18 March 2015

Tower Hamlets Violence Reduction Collaborative

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Andy CBy 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.

After the last event, there was the usual energy and optimism that often follows new initiatives. In my experience this often gives way to a vague sense of disillusionment as the realities of progressing ideas and doing things differently begins to take hold. The attrition of enthusiasm is normally attributed to resistance in practice; if not in principle; of colleagues and our patients. We are truly creatures of habit and normality is something as assuring as it can be exasperating. I was struck by Pedro Delgado’s address at the QI Conference on Tuesday 10March; where he talked about the need to establish the “new normal”. It is a fact that we want to create the conditions in which violence is seen as an abnormal event. However, in order to do this, we have to change the notion of “normal” in a much greater sense; in our thinking, in our behaviour and in the way we do things together. That’s a stretch for us. It is easier to have the idea – harder to get it into practice and then harder still to measure if it is having the anticipated or hoped-for effect. So resistance is part of this work – resistance to change, resistance against the methods used or the ideas proposed.

Don’t get me wrong – I think resistance from ourselves, colleagues or patients is hugely informative and helps us gain deeper insights into why we may need to pause, think and change tack. However, procrastination is the thief of time and nothing really beats trying things out – so long as we are clear about the ethical implications of our actions. In this regard, the collaborative have already been hugely impressive. Their alacrity at pushing forward ideas into actions has impressed me enormously. Their challenge is to meet the resistance to their ideas and use it to progress and not allow it to stall what is a fundamentally decent ambition – to make violence so rare we will all see it as the abnormal event it should be. But there is more to say about their progress.

I was so struck in our meeting at how much curiosity is a feature of improvement work. Many of the people engaged in this were asking themselves and their teams “why do we do it this way?” or “what if this were different? What would that look like?”. This is the essence of the changes we are beginning to see.

The ideas range from changing ward rounds to daily reviews; creating new ways of having difficult conversations that focus on care and concern – not blunt control and coercion; paying attention to atmosphere and noise; creating nursing “zones” – as well as the established care bundle being used more reliably.

And so, what are the signals from our system? Well, although it is too early to say that it’s definitely working (this will take much more time and we will need to understand the influence and interactions between the change ideas) there has been a reduction in violence of some 20% on our acute wards in the last 6 weeks and several consecutive violence free days on the Women’s Psychiatric Intensive Care Unit. A very promising start!

One of the change ideas is a daily mindfulness group – we all took part in the exercise and there is something very apt about learning to focus, control our attention and lower our tension. These themes are universal and offer new ways of connecting with our patients and helping. It’s really good stuff!

We will meet again in 6 weeks and I’m really looking forward to it. They’re an amazing group to connect with – if you want to know more please get in touch via Andy.Cruickshank@eastlondon.nhs.uk

Thanks for taking the time to read this.



Read Andy’s first blog on the collaborative here >>

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