Low Secure Units Research Articles

Enhancing the Healing Environment

A new low secure unit was able to significantly reduce incidents of violence and aggression through implementing the ‘Enhancing the Healing Environment’ programme. James Dooher and Clare Kozlowski explain how a Midlands NHS Trust listened to the service user voice, and took steps to achieve positive results for all

An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit

Psychosocial intervention (PSI) training results in enhanced knowledge, more positive attitudes, increased confidence and lower levels of clinical burnout for qualified mental health professionals and better outcomes for service users who they work with. This paper describes an evaluation of a PSI training course for qualified and unqualified nurses working in a low-secure unit. Forty-two staff (21 qualified) were randomly allocated to an experimental training group or a waiting list control group. Knowledge, attitudes and burnout were assessed before and after the training. In addition, a random sample of 44 care plans written by the qualified nurses were audited before and after to examine evidence of implementation of PSI in practice. Qualified and unqualified nurses in the experimental group showed significant improvements in knowledge and attitudes compared with the control group. Care plans showed a significant increase in the implementation of PSI. The only significant change in burnout was a reduction in depersonalization for qualified nurses in the experimental group. The PSI training may result in improvements in knowledge, attitude and practice in qualified and unqualified nurses working with severely mentally ill patients in low-secure settings, but in this study the training did not incur protection against burnout.

Audit of the Rapid Tranquilization Policy in the 2gether NHS Foundation Trust

Rapid tranquilization (RT) is a procedure used in an inpatient setting to deal with acute behavioural disturbance not manageable by other means. The 2gether NHS Foundation Trust has an RT policy which incorporates the National Institute of Clinical Excellence (NICE) guidance on best practice which breaks down into eight domains.The aim of this audit was to scrutinize practice in relation to this policy.The audit team sampled 50 Prevention and Management of Violence and Aggression (PMVA) incidents that occurred over a four month period at Wotton Lawn Hospital and the Montpellier Low Secure Unit in Gloucester. PMVA is a method of organized restraint involving a team of three staff used to administer parenteral RT as well as managing disturbance. Data was collected using an audit proforma.This audit demonstrated adherence to the majority of standards in the RT policy in most incidents. However, there was a significant non-compliance in two areas: appropriate physical observations being carried out after an RT incident and administration of RT in a private area. It may be that standards were in fact met but that there was no evidence for this in the documents examined.The authors believe that clinical practice can be improved by effective training of staff that emphasizes the need to meet standards and the importance of contemporaneous documentation following an RT incident. They have disseminated the results of this audit to appropriate clinical leads and trainers.The audit will be repeated in 12 months’ time.

Health Service Inpatient Units for People with Intellectual Disabilities and Challenging Behaviour or Mental Health Problems

Background As institutions for people with intellectual disabilities have been replaced with community services, health care provision has developed to provide assessment and treatment, low and medium secure units for people with challenging behaviour or mental health problems. These include both public and private sector provision. Little is known about these services. The aim of this study was to describe the characteristics of the services studied and to compare the different types of service.Methods A survey was carried out of National Health Service (NHS) and independent sector (IH) health settings providing specialist inpatient services for people with intellectual disabilities. Data were collected on setting and patient characteristics, staffing and management and care processes and outcomes.Results Services were very unevenly distributed across England. There were differences between NHS and IH settings. IH assessment and treatment units were bigger, had higher occupancy and lower staff ratio. In all three types of unit, IH units had fewer visits to patients, used more seclusion, physical restraint and had more locked areas. They had more complaints in more services from users and (for assessment and treatment units and low secure units only) from relatives. In low secure units, they had more adult protection referrals. On the other hand, IH units used fewer agency staff in assessment and treatment units (though more in medium secure units) and provided more appraisals, more visits from commissioners, more consultations with GPs and dentists and more use of whistleblowing procedures by staff. A quarter of people in NHS assessment and treatment units had finished treatment but had no plan for discharge.Conclusions Further research is required to determine the reasons for differences observed between IH and NHS units. The large number of people who have finished treatment emphasizes the importance of developing housing in the community with sufficiently skilled support. The large number of patients in low secure services raises the question whether this type of service is recreating the intellectual disability institutions which government policy intends to close.

P02-380 - The social climate of a women's forensic pathway of care according to level of security, diagnosis and therapeutic alliance

IntroductionThe social climate of a unit is an important feature in treatment outcomes (Moos 1974). The Essen Climate Evaluation Schema (EssenCES; Schalast et al 2008) has been developed specifically for forensic settings but research in secure settings for women has been limited.ObjectivesTo compare staff and patient perception of social climate and it's relationship to therapeutic alliance, motivation to change and level of disturbance across levels of security within a women's secure care pathway.AimsTo assess the implications for therapeutic milieu and service development.MethodQuestionnaire survey of staff and patients in 2 medium and 2 low secure units using; EssenCES (Shalast et al 2008); California Psychotherapy Alliance Scale (Mormar et al 1986); and Patient Motivation Inventory (PMI; Gudjonsson et al 2007).Comparisons are made across levels of security, treatment programme, therapeutic alliance, patient motivation and disturbed behaviour.ResultsSocial climate varied between levels of security and was also found to co vary with perceived therapeutic alliance and patient motivation to change. Differences between staff and patient ratings along with treatment implications are discussed.ConclusionMeasuring the social climate in a secure women's service is an important part of a wider assessment of the therapeutic milieu that has practical implications for the ongoing development of therapy services.

Clinical characteristics of patients with self harming behaviour in a low secure mental health unit

Aims: To describe the methods of self harm incidents in a low secure unit population and to identify and compare the clinical characteristics of patients displaying inpatient self harming behaviours with those who do not display such behaviours.Method: A retrospective case control study was conducted. Details about the inpatient self harming incidents were collected from an incident database. Clinical characteristics of those who displayed inpatient self harming incidents (cases) and those who did not display such behaviours (controls) were compared. Analysis was performed to establish statistical significance on the observed differences.Results: 80 admissions resulted from 78 patients during a 6½ year period. 21% of patients presented with inpatient self harming behaviours. 57% of the incidents were caused by 13% of patients. Clinical characteristics such as white ethnic background, histories of self harm, physical or sexual abuse, childhood conduct problems and lack of educational qualifications and having a diagnosis of schizoaffective disorder were more likely to be associated with inpatients self harming in low secure settings. Sexually inappropriate behaviours and a diagnosis of schizophrenia were less likely to be associated with this group.Conclusion: The majority of self harm incidents are caused by a minority of patients. Most of the clinical characteristics associated with the low secure inpatient self harming patients are similar to those observed in other psychiatric inpatient settings.

Clinical predictors and patterns of absconding in a low secure challenging behaviour mental health unit

Aims : To compare the clinical characteristics of patients who absconded and those who did not abscond; and to show the types of absconding behaviour in a low secure challenging behaviour mental health unit. Method : A retrospective case control study was conducted. Details of the absconding incidents were collected from an electronic incident database. Clinical predictors of patients who absconded (cases) and those who did not (controls) were compared. Statistical analysis was performed to determine statistical significance of the observed differences. Results : 80 admissions resulted from 78 patients during a period of 6½ years. 22% of the inpatients absconded from the unit. 84% of the incidents occurred while patients were utilising their unescorted leave. Only one patient escaped from the building. No serious incidents resulted from any of the abscondings. On univariate analysis, the following predictors were more likely to be statistically associated with patients who absconded from the unit: a history of absconding behaviour and a history of substance misuse or dependence. A history of non-compliance with treatment, a history of sexually inappropriate behaviour and a history of childhood conduct problems showed a trend towards statistical significance. Conclusion : The clinical characteristics of patients who abscond from low secure units show similarities with those who abscond from other psychiatric inpatient settings. Declaration of interests : None.

Introducing trampoline use within an acute mental health care hospital setting

This practice evaluation paper will present the case for the use of trampolining as a therapeutic activity within an acute care setting for people experiencing mental ill-health. A brief history of this activity within a therapeutic context will be outlined and a theoretically analysed rationale for the development of trampoline sessions explained. A case vignette will illustrate the argument that trampolining is a realistic and therapeutic option for people who need the care of a Psychiatric Intensive Care Unit (PICU) or Low Secure Unit (LSU). The paper will conclude that service users can find trampoline activity useful as part of a recovery journey from acute mental illness.

A comparison of NHS and private low secure units: Unit and patient characteristics

Background: Both the National Health Service (NHS) and the private sector provide low secure care. Little is known about the differences between the two sectors regarding the unit functioning and characteristics of patients admitted to low secure units (LSUs).Aim: To compare the unit and patient characteristics of NHS and private LSUs.Method: A cross sectional census day postal design was employed.Results: The analysis is based on 128 LSUs (98 NHS, 30 private). NHS LSUs accommodated 1084 patients and the private LSUs accommodated 359 patients. Analysis of the data showed that some differences existed between the two sectors related to the number of beds, unit facilities, interventions and the referral-discharge route. The demographic characteristics of NHS and private patients were similar. The majority of patients were white, male, unemployed and single.Conclusion: Although the NHS and the private sector LSUs work similarly and share many characteristics in terms of the unit functioning and the patient characteristics, a few very significant differences between the two sectors have also emerged.

Psychiatric intensive care and low secure units: where are we now?

SummaryThe last decade has seen clinicians and policy makers develop psychiatric intensive care units and low secure units from the so-called ‘special care wards’ of the 1980s and 1990s. Psychiatric intensive care units are for short-term care, while low secure units are for care for up to about 2 years. Department of Health standards have been set for these units. A national survey has shown that there are two main patient groups in the low secure units: patients on forensic sections coming down from medium secure units and those on civil sections who are transferred from general psychiatric facilities. Recent clinical opinion has emphasised the important role both psychiatric intensive care units and low secure units play in providing a bridge between forensic and general mental health services.

Aggression patterns and clinical predictors of inpatient aggression in a mental health low secure unit population

Aims : To describe the pattern of aggressive incidents, compare clinical characteristics of aggressive and non aggressive inpatients and determine predictors of inpatient aggressive behaviours in a low secure mental health unit population. Method : Clinical data were extracted from inpatient records and a critical incident database for a low secure unit population. Clinical variables between those with inpatient aggressive behaviours (inpatient aggressors) and those without inpatient aggressive behaviours (inpatient non aggressors) were compared. Statistical analysis was carried out on the differences to establish predictors of inpatient aggression. Results : 80 admissions resulted from 78 patients during a 6½ year period. 44% of patients presented with inpatient aggressive incidents. 64% of aggressive incidents resulted from 15% of patients. 54% of aggressive incidents were directed towards staff, 16% towards property and 15% towards other patients. 8% and 4% contributed to disturbed behaviour (non-directed aggression) and sexually inappropriate behaviour respectively. Most aggressive incidents are perpetrated by males and directed towards staff though a larger proportion of females (compared to males) were aggressive. On univariate analysis, clinical variables of more than one previous psychiatric admission, auditory hallucinations and delusions of control and persecution were significantly higher in patients displaying inpatient aggression. Logistic regression analysis identified the former two as predictors of inpatient aggression. Conclusion : In a low secure inpatient population, the majority of aggressive incidents are perpetrated by a minority of patients. Clinical variables such as history of more than one previous psychiatric admission and psychopathological symptoms such as presence of auditory hallucinations and delusions of control and persecution can influence inpatient aggression.

UK low secure units in the spotlight

UK low secure units in the spotlight

Ethnic group and other characteristics of patients referred to a low secure mental health service

This longitudinal audit aimed to determine the ethnic groups and other characteristics of patients referred to a Low Secure Unit in South East London over a period of 9 years between 1997 and 2005. The data provide a picture of the characteristics of those most likely to be referred to a Low Secure Unit, and highlights an over-representation of Black Caribbean and Black African people. Discussion is provided for this latter finding.

The impact of low secure unit care on patient outcomes

A significant number of people with psychosis require inpatient admission under the Mental Health Act. Department of Health documents have highlighted the importance of delivering effective care to individuals with psychosis treated in low secure conditions. Research into patient outcomes in these settings has so far been neglected. The aim of the research reported here was to assess outcomes for patients tested at three six‐monthly assessments during their residence at a new community low secure facility for people with psychosis and challenging behaviour. Although there were numerical reductions on many of the outcome measures over time, few were statistically significant. The main significant improvements were in Positive and Negative Syndrome Scale total and delusions scores over time. Initial evidence indicates that this type of care may have promise, but further research is needed to extend these findings.

Does hyoscine need to be ‘legally’ prescribed?

A recent visit to the Wickham Unit (a low-secure rehabilitation unit) at Blackberry Hill Hospital, Bristol, by the Mental Health Act Commission raised a controversial issue regarding the legal prescribing of medication for individuals who are detained under the Mental Health Act. There was a case of

Predicting outcome in low secure environments: A case series from one low secure unit

Aims: To measure the effectiveness of treatment in a low secure challenging behaviour unit and to identify predictors of change.Method: Routine clinical data and outcome scores were collected on a case series of 86 patients admitted to and discharged from one low secure unit.Results: Significant improvements were found on Health of the Nation Outcome Scale (HoNOS), Staff Observed Aggression Scale (SOAS) and the Global Assessment Scale (GAS). Improvements in GAS and HoNOS were associated with moves to a lower level of security. Patients with a history of conviction for property damage, cannabis use, who were admitted on a forensic section or with a diagnosis of personality disorder were more likely to move to a higher level of security. Increased length of stay was related to the presence of physical assault, physical health problems and anxiety symptoms.Conclusions: Clinical outcomes and behaviour improve during admission to one low secure unit and characteristics of the type of patients who respond to this form of treatment are proposed.

Supply versus demand: Market forces in Low Secure and Psychiatric Intensive Care Units

Supply versus demand: Market forces in Low Secure and Psychiatric Intensive Care Units

It’s your move

An innovative project has enabled people with mental health needs to have a real say in their environment and as a result they have gained in confidence.

Engaging the disengaged: collecting the views of patients in a low secure unit on methods of observation

This article discusses the methodology used to engage a group of patients in a low secure unit in a research project to evaluate the effects of methods of observation.The results are summarised, and some surprising themes from the interviews are reflected upon.This very small scale, qualitative study suggests that patients in secure units can be meaningfully engaged in research; and this must continue, as this project has demonstrated that these patients have views which other published research has not brought to light.

Outcome study of patients exhibiting challenging behaviours four years after discharge from a low secure mental health unit

Aim: To follow up a series of patients admitted to a low secure mental health unit for challenging behaviour. Method: Clinical outcome measures (Health of the Nation Outcome Scale (HoNOS), Global Assessment Scale (GAS) and Staff Observed Aggression Scale (SOAS)) and keyworker interviews were used to follow up the progress of patients at least one year after discharge. Results: 33 patients had a mean time since discharge of 43 months. The typical patient was a man with a history of violent offences, admitted from an open ward because of aggression. The observed improvement on HoNOS and GAS during admission had been maintained at follow up. There had been no re-convictions. All patients were compliant with medication. Five patients had been re-admitted to hospital during the follow up period. The current placement showed that more of the patients were in the community compared with at discharge. Conclusion: Patients admitted to a low secure unit improved during their stay and this improvement was maintained at follow up.