DESIGN IN MENTAL HEALTH CONFERENCE 2019
national drive towards an overall reduction in the use of physical interventions in mental healthcare. We felt we weren’t simply going it alone. Driven by some well- publicised scandals over abuse of patients, and its issuing in 2014 of the guidance, Positive and safe: reducing the need for restrictive interventions, the Department of Health was going to be firmly driving this change.”
Explicit organisational commitment
Key to a ‘re-design’ in this area, the Mersey Care speaker said, was ‘an explicit organisational commitment’. He elaborated: “We had people at senior level, right up to the chief executive, saying: ‘This is an organisational priority for us. We cannot continue with these high levels of interventions’. For me – as a passionate advocate of reducing physical interventions – I cannot over-stress the importance, in any such programme, of getting somebody at the top, who is really supportive, on board.”
Dave Riley went on to explain that Mersey Care now has around 60 inpatient mental health and learning disability units; thus it was ‘not possible to change the world overnight’. He said: “So, what we did in terms of change was to identify particular people – such as ward managers – who we knew had a passion about these issues, and who we knew felt we could do things differently.” His team worked with four of these individuals ‘to start making significant changes on the ward’. “The key to moving things forward is to demonstrate some local success,” the speaker explained, “but the problem we had in 2013 was that many of the staff thought the concept of reductions in physical interventions was from the US, and that they could not realistically apply here, since the NHS was ‘different’.” The team had to counter this, he explained, by providing some good examples of local good practice using some ‘highly committed’ ward managers and clinical teams.
Multiple pressures on clinical teams One of the initiative’s key challenges was how to put the team’s commitment on reducing levels of restraint and intervention at the top of the agenda of clinical teams facing a lot of their own pressures. He said: “What we found was that if you simply tell people they have to change their existing practices, they are reluctant. They might superficially ‘buy in’, but will find it hard to change at a practical level. Instead it’s vital to make an emotional connection with people.” The Perfect Care team thus had to create an environment where the Trust’s clinical teams felt they needed to make the changes ‘at a personal level’.
Dave Riley said: “The key is co- production – working alongside people with lived experience who have used inpatient areas, and have experienced
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restrictive interventions and practices, and giving them the chance to tell their story.” One of the elements the team had managed to move forward particularly had been integrating such messages into training packages, and into wider engagement with staff. This entailed suggesting that personnel training nursing and other clinical staff used ‘some real-life’ service-user stories about the traumatic impact that physical restraint had had on them, and how – in many cases – this experience had reignited in their minds serious occurrences of childhood abuse. “These are difficult messages for some staff to hear,” Dave Riley acknowledged, “but we had to win around people’s hearts to the process’s importance. The result was that staff then came to the team saying that, rather than simply feeling pressured to ‘do things differently’, they actually wanted to do so.”
‘Brave stories’ told
He added: “The brave stories of service- users – and the fact that it took nerve for people to stand up and explain how they had felt when staff had, for example, held onto them physically – had a real impact. We now have a core of service-users who do this regularly.”
One of those who had used Mersey Carer services and made their stories an integral part of training, Jeanette Murray, reflected on the importance of setting out the difficulties of an inpatient admission, saying: “A more caring approach is important to me because we are all human and have feelings. Being in a hospital at a time of crisis is bad enough as it is. At those times it is the little things in life – those small acts of kindness – that make the biggest difference.” Another key ‘Expert by Experience’, Wayne Ennis, added: “Textbooks are okay, but you can’t beat the real impact of real experiences, shared with an audience face to face. This sort of approach really develops the idea of delivering care with, rather than to, people.”
One of the team’s other key interventions had been to look at restrictive practices ‘as a whole’. Dave Riley elaborated: “For example, we now work constantly with ward managers to make sure they have a ‘Reduced restrictive practice action plan’ – which needs to be constantly updated to ensure that rules
Promoting stimulating, relevant activity to reduce frustration.
and regulations on a typical inpatient ward aren’t driving the ward’s users to frustration.”
Couched in the language of safety While ‘historically’, the idea of restrictions and rules had been couched in ‘the language of safety’ – for instance that rules on particular doors being locked were essential from a safety standpoint – the speaker said his team, and indeed others in mental healthcare circles, had been arguing over the past 5-6 years that many such ‘rules and regulations’ were actually in place due to ‘long-term rituals enshrined in care settings for many years’. Dave Riley said: “It’s been challenging, in some cases, just to get our staff to move away from these traditions, particularly if they have provided services for decades.” The team was thus now constantly encouraging staff to ‘free up service-users from unnecessary rules’, which the speaker said could cause ‘incredible levels of frustration’, lead to conflict, and, ultimately, result in instances of restraint and seclusion.
In the Perfect Care team’s ‘re-design’ of ‘the culture of care’ for Mersey Care’s inpatients, Dave Riley explained that data had been ‘incredibly important’. He elaborated: “We can now provide weekly reports to our inpatient units, that outline the number of restrictive interventions on a particular ward.” This data was, ‘very importantly’, the speaker stressed, not being used as a tool to ‘criticise’ wards that had had challenging periods. He explained: “We cannot become the enemy of clinical teams and force change down their throats. What we are striving to get across is that for environments with particular challenges, and service-users with levels of distress requiring restrictive interventions, we have a clinical support mechanism in place, in our centre for Perfect Care, to go into those environments and help people. Areas with high levels of intervention for short periods are not in any way deemed to have ‘failed’. That is the wrong type of message, and simply creates a sense of despondency and failure, and the risk of re-introducing the cynicism present in the past.”
Improved de-escalation training has been a key feature of Mersey Care’s recent work.
Celebrating achievement Those areas ‘doing well’, conversely needed a different approach. Although historically, such teams had tended to be ‘somewhat ignored’, Dave Riley said
OCTOBER 2019 | THE NETWORK
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