Developing a ‘Decision Resilient’ Workforce

Each year an increasing number of calls are made to emergency and healthcare services from individuals in crisis. However, a disproportionately small amount of users account for the majority of the demand for these services.

In this case study, Paul Jennings, Network Director at High-Intensity Network explains the complex nature of these individuals and the resultant pressures on NHS and Police staff’s own mental health. They highlight the importance of better training to equip those making the decisions with the right mindset to provide the best care.

Key Findings

• A small number of high-intensity users who struggle with complex trauma and behavioural disorders account for 70% of the demand on emergency services

• A multi-faceted and integrated approach between the health and police services is required to effectively handle crisis situations

• A personalised support system after the crisis event is necessary to ensure the mental stability of staff

• The psychology behind both the high-intensity users’ actions and that which informs staff responses is crucial to elucidate in the training

The Challenge

High-intensity users present themselves in a variety of different ways. An individual might regularly try and block traffic on a motorway, climb onto a public bridge, or another activity that causes widespread disruption on a large scale.

These scenarios are incredibly stressful for both the individual and those responding to it, as well as being highly costly and resource-heavy.

The above graph shows the use case of one high-intensity user, displaying the total units of emergency service resources used in the space of 12 months. The breakdown is as follows:

• Blue areas indicate calls to the police, with the darker shade indicating a police vehicle was deployed

• Green areas indicate calls to the ambulance service, with the darker shade showing when an ambulance was deployed

• Yellow areas represent A&E

The total cost to the emergency services of this individual’s actions was £111,000 in 2020.

Understanding that behind high-intensity users have a complex makeup of psychological, socio-economic, and behavioural difficulties can help inform good and resilient decision-making.

Ensuring NHS staff, as well as those also involved in dealing with highly stressful situations including police officers and members of the fire service, have a good knowledge of high-intensity users is key to the training delivered by the High-Intensity Network.

The other side of the coin is focussing on the mental well-being of the public service members dealing with these situations.

The question guiding their work is; “how do we improve the ability of our staff to make decisions about care under pressure without psychological harm?”

The Science Behind the Training

High-intensity users can largely be grouped as adhering to a particular set of schemas.

Schemas are cognitive organisational frameworks the operate in a person’s mind. They are the brain’s toolkit with which information is organised and interpreted.

They consist of patterns developed through personal experience drawn from:

• Memories
• Beliefs
• Emotions
• Thoughts

The most frequent schemas at play when looking at high-intensity users are maladaptive schemas.

Maladaptive schemas are self-defeating, emotional and cognitive patterns established from childhood and repeated throughout adulthood.[2]

The schemas that appear most frequently when looking at high-intensity users are as follows:

• Abandonment
• Defectiveness
• Mistrust/Abuse
• Social Isolation

Taking abandonment as an example, someone who suffers from those feelings will hang off a five-story car park in order to get into the hospital and feel safe and cared for.

Understanding these base reasons and themes that dictate anti-social and high-risk behaviours can allow for NHS and other emergency service staff to make more informed decisions when dealing with these patients.

Taking the same framework of schema theory and applying it to NHS staff is the second key underpinning of the High-Intensity Network’s training.

Across the 45 teams who are part of the training program, four schemas have been identified as dominant when making decisions that affect the care of high-intensity service users. These are:

• Legally ambiguous
• Excessively responsible
• Fearful of consequences
• Lacking in self confidence

The legal ambiguity stems from a rough understanding of the law when it comes to treating and dealing with patients, but a lack of clarity around the details of exactly how the law will function and what the boundaries are.

Feeling excessively responsible has resulted from the duty of care becoming overwhelming due to the how frequent and severe the situations become. Essentially staff don’t know where their duty of care starts and ends, meaning they will overcompensate and hold more risk than is actually expected or required of them.

Being fearful of consequences is not unique as a maladaptive schema to NHS staff, but not knowing what is going to happen because of their actions in such an intense environment where it may be life or death has a huge impact on decision-making.

Lacking self-confidence about being competent in their job can again hamper clear decision-making.

The Solution

To tackle the maladaptive schemas influencing emergency service staff’s decision-making abilities, the High-Intensity Network hone in on the four areas above and aim to inform and educate staff to alleviate the immense pressure they are under.

Legal Ambiguity

Combatting the legally ambiguous schema, the training highlights that the UK operates under a common law legal system. This in effect means we are each the judge of each other’s behaviour, and the guiding principle is that reasonably held beliefs and common sense dictate whether their actions were lawful.

This means that staff aren’t being judged by some kind of ‘other’ agent of the court, but by the reasonable expectations of their common man.

Educating staff on the legal process and that their decisions will be judged by common sense rather than statutes can help them feel confident in making a decision and remove some of that fear of not knowing the exact law pertinent to the situation.

Excessively Responsible

Believing that because something bad has happened means there must be someone at fault is a fairly normal thought process when reacting to a situation.

However, it is not the case and it doesn’t make sense to see this as a logical way of looking at bad results.

Taking suicide as an example, because of the culture that death must be prevented at all costs, suicide is treated as a huge failure that individuals put on themselves.

While a difficult issue and not one spoken about widely, suicide is a legal act in the UK. Of course, preventing suicide is a priority when dealing with a high-risk individual, but it is not healthy nor right to place blame or feel at fault if a suicide does occur.

Understanding that incidents such as suicide are going to happen, whether you offered care or not, should help define the boundaries within which emergency service staff are operating in from a moral standpoint and reduce that extreme excessive responsibility they feel.

Shifting the culture away from death always meaning someone must be at fault is crucial to helping healthy decision-making and maintaining strong mental health should unwanted results present themselves.

Fearful of Consequences

A lot of decisions are driven by fear of getting it wrong, and a negative consequence happens as a result of that decision.

This is again the wrong way to look at how events and situations unfold. The training highlights that very often when dealing with high-intensity users, the outcome is out of the control of those offering care and support.

What is important is the quality of the decision-making process. Doing things for the right reason, whether the outcome is good or bad, is what should drive good decisions. It should never fundamentally be about what the outcome is as no one can accurately predict the future.

Lacking Self Confidence

Due to the environment, emergency services operate within, lacking confidence in your decisions and competency is exacerbated, with the stakes being life and death.

A big part of this schema manifests from Coroners Court, which is not actually a court but an inquest into the death. What is being highlighted through the training is that there isn’t a judgement being made to incriminate someone, but it is more a fact-finding mission to uncover the chronology of what led to the death.

Seeing Coroners Court as a helpful function in the system rather than as a reason to doubt your own ability is a crucial culture shift.

The Impact

Following the training, NHS staff and other members of the emergency services should be able to look at the legal system as supportive, fair, and protective of them. It is not there to trip them up but is a transparent process.

Another key learning outcome is that the primary duty of care of the patient is owned by the patient. The role of the services providing care is to support and help, but it is impossible to expect that you can stop death and aid life.

Thirdly, what happens as a result of the decisions made, which were made in good faith, are out of their control. Understanding that it is the patient who ultimately decides whether they are going to live or die helps alleviate the pressures felt when making decisions, leading to better decisions being made.

Finally, restoring faith in the ability of care providers and enabling them to say “I’m a great nurse, I am good at what I do, I’m happy to tell a Coroner about what I did and why” is the last piece of the puzzle.

Eliminating these schemas will help staff make more resilient, better quality decisions, and also result in a healthier workforce with stronger mental health.

The Future

The High-Intensity Network is already working across:

• 43 Police Forces
• 10 Ambulance Trusts
• 230+ A&E Departments
• 57 MH Trusts

The goal is to expand this integrated network further, to not only better equip staff to become more resilient decision-makers, but the bottom line is to provide outstanding care for the thousands of traumatised cross-border service users.

Building upon their initiative, the High-Intensity Network is aiming to improve personal, professional, and national safety. Their belief is that we are safest when we connect as a single, national health and urgent care community.

[1] Jennings, Paul. 2021. Developing a ‘Decision Resilient’ Workforce

[2] Young, Jeffrey E; Klosko, Janet S; Weishaar, Marjorie E. 2003. Schema therapy: a practitioner’s guide.