Dignity in mental health residential services

Hi William,

This isn't an area I have any expertise in, but my initial thought - and I think you might get some genuine 'expert opinion' from some readers of this website - is 'this is somewhere between complicated, and really complicated'.

My instinct, is that 'you can encourage but not necessarily impose' for many things: and that if [legally] the situation is that you cannot impose, then you must be careful to only 'encourage fairly gently'. Putting that in simple language, I don't think you can legitimately 'nag' if you legally cannot impose. The CQC is starting to push/highlight user/patient 'rights regarding making their own choices' much more strongly, in its recent press releases, guidance, etc.

However, as I was notably depressed for a couple of years myself, I can understand the difficulty re 'encouraging people to be motivated' when their mental state involves demotivation.

I'm not sure if that help at all !

Hope you get some responses from experts, all the best Mike

Hi William thank you for raising this debate, it is really positive that the training you attended has stimulated your thoughts and that you are revisiting your practice. I agree with Mike, people should be encouraged rather than imposed upon, however, I note you say you that people are encouraged to attend your morning meetings, Just a few first thoughts, Have people who use the service been given sufficient information to make real choices on the benefits and consequences of attendance/non attendance? I'm sure you would agree that it is important to determine whose needs are being met - the people who use the service or the staff? Has practice become institutionalised? People should have individual care and support plans written specifically to meet their needs and although I do recognise that for some that includes introducing structure and routine this should be determined by what the person agrees they have the potential to achieve. They should also identify clear steps to take to help them achieve this. Perhaps you could use the Ten Dignity Do's or the Dignity audits available from this website in one of your team meetings to review practice. I will copy your question to our Dignity in Action Facebook page to seek other views - watch this space.

Hi William here is the first response from Facebook.
It is difficult to give an answer to your question your service sounds that it may have an element of rehabilitation, then it depends on the contracts or care plans you have agreed with your individual service user. Dignity and respect can come from enabling and motivating people to reach a goal how ever small,. You need to discuss with your team ask your service users what would happen if you changed the ethos of your service what would be the outcomes.

Hi all,

Thanks for your responses so far. They're very helpful and much appreciated!

Will

Another response Will.
Sounds well intended but seems this has been created through the perspective of what is convienient for staff (meetings at 8.30 seem sensible for a start to the working day). For this to be person centered and truly inclusive then the first question to ask is when people want to meet, how often and why.....then build the working day around that. It is not about fitting the people who use your service around that working day but it is about building up your working day in ways which meets the needs and desires of the people you are there to serve. Giving people a choice shows respect, delivering the outcomes which are meaningful to them demonstrates dignity.

I think the Facebook responses highlight two fundamental issues:

'... it depends on the contracts or care plans you have agreed with your individual service user'

and

'It is not about fitting the people who use your service around that working day but it is about building up your working day in ways which meets the needs and desires of the people you are there to serve'

The first one, is effectively a way around the 'you can't impose' issue via agreement.

The second one, is a recurring issue with service provision - there seems to be an inevitable 'tendency towards' services moving towards doing what suits the service provider [and the professionals involved] as opposed to the [often trickier to arrange/organise] 'making things suit the service user'.

I'm pleased that William is getting responses.

Three more responses Will..........
E E I agree with C . It's about their choice what time they get up. It should be person centred , care should be about the person and not the service!! A review of their care plans should be done asking them what they want and how they want to go about doing it, and who with. I agree totally that there should be encouraged to be empowered, enabled etc but it should be with total dignity and respect.

V H It seems a bit ott getting people up, if they are adults they will get up if they have something meaning ful to get up for otherwise they are being treated like children. I am have been in many rehab schemes over the years and have always found having a genuine personal reason to get up far more successful than some management developed tick box exercise. Also when so many jobs are shift work the idea that you have to be in work for 8.30 is an out dated model.. I know a lot of people who don't start work until gone 5 pm

J C Your establishment sounds like it is a caring one. I was listening to a radio 4 article that talked about routine and completing jobs keeps the person active and enables the mind to remaiin engaged.avoiding

EE I agree with C . It's about their choice what time they get up. It should be person centred , care should be about the person and not the service!! A review of their care plans should be done asking them what they want and how they want to go about doing it, and who with. I agree totally that there should be encouraged to be empowered, enabled etc but it should be with total dignity and respect

VH It seems a bit ott getting people up, if they are adults they will get up if they have something meaning ful to get up for otherwise they are being treated like children. I am have been in many rehab schemes over the years and have always found having a genuine personal reason to get up far more successful than some management developed tick box exercise.. Also when so many jobs are shift work the idea that you have to be in work for 8.30 is an out dated model.. I know a lot of people who don't start work until gone 5 pm

J C Your establishment sounds like it is a caring one. I was listening to a radio 4 article that talked about routine and completing jobs keeps the person active and enables the mind to remaiin engaged.avoiding

Jan, did you chop of a 'C' from one of the first two responses (and something else from the other one) ?

'EE I agree with C', had me looking for 'C' - I don't use FaceBook, but I think I've twigged that 'EE' identifies the person commenting - I assume that the second (?) Facebook one was actually:

C Sounds well intended but seems this has been created through the perspective of what is convienient for staff (meetings at 8.30 seem sensible for a start to the working day).

?

Good that people are getting involved in this, Mike

Hi Mike - Yes I have removed peoples names they are the initials of the people who responded - although I have informed them i am posting their responses on to the forum. C's comments commenced 'it is difficult to give an answer to your question' the first response - the second comment was from A.
Sorry Mike I will make sure I copy initials of everyone in future
Yes it is good that people are getting involved -

Thanks Jan,

And I'm assuming that Will intends to give us some feedback here, about the responses from his colleagues when he takes 'these comments' to his staff meeting - I will be very interested to see what 'the people on the inside' think.

A little off-topic, Nursing Times online allows people to post comments under their real name, a 'user name' (for example 'Tinkerbell'), or as Anonymous. Most people post as Anonymous - it really 'irritates' me, looking at 15 or more posts, to try and figure out which posts are by any particular 'Anonymous' (and are therefore part of a chain of ongoing comments) and which are one-offs, etc. I can't figure out, why anybody would prefer to post as 'Anonymous' instead of as 'Fred the Medic' or whatever, in a discussion.

mmm Mike I wonder so many people enter posts using the name Anonymous is it fear? is it cowardice? is it safety? who knows only the people who use the name.

Hi Jan,

Judging from the posts on Nursing Times about nurses who has raised a concern and then been 'bullied and harassed' by their colleagues or 'the NHS organisation they work for', I would say that fear of 'criticising my boss' is a major factor. Although some people have probably also experienced 'general online bullying' as well.

I don't like 'cowardice' - you shouldn't NEED to be brave to raise a legitimate concern, in my opinion, so if the process 'requires bravery' something is badly wrong !

No Mike you shouldn't need to be brave to raise a legitimate concern but it is my experience that unfortunately a great deal of bravery is needed for some. One of our Dignity do's is that people should feel free to complain without fear of retribution - how many people say don't say anything!!! Yes maybe the term cowardice is not likeable I will think about that.
I would still maintain that the culture and leadership of an organisation needs to be healthy and positive to facilitate people being able to work in a non blameworthy environment - learning organisation.

Hi all,

thank you very much for your responses, it certainly shows me we should be looking at this issue more closely. Our staff meeting is tomorrow afternoon and I intend to do the dignity audit that Jan mentioned. I'll let you know how I get on!

Thanks again everyone,

Will

Hi Jan,

re your:

'I would still maintain that the culture and leadership of an organisation needs to be healthy and positive to facilitate people being able to work in a non blameworthy environment - learning organisation.'

I think Sir Robert Francis did point that out, using his own words, in his recent 'whistle-blowing' report. The question, is how do you get there when 'bad events often result in unbalanced knee-jerk media and [then] political fire-storms', and how will we ever get there if employers continue to use 'damage to the organisation's reputation' as an excuse to discipline staff who make concerns public ?

Hi William, I'll be interested to read how you got on at the meeting.

Thank you for the update William I very much look forward to hearing what happens next!!!
Mike glad that my thoughts synergies with Sir Robert Francis. I have no snappy response to your questions on how a positive culture and a learning organisation can be achieved. lots of academics have written tomes on how these could be achieved but there has to be a will to create this type of culture and I'm not sure how many organisations are willing to do this - is this a job for the too hard box?

Good Leadership and the right people in post!
------Original Message------
From: Dignity Champions forum
To: [log in to view email address]
Subject: [Dignity Champions forum] - Re: Dignity in mental health residential services
Sent: Mar 17, 2015 18:30

Message sent by Jan Burns.

Thank you for the update William I very much look forward to hearing what happens next!!!
Mike glad that my thoughts synergies with Sir Robert Francis. I have no snappy response to your questions on how a positive culture and a learning organisation can be achieved. lots of academics have written tomes on how these could be achieved but there has to be a will to create this type of culture and I'm not sure how many organisations are willing to do this - is this a job for the too hard box?

Hi Jan -

'but there has to be a will to create this type of culture and I'm not sure how many organisations are willing to do this - is this a job for the too hard box? '

It might be possible - I can't see how you can ever get there, unless:

1) Staff can raise 'non-personal' concerns (things such as 'our staffing levels are so low that patients are in danger at weekends' is 'non-personal' - but 'Fred is so incompetent, he is a danger to patients' is personal) via an 'independent party who is neutral re both staff and management', and that independent person can look into 'has this concern got legs' and also 'pursue it - if necessary to Board level'.

Sir Robert 'sort of goes with that';

2) Both the concern raised, and how it is addressed or 'dismissed' should be published 'open source' - so that staff AND USERS OF THE SERVICE can see the issues and 'both sides of the [internal] argument - in a nutshell, 'much more transparency'.

However, I note that politicians 'support transparency within the NHS' but if you say 'why can't we see what you were arguing in your own political decision-making meetings' they will say 'that would stop us from debating freely enough, to sort the issues out properly' - in other words, everyone 'wants transparency from other organisations/people, but tends to think 'but my own situation is special, and an exemption: I/we can't be fully transparent, that would not help'' !

Mike thank you for your very positive and helpful response to my open ended questions - I wonder what other people think. It would be productive to open this debate further............Would the heading where there's a will there's a positive culture????

Hi all,

Thanks for your responses so far. Some very interesting discussions happening! I took this issue to our staff meeting on Tuesday - apologies for the slight delay.

The team have decided that our service users will continue to be expected to attend morning meetings as we wouldn't be meeting our responsibilities as support providers otherwise. However, we had some interesting discussions about how this is done, such as being conscious of how often we knock on their door and what we say when we do.

To maintain choice, we have asked our residents how they feel about the time of the morning meeting (this is at 9.30am, but we will continue to wake people up before our handover at 9am). Our service users agreed that they were fine with this being the time of the morning meeting, but would like there to be more incentive. One suggestion from a service user was to have breakfast each morning, which we will support people to cook.

Does anybody have any comments on this? I'm interested to see what people think of our solution!

In other news, we went through the ten 'dignity do's' and discussed how these applied to our service. This turned out to be a good piece of reflective practice and we have some good ideas moving forward. We also looked at the dignity audit and, although we didn't have time to complete this in our staff meeting, all staff have agreed do this within the next two weeks so we can discuss it at our next meeting.

Many thanks again for the responses,

Will

Jan,

You are right that the 'raising concerns issue' is intruding on Will's topic.

I've just started to post an Argue The Toss series for similar 'debates' - would you like to post one, or would you like me to post one ?

I admire bravery and courage, but if I look back at 'my own limited instances of bravery' and then subtract what was due to ignorance, stupidity or pig-headedness, I'm left doubtful about how much [if any] bravery and courage I've exhibited myself !

Will, I'm only on the computer for a few minutes at the moment - I'll think about the question you asked above, and perhaps reply later. I'm pleased you seem to have prompted some reflective thinking - and that you have been asking your residents for their views.

Hi Will,

I'm back with more computer time. I'm not sure if I can make much of a comment about what you posted, but re:

'but would like there to be more incentive. One suggestion from a service user was to have breakfast each morning, which we will support people to cook. '

You also said you wake the service users up at 9-00 (it was 'around 8-30' in your original post), and I'm not clear when breakfast fits in ? It seems to me, that if the service users are cooking their own breakfasts (either on a group or individual basis - not sure which you mean) it might make sense to get up, have a wash, get dressed, eat breakfast and then have this morning meeting - I don't see how that would fit in to 30 minutes (and I don't know, if it fits into an hour). Unless your users prefer it to go 'meeting followed by breakfast'.

Hope the dignity audit goes well.

Hi Will,

I'm back with more computer time. I'm not sure if I can make much of a comment about what you posted, but re:

'but would like there to be more incentive. One suggestion from a service user was to have breakfast each morning, which we will support people to cook. '

You also said you wake the service users up at 9-00 (it was 'around 8-30' in your original post), and I'm not clear when breakfast fits in ? It seems to me, that if the service users are cooking their own breakfasts (either on a group or individual basis - not sure which you mean) it might make sense to get up, have a wash, get dressed, eat breakfast and then have this morning meeting - I don't see how that would fit in to 30 minutes (and I don't know, if it fits into an hour). Unless your users prefer it to go 'meeting followed by breakfast'.

Hope the dignity audit goes well.

Hi Mike,

thanks for your reply. We do wake them up before nine, and tends to be around 8.30. The idea was to have breakfast ready for everyone to have at the meeting, so you make a good point about the time periods to achieve this. We'll see how it goes in practice and review accordingly!

Cheers,

Will

Hi Will,

I had considered 'breakfast during the meeting' but decided not to mention that possibility - so inevitably, it turns out it is what you do ! Holding a meeting while also eating breakfast, does I think introduce 'a less formal atmosphere', which could be a good thing.

Unless a dispute heats up to the point when people start throwing food at each other - bad thing !

I don't really have a reason to get up myself - and I must admit that when I was noticeably depressed a few years ago, my getting up process was even slower than it is now (and take my word for it, it is very slow even now !). I'm not sure if I'm still depressed 'to any significant extent' in the clinical sense, or merely 'old and very grumpy': I know that when I became depressed I lost all ability to enjoy anything (either while it was happening, or 'in anticipation [of something good]'). I still don't think I 'enjoy things' as much as I did before I was depressed - but I'm also older now, so it is tricky to try and 'disentangle things'.

My personal experience of depression, was 'academically interesting' (but I would NOT recommend that anybody became depressed, just to better understand depression - however, I think that people who have been depressed themselves, will then understand it much better). While I was depressed, I don't think it affected my analytical reasoning capabilities at all (it affected my concentration, but strangely although 'concentrating for the purpose of enjoyment' (watching TV, reading a book) was hopeless, 'concentration for writing about the NHS behaviour which damaged me' was fine) - it just destroyed my motivation for most things, by removing all enjoyment. What did surprise me, was that the first sign that 'my depression is lifting' was the return of my ability to 'laugh at certain types of 'funny things'' - not jokes, as such, more the stuff that you come across and is 'so ironic, that it is funny'.

I was rambling there - still, it might interest somebody.

PS

'I don't think it affected my analytical reasoning capabilities at all'

I split opinion there - some people think I'm a pretty decent analyst, while some others reckon I'm an idiot.

Digressing again to Jan's 'raising concerns' topic - there is an interesting discussion on that developing at:

http://www.nursingtimes.net/opinion/nt-blog/the-jeremy-clarkson-fracas-highlights-whistleblowing-fears/5083288.blog?blocktitle=Practice-blog&contentID=8079

You do need to be registered with NT to get at it - but I rapidly lose track of NT articles, unlike these DIC forum pieces, so I will now be able to 'find it' from here !

Someone called Paul raised an issue about agency staff:

'What seems to have been missed is the fact that Agency staff are very vulnerable and not covered by employment law to the extent of fully employed staff.'

Then the next Anonymous poster wrote this:

Hello Paul
sorry to hear about your troubles, I had some bullying sometime ago by a line manager who wanted to treat the pace of work as it was her own business to do as she wanted. She did not like me as I just wanted the right thing to be done.The union was no help to me as the rep was also a manager who worked next to my line manager's boss who was backing my line manager, because if the protective wall goes up around my line manager then this manager don't get to answer questions. It was a case of protecting themselves by putting up walls.
I am not in the union any more, if there is another case I will be getting my own lawyer.
My friend who work in another job outside of the NHS also got into hot water for standing up to bullying.
I feel there is a wave of the strong doing every thing possible to stay in position and the workers at the bottom end have no support.
The unions are all the people have, but it has been invaded by people who do not have the fire for justice.

There are 2 further comments so far, but the piece above is reasonably representative, of what nurses who think 'I was bullied after I raised a concern/complaint' tend to write on Nursing Times.

It does need sorting out !

Returning to the 'raising concerns' and anonymity issue, there is a piece titled ''Anonymity online is 'safe' but can hinder a discussion's validity' (March 18) on Nursing Times at:

http://www.nursingtimes.net/opinion/anonymity-online-is-safe-but-can-hinder-a-discussions-validity/5083405.article

This has just appeared in the comments, and it is why nurses who have 'fallen foul of the system' like to stay anonymous:

James Hunt | 4-Apr-2015 1:15 am

Most people won't speak up because they are intimidated by the bullying culture that dominates middle management in the NHS. And we all know which profession dominates middle management. We don't look after each other. Some tend to defecate on others in order to climb the greasy pole. There are so many of us, but we are so easily divided and are led by sycophants into being put down and kept in check. No wonder people preserve their anonymity.

I have not much knowledge on mental heath services, but I did work with someone with mental health issues, I went into his home and supported him, he was very good at doing his chores and enjoyed doing them his words not mine. he showed me around his village and introduced me to his friends. he felt he needed a regime that gave him some control this made him feel safe. but this only one person and totally different from a group of people, insight into people in their own homes but I hope it gives you some ides's

Again returning to this 'anonymity and raising concerns' point that Jan and I were discussing (off-topic !) - it seems too late to move it elsewhere - Nursing Times has got a piece at:

http://www.nursingtimes.net/nursing-practice/specialisms/whistleblowing/legal-protection-for-whistleblowing-extended-to-student-nurses/5084095.article?blocktitle=News&contentID=4385

Whistleblowing detriment legislation extends to student nurses (April 10).

The comments to date are not encouraging, about 'the raising of concerns by staff':

michael stone | 10-Apr-2015 2:00 pm

Good - everyone who raises a genuine concern 'should be legally protected', in my opinion.

Stronger protection [all round] is necessary full stop - as Sir Robert pointed out in his report.

Unsuitable or offensive?

Anonymous | 10-Apr-2015 4:20 pm

So they'll now get the same protection as everyone else.

Wow, but that translates in reality to virtually no protection at all.

That's the way it is.....and RF's Review has done little to change that.

He did say the situation was bad, but then we already knew that.

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Anonymous | 10-Apr-2015 9:11 pm

I cannot tell you just how many nurses i come across, who speak up about bullying, harrassment or neglect to patients, only to be informed that if they pursue this line, their career will be at an end, with no reference and everyone will be made aware of their conduct. Either that, or a case is built against them to discredit their claims.
Every bit helps, the culture first needs the middle to senior managers to be taken to task with absolute zero tolerance towards bullying and harassment within hospitals.

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Anonymous | 11-Apr-2015 12:02 pm

Nurses are too scared to whistleblow for fear of negative consequences. There needs to be a strong protection policy in place.

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