Project reduces self-harm in children and adolescents
A systematic approach to data collection has helped staff at a child and adolescent mental health service (CAMHS) unit to identify ways to cut its average length of stay by 75% and reduce incidence of self-harm among inpatients by 85%
A systematic approach to data collection has helped staff at a child and adolescent mental health service (CAMHS) unit to identify ways to cut its average length of stay by 75% and reduce incidence of self-harm among inpatients by 85%.
Patient safety consultant nurse Jill Bailey set up the project in June 2014 at the CAMHS unit at Marlborough House in Swindon, part of Oxford Health NHS Foundation Trust.
By June 2015, the project had reduced the average number of self-harm incidents from 12 a month to just two.
These results are welcome at a time of widespread cuts to CAMHS budgets. Statistics from children’s mental health charity YoungMinds show that 75% of mental health trusts froze or cut their budgets between 2013-14 and 2014-15, and that more than one in five local education authorities have frozen or cut their CAMHS budgets every year since 2010 (YoungMinds 2015).
Ms Bailey attributes the project’s success to the collaborative efforts of the unit’s safer care team, which she leads.
Marlborough House accommodates young people aged 11-18 with complex mental health problems, including eating disorders, depression and emerging personality disorders. The inpatient unit has 12 beds, and care is also provided for day patients. There had been a history of young people self-harming in the unit, and the team had been concerned about the increase in severity of incidents, including the use of ligature points.
‘The children were distressed,’ recalls Ms Bailey. ‘This wasn’t something we wanted to see in a young person’s unit, but we could tell that the problem was multifaceted: these things don’t happen for a single reason.’
Marlborough House charge nurse Lorna McGuigan says: ‘The environment was stressful and difficult to manage, so we knew we had to do something.
‘We weren’t sure where to go and were happy to receive support.’
Ms Bailey began by looking at harm reduction. The first step was to train the team in the Plan, Do, Study, Act (PDSA) methodology from the NHS Institute for Innovation and Improvement.
This is a four-stage, problem-solving model used to improve a process or undertake change. It involves planning a change to be tested, carrying out the test, analysing data collected before and after the change and reflecting on it, and planning the next change cycle or deciding the initiative can be implemented fully.
The team began to carry out instant reporting of incidents. This led to the creation of ‘heat maps’, which break down incidents by the hour, allowing staff to filter the data to observe how many self-harm incidents occurred, and when, where and how they were carried out.
This information was used to assess how staff were allocated during their shifts, and to see whether this might be at the root of some of the problems.
Claire Norman, previously a staff nurse at Marlborough House and soon-to-be staff nurse at Abertawe Bro Morgannwg University Health Board in south Wales, says: ‘Getting permission to say when something on the unit was concerning, and then having your view validated by other people, was helpful. That’s when you can do something about it.’
Ms Bailey says this reflection process was crucial to the project’s success. ‘Taking time to step back and looking objectively at what’s happening in the moment was important. The methodology lays open the problem and where we can start to work, and that empowered the team. It’s helpful because people stop and look at it in depth, rather than rushing.’
Tests of change
After creating a driver diagram, 12 tests of change were set up, focusing on three critical factors: nursing in communal areas, case management reviews and permission for home leave.
The communal area testing involved collecting baseline data three times a day to give an idea of how many staff were present. It was clear that two members of staff were needed in these areas to be able to provide adequate contact for the young people.
This change was adopted quickly by staff and had a dramatic effect, transforming the service for residents and changing the culture of the unit.
The statistical analysis allowed the team to experiment with various approaches. ‘If the team comes with ideas and there’s one we are unsure about, the approach would be to test it,’ Ms Bailey says.
‘If it works, it would be amazing, and if we have evidence it doesn’t, then we ask whether we can tweak it or do something different. The constant cycle of PDSAs is valuable in practice but it has to be systematic.’
She is full of admiration for the team members because they made the time to make necessary changes in the middle of a busy work schedule: ‘The team did beautifully amid the chaos and this was critical to the improvements.’
The team’s goal was to use the systematic PDSA cycles to reduce self-harm in the unit by 25% in a year, but it far exceeded its own expectations, achieving and sustaining an 85% reduction between June 2014 and June 2015.
Modern matron Amanda Cadder says these results have improved the culture of the organisation and empowered staff. ‘It has been an amazing change,’ she says.
‘At a time when we were having a high number of ligature incidents, people were worried about coming into work. Newly qualified nurses had not dealt with it before and it was affecting morale.
‘It is important that everyone is part of the team. That is why the project has been so successful. It has been a whole-team approach.’
Ms McGuigan says although the project’s aim was to reduce incidence of self-harm, the changes made to how staff work have also had a positive effect on the ward environment.
‘We have improved our relationships with the young people so I see the benefits, regardless of the figures coming down,’ she said.
‘Getting permission to say when something on the unit was concerning, and then having your view validated by other people, was helpful’.
Dialectical behaviour therapy
As part of the project, nursing staff at Marlborough House have been trained in dialectical behaviour therapy, which has informed how the team observes young people’s behaviours.
Following this training a series of regular group meetings were held so that the young people could discuss coping skills and how to modify their behaviours.
These developments have led to a reduction in the average length of stay at Marlborough House by 75%. In the first year of the project, average length of stay fell from 160 days to 60, while the most recent audit shows average length of stay is now 40 days. The re-admission rate has also fallen.
The harm reduction project has focused on communication between staff, and between staff and the young people and their families and carers. For example, team members now provide clear information about case management meetings to the young people.
Ms Norman believes that including patients in the decisions made about them has contributed to the reduction in self-harm: ‘One of the issues of people going into case management used to be that the young people would not receive information.
‘If information is not being shared with you, how can you have confidence in the service? And if you haven’t got confidence, there is a danger you will revert to harming behaviour.’
Ms Norman says a crucial part of the project’s success is that the nurses recognise the difference between being present in the communal areas and having a ‘nursing presence’.
If staff get to know young people on the wards, they will be alert to them becoming agitated.
‘This project was about developing a relationship and a therapeutic bond,’ she adds. ‘People felt they had to act out to show they are distressed, but now we can pick up on the cues when something’s not right.’
Lessons learned from the project include understanding the benefits of meticulous measurement and recording of behaviours, working out which changes will help, and persevering until the desired change comes about. And staff must want to alter their behaviours if good outcomes are to be achieved.
Ms Norman says for every incident of self-harm avoided, there is a young person who has found a more successful way to deal with their troubles. ‘And that’s what it’s about,’ she adds.
- Review handover document
- Ensure weekend leave is discussed by multidisciplinary team and documented
- Ensure community meeting feedback is shared with all parties and documented
- Review nursing team role
- Greater staff presence in communal areas
- Ensure staff are trained in personal and environmental searches, and appropriate equipment is available on unit
- Self-harm policy and programme
- Regular safer care meetings and ensuring changes are communicated with the team
- More therapeutic time
- Development of timetable for regular group supervision/reflective practice
- Dialectical behaviour therapy skills training for the team
- Regular allocated time for unit skills sharing and teaching sessions
- YoungMinds (2015) Widespread cuts in children and young people’s mental health services.