Service users from our wards are often discharged back into the care of their family. Working more closely with family members in this process is likely to have benefits for risk management in the post-discharge period and therefore also has the potential to reduce re-admission rates. Family work includes information-sharing and specific ‘staying well planning’ to allow family members to be partners in their relative’s care.
What We Did
The Schizophrenia Commission (2012) showed families who are carers to save the public £1.24 billion per year but that they were not receiving adequate support or treated collaboratively. We were keen to change this. Service users from our wards are often discharged back into the care of their family. Working more closely with family members in this process is likely to have benefits for risk management in the post-discharge period and therefore also has the potential to reduce re-admission rates. Family work includes information-sharing and specific ‘staying well planning’ to allow family members to be partners in their relative’s care. There is clear evidence that Family Intervention for psychosis (FIp) does work in consistently reducing relapse (NICE, 2014).
A number of national polices have highlighted the importance of mental health services working collaboratively with carers and service users (Department of Health, 2010; 2011) and that family intervention should be offered to all those with psychosis (NICE, 2014). The Triangle of Care (Worthington, Rooney, & Hannan, 2013), published by the Carers Trust, defines six elements required to achieve better partnerships between service users, staff members and carers through an acute episode. Our trust is in the process of signing up to embed the Triangle of Care. Therefore, we were keen to improve access to psychological intervention for service users and carers from our wards, reduce readmissions, and work towards meeting the Triangle of Care principles.
We are a MDT consisting of a psychologist, three nurses, and a doctor and work across two acute inpatient wards for those with severe mental illness. We are passionate about inpatient care and over the last two years have designed and led an innovative new family service on our wards alongside our primary roles working on these wards. This has allowed us to provide better patient care, work in line with national guidelines, and provide greater access to psychological interventions. We have involved service users and carers throughout the development and implementation of this project to seek their expertise and ensure the service we offer is beneficial. We have collected outcome data that shows it is. This pilot service that begun on two wards has now gained interest from our Trust Executive who are in discussions with us about dissemination to our other borough acute inpatient wards highlighting its wide applicability and scalability. By involving families in a patient’s care we are enabling increased patient and carer safety which is why we believe we are worthy award winners.
The family work options we offer were outlined according to different levels of provision, given that not all families will require a full intervention but all families should be included in a collaborative approach to care, which takes account of their needs. With this in mind, three different types of intervention across the acute wards within the Gresham Unit (Gresham 1, 2, and PICU) were implemented over two years. A family ‘awareness-raising’ teaching session was provided to staff. A carers’ clinic was made available and structured family work was offered to clients with a psychosis spectrum diagnosis or bipolar affective disorder and their families. This consisted of Behavioural Family Therapy (BFT; Falloon et al., 2006) as recommended by NICE guidelines.
Wider Active Support
We have involved service users and carers throughout the development and implementation of this project to seek their expertise and ensure the service we offer is beneficial. For example, it is hoped this service can improve access to psychological interventions for black and ethnic minority groups and when this work was presented at the Mind The Gap (Cairne et al., 2012) conference it received much positive support. The following service user and carer groups have provided feedback: Family Resource Centre UK Counselling, MIND, ReThink Mental Illness, Hear Us:
“In my capacity as an Agency Manager of Family Resource Centre UK Counselling in Thornton Heath, Croydon, I attend Mental Health Forums regularly at CVA House, London Road, Croydon and attended the presentation given by Dr Rumina Taylor on Wednesday 22nd January 2014. I was very impressed with her initiative in providing family work within the Wards for her patients & their families. As an Counselling Agency Manager, I have received many phone calls from partners, siblings etc. of people who have been diagnosed with mental health issues, so I feel that Dr Taylor’s work with families is vital as mental illness has the potential to affect a whole family, not just the sufferer, particularly when a stay in hospital is necessary for their recovery. I personally feel that this kind of therapy is vital for a family and will have a positive affect as any fears or uncertainties about mental health conditions can be brought out into the open of family therapy, rather than staying in the “unknown”. My hope, as a counsellor and agency manager, is that this initiative will become standard practice within all NHS Mental Health wards!”
Shelia Crabb, Agency Manager, Family Resource Centre UK Counselling
“As Hear Us Linkworkers, we see this service as an integral part of the acute inpatient wards, assisting patients to enhance relationships with their family. By talking and supporting patients and families, admissions can be meaningful and therapeutic. The family work service has received excellent feedback from carers and service users and we are keen for it to continue and for the service to be expanded to other wards.” Julie Connolly and Lucy Michalak, Hear Us
We have involved service users and carers throughout the development and implementation of this project to seek their expertise and ensure the service we offer is beneficial as described above. We continue to ask service users and carers for their feedback on accessing the service by using questionnaires to gain quantitative and qualitative feedback. To date all have reported being very satisfied/satisfied and all would recommend the service to others. Service user and carer complaints reduced since implementation of the service. The service has received positive feedback:
• “Just know how grateful I am that I am not on my own battling to get the care my sister needs.”
• “This is a helpful service for people who are not knowledgeable about mental health like myself and provides a service for them to understand what is going on behind the scenes.”
• “These meetings have made me feel that someone cares and was willing to listen to my concerns. I feel a lot better and not so alone.”
• “It has felt like someone has listened and acted practically for the first time in around 10 years. We have felt supported as a family, felt as if X (service user) was truly cared for, respected and understood, and that we know where to go if things become bad again. For the first time I feel like I know what to do if X (service user) falls unwell again. Thanks!”
Looking Back/Challenges Faced
We would have liked to offer our service to more wards and in different trust boroughs. However, we have designed and led our service alongside our primary roles working on these wards which already stretched our limited resources. We could have trained and shared our service initially with more staff from other wards but we needed to pilot the service first and evaluate it to see if it was beneficial. Training other staff may have increased scalability but we would not have had the resources to support staff to implement the service which would have affected sustainability and fidelity. Now we have evidence our service works we are in discussions with our trust to roll out the service to other wards.
We have been improving access to psychological interventions and in particular family work for carers and service users within the context of a stay on an acute ward. However, admissions can be very distressing to family members and service users and at times it has been challenging to facilitate family work. We have had to be flexible with the service we offer, work collaboratively with carers and service users, and at times realise that perhaps now is not the right time for family work for some people. There is also a limited evidence base with regard to family work on acute wards and therefore little guidance as to what we should be offering. We have had to draw on our clinical expertise, ask families and clients what they need and want, and have collected our own data to evaluate our service to see what works and for whom.
We have trained a number of MDT staff, present and share our work through training, presentations, reports, and academic papers. We have the support from ward managers to continue to train more staff annually to allow our service to grow.
The service was evaluated over a two year period once it was established on the wards (Nov 2013-Nov 2015) as part of a research project conducted by a trainee clinical psychologist on placement on the wards.
In addition to evaluating the rate of attendance and carer satisfaction, the number of ward complaints received was collected. Structured family work was evaluated using pre-post questionnaires assessing carer and client distress, wellbeing, and perceptions of illness. Readmission rates were recorded using patient notes.
A total of 102 MDT staff attended training across the three wards over a two year period, with 48 attending in year one and 54 in year two. The target of training at least 50% of all MDT staff per ward was achieved. There was an increase in the numbers of staff-family interactions following training for PICU staff. With regard to confidence with working with families, 62% of staff rated themselves as ‘confident’ prior to teaching. This increased immediately after training with 96% rating themselves as confident. At three months, 71% of staff rated themselves as confident. However, after training and at three months no staff member rated themselves as ‘unconfident’. All staff feedback that the training was either excellent (57%) or good (43%) and described the session as ‘relevant and useful’.
Over a two year period 119 caregivers attended the carers’ clinic. The majority were mothers of clients (29%) with a form of psychosis (64%). All meetings started with an account of events leading up to admission, the impact on the family and client and expectations for admission. The majority of meetings were additionally then focused on providing individual carer support (44%) or sharing information about the client’s current care plan (43%). All caregivers reported being ‘very satisfied’ or ‘satisfied’ with the clinic and all would recommend the service to others.
FIp has been provided and all carers and clients reported having made ‘progress’ during the sessions. 97.5% felt ‘very satisfied’ or ‘satisfied’ with the family meetings
and that their therapist understood their problems either ‘very well’ or ‘fairly well’. 92% said that they had a lot of confidence in their therapist.
Pre/post outcome measures showed statistically significant differences between pre and post scores for measures of carer global distress, overall wellbeing, burden and negative illness perceptions. Service user distress and wellbeing improved but was not statistically significant. Prior to FIp, 65% of caregivers felt that they had someone to confide in. This increased to 96% following FI. Readmission data shows clients are extending their time in the community following family work suggesting this intervention supports greater resilience. Client and carer complaints reduced since implementation of the service.
We present at conferences and share our work through training, presentations, reports, and academic papers. We are about to publish our paper showing our findings in the Journal of Psychiatric Intensive Care.