Quality improvement in forensic mental health: the East London forensic violence reduction collaborative

Reducing violence and aggression: a quality improvement project for safety on an acute mental health ward

Violence and aggression (V&A) are identified as an issue on mental health wards that negatively affect staff, patients, care delivery and safety. This project took place on a male acute mental health ward where V&A are known to be an issue with an average of 21.3 incidences per month in the 6 months preceding the project.The aim was to use QI (Quality Improvement) methodology to reduce incidences of V&A by 20% over a 4-month period. A root cause analysis was completed with staff, previous QI projects and literature on interventions for V&A were reviewed. Two changes were introduced via PDSA (plan, do, study, act) cycles; first was a safewards bundle including a training package, weekly emails and noticeboard displays, the second was safety crosses displayed on the ward.There was a reduction in incidences of V&A across the project, mean weekly incidences reduced from 2.5 at baseline audit to 2.0 at the end of the project. This equates to a 20% reduction in V&A. The project did result in an increase of safewards interventions recorded and staff ratings of ward safety improved. There was a statistically significant correlation found between incidences of V&A and rates of restrictive practices.Further analysis of the 20% reduction did not find a special cause variation, so results may be due to a common cause variation rather than the QI interventions. Safety crosses were not found to have an impact on rates of V&A, it is likely these need to be more embedded into communication about V&A on the ward. Potential confounding patient variables such as illicit drug use and history of V&A as well as staffing should be recorded and monitored in future projects. Recommendations to enhance further change should include regular meetings with both staff and patients to support open communication about the topic.

User violence prevention and intervention measures to minimize and prevent aggression towards health care workers: A systematic review

Workplace violence in the health care setting is a social problem of great interest both at the health care level and in research in recent decades. The most common type of violence is the one coming from the user towards the professional. Although the bibliography includes multiple preventive actions focused on working with professionals, there are hardly any studies that explore and collect actions aimed at the user. The aim of this study is to analyze the results of the literature to provide an overview of the current evidence. Specifically, it aims to describe the various user-directed strategies or interventions aimed at reducing workplace violence experienced by professionals within the healthcare sector. A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), methodology of publications published up to December 2022 in the main databases. Studies that met the previously established eligibility criteria were identified. A peer review of the risk of bias was performed and the data were extracted from a previously elaborated template. The search yielded 5231 articles of which 11 were finally included in the review. Of these, 3 had a quantitative design, 7 had a qualitative design and one had a combined design. Of these, 38 measures or actions aimed at the user were compiled, grouped into four blocks according to the attitudinal objective pursued: Improvement of communication and creation of links, involvement of the user in joint decisions with the staff, informing and training the user, and other independent proposals. This study makes it possible to explore actions aimed at users with the objective of reducing violence towards health professionals. It collects and makes available to the scientific community a set of measures aimed at making a change of attitude in the perpetrator themselves, with the involvement of the perpetrator in the health system. This set of collected measures provides researchers with a basis to be taken into account for the implementation of future prevention plans according to the new multicomponent prevention models and with the involvement of the perpetrator themselves.

Prevalence of Physical Violence in the Medical-Forensic Approach in the Years 2015-2020 in City and Neighboring Municipalities: Perspectives from Poland-Poznań Study

Forensic medical opinions serve the appropriate classification of a crime against health. Violence, a multifaceted phenomenon, requires forensic medical examination in the case of causing damage to health. Due to the effects caused by the perpetrator, the damage to health is divided into severe, medium, and light. This study analyzed 7689 incidents of violence from 2015-2020, taking place in the area subordinate to the Provincial Police Headquarters in Poznań, based on anonymized documentation of forensic medical examinations performed at the Department of Forensic Medicine in Poznań at the request of the Police and privately. The analysis took into account: units ordering the test, type of exposure, medical help, sex and age of the victim, places of the incident, classification and localization of injury, manner of impact, attitude of the perpetrator to the victim, profession of the victim, gender of the perpetrator, and remarks. In Poland, statistics on violence victims are underestimated, resulting from the low reporting of crimes committed to law enforcement authorities. There is a need for programs to educate the perpetrator of violence on methods of conflict resolution and programs to prevent violence, covering events taking place in public spaces.

Sources of Conflict and Prevention Proposals in User Violence Toward Primary Care Staff: A Qualitative Study of the Perception of Professionals

Background

Some studies indicate that at least one in four cases of workplace violence occurs in the health sector, with a higher incidence in Emergency Departments, Mental Health Services or Primary Care. Unlike other professional groups, healthcare workers perceive this type of behavior mainly from users or patients. This is the reason why both the detection of conflict between users and professionals and the ways to face and reduce these conflicts has been and is one of the main fields of study in this population. The aim of this study was to delve into the sources of conflict between users and professionals in Primary Care from the perspective of the professionals themselves. In addition, the aim was to explore the proposals for intervention/prevention of this conflict that the professionals perceived as necessary to improve the work environment.

Methods

This study uses qualitative methodology conducting 8 focus groups with professionals related to Primary Health Care. The final sample was composed of 44 workers who were part of the regional management, labor unions, area coordinators, center coordinators and representatives of the professional groups of these centers (medicine, nursing and administration). Thematic analysis was used to extract topics and subtopics.

Results

The results are divided into areas of conflict and intervention proposals. The professionals detect a lack of training or education in themselves, absence of functional multidisciplinary teams or competencies to improve the patient-professional relationship, among others. To address these shortcomings, they propose the creation of protocols for action in the face of aggression, the formation of spaces and channels of communication both among the center's own workers and between them and other organizations (e.g., hospitals), fostering a positive relationship with the user community and ongoing training in various topics such as self-safety, management of emotions, empathy or interpersonal communication.

Conclusions

This study allows to highlight specific areas of user-professional conflict in Primary Care. Furthermore, the inclusion of intervention proposals by the professionals allows to propose starting points for the development of complete plans.

Flip the Triangle: using quality improvement methods to embed a positive behaviour support approach on a medium secure forensic ward for men with intellectual disabilities

Incidents of violence and aggression are serious concerns on a secure ward for people with intellectual disabilities and are often met with increases in physical and restrictive interventions. However, these interventions are usually high risk for both patients and staff and are ineffectual in promoting long-term behaviour change. This study aimed to promote positive culture change and embed the evidence-based practice of positive behaviour support by shifting focus and efforts from the use of physical and restrictive interventions to manage crises to intervening positively and proactively to prevent crises from occurring. The key drivers for change involved increasing access to positive engagement opportunities, expanding the staff team’s repertoire of proactive interventions through training and skill development and supporting staff well-being and resilience. Change ideas occurred alongside a shift in culture that promoted the development of a learning culture, psychological safety and consideration of contextual fit. Quality improvement methods helped the project increase the rate of positive and proactive interventions from 70.65% in December 2018 to 97.18% in January 2020. Increases in staff’s knowledge, confidence and safety were also reported. Lessons and limitations of the project are discussed.

When policy fails try something different integrated practice improve outcomes for dual diagnosis co-occurring service users accessing mental health services

Purpose

This paper aims to discuss an initiative developed between, Leicestershire Partnership National Health Service Trust and Turning Point, which is the locally commissioned drug and alcohol service in Leicester, Leicestershire and Rutland. The aim was to improve outcomes for clients with dual diagnosis (co-occurring mental health and substance misuse) issues. The purpose of the change in working practice was to engage with local substance misuse agencies more effectively to improve clinical outcomes within this service user group. This was achieved through four interrelated approaches. This comprising providing an integrated service. It included building relationships with substance misuse services, providing specialist dual diagnosis clinics and the introduction of substance misuse workers onto mental health wards and group work specific to substance misuse. The outcomes included easier access to services for service users and greater uptake of service users who were moving onto substance misuse services. This led to a reduction in risk related to prescribing and fewer incidents related to prescribing changes and greater engagement in services. When service users were moving between services better communication led to prescriptions being transferred with no delay and to reduced dropout rates in service. There was improved access to substance misuse services, more referrals and take up of service taking place. There was a greater understanding by staff of co-occurring substance misuse and how to work with this client group. Closer working relationship with substance misuse services and shared skills led to greater confidence in managing this service user group. This demonstrates a cost effective service that can be replicated within similar settings.

Design/methodology/approach

In clinical practice, shared treatment has proved challenging in light of different service models (Laker, 2006). Substance misuse works on the premise of change comes from the individual, where recovery models in mental health offer a formalised approach. One of the challenges faced by services has been the inability for mental health services to recruit and services become overstretched (Rimmer, 2018); this gave an opportunity for a new method of working to be considered. This led to the development of a new service model.

These changes were:

• Improving the interface with substance misuse services to improve access to community substance misuse services for mental health clients.

• To provide specialist staff within the dual diagnosis field to provide a clinic jointly with local drug and alcohol services.

• Introduction of substance misuse workers as team members on acute mental health and rehab wards.

• Group Substance Misuse programmes.

Findings

Working within an integrated model, yet maintaining separate organisations, by offering joint training and clinics has led to a greater understanding of each organisation’s work and increased engagement within the service user group.The introduction of substance misuse workers to acute and rehab mental health inpatient services encouraged service users to engage at the point of admission and to be referred into locally commissioned substance misuse services prior to the point of discharge. Engagement with staff has demonstrated better engagement with substance service by service users following discharge.For clients able to take leave assessment could take place prior to discharge. This led to an increased uptake in services. Due to no opiate substitution given on discharge decreased risk of prescribed medication overdose at point of discharge and led to increase in returning straight to substance misuse services. This meant that service users received medication quicker and the right dose and on discharge ensured reduced risk. The prescribing of Naloxone at discharge is yet to be assessed, but the risk of an overdose within seven days is well-documented and Naloxone is key in reversing this trend. This change in practice can be replicated in any mental health setting and has increased access to services for those using substances.

Originality/value

Is original no other services have substance workers or joint clinics across the UK. First inpatient unit to welcome patients back post-discharge to attend groups.

Quality improvement at East London NHS Foundation Trust: the pathway to embedding lasting change

Purpose

East London NHS Foundation Trust (ELFT) is a major provider of mental healthcare and community health services. Quality improvement (QI) has become central to its organisational policy and goals for which it has received national and international attention.

Design/methodology/approach

This piece reflects on the Trust's transformation and its approach. It provides many examples and discusses several of the associated challenges in building and sustaining QI momentum. It is the result of a range of perspectives from staff involved in planning and building large-scale QI capability. It contextualises QI's current status in UK mental healthcare.

Findings

Several key factors were identified: board-led commitment to organisational transformation; investment in training and resources to support staff motivation; clear and realistic project goals in line with the service's over-arching strategic direction; support for service users and staff at all levels to get involved to address issues that matter to them; and, finally, placement of a high value on service user and staff qualitative feedback.

Practical implications

Building QI capability represents a significant challenge faced by all large healthcare providers. Sharing experiences of change can assist other organisations achieve the necessary buy-in and support the planning process.

Originality/value

Achieving and sustaining lasting organisational change in healthcare is challenging. This article provides a background on QI at ELFT and reflects on the pathway to its present position at the forefront of the application of QI within healthcare.