The evaluation confirms that by focusing on an enabling hospital environment promoting the building of social systems and social relationships both within and outside the ward while enhancing self-identity and self-responsibility, as supported by the EMERALD model, service users feel more able to manage self-harming urges and are more prepared to transition successfully to the community following discharge.
DBT and shared decision-making approaches to care and treatment management were introduced. Increased access to activities was introduced such as:
- Vocational skills practised in the hospital shop
- Plan my week
- Volunteering/vocational roles
- Occupational therapy clinic
- OTA clinic
- Walk and talk
- Therapies clinic
And hospital activities include:
- Coping skills
- Art and wellbeing
- Know your own risk
- Mindfulness and relaxation
- Social communication
- Music and me
The cumulative evidence base suggests that the innovations promoted by the EMERALD model, building on the Springbank model and the Haven project, the evidence base for the role of DBT and the practice of shared decision-making approaches, has considerable positive implications for future practice. These many practices build the potential to provide an effective frame for hospital-based care delivery for women diagnosed as having PD. While the evidence base supporting the EMERALD model is promising, the small size sample and data collected solely from a single setting, limits the validity of the conclusions within the setting, and hence further research would need to be conducted to consider its overall effectiveness.
Important Takeaways
Flexibility when working with people with people with a diagnosis of Personality Disorders
It was difficult to engage this client group due to the women’s high level of anxiety, distress and fluctuating levels of wellbeing. Researchers rescheduled interviews on more than one occasion, as often interviews were cancelled at the last minute, with interviewees deciding they didn’t want to participate at that time.
Some participants chose not to participate in a second interview, as they were experiencing high levels of distress, but then chose to be interviewed at the third point. We noted that sometimes a period of distress preceded a period of growth and recovery. It was thus important to enable the women to remain in the study and be offered the opportunity to participate at different points.
Support from staff
Ongoing and dedicated support from ward staff, general hospital staff and Experts by Experience on the ward was essential to ensure the interviews took place as planned.
Staff reports on the changes
“Before we implemented the DBT model in 2022 Roseacre was running on high risk multiple incidents. We had high levels of observation, including multiple 1-1’s, 2-1s. Our incidents included daily choking risks with abdominal thrust, back slaps and intrusive interventions of swallowed or attempted swallowed items. Patients regularly attempted to swallow plastic bottle tops, tissue paper, jewellery etc. on at least one occasion we did abdominal thrusts to an unconscious patient due to self-inflicted windpipe blockage.”
“Since the implementation of DBT there has been a marked decrease in the degree and frequency of presenting risks, and a therapeutic focus of ownership of actions. This has result in an overall improvement of patients long term outcomes. With this there is an intrinsic understanding of risk, nature and cause of risk, as well as patients being upskilled with more positive and safe ways to conceptualize risk. Resulting in many benefits for the patients and the service, including reduction of number and degree of incidents. Patients being able to recognise detrimental factors and to engage with positive interventions earlier.”
The patient perspective
“The patients clearly valued the support of staff from the ward and noted how different the ward was to other environments. They valued the greater autonomy and independence provided through such examples as taking greater control over their treatment and medication and the opportunity for peer leave. At times this could create greater anxiety for patients as they managed their experiences of distress. DBT was valued by many. Sometimes the busyness on the ward and the distress of other patients could be disturbing and cause distress amongst other peers. However, any disruption was usually managed by de-escalation techniques such as talking and negotiation.”
Future research
The cumulative evidence base suggests that the innovations promoted by the EMERALD model, building on the Springbank model has considerable positive implications for future practice and has the potential to provide an effective frame for hospital-based care delivery for women diagnosed as having PD.
While the evidence base is promising, the small size sample and data collected solely from a single setting, limits the validity of the conclusions, and hence further research would need to be conducted to consider its overall effectiveness. It would be helpful to undertake a longitudinal research study to explore the effectiveness of this new model on the patients’ recovery journey following discharge and beyond, considering their future community participation and integration, their life course opportunities, and any future hospital readmissions.
The EMERALD Study Part Three: Ward Environment and Actions >>