Ward-based violence is the most significant cause of reported safety incidents at East London NHS Foundation Trust (ELFT). It impacts on patient and staff safety, well-being, clinical care and the broader hospital community in various direct and indirect ways. The contributing factors are varied and complex. Several factors differentiate the forensic setting, which has been identified as a particularly stressful work environment. Staff must constantly balance addressing therapeutic needs with robust risk management in a complex patient cohort. ELFT identified reducing inpatient physical violence on mental health wards as a major quality improvement (QI) priority. The aim was to use a QI methodology to reduce incidents of inpatient violence and aggression across two secure hospital sites by at least 30% between July 2016 and March 2018. Collaborative learning was central to this project. It sought to foster a culture of openness within the organisation around violence and to support service users and staff to work together to understand and address it. A QI methodology was applied in medium and low secure inpatient settings. A change bundle was tested for effectiveness, which included: safety huddles, safety crosses and weekly community safety discussions. Operational definitions for non-physical violence, physical violence and sexual harassment were developed and used. Reductions of 8% and 16.6% in rates of physical and non-physical violent incidents, respectively, were achieved and sustained. Compared with baseline, this equated to one less incident of physical and 17 less of non-physical violence per week averaged across seven wards. Three wards achieved at least a 30% reduction in incidents of physical violence per week. Five wards achieved at least a 30% reduction in incidents of non-physical violence per week. This collaborative brought significant improvements and a cultural shift towards openness around inpatient violence.
Incidents of violence and aggression are serious concerns on a secure ward for people with intellectual disabilities and are often met with increases in physical and restrictive interventions. However, these interventions are usually high risk for both patients and staff and are ineffectual in promoting long-term behaviour change. This study aimed to promote positive culture change and embed the evidence-based practice of positive behaviour support by shifting focus and efforts from the use of physical and restrictive interventions to manage crises to intervening positively and proactively to prevent crises from occurring. The key drivers for change involved increasing access to positive engagement opportunities, expanding the staff team’s repertoire of proactive interventions through training and skill development and supporting staff well-being and resilience. Change ideas occurred alongside a shift in culture that promoted the development of a learning culture, psychological safety and consideration of contextual fit. Quality improvement methods helped the project increase the rate of positive and proactive interventions from 70.65% in December 2018 to 97.18% in January 2020. Increases in staff’s knowledge, confidence and safety were also reported. Lessons and limitations of the project are discussed.
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