Perspectives from City & Hackney Inpatient Unit…

Jen & Jane

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.