1 Aug

Evidence base

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:

  1. Mental health inpatient care
  2. Quality of life, happiness and patient preferences
  3. Customer care
  4. Employee satisfaction and leadership
  5. Innovation, social enterprise and social marketing
  6. Delivering Star Wards’ objectives



  1. Mental health inpatient care

Mental Health

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.

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! 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.



Inpatient care

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.”

The Royal College of Psychiatry also runs the “Enabling Environments Award “, which is a quality mark given to those who can demonstrate they are achieving an outstanding level of best practice in creating and sustaining a positive and effective social environment.

From the website:

“Enabling Environments are:

  • Places where positive relationships promote well-being for all participants
  • Places where people experience a sense of belonging
  • Places where all people involved contribute to the growth and well-being of others
  • Places where people can learn new ways of relating
  • Places that recognise and respect the contributions of all parties in helping relationships

The Enabling Environments Award is based on core values that contribute to healthy relationships. Through a standards-based accreditation program your organisation will be supported in providing evidence that you are achieving excellence in providing a healthy relational environment for all their participants. For more information, look here.


NICE guidelines

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.


Anything written by Prof Len Bowers or Prof Alan Simpson.

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.



Len’s work has resulted in a major project called Safewards that we just love and are happy to endorse. Safewards’ evidence based interventions are designed to make wards safer for staff and patients.

There is a dedicated website with all you need to know about Safewards, and our own Geoff Brennan worked on the project with Len and many others. Since the research for Safewards was completed in 2013, Geoff (with Len’s blessing) has been promoting it as part of Star Wards, if wards would like to try it out.

For more information on Safewards look here and for a light hearted read about the how Star Wards and Safewards fit together, try this.

And if you are one of our wonderful Australian friends, why not check out the Safewards project in Victoria led by the lovely Anna Love here.



Marion 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.


  1. Quality of life and happiness


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 – a gripping read and so interesting, as well as wise. It is truly inspiring. And it includes a few pages about Star Wards! Henry describes Star Wards’ unswervingly positive approach and practical help for wards and goes on to say:

“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”.

  • Giving
  • Relating
  • Exercise
  • Appreciating
  • Trying out
  • Direction
  • Resilience
  • Emotion
  • Acceptance
  • Meaning

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:

  • Managing mental health
  • Self-care
  • Living skills
  • Social networks
  • Work
  • Relationships
  • Addictive behaviour
  • Responsibilities
  • Identity and self-esteem
  • Trust and hope


  1. Customer care

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.


  1. Employee satisfaction and leadership

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.

Results-Only Work Environment

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.


  1. Innovation, social enterprise and social marketing

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:

  • Reason (our rationale for Star Wards is informed and supported by staff, patients and carers)
  • Research (we may be a bit anarchic or free-form but even this has a credible book attached to it)
  • Resonance (it’s clear from our members that it’s the extent to which Star Wards’ tone, intention and contents resonate with them that plays a big part in their motivation to participate)
  • Representational redescription – rather a clumsy phrase, contorted for consistency with the other re-s, and meaning what symbols and images are used to represent the issue or message (Buddy, Marion’s dog, minimally conveys an accessible, unthreatening, informal organisational ‘personality’. And is particularly appreciated by dog-lovers. Particularly by Tibetan Terrier lovers.)
  • Resources and rewards (sharing of information and practical resources; staff public recognition through non-competitive awards’ schemes)
  • Real world events (our suggestions, strategy and practice are informed and continuously adapted in line with what’s happening out there)
  • Resistances (our appreciation of the realities of the multiple, heavy-duty challenges experienced by acute wards helps us to work with them to overcome impediments to involvement)


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:

  1. Decide your focus – what’s the core problem. Find a few vital behaviours. What are the High leverage behaviours? What does the person need to do?
  2. Choose one or two behaviours. Not 20.
  3. Study positive deviance – where the problem should exist but doesn’t, and what behaviours prevent it. Need to identify behaviours which are recognisable and replicable. Then test out with target group what seem to be the vital (positive deviance) behaviours.
  4. Search for recovery behaviours . ‘People are going to make mistakes, so you have to develop a recovery plan.’ Identify corrective action.
  5. When direct experience isn’t possible, vicarious experience is beneficial. Example of phobias – more tolerable to watch someone else handle a snake first and move closer to holding it oneself. “expose a subject to a vital behaviour”. “surrogate experience”. Soaps also provide vicarious experiences, and allow viewers to lower their defences.


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.

The 60 Second Leader

Learning to Live with Huntington’s Disease


  1. Delivering Star Wards’ objectives

Our greatest influences and teachers are our supporters. We are continuously dazzled by what we learn about and from their work with seriously mentally health problems.  We relied on the Star Wards’ community to tell us about 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 do. And the process 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.


Appreciative Inquiry

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:

  1. DISCOVER: The identification of organizational processes that work well.
  2. DREAM: The envisioning of processes that would work well in the future.
  3. DESIGN: Planning and prioritizing processes that would work well.
  4. DESTINY (or DELIVER): The implementation (execution) of the proposed design.

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

During our time we monitored:

  • Number of wards as members; what we saw and were told during visits to member wards; information researched and contained in articles written by and about member wards; information from hospitals’ Star Wards’ steering groups; findings of research about and/or commissioned by mental health hospitals; information from the members’ joining form
  • Usage of our website; comments in emails, feedback forms etc; feedback from events; anecdotal evidence through the mental health, especially inpatient care, grapevine including via Twitter
  • Being referenced in policy documents, academic papers, books etc
  • Feedback from funders and trustees


We were also fortunate to have two pieces of research carried out about Star Wards’ impact during our time as a charity. Prof Alan Simpson at City University carried out the members’ survey in 2010 which is available in full from our website. Key results include:

  • Improvements in staff morale, patient satisfaction and quality of care, less boredom and improvements in ward atmosphere and environment. A wide range of creative, innovative initiatives and new facilities have been introduced.
  • Reduction in aggression on the ward was reported by 71%
  • An increase in patient-focused activities on 83% of the wards, with over a third reporting a ‘big’ or ‘massive’ difference

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:

  • service users reported being:
  • new group activities  were developed in consultation with service users eg carer support, health and wellbeing, and ‘hearing voices’, and a comprehensive programme of group activities now takes place on each ward.
  • the development of a ward library, a gardening group and a ward-based internet café, and the running of regular movie nights.
  • offered more information when they arrived on the wards
  • more involved in decisions about their treatments
  • more occupied in useful and relevant activities
  • respected more
  • more satisfied with the care they received.

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’.

But the real evidence is in the power of action – so give us a go and find out for yourself if there is any effect. And remember William Bruce Cameron “Not everything that counts can be counted, and not everything that can be counted counts”

Good luck!

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