Impact case study database

The ongoing research of Professor Andrew Lovell and his colleagues has contributed to regional, national, and international changes in staff practice within organisations requiring de-escalation skills, with particular emphasis on service-users with learning disabilities.

DVD and training package

One outcome was the decision to produce a DVD, presenting scenarios related to violence and aggression, and supporting materials, examining how nurses can use their interpersonal skills most effectively to prevent violence [S1]. The training package “ Violence in health and social care settings: A training resource package for organisations and individuals” includes analysing the DVD scenarios, and focusing on how staff dealing with potentially violent situations might react in such circumstances.

The DVD was presented internationally, and purchased by several organisations, including a Czech national trainer, and the material was presented by invitation in Prague (Vysoká škola tělesné výchovy a sportu Palestra: 10^th Scientific Conference) on 14^th May 2014. The DVD was also used by Oud Consultancy of Amsterdam [S2a & S2b].

Examples of UK national impact include use of the DVD in staff training by three specialist learning disability services: New Focus [S3], Calderstones Partnership NHS [S4], and Merseycare Learning Disability Directorate. New Focus, an independent sector organisation closely linked with the work cited here, used the DVD in teaching staff about de-escalation, using staff to the theoretical model as a means of working with offenders with a background of violence and/or offending behaviour as part of the community support packages provided by the organisation [S3].

Further development of this research resulted in the production of a model of violence and aggression, highlighting how the interaction of service-users’ life histories, mental health conditions, and cognitive status (defined as complexity) contribute to aggressive and violent behaviour. The model also emphasises that nurses’ understanding of their own response to situations and others’ behaviour influences how they evaluate and address aggression and violence.

Workshop

In 2016, discussions took place with Merseycare Learning Disability Secure Services to develop a teaching package supporting its existing approach to managing violence. The esteem generated through Professor Lovell’s research and connections assisted in the development of this intervention; “Through our pre-existing relationship with Professor Andy Lovell, and his long-established record of conducting research in this area over many years, we were fortunate enough to find a natural partner… Clearly Professor Lovell had extensive knowledge and experience of the Subject” [S5]. A two-day interactive workshop was developed which incorporated tasks to facilitate participants identify what triggered their anger, their response when faced with aggression, and how to evaluate situations to avoid escalation.

Previously, the emphasis within de-escalation has generally focused on the acquisition of certain key skills, whereas we accentuate understanding of service-users (background, learning disability, additional diagnoses), and how to apply this knowledge when addressing incidents of violence and aggression. Moreover, the workshop also emphasises how application of practical skills such as observation and active listening, in tandem with understanding service-users’ life histories, can result in early identification and de-escalation of situations which may result in a violent incident. Theoretical information was also delivered, including discussion of the de-escalation model we have developed. The value of the workshop and the model relates to nurses leading the way in supporting this population to lead healthy and productive lives.

We were subsequently commissioned to deliver a series of workshops to all Merseycare Learning Disability Secure Service nursing staff (qualified and unqualified) and some allied healthcare professionals (clinical psychologists, occupational therapists). Staff trainers from another Merseycare site also attended to assess whether the workshop would benefit staff working in high-secure mental health settings. Seven workshops with a total of 106 attendees were delivered between October 2016 and April 2017, generating income of £15,000. Each workshop was evaluated in terms of how staff attending perceived the potential benefit for their work in clinical practice, and evaluations were subsequently collated to determine the overall impact for the workforce [S6].

Feedback from managers was positive; “Throughout the course of the project, Professor Lovell and his team proved to be an invaluable asset and trusted partner. His expertise, coupled with an ability to relate to and engage with staff at all levels, were undoubtedly the main factors in the results achieved” [S5]. Feedback from attendee evaluations was also positive, especially the emphasis on the need to understand individual complexity when working with potentially violent individuals. 77.3% attendees reported the workshops would impact practice, primarily through the discussion facilitated on the course, the exercises undertaken (attendee involvement was critical), and improved knowledge about de-escalation; additionally, 92.4% of attendees stated they would recommend the workshops to colleagues [S6].

Pedagogy

The research and resources developed have also changed pedagogic practise at the University of Chester. Initially, the DVD was utilised in teaching sessions with students of learning disability nursing, and focused on approaches to and management of potentially violent situations. Once developed further, the de-escalation model was incorporated into the nursing curriculum, providing insight into the development of service-user potential violence, and influencing how we respond to it. The model is now embedded within the University pre-registration nursing curriculum [S7].

Overview

The GMHAT project has had three main areas of impact. The first is the training of healthcare workers to improve their skill and efficiency in identifying mental health problems, and consequently supporting the needs of people in distress. The second is the supporting of community-level projects to meet the needs of those communities. The third is to positively impact on policy and guidelines to support quality improvement in services. GMHAT is culturally sensitive and directly benefits persons with mental health issues to be identified, supported, and signposted into available local services. A real strength is that it can be used in resource-poor countries and across an individual’s life course.

Training

Professor Sharma and his colleagues have trained over 100 health professionals in the UK, 500 health professionals and NGOs in India between 2015- 2018 ( Rajasthan, Maharashtra, Madhya Pradesh, Karnataka states), over 50 in Colombia, 20 in the Middle East, and 30 in Africa. GMHAT training programme workshops have been organised at the World Congress (World Psychiatry Association 2018), and National conferences in India (2019) and Colombia (2012- 2018). The tool has been translated into multiple languages, including Hindi, Chinese, Spanish, Arabic, Dutch, German, Tamil, Welsh, and Portuguese [S4]. The Arabic version of the tool was published by the Eastern Mediterranean Regional Office of the World Health Organisation, with plans to train non-specialist health practitioners who are involved in the care of Syrian refugees in Turkey to adopt the GMHAT in the assessment of mental health issues [S8]. GMHAT can be accessed via a computer, tablet, or mobile phone, increasing its potential to be used in rural and hard to reach communities [S2a]. The Marathi version of the tool has both PC and portable android versions, and has been used by many nursing and psychiatry professionals completing postgraduate studies [S8]. To date, GMHAT training has been delivered to, and implemented by, nurses, ASHA (Accredited Social Health Activists) workers, psychologists, doctors, and social workers, and GMHAT has been used in hospital and community settings in different parts of the world [S2a, with specific examples in S4, S5, S6, S8, S9].

In India , Professor Sharma was involved in training frontline health workers via mental health camps and workshops, which were followed up with further advice via video calling and WhatsApp messages; after attending training, frontline health workers were able to gain a better understanding of mental health, and appreciation of its significance, with one trained worker noting “When we went to the field and looked at the survey, we found that mental health is as important and necessary as physical health” [S5]. The trained frontline health workers were able to administer 918 GMHAT interviews, thereby identifying 84 cases of psychiatric illness in rural areas of Rajasthan [S5]. Professor Sharma is said to have “successfully created a new generation of mental health clinician researchers in India who are leading the mental health primary care research” [S4].

In Columbia, the virtual course "Training in mental health for health professionals through the use of GMHAT" has been running since 2019, and has been completed by 57 people, including nurses, doctors, and psychologists. At the beginning of the course, students' knowledge about mental illness averaged 6.6/10, and the ability to perform a mental exam assessment was 6/10. At the end of the course, these values increased to 8.2/10 and 8.7/10 respectively. 85% of the participants rated this course as good or excellent [S6].

Community-level projects

The research studies led to worldwide recognition of GMHAT. More importantly, this has led to improving skills and knowledge of health workers in detecting and managing mental health problems; “Professor Sharma’s contribution and commitment to a non-commercialised and freely available tool is considerable, bringing comprehensive mental health assessment to non-psychiatrists, particularly those working in primary care and community settings” [S3a].

At a regional level in North West England, the tool has been trialled at two GP medical practices (Blackheath Medical Centre and Kings Lane Medical Practice, both in the Wirral) to ascertain the utility of the tool for use by GP practice staff (including doctors, practice nurses, and health care assistants) in the assessment of their patients’ mental health symptoms. This health care professional-led research is ongoing [S3a, S3b]. A validation study is also taking place in South West London to use the tool as part of community addiction services; non-specialist health and social care staff are being trained in the use and application of GMHAT for the recognition and diagnosis of mental health problems in service-users with alcohol and drug misuse issues [S8].

At international level, the South Asia Self Harm Initiative (SASHI project) has utilised GMHAT. The Co-Director of Centre for Mental Health and Society from Bangor University was awarded a grant from the Tropical Health Education Trust’s Health Partnership Scheme, which is funded by the Department for International Development (2015-2017) [S7]. The £60,000 award supported an educational programme in India focusing on training-the-trainers to establish a sustainable programme, so that 100 general doctors in two hospitals will be able to assess people who have harmed themselves, and arrange treatment for mental illness where appropriate.

The Professor of Social Psychiatry at Bangor University explains: “ This project has been designed with our colleagues in Mysore to meet a need that they have identified. We are working as a true collaboration, and sustainability beyond the life of the project is a key element. The team used GMHAT developed by Professor V. Sharma, which guides health professionals with no psychiatric training through an assessment process.” This supported the development of a suicide register, which was an important policy/practice change, to help address the under-reporting and therefore unmet need of people who experienced suicidal thoughts [S7].

Policies and guidelines

As a result of the success of the research, the Home Office and Public Health England approached Sharma with the possibility of using GHMAT to address the unmet needs of immigrants arriving in the UK, including some 20,000 Syrian refugees [S8]. In December 2016, the Home Office and Public Health England in collaboration with the International Organization for Migration (IOM) began a pilot of the Global Mental Health Assessment Tool (GMHAT) among Syrian refugees who have been accepted for resettlement to the United Kingdom (UK). This evaluative report found that the tool worked in practice at identifying immediate mental health needs requiring urgent attention during the pre-departure stage, and in facilitating diagnoses, referrals and treatment once in the UK [S1]. The tool was tested in one clinic in Beirut, Lebanon, with 200 Syrian refugees aged 18 years and above who were being processed for resettlement to the UK as part of the Vulnerable Persons Resettlement Scheme (VPRS). This early intervention allowed those identified to receive care on entry to the UK. The findings suggest that a pre-departure mental health assessment could be a useful and valuable tool to facilitate UK authorities matching and preparing for new refugee arrivals, and a valuable resource for GPs during the initial consultation. 18 out of 200 (9%) presented with a likely diagnosis of mental health issues, with an impact on functioning and significant subjective distress as identified by the GMHAT, most commonly depression and anxiety. The findings suggest that it may be necessary to expand the provision of culturally-appropriate mental health services for refugees for the pre-departure mental health assessment to have maximum impact. Recent work by the Home Office to map the coverage of mental health services for refugees and asylum seekers in England may be helpful in addressing some of these gaps. Public Health England has now adopted GMHAT and is scheduled to use it for the mental health assessment of 4,000 refugees from the Middle East and Africa in 2021 [S8]. Promotion of GMHAT by the Home Office and Public Health England is a clear marker of the tool extending its reach at a governmental policy level [S1].

The research has already led a significant cultural change in integrating mental health in general health, and raising mental wellbeing in the whole of the Indian Border Security Force (257,000 staff) [S2a, S2b]. As a result of the success of using GMHAT, there has been a policy change to implement its use as part of their annual routine health check. Rajasthan State Police (India) has already taken the same approach where we trained their 50 doctors and nurses in the use of GMHAT [S5]. Since 2017, the Indian Border Security Force has incorporated GMHAT as part of their health and wellbeing assessments. Additionally, an epidemiological study was conducted using GMHAT (conducted by Atal Bihari Vajpayee, Institute of Good Governance and Policy Analysis in Bhopal), to understand the wellbeing of government employees across a range of workplaces, including banks, police services, schools, and hospitals [S2a].

GMHAT is a tool and training approach with international reach for direct societal citizen benefit, which helps in raising standards of mental health provision worldwide.

What is the overarching impact?

The impact of this research is through improving practice and changing or adding to new policies in delivering the exercise component of cardiac rehabilitation in the UK, and globally through the WHO. Professor Buckley’s route to translating his research into national and international policy started to gain traction around 2006, following presentation of his research (section 3) at conferences, which then led to invitations to author national standards for the British Association for Cardiovascular Rehabilitation (BACR) and the ACPICR. Coinciding with these roles, he gained influential positions such as President of the BACPR (2009) and in collaboration with the Canadian Association of Cardiac Rehabilitation (CACR), his research and authorship on policies and practice led to further collaborations in setting up the ICCPR in 2012. The policies and practice standards of the ICCPR, including this research from the University of Chester, became of interest to the World Heart Federation, especially in 2016 where he presented his research at their World Congress in Mexico, at which point he was a co-signatory of the “Mexico Declaration” for global heart health. The common thread running through these events and opportunities is that this research was valued by front-line practitioners, which has made the testing of fitness, and guidance of exercise, more achievable in non-clinical settings. This is a core aim of all countries (developed and developing), and especially the WHO, in wanting to widen access and uptake of the very cost-effective component of cardiac care well-known as rehabilitation and secondary prevention.

Overview of National and International Collaborators and Corroborators

Professor Buckley’s collaborators and corroborators in the UK include the BACPR [S1], and the ACPICR [S2]. Front-line education and service impacts [S1d] are corroborated by testimonial statements from some of the UKs largest and leading cardiac rehabilitation services in Manchester, London and Caerphilly [S2, S3 and S4]. Similarly, internationally and globally, these include the IOC [S5], the ICCPR and the WHO [S6]. Service and patient impact testimonials are also included from Canada’s largest and leading cardiac rehabilitation service [S7], two of India’s leading authorities and service providers in Manipal and Mumbai [S8, S9] and the Singapore Heart Foundation [S10].

National Impact

The British Heart Foundation’s (BHF) annual audits of cardiac rehabilitation, dating back to 2007 ( http://www.cardiacrehabilitation.org.uk/), have shown a clear evolution of service delivery increasingly being shifted towards community and home (nearing 50%). In ~60% of cases, an exercise capacity test is not performed and in >85% of cases not performed at discharge to evaluate both programme effectiveness and support patient’s on-going exercise behaviour change as lauded by the WHO. The need for pragmatic exercise assessment and monitoring tools, are thus of increasing significance, which begins with the training of front-line practitioners. Since 2006, the BACPR has therefore rolled out specific training courses based on Professor Buckley’s research into practical field-tests and improving exercise intensity monitoring with heart rate and ratings of perceived exertion.

In 2019/20, to determine the impact of these BACPR education courses and demonstrate translation into practice and policy change in the UK, a BACPR national survey on Practitioner and Patient benefits was performed [S1d]. This survey was sent to 210 of the 350 NHS cardiac rehabilitation programme service providers throughout the UK, where 51 surveys were returned. This represents 15% of the cardiac rehabilitation patient services offered in England, Wales and Northern Ireland (BHF National Audit data), representing the care of ~15,000 patients (BHF National Audit Data). The main results were that 75-84% of BACPR course attendees felt that the CPD training programmes had a ‘good to very significant’ impact in three areas: i. the development of professional skills to more accurately assess fitness and prescribe exercise; ii. it enhanced quality of their service delivery; and iii. it directly benefited patients’ improvements.

To support the learning and teaching described above, Professor Buckley’s research has impacted on the creation of new evidenced-based education and training materials, guidelines, and standards for the BACPR [S1] and the ACPICR [S2]. The testimonials confirm that, as a result, there has been an enhanced consistency of quality procedures and guiding practice throughout the UK. The Chair of the ACPICR, who is also clinical lead physiotherapist at the Wythenshawe Hospital in Manchester, stated “ The knowledge gained from these two courses, both by myself and my cardiac rehab colleagues, have ensured that exercise prescription and exercise delivery for the UK cardiac population is effective and safe” [S2]. To further substantiate this, the BACPR Executive Director stated “ Over the last 15 years John has developed and delivered face-to-face BACPR CPD courses based on his research on Monitoring Exercise Intensity and Assessing Functional Capacity. These courses have been delivered to a wide audience of exercise and health professionals working in cardiovascular rehabilitation and have become key learning for professionals who are involved in the exercise component of cardiac rehabilitation” [S1].

Key examples of the evidence of impact on policy and practice in individual cardiac rehabilitation services are demonstrated at the University Health Board, Ystrad Fawr Hospital, Ystrad Mynach, Caerphilly, Gwent, Wales [S3], and the Imperial College Hospitals Trust London [S4]. The Senior Exercise Practitioner in Cardiac Rehabilitation of Aneurin Bevan University Health Board stated [S3] “ Since attending these days I have been able to improve the quality of service delivery by standardising our clinical exercise protocols and procedures across all 4 cardiac rehab sites within the health board. As a result, all our exercise staff now assess functional capacity, prescribe exercise and monitor intensity in the same individualised way, as thought by John.” The Senior Physical Activity Specialist at Imperial College NHS Healthcare Trust stated, “ The structure of the course was clear, logical and effective, which gave me the confidence to implement new techniques into my clinical practice immediately.” [S4]

International and Global Impact

Following on from the known success and research in the area of pragmatic ways to assess fitness in non-clinical settings, he received an invitation from the IOC to author the chapter on cardiac rehabilitation in their Manual of Sports Cardiology [S5]. His research, noted in section 2 [R2, R3 and 4], was instrumental in his contributions to an international statement in 2016 on delivering exercise rehabilitation in low-resource settings of low-middle income countries, which obviously became of great interest to the WHO. This became a main lever of his invitation in 2017 to become part of the WHO’s first meeting of the Rehabilitation 2030 initiative, linked to “rolling out” their Universal Health Care policy. Hence, between 2017 and 2020 Professor Buckley contributed to the new WHO Standards for Cardiac Rehabilitation, alongside only 9 other panel members from around the world. The Unit Head for Sensory Functions, Disability and Rehabilitation at the WHO stated that the “ work is very valuable and contributes to the development of a high quality and evidence-based Package of Interventions that will help to increase global access to cardiac rehabilitation”. [S6]. ( https://www.who.int/rehabilitation/rehab-2030/en/)

International examples of Professor Buckley’s work with the IOC, ICCPR and the WHO include statements from a number of leading authorities from Canada, India and Singapore. A leader in Exercise Physiology and Cardiovascular Science at the University of Ottawa Heart Institute stated, “ These findings [R1 in section 3 ] sparked substantial discussions and action in promoting and integrating submaximal exercise testing in the cardiovascular prevention and rehabilitation program at the University of Ottawa Heart Institute, Canada’s largest and foremost cardiovascular health centre.” [S7]. This centre directly serves about 2,000 of the 63,000 Canadian patients attending rehabilitation per year.

The testimonial evidence at S8-S10 has demonstrated practice/policy implementation at Manipal College of Health Professions (India), the Sir HN Reliance Foundation Hospital (Mumbai, India), and the Singapore Heart Foundation, respectively. A Senior Lecturer at the Department of Physiotherapy at the Manipal College of Health Professions stated that the work “ has been important to not just me professionally, but also in the academic realm, where I teach my students cardiac rehabilitation” [S8]. Similarly, the Director of the Department of Rehabilitation and Sports Medicine at the Sir HN Reliance Foundation Hospital stated, “ I am happy to say, that I have implemented several of these in the clinical protocols we use at our hospital, where we treat close to 200 patients a day, in our out-patient rehab unit” [S9].

Following on from Professor Buckley’s invitation to deliver workshops and present his research to Singapore Hospitals at the Singapore Prevention and Cardiac Rehabilitation Symposium and their Sports Medicine society (between 2015 and 2018), the senior Cardiac Physiotherapist of the Singapore Heart Foundation stated “ As a result we have adopted these procedures into our standard protocols at the Singapore Heart Foundation including incorporating these into our use of the Chester Step Test” [S10].