We strive to provide high quality, safe care to our service users in an environment and culture which supports their needs and reduces to a minimum the need for restrictive interventions. The Trust embarked on a programme of changing the culture and practice within the organisation. SHSC had received feedback from patients that the way staff approached managing disturbed behaviour on the inpatient wards could be better as it caused patients additional distress.
This feedback led to SHSC reconsidering how disturbed behaviour could be managed differently. A lengthy consultation process of service users and front line staff led to a recommendation to change the training for managing violence and aggression. A new training package of RESPECT Training was adopted by the Trust and an intensive training plan was agreed and implemented.
Sheffield Health and Social Care NHS Foundation Trust (SHSC) is proud that we are making progress to providing an ever-improving service for people who are admitted to our inpatient services. We strive to provide high quality, safe care to our service users in an environment and culture which supports their needs and reduces to a minimum the need for restrictive interventions. The Trust embarked on a programme of changing the culture and practice within the organisation. SHSC had received feedback from patients that the way staff approached managing disturbed behaviour on the inpatient wards could be better as it caused patients additional distress.
This feedback led to SHSC reconsidering how disturbed behaviour could be managed differently. A lengthy consultation process of service users and front line staff led to a recommendation to change the training for managing violence and aggression. A new training package of RESPECT Training was adopted by the Trust and an intensive training plan was agreed and implemented. This training meant that all staff were released to attend training with an emphasis on identifying and dealing with the causes of disturbed behaviour.
The RESPECT training involves service users telling personal stories about experiences of restrictive practise on the in-patient wards. Staff are equipped with a range of skills to de-escalate situations and to safely restrain patients to prevent harm. The training emphasises that each person is a unique person with strengths which can be harnessed positively. SHSC is planning a significant building programme to create a new inpatient unit and this work is informing the new environments to ensure the new wards have suitable therapeutic spaces.
This work has involved working with commissioners and being creative with targets. Our commissioners agreed a CQUIN target to promote RESPECT training and report progress. This target was met in full and is a meaningful way to use the often bureaucratic systems the NHS has to promote compassionate care. The Trust monitors outcomes very closely through its Restrictive Interventions Project Group, chaired by the Medical Director. There has been a significant improvement in the recording of all incidents and as a consequence it has been possible to identify a downward trend in the severity of assaults against staff.
This work has been supported enthusiastically throughout SHSC from front-line to boardroom with significant investment of resources. Leadership and the support of the Board was essential. Our RESPECT Training is co-produced and delivered by a team of dedicated service users. By sharing their personal experience of being restrained they help us to ensure that our staff appreciate the traumatic impact of restraint which can have lasting consequences. In addition to the RESPECT Training, we have increased access to meaningful activities for service users on our inpatient wards, including the introduction of new physical activity groups such as cycling and football which improve service users’ mental and physical wellbeing. ‘Cardio walls’ have been installed in wards for patients who are unable to leave the ward and provide a gentle or seriously intensive workout.
What makes your service stand out from others?
The Trust was approached by a group of African Caribbean service users calling themselves the ‘MAAT Probe Group’. They wanted to share the outcome of a qualitative study which they had conducted into the levels of satisfaction amongst black mental health service users in terms of the responses of staff in mental health services to service users behaving in a way which may be perceived as aggressive and/or violent. They wanted to change the environment to be the ones doing the research not the ones being researched. The outcome from the ‘MAAT Probe Group’ study was that there was universal dissatisfaction among African Caribbean service users regarding the use of physical restraint on inpatient wards throughout SHSC. The chief concern was one of physical and psychological injury sustained by many of the service users included in the study through the process of being physically restrained.
The MAAT Probe group acknowledged that there is a high standard of community mental health care in SHSC and that their issue was one which was directed at the inpatient services. They asked SHSC to review its training provision for responding to disturbed behaviour. Working together, a lengthy period of consultation began, which included service users and front line staff; this resulted in the Board agreeing to a change in the training provided to staff for the purposes of responding to aggression and/or violence. The package of training which was selected was RESPECT Training Solutions originally developed by Navigo.
This training package was chosen for a number of reasons; there is no prone or ‘face down’ restraint of service users, there is no reliance on ‘pain compliance’; the central tenet of the training being ‘no pain – no panic’, there is a greater emphasis on identifying the causes of aggression and the ‘function’ of the behaviour for any individual who displays aggressive and/or violent behaviour in mental health services. Another difference in this training is that there is an entire morning of each course given over to service users who are an integral part of the RESPECT training team; they bravely and generously share their personal stories about their experience of mental health services, both positive and negative, with staff attending training.
This session has a huge impact and is always incredibly well evaluated. The training delivered to staff places greater emphasis on regarding the individual as a unique person with strengths which can be harnessed positively within a healthy and collaborative relationship with mental health care teams. This innovative programme has significantly improved safety for both staff and service users, with a reduction in incidents, and also the severity of incidents.
The process of training all staff in the Trust in the new training was achieved by priority being given to staff from inpatient areas; an 18 week training programme releasing two staff from each ward each week began. Within a few months, all inpatient teams in the first wave of training from all directorates had implemented the new training. To support the implementation of the new training and the development of a different culture in responding to perceived risks from aggression and violence it was essential to engage service users and frontline staff. To this end the ‘Alternatives To Seclusion Group’ was formed. This group pre-dated the national drive to reduce restrictive practice. From the work of this group it became evident that the environments in Sheffield do not always lend themselves well to de-escalating any challenges; thus ‘Green Rooms’ were created on the wards which had the space to accommodate them.
Green Rooms are safe, quality spaces for staff to work intensively with people who are disturbed or distressed with a view to de-escalation. These rooms contain many sensory items for the purposes of encouraging engagement with staff and relaxation. For those wards without sufficient space to accommodate a Green Room, ‘Green Boxes’ were provided. These boxes contain all the sensory items contained within the Green Rooms and can essentially be used to create a Green Room wherever that service user may be. Staff like the Green Rooms as they provide a direct alternative to seclusion for them to use and they are popular with service users as they feel safe and the fear of seclusion is removed.
The Trust were keen to avoid the ‘disconnect’ between the training room and the clinical areas; thus the Lead and Assistant Lead for Respect Training and Implementation posts were created to support clinical teams and deliver training in the classroom. These clinical leadership posts have been pivotal to the success of Respect Implementation in SHSC. As part of the training structure provided within the Respect training an additional role of ‘Technical Assistants’ within each clinical team was created. Technical Assistants are identified by trainers as being people who have the appropriate value base and attitude along with an aptitude in terms of accurately using the physical interventions; they are provided with additional training above that of other staff, but below the level of trainer. The Technical Assistants are able to facilitate practice sessions for their colleagues if they are lacking in skill when applying the physical interventions. Further to this role they are also often ‘the eyes and ears’ who can feed back to the trainers any issues which may be germane to either the training provision and/or the implementation part of this process. It was necessary to review and revise many of the policies within the Trust to take into account the new training provision and the aspiration towards a better experience for staff and people using the services in Sheffield.
Who is in your team?
RESPECT Training Lead Assistant RESPECT Training Lead Senior Nurse for Quality Experts by Experience (service users volunteers)
The package of training which was selected was RESPECT Training Solutions which was developed by Navigo in Grimsby. The Trust works closely with ‘MAAT Probe Group’ whose research initiated the change in use of restraint. Work is now taking place across all services in the Trust to reduce all restrictive interventions, not just physical restraint but chemical and mechanical restraint as well. Our Intensive Rehabilitation Service at Forest Close no longer has a seclusion room as part of their commitment to providing high quality care in the least restrictive environment. We are also working with colleagues in estates to build better environments for our in-patient units, to increase feelings of wellbeing and harmony and to support a less restrictive environment. Service users are at the heart of this work.
Do you use co-production approaches?
The introduction of RESPECT training was a direct result of feedback from service users as outlined above. A cornerstone of our use of the RESPECT Training programme is putting the service user experience at the heart of the training. The RESPECT training involves service users telling personal stories about experiences of restrictive practise on the in-patient wards. Staff are equipped with a range of skills to de-escalate situations and to safely restrain patients to prevent harm. The training emphasises that each person is a unique person with strengths which can be harnessed positively. Our RESPECT Training is co-produced and delivered by a team of dedicated service users. By sharing their personal experience of being restrained they help us to ensure that our staff appreciate the traumatic impact of restraint which can have lasting consequences.
Feedback from staff repeatedly evidences how powerful hearing from the service users is for staff: “I thought meeting Catherine was one of the most insightful experiences of my life. I feel everyone should be given the chance to listen to personal stories like this, to help mental health be less stigmatised.” “Thank you for sharing your personal experiences with the group. Service user experiences are very important for staff to listen to and to learn from.” Our aims that all RESPECT training at all levels is fully co-produced with service users in future and this is clearly outlined in our training plans.
Do you share your work with others?
The Trust has had many requests from other NHS Trusts to come and visit to see what work has been done here in Sheffield; we are always happy to facilitate these visits as we are tremendously proud of all the staff and the Board for all the hard work they are doing to continue to support this work. We have also engaged with clinical teams who did not historically seek support/advice/input from the training department, such as the Community Learning Disability Services who often are supporting service users to remain in the community despite having some behaviours which disconcert others (parents, friends, families or the general public) in terms of risk. Because of the fact that both the substantive posts in the RESPECT training team involves working in to clinical areas it has lent itself incredibly well to connecting people up with each other across the various services thus enabling them to draw on each other’s specialist skills, knowledge and experience in working with some of the more complex people who use our services. We are committed to further improvements in how we support service users’ needs in a way that reduces the use of restrictive interventions of all kinds. Our service users continue to work closely with us to help drive this innovative work forward. A nationally recognised success story.
Outcomes and evaluation
The Trust wanted to measure the effects of introducing Respect Training. There was a need to provide quantitative data which could be used to measure outcomes; the use of seclusion and the number of and severity of assaults against staff were two of the markers selected as quantifiable. It was also acknowledged that as the reason the Trust was embarking on this process had originally been precipitated by service users feeding back to the Trust about the quality of their experience, there was a need to also gather qualitative data.
This qualitative data gathering is supported by service user volunteers who go into clinical areas and work through questionnaires with people who are inpatients and then collate the results. Staff are also asked to rate their experience by way of a ‘survey monkey’. Through the collection of data around the use of seclusion and assaults against staff it has been possible to continually refine the training provision to be responsive to the needs of service users and staff in SHSC. Since the outset of this process there has been a reduction in seclusion and restraint on our inpatient wards.
Additionally, there has been a significant improvement in the recording of all incidents and as a consequence it has been possible to identify a downward trend in the severity of assaults against staff. There has also been close monitoring of any incidents of assaults against staff. With encouragement from all quarters in the Trust (a multi-faceted approach!) there has been a significant improvement in the reporting of incidents of assault no matter how insignificant. As a consequence of improved reporting it has been possible to tailor the training provision to directly meet the needs of service users and staff in Sheffield. SHSC is leading the way nationally in eliminating the use of face down restraint on its in-patient wards. Figures released by NHS Benchmarking, show that SHSC has the lowest level of face-down restraint across England and Wales and year on year the use of face-down (prone) restraint in the Trust has reduced. In the past eighteen months there has been no use of face down restraint in SHSC. As with many NHS Trusts the complexity of patients has increased with more formal detentions and with fewer beds. We are proud that our restrictive practice figures have not been affected by these changes
Has your service been evaluated (by peer or academic review)?
The most recent CQC inspection report on Sheffield Health & Social Care NHS Foundation Trust highlighted the work on reducing restrictive interventions in the Well-Led domain: “Within this programme the trust have a specific focus on improving safety in respect of improved physical health outcomes and reducing restrictive interventions.” In the Safe domain the inspection also highlighted: “Following the previous inspection in 2014, the trust established a trust wide Restrictive Interventions Group which reviews practice issues relating to seclusion, long term segregation and the use of physical restraint. An established programme is now in place to review current practices and deliver a range of improvement initiatives informed by the outcomes of the review.
The review focused on: • The time people spend in seclusion. • Ensuring that face down restraint is not used • Adoption of reflective practice and other methods to review incidents of seclusion, which includes service user and staff experiences, including fears and anxieties of using seclusion. • Developing a patient focussed ‘toolkit’ for use by service users who have been secluded or are at risk of further seclusion. The focus includes psycho-education work involving distress tolerance, emotional regulation and relaxation and physical activity. Each directorate produced a monthly restrictive practice incident report which identified themes and trends in restrictive practices and gave a detailed breakdown of restrictive type by ward.”
Development and sustainability
Two substantive posts have been created in the form of a Lead and an Assistant Lead for RESPECT training and implementation thus ensuring that the work on improving the service provision and experience for people using services continues irrespective of people leaving the Trust or moving on to other opportunities. The current Lead is a senior clinical nurse with extensive experience of working in forensic settings (high, medium and low secure) and PICU alongside having a great deal of experience in terms of the assessment of risk and the least restrictive strategies to mitigate the risk.
What aspects of your service would you share with people who want to learn from you?
If we had known at the outset what we know now, there are several things that we would do differently. Foremost among these being to ensure the service users involved be better communicated with, and more frequently, as they found the length of time between requesting that the Trust review the training provision for staff, to the Trust commencing the implementation somewhat lengthy. Similarly, we would have engaged more frontline staff earlier in the planning process and involved them in the discussions sooner as it became apparent upon commencing the training, that all sorts of ‘fears’ were circulating amongst staff groups. Staff were fearful that they would be placed at risk as a consequence of the new way of responding to disturbed behaviour; one senior manager was concerned that we were “throwing the baby out with the bath water” (sic) by changing the training provision. Another aspect that we would have done differently is that we would have had a broader focus in terms of quantifying what change there might be in terms of the training provision; we chose to focus on the use of seclusion but have since broadened our perspective to include quantifying the use of ‘restraint’ of any kind in the Trust, be it chemical, physical, environmental or mechanical.
Further to this we are now gathering even more qualitative data from both staff and users of the service and carers to inform and continuously improve the training provision and to ensure that we are responsive to the needs of staff and people using the service. It was necessary to review and revise many of the policies within the Trust to take into account the new training provision and the aspiration towards a better experience for staff and people using the services in Sheffield. It was also felt that it is important to fully engage with clinical teams and ensure rigorous peer review of the use of seclusion in the service; to this end the Seclusion Review Group was created. This group meets every two months and is chaired by the Deputy Medical Director of the Trust and is attended by senior staff from ward environments, the risk department, the Quality Improvement Group and Respect training. Through the collection of data around the use of seclusion and assaults against staff it has been possible to continually refine the training provision to be responsive to the needs of service users and staff in SHSC.
City of Sheffield and surrounding South Yorkshire and North Derbyshire area
Size of population and localities covered:
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
NHS Sheffield Clinical Commissioning Group
Provided by (e.g. name of NHS trust) or your organisation: *
Sheffield Health & Social Care NHS Foundation Trust
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