Theme Summaries

Reviewing and summarising each transcript led to the identification

of key themes in the data from Lawrence ward (outlined in the

methodology section). Keywords identified from the interview summaries contributed to minor themes that have been collapsed into the thematic categories below. A brief summary of these themes is outlined.

4.1.7.1 Lawrence Ward Decision Making Process

Decisions were identified as taking place in team forums such as ward round, handover, and informal office discussions. Decisions tend to be made physically and structurally away from the service user and those who are described as close to the service user, families and health care assistants (due to the time spent with patients). Decisions were made by the multidisciplinary team and led by the Consultant. Possible options were discussed between staff in the office and

attempts are made to seek service users’ views. However, barriers are

described as to why this is difficult, in particular resources. The consultant was recognised as holding ultimate decision making power.

There’s an escalation process for decisions structured by the level of

risk a person is perceived to present. Decision making individually or shared with each other is acceptable or desirable for the nursing staff where the level of risk is not perceived as significant. Where risks are larger, decisions are deferred to medical staff. This position is reinforced by structural arrangements; for example a consultant decides on discharge, section leave has to be agreed by medical staff. Amongst nursing staff there was some frustration at the power of the consultant but also acknowledgment of the benefits of someone else taking ultimate responsibility, especially if things go wrong.

148 Risk

Risk was discussed by all participants and identified as an influence on decision making. Risk was defined as being the behaviour of service users, either in terms of aggression and violence or self-harm,

suicide and vulnerability. Participants’ relationship with service users

impacted on how risk was perceived, knowing the person well was identified as enabling some practitioners to support positive risk taking. Their own experience and values was also identified to impact on assessment and management of risk.

Risk was outlined as the factor which governed whether someone would be admitted or discharged from the ward and a significant influence on decision making. Level of observation was associated with risk, the higher the risk the more frequent the observations. Some suggested that it was easier to increase rather than reduce the level of observations which is reflected in ward policy for this intervention. Medication was a key response to risk through level or requirement for psychiatric drugs.

Blame

Blame is discussed by all the participants in Lawrence ward. Cautious decision-making in relation to risks was associated with avoidance of being blamed (for example people staying on section until a tribunal removes them). Awareness of coroners court was present in the context of decision making, with participants identifying a fear of being exposed to this and blamed for a serious event (such as death) happening. Four out of the six participants interviewed had been

involved in attending coroner’s court or involved in internal

investigations following incidents. Participants identified that their employing organisation may point the finger of blame towards them but that professional bodies and families may also hold them to account. The consultant interviewed suggested that responsibility is falsely shared with the organisation until things go wrong when the

149 responsibility for decision making to doctors as they identified this afforded some protection from blame.

Relationships

Nurses were able to discuss service users’ views in one to one

sessions. This was viewed as an opportunity to represent these views in decision making forums such as ward round which was supported by the recent introduction of the patients ward round sheet. Two nurses identified that their relationship and knowledge of an individual service user enabled them to feel more confident in their decision, particularly where this may involve for example time off the ward. It was highlighted that on the shifts observed that there was a limited time spent between the nurses and service users.

Dilemmas

Dilemmas were acknowledged as frequently occurring in mental health practice. There were a number of areas where a lack of consensus or difficulty associated with making a decision were narrated or observed. These included differences in perceptions about the risk a person poses in using the Mental Health Act, reducing levels of observations, disclosure of information in a safeguarding situation, prescription of medication for rapid tranquillisation and the use of restraint for taking bloods. The level of risk that a person was perceived to present was a feature of some of these dilemmas. The

person’s autonomy, recovery or choice was not mentioned.

4.1.7.2 Assertive Outreach Team Decision Making Process

Decisions were identified as being made with the service user during a visit, in MDT meetings and CPA reviews. There was an escalation of decision making with the most straightforward (such as when to visit) being made with the service user and the more complicated deferred to the multi-disciplinary forums. Decision making

150 responsibility is geared towards the care coordinator though there is a complex interaction with the doctors in relation to this. From the doctors point of view there is a desire to share decision making but a suggestion that external influences on their role make this difficult. From the care coordinators there is a desire to ensure agreement with the consultants as a protective mechanism (see blame theme), though there are one or two exceptions to this. A number of participants raised the issue of how the service was perceived in the eyes of others such as neighbours, family and society. These perceptions were related to a desire for services to provide a solution to a range of problems and therefore take responsibility for the individual.

Risk

Risk is identified as a key influence on decision making and is linked to the occurrence of negative incidents, such as homicide or suicide. A number of participants acknowledged that this means risk can dominate mental health practice. It was identified as a means of prioritising work with service users and the teams employ a communication system to draw attention to changes in the level of

service users’ risk. High risk levels associated with service users would prompt the involvement of the teams’ managers in decision

making. The role of acute wards was described as one of risk management with the level of risk ever increasing before an admission will take place. Participants described how their perceptions of risk may be influenced by how well they know a person. On the whole risk was linked with increased interventions in terms of medication and visits, though two interviews gave an alternative perspective to this and a further two adopted a critical perspective of the role of risk in health care.

Blame

There was fairly frequent reference to desires to do ‘the right thing’ and avoid doing ‘the wrong thing’. The right thing was often linked

151 was seen as providing a guide on this. The wrong thing was associated with significant incidents and inquiries. Thorough documentation provides a means to defend against investigation if incidents occur as well as a marker of the quality of care. Both of these assumptions are linked to issues of blame and responsibility particularly when things do go wrong and a fear the responsibility for this will rest with an individual staff member. Participants expressed fears of repercussions from their employing organisation, professional bodies and the media. The NHS Trust that the teams were part of were seen to drive priorities, establish targets and through this impact on decision making. This is influenced by a desire to protect themselves potentially from blame, litigation and damage to their reputation. These issues were discussed in the light of a homicide inquiry taking place in another assertive outreach team in the organisation.

Relationships

Engagement with service users was identified as important to enable contribution to decisions but a lack of capacity could act as a barrier. The nature of assertive outreach service facilitated long term work with service users and this work depended on the engagement that professionals and service users built. There was some discussion that the length of this relationship could be a barrier and that staff could

find it difficult to “let go” and enable people to move on. Although

relationships were identified as important in relation to decision making the service user was rarely mentioned as having a voice or

any influence in ‘complex’ decisions that impacted on their own care.

Dilemmas

Participants acknowledged that they experienced dilemmas and difficulty reaching decisions. Specific examples were narrated around a wide variety of scenarios including the use of therapeutic funds, appointeeship, use of the team base and facilities, Mental Health Act and when to admit someone to hospital. There was one

152 dilemma that was discussed from different perspectives by four of the participants. It related to a service user who was admitted to hospital involuntarily, following this he refused to talk to members of the team. When he was admitted some of his clothes were in the washing machine and his lack of contact with the team meant they were unable to gain permission to enter his property to remove the clothes from the machine and save them from being thrown away. The dilemma was presented in relation to his capacity to make that decision and concern regarding the lost items. Two of the participants favoured

going into his house to remove the clothes and two didn’t.