Stories of change

Te Whare Ahuru

Providing alternatives to seclusion and restraint

     "...the nurses just said:
let's open that door."

     Dr Emanuel Garcia,
clinical director.

The profile

The Hutt Valley District Health Board (DHB) has a catchment area of 142,000 residents. Currently 2000 people access mental health services, of which 801 have complex needs. Te Whare Ahuru is the acute inpatient unit of Hutt Valley DHB.

The unit is smokefree. It has a flexible therapeutic program that focuses on wellness and recovery. Service provision is characterised by lowered use of seclusion through providing a low stimulus environment and by emphasis on staff skill development and training.

Currently the Te Whare Ahuru team consists of 25 nursing staff including the nurse manager and two associate nurse managers, three healthcare assistants, two social workers and an occupational therapist as well as four psychiatrists, two registrars and rotating house surgeons.

 

"We have to keep working hard, we have to set goals. Goals, which are achievable and not too high because we fall back. We have to keep having high hopes in developing our skills in reaching those goals."

Moontaz Azmutally,
associate clinical nurse manager.

The beginnings

"If this was for a family or friend I couldn't even justify having to come here"
Dr Emanuel Garcia, clinical director.

Te Whare Ahuru has been in operation for over 10 years. It is based in a low socio-economic area, which has relatively high levels of crime, drug use and family violence. Historically, the unit had a high incidence of the use of seclusion and restraint, a high staff turnover and a lack of sufficient medical staff. There was little opportunity for service users to engage in meaningful therapy. Smoking was the predominant activity, which contributed towards making the unit environment unwelcoming and dirty.

In 2007, the clinical director of Hutt Valley mental health services, with the support of the service manager and some of the other senior staff, began a process of change at Te Whare Ahuru. The implementation of a smokefree policy was the first step in the transformation. While not directly related to the reduction of seclusion and restraint, this contributed to creating a clean, open and healthy environment. Initially many service users and staff resisted this policy but with support from a core group of staff, a smoking ban was instituted and nicotine replacements and counselling offered.

A core group of senior clinical staff, including the clinical director, worked with the team to change attitudes and instil confidence in planned changes to the unit. Concurrently, staffing levels, which were below the minimum requirement, were increased. By 2008 staff embraced a philosophy of intensive nursing. A more holistic approach to care, influenced by Maori mental health model developed by Mason Durie, Te Whare Tapu Wha, was developed. This underpinned the opening of the intensive care unit (ICU) and conversion of part of this area to Te Rangimarie, the low stimulus environment in June 2008. Te Rangimarie was blessed by a priest and the tapu lifted by a kaumatua. Te Rangimarie focuses on low key activities and creating a calm environment.

Central to these changes has been a focus on increased staff in-service programs and service evaluation. Unit staff have received training in de-escalation and non-violent crisis intervention. While all clinical staff are still trained in the use of calming and restraint techniques, the unit is reviewing the use of this model. Registrar training now includes training in brief psychodynamic therapy and all staff attend cultural safety training. Instead of two teams separated by a locked door, unit staff now work as one team.

Evaluation has become a focus. For example, the unit staff analysed 179 past critical incidents and found that 140 of incidents related to only six service users. They were then able to review what to do differently to provide individualised support and reduce the number of critical incidents.

The process

On admission to Te Whare Ahuru, interviews take place in an informal ‘social type setting".. While medication is, sometimes necessary in larger doses for extremely unwell patients at the time of admission, the use of additional per required need (PRN) medication is reduced. Unit staff have developed a number of strategies to minimise the need for seclusion including setting practical behaviour boundaries with the service users on admission and placing an emphasis on one-to-one interactions and continuity.

Intensive nursing is used to de-escalate volatile situations. Staff provide the opportunity for service users to vent anger and frustration and attempt to set mutually agreed treatment goals. When seclusion is used it is for a maximum of two hours. The decision to discontinue seclusion is made by nursing staff in conjunction with the service user, and is followed by a debriefing for both the service user and staff. Rather than restraint, unit staff now first attempt to use non-violent crisis intervention. When seclusion or restraint is used the consultant and clinical director are always contacted and a seclusion and restraint register is kept. The data and relevant analyses are reported back to the team monthly and sent periodically to the Ministry of Health.

 

"The reduction of seclusion is really quite a simple concept about what good practice is, what is good treatment and what is about being able to provide a good therapeutic environment for people. Obviously we need to make sure people are safe when they need to be safe, but seclusion is predominantly, in my opinion, an archaic, one-dimensional practice. As health professionals in 2009, we should be able to be a bit more creative about how we deal with challenging people and challenging behaviours".

Steve Allsop,
clinical nurse manager.

A therapeutic program of activities and groups is tailored to each service user's level of wellness or need. The program is available to both inpatient unit and community service users and includes physical activities such as Tai Chi, skills based activities like cooking, wellness management and a programme of guest speakers. Some of the activities are service user led. The focus on wellness and recovery has also seen the development of a transitional liaison service which offers support to patients on leave. This service has created a safe means of supporting patients to have over night leave andenable earlier discharge. Attention to cultural, familial, spiritual and social environments is now part of the therapeutic environment. Strong links have been created with the Maori mental health services - Te Oranga Hinengaro. Maori mental health and whanau hui are held for Maori service users.

Staff meet daily to discuss the progress of admitted service users. Additionally, multidisciplinary team meetings, including the unit kaumatua, are held weekly. Te Whare Ahuru has its own localised critical events group which reviews every incident on the unit. Staff meet regularly with the local consumer group, Oasis, and conduct regular service user satisfaction surveys. Service user feedback via surveys and anecdotally, has been increasingly positive.

The unique approach

"How many people have got a mental health issue or a concern and are still out there living a well life? Don't discriminate and think everyone with mental health concerns lives under a bridge or doesn't have access to making choices in their own lives."

Sara Shaughnessy,
service manager, Mental Health Services.

• Treatment focus has changed to a recovery-based, non-discriminatory and holistic approach. 
• Creating a more open and smokefree environment has changed how both staff and service users feel about being in Te Whare Ahuru.
• Seclusion and restraint is used as a last resort and only for brief periods. Notification of senior medical staff is mandatory. 
• Both service users and staff are debriefed after critical incidents.
  

The results

"It makes me feel like I have achieved my goal as a nurse to be able not to seclude clients."
Steve Allsop, clinical nurse manager.

Te Whare Ahuru have not yet fully implemented all of their seclusion reduction policies and practices, therefore full results cannot yet be realised. However, early indications seem to show that seclusion reduction has been beneficial for both inpatients and staff, and bringing positive results the culture of service delivery.

• The unit is now smokefree and along with the long term health benefits for patients and staff, the cigarette token economy was eliminated improving the cleanliness of the environment.
• Te Whare Ahuru now operates as one unit with an unlocked low stimulus area, Te Rangimarie.
• The rate of use of both seclusion and restraint has reduced significantly from 2710 seclusion hours and 101 restraints in 2006, to 1071 seclusion hours and 40 restraints in 2008. The unit has accrued 232 hours of seclusion and six recorded restraints to date in 2009. The staff and management are hopeful that they can record less than 500 hours of seclusion this year and under 20 restraints which would represent a drop of 50 per cent on the previous year.
• A 50 per cent increase in staff undergoing supervision has occurred with a target of all stall to be in supervision by the end of 2009.
• Clinical staff have reported improved relationships and job satisfaction. Better communication through daily unit meetings and weekly multidisciplinary team meetings has increased the sense of ‘team problem solving'.
  

"People are getting better treatment and they appreciate it."
Dr Emanuel Garcia, clinical director.

The lessons learnt

"If acute services are not rendered in an expert, humane and excellent fashion, confidence in all other services will never be high, nor will appropriate clinical practice evolve soundly."
Dr Emanuel Garcia, clinical director.

• It is important to have strong leaders setting big challenges, and that these challenges are communicated clearly. The roles played by the clinical director and a core group of senior staff have been crucial to change. 
• Training staff gives them access to a range of interventions that can replace the use of seclusion and restraint.
• Embracing an anti-discrimination perspective can support the creation of a therapeutic environment.
• Staff training and appraisal is an essential component of service change.
• An open and well maintained physical environment assists recovery.

More information

Contact

• Stephen Allsopp at Stephen.Allsopp@huttvalleydhb.org.nz, phone 04 570 9461, mobile 027 490 5768
  

Website

• Hutt Valley DHB website - Acute Inpatient Services Te Whare Ahuru

 

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Page last updated: 7 November 2008