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PROactive Management of Integrated
Services & Environments
Manaan Kar Ray
22nd June 2006
I was working as a specialist registrar and was asked by my team to join a Mental Health Act assessment. The patient concerned had been reviewed by myself a month before and we had formed good rapport. However, in the last fortnight, family had expressed concerns that he might have stopped taking his medication and was becoming paranoid and suspicious. Efforts by the team to engage him had failed in the last week. He had a past history of violence and the team contacted the police to be on the safe side.
Along with the patient’s GP and a social worker we arrived at the patient’s family home and were invited in by his mother. We sat down in the living room and the police stayed outside at the door. The patient came in and seemed generally happy to see us and shook my hand. Fairly relaxed he sat down right beside me, it was one of those settees into which you sink in. The social worker started explaining why we were here.
The patient appeared to be listening intently, when suddenly he turned towards me and swung his right fist, catching me on my lips completely unaware. He was training to be a boxer and packed a punch. Even 9 years on I can still graphically remember each detail. Blood splattered on my shirt with the thud of the fist, my specs flew off, and everything seemed to slow down. The two policemen made a quick exit. I pushed myself off the settee, dropped the notes and tried to make for the door. Acutely aware of his presence half a metre to my right, still screaming and swinging his fist, I saw the police on their radios as they ran out the door. Right behind him was his mother, crying and pleading him to stop. The tirade of verbal abuse continued but within 5 minutes two police vans turned up and took him away.
It was back to base and then to A&E where I was painfully pushed and prodded by a Junior Doctor. The thing that stands out in my mind is the expression on her face when she told me that Max Fax (Speciality dealing with head and neck conditions) would need to take a look. With gums so swollen that I could barely speak, I muttered back ‘no one is touching me’. Fortunately, the X Rays did not show any fractures, but frighteningly the Max Fax registrar announced that that lack of blood supply to my upper incisors would cause them to turn black and nonviable. At that point I was only interested in giving him a wide birth to avoid more touching and poking. Once back at base I ignored my consultant’s advice and drove home.
My wife was aghast at my state, I did not want to talk about anything, it’s a different matter that I could not. My in laws were visiting from India, for some reason I felt ashamed that they had witnessed me in this state. Lying down beside my 11 week old daughter was a great comfort, especially the softness of her touch. I was mentally exhausted but it was impossible to switch off, although it wasn’t so much that the assault played on my mind. It was more the fact that I believed that I had formed a good relationship with him and that my trust had been violated. Drifting in and out of sleep I kept thinking ‘how could he?’ for a while and then fell asleep and slept right through to next morning.
A new day and I was resolute that I was not going to let this affect me. The swelling was worse so I had to stay in as I did not want others to see me in this state. Fortunately, by the next morning, the swelling had subsided and 9 years on I still have my teeth. When the opportunity to do another mental health assessment came up 4 days after the assault I took it up. This was by choice as I did not want the incident to put me off difficult clinical scenarios. The second visit also involved violence and threatening behaviour which had the effect of making me very perceptive to signs of aggression, even the faintest change in tone of voice in a patient would set my heart racing. This settled down over the next three to four months. I have been part of many difficult clinical conversations since then where I have had to use the Mental Health Act to bring patients into hospital or use coercion in more subtle ways, generally around convincing patients to engage with their care plan to avoid hospital admission. Fortunately, barring the occasional display of anger and frustration in verbal aggression, I have not been at the receiving end of any further physical assaults.
Writing this after so many years, I should be objective but I still find this quite emotionally challenging. This is the version of events from my perspective and I cannot speak as to how the events panned out from a patient perspective. How cornered must a patient feel when someone turns up at their door accompanied by police with clear intent to take their liberties away. Coming to terms with events like this was a lonely affair for me and it was in that loneliness that I developed empathy for how alone patients must feel when an organised or united group of staff decide to use powers vested in them. This might be what staff believe is in the best interest of patients but this is not a perspective that is accessible to patients at that time.
Why did I share this story?
Leading on the PROMISE project brought a lot of these memories back. There are plenty of rewarding clinical interactions as well which bring alive the reasons why we entered into the caring profession. Unfortunately when it comes to memories the ones that are retrieved first are those that have affected you the most. For me it is memories like the one above, which at first glance seems completely unprovoked. But was it? I was the one who turned up at the patient’s door with the police with clear intent to take his liberties away. Reflecting on it later I realised he was a boxer and responded in the way he knew best. This is not to say that being assaulted is to be expected but once I had reframed it I could contextualise what he was going through. In situations like this other patient’s respond to the threat in ways that are familiar to them and I had never encountered overt aggression like this before, so it was unpredictable for me. However, there are those incidents which can be predicted, or at least one can see the origins with hind sight. This may be due to rising frustration in a patient as a result of unmet needs or staff being stretched and unable to fulfil expectations or promises. Nurses and health care assistants are often at the receiving end of such incidents, on a busy ward sometimes on a daily basis. Also carrying out the same caring role everyday can takes its toll and present as desensitisation. This might be perceived as being inattentive or insensitive by a distressed patient. Daily exposure to the levels of need they have to meet and patient’s frustrations when they are not met does have an impact on their ability to engage in kind compassionate care. Not acknowledging this would be a mistake.
The challenge to empathise with individual patients reaches new heights in situations which are completely predictable but staff feel helpless in thinking outside the box, to break the downward spiral. On one of our wards, a patient needed to be restrained three times a day to be fed. This was essential to keep the patient alive. However staff were being spat at and verbally abused while they were engaged in this life saving intervention. Both staff and patient were entrenched in a daily pattern that could not easily be broken. One cannot begin to imagine what the patient must have been going through, but it also affected the morale of staff and all the other patients on the ward. After three months of this, the ward lost 10 members of staff in one month. Leadership could see this coming but felt almost as paralysed as the frontline staff. In the end the deadlock was broken by moving the patient to a different ward, but it was too little too late and the staff had left, leaving the ward in a precarious situation. It took a while for that ward to attract new staff and get back on its feet. In heart sink situations like this the resilience that our frontline staff generally show is amazing but it seldom gets acknowledged, let alone celebrated. The systems we work in holds care professionals to a code of conduct that is much higher than for the general public. If a lay person was assaulted we would not expect them to be anywhere near the perpetrator let alone provide care to them. However, that is exactly what we expect of our staff. This is a responsibility that we embrace when we come into our profession and we will not have it any other way. No one comes to work to be assaulted but we are meant to be equipped to appreciate that aggression is an expression of the depth of distress. However, this is not easy and it is nice for the resilience in frontline staff like those in the situation above to be acknowledged and for leadership to walk in their footsteps every now and then.
My own experience of being assaulted does help me empathise with what our staff go through fairly regularly. It has helped me make the case for change. Reliance on the exercise of force, even if it is in the best interest of patients, breeds resentment, frustration and aggression in return and frontline staff are often at its receiving end. Knowing the patient, understanding their personal triggers and how they might react in times of deep distress can help to alleviate those flashpoints. Ultimately, the way to overcome this is through early detection and treatment so that the patient can retain reasonable insight and remain in the driving seat. Shared decision making, advanced decisions, crisis plans can all help decrease aggression towards staff and staff needing to rely on the exercise of force.
To this day I wonder ‘did he know what he was doing?’ My colleagues in old age psychiatry who work on dementia wards are more frequently at the receiving end of agitation and aggression. However they tell me that there is something in the fact that dementia patients are not cognizant of the impact of their behaviour makes it more tolerable and forgivable. Although Crown Prosecution would not take my case on, I was encouraged to press charges by my Trust and initially I asked the legal staff to proceed, but then did not have the heart to go through. Perhaps that was wrong and he never learned the consequences of his actions and his treatment should have been twin tracked with proceedings in the judicial system. However, that rarely happens as the crown prosecution service only takes cases on if they are convinced that a prosecution is likely and a patient being mentally unwell often convinces them otherwise. This is a judgement call that they make in a rational way so that tax payers money is put to best use. But for staff who might have been assaulted there is not much that is rational about the incident, it is emotive and one does feel that if you are working in a caring profession there is not much justice. Keeping the motivation to wake up in the morning and look forward to a day’s work in these circumstances is not easy, but our staff do it, day in and out.
A large part of me feels that although he was unwell, he knew what he was doing. But why does that matter? It matters because the pain and the physical trauma subsides quite quickly, however it is the violation of one’s trust and one’s ability to engage in care provision without feeling anxious that takes much longer to overcome. Strangely enough looking back at my emotional response shame comes up as the primary response which is difficult to understand. Shame for what? Perhaps I read it wrong, perhaps I should have known better and read the signs, perhaps shame at feeling anxious in the first few months after the incident. After an incident like this the emotional response I assume is individual to the person, but perhaps at some stage everyone arrives at the question, why did it happen? We can reason this away as someone being unwell or someone being inherently violent, but that would be a missed opportunity to ponder on what it must have felt like to be the patient. If three professionals turned up at your home with the police with intent to take your liberties away when you are already feeling suspicious of everyone’s intent, how would you react? Like I did after being assaulted, would you feel your trust was violated and would it make you anxious receiving care from people you believed to be perpetrators? What emotional responses do our patients have. Do our patients feel shame after being at the receiving end of force, as I did after the assault.
An organisation aspiring to push boundaries of humane care would want their frontline to consider these questions. However when envisioning a change story, it is important for the leadership not to forget to empathise with what the frontline have to go through on a daily basis as well. If one cannot do this the frontline will feel misunderstood, unappreciated and undermined and the difficult jobs they already have will become insurmountable. Although there is a clear case for how eliminating reliance on the exercise of force benefits both staff and patients, it does stir up the past and if not done in a sensitive fashion it will be quite easy to lose staff on this journey. If we want staff to imagine what it would mean for a patient who is experiencing extreme distress, perhaps feeling cornered and thus lashing out, then empathy is the key to unlocking this reflective space. If leadership does empathise with the challenge at hand on the frontline, then staff will be able to mirror that behaviour in their ability to empathise with the distress the patient feels. Making the case for change around eliminating reliance on the exercise of force will be one step easier.
It has taken me 9 years and the responsibility to lead a major project like PROMISE to come forward and tell my story. But how many stories from patient perspective remain untold? We hope that the PROMISE qualitative study, which is designed to explore the experience of both patients and staff involved in physical interventions, will bring new insights. A rich gamut of untold experiences will help frontline staff to empathise with the isolation patient’s face when at the receiving end of coercion and help patient’s walk in the footsteps of staff who have to deal with distress of this nature every day. This article is one sided and mainly presents the staff perspective, what I would really like to do is co-author a story with a patient who has experienced restraint or coercive practice from psychiatrists like myself. Only then can we formulate a balanced view and perhaps a stronger case for the need for change.
Reading and rereading this article as part of the editing process evoked many different emotions and it has touched me in ways I hadn’t expected. It has also led me to reflect on an incident that occurred 10 years ago during an inpatient stay. Stepping outside myself I was able to see things from a different perspective and imagine how the member of staff concerned might have been affected.
Following a frightening episode of self-harm I sought help from one of the nurses whose first response on seeing blood was to turn his head away. The reason this memory remains ingrained is because he physically recoiled as if I was an object of revulsion. At that time my feelings were entirely centred on the impact this had on me but being closely involved in the writing of this article has broadened my understanding. It has made me think more about the effect that this type of incident has on frontline staff who must be experiencing a gamut of emotions on a regular basis.
- Sarah Rae
|Values, Vision, Mission|
|Preslude to PROMISE|
|Introduction to PPI|
|Reflections on PPI|
|Open Arts - Navigating Rocky Waters|
|Breaking The Chains|
|Power to Emower|
|Person Centred Care|
|3-3-3 Mulberry Wards|
|3-3-3 Oak Wards|
|Eating Disorder Ward|
|George Mackenzie House|
|Older Adult Wards|
|Learning Disability Wards|
|Reflective Space - No Audit|
|Recovery College East|
|Peer Support Worker|
|Shared Decision Making|
|Mind the Gap|
|Interfaces across Care|
|Road So Far|
|Global Mental Health|
|Breaking the Chains|
|Maintenance - Help or Hindrance|
|Enhanced Primary Care|
|Psychological Wellbeing Service|
|County Council Perspective|
|Caring for Carers|
|Crisis Care Concordat|
|Next Generation Psychiatry|
|New Age Nursing Prospectors|
|Making our services safer|
|Food and Mood|
|Space for Carers|
|Best at Basics|
|ARC: CPFT’s Interface|
|Research in CAMEO|
|PD Pathway Interfaces|
|Affective Disorders Care|