Developing Acute Inpatient Services Change Drivers Service user & carer concerns Professional concerns National reports - inpatient care struggling – peoples’ needs not being met – poor environments Risk averse, defensive practice prevailing – culture of clinical observation rather than clinical engagement Stifling effect on practice development Undermining attempts to meaningfully engage with people and their carers National directives
Developing Acute Inpatient Services The Perceived Role of the Ward Nurse Prevention of untoward incidents and physical harm increasingly being seen (by some) as the sole focus of the role. Perception that the role is not as dynamic as that of community colleagues However However Mental Health Nurses have a critical part to play in supporting people towards recovery.
Developing Acute Inpatient Services Gartnavel Royal Hospital New Build Guiding Principles Care will be person-centred. Single room accommodation. Flexible use in terms of gender specification – enabling single sex segregation Must respect the individual and recognise their full rights and responsibilities as a citizen. Promote a personal sense of safety and security Vulnerabilities will be managed by the least restrictive means necessary
Developing Acute Inpatient Services Gartnavel Royal Hospital New Build Guiding Principles A sense of safety will be promoted by a range of approaches including: -Appropriate levels of staffing -Effective engagement and involving people in their own care -Informed clinical judgement -Safe systems of work -Environmental and physical security integral to construction requirements People will have access to information on their care Care plans will promote self determination, informed choice and equity. Each person will be viewed and treated as a unique individual and not pre-judged.
Developing Acute Inpatient Services Recovery A personal, collaborative process which seeks to overcome the negative impact of diagnosed mental illness / distress despite its continued presence. About self-determination, recovering control over one’s life, feeling valued as a person, feeling heard, contributing to the community, helping others………… Not just about symptom control.
Developing Acute Inpatient Services What Would be the Key Attributes of a New and More Effective Approach? Acknowledge the central role of people in assessing their needs and planning, implementing and evaluating their care. Respect people, value their contributions and preserve their dignity. Empower people to take control of their lives and instil hope. Bring structure and clarity to the role of the mental health nurse. Provide a platform for further practice development.
Developing Acute Inpatient Services Principles of Care. Professional curiosity – what makes this person different from every other person with the same diagnosis. Harness the person’s natural resources – work with the person’s assets and strengths – inner and environmental / situational Respect – value the person’s wishes and aspirations, recognise the person is the expert in their personal situation. (The wisdom that comes from the lived experience) View crisis as an opportunity – as a natural signal that something has to change. Think small and simple – achievable highly specific goals are best - look for straight-forward uncomplicated interventions Work with the person – caring with & caring about but not caring for
Developing Acute Inpatient Services Key Questions How do we ensure that we really listen and respect the person’s story. How do we balance the professional perspective of the person’s needs with their perspective? What is the person’s personal theory? – How does the person understand their problem, what is their experience of it? How do we seek to limit restrictions? – Aim to use the least restrictive means of helping the person resolve their difficulties.
Developing Acute Inpatient Services Suggested Components of an Inpatient Recovery Model. Multi-disciplinary assessment Person’s personal assessment of their situation Planning the joint management of vulnerabilities One-to-One Sessions Group-work
Developing Acute Inpatient Services Aims of the Personal Assessment Gives the person the opportunity to describe, discuss and examine their experience of illness and health. Focused on the person’s needs as s/he sees them. Identifies their chief problem(s) - problems are rated Written in the person’s own words and signed off by him/her. Demonstrates the nurse’s understanding of the person’s situation Sets the agenda for the ongoing one-to-one sessions Ensures that the careplan addresses the person’s concerns as well as professional concerns
Developing Acute Inpatient Services PERSONAL ASSESSMENT Beginning of Problems: When I first noticed or became aware of things. Past Effect of Problem(s): How this affected me at first. Past Emotions: How I felt at the beginning. Developmental history: How things have changed over time: Situation, Relationships and Practical Resources/Problems: How this has affected my relationships / Other aspects of my life – e.g. finances, family/friends, others, housing, employment/unemployment Thinking: My view of things or what I think about them. What I think about:- My present situation / My memory and concentration / My view of myself / My life generally / My view of others / The future: Emotions, Mood and Feelings: How I feel now within myself
Developing Acute Inpatient Services PERSONAL ASSESSMENT Physical feelings, health and symptoms: My view of my Physical Health – e.g. known physical conditions or illnesses, weight, appetite, bowel habits, sleep, pain, mobility, smoking and drinking/substance use habits. Behaviours / activity levels: My view of how I am behaving and coping, organising my life and getting on with things. My involvement in interests and hobbies & socialising and meeting people: What all of this means for me. What all of this says about me as a person. Needs, wants, wishes: What needs to happen now, What I want or wish to happen. Expectations: What I think the ward team could do for me. My Signature Nurse Signature
Developing Acute Inpatient Services Planning the Joint Management of Vulnerabilities. Integral to the careplan Requires to be reviewed and updated regularly. Linked to a planned process of engagement Identifies what (exactly) the person might be able to do for themselves to reduce the likelihood of untoward events occurring and help them feel safe Monitoring promotes engagement
Developing Acute Inpatient Services Benefits of Jointly Managing Vulnerabilities. Not just about keeping the organisation ‘safe’. Person is actively contributing to their own careplan Identifies the kind of support the person might need from the clinical team to help self-manage their own vulnerabilities – not what is going to be ‘done to them’. Clearly sends the message that the clinical team recognises that the person has strengths and potential to recover Less paternalistic approach, promotes self-esteem and instils hope
Developing Acute Inpatient Services Example of an Individual Vulnerabilities Management Plan. I have discussed my specific needs with my keyworker and we have agreed that I will: Read over letters from my family everyday to bolster my self esteem Make a note in writing each day of the people who have demonstrated that they value me for who I am Listen to music on my walkman and talk to people as a means of distracting myself and dealing with my voices Seek out my Named Nurse if I am feeling vulnerable Attend the Recovery Groups in the mornings What can others do that I might find helpful? The nurses will spend time with me to find out how I am coping at least 4 times every day and will be happy to talk to me over and above that whenever I feel the need. -
Developing Acute Inpatient Services Focus of the One-to-One Work. Addressing the immediate needs of the person and the continuation of the personal assessment and problem solving process. Jointly identifying simple achievable goals Encouraging the person to become aware of the part they can play in identifying needs and working out potential solutions. Instilling hope by developing the person’s awareness of change – however small or gradual.
Developing Acute Inpatient Services Aims Of The Group-work. Share experiences of difficulty, distress and disability. Obtain support from other group members. View problems from a different perspective and learn from the experiences of others. Experience helping others. Share information Explore new options for resolving problems. Develop assertiveness, social skills and problem-solving skills
Developing Acute Inpatient Services Engagement not just Observation Engagement level 4: Everyone is offered at least one therapeutic session per day – one-to-one, group meeting, family meeting etc. Engagement level 3: Nurse makes formal contact at least 3 times during the day Engagement level 2: Nurse makes frequent enquiries throughout the day to assess persons wellbeing Engagement level 1: Nurse in constant attention throughout the day to offer support
Developing Acute Inpatient Services Key Messages. Listen to the person’s story – listen intently, listen, enquire, listen again – don’t assume. First question - what is it that makes this person different from other people I have met with the same illness? Work in partnership with the person – do ‘with’ not ‘for’. Demonstrate understanding - use the person’s own words to describe their situation and support them to address their chief problems - as they see them.
Developing Acute Inpatient Services Understanding the Person. Be professionally curious: Never assume you know everything about the person (or about nursing). If the nurse acknowledges they don’t know everything they need to know it encourages humility. Cultivate a non-judgemental approach / attitude: Let go of preconceptions - if we pre-judge a person as good or bad we will fail to understand them. There is no such thing as good solutions or bad solutions – what works for one person might not work for another. If the nurse is non judgemental then respect for a wide diversity of opinion, thought and culture should follow.
Developing Acute Inpatient Services Key Leadership Messages Listen to the concerns of staff and service users / carers and explore potential solutions with them. Communicate the new approach as a solution not another task on top of everything else. Plan - prepare the ground – visits, meetings, consultation events, highlight the potential benefits Be able to communicate the vision but be flexible - ensure scope for local input and innovation - don’t tell people precisely how to do things Don’t get obsessed with documentation
Developing Acute Inpatient Services Key Leadership Messages Invest in training at all levels Identify, invest in and support practice development champions Ensure effective collaboration – steering groups / local implementation groups with input from all stakeholders Be brave enough to try new things but big enough to admit when things are not working and learn from the experience Evaluate locally – more evaluation less routine audit! Don’t just invest in the pilot areas and expect things to work elsewhere without the same level of support.