Working together to improve the

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Working together to improve the quality of mental
health services
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• National Audit of Violence
• Key findings and recommendations
• Maureen McGeorge, Leanne Shinkwin
• and Graham Hinchcliffe

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• Summary of presentation
• Outline of the audit
• Key findings
• - acute services vs older peoples services
• - 2004 vs 2006
• Main messages
• Questions

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• Outline of the audit May 2006 - July 2007
• Introductory Workshop
• Contextual data
• Module 1 survey of the experiences of staff,
  patients and visitors
• Module 2 environmental audit
• Module 3a review of a series of incidents
• Module 3b case note audit of the use of rapid
  tranquillisation
• Feedback Workshop
• Action plans

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• Key findings the environment
• Support systems
• - 20 acute ward nurses rated alarm systems as
  inadequate (25 of OA nurses)
• - 31 nurses knew who their LSMS was (20 in OA
  services)
• Space over 40 nurses in both specialties rated
  space as inadequate
• Temperature around 60 nurses and non-clinical
  staff in both specialties rated the wards as too
  hot

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• Key findings communication and culture
• Admissions
• - 70 nurses did not have a say over admissions
  (76 in OPS)
• - 50 staff in both specialties unable to access
  additional resources if they had a difficult
  mix of patients
• Being listened to around 30 nurses from both
  specialties felt their concerns were not taken
  seriously and acted upon

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• Key findings supporting staff
• Ward staffing
• - 42 staff felt staff ratios were not
  appropriate to resident population (30 OPS)
• - 30 nurses and clinicians felt skills mix were
  not appropriate to resident population (25 OPS)
• - 39 nurses felt gender mix were not
  appropriate to resident population (50 OPS)
• Supervision 40 nurses said they were not
  receiving one-to-one clinical supervision (44
  OPS)
• Level nurse satisfaction with supports from
  colleagues was high (92 satisfied/totally
  satisfied)(90 OPS)
• Levels satisfaction with supports from senior
  management
• team low at 61 (68 OPS)

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• Key findings staff training
• Of 85 of nurses involved in managing severely
  challenging/violent incidents (79 in OPS), 29
  had not received PSTS training (34 in OPS)
• Of 94 of nurses involved in carrying out
  observations, only 31 received ongoing
  competency training (27 in OPS)
• Of 68 of nurses involved in admin/prescribing/
  monitoring rapid tranquillisation (48 OPS)
• - one-half had received training around the legal
  framework authorising its use (36 in OPS)
• - 41 in the use of pulse oximeters (39 in OPS)
• 68 ongoing competency training to a level of ILS
  
• (72 in OPS)

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• Key findings patients experiences
• Almost one-fifth shared space with members of the
  opposite sex when they didnt want to (16 in
  OPS)
• 43 did not have privacy when being given their
  medication (40 in OPS)
• 22 did not have opportunities to go
  outdoors/leave the ward (24 in OPS)
• Over one-fifth did not feel their concerns were
  taken seriously and acted upon (12 in OPS)

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• Key findings patients experiences
• 27 said they had not been given enough
  information about why they had been admitted (36
  in OPS)
• Almost one-third were not satisfied with their
  involvement in decisions about their care
  (one-fifth in OPS)
• Only one-half agreed that there were daily
  opportunities for physical activity/exercise (62
  in OPS)
• 56 did not agree that there was an adequate
  choice of therapies available during the day (48
  in OPS)

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• Some quotes contrasting environments
• A pleasant and homely environment. Staff and
  patients friendly and welcoming. (a visitor)
• This ward is friendly and kind. Just the way
  it should be. (a patient)
• The ward appears dirty, the decor is unpleasant
  and the bedrooms are quite frankly dank and
  horrible with plain walls and nothing homely
  about them. (a nurse)
• The patient does not like shouting, so when
  someone is kicking off, he hides in his room and
  tends not to come
• out again. (a visitor)

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• But are things getting
• better or worse?

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• Key messages older peoples services

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• It shall be the duty of every employer to
  ensure, so far as is reasonably practicable, the
  health, safety and welfare at work of all his
  employees. (HSE, 1974)
• 64 of nurses on older peoples wards reported
  that they had been physically assaulted. These
  figures were higher than any other staff group in
  this specialty, or in services for adults of
  working age. As one nurse explained, Sometimes
  it feels very much part of the daily routine to
  be either verbally or physically abused by
  patients.
• There are many causes of violence on wards.
  Trusts must use their local audit findings to
  develop plans that address
• their problems.

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• Healthcare services are provided in
  environments which promote effective care and
  optimise health outcomes by being a safe and
  secure environment which protects patients,
  staff, visitors and their property, and the
  physical assets of the organisation. (Core
  Standard C20a)
• Over 40 of staff did not have access to a
  personal alarm, and 25 of nurses described the
  emergency alarm system on their ward as
  ineffective.
• Many environmental precipitants to violence are
  amenable to improvement and should be tackled as
  a matter of urgency.

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• The NICE Guideline (2005) details the training
  that those involved in preventing and managing
  violence on wards should receive.
• Staff in older peoples services were less
  likely than their colleagues in services for
  working age adults, to have been trained. For
  example although almost 80 of nurses were
  involved in managing incidents, only 66 of those
  had received the recommended training many staff
  complained that their training was not tailored
  to the particular needs of older peoples
  services.
• Trusts must deal with shortfalls in training as
  a priority.

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• The Governments Core Standard C13a requires
  that healthcare organisations have systems in
  place to ensure that staff treat patients, their
  relatives and carers with dignity and respect.
• 92 of patients reported that they had been
  cared for in a dignified manner only 5 felt
  that their religious or cultural need had not
  been respected.
• Trusts should commend their staffs good
  practice.

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• The NSF for Older People (2001) expects that
  older people will be treated as individuals and
  enabled to make choices about their own care.
• The audit revealed high levels of satisfaction
  with their experiences 81 of carers reported
  that they had been asked to share information
  about their relative/friends likes, dislikes and
  fears 98 said that they had witnessed staff
  caring for patients in a meaningful,
  person-centred way.
• This good practice should be shared between
  organisations.

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• Key messages
• services for adults of working age

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• Being treated with respect and dignity, and
  given privacy and choice
• A number of problem areas were highlighted
• Local practices relating to the administration of
  medication
• The involvement of patients in decision-making
  about their own care, particularly in relation to
  choice of medication and their preferred way of
  being managed in the event of their becoming
  violent
• The involvement of patients in decision-making
  about aspects of how the ward is run, e.g.
  mealtimes, choice of menu, availability of
  refreshments outside of mealtimes, waking times.

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• Being offered meaningful occupation
• Boredom was still a problem on many wards.
• It is vital that wards address this area as a
  matter of priority measures should also be put
  in place to ensure that activities and therapies
  are reviewed regularly so that the provision is
  appropriate to the current patient and staff mix.
• Being given adequate information
• In the large majority of wards, staff are
  communicating effectively with patients, even
  during stressful times - such as an admission.
• If not currently available, wards should
  consider providing written information, in a
  leaflet or on a notice board,
• to reduce any potential confusion.

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• Ward communication systems and culture
• The overall picture nationally was of cohesive,
  supportive staff teams, with well-structured
  communication systems and strong
  multi-disciplinary working. The issue of poor
  skills mix on wards was raised many times, with a
  range of underlying factors.
• Staff training
• Access to training relating to the prevention
  and management of violence was variable, both
  between services, and between different
  respondent groups. Areas for comment
• training for nursing staff in undertaking
  searches
• training for all staff in recording incidents
• on-going competency training in observation for
  nurses
• access for nurses to all recommended training
  related
• to the use of rapid tranquillisation.

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• Supports from other colleagues
• The majority of staff were satisfied with the
  supports they received from their team on the
  ward, though less so with supports from more
  senior managers. On wards where the staff team
  was unstable and/or there was a high reliance on
  bank and agency staff, individual team members
  were often left feeling vulnerable, unsupported,
  and unappreciated
• The trust needs to look at the support it gives
  to the nurses they have working for them on the
  wards. Some of these wards are not a pleasant
  environment the staff are coming to with regards
  to violent/aggressive/abusive patients - who are
  obviously unwell. So they should at least make
  staff feel
• more appreciated for the efforts they do.

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• Contact details
• Maureen McGeorge
• Royal College of Psychiatrists Centre for
  Quality Improvement
• mmcgeorge_at_cru.rcpsych.ac.uk
• www.rcpsych.ac.uk/nav