Patients (like everyone including staff) are relational beings and have powerful feelings about and responses to other people. The impressively low levels of aggression and violence on wards (given their complexity, constraints and populations) is largely thanks to patients feeling listened to, cared for and safe. This in turn helps patients trust and respect staff and other patients.
Relational security is a term that seems to have been (rather brilliantly) conceived by the Department of Health. It neatly captures the crucial element of safety on the wards – the quality of relationships between staff and patients. They’ve produced two outstanding resources on relational security, and while they were designed for secure mental health settings, there’s great, practical advice for all mental health wards:
The handbook See, Think, Act – your guide to relational security
A nifty one page summary: Relational Security Explorer
Relational security is not simply about having ‘a good relationship’ with a patient. It is best seen as the knowledge and understanding staff have of a patient and of the environment, and the translation of that information into appropriate responses and care.
Clearly there are other essential elements in providing safe care for patients, which are broadly:
- procedural security (policies and procedures such as ways to prevent patients being off the ward without agreement)
- physical security (ward design, locks etc.)
But even when these are robustly in place, it’s the relationship between staff and patients which can make all the difference between preventing fraught situations from escalating and calmly diffusing a crisis. One of the many astute points that the DH make is that the ‘staff team’ includes “every member of staff who has regular contact with patients. That includes domestic, catering and short-term staff. Everyone has a responsibility for relational security.” Nice one, DH.
- Changed from control and restraint to SCIP (Strategy for Crisis Intervention and Prevention) and service users teach on the course. They’ve had 3 incidents in 5 years!
- We ran a focus group on the wards asking patients what makes them feel good. Some of the words patients said were: Relaxation, Nature, Worship, Pampering, Calm, Enjoyable, Creation. They said that just taking part in this group and being asked what makes them feel good was itself therapeutic.
- We’ve created a display on the ward about recovery. Rather than tell patients what recovery means in our words we asked them. We created a recovery tree which included the key principles of recovery from the Wellness Recovery Action Plan model. Patients wrote on the speech bubbles what recovery meant to them.
- Patients are offered a range of recovery tools and are encouraged to pick one that they feel suits their needs. They are supported to complete this with their named nurses during protected sessions.
- All patients are provided with a personal recovery file to collate certificates, achievements, reflections and details of progress, which they can showcase at CPA meetings.
- Short Term Assessment of Risk and Treatability is completed 8 weekly by MDT and Daily Risk Assessment is completed daily by Nursing staff and Support workers.
- WRAP is completed with each patient.
- All Named Nurses and Key workers have protected 1:1 time with each of their patients on a weekly basis.
- “As well as informing patients what is expected of them, making it explicit what patients can expect from staff is also really important.”
- “Often time restraints, a busy ward environment and lack of staff can prevent some sessions from going ahead but remember one to one sessions only require two people, and even a quick chat, can give a patient that opportunity to discuss their thoughts and feelings, which can help them to feel safe, looked after and may lift their mood.”
- I felt the best way to understand my triggers was to talk them through every time I noticed them.
- I learned to accept that you can’t get on with all people and all staff. The staff team seemed to acknowledge this too and made every effort to get the balance right of who was available to talk to.
- I am fortunate to work with some great doctors. I’m so grateful that they treat me like a human being.
- If something was bothering me about the ward I would speak to a member of staff about it. This stopped me feeling frustrated.
- I agreed to speak to a member of staff if I felt like self harming which meant I never self harmed during my stay. I was really pleased with myself and was shown many coping techniques which I still use today.
- I was sectioned for a second time but I decided to accept the situation. I felt I recovered quicker as I realised it was for my own good.
- I felt it was important to always be back on ward at the agreed time – it helps build up a good relationship with the staff.
- Staff aren’t just staff…they are individuals in their own right…and we, as patients, are too. This was a key feature of the ward I was on.
- I got to know myself more through creative work. Some of what I discovered was quite surprising but the staff made sure I felt safe.
- Some of us would struggle with rules, particularly when feeling bad, and there was always space to talk about this without fear of being judged.
- My favourite member of staff talked to me as a supportive friend not as my captor.
- I worked with many different teams before I was admitted so every month we all get together on the ward and discuss how I’m doing. It makes me feel safe and supported.
- When people keep their faith in me it stops me from losing mine.
- My CPN is like a close relative now.
- The ward provided security, structure, a sense of belonging and community.
- I’ve had the same CPN for years. I trust him and he knows me well now. Having lasting relationships with the staff who care for you is really helpful.
- I used staff as a ‘second brain’ during my recovery…bouncing ideas off them, testing the waters, problem solving.
- You’ve got to trust the staff otherwise you just get more paranoid and get nowhere.
- I feel much calmer when I understand the boundaries on the ward.
- First there had to be self-trust and then staff trust before I had a sense of hope
- Staff do this thing where they keep challenging you but with a kind of friendliness that’s hard to miss.
- It was essential to me that when I said something to staff that they not only listened but understood my perspective. It helped cultivate a relationship with trust and openness.
- I don’t believe in myself right now but it’s clear the staff believe in me. I don’t know why they do but it makes all the difference.
- Being believed is important. People thought my voices were just thoughts but the staff really believed that I experienced voices.
- I had never been on a section before and was so scared but the staff sat down with me and explained it and I had a named person I could talk to about it whenever I need to.
- A simple acknowledgement of the agony that can be mental illness is like having your hand held in the darkness.
- The ward was the one place I felt like I could test out different versions of me safely.
- Sometimes I need staff to just be bluntly honest with me. They can do that now because I feel I can trust them.
- I just had to trust those looking after me, a big (and a big thing for me) risk but it paid off.
- The staff and I have built up mutual trust over time. They know me and I know them.
- I think the Occupational Therapy is a good idea. I know for me, the staff who I could ‘talk’ to, were the ones who related to me as a person, and also didn’t seem to be afraid to voice their opinion if they didn’t agree with everything.