AIM: To reduce incidents of inpatient violence and aggression across two securehospitalsitesbyatleast30%betweenJuly2016andJune2018.WHYDOESTHISMATTERFORSERVICEUSERSANDSTAFF?• Mostsignificantcauseofreportedsafetyincidents(18%of2013total).• Immediateconsequencesforserviceusers,staffandworkingenvironment.• Complexcontributingfactors:patientmix,securesetting• Support exists for structured risk assessment, safety discussions at ward
communitymeetingsandrestrictivepractices.[1,2,3]• Mentalhealthnursesreporthighabuserates:physical(80.6%),verbal(41.3%).• Lowerreportingforverbal(57.9%)thanphysicalabuse(85.6%).• Poorsatisfaction:approx.halfweresatisfiedwithreportoutcome.• Approx.40%didnotreportastheybelievednothingwouldchange.[4]• ReducinginpatientphysicalviolencewasidentifiedasamajorELFTQIpriority.METHODS:• QImethodologyappliedacrossmediumandlowsecuresites(JohnHowardCentre
&WolfsonHouse)fromJuly2016– June2018(Fig.A).Changeideas:
1. Safetyhuddles(Fig.B)2. Safetycrosses(Fig.C)3. Safetydiscussionsinweeklycommunitymeetings
• Safetycrosseswereadatacollectiontoolforstafftocaptureincidents.• Operational definitionsweredevelopedanddisseminated to ensure consistency
(Fig.D).Correspondedtocoloureddotsusedbystafftorecordincidents.Agreedelectronicincidentreportsystemwasinadequate.
• Changeideasfortheforensicviolencereductioncollaborative(FVRC)derivedfromTower Hamlets violence reduction collaborative and developed throughexplorationoftheoriesoninpatientviolenceandinterventionstominimisethis.[5]
• FVRClaunchedonthefourmediumsecurewardswithhighestincidentrates.• Laterexpandedtofivewardsandfinallytoatotalofeight.Thelatterthreesought
tojoinoftheirowninitiative.• Operationaldefinitions for sexualharassmentwerenot initiallyused.Theywere
developed and added to bundle following feedback from LDwards where staffreporteditwasnotadequatelybeingcapturedbyusualmeans.
Like all ELFT QI projects, it benefited from a framework ensuring close support,advice,supervisionandQIcoaching.Monthlycollaborativemeetingswereattendedbypatientrepresentatives,otherwardsandservices.ELFTusesastandardapproachto improvement: identifying and defining a problem, analysing causes, creating atheoryofchange,testingideasandevaluatingtheirimpactonthesystematregularintervals.TheModelforImprovementisusedtoguidetestingandimplementationofthechangebundleintoclinicalpractice.[6]RESULTS:• Reductions of 8% and 16.6% in physical and non-physical violent incidents,
respectively,wereachievedandsustainedper1000occupiedbeddays.• Comparedtobaseline,thisequatedtoonelessincidentofphysicaland17lessof
non-physicalviolenceperweekaveragedacrosssevenwards(Fig.E).• Threewardsachieved≥30%reductioninincidentsofphysicalviolenceperweek.• Fiveachieved≥30%reductioninincidentsofnon-physicalviolenceperweek.• Onewarddidnothavecompletedataandwasexcludedfromthefinalanalysis.LEARNING:DespitetheFVRC’spartialsuccess,itbroughtsignificantimprovementsindifficult-to-measure areas. A cultural shift towards openness and collaborative working wasexperienced around ward-based violence, aggression and sexual harassment. Thisfosteredstaffandserviceusers to takeownership in tackling it together.Locally, itledtoformationofasteeringgrouptoaddresssexualaggressionandviolencewithplans for increased staff training and standardised support. In 2018, nationalstrategicdirectionwaspublishedonthis.[7]QIcanbeeffectiveinreducinginpatientviolenceandaggressionwithinsecurecare.AtELFT,QIhasbecomeintegrated intothelivesofstaffandpatients.Indevelopingchangeideas,keyemphasisisplacedonservice user involvement and staff input. To progress to lasting transformationalchange,broadorganisationalsupportisvital.OTHERELFTFORENSICQIPROJECTS… Improved access to employment for service users,[8] implemented self-cateringmealsinanLSU[9]andimproveduserexperienceatanMSUreception.Twenty active projects e.g., increasing videoconferencing use, improving wardenvironmentsforpatients’sleepandimprovingstaffsatisfactiononacutewards.Theviolencereductioncollaborativecontinuestoscaleupacrossthetrust.
DrOwenPO’Sullivan,SpecialtyRegistrarinForensicPsychiatry(1,2)NynnHui-Chang,ImprovementAdvisor(2)DayNjovana,QISponsor,HeadofNursing&AssociateClinicalDirector(1,2)DrPhilipBaker,ConsultantForensicPsychiatrist&HeadofForensicServices(1,2)DrAmarShah,ConsultantForensicPsychiatrist&ChiefQualityOfficer(1,2)
1. JohnHowardCentre2. EastLondonNHSFoundationTrustContact:Owen.O’[email protected]
Qualityimprovementinforensicmentalhealth:theEastLondonforensicviolencereductioncollaborative
References
[1]AbderhaldenC,NeedhamI,DassenT,HalfensR,HaugHJ,FischerJE.Structuredriskassessmentandviolenceinacutepsychiatricwards:randomisedcontrolledtrial.BritishJournalofPsychiatry.2008Jul;193(1):44-50.[2]LanzaML,RierdanJ,ForesterL,ZeissRA.Reducingviolenceagainstnurses:theviolencepreventioncommunitymeeting.Issuesinmentalhealthnursing.2009Nov10;30(12):745-50.[3]vandeSandeR,NijmanHL,NoorthoornEO,WierdsmaAI,HellendoornE,VanDerStaakC,MulderCL.Aggressionandseclusiononacutepsychiatricwards:effectofshort-termriskassessment.BritishJournalofPsychiatry.2011Dec;199(6):473-8.[4]RoyalCollegeofNursing.EmploymentSurvey2017.RoyalCollegeofNursing:London.2017.
[5]Taylor-WattJ,CruickshankA,InnesJ,BromeB,ShahA.ReducingphysicalviolenceanddevelopingasafetycultureacrosswardsinEastLondon.BritishJournalofMentalHealthNursing.2017Jan2;6(1):35-43[6]LangleyGJ,MoenRD,NolanKM,NolanTW,NormanCL,ProvostLP.Theimprovementguide:apracticalapproachtoenhancingorganizationalperformance.JohnWiley&Sons;2009Jun3.[7]NHSEngland.Strategicdirectionforsexualassaultandabuseservices.2018[8]BeckC,WernhamC.Improvingaccesstocompetitiveemploymentforserviceusersinforensicpsychiatricunits.BMJOpenQuality.2014Jan1;3(1):u204182-w1821.[9]O'ReillyA.Improvingwardenvironmentsanddevelopingskillsfordischargewiththeimplementationofself-cateringonalowsecureforensicunit.BMJOpenQuality.2016Dec1;5(1):u210929-w4509.
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