Leading change

The staff nurse on Hume Ward at South West London & St George’s Mental Health NHS Trust (SWLSTG) identified unwarranted variation in service user engagement to having their physical health checked while staying on the secure ward. The staff nurse led on enhancing the provision of physical health checks; through staff training, service user empowerment and raising awareness of the importance of the checks. This led to improved outcomes, experience and use of resources on the ward.

Where to look

The physical health lead for Hume ward (staff nurse) completed an audit and identified that compliance with vital signs monitoring was not standardised across the wards at the Trust which would be recommended practice (Downey et al., 2018). At the time of the physical health assessment pilot, the ward had four service users with physical health needs which required regular monitoring. The ward nurse recognised a noticeable decline in compliance rates. There was also no structured / individualised care plan for physical health. The staff nurse identified unwarranted variation in physical health check compliance when completing the audit as a part of a quality improvement (QI) project for the Burdett BAME programme (a customized skills and leadership programme specifically for Black, Asian and Minority Ethnic nurses in the Trust).

What to change

Before the change (which was also prior to the Trust becoming Smoke Free), nursing staff encouraged service users to have their vital signs taken before or just after they returned from their ‘ward leave’ (e.g. after having a smoking break). Once the Trust became Smoke Free, the staff nurse on Hume ward observed a sudden decline in rates of physical health monitoring. This was attributed to service users not having a regular structure to the day and not having the understanding or empowerment that the vital signs were a key indicator of their physical health. If a service user refused, then staff would document the outcome, often without making further attempts to explain the importance of vital signs monitoring. Research literature indicates the importance of undertaking vital signs monitoring to improve physical health outcomes for our service users. Howard et al. (2011) identified that individuals with serious mental illness are over three times more likely to have a physical health problem, more likely to engage in health-risk behaviours and may die up to 10–20 years earlier than the general population. The staff nurse recognised a need to simultaneously empower service users to understand and engage with their own physical health monitoring as well as train and support staff to provide the highest value care to influence outcomes and experience.

How to change

The Physical Health Lead on the Hume ward informed and provided information to both staff and service users on the importance of physical health monitoring and compliance, particularly when service users declined to have their vital signs taken. This was implemented in various ways including:

• Community meetings that specifically asked service users what would increase their engagement in completing physical health observations;
• One-to-one sessions with staff;
• Development of a poster board with up to date guidance and signposting;
• Multi-disciplinary team (MDT) meetings to specifically demonstrate the importance of physical health;
• Teaching sessions also took place on the ward to enhance staff knowledge and skills re. vital signs monitoring; and,
• Healthcare assistants (HCAs) were given additional training and an e-Learning package.

Building on the initial success of the above improvements, Hume ward subsequently opened a Physical Health clinic every Saturday. This targeted promoting healthy lifestyles, providing information on physical health and address any concerns in line with CQUIN physical health targets.

Adding value

Better outcomes – There was an increase in compliance as shown by a follow-up audit.  Questionnaire feedback from both staff and service users suggested that involving the service user encourages them to take ownership re: care planning and engage more with physical health monitoring.

Better experience – Staff expressed they feel more confident using the equipment, undertaking the monitoring and recording the readings. Most service users expressed that selecting the times they wanted their vital signs taken works better for them.

Better use of resources – Staff can access the skills lab at the Trust to practise and improve their clinical skills. This project has encouraged more focus and emphasis on service user engagement and tailoring an individualised care plan for physical health. This saves time as everything is planned and in collaboration with the service user. Early detection of symptoms of physical health conditions means early prognosis and treatment, which is cost-efficient in the long term as well as of significant benefit to service users.

Challenges and lessons learnt for implementation

Compliance with physical health monitoring helps early detections of conditions, which in turn improves morbidity and mortality.

Change can be difficult to implement as you can face resistance, particularly when people are not comfortable with change.

Always involve the service user in discussions and give them chance to voice their opinions and concerns.

The nursing team are working to place visual reminders / displays for clinical staff in the clinic, undertaking physical observations to escalate their concerns if vital signs are out of range. This might include signposting such as recommendations to raise concerns to nurse in charge / doctor on call if systolic BP gets too high.

For more information contact

Louisa Mubika
Staff nurse
Hume Ward
South West London and St George’s NHS Trust
Louisa.Mubika@swlstg.nhs.uk