Knowing how to open the Johari Window for a brighter future for the NHS

On Friday I was stuck in a traffic jam on the M6. It’s not unusual, and never more so than on a Friday afternoon. There is nothing you can do other than to sit there, listen to the radio and wait for the traffic to move forward another six feet or so. I was listening to Radio 4’s Last Word, which this week reflected on the life and times of Donald Rumsfeld, who died recently. Donald was certainly a colourful and at times, a controversial person. He served four different US Presidents during his lifetime, the last being George W Bush. It was during this time, as Defence Secretary, that he masterminded the invasion of Iraq following the terrorist attack on the twin towers in New York. It was a war that cost the US over £500 billion and some 4,400 American lives, not to mention the thousands of Iraqi lives lost in the conflict.

He was also a man famous for the way he expressed himself – for example, ‘all generalisations are false, just as this one is’ – but he is probably most famous for his response to whether Iraq actually had weapons of mass destruction (one of the given reasons for invading the country) or not. He said: ‘there are known knowns, these are things we know that we know. There are unknowns, that is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know’. It is a quote that has been used frequently since by many folk charged with strategic planning and management.

Of course, the concept of ‘unknown unknowns’ is not new. Joseph Luft and Harrington Ingham, two American psychologists came up with the notion way back in 1955 (a great year) during their research into group dynamics. Their work led to the development of the Johari Window. It is a model that is used to help individuals better understand their relationship with themselves, as well as with others. I have often used the approach in small group work with students to help them understand the concepts of inter-personal, intra-personal and extra-personal relationships and how people use these in their everyday lives. Indeed, drawing upon psychodynamic and managerialist analytical discourses, a large part of my research and writing has focused on exploring the impact of such relationships on nursing practice, policy, organisation and education. Much of this work being focused on mental health nursing.

I still find it amazing that it was more than 46 years ago since I started my mental health nursing journey. And last week I was taken back to those wonderful days through a visit I made to the mental health unit on our Acute Hospital site. It is an interesting collection of services. There is provision for those experiencing an acute episode of mental ill health; a small forensic ward; and unusually these days, a small service for people with complex needs who are likely to require long term care. It was lovely to be able to walk around the various wards and to have conversations with the staff and patients alike.

Some things had changed, yet at the same time remained the same. When I did my training, we had to wear uniforms, which for men included the ubiquitous white coat. By the time I qualified and got my first Staff Nurse’s job, we were all wearing our own clothes. Last week I was surprised to see the nurses back in uniform once more, albeit their uniforms were modern and stylish. However, they talked about their experiences of working through the early days of the pandemic and the fact they were required to wear full PPE. PPE, and even simple masks were not seen as being helpful in building and maintaining effective therapeutic relationships, the core of mental health nursing. Of course, the nurses all understood why PPE was necessary, but 15 months on, whilst still wearing masks, the other forms of PPE were no longer being used.

The other big issue that remained was the numbers of staff who were having to isolate, because they had been in contact with others who had tested Covid positive. As with other fields of practice, there is an acute shortage of qualified mental health nurses, which the pandemic has brought into clear view. Equally, as in many other areas of health care, the staff were pretty exhausted, although there were lots of smiles to be seen and positive thoughts expressed about the future. I think for me the highlight of the visit was meeting the mental health liaison team. They were the embodiment of the notion that ‘there is no health without mental health’. They worked across the Acute Trust and not just in the Emergency Department. Listening to them talk about their work, it was easy to see that their underlying approach was one of integration and collaboration. 

Whilst they were experts in their field of practice, they worked with other staff in holistically meeting the needs of each individual. It was a far cry from the days of my training where meeting the mental and physical needs was exclusively the domain of either ‘psychiatric’ or ‘general’ nurses. Last week, the way of working I heard described was much more about interdependency which, in an age of collaboration and partnerships, bodes well for the future.

Speaking of collaboration, I was really pleased to see that the Health and Care Bill was introduced to Parliament last week, with the second reading due as early as this Wednesday. It is the start of a process that will see, by next April, the end to the disastrous Lansley reforms of 2012, reforms that have beleaguered the NHS since that time. Whilst there are still a great number of known unknowns arising out of the new legislation, we don’t need to look through the Johari Window to know that there is a much brighter future ahead of us. All we need now is for Sajid Javid to deliver the Prime Minister’s promised oven-ready plan for social care. Something that is now long overdue and cannot come soon enough.