Problem

Shoreditch Ward is a 14-bedded medium secure service for men with intellectual disabilities in East London. The service provides assessment and treatment to men over the age of 18 who have committed a criminal offence and/or are currently displaying high levels of challenging behaviour that cannot be safely managed in lower levels of security. Service users on Shoreditch Ward also present with multiple comorbidities including autism, Attention Deficit Hyperactivity Disorder, psychosis and personality disorder. The service receives referrals from across London boroughs and the patient population represents men from a range of ethnicities and varying degrees of socioeconomic status.

As a forensic service, we are particularly skilled at risk assessment and risk management. However, this meant much of the team’s focus was directed at managing incidents of violence and aggression when our patients were experiencing a ‘crisis’ episode. Intervening at crisis points could commonly be associated with the most risk to both patients and staff and often involved physical and restrictive interventions. Focusing on crisis situations could also mean patients displaying ‘settled’ behaviours were sometimes overlooked and their positive behaviour was not acknowledged or reinforced.

While Shoreditch Ward had positive behaviour support (PBS) plans to proactively manage challenging behaviour in place for its service users, there was still a high incidence of violence and aggression on the ward. To explore this further, the team undertook an exercise to analyse the daily safety plans developed in ‘Safety Huddles’. This highlighted that the most common plans were ‘low-threshold for seclusion, give pro re nata (PRN) and maintain boundaries’. It became clear that the PBS plans were lacking ‘contextual fit’, did not involve the whole multidisciplinary team (MDT) and there was no system in place to operationalise and implement the plans in clinical practice.

The ‘Flip the Triangle’ quality improvement (QI) project aimed to develop a model of care and culture on the ward to take an embedded and multidisciplinary PBS approach. This involved ‘flipping’ the attention and effort of our staff team to increase focus on positive and proactive interventions to manage and prevent challenging behaviours (eg, violence and aggression) before they occur. Therefore, the project’s primary aim was to increase and maintain our positive and proactive interventions to a rate of 95% by January 2020.

Background

Incidents of violence and aggression are a serious concern for mental health services and evidence suggests QI methods can be an effective tool to examine and implement changes to reduce violence in mental health and secure settings.1 2 Recent research found physical assaults to be the most common form of incidents on an intellectual disability secure ward,3 and incidents of violence and aggression are most likely to be managed through a number of physical and restrictive practices, including restraint, seclusion and medication.4

The ethics of using physical and restrictive interventions have been contested by researchers, policymakers and advocacy groups, with these interventions often described as aversive and traumatising while also proving ineffectual in creating long-term behavioural change.5 6

In the UK, a number of government policies and strategies aim to reduce physical and restrictive practices in intellectual disability services. While early literature focused on removing access to restrictive practises (eg, closing seclusion rooms, outlawing restraint), modern literature recognises the complex systemic changes needed to successfully reduce restrictive practices. Focusing on simply reducing or eliminating restrictive practises without the appropriate supportive structures can contribute to a culture of fear and blame within mental health services.7 What is now recommended is a service-wide cultural shift towards recognising and improving leadership, education, support, service user involvement, preventative action and the therapeutic environment.8

The National Institute for Health and Care Excellence guidelines9 10 recommend a move towards positive and proactive approaches to manage challenging behaviour. PBS is a person-centred approach that understands challenging behaviour to be driven by unmet needs. Positive and proactive interventions involve making environmental and interpersonal changes to support individuals to meet their needs through alternative, positive strategies, while also teaching new skills in order to increase quality of life.

While the efficacy of PBS approaches has been studied in a number of different contexts, a recent study11 was the first to examine the effectiveness of this model in a medium secure setting for men with intellectual disabilities. PBS was found to be an effective method for reducing the frequency, severity and management difficulty of aggressive challenging behaviour.

Collaborative safety (CS) plans12 are a whole-team approach to PBS whereby multidisciplinary professionals, service users and their families collaborate together to develop meaningful plans. CS plans have been developed based on the time-intensity model of escalation13 and incorporate background information and a brief formulation of challenging behaviour, baseline presentation, triggers, three phases of escalation (early, mid and late), crisis and postcrisis, in addition to strategies to manage each phase. The ethos of this six-page document is that it is a live and accessible document that is regularly updated and reviewed as new learning is achieved.

Due to the flexibility and adaptability of the CS plans, they are designed to consider the ‘contextual fit’ of the PBS approach. Contextual fit refers to the ‘congruence between the behaviour support intervention and the values, skills, resources, and routines of those who will implement the intervention’14 and can be associated with the effectiveness and sustainability of the approach.15

Therefore, the culture and values of a service can be key for the successful and effective implementation of PBS approaches. A ‘Psychologically Safe’ culture refers to a culture in which all members of a team feel able to share ideas and opinions without concern they will be judged negatively by other members of the team.16 Psychological safety has been associated with greater team effectiveness as it can create a ‘learning culture’ whereby individuals feel comfortable and confident engaging in learning behaviours; asking questions, speaking up, sharing ideas, listening to feedback, taking positive risks and trying new things.17

Measurement

Physical and restrictive practice data comprised the number of days spent in seclusion, days on enhanced observations, incidence of restraint, incidence of intramuscular rapid tranquilisation and number of doses of PRN medications (including sedative medications prescribed as regular). The number of positive and proactive interventions was initially collected through reviewing daily entries in each patient’s electronic record; for example, leave, 1:1s, therapeutic sessions, references to de-escalation, facilitating family contact. Data were collected weekly and each week, the percentage of positive and proactive versus physical and restrictive data was calculated and entered into the QI life system. Baseline data were collected between October and December 2018 and we found that 70.65% of our interventions were positive and proactive. We also measured the staff team’s confidence responding to service users’ challenging behaviour, understanding of service users’ challenging behaviour and how safe the staff felt working on Shoreditch Ward.

Design

The project’s primary aim was to increase and maintain our positive and proactive interventions to a rate of 95% by January 2020. Although defining and collecting data regarding physical and restrictive interventions was relatively straightforward, defining and collecting data for positive and proactive interventions was more complex. We initially measured positive and proactive interventions by reviewing notes on the electronic system; however, it was noted that this system may not truly reflect the breadth of interventions delivered. This was changed early on in the project to a ‘dots based’ system. Every morning, a chart with each patient’s initials at the top was placed on the inside of the door to the nursing office. When a staff member had engaged in a positive and/or proactive interaction with a patient, they placed either a light blue or a deep blue circular sticker under the patient’s initials. Operational definitions of light blue and deep blue dots were cocreated and shared among the team. ‘Light blue’ interventions consisted of ‘everyday’ and ‘routine’ positive and proactive interventions aimed at keeping a patient at baseline (eg, supporting a patient to attend work, escorting them to the barber, making them a cup of tea, having a short 1:1). ‘Deep blue’ interventions required additional thinking or effort from the staff team. For example, careful consideration by the MDT and planning among escorting staff to safely organise a home visit for a service user who has not been home for a number of years or engaging in a period of proactive de-escalation once a service user has entered an escalation phase.

The QI team adopted an approach of flexible membership and invitations to QI meetings were open to all staff members (including bank and student staff) in order to promote a bottom-up approach and redistribution power and involvement across the professional hierarchy. There was a core multidisciplinary team who attended all meetings which included representations from psychology, nursing, speech and language and occupational therapy, alongside the QI coach.18 QI meetings were consistently held weekly and attendance would often be between 8 and 12 people.

As the project evolved, the importance of coproduction and meaningful service user involvement became imperative. Our service users could sometimes struggle to engage in large meetings and we were aware of different needs and priorities among our patient group. Therefore, to include a diversity of views, we developed creative and meaningful ways to help service users input to the project and held several focus groups to understand what care and support was important to them. Service users identified 10 domains of care that they valued (table 1) which were illustrated on to a 1.5 m diameter Perspex wheel. Symbols sat like a clock round the edge of the disc and patients could ‘blue dot’ next to a domain if they recognised the type of care they value or in the middle if they were unsure. The wheel was photographed once a month to record where our care was most/least highly perceived and valued. This approach allowed us to monitor and respond flexibly to the experiences of different patient cohorts.

In order to achieve our aim, the team noted three important drivers for change (please see figure 1): (1) staff having the knowledge, understanding and confidence to be able to implement proactive strategies, (2) staff needed their well-being to be acknowledged and supported to have the resilience to implement changes, and (3) maximising the number of opportunities for positive engagement between service users, staff and families.

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Figure 1

Flip the Triangle driver diagram. CS, collaborative safety; PBS, positive behaviour support.

Strategy

The strategy for improvement involved implementing 'Plan, Do, Study, Act' (PDSA) cycles in line with the three drivers for change. Figure 2 provides a visual timeline for each cycle of change.

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Figure 2

Graph to show percentage of positive and proactive interventions versus physical and restrictive interventions alongside timeline of PDSA cycles. CS, collaborative safety; PBS, positive behaviour support.

Lessons and limitations

A key learning point that emerged from involvement in the Flip the Triangle project was that it required an embedded and whole-team approach in order to make a cultural shift. The QI methodology, including implementing change ideas and meeting regularly to reflect and act on PDSA cycles, helped develop a learning culture on the ward. This model of hypothesis testing also aligned particularly well with the model of PBS and therefore strengthens PBS as an embedded approach across the whole team. The development of the learning culture appeared to have a reciprocal relationship with the team moving to a position of psychological safety; the increased emphasis on learning rather than blaming helped individuals to feel more comfortable sharing creative ideas, generating hypotheses and taking positive risks.

The team often commented on taking a ‘why not?’ position when confronted with entrenched practice, policies and procedures that acted as barriers to potential positive engagement opportunities. The ‘why not?’ approach helped junior members of the team feel empowered to question existing practice which, in turn, created more flexibility within the restrictive forensic system.

The QI approach allowed the whole team to come together around a shared goal and use common language that transcended professional boundaries and hierarchies. For example, PBS principles and language were often held by the psychologist, but ‘Flip the Triangle’ condensed complex PBS principles into a short phrase and shared operational definition that was held by everyone.

There were several limitations to consider regarding the blue dot data collection system. Despite regular discussions concerning the operational definitions of ‘what constitutes a light or deep blue dot’ by its nature this was a subjective system of collecting data and therefore may be open to bias. Each time staff members added a light or deep blue dot to the chart, they needed to use their personal judgement to consider which was most appropriate (without independent assessment) and some staff members may have overestimated or underestimated the role of the care they provided. Additionally, due to the nature of working on a busy ward, there are likely to have been instances whereby staff forgot to record every positive and proactive intervention they engaged in. Again, this may have led to skewed data as busy days, where more interventions were being offered, may have produced relatively less dots than quieter days where dots may have been recorded more accurately.

While there were limitations with the blue dot data collection system, it also proved key in facilitating cultural change. Although we discussed trialling simpler methods of data collection, the existing system required staff to ‘stop and think’ and move away from an automatic and reactive approach to an approach of mindfully and responsively providing care. It allowed both staff and their colleagues to recognise the positive and proactive care they provided, their skills and achievements and therefore motivated them to keep providing quality care. On reflection, it was important that the data collection system integrated with existing processes on the ward (the ward was already familiar with recording dots due to previous QI projects), therefore helping the project to have contextual fit. The blue dot feedback system for service users also helped to have frequent, meaningful conversations with service users about care and helped staff understand how their care was recognised or received, allowing us to be responsive and make continued adaptions.

An additional limitation of the project was that we struggled to find a robust system of data management. A huge amount of data was collected on a daily basis through various systems (eg, blue dot charts, medication charts, DATIX, Rio) and therefore developing a method of managing and reporting the data on a weekly basis became quite difficult, especially during busy periods on the ward. If we were to conduct the project again, we would create more robust data management systems that would allow for weekly reviews of data in QI meetings. Due to the challenges around data management, in combination with unintended but positive impacts of the dots-based data collection systems it has been more challenging to isolate which elements of the project have promoted the most significant change. We would encourage services who want to embed PBS on their ward to examine the key areas of change highlighted by this project and replicate or adapt our change ideas by examining their individual context and existing structures. For example, increasing access to positive engagement opportunities, expanding repertoire of proactive interventions and supporting staff well-being and resilience will all be important drivers for change, but we suggest a service should also examine how they will create and support a learning culture, how they will move their team to a position of psychological safety and how they will use existing structures and values of the team to ensure changes have contextual fit.