Looking back and looking forward: the Forensics Violence Reduction Journey
Nynn-Hui Chang –
Improvement Advisor
This is the story of how eight Forensics wards worked hard to achieve and sustain a reduction of 8% in physical violence and a 16.6% reduction in non-physical violence incidents per 1000 occupied bed days as part of the violence reduction collaborative. Words by Improvement Advisor Nynn Chang.
Last month, Forensics celebrated not only their 2 year anniversary since embarking on the violence reduction journey but also the positive impact noted as a result of the improvement work. This month, we are going to look back and reflect on how it all started for Forensics, the challenges, and what helped to transform the culture and perceptions towards violence in the directorate.
Why was reducing violence and aggression important to Forensics?
The nature of the service meant that there were higher levels of violent and aggressive incidents compared with the adult mental health wards across ELFT. Reflecting on serious incidents in Forensics, evaluating the leavers’ profiles and staff sickness rates, it was apparent that violence and aggression was centre to it all. Staff did not feel safe at work. It was therefore a priority for the service to improve on safety because the negative impact of violence is not only costly on an operational level but also psychologically for the victims, witnesses, team and ward’s morale. It is a very much a downward spiral for both staff and service users as highlighted in Figure 1 (please click to enlarge).
Fig:1 Negative impact as a result of violence for staff (left of the spiral) and service users (right of the spiral). Please click on the image to enlarge it.
Attending wards’ away days during the early phase of this violence reduction work, it was evident that some wards have reached the tip of the downward spiral. Staff morale was very low, and bank staff will not take shifts on certain wards where a poor reputation has developed from housing very high levels of violence and aggression.
Forensics had trialled different interventions since 2012 such as using the Broset Violent Checklist (BVC) and involving local police post violent incident. However, the impact of these interventions was minimal. Learning from colleagues in Tower Hamlets who succeeded in making remarkable reductions on their inpatients ward, Forensics adopted their change package (safety cross, safety huddles, and safety discussion in community meetings) to test in Summer 2016. Four wards with the highest number of violent incidents in Forensics were selected to be part of this quality improvement (QI) initiative, and together they formed the violence reduction collaborative with one united aim – to reduce violence and aggression by 30% by December 2017. The collaborative expanded to five wards in January 2017, then to a total eight wards by July 2017. The latter three wards came forward on their own initiative wanting to also tackle violence and aggression on their wards using the change package. The aim was then extended to March 2018 to account for the new wards joining the collaborative.
On a collaborative level (aggregate data for seven wards, one ward stopped collecting data in April 2018), they achieved and sustained a reduction of 8% and 16.6% in physical violence and non-physical violence incidents per 1000 occupied bed days respectively. Although it is not a 30% reduction as envisioned, the improvement seen to date means that on a weekly average, there is 1 less physical violence, and 17 less of non-physical violence happening across the seven wards, compared to baseline.
On a ward level, there was a greater degree of success with reaching the aim for a number of wards. Three wards achieved at least 30% reduction with their physical violence incidents each week. Five wards also attained at least 30% reduction with their non-physical violence incidents each week. See table below for the summary of these reductions (please click to enlarge):
Please click on the image to enlarge it.
Did Forensics achieve what they set out to achieve?
Despite not all wards meeting their aim, there were still some significant improvements that the violence reduction work has brought, which cannot be quantified solely by numbers. For example, wards describe a culture shift towards collaborative working with the service users on the wards, building a real sense of community whereby staff and service users are taking ownership in tackling violence together. Before the improvement project, violence was not openly discussed, blame and shame were often associated with violence, and only senior management held the responsibility for tackling violence.
Staff and service user representatives from the collaborative wards also shared what they are proud of as a result of the violence reduction work, and why they felt it is important to make Forensics a safer environment. Hear it directly from them in the video recorded during the celebration event.
Hear it from other staff and service users when we asked if they are feeling safer:
What were the key ingredients for enabling the work?
As with all QI projects at ELFT, there is a QI sponsor. Their main role is to champion improvement projects, and help the project teams to unblock challenges. Hear it from Day Njovana, QI Sponsor for the violence reduction work in Forensics. He reflects on his role as the QI sponsor, the challenges in getting the work started and top tips for overcoming the barriers.
Having a regular monthly collaborative also helped bring people together to stop, think and to go faster with the violence reduction work. It allowed wards that are implementing and testing the change package to connect, learn together and from each other, challenge the perceptions of violence, and build a collective understanding of why it occurs. For example, Bow ward found the value by recording each of their safety huddles as it helped to bring clarity on the agreed plan. It also improved communication to staff coming on the next shift to know what has been discussed in the previous huddle, for example who is feeling unsafe and which service user will be dissatisfied with their care today. As a result, Bow ward created a safety huddle book. This best practice was shared at the collaborative, and it was adopted by five other wards.
Service users are invited to join in the conversation at every collaborative. They add the richness into the discussion by providing expert insight into why violence and aggression matters and how it occurs on wards. Having service users at the collaborative also gives staff the confidence to involve and work more collaboratively with them on a ward level. One service user on West Ferry ward, which is a Psychiatric Intensive Care unit, described the impact of being involved as part of the safety discussion in their weekly community meetings as follows:
“When you guys first brought it to community meetings it felt like we were being blamed especially when you looked at all those orange and red dots on the map. You found that we ended up arguing amongst us and others would even walk away from the meeting.
Over time, continuing to talk about it made us realise that we were also a part of the issue and we needed to understand how to support each other and live safely as a community.
Talking about violence also made us feel listened to as the whole team was there and we could reflect and how staff or us could work or treat each other to make sure the ward was safe.” – Service user, West Ferry ward
Celebrating success frequently along the way also helped with sustaining momentum with the work. For example, wards took the initiative to celebrate three consecutive green days (incident-free days) with their service users. It created a community approach to make this a priority. It was also a more meaningful and relatable outcome than a 30% reduction in violence and aggression incidents for the service users. This also helps to motivate both staff and service users and building the degree of belief that safer wards are possible with the change package.
Looking forward
As captured nicely by one of the collaborative wards (Ludgate), the violence reduction journey to date has been a bit like “weathering the storm and sailing into the sunset”.
We feel this analogy applies to the overall collaborative journey as well. Sometimes we have to pause and look back on how far we have sailed past the storm. There is still some distance to go, for example focusing on the next strand of the violence reduction work on sexual violence and aggression. It may get stormy again on the way as that is life, but we are better equipped this time round. So with our heads up, we will continue our journey sailing into the sunset to a much safer work, and therapeutic environment for recovery for both service users and staff.
