'No Force First' is Mersey Care NHS Foundation Trust’s restrictive intervention reduction programme that seeks to transform the experience of people who use our mental health and learning disability inpatient services. In response to national care scandals and progressive national guidance we have an audacious goal to completely move away from the historical use of physical restraint as a means of supporting people who become distressed. We feel that our main achievement is changing the culture of care within our services and transforming the care narrative from 'containment' to 'recovery'.
What We Did
‘No Force First’ is Mersey Care NHS Foundation Trust’s restrictive intervention reduction programme that seeks to transform the experience of people who use our mental health and learning disability inpatient services. In response to national care scandals and progressive national guidance we have an audacious goal to completely move away from the historical use of physical restraint as a means of supporting people who become distressed. We feel that our main achievement is changing the culture of care within our services and transforming the care narrative from ‘containment’ to ‘recovery’.
We believe that our deliberately audacious goal of eliminating the use of restrictive interventions from our services is a testament to our ambition in this area and the ability of our staff to innovate. For generations it has been assumed that conflict in mental and learning disability healthcare environments is inevitable and can only be addressed with restrictive interventions, such as physical restraint, to ensure safety. We feel that we are on a journey of discovery with the people who use our services to transform the culture of care by appealing to the very best instincts of our staff teams. We understand completely that staff hate having to use restrictive interventions and much prefer to take a compassionate and tolerant approach to support vulnerable people at times of distress. We consider that the underpinning, recovery focused principles which underpin No Force First have freed staff up to try new approaches to improving the in-patient experience and reduce conflict as a result. When challenging behaviour occurs now, which of course it still does, staff know they will be supported and celebrated for taking approaches that are less restrictive. We are proud that our determination to move forward in this area has been acknowledged at a national level by both the Care Quality Commission and the Department of Health as leaders in this area, as mental health and learning disability services have moved to respond to national concerns about the overuse and abuse of restrictive interventions in our services.
Our utilisation and analysis of incident data which is fed back weekly keeps our teams constantly engaged in the process and increases motivation to progress. Culture change is incredibly challenging but we feel strongly that we are well on the way to establishing a culture of continuous improvement in this area and a critical sense that there is a new way forward. We have connected with front line staff at an emotional level through telling stories from ‘survivors’ about the traumatisation that physical intervention can cause for people through our engagement sessions for all staff.
We utilise quality improvement methodology in the shape of Plan, Do, Study, Act cycles (simple, measurable changes to ward practices, service and activities) to reduce conflict through collaboration between ward teams and the people they serve. This mechanism of testing out new ideas over short periods of time creates a more dynamic approach to change that is replacing traditional long term studies that tended to delay innovation and implementation. A great example of this was one of our wards that worked on a new model for more positive, recovery focused nursing handovers and rapidly implemented training in this area, with associated positive results which led to other teams adopting the approach. We have produced a comprehensive No Force First Guide to support wards embarking on the change process through implementing Plan, Do, Study, Act cycles on the ward to support an improved inpatient experience and measuring the impact of these changes on levels of challenging behaviour. While the ward teams, and the people who use services, are encouraged to develop the cycles that address their own needs, the guide showcases particular Plan, Do, Study, Act cycles that have been particularly effective for our teams. Our collaboration with the Advancing Quality Alliance (AQuA), a body to improve the quality of care in the NHS in North West England, was essential in supporting the creation of the No Force First process and members of our team hold their Advanced Improvement Practitioner qualification. The ward teams are also supported by Aston Team coaching to enable them to develop and deliver team objectives in relation to reducing restrictive practice.
The customer focused message of No Force First and the crucial role of people who use services in its delivery has helped the trust develop a national reputation for innovation, exemplified by our success in winning the award for culture change at the Health Service Journal Patient Safety Awards in 2015 and our position as finalists in the Mental Health category at the 2017 Health Service Journal Patient Safety Awards. One of our ‘Experts by Experience’, Iris Benson MBE, is one of the Health Service Journals Fifty Patient Leaders.
We have seen many incredible stories of transformational innovation. A prime example of this is when staff on one of our wards, motivated, inspired and concerned, by an account of restrictive practices from a person who had used the services and the negative impact on her, embarked on a process of working collaboratively with the people using this service to develop standards for a ‘Perfect’ In-patient experience. These consumer driven standards, and the willingness of the team to embrace new ways of working to meet these standards, were celebrated at the most senior levels of the organisation, including by trust board members. Stories like this illustrate a ‘success based’, positive approach to change, where it grows organically from the best instincts of staff, rather than change being grudgingly adopted (or even resisted) through top-down directives. We strongly believe that the key to transformation is co-producing initiatives with the people we serve to unleash the potential for collaboration and change within our teams. We are so proud of what our wards have achieved!
We do not believe that any area of care, or any person, irrespective of their level of distress or their history of challenging behaviour, should be left behind as we move forward. The HOPE(S) model of care successfully adapts the principles of No Force First within our High Secure Services at Ashworth Hospital. People using our services, who have historically been deemed so difficult to support that they have been nursed in long term segregation, are now seeing their lives transformed by an approach that, while recognising the need for safety for all, encourages de-stigmatisation, positive risk taking and the need to develop a culture of compassion in the most challenging of circumstances. Ward staff are supported by specialist practitioners, who help them through the often understandable psychological barriers to moving away from restrictive solutions, as well as role modelling the person-centred approaches required as people integrate successfully back into the ward community – sometimes after years of hugely traumatic isolation. The success of the HOPE(S) approach is critical in emphasising to our workforce that there is no person that cannot be supported by these compassionate principles and that recovery is wholly attainable when we are aware of our own cultures and the bias and stigma that may exist around mental health issues and challenging behaviour. The critical message of reduced levels of segregation and reduced levels of harm that HOPE(S) has delivered is that this approach really can succeed anywhere. Once again, the journey of transformation of our High Secure ward teams in order to adopt these innovative approaches and restore hope where it didn’t seem to exist, is a source of huge credit to them and a source of huge pride to Mersey Care.
We have strong links with ImROC – Implementing Recovery Through Organisational Change. This is a body that was originally established by the Department of Health to champion its ‘Supporting Recovery Initiative’. This has enabled us to establish the principles of recovery within the organisation and it’s values and it gave our ward managers a critical grounding in the compassionate principles that would underpin their participation in the No Force First process.
We are prominent members of the national body, The Restraint Reduction Network. Which aims to bring together like minded organisations and commit them to delivering approaches to reduce coercive interventions across care services. We have presented at their national conference on a number of occasions and one of our experts by experience is a part of the Steering Group that establishes policy and approach.
We recognised right from the outset that co-production of both strategy and process would be critical to developing a ‘No Force First’ culture. Truly authentic co- production occurs when the people who provide and use services work together in a relationship of equals, with no half measures. We trust in each other’s knowledge and skills, bring them together, and use and harness both, to deliver compassionate, person centred outcomes. All of the interventions and strategies developed through No Force First are co-produced. Experts by Experience are accorded an equal role and status within the process and this is reflected in job title and banding of the Expert by Experience who has a lead role in No Force First.
Harnessing the lived experience of what it feels like to be physically restrained and working together to find innovative and creative solutions has enabled a wider range of people to engage in the programme and support the changes required as a result. The range and breadth of co-production and how it drives ‘No Force First’ implementation is outlined below:
• Our initial ward engagement sessions are fully co-produced and developed by our staff and the people that use services. They set out, in quite stark terms, the negative impact of restraint on people with mental health and learning disability challenges as a means of developing an emotional engagement with the need for change, and inspiring innovation to improve our services.
• We have co-produced a Guide to Reduce Restrictive Practices, which is being embedded on all in-patient wards, to support implementation. The guide covers the philosophy, key interventions ( generated from the experience of pilot wards) and a tool box of extra strategies teams can use to reduce conflict and improve care.
• We have co-produced a No Force First video, https://youtu.be/WvkoAAq2tCw, that is delivered as part of our Personal Safety Training curriculum. This area of training has traditionally tended to focus on restrictive interventions and we are now delivering a transformation in content towards preventative strategies, in line with national guidance, through enhancing the lived experience component.
• We have set up and are developing Experts by Experience working groups as a further commitment to collaborative, co-produced training content.
• We have developed a Recovery College Peer Tutoring Course which will enable Experts by Experience to co-deliver Personal Safety Service training to all staff this year across the three divisions.
• We have patient (Experts by Experience) representation at the Trust Reducing Restrictive Practice Implementation Group, recognising the link between restrictive ward environments, frustration, and conflict.
• We have co-produced a set of standards in relation to supporting a further focus on ‘Trauma Informed Care’ at the heart of our teams. Further work is required to begin to audit these in practice but they are being used to underpin Personal Safety Training.
• The ‘Having The Conversation’ Course at our Recovery College is another example of how we have used the underpinning principles of ‘No Force First’ & co-production to rebalance the power within relationships between people providing services and those using them. People who use services have worked with staff to devise a course that seeks to empower people within services to ensure that they get the highest standard of care through knowledge of what they can expect from providers, as well as a grounding in the skills to assertively and constructively emphasise their needs. This course is delivered by nursing staff and Experts by Experience, who are committed to this new, equal, way of working. Empowering people who use services to communicate their right to optimal care from mental health services marks a sea of change from traditional approaches, which assumed that the professional knew best and that people who used services were passive recipients of care. We firmly believe that courses like this make services more responsive to the needs of people at all times, including those of distress, by developing the understanding that recovery is delivered through collaboration and mutual respect.
• As the spread of No Force First has moved to our Specialist Learning Disability Division work has begun on ensuring that ‘Experts by Experience’ from that particular area are able to bring their own experiences into the No Force First engagement process. Experts by Experience from other divisions are meeting with people using the Specialist Learning Disability services to encourage and support them to share their experiences of restrictive practices. This challenging role is invaluable to helping staff understand and reflect on the impact that their care has on people that they directly support. Staff are there to support the lived experience narrative, but those experiences are central to the engagement process and winning the hearts and minds of care teams, inspiring them to take new approaches.
• The team delivered a Co-production Master Class at the last National Restraint Reduction Conference on 6th October 2016 – with the aim of sharing our approach to co-production and its impact in terms of reducing restrictive practice more widely and enabling others to harness this approach.
• The role of our Peer Support Workers is key to shifting the culture of the team further to support people’s recovery and inspire hope. At the heart of the peer support intervention is co-production. These staff utilise their lived experience of in-patient services to provide a critical sign of hope for people who are recovering within services. Their ability to empathise with the stress of in-patient admission from their unique perspective, is a crucial mechanism to reducing conflict.
• Co-production is at the heart of our approach to further developing and using Values Based Recruitment (VBR) across the organisation. To date 105 staff have been trained in VBR and these sessions have been co-produced and co-delivered in practice. This training will continue across the organisation and will include service user and carer representatives who will continue to support the delivery of values based recruitment panels and assessment days. Values based recruitment is a crucial organisational underpinning to provide teams with a compassionate, flexible and collaborative workforce that will deliver non-conflict solutions.
Looking Back/Challenges Overcome
Any change process of this scale and ambition will have its challenges. Perhaps, looking back, we may have needed to be more robust in initially setting out that, whilst a restraint free future is an absolute ambition, we were not saying to staff right at the outset that we were stopping them from using interventions that may help people to feel safe. We feel that we addressed this through developing a message based on ‘organisational humility’. We had to acknowledge the concerns, accept that we had trained staff in ways of intervention that now needed to change, perhaps it could be said that our past clinical values had not reflected our current aspirations? Our organisational commitment to a ‘just and learning culture’ – not based on blame, has been invaluable in this area. We cannot blame staff for doing what they have been taught to do in the past and the recognition that systems and cultures, rather than people, can often let us down, should provide a sense of psychological safety amongst our teams, that will free them up to deliver interventions based on positive risk taking and flexibility, which are at the core of No Force First.
We do feel that any cynicism that may have existed about the process, as being indirectly critical of staff and their interventions, has been successfully replaced by the positive and celebratory nature of our supportive role of the team delivering No Force First. A ward experiencing challenges is ‘a ward to be supported’, not criticised, and a ward delivering positive practice is a ward to be lauded and thanked extensively throughout the organisation. Our Experts by Experience will identify restrictive issues that impact negatively on their care but will be sensitive to the challenges staff may face and how so much of what we deliver in terms of care is constantly improving, and how that changes their lives positively.
By expanding and enhancing the role of our Experts by Experience in co-production within the Trust we now have a strong sense that initial anxiety about the shift in power, from staff to people using services, that may have undermined confidence in the validity of the No Force First Process, has been largely addressed and removed. Our staff are seeing the huge potential of more positive, reciprocal relationships and the link to enhancing recovery and safety.
We have a group of staff dedicated to implementation, with designated leadership of the process across the divisions. No Force First is identified as one of our four ‘Perfect Care’ priorities to ensure that its profile is embedded into all areas of training, policy, practice guidance and staff appraisal, across the disciplines. The Trust board have a long term commitment to the process and have dedicated resources and organisational emphasis to sustaining the positive achievements so far. We have identified ward manager ‘champions’, who live the values of the process and share their expertise and insight with other staff teams. We have also developed a comprehensive Reducing Restrictive Practice Guide for Mental Health Services to ensure consistency and sustainability of the implementation of the approach. In High Secure the HOPE(S) model has been incorporated into newly developed Best Practice Guidelines for people cared for in Long Term Segregation for all three of the High Secure Services in the UK and embedded in the review process.
Evaluation (Peer or Academic)
We are keen to measure impact both locally and at a national / strategic level. Impact is evaluated through our incident data and service user satisfaction data. Personal safety training, which delivers the bulk of the key themes, is evaluated fully. The lead for No Force First provides continual reports to the executive stakeholders. External insurance bodies independently evaluate impact in areas such as staff sickness absence related to assaults. We have also carried out a thematic analysis from interviews with staff and focus groups in order to generate a driver diagram of quality improvement for further implementation.
We are working with Liverpool University to evaluate the qualitative benefits in relation to service users and staff (whether service users and staff feel safety and or recovery outcomes are improved or reduced) and also to evaluate the efficacy of different components of the approach .
We are also a partner in a future programme bid in the autumn with The University of Central Lancashire to evaluate the long term impact of physical intervention reduction programmes specifically in relation trauma-informed approaches.
Our initial pilot wards recorded reductions in the use of physical intervention of around 60% in the first two years. As the process has been implemented across all wards in the Trust we have managed to achieve 25% reductions in restraint use since April 2016 across all areas. Concurrently, the assaults on staff have decreased significantly by 46%. NHS Protect data identified the trust as being 65% below the national average for serious assaults on staff in 2015/16, whereas in 2012/13, as No Force First implementation began, we were 8% above the national average. Inevitably, as fewer staff are involved in physical interventions and are less exposed to assault, there are financial savings in terms of reduced replacement costs for work related sickness absence. For example, in the secure division of the service last year these savings equated to £249,069. These cost savings are in addition to the obvious qualitative benefits of the approach in terms of reported positive experiences of our staff and the people we serve.
We are fortunate to have developed a national and international profile in this area. Healthcare agencies from countries as far afield as Denmark and Japan have visited our services. In this country we have welcomed innumerable mental health and learning disability care providers to the trust to gain an insight into process. We have run our own No Force First showcase event last year which attracted no less than 29 NHS Trusts, third sector and external agencies.
The No Force First process features in a good practice case study for the National Quality Board.
We have co-produced a feature on the process, in terms of how it addresses critical human factors, which featured in The Ergonomist publication in 2016.
We have delivered training in the HOPE(S) model to the two other High Secure Hospitals who are adopting full out and the UK High Secure Prisons, three of which have commenced with piloting implementation of the model.
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“I used to believe that I could never achieve anything, or be anything useful in my life. Working in a co-productive way and using my lived experience of trauma, has had a massive impact on my life. In my opinion a co-produced approach to learning harnesses both sets of skills in a way that wins hearts and minds, bringing lived experience to life. It really helps to reduce the stigma I have experienced over many years and stops a ‘them and us’ culture, where people like me are not seen as equals and don’t feel valued or heard.
My experiences of restraint have left me traumatised, and caused harm, or even death, to many others. It is crucial that we enable and support people like me to have their voices heard. My role can support others to become more actively involved in speaking out, we have nothing to fear by people speaking out. If we don’t say what’s wrong we can’t make it better. By role modelling co-production, by working truly together, building trusting relationships with people who provide our care, we can enable change together.
Perceptions of mental health have changed in my lifetime but there is still a long way to go. My role in No Force First shows that it can be done. I am the living proof that co-production changes lives”.
Iris Benson MBE
Improvement Lead for Perfect Care
(Expert by Experience)
Mersey Care NHS Foundation Trust