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The role of healthcare professionals: communication

Cliona continues discussing social exclusion and the role of healthcare professionals when caring for those affected by this.
So a question that I sometimes get asked is, why is this my problem? Is this not the problem of social care services? And I would argue that it isn’t. And because we play a really important role in either perpetuating that cycle of exclusion in health, or trying to address it and reverse it and get people back to a more equitable, a fairer level of health.
I think it’s also important to realise that these very high-need, complex patients are really rewarding, both clinically in terms of if you can get them through their illness, and it’s very satisfying because they will have been very unwell and are now much better, and also financially in terms of bed occupancy and things like that, that your hospital and Trust will care about. So they provide a really good opportunity for us to do work that is meaningful both personally and in terms of hospital funding. So in order to address these issues, we need to understand what is happening. So what is underneath the behaviour, the very challenging behaviour, of the young lady that I described?
So on the outside, when people saw April, they saw somebody who was incredibly angry and being very aggressive, verbally aggressive, being aggressive in the way that she was using her body, and being very dissatisfied with her care. And that is very scary, and health care providers are human too, and that’s unpleasant and frightening to be subjected to. What she saw from her eyes was something that she was very used to throughout her life history, which was being punished and being given out, to being told she was doing the wrong thing, being threatened with not being able to leave the ward, being threatened with being excluded from the hospital.
And in her mind that brought her back to her own very, very difficult childhood in which being punished and experiencing violence by adults was unfortunately a common occurrence. I think the other emotion that we don’t talk a lot about in health care, but that’s really central to the lives of people who are socially excluded, is a sense of shame, and that shame may go back to their childhood again.
It may be as a result of experiences in school, experiences of being a victim of abuse, and then is perpetuated in adulthood where being a homeless person who hasn’t changed their clothes and who hasn’t got an education, who is illiterate, all of those things, are very perceived by the patient, the person experiencing them. It’s very shameful.
And I think, again, going back to our end of the bed, there can be a huge sense of frustration in health care providers. And so it can feel very frustrating that you’re putting all of this work into getting this young lady better and at every opportunity she’s almost sabotaging that attempt. And despite all your hard work, she’s still not getting better. If we look beneath all those difficult emotions, I think we come down to an experience of adversity in childhood, and we know from a lot of research that children, their brains are still forming.
They’re very vulnerable, in terms of requiring adults to provide them with shelter and food and affection, and they don’t have the same tools to be able to navigate the world as adults do. So when children experience abuse and neglect in childhood, it has a very, very profound effect on their brains and on their way of interacting with the world, what they think that people will do, and what skills they develop in trying to get their needs met and proceed safely through life. And we know that ACEs affect people’s health. The more ACEs you have, the more likely you are to develop cardiovascular disease, cancer addiction, mental health issues, infectious diseases. This is probably ringing some bells.
And we also know that people who are socially excluded and most of the homeless people in Ireland, for example, have experienced eight or nine adverse childhood events, so they’ve experienced very, very difficult childhoods. And in my clinical practise I would really see that the difficult behaviour that a patient exhibits is usually directly correlated to the amount of adversity and abuse they have experienced in childhood, and that was very much the case in the young lady I described earlier, who had had an absolutely horrendous childhood characterised by neglect and physical and sexual abuse.
And I think, again, looking underneath that interaction at the bed where April is giving out and we’re all getting frustrated with her, is a sense that we have as individuals in the society as to who deserves what. You know she has brought on her illness by her own injecting drug use. Does she deserve the same amount of care as the 92-year-old lady who has cancer? And you know that is a human way to allocate resources, to allocate our energy. But I think we do need to question it as health care providers when it’s affecting the care that we provide.
I think finally, and I alluded to this earlier, addiction plays a really important part in this pathway between very difficult childhoods and people who society and health care providers see as being too difficult or not worth looking after. And it is important to realise there’s a propensity to addiction. Susceptibility to addiction is not evenly distributed through society, and, in fact, is very closely linked with very difficult experiences in childhood, making people much more likely to develop addictions. So not an even playing field there either.
So as providers, what can we do? So I think really the essential thing is to recognise that people come in different shapes, and that their childhood experiences and life experience determine those shapes. And that as a healthcare service we’re the box that the square block is trying to fit into, and we can change our size and our shape to enable that person to access health care. And to enable us to provide them with a good and fair service. And I think it also greatly reduces staff burden and staff burnout. And what we practise is called trauma-informed care. And you can read about that if you google it.
And essentially our foundation is that our patients usually have experienced severe trauma in childhood, and we tailor our interventions and our behaviour to act with a lot of calming, deescalating, clear boundaries, and consistency. And all of those things can make a dramatic difference in the person’s ability to engage in care.
You need a wraparound team and service, because these people frequently have interactions with multiple health and social care services, all of whom need to be talking to each other to meet their needs. And it works. So we brought in this approach called inclusion health in our hospital and saw a real decrease in the amount of unscheduled hospital care, which is very costly, and used by people who are homeless in Dublin. Meeting people’s needs earlier, in a more coordinated and efficient way. That means that they don’t need to access costly unscheduled care. And to end, April is now doing really well. She’s being housed. She hasn’t used any heroin in two years.
She has a good relationship with her very patient and understanding key worker. And she’s planning to return to education. So change is possible. It takes time, but it is worth investing in. Thank you.

In this video, Cliona ni Cheallaigh talks about what we can do as healthcare professionals to help meet the needs of these vulnerable patients. Helping high-need patients is rewarding both personally and financially for the healthcare system.

As mentioned previously in step 1.7, patients who are socially excluded can be aggressive towards healthcare and hospital staff, which can be frustrating as it can feel like the patient is sabotaging their recovery. These emotional reactions can be because they feel threatened or uneasy about not being able to leave the ward.

It is important to understand the reasons behind difficult emotions and reactions which often are a result of adverse childhood experiences (ACEs). ACEs can affect health and often increase the risk of cardiovascular issues, cancer, addiction, mental health issues and infectious diseases. Socially excluded patients often have multiple ACEs and increased difficult behaviours are correlated with increased ACEs.

It can be common to question whether patients who suffer from addiction deserve the same amount of care as an ordinary person. As healthcare professionals, we need to be aware of imbalances within the healthcare system and alter the healthcare provided. Practices such as trauma-informed care for patients with ACEs consist of tailored interventions and behaviours with calm de-escalation, clear boundaries and consistency. Wrap-around teams and services which effectively communicate together contribute to decreasing unscheduled care of vulnerable patients.

Change is difficult and timely but worth investing in, as proven by the patient in Cliona’s story who: has not used heroin in 2 years, has a good relationship with healthcare staff and is going back into education.

Let us know about your experiences of communications between healthcare professionals in the next step.

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Infection Prevention for Vulnerable Patients

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