Reducing Harm from Violence
- Overview
- BBC London – Violence reduction in Newham – August 2018
- Celebrating 65% reduction in violence and the impact on staff and service users through the City & Hackney Violence Reduction Collaborative
- Newham QI Wall artist Jonny Glover interviewed BBC Radio London
- Violence Reduction on Adult Inpatient Units; what has been achieved so far at ELFT?
- Reflections and thank you from Professor Jonathan Warren
- Developing a Quality Control Strategy for Violence Reduction
- Forensics: First steps, early signs of reduction and an exciting journey ahead!
- Perspectives from Newham Inpatient Unit…
- Perspectives from City & Hackney Inpatient Unit…
- Safety Huddle Implementation
- Violence Reduction Collaborative Stories
- The Violence Reduction Collaborative
- Violence reduction on older adult mental health wards
- Reducing incidents of physical aggression on the Coborn PICU
- Newham Violence Reduction Collaborative
- City and Hackney Violence Reduction Collaborative
- Reducing physical violence and developing a safety culture across wards in East London
- Violence Reduction Collaboratives in Newham and City & Hackney
- Reducing Physical Violence on the Globe Ward
- Safer Wards: Reducing Violence on Older Peoples Mental Health Wards (BMJ Quality)
- Tower Hamlets Violence Reduction Collaborative
- Blog on Tower Hamlets Violence Reduction Collaborative
- Update on Violence Reduction Work
- Reducing Violence on Acute Wards
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Reducing Harm from violence has been one of our priority areas for improvement since the foundation of our QI programme in 2014. Collaborative efforts to reduce harm from violence have made a significant difference in our Luton and Bedfordshire, Tower Hamlets, City & Hackney, Forensic and Newham Adult Mental Health Services, who have now moved into a Quality Control phase with this work. We are currently working with teams to implement our first high priority trust wide quality control system which involves defining what will now be standard work and creating visual management boards.
In this collection you will find a selection of project stories, interviews, posters, published papers that tell some of the story of this great work.
Below is a video that sums up the Violence Reduction work at ELFT:
BBC London – Violence reduction in Newham – August 2018
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Celebrating 65% reduction in violence and the impact on staff and service users through the City & Hackney Violence Reduction Collaborative
Jane Kelly, Associate Director for Inpatient Services & Lead for the City & Hackney Violence Reduction Collaborative, supported by Jen Taylor-Watt, Improvement Advisor for City & Hackney
In early 2016, a person was injured every 3.7 days on our inpatient unit from incidents of physical violence. Some staff reassured themselves about the threat of violence when they came to work with the idea that “A&E is only next door”.
As the Associate Clinical Director for Inpatient Services & Borough Lead Nurse, on hearing this, I felt devastated. Things were getting worse and worse, and I felt I was failing my ward teams and communities, by not being able to stop them experiencing such very high levels of violence and aggression.
I knew that something needed to change, and with the support of Jen Taylor-Watt, Andy Cruickshank and the QI team, in February 2016 launched the City & Hackney Violence Reduction Collaborative, using a package of change ideas that had been proven to help reduce violence on the Tower Hamlets inpatient unit.
Fast forward 22 months, and we have just spent 2 wonderful afternoons with inpatient staff, reflecting together – and with friends from the broader system – on the achievements of this work within Hackney. Our inpatient wards have succeeded in reducing violence across the unit by 65%, using data over time and this has had a huge impact on us as a unit.
Changing course
Gardner Ward and Joshua Ward were our 2 acute admissions wards with the most violence 2 years ago. Staff talk about running from the door to the office on the Gardner Ward because they were so scared to be on the floor. Some of our new starters on Joshua Ward were so frightened when they were on the ward they needed to be escorted by other staff members. Gardner and Joshua have now both reduced violence by over 70%.
Rebecca Finnegan, Ward Manager on Bevan, our intensive care unit, which cares for our male service users who are most unwell, describes sitting in her office and hearing the pinpoint alarms going off 2-3 times an hour; levels of violence which meant the dominant mentality was “how am I going to get through the next 12 hours before I go home, rather than having a sense of fulfilment in the job”. Bevan has now reduced violence by 39% as a straight count of incidents, or 61% if you take into account changes in occupancy on the wards (as a rate per 1000 occupied bed days). In August-September 2016 there were 61 incidents of violence on Bevan. In the same period in 2017 that’s down to 14 (see image).
So what impact have these reductions had on our wards? What is the meaning behind the numbers?
Staff and service users spent time reflecting on this and bringing their feelings to life on artwork that we shared at the afternoon events. See the journey of each ward here:
As you can see, each ward has represented their experiences differently, but there are movements from darkness to light, from division to togetherness, from fear to calm, etc. We have also created a film, on which staff and patient representatives shared their perspectives on the impact of violence and aggression and the difference this project has made. View it here.
Journey
Brett Ward’s second canvas makes clear that they are still in transition. They’ve come a long way and the present state is much better than where they were 2 years ago, but staff and service users can see a future where things can be even better.
This is true for all of us on the unit in Hackney. This package of change ideas has had an incredible effect on the culture and functioning of the unit; such simple ideas like having proactive conversations about safety and violence in community meetings and bringing the team together to manage risks in safety huddles have really changed the dynamic of the care environment… but we can go further.
It’s a bit like we are a sail boat, which 2 years ago made some adjustments to slightly change the angle of our course. At the time, these felt like small changes; almost imperceptible initially, but after a bit of time we began to notice that we were going in quite a different direction and the sea around us began to look different. Less choppy, more calm.
That change in angle means that, nearly 2 years on, we now really are in a completely different part of the ocean from where we would have been. Rebecca Finnegan talks about how the changes on Bevan Ward mean staff and service users can now spend time on creative projects together, like making jewellery and bookmarks to sell at events and raise money for a bilingual ward library. This really was unimaginable 2 years ago; in terms of where the staff team were at, how service users felt on the ward and the dynamics and culture of everyone together. She comments,
“when you take away the violence, the fire-fighting, that stress of constantly feeling like you’re battling against your patients, you open your service up to doing so much more”
Experiences and expectations have changed.
Staying the Course
The key, of course, is that we ensure we carry on with this new trajectory. It’s so easy, when you do work like this, to get buffeted back to where you were before. The demanding nature of what we do unfortunately contributes to this, as well as the fact that continuing these new ways of working requires continued leadership and energy – the whole crew of the boat committing to continue working in the same direction, if you like. Hear about the leadership this work has already involved here.
Our recent events were partly celebration, but also a time to reflect together on where this work has taken us and to renew our commitments to each other to continue to chart our different course. As well as reflecting on what we found most inspiring about the sessions, we made commitments to each other – as ward teams, clinicians and other partners in the broader system and our Trust and Directorate Management Team – about how we could support each other to hold the gains. See these in the slideshow below.
We also needed to acknowledge as a unit the incredible support and commitment we received from Jen, without whom we would not have achieved the results we did. Her input enabled the ward teams to be creative and fun, as well as achieving and maintaining great results. Jen has certainly been the first mate on our boat and we will miss her leadership and guidance!
So finally, I’d like to renew this call – to everyone in Hackney – to support this work. To encourage your team to do your safety huddles, to make sure you are recording your incidents on your safety cross and to continue to talk openly as a ward community – staff and service users – about your experiences and learning from violence and aggression. Service users and relatives, please discuss and challenge your ward teams to keep up with this work. People from beyond the wards in the broader system, please show interest and support when you are working with us. All of your leadership and interest will make a difference.
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Newham QI Wall artist Jonny Glover interviewed BBC Radio London
Jonny Glover, the artist behind our Newham Centre for Mental Health Quality Improvement Wall was interviewed about his work on BBC Radio London recently.
Jonny talked to Robert Elms about this fantastic project which won a prize at the 2017 World Illustration Awards
You can listen to the interview below and visit Jonny’s exhibition at Somerset House in London from 31 July to 28 August. Further details here>>
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Violence Reduction on Adult Inpatient Units; what has been achieved so far at ELFT?
Between 2012 and 2015, Tower Hamlets Adult Mental Health inpatient wards reduced violence by over 40% and by 60% on the acute admissions wards, using a Quality Improvement approach. Since then we have scaled up the work to City & Hackney in early 2016 and Newham in mid-2016. Forensics also launched its own Collaborative in late 2016, testing the extent to which ideas developed in general adult units is effective in Forensics, as well as developing their own ideas.
Overall, violence reduction work across ELFT has meant that we have seen a 42% reduction in incidents of physical violence across our East London services since 2013 (see figure 1).
The change ideas that have helped in general adult settings work on 2 main drivers:
- Increasing teams ability to identify and predict risks of violence and to take action proactively as a team. Two change ideas work on this; Safety Huddles and the Broset Violence Checklist
- Creating a culture of much greater openness and transparency around the issue of violence with the whole ward community, including service users. Two ideas work on this: using Safety Crosses and having proactive discussions around violence and safety in ward community meetings. (See articles on City & Hackney and Newham Adult Mental Health Services)
For more information about these ideas see the other articles in this newsletter and this article, published in February 2017 in the Journal of Mental Health Nursing>>
Local reductions
Since the beginning of the work, local collaboratives have achieved the following reductions:
Tower Hamlets has reduced violence across all 6 wards by 40% and restraints by 60%, using Datix data. There has been a 57% reduction in violence and a 77% reduction in restraints across the acute wards.
In City & Hackney, violence has reduced by 40% across the unit and upwards of 60% on the acute wards, according to Datix data. Gardner Ward and Joshua Ward in City and Hackney have sustained 65-75% reductions in violence for 6-9 months. There has also been a 54% reduction in use of restraint on Conolly Ward and there are early signs of reduction on Bevan Psychiatric Intensive Care Unit (PICU).
In Newham , Topaz Ward has seen a reduction of 66%, Emerald Ward has seen a reduction of 74% and Sapphire has seen a reduction of 84%. Jade Ward are also seeing very positive signs of change, with no incidents at all between 30th September 2016 and 12th January 2017.
Forensics has just seen early signs of a 51% reduction in physical violence across Bow, Broadgate, Clerkenwell, Shoreditch and West Ferry wards. Shoreditch and Bow have seen individual reductions of 82% and 51% respectively. For more information see our article – Perspectives from Forensics; Early signs of reduction and an exciting journey ahead for further specific detail on the directorate’s journey for far and the impact this work has had.
In 2017-18 we will be looking at extending the work to Luton and Bedfordshire and focusing dedicated work on restricted practices, as well as consolidating the work in existing Collaboratives and developing a Quality Control strategy (see this article).
For any queries get in touch with Jen Taylor-Watt, QI Lead for City & Hackney & IAPT and Lead Improvement Advisor for Violence Reduction and/or Andy Cruickshank, Associate Director of Nursing for QI and Senior Improvement Advisor for Violence Reduction.
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Reflections and thank you from Professor Jonathan Warren
Jonathan Warren is Deputy Chief Executive, Chief Nursing Officer & Executive Sponsor for Violence Reduction
Whenever I think about what we’ve achieved already in terms of violence reduction at ELFT, I’m reminded of the time Andy Cruickshank (former Borough Lead Nurse in Tower Hamlets and now Associate Director of Nursing for QI) came to see me to say that he wanted to work on reducing violence in Tower Hamlets.
I will be very honest with you now and say that I was rather sceptical of whether he would be able to work on this and whether change was truly possible in this area. I tried to encourage him to do work on medication errors instead – because there was a good evidence base around how you could do that.
Andy was insistent though, that violence reduction was what the unit needed to work on – and now, to see the results of the work our wards have done, and the way in which our staff and service users have been able to transform the experience of the wards, is truly incredible.
It has also really been a lesson to me – of the power of listening to staff and service users and allowing them to work on what is important to them. From this you get what can really make a difference.
So, my message to everyone who has been part of this work is really is to say thank you. It is truly world class. When you see and hear about people from around the world truly fascinated in the work that you have done and the results that you have achieved, you must feel incredibly proud.
We know, of course, that our work isn’t finished. We are the only Trust in the country that has been rated as “outstanding” for our work on acute wards by the CQC, but we’ve still got a lot more to achieve in this, and other areas, to improve what we do. Sustaining and achieving further gains needs all of your leadership and commitment every day to strengthen our system, so let’s all keep going with this.
Today though, my main message is thank you again for all of your work – on violence reduction, on other improvement projects – and for the commitment and care you show every day.
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Developing a Quality Control Strategy for Violence Reduction
by Jen Taylor-Watt, QI Lead for City & Hackney and IAPT and Lead Improvement Advisor for Violence Reduction &
Andy Cruickshank, Associate Director of Nursing for QI and Senior Improvement Advisor for Violence Reduction
In order to hold the gains we’ve achieved through the Violence Reduction Collaboratives, it’s key that we develop strong structures and processes for understanding the health of our inpatient systems, enabling teams to identify quickly when there are risks of things going out of control. A key step we have used to do this to date has been the unitwide safety huddles, and we are now taking this a step further with the introduction of visual management strategies within unitwide huddles.
A key structure; the unitwide huddle
Like on a ward level, unitwide huddles help the whole unit to come together to understand what the concerns and issues are and to agree actions to be taken as a team. It enables managers and staff from across the unit to be conscious of problems and to support each other to address these; thereby functioning more as a whole system, rather than isolated wards.
For example, at a unit-wide huddle in City & Hackney last week, the representative from Bevan PICU (Psychiatric Intensive Care Unit) raised the fact that a service users’ glasses had been broken on the ward and this was understandably leading to unhappiness and agitation, because they couldn’t see properly. Bevan was low on staff that day though, so couldn’t safely release anyone to escort the service user to replace his glasses. The unitwide huddle quickly agreed it was a priority for the unit to sort this as quickly as possible and another Ward Manager immediately agreed to release a member of their staff to support the PICU address the person’s needs.
Quality Control through visual management; the Quality Control Board
The QI team is working with the units in Tower Hamlets and City & Hackney to look at how we can strengthen our Quality Control strategy further, through using the ideas of visual management by developing Quality Control Boards, as shown in figure 1, Tower Hamlets, and figure 2, City & Hackney.
As you can see from these images, Quality Control Boards attempt to bring together all the key data, which gives a sense of how a system is functioning. Rather than just relying on the information that individuals decide to bring to the huddle, teams go through a process of reflecting on the data they need every time to understand how their system is functioning. This therefore mitigates against the risk of important information and connections being missed. It provides a more objective framework that the whole team can work with to see what is important and what needs discussion. It therefore helps to more systematically manage the control of the hospital as a system and focuses staff on what they need to pay attention to.
Staff from Tower Hamlets, who are the furthest ahead with developing their approach to using Quality Control Boards, have reflected that the Quality Control Board also really helps the unit learn, and that use of the board is a step up from previous huddles, making them better aware of unit wide issues. They have fed back that it is also improving their problem solving and critical thinking, and helping them to more fully consider and keep track of follow-up plans.
Tower Hamlets staff are keen to emphasise that they’re nowhere near finished with refining their Quality Control Board. It is very much a process of getting started, seeing what is useful and reflecting on ways in which it could be strengthened even further. Becks Lingard, Matron for Rosebank PICU and Brick Lane Ward in Tower Hamlets, kindly supported City & Hackney leadership to get going with their Quality Control Board, so we now have the opportunity to share the learning across the two units as they both take this forwards. Newham also plans to start soon.
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Forensics: First steps, early signs of reduction and an exciting journey ahead!
By Nynn-Hui Chang, QI Lead for Forensics and Improvement Advisor to the Forensics Violence Reduction Collaborative & Day Njovana, Lead Nurse for Forensics & Lead for the Forensics Violence Reduction Collaborative
Forensics is a unique setting in that the majority of patients are admitted following a violent index offence in the context of their illness, which differs greatly from the general adult wards. For this reason, we were unsure if the bundle of ideas, developed on the general wards would help us to reduce violence in Forensics. It’s been important therefore, for us to take it slowly; exploring and understanding how the issue manifests itself in our setting and the dynamics of how we are responding to it.
Something that we realised early on was that we had particular issues with sexual behaviours, particularly on our learning disabilities wards. We’ve created a different coloured dot to record this on our safety crosses, so we can keep track of the frequency of this, and we’re continuing to work to understand the drivers of these behaviours so we can address them.
Meeting together as a learning Collaborative gave us a chance to reflect on the change package from the general wards. Although we need to continue to understand things specifically in Forensics, we felt that it was worth testing a number of elements of the change package. Although there are differences between Forensics and non-Forensics settings, we too need to ensure we are communicating as effectively as possible and to try to predict risks before they occur – so we thought it was worth seeing if Safety Huddles could make a difference. As already noted, we also agreed that using Safety Crosses would help us to understand frequency of violence and share this across the service.
The fantastic news is that we’ve already seen a 51% reduction in violence across the group of wards involved in the work to date (Bow, Broadgate, Clerkenwell, Shoreditch and West Ferry) through using these ideas. Three more wards have now been inspired to join the Collaborative; Clissold, East India & Ludgate.
Shoreditch and Bow Wards have also seen individual reductions of 81% in physical violence and 54% in non-physical violence, respectively.
We asked project leads from Shoreditch & Bow what was the impact they noted from the violence reduction work. Here is what they said:
It’s been a great start. There is lots of energy and enthusiasm around this work in Forensics to stop violence and aggression being an accepted part of work.
Staff and patients are reporting that they feel safer on the wards. Safety crosses are starting to be discussed in community meetings on the wards, so that staff are working together with the patients to improve understanding and patients’ experience.
We’re really looking forwards to where the next year might take us!
“For me the Violence Collaboration has meant that we have started to address the unspoken , unchallenged ideas . The dirty word “violence”. Never has there been a focus in forensic services on this one main driver for staff and patient satisfaction.
The early results have been encouraging for staff and mainly our service users. It has given staff the basis to pre-plan, support and engage with service users in times of distress.“
Day Njovana, Lead Nurse for Forensics &
Lead for the Forensics Violence Reduction Collaborative
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Perspectives from Newham Inpatient Unit…
The power of safety huddles; identification, prediction & strengthening team work.
By Emma Binley, QI Lead for Newham & Improvement Advisor to the Newham Violence Reduction Collaborative
& Paul McLaughlin, Borough Lead Nurse & Lead of the Newham Violence Reduction Collaborative
The safety huddle is one component of the safety bundle that has been tested on the inpatient wards across Newham. All of the wards in Newham are now using safety huddles and are trying to huddle at least three times a day.
Where do safety huddles come from?
Safety Huddles are used in other areas of healthcare to encourage effective communication and teamwork and, funnily enough, the idea of huddling originally stems from completely different contexts like American Football and the US Army. Any time you have a group of people trying to achieve a shared aim, you need to have an effective means by which they are encouraged and supported to work together – specifically to take a pause, reflect on what is going on and then to develop strategy and ensure everyone is clear on their roles. This is what happens in American Football – and now this is happening on almost all of our inpatient wards, where we are working together to deliver the best possible care and striving to keep our patients and staff safe and free from harm.
How we structure safety huddles in adult mental health settings?
We believe we’re one of the first organisations around the world to use safety huddles in adult mental health settings. The safety huddle, developed at ELFT, is really focused on providing staff with a structure to help identify and predict when there are risks that are likely to result in violence and aggression and then to take action on these as a team. To do this, we focus on two key questions; staff in the huddle ask “Are you safe?” and “Will anyone be dissatisfied with their care today?”
The first question is prompting staff to reflect on whether there are any pressing risks on the ward, both in terms of individual patient’s behaviour which is likely to result in violence, and ward issues, such as staffing levels or ward occupancy. The second question is drawing on ideas around the importance of human needs and how when needs are unmet, this can lead to agitation, aggression and ultimately violence. If we can better connect with these needs, do what we can to meet them, and show empathy and understanding if we can’t, our work has shown we can prevent incidents. So, the first step is to identify when a need is not being met; reflecting whether anyone one the ward is unhappy really helps us to do that.
Experiences using safety huddles in the Newham Violence Reduction Collaborative
At one of the collaborative learning sets in Newham, staff from Sapphire ward spoke about how the huddles had improved team working on the ward, as it enables them to create and agree on a plan to ensure the safety of others. They also expressed how the huddles create an opportunity to learn new things about the service users on the ward; for example if a staff member knows that a particular service user enjoys something or finds something helpful in a time of distress they are able to share this more effectively with the team.
The safety huddles promote collective leadership and also ensure that risks and concerns are not individually managed but are shared and owned by the entire team. Staff in Newham have spoken about how they feel that the safety huddles are most effective when they are multidisciplinary, as this improves the efficiency of decision making. Ruby Triage spoke positively about how consultants help to initiate the huddle each day at a set time which works really well.
Not only have the huddles strengthened team work they have also provided an opportunity to create dispersed leadership. The safety bundle has empowered some of the more junior staff in Newham to lead on the violence reduction work and they have played a vital role in supporting the ward teams to become more reliable with using the change ideas. One of key learning points identified from the teams is that the improvements and reliability cannot be sustained when it relies on one individual; it needs to be a team effort.
In addition to the fantastic reductions in physical violence on many of the wards in Newham, the safety bundle, collaborative learning sets and empowering leadership has transformed the culture on the inpatient wards, with safety and teamwork being at the heart of this.
At the last collaborative learning set, Opal ward reflected on what works well on days when they do not have incidents of physical or non-physical violence and the group asked if they did anything different on these days. The staff shared that there is the feeling on these days that everyone is on the ward and together working towards making everyone else’s day better.
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Perspectives from City & Hackney Inpatient Unit…
The Power of the Safety Discussion in Community Meetings; How openness, transparency and proactive conversations about violence in ward community meetings are helping us to develop a safety culture
By Jen Taylor-Watt, QI Lead for City & Hackney and IAPT and Improvement Advisor for City & Hackney Violence Reduction Collaborative
& Jane Kelly, Associate Clinical Director for Inpatient Care & Lead of the City & Hackney Violence Reduction Collaborative
For a long time on adult inpatient wards, violence and aggression has been a huge issue that really affects everyone – service users and staff alike – and undermines people’s experience of the ward environment. Despite this, it has not been something that we have talked about and shared openly and proactively together. In this way, we’ve allowed it to become the so-called ‘Elephant in the Room’; a force that has a huge effect, but that we’ve continued to pretend isn’t there… probably because we’ve been a bit afraid to admit it’s presence, as we haven’t known what we could do about it.
That was true up until the start of the violence reduction collaboratives, which of course have helped us to understand the forces that can drive greater safety and actually be able to reduce violence on the wards (see introductory article in this newsletter for overview). Along with strengthening our ability to identify and predict violence, and to take action on this as a team (through Safety Huddles and the BVC, see other articles in this newsletter), we’ve discovered that a key driver is in fact ‘dealing with the elephant’ through very proactively creating a culture of greater openness and transparency towards the issue of violence and strengthening safety as a core value in our ward communities.
As Associate Clinical Director for Inpatient Services in City & Hackney, I came to better understand the importance of this early on in the project when talking to staff about their experiences of violence and aggression. I remember a Life Skills Recovery Worker saying that she was ok with working in the unit, because she knew that A&E was next door (in case she was injured). That was not an easy thing to hear, but it was so important to have provided the space to start talking directly about how staff were experiencing and thinking about this issue. These conversations were essential for getting the work underway. Another example of feedback from some staff about their feelings and experiences of violence and aggression is shown on the slide below – this is the output from just one away day conversation in April 2016.
In City & Hackney we also ensured the conversation was had more broadly than the ward nursing teams at the beginning of this work. I took the qualitative feedback and data, showing the frequency of violence and injury on our wards, to the Directorate Management Team and meetings of consultants and operational managers outside the inpatient unit. I think it stopped people in their tracks to hear that a member of staff or a service user was bring injured on the Hackney inpatient unit every 3.7 days. It felt like we were beginning to actually stare the elephant in the face together and it really meant a lot to be offered concern and support from colleagues, such as our psychotherapy service, who offered therapeutic support to staff who were traumatised by their experiences.
Of course, to fully address our elephant we needed to be having the conversation with the other group of people who were so greatly affected by violence and aggression on the wards – our service users. The change package developed in Tower Hamlets gave us two ways to do this…
Firstly, using a Safety Cross, which is a simple calendar that you put on up in the public area of the ward, on which staff and service users record incidents of violence and aggression. It sounds like a small thing, but this is a vital first step to acknowledging proactively that this is happening. We use red dots for incidents of actual physical violence and yellow or orange dots for aggressive behaviours.
The next step, and the focus of the rest of this article, is what we call the Safety Discussion in Community Meetings, which is when staff and service users have a proactive open conversation every week about experiences of violence and aggression on the ward within ward community meetings.
This starts with reflecting together on what is recorded on the Safety Cross, and then staff and service users support each other to explore how this has been experienced, with the aim of identifying and working through issues and learning together. Originally ELFT got the idea for this from some work in the US by Lanza et al[1].
There is so much to say about the impact that these conversations can have in changing the dynamics around this issue on wards. As a quick summary, staff in City & Hackney have mentioned the following impacts:
- A shift in what behaviour we understand to be aggression & a reduced tolerance for behaviours like bullying and verbal threats
- Service users are more inclined to speak about how they really feel about violence, aggression and other unacceptable behaviours
- Service users feeling empowered to voice when they feel unsafe and what they need to feel safe
- There is improved communication, through creating a forum in which service users’ voices are really heard on this issue
- There is more meaningful and thoughtful discussions about triggers for violence and aggression on the wards
- There is better identification of difficulties that might have previously been unspoken and therefore continuing to cause problems under the surface, without staff being able to address them (for example, some issues that have come up have been a sense of divide between service users and staff, not feeling able to get enough support from doctors)
- There have been changes in the way service users interact with each other; with a greater confidence in people’s right to feel safe on the ward
- Service users are feeling more able to raise problems of safety with staff
We feel that all of the above is evidence that we are shifting the culture to one which explicitly holds safety as a core value of our wards. Other ideas in the change bundle, like safety huddles, have helped with that, but the safety cross and safety discussion in community meetings have been critical to ensuring this dialogue has been had not just with staff, but across the whole ward community. The following provides some case examples from the past couple of months in City & Hackney, which illustrate some of the impacts noted above…
Identifying & addressing problems
An example of when the Safety Discussion in Community Meetings helped the ward community to identify problems leading to violence and aggression occurred recently on one of the male wards, during a conversation facilitated by one of our psychologists. During the safety discussion, a service user who had contributed to violence and aggression on the ward reflected on what was underlying his behaviour. He was able to identify that he had been left feeling anxious, angry and in physical pain because of not being able to see a doctor quickly enough. Others in the group shared this frustration, which led to the team raising the issue with medical staff, who agreed to visit the ward more regularly to avoid service users feeling like this.
Changing dynamics
We have also seen the safety discussion in the community meeting changing the dynamics between service users. A Life Skills Recovery Worker on one of the female wards recalls that a day after a community meeting, she heard a service user challenging another on their behaviour, saying “You’re aggressive and that’s not fair on anyone. They said that’s not allowed here, so you need to stop”.
The Ward Manager on the same ward noted there was another incident when a lady challenged another service user who had been exhibiting bullying behaviour for some time:
“It was honestly one of the best moments of my career so far to hear this service user standing up to her and saying ‘you’re bullying me and that’s not ok. I’m not going to stand for it anymore’ “
The Ward Manager continued to reflect on this, noting that the team had obviously been trying to address these issues between the two service users, but it had such power when the lady stood up for herself;
“I think it was crucial that we were talking about it regularly as a ward community; thereby making clear our norms and values around safety and respect for each other”.
A Ward Manager on one of the male wards gave an example of how this shift in culture, through the introduction of the safety discussion, has changed the way in which service users are feeling and relating to staff. They day after the community meeting, a service user, who had in fact been quite agitated and aggressive towards others, came up to the Ward Manager and said “I don’t feel safe”. The Ward Manager felt the person had been processing and reflecting on the conversation from the previous day and that it was really powerful that he had used the exact words from the safety discussion; like he had really internalised the message ‘we all deserve to feel safe here’.
The service user coming to discuss this so openly with the Ward Manager meant that she had a clear opening to explore the person’s feelings with him, and also importantly to get him to reflect on how his behaviours might be making others feel threatened and therefore more challenging towards him.
As a final parting thought, we’d emphasise that this is very much a journey and we’re still learning how to use and get the most out of the safety discussion in community meetings. It’s not always easy to start these conversations. Staff and service users alike are not always comfortable and it can bring up issues between people which are quite challenging to manage. But we’re convinced that this openness and transparency is essential to moving forwards with our ambition to continue to reduce violence and aggression on our wards.
The elephant isn’t totally gone yet, but he’s definitely less powerful than he used to be.
City & Hackney adult inpatient unit started their Violence Reduction Collaborative in February 2016. Violence has reduced by 40% across the unit and upwards of 60% on the acute wards so far (referring to Datix data). Gardner Ward and Joshua Ward in City and Hackney have sustained 65-75% reductions in violence for 6-9 months.
[1] Lanza ML, Rierdan J, Forester L, Zeiss RA (2009) Reducing violence against nurses: the violence prevention community meeting. Issues Ment Health Nurs 30(12): 745-50.
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Safety Huddle Implementation
Being part of the violence reduction collaborative at ELFT has seen a significant reduction in violence and aggression on the ward…
This clip was shown to delegates attending the 2017 Annual QI Conference in London
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Violence Reduction Collaborative Stories
Being part of the violence reduction collaborative at ELFT has seen a significant reduction in violence and aggression on the ward…
This clip was shown to delegates attending the 2017 Annual QI Conference in London
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The Violence Reduction Collaborative
Being part of the violence reduction collaborative at ELFT has seen a significant reduction in violence and aggression on the ward…
This clip was shown to delegates attending the 2017 Annual QI Conference in London
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Violence reduction on older adult mental health wards
The Safer Wards project aimed to increase the safety of patients with mental health needs, specifically tackling the level of violence and aggression on older adult wards in Newham and Hackney, sites covered by our East London mental health trust. We developed a strategy to tackle this issue based on Quality Improvement methods, to better understand the issues underlying the problem, and plan a service improvement that would be feasible within financial and resource constraints. The specific aim of the work was a 20% decrease in violent incidents on the 3 wards in City and Hackney, and Newham
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Reducing incidents of physical aggression on the Coborn PICU
This projected was presented at the 2017 Annual QI Conference.
Overall Aim: To improve the number of incident (physical aggression) free days by 50% for each admission on Coborn PICU (Psychiatric Intensive Care Unit) by May 2017.
Rationale:
- Improve patient care and experience
- Reduced number of restraints and use of rapid tranquilisation
- Improve staff safety, morale and staff confidence in managing risk
- Create a safe environment for young people
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Newham Violence Reduction Collaborative
This projected was presented at the 2017 Annual QI Conference. Since June 2016 Newham’s Inpatient wards have been part of planned experiment to test and evaluate the Safety Culture Bundle which was originally developed in Tower Hamlets. Each ward is testing out different combinations of the below change ideas
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City and Hackney Violence Reduction Collaborative
This projected presented at the 2017 Annual QI Conference is working to reduce violent incidents across our City & Hackney Adult Mental Health Directorate.
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Reducing physical violence and developing a safety culture across wards in East London
Violence is the biggest cause of reported safety incidents at East London NHS Foundation Trust. Evidence suggests the utility of structured risk assessment, discussion of violence in ward community meetings and the use of restraint and seclusion in psychiatric wards. The Tower Hamlets Violence Reduction Collaborative brought together six wards with the aim of reducing violence by 40% by the end of 2015. A collaborative learning system was used to test a bundle of four interventions on the four acute admissions wards and two psychiatric intensive care units. A 40% reduction in physical violence was seen across the six wards. Physical violence reduced from 12.1 incidents per 1000 occupied bed days in 2014 to 7.2 in 2015. Across the four general acute admissions wards there was a 57% reduction in physical violence. Key elements of the system that have been addressed through this work have been developing a more predictive approach, and developing a more open and shared experience of violence and aggression on the wards.
Click on the image to read the full article
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Violence Reduction Collaboratives in Newham and City & Hackney
Newham and City & Hackney Inpatient units have been working since early 2016 to reduce violence and aggression on the inpatient wards, building on the work of the Tower Hamlets Violence Reduction Collaborative. Sustained reductions in violence are now being experienced in both services, with reductions of up to 86% linked to the project on some wards.
The wards and Psychiatric Intensive Care Units (PICUs) have been working hard to reliably use change ideas from Tower Hamlets, including for example Safety Huddles, which are brief stand-up meetings during which as many staff as possible from the ward come together to try to identify and predict risks and then develop plans for how to manage these risks together.
Both units have developed creative ways to boost the reliability of using their change ideas, including the Newham Reliability Race and the City and Hackney Safety-Huddle-o-Meter (see figures 1 and 2). Along with ward-level strategies, these visual displays help to raise awareness across the units and foster friendly competition between the wards!
Violence and aggression obviously has a profound effect on inpatient settings, compromising our service users’ care and staff experience at work. The hard work and courage of staff in City and Hackney and Newham to share and learn together in their local violence reduction collaboratives, is now changing the systems people are working in and transforming experience. This is reflected in recent comments from staff and peer support volunteers, which you can read in in figures 3 and 4 below, as well as the collaboratives’ numeric data, shown in figure 5.
Reducing violence and aggression isn’t easy – and we know we’ve got a lot more learning to do together – but we’re very excited by all that has been achieved so far.
We’re looking forward to the further learning and reductions to come in 2017!
The Forensic service has also launched its own violence reduction collaborative, with the support of the QI team, developing an understanding of the unique drivers of violence and solutions within forensic settings. This will be featured in a future newsletter.
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Reducing Physical Violence on the Globe Ward
Please learn more about this completed ELFT QI project from the adjacent poster.
ELFT staff, service users and carers can access full details of this project on QI Life.
The project code is 100909, please log onto your QI Life account before clicking the logo below.
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Safer Wards: Reducing Violence on Older Peoples Mental Health Wards (BMJ Quality)
Through the Safer Wards project we aimed to reduce the number of incidents of physical violence on older people’s mental health wards. This was done using quality improvement methods and supported by the Trust’s extensive programme of quality improvement, including training provided by the Institute for Healthcare Improvement. Violence can be an indicator of unmet needs in this patient population, with a negative effect on patient care and staff morale. Reducing harm to patients and staff is a strategic aim of our Trust.
Please click the PDF to the left to read more about this ELFT QI Project published in BMJ Quality.
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Tower Hamlets Violence Reduction Collaborative
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By Andy Cruickshank, Borough Lead Nurse/ Associate Clinical Director Tower Hamlets
On Thursday 12 March, the Tower Hamlets Violence Reduction Collaborative met for the second time. A great deal has happened in the 6 weeks since we last met.
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Blog on Tower Hamlets Violence Reduction Collaborative
By Andy Cruickshank, Borough Lead Nurse/ Associate Clinical Director Tower Hamlets
On Friday 30 January, we held the first ever learning set for what has been titled the Tower Hamlets Violence Reduction Collaborative. This is a way of creating a community who learn together and from each other, about what they have tried to do to reduce violence on our wards.
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Update on Violence Reduction Work
Within Older People Services there are a number of initiatives being tried and tested in order to reduce violence and aggression on our wards. MHCOP have set up a Directorate Project Group to oversee the work and three wards with the highest levels of violence were identified to be designated pilot areas. The testing wards are Sally Sherman (East Ham Care Centre), Cedar and Larch (both at The Lodge in Hackney). Both Sally Sherman ward and Cedar are Continuing Care Wards and Larch is an Acute Admission Ward.
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Reducing Violence on Acute Wards
As the Trust’s quality improvement programme starts to take shape (with the strategy agreed by the Trust Board, the project structure coming into place, and our procurement of a strategic partner due to complete in February), we’d like to share with you the quality improvement journey of one of our teams that has been testing this approach for the past year as part of a pilot. In this article, Paul McLaughlin, Modern matron on Globe Ward at the Tower Hamlets Centre for Mental Health tells us what they have been doing to improve quality.
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