1. Show and tell Friday 30th October 2009Amy Beeson Duncan Moss

2. Relational security the story so far 3. BackgroundRelational Security Project team Creative Amy Beeson & Duncan Moss Account Manager Gerry McElearney Project Manager Ben Watson Additional creative input from Fanny Sigler, Peter Walker and Nicola Humphreys 4. Background Relational Security Our challenge The main aim of this project is to reduce the number of serious untoward incidents and escapes in secure mental health services and to spread understanding of relational security and the behaviours and actions needed to maintain it. 5. Background Relational Security Target audience Ward based staff (qualified and unqualified, including domiciliary staff) in secure mental health settings (NHS and private sector) Operational managers and clinical leads of secure mental health services (NHS and independent sector) Secondary audiences Patients Visitors Other secure services e.g. prison services Government Press 6. Our clients biggest fearThat staff will never look at communications and theyll end up on the shelf or stuck in a draw. 7. Relational SecurityStage oneDevelopment ofpropositions 8. Development of propositions Relational SecurityProposition oneEmpowerment through knowledgeIf we want mental health staff to see the signs andstop escapes, they need to understand what relationalsecurity means. They need to know what to look forand what to do if they see it. 9. Strapline for proposition one Naming options Relational Security Proposition 1 Proposition 2 Empowerment through knowledge Personal responsibility Be aware be secureSecure thinking, safe working Be aware be alert Security is your responsibility Think safe, work safe Keep everyone safe [variable message] Aware Alert Act Take responsibility, be aware Secure thinking Say something Know the risks, know the limits See it and say something Know the risks, be awareIf you see something say something Stop Think ActYou can stop it if you say something Look Think Act Inform Think Act Think Act Stop See Think Act Think Act Prevent See it, Stop it See it, Say it, Stop it Be safe Be secure Be alert and act 10. Strapline See Think ActNaming for proposition one Relational Security SEE THINK ACT SEE THINK SEE THINK SEE THINK SEE THINK SEE THINK SEE THINK ACT ACT ACT ACT ACT ACT 11. Design concepts proposition one Relational Securitynk Act - Approach 1 See Think Act - Approach 1RELATIONAL SECURITYUnderstanding how relationships betweenstaff and patients can stop escapesRelational SecuritySEETHINKACT You cant read minds,but you can learn toSEETHINKspot when somethingACT isnt right13Lorem ipsum dolor sit amet non iriureLorem ipsum dolor sit amet, euismod tincidunt ut laoreetNam liber tempor cum Nam liber tempor cumKnow your consectetuer adipiscing elit, dolore magna aliquam eratsed diam nonummy nibh volutpat.option congue nihiloption congue nihilpatient boundarieseuismod tincidunt ut laoreetimperdiet doming id quod.imperdiet doming id quod.dolore magna aliquam erat Ut wisi enim ad minimvolutpat. Ut wisi enim ad veniam, quis nostrud exerciPrevent an incident minim veniam, quis nostrudtation ullamcorper suscipitpossim assum.possim assum.exerci tation ullamcorper lobortis nisl ut aliquip ex eaamet, consectetuer amet, consectetuersuscipit lobortis nisl ut aliquip commodo consequat. Duis adipiscing elit. adipiscing elit.ex ea commodo consequat.autem vel eum iriure dolorin hendrerit in vulputate velit euismod tincidunteuismod tinciduntDuis autem vel eum iriure esse molestie consequat,vel illum dolore eu feugiat aliquam erat volutpat. aliquam erat volutpat.dolor in hendrerit invulputate velit esse molestie nulla facilisis at vero eroset accumsan et iusto odioconsequat, vel illum dolore et accumsan et iusto odiodignissim qui blandit.eu feugiat nulla facilisis at dignissim qui blandit praesentvero eros et accumsan etluptatum zzril delenit auguedelenit augue duis doloreiusto odio dignissim quiduis dolore te feugait nullate feugait nulla facilisi.blandit praesent luptatum facilisi.zzril delenit augue duisNam liber tempor cum soluta SEEdolore te feugait nulla facilisi.Lorem ipsum dolor sit amet, nobis eleifend option congueDuis autem vel eum iriure dolor in hendrerit in vulputate velit esseconsectetuer adipiscing elit, nihil imperdiet doming id molestie consequat, vel illum dolore eu feugiat nulla facilisis.sed diam nonummy nibh quod mazim placerat facer SEE THINK THINK ACTwww.seethinkact.nhs.uk ACT 12. Design concepts proposition oneRelational SecuritySee Think Act - Approach 2 See Think Act - Approach 2Nam liber tempor cumNam liber tempor cum Relational Security imperdiet doming id quod. adipiscing elit.DID YOUSEE THE STOP ITWARNING Relational Security Relational SecuritySIGNS? HAPPENINGlobortis nisl ut aliquipcommodo consequat vel eum AGAINiriure dolor in eum hendreritLorem ipsum dolor sit amet, Lorem ipsum dolor sit amet, minim veniam, quis nostrudconsectetuer adipiscing elit, consectetuer adipiscing elit, exerci tation ullamcorpersed diam nonummy nibh sed diam nonummy nibh suscipit lobortis nisl ut aliquipeuismod tincidunt ut laoreeteuismod tincidunt ut laoreetex ea commodo consequat.dolore magna aliquam erat dolore magna aliquam eratvolutpat. Ut wisi enim ad volutpat. Duis autem vel eum iriureminim veniam, quis nostruddolor in hendrerit inexerci tation ullamcorper Ut wisi enim ad minim vulputate velit esse molestiesuscipit lobortis nisl ut aliquip veniam, quis nostrud exerci consequat, vel illum doloreex ea commodo consequat.tation ullamcorper suscipit eu feugiat nulla facilisis atlobortis nisl ut aliquip ex eavero eros et accumsan etDuis autem vel eum iriure commodo consequat. Duis iusto odio dignissim quidolor in hendrerit in autem vel eum iriure dolor in blandit praesent luptatumvulputate velit esse molestie hendrerit in vulputate velitzzril delenit augue duis.consequat, vel illum doloreeu feugiat nulla facilisis at Lorem ipsum dolor sit amet,vero eros et accumsan etconsectetuer adipiscing elit,iusto odio dignissim quised diam nonummy nibhblandit praesent luptatum euismod tincidunt ut laoreetzzril delenit augue duisdolore magna aliquam eratdolore te feugait nulla facilisi. volutpat. Ut wisi enim ad SEESEETHINK THINK ACTACT DID YOU SEE THEDID YOU DID YOU WARNINGSEE THE SEE THE SIGNS?WARNING WARNINGSIGNS?SIGNS? Duis autem vel eum iriure dolor in hendrerit in vulputate velit esse molestie consequat, vel illum dolore eu feugiat nulla facilisis.SEEDuis autem vel eum iriure dolor in hendrerit in vulputate velit essemolestie consequat, vel illum dolore eu feugiat nulla facilisis.SEETHINK THINK www.seethinkact.nhs.uk ACT www.seethinkact.nhs.ukACT 13. Development of propositions Relational SecurityProposition twoPersonal responsibilityWhen we do the same tasks day in day out its easy tobecome complacent; its easy to think thats not myproblem. But security and safety is everyones problem.Staff need to see the signs and behaviours we know leadto escapes. They need to say something every time thereis a risk. Its always better to say something then to keepsilent and hope it wont happen. Relational security isnot something that can be ignored. 14. Naming for proposition twoRelational Security Proposition 2edge Personal responsibility Secure thinking, safe working Security is your responsibility Keep everyone safe [variable message] Take responsibility, be aware Say something See it and say something If you see something say something You can stop it if you say something 15. Strapline Keep everyone safeNaming for proposition two Relational SecurityKeep everyone safe say something Keep everyone safe tell someoneKeep everyone safe act on it Keep everyone safe see the signs Keep everyone safe report it Keep everyone safe do somethingKeep everyone safe stop it now 16. Keep everyone safe Approach 1 Design concepts proposition twoRelational Security 3Can you see LOREM IPSUM DOLORSIT AMETthe signs?Lorem ipsum dolor sit amet,consectetuer adipiscing elit,sed diam nonummy nibhUt wisi enim ad minimveniam, quis nostrud exercitation ullamcorper suscipitDuis autem vel eum iriuredolor in hendrerit in vulputatevelit esse molestie consequat, RELATIONAL SECURITYeuismod tincidunt ut laoreetlobortis nisl ut aliquip ex eavel illum dolore eu feugiatdolore magna aliquam erat commodo consequat. Duis nulla facilisis. Why didntvolutpat. Ut wisi enim ad autem vel eum iriure dolorminim veniam, quis nostrudin hendrerit in vulputate velitesse molestie consequat,Keep everyone safe Approach 1exerci tation ullamcorper Nam liber tempor cumsuscipit lobortis nisl ut aliquip vel illum dolore eu feugiatex ea commodo consequat.nulla facilisis at vero erosoption congue nihil anyone doet accumsan et iusto odioimperdiet doming id quod.Duis autem vel eum iriure dignissim qui blandit praesentdolor in hendrerit in luptatum zzril delenit auguepossim assum.vulputate velit esse molestie duis dolore te feugait nullaconsequat, vel illum dolore facilisi. amet, consectetuer somethingeu feugiat nulla facilisis at adipiscing elit.vero eros et accumsan etNam liber tempor cum solutaiusto odio dignissim quinobis eleifend option congueeuismod tinciduntblandit praesent luptatum nihil imperdiet doming idquod mazim placerat facer aliquam erat volutpat.zzril delenit augue duis about it?dolore te feugait nulla facilisi. possim assum. Lorem ipsumet accumsan et iusto odioLorem ipsum dolor sit amet, dolor sit amet, consectetuerdignissim qui blandit.consectetuer adipiscing elit, adipiscing elit, sed diamsed diam nonummy nibh nonummy nibh euismoddelenit augue duis doloreeuismod tincidunt ut laoreetdolore magna aliquam erattincidunt ut laoreet doloremagna aliquam erat volutpat. RELATIONAL SECURITYte feugait nulla facilisi.RELAvolutpat. Ut wisi enim ad minimveniam, quis nostrud exercitation ullamcorper suscipitYou know when something is going on lobortis nisl ut aliquip ex ea Whats behindlike if a patient is using the phone moreYocommodo consequat.than usual. Do you think they are Keep everyone safe report it planning to escape? Dont walk away,say somethingyou can stop it beforeit happens. the smile? Keep everyone safe tell someonebu Everyone deserves to be treated fairly. Its important that all staff understand their patients and know when Be a somethings up. Theres always a reason why peoples talki behaviour changes spot it, think about it, talk about it.some Together we can stop escapes.they Lorem ipsum dolor sit amet consectetuerLorem ip adipiscing elit. Sed diam nonummy nibh adipiscin euismod tincidunt ut laoreet. Keep everyone safe act on it euismod 17. ryone safe Approach 2 proposition two Design concepts Relational Security RELATIONAL SECURITY50,000violent incidentstake place acrossNHS mental health everyoneKeepsafe Approach 2units each year.How many did you stop? Keep everyone safe do something 50% 9 10 RELATIONAL SECURITYRELATIONAL SECURITY13 LOREM IPSUM DOLOR SIT AMETOUTOF in Lorem ipsum dolor sit amet, consectetuerconsequat, vel illum dolore eu feugiatNam liber tempor cum adipiscing elit, sed diam nonummy nibhnulla facilisis at vero eros et accumsan et euismod tincidunt ut laoreet dolore magna iusto odio dignissim qui blandit praesent aliquam erat volutpat. Ut wisi enim adluptatum zzril delenit augue duis dolore te nihil imperdiet doming id quod. minim veniam, quis nostrud exerci tationfeugait nulla facilisi. ullamcorper suscipit lobortis nisl ut aliquip consectetuer adipiscing elit. MENTAL HEALTH STAFF ex ea commodo consequat.Nam liber tempor cum soluta nobis eleifend option congue nihil imperdietSTAFF tincidunt will nd themselves in Duis autem vel eum iriure dolor indoming id quod mazim placerat facer hendrerit in vulputate velit esse molestiepossim assum. Lorem ipsum dolor sit erat volutpat. consequat, vel illum dolore eu feugiatamet, consectetuer adipiscing elit, sed compromising situationsof all staff were involved in nulla facilisis at vero eros et accumsan et diam nonummy nibh euismod tincidunt et iusto odio dignissim qui blandit. iusto odio dignissim qui blandit praesent ut laoreet dolore magna aliquam erat every week. Is that you luptatum zzril delenit augue duis dolore te feugait nulla facilisi. Lorem ipsum dolor volutpat. Ut wisi enim ad minim veniam, quis nostrud exerci tation ullamcorper duis dolore te feugait nulla facilisi. today?a serious incident. Can you sit amet, consectetuer adipiscing elit, sed suscipit lobortis nisl ut aliquip ex ea diam nonummy nibh euismod tincidunt utcommodo consequat. laoreet dolore magna aliquam erat. believe most incidents Duis autem vel eum iriure dolor in hendreritrecognise the signs? Ut wisi enim ad minim veniam, quisin vulputate velit esse molestie consequat, nostrud exerci tation ullamcorper suscipitvel illum dolore eu feugiat nulla facilisis. Keep everyone safe tell someone lobortis nisl ut aliquip ex ea commodo consequat. Duis autem vel eum iriure dolor in hendrerit in vulputate velit esse molestie can be prevented. Do you?3Lorem ipsum dolor sit amet, consectetuer adipiscing elit,Lorem ipsum dolor sit amet, consectetuer adipiscingsed diam nonummy nibh euismod tincidunt ut laoreet elit, sed diam nonummy nibh euismod tincidunt utdolore magna aliquam erat. Lorem ipsum dolor sit amet, laoreet dolore magna aliquam erat. Lorem ipsumconsectetuer adipiscing elit, sed diam nonummy nibhdolor sit amet, consectetuer adipiscing elit, sed diameuismod tincidunt ut laoreet dolore magna aliquam erat.nonummy nibh euismod tincidunt ut laoreet dolore magna aliquam erat.Lorem ipsum dolor sit amet consectetuerLorem ipsum dolor sit amet consectetueradipiscing elit. Sed diam nonummy nibh adipiscing elit. Sed diam nonummy nibheuismod tincidunt ut laoreet. Keep everyone safe act on it euismod tincidunt ut laoreet. Keep everyone safe stop it now 18. Relational SecurityStage twoMore research 19. Stage two research Relational SecurityWe interviewed mental health staff about their understanding of relationalsecurity. When we looked at what they said there were some clear themescoming through around the eight areas of relational security Team Other patientsTherapyBoundariesPatient mix Patient dynamicInconsistent treatment Staff too busyPast historiesWhispering/plottingChange in staffNot questioning behaviour Safe place to comeBullyingPatient involvementNot knowing the history Involving patientsCoercion/tradingAgree working approaches Inappropriate relationships New patients arriving Escalating behaviourStaff being singled outComplacency New relationships Change in atmosphereInside worldOutside worldPersonal world Physical environmentVisitorsOutward connectionsIgnoring small changes Putting things together Family visits More telephone callsSeeing the patternsGiving time to patients New visitor added Hanging around exitsAsking questions Understanding the risks Change of frequency Wanting medical attentionSeeing the risks Raising the alarm Visit from partnerTampering with handlesWhats affected them?Handover informationSolicitors visit Going on leave 20. Deliverables Relational SecurityDeliverablesStaff told us they wanted the information on relationalsecurity to be face to face and interactive. So we beganwork on Posters for areas of relational security team exercise to explore problems and solutions Handbook to give more information Training materials Promotional materials 21. RELATIONAL SECURITY RELATIONAL SECURITYRELATIONAL SECURITYSpot the difference? You hear it, but areWhats behind you listening?the smile?Its easy to take things at face value. But noticing You know when something doesnt sound right. small changes in patients will give you clues about You know when somethings up. Theres always aIt might be the smallest thing but its always betterwhats really going on in their lives. Its time to reason why someones behaviour changes. Spot it,to say something than do nothing.nd out whats behind the change. think about it, talk about it. Together we can keep people safe.relational securityrelational security relational securityYour guide toYour guide to Your guide to Read SEE THINK ACT, Read SEE THINK ACT, Read SEE THINK ACT, your guide to your guide to your guide to relational security. Keep everyone safe act on it relational security. Keep everyone safe act on it relational security. Keep everyone safe act on itRELATIONAL SECURITY RELATIONAL SECURITY RELATIONAL SECURITYRELATIONAL SECURITY RELATIONAL SECURITYRELATIONAL SECURITYCrossed the line? Said too much?Playing by the rules?Stop have youIts good to see you!Can you see the signs? passed it on? Visits can make a big difference to patients. ThinkWe all deserve to be treated fairly. Rules are about the impact you might have on the personIts easy to say too much when we get chatting, there to keep you safe. If you know that youre visiting. If theres something staff need tobut giving patients personal information puts you someone is breaking the rules, you can helpAt the end of the shift, we all just want to get home.know, say something before you go. You know when something is going on like ifat risk. If things have gone too far, nows the timeput a stop to it just say something. But when you rush its easy to forget about thosea patient is using the phone more than usual.Bending the rules for a patient just that once canto get back on track.small things that tell us something is wrong. Stop.Its time to ask yourself why? Dont walk away,be an easy thing to do but a hard place to getback from. If things have gone too far, nows theYou need to pass everything on before you go.say something... you can stop it before it happens.time to get back on track.Read SEE THINK ACT, Read SEE THINK ACT,Read SEE THINK ACT, Read SEE THINK ACT,Read SEE THINK ACT, Read SEE THINK ACT,your guide to your guide toyour guide to your guide toyour guide to your guide torelational security. Keep everyone safe stop it now relational security. Keep everyone safe stop it nowrelational security. Keep everyone safe act on it relational security. Keep everyone safe act on itrelational security. Keep everyone safe report it relational security.Keep everyone safe report it 22. Training wheel Relational SecurityOT HE MR A ixPA tmTE ThTI enENeratiTS py PaBo unnt dartie mic iesPa n a dy PATIENTRATING SCALEOT HER 10 Extremel ardM PerA ixtw n s PAtmTEw o s onaTh Ou tio TI 9 en ENera rld lti TS necpy Pa Boun nt8ontie icdarc ies Pa n a m dy Ph iron 7rsen OUito ysi PATIENTD6vRL TS Viscal entardPer tw wo sona Ou tions5O ID ecrld l n con m WW E Ph ironsE4en OU r O ito ysiD Dv RLSI RLTSViscal ent OIDD3IN mWWEO DERL D SIIN 2 1 No cond 23. HandbookRelational Security Team01Therapywhat youneed to knowUnderstanding theuse of therapy inrelational security01 The importance Relational security is one of the of therapy and clear Therapy should give patients hope and belief in their most important elements inensuring therapeutic progress.own recovery. Staff must understand the care and treatmentTherapy is based on trust, which 02 02 patient boundarieseach patient needs and the risks involved.in the secure mental healthenvironment can be difcultto create.Patient Ts storyPatient T became isolated from allworking with staff to recover. Patient Lack of knowledge about a the staff on the ward. When new T responded by singling out the newpatient and no clear plan about OT For you to maintain relational security there 03 During Patient Ts rst two years on members of clinical or domestic nurse with extremely aggressivehow to manage change will03the ward she had a good relationship staff came onto the ward shebehaviour. The new nurse challengedescalate behaviour. Without staff MHE R needs to be trust between patients and staff.with only one member of staff, would single them out and taunt Patient T and asked why was sheworking together to create a Awho she talked to about what was them with aggressive behaviour. behaving like this, and said did Patientix Every member of staff who has regular contactmore positive relationshipPA tmTEhappening in her life. But she didntStaff didnt have a consistentT realise it was this behaviour that there is no way for a situation ThTI with patients whether they are clinical or want this information to be shared approach to this and it was left to was stopping her getting leave for theento improve and it will just getEN erawith anyone else. So when theindividual members of staff to cope weekend. Patient T responded to this ti 04 worse and worse.04TSpyPa Bodomestic has an impact on patients lives, trusted staff member left, Patient T in their own way. Some would avoidby becoming withdrawn and quiet.unntfelt abandoned and refused to talk toher and others became frustrated in Staff left her to it, and hoped she hadDeveloping therapeutic dar tie iccare and recovery. That means every member ies Pa nam anyone else. being unable to nd out what waslearnt her lesson. That weekend therelationships is an important part ofdy behind her behaviour and gave up on new nurse was attacked by Patient T of staff has a part to play in understandingtrying to gain Patient Ts trust. during the nightshift.relational security. The benets ofStaff didnt talk about therapy include better managementPATIENTand actively supporting relational security.05Patient Ts treatment.of violence and improvement in05Everyone treated her inStaff were not in controlthe patients responses to changeand intervention. ardPer a different way and sheof the situation. Theytw w o s ona Within your team there are two aspects of Ou tions rld ldidnt talk about changesStaff must work together across necmade no improvement. con relational security to explore they are therapy in Patient Ts behaviour the team to see the individualPh iron and what needs of patients and give them rs 06 06 enOU and boundaries. This chapter will give you the During the months that followed,itoysithe opportunity to say howD was behind it. vthere were times when she wouldRLTS Vis cal enttheir care could be managed. information to build on your knowledge ofsuddenly become aggressive andOIDWhen there are good therapeuticm W Wstaff didnt know whatE A new nurse started work on the O DEthese areas to help you keep everyone safe.had triggered this behaviourrelationships on the ward it helps RL SI ward in the same week Patient Tsdo you feel to provide a safe place whereDIN or the best way to deal with it. How condent d? friend got a leave of absence. y on your war patients treatment plans are 07 Patient T said she saw no point in her about therap 07r next team understood and followed.treatment and that she had Patient T wanted leave as well butDiscuss at you -to-one.no belief in her own recovery. was refused because she was not meeting or one 08 08What you can doRELATIONAL SECURITY 0101Steps you can take to improve patient therapyEvaluate how well you are doing You can take action toEncouraging patients to believeYou know you are getting therapy right when Whats behind improve relational security through therapy by: in their own recovery and helping them to see what they can do to improveBoth staff and patients understand how the ward should beand how we deal with any issues. 02 the smile?02 Planning how to manageBeing consistent and caringPatients take part in therapy and social activities. transition and change in treatment of patientsPatients have hope and want to recover. Being a positive role model Helping patient recovery in 0303Patients know what they need to do to progress and recover. and setting a good exampleeverything you do (therapy shouldnt just happen in the We know that even small changes, can have an impact on patients, Engaging with patients and treatment room!) so we talk to them about how they feel and manage any change. making a commitment to their treatment Helping patients prepare for We look for opportunities to reinforce therapy in everything experiences with the outside we do with patients. 0404 worldPatients feel connected and prepared to go out into the community. Its easy to take things at face value. But noticing What else could you and your team dosmall changes in patients will give you clues about to improve things?Add in your own ideas for how you want to see whats really going on in their lives. Its time to 0505 your ward change nd out whats behind the change.Keep everyone safe act on it 0606 07Remember to take your handbook with you to any07 staff meetings on relational security so you can record your thoughts and individual actions. 0808 24. Outcome Relational SecurityNext steps Test new version of tool Complete and test handbook Develop training materials Develop promotional materials 25. Relational SecurityThank you. Any questions?