Leading change

The Senior Development Nurse in South West London and St George’s Mental Health NHS Trust (SWLSG) Psychiatric Decision Unit (PDU) led on a programme of work to develop and implement a welcome pack for service users, carers and their families to reduce unwarranted variation across the Trust. The programme has led to improved outcomes, experiences (particularly by truly engaging carers) and use of resources locally.

Where to look

The World Health Organisation (WHO, 2010) highlights that historically, people with mental health conditions have not been empowered and included in decision-making on their own mental health care. In a mental health context, ‘empowerment’ refers to the level of choice, influence and control that users of mental health services can exercise over events in their lives. Key Standards in the Triangle of Care state that services should offer a “relevant range of information across the care pathway [and] a range of support services is available” (Carers Trust, 2013).

SWLSG is a provider of NHS mental health services to a population of over 1 million people of all ages in the London boroughs of Kingston, Merton, Richmond, Sutton and Wandsworth.  The PDU is designed to work with service users from across all 5 local authority boroughs, unlike other wards within the Trust which were aligned to specific boroughs.

The Development Nurse identified unwarranted variation in both knowledge of staff as well as supportive information provided to services users and their carers at the PDU in comparison with other wards across the Trust. Whilst other wards provided Welcome Packs with information about the ward and local community support, this was not routine at the PDU. The nurse lead saw an opportunity to ensure that PDU service users, their carers and families were provided with meaningful choice, giving them an opportunity to explore the whole range of options that might be relevant, and receive any required and reasonable support to choose among them (WHO, Europe 2010).

What to change

When reviewing the service provision, notably around resources and service user information, the development nurse identified that although a few of the PDU team had completed designated training, or had experience in supporting carers, there was room to expand on this and ensure it was routine. Current practice meant that the team were also sourcing resources on a case-by-case basis, for instance using internet browsers to identify carer groups and support options in different boroughs, which led to inconsistency in the offer to service users, their families and carers. As a team, there was some knowledge about specialist agencies available locally but no standardised approach or package of resources for staff to share. Staff also reported anecdotally that they were concerned about inconsistency between the information and resources given during each carer contact and requested that more be done to standardise engagement, interactions and carer support. This was built into a project by creating a checklist and Admission Entry pro forma which captured contact details for ‘next of kin’ and any additional requirements they had.

The Nursing lead built on this opportunity to standardise resources, ensure they were distributed as relevant and where needed enhance staff knowledge. This could improve the offer to service users, their families and carers when using the PDU services.

How to change

The Development Nurse Lead identified the initial need to develop a welcome and information pack for use by staff on the PDU. An exploration of the types of resources that a carer might benefit from most was undertaken, as well as a review of the literature on carer resources. The literature suggested that multiple methods could be utilised to improve carer health and wellbeing, including structured psychological therapies and informal group or 1:1 befriending services (Livingston et al., 2013), as well as specialist advice on finances and employment (Mind, 2017). The scoping of local services based on this information generated several key agencies and services that may be useful signposts for those carers supporting service users attending the PDU. An information pack containing comprehensive contact details for these organisations was developed; a ‘Carers’ Directory’. This was stored digitally on the ward so that it was accessible for all team members. They could print out the relevant section for each carer dependent on their location, preferences and specific needs.

In collaboration with the Trust’s experience team, Trust feedback resources were collated and included in the Welcome Pack for carers to have direct access to the Trust’s online resources as well as opportunity to provide feedback. The nurse hoped this would allow the PDU to continue to develop the resource pack with the support of carers and to ensure the services provided were meeting service user, carer and family needs.

Alongside the launch of the carer welcome packs, an in-house training package was also rolled out to support staff to recognise the importance of engaging with carers in a timely and therapeutic manner to improve outcomes and experiences of both carers and service users. The initial training sessions included how to access the ‘Carers’ Directory’, how to tailor the Resource Pack to individual need and how to ensure that all treatment, discussions and interventions are clearly documented. Further training is planned to build on the skills and expertise the staff have developed, to ensure they remain confident in supporting carers on the unit and engage them as the provision of services continues to evolve.

Adding value

Better outcomes – Initial data suggests there is increased feedback from carers. It is felt that this indicates that they are now better engaged with staff – a clear positive. The shift towards enhanced carer integration has also improved the number of family interventions completed by the team when offering psychoeducation, completing collaborative crisis plans and signposting to specialist therapy for families and couples. This has anecdotally improved the success of community discharges and may have influenced readmission rates – however objective evidence is pending.

Better experience – Feedback collected in May-July 2017 compared to the feedback from May-July 2018 is planned, to observe changes, areas to celebrate and areas for improvement. Further, a structured audit is planned (biannually), to look at the outcomes listed in the Triangle of Care audit, to consider how the team are identifying and engaging carers. Anecdotal evidence is currently positive, and the pro-forma has been requested by students and staff on other wards to enhance the continuity of care for both service users and their carers. Staff feedback has been positive with reports suggesting the introduction of the pack has helped them to feel informed to signpost to appropriate resources, and collect necessary feedback from carers to shape practice. Feedback from families and carers on the unit has been uniformly positive, and they have reported that improved integration of their carers has removed some of the worries they had previously.

Better use of resources – Although a full analysis of the impact on resources hasn’t been undertaken, anecdotal feedback suggests the new approach to carer support is streamlining processes on the unit by making sure people can access the right services and information earlier in the process, which has positive implications. This will hopefully allow staff more time to provide care to service users, their carers and families using the unit.

Challenges and lessons learnt for implementation

Relatively small changes in the provision and standardisation of resources available on a unit can truly enhance the way carers are included.

For a project to be a success, motivation is key. Also ensure full engagement with those around you.

When you are passionate about the change you want to implement, nurses can create incredible outcomes both for the people they are caring for and the colleagues they work with.

Find out more

For more information contact:

• Hazel Nash, Development Lead, South West London and St Georges NHS Mental Health Trust, Hazel.Nash@swlstg.nhs.uk