seclusion and restraint

NSW government vows to implement findings of mental health care review.

The state government expects the use of seclusion and restraint in acute mental health units and emergency departments (EDs) to decline after it implements a review panel’s recommendations.

The government has accepted all 19 recommendations aimed at preventing the “inappropriate” use of seclusion and restraint.

The review was led by the state’s chief psychiatrist, Dr Murray Wright.

Other members of the review panel were:

Ms Karen Lenihan, Principal Official Visitor
Dr Kevin Huckshorn, CEO, Huckshorn and Associates, a US a behavioural health consulting business
Ms Julie Mooney, Executive Director, Nursing and Midwifery, Southern NSW LHD
Dr Robyn Shields, Deputy Commissioner, NSW Mental Health Commission
The late Ms Jackie Crowe, Commissioner, Australian Mental Health Commission (consumer representative).

“Seclusion and restraint incidents have been gradually declining since 2011 and once we begin implementing the review’s recommendations, we expect this trend to accelerate,” said Minister for Health Brad Hazzard and Minister for Mental Health Tanya Davies in a joint statement.

They said the death of Miriam Merten from injuries sustained in a seclusion room in Lismore in 2014 was the catalyst for the review.

The Ministry of Health is expected to deliver a plan to implement the recommendations this month.

“Whilst the government will need to work with our local health districts to bring about change in practices and procedures, the message from the review is loud and clear – seclusion and restraint of mental health patients should be a last resort,” the statement said.

“The NSW government will immediately invest $20 million, so hospital managers can work with their staff to improve the therapeutic environment inside acute mental health units.”

A review of EMERGENCY DEPARTMENTs to come

In accepting the review’s recommendations, the ministers said the government would also review
the use of safe assessment rooms in emergency departments (EDs).

The review panel said they witnessed examples of “positive leadership and constructive collaboration with mental health staff in caring for mental health consumers” in EDs.

There were “noteworthy examples of emergency department leaders who displayed concern and compassion for mental health consumers, and who made constructive efforts to improve the environment and the processes”.

However, “There were also examples of stigmatising, discriminatory and hostile behaviour towards consumers and mental health staff” the panel said.

“At multiple site visits, emergency department staff displayed unprofessional attitudes and openly discussed people presenting with a mental illness differently from those presenting with a physical illness.

“In some emergency departments, all mental health consumers were only seen in a safe assessment room and there was a low threshold for using security guards.

“The use of inappropriate language such as referring to mental health consumers as ‘taking up emergency beds’ and ‘distracting our services from looking after patients who are more in need of emergency services’; referring to ‘your mental health patient’ as a way of disowning any responsibility for the delivery of care; or mentioning that ‘mental health patients are dangerous, and disturb the other patients with legitimate medical problems’ was a common issue.”

Workforce short on mental health experience and skills

The panel found that most mental health staff “are motivated to provide quality care in a challenging environment.”

However, “The review team heard repeatedly that many staff were recruited to work in mental health inpatient settings with little or no previous mental health experience or skills.

“Some staff working with mental health consumers knew little about trauma-informed care or its relevance in restrictive practices, and in some cases expressed views and opinions that reflected stigmatising attitudes towards consumers.

“Training in systemic, multifaceted and evidence-based strategies to prevent seclusion and restraint was uncommon but, where it was implemented and supported, it was clearly beneficial.”

The review said “discriminatory and stigmatising behaviour and attitudes” were observed at all levels of the workforce.

“NSW Health should ensure that recruitment and performance-review processes include appraisal of values and attitudes of all staff working with people with a mental illness.”

Leadership is important

The review team “witnessed some notable, although infrequent examples of positive and active leadership. These provided hope and showed what can be achieved by determined and strategic leadership, within existing resources”.

However, “The tolerance of leaders for outdated, discriminatory and damaging attitudes and behaviours among staff was a matter of considerable concern, and was at odds with some of the submissions by professional groups emphasising the importance of leadership”.

Inadequate oversight

During site visits, the review team heard that “decisions about the use of seclusion and restraint were often left in the hands of the nurses on the mental health inpatient unit, with limited external scrutiny or available supervision”.

“This was an indication of the unreliability of on-site clinical supervision and support to safeguard good practice, assist in complex decision making, and ensure all staff are both supported and accountable.

“Services lacked explicit guidelines for delegation and escalation in preventing seclusion and restraint.”

The review team were “disturbed to discover that some mental health inpatient units very rarely
received visits from the on-site, after-hours senior nurse managers.

“Senior managers were said to be too busy ‘running the business’. This was despite the likely role that a lack of external after-hours scrutiny played in the deviation from acceptable practice on the unit where Ms Merten was secluded (in the opinion of the review team).”

Members of the NSWNMA: share your thoughts on articles in the Lamp or anything else important to you as nurses and midwives by sending a Letter to the Editor. Four letters are published in the Lamp each month and the letter chosen as Letter of the Month will win a gift card. Please include a high-resolution photo along with your name, address, phone and membership number. You can submit your letter by emailing the Lamp: lamp@nswnma.asn.au

Seclusion and restraint report is vague on workforce improvements.

The review of seclusion and restraint in acute mental health units and emergency departments makes no mention of vital workforce issues raised by the NSWNMA.

These include the lack of clinical nurse educators, the statewide shortage of psychiatric intensive care (PICU) beds, excessive workloads and inadequate skill mix.

Some of the review’s positive recommendations lacked substance.

For example, the review said all mental health inpatient services “must have 24-hour, everyday on-site supervision from accountable management representatives. This supervision must include in- person rounding on every shift”.

Mental health nurses point out that units attached to public hospitals may already be supervised by a person doing rounds every shift.

However, that person often has no mental health qualification and no understanding of what they are supervising.

Some nurse unit managers of acute mental health services have no mental health experience, yet are expected to understand the complex management of mental health patients and lead the nursing team effectively.

The review recommended that NSW Health develop and implement minimum standards and skill requirements for all staff working in mental health.

However, as Jack Schwartz, a veteran of 40 years mental health nursing, points out, the review does not say what those minimum standards should be.

Seclusion is already a last resort

Jack is president of the Coffs Harbour mental health branch of the NSWNMA and delegate to the union’s mental health reference group.

“The inquiry did not sufficiently recognise the implications of a lack of qualifications, training, and experience,” he says.

“On my unit fewer than half of the nurses working have been trained in prevention and management of aggression, or sensory modulation, and de-escalation techniques.

“No one likes to seclude anyone – if only because of all the paperwork involved.

“If someone is secluded it is pretty much done as a last resort.

“The ministry wants trauma-informed care but nurses working in mental health often do not have the expertise in counselling to do this appropriately.

“The review fails to recognise that 80 per cent or more of nurses in mental health units are not psychiatrically trained and therefore don’t know how to deal with a lot of behavioural problems.

“The health system did away with psychiatry as a nursing specialty because general nurses were paid less.

“NSW Health does not train mental health nurses any more. They train List A nurses who may later gain a mental health endorsement.

“By then they are already working in a mental health ward and are usually not equipped with the knowledge they need.

“Often they don’t have the experience and skills to cope without the need for seclusion.

“Because of this lack of training they often take the easy way out of situations, which creates problems for nurses who stick to protocols.”

Use of unskilled staff is problematic

Jack says the use of enrolled nurses and assistants in nursing has added to the problems facing RNs.

“AiNs are unregulated and have minimal training; they have no skills to complete a mental health assessment and therefore cannot do a risk assessment of the patient.

“This puts the patient and the AiN at risk. It robs the patient of the quality of care that an RN, can provide and creates more work for the RN who has to closely supervise the AiN.

“This takes away valuable time that the RN should be spending with their own patients. AiNs have a place in health, but not in acute mental health.”

Smoke-free policy puts patients and staff at risk

The inquiry called for “an immediate reinvigoration” of the implementation of the NSW Health smoke-free policy, “which includes increasing the knowledge and use of nicotine replacement therapy”.

However, Jack says patient reaction to the policy has put patients and staff at risk while funding for nicotine replacement has declined.

“Easily half our ‘aggro’ happens because we don’t allow people to smoke. As far as most patients are concerned, nicotine replacement is not the same.

“Cigarettes get smuggled in and problems arise when we have to take away their lighters and cigarettes. No matter how we try to stop patients from smoking they will find a way to smoke.

“The review report was obviously written by people who don’t actually work in a mental health unit and are taking a pie-in-the-sky view of things.

“For example, they recommend a staff member sit outside the seclusion window and monitor the patient visually for at least an hour immediately following seclusion.

“If you put someone in there because they have just attempted to assault you and your fellow workers, that patient is irate as can be.

“Now you are going to stare at them through a window for an hour? That would just be a red rag to a bull.

“The abuse you would get for that hour would give you post-traumatic stress.

“It is a ridiculous suggestion.”

The review says all mental health units should have “a multidisciplinary team with the skills to deliver a therapeutic program and environment on an extended-hours basis”.

However, budget constraints have eroded day programs and evening programs in mental health facilities.

The review was critical of nurses having to make decisions about seclusion “with limited external scrutiny”.

Jack says the nurse often knows more about the patient’s mental and physical state than the on-call psychiatrist.

If the ministry wants more supervision of nurses it must employ more resident psychiatrists and resident psychologists, he adds

Members of the NSWNMA… share your thoughts on articles in the Lamp or anything else important to you as nurses and midwives by sending a Letter to the Editor. Four letters are published in the Lamp each month and the letter chosen as Letter of the Month will win a gift card. Please include a high-resolution photo along with your name, address, phone and membership number. You can submit your letter by emailing the Lamp: lamp@nswnma.asn.au

Seclusion and restraint forecast to decline

Review dodges vital issues