“How incidents became more about compassionate leadership in sustaining compassionate care ”

1. “How incidents became more about compassionate leadership in sustaining compassionate care” Dr Jo Nadkarni, Consultant Applied Psychologist-Professional lead Durham & Darlington jo.nadkarni@nhs.net Jenna Grocott, Higher Assistant Psychologist jenna.grocott@nhs.net

2. What we plan to do • Journey of an inpatient service • Apply and share learning from your service experiences

3. Why? • CYPS inpatient services, especially low secure were a trust outlier in incidents. • 2016 – ‘Deep dive’ report with analysis of incident data, clinical context, challenges and positive & proactive approaches. • Minimal use of severe restrictive interventions e.g. prone restraint, segregation & seclusion. No use of mechanical restraints.

4. What is your understanding of incidences in your service/s? • Nature • Factors affecting • Patterns • Culture

5. Responding to high-risk behaviour and incidents is a ‘wicked problem’, not resolved with simple solutions.

6. Prior Learning • Frequency and nature of incidents across Tier 4 CYP inpatient services (3 month period - December 2015- March 2016) • Low Secure Service highest outlier

7. How have you approached reducing incidences in your service?

8. How? • Shift from external scrutiny with reviews, action plans to shared understanding and organisational support • Embedded Trust 7 strategic interventions for positive and safe approaches • In-service training - relational security, attachment, impact of trauma, Safewards, Positive Behaviour Support, orientation to Dialectical Behaviour Therapy, Compassion and Wellbeing • Working with IT to create a ‘bottom up’ visual dashboard for incidents, physical interventions to aid clinical decision making

9. Senior nursing staff providing cover to embed • Alternative injection site/ beanbags • Debrief tool • Environmental improvements - sound proofing and art • MDT composite/psychology • Continue positive behaviour support plans - young people, parents/carers and staff perspectives • Continue purposeful activity – education and OT • Evaluate efficacy of Safewards(& prior evaluation of relational security and attachment framework)

10. Audit of PRN medication – psychiatry & NICE guidance. • Experts by Experience - training, recruitment and external forums. • System of qualitative feedback from patients, families and staff. • External assurance - joint work with NTW and start of national Low Secure Network, leading multidisciplinary security group, national IAPT inpatient CYPS team training • Culture shift, multi-professional Responsible Clinicians, reflective practice • Collective, collaborative, compassionate leadership to sustain compassionate care

11. Your experiences: • What has made the most difference? • What have been the main challenges?

12. How incidences became more about compassionate leadership in enabling and sustaining compassionate care • The bottom line when peoples risk behaviour increases along with incidences • ‘My’ compassionate leadership behaviours • Service Evaluation Aims • To understand compassionate care • Leadership behaviours

13. Service evaluation • Mixed methods approach • Multiple perspectives • 26 Interviews: 5 young people, 6 families, 15 staff • observation of practice (12 hour shift) • N=50 standardised measure of Professional Quality of Life (Stamm, 2010) • Thematic analysis • Self-reported levels of compassion • What done to promote and overcome barriers to compassionate care. • Overarching themes • Learning- self, individuals team and organisation

14. Framework for compassion Gilbert (2010) six aspects of compassion • Sensitivity • Sympathy • Empathy • Motivation • Distress tolerance • Non-judgement.

15. Model of Compassionate leadership West et al (2017) • Inspiring vision and strategy • Positive inclusion and participation • Enthusiastic team and cross-boundary working • Support and autonomy for staff

16. How people saw compassionate care • Reciprocal relationships • Security in attachment • Feeling safe withboundaries • Understandingand equity in individualised effective treatment by a competent team. • Behaviours

17. Benefits - Service users • Feeling better about themselves • Understood • Cared for, closer, calmer • Giving hope • Opening up • More effective decision making • More likely to listen • Families reduced anxieties and supported trust.

18. Emotional Impact if lacking • Mistrust, unhappy, upset, frustrated, hopeless • Abandoned, isolated, ignored, unsupported • Expectations to sort themselves out • Experiencing practitioners as uncaring, not listening • Not knowing how to help or misinterpreting distress • Increased self-harm, attempts to elicit care • People getting hurt in restraint and remaining in hospital

19. Impact on professional behaviour if lacking • Focusing on tasks & avoidance behaviours • Strong negative feelings • Simplistic understanding of needs • Judgements • Focusing on observations, being busy, moving away, not engaging, disinterest, less empathy, perceived unfair distribution of observations. • Perceived discrimination on basis of diagnosis, ‘blaming’ and exhaustion in caring for the young person • Invalidating comments e.g. ‘attention seeking’ or ‘behaving on purpose’, emphasis on rules, not taking positive risks, raising anxieties or tone of voice.

20. Emotional Impact on Staff • Fearing risk of patient death • Feeling dismissive, irritated, impatient, angry, frustrated, helpless, shocked or disgust • Disappointed if a young person self-sabotages or fear compassion may maintain difficulties • Traumatic impact of managing severe self-harm and suicidal risk • Restraint • Finding it harder to be empathic YP personality or eating disorder • Feeling incompetent

21. Summary - Compassionate Care • Patients- impact of compassionate care in how they felt and saw themselves • Families – their involvement, managing anxieties and individual needs • Practitioners - impact of emotional distress, progress and difficulties sustaining compassionate care when patients show high risk behaviours, distress or don’t progress

22. ‘My’ compassionate leadership behaviours • Inspiring vision and strategy: “The way you communicate things to the ward, being able to get staff to see what the vision is for an individual, the plan and how we’re going to get there”. • Facilitating positive inclusion and participation:“Getting people in to talk to us about equality and gender diversity... leading in a way that promotes that, not being afraid to step out the box…what do we do about practical stuff like name changes”. • Enabling enthusiastic team and cross-boundary working: “Liaising with neighbouring trust around risks and with the low secure network, it’s not just about us as a ward but wider sphere”.“Responsible Clinician for young people, working with other services for transitions, networking”. • Providing support and autonomy for staff to innovate: “Receptive and open to people’s ideas…if you can see something in that idea you will go forward with it, or bring it to the wider team…you don’t dismiss things”.

23. Themes- Compassionate leadership • Embodied compassion • Feeling safe • Really knowing and understanding • Equal as humans, as individuals unique • Firm around the edges • Landscape and capacity • Do what works together • Time to process emotion

24. Embodied compassion Leading through being compassionate, this driving motivation and consistent with the messages given and what do. • MDT: “I think you always present alternative viewpoint, question things and trying to explore things, role model it – you are compassionate and that is something you can just see. And you don’t give up. You don’t write people off”.

25. Feeling safe Providing a secure base and sense of safety through reciprocal relationships and trust. • Patient: “You’re very consistent coming down to see me and never really miss a session… feel comfortable talking to you…I’ve got a good Doctor… not just stopping session straight away and keeping calm if I’m struggling and trying to support”. However… • Patient: “Pushing people past their comfort zone. Which is positive but depends on how that person sees it…needs to happen”.

26. Really knowing and understanding Deep understanding of the person, their wider context and possible reasons underlying any behaviour, that is based on the patient and families experiences, theoretical, clinical experience and self-awareness. • MDT: “I think you always see and take into account the young persons and family perspective on their experiences and try to support them and understand…you don’t just keep hold of that but you share that with the team and so the organisation understands the work we do”. • Patient: “Talks to staff to try get them to understand that it is difficult but it’s also difficult for us. It’s hard for them to work here and it’s hard for us to be here”.

27. Equal as humans, as individuals unique Humanist values and interest in the uniqueness of individuals, fairness, child and family centred needs and enhancing the benefits of equality and diversity. • MDT: “I see you challenge the nursing team…you build a case around “why not?” and how can we do this in a planned way, not being as restrictive, remembering the rights of the person”.

28. Firm around the edges Warm approach with boundaries and flexibility that consider risk of harm and opportunities for development. • (Patient Smiles) “The way you talk to people, way you interact…you’re compassionate but you have boundaries. Sort of warm way but being flexible at same time…you make the staff well informed”. Too much compassion.. • MDT: “When people are feeling negative, they might think you’re not seeing the bigger picture as you’re too compassionate. Changing your role has helped with this. I think the change as Approved Clinician has opened up opportunities to see the bigger picture…managing that risk”.

29. Landscape and capacity Creating a compassionate environment, sustaining a culture of compassionate care and capacity to be compassionate. • Ward-based: “Trying to identify things on the ward and how to develop a better working environment…working as an MDT…provide resolution or offer assistance to other members of the team to get stuff done”.

30. Do what works together Delivering and coordinating effective treatment as a team that is high in quality, focused on recovery and based on what we would want for those we love. • Ward-based: “Debrief with the young people. I’ve been in Clinical Team Meeting…way you addressed young people and the way you treat them. Delivering training around those sort of values. DBT…I really enjoyed that session…some doctors would talk really formally…you’re quite relatable and approachable”.

31. Time to process emotion Recognising and prioritising the need for reflection and space to process difficult emotions in managing young people’s complex mental health difficulties, associated high levels of emotional distress, risk behaviours and wider system expectations. • MDT: “What I value in you is your reflective component, and always questioning and not just doing things because we do them that way, but how does it apply to that young person at this moment in time and their needs. You are always cool and calm and collected”.

32. Factors supporting compassionate care • Leading by example • Attachment behaviour • Recruitment of compassionate staff • Managing relationships • Time • Availability • Competency - increased understanding, communication, effective treatment, recovery focus, boundaries • Coordination, involvement, visibility, • Support and supervision to reflect and process feelings.

33. Barriers to compassionate care • Insufficient time/breaks when patients challenging • High levels of acuity, incidents, multiple demands • 12-hour shifts • No time to process emotion • Task focus, negative approaches • Feeling incompetent or threatened, stress, negative judgements, lack of relationship and mistrust. • Medical model • Staffing • Audits and external quality assurance

34. Incident Type

36. Impact on incidents • Over a quarter sustained reductions in low secure incidents and all forms of physical intervention this financial year compared to last, with further reductions in physical interventions and self-harm since October 2017. • Staff report average or high compassion satisfaction and low to average compassion fatigue. • Shift in narrative, supporting and enabling, less judgements about patients’ presenting needs. • Processing the emotional impact of tolerating distress CULTURE CHANGE

37. Collective, Collaborative, Compassionate Leadership

38. Next Steps… • What are you taking away? • What do you plan to do next? Write your action