By this time I had only been a regular member of staff for a short period of time, this explains why, possibly they felt they could not trust me and were sceptical about my project. I recall Mrs *E who suffers from borderline schizophrenia saying to me ‘are you really gonna do something we wanna do?’, and of course I replied ‘yes’ in a most sincere tone as possible. ‘Good practice is based on relationships that develop trust’ (Tilbury, D, 2002). After consultation with the RMN, We both decided that I should carry out face to face semi structured interviews rather than use questionnaires.
Arranging time to visit the service users was quite difficult as I had to use time where I was not working to talk to them specifically about the project. The RMN allocated dinner times for me to be bale to make announcements but otherwise I would have to use my lunch breaks to carry out the research. This was to ensure that I did not let the project interfere with my actual work.
I endeavoured to carry out the interviews using the same questions but decided to expand on the last two questions and ask the service users to expand on why they felt the way they did about certain aspects of their activities. I also left room for him/her to ask questions that they may have concerning the project. Rubin, H and Rubin. I (2005) suggest that ‘often the information obtained from semi structured interviews will provide not just answers, but the reasons for the answers’.
I felt quite anxious about conducting the interviews with the service users partly because I was worried that they might be very unresponsive or give me one word answers. Furthermore because I did not have any experience in interviewing someone before but had spent some time practising with a friend to have a feel of what it may be like. It would have been preferable to practise with a member of staff who is familiar with the behaviour of the clients and therefore could have given me a more realistic reaction as to how they may have behaved during the interview. However other members of staff were disinterested or told me that they were too busy.
On my very first interview I decided to have one of the support workers present who seems to have a good relationship with the service users, I felt that this would make the patients feel more at ease by having a member of staff that they were more familiar with and comfortable with to be in attendance.
Gibson, 1998 suggests that “focus on developing rapport and establishing a relaxed, comfortable climate” is key when undertaking interviews with mental health patients. I started off the interviews by asking the service users background questions about themselves, as these often provide necessary information and serve to ‘warm up the interviewee; that is, they’re easy to answer and allow the interviewee to get in the interviewing mindset’.
Interviews
The first interview I conducted was with *John who suffered from mania which is a ‘severe condition characterised by extremely elevated mood, energy and unusual thought patterns’ (Jamison, K. R, 1996). It is also often associated with bipolar disorder. At around midday when I started the interview John was going through a ‘severely elevated mood’ as described by the RMN and answered my questions with rapid speech and seemed to have racing thoughts, therefore could not keep a level of concentration. Though White and McCollam, (1999) suggest that “providing written information in advance to the person interviewed can be useful, as people may be apprehensive and not able to absorb what they are told face to face”. I had a statement written at the beginning of the questionnaires when I sent them out but unfortunately did not use this when doing the interviews.
Of course different people placed different emphases on different issues, but overall, the themes that emerged from different individuals in the interviews were remarkably similar, which strengths belief that what service users had to say is likely to reflect the views of other mental health patients in the same situation.
Three descriptive categories emerged: patients wish to have their personal needs addressed; patients must see to it that their personal views/interests are addressed; patients lack confidence in health care workers with regard to discussing change in the way their recreational needs are met. The findings show that patients actively sought the assistance of nurses to meet their recreational needs. They turned their thoughts inwards and found community with other patients, while nurses often avoided addressing the spiritual dimension.
After conducting the interviews the results showed that the younger service users were very interested in aerobics and games. A majority gave the reason for interest down to the news reports they had been watching the day before about the continued drive by the government for a five-a day fruit and vegetables drive and living healthy. Others mentioned that the occupational therapist had explained to them before about the keeping healthy and exercising. The other service users were expressed a desire for aerobics as a way of doing a group activity and found it a way of interacting with other patients of different ages and sex. Some service users were pleased that they would get to see their ‘best friend’.
However, when I mentioned this to the ward manager she said it would be a problem because there are two patients that were monitored on a one-to-one basis when they were taking part in activities. *Mrs E who exhibited ‘promiscuous behaviour’ was always trying to show affection to John during dinner times. She would try to touch him, kiss him and would say she loves him. John would also routinely try and grope female nursing staff and is only allocated to male staff at the moment.
One could argue that these patients’ behaviours are due to their illness however it could also be that their sexuality is purely perpetuated by boredom. The Ward manager told me that it would be a risk for me to do an activity with both Mrs E and John at the same time however it states in the UKCC Guidelines (1998) that “Patients (including those with learning disabilities and/or mental illness) have as much right as any other individual to express their sexuality within the confines of the law, either as an individual or within an encounter”. However because nursing/medical staff assess ‘whether or not the patient has was deemed capable of giving informed consent prior to any incident occurring’ their right is rarely exercised.
Some patients were disorientated during the interviews because of their medication; therefore some interviews had to be done again whereas some took longer than expected. I was very pleased when I found that majority of the service users had responded during the interviews and also had an interest in exercise and games which would be activities that would be beneficial to their wellbeing. A disadvantage to using semi structured interviews is that of “varied responses, resulting in varied results” (Bryman, 2000). In this case I was fortunate to have responses that were fairly similar and the main objective of realising that there was actually a need had been proven correct.
I then visited the patients in their rooms and made sure to remind them of the project, the reasons I was doing it and finally the majority results that had come from it. Again the service users who actually had an interest in the games and exercise were happy to hear the news but the other service users were of course not pleased but I assured them that I had shown all their comments to the Ward manager for consideration even though I was not sure as to whether she would even give a glance.
The patients who had an interest in the aerobics class said that they would enjoy it more with background music playing in the background, pop music was preferable by most. The desired setting for the aerobics class and games was the garden because of the looming of spring and the warm weather outside, furthermore many of the patients were excited at the prospect of having a little time outside as they very rarely had the chance to do so because of health and safety issues conveyed by the senior members of staff.
I conducted some research on exercise and the benefit it could have for mental health patients. I discovered that people with severe and enduring mental illnesses such as schizophrenia and bipolar disorder are at an ‘increased risk of a range of physical illnesses and conditions, including coronary heart disease, diabetes, infections and respiratory diseases and greater levels of obesity’.(Hillsdon et al, 1999) .
This information reinforced the desire for me to encourage the aerobics and playing games with the patients. Meltzer (1996) suggests that ‘physical activity is thought to help ease stress, and improve general well being and self esteem’. It was important for risk assessments to be carried out for every patient because ‘Risk management and risk assessment are regarded as key elements of the CPA’.
The service users may feel an improved sense of self esteem because there would be a change in their body image. I then pitched the idea to the Ward manager who said she would review it and give me an answer.
I found it increasingly difficult to gain recognition with the ward manager and senior members of staff and this could be because I was at the bottom of the multidisciplinary team, Souminen et al 1997 suggested that “the prevailing culture perpetuated a hierarchy and those who get things done ('the bosses') have power while nurses have 'relational' power”.
The Ward manager told me she liked the idea of exercise however it would also ‘fall within the company’s policies’ to discuss healthy eating options though an aerobics class could be difficult because of health and safety risks thereafter and expressed once again that playing games in the garden could also be a major risk and furthermore that staff shortages could be an issue.
I explained to the ward manager that the service users were looking forward to the aerobics and playing games.
My final idea after consultation with the ward manager was to come up with a group discussion to converse with the service users about healthy foods with the aid of a short presentation. I was no longer allowed to carry out the short session of aerobics and playing ball games. I felt that the use of a PowerPoint presentation would be slightly more interesting than just routinely talking to them. Moreover there could be room for them to ask questions and generally chat about their favourite foods and so on. I was going to help the service users identify healthy foods which in turn would give them the ‘power’ to choose healthy meals from the menu.
However, in practice this was different because many NHS funded organisations have had to cut back one way or another, for example ‘In Suffolk, the chief executive of East Suffolk Mind has said that the charity might have to reduce services to tackle a possible budget shortfall of £200,000 next year, because of PCT cuts’ (Indymedia, 2006). The meals that are offered should meet the Essence of care standards which state that ‘all patients are entitled to three balanced meals a day including snacks 24hrs a day’. However it also states that “Community and Mental Health services are therefore:- not required to adopt the menu format as set out in the NHS Recipe Book - but are encouraged to do so where this is appropriate”.
The Ward Manager mentioned that cutbacks in the food menu and other areas were needed to meet the budget and therefore I was urged to quash hopes of games sessions as funding would be needed for items such as balls etc. Even though there were clearly many health benefits to the patients undertaking exercise rather than being ‘schooled’ on a balanced diet, the latter was favoured because it was the safer option, but the question was safer for whom?
I then went to work on my presentation and used PowerPoint and incorporated the use of flashing images and sounds to gain the attention of the service users (my audience) and also to try and make the session as least boring as I could. The biggest dilemma I faced however was that of telling the service users that the activity that they had taken their time to choose had been greatly modified if not completely disregarded.
During lunch on the day before the proposed ‘new activity’ was to take place I had to announce to the service users the change in structure. Many of them did not respond verbally but I could see by their facial expressions that they were extremely disappointed. I explained to them that it was to safeguard their health and safety and proposed my talk about health talk the following day, I had complete reservations about the attendance of the session.
As expected, almost all of the service users did not show up, with exception of only two, Mrs. E and John. It was apparent that the service users had lost trust in me and were obviously conveying their feelings by refusal to show up. Mrs. E and John only managed to stay stationary for less than five minutes and had begun to fondle each other. The support workers had to pull them apart and I was unable to carry out the rest of my presentation.
On Reflection
Looking back at my research project I would not change the way in which I carried it out however I feel it would have been beneficial if I had known the residents for as long as I have known them now. ‘There are also indications that more accurate, detailed information is provided when the researcher has spent time getting to know people and has regular contact with the participants during the research’(Cornwell, 1984).
I also did not take into account how much of an impact the organizations policies were going to have on the project. I would have preferred for the project to have had a positive impact on the service users however I feel that it may have lowered their self esteem even more. Nonetheless McIver (1991) suggests that ‘where an evaluation has explored in some depth the nature of the service individuals receive as well as the impact it has on the recipients, the task of establishing the relationships between these two sets of data is challenging but nonetheless of considerable importance to the future development of policy and provision’.
As services strive more and more to offer an individual service to their users this can complicate attempts to aggregate outcomes, and produce misleading results for the project as a whole. Whilst planning the project and undertaking it there are many issues that I encountered that may need reviewing and others changed completely. Firstly, the main problem was that the organisation did not look at the patients as people and disregarded what they wanted. The problem many healthcare workers face is that they get stuck in a situation where they routinely treat the patients as a whole and do not take the time to get to know them personally and take heed to their individual likes and interests.
The National Service Framework (1999) states ‘All mental health service users on CPA should receive care which optimises engagement’ however one could argue that this was not the case when the Ward manager refused an activity that offered many advantages. Furthermore The Community Care Act (1990) states that ‘In some cases, resources should not be taken into account, for instance, if a person would be at severe physical risk if a service were not provided’.
Even though the service users (especially the heavier ones) may not suffer straightaway, over a period of time they could be at physical risk from not having any exercise. Moreover because research suggests that exercise eases stress and may cause a reduction in low self esteem it could possibly slow the processes of patients becoming more depressed.
“Discrimination against people with mental health problems is rife and extends into the health professions” (Chadda, 2000) and discriminatory behaviour is conveyed by certain members of staff at the unit. The National Occupational Standards state that one of the key purposes of Mental health services is ‘to provide equitable and non-discriminatory services, across all age groups and settings’ however one could argue that the senior members of staff may discriminate against Mrs. E and John because of their expression of their sexuality.
It is possible that staff separate Mrs. E and John for their own benefit rather than for the benefit of the service users themselves because it seems that the more they are not allowed to interact with people of different sex it makes their ‘exhibition of promiscuous behaviour’ even worse.
It is apparent that the organisational structure of health and social care services has developed a culture of ‘just do it’ and do not ask questions. This could be because of a number of several factors. The healthcare market has grown dramatically and this is reflected also by the many consumers.
Statistics (2000) show that there has been a dramatic increase in the number of people being referred to psychiatric services since the 1940s - particularly men and young people. Furthermore ‘65% more are being referred to psychiatric hospitals for the first time’. This obviously has an impact on the healthcare sector as a whole because the Government has had to up funding over the years to cope with the demand for care services.
This is in turn puts pressure on the many NHS funded hospitals and psychiatric units to keep up standards and not go over their budgets. This is reflected in the way the ward manager runs the unit and may give reason to as to why she refused the recreational activity chosen by the service users because of factors such as the funding to buy equipment, the time and effort in doing the risk assessments for each and every patient who takes part and also the allocation of staff.
Care vs control is also a major issue as I found it hard to interview some patients because of the medication that they had received which made them drowsy and rarely alert. The nursing staff may sometimes give medication to the patients before the allocated time ‘so that they don’t act up’ or when they are being aggressive than usual. Healthcare workers need to take into account that it may be possible for the service user may be upset about something and may be lashing out just as ‘normal’ people do.
Conclusion
There are a number of factors which work together to strengthen the case for giving greater priority to evaluation in the planning and delivery of services for people with mental health problems. “The inclusion of users’ perspectives in the evaluation of mental health is increasingly seen as a way of giving a marginalized group more of a voice”( White and McCollam,1999). However this is much easier in theory than it is in practice.
Many psychiatric patients continue to need long-term care in institutions in the public and private sector, despite the development of community facilities. Long-stay psychiatric institutions vary in size, level of security, facilities and type of care provided. Patients are usually regarded as long-stay if they are in an institution for more than a year. Inevitably, many long-stay in-patients experience limitations to their freedom, personal choice and activity, usually compounded by a low income and relative isolation from the community.
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