“Violence was the elephant in the room” – Empowering Staff to Face Hard Truths and Lead Change
Why It Matters
Over the past four years, East London NHS Foundation Trust (ELFT) has been on a journey to put the tools of improvement in the hands of those at the frontline – both our 5,000 staff, who provide mental health and community services, and our 65,000 service users.
We’ve seen incredible improvements and achievements over this time: reductions in waiting times, drops in harms such as pressure ulcers, and less use of restraint. We’ve won national awards for patient safety and staff engagement, and we’re one of only two Mental Health Trusts in the country to be classified as “Outstanding” by our national regulator, the Care Quality Commission.
What has been amazing to see, alongside these achievements, is how our system is transforming into one that fosters improvement by empowering staff to lead change.
How did we do it? As an Improvement Advisor supporting teams on the ground, I’d like to share some stories of how this change is happening.
Before we began our improvement journey
A few years ago, our inpatient adult mental health wards were not the therapeutic spaces we wanted them to be.
Like mental health inpatient wards around the world, they were stressful and often violent environments for both service users and staff. Our teams felt demoralized and guilty whenever they couldn’t keep the people in their care safe from harm. Violence was the elephant in the room that people didn’t name or acknowledge — largely because they felt powerless to stop it.
For years, managers responded to problems like this with the implicit message that staff just needed to try harder to solve them. Managers also felt powerless to make things different. Addressing the big challenges in health and health care are always too much for one person. They’re too complex. Too many factors contribute to them.
In 2010 we had a number of very critical incidents of violence in our adult inpatient service in Tower Hamlets, one of our three inner East London boroughs. In addition to serious assaults on staff, we had the worst possible safety event in our setting – a homicide, where a patient with serious mental health difficulties killed another patient on one of our wards.
ELFT’s executive team was devastated and dismayed. Our “R-A-G” (Red, Amber, and Green) performance scorecards and quarterly reports of static data were telling us everything was fine, but clearly they were not. We realized we needed another way to look at data, and another approach to support staff to work on these difficult problems.
Starting in 2012, our organization began introducing the Model for Improvement to ELFT and one of our first areas of work was how to reduce violence and aggression on our inpatient wards.
Developing a learning culture
One of the change ideas our staff have developed to reduce violence is safety huddles. At ELFT, safety huddles are brief standup meetings where staff share information about safety risks three times a day. We try to predict aggravation and unmet needs, and plan to mitigate these risks.
Safety huddles have provided our staff with a forum to communicate as a team, creating a culture of openness and proactive problem solving. Staff no longer carry anxieties alone, but have a space to vocalize and address these challenges.
Having introduced safety huddles and a number of other ideas, one of our ward teams in Tower Hamlets, Lea Ward, achieved a 58 percent reduction in violence in early 2015. But later in the year they saw a spike in violent incidents above their upper control limit (see figure 1). In years past, this situation might have sent the team into a tail-spin of guilt, shame, and defensiveness. But this time, nurses from the Lea Ward team came to our learning session and talked openly with colleagues from other wards. They knew they weren’t to blame, but they also knew they could learn from the data. They were ready to share their theories on why it had happened.
The Lea Ward team believed the spike revealed another dimension to the problem. Our wards work in three shifts per day; morning, afternoon and night. The team realized that there was a problem in not passing information learned in safety huddles from shift to shift. In response, Lea Ward focused their next PDSAs on addressing these issues, and they have since sustained their 58% reduction in violence with no further spikes above the upper control limit.
The smallest interventions
The work on Lea Ward shows how QI can drive results across an entire ward. But the introduction of QI methods has also led to cultural change with how teams work together and with service users in small ways.
We saw this happen in an incident described by one of our social therapists, Shabanaz Begum. A male service user arrived on the ward in acute distress; he was very unwell and a safety risk to himself and others. Some team members felt that he needed to be transferred to a unit with more intensive support.
In the meantime, however, a junior member of the nursing team had learned that playing table tennis helped the man feel calmer, and shared this in the safety huddle, working across the typical hierarchies in health care. Something about playing the game helped the service user open up.
Shabanaz marveled that it was something so simple that enabled the team to prevent the transfer. “We forget sometimes,” she pointed out, “that it's the smallest interventions that can have the most amazing effects."
The role of an Improvement Advisor
As one of ELFT’s Improvement Advisors, my job is to support and to facilitate our QI efforts, helping frontline teams develop the skills and understanding to achieve change.
There’s a deeper level to this though, and my understanding of this continues to develop the longer I do this role. One of our nurses described how service users need her when they’ve lost hope. She said, “If we don’t hold it, who else is going to hold it?” That line affected me very deeply. It resonated with a feeling I have had about my own role as an IA.
System change is incredibly difficult. It involves letting go of behaviors and ways of working, and it also requires a new way of understanding yourself in your role, your team, and in your profession. It can feel overwhelming and staff can feel threatened or doubt that change is possible. As IAs, we must be there with them, to acknowledge these feelings, and if needed, to hold their belief things can change until they are ready.
Continuing our improvement journey
Our staff are talented and caring, and they used to go home with the nagging feeling that things weren’t the way they should be. They did their best, but they didn’t have the tools and support they needed to solve complex issues.
For many across our organization, that has all changed. Staff now know that if something in the system isn’t working, if they’re not seeing the outcomes they want to see, they have the power to make it better. Shabanaz would tell you that her world has changed, because now she knows she really is doing her best for her service users every day she comes to work.
Every day I wake up feeling privileged to work as an IA and to play a part in making this happen at ELFT. We’re changing systems — and changing worlds — throughout our organization.
Jen Taylor-Watt is an Improvement Advisor with the East London NHS Foundation Trust.
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