Leading change

The Nursing Ward Manager in the Neuropsychiatry Unit at North Staffordshire Combined Healthcare NHS Trust (NSCHT), led the introduction of a personalised care approach for patients admitted to the ward. This new approach has led to improved outcomes and experiences across the unit.

Where to look

The Nursing Ward Manager at NSCHT identified unwarranted variation in the treatment approach for people admitted with brain injuries and a need to tailor this to suit the individual in line with recommendations. The ward manager recognised that tailoring the care on the ward to a person-centred approach would address the unwarranted variation in practice and lead to improved outcomes and experience.

The Royal College of Nursing (2018) identifies that being person-centred is when we plan care with the person, we think about the effect of what we’re doing on the person as a whole. Where patients have a cognitive impairment, it is important not to assume that a person will be able to tell us what they want, need or how they are feeling. Having the person’s safety, comfort and well-being uppermost in the mind of those caring for them and ensuring people are comfortable calls for staff to think differently and consider factors that may cause discomfort, pain or distress before and taking steps to relieve them. Where individuals live with a mental health condition, dementia, physical disability or a learning disability, effective communication is paramount and can be complex. This requires a considered, varied skill set.

What to change

NSCHT is a provider of mental health, social care and learning disability services in the Midlands. Ward 5 is a 15 bed Neuropsychiatry unit, providing specialist services for neurological disorders for patients 18 years of age and over. Patients with Huntington’s disease, early onset dementia, epilepsy and brain injury are all treated on the ward. Before the change, ward staff utilised traditional methods of patient care, which did not routinely consider individual patient complexities, such as the early warning signs of escalation.

NICE guidance (2015) highlights that health and social care provider organisations should give staff training in de-escalation that enables them to:

• recognise the early signs of agitation, irritation, anger and aggression;
• understand the likely causes of aggression or violence, both generally and for each service user;
• use techniques for distraction and calming, and ways to encourage relaxation;
• recognise the importance of personal space;
• respond to a service user’s anger in an appropriate, measured and reasonable way;
• avoid provocation.

The ward manager recognised that to embrace the opportunity to tailor a patient’s care by adhering to these training points would support staff to personalise the care offered to the patients on the ward.

The National Development Team for Inclusion (2013) supports an approach in seeking more person-centred approaches to challenging behaviour. Advice identifies that positive behaviour support (PBS):

• can be utilised as an approach for group and individual support;
• is proactive rather than reactive – prevention is the focus;
• provides strategies and interventions for a variety of mental health problems;
• promotes understanding of behaviours;
• leads to positive changes;
• is recovery focused
• is a holistic approach prompting optimum functioning.

The ward manager identified that the provision of ‘person-centred care training’, specialist support and the introduction of new ways of working could further improve patient outcomes and experiences on the ward.

How to change

A programme of work was agreed within the Trust and with local commissioners. This programme focused on:

• Increasing health and wellbeing, recognising that prevention would enable health improvement;
• De-escalation techniques and supporting PBS;
• Providing additional educational support for all ward staff on approaches of personalised care;
• Working in collaboration – a team approach in supporting people who present with complex needs, particularly if the patients are distressed;
• Establishing patient focus groups to involve and engage patients in the programme.

To support the implementation of the programme, the ward manager supported the development of a ’getting to know you’ booklet to support patients, families, carers and staff. The ward manager also worked alongside the nursing team to develop the ‘my preferred day’ tool. This tool supported conversations to enhance understanding of an individual’s preferences which promotes person-centred care. The nursing team provided PBS training for all staff and began using tools such as ‘one-page profiles’, which helped patients, with support from ward staff, to identify their needs and clearly plan for these. Positive behavioural planning was also undertaken with patients, their families and carers and the Learning Disability team supported staff with the changes.

Adding value

Better outcomes – Following the implementation of the new approach, Ward 5 has seen a significant reduction in the number of incidents related to patient distress, violence and aggression. This has decreased from an average of 8 incidents to 1 incident per month. Staff have reflected that this is associated with the approach to both personalised-care and escalation training. Staff have also observed that it has reduced the need for reactive medical intervention.

Better experience – The new, personalised approach has had a marked impact on feedback on the Friends and Family Test and responses on patient surveys. Feedback included:

‘I felt more involved in my care, the staff really listened’

‘I don’t know what I would have done without the kindness shown to me on my visits to the ward’ (carer)

‘Thank you to the wonderful staff who have supported myself and my husband’

‘Thank you for your care, understanding, friendship and patience’.

Better use of resources – The approach to personalised care has also encouraged collaborative working across the teams on the ward. Staff feel this has improved quality of care and enabled staff to support patient health and wellbeing to greater effect. Utilising an education package for staff has ensured both a personalised and streamlined way of working on the ward, attributed to enhanced skills and confidence, supporting the needs of patients and enabling better use their time.

Challenges and lessons learnt for implementation

People enjoy being more involved in their care and feel more empowered. This has resulted in patients and staff taking greater ownership of what is happening on the ward.

A proactive approach encourages positive outcomes for all involved.

It’s important to have the courage to change things if there is evidence to suggest improvements are possible.

Maintaining momentum has been challenging, however working as multidisciplinary team has helped this.

For more information contact

Janet Taylor, Ward Manager, Team Ward 5, Neuropsychiatry
JanetE.Taylor@combined.nhs.uk

Julie Anne Murray Deputy Director of Nursing, AHP and Quality
JulieAnne.Murray@combined.nhs.uk

North Staffordshire Combined Healthcare NHS Trust