AWARD WINNER 2014-15: Johanne, a nurse at HMP Stafford, receives an Award for her work in the management and care of prisoners with anxiety disorders, in particular with veterans with PTSD and related conditions. Johanne was nominated by a prisoner, and armed-services veteran, who praised her “complete dedication, understanding, commitment and professionalism”. [This Award is supported by G4S Care & Justice Services.]

Johanne Tomlinson, the Lead Nurse for Anxiety Management at HMP Stafford, has already garnered an array of awards for her work, including an Order of the British Empire in the Queen’s Birthday Honours List for Services to Prison Nursing, and as overall winner of the Nursing Standards award, Nurse of the Year 2012. She was nominated for a Butler Trust Award by a prisoner who says “she has shown complete dedication, understanding, commitment and professionalism when conducting the Veterans’ Anxiety Group. The first of its kind in HMP prison service, [Johanne] has developed a course that can and will only grow stronger throughout the prison service.”

That group, geared to ex-servicemen struggling with post-traumatic stress disorder (PTSD), was one of several Jo created to address anxiety among HMP Stafford’s offenders. With a background in Child and Adolescent Mental Health Services, Jo had noticed the prevalence of anxiety – what she calls “the common cold of society” – and its impact on behaviour and risk among prisoners, including the vulnerable and veterans. She notes that recent studies claim 72% of male and 52% of female young offenders suffer with anxiety-related disorders badly enough to warrant specialist intervention.

Jo reports that her idea of specifically addressing anxiety initially “met with scepticism,” with “prison culture suggesting containment and medication was the primary avenue of treatment.” However, as so often among those working in prisons who confront a roadblock to change or innovation, she responded by applying “personal determination and persuasion to drive through the need for improvements.”

Now, however, she has the enthusiastic support not only of the prisoners under her care but colleagues, too, including HMP Stafford’s Governing Governor, Bridie Oakes-Richards, whose hand-written recommendation is worth quoting in full:

“Johanne’s work on anxiety management within a custodial setting is ground-breaking and will influence the future direction of nurse-led interventions in this arena. Anxiety disorders in prisons are diverse, complex, and common, and this is true for veterans who are in custody. Johanne recognised unaddressed anxiety disorders in our prisoner population which were potentially developing into depression, suicidal thoughts, poor self-concept and low self-esteem, poor coping skills, personal isolation, diminishing health and numerous fears relating to release; she worked with others to design and deliver an anxiety management programme that prisoners, including ex-servicemen, find beneficial, helpful and empowering. Johanne’s insight, care and professionalism single her out as a very special person who has positively touched the lives of many people living and working in HMP Stafford.”

In an affecting short film for the Royal College of Nursing Congress in Liverpool, a number of prisoners describe the impact of Jo’s work. “Jo’s the first one I’ve ever come across who takes a personal interest in how you feel,” says one, while another adds, “It made such an impact on me, and I’m a hard person to make an impact on, believe you me, but this did.” As one put it simply and powerfully, “It’s like a whole world has opened up in front of me.”

Jo’s work not only has an impact on the prison system – and she has ambitions to extend her good practice both nationally and internationally – but, as she herself notes, on others too. “You’re not just giving a future to the men you’re working with,” says Jo, “but you’re giving a future to their families as well.”

As well as decreased anxiety levels, Jo reports better self-management skills, improved self-esteem, reduced incidents of self-harm, and reduced incidents of antisocial behaviour.

In her work with veterans’ group, she has forged links with a number of charitable organisations, including Combat Stress, THRIVE and Shoulder to Shoulder mentors, including access to Combat Stress’ 24 hour Freephone helpline for veterans manned by specialist mental health workers.

Jo is now taking the lead in rolling out her programme within all 6 prisons in her organisational cluster, while campaigning to extend it regionally, nationally and, if given the opportunity, internationally. “I feel I have changed the culture and treatment of anxiety disorders within the custodial setting to the benefit of all,” says Jo – and so do we.

IN THEIR OWN WORDS

[Johanne Tomlinson gives her account of the work for which she won her Award]

It has been said by some that “anxiety is the common cold of society”

I have developed for HMP Stafford an anxiety management programme to address the link between anxiety, self-medication and offending behaviour the intervention assists in educating participants on what it is? What causes it? and how to cope. This has led to decreased anxiety and increased self-esteem and self-belief all vital attributes required to reduce reoffending.

The Anxiety Management intervention at HMP Stafford addresses the link between early onset anxiety disorders in childhood, life experience and the potential for future behaviour. It recognises the impact that untreated anxiety can have within the prison population. The Nurse Led Intervention that I developed provides education for clients suffering anxiety while facilitating self-awareness into the cause and effect of heightened anxiety aiming to provide a service that delivers both practical and psychological support. Components of the intervention include:

• Psycho educational
• Thinking styles/Challenging faulty thinking
• Self awareness
• Self esteem
• Problem solving
• Goal setting
• Coping skills
• Assertiveness/Communication skills
• Healthy lifestyle
• Relapse prevention

A supportive psychological environment has been established reducing instances of drop out by helping participants to understand the reasons for their changes in mood. Participants enjoy a relaxed and informal atmosphere in which they are encouraged to discuss thoughts and feelings openly the results have been;

• Decreased anxiety levels
• Better skills to self-manage anxiety
• Improved self esteem
• Reduced incidents of antisocial behaviour
• Reduced episodes of self-harm
• Improved self-belief
• Better problem solving and coping skills
• Hope for the future on release from prison
• Reduced need to self-medicate with alcohol and drugs which in turn reduces the risk of reoffending

There is an increased awareness of the high numbers of ex-service men entering custody many have experienced active service in war zones and now suffer the psychological disorder Combat Stress. As lead nurse for the anxiety management at HMP Stafford I found I was receiving increased numbers of referrals from concerned staff about these prisoners the only service provision at that time was GP referral and monitoring by primary mental health which was not enough to support these men while in prison It was not dealing with the issues of the immediate and long term effect and for many of them this meant suffering in silence.

So to meet these needs the service was developed further to include a care model for prisoners who were ex forces personnel suffering issues with emotional wellbeing and heightened anxiety this was in the form of a “ten point care pathway” providing support whilst in prison as well as a structured support package on release back into the community.

Both interventions have been well received by all departments within the prison with the results themselves demonstrating the significant role that such a service plays in the custodial setting, proving to assist in safer custody for those who may be suffering with anxiety and until now had been labelled as “just another difficult prisoner”, improving outcomes not just for the prisoner but also family, friends and society as a whole.

My own professional background is in Children’s nursing within Child and Adolescent Mental Health Services and it was at this time that I identified the link between untreated childhood stress and anxiety, self-medication with alcohol and drugs and offending behaviour by young people. After working in this area for four years I made the decision to apply for a nursing position within offender health in prisons with the intention of investigating and Identifying whether high levels of anxiety disorders do in fact exist in prison settings and if so to assist in the development of a suitable service to demonstrate that behaviour modification could take place with appropriate service provision hence resulting in increased opportunities for reduced reoffending and successful resettlement on release back into the community.

Initially when I discussed my idea with prison Governors and Healthcare managers both were very supportive giving permission for me to research an appropriate intervention and develop the anxiety management service. However my idea was met with scepticism within the prison environment itself this may have been due to a number of factors including a fear of change by staff with Prison culture suggesting containment and medication was the primary avenue of treatment, nevertheless I used my personal determination and persuasion to drive through the need for service change and improvements.

I achieved this through building positive relationships within all departments along with demonstrating the positive outcomes from such a service, once other staff within the prison saw the benefits of the Intervention it very quickly grew momentum and became a well-respected service one that Governors, Prison Officers and staff from all departments engaged with to access advice, guidance and support. Prison Officers own knowledge on the impact of anxiety developed alongside their personal and professional skills assisting them in dealing positively with these men which in turn reduced confrontational situations. It is worth mentioning that sometimes when something has always worked in a certain way and staff have been a part of that service it can generate a “fear of change” but this can be overcome through taking a thoughtful approach and involving staff so they feel a valuable part of that service too. I found by raising staff awareness in addition to educating on the benefits of new ways of working these barriers were able to be removed.

Other challenges along the way have included finances, resources and operational pressures-in this never ending era of public service cutbacks nobody is safe and to keep the service going has meant “staying with it” and “continuing to push it through” this has been achieved through maintaining positive relations with internal and external stakeholders and constantly producing new evidence to demonstrate the importance of this service and the” beneficial domino effect of such a service”

While we talk about producing good practice and the success of interventions it is important to highlight that one of the main considerations in the successful implementation of any service is good team working and relations, without this it would be extremely hard to run any service particularly within a prison environment. I always refer to a prison environment as a “community within a community” and within that community are various personalities and professions, so supporting each other and sharing “what works” is paramount to success.

One would have thought that in a male Cat C prison gaining the trust and engaging with the prisoners themselves would be the biggest challenge but surprisingly this was easier than I initially thought with many of the men talking of “feelings of relief” at finally having an understanding as to why they have felt and behaved as they have for so many years, no longer feeling alone and pleased to discover they are not the only ones feeling as they do, they support each other on the residential wings and also “look out for others” that may have anxiety issues and offering support to them, for these men the service has meant opening up a whole new support network one that they rely on and trust providing them with a “whole new world of opportunity”.

Due to recognition of the value of such a service within offender settings the service is currently undergoing further development both at HMP Stafford and within our organisations other five prisons and youth offender services current developments include;

• Setting up the service as a “Nurse Led intervention for emotional wellbeing” this extends the scope of the service to prisoners suffering various types of emotional issues rather than restricting access to those only suffering with anxiety.
• Implementing and extending service into all six prisons, youth offending institute, juvenile establishments.
• Integrating the intervention into the service structure of the “Primary mental health team” as part of a commissioned serve-this improves the accessibility for prisoners suffering anxiety and emotional distress.
• The service is now investigating how similar interventions can be developed and used within our Youth Court Diversion service. The main aim of these interventions would be engaging the young person through the provision of innovative, creative, interesting interventions that will allow the young person to access support with any personal or health issues reducing the risk of any reoffending behaviour.

The latest development of the service is a twenty eight day nurse led intervention to support prisoners on release from prison using digital health and skype. I am hoping that this will provide a window of opportunity to support the transition from custody to successful resettlement back into the community and at the same time reduce the risk of reoffending behaviour. The initial pilot will be launched from HMP Drake Hall a female prison where evidence has demonstrated a large proportion of the population have a diagnosis of an anxiety disorder which manifested itself prior to the offending behaviour.

Sharing good practice is paramount to improving service provision and outcomes I have had the opportunity to present my work on a local, national and international level. Since being awarded the Butler Trust award I have had further opportunities to share good practice with others and to also develop the service further which has inspired colleagues and given them the confidence to take their own ideas on service improvement forward.

I now plan to apply for a “Winston Churchill travel fellowship” this would enable me to visit the USA and Australia where research demonstrates that there are innovative early intervention schemes for children and young offenders with anxiety disorders taking place – this would assist with my own research and allow the gaining of knowledge and a two way sharing of good practice.

I have taken up a new post as research nurse leading on offender health and community studies at the same time I am studying for my professional Doctorate which will feature a written thesis titled “The lived experiences of adults who suffered anxiety as children”- How did society respond and was this enough?

I feel as a result of developing the anxiety management service at HMP an encouraging transformation has occurred in both the culture and treatment of anxiety within prisons which can only result in improving opportunities for successful resettlement back into the community and a marked reduction in reoffending rates among this group. However if we are to succeed in lowering offending rates in the community then childhood anxiety and access to early intervention services needs to be taken seriously as the saying goes “prevention is better than cure”.

A large scale awareness needs to be raised on the debilitating effects of untreated childhood anxiety many of the prisoners that have engaged with the anxiety intervention to date claim to have developed their anxiety as children unfortunately this either went unidentified, inappropriate services were offered or no service provision was put in place with many going on to self-medicate with alcohol or drugs to relieve symptoms or make themselves feel better in turn leading onto their offending behaviour.

We as a society cannot wait any longer the change in access to and the existence of early intervention services must become a reality – not just a talking point or a tool for a political debate-this topic must be taken seriously too many children are being let down by a society and system that should be caring for them and ensuring their needs are met. How many more children’s futures will be blighted? How many more families will suffer? And how many more victims of crime will there be before something is eventually done? This issue requires people or a person to have the personal determination and passion to drive this through the difficult and challenging process of becoming a reality and sometimes it just takes one person to push through change-maybe that person will be me?