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A mental health unit dramatically reduced violence and increased staff satisfaction by developing the quality improvement capability of their staff and engaging their service users.
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Rethinking Expectations: Reducing Violence in Mental Health Using QI

By Andy Cruickshank | Friday, August 12, 2016
Reducing Violence in Mental Health Using QI

If you had to guess where you’d find one of the highest staff satisfaction rates in England’s National Health Service (NHS), what would you say? A maternity ward? Maybe some kind of pediatric setting?

You probably wouldn’t think of a mental health unit in London that treats very acutely mentally unwell adults, would you?

A few years ago, I wouldn’t have either. But the organization I work for — the East London NHS Foundation Trust (ELFT) — has undertaken a harm reduction effort involving both staff and service users. Our aim is to provide the highest quality mental health and community care in England by 2020.

Since the start of our quality improvement efforts in 2014, ELFT has seen significant changes. Dramatic reductions in violence, staff sick days, and staff absences due to injury have helped transform our organization. By rethinking some of our expectations, we’re using the science of improvement to make inpatient mental health settings better places for both service users and staff.

Expectations about Violence

Anyone who works with people with serious mental health issues knows there is potential for violence to occur. We commit to this work despite this possibility. Consequently, most of us never imagine we can learn ways to dramatically reduce it.

ELFT began to look more closely at the impact of violence — on service users and staff — within our inpatient services. Not surprisingly, experiencing violence negatively affected how staff felt about coming to work and their level of work engagement. We also started to ask questions about all of our service users — not just the people who become violent, but also those who witness violence. How does violence influence their treatment? How does it change their pathway through our services?

Beginning these conversations with ELFT staff was a revelation for all of us. Violence was something we’d come to expect as part of the work. Staff hadn’t before had the opportunity to think through and openly talk about these issues.

With IHI's support, ELFT has trained hundreds of staff in quality improvement methodology. Using what we were learning about the science of improvement, we started very small, on one ward, and found our way forward with some improvement ideas that gradually evolved into a bundle of changes to test.

Walking in a Patient’s Shoes

Violence is a very complex social problem, and our hospital system is dealing with people who are very acutely mentally unwell when they come in. We decided the changes shouldn’t focus at the individual patient level. We had to look at how our teams functioned.

In our attempt to learn from safe practices used in hospital settings, I tried to find the equivalent of a “surgical safety checklist” for violence. We came across the idea of safety huddles, and wondered how we might tailor them to help ELFT staff anticipate and address agitation and aggression. We also started using a relatively simple observational scale developed in Norway called the Brøset Violence Checklist to predict possible violence.

Effective safety huddles require that you try to walk in a patient’s shoes as you try to anticipate their needs. This changed our goals and the language we used. ELFT staff began focusing more on problem-solving, identifying service users’ strengths, and attending to the issues and challenges they face as people. The huddles compelled us to consider what we might do to help a service user feel calmer and more in control of their emotions and actions. Once we understood the safety huddle’s potential, they became really important to and for the staff.

ELFT teams try to hold safety huddles three times a day, with all staff present on the ward invited to participate, including domestic staff and visiting clinicians. Those present talk about the people they’re concerned about, and make plans to change interventions around their care. Huddles have changed traditional hierarchies within ELFT because the most junior staff often provide the most relevant information about the service users. 

Going through this process and learning to use these skills, techniques, and interventions helped assure staff that they had a voice. They could say when they were worried and be much more proactive. They didn’t have to wait for violence to happen. 

It’s been great to see the range of strategies that ELFT staff now employ to prevent violence, instead of assuming prescribing medicine or implementing restriction are the only answers. We talk about what service users like, what matters to them, and how we can engage them in conversation. We also ask how we might distract them if they’re having unpleasant symptoms.

As ELFT staff became more skilled at identifying, responding to, and predicting issues, we turned our attention to engaging with service users by starting safety discussions with them in our community meetings. During these meetings, everyone on the ward, staff and service users, comes together and reviews a safety cross used commonly in other industries to note how many days it’s been since the last incident.

We talk through the reasons why the last incident might have occurred. We ask those who witnessed the incident to describe how they felt. Increasing prediction and responsiveness, community engagement, and openly talking about violence as an issue within the community has had a much more profound effect than we’d imagined.

Before and After

When you’re in the midst of making big changes, sometimes you don’t see the improvement. Some ELFT service users with longer-term conditions pointed out to staff the drastic changes they experienced. Since they typically come in and out of hospital over the course of many years, they had some of the most important insights pre- and post-QI.

Their comments took us by surprise. “What have you done?” “How did this happen?” “This is great!” Some service users confided that the wards used to feel like a war zone to them. Some said it now felt tranquil. This may sound utopic, but what they describe is a sense of calm. They talk about how staff were always dashing about, looking very busy and officious. Now, with the improvements implemented, users observe more relaxed behavior and easier communication with staff. I knew if they could see and feel the changes, our improvements were really taking hold.

One of the most powerful revelations for me came from service user comments during our community meetings, describing how they felt during violence they witnessed toward staff. “I was scared for you.” “I was worried when that patient threatened you.” “I thought you might get hurt.”

The realization that care goes both ways shouldn’t have been surprising, but I must admit it was. The staff hadn’t realized how closely service users observed their behavior, but — more profoundly — they didn’t know how much the service users care about them. Talking openly during our community meetings gave people a way to connect in a genuine and immediate way. It changed the dynamic from “You’re a nurse and I’m a patient” to “I’m a person and you’re a person, and wasn’t that thing we both went through horrible?” It made us realize that violence is something that touches us all as members of the same community.

I don’t want to paint too rosy a picture. It can be deeply uncomfortable to openly address violence, particularly when you’re working with people who’ve had some horrendous experiences in their life. Their hostility, defensiveness, and unwillingness to open up or engage with people is often understandable. Having conversations about these issues takes skill, but so many of us — service users and staff — have been experiencing the difference it makes, and it helps us engage with these efforts in a wholehearted way.

Caring Defines Us

One of the intensive care unit nurses helped me understand how much things have changed. His unit works with some of the most unwell and disturbed individuals in our system, so it was a real challenge to tackle violence in this area, but their work is starting to make a difference.

He told me how he used to come to work and say, “No!” all day. Every day, he had to restrain or medicate people. His days used to be full of tears and shouting.

Not all of that has gone, obviously, but now he can talk with and get to know patients. “I’ve got time to care for people in different ways,” he explained. “The other stuff doesn’t define me as a mental health professional. Caring is what defines me.”

Andrew Cruickshank is Associate Clinical Director and Head of Nursing for Quality Improvement at East London NHS Foundation Trust (ELFT). ELFT will share their improvement story at session D15: Quality Improvement as the Route to Enhancing Joy in Work and other learning opportunities at the IHI's annual National Forum on Quality Improvement in Health Care.

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