A Just Culture and Psychological Safety: Top-Down Transformation for Mental Health Services

An independent review into Greater Manchester Mental Health Trust (GMMHT) was published last month, following an exposé on BBC Panorama which showed abuse of patients in a secure setting. Patients were mocked, inappropriately restrained and assaulted.

Searching through Panorama episodes, a number of shows over many years reveal systemic and sustained abuse of vulnerable people from staff working for statutory organisations that exist to support and care for people at the point of their need.

When NHS bosses point to rogue staff on the frontline and sack them, it helps us to feel we understand the cause and that we have seen justice but the flaws in this belief are revealed by the reality that abuse of patients is still occurring and is systemic. From Winterbourne to Edenfield, public shock and retributive justice against abusive staff has not led to transformed public health and social care services.

The GMMHT review led by Professor Oliver Shenley, who was awarded an OBE in 2016 for services to Mental Health and Learning Disability nursing, pivots the focus of learning from the training and dismissal of care staff to the complexities of organisational culture and accountability.

Problems such as operational voice superseding the clinical voice, leadership lacking compassion and trust but being unable to see how their behaviours have contributed to issues and a lack of diversity are notable in the GMMHT review. Counter actions in all these areas are vital but with what overarching purpose? Shenley suggests a ‘Just Culture’ and psychological safety.

In the NHS Just Culture is promoted as the investigation into how systems lead to sub-optimal behaviors but the term has a wider scope for our sector. Five principles guiding just culture can be applied for equitable working and healthy practice that is preventative; fairness, respect, equality, dignity and autonomy (FREDA).

To make these principles practical for health and social care staff structures, applying best practice support models that staff are expected to deliver when supporting service users, alongside employee management, staff relationships and well-working practice and norms, will embed person-centred thinking into organisational culture. This will increase the ability of health and social care teams to take a person-centred approach to supporting service users.

Enabling an empathic and equitable staff structure that features a dynamic approach from the top down, will create an environment characterised by cultural humility and equality. Adapting and applying models and principles of trauma informed approaches, de-escalation and empathy training, creates a professional early intervention and preventative tool to stop the desensitised behaviour that enables patient and service user abuse.

Mirroring care and support models in employee relations and structures can also act as a powerful counter to the hypocrisy we can sometimes have as employees, seeing ourselves through the unconscious bias so prevalent in society that assures us that we are in some way different, and better, than our service users. Realising that we all need healthy structures and support to thrive, allows us to accept and embrace our own vulnerabilities, and empathise with the vulnerabilities of others, especially when we have a duty of care towards them.

At Social Interest Group, we do not use restraint against residents and participants of our services. Instead, we apply de-escalation principles to build rapport, express empathy, and convey understanding. This requires training and extensive upskilling so that we can actively listen, read body language and acknowledge environment, affirm the experiences of others and acknowledge their autonomy.

Last week, the Prisons and Probations Ombudsman released their second Policy into Practice publication, sharing key learning for officers on the use of force in prisons. The emphasis on de-escalation is cyclical in their guidance; de-escalation is the golden thread throughout any interaction and should be consistent from the beginning to end of any crisis situation. This approach is positive as it keeps the opportunity for a safer and healthier outcome open at all times.

Other principles of FREDA inform de-escalation training too, as cultural awareness and mutual respect are applied to create common ground from which an equitable and safe outcome can be negotiated. Enabling mutual respect as opposed to imposing and enforcing conformity upon colleagues and service users prevents coercive control, abuse and bullying.

The urgent need for preventative measures and a proactive approach to create an enabling culture within the NHS is evidenced by the long term impact of institutionalised staff culture on its employees. Last week, a freedom of information request from the Liberal Democrats revealed that 8,614 NHS nurses are currently off work with long term health conditions. The Health and Safety Executive revealed that 49% of the 1.8 million people off work in 2022/23, cite stress, depression or anxiety as the cause.

As the NHS moves forward with its Long Term Plan, outlining workforce development and access to mental health care as key components, the connection between the two will have to be acknowledged. Stressful work environments and coercive management structures enable patient neglect and abuse. It is our hope that better staffing structures, accountability from executives, and enabling work environments for NHS staff will result in frontline staff delivering dignified, enabling and safe care and support for all service users.