Secure Learning Disability Service Research Articles

Let’s talk about sex!: Reflections on running a sex education group in female learning disability secure services

This article serves to reflect on the challenges of facilitating a Sex and Relationship Education Group in a female secure learning disability (LD) service. Topics covered included relationship types, boundaries, sexual intercourse, sexual health, consent, sexual orientation and gender identity.

Exorcising restraint: reducing the use of restrictive interventions in a secure learning disability service

Purpose The purpose of this paper is to describe the nature and impact of a restraint reduction strategy implemented within a secure learning disability service in response to the national Positive and Safe programme. Design/methodology/approach The strategy was comprised of three primary interventions – Safewards, positive behavioural support and data-informed practice – and utilised a programme management approach to ensure effective delivery. Baseline measures were collected from 12 months of data prior to implementation of the programme and the frequency of each category of restrictive intervention was then measured prospectively on a monthly basis throughout the duration of the programme. Findings Upon completion of the programme the following results were achieved: elimination of prone restraint – elimination of mechanical restraint – 42 per cent reduction in general use of restraint – 42 per cent reduction in use of seclusion – 52 per cent reduction in rapid tranquilisation. Originality/value The paper adds to the growing body of evidence that carefully designed interventions can reduce the frequency of seclusion and restraint. In this case, Safewards and PBS have combined to exert their effect. Data-led practice and senior leadership were also found to be of critical importance. Finally, the need for a stable workforce is considered.

The use of observation on patients who self-harm: Lessons from a learning disability service

Background: Observation is an important approach to care that is commonly used in inpatient learning disability services to prevent self-harming behaviours. It is often implemented when there is a perceived increase risk of self-harm. Most nurses who implement observation have little or no training in the use of this practice. The literature on this subject is also biased towards mental health settings with learning disability services much neglected.Aim: To explore nurses' knowledge and understanding of the use of observation on patients who self-harm in a learning disability service in the United Kingdom.Design: and methods: This study adopted a qualitative approach, and utilised interpretative phenomenological analysis as a design and as a tool of analysis. The study was conducted in a secure learning disability service in the United Kingdom. Data were obtained from registered nurses using individual interviews (n = 20) and focus groups (n = 3 x 5 = 15). Data were analysed thematically using the principles of interpretative phenomenological analysis.Results: Three superordinate themes emerged from data analysis: 1) observation: its meaning, 2) observation: does it prevent self-harm? 3) Observation: making it work.Conclusion: Observation is a useful practice in in-patient learning disability services, which can be used to prevent or reduce the incidence of self-harm in these settings. This approach should therefore be an integral part of nurses' daily therapeutic activities in inpatient learning disability services.

The use of observation on patients who self-harm: Lessons from a learning disability service

BackgroundObservation is an important approach to care that is commonly used in in-patient learning disability services to prevent self-harming behaviours. It is often implemented when there is a perceived increase risk of self-harm. Most nurses who implement observation have little or no training in the use of this practice. The literature on this subject is also biased towards mental health settings with learning disability services much neglected. AimTo explore nurses' knowledge and understanding of the use of observation on patients who self-harm in a learning disability service in the United Kingdom. Designand methods: This study adopted a qualitative approach, and utilised interpretative phenomenological analysis as a design and as a tool of analysis. The study was conducted in a secure learning disability service in the United Kingdom. Data were obtained from registered nurses using individual interviews (n = 20) and focus groups (n = 3 × 5 = 15).Data were analysed thematically using the principles of interpretative phenomenological analysis. ResultsThree superordinate themes emerged from data analysis: 1) observation: its meaning, 2) observation: does it prevent self-harm? 3) Observation: making it work. ConclusionObservation is a useful practice in in-patient learning disability services, which can be used to prevent or reduce the incidence of self-harm in these settings. This approach should therefore be an integral part of nurses' daily therapeutic activities in in-patient learning disability services.

Outcomes from the National High Secure Learning Disability Service: findings and challenges

Purpose – The “outcomes revolution” in healthcare has yet to impact strongly on secure intellectual disability (ID) services in the UK. The purpose of this paper is to review the service-level outcome studies that exist for this population, and to explore some of the challenges of conducting such research. It further describes some illustrative routine outcome data from the National High Secure Learning Disability Service. Design/methodology/approach – Routinely collected outcome measures (length of stay; violent incidents; Emotional Problem Scale (EPS) Behaviour Rating Scale and EPS Self-Report Inventory) were analysed for two overlapping cohorts of patients resident in the high-secure service between 2008 and 2013. Findings – The median length of stay of those discharged during the study period (n=27) was around 9.9 years (range one to 40 years). A significant proportion (25 per cent) of discharges resulted in an eventual return to high security. There did not appear to be a treatment effect over two to three years using staff-rated global clinical measures, but patient-rated clinical measures did reduce. Violent incidents also reduced significantly over a longer period of four years in treatment. Research limitations/implications – There are identified challenges to research design and outcome measurement which need to be addressed in any future cross-service studies. Originality/value – There are relatively few published outcome studies from forensic ID services. None of the studies have used clinical measures of changes or patient-rated outcome measures.

A qualitative investigation into nurses' perceptions of factors influencing staff injuries sustained during physical interventions employed in response to service user violence within one secure learning disability service.

The aim of the study was to examine learning disability nurses' perceptions of incidents involving physical intervention, particularly factors contributing to injuries sustained by this group. This article reports on a qualitative study undertaken within one secure NHS Trust to respond to concerns about staff injuries sustained during physical interventions to prevent incidents of service user violence from escalating out of control. The context of the study relates to increasing debate about the most effective approaches to incidents of violence and agression. A qualitative research design was utilized for the study. Semi-structured interviews were undertaken with 20 participants, two from each of the 10 incidents involving staff injury sustained during physical intervention. Four themes were produced by the analysis, the first, knowledge and understanding, contextualized the other three, which related to the physical intervention techniques employed, the interpretation of the incident and the impact on staff. Service user violence consistently poses nurses with the challenge of balancing the need to respond in order to maintain the safety of everyone whilst simultaneous supporting and caring for people with complex needs. This study highlights the need for further exploration of the contributory factors to the escalation of potentially violent situations. Services may have good systems in place for responding to and managing service user violence but appear less effective in understanding the reasons for and developing strategies to prevent violence occurring.

Seizing the opportunities to improve neuropsychological services in a High Secure hospital

Purpose – A significant number of people held within the secure forensic hospital estate in this country suffer from neuropsychological deficits (e.g. Lowings, 2010; Williams et al., 2010). These deficits, many of them cognitive, have a detrimental impact on patient's abilities to benefit from psycho-educational materials thereby slowing the progress of their rehabilitation. Understanding these difficulties enables interventions to be more effectively targeted and facilitated to the patients’ cognitive strengths. It was against the backdrop of the evidence that a review was commissioned into neuropsychological activity at Rampton Hospital. Design/methodology/approach – The review of the neuropsychological assessment activity was confined to the male patients residing within Mental Health Services (MHS) and the National High Secure Learning Disability Service (NHSLDS) of the hospital. With regards to the MHS, 129 patient files were examined in order to identify the volume of neuropsychological assessment previously undertaken and the make up of the neuropsychological test batteries administered with the current patient group. With regard to the NHSLDS 48 files were similarly examined. In addition, MHS psychologists were surveyed to assess their knowledge of patients within that service who to their knowledge had previously suffered an acquired brain injury (ABI) or had suffered a significant neurological illness likely to have resulted in cognitive impairment. Findings – A scoping exercise identified that a significant amount of neuropsychological assessment was being undertaken, albeit in an unstructured way. This led to a number of patients being subjected to a significant delay before the need for neuropsychological testing and rehabilitation possibilities became apparent. There was a huge variance on when a patient was tested ranging from one month to 14 years and the size of the test battery used, with the number of tests conducted per patient ranging between one single test to 16 tests during a patients stay at the hospital. Practical implications – Opportunities to more appropriately place patients based upon their abilities could be achieved if the hospital were to adopt a policy of conducting neuropsychological assessments, including cognitive functioning, for all patients upon admission to the hospital. A proportion of patients were known to have had a ABI or a significant illness likely to have resulted in cognitive impairment. This was considered to be an underrepresentation and the taking of a thorough history specifically covering ABI and specific illnesses known to have an impact on cognitive ability and behaviour was also recommended. Originality/value – In light of this review, services are to take a more systematic approach to assessing neuropsychological difficulties. Consideration is being given to neuropsychological screening becoming part of the admission process.

The evolution of a therapeutic community for offenders with intellectual disability and personality disorder: part one – clinical characteristics

PurposeThe purpose of this paper is to describe the profile of community members admitted to the first high secure Therapeutic Community (TC) for males with learning disability and personality disorder.Design/methodology/approachThis paper presents descriptive data.FindingsThe characteristics of the men admitted to a TC in the National High Secure Learning Disability Service are likely to present considerable challenges to the development and delivery of the service.Originality/valueThere is very little literature describing interventions for offenders with learning disability and personality disorder. This paper is one of a series that will describe the effectiveness of a TC for men with such difficulties.

“Shared Pathway” national pilot project: the experience of a secure learning disability service

PurposeThis paper aims to describe the experience of a secure learning disability service in participating in the national Shared Pathway pilot project in secure services.Design/methodology/approachSome background drivers to the project are explored as well as the experience of service users and staff who were involved in the pilot project. Recommendations on service‐wide implementation of the Shared Pathway are made.FindingsThe Shared Pathway will lead to considerable changes in practice. This will also have resource implications.Originality/valueThe paper shows that the Shared Pathway may be useful in ensuring evidence based outcomes are routinely used by clinicians in secure services in collaboration with patients. It may also clarify to patients what their role is in engaging in treatment that helps them in moving through secure services.

‘I can try and do my little bit’ ‐ training staff about self‐injury

This article is written from the point of view of a service user who is involved in training staff about working with people who self‐injure in the secure learning disability service where he lives.• I am a service user living in a secure unit who talks to staff in training about self‐injury.• I do an hour each month answering questions and I get paid for it.• I enjoy training the staff and it has made me more confident.• I get some good feedback about my work from the staff.• I wanted to tell other people about this experience.• This report is made of parts of a recorded interview that I did with a member of staff and meetings with her to write this into an article.

Adapted dialectical behaviour therapy for male offenders with learning disabilities in a high secure environment: six years on

Dialectical behaviour therapy (DBT) (Linehan, 1993) is a comprehensive psychological treatment that was first developed for suicidal individuals with a diagnosis of borderline personality disorder. The model has successfully been used to address violence and aggression in a forensic setting (Evershed et al, 2003). The National High Secure Learning Disability Service (NHSLDS) piloted an adapted DBT programme suitable for men with mild learning/intellectual disabilities in 2004, and the programme has been developed over a period of six years. This paper describes the rationale for development of the programme, how the programme has evolved, the major modifications to mainstream DBT that it incorporates, and the challenges that remain.

`It's OK for people to feel angry'

Ward managers working in a medium secure learning disability service were asked to identify members of staff who they believed to be superior in the management of violent and aggressive individuals. A grounded theory approach was used to interview staff about their management of imminent aggression. The participants explained their strategies in terms of the following eight themes, which were common to all interviews: safety and de-escalation, attribution and control, relationships, understanding and empowerment, anticipating reactions, creating a façade, communication, and humour. The participants described the importance of building up trusting relationships with clients when trying to understand the reasons for the client's behaviour. They also explained how they offer a ;get-out clause' to the client, a way for the client to decide to calm down without losing face. The participants also reported that creating the appearance of being in control can help, as does the use of humour to aid communication.

The last resort?

This study provides feedback from research with staff and clients of a medium secure learning disability service in north-west England. Participants were asked about incidents which required the use of physical intervention, using unstructured interviews within a participatory research framework. The article explores clients' and staff accounts of aggressive incidents and the consequences of physical intervention. Clients cited other clients and the ward atmosphere as the main reasons for aggressive behaviour. Some clients said that the use of physical intervention made them more frustrated and brought back memories of frightening experiences. Staff reported that incidents of aggression and the use of physical intervention were upsetting and traumatic, causing feelings of guilt and self-reproach. Staff said that they always used physical intervention as a last resort, although clients often reported otherwise. Time out and post-incident discussions were valued by both groups, as were strong staff/client relationships.

Working with People Who Harm Themselves in a Forensic Learning Disability Service

This paper provides feedback from research with staff who work with people who self-harm in a medium secure learning disability service in the north-west of England. It outlines some of the experiences described by staff, as well as personal and organizational responses to incidents of self-harm; explanations that staff use to understand the behaviour; and recommendations for change to treatment models and the staff support system. The information was gained using in-depth interviews, within a participatory research framework. Staff reported experiencing powerful emotional responses to incidents of self-harm, ranging from feelings of anger to feelings of inadequacy and guilt. A number of explanatory models were used by participants to understand the behaviour, and these were generally carefully considered and related to the client's individual situation. The staff/client relationship was often reported as being very rewarding but sometimes staff felt the client was manipulating them. This raised issues about the balance between client autonomy and risk, which was a concern for all staff. When discussing support needs, participants commented that there should be more training that they are able to use in practice, and that more support is needed in the form of discussion groups with colleagues. The findings from this study may be relevant to similar residential facilities.