Co-Production to reduce violence and aggression on mental health wards

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By the PMVA Team at Middlesex University.

The prevention and management of violence and aggression (PMVA) team at Middlesex University has been delivering training [the General Services Association (GSA) model] to the local National Health Service (NHS) Trusts staff and the University students since the early 1990s. The model developed in line with the National Institute for Health and Care Excellence (NICE 2015) framework promotes the principle of preventing and de-escalating incidents and only when absolutely necessary using physical restraint in a patient caring manner.

However, the tutors that deliver the training, recognise the potential rift between the theoretical principles and the application of such principles in practice. The challenge is how to bridge the gap.  One of the ways the team tries to do this is to invite service users who have experienced being restrained whilst admitted to the ward, to join the team in delivering the training. The hope is that their contribution may motivate the clinicians to translate learning into practice. As argued by authors including Repper and Breeze (2007), service users’ involvement in student learning motivates students to show more sensitivity and empathy and to adopt a more individualised approach in practice. Reiterating Russell (2014) and Speers and Lathlean (2015) say that learning is deeper and transformative and could result in positive changes in attitudes and patient-orientated practice.

As a result, the team has facilitated this training in partnership with mental health service users since 2008. Obi-Udeaja et al. (2010) the team’s first publication gives detail of this co-training relationship including the views of the course participants and those of the service user trainers regarding it.

For example,

I think the session today with the service user was a really great idea. She helped to really emphasise the importance of communication and care before restraint – if restraint is really necessary then it will come after all communication and de-escalation has been attempted. The speaker gave us insight as to how service user may experience emotion bedside their illness. This session is certainly something that should happen at the end of every PMVA course
Participant’s feedback

… it makes me feel good to know I can help improve the NHS
Service user trainer views, Garry

Hopefully my involvement will get staff to see that while they are restraining patients, those patients are real people with real feelings and who feel pain and fear. That staff return to their teams and that some of what they have heard filters down, so that good practice can be enriched
Service user trainer views, Kate

Our conferences and events

Meanwhile, Obi-Udeaja, Crosby and Ryan (2016) gave details of the team’s international presentation in Dublin in 2014. The overwhelmingly good feedback from this conference presentation captured the attention of the conference chairman Dr. Paterson. Subsequently, our proposal that mental health service users should be involved in staff training on prevention and management of aggression resulted in a debate on the issue at the 9th European Congress on Violence in Clinical Psychiatry, held in Copenhagen in October 2015.  Obi-Udeaja, Crosby and Ryan (2017) cover our contribution to the debate.

Our journey – the past

We mentioned above that our model of training is the GSA model. In 2010 we went to Edinburgh where we presented at the Annual General meeting of the Association. We gave a comprehensive coverage of why we work together, what we do and how; as covered in the above referred journal. During our presentation, there was an air of scepticism among some of the trainers. There were obvious doubts about what we were proposing in 2010 as it was a new way of working. We are delighted to share through this blog that the Association invited us to its 2017 Annual Conference in order to once again share with its national and international body of trainers how we work together.  By this time some individual trainers and teams among the delegates were already including forms of service user representation such as recorded experiences and views of service users in their training.   We networked, shared ideas and congratulated one another on our contributions to the new phenomenon.

The Association positively acknowledged our contribution:

Dear Jane,

  The General Services Association would like to convey its gratitude for your contribution and support to the conference. The feedback from the delegates has been very positive in relation to the quality of the speakers and the subject matter presented (The GSA).

These invitations to us and to others with interesting initiatives effectively demonstrate the Association’s commitment to continuous development and improvement of the model in order to ensure that it continues to meet ethical, legal and all other expectations.

Our journey – now

Undoubtedly, a progressive culture change is taking place and it is very encouraging. Today, co-working with service users in our subject area is growing in acceptance. We consistently receive positive feedback on our work and less concern about our approach. Trusts are more receptive to PMVA co-production with service users. Recently a Director from an NHS Trust invited us to present to the Trust’s Board on how we deliver the training in partnership.

The following email message was the feedback on the presentation:

Dear Jane,

The board presentation on Tuesday went superbly and thank you for sparing the time to come down from Hendon with Kate and Garry to make the presentation about restraint and PMVA. Your strongly communicated messages about what a ‘good’ restraint means by way of respect for service users and the ward community when it is done properly and equally, what the impact of poorly managed restraints mean came across powerfully. It was an impactful 25 minutes and the first time the chair has allowed extra time for this slot.

Garry and Kate’s contributions were hugely helpful and thank you for letting them have the air time after your introduction, to tell their stories and to advise the board from their perspective what more could be done to improve the experience for service users of this intervention. I do not have their email addresses and I would be grateful if you might pass on our thanks and appreciation to them both.

This proved to be one of the most powerful patient experience sessions we have had so far and board members were still talking about it after the formal meeting closed.

I look forward to working with you on this significant issue moving forward.

What have we learned along our co-production journey?

It became obvious to us along the way that our initiative for service user involvement in PMVA training delivery was tantamount to a proposal for a culture change. This was aptly stated by a delegate as she followed us into one of our conference workshops:

I am interested in your presentation because I need some inspiration.  I want to see how you do it.  I’m trying to do something similar in my area of work but it is hard to break the culture
(our workshop attendee)

We find it incredibly rewarding that our humble contribution intended simply to improve nursing practice in the management of patients’ anger and aggression on the ward has moved on to both national and international platforms. We are bombarded by emails from all over the globe requesting presentations at conferences or publication in journals. Even as we share these milestones, we feel a sense of encouragement that our Vice Chancellor Tim Blackman is similarly interested in what we are promoting:

Thank you Jane… It’s very interesting how you’re involving service users who’ve experienced restraint.
(Email communication)

Co-production in PMVA and research

It is perhaps important to share that our service user involvement in PMVA campaign at Middlesex University develops alongside determined and persistent academic inquiries on physical restraint as carried out on mental health inpatient wards. At its inception, an inquiry on service users’ experiences of being restrained on the wards with the aim to inform our training (Obi-Udeaja 2009) was simultaneously in progress.

The findings from that study triggered another research study (Obi-Udeaja 2016) to get the staff’s perspectives of what actually happens during physical restraint processes. This later research was for the award of Master in Professional Studies (MProf). The findings from it are driving a current inquiry for a doctorate degree – an evaluation of the impact on the practice of service user trainers’ contribution to PMVA training – which we aim to publish in a year.  Hopefully, the outcome will provide a further evidence base to support service user involvement in the prevention and management of aggression training campaign.

Do follow us along this evolutionary and exciting journey.


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