Česky
Unfortunately, psychiatric care is still shrouded in many myths and suffers from stigma. In many cases, these perceptions are reinforced by the old buildings in which psychiatric care is provided. In this and other respects, the Centre for Mental Rehabilitation Beroun, which is being built under the AKESO holding, could help to break down prejudices. In addition to an environment unprecedented in Czech psychiatry, it wants to offer a slightly different approach to care, favouring a wide range of interventions from phototherapy or nutritional therapy to various group therapies and the possibility of using fitness or sauna. But to fulfil its ambitions, the centre needs enthusiastic and committed staff covering the full breadth of expertise. As is well known, there is a problem in the Czech healthcare system, especially with the shortage of nurses. The centre would like to attract them not only with a range of benefits, a safe and modern environment or the opportunity to fulfil their work, but also by participating in their education. Zdravotnický deník talked to Pavel Scholz (PS), deputy for project management of AKESO Holding, and Eliška Pouskova (EP), station nurse of the Mental Rehabilitation Centre, about what care should look like in the Beroun Mental Rehabilitation Centre and where to get the staff to provide it.
This summer, the Centre for Mental Rehabilitation (CDR) should start operating. Why was Beroun chosen as its location and how will the care differ from what is common in psychiatric care in the Czech Republic?
PS: The Mental Rehabilitation Centre being built complements the network of inpatient psychiatric care in the Czech Republic in the southern and western part of the Central Bohemian Region, where such services have been lacking for a long time. The increased availability of comprehensive inpatient care will directly affect the quality and cost-effectiveness of psychiatric care. It will reduce transfers to distant inpatient facilities, shorten hospital stays and improve the reintegration of patients into their original social environment after hospitalisation. The lack of availability of psychiatric care in the region leads to patients being hospitalised at a great distance from their natural environment, which results in an unwanted disruption of family ties and of the patient's contact with the natural community. A modern approach focusing on individualised care and early psychiatric rehabilitation will avoid unnecessary hospitalisations and reduce the number of re-hospitalisations by linking with out-of-hospital services (health and social). Innovative treatment methods, in particular full-spectrum circadian lighting throughout the facility, will contribute to a more efficient use of hospitalisation time.
Realistically, and from the experience of our patients at the Hořovice Hospital and the Beroun Rehabilitation Hospital, it appears that citizens in the Beroun area do not have access to psychiatric care. The Mental Rehabilitation Centre is absolutely right in terms of location and location on the premises of the Rehabilitation Hospital Beroun. The building itself will have a healing effect, not only because of the human and professional approach of our staff, but also because of the complete circadian lighting and technologies that should make the treatment and stay more pleasant. The rooms are maximum double rooms, one whole floor is single rooms. Among the therapeutic methods there will be phototherapy, music therapy, drama therapy or therapy using virtual reality. Massage, fitness, wellness or swimming pool will be available in the hospital as part of the higher comfort of care; among the methods that will be new in the hospital, for example, nutritional therapy, where people will learn to cook at a reasonable cost of food. Of course, there will be no shortage of occupational therapy, where patients will be able to create with clay or textiles or paint.
EP: At CDR, we will be applying the Safewards model, which originated in the UK and is based on the study of over a thousand scientific articles. It works with two concepts - conflict and control. A person develops conflict in the form of verbal or physical aggression, tension, self-harm or anything that can lead to harm, and control is the intervention that staff use to manage conflict. In most cases in psychiatry, the approach is to confine the patient to bed or to administer calming medication. This is what the Safewards model seeks to avoid. Above all, we try to prevent conflict situations, spot the triggers of conflict in a person early on and try to prevent conflict from happening. And when it does occur, to choose appropriate controls that will not lead to a worsening of the situation. The Safewards model includes ten interventions, such as ward calming aids. These can include a punching bag, squeeze balls, music, or even just a paper and pencil where the person writes out or draws out their feelings. Other interventions are positivity and appreciation. A big annoyance in wards tends to be that only the problems, i.e. what they have done wrong, are communicated about people when they are handed over the service. We tell ourselves that Mr. Novak was aggressive and wanted to run away, but we no longer communicate what he did well, such as that he was engaged and enjoying himself during activities. It should be balanced, and if I say something positive to a colleague when handing over a shift, that too will evoke a completely different feeling and approach to the patient. I will also mention an intervention called getting to know each other. Each member of staff has a medallion that is publicly available to patients. Of course, there is no personal contact or information that could harm the employee. His/her interests are there, and when the person reads it, he/she finds common topics to talk about with the employee. It makes communication very easy. For example, dismissal notes work as well. Anyone leaving can write a message to current and future inpatients. They can write about how they felt on the ward or whether the treatment there helped them. For example, a tree painted on the wall or a chronicle can be used for this. Messages motivate other patients to take up treatment, to realise that it is worthwhile.
PS: Care on the wards, which will have a capacity of around 22 beds, will often take place in the community.
The wards will form groups, led by a psychotherapist, in which patients will share experiences, find common solutions to problems and help each other in their recovery. In the inpatient ward, everyone will have spaces for relaxation, social games or other individual therapy. Within the building will be a spa, cinema, theatre and other activities to spend time effectively.
Have you already assembled a core team of professionals? Are you discussing exactly how care should be delivered?
PS: Yes, fortunately we do. The Mental Rehabilitation Centre is a project that started in 2016, but realistically we have been discussing the specific staffing for the last year or six months or so. With a key team of experts in the field, headed by Martin Hollý, we are mutually alienating the rules of operation, the use of modern therapies and thus creating a harmony between a modern building and the expectations from patients, health professionals and, last but not least, the management of the hospital (holding) that I represent.
Each of the experts we have in the team today helps with their know-how and opinion to create a unique environment and operating rules. This is objectively impossible in older facilities - they already have their walls, layout limits, customs and guidelines. We are currently collaborating with most educational institutions towards healthcare professionals and starting a series of lectures for them. We are particularly targeting specialist psychiatric nurses, general nurses, practical nurses/health care assistants, occupational therapists, physiotherapists, social nurses, "field" general nurses, but also other professionals who can help people in CDRs, such as financial advisors and others.
But you already have a concept of what care will look like on inpatient wards...
PS: Yes, and the basic dogma for us is recovery-oriented practice, a coordinated, efficient and humanistic system, non-selected acute care, a proactive and assertive approach to treatment through collaboration/participation with mental health centers and other prevention activities in the region, or continuity to follow-up care, both residential and out-of-hospital. And, of course, sufficient and stratified psychotherapeutic services, a multidisciplinary approach, i.e. the involvement of not only health professionals and, as a result, a focus on physical health care. In addition to outpatient and inpatient care, we will have day hospitals where clients can be in at certain times of the day, be exposed to health professionals, the group and the environment, use some of the therapeutic facilities in the building, and return home after dinner. We will also be active in the field. The first acquisition in this area for our centre was the Day Psychotherapy Sanatorium in Ondrejov, and we also work with mental health centres. We built the CDR building so that the facilities and network infrastructure are ready for future technologies, which is a huge problem in hospitals located in historic buildings.
EP: We want there to be virtual teams where there will be collaboration between the inpatient facility and the CDR or community team.
Can you elaborate on what these virtual teams are?
EP: Multidisciplinary collaboration happens on three levels. The first level takes place within one team that is on the ward and is made up of the team working directly on the ward and the community organisation. Multiple professions are part of the team, each with their own expertise, and they interact for the benefit of the client. In the second level we come to the virtual teams mentioned above, which means collaboration between two teams - inpatient and community teams, which are, for example, mental health centres (MHCs). There is a coordination of care for one particular patient. The aim is to create as broad a structure as possible, where multiple CDZs are involved in collaboration with the health facility and targeted care for individual patients takes place. It takes place early in the hospitalisation and the patient is provided with follow-up care. Example: a hospitalized patient will have an established collaboration with a mental health centre. We can connect with the CDH team and invite them to a virtual team meeting and of course, with the patient's consent, share information. Often the outreach team will send a case manager or worker who is caring for a particular patient. The person feels more secure, meeting a person they know and trust. That way, it is also possible to talk directly to a specific worker and plan better for psychiatric rehabilitation. Telling each other what will be needed when someone is discharged, while also aligning their plan that they have already arranged with the client. Hospitalization is then not an interruption or a barrier. The goal is not to do everything for the patient, but to encourage and guide them so that they can do things on their own. When he is discharged, he will know that he has someone to turn to. He will feel more secure and confident. The virtual title is a working title within the mental health care reform project because it is not under one organizational unit. Teams are not 100% virtual, communication is not just online. On the contrary, the aim is for the CDZ worker to come and meet a specific person. But if people are interested, we will also facilitate contact online. I would like to stress that we will always contact the CDZ only after a joint agreement and consent of the patient.
Psychiatry is already beginning to appear among the fields that nurses would like to pursue early in their careers, says Eliska Pouskova.
How many employees should work in the centre and how many have you already managed to recruit?
PS: We have not yet launched a sharp recruitment campaign. In total, we should have around 300 employees in just over 16 months from the start of operations, but the start will be gradual. We emphasize quality, safety, efficiency and collaboration, and that takes time and energy from all of us. In any case, we need around 50 nurses in the first phase. The subject of the shortage of general nurses is well known to the public. There is not such a shortage problem for practice nurses, but there are already challenges for general nurses. There is a stigma attached to psychiatry, and when choosing a specialty for a nurse, it is not the first choice. In schools where they allow us, we want to enter the classroom with a two-hour presentation, offer a tour of the centre and an introduction to the team to motivate students. Once we have the facility up and running, we will also offer educational and research facilities.
EP: On the other hand, psychiatry is already starting to emerge as a field that nurses want to pursue early in their careers, although it's slow going. In any case, for me, when selecting staff, such as nurse practitioners, the key thing is their motivation to care for people with mental illness. Also whether they have an interest in further education, an interest in psychiatry in which they want to continue to improve and don't mind doing things differently than perhaps the standard in the current system.
PS: We now have key individuals that we will then bring new colleagues to. Once we launch a sharp campaign, we will not only target nurses who work in the field, but also nurses who are outside the field, and of course, as I mentioned, future graduates.
What will you be targeting in the sharp part of the campaign?
EP: We are attracting employees to the existing benefits that the Beroun Rehabilitation Hospital offers. There are a lot of them, and besides the classic ones, such as a pension contribution or a Multisport card, we offer, for example, free beauty services once a month. You can get a free massage, a hairdresser's allowance, a manicure or a free gym membership. We have a discount in the hospital pharmacy and café. There will be a swimming pool and sauna in the Mental Rehabilitation Centre. We also offer transport services or fully equipped apartments in Hořovice. Last but not least, we have a scholarship program where you are entitled to a scholarship of up to 10,000 per month when you study a field that expands your qualifications in the health care sector. Above all, we will be attracted to the new and safe environment and opportunities that the Mental Rehabilitation Centre will offer.
PS: And it's also about the possibility of implementation, many people want it to be about something practical. When you walk away with a person who is cured, there's a clear outcome. If a patient leaves and you, in collaboration with a multidisciplinary team and supported by Mindwell-type e-therapy programs, pursue a pathway to improved mental health, that's great.
Both Elisha and I are very appreciative that we can put our personal enthusiasm and the enthusiasm of other professionals working with us into this project. An environment with the opportunity to share your opinion is one of the most important things for us.
You mentioned presentations for students. Do you want to participate in education in other ways?
PS: We have started communication with colleges and high schools of nursing. In our discussions, we came to the understanding that there is an interest from the educational institutions to help each other. Logically, we are helping professions. We as AKESO holding are interested in having specialized nursing staff in psychiatry with an interest in the field. If an agreement is reached, we will allow distance learning for our nursing specialists right in the environment of our Mental Rehabilitation Center. We will utilize the medical and teaching capabilities of the Mental Rehabilitation Center in teaching. The institution we are dealing with has accredited the program. For staffing reasons, they have not been able to start it, which we could resolve by working together.
The field of psychiatry is stigmatized. What are other ways to attract people into it?
PS: You have to get people excited and let them implement their ideas, which is one of the reasons for the success of AKESA owner Sotiris Zavalianis. We don't want workers that we will employ for half a year. We offer understanding, respect and stable employment where people will have the opportunity to realise their skills and, for those who are lucky, their professional dreams. In addition, we are talking with Professor Prasek, whom we have on the close board of the Centre for Mental Rehabilitation, about establishing a research organisation and also about supporting the education of our future staff and graduates. Psychiatry itself is both helping and about helping oneself.
EP: Some may have the misconception that a psychiatric nurse is like a guard. Someone who gives orders and the patients obey. But that's not the case today. It must be understood that the field of psychiatry is different from the somatic fields. Whoever enjoys communicating and treating with words, this is the field where he can realize himself. Part of the reason graduates are not interested in psychiatry is because they don't learn much about the field in school. Therefore, it would be appropriate to get the subject into high schools as well. For nurses to become interested in working in psychiatry, it needs to be destigmatised. The general public should also know what a psychiatric nurse actually does.
So can you give an overview of her work?
EP: The role of a psychiatric nurse is to carry out, for example, psychiatric rehabilitation and psychoeducation. The nurse should talk a lot to the person in her care about how her illness is progressing. She should look for early warning signs with him. For example, a patient with schizophrenia starts to lose touch with reality before the full onset of an attack, has delusions, hallucinations, insomnia, bad dreams or migraines. Everyone's early warning signs are different. We look for them together in psychoeducation. The aim is that in the future the patient will recognise the warning signs of his illness himself and be able to deal with them in the next possible treatment, before the full onset of the illness. This would mean that they would not need to be hospitalised, but could manage with perhaps just outpatient support or community care support, with which CDR will work closely. We also educate the patient about their disease as they often lack insight. He doesn't realise he has the disease, he downplays it. The nurse must sensitively explain to him that what is happening is not something that cannot be addressed. He needs to know about it and accept it internally. Psychiatric rehabilitation then consists of intervening to return the patient to the life he or she was living before the illness struck. In this process, even ordinary things are a problem for the person, such as not being able to make a doctor's appointment, call the office or go shopping on their own. Often the family does not understand this comprehensively. Therefore, the psychiatric nurse should also educate the patient's environment so that it is supportive. In psychiatric rehabilitation, we guide the patient towards independence and are his guide to manage things.
PS: It is also a link between the medical and social segments, where the nurse helps with communication with both the doctor and the social worker.
EP: Other competencies of the psychiatric nurse include guiding relaxation techniques, and can work as a co-therapist in therapy groups. She provides psychotherapeutic support. May coordinate cooperation between inpatient health care facilities and outreach services, actively̌ work with persons designated by the patient and together create conditions for the return of each person to their own social environment. He or she may also assist with electroconvulsive therapy or repetitive transcranial magnetic stimulation, participate in chronobiotherapy with patients, conduct supportive conversations with people and their families, and of course, in addition to all this, perform standard nursing interventions such as the administration of infusion therapy or medication.
Will the work of a psychiatric nurse in the Beroun centre be fundamentally different from that of a psychiatric nurse in other institutions?
PS: Definitely in the management approach and support. It is not common in the Czech health care system for the management of an organisation to have contact with the first line of employees (apart from casual personal acquaintances). We want to use communication and team building activities to present our ideas and work with the ideas and enthusiasm of our experts, as long as they are in line with the basic goal of the project, of course.
EP: The principle of work will definitely be different. The Safewards model alone is something that is applied very little in the Czech Republic, I think only in two places. We want to do the work in a human way, to approach patients in a friendly and professional way. It is also very important for me to create a safe environment for the staff who will be working for us. I think we need to give space to everyone in the implementation. I will be pleased with every idea that a staff member comes to me with. We can then discuss it as a team and develop a system of care together. My wish is that staff feel safe with us and are not afraid to come to their station nurse with any problem or idea.
In your opinion, is psychiatric nurse education set up correctly?
EP: We are planning to organise other activities for staff training within the Mental Rehabilitation Centre in Beroun, in addition to possible specialisation training, for example, to create certified courses for nurses on post electroconvulsive therapy nursing care or a course on de-escalation techniques and acute management in psychiatry, perhaps even directly on the Safewards model.
PS: In any case, we would like to be an inspiration to others with our methods and the building concept itself. I don't want it to look like we do things differently here - we don't. We just have the ability to do it "from the ground up" the way we want. In preparation, my colleagues and I also visited psychiatries around the country, where we were given recommendations on what to avoid. And each of us has respect for the current system of psychiatric care and each of the providers of that kind of care. Based on good relationships, we have been able to avoid some mistakes, and we are grateful for that.
We will not do things completely differently at the Mental Rehabilitation Center, but we have the opportunity to set things up "from the ground up" and avoid some mistakes thanks to the experience of others, says Pavel Scholz.
Coming back to attracting staff, what about the working environment? This is at least as strong a topic as money for many healthcare professionals today.
EP: We want to create an environment for staff where they enjoy coming, where their work is meaningful and where they are not afraid to confide in their superiors about any bad feelings or perhaps ideas for improving care. My experience at AKESA is that it really works that way, the staff is friendly and human. We want to do psychiatry the same way. Even for non-medical staff we want to introduce interviews and supervision so that problems but also joys are communicated. It should not just be communication between supervisor and subordinate, but across the whole multidisciplinary team. This is the basis of a safe environment and making people feel comfortable in it. At the same time, we strive to make sure that the wards are well staffed so that staff have enough time and space to work with the patient.
PS: All of our interviews include the presence of a psychotherapist. A number of staff are burnt out and leaving the health service. Yet, for example, with burnout syndrome, we are able to help physicians and non-physician health care workers or any other professions. Staff will gradually receive training in psychotherapeutic methods, but also in other methods of working with themselves. Part of the operation will also include group work, not only in terms of superior-subordinate relationships, which are standard in the health sector, but also from a team perspective. Respect for each other is thus essential.
In addition, you will also use modern technology in the centre, which can be a challenge in itself for some healthcare professionals. What will that look like?
PS: There are many things, for example, using virtual glasses, we will help people who have specific phobias under the guidance of a psychotherapist or psychiatric nurse. For example, they are afraid of large numbers of people, communication or confined spaces. With the help of virtual reality and the work of a psychotherapist, we can get rid of these phobias. For example, for fear of heights, we simulate climbing stairs at level one, standing at the top of a high-rise building with a view down at level ten. In this way we gradually guide the patient how to work with these feelings without having to leave the building. In addition, the mental rehabilitation centre is being built next to a hospital where, for example, rehabilitation of patients after car accidents takes place. If someone has an accident in a tunnel, they may become afraid of tunnels and avoid them at all costs. We can get rid of the problem. In Beroun we can cure these patients both somatically and psychologically.
Mgr. et Mgr. Eliška Pousková, DiS.
Eliška Pousková is a general nurse specialized in psychiatry and addictionology. In 2019 she completed her studies at the 3rd Medical Faculty of Charles University in the field of general nursing. Already during her studies, she started working at the psychiatric clinic of the General University Hospital in the acute ward for men, where she worked until the end of 2022. After graduating from the 3rd Medical Faculty, she completed a master's programme in adictology at the 1st Medical Faculty of Charles University. She became qualified for nursing care in psychiatry by completing a master's degree at the Medical Faculty in Ostrava. She also completed specialisation training in psychiatry at the VFN Prague under the NCO NZO Brno. At the psychiatric clinic she worked, among others, in the team of neurostimulation methods, where she had the opportunity to learn about the possibilities of biological therapy in psychiatry, especially ECT and rTMS. Since 2020, she has been a member of the community psychiatric team at the Podskalí Mental Health Centre, where she has been involved in psychiatric rehabilitation, education and often dealt with social issues with clients. In 2023, she completed the training of regional therapists in the PARAFILIK project, where she became more familiar with the diagnosis and possibilities of therapy with clients with unusual sexual preference, the project is organized in cooperation with the National Institute of Health. She is also currently training in psychotherapy at the PVŠPS, where she is studying daseinsanalytic therapeutic training. Since August 2022, she has been working in the psychiatric outpatient clinic Esmedicum Ltd. Since 2023 she started working at AKESO holding in the Rehabilitation Hospital in Beroun.
"My personal promise from working at the Mental Rehabilitation Centre is that we will create a pleasant working environment, a family atmosphere, listen to each other and respect each other. We want every employee to feel that they are important and that their work is meaningful. We will treat each person, and I stress this, both patients and staff, in an individual way. We would like to create a space, care and working environment that allows us to listen to people. We want psychiatry to be different, we want it to be human. The Mental Rehabilitation Centre is a unique project that will bring completely different standards than the existing psychiatry in the Czech Republic."
Mgr. Pavel Scholz, Ph.D., Deputy for Project Management AKESO holding a.s.
Pavel Scholz holds the position of Deputy for Project Management at AKESO Holding. He joined the company in 2020 to build new projects, in particular the completion of the Diagnostic Centre of the Hořovice Hospital in Prague, which he took on during his first 6 months at AKESO. In mid-2021, he accepted a challenge from the owner of the holding in the form of managing the unique project of the Mental Rehabilitation Centre and is actively involved in managing all areas necessary for the start of operations.
"In the public sector, I have always been troubled by long delays in the completion of buildings and projects, exorbitant contract prices, politicking and an economically inefficient model of care. At AKESO Holding, I have found an outlet for common sense and moving projects forward. The Mental Rehabilitation Center will offer employees and patients an adequate environment for comprehensive care of body and mind. It is rare to see as many enthusiastic people as we currently have applying to the centre. Colleagues across the holding help me to be a better manager and person and for that I owe them a big thank you!"
Author: Michaela Koubová, Photo: AKESO
