A Love of Groups

October 19, 2010
Jeanne L. Johnson, MSN, RN

I am a Registered Nurse of 37 years who has worked in hospice care and psychiatric emergency; I’ve worked as a med/surgical manager and (now) as an inpatient psychiatric nurse. Throughout it all, I most enjoy seeing a patient realize he/she is getting well; I also enjoy conducting small teaching groups to help the patient know how to stay well.

I am a Registered Nurse of 37 years who has worked in hospice care and psychiatric emergency; I’ve worked as a med/surgical manager and (now) as an inpatient psychiatric nurse. Throughout it all, I most enjoy seeing a patient realize he/she is getting well; I also enjoy conducting small teaching groups to help the patient know how to stay well.

The Magical Small Groups that exist in today’s inpatient psychiatry world are short events during a patient’s stay of a week or longer. Mine is a treatment planning group in which we discuss all manner of ways that patients can participate in their care. My unit has between 30 and 38 souls at any one time; we get anywhere from 3 to 13 participants depending on who can drag themselves away from the TV screen and the baseball or football game. Sometimes, those who participate are the ones I talk into staying... “It’s only 40 minutes... you’ll be back for the half. . . I do my group on Sundays at 1pm. . . it will be short. . . you’ll see.”

Many patients don’t know what they think about their care plan or even if anyone cares what they think. A few don’t even know why they are in the hospital. I take out sample blank care plans and hand them around. I introduce myself and ask them to do the same. “My name is Betty… (No! the group sighs. . . that is Eloise, whom they see every day at breakfast and have helped her to her room). . . My name is John and I am having trouble concentrating, so if I have to write something, I might have to leave. . . I’m Mary and I don’t remember coming in to the hospital.” After the introductions, the teaching begins for everyone-including myself.

The treatment plan has been filled out and signed by the patient on admission, but almost no one in the group remembers signing the form. I explain that the form is about how the nurses evaluated them when they arrived. I ask “what are your assets and the things you have trouble with (liabilities)?” (I can’t read without my glasses-what’s an asset?”) Sometimes we talk about these assets. . . family and friends, hobbies, an income, a place to stay. “I’m homeless” Sandy says. “I’m afraid to go back to the streets. . . my family is in Maryland.” “I can’t find anything good about myself,” states Sam. And then the group is polled about Sam’s assets. . . “You’re always ready to talk to me,” Mark states, “and I talk a lot” (the group laughs).

I ask the participants if they know who their doctor is, who their nurse is, and what their problems are. Sometimes, I ask them how they would fill out their own treatment plan and what evidence they have that they are getting better? I remind them that the treatment plan is just words and without their participation, what does it mean? One patient admits that he feels like he is part of a machine that takes him in and spits him out after a week. A couple of heads nod. “What would make it better?” I ask.

Blank stares greet this question. I then talk about whether participants are sleeping, whether their medications are working, and if they hear voices sometimes. “I’m pretty sure that my doctor is poisoning my food” Dan whispers. I poll the group about what they think their doctor should know about them. “I can’t talk to my doctor. . .. he isn’t listening to me. . . I don’t like my doctor either,” states Janie, “and you know what, I fired him and now I have someone I can talk with.” This is the time when we discuss what a doctor should know, (ie, side effects from medication; should I have ECT? could the doctor talk to my family?). I ask each patient to make a list of the things his or her doctor should know so if the doctor is in a hurry, all their questions will be answered. Do they know their diagnosis and what it means?

I talk to them about where they will go and whether they have thought about outpatient treatment. “I don’t know what to do. . . what is outpatient treatment?” And once again I poll the group. “Has anyone been to outpatient treatment?” Usually there are a few different viewpoints about being at the hospital part-time. Many patients have been to the hospital before, and know some but not all of what they need to know to feel better.

I like to ask patients where they see themselves in their treatment, and the answers are always enlightening. “I’m not taking the right kind of medicine. . . the doctor has to get it right . . . I’m still not sleeping. . . I don’t have a place to stay. . . I still feel suicidal, and every day I wish I could die. . . I’m in so much pain.” “Tell me more about that” I say. They respond, “I can’t see anything about myself that is worthwhile. . . I’m angry, no one likes me.” Taking a risk, I look around the group for their input. (They never let me down.) Ted says, “Are you kidding…you are the smartest man I know. You are also the funniest.” Mel, the suicidal man, starts to smile and looks like he just won an academy award. “Am I really that funny?” and all participants laugh with the patient.

The group always ends on a positive note. I tell them how important I feel their treatment is to me and that they are encouraged to look at their care plan in their chart and critique it. I also tell them how important each of them is. And I tell them that if they have questions, they can stop me and ask.

You might ask why I would want to write this article for other staff working with psychiatric patients. In this age of computer assessments and computer relationships, old school communication is missing …TALKING AND LISTENING TO THE PATIENTS and hearing positive feedback engenders a more productive stay. As their group leader, I provide a safe environment for group members to seek me out and speak more openly about their concerns. . I also understand and feel greater compassion for patients who participate in this process.

I see the group helping to empower and support the healthy part of the patient who can then step forward and interact with his doctor during the their 1:1 therapy. After each group, patients concerns are jotted down in the “group notes” section of the chart. Occasionally, critical information such as suicidal ideation or side effects from medication are communicated directly to the physician.

I am also experimenting with a variety of teaching videos in which staff provides content to stimulate discussion. The effect of anger and coping skills on treatment are discussed. Patients are provided alternatives to anger and how to improve their ability to respond to stress. This information may be used as a springboard for further discussion topics related to how they are improving in the hospital setting. Pts not only see brief segments by their physician, but also nurses, activity therapists, social workers, security guards, and psychiatric technicians. All contributions describe concern for patients, and support for their welfare.

Treatment planning groups are thus one way of expediting the treatment process with ever shorter hospital stays. These groups help staff connect with the patients and invigorate 1:1 patient-physician interaction by focusing the patients on their greatest concerns and needs. These groups also assist the patients in navigating the hospital system in a supportive and humane environment.