Leadership & Reducing Restrictive Practice

Roy Deveau, Honorary Research Associate - Tizard centre, University of Kent and Research Associate, Studio3

The programme

• Morning:• Introductions• Examine staff practice and leadership • Afternoon:• Examine frontline practice leadership and

apply to our contexts to reduce RP• Make plans for some sort of action/change

• Why leadership?• See references: Allen and Colton

IASSIDD 2014 Vienna

Reducing the use of restraint and restrictive approaches to support ordinary community living

Roy Deveau, Tizard centre, University of Kent and Studio3, UK.

This presentation discusses

• implementation of Government policy at the frontline.• Recent reverses to the policy of limiting the use of

hospital settings for people with ID and challenging behaviour.

• Implementation of policy and its relationship to frontline staff practice.

• what determines frontline staff practice, drawing on the distinction between management and leadership.

Deinstitutionalisation

• UK Government policy to enable people with intellectual disabilities and especially those who exhibit challenging behaviour to live in smaller ordinary community houses rather than large scale, isolated, long stay, NHS hospitals has been largely achieved.

• Scandals in the media helped drive this policy.

One county learning disability hospital closed in 1990s

Re-institutionalisation

• Another hospital scandal drew attention to increasing use of hospitals again. Government policy commitments followed the BBC TV Panorama investigative documentary into Winterbourne View Hospital (May, 2011).

Re-institutionalisation

• A recent letter to the Prime Minister, Cameron from two major charities representing families and people with LD highlighted the failure to meet policy deadlines for moving people out of A&T hospitals and into local community places by 1 June 2014 (e.g.3,250 people in hospitals, 2014). MORE people are being admitted than being discharged (over 6 months, 544 admitted & 339 discharged).

Winterbourne View, a modern hospital

• Apart from being illegal, this clip illustrates something that hospitals, are and always have been, designed to achieve. The exercise of CONTROL over unsafe behaviour through the use of restrictive environments and staff practices e.g. seclusion rooms and the most restrictive restraints - Floor restraints, requiring 3/4 staff.

• These practices and environments require staff that are trained and reinforced to exercise control AND are counter productive to achieving community living.

Policy into practice

• Many examples (I am sure the UK is not unique) of Government policy not achieving what was intended. Poor policy, unintended consequences, poor implementation may be factors.

• I am interested in staff attitudes, cultures and practices at the frontline that can support or deny people the opportunity to live in ordinary small scale local communities.

7H People who use services benefit from practice where the use of restraint and management of behaviour that presents a risk is:●● Always risk assessed to ensure the appropriate techniques are used.●● Practised in a way that protects the dignity and respect of people who use services and protects their human rights.●● Discussed, agreed and documented in advance, wherever possible, with the person who uses services as part of the processes for planning care.●● Identified and documented in a plan that sets out preferred measures to prevent and minimise the use of restraint, which is reviewed as the person’s needs change.●● Used as a last resort and is the minimum response necessary for the shortest possible time, to make them and others as safe as possible.●● Recorded.●● Where applicable, used in line with the restraint guidelines in the Mental Capacity Act 2005 Code of Practice and the Mental Health Act 1983 Code of Practice and including a best interest assessment.

Policy examples, Health & Social Care Act 2008 CQC Regulations 2010

• An increasing trend for using a human rights approach to support e.g. Council of Europe declaration (2004) Persons with mental disorder should have the right to be cared for in the least restrictive environment available and with the least restrictive treatment available ---.

• Mental Capacity Act 2005 (DOLS)

Reducing RP - emerging legal issues

• Restrictions can include:• Close supervision in the home• Use of some medication e.g. to calm a person• Requiring a person to supervised when out• Physically stopping someone from harming

themselves.

(Social Care Institute of Excellence, 2011)

WE HAVE PLENTY OF POLICY; WHAT ABOUT ACTION. What determines good staff practice – what does good & restrictive practice ‘look like’

• Have a quick look at your organisation brochures and discuss in small groups what they say about how your organisation is going to determine staff practice is ‘good’ and how this should be experienced, what about restrictions?

• And let’s discuss restrictive practice (RP) The Slippery Slope (McDonnell et al., 2014) suggested that small RPs are common and can lead to major RP and abuse, if allowed to. In your groups, each discuss an example of a small RP that either became major or you felt strongly about but couldn’t get agreement it was a problem or do anything about.

Two views of an organisation

• Neat organisational tree

As a chaotic system

• Analysing organisations as complex adaptive systems “-- neural-like networks of interacting, interdependent agents” (Uhl-Bien & Marion, 2009 p.631)

Rome IASSIDD conference 2010. Are the variables that determine of staff practice: simple, complicated or complex (Bigby et al., 2010)

Management versus Leadership

Leadership is a dynamic human process, in essence the use of social influence to develop and achieve organisational goals, focus on organisational values and culture.

Management is the scheduling and monitoring of staff to ensure routine policies and procedures are carried out

A framework for thinking about frontline management /leadership in ID (Deveau & McGill, in

submission)

Performance of designated routines & tasks. Paperwork, housework, safety, personal care. Linear relationships expected. Written evidence required.

Emerging activities and relationships are unpredictable. Internalised rules, values and culture reinforce actions. Non linear relationships expected. Observation & testing required

-planning-setting goals-monitoring-controlling-improving

-doing things right

-efficiency-budgeting

-visioning-strategic thinking

-aligning-inspiring

-doing the right things-effectiveness

-opening doors-building alliances-removing blocks

-coaching

-developing others

-networking-acting as a role model-creating a

climate

Formal Administrative system

Informal interaction system

Management Leadership Combined in

Formal organisational culture

Informal organisational culture

What determines good frontline/practice leadership – what does good leadership ‘look like’

• Do your brochures say anything about leadership?

A confession - general answers to these questions are not available. Because these questions and answers are specific to particular contexts – the people – the environment etc. Example from an NHS provided service tendered out to a charitable organisation

Leadership in three major public services

• NHS Leadership Academy .Towards a New Model of Leadership for the NHS (June 2013). Motivated by failures in health care and media scandals e.g. Staffordshire hospitals. Excellent review of the leadership literature.

• National College for School Leadership. 10 strong claims about successful school leadership (2010). Excellent summary of school leadership based upon many years of the College’s research since 2000.

• National Skills Academy for Social Care. Leadership starts with me (2013). In part a response to winterbourne view scandal. Not based upon research but a focus group exercise involving many parties, providers, purchasers service users, discussing what they want from leaders. Only recently started discussing leadership in social care.

NHS leadership Academy ( a decade of leadership development)

Towards a New Model of Leadership for the NHS, snippets: “the overall goal – offer a view of what good leadership in healthcare ‘looks like”. Research review organised into 3 elements which “contain sets of leadership behaviours”

1. provide a clear sense of purpose: an ‘explicit focus of the needs of service users’reinforce an inspiring vision of the mission

2. motivation of teams & individuals to work effectively: a positive emotional climate

3. improve system performance: “construct compelling case for change – find ways to intervene informally – modelling learning new behaviours – analyse self and unit – reveal some self doubt & mistakes”

National College of School Leadership providing research and development since 2000

10 strong claims, snippets: Head teachers (HT) are main source of leadership in schoolsHT defined success in terms of social and personal outcomes not just exam resultsHT personal values are key to their success “ who they are”No single model of leadership for achieving success but some basic practices (behaviours i.e. NHS) Difference in context affect nature and pace of successful leadership actionsAct incrementally layering strategies and actions depending upon contextSuccessful HT distribute leadership progressively based upon developing trust (NHS document criticised

distributed leadership) Measuring outcomes informally and formally is crucial to developing trustHT use 8 key dimensions: define values and vision to raise expectation – set direction & build trust – enrich

curriculum – enhance teacher quality – build collaboration internally and externally – reshape conditions for teaching and restructure organisation and leadership roles/ responsibilities.

Some examples of successful HT behaviours: They HTs are all over the place you don’t know where she will turn up – support trials and experiments – have

a go mentality - open door access – still undertake some real work – ‘it ain’t what you do it’s the way that you do it’ (different emphasis to the NHS) - encourage use of data and research.

Social Care (national skills academy)

Leadership starts with me, snippets:WHAT: values: integrity- dignity – compassion –promote equality- praise

effortPractice principles: social purpose – co-production- innovation – risk

responsibilityQualities: self wariness – managing self – continuous personal developmentBased upon these, leadership in practice ‘looks like’ - quality of

personalised support – understand risk & safety - find shared purpose - any worker can exercise leadership - relationship between practitioner and service user is key - leaders need to be developed and emerge.

HOW TO IMPROVE LEADERSHIP: follow programmes and activities – ‘produce a statement of social care leadership intent’

Map assets - stick to budgets

Leadership in ID the forgotten factor n outcomes WHY?

• Some work on organisational culture (Hastings et al., 1995; Noone et al ., 2003; Hatton et al., 1999)

• Some on frontline/practice leadership (Deveau & McGill, 2014; Clement & Bigby, 2010; Lowe et al., 2010)

• Yet when I ask experts what makes the difference between poor and good staff practice – usual answer the on-site manager.

We have experts in ID: speech, occupational, behavioural - so why do we need leadership?Low political priorityClarity of gaols, what is social care supposed to produce, what do/should leaders aim for as a vision?

The rational and irrational in leadership (FT management blog, August 2014)

• Most chief executives think of themselves as rational. Certainly, in the world of closely scrutinised listed companies, it would be unwise for corporate leaders to project any other image.

• But, as Manfred Kets de Vries of Insead business school puts it in a new working paper … “our everyday lives consist of webs of constantly shifting and irrational forces that underlie seemingly ‘rational’ behaviours and choices – and life in organisations is no exception”. To lead successfully, he suggests, requires a “psychodynamic approach” that seeks to understand the hidden factors motivating teams. . Organisations have to try to unearth these “messy complexities”…. using coaching, 360-degree feedback, group exercises, and leadership questionnaires... After all, a little self-knowledge can go a long way

Good afternoon

• We start by looking a some of the relevant research in ID and challenging behaviour.

• We then think about our own work and devise RP reduction plans/ideas suitable to our work contexts.

What makes great leaders?

Followers

Leadership research in ID• Practice leadership (PL) introduced in ID (Mansell et al., 1993) “Perhaps the most difficult

part of the interventions was redefining the role of house managers and patch managers as primarily concerned with “practice leadership” rather than administration” .

• PL defined in context of implementing Active Support is ‘the development and maintenance of good staff support for service user through managers: spending time observing staff work, providing feedback and modelling good practice, providing staff with regular one-to-one supervision and facilitating team meetings focused upon improving service user engagement (Beadle-Brown et al., 2009) and developed a PL questionnaire.

• Using the PL questionnaire not much PL is being experienced by staff (Beadle-Brown et

al., 2009) also when using interviews/observations and survey (Bigby et al., 2014). However, staff of a self selected group of Registered Managers experience greater PL ( Deveau & McGill, 2014).

• Higher PL is associated with better staff experiences of working with CB and implementation of Active Support.

Driving up Quality Code.One organisation self audit staff survey results: Leadership &

management

• PL measure (16 items) how often staff experience: individual supervision, team meetings and being watched whilst working and receiving feedback. What subjects are discussed and are the main focus with managers i.e. supporting service users to participate in activities or form filling.

• The organisation’s staff (53% response rate n=57) average PL score was high 76%. This compares with 41% for large sample from a national charity and 68% from 21 services (Deveau & McGill 2014).

• On the PL (and other) measures a good result.

One organisation’s staff audit results: Leadership & management

• High PL results show staff feel well supported during supervision and team meetings, that are meaningful and useful and discussion is focussed upon how to engage service users in activities.

• However, results were less positive for staff’s experience of being observed and provided with feedback by managers on their work (similar to Deveau & McGill, 2014).

• For example, “When they (managers) watch you work do they show you how to work well with the service user you support?” 44% responded always but 19% responded, rarely or never . And 46% of staff agreed or strongly agreed with the statement. “My manager only gives me feedback when I have done something wrong”

• There are no widely recognised and implemented standards for managers observing and giving feedback on staff practice.

Leadership & Management, overall organisational focus & mission

Jim Mansell and many others have pointed to the vital role of organisation’s most senior managers/leaders providing the overall focus/direction/ vision in their organisations.But as with being observed and provided feedback on practice by frontline managers this aspect of the organisation was less positive:• For example, 81% of staff agreed or strongly agreed with the

statement “Managers don’t get involved much in how we support service users”

• And 75% of staff agreed or strongly agreed with the item “Management is more interested in smooth running than in helping service user engage in meaningful activity”

Qualitative interviews conducted with 19 managers

(Deveau & McGill, in submission) settings• Large house in ordinary

residential area was the usual setting

• 123 service users in total Mean per service 6.5 people

• Max 11 in one house• Min 3 in two houses

Intellectual disability• MMID 67 people• SID 46 people• PMID 10 people

A variety of challenging behaviours described76 people (61%) had Autism 8 services had all people with Autism

Method, Interpretive Phenomenological Analysis (IPA)(Smith et al. 1999)

Some less specific topics: What made you the sort of manager you are now?

Some very specific topics: How do you develop behaviour support plans?

Semi- structured interviews, were aimed at gaining an understanding of the daily lived experiences of managers as they interact with staff and their wider environment to support people with challenging behaviours .

Final thematic structure

• 16 themes organised into five groups .

Manager’s personal feelingsand values

Influence of employing and external organisations

Manager’s developing and shaping staff performance

Developing new ways of working with service users

Manager’s knowing what’sgoing on/ monitoring

Group 1.

Managers knowing what’s going on/ monitoring

Group 2.

Developing new practice and ways of working with service users

Group 3.

Manager’s approach to developing and shaping staff performance

Group 4.

Influence of employing and external organisations

Group 5.

Manager’s personal feelings and values

The importance of personal observation and knowledge for managers

Degree of staff inclusion/involvement in developing new practice

The importance of personal observation and contact to inform shaping performance

Positive/negative influences of external organisations on managers

Managers promoting their value base within the team

Covert/informal versus formal/structured approaches to monitoring

Recognising and using individual staff abilities & observations

Long-term, patient development of staff, but happy to ‘let them go’ if performance will not improve

Positive/negative influences of employing organisations on managers

Managers working within the constraints and strengths of their own personalities and experiences

Keeping on top of staff performance which can go ‘downhill’ very quickly

Using in-house and external professionals

Using positive/negative feedback

The prime importance of development of self, staff and service users

Implementation of new practice requires more formal management processes

Use of modelling & role play

Group 1-Manager’s knowing what’sgoing on/ monitoring

Keeping on top of staff performance which can go ‘downhill very quickly.

Covert/informal v formal/structured approaches to monitoring

Theme - Covert/informal v formal structured monitoring

Some managers felt they would get a more realistic idea of how staff were behaving:

“Staff behave differently when the managers around.. All that means is they know how to behave.. I keep it informal, sit around and then you get to see how staff actually behave towards the residents”

Theme - Covert/informal v formal structured monitoring

Some managers placed importance upon hearing rather than seeing:

“They (staff) really don’t realise how much I can hear through the floor here… so I know how they’re talking to clients, I know what the resident is doing at the time”

and having a central, accessible, office:“I’ve been told by my line manager that sometimes I just

need to shut that office door and say “no I’m busy, I struggle with that I really do”

Do trainers emphasise formal approaches & why?

Group 1 Keeping on top of staff performance which can go ‘downhill’ very quickly

Only 2 managers discussed the speed with which staff practice can deteriorate without their intervention:

“It snowballs doesn’t it, and then the whole team starts failing. You get one person that’s not doing it, especially if you’re in such a small knit team such as we’ve got here. It really does snowball if you don’t nip it in the bud and keep things under control” (9, 43).

‘The Slippery Slope’ article emphasised gradual RP leading to abuse?

Group 2- Developing new ways of working with service users

Recognising and using individual staff abilities & observations – emerging behaviours

Staff involvement in developing new practice

Good or bad

Theme - Staff involvement in developing new practice

Most managers described extensive staff involvement, leading to various benefits, including:

Better implementation:“I’m not the one… trying to get that person doing that new thing

every-time... If you want staff to be successful then the best way … is for staff to feel that they have involvement”

Better plans:

“ the staff, they work with them day in day out, they’re faced with the problems ….Yes, we can sit in the office and come up with ideas, but they (the staff) will help finalise the idea, how they think it will be better. Because they’re always in the environment and they’re the ones dealing with the challenging behaviour, a little bit more than people up here making decisions” (9,14).

Theme - Recognising and using individual staff abilities & observations – emerging behaviours

• “Something you maybe took for granted, you actually think…..well it is only that person who does that, you know or it’s only that person who tends to have that rapport with that service user…..if something’s working well for one service user with one staff member, we’ll try and incorporate that into the support plan so all staff have the opportunity to work at that level with that service user” (5, 5).

• “…..recently, we’ve got L. (a service user who needed a physical intervention (PI)

to get him out of the car). M (the behaviour specialist) and I did a lot of work with the staff team. However,…..because we got them involved (two staff who worked a lot with L) they literally changed the whole guidelines from what M. and I thought, into how they felt and basically they ended up leading the sessions with the staff team and they were sort of doing their little role play and showing the staff as well, whilst M and I are sitting there observing them doing it…..we haven’t used a PI for months” (3, 4).

• How do structured training approaches combine with the certainty of and potential benefits from emerging practices?

Managers being themselves‘leadership starts with me’

Managers described developing a ‘team’ based upon getting people with the same values. The managers own experience of ‘life’ and work mentors/role models both good and bad shaped their actions and values:

“I think my own life experiences, my upbringing was…..if you’re not going to do it, don’t expect everyone else to” (5, 20).

“I think I had a really good mentor when I came into the profession… I started off as a support worker. And I think I’ve always been quite fortunate that I’ve always had good mentors.. I think that’s had quite an impact”

And poor role models had an effect on how managers express their values:

“I always thought that when I get my first managers role, it’s something that stuck in my mind.. Not to be like that.. So I will always listen to people’s ideas. I suppose that’s part of why I am what I am”

Managers being themselves‘leadership starts with me’

Managers being themselves‘leadership starts with me’

• The managers expressed their experiences in ways which showed how committed and personally they were involved. These were not technocratic, transactional leaders.

• Some showed courage:• “Now, we have individuals here who staff wouldn’t dream of

taking out on their own arguing that in the past it’s always taken two or three staff. I have taken four of the client group on my own to the cinema, with everybody going, you’re mad, it’s dangerous, (I explained my risk assessment and how I would deal with any problems). It is hopefully demystifying and de-demonising” (17, 12).

Managers being themselves‘leadership starts with me’

• Challenging potential restrictive practice.

“ I’ve had a man start this week and it’s his tone of voice and his body language, that it just appears quite aggressive and he’s already been involved in a couple of incidents…..”

Researcher: “how are you going to go about changing this staff?” Manager: “In all truthfulness, with this one and this isn’t going to look very good on

me, but I’m not convinced that I’m going to…..(my deputy) and I are going to have a chat with him about how he needs to sit and read the support plans thoroughly, because they talk about body language and tone of voice…..I think we can only support him, keep telling him and give him supervision, but…..with this one it’ll be either he leaves or there will be an incident where by he has to leave…..he’s come in as an experienced man and who are we to jump on this…..He said to me, don’t you think you’re over the top what you do with C…..(Regarding the staff member changing his work) he will have to, he will absolutely have to and we’ve got to give him the benefit of the doubt…..but if at the end of the day that is still not happening then he won’t be able to work here” ( 6,8-9-15-13).

Managers being themselves‘leadership starts with me

• Challenging potential RPThe manager of service 7 described her response to the staff member who had

attempted to stop the service user making herself a sandwich, then the manager of service 17 explains how he got his staff team to accept the kitchen door being unlocked:

“She (staff) felt she’d supported the client and now I’ve actually said (to the client) you

can absolutely go, it’s your kitchen, so she (staff) felt, I think, undermined. What was important to me was not that she felt undermined but that she understood why we couldn’t make that decision.” (7, 9).

“When I came I basically indicated the kitchen would be opened, I met an awful lot of

resistance from staff, I then offered a compromise that we would lock the kitchen as long as the lounge was also locked and that personally I would rather be hit by an empty kettle than a television. Needless to say I won the argument.” (17, 6).

• All people in supported living should have at least one active goal and support plan that reduces RP

• If a restriction is felt to be necessary then one should be reduced – The one in - one out principle.

• All restrictive practice should be reviewed and advocates, staff team and managers, commissioners involved. Although I am amazed at how much groups will accept.

• At 2007 BILD conference it was suggested that any service that has a BSP that includes RPI should also include a BSP to reduce the restrictiveness or frequency with which this is used (Deveau & McGill, 2007)

Reducing RP: quick guide

So lets try to sum up some triggers for you in your work

• Leaders are no good without followers – make sure somebody trying to achieve change doesn’t think they can do it alone. What about trainers not being engaged over the long term?

• Do trainers help to build support from all staff for registered managers to achieve change.

• Frontline/practice leaders need a supportive context – what does the CEO expect, how much paperwork is there to do, what expectation are placed upon frontline/ practice managers - how is their work measured – incident reports – budgets - adult protections or RP reduction and service user progress.

• How do frontline managers include staff in practice developments, do they observe staff working, informally, formally, do they give feedback, structured or informal.

• Can managers be tough enough to set a direction, can you see that evidenced. Not accepting pressure from staff for small RP.

• Do trainers/practitioners attempt to intervene in the wider context or just pile more pressure upon the frontline practice leader.

• Lets discuss some more

What are you going to do to reduce RP

• In pairs make some plans and more important decide some actions.

• Remember: “Those who fail to plan, plan to fail” (David Allen, 2011) However, “Plans are only good intentions unless they immediately deteriorate into hard work” (Peter Drucker, cited in Deveau, 2012).

• Thank you for listening and being such a rewarding audience.

• If you would like to chat about the ideas we discussed or can’t get hold of any of the references please feel free to contact me roydeveau@aol.com.

Useful references• Towards a new model of leadership for the NHS (June 2013) available form

www.leadershipacademy.nhs.org• 10 strong claims about successful school leadership (2010) available from

www.ncsl.org.uk/publications• Leadership starts with me (2013) available from www.nsasocialcare.co.uk • Colton, D. (2004). Checklist for assessing your organization’s readiness for

reducing seclusion and restraint. http://www.ccca.dmhmrsas.virginia.gov/content/SR%20Checklist.pdf

• Colton, D. (2007). Leadership’s and Program’s Role in Organizational and Cultural Change to Reduce Seclusions and Restraints. Nunno, M., Bullard, L., and Day, D., (Eds.). For Our Own Safety: Examining the Safety of High-Risk Interventions for Children and Young People. Washington, DC. Child Welfare League of America. 143- 166.

• McDonnell et al., (2014) How nurses and carers can avoid the slippery slope to abuse. Learning Disability Practice, 17, (5) 36-39.

Useful references• Deveau, R. & McDonnell, A. (2009) As the last resort: reducing the use of restrictive physical

interventions using organisational approaches. British Journal of Learning Disabilities, 37, pp 172-177.

• Deveau & McGill (2013) Leadership at the front line: Impact of practice leadership management style on staff experience in services for people with intellectual disability and challenging behaviour. Journal of Intellectual and Developmental Disability, http://dx.doi.org/10.3109/13668250.2013.865718

• Deveau & McGill (in submission) Practice leadership at the frontline in supporting people with intellectual disabilities and challenging behaviour : A qualitative study of Registered Managers of community based, staffed group homes.

• David Allen (2011) Reducing the use of restrictive practices with people who have intellectual disabilities: A practical approach. BILD Publications.

• Noone et al., (2003) Experimental Effects of Manipulating Attributional Information about Challenging Behaviour. Journal of Applied Research in Intellectual Disabilities,16, 295-301.

• Hastings, R.P. (1995) Understanding factors that influence staff responses to challenging behaviours: An exploratory interview study. Mental Handicap Research, 8, pp 296-320.

• Driving Up Quality Code: Self Assessment Guide. Available at (www.drivingupquality.org.uk)