A whole system approach How NVR can support

A whole system approach: How NVR can support staff, carer’s and parents within and following discharge from the adolescent inpatient setting Nicky Maund, Lydia Stafford and Jo Buchmuller

How it began in Birmingham…. A group of staff were trained to advanced level in 2013 selected from one inpatient unit; Nurses and the Systemic family therapist. (Supporters i. e. Systemic training dept) Specific day offered focussing on CAMHS inpatient context facilitated by Nick Goddard. Shared vision for a whole system approach and ideas for small basket first steps.

First Steps Bringing the ideas into staff support to explore the patterns of escalation on the ward. First attempts at writing announcements to young people and a shift in involving parents to increase their presence. Learning from “striking when the iron is hot” and the importance of being a regulated team. Acknowledging that the team were traumatised and working to address this. Whole team away days; baskets and ward announcements. Parent Groups can be a useful starting point (Jo will outline in detail her experience of setting up a parent group in an inpatient setting)

The NVR Map De-escalation Reconciliation Gestures Looking after yourselves Parental Presence Inside the home Outside the home Young person’s perspective and needs Siblings Baskets Rebuilding The Relationship Supporters Sit In Announcement 4

NVR skills group for parents/carers: An example Aimed at parents of young people admitted to a short stay adolescent inpatient unit in South Wales Family therapist and ward manager plus observer Closed group of up to five families (allow for dropout) 6 week programme, including an introductory session (2 hour duration) Evening ‘v’ daytime groups

NVR skills group for parents - structure Serve refreshments prior to start to allow for parents to share experiences/support each other Cover specific skills and allow time for discussion week by week Parents discussion expands as weeks progress Allow time after each session to spend 1: 1 time with parent to discuss specific issues if necessary outside of group time No power-point!

NVR skills group for parents - content Condensed 12 week programme into 6 weeks Concentrated upon: 1. Raising parental presence, 2. Escalation/striking when the iron is cold 3. Re-connecting gestures 4. The basket exercise/the announcement/sit-in 5. Supporters

NVR skills group for parents - content 6 Provide handouts to accompany each session: e. g. an example of a real announcement letter 7 Encourage parents to bring real life experiences of using the skills at home

NVR skills group for parents - selection mixture of diagnoses Parents can continue post-discharge Three families is ideal to allow for 1: 1 focus Small group is necessary in inpatients to manage boundaries between the group work and treatment and care planning

NVR skills group for parents - supervision Supervision – ongoing 1: 1 supervision from a NVR supervisor plus informal peer group supervision

NVR skills group for parents - feedback “At first I didn’t think it would be helpful to us to do because of the title “Non Violent Resistance” but I am glad we did it because it has helped and given us confidence”. “It has made me realise that I’m a good parent, NVR has helped me recognise this”. “It’s helped me think before I act”. “Knowing the facilitators knew my daughter made is easier for them to understand our family etc. , ” Face to face graduate parent feedback is best but written feedback is also helpful

NVR skills group for parents - ROMS Routine outcome measures used: 1. SCORE 15 (pre/post group) 2. Brief Parental Self Efficacy Scale (pre/post group) 3. Likert scale after each session E. g. , one parent SCORE 15 result decreased by 17 points which indicates a very significant improvement in the family functioning. One parent indicated on the Brief Parental Self Efficacy Scale that they had increased their confidence in parenting from 17/25 up to 22/25.

How it developed in Bristol, Wales and Birmingham… Parent Groups were the starting point in Bristol and Wales; they were also introduced early on in the process in Birmingham. Parent groups and their presence influencing the evolvement of ward based NVR. Staff learning through joining groups; practice Sowing the seeds of change…slowly Recruiting organisational supporters and navigating systems; politics! Individual NVR with parents Bite size and team 1 day training Charitable bids and further staff were trained Sparkling moments that enabled persistence

Moving towards a whole service approach. NVR presence was diminishing in Birmingham Creative ways of training staff Nicky re-joined the Birmingham team NVR presence re-ignited with increased support. The Proposal

Where we are now… 30 staff trained to a foundation level in collaboration with Partnership Projects. A consensus NVR is an approach that we can use at all levels; across 3 wards, therapeutically, operationally. Agreement that it is central to our clinical model and could be the framework for the Therapeutic Milieu.

Where next…. Plans to deliver NVR training to all staff To include NVR in the training offered to all new starters in the service Provision of weekly NVR supervision for inpatient teams To extend this to other services in Birmingham To make links with other services implementing NVR to support and offer training.

Thoughts for other services… How you implement is dependant on where your service is at. Factor in sustainability Failure is always feedback! Pace it; expect it to take years before there is a whole service shift in culture.

Questions?

“Its all been fantastic…I can’t wait to share with the rest of my team tomorrow! “Baskets is applicable to every aspect of ward life!” “I feel understanding parental presence and how vital it is to NVR has been the most useful, also that it is about how “you” respond not the response of the other. ” “Listening to the experience of a graduate parent was invaluable. ” “It’s all been extremely relevant, thoughtfully put together and sensitively delivered throughout. ” “It was all I hoped for…I think NVR can become an underpinning framework for the whole clinic. ”

Contact Details Jo : joanne. buchmuller@wales. nhs. uk Lydia: lydia. stafford@nhs. net Nicky: nicky. maund@nhs. net (further questions or interest in training)