November 2011
“It’s a change in culture for us. This initiative has brought about an increased understanding of the traumatic effects of seclusion for people, and the importance of using alternative interventions.
Staff have commented on how much better it is now, and are making comments such as
‘I can’t believe how much we used to use it’.”’ at a glance
What: To implement a seclusion reduction strategy across a district health board mental health inpatient unit.
Why: To reduce the frequency and duration of seclusion and restraint episodes with a view to becoming a seclusion-free environment.
How: Using a strategic plan based on the National Association of Program of State Mental Health
Directors (NAPSMHD) six core strategies© to reduce the use of seclusion and restraint (see http://www.nasmhpd.org/publicationsOTA.cfm
) to develop specific actions and measurable goals regarding the reduction of seclusion and restraint.
Target: Adult service users experiencing distress or heightened states of arousal in an in-patient mental health unit.
Where: The seclusion reduction strategy is being implemented across the Waitemata District Health
Board, driven by the mental health in-patient services. the profile
The Waitemata District Health Board (WDHB) serves more than 525,000 people, the largest DHB population in New Zealand. It covers the areas of North Shore City, the Rodney district, and Waitakere
City. The Waiatarau Mental Health Unit is on-site at Waitakere Hospital, which provides adult in-patient mental health services for adults aged 18-65 years. Waiatarau has 32 beds, including eight intensive care beds. Like other acute units, seclusion and restraint have been used as clinical interventions. The WDHB is attempting to reduce the use of these.
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the beginnings
In 2010, the team at Waiatarau embarked on a strategy to achieve the WDHB’s vision to eliminate the use of seclusion in acute mental health units across the Waitemata district by 2012. Elimination is both a contentious and difficult goal; therefore the initiative centred on gradually reducing the use of seclusion and restraint rather than advocating complete elimination.
The first step in seclusion and restraint reduction involved visits to other DHBs. Using a combination of the information shared through these visits and literature published by Te Pou and international sources, the team at Waiatarau set about developing a detailed strategy to reduce the use of seclusion and restraint in their unit. The strategy was built around the six core strategies outlined in the US National Association of State Mental Health Program Directors Training Curriculum for the Reduction of Seclusion and
Restraint:
1.
Leadership toward organisational change
2.
Use of data to inform practice
3.
Workforce development
4.
Use of seclusion and restraint prevention tools
5.
Full inclusion of consumers [service users] and families
6.
Making debriefing rigorous. the process
The six core strategies were enacted in the following ways:
1. Leadership toward organisational change
The initiative was spearheaded by senior occupational therapist Kate McGeady and clinical nurse specialist Kim Wroblenski with support from Kirsten Norris, the manager of Waiatarau, and senior management of WDHB’s mental health services. Together, this team oversaw the development and implementation of the strategy and held regular meetings to look at planning and tracking progress.
2. Use of data to inform practice
Data was used in two ways to inform practice. Firstly, statistical data on the number and duration of seclusion episodes was collected and displayed visually. Graphs demonstrating the change in the use of seclusion and restraint over time were displayed where staff, service users and visitors could view them.
The statistical data presented at fortnightly staff meetings was encouraging for staff and improved their confidence in using alternatives to seclusion and restraint.
Secondly, staff were regularly affirmed for their efforts. When feeding back information to staff, an emphasis was placed on celebrating the reductions in the use of seclusion that the team had achieved. Staff were acknowledged and praised for their efforts individually and at staff meetings, as well as through emails from management when the unit successfully achieved one month without using seclusion.
3. Workforce development
To support the reductions in the use of seclusion, the team were up-skilled in alternative strategies such as sensory modulation, and given refreshers on general de-escalation techniques, and trauma-informed care principles.
In 2010 a training day was provided to all staff at Waiatarau and covered the following topics; trauma informed care, behavioural disturbance acute management (medication), de-escalation and
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sensory modulation. This day was also an introduction to the procedures and documentation outlined in the seclusion reduction plan.
A.
The requirement for a staff member to remain outside the seclusion room for the entire duration of every seclusion episode. What this provided was the opportunity for staff to talk to service users while they were in seclusion with the goal of reassuring and supporting them, applying verbal de-escalating techniques and explaining what was needed for the person to come out of seclusion. This represented a major change for staff after having previously undertaken checks only at 10 minute intervals.
B.
Comprehensive documentation of seclusion episodes. A series of forms, templates and registers were developed to collect information for monitoring progress and informing practice. A seclusion clinical note template is used to capture information such as the date and time each seclusion episode is initiated and terminated, attempts to use alternative interventions and rationale for the on-going use of seclusion. Hourly reviews are conducted during all seclusion episodes to regularly reassess the need for continued seclusion and to compile a step-by-step account of the procedures that were taken. The documentation requirements include:
1. Seclusion authority forms are used to summarise date/time/duration of seclusion.
2. A seclusion register is used to collect basic information such as service user name and time the seclusion episode starts and finishes.
C. Review of all seclusion and restraint episodes. A review of seclusion episodes is conducted by a panel of six reviewers.
Weekly seclusion review panel . The panel includes representation from the clinical nurse specialist, senior occupational therapist, clinical charge nurse, service clinical director, consumer advisor and a cultural consumer advisor. Every seclusion episode is reviewed on a weekly basis. The panel reviews whether seclusion was appropriately used, and what could have been done differently. The panel completes a written report and provides individual feedback to the staff members involved in the seclusion episode.
The monitoring of the progress towards the goals of reducing the seclusion and restraint episodes were also linked into the “Knowing how you’re doing” module of Productive Wards.
1
1
NHS   Institute   for   Innovation   and   Improvement   (2008).
The   Productive   Ward  ‐  Releasing   Time   to   Care.
Knowing   How   we   are   Doing.
Version   3.
Retrieved   from
http://www.institute.nhs.uk/quality_and_value/productivity_series/productive_ward.html
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4. The use of sensory modulation:
All staff have been trained in the use of sensory modulation, and continue to be supported to implement this in their daily practice, with emphasis on using it as a de-escalation tool when service users are distressed and requiring support to regulate their arousal levels. Sensory modulation rooms have been developed in the intensive care unit, and on the open ward. Sensory modulation processes and guidelines have been developed, and de-escalation preference forms are completed with every service user. Sensory modulation has been used effectively as an intervention to support service users to de-escalate.
5. Full inclusion of consumers and families
Right from the planning stages, the consumer advisor has provided input to the seclusion reduction strategy and continues to be involved through the review panel. Service users provide input through the debriefing process. Weekly community meetings also present an opportunity for service users and their significant others to voice their opinions, and their comments are included in a summary of minutes that is distributed to staff. Alternative strategies, such as sensory modulation, have received very positive feedback from service users, and the team collect formal feedback about these interventions from service users.
6. Making debriefing rigorous
Debrief sessions are held as soon as possible after every seclusion and restraint event. Separate sessions are held with staff members involved, with the service user that experienced the seclusion, and other service users who witnessed the event. Templates are used to provide structure and consistency to these sessions, and the service user’s debrief is recorded in their clinical notes, so that de-escalation preferences can be incorporated in their plans.
the unique approach
The team at Waiatarau has taken a unique approach encouraging their whole unit to prevent and respond proactively to every seclusion episode. Setting statistical targets around the use of seclusion and feeding the results back to staff and service users in the form of graphs has provided a simple but powerful way of communicating progress.
The team has also made a point of keeping the end goal of eventually eliminating the use of seclusion at the forefront of their practice. By embracing a mindset of collective learning through experience, the team continually challenges their actions in constructive way by asking ‘how would we handle this situation if we didn’t have the option of seclusion?’ Focusing on the learnings from each episode, examining what could be done differently and positively reinforcing the use of alternatives to seclusion and restraint has crafted a culture where seclusion is now considered a last resort.
“We had two seclusion rooms, we now have one. Because we’ve reduced seclusion so much, we’ve set one of those rooms up as a sensory modulation room in our high-care area.” the results
The team at Waiatarau are pleased with the progress they have made toward achieving better outcomes for service users. A sustained reduction in the number and duration of seclusion episodes has occurred over the past 12 months and is testimony to the effectiveness of the team’s labours. To date, an 82 per cent reduction in the number of seclusion episodes has been achieved, and the average duration of seclusion episodes has reduced by over 75 per cent. To date, Waiatarau have been 20 weeks seclusion-free.
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Decreased use of seclusion has been so marked that the need for two seclusion rooms has diminished to the point where one of the rooms previously used for seclusion has been converted into a sensory modulation room.
There has also been a change in organisational culture around the use of seclusion since the initiative started. The positive results are helping to grow confidence among the team around using alternatives to seclusion. Since staff have been seeing definite results, there has been acknowledgement that things can be done differently and members of the team have been commenting on how they can’t believe how much seclusion was previously used in the unit.
“When I look back to the distress and the feedback from service users who have experienced seclusion, I think absolutely the work that the staff have put in has resulted in a great outcome for service users.” the lessons learnt

Having a structured plan with specific and measurable goals has helped to establish and track the effectiveness of new practices.

Introducing tools and techniques, such as sensory modulation, to support de-escalation are essential to complement concurrent efforts to reduce seclusion.

Giving positive feedback to the team and building their capacity and confidence to manage situations without the use of seclusion is an essential part of changing organisational practices.

Collecting and reporting back data as user-friendly graphs is a powerful way to communicate with staff and service users.

Reflective learning in ways that are supportive of staff has helped contribute to the collective knowledge of the team.

Service user involvement throughout is pivotal. more information
Contact
Anne McDonald, Clinical Lead - Te Pou.
Direct dial phone: 09 300 6855 or email: Anne.McDonald@tepou.co.nz
Kim Wroblenski, Clinical Nurse Specialist - Waiatarau Adult Mental Health Unit, Waitemata District
Health Board.
Email Kim.Wroblenski@waitematadhb.govt.nz
Website http://waitemata.webhealth.co.nz/provider/service/view/857187/
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