Improving care for people with a personality disorder
Summary
A quality improvement project on a female acute inpatient ward has had a dramatic impact on patient care and staff morale. Incidents of self-harm fell by 93% and average length of stay was reduced by more than a month. There were related cost savings and improved adherence with NICE guidance. More people with a personality disorder were able to resume their lives more quickly following a crisis.
Problem being addressed
Personality disorders affect about 5% of people in the UK. They are challenging to treat and can go undiagnosed for a long time. A personality disorder is a condition that affects how someone thinks, feels, and behaves. People with personality disorders are at higher risk of suicide and self-harm.
Effective treatment for personality disorder lies in psychological interventions, with medication and hospital admissions for brief periods only. Research has shown that patients with personality disorder have reported feeling powerless and unsupported particularly when in hospital during a time of crisis. Staff also report similar feelings.
Operational planning guidance/Government priorities
- Treatment to prevention
- Hospital to community
- Patient safety
Clinical area/Population
Psychiatric inpatient care. Adults with diagnosis of personality disorder
Network support
Health Innovation Oxford and Thames Valley’s Patient Safety/Mental Health team worked with staff, patients and carers run by Oxford Health NHS Foundation Trust over an extended period to allow time to understand problems, engage and build trust.
The quality improvement project came out of an initial focus around reducing restrictive practices as part of the national Mental Health Safety Improvement Programme (MHSIP). It became clear that there was a strong link between restrictive practice and incidents of self-harm, particularly with patients with a diagnosis of personality disorder.
This created a process map from admission to discharge for someone with a diagnosis of personality disorder, including issues and challenges from all perspectives. This led to collaboratively deciding on change ideas to test. Initial findings:
- High levels of anxiety in staff around patients self-harming, resulting in hypervigilance and reactive therapeutic engagement.
- Feelings of helplessness, guilt, unclear roles and unrealistic expectations from patients, carers and the organisation.
- Staff perspectives of their roles centred around risk and stopping self-harming.
- Patients and carers felt that their expectations of what could be done for patients in hospital, keep them safe and ‘fix’ things, were not met or well managed.
Actions taken
- Purpose of admission form and crisis admission (up to 7 days)
- Ward leaflet to manage expectations and signpost to resources for patients and carers
- Co-produced training delivered to ward staff
- Changes to staff and patient engagement meetings
- Adaptations to daily planning meetings and ensuring patients are able to utilise their leave in a timely manner
Impacts
- A huge culture shift was identified – from a focus on keeping patients safe and stopping them self-harming to offering compassionate support with recovery and during crisis, offering time to talk, recognising triggers and building coping skills. This led to a reduction in escalation and impact on other services.
- The average length of stay was cut by 36 days (73%) from 49 days in 2023 to 13 days in 2024.
- The number of self-harm incidents on the ward fell by 93% – from 481 in 2023 to 35 in 2024. That amounts to 446 fewer incidents. The monthly average dropped from 40 to three.There were also savings due to reduced need for secure transport (often related to treatment for self-harm). These costs amounted to £95,769. In the first six months of 2023. In the same period in 2024 they had fallen by two-thirds (67%) to £31,761 – a reduction of approximately £64,000 relating to a single ward.
PPIE conducted
Co-production with carer and patient representatives who had experience of the ward and personality disorder. Co-produced training has been found to reduce the risk of burnout in staff and improve attitudes towards people with personality disorder.
Scalability/Next steps
The project is continuing. The team meets regularly to review progress and continue to work towards meeting NICE guidance. There is specific focus on reviewing and converting Mental Health Act section admissions to voluntary admissions at the earliest point.
The results of this project have been shared with the regional mental health steering group and the trust’s QI hub. Opportunities share the learning more widely are being pursued.
Quote/testimonial
“Working with Health Innovation provided me with the inspiration and expert coaching I needed to help my project succeed. The changes we implemented have significantly improved our ward in many ways. We have reduced the length of stay and incidents of self-harm, creating a much safer and more supportive environment. Thanks to the coaching we received in our Quality Improvement project, our ward is now a better place for both patients and staff.” – Project lead
“I feel staff are less stressed around crisis admissions due to there being a clear plan for patients.” – feedback
“It has been a privilege to have been involved in supporting and enabling this project. I am delighted to see the demonstrable improvement for patients resulting from this collaboration between the Health Innovation Oxford and Thames Valley patient safety team and our ward staff. The resulting culture change and improvements in patient experience and outcomes are worth celebrating and sharing widely. Reducing the duration of hospitalisation and related self-harm are direct patient benefits, with improved staff morale as a secondary benefit.” – Dr Karl Marlowe, Chief Medical Officer, Oxford Health NHS Foundation Trust
“Approaching care of patients with personality disorders with knowledge, understanding and compassion is key to effective treatment and more positive outcomes.” – Dr Chris Tibbs, Acting Regional Medical Director, NHS England South East
Contact
Hayley Trueman, Mental Health Improvement Manager Hayley.trueman@healthinnovationoxford.org