From Policy to practice: Reducing violence in mental health services

1
From Policy to practice Reducing violence in
mental health services

• Gail Miller
• Associate Director
• West London Mental Health Trust

2
Policy Initiatives

• Blofeld Inquiry 2004
• BILD
• RCP National Audit 2005
• NIMHE interim positive practice standards 2004
  (definitive standards 2007)
• NICE Guideline 25 2005
• NHS SMS Directions 2003 / 04
• Promoting Safer and Therapeutic Services
  developed, launched October 2005
• NES
• Welsh Assembly

3
Evidence baseViolence reduction (Colton 2004)

• 1. Leadership
• 2. Orientation and training
• 3. Staffing
• 4. Environmental factors
• 5. Programmatic structure
• 6. Timely and responsive treatment planning
• 7. Processing after the event
• 8. Communication and consumer involvement
• 9. Systems evaluation/quality improvement

4
Legal and ethical issues

• Human Rights Act
• Criminal Law Act
• Health and Safety at Work Act
• Secretary of State Directions
• Health Care Commission Standards
• Organisational responsibility
• Individual responsibility

5
Evidence baseHSE Evaluation of training

• Contextualised in organisational structure
• Theoretical basis
• Legal and ethical framework
• Teaching physical interventions alone not
  effective
• Standards for trainers
• Service specific
• Subject to ongoing evaluation
• HSE Report 440 (2005)

6
WHO, World Report on Violence and Health 2002

• Violence is not inevitable. We can do much to
  address and prevent it.

7
The public health model
Physical interventions, post-incident reviews
debriefs
Reactive responses de-escalation techniques
8
Over-reliance on training in crisis management?

• Nurses are trained to expect violence and how to
  react to it but not how to stop it happening.
  (Nursing and Midwifery Council (NMC) 2004)
• A culture of violence in mental health care in
  the UK (NMC 2004).
• Service users perceptions that restraint of
  service users was the main goal at all times
  (Horton 2001).

9
Consider?

• Is violence a result of service user behaviour or
  service behaviour?

10
How would you rather manage violence?

• Or this?
• Think problemsStop/think...

• With this?
• Think people

Empathy
Listening
Restrain
Prosecute
Understanding
Patience
Compassion
Caring
Seclude
Medicate
Section
Helping
Hearing
Talking
Empowering
Sharing
Inject
Contain
Paterson and Miller 2005
11
What would describe a mental health problem?
STOP/THINK

• Challenge the language

• Change the culture

She went crazy
Frightened
It is just behavioural
Distressed
She is acting up
Agitated
She is a typical P.D.
He is playing up
It is just attention- seeking
Unwell
Angry
He is bad not mad
Upset
He kicked off
Paterson and Miller 2005
12
Promoting Safer and Therapeutic Services Non
physical intervention training

• Speciality specific
• Policy context
• Theories of violence
• Individualised care
• Recognition
• Prevention
• De-escalation
• Restraint-related risks
• Attitudes
• Communication
• Support

13
Next steps?

• Refocus on values
• Quality assurance structures
• Mandatory managers briefings
• Organisational assessments
• Shared responsibility
• Continuous evaluation

14
Educational / Developmental
Defined access routes
Professional Development plans
Professional
Legal and ethical framework
Relevant Values based
Evidence based
Role specific

Professional self respect
Caring
Service user inclusion
Empathy

• Solution
• focused
• Ownership
• Problem
• solving

Defined roles and responsibilities
Formal and informal education Continuous learnin
g Shared knowledge

• All care
• Needs
• Physical
• Psychological
• Environmental
• Cultural

Values
Recovery focus

• MDT
• Working
• Partnerships

Robust Record keeping
Transfer of skills to practice

• Respect
• Colleagues
• Service users
• Others

• Therapeutic safety
• Relational
• security

• Engagement
• Compassion
• Understanding
• Non judgemental

Structured supervision
Regular, rigorous evaluation
Post training supervision
Professional Self regulation
Evidence of application in practice
Disseminating knowledge and skills to others
Miller 2007
15
Desired outcomes?
Organisation
Individual
Team
16
Positive outcomes?

• National Audit of Violence (2007)
• 2003 -2003 audit action plans related to
  management
• 2007 action plans related to prevention
• Training contextualised to service real
  incidents discussed
• Improved therapeutic involvement
• Use of advance directives
• Restraint is a last resort
• Good result?

17
A vicious circle?
Violence
Staff frustrations
Conflict
Coercive practice
18
Change management

• Challenges
• Limited authority the need to influence others
• Relationship with service users and staff
• Massive task that needed to be tackled
  systematically
• Culture change requires time

• Drivers
• Desire to improve the safety of service users and
  staff
• Absolute belief that change can happen
• Keeping knowledge up to date
• Determination
• Support from others who share the vision!!

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Key messages?

• Physical intervention is not enough
• Zero tolerance does not address the problem
• Collaboration to achieve culture change is
  essential
• Who needs training, what skills are required and
  are we delivering?
• Is change happening? If not.WHY?

20
Outcomes

• The future belongs to those who believe in the
  beauty of their dreams
• Eleanor Roosevelt

21
Thank you

• Gail Miller
• Associate Director
• West London Mental Health Trust
• Gail.Miller_at_wlmht.nhs.uk