Positive And Proactive Care.

Reducing Restrictive Practice

The PICU setting

Presented by

Laura Woods Charge Nurse Pavilion PICU, Julie Allan Art therapist

&

Natalie Cadman Ward Manager Amber PICU

Sussex Partnership NHS Foundation Trust provides inpatient mental health services for young

people, working age & older adults. The Trust covers the South East of England and beyond There

are four mental health wards and a substance misuse detoxification unit at Mill View Hospital:

Regency (Male Acute Care), Caburn (Female Acute Care), Meridian (Integrated) and Pavilion Ward

our ten bedded Psychiatric Intensive Care Unit

Philosophy of care – vision statement

‘Philosophy of care’ refers to the values and attitudes on which the service you receive is based. We express this through our ‘vision statement’ as follows:

Pavilion PICU Vision Statement

Welcome to the unit

Pavilion PICU is a ten bed, male only locked unit providing intensive care for people who are

experiencing acute mental health problems or need assessment.

We aim to provide a safe environment for all patients, staff and visitors.

We value and respect the differences in individuals and we will treat people individually with

compassion, fairness and equity.

We are committed to providing excellent standards of care and treatment to optimise recovery.

We recognise the importance of good, clear communication that all patients, carers and relatives can

understand.

We will act as advocates for patients, carers and relatives.

We recognise that Pavilion PICU is the first step to recovery and will encourage all patients to take an

active and responsible role in this process.

4

Restrictive Practice Seclusion use..

The team on Pavilion PICU collect data relating to seclusion. This shows a reduction in the use of seclusion over a four year period.

0

20

40

60

80

100

120

140

160

Incidents

1 2 3 4

Year

Incidents of seclusion 2011-2014

How have we reduced?

•Focus Group

•Environment

•Formulation

•Relational Security

•Team culture

Team Culture

“A culture of teamwork and client focussed care is embedded in everything that

is delivered”

Anne Martin Practice Education Facilitator

“My Placement on Pavilion PICU restored my faith in mental Health Nursing”

Return to Practice Nurse

A culture of reflection is central in reducing

restrictive practices. Providing a space for

relational security to be established and

maintained ensures restrictive practice is as a

last resort always.

Environment…

“The garden provides patients with a productive role on the ward – giving them a sense of purpose and achievement during a very difficult time in their lives when their usual daily roles and routines are taken away from them.”

“Patients were involved in the planning process, choosing what they would like to grow. They were encouraged to take ownership of the garden – from watering the plants to picking the vegetables to eat during ward cooking group and picnics”

The impact of the physical

environment on restrictive

practice is well documented.

Clean, quiet, open spaces

which patients take ownership

of reduce aggression and

disturbed behaviour.

Formulation

•At its best formulation creates and restores meaning, agency and hope, for both service users and professionals

•It is held every week for an hour (community team invited to attend) •Brief summary of patients personal and psychiatric history is brought along • Include Past –significant events in the persons past and how have these affected them: Present - What are the most pressing issues in the persons life now e.g. chaotic lifestyle, no personal relationships. Future: How are we working on these issues? What are we working towards e.g. Self management of symptoms, less chaotic lifestyle •Discuss what is the current issue or “stuck point” •Following sessions with the team a document is produced

The process of team formulation provides a space for the team to think and feel about the service user, and to combine these two processes in a framework for intervention.

Focus Group

• Arose out of formulation session, ex-patients who had a recent experience of seclusion were identified and invited to attend

• Held in Community centre and facilitated by art therapist and health care assistant

• A series of questions were asked about peoples experience of seclusion. The session was recorded on a Dictaphone

• Some of the quotes were: “I spent quite a lot of time in seclusion, didn’t I but I don’t really remember it too clearly, I was definitely psychotic……the rooms alright but you could probably do with a blanket. “

“The lights were sending me spinning, they are really bright, could you get blue

or softer lights ?”

• As a result of this, changes were made to the way seclusion is used, for example a weighted blanket was purchased and patients are offered a debrief with a member of the wider MDT.

To really hear the voice of PICU patients, their views, feelings and experiences challenges the

team to reflect, adapt and keep recovery focused interventions at the core of care. There is

no other approach a team can adopt that has as much positive impact on the reduction of

restrictive practices.

Ward ongoing commitment

• Making the patient experience central to everything we do. Currently the pilot ward for experienced based co- design project

•Continuing reduction in use of Seclusion and encouragement of “low stimulus” rather than “no stimulus” (eg: trolley of sensory modulation resources that could be tailored to the calming preferences of individual service users)

•Implementing post incident reviews in a more formalised way.

•Individualised recovery plans utilising advance directive model in relation to restrictive practices.

At SPFT we adopted the No Force First notion and have steadily built it into our training and clinical practice or made plans to do so. This has required a thorough approach and involved networking & other information gathering, literature reviews and feedback from patients at the Trust and elsewhere. We realise that completely stopping seclusion and manual restraint could well compromise safety in some of our inpatient settings, but we are inspired also to look at reducing these generally and reducing especially the features that could be considered coercive. For example, as well as promoting the NFF principles we are among those working on a sitting seclusion technique that can be used when a patient will not allow staff to walk out of the room (ie.when seclusion starts). This may allow us to reduce use of the prone seclusion technique further and keep it only for a tiny minority of occasions. CNO’s 6 C’s award was won by Fir Ward in SPFT for reducing seclusion use.

Sussex Partnership NHS Foundation Trust’s commitment • Policy Review • Considerations to long term segregation (separate policy) to aid a better standard of living

during acutely disturbed phases and more freedom • All episodes of care which meet the definition of seclusion being treated as such • Clear standards of facilities, that they are identified and equipped for seclusion ensuring

clear implementation guidelines and robust monitoring • The use of de-escalation rooms, calm rooms • Being clear within care plans that Seclusion can not be planned for, that the facility is

available when all other interventions have not been effective or practicable • The cross over of other policies such as the Search Policy, Therapeutic Observation and

Engagement Policy, Prevention and Management of Violence and Aggression Policy, Rapid Tranquilisation Policy.

• Consideration to admissions to PICU settings if the Seclusion Area is in use. • Consideration to reintegration plans with patients following an episode of seclusion, offering

an opportunity to immediately defuse, consider how to integrate back onto the main ward, consideration to advance directives for future risk and mental health care planning.

• Staff- training • Staff support consideration to the implementation of Safe Wards such as “positive words”

during handovers, development of “Calm down methods” and “talk down tips”, “mutual expectation” statements, “Bad News Mitigation”

• Offering staff “fizzy moments”