Guest blog by Dr. Colin Dale, Chief Executive, Caring Solutions (UK) Ltd
In the middle of the 19th Century, Florence Nightingale said, ‘It may seem a strange principle to enunciate as a first requirement in a hospital, that it should do the sick no harm.’ One and a half centuries later it is difficult to escape the fact that health services established to alleviate health-related problems can fail to keep people safe during the period of treatment. Acute care staff face the complex task of managing acutely ill individuals at a critical stage in their lives when they are most vulnerable and in need of help. Symptom severity, risk to themselves and others, unclear diagnosis and deterioration in their mental state and capacity to reason and make judgements are all likely features in their presentation. Adherence to treatment or compliance to the ward care regimes, routines and expectations may be inconsistent. Also services continue to receive concerns expressed by coroners and distressed relatives who highlight what they see as shortcomings in systems and procedures in ensuring the safety of seriously at risk people. Striking a balance between safety and maintaining autonomy and liberty and ensuring a therapeutic culture rather than custodial environment is clearly a major challenge.
The Health Care Commission (HCC) calls for acute mental health services to be sources of comfort and help, and states that service users and staff should experience safety of person, particularly in inpatient settings. Preservation and promotion of dignity, safety and safety for all service users should be a primary consideration. However, data from MIND’s Ward watch in 2005 found that the majority of patients recently experiencing inpatient care had been involved in or witnessed a patient safety incident.
‘Unsafe’ wards: contributing factors
Boredom and a lack of therapeutic activity has long been recognised as a ‘side effect’ of hospital admission. In one survey 30% of service users said they weren’t involved in any therapeutic or recreational activity at all during their hospital stay. As well as the ‘nulling’ effect this has on recovery, boredom and frustration is a known precursor to violence.
A number of other factors have been identified as contributing to the instability and the sense of feeling ‘unsafe’; I place these issues in no hierarchy:
Unfilled staff posts; staff absences and the overuse of bank and agency staff have all been cited as potential destabilising factors. The absence of regular staff with the skills to build trust and understanding is problematic.
Lack of respect and dignity; poor cultural sensitivity; overuse of containment methods; and even harassment or assault perpetrated by staff have been cited as experiences by service users.
3. Poor or absent ward leadership
The HCC audit identified lack of senior nursing staff at ward level and a high percentage of wards without an identified consultant psychiatrist leading the clinical care of the patient.
4. Increased acuity
One of the effects of the introduction of Home Treatment Services and Assertive Outreach is that those admitted to the ward are more acutely ill; in some areas there is poor or no access to a Psychiatric Intensive Care Unit (PICU); more units report a pressure on beds and high throughput.
5. Poor environment
Ward environments have improved in recent years. Many examples of high standard new units, both in the public and independent sector, have replaced archaic environments. However, relics of the Victorian era continue to exist with mixed sex wards, poor surroundings, no access to outside space, poor observation and unsafe designs.
6. Substance misuse
The single most common factor associated with violence is substance misuse. Services have seen major increases in substance misuse in recent years for both illicit substances and alcohol.
Self-harm can generate a sense of helplessness amongst staff and it is impossible to control all access to things that harm.
Achieving a ‘safe’ environment
Safety can be achieved in a mental health service by the means of dynamic and passive measures.
Dynamic safety may be promoted by:
- Treatment and care programmes
- Good inter-personal relationships
- Effective procedures and operations.
Passive safety may be promoted by:
- Physical and structural elements
- Technological systems.
The degree of safety achieved will rely upon a combination being made between the passive safety measures providing a supportive framework to the dynamic safety measures. All of these features, however, are interactive and mutually supportive.
Treatment and care programmes
Studies have repeatedly shown that effective treatment and care programmes play a significant part in enhancing safety. Key factors include the level and type of contact between staff and patients, the ward milieu and how the patients spend their day (Davis 1992). Within health care all professions have adopted codes of practice, which have as their basis, the principles that the health of the patient will be the first consideration and that human dignity will always be respected. (Dale et al 1999).
The legal rights of patients are protected by bodies such as the Mental Health Act Commission but their ‘moral’ rights seem less clear. The consent of patients is necessary for the majority of healthcare interventions (McLean 1989). In mental health care, however, an element of coercion may be suggested, as patients may feel compelled to cooperate with treatment programmes for pragmatic reasons in relation to the prospect of earlier discharge or transfer from hospital (Chaloner 1998)
The patient’s recovery depends on the maintenance of a safe, calm, therapeutic environment, and this is only possible if medical and nursing staff can control violent behaviour. However, there must be no malice, no ill treatment or wilful neglect and any force used must be reasonable in the circumstances (Mental Health Act Commission 1999).
Good inter-personal relationships
Relational safety is concerned with developing good interpersonal and sound professional relationships between the clinical team and the patients. Building up trust will enable the staff to get to know and understand their patients, their moods and problems, to facilitate interventions before these become major problems, or lead to incidents of a safety nature (Kinsley 1998).
Effective procedures and operations
Procedural and operational issues are crucial in underpinning safety and include dealing with: emergencies; incidents; searching; patrolling; escorts and movements; and by training programmes. Recent studies have shown that policies, procedures and standards are often not made known to patients, and that they have little input into their development.
Physical and structural elements
Inpatient units need to be safe, containing and therapeutic with proper attention paid to reducing the risk of service users harming themselves or others and to overcoming some of the design and space limitations of past provision. While safety is not primarily an issue of physical provision, particular attention needs to be given to:
Provision of circulation space
A sense of space by generous provision of circulation space (some architects recommend 40% of total floor space) is particularly important in helping to reduce the potential ‘pressure cooker’ atmospheres often associated with inpatient units.
Specific good practice guidance on the requirement to achieve effective gender separation has been produced by the Department of Health. Key components include individual, preferably en-suite, bedrooms, separate sleeping and bathing areas accessed without passing through mixed areas and women only lounges. Appropriate zoning of accommodation offers an alternative to separation on the scale of a whole ward and may facilitate effective gender separation in smaller units. In some cultures a mixed sex environment outside the family is alien and additional specific women only provision may need to be in place to meet the cultural needs identified from the catchment area’s population.
Points of entry to and exit from the unit and the wards
Careful consideration is needed to achieve a satisfactory balance between preventing patients going missing and trespass by outsiders, while avoiding the creation of too custodial an environment. Much good practice in the provision and management of restricted yet therapeutic environments has been developed by Psychiatric Intensive Care Units.
Electronic aids to safety and security have continued to emerge in recent years and are now accepted by many as a useful contribution to mental health services such as: the use of person-to-person communications; door alarms; motion detectors and other electronic means of perimeter awareness; the use of pin-point infrared, ultrasonic and radio personal alarms systems; electronic health records and information systems (Dix, 2002).
Within the Health Service there is a wide debate on extending the use of electronic systems such as CCTV to the direct monitoring of patients and units, focusing on the conflict between possible opportunities to reduce risk, the privacy of the individual and the clinical potential of TV monitored records. However, no clear association with the use of closed circuit television; the observation of patients and reduction in violence and incidents has been conclusively demonstrated in inpatient services.
The increasingly ‘risk orientated’ attitude towards mental health services, with hostile media and anxious services, makes it difficult to avoid the feeling that mental health services will need to use technology to enhance practice. Dix (2002) states:
While mental health clinicians must remain open minded and creative with regard to practices, a high degree of caution is necessary to ensure that one of the institutions great strengths being the development of a trusting relationship, based on the principles of interaction and proximity with the staff, should not be superseded by the cold face of technology.
A safe environment for care should be seen as a partnership between service users, their families and staff. What units should strive for is a balance between the measures available to ensure that the environment is as least restrictive as possible whilst offering appropriate levels of safety and security for all. It is inevitable that some curtailment of freedom will be a consequence of safety measures but in contemporary society it would be undefendable for services to ignore the potential risks posed in operating an inpatient service.
SafeWards – www.safewards.net
Relational and Physical Safety in Child and Adolescent Inpatient Wards – www.camheleon.org
This article was first published in ‘Star Wards – Second edition’ 2008