Reflections of an improvement coach in reducing restrictive practice in mental health in-patient settings across the North West of England

In this blog Paul Greenwood, Programme Manager, Advancing Quality Alliance (Aqua) discusses his involvement as Improvement Coach for the Innovation Agency NWC and Health Innovation Manchester as it nears the end of its commission later in 2023.

For the last 18 months, I have been working in partnership with Health Innovation North West Coast and Health Innovation Manchester (previously known as AHSNs) in the North West of England, as an Improvement Coach, to deliver the Mental Health Safety Improvement Programme: Reducing Restrictive Practice

Over the past 10 years, I have been heavily involved in implementing least restrictive practice using improvement methodology. I have seen big strides made within mental health in-patient settings, although in recent years it has felt like two steps forward and one back with the challenges around capacity and demand impacting upon services.

The challenges facing the services could lead you to feel now is not the time to implement least restrictive practice, or that it isn’t sustainable. I want to challenge that view and focus in on work done within the programme in three areas, workforce, environment and culture.

Is it possible to implement improvements when there are high levels of staff turnover/vacancies or agency use?

When working in a least restrictive way, teamwork is everything. Wards work best when they retain a good skill mix and involve allied health professionals, Psychologists and activity coordinators, and make them all feel a part of the team.

I know shifts are stressful due to acuity and staffing, but in this work, I have seen staff focus on their wellbeing through psychological support on the wards and how important this is for both staff and patients. Positive recognition that you are valued, no matter how small, can make a world of difference.

I have seen time and again teams who are close-knit, supportive and resilient, turn around situations for the better without the need for restrictions. Maybe there is never a perfect time to improve but maybe when it’s challenging is the best time. Keeping improvement small and simple is the key to success.

It’s always good to aspire to achieve great things but do what can now to make a difference.

Are in-patient environments conducive to maintaining least restrictive approaches?

In-patient environments can sometimes feel claustrophobic with limited space to do activities. Courtyards that are difficult to access, and limited visitor spaces with noise and poor acoustics that can impact patients’ sleep and recovery.

In this programme, staff and patients have worked creatively on improving courtyards, utilising sensory resources from comfort boxes to relaxation rooms, and improving activities in the evenings and weekends. The list is endless when it comes to being creative with what you have.

I think the challenge is more about bringing others along with you to make those changes. So you need to build your supporters: whether it’s colleagues who are more risk averse and prefer to keep the status quo, patients, carers, quality improvement leads, or managers (especially execs).

Incidents do happen and a blanket rule approach to say “stop doing it”, can be detrimental. So let’s move towards collaboration and co-production, involving people in finding solutions.

Is ward culture sometimes driven by a ‘tasks and rules’ mentality, particularly when demand is high?

Besides the environment, it’s also how patients and staff engage with each other in a busy, complex environment with many rules and procedures.

I have found that going through unwritten and blanket rules is a good way of holding the mirror up to a team. Within the programme, the teams have been looking at the rules alongside patients and working to amend or get rid of some of them. We all like a rule that works in our interest, but wards need to work with compromise and have clear rules that have value to everyone. Some rules may be dropped and reinstated if the situation changes, but some rules are beyond the pale and need to be binned.

So how can least restrictive work be sustained in challenging environments like in-patient settings? These are some of my thoughts:

  • For patients and staff, trauma should be recognised and discussed in individual and group supervision/formulations.
  • Patients, carers and families should feel they are valued participants in how in-patient units work. What might be seen by staff as ‘least restrictive’ can be challenging for others, so be open to the consequences of being least restrictive.
  • Staff and patients should feel competent in utilising sensory resources to support emotional regulation, with policies and procedures developed to support staff in their use.
  • Data should be trusted by teams and used to tell their story and help drive best practice.
  • For continuous improvement to be effective, it must be understood and appreciated by management, and that performance is driven by improvement – not the other way around.

How about starting a conversation with your colleagues about being least restrictive and trauma informed?  If you don’t start the conversation, then service users will.

Any views or opinions represented in this blog are personal and belong solely to the blog owner, and do not represent those people or organisations that the owner may be associated with.

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