IMPROVING THE CONTAINER: WARD COMMUNITY GROUPS AND THE MODERN ACUTE PSYCHIATRIC IN-PATIENT SETTING

IMPROVING THE CONTAINER: WARD COMMUNITYGROUPS AND THE MODERN ACUTE PSYCHIATRIC

IN-PATIENT SETTINGbjp_1142 477..490

Philip Crockett, Michael Forrester and Linda Treliving

abstract Ward community groups have been mostly lost from acute psychiatricin-patient settings in recent years with changes related to care in the community andaltered therapeutic expectations. This paper outlines the re-introduction of wardcommunity groups to such a setting and, by using the quantitative measure of patientcomplaints and qualitative observations, offers evidence for their usefulness as atherapeutic medium, beneficial to the acute psychiatric in-patient ward, and as acontainer for disturbed states.

Key words: ward community groups, psychiatric in-patient, container, patient com-plaints, therapeutic

Background

The Framework for Mental Health Services in Scotland was launched by theScottish Office (1997), in response to the Select Committee’s report into theclosure of psychiatric hospitals in Scotland. Its emphasis was on developingcare in the community as a main tenet of modern psychiatric practice result-ing in shorter lengths of stay on in-patient units and higher turnover ofpatients. Its focus turned away from the inpatient wards with less emphasison the therapeutic culture.

The Mental Health (Care and Treatment) Act (Scotland) 2003 includedparticipation, involvement, reciprocity and respect in its 10 guiding prin-ciples which set a responsibility for local Health Boards to provide fit forpurpose in-patient facilities. The National Institute for Mental Health inEngland (NIMHE) published a report in 2004 (Clarke 2004) following onthe work of the Acute In-patient Programme outlining the need forpatients and staff to feel empowered in their contribution to the wardsetting as a means of promoting recovery and optimism and shaping theprocess of care.

At the beginning of 2004 Philip Crockett (PC) and Michael Forrester(MF) were invited to help establish Community Meetings in the four AcuteWards at Royal Cornhill Hospital (RCH), Aberdeen, a general psychiatrichospital with 100 acute adult beds covering Aberdeen and Aberdeenshire

phil crockett is a Group Analyst and Consultant Psychiatrist in Psychotherapy andEating Disorders, and he and his co-authors work at the Royal Cornhill Hospital,Aberdeen.mike forrester is a Psychodramatist, and linda treliving is a Consultant Psychi-atrist in Psychotherapy. Address for correspondence: [[email protected]]

© The authorsJournal compilation © 2009 BAP and Blackwell Publishing Ltd, 9600 Garsington Road,Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. 477

populations. In common with other major psychiatric centres, RCH has seena substantial reduction in beds and changes in the in-patient population.

Ward community meetings have a long history in the psychiatric services,certainly in the UK, back to the wartime Northfield experiments (Main1946) that were the forerunners in many respects of the modern therapeuticcommunity. Many senior mental health nursing staff recall ward communitymeetings being held on the in-patient wards when they were training andduring their early careers.

For two staff well immersed in Therapeutic Community work it was aninteresting challenge to translate psychodynamic ideas to the acute wardsetting. This required ongoing training and supervision from the psycho-therapy department and will be described further.

Ward Community Groups: The Evidence

There is a lack of evidence for the usefulness, or otherwise, of ward commun-ity groups. This was demonstrated by a computerized and manual literaturesearch that took in Medline, Psychinfo, Embase and Cinahl, as well asmanually searching back issues of the British Journal of Psychotherapy andGroup Analysis. The electronic searches used the keywords: ‘ward commun-ity meetings’, ‘community meetings’ and ‘ward groups’. Only four paperswere found that dealt with outcome, and fewer than 50 papers that dealt withrelated topics.

Marotos and Kennedy (1974) compared having a community meetingwith not having one, using a cross-over design. They found a significantreduction in ward incidents, especially those involving aggression thatreturned to previous levels once the meetings had finished. There was noclear, consistent definition of what constituted an incident across thepapers. Ng et al. (1982) compared no-meeting/nurse-led/doctor-led/non-directive meetings. They found, in Hong Kong, that both nurse-directed andnon-directed meetings reduced incidents, whereas doctor-led meetingsmade no difference. They made use of the short form of the Ward Atmos-phere Scale (WAS) (Moos 1974) which showed no significant changes withany form of meeting. The WAS appears in a significant proportion of theliterature around this topic. It is a self-report scale for patients andstaff that rates factors in a ward or treatment programme, ranging fromorganizational features to the extent emotional expression is facilitated orcontrolled.

Other studies concentrated on the process, design and content of groups.For example, McLees et al. (1992) looked at the process and content of themeetings and found evidence of the patients dealing with pertinent unitissues. Kahn et al. (1992) found that patients’ engagement and focus indiscussion groups were aided by higher levels of perceived spontaneity andsupport in the ward environment. Conversely, high anger and aggression and

478 BRITISH JOURNAL OF PSYCHOTHERAPY (2009) 25(4)

lack of organization as measured on the WAS predicted high group conflict.From these and other findings the authors concluded that to some extentinpatient dynamics predicted the group dynamics.

There have been two reviews of the community meeting literature, Lanza(2000) and Ng (1992). These emphasize the wide-ranging nature of ward-based community meetings in terms of purpose and structure. There is littleconsistency, however, so discovering helpful elements is difficult, and there isno agreement even over what the meetings should be called (Lanza 2000).Some groups favour a more psychodynamic focus, some a process more akinto information-sharing with an agenda. Some have set out with a very clearpsychotherapeutic agenda, informed by the work of S.H. Foulkes (1975) whosuggested a less interpretative technique. Groups are sometimes closer inprinciple to sociotherapeutic groups (Edelson 1970; Lipgar 1999) which focuson the current understanding of working relationships between staff andpatients. This approach emphasizes a clear structural framework and lead-ership. Some of the studies noted here have used clear leadership by staff;others have advocated meetings being patient-led (Lanza 2000). Variousaspects of group dynamics, mostly median and large group (de Maré 1991;Kreeger 1975; Main 1994), are quoted as ways of developing a deeperunderstanding of what occurs within the group sessions and what theireffects can be. There is therefore literature available that can guide thedevelopment of ward community groups and support their running;however, it is limited in extent. What is also notable from the literaturesearch, and the review articles available, is that most of the relevant researchwas generated prior to the changes towards community-based care in psy-chiatry in the UK.

The question that the Psychotherapy Dept research group at Aberdeentherefore started with was whether ward community meetings are actuallyobjectively helpful in this context, with the different dynamics now presentwithin NHS psychiatric practice.

This led on to the following objectives.

Objectives

• To establish in each ward individual and unique meetings that improverelationships, reduce disturbance and improve staff morale.

• To make qualitative observations of the process of setting up thegroups and the running of them, from the perspective of supervisionsessions.

• To observe any relationship between the numbers of complaints madeon the four general adult acute wards and the institution of wardcommunity meetings.

PHILIP CROCKETT, MICHAEL FORRESTER AND LINDA TRELIVING 479

Methods and Description of the Aberdeen WardCommunity Groups

Following a short process of informing and training staff, ward communitygroups started up in all four of the acute adult wards in Aberdeen in May2004. As many patients and staff as possible were encouraged to attendweekly ward-based groups to look at issues arising from the ward environ-ment. In practice, probably no more than a half of current patients andtwo members of staff, meaning trained nursing staff, attended at any onemeeting.

The well-attended (20 representatives from the four acute wards) firsttraining seminar, run by PC and MF, was followed two weeks later by thefirst groups, all in May 2004. This was a good turn-out, with five staff beingreleased from each ward. This represented considerable commitment frombusy areas of the hospital and was seen as a good indicator for the long-termsupport and success of the project.The training was aimed at helping nursingstaff to actualize skills they already had, but that were lost in the pressuresof the acute environment. It was seen as important to develop a sense ofownership of the meeting by the people who lived and worked in each wardand to help nursing staff strengthen their sense of involvement in the treat-ment process. The support of the nursing management was high and wasessential to the viability of the project. Monthly, optional supervision meet-ings continued for a year after the groups were set up, again run by PC andMF. It is from these meetings that the qualitative findings are taken. Thegroups were allowed to develop freely within each ward, whilst retaining anumber of principles in that they were nurse-led and encouraged the use ofclear boundaries of time and space.

A considerable amount of staff time was invested in this project, prompt-ing the search for a further, quantitative means of measuring its effects. Themost consistent measure in the available literature was incident data. Wardincidents were not actively studied for this project as it was known that whatconstituted an incident differed from ward to ward in practice, and thecollection of data on this did vary widely.

A potentially useful indicator was suggested in the form of complaintsmade by patients on the wards before and after the ward community meetingswere started. Complaints proved to be a measurable variable, allowing iden-tical methods on each ward for the collection and collating of the information.This has the advantage of being generated by patients’ perceptions of theirtreatment and the ward environment, and though influenced by many otherfactors is likely to be related to patient satisfaction and may have an effect onstaff morale. It is not dependent on others’ perception of what constitutes acomplaint, except that it is submitted through the official ward-based com-plaints channels and into the Trust’s complaints procedure, which providedthree-monthly returns. It included brief details on the nature of the complaint


which enabled a check on its validity for the study.This data was anonymousso the authors had no awareness of the identity of the complainant.

Results

Qualitative Observations

These observations can be placed into four, linked, thematic areas. Thesewere developed through discussions between MF, PC and Linda Treliving,following the supervision groups. All of these represent dilemmas or newchallenges to nursing staff in particular, but also to those supervising: struc-ture and boundaries; control vs. expression; intrusions; new developments.

Structure and Boundaries

The process of creating the groups started with the training sessions. In theseMF and PC concentrated on practical problems of space and time. Theoutwardly simple issues of numbers of chairs, finding a suitable location andpreventing interruptions in the acute setting were fraught with complexities.Each ward decided how long their meeting would last, though time-keepingwas emphasized. It was clearly difficult for many nursing staff not to endearly if apparently there was nothing being talked about. There appeared tobe a concern that the uncertainty might be intolerable for the patients insome way. This was challenged early on. Another feature of therapeuticgroups was explored – namely that people raise difficult issues near the endin the knowledge that the group will end soon. Avoiding this discomfortingperiod therefore created anxiety about the safety of the group. However, itsometimes felt to the supervisors that it was an unreasonable expectationthat two psychotherapists ask the ward nurses to sit in silence with a groupof acutely disturbed people. Learning to be tolerant and adopting a policy ofreinforcing the message with accounts of experiences in groups encouragedthe staff to have more faith in the idea of time boundaries and to help themreflect on the roots of the anxiety created within themselves.This experienceof the ward community groups, among others, contrasted with their previousexperiences in their ward work, where contact with patients usually had aclearly defined objective in nursing or psychiatric terms, or simply fulfilledthe need to appear busy.The issue of there being a required outcome seemedto have dictated ward-based relationships.

Issues of authority emerged here also and were explored in the context ofthe nurse–patient relationship. Nursing staff were open to the idea of sharingsome responsibility with the patients. Useful ideas then emerged aboutminute-taking and time-keeping, activities that could be taken up by bothstaff and patients and would allow a sense of ownership for both sub-groups.

This theme of structure and boundaries is further embedded in the fol-lowing three themes.


Control vs. Expression

Here further resistances were apparent. There was a dilemma for nursingstaff who had to find a balance between their usual role of control of thedisturbed and disturbing behaviour, protecting the patient and societyfrom the disturbance, and the task of a ward community group being aforum for patients to say how they felt and comment on their experiences.There was clear anxiety for the nursing staff regarding this dilemma. Theview was frequently expressed that only those patients who were willingand mildly disturbed should attend meetings. The question was then askedas to whether attendance could be prescribed as part of the treatmentregime. The response to this was one of silence leaving the supervisorswith a sense of having ventured into dangerous territory. This was a power-ful counter to the initial ideal of a meeting attended by all staff andpatients.

It was apparent in this modern ward environment that only nursing staffwere expected to attend. Medical staff (an inexperienced junior) only everattended one meeting. It seemed that the nursing staff were preoccupiedwith managing the patients so that the doctors could treat them, and that thenature of the relationship between doctors and nurses was one that suitedboth parties, possibly in a limiting way. Concern was expressed that thepresence of the medical staff would alter the focal point of a meeting fromthe ward community to individual patient’s drug regimes.The modern, acuteward context, where turnover and bed status are emphasized, also played arole here, in limiting staff availability from all professional groupings fortasks not recognized as a priority. There was never any expectation orsuggestion that the domestics or other ancillary staff would attend, almost asthough their role in the ward culture was unacknowledged.

As the sessions progressed, an early pattern began to develop, however,with complaints becoming a medium for expression of feeling, often witha clear symbolic meaning. For instance, complaints about teaspoons andkitchen equipment being in short supply came up in more than onemeeting and across more than one ward. This and other complaints aboutthe catering left the impression that a purely controlling role for the nurseswas somehow leaving patients under-nourished. Nursing staff remainedconscious themselves in supervision of the continuing constraints on theirtime.

The meetings, through such issues, addressed questions like ‘how is it tobe here?’ and ‘what would we like to be different?’, and so potentiallygave more space to the expression of feelings as well as opportunity for amore creative response. While initially the staff involved in the groupswere generally uncomfortable with many aspects of this area of work, astime went on they began to report a growth in confidence with the newway of working.


Intrusions

Early measures were introduced on all the wards to protect the groupsfrom intrusions like telephone calls and visitors. These were relatively easyfor the wards to implement, though not always foolproof. As the groupsdeveloped, however, a variety of attempts to intrude on them, or perhapseven to take control of them appeared. Some of these attempts wereovertly successful in that the intrusion was accepted in some way. First ofall a representative from the Local Health Council wanted to be involvedin running them. Next the Advocacy Service sought to have input into thegroups. Then the chair of the Mental Health Users’ Group began to attendgroups.

Staff were unsure in their response. It seemed to go against all the rulesof political correctness, and also the rapidly developing guidelines on‘service user’ involvement, not to include these undoubtedly well-meaningpeople, but there was also a sense of them intruding into the ward’sgroups. They were not directly employed on the wards, nor resident onthem. Through the supervision process the staff were able to develop aresponse to these intrusions. One representative was described as like a‘travelling salesman’ in this context. It was agreed that he could come inonly if invited, as he may have some useful things on offer. Subsequentlysome of the groups have developed a model of occasionally, according tothe group’s wishes, inviting people to their meetings, including the cateringmanager as well as the smoking cessation officer. There were frequentgrievances (from patients and staff) around interruptions to the groupspace. This was remedied in one case by displaying large warning signs atthe front entrance of the ward while the group met. Both nursing staff andpatients seemed involved in the task of making their space safe fromunwanted intrusion. This was part of the forming identity of the ward com-munity groups. Some of the intrusions to the group boundary were verymuch internal, with difficult situations between group members, or frankconflicts breaching the boundaries by, for example, people leaving thegroup in a stormy fashion. All groups reported a settling down of thisprocess during the formative stages of establishing the groups and, despitethe continuous turnover of patients, intrusions became a less frequentlyreported issue as confidence grew.

New Developments

The ward community groups acted as a spur to fresh developments on thewards. In a number of cases possible improvements were discussed, such asnotifying the ward community of future meetings via notice-boards. Thisdemonstrated how the effects of the group expanded into other areas of theward community. During the first year it became apparent that new, addi-tional groups were being started and led by nursing staff. They frequently


expressed that this way of working was more akin to their expectations oftheir role on entering mental health nursing. Their confidence had beendeveloped by their experiences. These additional groups included a new artgroup and other activity groups. One ward latterly developed ward thera-peutic time where the ward was closed to enquiries, telephone calls andnon-urgent visitors, and nursing time was given over to direct patientcontact. A number of nursing staff expressed interest in further training ingroup working.

Continuity of the groups is now in the hands of ward staff and theirmanagement team. Supervision continued on a monthly basis for a year runby PC and MF, which may have ensured the continuation of the groups. Allgroups are still running at this time. Now further training sessions for newstaff take place as required to ensure that the developing culture has a firmand nurturing base. Responsibility for supervision has been taken on byward managers and individual staff as part of their personal supervisioncommitment.

Quantitative Research Results and Statistical Methods

The research variable being observed during this period was that of com-plaints made by in-patients on the wards concerned. This data was collatedcentrally by management staff who provided three-monthly returns. Thenumbers of complaints on each ward have therefore been broken down intofive three-monthly periods before and after the groups started (see Table 1).

Table 1 shows the raw data on this as collected. These results, in their rawform, show a percentage reduction of 62.5% in total number of complaintson the acute wards before and after the groups starting. This is bestexpressed however in terms of significances, as explained further below inFigure 1.

Figure 1 expresses this as means and standard deviations pre and post thegroups starting, across all four wards taken together. The raw data has alsobeen converted by way of a Mann Whitney U test in a calculation of signifi-

Table 1. Numbers of ward-based complaints per three-month period pre-and post-ward community groups (May 2005, groups began at period 6)

Ward3 monthperiod

1 2 3 4 5 6 7 8 9 10

pre pre pre pre pre post post post post post

Ward A 6 10 6 6 6 2 2 4 2 3Ward B 7 3 3 2 3 1 0 1 5 1Ward C 0 2 3 4 3 2 0 0 1 1Ward D 1 5 6 2 2 4 1 0 0 0

Totals 14 20 18 14 14 9 3 5 8 5


cance, which confirms that there is a statistically significant reduction incomplaints across all four wards pre and post the groups.

Figure 2 demonstrates essentially the same calculation, except with theaddition of a Kruskal-Wallis test for significance due to the smaller samplesizes, comparing each ward pre and post ward groups.This data, representedin Figure 2, shows that the only ward showing a significant change on its own,pre and post groups, is Ward A.

These results will be discussed further in the next section of this paper.

Discussion

The project was a challenging one for all concerned. It involved staff inexploring new roles for themselves as facilitators of feeling, while thepatients’ role developed with new opportunities for appropriate self-

0

1

2

3

4

5

6

7

Pre Post

*p<0.01

Fig. 1: Mean complaints, across all wards, per three-month period, pre andpost groupsSignificances (p) in italics, standard deviations represented in stems.

0123456789

10

Pre

Post

0123456789

10

Ward A Ward C Ward B

Pre

Post

*p<0.05

p=0.1

p=0.1

p=0.06

Ward D

Fig. 2: Mean complaints per three-month periodSignificances (p) in italics, standard deviations represented in stems.


expression and responsibility-taking. The process of setting up and runningthe groups sometimes mirrored the powerful contradictions that are often atthe root of psychopathology. The patients involved were typical acute psy-chiatric ward in-patients who would often be at odds with society or them-selves, with severe impairments in self-expression and attachmentbehaviour. There would sometimes be marked difficulties in the psychoticspectrum. The established groups allowed for their safe expression.

There emerged four consistent qualitative themes in the experience ofsupervising these groups. Firstly, the structure and boundaries that presentednew dilemmas to the staff involved. Many nursing staff were new to groupworking which led to such questions as how long a group should be, andwhat constituted the leadership role. There was also the contrast for them ofbeing asked to provide less rather than more structure during the period ofthe group. This was a difficult challenge to the staff involved and generatedanxiety. It reflected dilemmas at the heart of modern psychiatric nursingpractice, and contradictions between the normative primary task of nursingtowards recovery and the phenomenal task (Lawrence 1977) of control forsociety of troubled states of mind.

There was then the control vs. expression tension which brought furtheranxieties for staff. Primarily this reflected to us an in-built tension betweenthe socially constructed task of mental health nursing as mentioned aboveand the possibility of encouraging greater freedom of expression. As men-tioned, nursing staff were the only professional group represented from thewards.Through this unfamiliar medium of working a more sustaining culturewas developed, however, and a potentially more nurturing environmentcreated. The importance of this was suggested by the frequent allusions tothe deprived feeding environment, and related complaints. The staff’s con-fidence in working in this way grew substantially over time, and their anxietyreduced.

Thirdly, there was the intrusion dimension that had seemed to be anaccepted part of ward life, but supervision led to staff taking a more thought-ful and boundaried line in some cases as the groups developed. This can bea thorny issue with respect to the growth in patient representation. Clearlysuch representation is a movement in the right direction, but it can bepotentially generative of confusion when the representatives are not actu-ally chosen by the patients themselves, and are not directly part of the wardculture. Events in this context can be seen as basic assumption (Bion 1961)activity which was resolved through the growth in experience mediatedthrough supervision.

The final dimension was the emergence of new developments, as staffconfidence increased so they became enthused to take on new developmentsin group settings. Again using Bion (1961) as a model, the work groupappeared. This seemed to be a process of taking mental health nursing backto core values that they had expected to be using in their day-to-day work,


when they originally trained. Some of this drive was already in place with theguidelines on increased ‘service user’ involvement and other initiatives forthe acute ward settings, but the qualitative observations suggest that devel-opments increased with the growth of confidence in group working. Some ofthose involved expressed interest more generally in training further in groupworking. The groups were set up with clear ideas of what they could looklike, which in many respects differed from the reality of the acute wardsetting. Nevertheless the groups appeared to foster a new interest andculture based around dialogue, which in the large group literature is identi-fied as a step towards the transformation of hatred, which prevails whenimpersonal relationships dominate (de Maré et al. 1991).

As for the quantitative findings, ward community meetings were associ-ated with significant reductions in the level of complaints made by theresidents in this study. This agrees with the literature that suggests wardgroups lead to a reduction in incidents (which can also generate complaints).The fact that the groups are fora for patients to air their concerns directlywith the staff may also then reduce the need for them to make them inwriting to the ward management. The ward with the highest initial numberof complaints had the single most substantial decrease, but across the entireunit the decrease was also significant.

The qualitative observations of the supervision and training sessionsaccorded with this finding in that frequently grievances were aired, andcomplaints made, but kept within the boundaries of the ward communitymeeting.Thus a systematic bypass obviated the need for these grievances andcomplaints to be taken down the formal route. Nursing staff expressedconcern about this, wondering if the frequent complaints in the groups werea sign that the groups were having a detrimental effect, whereas in fact thedata suggests it was having a beneficial effect on aspects of the environment.Perhaps the beneficial effects of the groups can be understood in relation toBion’s (1962) idea of the container which allows for expression and themetabolizing of the material within it and allows a process to emerge wherebyindividuals feel less aggrieved and more understood. Obholzer and Roberts(1994) talk of the importance of appropriate containment for anxieties, that afunction of institutions should include this, and that facilitating clear commu-nication is part of this process. In a linked way, complaints can be seen asexisting in the transitional space (Winnicott 1951) of the ward environmentmuch as the protesting infant may act out within the space of their family andmaternal relationships.To merely put the complaint out of mind and into thehands of a ‘higher power’ risks losing its creative potential. We also hypo-thesize that the expression of complaints within the safe container of thegroups is likely to aid the therapeutic work of the ward and its staff.

Though the finding of reduced formal complaints accords with commonsense such dramatic results demonstrate the potential to reduce a unit’soverall complaint figures in a way likely to make most management teams


happy! Feedback about such resultant positive effects could additionallygive nursing staff a greater sense of agency in the generation of an improvedward culture as well as greater belief in their own therapeutic efficacy. In ourexperience formal complaints also have a significant effect on the function-ing and morale of staff and hence this finding is important at a number oflevels.

There may also have been other direct positive results on ward moraleand social climate. One of the wards involved (A) reported a 50% reductionin incidents in the same time-frame, confirmed by the authors, but method-ological problems with this variable mean it is not possible to draw clearconclusions. Nor is it possible to tease out from this finding the relationshipsbetween reduction in complaints, patient and staff morale and dimensionsin the ward atmosphere. It is hoped that current studies undertaken by theAberdeen group on studies using measures such as the Ward AtmosphereScale (Moos 1974) will produce more conclusive results. It would also beinteresting to look at the observation levels accorded to patients on the basisof risk assessment, observation levels being the degree of monitoring of apatient usually indicated by risk or illness behaviour concerns, though againward practices vary greatly in this regard.

Limitations of the studies’ findings also include a failure to consider other,unknown, reasons for the reduction of complaints such as other changesinstituted on the wards. However, no other ward-based intervention wasidentified that would have affected all wards in a similar way, or that startedin May 2004. Hence the most likely explanation is that the complaints havefallen as a result of the community meetings. We would also contend thatthe qualitative observations reinforce the findings concerning the complaintdata, given the content and its meaning regarding the group’s need forexpression. Further studies, as previously described, could potentiallyconfirm this by looking in greater detail at aspects of the ward culture andhelp elucidate further aspects of the processes involved.

Another potential limitation is the lack of direct patient reporting into thequalitative observations: patients’ opinions about the groups were onlyreceived indirectly, from nursing reports of their opinions. Again this couldbe addressed in later studies.

Conclusion

Perhaps the single most useful aspect of this development and study seemedto us to be the creation of more space for patient self-expression and cre-ativity, and nurse–patient contact time.The reduction in formal complaints isan important result of this.The emergence of new initiatives run by engaged,committed nursing staff with feedback from the patients is clearly animprovement from the position in which they are so often left in the wake ofthe restructuring of mental health wards in the UK.


The groups were a novel exercise for almost all the participating nursingstaff, as they were constantly required to challenge their assumptions aboutwhat their roles were and what the groups should look like. These groupswere supported at their inception and on an ongoing basis by the nursingmanagement team; this appears to be a vital constituent to their viability assignificant staff time is involved, as is the regular supervision for them.

As mentioned, these groups have continued and new developments areemerging which may result in a synthesis of the changed culture of in-patientpsychiatry and the determination to use groups as one way for psychiatricnursing to express its creativity.

Acknowledgements

We should like to thank Mr Scott Dyker, ‘3R’s Project Manager’, the acute wardnursing staff and their management team.

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IMPROVING THE CONTAINER: WARD COMMUNITY GROUPS AND THE MODERN ACUTE PSYCHIATRIC IN-PATIENT SETTING