SHINE: Safety Care Bundle
Health Foundation Funded Project £72,000
Norman Young Nurse Consultant,
Dr Mark Haddad Clinical Research Fellow.
The problem
• Acute inpatient units are complex and challenging
environments
• As community services have expanded the severity
of problems has increased.
• 78% of nurses and 37% users report being subject to
violence or threats (Chaplin et al 2006).
• The Care Quality Commission report that 55% of
mental health inpatients do not always feel safe and
16% do not feel safe at all.
Effects on services: morale & performance
• These stressors have an effect on the morale
and performance of staff.
• NHS staff have relatively high levels of
sickness absence:
• 10.7 days a year,
• - compared to
• 9.7 in public sector,
• 6.4 days in private sector.
Estimated incidence of self-reported illnesses caused or made worse
by work in Great Britain, by illness kind, 2007/08
Stress, depression or anxiety
Bone, joint or muscle problem
Other type of complaint
Infectious disease (virus,
bacteria)
Heart disease/attack, other
circulatory system
Breathing or lung problems
0
100
200
300 400
500
600
700
800
900
Per 100,000 workers
Source: Health and Safety Executive based on Labour Force Survey
Are NHS workers more stressed than other workers?
Non-NHS workers
NHS workers
Bone, joint, muscular
problem
Stress, depression or
anxiety
Other
Infectious disease
Breathing or lung
problem
Heart disease/attack,
circulatory problem
60 50 40 30 20 10 0 10 20 30 40 50 60
Percentage of workers
Staff sickness
Sickness absence rate* is high for mental health staff –
5.24% compared with 4.48% for the NHS (2005 data).
Sickness rate ranges across different mental health trusts
(1.95% – 6.91%) indicate that factors affecting sickness
absence, e.g.
staff injury rates,
stress levels,
job satisfaction,
- are amenable to interventions.
* dividing the total number of sickness absence days by the total number of available days
Setting: Llanfair Unit
•410 incident reports of
aggressive or violent
behaviour.
•11 incidents resulting in 3 or
more days of work.
•1 incident more that 6 months
leading to a cost of approx
£42,000
• Currently average sickness
cost are £119,352.
•Indirect costs through
increased length of stay,
medication use and one to one
nursing.
The Intervention
• There is evidence that a structured risk
assessment process carried out twice a day
for the first three days of admission reduce
incidence of violence and aggression
(Abderhalden et al, 2008)
The Intervention
• A tool and process were developed to
systematically assess risk for all admissions
• This was accompanied by ward based
teaching and the use of safety briefings
Evaluation questions and measures
Is the care bundle associated with
changes in:
•
•
Patient safety incidents (incident reports major, minor, severe; absconding) &
management of risk (special observations;
forcible medication; patient restraint; patient
seclusion; patient).
% of individual patients/ no. episodes;
Evaluation questions
Bank & agency staffing.
• Weekly spend; excess in relation to ward
staffing budget.
Staff morale & staff sickness
• MBI - cross-sectional data, 2 time-points;
• Number of full-time equivalent staff days lost
to sickness absence; % staff members with
sickness absence >7,10, 14, 21 days
Evaluation questions
Is the care bundle feasible & acceptable in
routine practice?
•
•
Staff interviews (semi-structured
quantitative/qualitative interviews with nursing staff
to examine understanding & satisfaction with
intervention package).
Patient questionnaires at discharge [questions
adapted from NHS Mental Health Acute Inpatient
Service Users Survey Questionnaire (NHS, 2008)].
Stepped Wedge Design
Preliminary findings: Burnout and incidents
• Sixty seven completed MBI questionnaires
were returned 72% completion (n=92)
• There were no statistical difference between
the wards on the measure of burnout.
• However higher scores for exhaustion and
cynicism were evident on the ward with the
highest number of incidents (116 over
12-months).
Preliminary findings: Burnout and incidents
• Male staff were reported more cynical attitudes than
their female colleagues, this was a statistically
significant difference: Independent samples t-test: t
(65)=1.591, P=0.04.
• Male respondents recorded slightly higher
exhaustion and slightly less professional efficacy.
• Band 3 and 4 staff reported highest levels of burnout
(cynicism and exhaustion).
• Regression analysis indicates that staff grade has a
significant influence on cynicism responses when
other variables are accounted for.
Process and Outcome Measures
U Chart of Inermittant Observations Gorwel Pre, Gorwel Post
Gorwel Pre
Inermittant Observations
12
Gorwel Post
UCL=11.39
10
8
6
_
U=4.81
4
2
0
LCL=0
1
16
31
46
61
76
91
106 121
October 2009 to March 2011
136
151
Good Risk Management
Past
Tools
Present
Clinical
Judgement
Patients
The Plan
Risk
– Male
– Young age
– Socially disadvantaged
neighbourhoods
– Lack of social support
– Employment problems
– Criminal peer group
Childhood maltreatment
History of violence
First violent at young age
History of childhood conduct disorder
History of non-violent criminality
Clinical history
Psychopathy
Substance abuse
Personality disorder
Schizophrenia
Cognitive impairment
Non-compliance with treatment
Risk
Risk
Anger
Impulsivity
Suspiciousness
Morbid jealousy
Criminal/violent attitudes
Command hallucinations
Lack of insight
Early Recognition
Confused

Appears to have lost their bearings; confused as to time or place or
personal identity. Not limited to cognitive impairment and can include
psychotic confusion.

Irritable

The person is easily irritated or annoyed by people or situations. The
person is easily inflamed or exasperated, they have a poor tolerance to
frustration.

Boisterous

The person is sufficiently noisy; rough; expansive to draw attention to
themselves or intrudes into others personal space or “auditory space”.

Early Recognition
Physically threatening

The person actively or passively behaves in a way that threatens
another person physical well-being or causes fear of imminent attack.
This includes threatening gestures, deliberately obstructing people,
intruding into an individual's personal space.

Verbally threatening

The use of language which would cause a person fear of injury or
harm. This can include phrases directed at an individual or a group of
people.

Attacking objects

The person acts in ways that could or actually causes damage to
property.

James a fifty five year old man is on the third day of his
admission. he has been admitted for low mood. He
was transfered from recovery following carbon
monoxide poisoning. During the assessment period
he has asked several times what day it is, and when
can he go home. Another patient complained that
James was in his room and would not leave saying it
was his room. This led to James shouting "get out or
you'll get some" and clenched his fist at him.
Martin a twenty one year old man is admitted to the ward from
the crisis team. He feels that God is inside him and that he
has the ability to help save lives. He hears the voice of God
telling him to 'go and save people'.
Over the past hour Martin has been in and out of his room 7
times and in and out of the office 6 times. He is chain smoking
and walking around the ward sitting for 30seconds before
getting up. He does not have conversation but walks up to
people and says loudly 'why am I here' 'you are wrong' 'you
are bad people'. Twice he shouts 'bastards' towards the office
door and once hits a table.