A key concern mental health nurses have about moving away from seclusion completely is the current lack of alternatives, says Heather Casey.

The Southern DHB mental health, addictions and intellectual disability director of nursing is one of two nursing advisors on the Health Quality & Safety Commission’s mental health and addiction quality improvement programme, along with Canterbury DHB director of mental health nursing Stu Bigwood.

The programme’s first project is Zero seclusion: towards eliminating seclusion by 2020, a project seeking to reduce and eventually eliminate the use of restrictive practices in in-patient care.

Reducing the use of seclusion had been declining since 2009 but recently plateaued, around the same time as mental health staff began reporting being under increased workload pressures – including assaults – to deal with the fast growing demand for mental health services. Those concerns helped prompt the Government’s current Mental Health & Addiction Inquiry.

Casey says she and Bigwood have the role of making sure nurses’ voices are heard throughout the Commission’s quality improvement programme’s work which also involves mental health and addiction service consumers, families, whānau and district health board (DHB) mental health and addiction staff working with the Commission and Te Pou.

A challenging area of mental health practice

Casey says, for her, the use of seclusion has never sat comfortably.

“Both consumers and staff are traumatised by the use of seclusion. So we need to eliminate it.”

“Nurses never enjoy having to put someone in seclusion. Staff can get hurt during seclusion procedures as they often have to restrain people to get them into seclusion”.

She says a key concern nurses have about moving away from seclusion completely is the current lack of alternatives.

“Nurses don’t choose to use seclusion as a first intervention, it’s when they feel they’ve got no alternative. So until we’ve got a range of alternatives, people are in that position where they feel they have no option. It’s not as simple as saying ‘don’t use seclusion’, rather it’s about looking for alternatives so it doesn’t have to be used.

“The Commission recently held a workshop on reducing seclusion. One of the issues that was coming up constantly was people presenting with the effects of frequent methamphetamine use and the absolute aggression nurses can be faced with.

“Nationally, the response to that is connecting with people who are experts in addiction around the country, such as Matua Raki, the national centre for addiction workforce development in New Zealand, and really starting to explore that further.

“For example, is an acute mental health facility the right place for people who are intoxicated with any substance? And if so, how do we manage that? What are the best practice examples? Is it about intoxication, is it about substance-related emotional and behavioural disturbance, is it about withdrawal? Are there other complications that we need to be thinking about?”

She says smoking is another issue nurses raise; how do we improve our response to people addicted to tobacco?

“These are the types of issues that will benefit from a national approach, based on the most recent evidence and what has worked in other areas.”

Co-design and quality improvement

Casey says her and Stu Bigwood sit on the sector leadership group that advises the programme, to add a nursing perspective, and also work with the Commission a few days a month specifically to ensure nurses are engaged with the programme at a local level.

Every DHB with a mental health in-patient unit has pulled together a team to work on the zero seclusion project, with nurses well represented on most teams. Teams are learning co-design and quality improvement skills, through workshops provided as part of the project.

“Nurses know what the issues are, and as a member of a consumer’s health care team, they have input into the decision-making process around whether to use seclusion. The good ideas they generate will be absolutely essential in developing alternatives to seclusion,” says Casey.

“We have co-design ‘masterclasses’, where teams listen to the voices of consumers and their family and whānau, as well as to mental health and addiction staff.

“Teams have now started pulling together the ideas generated through the co-design workshops. The next step is to test and modify the ideas. That might include looking at data to better understand what is happening.

“For example, when is seclusion most likely to occur – in the evening, at weekends? Is it at shift handover? Is it more likely to happen when certain people aren’t there? What are the factors that lead to seclusion and what are the solutions teams might be able to come up with?

“Approaches being tested might include doing more work using sensory modulation, providing better cultural support, looking at rostering or introducing a de-escalation room.”

Change must begin before admission

Casey believes creating an environment in which seclusion is unnecessary begins well before a person is admitted to hospital.

“It’s not all about in-patient areas. Can we be intervening earlier so that by the time people reach in-patient wards they’re not acutely distressed and presenting as aggressive? Can we be planning admission more rather than reacting to a crisis. Can we be looking at medication regimes earlier? If people are in crisis, can we intervene earlier?”

She says the SPEC[1](Safe Practice Effective Communication) training underway has been extremely beneficial. “It ensures people really focus on de-escalation, it’s really honing those skills.”

Sensory modulation can also be very effective in reducing the need for seclusion.

“If someone who lives rurally is acutely unwell and needs to go to hospital, it might be a two-and-a-half-hour trip, often in the middle of the night.

“One of the southern rural teams has been using some lovely big blankets. People curl up in those in the back seat and it gives them a bit of a barrier between them and the person escorting them. They’re nice and warm and cosy. That’s an example of a sensory modulation item that really helps.

“Another example are soft weighted toy dogs that are available for use. We had a young woman admitted who was in the crisis service for a number of hours being assessed. She had the dog and it was obviously soothing her. So rather than saying, ‘you can’t take the dog with you’, she took it with her to the in-patient unit and it made the whole process much better because she was feeling secure hugging this dog.

“It makes a difference to how distressed people are when they come. And then you don’t get in a position of even having to think about using seclusion.”

Safewards approach

Casey was involved in the introduction of ‘Safewards’ at Southern DHB – the first DHB in New Zealand to adopt it. Safewards is a model of care, born out of research in the UK. The model offers several different ways to help wards understand and manage conflict.

“The aim is to make in-patient wards a more therapeutic and peaceful place and to create a safe environment for everyone. This is achieved by enhancing relationships and trust, and reducing conflict and containment as much as possible.”

The model recommends ten interventions. These include having mutually agreed and publicised standards of behaviour, by and for consumers and staff; use of de-escalation; a requirement to say something good about each consumer at the end of a nursing shift handover; and sharing innocuous personal information between staff and consumers (for example, music preferences, favourite films and sports etc).

A randomised controlled trial of the Safewards approach found that simple interventions aiming to improve staff relationships with consumers can reduce the frequency of conflict and containment.

Casey says aspects of Safewards or the Six Core Strategies© checklist, New Zealand adaption (Te Pou o te Whakaaro Nui 2013) may be used by teams to support their change ideas.

Further information

Nurses who wish to have input into the zero seclusion project can talk to their mental health and addiction nurse leader. They can also contact the Commission mental health and addiction quality improvement project direct through MentalHealthAddiction@hqsc.govt.nz.

[1]SPEC is a collaboration between all district health boards, under the leadership of the National Directors of Mental Health Nursing (DOMHN), key stakeholders including service user groups and Māori, and Te Pou. It provides national consistency and best quality evidence based therapeutic interventions for effective communication to reduce restraint and seclusion.

This is the edited version of an article contributed by the Health Quality & Safety Commission.



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