How do you address trauma in a busy hospital

setting?

Mental Health Nursing & Acute Inpatient Mental Health Services.

Luke Molloy (University of Tasmania) Paul Beckett (St Vincent’s Hospital)

Hospital based care.

Hospitals provide inpatient care for consumers experiencing acute symptoms of mental illness.

Biomedical model.

The reorientation of hospital services towards supporting personal recovery as well as promoting clinical recovery remains a significant challenge.

Acute Inpatient Mental Health Services

Compelling evidence base for inpatient mental health nurses to become trauma informed 90% of people seeking treatment for serious and

enduring personality disorders, substance abuse, and mental illnesses were exposed to significant emotional, physical, and or sexual abuse in childhood.

To better meet the needs of persons accessing these services, trauma-informed care has therefore emerged as a key paradigm.

Trauma and inpatient mental health nursing

Re-traumatisation of consumers within a mental health inpatient setting.

Many studies report consumers feel unsafe in psychiatric inpatient units

Literature highlights the prevalence of aggressive behaviour in acute mental health inpatient facilities

Research raises concerns about sexual safety in mental health units

Those with a previous history of trauma reported feeling increasingly unsafe, fearful, helpless, and distressed

Trauma and Acute Inpatient Mental Health Services

Systemic abuse refers to abuse perpetrated either purposefully or unknowingly by staff through system practices, policies, and protocols (Department of Health, 2000).

Consumers who felt they had no control concerning decisions around their care report high rates of frightening experiences.

Coercive practices, such as being forced to take medication on threat of seclusion or other negative outcomes were identified.

Trauma and Acute Inpatient Mental Health Services

Hodas (2006) stated that trauma-informed services are those that are cognisant that their services can re-traumatise consumers who have significant trauma histories through the indiscriminate application of coercive practices.

These services commit themselves to “do no harm” (Fallot & Harris, 2009, p.2).

Trauma and Acute Inpatient Mental Health Services

27 bed acute admission ward High incidence of co-morbidity

Drugs and alcohol Homelessness Frequent contact with police & criminal

justice system High demand & high occupancy Average length of stay < 14days

Caritas Ward, St Vincent’s Hospital

Most admissions to ward via ED Police involvement common Drug and alcohol intoxication often

complicating factor IV sedation, mechanical and physical restraint

used to manage aggressive and disturbed behaviour

Admission

Nursing team responsible for the day-to-day management of patient care and ward safety.

Experience of nursing staff in acute setting is often reported as

negative – emotional fatigue can lead to avoidant or overly

controlling responses to consumers

Negative Interpretation of consumer behaviours - perceived as

challenging or uncooperative; deliberately bad.

Anxiety related to consumer aggression

Medical Model dominant treatment approach

Mental Health Nurses

Seclusion reduction project 2008 –

During 3 year period reduced seclusion by 80%

Trained in de-escalation & physical restraint Seclusion and restraint as last resort Reduce reliance on security staff

Pharmacology research and training Lower doses of medication used for sedation Reduce incidence of over-sedation

Practice Improvement Strategies

Strengths-based Practice Integration of strengths philosophy and

principles Challenging attitudes and language of deficit

focus Encouraging compassion and collaboration

Sexual Safety training and practice development Improved staff awareness through training Policy and procedure development Segregated, female-only bedroom areas

Practice Improvement Strategies

Therapeutic art and group activities Allied health staff provide a range of group

activities Focus on interpersonal relationships &

relaxation Opportunities to participate in ward

improvement

Practice Improvement Strategies

Staff training to raise awareness of trauma and reframing of ‘symptoms’

Acknowledgement of the high incidence of trauma in consumers admitted to the ward - survey indicated over 75%

Physical restraint avoided as much as possible – > sexual trauma

Minimise participation of male staff in restraint of female patients, particularly when there is a known history of sexual assault

Reduce the duration of seclusion episodes

Post-incident debrief with consumers and opportunity to discuss safety planning

Trauma Aware

It is possible to incorporate trauma-informed care in inpatient settings, but…. Whole of service model Needs to be incorporated into an holistic

approach Improved clinical pathways for people who are

intoxicated – reduce demand on inpatient beds Staff need to be trained Peer support workers part of the clinical team Clinical supervision and support for staff

Conclusions