Closing the Gap

Paul Greenwood, Linda Martin, Dr Sian Bensa

• The Advancing Quality Alliance (AQuA)

and the lead partner organisation; The

University of Central Lancashire

(UCLAN) were invited by the Health

Foundation (HF) to bid for a grant to

support a programme that will aim to

reduce the use of restraint.

Closing The Gap

• reduce the incidence of harm caused to

patients and staff as the result of a 80%

reduction in physical restraint by the end of

the programme in June 2016.

• implement a robust approach to improving

quality and patient safety

Aims of CTG

Wave 1 (6 months per wave)

• Cumbria Partnership NHS Foundation Trust

• Lancashire Care NHS Foundation Trust

Wave 2

• Merseycare NHS Trust

• Five Boroughs Partnership NHS Foundation Trust

• Cheshire and Wirral Partnership NHS Foundation Trust

Wave 3

• Manchester Mental Health and Social Care Trust

• Pennine Care NHS Foundation Trust

Participating teams

AQuA Six Step Toolkit

• Number of physical restraints per month

• Number of violent incidents per month

Balancing measures

• Monthly PRN medication

• Seclusion use and transfer to PICU

Measures

• Project charter

• Improvement workshop

• Team training on 6 Core strategies©/ReSTRAIN Yourself

• On site weekly visits for 6 months.

• Ongoing PDSAs developed including coaching from Improvement Advisor on site.

• Measures and safety crosses/SPC charts

• Sign up to the Restraint Reduction Network

Implementation

8©2015 Advancing Quality Alliance Back to Links page

Challenges

Workforce

• Staffing levels

• Psychology not on all wards

• Activity co-ordinator not on all wards

• OT limited on some wards

• Disconnect from board to ward. Staff feel lack influence.

• Medical cover/Consultant role

• Peer support worker role

Policy and practice

• Blanket rules

• Unwritten rules

• Over cautious prescribing

• Task orientated driven by ‘to do list’.

• Them and us relationship between staff and patients.

• Data collection not standardised across trusts

• Lack of data analysis feedback.

• Legal highs

• Low levels of restraint -1 patient can be focus.

• Focus too much on behaviour rather than ‘What is behind it’.

• Police response mixed.

• Wards have become a very task orientated culture

• Nursing office dynamics with patients “in a minute”

• Focus on permission rather than innovation

• No staff surveys done on a regular basis

• Smoking rules

• Eating with patients

• Mixed level of multi disciplinary working/tension

• Middle management – mixed messages

• Appropriate admissions – LD/Autistic spectrum

• Observations and staff interactions, particularly agency staff

• Barrier to access qualified nurses - right staff, right time and right place.

• PICU pathway – inconsistent/tensions.

Observations

Positive practice

• Self harm pathway

• Formulation meetings

• New builds

• Meaningful activities throughout the day and evening (use of external

facilitators).

• Engaging teams

• Multi disciplinary working

• Mindfulness

• Charge and discharge

• Patients consistently positive about the staff but perception of roles

isn’t clear.

Observations

Leadership 15 step challenge/Executive walk rounds

Data Safety Crosses/run charts

Workforce Development

Handovers/de-escalation ward sessions/least restrictive planning

Prevention tools Sensory/comfort rooms and My Safety Plan

Users/Carers Community meetings and ward mood

Debrief Formal debriefs

Improvements

My Safety Plan

Measures wave 1

Measures wave 2

Measures wave 3

Ward example

• PRN medication and use of

seclusion/transfer to PICU- numbers very

low and stable.

• PRN below 10 per month

• PICU/seclusion below 2 per month on all

wards. Issues with pathway.

• Common theme of concern about under

medicating

Balancing measures

REsTRAIN Project

Weaver Ward, Brooker Centre, Halton

Linda Martin (Ward Manager)

&

Dr Sian Bensa (Clinical Psychologist)

2016

Setting

• Weaver Ward, Halton (Runcorn and

Widnes catchment areas

• Acute Female Inpatient ward

• 14 - 16 beds

• Ward team: 33 nursing staff, 2/3

psychiatry / medical staff, 2 pharmacy

staff, 1 clinical psychologist, 1 activity

worker, 1 Team Secretary

Interventions

Commenced February 2015…

• Safety plans (nursing)

• Least restrictive planning & team formulation (Psychologist, Sian)

• Community Meetings; “You said, We Did” (Activity Worker, Audrey)

• Low Simulation Room (nursing)

• Handover (Deputy Manager, Charlotte)

• Team debriefs (nursing)

• Patient debrief (nursing & Sian)

• Gardening (nursing)

• Principles taken from Self-injurious behaviour e.g. psychology at Wigan (nursing)

Findings: Statistical Process Chart for Violence

Findings: Statistical Process Chart for Restraint

Changes in Violence & Restraints

• Restraint goes down; average was low anyway (2 per month) and not really changed over time.

• Over time where there were high levels of acuity (up to 100 per month) restraint did not rise alongside this; hence, staff response towards challenging behaviours may have changed.

• Staff’s attitude has changed from sense of personal/individual responsibility to team responsibility (i.e. shared anxiety, have a strategy and belief can deal with challenging behaviours better, which has brought the anxiety down).

• Staff not feeling as though they will be criticised and blamed for incidents or way things are managed.

Examples

26 year old lady, diagnosis of PD

Ligaturing x3 plus per day

• Formulation, space to reflect, develop team plan of what could be done differently, let ligature, notice, encourage self-removal of ligature when ready, not over soothing or positive reinforce behaviour, boundaried one to one time at set times continued (as per self-injury ideas).

• Reduced observation levels.

• Rationale and explicit discussion re change in practise / support.

• Safety plan.

• Patient asked to remove ligatures safely on her own.

• Debrief, said she did not realise that staff did not like getting into removing ligatures and restraints.

• Staff wait outside.

• Number of ligatures reduced.

• No restraints / incidents.

• Discharge after 7 days.

Examples59 year old lady, diagnosis of schizoaffective disorder

“Defacto seclusion”

• Staff reluctant to let patient out of low stimulation room, patient shouting, getting distressed, seemingly “paranoid”, threw drinks, threatening to harm staff.

• Staff observe what they see rather than what they are doing, monitoring as opposed to lack of active engagement by staff not helpful.

• Team reflection on how could have been managed differently, let her be distressed in ward, she was not a risk to others or self, shouting.

Challenges for ward

• Staffing issues

• Wider system issues (within and outside trust)

• Bed management (pressure, out of area

placements, number of clients, mix of patients

not considered when admitting)

• Lack of suitable local accommodation for

some to move onto, frustrations in time taking

due to processes

• Medics (psychiatry inconsistencies,

prescribing, reviews, plans)

Wider system issues

• Lack of IT support… white “boards”

• Inputting onto IT system, no feedback re incidents occurring.

• 2 systems for record keeping(e.g. medics write in paper notes, everyone else has to use IT).

• Safety plans are not on IT system.

• Concerns about accountability.

• Bed management & pressures

Wider system issues: what would help?

What would help?

• Centralised case note recording.

• Place to include safety plans on shared IT system.

• Risk aversion, concerns about individuals being blamed.

• Recognition of patient mix by bed management / clinical

risk management by bed management (e.g. clinical staff,

shared acuity support across other acute wards where

necessary).

• Crisis beds in community.

• Options for accommodation in community & support e.g.

LD services, neuro, rehab services, shared homes etc.

• Adequate PICU support.

Psychiatrists

• Turn over of locum consultants and variations in practise.

• Risk averse.

• Not aware of ward practises, e.g. management of self-harm, avoidance of restraining to medicate.

• Not working as part of the MDT or sharing responsibility.

• Unreliable, patients (plus relatives / carers and care coordinators) not seen when expected to be.

• Psychiatric treatment plans not followed through / changed / unclear.

• Not involved in team formulations and debrief.

Psychiatrists: what would help?

What would help?

• Offer team approach to supporting psychiatrist.

• Planned review times so patients and others

know when to attend.

• Invite to formulation meetings.

• Engage in MDT discussions and decision

makings.

• Share sense of responsibility for risk taking.

• Documentation updated promptly (e.g. plans,

S17 signed, med prescribing)

Key learning points

• Culture shift / attitude change in relation to restraints, dealing

with self-injury.

• Shared team responsibility.

• Providing interventions when someone is distressed, rather than

just monitoring.

• Reflecting what a culture shift has meant for patients / more

patient centred approach / compassion / empathy etc.

• Using debriefs with patients, have explicit and open

conversations, and discuss responsibility.

• Providing some space for reflection and developing team and

holistic support plans.

• Reflecting and learning from what helps and what does not.

• More proactive to engage medics.

Key learning points

• Culture shift / attitude change in relation to restraints, dealing

with self-injury.

• Shared team responsibility.

• Providing interventions when someone is distressed, rather

than just monitoring.

• Reflecting what a culture shift has meant for patients / more

patient centred approach / compassion / empathy etc.

• Using debriefs with patients, have explicit and open

conversations, and discuss responsibility.

• Providing some space for reflection and developing team and

holistic support plans.

• Reflecting and learning from what helps and what does not.

• More proactive to engage medics.

• Identified wards (5 per trust)

• Identified champions (4 per ward)

• Training

• Patient survey

• Action learning sessions

• Coaching and site visits as required.

• Supporting PMVA teams in developing corporate

training.

AQuA restraint reduction

programme

• The AQuA restraint reduction programme is available as a

package of support to non members.

• Contact paul.greenwood@srft.nhs.uk for more information

• www.aquanw.nhs.uk

• @paul_AQuA

• Toolkit will be available on above website in October 2016

including;

www.health.org.uk

www.uclan.ac.uk

www.restraintreductionnetwork.org

Support

Thank you