The Trials and Tribulations of a CPA Teacher in Wales

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Most Useful article in The Approach as awarded by the readership

Do I dare take myself out of my ‘comfort zone’? This was the question I asked myself in May 2005 when I saw an opportunity for a secondment as a Care Programme Approach Trainer in Cardiff and Vale Trust. Initially I dismissed the idea, for no other reason than I was enjoying being in my comfort zone, with twenty years of nurse experience, the last ten of which I had spent as a Community Mental Health Nurse, (CMHN), in Low Secure Services. What I hadn’t accounted for was the effect that the Royal College of Nursing, (RCN), Clinical Leadership Programme would have upon me. As a participant, the only one from mental health services, I was actively encouraged to challenge practice, to be innovative, to go where no man has gone before! With this in mind and some previous teaching experience I applied, maybe it was time to leave my comfort zone, albeit temporarily.

That, in a very small nutshell, is how I was appointed on a twelve month secondment to the grand title of ‘Clinical Practice Teacher for The Care Programme Approach’. I became part of a very exclusive club in Wales, with a membership of one as the only full time dedicated CPA teacher.

And so began my trials and tribulations, though I am sure many of my experiences are unsurprising to those of you who have been implementing CPA over the past sixteen years or so. I saw in the CPA process a means of streamlining and formalising procedures across a mental health service, which covers a population of 443,000, and I was eager to tell my colleagues about it. I set up a training programme, which would be multidisciplinary in its approach including Local Authority staff. The training would be delivered over two days, though not necessarily run consecutively. The first day looked at the process in depth, breaking the CPA process down into its constituent elements. The second day examined Risk Assessment and Risk Management to emphasise how important both were within CPA.

I decided to target the Community Mental Health Team’s (CMHT’s) initially, and, to test the waters as it were, I decided to deliver the first session to the team I had left to take on the secondment. It paid off, they were kind, they nodded sagely in all the right places, they seemed to be embracing the message I had been tasked to put across. Things went down hill from there on in. I rated subsequent sessions with the (CMHT’s) on a ‘hostility scale’. Staff responses started at ‘mild annoyance’ and escalated to ‘imminent personal danger’ (to myself, not them!)

Colleagues who I might have called my friends, my past drinking buddies, were openly hostile to CPA , who was I to tell them what to do? It was all my fault, had I invented CPA ? A crash helmet would have been handy at times, just to dodge the rotten fruit being thrown my way.

This was all assuming I got enough people in the room in the first place. Getting bums on seats was a challenge in itself. While training was my priority, it wasn’t theirs. You can understand why - they were sent on training, there was no end academic reward as such, and I was up against general staff shortages, sickness and anything else, which was always perceived as more important.

But I was not going to be defeated and took solace and shelter in the CPA office, supported by Alison Davies the Lead CPA Co-ordinator and Linda Sheppard the CPA Administrator. I hadn’t accounted for staff being so resistant to change, though I should have known better after twenty years service. A comment from a well respected colleague, ‘Why have you decided to make yourself the most unpopular person in the service?’ was also a small clue to the task I had ahead. In the spirit of the RCN Clinical Leadership Programme I decided to start each session with a thought for the day. This was accredited to Brian Tracy, someone who had written extensively about leadership in the States. He said:
‘Resolve to be a master of change rather than a victim of change’

How apt, I thought, in relation to implementing CPA . And that is what I told our staff. That you have to take control, make it work for yourselves. Don’t ignore it, because it’s not going away, as I think some people thought.

The one faction that has probably been most resistant and conspicuous by their absence at training is that of our medical colleagues. In fairness some have been receptive, though many more have not and this is an issue, which perpetuates to this day.

The CPA training has also highlighted further training needs. Staff have pointedly said they feel they need training on writing care plans from a needs and strengths perspective, never mind trying to cover the whole issue of risk assessment and risk management in one day!

But it has not all been doom and gloom. There are like minded individuals who do embrace change and want to get it right. These are the practitioners who have always done what is expected of them and will say ‘Well we do that anyway’.

As time has gone on tempers have cooled. Those staff who now attend training have a much better understanding and working knowledge around the documentation and the process as they use it in the work place. A twelve month audit carried out by the CPA Lead has shown a marked improvement in quality in eight out of twelve clinical areas. More staff are commenting how they see the process as a positive one with definitive gains for service users.

The implementation of CPA has been a steep learning curve for all concerned. From July 2005 to the end of October 2006 approximately 770 staff in mental health services in Cardiff and Vale Trust have completed CPA training. My secondment, which was originally for twelve months was extended for a further four months, but is now at an end. Despite the trials and tribulations I have enjoyed the experience and it has not dented my enthusiasm for CPA and my faith in it as a process, though I am not sure I would have survived it this long without the support and even greater enthusiasm of Alison and Linda in the CPA office. Would I do it all again? Well, yes I would, I’m a sucker for punishment! But I am not returning to my comfort zone entirely. I will continue to deliver training two days a month, to catch new starters and those staff who have fallen through the CPA training net.

It will be strange going back to clinical practice, picking up where I left off in many respects and, as one colleague pointed out, I will have absolutely no excuse for not getting CPA right!

Laurence Doyle, RGN RMN MSc PGDip, Clinical Practice Teacher for CPA and Risk Assessment (Seconded), Mental Health Services, Cardiff & Vale NHS Trust