Evaluation of a Dialogical Psychologically Informed Environment (PIE) Pilot

Addressing homelessness, re-offending, substance abuse, and mental illness

Sophie Boobis

• Publisher: Loving Healing Press
• Year: 2016
• eBook ISBN: 9781615993277
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

The Fulfilling Lives Programme is seeking to help people with multiple and complex needs to better manage their lives, by ensuring that services, across Newcastle and Gateshead, are more tailored and better connected to each other. The focus of the programme is on those people who often spiral around the system(s), are excluded from the support they need and experience a combination of at least three of the following four problems; homelessness; re-offending; problematic substance misuse and mental ill health.
During the early stages of the delivery of the Fulfilling Lives program a systemic problem was identified relating to clients with complex needs finding it difficult to access mainstream mental health services, with a number of reasons given such as alcohol and drug use as well as poor engagement with services. Despite many of these individuals having complex trauma histories and serious mental health problems they did not easily fit into the existing statutory mental health offer. However it was observed that Fulfilling Lives clients were accessing accommodation based and homelessness services and building relationships, and engaging, with the staff in these services.
Fulfilling Lives reflected on these observations from the frontline of service delivery. As a response a literature review was conducted around meeting the psychological needs of homeless people. A growing community of practice was identified around an innovative approach to this longstanding and entrenched system failure. This new approach was called "Psychologically Informed Environments (PIEs)". Supported by three services from within the Fulfilling Lives core partnership (Mental Health Concern and Oasis Aquila Housing) a pilot was delivered looking to introduce three different services to the PIE model.
This report seeks to answer what was the impact of the PIE pilot? and What are the implications for the wider multiple complex needs system? Drawing on interviews and focus groups conducted with staff and managers of all the participating services this report uses learning from the delivery and outcomes of the pilot to provide recommendations for embedding PIE in the wider system.
From Fulfilling Lives - Newcastle & Gateshead

Impact of the PIE pilots

The following section of this report looks at the impact of the PIE pilots on the three services. No specific outcomes were set at the start of the pilot so the evaluation is looking at impacts as entirely self-reported by those that participated in the pilots and was interpreted using a grounded theory approach. Despite no intention on the part of the researcher to match the reported outcomes against the five key elements often used to define what a PIE should look like, generally the outcomes discussed naturally fell within these headings (with the exclusion of the fifth element – evidence generating practice, of which this report falls under). As such this section will look at the findings of this evaluation in relation to four of the key principles of delivering a PIE:

1.Relationships

2.Staff support and training

3.The physical environment and social spaces

4.A psychological framework

These are the key elements that are highlighted in the Westminster guidance³ (2015) for creating a PIE. To create objectivity and a transferable approach to this evaluation the objectives used for each principle within the Westminster guidance have been used as a mechanism for measuring success of the pilots. These objectives appear below their relevant section headings.

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³ No One Left Out: Solutions Ltd. [MEAM] (2015) Creating a psychologically informed environment. implementation and assessment. London: Westminster City Council.

Relationships

-Relationships are recognised as a the principle tool for change

-The impact of positive peer relationships is harnessed

-Clients with complex needs are not excluded

In looking at the impact of the PIE pilots in relation to the above objectives, strong positive outcomes can be seen. This is in particular for two of the services involved: the day centre and one of the accommodation projects. The second accommodation service was less receptive about the impact of PIE although positive outcomes were also observed.

A common theme that was represented in all the focus group discussions was the opportunity PIE had given them to open up conversations about a client to a wider peer group and embrace different perspectives:

“When there’s a few of us there, we’re picking the brains of colleagues and things, we’re thinking, “Well that actually might work,” and people are just saying, “Well have you tried this?” or, “Is this person doing this because...?” or, “Is the approach wrong?” It just gives you the mindfulness to think, “Well actually it might be wrong. This person might not be responding to the A, B and C that’s in black and white, they might need something else outside the box.” It gives you a bigger picture.” (FG-2)

This was particularly observed in how the implementation of PIE had influenced perceptions of role hierarchy in the two accommodation services who employ nurses. Across the interviews and focus groups at both these services the hierarchical nature of nursing was raised. In particular in that it creates a situation where “the nurse has the power, and the nurse writes the stuff down, and the nurse knows what her outcomes is going to be”. PIE introduced a space where those boundaried roles were levelled out into “a more even playing field”. The benefit of this was recognised across both services as it helped to encourage input and ideas from different roles in a positive environment: “what I got from it was support workers’ views and I found, as well, that they were more open in a setting where they could say what they wanted to say, without fear of any repercussion” (FG-3)

In relation to hierarchy and nursing there was an interesting contradiction that presented across the two accommodation services. As discussed above, in both services the influence of PIE breaking down a traditionally very hierarchical structure was raised. However whilst in one service PIE was seen as “the nursing process but with more detail” (FG-3) in the other it was seen as something that would “challenge the way that we traditionally work as nurses” (Interview-2). The former of these services was the service where the PIE was seen to have less of an impact than amongst the other two services. It’s interesting to note that in the interview and focus group for this service boundaried roles were discussed significantly more than in any of the other services, and there were repeated mentions that nurses may have found the training more accessible than support workers. Interestingly, despite commenting that “we’ve got very good support workers who would tell us anyway” (FG-3) there was still a strong implication in the language that there was a divide between nursing staff and support workers. This was echoed by the language used by support workers themselves: “I didn’t know what to expect [from PIE], not being a trained nurse. I’d never heard of it before” (FG-3). The implication of which is that a trained nurse would know about PIE, despite it being a new concept for all involved. It’s interesting to observe the contradiction in the language and underlying attitude in contrast with the observed benefits of PIE in helping to encourage a more horizontal rather than hierarchical relationship between staff members.

How building and developing positive peer relationships translates to impacting on clients was highlighted by one of the accommodation services who talk about changing attitudes towards a high risk service user with complex needs:

“we’ve got a service user who’s got a diagnosis of emotionally unstable personality disorder, and she’s got a long history of being in very contained environments, and, before we actually met her, we got a risk assessment through for her, which was really scary, when you read it; it was really frightening.” (Interview – 2)

“We went into that meeting quite negative, thinking this is a woman who came from prison, came straight back to our services, was alcohol dependent and we just did not know which direction to go with her.” (FG-2)

The staff discussed how having the opportunity to use those peer relationships helped them to understand how to approach working with this client and that changed their attitudes towards working with someone with a high level of complexity and need.

“I got feedback from other members of staff, particularly I think it was support workers and students…She had highlighted that she wanted to do some cleaning so we introduced a little bit of that. She hasn’t drank now for nearly four weeks. So there is, I mean I’m not saying that’s going to happen for everybody, but to get just a little bit of glimmer that there’s a little way in there to try and help s...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Executive Summary
• Findings
• Foreword
• Introduction
• Impact of the PIE pilots
• Implication for the wider system
• Recommendations