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37. Arriving and leaving

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All my bags are packed

Introduction

Our first moments in a new environment are disproportionately important in setting the tone for the rest of the experience. Especially when the new environment is one that carries considerable anxiety or even terror.

There are few times in life when we are sent somewhere against our will or with so much negative expectation (visits to in-laws notwithstanding). Even voluntary patients can experience an enormous sense of humiliation and distress, and is certainly heightened for those arriving attached by handcuffs to a police officer. Paradoxically, leaving hospital can also be hugely daunting, and the more positive and healing the patient’s time on the ward, the scarier and less attractive it can feel for many patients.

You don’t need to just take our word for it! There’s a bunch of social psychology research demonstrating the lasting power of primacy and recency (i.e. first and last experiences) and, interestingly, the more all over the shop people are, the stronger these effects. The intensity of these moments provides lots of scope for making them actively therapeutic for patients.

A little note from Marion Janner (founder of Star Wards)

The power of Yes!
I was in Costa Rica at the end of a delightful cycle jaunt, all sweaty and grubby. We came across a magical outdoor café, built in, around and from trees. The guy at the counter shouted across: “Whatever you want, the answer is yes!” This was some 15 years ago but I remember it vividly. I can’t remember the name of the town (I can scarcely remember what I had for breakfast three hours ago) but the feeling of being so generously, unconditionally welcomed remains palpable.Slightly more relevantly, I recently had an interesting ‘hydrotherapy’ experience in an Israeli spa. I had no idea what to expect (and it turned out to be pretty unusual!) but the therapist looked at me and said: “I’m here to look after you for this hour so you don’t need to worry about keeping your balance or what your limbs are doing. Just relax and enjoy the journey.” We’re not actually recommending saying either of these things to the newly arrived patient, but it’s worth trying to replicate the hospitality and reassurance that these statements convey.Similarly, but without any little travel anecdotes, patients’ experiences of leaving hospital are disproportionately influential in how they look back on their admission and look ahead to returning home. It’s enormously difficult in the hurly-burly of ward life to carve out the extra time and effort to ensure that patients’ arrivals and departures are as positive or at least untraumatic as circumstances allow.

Ward examples

  • Small toiletries’ bags are offered to patients on admission. Feels very hospitable and saves giving big bars of soap, and shampoo, so also saves money.
  • Checklist for arrivals and departures that both staff and patients have a copy of.
  • Patients get pre-briefing: a ‘warning’ about what tricky things might happen on the ward. Research suggests this reduces Post Traumatic Stress Disorder etc.
  • Community in-reach care co-ordinators work on wards with patients.
  • GP referral scheme, linked up to GP practice for free yoga, exercise in community. GPs send reports on how discharged patients are doing.
  • OTs work across inpatient and Crisis services.
  • OT works for up to 8 weeks post discharge. Satisfying for patients and staff.
  • Two post-discharge staff work with inpatients.
  • Partnership with Rethink – ex service users mentoring patients to support them when they leave.
  • Patients have devised a welcome pack for new admissions to support them following admission.  The pack outlines ward rules, procedures, therapies offered and general information regarding ongoing care, treatment and recovery.
  • The patient rep for the ward is encouraged to provide a brief ‘induction’ to the ward and offer advice.
  • The ward’s Link-OT and a Staff Nurse run a weekly ‘ Moving Forward’ group.
  • All patients are given individual therapeutic timetables which incorporate at least 25 hours per week of structured therapeutic activity.
  • All patients access groups in the community rather than all sessions being held within the hospital. As an example, patients attend Sheffield Afro Caribbean Mental Health Association (SACMHA)
  • All patients complete a Wellness and Recovery Action Plan with their named psychologist prior to discharge.

Include Ward Buddy in your welcome packs!

Ward Buddy, our very own ‘Recovery Companion’, provides a gentle and useful introduction to ward life, with a strong peer support approach. It’s designed to accompany inpatients through various experiences of ward life; from arriving on the ward to the rediscovery of hope, amongst other themes. The booklet is filled with experiences of recovery and mini snippets of ward life that have been kindly offered and beautifully illustrated by people who have had stays on mental health wards.

  • As a journal or diary
  • As a note pad
  • As a way to plan and remember what to speak about with staff
  • As conversation starters
  • Use it alongside recovery plans
  • Simply read it
Harrison House     
Harrison House is a fabulous new hospital in Grimsby. Just one aspect of their fresh, patient-centred approach is that they have a combined inpatient and home treatment team. Superb. Here’s their Ellie Walsh describing the team.This is what they’ve boldly done to improve acute care co-ordination and delivery by merging their inpatient and crisis services.In February 2009 we disbanded the Crisis Home Treatment Team and allocated the staff to be part of the inpatient establishment. Now
ALL qualified staff at band 6 and above do crisis assessments, and home treatment is delivered from band 3 Nursing Assistants up to me which now provides a continuity of care from assessment to inpatient and/or home treatment package. Some staff voted with their feet, most are loving it, we are growing band 5’s into band 6’s, the junior staff are bloody marvellous.We based it on Yarmouth and Waverly NHS – who are working to this model. We had a major restructure to do it with 2 band 8as leading the service on Diamond and Sapphire (Diamond being me!!), then we have four band 7 service leads who all have a specialist interest. All of us work 40% managerial and 60% clinical which means the most senior staff have time to lead by example eg, doing crisis assessments with junior staff, leading with home treatment and taking shift leader roles on the wards.
We presented it to our regional forum in January as lots of people are interested in what we are doing. It’s been really hard and still is – it’s a major change to how we have all been working. The Director fully supports it and Mike Reeve Acute Mental Health Manager led on this. This is all in preparation to moving to a new purpose build hospital in February 2010.Ellie Walsh. East Service Manager

Welcome Bags

Here’s a magnificent idea from Northumberland, Tyne and Wear:

These bags are given to new patients from existing patients forming a patient’s mutual support system. This has helped with the well-being of patients who have been attending the welcome bag activity group. From the feedback that has been received they feel they are contributing not only to their own well-being but are showing the new patient that they care. Many new ideas continue to pour in from patients as to what could be put into the bags. Important telephone numbers, i.e. PALS, Carers Support Groups, and appointment cards.‘The idea for the Welcome Bags came about from the information we received for the Star Wards Festival Celebration Bags which we actively took part in. A group was formed whereby the Festival Bags were made by service users from the East and West Willows wards and were sent away to London. During the festival bag activity group one of our patients asked if they could make their own bags to give to new patients on their ward to help them feel more welcome and dispel their own fears about being ill and away from home. The idea for ‘Welcome Bags’ was adopted. It was suggested that we could scale down the original festival bag.  Inside the bag would be placed a written information leaflet about the ward, a kind word greeting card, a timetable for on/off ward activities. Some patients would also put in a small sachet of hand cream, shampoo and hair conditioner, etc, thus making the bag a more personal item.  The idea for the ‘Welcome Bags’ were created.

Since starting this welcome bag activity group we have had patients approach us who have received a welcome bag and have requested to participate in creating their own bag to give to someone else who has just arrived on the ward. During one of our groups one of our patients had finished their bag and was so happy and proud of her achievement that it was suggested she keep the bag for herself.   “No she replied, I’ve made this for someone else to help them feel better”.

The message we are simply saying from these bags is WELCOME!’

 

Cambian’s WOW! Packs

This is an amazing (really Wow!) way of making a patient feel welcome and valued. A sample pack for a newly arrived male patient

  • Toothpaste, toothbrush, soap, shampoo, shower gel, roll-on deodorant
  • Face cloths, hand towels
  • Bath Robes
  • Philips Shavers
  • Men’s Toiletry Bag
  • Rucksack
  • CD Player
  • Radio & CD Alarm Clock

Engaging with Information Trees

Providing good information in an accessible way is a challenge for all wards – and this ward has devised a new and creative way of providing information to service users and visitors. The information can be washed off easily, which allows us to keep the information up to date and relevant to people’s needs. Information displayed includes: visiting times, phone numbers, and what to bring to the ward.

Providing good information in an accessible way is a challenge for all wards – and this ward has devised a new and creative way of providing information to service users and visitors. The information can be washed off easily, which allows us to keep the information up to date and relevant to people’s needs. Information displayed includes: visiting times, phone numbers, and what to bring to the ward.

Arriving

Understandably, the focus of a newly admitted patient tends to be the onerous paperwork and practicalities. But we’d argue that the immediate priority needs to be making patients feel welcome, safe and cared about. For them not to feel like a burden, a loser, a statistic. It’s worth reviewing, perhaps with service user representatives, what patients on your ward experience in their first minute, 10 minutes, hour.

  • What are patients feeling, expecting, dreading, looking forward to (including getting home!)?
  • What are the absolute priorities in terms of the patient’s experience, information, risk management?
  • Where is the patient?
  • Do they feel like they’re in some strange, institutional waiting room, or a delightful reception space?
  • What are they doing?
  • Who is with them?
  • What are their senses experiencing? What does the ward look, sound and smell like?
  • What impression is given of how staff act, dress, talk and, above all, interact with patients?
  • When was the last time the person had a meal or a drink?
  • What process have they just been through that culminated in them being admitted?
  • Do they need a debrief from this before they can start to adjust to being an inpatient?

Simple things can make a big difference, like being offered a drink or snack, having magazines to flick through or a TV to stare at or a friendly patient to chat or sit in companionable silence with. Using the person’s name, having checked what they like to be called – Robert, Bob or Mr Jones?

If searches are necessary, has this process been reviewed with service users? It can be an excruciatingly humiliating and necessarily intrusive experience, but a nurse’s tone of voice, body language and explanations can greatly reduce the trauma. Patients who have been admitted because they are suicidal may also have a long history of using self-harming to cope, including while in hospital. Although the prospect of being disarmed can be terrifying, if this happens in the context of feeling that staff genuinely care about their safety and well-being, this can be deeply reassuring and start the process of trusting staff and recovering from this acute crisis.

By the time a patient is admitted they may well feel thoroughly assessed. And possibly exhausted, ashamed and despondent. Again it’s worth reviewing the assessment process with service users. Is their flexibility with the timing and pacing of any further assessment?  Does it make the patient feel understood, cared about, in some control over their situation and treatment?

‘Meeters and greeters’ are increasingly common in general hospitals, and it’s a great role for volunteers, especially ex-patients. They have the time and focus to help new patients feel welcome and safe and to start the introductions to the ward and its inhabitants. Instead of the patient’s first minutes and hour being one of confusion, anxiety and frustration, it’s transformed into one of comfort and companionability.

Leaving

Many patients are thrilled to be going home. They may have hated being in hospital, especially if they believed they weren’t ill in the first place or if the ward at that time was a tough place to be. More commonly, people have mixed feelings – pleasure at returning to family, friends, pets and autonomy tinged with regret at leaving the security and support they had from the ward. But the extent of grief and fear that some patients experience shouldn’t be under-estimated:

Ironically, the patients who most enjoy being on the ward pay for the sense of security they have enjoyed with a heightened perception of insecurity in relation to their return home. They experience a sense of loss of social support, both from staff and other patients. This ‘discharge grief’ may account for the high risk of suicide during the immediate post discharge period (Geddes and Juszczak, 1995; Goldacre et al, 1993). The need for appropriate discharge arrangements and ongoing support is therefore self-evident.The City 128 Study of Observation and Outcomes on Acute Psychiatric Wards

To recap on the potential benefits of an admission, and therefore the losses patients can experience or at least worry about, hospital provides:

  • Escape from the stresses which contributed to them being admitted
  • Being relieved of day-to-day demands of caring for kids, work, study, paying bills, getting dressed, trying to appear cheerful etc
  • A sense of being protected, including from their self-destructive urges
  • ‘Proof’ that life at home has been incredibly difficult and confirmation that their illness is indeed incapacitating
  • Being with other patients, for companionship and also the mutual support and coping strategies which can only come from people in a similar situation to themselves
  • Skilled and compassionate support from staff
  • A structured day, with meaningful, enjoyable activities
  • Three meals a day which they don’t need to plan, prepare or clear up (unless it’s a rehab ward….)
  • A physical environment which might be much nicer than home eg garden, nice big telly, lovely artwork etc

For some patients, this will have been the first time they have felt truly understood and cared about and their therapeutic relationship with staff may have been pivotal in overcoming long-standing traumas. Psychodynamic attachment issues about leaving hospital are likely to be considered for patients with borderline personality disorder, as this condition is now recognised to be partially caused by childhood attachment trauma. But staff also need to consider the potential emotional upheaval for all patients with whom they have successfully formed a strong ‘therapeutic alliance’. At the end of what might have been a long, difficult shift, it can be very tempting for staff to nip off. But making at least 10 minutes for a proper goodbye can greatly help a patient express their appreciation and perhaps their concerns about managing without the support of the nursing staff.

Some things that might help

A handy principle for planning patients’ departures is… no surprises! The patient needs to be and feel well-prepared, family and friends need to be expecting them and feeling they can cope, community services need to know all the whens and hows.

1. Timing of leaving

Most wards, especially in inner-city areas, face extraordinary problems of over-occupancy and pressure to get patients back home. But an extra day or two can make all the difference between a patient, and their support circle, being able to cope. As well as the logistics, enabling patients to have as much choice as possible about when they leave can help them feel better about the transition and themselves. Similarly, being able to decide what time of day to head back home can mean patients can travel in the most conducive way. This might mean waiting til their partner is back from work in the evening, or getting a lift from a mate early in the morning. Hospital transport might need to be lined up.

2. Home

Practical arrangements and how the patient feels about going home will vary depending on, for example, whether a patient has a home to go back to, who (if anyone) will be there for them, what sort of state the place is in etc.:

  • Is the home going to be warm, reasonably clean and tidy?
  • Will there be milk, bread and other food basics?

3. Income

Clearly essential!

  • Cash for the first few days back home
  • Arrangements for regular income – benefits, wages

4. Friends, family and carers

If the patient is going to be returning home to live with family or friends, they’ll need as much relevant information as the patient allows. They may also want direct support and advice including who they should contact if they have concerns. This is also very important if the patient has problems with drugs and/or alcohol.

Patients who have kids, pets or dependent relatives may be worried about how they’ll cope with resuming their caring responsibilities and reassurance plus practical suggestions will go a long way.

5. Education, employment, occupation etc

Patients may need a ‘bridge’ back into employment or education, or occupation in the broadest sense. This can take the form of general support, referrals to mental health employment services, for example. As a kind of by-product, admission to mental health wards can often be a turning point. At their best, they can provide the space and time to reflect and make plans for the future, including thinking about work and/or study.

See Idea

6. Information

  • Ongoing and crisis support names and contact details – Crisis Resolution and Home Treatment, GP, Community Mental Health Teams etc
  • Recovery skills and plans for incorporating these skills and ideas into daily schedules and home, school and/or work environments.

7. Community support services

As well as the patient’s mental and physical health local services being informed and prepared for the patient’s return home, ideally an appointment should be  lined up within the first few days, or sooner if the patient may be at risk of suicide.

An under-used source of post-discharge support is the Samaritans. Your local branch might be able to offer to establish contact with the patient while they’re still in hospital, and to ring them as soon after they return home as the patient would like. Samaritans might also arrange with the patient to ring them at agreed times while the person is getting used to being back home – or indeed to being in a new home.

Some wards are happy to have continued contact with patients, perhaps on a tapering basis, whether by phone, the patient coming in to the ward or staff going out to see them.

8. Medication

  • Supplies, ability to take medication as prescribed
  • With the patient’s consent, and especially if they are likely to have difficulties taking their medication when back home, it’s best if relatives or carers can understand what medication needs to be taken, why, when, how etc.

9. Leaving well

  • Send-off arrangements are going to be different for someone leaving an acute admission ward after a week and a patient moving on after a year on a secure unit.
  • Leaving pack of resources (see Welcome Bags below) eg:
  • wellness kit
  • choice of medication dispenser
  • library card
  • Mp3 player with music
  • good luck card signed by patients and staff
  • warm letter from key-worker outlining person’s progress

Patient Examples

  • When I first came into hospital the last thing on my mind was my responsibilities but eventually I knew they had to be attended to. But it’s okay to have a break from all that and rest.
  • I think being in hospital gives you a lot of options. You find out about all the services and groups out there that can help.
  • Taking back control is really important – like paying the bills and managing your life again. I feel I’ll be able to do this again when I am discharged.
  • Finding the courage to start-over and knowing that life may be different after the admission but at least I’ll be in a better place.
  • I really enjoyed watching films with other patients. I was quite sad to leave the ward , but knew I was ready to move on.
  • I realised only I could choose to get better so coming in as a voluntary patient was the first step.
  • When you get offered leave take it as it is a step towards getting well and being independent.
  • I was given a welcome pack which gave me all the information I needed to know about the ward –very helpful and worthwhile reading.
  • Before being discharged from hospital I treated myself to a cut and blow dry at the hospitals hairdresser – I felt a new woman.
  • Chatting to my named nurse was really good. She made me realise I had made the right decision to come in as a voluntary patient.
  • I was given a gift pack with essentials like toothpaste deodorant and shampoo. I had arrived with nothing, and this made me feel welcome.
  • I felt very shy when I arrived on the ward, but I started to enjoy being with other people after staff introduced me.
  • After a few days of being on the ward I noticed other patients had a welcome pack. So I asked the staff for one. It was helpful and gave me more of an understanding of the ward. Well worth asking.
  • Just asking staff about the visiting hours when you first arrive is a huge help. The first thing I wanted was to see familiar faces.
  • I think knowing what is what when you arrive helps.
  • At first I didn’t want to fit it. By the end of my stay I didn’t want to fit out…
  • I ddidn’t have a mobile phone on me when I got admitted and the payphone was broken! But staff let me use the cordless office phone in a private room.
  • Knowing you’ve been here before but got discharged and felt better.
  • I never really saw anyone before I came into the ward. At first I felt overwhelmed by all the human contact but it’s got me used to being with others.
  • A real effort was made right from the start to help me feel part of the ward.
  • It’s one big journey; sometimes there are ups and sometimes there are downs. Knowing I’ve been down in the past and that I’ll get back up again is a big help.
  • I was in for four weeks and didn’t want to leave. But good to return back to my normal life.
  • Being admitted removed me from all the bad stuff around me. It let me recover and have the confidence to go back out and tackle things.
  • I thought my life was over when I was admitted. I think the staff knew I felt this way because they kept a close eye on me and helped me plan my recovery journey and even my discharge!
  • I tried to be patient when I was first admitted because I didn’t want to be under pressure to get to know everyone at once.
  • Being admitted was my fresh start for learning to care for myself. It was a safe environment to do so…a bit like a training pool where my feet could always touch the floor if I needed a rest.
  • When I was leaving the ward the staff told me I could call them whenever I wanted. I now call from time to time and it’s nice to speak to the staff I got to know. I even call in the middle of the night and that’s okay.
  • I am quite shy so being around so many people was very overwhelming at first. There was a buddy system on my ward so for the first day one of the other patients showed me around. It was nice to be introduced to everyone at my own pace
  • On my admission I sat down with staff and they asked me about all my triggers. We came up with a care plan together to help me cope if any of them did arise. Now there are only a few key ones I still struggle with.
  • First impressions are made in an instant so I think it is vital that a ward is immediately welcoming and able to put you at ease.
  • Seeing others get better and leave the ward gives me some hope.
  • Knowing they’ll be support in the community when I left hospital kept me going, I think.
  • It was too painful to think about all my responsibilities outside of the ward but the ward had a pre-made checklist of things that might need sorting out on admission so all I had to do was tick the boxes and they helped arrange the right people to deal with each issue one step at a time.
  • Everything felt so alien the first time I left the ward. Luckily I had arranged a time to call in to the ward for a chat….it just gave me that extra bit of encouragement to keep at it.’
  • I needed a goal. I felt like I was drifting. My aim was a college course and that target underpinned a lot of the therapeutic work I did whilst in hospital.
  • When you first come in it’s like, ‘Oh my God I’m now a mental patient. What am I doing here?’ But actually it’s no different to being a patient on a physical health ward.
  • I love lists. Each time I spend time with the staff we look at my lists and together and we tick the most important things off. The last tick was make a cup of tea in my own home 🙂

 

Categories: Generosity, Wardipedia

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