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PROCESSPROduce Creative Effective Simple Solutions:Transforming Frontlines to Frontiers
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PROMISE is a paradigm of co-producing an alternative discourse inmental health care. A discourse that creates hope and agency andempowers patients to take the driving seat in moving towards life
beyond illness. A discourse that empowers staff to ‘re-innovate the wheel’and continuously improve on the small changes that make a big difference.A discourse in which patients and professionals can empower each otherto eliminate reliance on force across the entire recovery journey.
However, engaging staff and patients in scripting and enacting this newdiscourse is a fairly complex affair. Creating a change story to eliminatereliance on force when staff who resort to it firmly believe they are actingout of necessity and in the patient’s best interest can be disheartening,divisive and a tricky affair, to say the least. Once patients are at thereceiving end of such interventions they are usually extremely distressedand may be unable to draw on their inner resources. They too will struggleto see that there have been opportunities to influence the course of events.For both staff and patients a delicate balance needs to be struck betweensupport and challenge. Acknowledging staff sensitivities without diluting the
MANAAN KAR RAYSARAH RAEAIDAN THOMAS
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need to continuously push on the frontiers ofhumane care is not easy and does not fit neatly intoany conventional change model. Also, the existingmodels do not pave the way for patients to see howco-produced solutions will enable them to activelyshape the care they receive. For leadership ofother organisations who may have aspirationssimilar to ours we have tried to parcel our journeyinto bite size chunks. However, this is not meant tobe a road map, just a compass which hopefully willhelp navigate through some difficult terrain.
Envision: Insight to Ideas
Engaging hearts and minds in a dialogue ofappreciative enquiry and exploration is thefirst objective. Leadership’s ability to
empathise with the frontline will be mirrored byfrontline staff’s willingness to open themselves up tothe experiential journey of the patient. Co-producinga story that captivates the imagination of theworkforce is central to gaining the initiative.
The three key phases and theircomponents are:
Envision: Insight to Ideas
Enquire: what’s good and whatcould be better
Explore: the contradictions atthe heart of mental health
Empathy: help people imagine‘what might be’
Enable: Ingenuity to Innovation
Empower: create a culture ofpersonal responsibility
Exchange: celebrate innovationsby replicating
Evolve: re-innovation forcontinuous improvement
Enact: Initiative to Implementation
Execute: make it happen
Evaluate: critically analyse thejourney
Embed: culture of continuousimprovement
Envision involves enquiry and exploration withempathy.
Enquire: what’s good and what could bebetterExplore: the contradictions at the heart ofmental healthEmpathy: help people imagine ‘what mightbe’
Enquire: Every health care organisationhas areas of good practice they feel proudof. In fact every team, however stretchedthey might be, has something they do welland they would want to showcase aspositive and proactive. Valuing ‘the best ofwhat is’ is the key to unlocking ‘what mightbe.’ Showing genuine curiosity in whatworks and why can engage staff in adialogue that initiates the improvementjourney. This vital step of appreciatingwhat’s good in the present and engagingstaff in problem solving to eliminate relianceon force, helps avoids defensiveness. Stafftruly believe they work in the best interest ofpatients. These beliefs may stem from yearsof training or practice, from theorganisation’s ethos or from common-sensehuman responses to concerns about safety.If staff feel criticised, the leadership willhave to contend with beliefs like ‘we alreadydo this’ or ‘you have no idea what goes on’.If this happens, the leadership is likely torespond in a more forceful way, thusmodelling the exact behaviour and powerdynamics they are asking staff to eliminate.However, inquisitiveness about what’s goodcan break down the barriers and so easilylead to a conversation about how it could bebetter. It is our experience that if staff feelsupported and understood they are the firstones to recognise the room forimprovement. All improvements benefit bothpatients and staff.
Explore: There are fundamentalcontradictions at the heart of mental health:care and control; compassion andcontainment; risk and recovery. The
dilemmasposed arenot easy tonavigate orreconcile.AtPROMISEwe haverealisedthat to walk in each other’s shoes is perhapsthe principal way to gain insight into theexperiential journey of the other. However,when facing one’s own challenges, whetherit be experiencing distress as a patient orfeeling overworked as a staff member, it isdifficult to hear one’s inner voice or openoneself up to navigational guidance from theother. For staff to feel what patients aregoing through requires a reflective spacewith low stress levels. The same applies topatients who would otherwise struggle tosee beyond their overwhelming distress.There is a time and place for experientialexploration. When we get this right we findthat binary positions (e.g. being caring vscontrolling) fade and instead continuumsemerge. Either-Or replaces And. We beginto realise that these supposedcontradictions are two sides of the samecoin. One does not exist without the other:with the right care the patient will have morecontrol; without risk there is no recovery.
Empathy: On the PROMISE journey wefound the key ingredient of meaningfulenquiry and exploration to be empathy. Thisis the quality that often initiates a career inmental health. Sometimes, though, perhapsdue to overwhelming pressures in the job oryears of working with people who arestruggling to find hope, we may becomedesensitized to the distress or helplessnessa patient often experiences when at thereceiving end of a well-intended butcoercive act. There is no doubt that theability to empathise is always there, it isthere in every human being and more so inthose who are working in mental health.
Peers who have been on their ownrecovery journey are a valuable resourceand have the ability to hold a mirror up tostaff by sharing their own experience.Within PROMISE we realized that when theleadership makes a genuine effort to putthemselves in the shoes of frontline staff,the efforts are mirrored by those staff whoare then able to put themselves in thepatient’s shoes. This can open upeveryone’s imagination about whatchanges might be needed in order tocompletely eliminate reliance on force.
In PROMISE we found that appreciativeenquiry and empathic exploration allowdefences to break down, and staff who feelstuck in the reality of the present and theculture of the past can emerge energised intoa future full of possibilities. It is necessary toengage leadership at every level in a dialogueabout where we are, where we need to be andwhy we need to get there. Once the processhas begun, co-producing a story that capturesthe imagination of all staff is vital. Some willbe moved by emotion, others by logic andrationality. A tipping point comes and we haveto seize the initiative and encourageleadership at all levels to engage more fullywith colleagues and tell the story at everyopportunity. By creating the overarching visionof what success would look like we allow thestory to organically change without losing itsessence, thus creating ownership and buy-in.If this goes well the frontline will come forwardwith a bank of ideas to be capitalised on.
Enable: Ingenuity to Innovation
Atul Gawande spoke about ‘The Idea ofWellbeing’ in the 4th Reith Lecture 2014:
‘If no one cares when someone takes thetrouble to do things right, nothing changes.And the overwhelming message to the peoplewho work at the frontlines of care around theworld is that no one notices excellence and noone cares. That is the biggest source of
burnout and discouragement for health careworkers everywhere.’
Celebrating excellence is vital to keep staffenergised. The motivation for change cutsacross five domains: what’s in it for me; mypatient; my team; my organisation and mysociety. Research shows that staff motivationdifferentiates equally into these five groups(Scott Keller and Carolyn Aiken: TheInconvenient Truth About ChangeManagement). So if a change story can touchall five domains it can unleash tremendousenergy throughout an organisation. However,we have found that change works best whenfrontline staff craft their own ideas and fosterindividual talent. Positive changes occurnaturally as one taps into the collectiveconsciousness, intelligence and imagination ofthe workforce.
Enablement involves creating an empoweredenvironment in which staff can come up withingenious ideas and exchange continuouslyevolving innovations.
Empower: create a culture of personalresponsibilityExchange: celebrate innovations byreplicatingEvolve: re-innovation for continuousimprovement
Empower: Power to empower lies withinevery individual. An automatic by-productof empathic exploration is the willingness tobe open to the experiential journey of ‘theother’. This could be in a patient-staffconstruct or between a senior and juniorcolleague. When it goes right, the otherbecomes one with the self, both feelingempowered to work together to achievecommon goals. In a clinical context thisway of working enables patients to makerapid strides in their recovery journey,encouraging hope and agency togetherwith a strong sense of being wellsupported. In an organisational context itstarts to break down the barriers ofhierarchy and encourages leadership at all
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levels. If we encourage autonomyorganisationally we find that, rather thanwaiting for permission or decision-makingby committee, everyone is able to act in thebest interest of the patient and bring aboutthe changes we all seek. In complexhealthcare systems leadership often fearspotential chaos from such a degree ofautonomy but the reality is quite different.With freedom staff embrace responsibilitytoo: they not only act appropriately butalso think through risk at a much deeperlevel than if decision making happenselsewhere. The wisdom they bring offersfar more than any top-down riskassessment paperwork could achieve. Onthe PROMISE journey we have found thattrust in the power of human relationship isvital and puts the soul back into the art ofmental health care.
Exchange: It is essential to capture andcollate the ideas and innovations, thesuccesses and failures. This may be via avirtual exchange or in a physical format.Identifying barriers and reflecting on whatmight have been done differently is animportant part of the process. Organisingall the change initiatives into key themeswill allow for easy and rapid sharing andreplication. Ensuring that due credit isgiven to the innovator or innovating teamwill result in an ever-growing bank whichcontinues to push the frontiers. However, itis in the replication of success that the truebenefits lie. Acknowledgement ofexcellence comes when others adopt anidea, thus boosting the confidence of theinitiating individual or team. The self-beliefthis generates at the frontline is the key tocreating the pathfinders of tomorrow.
Evolve: Early adopters of an innovationcan refine an idea and adapt it to theirparticular service. This creates ownershipas what gets implemented is a re-innovation, a newer version. In the pursuitof excell-ence, knowing when and how toreinvent the wheel is the trick. The wheel’s
evolutionaryjourneydid notstart withpneumatictyres orcartwheels.From sliced up tree trunks to modern daywheels is a journey of continuousimprovement. This is a fundamentalconcept to grasp as there is always roomfor improvement, and when theseinnovations get synthesised into recoverypathways, patient benefits are immense.To support these new pathways, old rulesand policies will need to evolve. It is alsoimportant to acknowledge that someinnovations will lead to a dead end, but alearning organisation embraces these aswell to shape its future. With this approachthe roadmap will never be static. Staff andpatients working together will continuallyredefine the frontiers of humane care.Success breeds success and celebratingnew standards and the achievements ofthe pathfinders will result in ideas andinnovations springing from all sectors andlevels of the organisation. This will furtherbolster the culture of leadership at alllevels. There is a need to track the ideasas they rapidly develop and change duringreplication but it is important to resist thetemptation to do version control. The roleof leadership is to provide the support andframework within which evolution can takeplace. What works dictates which versionremains on the knowledge exchange asthe established path for the organisation.
The Enable phase empowers frontline staff tostep outside their traditional role, perhaps as anurse or a health care assistant on a ward.Once they can look afresh at the patientjourney many new ideas will emerge which, inthe right crucible, will soon become effectiveinnovations in practice.
Enact: Initiative to ImplementationThe proof of the pudding is in the eating. Fromimagination to insight, from ideas to innovation,there will be very limited benefits unlessappropriately implemented. Just because onehas a roadmap does not mean anyone isgoing to follow it. Any change, even if itoriginates bottom up rather than top down, isbound to generate some resistance from somepeople. If there is no challenge or scepticismperhaps the change is not a meaningful oneand not worth spending time and energy on. Itis important to remember that there will bevariation in the degree of reluctance toembrace any change. It is important, therefore,to expect and prepare for resistance and tokeep in mind staff sensitivities aboutestablished practice. It is crucial to suspendjudgement about the present, to harness anyresistance and transform it into propulsion forthe Enact phase.
Enact involves a continuous cycle of executionand evaluation along with external exposure toembed an improvement culture.
Execute: make it happenEvaluate: critically analyse the journeyEmbed: culture of continuousimprovement
Execution: Execution is the engine thatkeeps the cycle going. As the dominantculture creates the mind-set within whichstaff behave, without execution all theengagement will gradually fade intoinsignificance. To purposefully execute thevision of eliminating reliance on force,encouraging and engaging staff to come upwith ideas has to be followed up by theleadership removing barriers toimplementation of those ideas. This mightinvolve cutting through red tape, creativelyresourcing requirements or escalating anissue to the next level while continuouslyfeeding back to frontline staff what ishappening. If we still do not get results acourageous conversation is called for, with
someone asking why or why not? Whenan organisation creates a culture thatembraces fluently-flowing dialogue,irrespective of hierarchy, it gains a keyenabler for execution and emergence fromsituations where the change engine has gotstuck. In spite of the groundwork inenvision and enable phase, generatingproof of concept followed by a scale up toproof of feasibility has its challenges. Toovercome them, the PROMOTE(PROactive Modelling Of TherapeuticEnvironments) framework providespractical tools and guidance for ideageneration, development and innovationdeployment.
Evaluation: Fundamental to progress iscontinuous evaluation, whether it beestablishing baseline at the enquiry stage,measuring progress on the ground ortracking organically evolving innovations.Numbers tell the story we want to hear so itis important that organisations are ready todig deep and consider all versions ofreality. Quantitative evaluation, thoughhelpful, is not the main source informingour journey. Force is a continuum and itsuse in coercive practice is often originatesin genuine concern for the patient. Itstretches from the covert, subtle hints inconversation about what might happen if apatient does not take their medication tothe overt, physical intervention that may beneeded to maintain safety. In attempting toeliminate reliance on force figuring out who,what, where, when, why and how may beeven more important than incident figures.This does not mean flouting governance orthe statutory duty to provide incident data,rather that we dig deeper into the data tocontinuously learn and improve. We shouldbe able to pick up changes not just in howmany physical interventions take place, butwhat led to each intervention, how it wascarried out and what followed it, etc. Aspractice evolves we expect the evaluation
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and focus will shift from one parameter toanother, depending on where theorganisation is on their journey to createhumane services that do not rely on forcebut on positive, proactive care. Clear line ofsight from board to ward is essential toensure steady progress. However makingthe key performance indicators relevant atevery level, from individual patients andclinicians to entire health care systems ischallenging. PROGRESS (PROactiveGovernance of Recovery Settings andServices) provides a framework forintelligent selection of metrics, bringing themto life and making them meaningful at everystrata.
Embed: Holding the gains and evolving asrequired is essential to maintaining theinitiative. Repeated cycles of ‘Plan – Do –Study – Act’ will generate new standardswhich need incorporation into business asusual. The two key challenges tosustainability are initiative decay, wherethings slip back over time and that ofimprovement islands, where change in onearea does not spread elsewhere. Howeverwe do not want change that is absolute in itssustainability. A sustainable change todaycould become resistance to changetomorrow. Instead we want change that issustainable till a new idea comes along. Andthe way to expose oneself to a larger pool ofideas is to get out there and get it out there.All organisations involved in mental healthwill be some way along the journey to createhumane services. There is a lot ofknowledge and experience that we can allgain from and contribute to. The aspirationto create a new discourse is like building amassive, multi-dimensional jigsaw. We donot know where we will find the next piecethat will fit in, the answer might lie in a localcharity down the road or right across theglobe, where the parameters of care mightbe quite different. As we start to feel we aregetting somewhere with our jigsaw a newdimension will evolve which will take the
organisation and thecareprovided atthe frontlineonto adifferentplane.Developingand nurturing partnerships are therefore ofkey importance. A competitive stancebetween care organisations is pointless, thepower of the information age is such thatinnovations get rapidly replicated, so if onehas to compete, one should compete oncollaboration. Others will mirror onescollaborative stance and all can benefit fromsharing of successes. Exposing ourservices to external scrutiny and recognitionwill only improve them further. Exposure forour key pathfinders to potential partners willalso enrich their leadership journeys andcreate conduits through which knowledgeand wisdom will flow.
Cross-pollination is at the heart of adaptivemutations, otherwise known as innovations.New insights from organisations which havebeen on their own journey of self-discovery willprovide the new tools or concepts for furtherre-innovation and emergence onto a higherplane. PROMISE Global provides such aplatform so we can benefit from each other’ssuccesses. The principal objective of this globalalliance is how together we can expedite thetransformative journeys of the frontline of ourmental health organisations. The frontiers ofour organisations will no longer be a barrier tojointly redefining the frontiers of humane care.
Acknowledgement: PROCESS has beenenriched by the input of the entirePROMISE crew (over leaf). Special thanksto Sheena Mooney for copy writing.
Steering PROMISE
Manaan Kar RaySarah RaeZahoor SyedJudy DeanCeri WilsonLorna RouseSarah RussellIliana RokkouEmma GreenTerry HillSep HafiziJorge ZimbronStephen PaulAnne Markwick
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 in ourservices which set aside patientsfrom staff. Sandwiches in thecafeteria for patients in plainpackaging and for staff in attractivecommercial packaging, separatestaff and patient toilets, patientshaving to seek permission for thesimplest of tasks which staff don’thave to. Some are tangible andsome less so. Either way thesesymbols create and reinforce aculture of them and us.
Terry Hill, a recent appointment onMulberry 3 in the role of interimward manager came in with fresheyes on to the ward. Newcomersare often able to spot custom andpractice that is out dated. Forexample on this ward medicationhad always been dispensed acrossa hatch. The clinic room door splitslike a stable door, the nurse wouldstand inside with the medicationtrolley and patients were obliged toqueue up outside. Terry came fromMulberry 2 where they had made
changes to how medication wasdispensed. Being very aware tohow medication time can be asource of conflict Terry proposed asimple but powerful change thataddressed all the power dynamics,the dignity and confidentialityissues and the boundaries of themand us. ‘Ditch the hatch and invitepatients into the clinic room to taketheir medication.’ This creates ashared private space for anydialogue around medicationwithout the worry of others overhearing or pressure to quicklycomply to keep the queue moving.
We are all guilty of not questioningpractice that are prevalent in ourown teams as they are theestablished norm. A fresh pair ofeyes or perhaps even a fresh lookby us can pick up these symbolswhich if we address we can sendout a message loud and clear thatwe are on the same side, workingtogether on the recovery journey.
INSIGHT
IMAGINATION
INNOVATION
Parity
Promoter
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Overview: PROCESS (Envision - Enable - Enact) underpins thePROMISE PORTFOLIO. The portfolio comprises of key insights, bottomup ideas, innovations, implements and indices to track progress. It is aframework to transform the nature of day to day interactions at thefrontline. Celebrating the best of what is, learning from our successesand knowing when and how to reinvent the wheel is central to thejourney. Within Cambridgeshire and Peterborough NHS FoundationTrust, this engagement process has encouraged many pathfinders topush the boundaries of humane care. Our pathways continue todevelop through the partnerships we are building regionally andglobally and we hope that through these alliances, our folio willcontinue to grow and be instrumental in laying the foundation of analternative discourse in mental health care.
