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There is a fundamental contradiction at the heart of mental health servicesbetween care and control, risk and recovery. On our PROMISE journey wehave grappled with our understanding of these binary dilemmas. In thisbrief article we share our evolving insights that might help organizationswho are setting out on this journey.

Board briefing

Compassion is not a binary position. Most staff engaged in usingcoercive practices believe that they are acting in the patient’s best interestand what they believe is kind compassionate care.

MANAAN KAR RAYSARAH RAE

www.promise.global

Painting the picturewhich conveys the case forchange is a tightrope betweenstaff feeling they have a role toplay and feeling criticised. En-gaging defensive staff couldbe challenging, especially if itis over what they thought wasan act of compassion.

To change culture oneneeds to somehow get front-line staff to own and lead thechange process and openthemselves up to the experien-tial journey of patients.

Need to know: One cannotpull a lever and make thishappen, but they can set thetone and act as catalyst bycreating the environment inwhich staff feel safe andsupported to take positive andproactive risks.

Frontline insight

Force is a continuumnot a binary position. Everyinteraction is an opportunity torely more on the power of hu-man relationship and less onthe one that stems from pro-fessional authority or organiza-tional policies and procedures.

Each act of use of forceeven in the patient’s best inter-est is preceded by many lostopportunities to pre-empt anddiffuse situations.

Problem patients arepatients amidst problems, pos-itive and proactive care targetsproblems unlike the use of

force where the patient invaria-bly ends up feeling targeted.

Need to know: There is abelief that use of force is a partof the job but it spoils the job,the reality is there is nearlyalways a choice and whensupported by the leadershipthese positive and proactivechoices can provide fulfilmentin ones daily work.

Patient’s journey

Recovery is not a binaryposition, it is a journey, andevery interaction is an opportu-nity to take the next step to-wards life beyond illness evenwhen symptoms persist.

Understanding onesmental health challenges andtaking the initiative is a keypart of staying well and avoid-ing being at the receiving endof any well intentioned coer-cive practice.

Situations that warranthelp to be enforced are oftenpreceded by many lost oppor-tunities. One can ask for helpand in the process alert staff tocapitalise on the opportunitiesto pre-empt and diffuse a situ-ation that might otherwise beoverlooked.

Need to know: If one does notask for help, help is oftenenforced by friends, family orprofessionals. Making positiveand proactive choices putsone in the driving seat andengenders self-belief, agencyand hope.

Power to Empower,Insights toInnovations,Pathways toPathfinders.

Impetus for the PROMISEjourney emanates fromthe key insights. As laidout in this articleunderstandingcontinuums gives one theconfidence to move awayfrom a paradigm ofsuccess and failure andtake the risks to make thesmall changes which arethe seeds of innovation.When these innovationsare shared, celebratedand incorporated intosystems of care, wecreate recoverypathways. Actions speaklouder than words, andfor frontline staff to seetheir change ideasmaking a differenceinculcates not justfulfilment but creates anethos of leadership at alllevels. Nurturing creativityis the essence of creatingthe workforce oftomorrow, the pathfinderswho will continue toredefine the frontiers ofhumane care.

Manaan.kar-ray@cpft.nhs.uk

Power to Empower

Power is not a binaryposition, the contours of thelandscape dictate how it ebbsand flows. Power-play occursin every relationship, whether itbe in the one between theboard and the frontline of anorganization or within thepatient professional duo.Leaders often believe thatpower flows from theirpositional advantage, butleaders are only powerful iffollowers follow. When it comesto power related culturalchange and changing thenature of day to dayinteractions at the frontline,leadership have to be aware ofthe need to role model and livethe change they are proposing.Dictating from the top is a futileexercise, as the balance ofpower lies in the accumulatedinertia of what we call culture.The goal has to be to winhearts and minds so thefrontline feel empowered totake the initiative and takeownership of the organizationaljourney.

If such power is invested inthe frontline they then will havethe influence and attributes toempower patients.Traditionally, in the patientprofessional relationship, theone with the clinical experienceand theoretical knowledgeholds all the aces, i.e. theprofessional. The patient’sexperiential knowledge is oftenundervalued and sometimesdisregarded. When power isskewed in this fashion it can

result in patients trying toassert themselves in anunhelpful way, as theyinherently feel ‘done unto’.These power struggles whichoften play out in the form ofcoercive practice stemmingfrom professional concern forthe patient, can so easily beavoided by ‘doing with’ ratherthan ‘doing to’. In order to worktogether and come to aconsensus, professionals needto be able to see things fromthe patient’s perspective i.e.understand their values andpriorities, attitudes to illnessand risk. If knowledge givesrise to power, then surely anincrease in the availableknowledge bank will increasethe power to improveoutcomes. Since hope, agencyand self-belief are such vitalingredients of recovery thisapproach of combining poweris not summative butmultiplicative. Unfortunately thecultural inertia in thisrelationship is such that eitherthe professional unconsciouslytakes a paternalist role or thepatient a subservient one. Theopportunities lost from notutilising the combined powerthat lies in a partnership areimmense. There is a strongcase for the frontline to redressthis balance by transferring thepower they have inherited fromthe top, thus empoweringpatients to identify their values,needs and goals. How to do sois the question and inPROMISE therein lies theanswer.

PROMISE is aparadigm ofco-producing analternativediscourse in MentalHealth Care.

A discourse thatcreates hope, agencyand empowerspatients to take thedriving seat towardslife beyond illness.

A discourse thatempowers staff tore-innovate the wheeland continuouslyimprove on the smallchanges that make abig difference.

A discourse in whichpatients andprofessionalsempower each otherto eliminate relianceon force.

www.promise.global

Steering PROMISE

Manaan Kar RaySarah RaeJudy DeanCeri WilsonLorna RouseHaseena HussainSarah RussellIliana RokkouEmma GreenTerry HillTom Spencer

PROMISE Crew

Many of the proactive careinitiatives being developedare led by Trust frontlinestaff. Staff from across ourservices are seeking outand embracing new ideasand, in the interests ofperson-centred care, arecontinuing to developcompassionate and creativepractice. At the helm, ourward leaders have much tobe proud of, to celebrateand to continue to steerwith their teams. In theinterest of not missing outfrontline innovators we haveactively resisted thetemptation to take names.Subsequent PROMISEpublications on specificinitiatives will carry duecredits.

PROMISE has been fundedand supported by theNational Institute of HealthResearch (NIHR)Collaboration forLeadership in AppliedHealth Research and CareEast of England (CLAHRCEOE).

There are powerful symbols inour services which set asidepatients from staff. Sandwichesin the cafeteria for patients inplain packaging and for staff inattractive commercialpackaging, separate staff andpatient toilets, patients having toseek permission for the simplestof tasks which staff don’t haveto. Some are tangible and someless so. Either way thesesymbols create and reinforce aculture of them and us.

Terry Hill, a recent appointmenton Mulberry 3 in the role ofinterim ward manager came inwith fresh eyes on to the ward.Newcomers are often able tospot custom and practice that isout dated. For example on thisward medication had alwaysbeen dispensed across a hatch.The clinic room door splits like astable door, the nurse wouldstand inside with the medicationtrolley and patients were obligedto queue up outside. Terry camefrom Mulberry 2 where they hadmade changes to how

medication was dispensed.Being very aware to howmedication time can be a sourceof conflict Terry proposed asimple but powerful change thataddressed all the powerdynamics, the dignity andconfidentiality issues and theboundaries of them and us.‘Ditch the hatch and invitepatients into the clinic room totake their medication.’ Thiscreates a shared private spacefor any dialogue aroundmedication without the worry ofothers over hearing or pressureto quickly comply to keep thequeue moving.

We are all guilty of notquestioning practice that areprevalent in our own teams asthey are the established norm. Afresh pair of eyes or perhapseven a fresh look by us can pickup these symbols which if weaddress we can send out amessage loud and clear that weare on the same side, workingtogether on the recoveryjourney.

INSIGHT

IMAGINATION

INNOVATIONParity

Promoter