We took a fresh approach to a failing service where staff and patients were unhappy, the environment was unsafe and there were high levels of serious incidents relating to self-harm, aggression and physical restraint. The current staff team are happy and fulfilled, they are now nurses not prison wardens and have excellent working relationships with the patients and carers. 6 of our Nurses trained to be DBT therapists and are now delivering DBT as the core therapy on the ward. The environment is safe but not sterile. We have been able to introduce ceramic crockery and metal cutlery on the ward. We have invited visitors in to dispel myths about personality disorders. We encourage patients to do 'normal' things like go shopping, to the cinema and even the pub. We even have guinea pigs!
What We Did
We took a fresh approach to a failing service where staff and patients were unhappy, the environment was unsafe and there were high levels of serious incidents relating to self-harm, aggression and physical restraint.
The ward was very risk averse and reactive. Patients were not encouraged to be an expert in their own care and there was little meaningful activity. Observation levels were high and focus was on containment rather than recovery. Patients had no clear direction or goals and held very little hope.
Staff were very disillusioned and sickness levels were high. The ward were unable to recruit new staff and ran on a high level of bank and agency.
The current staff team are happy and fulfilled, they are now nurses not prison wardens and have excellent working relationships with the patients and carers.
6 of our Nurses trained to be DBT therapists and are now delivering DBT as the core therapy on the ward. The environment is safe but not sterile. We have been able to introduce ceramic crockery and metal cutlery on the ward. We have invited visitors in to dispel myths about personality disorders. We encourage patients to do ‘normal’ things like go shopping, to the cinema and even the pub. We even have guinea pigs!
We hold events as ward such as walking in the Derbyshire Dales or Camping in Norfolk, Poetry evenings at a local Recovery café and fundraising. These activities are all done socially as a whole group rather than as individual ‘patients and staff’ groups.
We now genuinely enjoy each others company and the ward has grown into a community.
Wider Active Support
There are few good examples of other units like the one we were striving for so working effectively with other partner organisations was difficult. We did however embed some principles form other Trusts. The work of Mersey care Trust in promoting Positive and proactive care had a big impact on us.
We took a closer look at our use of physical restraint and how we could approach situations differently to avoid this. We also looked at the use of blanket rules and how we could alternatively be imaginative and flexible within those rules and policies.
When we set out on our new pathway we thought it essential that we involve patients and carers as well as staff. They were the real experts in the field and we wanted to hear how things felt form their perspective, what they thought we did well, what we didn’t do well, how we could improve things together.
We organized an away day with patients staff and carers where we went to a local village hall, had lunch, did some ice breaking exercises and then mapped out our ideal service together as one big team. the feedback was excellent and this is something we plan to repeat yearly.
We have a daily community meeting that all staff and patients attend, to discuss the coming days events but also to give everyone on the ward an opportunity to bring ideas, challenge decisions and make changes in a safe and supported environment.
Looking Back/Challenges Faced
Looking back the biggest challenge was undoubtedly a change in culture for staff and patients with an emphasis on values rather than rules.
Some staff found it very difficult to see things from a different perspective and get out of the ‘we’ve always done it like this’ culture. They found the idea of giving responsibility back to the patients very anxiety provoking and initially they felt very unsafe.
The patients also found the prospect of a recovery and discharge plan very anxiety provoking (some had been on the ward for over 3 years) however, they came round to the idea of being in control of their own recovery with support from the staff.
We did lose some staff along the way but that wasn’t a bad thing. if they didn’t buy into the idea, it was not going to work for them. We have now got a fully staffed ward, staff waiting for vacancies as they would like to work here and happy patients living meaningful days and looking forward to a future. I don’t think we would do anything differently if we did it all again.
The Ward has arrived at a place where culture and practice has become embedded as a way of life. Staff are committed and no longer want to leave as we are now benefitting from the results of our hard work and more importantly so have our patients.
We have just booked another round of DBT therapy and core skills training for our trained nurses and Healthcare Assistants. We have employed 3 recovery workers and a peer support worker and have just appointed a discharge planning and liaison nurse to give extra support to patients and carers throughout the admission but especially towards the end when anxieties are often running high. These plans for the future will ensure that the culture continues to thrive and grow.
Evaluation (Peer or Academic)
We have a patient and carer experience survey which is completed monthly. Evidence from this shows that patients and carer experience has been greatly enhanced by the changes in the service.
Our incidences of self-harm have reduced significantly. We accept that people with borderline personality disorders will self-harm at times but we work with then to identify triggers for this and mange it safely.
We have not had any incidents of physical intervention for well over a year and patients engage fully in the group and individual programmes.
Elimination of violent incidents and physical restraint
Greater patient satisfaction
Greater staff retention
Reduced staff sickness
Increased level of successful discharges with patients taking up vocational or meaningful activities on discharge
Patients and carer satisfaction
Successful promotion and sharing of good practice
We have attended numerous improving practice events and conferences to share our story and have had a lot of interest in our work. We have had visits form NHS England, The Maltese Minister for Health, and from other Trusts. Our Clinical Nurse Specialist is offering training on personality disorders and supervision to other wards within the Trust.
We welcome anyone who is interested in our journey.
Is there any other information you would like to add?
I have not been able to attach power points we use to demonstrate our journey but can supply these if you are interested