Sophie Farrer is a Nutritionist working within Secure Inpatients Services at Roseberry Park hospital. She covers wards which include Mental health, Learning Disabilities and Autism. This is her first year in the role since graduating from Sheffield Hallam University as a Registered Associate Nutritionist.
Dale Crookes is the Clinical Lead Dietitian for Secure Inpatient Services at Roseberry Park Hospital. Her role involves managing the Dietetic team in the Secure Inpatient Setting as well as clinical work with low and medium secure service users including service users with extremely complex mental health issues, learning disabilities and autism.
Sophie, could you tell us about your role and what it involves?
As a nutritionist it is my responsibility to provide personalised evidence-based nutritional advice, to improve overall health and wellbeing, through encouraging healthy lifestyle changes. I currently support around 40 male and female service users with learning disabilities, autism and mental health illnesses who are situated on both low and medium secure wards. I support service users both on an individual and group basis, covering predominantly weight management strategies and nutrient requirements. The main focus is ensuring individual nutritional goals are created to achieve and maintain a healthy weight and a optimal nutritional status. In addition to this, the onsite cafes also require nutritional input to ensure adherence with CQUIN targets. Developing and analysing menus reducing sugar, salt and saturated fat content in products available across the service. Traffic light labelling, health promotion displays and resources are currently being encouraged across the site.
Dale, could you tell us about your role and what it involves?
From a clinical point of view my role involves working in a mental health setting focusing on service user’s physical health conditions to try and ensure nutrition status is optimised and service users are safe. I also line manage the dietetic team within SIS, am part of the clinical lead management team for the AHP team in SIS and work as part of the Dietetic Leadership Team within the wider Trust.
How did you both end up working in this area?
Sophie: During my mid-late teens I always knew I wanted to pursue a career in Nutrition due to my love and enthusiasm around food and exercise. At this point I was unaware of the different career paths linked to having a nutrition degree which lead me to study Bsc Nutrition, Diet and Lifestyle at Sheffield Hallam University for 3 years. I graduated in November 2019 with a first class honors. Once I had finished my final year of university I started volunteering for Wellbeing for Life which is a service delivered by County Durham and Darlington NHS foundation Trust. I used my knowledge from my degree to help support individuals in the community making healthy balanced choices which included the use of goal setting techniques. In January 2020 I started in my current role as a band 5 Nutritionist within Secure Inpatient Services.
Dale: My training started in 2009 as a Nutrition and Food student at Leeds which then led me to Coventry University to complete my Dietetics Degree in 2012, once I graduated in 2016 I was able to secure a band 5 rotational job at University Hospital of North Tees which allowed for experience in the following areas: Gastroenterology, Trauma, Women’s Health, Pediatrics and Gastroenterology Pediatrics and General Medicine which helped me to really develop my dietetic skills and knowledge. After a year in a rotational role, in 2017 I was lucky enough to progress into a band 6 Secure In-pt Services Specialist Dietitian working in my current place of work where I was able to develop my knowledge in mental health setting and really specialise in a very unusual but fascinating area of dietetics.
What does a typical day at work look like for you both?
Sophie: Usually I start the day by checking my emails and looking to see if any referrals have come through. I will then organise and familiarise myself with my diary and to do list. My day is normally split 80% patient focused work which would generally include; 1-1’s, weight management groups, development/adjusting service users’ dietary plans, service development and writing up notes. The other 20% includes system level work such as; service user focused meetings, report writing, team meetings, team development meetings, nutritional analysis’ and audits. Normally I would see service users in the morning and early afternoon to ensure I have enough time to complete notes and any follow up tasks.
Dale: My typical day is pretty similar to most dietitians: checking the referrals inbox and emails from staff regarding any patients then plan my day as per priority cases we have on the case load, see the service users then write up notes. While in between ensuring the Dietetic team is feeling supported and managed well and providing leadership to wards who are caring for some service users with very complex needs where nutrition is a huge factor. I am able to complete audits and research to ensure we are moving the service forward in the best possible way. Along with continuing to develop the service for example taking a big role in the Maintaining a Healthy Weight in Secure Services CQUIN within the service as well as developing trust wide services such as the new recording system for clinical work.
What do you most enjoy about your job?
Sophie: I thoroughly enjoy my job. Although stressful at times, the majority of my time is spent engaging with service users on a 1-1 basis which provides me with the opportunity to undertake direct work with a variety of patients who have different diagnoses and associated issues. Due to my time spent engaging in 1-1’s, this provides a greater opportunity to help understand their mental health illnesses and previous trauma which can open up a whole new chapter of my role as a nutritionist.
I love the fact every day is different; there are undoubtedly ups and downs but overall I feel I am making a difference, however small.
Although I most enjoy working within the dietetic team but also as part of a multi-disciplinary team whether this be on the wards or during patient focused meetings. This has enabled me to gain an insight into a variety of perspectives in terms of mental health which in turn has helped to develop my role within the service. For example working closely with psychologists to develop risk formulations and plans to maintain safety while in hospital.
It is also rewarding seeing service user’s progress through the pathway and out into the community to live an independent life, especially if you have been there for part of their journey.
Dale: I love being able to know my service users well, due to the environment they are in the service usually for a minimum of 4 years, therefore I get to understand their needs well, so I can be as patient focused as possible. It’s a journey for them to get better and healthy, focusing on their mental but also physical health. I like the fact I know two patients aren’t ever the same; their mental health, trauma and dietetic needs are so different that it makes for new challenges every day. I also love the fact that as an MDT we work very closely together to ensure the best possible treatment for the service users.
Dale, what is the role of a dietitian in a forensics setting? What sorts of dietetic support do you provide to your patients?
I can see a range of service users in a day from weight management to restricting diet and refeeding risks which both can be linked to significant past traumas or poor mental health status. Many physical health conditions such as poor wound healing, diabetes, bowel disease and CVD, cancers etc. I also work alongside the wider team to provide things like formulations of a service users history especially around eating and drinking, help lead CQUIN’s within the service that are around food to make the service a less obesogenic environment to live in and also work alongside the Catering department to ensure nutritionally balanced meals are provided to service users.
Sophie, how does your role complement the role of the dietitians? What additional benefits does a Registered Associate Nutritionist bring to the team?
Unfortunately my degree did not include a placement year and as this was my first job as a Registered Associate Nutritionist I wasn’t really sure what to expect at first when working alongside a dietitian. I have noticed many similarities between our roles although there are also differences between our work and the registration requirements of each profession. As a nutritionist I am qualified to give evidence based advice to service users with pre-existing medical conditions for example type 2 diabetes, high blood pressure and high cholesterol; whereas dietitians are qualified / regulated health professionals who assess, diagnose and treat dietary and nutritional problems.
There are times where we can have the same service users on our caseload which is usually as a result of two separate referrals. As an example I (nutritionist) generally see service users for weight management but during this time a recent complex diagnosis may require a referral for dietetic support. This is where we can offer support to each other and work collaboratively ensuring the service user receives the best treatment.
Having a nutritionist allows the dietitian to focus on the more complex service users while maintaining a high level of nutrition based support. Further to this we have noticed that a nutrition degree focuses more on vitamins and minerals which are all really important in this service with the main focus being on vitamin D. Given the increased incidence of vitamin D deficiencies in patients with serious mental health illnesses coupled with the lack of natural sunlight exposure could lead to lifelong physical health issues. Therefore there is a requirement to ensure service users are aware of vitamin D, the importance and the recommendations to ensure they remain healthy.
I also tend to do a lot of work around nutritional analysis using Nutritics software whether it is for a specific service user or the hospital menus. This is something I enjoy doing (weirdly). I can then share this information with Dale who then accurately calculates the individual’s nutritional requirements. We compare both pieces of information to ensure we can provide the service users with the relevant advice, support and in some cases diet plans.
Dale, what are some of the key considerations when conducting a dietetic consultation with a secure inpatient service user? Perhaps link in with A, B, C, D, E dietetic care process
We use the ABCDE care process so we would look for the following in each section:
Weight Height BMI, Weight Change, SANSI Score
looking at blood results depending on their clinical need the same as dietitians would in any service, I need to take into consideration the blood results in line with medications such as antipsychotic medications.
I look at the PMH, Current issue/s, Family history, mental health diagnosis’, trauma history, previous admission to services, Formulations and risks etc.
Completion of nutritional requirements in line with PENG guidance
I would look at food and fluid charts, look at current diet, ask for usual diet, see if changes on weekend’s etc.
Would look at if they had leave from the service to access foods or activity, would look at risks around being in the kitchen, cooking skills, family access etc.
Why do you think there is a stigma about working in forensics/mental health? What could we do within the profession to address this stigma?
Dale: I think that the stigma around mental health comes from people not understanding it well, within dietetics there is not usually much teaching around mental health issues and how these can impact on a persons nutritional status. Our service users face stigmatisation from that point of view but also from a forensic point of view and being part of the justice system.
I think we can address this issue by teaching more in uni courses but also offering placements for students to have the opportunity to understand the service more.
I also think the more forensic dietetic teams are promoting their services will be beneficial. We need to educate people on what it is really like rather than letting peoples imagination run wild from listening to the media etc.
Sophie: Those admitted to forensic mental health services face double stigmatisation with regards to their mental health issues and their offence. There are many service users who have serious and complex mental health conditions but, at the end of the day they’re all still human, as are the staff who work there. It is important to find the balance between discussing the positives of working within forensics but like elsewhere this comes with its drawbacks. Some things we could do within our professions to address the stigmas:
- Knowing and passing on the facts. Raising awareness and increasing education opportunities focusing on mental health illnesses and substance use disorders. Challenge any incorrect information.
- Completing more podcasts but for other roles within SIS for example nursing and psychology.
- Live talks or question/answers on our forums whether that be the BDA or AfN.
Dale, how is staff safety and wellbeing prioritised in a forensics setting?
Staff wellbeing is extremely important within a secure inpatient service, our staff need to be well to be able to treat our patients effectively, therefore their safety is paramount. The service is a very challenging but rewarding place to work. We have a security team that are on hand when we are on the wards if there are any issues. We all have alarms to ensure that if assistance is needed we can get this within a matter of minutes.
Staff can become overwhelmed due to the traumatic things they hear and see. However as a service we offer a huge range of wellbeing activities such as an 8 week mindfulness course people can access if needed. We use regular supervision and debriefs for staff, we try to ensure we are promoting different positive coping strategies. We also have an amazing wellbeing team within TEWV who can also offer counselling or physiological input if this is also needed.
Sophie, what are the biggest challenges in your job?
Within the service we currently have over 90% of service users who are overweight or obese; this is a huge concern considering the physical health issues associated with having an unhealthy diet and excess body fat. It is well known that antipsychotic medication can have a significant impact on service user’s weight causing rapid weight gain. Antipsychotics are often reported to increase hunger and cravings for sugary foods as well as reducing satiety. This is coupled with lifestyle factors such as poor diet, previous smoking habits and low physical activity levels. Therefore when seeing service users for weight gain it is important to consider medication and ensuring they’re made aware of weight management strategies to prevent any further increase. However, despite having the support available to help make lifestyle changes some service users don’t want to be helped. This may be linked to their risks and it’s important to be resilient. I have learnt it takes time to build the positive, supportive relationships with service users who will after time begin to trust and allow you be a part of their care and recovery. Although without a doubt this takes time, consistency and perseverance.
I think one of the main challenges is that you’re not going to get a win every day. Each day is different whereby somedays you can see some good results and other days perhaps not.
How do you both maintain your CPD in this niche area?
Dale: I make sure I am doing a session monthly to keep up my CPD portfolio even if it is a reflection on something I have found more complex from a clinical point of view, looking at courses that are informative around physical health illnesses or new types of treatments. We also have team meetings regularly where we have CPD sessions as part of this to ensure as a team we are up to date. I think continuous learning is extremely important due to treatments always evolving from a physical and mental health point of view. I attend the mental health dietitians forums as well as the national forensic dietetic forum to help me to develop my skills further.
Sophie: Although we want to develop professionally while being mindful of maintaining a healthy work-life balance we are eligible for an afternoon per week to complete CPD. This is to ensure we are continuously learning, developing and thereby improving within our practice. I guess it is important to take every opportunity as it comes.
Furthermore, I am lucky enough to be starting external supervision with a nutritionist but within another field. I expect this supervision will provide me with further opportunities to enhance my CPD. Since a lot of events have become virtual as a consequence of COVID-19, this has saved time with regards to travelling, giving us the opportunity to reflect.
I am included in some graduate nutrition forms on social media which also keep me in loop of any upcoming CPD which may be of interest.
After 3 years of professional experience in nutrition as a Registered Associate Nutritionist I am able to apply to become a Registered Nutritionist. This requires the development of portfolio which shows I have kept my professional knowledge up-to-date and how my nutrition skills have developed through professional experience since graduating.
What impact does your service have on patients/service users? Do you collect any outcome data?
Sophie: With regards to the outcome data, we have recently completed a piece of research which looked at the effects of lockdown on BMIs in SIS. We had some quite positive results from this whereby 39.5% of service users BMIs reduced during the first lockdown. This weight loss was linked to the following reasons; reduction of takeaways, increase of ward based exercises eg ‘move and grove’, cycling challenges and unable to access as many unhealthy snacks. It is important to consider that during this time all leave and visits to and from the hospital were put on hold which was noted to be particularly detrimental to the patients mental and physical health. I think this was data collection was helpful to help recognise the impact lockdown measures can have on service users within this setting. We have also been able to establish good areas of practice which have continued to be implemented onto the wards due to seeing good results and positive feedback.
Dale: Nutrition and BMI Clinical Link Pathway / SANSI was implemented in Tees Esk and Wear Valley and each service is auditing the completion and accuracy of the care documents and the intervention plans put in place to help people maintain a good nutritional status.
Do you have any tips for those interested in working in this area?
Dale: I would defiantly encourage people who are kind, compassionate and up for a challenge to consider working within a Secure Inpatient Setting. The setting is perfect for those professionals who want to work with some of the most vulnerable people in society and try to help make a difference to their lives for the better. The changes we see can be slow but the effect it can have on service users confidence and life skills is immense.
Sophie: I would definitely advise people to step out of their comfort zones. If it is something you’re interested in then perhaps look into career prospects within this area. During your time studying explore all the options for placements especially within forensics as this will help gain experience and improve confidence. Do some background reading beforehand, contact staff who work there who could help answer any questions or queries. If possible query any shadowing opportunities.