‘Improvement is embedded in ‘safety for all’ rather than towards elimination,’ says Brian Jackson in reference to restrictive interventions. Evidence has shown that ‘Zero statements don’t work.’
Brian has been the Director of Nursing at Royal Melbourne Hospital/NorthWestern Mental Health for the past 22 years, and before that he held several senior nursing roles in the UK. He speaks from deep experience, and will give a presentation at the upcoming ANMF (Vic Branch) OHS conference titled ‘A best-practice approach to the application of restrictive interventions promotes safety for all’.
His topic is that total elimination of restrictive interventions is not possible, so when their use becomes necessary it is vital to ensure they are done so in a way that is safe for everybody involved – ‘because restrictive interventions are equally challenging for the clinicians that apply them as they are for the consumer who’s receiving them.’
Safety for all
For Brian, safety for all means ensuring not only the physical, mental and emotional safety of the consumer and of the staff, but also addressing the moral distress experienced by nurses who reluctantly apply restrictive interventions while continually being lectured about impractical zero tolerance or elimination ideals.
At Royal Melbourne, their approach is perhaps best summed up as: prevention and early intervention is better than a later response. ‘Our clinicians have done Safe Wards training, sensory modulation training and more’, Brian says, ‘but we also have unique roles across our service called Mental Health Intensive Care Response Roles’. These roles have been introduced across the hospital’s acute inpatient units with the aim of ‘leading a team in early intervention’.
Elaborating, he explains that ‘it’s a bit like when somebody’s showing signs of distress from a cardiac viewpoint. Where they’ve got tachycardia, they’re breathless, then it’s a sign something’s happening. And when you can intervene early, before the subsequent heart attack, there’s going to be a better chance of recovery. Likewise, early intervention, early engagement has been our principle with these new roles.’
These senior leadership roles can respond quickly with a coordinated plan when a consumer is showing early signs of distress. That plan might mean ‘being gender sensitive about who is involved in treatment. It might be about recognising past trauma, or it might be what’s worked before.’
Intelligence in data
Brian also emphasises continuous improvement, noting that they peer review every restrictive intervention applied to see if there has been any misuse or misapplication of it. They interrogate the data. They don’t just look at seclusions and physical or mechanical restraints, but at the number of code greys, the number of RiskMans related to aggression, the WorkCover injury data and lost time. ‘We want to see the whole dashboard because nothing should be measured in isolation,’ Brian says.
He gives a theoretical example of a unit that over the course of one month records 30 seclusions. A detailed analysis of the data might show that one consumer was secluded 20 times, and two consumers were secluded for five times.
‘So the trend data is misleading,’ he explains. ‘It’s actually the way you interrogate data and understand what the data are telling us that’s important. If we look at a detailed picture of what’s happening with the consumer who has been secluded 20 times, I would hope that the next month we would see that same consumer isn’t being secluded 20 times.
‘The team now understands the consumer’s needs more, and there’s a recovery plan in place. And we’re recognising early intervention as we’re starting to learn what the antecedents are. That’s our measure of improvement,’ he adds.
‘Improvement isn’t elimination,’ he emphasises. ‘Improvement is high expectations relating to consumer-centred care and clinical practice standards with the data and related metrics and saying: what can we conclude from it? And what would we do differently?’