Case study 7: Brighton and Sussex University Hospital NHS Trust (Training)

Summary

case7Over an 18-month period in 2012-13, Brighton and Sussex University Hospitals NHS Trust (BSUH) has seen a  reduction in assaults, restraints and safeguarding incidents on wards following the introduction of a new training programme. The programme has been delivered within existing budgets and with minimal additional costs through integration of Conflict Resolution Training (CRT) and clinically related challenging behaviour awareness and assault reduction skills training.

Key success factors:

    • Thorough research of risks, causes and training needs
    • High relevance to staff by using real scenarios taught on a training ward
    • Buy in of the chief nurse and matrons aided staff release from wards
    • Security team support to wards post training has further improved communications, relationships and encouraged transfer of learning into working practices.

Background

The trust identified that a substantial number of reported assaults on staff were related to the clinical condition of the patient. This ranged from physical conditions to mental health issues, such as dementia, and sometimes a combination of these. This situation is not unique, as NHS Protect has identified that 77% of assaults occurring nationwide are clinically related in 2011-12.

The existing CRT and conventional ‘breakaway’ training, although effective in de-escalating conflict, is not appropriate for complex causes of clinically related challenging behaviours. The trust security function set out to address this gap by gaining trust wide support and the full backing of the Chief Nurse.

It engaged conflict specialists[1] to help research and design a bespoke programme that met CRT requirements and built an understanding of how to recognise, prevent and respond to clinically related challenging behaviour.

For staff in services experiencing higher levels of challenging behaviour, practical skills were included to help reduce risks when undertaking tasks in close proximity to patients.  This included positioning awareness and simple skills to re-direct and guide individuals, and guidance on how to reduce risks of harm to confused and vulnerable patients.

The initiative set out to achieve two complementary goals:

    • To design and deliver a bespoke training programme to help security and clinical staff teams work together to reduce clinically related challenging behaviours
    • To reduce the use of restraint and ensure patient safety and dignity is maintained when intervention is necessary.

Method

The first step was to analyse incident data to understand the nature and causes of challenging behaviours and identify priority areas for learning. As such incidents are often underreported, a staff survey helped provide a fuller picture and identify key scenarios that would form part of the training.

“The training design was based on a comprehensive Training Needs Analysis informed by a bespoke staff survey and review of incidents. It has been an incredibly thorough and risk/evidence based approach” Security Operational Manager

Staff completed eLearning and attended a one day course which covered CRT outcomes and included additional knowledge and skills to:

    • Recognise, prevent and defuse conflict and challenging behaviours
    • Avoid clinically related assaults through safer positioning and working practices
    • Safely guide and re-direct confused patients

Security staff had two further days of training including safer holding skills, ejection and incident response.

The training was mapped to the NHS CRT syllabus and to the National Occupational Standards for Work Related Violence, and it was City & Guilds accredited.

Bespoke eLearning provides a foundation knowledge of conflict management which is assessed and recorded through a sophisticated learning management system. The face to face training is delivered on a training ward with wheelchairs, patient trolleys and beds to provide extra realism and opportunities for manual handling; dementia trainers have been closely involved to ensure full integration.

A further key success factor has been ward based ‘coaching’ and the support internal trainers and security team have provided to clinical staff. This has helped to ensure transfer of knowledge gained in training into working practices and safer behaviours i.e. Level 3 Kirkpatrick evaluation.

“Everyone is now talking a common language about communication strategies, personalised care, de-escalation strategies and, where it becomes necessary, safer physical intervention”. Chief Nurse.

Roll-out

The programme has been rolled out to 32 Security officers and 761 clinical staff on a priority basis, i.e. to those wards experiencing the highest levels of clinical assaults and challenging behaviour. Members of the security team also attended the clinical courses to promote communications and teamwork between functions.

Resourcing and sustainability

When it started, the training programme faced a twofold challenge: covering costs of training delivery and securing the release of operational staff, who would need to be covered. To achieve support from local clinical managers to release and cover staff, the team presented their research on risks and needs at a stakeholder workshop with a taste of the proposed training.

The success of this initiative over the past 18 months has helped secure additional investment and in-house trainers are now in place to further ensure its sustainability and reduce direct delivery costs to as little as £12 per head.

“We have delivered a greatly enhanced training package within the same training time and at similar cost to the trust”.  Security Operational Manager

The thorough review of risks and training needs was key to getting senior managers’ buy in to the training and the stakeholder workshop and pilot courses helped win the support of local matrons and managers who had to release staff.

The feedback from the initial courses was excellent, which spread good news and led to staff asking to go onto the training. A matron for older people who came on one such course, said “Why didn’t someone show me this 20 years ago?” and immediately instructed her ward managers to come on the training and get their staff trained.

The commitment of the Health and Safety, HR, Clinical Divisions and Safeguarding and Security teams was excellent and the biggest turning point for the programme was obtaining the active backing of the Chief Nurse.

Results

There is strong evidence to show this training has resulted in a drop in assaults and restraints and has informed the development of good practice guidance in this area. Targeting of highest risk areas has been effective and the fully trained neurology unit has seen a reduction from 15 to 6 assaults in 12 months, which it attributes to the training.

“Evaluation of this training by security and clinical staff has been very positive and we have seen an 11% reduction in the number of reported physical assaults across the trust so far, and a reduction of up to 60% in targeted wards”. Security Operational Manager

Staff training evaluations post training consistently rate the training as ‘excellent’ and comment on its practicality and relevance to their work.

“All staff trained felt very positive and more confident in dealing with confused and aggressive patients and I see them putting the training into practice. Through teams training together, working relationships have improved and nurses are quicker to call security. This is the first course I have seen of its kind after 30 years of working with “challenging” patients. Thank you”. Matron Neurosciences

 Following implementation, restraints for a clinical reason are down from 87 to 69 and the security team are now using low arousal methods instead of the traditional ‘pain compliant’ techniques.

“Since the training the adult safeguarding team have seen a reduction in the number of safeguarding alerts raised in relation to allegations of physical abuse due to intervention by staff to manage violent or aggressive behaviour”. Associate Director, Quality/Safeguarding Adults

Conclusions

This training programme is successfully addressing one of the most complex areas of behavioural safety, which was also proving costly due to staff injuries and presented safeguarding concerns. The programme is an excellent example of partnership in developing and implementing training.

Learning has been successfully transferred to working practices by securing full management buy-in and ongoing support to wards from the trainers and security team. Relationships and respect between clinical and support staff have improved. The training has delivered a win-win outcome by improving staff safety and contributing positively to patient-centred care and safety.

“The programme we have piloted and implemented has strengthened relationships and had a positive effect on staff confidence and patients’ perception of safety.” – Chief Nurse

Source: Simon Whitehorn Security Operations Manager, Brighton and Sussex University Hospital NHS Trust and Bill Fox, Executive Chairman, Maybo

[1] Maybo www.maybo.co.uk