Case study 19.3
If you were one of the staff involved in John’s care, how might you engage with him in a way that would provide a safe and secure environment for him and others?
First of all it is important not to avoid John. Misconceptions about mental health and sensationalist news headlines fuel fear and stigma, which impacts on how the person experiences life including healthcare.
Safety (in this case related to personal, patient and public safety) is a concern for every healthcare encounter and we should make an initial assessment based on observations and prior knowledge. There is nothing to suggest that John is at any risk of violence to others at this point.
Think about how you approach and engage with all people in your care – with respect, warmth, kindness and without judgement or making assumptions.
It is usual in conversation to make some small talk, particularly in stressful environments to establish a connection, to allow the person settling down time, to transition from an open area to somewhere more intimate prior to discussing health concerns. You do this all the time.
However, as he appears unkempt, is hiding in the corner and may be hearing voices, it is important to find out how he is feeling and coping, for example, whether he is frightened.
Remember, the symptoms of John’s conditions could cause him to have difficulty with concentration and attention.
Think about environmental factors that might increase these difficulties and establish with John what might be a more suitable environment, e.g. a quieter room away from the main busy A&E environment if possible to help him feel safe and secure.
Don’t make assumptions about what the issue is – listen to John. What does he need help with?
Think about how you respond to distress in those in your care – listen, acknowledge, validate the experience – focus on the feelings, even if you don’t understand or have trouble believing the content. It is not the time to get into a debate – this would be unhelpful.
Remember not everyone who has unusual beliefs or hears voices find them distressing or unwanted – again, this is about not making assumptions.
What impact could John’s Psychosis have on him, what symptoms could he be experiencing and how can they be managed?
John is seen talking to himself – it may be that he is hearing voices and is responding to them by having a conversation. Remember that this might not be problematic for John and he may find this helpful or useful. It could be viewed as a socially unacceptable behaviour and attract a negative response in others.
Imagine have a running commentary, or hearing a conversation about you and simultaneously trying to have conversation with the person directly in front of you. Potentially John could have difficulty with holding a conversation with you if he is distracted by voices and may have difficulty voicing his concerns, making sense; he may appear inattentive, having difficult holding new information amongst other issues.
John is isolated in A+E, this may be related to previous poor experiences in healthcare or in general due to his condition. This may be because he feels scared in this environment due to delusional beliefs or voices and is keeping himself safe by choosing a place to sit carefully away from others. John may be isolated because of low mood or depression which is common with schizophrenia.
John is unkempt – this may also be indicative of mood, inadequate treatment of condition which leads to poor social functioning or poor physical health.
John may be experiencing side effects from his antipsychotic medication which may lead to his ‘jerky movements’. These may include dyskinesia, dystonia, parkinsonian like symptoms, for example, limb rigidity, tremors, shuffling gate and expressionless face and restless and agitated movements alongside an inner restlessness and urgency which is termed akathisia. Remember medication may have an impact on his physical health that are not visible (CVD, blood disorders, metabolic disorders, sexual health issues). Although primary care are responsible for monitoring physical health it may be appropriate to carry out investigations if clinically indicated. It may also be a good opportunity to ask if John is attending annual check-ups.
It is unlikely that in this situation that you will be focusing on how to assist John manage symptoms, but he may have his own strategies and preferences about how he manages and you can support him with this. You can find out from John what these are and ask if he wishes someone else to be there to support him. Consider, environment as before, information giving (verbal and back up with written information), clear and simple language, no jargon, checking for understanding might be helpful. Some people have distraction techniques, for example, using earphones and listening to music to help with voices. Some people may use a mobile phone to respond to voices to obscure what is happening.
What impact could John’s Psychosis have on the department you are working in?
There have been pressure in A+E services for some time about meeting waiting times, and questions raised about the ability and suitability of this service for those presenting with mental health crisis for varying reasons, for example – sometimes the person is viewed as having a lower status concern that with a physical problem, availability of staff with expertise. Liaison psychiatry provides valuable resource but not consistent across hospitals. Community assessment may be more suitable but has challenges in terms of resources. Complex needs may need a co-ordinated approach and lead to long waits. Reduction of in-patient beds for mental health.
Possible negative reactions from others in waiting room perceiving their problem to be more significant – or complaining about John’s behaviour.
Conversely, role modelling caring and appropriate responses by you and others in the team may serve as a challenge to stigma.