by a patient".. Now I don’t know if that happened or not, but it was stated as a powerful possible incentive not to engage with things like KEO. Almost as a kind of trump card.

The thing is, how do we change this? Perhaps a start would be to point out that, in this situation staff exhibit the same mistakes of thought that we often say patients have- a belief that certain over the top protective actions will give some form of protection against the rare but real dangers that exist in life. I wonder if the focus on risk, risk avoidance and a general sense that if things go wrong someone must be to blame – or more accurately the thought ” they will find someone to blame” leaves staff slightly paranoid! Hence the reaction is an elaborate form of safety – don’t tell them anything and you will be safe. (Actually, I don’t know how not showing your surname gives any form of such protection – and I don’t actually believe it does.)
The other thing is – this is not universal. Many nurses do not have these issues. The posts and general reaction to safewards does give an opportunity for the healthier side of nursing to have a solid platform. Therefore, the unearthing of resistance is unavoidable, indeed, it may even be essential to change.

All of which brings we to one point. We can’t let individual staff not engage with KEO. Patients will spot it a mile off if we do. After all, they are not stupid- far from it.

Did get a tweet that said we could change the questions to “what don people admire about me” etc, but not convinced this will lance the boil don’t think its the format, but the philosophy that people reisit.
Also had a post on facebook about needing time and resources for supervision etc. Fair enough, but we also should point pit what will happen in supervision

And some more thoughts about KEO (Know Each Other):

Intense demands are made on people in inpatient psychiatry. Incessant managerial demands. Demands for this and that services from patients. Demands from patients that are impossible to meet (let me out). Ward manager demands, do this do that do the other. From doctors too. The demands of the daily routine. Add on top of that the emotional demands. These should not be underestimated. They can feel excessive. Handling the anger of patients. The need to give care and all the complexities around that. Handling regressive emotions from patients. The sheer intensity of these regressive emotions. Plus the tragedy of mental illness, it’s life shattering effect, the disabilities the loss. Plus dealing with suicide and self-harm. The risks of what people might do. Self mutilation. KEO comes along with the other Safewards interventions, and it is something we can say no to. Esp. KEO. Nobody can make you do that. So it is a rare chance to assert yourself, to set a limit when you can’t to all those all too persistent and moral other demands. Nameless anger and resistance at being continually pushed around and told to do things.

KEO is also a symbolic and existential threat. To the affective neutrality we have been taught. We need it to give objective care, but it also makes us distant and cut off from our emotions. This is the professionalism which is threatened. Not the vulnerability to attack or harm, but the vulnerability to being made to feel something, to have our defenses pulled down (or our excuses for distancing).

On supervision, Maureen Deacon did some work on this years ago. She demonstrated that on wards the functions of clinical supervision were replicated in many different ways and in many different forums, sometimes on a one to one and sometimes in group formats. Dealing with KEO resistance doesn't need to be in a scheduled session. It can be in discussions here and there. In support offered between each other in the team. In what the ward manager says to the team at handovers and elsewhere. In open discussions we have with each other whilst undertaking other tasks. In what the team sits down and plans to do for each other.

And a multiplicity of other methods. For those who want to read about this in detail I've attached her report.

Len

Virginia Griffin, who has been having a few problems accessing the forum, has asked me to post the following on her behalf:

"Greetings Len could you copy and paste this on my behalf please.

I am aware that staff feel rather vulnerable about sharing information in the Getting to know you pack about themselves. The views expressed here are merely my own and I do respect the opinions of others who don't feel comfortable sharing information. Our GTKY pack is a basic information sheet which identifies a few things about us, name etc etc. To start with it might be worth remembering that staff are suppose to identify themselves anyway and most ID badges display our pictures along with our names. I am more comfortable with my name and face on a GTKY pack than using my ID badge. Firstly in a PICU it is dangerous to display a badge as they could be used as weapons as they are attached to you. Anybody could snatch them and setting that aside many have magnetic strips which allow you access into units.

Any information shared should be used for the benefit of the trust, the ward and the patient. Nobody has to reveal their life history, illnesses or where they live. Basic information we have revealed is just that basic, our hobbies, our interests, favorite quotes, music, likes and dislikes. These give the patient a basic background about us and really that is all one needs to build up a therapeutic relationship with the patients. I've heard staff mention issues surrounding confidentiality? The boundaries surrounding confidentiality are fine. In North Wales part of the Island of Anglesey we have the unit that treats many patients with mental health illnesses. As we are not a big Island and quite often you are bound to bump into a patient in a local supermarket, very often with your family members as well. A large majority of people where I reside are aware I am a RMN who works in Hergest and that has not come from me either. Word gets around but never once have I whilst out and about shopping ever discussed, disclosed or revealed any information about people who I have treated with village folk. Yes folk have made inquires and my answer is always the same "Sorry but I am not at liberty to discuss people, something I wouldn't do to you if you were in hospital either" or "No clue who you are talking about" Its never failed me yet.

Quote from Len The emphasis on maintaining boundaries with patients during training is so intense, that they have adopted a simple black and white rule to protect themselves from any potential criticism of 'inappropriate' relationships with patients - don't share anything!

Any inappropriate relationship is what the nurse has created for herself. However quite often patients will highlight sensitive issues and ask you what understanding you have of this? For me its safe to reveal some first hand knowledge without mentioning names, places or people but merely highlighting that you understand the situation because you know of somebody who experienced something similar and this was how it was handled. Its not putting yourself in the line of fire its merely stating you have a knowledge of this and how you can understand their feelings. How do we provide information about sensitive issues or give a patient empathy if we cannot understand it? Developing a relationship with a sick patient is all about give and take. They are giving us their life history, their personal journeys and quite often they feel ashamed because they perceive us to have these perfect lives. I recently met a patient who returned from living abroad for many years, like myself this person was born here but lived overseas for many years. I didn't feel uncomfortable sharing the fact that the transition from one country and culture to another is very difficult to adapt too and therefore understood how difficult this was for them. Its not breaking rules, its not giving anything away and besides my accent gives it away. I feel each patient and what we reveal comes with it own merits and risks which are tools we need to use. In other words use common sense about what you discuss with them. Information is dangerous, use it wisely. Like I pointed out our GTKY is basic, Sian Williams my ward manager has a file about each of her staff members for patients to see, it has worked a treat with patients. Some of the questions I've had about this file.
1. Gosh I didn't know you liked that movie, I loved it.
2. (Laughter) that quote is great, its really good
3) This person doesn't like bullying, me too.
4) How old were you when that picture was taken.
5) Her hair was longer in this picture.
6) Last but not least Why did you choose this career path?

So do our years of nursing experience? our hobbies? our dislikes? our likes? our taste in music, favorite book, movie, TV shows place us in vulnerable situations or do they break boundaries or confidentiality? No they don't they make human beings which patients want to see and feel.

We need to remember in order to assess people we need to build up a relationship with them. You don't build it up by letting them just talk about themselves. They need to know we understand their journey and we are helping them through this journey. In order to help them we need to give a bit of ourselves within reason which doesn't place us in a vulnerable or dangerous position. To much red tape surrounding what is right and wrong today. Think of how a patient feels when they are going into an operating room? they are exposed, they are put to sleep, they are placing their lives into a few peoples hands. We on the other talk directly to these people, if its safe to ask the man who is putting you to sleep what experience do they have, I think its safe to ask the nurse what experience we have or have had. GTKY is very similar its merely asking us or showing them a bit about ourselves within guided boundaries. Who better than a nurse with teenage children to share what teenagers are like with a patient who is detained in a unit and concerned about their children? Is that going breaking confidentiality? NO. "

Thanks for that Virginia

This topic has been rolling around in my head for a while - and I remembered the Star Wards "Bring yourself to work" idea (see link) which may also help people think about "Know Each Other". It does have some really good stuff and ideas attached and I think is a very complimentary idea.

Have a look and see what you think.

The idea, of course would need to think how to include patientes, but it could be "Bring yourself to the Ward" and be adapted for everyone? Have any starwards people tried this (apart from the truly brillinat Jo Spencer in Highgate - its in the clip)

www.wardipedia.org/35-bring-yourself-to-work-day/