Lee Dale – Expert Citizens C.I.C.
Mandy Jago – Volunteer VOICES and Expert Citizens C.I.C. Board Member
Sharon Sharman – Learning and Evaluation Manager VOICES

A Psychologically Informed Environment (PIE) “…is one that takes into account the psychological makeup – the thinking, emotions, personalities and past experience – of it’s participants in the way that it operates”
(Robin Johnson http://pielink.net/ 2012).

Many of the customers homeless services work with may seem to have difficulty managing their emotions, can appear impulsive and may not consider the consequences of their actions.  They may also appear to be withdrawn, isolated and seemingly reluctant to engage with support and / or exhibit anti-social type behaviours.  The purpose of PIE is to help staff understand where these behaviours are coming from and, therefore, work more creatively and effectively with people.
(adapted from Psychologically Informed Environments; Westminster City Council 2015)

How can we create a psychologically safe environment in our Emergency Department for people who have experienced multiple emotional traumas and are experiencing homelessness?

This conversation started some time ago with Julie Norton, an Accident and Emergency (A and E) consultant from the Royal Stoke University Hospital.  Julie had approached VOICES to seek ways of supporting departmental staff in developing best practice to support people experiencing multiple and complex needs. After meetings and several e mails, we decided that the best place to begin was by developing more awareness of why people may find themselves at A & E and what actions staff could take to best support them.

On 25th September and 12th October 2018, we delivered two workshops with some of the nursing and medical staff from A&E at the Royal Stoke, including two Consultants and an Administration Supervisor.  We explained some of the reasons why people experiencing multiple needs may attend A and E more frequently than others and shared our findings from the results of a recent research project conducted by Expert Citizens C.I.C., year 5 GP students, Keel University and Healthwatch Stoke-on-Trent. “Access to Primary Care Services for Patients with No Fixed Abode (2018)”

https://www.voicesofstoke.org.uk/wp-content/uploads/2018/08/29495-Access-to-Primary-Care-Services-Booklet-2018.pdf

This report demonstrates that only 27% of GP surgeries in Stoke-on-Trent would register people who have no fixed abode without conditions.  For people with no GP it is difficult to access other services that may support them with physical and mental ill health, so often, and when in crisis, their only way of getting health treatment is through A&E.  We also explained the difficulties faced by people experiencing homelessness in trying to access their benefit entitlement and demonstrated that, often, individuals are not only rough sleeping without support, but also have no income.  To further deepen understanding we challenged the view that rough sleeping and substance misuse is a “lifestyle choice”.  Creating empathy, we asked the delegates to consider what choice they feel they would have if they were in a similar situation.

What we do know is that, for many people, engaging with the VOICES Service Coordination Team supports them to develop more fulfilled lives and their need to access A & E hugely drops, demonstrating that when people do have real choices, they are able to make them with the right support. See our report ‘Hard Edges:  Stoke-on-Trent” 2018:

https://www.voicesofstoke.org.uk/wp-content/uploads/2018/08/29496-Hard-Edges-Booklet-2018.pdf

Lee Dale, Volunteer Educator from Expert Citizens C.I.C., talked about his own lived experience of homelessness and addiction, sharing insight into how he felt when he was experiencing mental ill-health and admitted to A and E.

“I was totally blown away by how staff created a safe and comfortable environment for me to be able to talk about my experience of being a rough sleeper, and the difficulties I had engaging with services. It was particularly special to see people’s enthusiasm and willingness to develop a culture that is not based on assumptions”.

Lee’s story provided great insight into how a service can be more welcoming and actively listen to patients and how follow up appointment times should be both flexible and sympathetically agreed with patients to ensure that they are able to sustain engagement with their treatment.

Thomas James, Consultant says, “Excellent presentation – good to have information to read later; extremely useful presentation from Lee Dale – he is an excellent speaker”. 

Staff Nurse attendee says, “Very informative – think having Lee there to speak to us and ‘open our eyes’ was very important – I feel more confident in helping these patients to access the resources available to them”.

Listening to and learning from lived experience is crucial if we are ever really going to understand the customer journey – seeking to find what works well and what doesn’t work well for individuals can be the best training we may ever receive and the best thing about this is: informal conversation costs nothing.  As summarised by another staff nurse,  “Not only educational, but also emotionally effective – to put myself in their shoes”.

So, what can staff in a busy A & E department do to create a more psychologically safe environment? Well – here’s what the team said:

• Understand the challenges that people are facing in addition to the treatment they need
• Challenge judgements – be proactive
• It’s made a really big impact:  I’ve changed my attitude towards homelessness
• Refer to homelessness services as soon as we are aware, not waiting until someone is discharged
• Give the GP cards to patients of no fixed abode, reassuring them that Healthwatch will support with registration
• Treat people with compassion and understanding, talk to them, see past the obvious appearance and give them information when they are ready to receive it

We all recognise that budgets are a challenge for services, but if we get together. like we did and share our experiences we can easily identify simple changes that can be made; as Sharon Sharman says,

“Small change in cups won’t solve a homelessness problem, but small changes in attitudes, behaviours and procedures can make a huge difference to someone’s support”

Following the two workshops and several meetings and e- mails later, we are blown away with the commitment from the teams and their leaders. Within less than three weeks, together we have achieved small change and actual system change:

• Delegates have committed to share the learning with colleagues
• We are developing visual reminders to display in A and E for patients to ensure their details are up-to-date, including address and, if registered, contact details for the GP
• We have committed to work with the departments administration team to identify best ways to notify medical staff of patients with no GP and / or of no fixed abode
• Service information has been placed in Homelessness Resource boxes throughout the department
• VOICES has designed and provided a ‘Quick reference guide’ for A and E staff to refer someone identified as no fixed abode to homelessness / housing services
• Consultant, Julie Norton, has gained authorisation to add an alert on the patient electronic system to flag to staff that a person is at risk due to homelessness

Julie Norton – Consultant Emergency Medicine says,

“The VOICES team and the Expert Citizens C.I.C.  gave the A&E team a unique insight into the challenges faced by people experiencing homelessness, mental ill-health and substance misuse.  We were inspired by the work that VOICES have done in order to improve the care these people receive. The team have committed to working more closely with local services and Expert Citizens C.I.C. in the future to identify and support homeless people”.

This is just the start of our work with this great bunch of people who are in constant demand, and yet, recognise the importance of listening, of learning from lived experience, of sharing information and of creating a psychologically safe environment.

We have now been invited to present to the Emergency Department Therapy Team, the Administration Team and to contribute to the departments 2019 training programme by sharing more examples of lived experience each fortnight from March to December.   As one recently qualified nurse states, “This is the stuff they don’t teach you at medical school”.