Some of the difficult and challenging behaviours exhibited by patients are due in part to lack of clarity about how they are expected to behave, or lack of consistency between the ward staff about what those expectations are. This ambiguity or lack of clarity is particularly problematic for patients who:

• cannot think clearly
• are distracted by psychotic thinking and preoccupations
• find it hard to concentrate
• have difficulty interpreting the verbal and nonverbal communications of others
• are undergoing extreme emotional states and moods that bias their perception and interpretation of what is going on around them
• have a distorted view of the world and others, particularly those in positions of authority, possibly due to past experience and upbringing.

These expectations work both ways, and just as the staff have expectations of patients, patients have expectations of the staff. Clarifying these relationships allows the staff to be consistent, and the patients to understand their obligations and those of staff. Communication between the two will be eased, and clarity in the social environment will assist patients to think more clearly, and experience less irritation and frustration. Lowered stress and anxiety help to reduce symptoms and aid patients’ recovery.

As patients find the word rules infantilising and objectionable. It is therefore much better to talk about expectations, guidelines or standards.

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Step 1, at a staff meeting, discuss the skeleton list of mutual expectations provided in the full description which you can download from the link below. Decide which the staff as a whole feel should be included, what should be added, and what should be changed and how. At this point staff should consider together whether some rules are trivial or unnecessary – perhaps such as limits on when hot drinks are available or how many patients can have, etc. Ask each other ‘who are we to say no?’

Step 2, hold a community meeting with the staff and patients, circulate the list of suggestions, and agree with the patients present what should be included in the commitments of staff and patients, as well as which are the most important. Be prepared to share the true reasons for these expectations with the patients. Be prepared to identify which ones are required by the Trust or the managers, and be prepared to explain to patients how they can appeal or ask to get such requirements changed. At the close of the meeting, agree the final list and contents, and choose a design format for these to be printed up. You could modify or work from one of the examples we have provided for you to download below.

Step 3, type up your agreed list of mutual expectations. You could design a completely new format (we recommend using powerpoint), or you could delete the contents of one of our examples and replace it with the mutual expectations you have agreed with your staff team and the patients on your ward.

Step 4, get your mutual expectations printed as a laminated poster to the ward, to your specified design with your specified content. Please hang this in a prominent and public space where it can be read by patients and staff. Some wards like to have more than one copy. Smaller copies can also be put up in patient bedrooms and/or included in welcome packs.

Step 5, make the poster part of the admission process, going though it with new patients, perhaps several times over the first week, making sure they understand the contents.

Step 6, refer to these expectations when asking patients to desist from certain behaviours, or when asking them to do something.

Step 7, encourage the patients to refer to these expectations with staff, when they fail to uphold them.

In addition to the documents provided below, you will need to have located a printing shop who can print out your poster, and a way for your organisation to order and pay for it. Alternatively identify a way for your organisation to reimburse you if you pay for it. Sort these things out before you start with the implementation of this intervention. Delays at a later stage can weaken the enthusiasm for this intervention.
You must download and read the full intervention description and look at the examples before starting the implement this intervention.

Download links to:

Full intervention description of Clear Mutual Expectations
Example 1
Example 2
Example 3
Templates

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