Blackburn with Darwen Action Learning Set

Blackburn with Darwen Action Learning Set – A Model for Improving the Interface Between Inpatient and Community Teams

West, Penny

Blackburn with Darwen action learning set was commissioned by the Blackburn with Darwen mental health local implementation team to improve collaboration between community teams and wards in order to develop the quality of care in Blackburn’s inpatient settings.

The action learning set (ALS) was introduced during a period of significant organisational change and flux in the senior management team and prior to the publication of an external investigation about a serious incident involving the death of a former inpatient. The overall aim of the initiative was to improve the quality of inpatient care by bringing together first-tier nurse managers of wards and community teams in a learning environment over an extended period. Most of the managers had not taken part in any post-qualification management training and none had any prior experience of action learning.

This article was written one year after the commencement of the ALS and prior to the formal evaluation. It suggests that action learning is an appropriate method of bringing together team leaders and that the subsequent improved joint working is beginning to have a significant impact on the way managers cope with the day-to-day stresses of their work and upon the inpatient experience.

Background and context

In 2001 a new acute mental health facility opened at the Pendle View unit, Queen’s Park Hospital, Blackburn. It provides three acute wards for residents of Blackburn with Darwen, Hyndburn and Ribble Valley. One ward is a female-only ward; another is male-only, with a third (providing beds to residents of Hyndburn) being mixed. There is also a psychiatric intensive care unit, Calder Ward, within Pendle View.

The Health and Social Care Advisory Service (HASCAS) was commissioned by the Blackburn with Darwen Local Implementation Team (LIT) to support service development within the acute unit. There were two phases to this work: the introduction of an action learning set and an audit of the multidisciplinary processes within the three acute wards. This article is concerned with the former. The Action Learning Set, an 18-month action learning programme, involved acute ward managers and their community team counterparts.

The ALS, started in September 2003, was scheduled to meet every six weeks or so for 12 sessions over an 18-month period. Three months into the programme it was agreed that a residential module would be added. The ALS main programme was facilitated by Penny West, senior consultant with HASCAS, who has extensive experience of working with inpatient care staff, having project-managed the Centre for Mental Health Service Development’s acute inpatient practice development network 1999-2002. Supervision and co-working on the residential component was provided by Dr Tony Ryan, service development manager and senior research fellow, HASCAS.

Action learning is not new (see Weinstein, 1995), but the author believes that this is the first time this approach has been used as a means of improving mental health inpatient care. The action learning approach was augmented with solution-focused techniques (see Jackson & McKergow, 2002) to offer participants different ways of reflecting on how they work with operational and clinical problems. This is compatible with the approach being taken by the Modernisation Agency Leadership Centre in the development of effective teamwork and leadership mental health materials which are now being rolled out through the NIMHE development centres (Modernisation Agency Leadership Centre, 2004). It is also in line with the best practice recommendations for acute inpatient mental health care (Sainsbury Centre for Mental Health, 2004). This stated that the design, delivery and evaluation of education and training programmes needs to become not only more innovative but also:

* more inclusive of service user and carer training roles

* more relevant to everyday practice

* more flexible and accessible to practitioners

* more integrated into service monitoring and governance.

Aims and design of the Blackburn ALS

* To facilitate closer and more effective working arrangements between hospital and community settings.

* To improve the quality of inpatient care for service users in Blackburn and Darwen.

* To support first-line managers in developing their skills and abilities.

The action learning programme commenced with an introductory day to raise awareness of what action learning is about, what might be the focus of the learning and the action, and what the key issues of concern were for service users. This day included taught input about the tenets of action learning and experiential sessions (temporary ALSs) so participants could understand what might be expected during the regular action learning sessions. The literature on action learning states that joining an ALS should be voluntary (Pedlar, 1996) but the people present had been obliged/instructed by their managers to attend. The facilitator emphasised that while management can require attendance, it is the individual that has to agree to contribute and support their peers in the learning process – that is, it is up to the individual voluntarily to make the psychological contract to attend and take an active part, otherwise the action learning process will not be helpful. Set members were asked at the end of the first day to consider whether they were able to make that commitment to attend and contribute.

The number of people attending varied somewhat during the 18 months: four members attended consistently throughout the programme; one member left and subsequently returned following maternity leave; two members asked to be withdrawn after six sessions; two new members joined after the third session. In spite of people’s best intentions there were usually five to seven members present at an ALS as sickness, annual leave and occasional other duties intervened. Slightly more women than men attended each session.

Following the introductory day, each set member was asked to complete a ‘contract’ with their line manager. This spelt out:

* the purpose of attending the action learning set

* where the action learning set sat in terms of the trust’s and the department’s strategy

* what was expected of the set member

* what support the set member could expect from their manager.

The 12-day programme commenced on 25 September 2003 and ran until February 2005. Following the introductory day, which ran from 9.30am until 4.30pm, it was agreed that each ALS would run from 9.30am to 3.30pm to accommodate members who needed to touch base with their workplace at the end of the day.

Format of the action learning sessions

Each session commenced with an introductory ‘warm up’ experiential session, which varied in content and theme during the course of the programme: learning styles questionnaire; priorities for change (collage exercise); identifying a project; ‘When I was at my best as a manager’; giving appreciation; Water the Flowers, Not the Weeds (Peacock, 2001); miracle question exercise on communication with senior management; ‘speed dating’ exercise on learning so far. The purpose of the introductory session was to help people become psychologically present in the group, to think and be stimulated, and to provide a framework for the process of selecting, developing and seeing through their change project.

The broad outline of the regular sessions was:

* 9.30am-10.15: introductory ‘warm up’ session often a solution-focused exercise.

* 10.15-11.15: ‘airtime’ for two set members

* 11.15-11.30: break

* 11.30-12.30pm: airtime for two set members

* 12.30-1.30: lunch break

* 1.30-2.30: airtime for two set members

* 2.30-2.45: break

* 2.45-3.15: airtime for one set member

* 3.15-3.30: action learning logs, reflection and close.

Each member had approximately half an hour ‘airtime’ each session, although this was varied depending on the numbers present and the needs of the group. The role of other set members during this airtime was to actively listen and then support their peer with ‘helpful questioning’ – not by giving advice, but by enabling the person in the spotlight to reflect on how they were approaching their project, how they might do things differently and what they are learning. Set members were encouraged to complete a log, recording what they learned from each session and what they might do differently in future.

The role of the set facilitator was to maintain time boundaries, to support the helpful questioning and reflective approaches, and to help the group as a whole maintain the balance between ‘action’ and ‘learning’. Importantly, the facilitator was not to be seen as the group’s chair, their teacher or a lecturer. However, it was part of the role of the facilitator to arrange external input when appropriate and in negotiation with set members. The Blackburn ALS had external sessions arranged on therapeutic engagement with the NIMHE North West inpatient lead, Phil Minshull, and on communication with their senior manager, Gary Chadwick. Further external input was arranged for the residential component.

Themes for projects

Each set member chose a project that was of relevance to the organisation and was of particular interest to him or her. It had to be sufficiently challenging to enable learning, but not so huge as to be overwhelming or unachievable. The projects had to be supported/approved by a ‘project sponsor’ who would endorse the project on behalf of the organisation. Each set member needed to be able to spend time outside the ALS to carry out action related to their project. One of the trust’s priorities for projects was to ensure they were targeted towards issues related to implementing the recommendations of the report of the external inquiry, while developing managers’ skills in relation to staff management and service user engagement.

Themes chosen for projects were:

* dual diagnosis and therapeutic activity on the ward

* developing multi-disciplinary review standards

* improving referral pathways to community support workers

* the service user’s journey through accident and emergency

* daytime reassessment of clients admitted during the previous night with a view to discharge and follow up by the home treatment team

* the assertive outreach team’s impact on inpatient care

* admission and transfer arrangements to PICU

* improving the discharge pathway

* role and function of F grade night staff.

The ALS residential component

The purpose of the residential component was to focus on individuals’ learning rather than moving their project forward. The agreed specific aims were to:

* develop managers’ personal awareness and communication skills

* help increase managers’ capacity to reflect and cope with change

* develop managers’ capacity as leaders in the wider mental health system.

Set members were looking to develop their leadership skills, build up their confidence and practice in using presentation skills, and generally move on professionally. The three days had sessions such as the learning from NASA and Belbin Exercise; a whole afternoon, facilitated by a qualified actor, on ‘personal impact’ and on making presentations (videoed); sessions on preparation for tackling challenging situations; and a pre-dinner meeting with Lancashire Care Trust’s chief executive, Finlay Robertson. This needed careful preparation with set members to ensure it would be a productive session. On the last morning each set member was required to make a presentation to the whole group about a work-related issue to demonstrate their learning from the residential component. During the three days each person was offered a solution-focused personal mentoring session. The evaluations showed this was highly valued.

Approach to the evaluation

Set members are required to write a report about the outcome of their project for the management. The facilitator will help participants to reflect on their learning but will not act as an external assessor for these reports. The ALS set members were also requested by the trust’s chief executive to make a presentation about their recommendations for service improvement to the chief executives and directors of Lancashire Care Trust and local primary care trusts in December 2004. This has helped focus the set members’ learning on presentational skills, as well as the organisational implications of the changes so far initiated through the projects. It has also been beneficial for morale since it has demonstrated Lancashire Care Trust’s commitment to taking firstline managers’ views seriously.

The HASCAS/LIT evaluation of the ALS will be via a questionnaire given to set members after the eleventh session. It will address issues of personal learning, facilitation and organisational learning for the trust and social services. A formal report of the views expressed from this questionnaire will go to the LIT.

Conclusions and recommendations to date

* Action learning, in bringing together ward managers and community managers, has been demonstrated to be a powerful vehicle for learning. Set members report they have built up new relationships across the inpatientcommunity interface that are benefiting service users and the service generally.

* Set members report that they have been able to use the knowledge gained in their normal work settings and that the ALS experience is influencing their approach in their day-to-day work with staff and service users. Set members have said that they have found the solutionfocused approaches particularly helpful in giving them new tools for tackling issues of poor staff motivation and performance.

* It is vital that the projects chosen by set members have the authority of a ‘project sponsor’ who is able to give an organisational mandate: two set members who had their project approved and then this approval withdrawn asked to leave the ALS. While their withdrawal may not have been directly related to their project status, it is demoralising to find out some way down the road that a project is not viable.

* Differences in grades and responsibilities between ward and community managers may have caused difficulties in peer relationships within the ALS. It is important to select set members who have broadly similar responsibilities and grades across the service since when working in an ALS set members can reveal feelings and insecurities that may result in individuals feeling quite exposed.

* It has been challenging for the organisation and for set members to maintain a focus for an 18-month period – priorities and line managers have changed during this time and so have some of the set members. The support of the chief executive has been very important in maintaining the motivation of the set members in helping them to feel that their efforts to improve the service have been valued and appreciated.

* It is important for the commissioner of an ALS to be clear about how it is to be evaluated: it could be evaluated from the outcome of the individuals’ learning, from the impact of projects, immediate outcomes for a ward or longer-term outcomes for the organisation and so on. Set members and the facilitator need to be aware of how the set is to be evaluated early in the programme.

Members of the ALS at the time this article was written were Allison Mellor, Darwen & Blackburn West Community Mental Health Team Manager; Barry Wilson, A&E Liaison Worker; lan McGlynn, CPN, Assertive Outreach; Pauline Cullen, Hynburn Ward Manager; Michelle Caton, CPN, Blackburn CMHT; Janice Saddington, Darwen Ward Manager; Susan Gregory, Deputy Manager, Ribble Ward.

References

Jackson P & McKergow M (2002) The Solutions Focus: The Simple Way to Positive Change. London: Nicholas Brealey.

Modernisation Agency Leadership Centre (2004) Effective Teamworking and Leadership in Mental Health. London: NHS Leadership Centre.

Peacock F (2001) Water the Flowers, Not the Weeds. Montreal: Open Heart Publishing.

Pedlar M (1996) Action Learningfor Managers. London: Lemos & Crane.

Sainsbury Centre for Mental Health (2004) Acute lnpatient Mental Health Care: Education, Training and Continuing Professional Development for All. London: Sainsbury Centre for Mental Health.

Weinstein, K. (1995) Action Learning: A Journey in Discovery and Development. London: HarperCollins.

Penny West

Independent Consultant

Senior Consultant, HASCAS

Copyright Pavilion Publishing (Brighton) Ltd. Mar 2005

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