|Our work has an eclectic range of influences, most of which also form the evidence base. There are all the predictable (and therefore important!) ones – the reports and research anguishing over the state of mental health inpatient care. These are included in the Star Wards’ publication. The following are the other publications, and people, that inform, influence and enliven our work.We seek out excellence in:
There are dozens of books which have really helped us understand mental health and illness somewhat better but none that we’d single out as a must-read for anyone involved in mental health. The terrain is too bumpy and complex for that! So here are some books that we’ve found particularly helpful and which we feel would be of interest to staff and some patients.
TalkWell (our conversation guide) and much of the contents of Wardipedia are underpinned by the skills of ‘mentalising’ or mind awareness – being aware of what’s going on in our own and other people’s minds. There’s a bunch of textbooks about mentalising, including Mentalizing in Clinical Practice by Allen, Fonagy and Bateman and shorter, more accessible information on Bright’s www.mentalising.com website.
The Chimp Paradox was written by the psychiatrist to the British Olympic cyclic team! Dr Steve Peters. It is a wonderfully clear explanation of the way in which different parts of our brains effect our emotions and the chimp metaphor works really well. The chimp represents the emotional part of our brain (broadly the limbic system) and Peters compellingly describes why we find ourselves trying not to blurt out something inappropriate but – hey, it’s suddenly out there! (Or is that just Marion?) It’s because our chimp, or emotional mind, always gets there first. The Chimp thinks five times more quickly than our logical mind and because it’s all emotional, it needs attending to before the logical mind can be properly back in control of things. Peters does a superb job in explaining practical ways in which we can manage our chimp and therefore our emotions, thoughts and actions!
F**k It – The ultimate spiritual path
Controversial title, but it’s sold 150,000 copies and lured Marion both to the book and a subsequent week of learning relaxation techniques in the Umbrian hills of Italy. The title in fact brilliantly captures the wacky Western Zenness of John and Gaia’s approach. The book is as good a laugh as any best-selling humorous novel and this makes it very easy for very unrelaxed people to absorb some of the wisdom and techniques.
There’s sadly very little written about inpatient care – which is why we’ve produced Wardipedia! The information and evidence that influence us the most are:
Royal College of Psychiatrists’ AIMS (Accreditation of Inpatient Mental Health Services) programme
AIMS is a very structured, highly evidence-based programme centring on a rigorous set of standards, produced by clinicians, service users and carers. Wards that take part enjoy the challenge of meeting the standards and get a huge morale boost when the ward is accredited. This is how AIMS describes itself:
“AIMS is a standards-based accreditation programme designed to improve the quality of care in inpatient mental health wards. Through a comprehensive process of review, we identify and acknowledge high standards of organisation and patient care, and support other services to achieve these. AIMS accredits acute and assessment wards for working-age adults, wards for older people, psychiatric intensive care units, inpatient learning disability services, inpatient rehabilitation units and care for young people on adult wards.”
Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services (2011). Some of the themes detailed in this guidance which are explored in Wardipedia include: empathy, optimism, patient involvement in decision-making, the importance of familiar and continuous relationships, patients’ views being taken seriously, regular emotional support and contact, the provision of meaningful activities, and means of providing safe and supportive ward environments.
Len and Alan have done outstanding research on inpatient care, producing practical advice for wards including two seminal pieces of research. All their work is essential for any ward to be able to run as therapeutically as possible, and below is a taster of why it’s invaluable.
The City-128 study was designed to test the City Model which predicted factors to help create a calmer ward. These wards would be those where the staff positively appreciated patients, could contain their natural emotional responses to difficult patient behaviour, and provided an effective structure of rules and routines for those in their care.
Total conflict and containment
Staff factors are relevant in the determination of conflict and containment rates on wards. Most importantly wards require an effective, well organised structure of rules and daily routines.
Constant special observation was not associated with self-harm rates, but intermittent observation was associated with reduced self-harm, as were levels of qualified nursing staff and more intense programmes of patient activities. We concluded that certain features of nursing deployment and activity may serve to protect patients. The efficacy of constant special observation remains open to question.
We concluded that clear policies relating to the management of verbal abuse by patients, high levels of order and organisation, and staff rotation and education, may all support high morale. Acute inpatient psychiatry is generally a happy and rewarding work environment, and identified problems are likely to be due to other factors.
Nurses and patients on acute wards
There continues to be evidence that ethnic minority patients are subject to an excessive amount of legal coercion in English mental health services. However the proportion of staff belonging to an ethnic minority is greater than the proportion of patients. Changes to recruitment strategies are required if ethnic concordance is to be achieved.
Investment in acute inpatient care
The cost of providing acute inpatient care varied fivefold between different Trusts. This variation comprised of numbers of beds/population, numbers of nurses/beds, and the proportion of nurses qualified. These variations were not fully accounted for by differing levels of social deprivation. Although service provision levels in London were higher, wide variation in costs existed in every region. Associations between nursing cost per bed and performance indicators were found.
Key factors associated with aggression
High levels of aggression were associated with several factors: a high proportion of patients formally detained under mental health legislation, high patient turnover, alcohol use by patients, ward doors being locked, and higher staffing numbers (especially qualified nurses). The findings suggest that the imposition of restrictions on patients exacerbates the problem of violence, and that alcohol management strategies may be a productive intervention. Insufficient evidence is available to draw conclusions about the nature of the link between staffing numbers and violence.
Ward features associated with medication refusal
We concluded that it may be possible to achieve greater medication concordance amongst patients in acute mental health wards through a more consensual approach to care. Paradoxically, fewer restrictions may promote better treatment acceptance and safer outcomes. Consistent nurse staffing and therefore better staff-patient relationships, are also likely to improve cooperation and outcomes.
Certain elements of the City Model were supported. The extent of a daily routine for patients on the ward was found to be predictive of conflict rates, providing a strong indication that structure is causal. Links were also found between positive attitudes to patients and ward structure as measured by different scales. The presence of regular staff on the ward was found to be associated with lower incident rates. Staff related changes were associated with upturns ad downturns in conflict and containment on the wards, in ways consonant with the City Model.
However evidence was found for several factors influencing conflict rates which were not in the working model. Stress in the ward community as a whole (admissions, ward rounds, weekdays, other incidents) seemed to be linked to incidents. The physical security of Psychiatric Intensive Care Units was found to be important in reducing absconding.
Unpredicted by the working model, adverse incidents and conflict levels led to an erosion of ward structure over time, demonstrating that structure and conflict were in a reciprocal relationship. Several predictions made by the working model were not substantiated by the findings of this study. Instead of determining conflict and containment rates, staff attitudes to patients were found to be products of those rates. More conflict led to more negative attitudes. More containment led to better attitudes.
In addition, the working model predicted that better technical mastery in interpersonal skills would lead to better staff attitudes and thereby to lower conflict, whereas in fact training courses incorporating de-escalation skills did not have any impact.
Bowers, L.; Van der Merwe, M.; Nijman, H.; Hamilton, B.; Noorthoorn, E.; Stewart, D.; Muir-Cochrane, E. (2010)The Practice of Seclusion and Time-out on English Acute Psychiatric Wards: The City-128 Study. Archives of Psychiatric Nursing, 24(4)275–286
Stewart, D., Bowers, L. and Warburton, F. (2009) Constant special observation and self-harm on acute psychiatric wards: a longitudinal analysis. General Hospital Psychiatry 31:523-530
Bowers, L., Chaplin, R. Quirk, A. and Lelliot, P. (2009) A conceptual model of the aims and functions of acute inpatient psychiatry. Journal of Mental Health 18(4)316-325
Bowers, L., Allan, T., Simpson, A. Jones, J. Van Der Merwe, M., and Jeffery, D. (2009) Identifying key factors associated with aggression on acute in-patient psychiatric wards. Issues in Mental Health Nursing 30:260-271
Van Der Merwe, M., Bowers, L., Jones, J., Simpson, A. and Haglund, K. (2009) Locked doors in acute inpatient psychiatry: a literature review. Journal of Psychiatric and Mental Health Nursing 16:293-299
Bowers, L., Allan, T., Simpson, A., Jones, J. and Whittington, R. (2009) Morale is high in acute inpatient psychiatry. Social Psychiatry and Psychiatric Epidemiology 44(1)39-46
Marion has had a real thing about ‘total institutions’ since reading Goffman’s classic Asylums. The fact that it is still highly relevant about 50 years after it was written illustrates the ossified nature and devastating effect of total institutions on people who live in these large, closed, usually involuntary establishments for decades. It’s heartening to see the reintroduction of some of the more ‘holistic’, life-enhancing features of asylums that were lost in the move to progressive, therapeutic inpatient care including the value of gardening and contact with animals.
Happy Ltd, founded and run by Henry Stewart, is regularly voted one of the best, as well as most ethical, workplaces in the country. Henry is actively supportive of Star Wards and convinced us at an early stage that rather than trying to impose yet more performance indicators, quality standards or prescriptive practices on wards, we should inspire and support. How right he was! Wards have come up with much more creative, sustainable and locally suited opportunities for inpatients than we could ever have done. And interestingly, most of our members have chosen to introduce a very systematic model of quality assurance, one that they have created and are committed to.
The Happy Manifesto is much lauded – Prof Richard Layard (yes, he of IAPT fame) said: “A wonderful book – a gripping read and so interesting, as well as wise. It is truly inspiring”
“Contrast this with how the government, or conventional management, would have approached such a change. They would have started by criticising the work currently being done (as the previous government did with teachers, police and others), and talking about the number of staff not doing a proper job. They would then prescribe a specific set of actions every ward must follow, set targets, introduce league tables and name and shame those not doing well. Then they would wonder why the changes were not being eagerly embraced and complain that people were resistant to change.”
10 Keys to Happier Living by Action For Happiness (2012). Everyone’s path to happiness is different. But a review of the latest research has found 10 Keys to Happier Living that consistently tend to make people’s lives happier and more fulfilling. Together they spell “GREAT DREAM”.
The Recovery Star by Mental Health Providers Forum. The Recovery Star is a tool for supporting and measuring change when working with adults of working age who are accessing mental health support services. The Recovery Star identifies and measures ten core areas of life:
Fred Lee’s If Disney Ran Your Hospital
Lee was a senior exec in Disney and a major US hospital and brilliantly brings together the customer care and leadership issues these share. The book provides inspiring examples of obsessive attention to the customer experience through the equally full-on trusting, equipping and supporting of staff. These two sentences transformed Wardipedia, as we instantly adopted the imagination concept as the scatablogue’s new framework:
Imagination creates empathy, which leads to compassion. Values and ethical beliefs alone cannot do this because in them is not where human passion resides.
The Happy Manifesto – as above.
Ricardo Semler’s large, disparate and successful Brazilian company is run in an astonishingly laid-back, employee-determined way, with staff deciding everything from their job titles to working hours. This is captured in his two books Maverick and Seven Day Weekend.
For an example of a completely different paradigm (i.e. throwing away the box!) it’s worth checking out ROWE.
From CBS News online:
ROWE is a management philosophy based on the premise that giving employees complete control over their time is the best way to increase productivity in the workplace. As Ressler and Thompson put it in their book, “In a Results-Only Work Environment, people can do whatever they want, whenever they want, as long as the work gets done.” This is not simply company-sanctioned flextime. A true ROWE has unlimited paid vacation time, no schedules, no mandatory meetings, and no judgments from co-workers and bosses about how employees spend their days. In other words, managers trust employees to get their work done and do not mandate — or even comment on — when, where, or how it happens. Because everyone is evaluated based on what they accomplish, as opposed to how much time they spend looking busy at their desks, it becomes clear very quickly who is actually getting work done and who isn’t.
Jugaad – Frugal innovation
Jugaad is a Hindi word meaning an innovative fix; an improvised solution born from ingenuity and resourcefulness. (Also known as DIY in the US, Gambiarra in Brazil, zizhu chuangxin in China, and Systeme D in France.) Frugal innovation embraces keeping things simple and making sure they’re what people need. For example, after the devastating earthquakes in Gujarat, a village inventor created a fridge made of clay cooled by water – fulfilling the frugal innovation criteria of products and services which are relevant, affordable, accessible.
The BBC’s Peter Day ended a programme on frugal innovation by saying it “turns innovation upside down by focusing on the things outside companies that perhaps people inside big business hardly notice. And then it uses cheap, cheerful and flexible ways to deliver the things that do the job without all the fuss that great big companies often apply to the rolling out of new ideas. Worth a try, this frugality.”
Honey Bee Network is “an organization which collects and disseminates traditional knowledge and helps facilitate and spread grassroots innovation throughout India and elsewhere. It is a crucible of like-minded individuals, innovators, farmers, scholars, academicians, policy makers, entrepreneurs and non-governmental organizations (NGOs).” It’s also been described as providing “institutional support for scouting, spawning, sustaining and scaling up the grassroots innovations.” That’s pretty much what we aspire to do in Star Wards (with fewer farmers), and Wardipedia is where we’ve put everything we’ve found.
Spreading the word, or ’social marketing’
Communication is what we do at Bright and Star Wards. We don’t sit next to anguished patients for hours, listening to them non-judgmentally and compassionately. We don’t wrestle with conflicting staff needs to create a viable ward rota, or have to find someone to cover a shift in an hour’s time because a nurse’s 5 year old son has been sent home for flicking a collage of wet toilet paper onto the ceiling of the school loos. We communicate. We find out about excellence in inpatient care and enthuse about and publicise this.
We’re into ’social marketing’ – identifying and meeting the needs of users of public services. (That’s not an official or even totally accurate description. It’s a messy one, which is more accessible than the jargony textbook ones.) Luckily, mainly because of its similarities with its non-identical capitalist twin, there’s masses of social marketing evidence on which to base our work.
It’s pretty essential to recognise that each of us is in a different place in relation to changes we are, or others want us to be, making. Stages of Change Theory was ground-breaking as well as firmly rooted in findings from the successful efforts of thousands of people who have got over addictive behaviours. Similarly, wards are at different stages of achieving excellence in their treatment of inpatients and efforts to engage and resource them need to reflect this.
It turns out that we’ve put together a structure and approach which covers what the masterminder of ‘multiple intelligences’, Howard Gardner, lists as the essentials for convincing people. According to Changing Minds, what’s needed are:
Other social marketing books that we love
Yes! 50 Scientifically Proven Ways to Be Persuasive. By Goldstein, Martin and Cialdini.
A handy summary of the inspired, practical techniques for achieving positive social change.
Nudge by Thaler and Sunstein
Nudges are policy interventions that encourage rather than mandate certain types of behaviour. They’re based on recognising the power of our ‘automatic thought system’ over our ‘reflective system’ – or the part of the brain that Steve Peters refers to as ‘chimp’ (see Chimp Paradox above.) The book describes the way that choice architecture (the ways in which options are presented to people) can be adjusted by some well-crafted nudges.
Purple Cow: Transform Your Business by Being Remarkable by Seth Godin
A galaxy of social marketing gurus with their top tips for being successfully distinctive. And thus to be the purple cow in a field of monochrome Holsteins.
Hands-On Social Marketing: A Step-by-Step Guide to Designing Change for Good. by Nedra Kline Weinreich.
Brilliant book. So practical. Based on six steps of the social marketing process: analysis, strategy development, program and communication design, pretesting, implementation, and evaluation and feedback.
Influencer: the power to change anything. Patterson and colleagues.
The sub-heading may be slightly overstating the case but this is nevertheless a genius book, bursting with wisdom, practical solutions and a handy framework for applying their insights into changing hearts, minds, and behaviour to produce meaningful, sustainable results. The sextuplet of authors advise:
Customer care and leadership
If Disney Ran Your Hospital – as above.
The following two books are related but not totally conjoined. We’re fortunate to be advised as well as influenced by Phil Dourado who is an expert in both areas. Phil also cares for his wife who has Huntington’s Disease and Phil’s and his family’s individual descriptions of their experiences are the most powerful accounts of carers’ lives and resilience we’ve come across.
Our greatest influences and teachers are our members. We are continuously dazzled by what we learn about and from their work with seriously mentally ill patients. We’d love to be able to commission Proper Research which explores and validates this – and any potential funders reading this should feel more than free to contact Marion day or night. In the meantime, we rely on, and the Star Wards’ community benefits from, accounts, visits to wards, survey responses, press cuttings, steering group minutes, emails, conversations…. anything that illustrates that despite the exceptional challenges faced by mental health wards, it is possible to provide superb care to inpatients.
Co-production is described on peopleandparticipation.net as “a way of working whereby decision-makers and citizens, or service providers and users, work together to create a decision or a service which works for them all. The approach is value-driven and built on the principle that those who are affected by a service are best placed to help design it.”
Star Wards’ focus swiftly changed from advocating a portfolio of 75 ideas, to being one of inspiring, discovering and sharing the great practice taking place on acute wards. Central to this is the recognition that front-line staff and patients necessarily have a much better grasp of what’s needed than we can do. And the process and fact of developing their own methods, priorities and practices also increase the likelihood of sustainable improvements. More specifically, Star Wards can only operate thanks to the generosity exercised by open source participants. This might be in software development, creating collaboratively compiled resources such as the invaluable Wikipedia or, in our case, members producing, adapting and sharing tools for improving inpatient care.
And let’s not forget Mao’s contribution to the introduction of dialectical behavioural therapy and comedy evenings on acute wards. Marx may have been more into dialectical stuff than Mao, but he didn’t come up with the Let A Hundred (sic – it has become swollen to the popular Thousand value) Flowers Bloom campaign. As a colleague pointed out, Star Wards is a bit like the blooming campaign but without the slaughter of the intellectuals. Right. The parallel is simply about providing some inspiration and guidance from the centre and then leaving local people to develop services in the ways most appropriate to local circumstances. A Star Wards’ example of this is our forthcoming Star Awards for healthcare assistants. We’ll set out some broad eligibility criteria for the three levels of attainment. But it’s an achievement/acknowledgment not an accreditation scheme, and different ward managers will apply the criteria differently, even idiosyncratically. And that’s great. Unheavy, unbureaucratic, trusting, validating.
Wikipedia describes Appreciative Inquiry as: …”primarily an organizational development method which focuses on increasing what an organization does well rather than on eliminating what it does badly. Through an inquiry which appreciates the positive and engages all levels of an organization (and often its customers and suppliers) it seeks to renew, develop and build on this. Its proponents view it as being applicable to organizations facing rapid change or growth.
Appreciative Inquiry utilises a cycle of 4 processes, which focuses on what it calls:
The basic idea is then to build – or rebuild – organisations around what works, rather than trying to fix what doesn’t. AI practitioners try to convey this approach as the opposite of problem-solving. They take a positive focus on how to increase exceptional performance instead of improving poor skills and practices.”
Wandering off the evidence-based path
There’s only so far that innovation can rely on the evidence base. By definition, when you’re in new territory, there has to be a certain amount of experimentation. And many, many blunders on the way to creating something effective.
There’s a book whose title and sub-title may not immediately inspire confidence A Perfect Mess – The Hidden Benefits of Disorder, by Abrahamson and Freedman. It’s a wonderful analysis of the costs of being highly organised and the converse benefits of informality, asymmetry, uncertainty and general scrappiness in many situations. The positive manifestations of these include diversity, flexibility, responsiveness, creativity, improvisation, adaptation, spontaneity, serendipity. (They do concede that it’s best to have meticulously organised and systematic pilots, brain surgeons etc. But wouldn’t the world be just that much lovelier if traffic wardens were given Semler-like trust to use their own judgement sometimes?)
Evaluating Star Wards’ effectiveness
We’ve also been very fortunate to have had two pieces of research carried out about Star Wards’ impact. Prof Alan Simpson at City University carried out the members’ survey which is available in full from our website http://starwards.org.uk/about-us. Key results include:
Philip Kemp and colleagues at South Bank University worked with North East London Foundation Trust to evaluate the impact of introducing both Productive Ward and Star Wards. Their article How to turn innovations into everyday practice was published in the October 2011 edition of Mental Health Practice and outlines some incredible achievements by NELFT eg:
The number of recorded incidents fell from an average of 30 per month during the first three months of the first year to an average of 13 per month during the last three months. And the average length of stay declined from 25.5 days to 20.3 days. Other remarkable service improvements included:
As for sustainability, here’s what the article said:
Structures and processes have been embedded in NELFT practice and will be extended to all inpatient facilities in the trust. Responsibility for the project practices has been transferred from the Star Wards and Productive Ward leads to modern matrons, and its outcomes have been incorporated into the trust’s performance framework. In other words, the developments have become ‘business as usual’.