Staff are central to this approach. In order to create consistency and maintain the standards of practice all new members of the rehabilitation staff team receive a 1 hour training session delivered by Clinical Psychologist to ‘socialise’ them to the case formulation model and importance of team approach and a 1 hour session delivered about Reflective Practice followed by an experiential group
What We Did
Three years ago work was completed on the strategy to develop Psychology Role’s on all of the inpatient wards and with the newly developed CERT team.
The broad aims of the Clinical Psychology posts were to:To work alongside the MDT to embed the role of the psychologist within the teams to develop a culture and practice delivering psychologically informed care.; Deliver direct psychological assessment, formulation and treatment interventions based on third wave Cognitive Behavioural interventions both individual and group, to develop the service users ability and skills to cope with and manage complex mental health problems.; It was envisaged that having a psychological view of service users care and treatment would aid risk management and positive risk taking and thereby reduce length of stay for some service users.; Work with the staff team building reflective practice, staff support and team based formulations to aid care planning and give staff protective space for supervision.
An example of the good practice with this is illustrated across the Rehabilitation Care pathway.
Rehabilitation Care Pathway The Community Enhanced Recovery Team was established, with the aim of providing intensive bespoke psychologically informed packages of care to support individuals living with complex, enduring mental health problems to live fulfilling lives in the community, as an alternative to long term rehabilitation or hospital care.
This service utilises a whole team psychological approach to understanding distress using Emotion Focused Formulation (Clarke 2007), interpersonal relating and communication and risk management for all service users. The inpatient Rehabilitation Unit has been reconfigured and is establishing the same whole team approach offering reflective practice and team based formulation to support the staff in delivering psychologically informed care.
Team Formulation The purpose of case formulation is to create a whole team approach by sharing the theoretical and experiential knowledge of the issues for the service users and how the staff feel about the service users and their experiences.
Through sharing professional expertise and building psychological frameworks for understanding why service users experience certain difficulties, a shared narrative account of an individual’s life the team can develop plans that originate from discussions together as a team.
Case formulation establishes a space to allow the sharing of team decisions around risk, designed to support positive risk taking. For example, the team are able to hold in mind the risks of completed suicide versus the loss of independence, self-efficacy and coping capacity for each individual. The meetings build collaborative approaches, which develops effective, consistent responses to service users and their difficulties.
It is is embedded in the teams routine practice and links to care planning, identifying staff training and support needs, governance and by inviting colleagues from across the Trust who are involved with the service users care, it places the teams within the wider context of services. A team formulation should therefore be more reliable than individual formulation by a single clinician.
By placing an emphasis on ‘everyone inputting’, ‘everyone sharing’, the whole of the clinical team are encouraged to share their experiences and knowledge. The aim is to build and maintain a team dynamic that is valuing, respectful and empowering for all, throughout highly challenging situations that can illicit strong emotional responses.
Case formulation is designed to ‘bring the team back’ to our core values and allows the team members to maintain a validating work environment and relationships with service users Through understanding the meaning in behaviour, and understanding staff members own responses, the staff members receive support and learn to recognise and understand “the desperation behind the behaviour, where it was developed and why” (Isabel Clarke)
Weekly reflective practice groups provide an opportunity for staff to reflect on their work in a safe space. It can provide an outlet for anxieties and frustrations generated by their work and help staff to hold a compassionate view of the service user. It can help staff to maintain a shared perspective of service users whom they have previously found upsetting, or “difficult” or hard to help and this opens minds to other possibilities, and day to day management and help staff to keep empathy with the service users difficulties.
The reflective practice groups, provide support and improves communication within the team and helps to promote a shared view and can improve job satisfaction.
Some examples of feedback provided by staff
“Having the team formulation and having like a diagram that explains your own responses so you know that sometimes the feelings that you are feeling are natural…you know where it’s coming from”
“It helps because you feel like you have understood the problem a bit more, that gives us confidence in what we are doing, it’s easier to give our Service Users confidence”
“Case formulation makes us look at the bigger picture. maybe you’re dealing with a crisis where someone is being verbally abusive you’ve got in the back of your mind all these discussions that you’ve had as a group about maybe why they are in that place right now, that it is not personal, its not because of you this has happened, and triggered loads of other feelings. it keeps it in the back of your head so that you are never kind of feeling animosity towards the service user for being aggressive because you’ve got a further understanding of what they’re going through”
Wider active support
Worked with the Division of Clinical Psychology within the British Psychological Society linking nationally with the development. Presented with others at the National Division of Clinical Psychology Conference “50”th in 2015 on this approach and in Glasgow in 2014.
Presenting at the BABCP 2016 Partnerships with South Yorkshire Housing
Staff are central to this approach. In order to create consistency and maintain the standards of practice all new members of the rehabilitation staff team receive a 1 hour training session delivered by Clinical Psychologist to ‘socialise’ them to the case formulation model and importance of team approach and a 1 hour session delivered about Reflective Practice followed by an experiential group where new members of the team have the opportunity to have an experience of reflective practice. Service Users are involved in collaborative care planning training.
Looking back/Challenges Faced
In order to manage resistance from some members of the team who have been trained in different approaches as this is a new experience and can feel exposing we have learnt that earlier discussions with individual’s supervisor to support and understand the nature of the resistance.
It will be importance that Reflective Practice groups become ‘owned’ by the staff team; the team can feel less confident to manage difficult or challenging discussions without the facilitation of the Psychology staff.
It has been recognised that support from senior team is crucial in enabling case formulation and reflective practice to be prioritised for the whole team. Each member for the team has a responsibility to ensure they are role modelling the importance of attending and contributing. Protecting case formulation as a model of service delivery is complex and demands time and this means the frequent need for members of the senior team to reiterate its importance in the face of complex service demands.
The Off Duty reflects prioritising the individuals for each mini-team to ensure maximum attendance for relevant meetings. The recovery coordinators ensure that the activity planners are supporting staff protected time, and the Care Coordinator on duty completes a check that all staff members have been protected to attend.
This model is sufficiently embedded within the team to allow this to continue with the support from psychology and the team manager.
A staff audit was conducted using a questionnaire designed to measure amongst others: the team compassion for service users, collaborative nature of the working relationships and job satisfaction. 65 members of staff from a range of disciplines completed the questionnaire. 92% reported that they felt that this had been helpful. Having the reflective practice groups/team based formulation they reported helped them to be consistent in their approach to service users and allowed them to maintain empathy with clients with complex problems.
In terms of staff feeling supported by reflective practice 95% of staff reported they did feel supported. Staff reported positive experiences of attending RP sessions, which included: Greater psychological understanding; Improved recovery focused care; Compassionate therapeutic alliance; Increased staff confidence with service users who they found hard to engage; Improved ability to provide a consistent approach; Positive management of complex problems.
Some of the staff comments are listed:- Helps staff to understand how patients are feeling; They have encouraged a more open collaborative way of working; …have conversation away from more traditional medical model led manner, towards a more client centred recovery focus; Psychologists manage to keep sight of the bigger picture for each client – this is useful for staff to regain perspective via MDT meetings which can be lost when working day to day on the ward; Formulation helped with understanding which in turn helps develop interventions that can be more consistent and meaningful for service users; Helps staff to understand how patients are feeling.
Improving staff awareness of distress Phase Two of the evaluation involved semi-structured interviews to gather the team perspective on their roles and responsibilities and the structures in place which support this intensive work. Initial results suggest the team have a strong positive experience of the weekly case formulation meetings and weekly Reflective practice meetings and reported positive impact on the team’s ability to deal with emotional distress, to empower the team, to develop consistency in approach and to focus on the individual rather than the diagnosis.
The findings from this initial research were presented with others at the National Division of Clinical Psychology Conference in 2014 and again at the 50th in 2015. The results specific to CERT were presented in a Poster presentation at the same conference and in a Poster representing crisis work on the acute wards.
The CERT team were awarded with the Chair’s Award at the SHSC trust annual wards in 2015.