Developing Acute Inpatient Servicesin Greater Glasgow & Clyde.

Developing Developing

Acute Inpatient Acute Inpatient

Services Services

in in

Greater Glasgow & ClydeGreater Glasgow & Clyde

Developing Acute Inpatient Services Developing Acute Inpatient Services

Change DriversChange Drivers

Service user & carer concernsService user & carer concerns

Professional concernsProfessional concerns

National reports - inpatient care struggling – National reports - inpatient care struggling – peoples’ needs not being met – poor peoples’ needs not being met – poor environmentsenvironments

Risk averse, defensive practice prevailing – Risk averse, defensive practice prevailing – culture of clinical observation rather than culture of clinical observation rather than clinical engagementclinical engagement

Stifling effect on practice developmentStifling effect on practice development

Undermining attempts to meaningfully engage Undermining attempts to meaningfully engage with people and their carerswith people and their carers

National directivesNational directives


The Perceived Role of the Ward NurseThe Perceived Role of the Ward Nurse

Prevention of untoward incidents and physical Prevention of untoward incidents and physical harm increasingly being seen (by some) as the harm increasingly being seen (by some) as the sole focus of the role.sole focus of the role.

Perception that the role is not as dynamic as Perception that the role is not as dynamic as that of community colleaguesthat of community colleagues

HoweverHowever

Mental Health Nurses have a critical part to Mental Health Nurses have a critical part to play in supporting people towards recovery.play in supporting people towards recovery.


Gartnavel Royal Hospital New BuildGartnavel Royal Hospital New Build

Guiding PrinciplesGuiding PrinciplesCare will be person-centred. Care will be person-centred.

Single room accommodation. Single room accommodation.

Flexible use in terms of gender specification – Flexible use in terms of gender specification – enabling single sex segregationenabling single sex segregation

Must respect the individual and recognise Must respect the individual and recognise their full rights and responsibilities as a citizen.their full rights and responsibilities as a citizen.

Promote a personal sense of safety and Promote a personal sense of safety and securitysecurity

Vulnerabilities will be managed by the least Vulnerabilities will be managed by the least restrictive means necessaryrestrictive means necessary


Gartnavel Royal Hospital New BuildGartnavel Royal Hospital New BuildGuiding PrinciplesGuiding PrinciplesA sense of safety will be promoted by a range A sense of safety will be promoted by a range of approaches including:of approaches including:

-Appropriate levels of staffingAppropriate levels of staffing-Effective engagement and involving people in their own careEffective engagement and involving people in their own care-Informed clinical judgementInformed clinical judgement-Safe systems of workSafe systems of work-Environmental and physical security integral to construction Environmental and physical security integral to construction requirementsrequirements

People will have access to information on their People will have access to information on their carecareCare plans will promote self determination, Care plans will promote self determination, informed choice and equity.informed choice and equity.Each person will be viewed and treated as a Each person will be viewed and treated as a unique individual and not pre-judgedunique individual and not pre-judged..


RecoveryRecovery

A personal, collaborative process which seeks A personal, collaborative process which seeks to overcome the negative impact of diagnosed to overcome the negative impact of diagnosed mental illness / distress despite its continued mental illness / distress despite its continued presence.presence.

About self-determination, recovering control About self-determination, recovering control over one’s life, feeling valued as a person, over one’s life, feeling valued as a person, feeling heard, contributing to the community, feeling heard, contributing to the community, helping others…………helping others…………

Not just about symptom control.Not just about symptom control.


What Would be the Key Attributes of a New and What Would be the Key Attributes of a New and More Effective Approach?More Effective Approach?

Acknowledge the central role of people in Acknowledge the central role of people in assessing their needs and planning, assessing their needs and planning, implementing and evaluating their care.implementing and evaluating their care.Respect people, value their contributions and Respect people, value their contributions and preserve their dignity.preserve their dignity.Empower people to take control of their lives Empower people to take control of their lives and instil hope.and instil hope.Bring structure and clarity to the role of the Bring structure and clarity to the role of the mental health nurse.mental health nurse.Provide a platform for further practice Provide a platform for further practice developmentdevelopment..


Principles of CarePrinciples of Care..

Professional curiosityProfessional curiosity – – what makes this person different from every what makes this person different from every other person with the same diagnosis. other person with the same diagnosis.

Harness the person’s natural resources Harness the person’s natural resources – – work with the person’s work with the person’s assets and strengths – inner and environmental / situational assets and strengths – inner and environmental / situational

Respect Respect – – value the person’s wishes and aspirations, recognise the value the person’s wishes and aspirations, recognise the person is the expert in their personal situation. (The wisdom that comes person is the expert in their personal situation. (The wisdom that comes from the lived experience)from the lived experience)

View crisis as an opportunityView crisis as an opportunity – – as a natural signal that something as a natural signal that something has to change.has to change.

Think smallThink small and simpleand simple – – achievable highly specific goals are best - achievable highly specific goals are best - look for straight-forward uncomplicated interventionslook for straight-forward uncomplicated interventions

Work with the person Work with the person – caring with & caring about but not caring for– caring with & caring about but not caring for


Key QuestionsKey Questions

How do we ensure that we really listen and respect the How do we ensure that we really listen and respect the person’s story.person’s story.

How do we balance the professional perspective of the How do we balance the professional perspective of the person’s needs with their perspective?person’s needs with their perspective?

What is the person’s personal theory? – HWhat is the person’s personal theory? – How does the ow does the person understand their problem, what is their person understand their problem, what is their experience of it?experience of it?

How do we seek to limit restrictions? – How do we seek to limit restrictions? – Aim to use the Aim to use the least restrictive means of helping the person resolve least restrictive means of helping the person resolve their difficulties.their difficulties.


Suggested Components of an Inpatient Suggested Components of an Inpatient Recovery ModelRecovery Model..

Multi-disciplinary assessmentMulti-disciplinary assessment

Person’s personal assessment of their Person’s personal assessment of their situationsituation

Planning the joint management of Planning the joint management of vulnerabilitiesvulnerabilities

One-to-One SessionsOne-to-One Sessions

Group-workGroup-work


Aims of the Personal AssessmentAims of the Personal Assessment

Gives the person the opportunity to describe, Gives the person the opportunity to describe, discuss and examine their experience of illness discuss and examine their experience of illness and health.and health.

Focused on the person’s needs as s/he sees Focused on the person’s needs as s/he sees them.them.

Identifies their chief problem(s) - problems are Identifies their chief problem(s) - problems are ratedrated

Written in the person’s own words and signed Written in the person’s own words and signed off by him/her.off by him/her.

Demonstrates the nurse’s understanding of Demonstrates the nurse’s understanding of the person’s situationthe person’s situation

Sets the agenda for the ongoing one-to-one Sets the agenda for the ongoing one-to-one sessionssessions

Ensures that the careplan addresses the Ensures that the careplan addresses the person’s concerns as well as professional person’s concerns as well as professional concernsconcerns


PERSONAL ASSESSMENTPERSONAL ASSESSMENTBeginning of Problems:Beginning of Problems: When I first noticed or became aware When I first noticed or became aware of things. of things.

Past Effect of Problem(s):Past Effect of Problem(s): How this affected me at first.How this affected me at first.

Past Emotions:Past Emotions: How I felt at the beginning.How I felt at the beginning.

Developmental history:Developmental history: How things have changed over time: How things have changed over time:

Situation, Relationships and Practical Situation, Relationships and Practical Resources/Problems:Resources/Problems: How this has affected my relationships / How this has affected my relationships / Other aspects of my life – e.g. finances, family/friends, others, housing, Other aspects of my life – e.g. finances, family/friends, others, housing, employment/unemploymentemployment/unemployment

Thinking:Thinking: My view of things or what I think about them. What I think My view of things or what I think about them. What I think about:- My present situation / My memory and concentration / My view of about:- My present situation / My memory and concentration / My view of myself / My life generally / My view of others / The future:myself / My life generally / My view of others / The future:

Emotions, Mood and Feelings:Emotions, Mood and Feelings: How I feel now within myselfHow I feel now within myself


PERSONAL ASSESSMENTPERSONAL ASSESSMENTPhysical feelings, health and symptoms:Physical feelings, health and symptoms: My view of My view of my Physical Health – e.g. known physical conditions or illnesses, weight, my Physical Health – e.g. known physical conditions or illnesses, weight, appetite, bowel habits, sleep, pain, mobility, smoking and appetite, bowel habits, sleep, pain, mobility, smoking and drinking/substance use habits.drinking/substance use habits.

Behaviours / activity levels:Behaviours / activity levels: My view of how I am behaving My view of how I am behaving and coping, organising my life and getting on with things. My and coping, organising my life and getting on with things. My involvement in interests and hobbies & socialising and meeting people:involvement in interests and hobbies & socialising and meeting people:

What all of this means for me.What all of this means for me.

What all of this says about me as a person.What all of this says about me as a person.

Needs, wants, wishes:Needs, wants, wishes: What needs to happen now, What I What needs to happen now, What I want or wish to happen.want or wish to happen.

Expectations:Expectations: What I think the ward team could do for me.What I think the ward team could do for me.

My Signature Nurse SignatureMy Signature Nurse Signature


Planning the Joint Management of Planning the Joint Management of Vulnerabilities.Vulnerabilities.

Integral to the careplanIntegral to the careplan

Requires to be reviewed and updated Requires to be reviewed and updated regularly.regularly.

Linked to a planned process of engagementLinked to a planned process of engagement

Identifies what (exactly) the person might be Identifies what (exactly) the person might be able to do for themselves to reduce the able to do for themselves to reduce the likelihood of untoward events occurring and likelihood of untoward events occurring and help them feel safehelp them feel safe

Monitoring promotes engagementMonitoring promotes engagement


Benefits of Jointly Managing Vulnerabilities.Benefits of Jointly Managing Vulnerabilities.

Not just about keeping the organisation ‘safe’.Not just about keeping the organisation ‘safe’.

Person is actively contributing to their own Person is actively contributing to their own careplancareplan

Identifies the kind of support the person Identifies the kind of support the person might need from the clinical team to help self-might need from the clinical team to help self-manage their own vulnerabilities – not what is manage their own vulnerabilities – not what is going to be going to be ‘done to them’.‘done to them’.

Clearly sends the message that the clinical Clearly sends the message that the clinical team recognises that the person has strengths team recognises that the person has strengths and potential to recoverand potential to recover

Less paternalistic approach, promotes self-Less paternalistic approach, promotes self-esteem and instils hopeesteem and instils hope


Example of an Individual Vulnerabilities Management Plan.Example of an Individual Vulnerabilities Management Plan.

I have discussed my specific needs with my keyworker and we I have discussed my specific needs with my keyworker and we have agreed that I will:have agreed that I will:

Read over letters from my family everyday to bolster my self Read over letters from my family everyday to bolster my self esteemesteemMake a note in writing each day of the people who have Make a note in writing each day of the people who have demonstrated that they value me for who I amdemonstrated that they value me for who I amListen to music on my walkman and talk to people as a means Listen to music on my walkman and talk to people as a means of distracting myself and dealing with my voicesof distracting myself and dealing with my voicesSeek out my Named Nurse if I am feeling vulnerableSeek out my Named Nurse if I am feeling vulnerableAttend the Recovery Groups in the morningsAttend the Recovery Groups in the mornings

What can others do that I might find helpful?What can others do that I might find helpful?

The nurses will spend time with me to find out how I am The nurses will spend time with me to find out how I am coping at least 4 times every day and will be happy to talk to me coping at least 4 times every day and will be happy to talk to me over and above that whenever I feel the need.over and above that whenever I feel the need.

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Focus of the One-to-One Work.Focus of the One-to-One Work.

Addressing the immediate needs of the person Addressing the immediate needs of the person and the continuation of the personal and the continuation of the personal assessment and problem solving process.assessment and problem solving process.

Jointly identifying simple achievable goalsJointly identifying simple achievable goals

Encouraging the person to become aware of Encouraging the person to become aware of the part they can play in identifying needs and the part they can play in identifying needs and working out potential solutions.working out potential solutions.

Instilling hope by developing the person’s Instilling hope by developing the person’s awareness of change – however small or awareness of change – however small or gradual.gradual.


Aims Of The Group-work.Aims Of The Group-work.

Share experiences of difficulty, distress and disability.Share experiences of difficulty, distress and disability.

Obtain support from other group members.Obtain support from other group members.

View problems from a different perspective and learn View problems from a different perspective and learn from the experiences of others.from the experiences of others.

Experience helping others.Experience helping others.

Share informationShare information

Explore new options for resolving problems.Explore new options for resolving problems.

Develop assertiveness, social skills and problem-solving Develop assertiveness, social skills and problem-solving skillsskills


Engagement not just Observation

Engagement level 4: Everyone is offered at least one therapeutic session per day – one-to-one, group meeting, family meeting etc.

Engagement level 3: Engagement level 3: Nurse makes formal contact at Nurse makes formal contact at least 3 times during the dayleast 3 times during the day

Engagement level 2: Engagement level 2: Nurse makes frequent Nurse makes frequent enquiries throughout the day to assess persons enquiries throughout the day to assess persons wellbeingwellbeing

Engagement level 1: Engagement level 1: Nurse in constant attention Nurse in constant attention throughout the day to offer supportthroughout the day to offer support


Key Messages.Key Messages.

Listen to the person’s storyListen to the person’s story – listen intently, – listen intently, listen, enquire, listen again – don’t assume.listen, enquire, listen again – don’t assume.

First questionFirst question - what is it that makes this person - what is it that makes this person different from other people I have met with the same different from other people I have met with the same illness?illness?

Work in partnership with the personWork in partnership with the person – do ‘– do ‘withwith’ ’ not ‘not ‘forfor’.’.

Demonstrate understanding Demonstrate understanding - - use the person’s use the person’s own words to describe their situation and support own words to describe their situation and support them to address their chief problems - as they see them to address their chief problems - as they see them.them.


Understanding the Person.Understanding the Person.

Be professionally curious: Be professionally curious: Never assume you know everything about the person Never assume you know everything about the person (or about nursing). (or about nursing). If the nurse acknowledges they don’t know If the nurse acknowledges they don’t know everything they need to know it encourages humility.everything they need to know it encourages humility.

Cultivate a non-judgemental approach / Cultivate a non-judgemental approach / attitude:attitude:Let go of preconceptions - if we pre-judge a person as Let go of preconceptions - if we pre-judge a person as good or bad we will fail to understand them.good or bad we will fail to understand them.There is no such thing as good solutions or bad There is no such thing as good solutions or bad solutions – what works for one person might not work solutions – what works for one person might not work for another.for another.If the nurse is non judgemental then respect for a If the nurse is non judgemental then respect for a wide diversity of opinion, thought and culture should wide diversity of opinion, thought and culture should follow.follow.


Key Leadership Messages Key Leadership Messages

ListenListen to the concerns of staff and service users / to the concerns of staff and service users / carers and explore potential solutions with them.carers and explore potential solutions with them.

Communicate the new approach as a Communicate the new approach as a solutionsolution not not another task on top of everything else.another task on top of everything else.

PlanPlan - prepare the ground – visits, meetings, - prepare the ground – visits, meetings, consultation events, highlight the potential benefitsconsultation events, highlight the potential benefits

Be able to Be able to communicate the visioncommunicate the vision but be flexible - but be flexible - ensure scope for local input and innovation - don’t tell ensure scope for local input and innovation - don’t tell people precisely how to do thingspeople precisely how to do things

Don’t get obsessed with documentationDon’t get obsessed with documentation


Key Leadership Messages Key Leadership Messages

Invest in training at all levelsInvest in training at all levels

Identify, invest in and support practice development Identify, invest in and support practice development championschampions

Ensure effective collaboration – steering groups / Ensure effective collaboration – steering groups / local implementation groups with input from all local implementation groups with input from all stakeholdersstakeholders

Be brave enough to try new things but big enough Be brave enough to try new things but big enough to admit when things are not working and to admit when things are not working and learnlearn from from the experiencethe experience

Evaluate locally – more evaluation less routine audit!Evaluate locally – more evaluation less routine audit!

Don’t just invest in the pilot areas and expect things Don’t just invest in the pilot areas and expect things to work elsewhere without the same level of support.to work elsewhere without the same level of support.

Developing Acute Inpatient Servicesin Greater Glasgow & Clyde.

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