1. 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)

2.  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

3.  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

4.  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

5.  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

6.  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

7.  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

8.  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

9.  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

10.  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

11.  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

12.  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

13.  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

14.  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