PROMISE: PROactive Management of Inpatient Services and ... · In April 2014, the Department of...
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PROMISE: PROactive Management of PROMISE: PROactive Management of PROMISE: PROactive Management of PROMISE: PROactive Management of Inpatient Services and Environments Inpatient Services and Environments Inpatient Services and Environments Inpatient Services and Environments Sarah Rae, Judy Dean, Haseena Hussain, Sarah Russell, Terry Hill, Iliana Rokkou, Tom Spencer, Ceri Wilson, Lorna Rouse and Manaan Kar Ray The PROMISE study has been funded and supported by the National Institute of Health Research’s (NIHR) Collaboration and Leadership in Health and Research Care East of England (CLAHRC EOE) Programme. The NIHR Research Design Service East of England has also supported the study. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. SO FAR WE’VE TALKED TO STAFF….. Who our PROMISE team spoke to: Dr Manaan Kar Ray and Sarah Rae presented at the CPFT Acute Quarterly Governance meeting (February 2014) to raise awareness of the PROMISE activities and project. Feedback from the interactive session with staff: This provided an experien- tial steer to the project and areas for further exploration including: • Do staff feel differently if the person lacks capacity re. incidents of violence and aggression? • The impact on therapeutic relationship between staff/service user • What makes it difficult for staff to operate compassionately when constantly reacting to circumstances, such as shortage of staff or culture on the ward? • If restraint is used less frequently do seclusion and other forms of coercion increase? WHAT’S HAPPENING IN THE UK? The Mind report (June 2013) found huge variation in the use of restraint in inpatient services across England. In a single year, one Trust reported 38 incidents compared to over 3000 by another which could be due to either variations in reporting or practice. They raised concerns about the fact that there were almost 1000 incidents of physical injury following restraints, and called for an immediate end to the use of face-down, (or ’prone’) restraint due to it being dangerous and life-threatening. In March 2014, Professor Len Bowers, Professor of Psychiatric Nursing, Kings College London (during his ‘Reducing Containment’ presentation), highlighted that despite very rare use of mechanical restraint, lower seclusion rates than other many other countries and being seen externally as leaders in containment reduction, there is still evidence of a creeping increase in coercive practices such as locking, community treatment orders, detentions, expansion of Medium Secure Units (MSUs) and opening of seclusion rooms. In April 2014, the Department of Health (DoH) published the guidance document ‘Positive and Proactive Care: reducing the need for restrictive interventions’. It states that all services potentially using such interventions must have restrictive-intervention reduction programmes to ensure that alternatives that are less detrimental and work to reduce the incidence of violence and aggression are used. Here are 4 examples of reduction strategies being employed in UK Services: • Six Core Strategies to Prevent Conflict and Violence: Reducing the Use of Seclusion and Restraint – National Technical Assistance Center of the National Association of State Mental Health Program Directors (NASMHPD) • ‘No Force First’ - Recovery Innovations, Inc. , 2006. • Positive Behaviour Support – established as the preferred approach when working with people with learning disabilities who exhibit behaviours described as challenging - British Institute of Learning Disabilities (BILD). • Safewards: a new model of conflict and containment on psychiatric wards - Bowers, L., 2014, Journal of Psychiatric and Mental Health Nursing, 21: 499–508 WHY PROMISE? Managing violence and aggression is a challenge for mental health services with the loss of beds and the increased acuity of patients on acute wards. There is also a fundamental contradiction at the heart of mental health, between care and control. The use of containment and restraint is viewed as a practice incompatible with the vision of recovery and implies treatment failure for the following reasons: ⇒ Risk of psychological harm ⇒ Risk of physical harm ⇒ Creates a ‘them and us’ culture ⇒ Patients describe it as humiliating and inhumane ⇒ At odds with core nursing values ⇒ Breakdown of therapeutic relationship As supporters of the Recovery philosophy we feel that there is no place for force in a person’s recovery journey. Proactive care initiatives are taking place throughout Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) and these practices inform the PROMISE project. CPFT’S PROACTIVE CARE INITIATIVES: A THREE PRONGED APPROACH Collaboration for Leadership in Applied Health Research & Care East of England SATISFIED STAFF CPFT are working to increase staff engagement and striving to change their perceptions of staff - to see them as an asset (and not an ex- pense). The Trust strongly value their staff and are committed to developing their skills, (through away days, and external and internal training) to facilitate the realisation of their full potential. Slide is from Dr Manaan Karay’s ‘Project STAFF presentation’ April 2014, CPFT HEALING ENVIRONMENTS On the Mulberry 2 Ward at Fulbourn Hospital, proactive changes include: • decorated and rearranged communal areas • making the ward feel more homely and less clinical • providing: tranquil spaces, sensory garden and chill room Pictures of CPFT ward initiatives, 2014 PERSON-CENTRED PATHWAYS Actions taken to break down barriers and reduce the ‘them and us’ culture include: • Introduced a ‘know me’ board in place of the photo ‘mugshots’ • Joined their patients for meals • Encouraged staff to be out on the ward and not in the office • Introduced a new group programme led by the patients • Carry out a ‘No audit’ reflective practice on refusal responses • Protected time Pictures of CPFT ward initiatives, 2014 NEXT STEPS NEXT STEPS NEXT STEPS NEXT STEPS ⇒ Conduct a retrospective qualitative study of service user and nursing staff perspectives involved in the actual restraint. Using a collaborative methodology we aim to explore: • Service users’ and nurses’ perspectives of the latest seclusion restraint experience ● The impact on service users relationship with immediate caregivers and wider services • Suggestions on how to reduce the use of restraint and improve practices of seclusion/restraint ● Impact of restraint on service users and caregivers • Perspectives on what could have been done differently ⇒ Co-produce and Co-deliver a training package with service users that is based on CPFT’s proactive initiatives, to ensure positive changes are implemented throughout the Trust. ⇒ Applying for funding for continued research to evaluate the impact of the practice changes have made (e.g. from NIHR Research for Patient Benefit programme) WHAT WE WANT PROMISE TO ACHIEVE WHAT WE WANT PROMISE TO ACHIEVE WHAT WE WANT PROMISE TO ACHIEVE WHAT WE WANT PROMISE TO ACHIEVE Aim: To co-produce an evidence based, pragmatic, replicable, proactive care toolkit that eliminates reliance on force in mental health services. Objectives: • Explore the fundamental contradiction at the heart of mental health services between care and control using both quantitative and qualitative methodology. • Engage staff and patients in coproducing and collating initiatives into a toolkit of proactive care. • Enable and encourage frontline bottom up proactive care initiatives and to chart the journey so that it can be further developed. • Evaluate the effectiveness of the toolkit in reducing the use of force in mental health services. …….AND LOOKED AT INCIDENT DATA AND PATIENT RECORDS What data we collected: Data from 67 CPFT incident forms and patient records, in January 2014. The sample of forms was taken from 20 wards, 1 prison, and 1 community service in the Trust. What we assessed: Incidences of rapid tranquillisation, safe holding and use of restraint over a 3 month period Initial findings: So far, we’ve found that some patients are repeatedly restrained (see pie chart) So, we’ve starting exploring: Factors correlating with use of restraint which included: • Care factors (collaborative care plan in place,1 to 1nursing time, medical review, length of stay, use of conflict resolution) • Staff Factors (staffing levels, unfilled shifts, bank staff) • Patient factors (demographics, diagnostic group, MH status) • Environmental Factors (care setting, activities, no of patients on observations, bed occupancy) Pie chart is from Dr Haseena Hussain’s presentation ‘Preliminary Data in Physical Intervention’, Jan 2014, CPFT Example of % repeated restraint use from a CPFT ward patient 1 80% patient 2 12% patient 3 3% • Staff from CPFT, including managers and clinicians from the wards and people in the Learning and Development team, attended a ‘No Force First’ conference in May 2014, organised by Mersey Care NHS Trust. • Enthused by the conference, the staff have made small but significant changes to practice by modifying the environment and adopting a more person-centred approach to care. http://www.thinkpromise.com/
Transcript of PROMISE: PROactive Management of Inpatient Services and ... · In April 2014, the Department of...
PROMISE: PROactive Management of PROMISE: PROactive Management of PROMISE: PROactive Management of PROMISE: PROactive Management of
Inpatient Services and EnvironmentsInpatient Services and EnvironmentsInpatient Services and EnvironmentsInpatient Services and Environments Sarah Rae, Judy Dean, Haseena Hussain, Sarah Russell, Terry Hill, Iliana Rokkou, Tom Spencer, Ceri Wilson, Lorna Rouse and Manaan Kar Ray
The PROMISE study has been funded and supported by the National Institute of Health Research’s (NIHR) Collaboration and Lead ership in Health and Research Care East of England (CLAHRC EOE) Programme. The NIHR Research Design Service East of England has also supported the stud y. The views expressed are those of the author(s) and not necessarily those of the N HS, the NIHR or the Department of Health.
SO FAR WE’VE TALKED TO STAFF…..
Who our PROMISE team spoke to : Dr Manaan Kar Ray and Sarah Rae presented at the CPFT Acute Quarterly Governance meeting (February 2014) to raise awareness of the PROMISE activities and project. Feedback from the interactive session with staff: This provided an experien-tial steer to the project and areas for further exploration including:
• Do staff feel differently if the person lacks capacity re. incidents of violence and aggression?
• The impact on therapeutic relationship between staff/service user
• What makes it difficult for staff to operate compassionately when constantly reacting to circumstances, such as shortage of staff or culture on the ward?
• If restraint is used less frequently do seclusion and other forms of coercion increase?
WHAT’S HAPPENING IN THE UK?
The Mind report (June 2013) found huge variation in the use of restraint in inpatient services across England. In a single year, one Trust reported 38 incidents compared to over 3000 by another which could be due to either variations in reporting or practice. They raised concerns about the fact that there were almost 1000 incidents of physical injury following restraints, and called for an immediate end to the use of face-down, (or ’prone’) restraint due to it being dangerous and life-threatening. In March 2014, Professor Len Bowers, Professor of Psychiatric Nursing, Kings College London (during his ‘Reducing Containment’ presentation), highlighted that despite very rare use of mechanical restraint, lower seclusion rates than other many other countries and being seen externally as leaders in containment reduction, there is still evidence of a creeping increase in coercive practices such as locking, community treatment orders, detentions, expansion of Medium Secure Units (MSUs) and opening of seclusion rooms. In April 2014, the Department of Health (DoH) published the guidance document ‘Positive and Proactive Care: reducing the need for restrictive interventions’. It states that all services potentially using such interventions must have restrictive-intervention reduction progra mmes to ensure that alternatives that are less detrimental and work to reduce the incidence of violence and aggression are used.
Here are 4 examples of reduction strategies being employed in UK Services:
• Six Core Strategies to Prevent Conflict and Violence: Reducing the Use of Seclusion and Restraint – National Technical Assistance Center of the National Association of State Mental Health Program Directors (NASMHPD)
• ‘No Force First’ - Recovery Innovations, Inc. , 2006.
• Positive Behaviour Support – established as the preferred approach when working with people with learning disabilities who exhibit behaviours described as challenging - British Institute of Learning Disabilities (BILD).
• Safewards: a new model of conflict and containment on psychiatric wards - Bowers, L., 2014, Journal of Psychiatric and Mental Health Nursing, 21: 499–508
WHY PROMISE?
Managing violence and aggression is a challenge for mental health services with the loss of beds and the increased acuity of patients on acute wards. There is also a fundamental contradiction at the heart of mental health, between care and control. The use of containment and restraint is viewed as a practice incompatible with the vision of recovery and implies treatment failure for the following reasons:
⇒ Risk of psychological harm
⇒ Risk of physical harm
⇒ Creates a ‘them and us’ culture
⇒ Patients describe it as humiliating and inhumane
⇒ At odds with core nursing values
⇒ Breakdown of therapeutic relationship
As supporters of the Recovery philosophy we feel that there is no place for force in a person’s recovery journey.
Proactive care initiatives are taking place throughout Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) and these practices inform the PROMISE project.
CPFT’S PROACTIVE CARE INITIATIVES: A THREE PRONGED APPROACH
Collaboration for Leadership in Applied Health Rese arch & Care East of England
SATISFIED STAFF
CPFT are working to increase staff engagement and striving to change their perceptions of staff - to see them as an asset (and not an ex-pense). The Trust strongly value their staff and are committed to developing their skills, (through away days, and external and internal training) to facilitate the realisation of their full potential.
Slide is from Dr Manaan Karay’s ‘Project STAFF presentation’ April 2014, CPFT
HEALING ENVIRONMENTS
On the Mulberry 2 Ward at Fulbourn Hospital, proactive changes include:
• decorated and rearranged communal areas
• making the ward feel more homely and less clinical
• providing: tranquil spaces, sensory garden and chill room
Pictures of CPFT ward initiatives, 2014
PERSON-CENTRED PATHWAYS Actions taken to break down barriers and reduce the ‘them and us’ culture include:
• Introduced a ‘know me’ board in place of the photo ‘mugshots’
• Joined their patients for meals
• Encouraged staff to be out on the ward and not in the office
• Introduced a new group programme led by the patients
• Carry out a ‘No audit’ reflective practice on refusal responses
• Protected time
Pictures of CPFT ward initiatives, 2014
NEXT STEPSNEXT STEPSNEXT STEPSNEXT STEPS
⇒ Conduct a retrospective qualitative study of service user and nursing staff perspectives involved in the actual restraint. Using a collaborative methodology we aim to explore:
• Service users’ and nurses’ perspectives of the latest seclusion restraint experience ● The impact on service users relationship with immediate caregivers and wider services
• Suggestions on how to reduce the use of restraint and improve practices of seclusion/restraint ● Impact of restraint on service users and caregivers
• Perspectives on what could have been done differently
⇒ Co-produce and Co-deliver a training package with service users that is based on CPFT’s proactive initiatives, to ensure positive changes are implemented throughout the Trust.
⇒ Applying for funding for continued research to evaluate the impact of the practice changes have made (e.g. from NIHR Research for Patient Benefit programme)
WHAT WE WANT PROMISE TO ACHIEVEWHAT WE WANT PROMISE TO ACHIEVEWHAT WE WANT PROMISE TO ACHIEVEWHAT WE WANT PROMISE TO ACHIEVE Aim: To co-produce an evidence based, pragmatic, replicable, proactive care toolkit that eliminates reliance on force in mental health services. Objectives:
• Explore the fundamental contradiction at the heart of mental health services between care and control using both quantitative and qualitative methodology.
• Engage staff and patients in coproducing and collating initiatives into a toolkit of proactive care.
• Enable and encourage frontline bottom up proactive care initiatives and to chart the journey so that it can be further developed.
• Evaluate the effectiveness of the toolkit in reducing the use of force in mental health services.
…….AND LOOKED AT INCIDENT DATA AND PATIENT RECORDS
What data we collected: Data from 67 CPFT incident forms and patient records, in January 2014. The sample of forms was taken from 20 wards, 1 prison, and 1 community service in the Trust. What we assessed: Incidences of rapid tranquillisation, safe holding and use of restraint over a 3 month period Initial findings: So far, we’ve found that some patients are repeatedly restrained (see pie chart) So, we’ve starting exploring: Factors correlating with use of restraint which included:
• Care factors (collaborative care plan in place,1 to 1nursing time, medical review, length of stay, use of conflict resolution)
• Staff Factors (staffing levels, unfilled shifts, bank staff)
• Patient factors (demographics, diagnostic group, MH status)
• Environmental Factors (care setting, activities, no of patients on observations, bed occupancy)
Pie chart is from Dr Haseena Hussain’s presentation ‘Preliminary Data in Physical Intervention’, Jan 2014, CPFT
Example of % repeated restraint use from a CPFT ward
patient 1 80%
patient 2 12%
patient 3 3%
• Staff from CPFT, including managers and clinicians from the wards and people in the Learning and Development team, attended a ‘No Force First’ conference in May 2014, organised by Mersey Care NHS Trust.
• Enthused by the conference, the staff have made small but significant changes to practice by modifying the environment and adopting a more person-centred approach to care.
http://www.thinkpromise.com/
