Trauma-informed care at a forensic mental health ward

Introduction

Bow Ward is the only female adult mental health forensic ward in East London NHS Foundation Trust (ELFT) and provides care for 15 females with severe mental health conditions. Continuous quality-improvement (QI) and service user involvement are embedded in our ward culture. The ward follows the ELFT sequence of improvement when approaching complex issues.

The mental health journey of inpatients spans acute admission to discharge. The experience of trauma and abuse among the inpatient population makes it a complex group with which to work; high rates of trauma are caused among staff and service users alike due to high levels of violence and aggression on the ward.

Background of the service

People who experience traumatic childhood experiences may also experience poor physical and mental health. Patient frustration is exhibited by frequent episodes of physical and verbal assault against peers and staff, often accompanied by racist comments. This resulted in poor staff retention and a turnover that was twice the rate of that on male wards in the same unit, and sickness rates that were almost three times as high as the unit average. Consequently, staff were stressed, demotivated and found it difficult to provide a trauma-informed environment to support service users therapeutically. There was a need to support staff and help them to cope with the complex care they had to provide.

To understand staff better, the multi-disciplinary team (MDT) and senior managers on Bow Ward completed a cause-and-effect (fishbone) diagram and identified several factors that were causing staff to feel burnt out. Our team believed staff had to be in a more positive position before they could facilitate trauma-informed care, so started by addressing staff issues before moving on to improving care for our inpatients.

Project aims

The QI project aim was to improve patient experience and staff satisfaction by 40% over a 12-month period by December 2022. The project was coproduced with service users from the outset and an MDT that included psychology and occupational therapy staff. Together, Bow Ward’s QI team generated many change ideas to test.

Implementing trauma-informed care

Although trauma-informed care is becoming more prevalent in the NHS, no other wards at ELFT adopted this for staff-focused work as well as for service users. Patient inclusion and using QI methods were crucial to the acceptability and success of this project. The MDT followed the ELFT sequence of improvement:

• Identifying quality issue;
• Understanding the problem – the team used inpatient surveys, staff experience and a fishbone diagram to explore the reasons behind burnout on the ward and what could be improved;
• Developing a change strategy – the team used a driver diagram to visualise their change theory;
• Testing – plan, do, study, act cycles were used to test change ideas, then assessed against their outcome measure;
• Implementation.

Staff and service users were offered trauma-informed care training that included identifying adverse childhood experiences, how these can affect us now, and how to use trauma-informed principles to reduce the chances of re-traumatising others. We could then introduce a pre-admission meeting so the MDT could talk through a service user’s history and identify areas where additional support or adapted ways of working might be needed.

“This is a totally person-centred nurse-led service. They value staff members and service users as unique human beings and have achieved amazing results” Judges’ feedback

Outcomes

Staff bullying and burnout

Staff reported difficult dynamics and bullying in the team; these were addressed through anonymous surveys and feedback, increased supervision with a specific check-in on bullying, focused team building and personality-type group work.

We used trauma-informed principles to get to know each other as individuals, and consider our own backgrounds and how they influence us at work. We discussed how people might communicate differently and identified areas where things could be misunderstood.

We also created a ward Bullying Charter, in which we identified and agreed on specific behaviours that were unacceptable. The matron conducted three-way mediation meetings with any staff who felt they had unresolved conflicts, and the ward psychologist ran a weekly reflective practice session with the team so they had a safe space to talk through any concerns.

Decreased racism

Our occupational therapist held a focus group with service users to discuss how racism makes them, and might make others, feel. We used an anti-racism board with inpatients’ pledges on how to reduce racism and reviewed this weekly in ward community meetings.

To promote transparency, a quality-control board is used so inpatients can track the number of incidents taking place each month; this supports an environment aligned with ELFT’s values – namely, we care, respect and are inclusive. Racist incidents decreased but, more importantly, this enabled us to have open, honest conversations as a ward community and to challenge things with which we did not agree.

Improved physical health

Successful change ideas on consulting with the local sexual health service for outreach cervical smears meant women could be screened without handcuff restrictions. Bow Ward staff used accessible groups to raise awareness and improve knowledge, for example ‘menopause bingo’, a game devised by the ward in which symptoms of the menopause were used instead of numbers.

Improved equity

The team successfully campaigned for free period products to be provided on the ward, and the hospital shop agreed to display feminine hygiene products on the shelves, not hide them behind the counter.

Inpatients and staff reported feeling that the environment was more positive, and patient–staff relations were improved and strengthened. Two service users expressed how improvements affected them:

“We are more involved with the care we receive; this helps to improve the environment.”

“Our ward would not be a success story without this. I feel well looked after, supported, loved and happily content with the care I receive.”

Patient care and service effectiveness

Work-related stress is common in a secure unit setting and more so in women’s services. The project strengthened staff–inpatient relationships, transparency around issues faced and ways to approach them. Job satisfaction increased, sickness rates reduced and staff retention improved: turnover rates decreased to 5% from 32%.

Inpatient care has been enhanced, with staff able to engage more therapeutically now they experience less burnout and fewer incidents of racism. Peer relations are also improved with the reduction of racism on the ward, and the introduction of more open forums and community meetings for service users to discuss issues that are troubling them.

Service users’ physical health care has improved, with access to cervical and breast screening established, and better awareness of menopause and other female health concerns. This improves their quality of life as potential problems are found earlier; this may also lead to cost savings. Patients are offered a wider range of psychological interventions and specific gender-focused groups were introduced that tackle a wide range of topics.

All information pertaining to the project is accessible through Life QI, a virtual platform in which the approach, progress and data for QI projects are stored. This is nationally accessible, so teams across the UK can use the learning from the work and adapt it to their own setting.

A structured approach and plan have been developed to scale up the ideas.

Conclusion

Storytelling, and sharing the progress and successes through local forums and community meetings with the wider MDT, helped influence others. The challenges of caring for inpatients in a secure environment meant the team had to adopt innovative thinking. The approach and changes made created a more harmonious environment and better therapeutic engagement with patients, leading to enhanced patient care and greater job satisfaction for staff.