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Keywords:

  • mental health;
  • families;
  • carers;
  • older people;
  • staff training;
  • in-patient

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Needs of families and carers
  5. Training programme for staff in in-patient services for older people in Somerset
  6. Introducing a systemic approach
  7. Reflections on the training programme
  8. Family liaison service
  9. Conclusions
  10. References

In spite of policies advocating the involvement of families in the care of mental health service users in the UK, there are few examples of initiatives to develop staff confidence and skills in partnership working. This article describes a whole team training initiative and family liaison service to promote family inclusive working on in-patient wards for older people in Somerset, UK. A three-day staff-training programme is described and training outcomes are reported. Staff report a substantial increase in confidence and family meetings held. A pre-and post- training case note audit shows increased consideration of the needs of families. To further increase face to face meetings with families a family liaison service has been established, whereby a staff member with systemic family therapy training joins ward staff to hold family meetings as part of the assessment/admission process. Evaluation of this service has shown it to be effective with positive feedback from families and staff.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Needs of families and carers
  5. Training programme for staff in in-patient services for older people in Somerset
  6. Introducing a systemic approach
  7. Reflections on the training programme
  8. Family liaison service
  9. Conclusions
  10. References

Recognition of the needs of family members and carers of people who suffer mental health problems has received increasing emphasis in UK mental health policy and guidance over recent years. This is particularly true in relation to services for older people, where the need to work in partnership with families and carers has been well documented (Department of Health [DoH], 2009, 2006). Carers' rights to a needs assessment of their own, together with a written care plan, was established in the Carers' Act of 1995 and reaffirmed in the National Service Framework for Older People (DoH, 2001). Further policy guidance including Developing Services for Families and Carers of People with Mental Illness (DoH, 2002), Everybody's Business (DoH and Care Services Improvement Partnership, 2005) and the National Institute for Health and Clinical Excellence Guidelines for Dementia (DoH, 2006) have outlined how services for families and carers should develop. However, the Health Service Ombudsman (Abraham, 2011) and charitable organizations such as the Princess Royal Trust for Carers (Warner and Wexler, 1998) and the Alzheimer's Society (2009) have emphasized that further progress is required in involving families in their relatives' care. Joint working between NHS and charitable organizations has recently led to development of ‘The Triangle of Care’, a guide to best practice (Worthington and Rooney, 2010). We would argue that staff require further training to develop the skills and confidence to work in partnership with families and carers (Stanbridge and Burbach, 2004; Burbach and Stanbridge, 2008).

Needs of families and carers

  1. Top of page
  2. Abstract
  3. Introduction
  4. Needs of families and carers
  5. Training programme for staff in in-patient services for older people in Somerset
  6. Introducing a systemic approach
  7. Reflections on the training programme
  8. Family liaison service
  9. Conclusions
  10. References

UK national policy has been developed in the context of feedback from families and carers that their ‘involvement in care is not adequately recognised and their expert knowledge of the “well person” is not taken into account’ (Worthington and Rooney, 2010: 5). The stressful nature of providing care has received increasing acknowledgement, although caring for vulnerable older people can be simultaneously positive (rewarding) as well as negative (Lopez et al., 2005; Robertson et al., 2007). Carers, however, are much more likely to experience mental and physical health problems than the average population and caring can have an adverse effect on work, social activity and leisure, health and finances (Brodaty and Hadzi-Pavlovic,1990: Coe and Van Houtven, 2009; Cuipers, 2005; Liu and Gallagher-Thompson, 2009; Pinquart and Sorensen, 2003; Schulz and Martire, 2004; Simpson and Benn, 2007; Singleton et al., 2002).

Research studies (for example, Exel et al., 2008 Leavey et al., 1997; Pinfold et al., 2004; Shepherd et al., 1994), and carers' organizations (Age Concern, 2007; Alzheimer's Society, 2009; Rethink/National Institute for Mental Health in England/West Midlands Carers in Partnership, 2003) have recommended ways in which mental health services can more effectively meet the needs of informal carers and families. What families would like from services includes being listened to and being involved in planning their relative's care and emotional and practical support, including respite care. In addition, they require information about diagnosis, treatment, services, benefits and whom to contact in an emergency. They also ask for advice on ways to respond to their relative and express a wish to develop additional coping skills.

However, most mental health professionals in the UK still complete their pre-registration training without specific skills training in working with families (Stacey and Rayner, 2008). This leaves staff lacking in confidence and ill-equipped to engage with families on the routine basis envisaged by national policy. In order to achieve effective partnership working comprehensive staff training programmes will be required.

Staff training programmes in in-patient services for older people

An extensive literature search revealed there were no training programmes specifically designed to develop the skills of working with families for staff working in older people's in-patient units. However, in the state of Victoria, Australia, the extensive ‘Get together FaST’ training programme in family-sensitive practice (Farhall, 2000) included an ‘aged stream’ alongside adult and Child and Adolescent Mental Health Services staff. This stream of 184 staff included some in-patient staff (17%) alongside staff from psycho-geriatric assessment and nursing home teams. This training was widely valued by staff and managers and led to some service improvements, together with increased awareness in staff, who regarded families as less difficult to engage than before training. However, it is interesting to note that the training did not lead to an increase in face-to-face contact between staff and families.

Training programme for staff in in-patient services for older people in Somerset

  1. Top of page
  2. Abstract
  3. Introduction
  4. Needs of families and carers
  5. Training programme for staff in in-patient services for older people in Somerset
  6. Introducing a systemic approach
  7. Reflections on the training programme
  8. Family liaison service
  9. Conclusions
  10. References

This staff training programme forms part of a trust-wide initiative that started in 2000. Following extensive consultation with a range of colleagues, service users and their families, we developed a strategy to enhance working partnerships with carers and families, which was adopted by the Trust Board in December 2002 and updated in 2010 (Stanbridge and Burbach, 2004). This led to the development of a carers and families steering group and a trust-wide training programme (for further details see Stanbridge and Burbach, 2007a).

Staff training programme

Following awareness-raising sessions throughout the trust we have developed a three-day training programme in family inclusive ways of working which we are delivering throughout the mental health trust by means of a whole-team training approach, beginning with the acute in-patient wards (Stanbridge et al., 2009). On completion of the training package in the five acute adult in-patient wards in the Somerset Partnership NHS Foundation Trust, the training was piloted on an in-patient ward for older people.

Pilot in services for older people

The pilot consisted of days one and two of the training package detailed in Table 1. A combination of professionally registered and non-professionally registered staff attended the 2 days. A staff survey completed on day 1 showed that most staff (93%; 27/29) had not received any formal training in working with families and would welcome further training. Few staff (28%; 8/29) recorded that they felt confident about their skills in working with families (a rating of 4 or 5 on a five-point scale) with a mean score of 2.93. An evaluation of the 2-day pilot found that the teaching methods had been appropriate for most staff (86%; 24/28, rating 4 or 5 on a five-point scale), with a mean rating of 4.3. All staff said that the material was appropriate to their needs and most staff (93%; 26/28 scoring either a 4 or 5) said they would recommend the course to colleagues, with a mean rating of 4.4.

Table 1. Three-day in-patient training programme
Day One
Carer's story and discussion.
Research findings on family/carer views on mental health services and review of literature on caregiver burden.
Introduction to national policy and Trust strategy for partnership working with families and carers, including exercises discussing current practice and personal/organizational obstacles.
Focus on information sharing and confidentiality using best practice guidelines and case examples.
Day Two
Introduction to systemic thinking and interaction cycles (including case scenarios).
Presentation by the carers assessment worker: assessments and resources for carers and electronic patient records demonstration.
The initial family meeting (introduce format and role-play).
Development of a ward action plan.
Day Three
Discussion of team progress and implementation of action plan.
Constructing a genogram (family tree).
The needs of children, including young carers video.
Clinical discussion with examples from the group.
Evaluation of the training

A combination of experience from the acute adult in-patient staff training (Stanbridge et al., 2009) together with this 2-day pilot study, led to the development of a 3-day training package for the remaining older people's wards. The structure of the package of training was similar to the acute adult wards, but the content was adapted to reflect the focus on older people.

The 3-day training programme was subsequently delivered on the two remaining older people's wards in the Trust. From an establishment of fifty-three staff from the two wards, 16 who were professionally registered and 22 who were not-professionally registered, representing 72 per cent (38/53) overall, attended days 1 and 2 of the training and 14 professionally registered and 19 who were not-professionally registered, representing 62 per cent (33/53) overall attended day 3. In all 58 per cent (31/53) of staff attended all 3 days; of those, 14 were professionally registered and 17 were not-professionally registered.

Team training on in-patient wards for older people

In order for staff to attend without closing the wards, the training was run twice on each unit with, where possible, half of the staff attending each time. Days 1 and 2 were provided consecutively to each group with day 3 taking place after a planned gap of a minimum of 1 month. The training took place on the first ward between April and June 2008 and on the second ward between July 2008 and March 2009. In order to involve as many staff as possible, day 3 was offered to staff on the second ward three times. A combination of staff attended the training, including both nursing staff who were professionally registered and those who were not professionally registered, together with ward and deputy ward managers and an activity organizer. The involvement of managers was significant, both in supporting the process and in operationalizing the action plans developed during the training.

Training approach

The training was provided by four of the authors who are all qualified systemic psychotherapists with a range of experience, including one author who had specialized in work with older people and another with many years of caring for a relative with dementia. The 3-day training package has been specifically designed to address staff attitudes, which has also been raised in other studies, for example, Kim and Salyers, (2008). Whereas some staff welcome the shift to more family-oriented services, it is still the case that others feel vulnerable in the face of emotionally distressed relatives and defensive in the face of possible criticism (Walker and Dewar, 2001). Some staff may not appreciate the disempowerment felt by families when their relative is admitted to a psychiatric hospital or the stresses involved in caring. There is thus a need to discuss with staff members the benefits of involving families and carers and to explore their attitudes and beliefs in relation to this. In this we have noticed some ‘cultural’ differences between adult and older people's wards. Whereas our experience in adult services is that staff do not have a history of routinely making contact with families, staff in older people's wards tend to describe contact, although not in formal meetings, with families as a regular and expected part of their work. We have found that involving carers in the provision of training is an effective way of addressing the required shift in attitudes (Stanbridge and Burbach, 2007b).

Each of our training courses starts with a family member telling their story. We encourage people to talk about both good and bad experiences of services but specifically ask them to comment on events leading up to contact with services, such as their first experiences and impressions of the services and in-patient unit; their subsequent impressions and experiences; whether they felt included by staff; the quality of their communication with staff and any recommendations they might have. This is followed by a discussion of the research findings into families and carers views on mental health services and the literature relating to caregiver ‘burden’. The training also focuses on helping staff extend their commonly held client-centred values and therapeutic skills to working with families. The qualities of empathy, warmth, genuineness and a non-judgemental approach also make up the therapeutic stance required to develop collaborative working partnerships with families and carers. In addition, the training explores the challenging practical and theoretical implications involved in making services truly family and carer friendly. We have found that a useful exercise is to ask staff to consider (individually and in groups) what personal and organizational obstacles stand in the way of family-inclusive practice (Kaas et al., 2003). This allows the trainers to empathize with their difficulties and then facilitate the group to find solutions. In addition, the course specifically addresses the subtleties concerning confidentiality and information-sharing, as this is often raised as an impediment to working in partnership with families (Clarke, 2004).

The three-day training includes a combination of brief didactic presentations and group exercises (see Table 1 for content of in-patient training programme). Although a focus on attitudes is necessary, it is not in itself sufficient for behavioural change, and we therefore emphasise the development of team action plans (which are followed up on day three) together with some skills training. The afternoon on day two is largely devoted to an extended role-play of an initial meeting with a family. We encourage all staff to take turns in interviewing the role-play family, using an agreed format and with intensive support from the trainers (see Table 2 for meeting format). In addition, we introduce other techniques such as genograms (family tree) and caregiving genograms (Zarit, J., 2009). Learning outcomes for the training are reported in Stanbridge et al. 2009.

Table 2. Initial family liaison meeting
Aims
To create a rapport with the family.
To identify and value the role of the family, and to encourage the maintenance of family relationships.
To create a platform for future collaboration (3-way partnership); including discussions around confidentiality and issues of risk.
To develop a shared understanding/aims.
To understand the context of the individual's problems.
To provide information on services, support networks (including carers' assessment) and services.
Content
Contact details; small talk (for example, did you have to take time off work; occupations); rationale for meeting (working together; value family's expertise/knowledge); who is in the household/ family/friends? Plan for session.
Who is in the family/social network and nature of their relationships/ involvement? Is there any history of mental health problems in the family?
Family's account of development of client's problems:
Initial onset of problems (what, when, triggers)
How did family members respond (what helped/didn't help)
Experience of (accessing) services
Who else has been involved
How have things developed
How have they made sense of what has happened
Information on client's interests and activities
Impact of the problem on the family/family members.
Expectations regarding treatment, including family's goals.
Family members' attitudes to working collaboratively:
Discussion around confidentiality and information sharing
Families views on any risk issues
Involvement in care planning process
Provide information about support and practical help for carers including the offer of carer registration and a carer's assessment.

Introducing a systemic approach

  1. Top of page
  2. Abstract
  3. Introduction
  4. Needs of families and carers
  5. Training programme for staff in in-patient services for older people in Somerset
  6. Introducing a systemic approach
  7. Reflections on the training programme
  8. Family liaison service
  9. Conclusions
  10. References

The aim of our training strategy is not to train large numbers of staff to be family therapists, but rather to increase awareness of the needs of carers and families and to create more family-sensitive mainstream services. However, organizations also need to support the training of a smaller number of qualified systemic family psychotherapists in order to meet more complex and specialist needs. We have found that this group is also well placed to provide the training described in this programme.

Systemic thinking and practice, however, does inform the training package. For example, on the second day the group is introduced to systemic thinking and invited to consider relationships in families in a circular rather than a linear way. There is a range of systemic ideas which are relevant to working with families and older people (Curtis and Dixon, 2005; Fredman, 2010; Richardson, 1997) and there are benefits to teaching these to teams working with older people with mental health problems (Anderson and Ekdawi, 2010; Dixon and Curtis, 2005). In our training programme we have found the mapping of interactional cycles, which consider both beliefs and behaviour, to be particularly helpful. This provides a non-blaming way of looking at the patterns that occur in families and which may maintain problems (see also Charlesworth, 2006). These mutual feedback cycles can be used to illustrate how problems can become more entrenched or increase in severity. For example, in Figure 1, the clients' sister construes her assertions as ‘nonsense’ and, ‘believing that she needs to be put back in touch with reality’, confronts and corrects her. The client perceives this behaviour as an affront, feels defensive and restates her position more firmly. In the face of challenges and corrections from significant others, people with memory difficulties who confabulate from time to time may begin to cling on to these beliefs more and more strongly and may eventually express grandiose fabrications.

figure

Figure 1. Interactional cycle: confabulation.

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In the training we explore both helpful and unhelpful patterns of interaction between carers and the cared for. For example, reciprocal warmth may lead to positive reactions and a decrease in carer burden (Reid et al., 2005). However, relationships may also become increasingly fraught and abusive (Cooper et al., 2010). Research has highlighted the significance of the quality of the prior relationship (Chesla et al., 1994; Lopez et al., 2005) and the subjective appraisal of care giving (Lawton et al., 1991). This research can be elaborated and illustrated by means of our cognitive interactional format. For example, carers who feel that they cannot cope and are resentful of the burden of care may become increasingly anxious, depressed and angry. This may relate to factors such as the current behaviour of the cared-for relative and the current restriction in the carers' activity (Williamson et al., 1998), as well as the nature of their prior relationship or attachment style (Browne and Shlosberg, 2006). This may become associated with escalating levels of abusive behaviour and neglect. Cared-for relatives may recognise they have become a burden, feel increasingly fearful and abandoned, and consequently become depressed and withdrawn. The problems associated with dementia may therefore become exacerbated, leading to the carer feeling more overwhelmed, hopeless and angry (see Figure 2).

figure

Figure 2. Interactional cycle: elder abuse.

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We have also found this perspective useful in the supervision process as a way of considering the patterns that can develop between staff and families/their clients (see Figure 3). If concerned carers feel that their relative's clinical presentation is deteriorating and perceives the busy staff member as not caring they will, understandably, complain about or challenge aspects of the care provided. Such behaviour may be construed by the staff member/s concerned as unreasonable (‘another difficult relative who doesn't understand’). Such beliefs lead to more defensive and distancing behaviour (Walker and Dewar, 2001) which in turn will reinforce the family members' perception that the staff are cold and uncaring. With their focus on each person's beliefs and behaviour, cognitive-interactional cycles provide a way of understanding each person's position, reducing blame and increasing tolerance. Considering interactions in this way offers the opportunity for reflection on whether the patterns are helpful or unhelpful and what might be done differently.

figure

Figure 3. Interactional cycle: older people's ward.

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Evaluation of training

The effectiveness of the training programme was evaluated in a number of direct and indirect ways, as discussed below.

1 Pre-training and post-training case note audit

We conducted an audit to examine the current practice of in-patient unit staff in recording information on seven specific areas relating to their work with carers and families. The first audit was undertaken immediately before the first 2-day element of the training and was repeated prior to the third day of follow-up training. It was then repeated 1-year post-training. In each case 10 current electronic case records were randomly selected by the Trust's audit department, representing 40 per cent (20/50) of overall case notes. The objective was to identify any changes in practice relating to working with families and carers since the initial two-day training (see Table 3).

Table 3. Overview of two older people in-patient ward audits pre-training and post-training (per cent)
 Pre-trainingPost-training1 year
Carer registered on electronic patient record?254545
Family or friends recorded in ‘Contacts’ on electronic patient record?8010095
Reference in care programme approach to carer needs, roles or contribution to care (including: family history, support network, carer's views)?659585
Carer involvement in relapse prevention plan?12.537.560
Any carer responsibility for issues identified as problems in the care plan?352525
Referral for carer's assessment?103025
Carer need identified in progress notes in electronic patient record?858595

This table reflects an improvement in the majority of the items audited: significant improvements were noted in the number of carers registered and the number of carers' assessments. In addition, it is evident there was considerably more carer involvement in the relapse prevention planning. The one-year follow-up audit demonstrated that the improvements since the initial pre- training audit were largely maintained.

2 Staff survey

A survey was undertaken at the outset of the training on day one to gain baseline knowledge of staff training, experience and confidence in working with families. Most of the staff (89%; 34/38) reported that they had not received any training in working with families. A few of the staff (11%; 4/38) had some experience of working with families, ranging from a Thorn course to experience gained in a family therapy clinic during their professional training. Few staff (16%; 6/38) rated themselves ‘confident’ (rating of 4 or 5 on the five-point rating scale) in their skills in working with families and most of the staff (97%; 37/38) said they would like further training in this area. The survey also asked staff the number of times they had sat in a room with a family to discuss issues in the previous month. The survey was repeated for all staff attending the third day of follow-up training. Confidence in working with families had increased – those rating themselves as confident increased from 16 per cent (6/38) to 55 per cent (18/33) and the mean rating increased from 2.7 (range 1–5) to 3.5 (range 2–4) post-training. There was a substantial rise in the number of professionally registered staff rating themselves as confident (from 25%; 4/16 to 79%; 11/14) and this was reflected in the reporting of the more than doubling of meetings with families (mean number of meetings held prior to training 3.2, post-training 7.4). However, this did not occur amongst the staff who were not professionally registered. While the number of staff who were not professionally registered rating themselves as confident increased from 9 per cent (2/22) to 37 per cent (7/19), their participation in meetings held with families was largely unchanged (pre-training mean 2.5, post-training mean 2.3).

A comparison of the staff surveys from each ward highlighted some interesting similarities and differences. Although the mean rating given by staff relating to their experience of working with families was similar on each ward (3.4 and 3.6 for professionally registered staff; 2.4 and 2.7 for non-professionally registered staff), four members of staff reported having had previous formal training in working with families on the second ward. This may be reflected in the differences noted for the number of meetings held with family members reported by professionally registered staff prior to the training package (mean score of 2.9 compared with a mean score of 3.4 on the ward where some staff had received prior training). There was a noticeable rise in the number of meetings held by professionally registered staff following the training on both wards, although this was more substantial on the second ward (the mean number of meetings held on ward one rose from 2.9 to 5.9 and on the second it rose from 3.4 to 9.3). In addition, there was an increase in the involvement of staff who were not professionally registered in family meetings on the second ward (pre 3.2; post 3.4), but a decline in their involvement in meetings held on ward one (pre 1.4; post 0.9). Lastly, the mean score relating to the self-reported level of skill and confidence in working with families of members of staff was very alike in both wards both before and following training (professionally registered staff mean scores increased from 3 to 3.8 and 3.1 to 3.8; similarly, the means of those who were not professionally registered increased from 2.6 to 3.3 and 2.5 to 3.2).

3 Action plans

At the end of day 2 the staff were asked to develop an action plan to take back to their wards from ideas that had been generated through the training. The following items were identified:

  1. To include more information for carers in the ward welcome and admission pack.
  2. To allow more protected time to meet with families and develop a ‘meet and greet’ policy for families and carers visiting units.
  3. To make contact with the family, where possible, within 48 hours of the patient's admission.
  4. To arrange family meetings within 7 days of admission and to include this on the admission checklist.
  5. To liaise and make links with the carers' assessment workers.
  6. To improve communication between the different ward, community and care home teams.
  7. To develop and identify a unit ‘family/carer champion’ and family liaison role.
  8. To increase the registration of families/carers on the electronic record system and, where appropriate, refer for a formal carers' assessment.

The action plans were reviewed on day 3 and it was evident that progress had been made on both wards. The staff reported that more families and carers were being asked about registering their details on the electronic patient record (EPR) and more carers' assessments were being offered. On both wards they reported that there had been an increase in contact with families and carers. On one ward this has been achieved through telephoning families and carers following admission. On the other ward it was discovered that most families and carers visited the ward on a Sunday, the day on which the drug-ordering schedule was completed, resulting in fewer staff being available. By the third day of the training, the day for ordering had been changed, thus enabling more staff to meet families and carers. Similarly, information following meetings with families was being recorded on the EPR and both wards had identified a member of staff to act as the unit champion. However, progress was more limited with regard to conducting family meetings within 7 days of admission. Relatively few meetings had been held, reportedly due to staffing levels and shift patterns. Within a busy ward schedule the staff felt that protected time was needed in order to allow family meetings to take place. Although this could not be addressed immediately, the other action plan items were receiving active support from the ward and service managers.

4 Evaluation of the training package

The staff completed an evaluation form at the end of the second and third training days. The teams rated highly the usefulness of the course (mean of 4.3 on a five-point scale) together with the appropriateness of its content and teaching methods. Common themes from the free-text comments were a reported raised awareness of carers' needs, the importance of involving them in the clients' care and an increase in confidence when working with families and carers.

Reflections on the training programme

  1. Top of page
  2. Abstract
  3. Introduction
  4. Needs of families and carers
  5. Training programme for staff in in-patient services for older people in Somerset
  6. Introducing a systemic approach
  7. Reflections on the training programme
  8. Family liaison service
  9. Conclusions
  10. References

We have had extremely positive feedback both from within the organization from staff and management, and from representatives of carer organizations. Although the evaluation of the project might be criticized on a number of grounds – for example parts of the survey might have been affected by a reliance on memory and the audit sampled only 40 per cent (20/50) of in-patient case notes, we are encouraged to note that the measures all reflect the same trend to more family-inclusive ways of working. The older people's staff training programme achieved the learning outcomes of increased awareness and the development of basic skills, and produced a shift in attitudes in both staff who were professionally registered and those who were not. The case record audit indicated a significant change in staff practice, highlighting substantial improvements in most areas following the training. The increase in the number of carers registered, family information recorded under the care programme approach and the referral of families for carers' assessments indicated that the staff were routinely holding families and carers in mind.

Similarly, the training had a positive impact on the confidence of both staff who were professionally registered and those who were not, as evidenced in the staff survey and comments made in the open-ended evaluation. While an increase in confidence was noted in all staff, a more visible development was apparent in professionally registered staff, which was further reflected in the number of face-to-face meetings held with families following the training. Interestingly, on one ward where four of the staff had received previous training in working with families, all staff were involved in more meetings with families, both prior to and following the training, compared to the other ward where no previous training had been received. This could imply that where staff had received training in family ways of working, these practices were already being disseminated to other ward staff, encouraging a more family-inclusive culture on the ward and reinforcing the link between training and increased contact with families (Kaas et al., 2003; Kim and Salyers, 2008).

The team action plans demonstrated a commitment from ward staff to implement and maintain the skills and knowledge gained during the training. This was confirmed on the third-day of follow-up where progress in a number of areas had been made, including changes in ward procedures that had enabled an increase in the face-to-face and telephone contact with families and carers. A combination of the training and the subsequent action plans meant that the personal and organizational obstacles to family-inclusive practice identified by staff in the exercise on the first day of training (see Table 4) were successfully addressed or bought to the attention of the ward managers.

Table 4. Personal and organizational obstacles
Personal
Lack of experience, training, knowledge and confidence
Concerns about family expectations and dynamics
Concerns surrounding information-sharing and confidentiality
Untrained staff raised questions surrounding the boundaries of their role
Organizational
Lack of time, appropriate meeting place and resources
Staff shift patterns and the pressure of the workload

Training into practice

Although there have been positive changes in practice following the training we are aware that further progress will require ongoing training, consultation and organizational initiatives. To bring about more regular family meetings is a particular challenge. We are approaching this in a number of ways. Following consultation within the Trust we have established best practice guidelines (available from the first author) that specify that families should be involved in the assessment process and a family meeting held within 7 days of admission. We have also developed the role of ward champions to promote family-inclusive working and have appointed a family liaison specialist (Carter, 2011) to support staff in carrying out family assessments in all our wards for older people.

Family liaison service

  1. Top of page
  2. Abstract
  3. Introduction
  4. Needs of families and carers
  5. Training programme for staff in in-patient services for older people in Somerset
  6. Introducing a systemic approach
  7. Reflections on the training programme
  8. Family liaison service
  9. Conclusions
  10. References

Although the training programme has resulted in positive changes in staff confidence, clinical practice and more families being seen, it did not lead to all families being routinely involved in the assessment process. In order to address this we have developed a family liaison service and established a family liaison specialist post to work alongside ward staff to hold meetings with families and carers as part of the admission process. This post provides 1 day a week to each of the three older people's wards. By providing extra time from a member of staff who has a systemic family therapy training and experience of working with families to work alongside in-patient staff it was hoped that more family meetings could be held within 7 days of a patient's admission. It was also hoped that this would increase the confidence and skills of staff in working more closely with families.

The family liaison service was initially piloted on one of the acute adult in-patient wards and resulted in a significant increase in face-to-face meetings between staff and families (Carter, 2011; Stanbridge et al., 2009). It has now been successfully implemented on four acute and three older people's wards with the provision of 1 day a week of specialist time on each ward. Feedback from families attending meetings has been very positive (Gore and Stanbridge, 2011) and semi-structured interviews with staff also report their positive experience of meetings (Rapsey and Stanbridge, 2009). For a full description of the family liaison service and an evaluation of its implementation on all adult and older people's psychiatric wards in Somerset see Stanbridge (2011).

The service has now been operating on two older people's wards for 12 months, with encouraging results. On one ward, out of sixty-two admissions over 12 months, 79 per cent (49/62) of families were offered a meeting. This figure rises to 89 per cent (49/55) when admissions where there was no family available are excluded. Thirty-five meetings were held representing 63 per cent (35/55) of admissions where a family was available.

On the second ward, out of 141 admissions over the 12 months, 65 per cent (92/ 141) of families were offered a meeting, rising to 71 per cent (92/129) when admissions where there was no family available are excluded. Seventy-one meetings were held representing 55 per cent (71/129) of admissions where a family was available. For case examples and discussion of family liaison meetings in both adult and older people's services see Leftwich et al. (2011).

Meetings were not always possible within the goal of 7 days; however, seventy-nine per cent of meetings were held within 14 days of a patient's admission. In most (61%) of these meetings the family liaison worker was joined by another member of staff, including nursing, occupational therapy and medical staff. The goal of holding a meeting within 7 days of a patient's admission is now an established part of the care pathway. It has been included in the admission checklist and is auditable by means of a specifically created screen in the EPR.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Needs of families and carers
  5. Training programme for staff in in-patient services for older people in Somerset
  6. Introducing a systemic approach
  7. Reflections on the training programme
  8. Family liaison service
  9. Conclusions
  10. References

Our training programme and family liaison service have led to staff having more direct involvement with families and carers and developing a greater appreciation of their needs. By working more collaboratively with families staff make it possible for families to receive both practical and emotional support together with the information they require in order to cope effectively.

For most families routine involvement in the initial assessment and admission process can form the basis for a successful ongoing three-way partnership between service users, families and professionals. However, some families may also benefit from more focused family-based approaches involving problem-solving or systemic interventions, in particular in order to access appropriate support systems and where family dynamics have become problematic (Richardson, 1997; Zarit, S.H., 2009).

We have found that the combination of staff training together with a new family liaison service initiative has successfully enabled increased partnership working. There have been a number of key elements in this process. Providing training to the whole team has been important in facilitating the development of a family-inclusive team culture. The involvement of family members and carers in providing the training has positively affected staff attitudes and has ensured that the experience of the family remains central to the training. Our experience has been that follow-up initiatives in the form of action plans, audits, top-up training, supervision and consultation, and the availability of specialist family therapy and carers assessment services have also been essential. In addition, the introduction of systemic ideas, including interactional cycles, has been helpful in providing teams with frameworks for understanding and supervision.

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  2. Abstract
  3. Introduction
  4. Needs of families and carers
  5. Training programme for staff in in-patient services for older people in Somerset
  6. Introducing a systemic approach
  7. Reflections on the training programme
  8. Family liaison service
  9. Conclusions
  10. References
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