The current article reports a project that intended to change ward practice within an acute mental health inpatient service. The aim was to establish trauma-informed care and practice (TICP). The project developed from a growing awareness among staff of the prevalence of complex trauma in many consumers admitted to the ward. This awareness led to efforts by the multidisciplinary team to create a ward culture and develop practices that were in line with the principles of TICP.
Derived from the ancient Greek word for wound, trauma has been defined in many ways. In the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), trauma has been defined as exposure to actual or threatened death, serious injury, or sexual violence in one or more of four ways: (a) directly experiencing an event; (b) witnessing, in person, an event occurring to others; (c) learning that such an event happened to a close family member or friend; and (d) experiencing repeated or extreme exposure to aversive details of such events (American Psychiatric Association, 2013). The concept of complex trauma has been used to describe the experience of multiple or prolonged traumatic events. Exposure to trauma has been identified as a significant public health issue (Ghafoori, Barragan, & Palinkas, 2014), with traumatic experiences in childhood found to be key risk factors for poor health in adulthood (Barrios et al., 2015).
High rates of trauma among adult mental health consumers have been well-documented (Anderson, Howard, Dean, Moran, & Khalifeh, 2016). Some studies have found exposure to traumatic events in childhood among consumers to be as high as 47.5% to 71% (Álvarez et al., 2011; Anderson et al., 2016). Epidemiological studies have provided evidence that experiences of childhood trauma are associated with dramatic increases in the risk of developing depression in later life (Heim, Newport, Mletzko, Miller, & Nemeroff, 2008). Studies have also indicated that individuals with a diagnosis of bipolar disorder report being exposed to more severe trauma in childhood than individuals without this diagnosis (Etain, Henry, Bellivier, Mathieu, & Leboyer, 2008). The intensity of these traumatic experiences has been reported to significantly influence frequency of hospitalization (Maguire, McCusker, Meenagh, Mulholland, & Shannon, 2008).
Individuals experiencing psychosis were reported to be 2.72 times more likely to have been exposed to childhood adversity and trauma than those without psychosis (Varese et al., 2012). Kelleher et al. (2013) found that exposure to childhood trauma predicted psychotic experiences as well as provided evidence that the cessation of traumatic experiences led to a reduced incidence of psychotic experiences in their study group.
This growing body of evidence highlights that a history of childhood trauma is the single most significant predictor that an individual will need support from mental health services (Kezelman & Stavropoulos, 2012). Despite this association, Australia's mental health services have been noted to have a poor record in recognizing the relationship between trauma and the development of mental health disorders and responding appropriately (Mental Health Coordinating Council, 2013). Most models in mental health services have evolved from institutional ideologies and practices from the early 20th century (Cleary & Hungerford, 2015). Therefore, TICP represents a paradigm shift for mental health services.
Inpatient mental health wards are clinical environments that have been purportedly designed to provide safe care and treatment for consumers who are experiencing mental illness and perceived to be a risk to themselves and/or others (Isobel, 2015; Muskett, 2014). The experience of nursing staff and consumers in these wards is often reported as being negative (Beckett et al., 2013). The ward culture and its associated practices can have a significant effect on consumers' experience of care and treatment. Differences can establish clinical environments where consumers feel empowered or disempowered (Isobel, 2015; Muskett, 2014).
Inpatient ward practices such as seclusion and restraint can be traumatic for consumers and cause further distress and harm. Although the reduction of seclusion and restraint is a key issue for mental health services, it is not an issue that is specific to TICP and should not be its sole focus (Muskett, 2014). Other practices such as the enforcement of ward rules, close observations, leave management, and information control must also be included as inpatient wards attempt to establish TICP (Cleary & Hungerford, 2015; Muskett, 2014).
Muskett (2014) identified the key principles of TICP as (a) consumers have a need to feel connected, valued, informed, and hopeful of recovery; (b) the connection between the experience of childhood trauma and current psychopathology is known and understood by staff; and (c) staff work with consumers, their families, friends, and supports in ways that are mindful and empowering and promote and protect autonomy. TICP can be used in mental health services to ensure every aspect of service delivery is trauma-informed and to promote a basic understanding of how trauma affects individuals who are service users (Fallot & Harris, 2009). By facilitating recovery through TICP, retraumatization from mental health service contact can be minimized and self and community wellness and connectedness can be promoted (Mental Health Coordinating Council, 2013).
In inpatient wards, TICP can be used within recovery-focused and/or person-centered models of care (Barton, Johnson, & Price, 2009). TICP complements these approaches, providing an explanation for unhealthy coping skills and how they can manifest in situations that may be frightening or stressful for individuals who have experienced trauma (Muskett, 2014). TICP acknowledges, validates, and attempts to understand and respond to trauma experiences (Barton et al., 2009). The approach promotes collaborative and empowering relationships and increases consumers' awareness about their coping skills in stressful situations (Isobel, 2015).
The aim of the current project was to improve the quality of care provided to consumers. The approach taken to achieve this goal was based on the belief that embedding the principles of TICP in ward practices, which promoted values such as choice, collaboration, trustworthiness, safety, and empowerment, would lead to practice improvement and cultural change. Assessment data from consumers highlighted that approximately 90% identified at least one experience of significant trauma in their lives.
The 27-bed ward was situated in a busy public hospital in Metropolitan Sydney, Australia. The ward was divided into a six-bed high dependency unit (HDU) and 21-bed acute unit. High demands for inpatient beds and the high acuity of consumers who presented were a daily management focus. The average length of stay was 11 days and there was a separation rate of >70 consumers each month. The consumer group had high rates of comorbidity, including problematic use of alcohol and other drugs, homelessness, and physical health issues.
Admissions to the ward were almost exclusively through the hospital's emergency department (ED), although a small proportion each month were admitted for psychiatric assessment from the local magistrate courts. Many presentations in the ED involved the police and ambulance services, with the involvement of hospital security staff, physical and mechanical restraint, and intravenous sedation a regular occurrence.
Mental health nursing staff were responsible for the day-to-day management of the ward environment, ensuring safety and care for all. High acuity, turnover of consumers through the ward, consumer aggression and hostility, and frustrations with the largely medical focus of treatment had left many nurses feeling negative about their role, resulting in cynicism and emotional fatigue. Aggressive and challenging behaviors were often interpreted negatively with consumers being labeled as antisocial, borderline, or forensic. A perceived lack of safety was a common theme among nursing staff, particularly in the HDU, and there was clear evidence of some staff avoiding and/or minimizing face-to-face contact with consumers in this part of the ward. The rates of seclusion were among the highest in the State, and uniformed, male hospital security staff were routinely used to restrain consumers due to the low rates of appropriately trained staff on the nursing team. Audits revealed an over-reliance on pharmacological interventions to manage aggression and disruptive behavior.
Trauma-Informed Care and Practice Workshops
The ward Clinical Nurse Consultant (P.B.) and Senior Clinical Psychologist (M.P.) devised a series of workshop sessions to raise awareness of trauma and trauma-informed care and stimulate discussions on how they might be useful in improving practice. Through these workshops, six key practice development areas were identified by staff and working teams were formed to explore these areas further. The six practice areas included: (a) reducing seclusion and restraint, (b) increasing staff confidence by improving skills in de-escalation and physical safety, (c) ensuring best practice for pharmacological interventions, (d) introducing strengths-based philosophy and practices, (e) providing sexual safety training and awareness, and (f) improving access to therapeutic activities on the ward.
During the next 3 years after conclusion of the workshops, seclusion rates were reduced by 80%, with the majority of seclusion incidents <60 minutes in duration. Training in de-escalation and physical safety combined with trauma-informed perspectives on behavior resulted in nursing staff feeling more confident and motivated to stay engaged therapeutically with consumers who were exhibiting high levels of emotional distress and behavioral disturbance. The use of security staff on the ward was also minimized. The changes to the ward environment enabled staff to use the seclusion suite as a voluntary, de-escalation area for consumers rather than a place of enforced detention.
A working party comprising staff from nursing, medicine, pharmacy, and consumer backgrounds was established to investigate the use of medication in the unit. A literature review to identify best practice in the use of pharmacological interventions resulted in the revision of rapid sedation protocols on the ward, emphasizing lower doses of sedating medication and more specific protocols for different groups of consumers, such as those who were neuroleptic naive, frail, or elderly.
The integration of strengths-based philosophies and practice was reflected in a reduction in the use of clinical jargon and pejorative descriptions of consumers (e.g., chronic schizophrenic) and efforts to focus on consumer strengths and resources during clinical discussions and handover. Greater awareness of childhood and adult adversity encouraged greater understanding, compassion, and respect for consumers.
Ensuring sexual safety in inpatient settings is an area of vital importance, and this was reflected in the staff workshops and practice development groups. One of the nursing staff developed a sexual safety training module, which all staff attended, and revised the ward policy and procedures to ensure best practice. A section of bedrooms, in clear view of the ward office, were designated as female-only, providing further security to female consumers. Avoiding the use of male staff in the restraint of female consumers was also a key focus of care.
Nursing and allied health staff worked together to improve the range and number of therapeutic activities on the ward. Many groups focused on relaxation, self-care, and positive relationships, including art, yoga, meditation, and strengths- and recovery-focused conversations.
The Consumer Participation Officer (D.H.) redeveloped the ward information booklet to improve the quantity and quality of information provided to consumers about the admission process. The Officer also ensured that there were regular opportunities on the ward for informal groups in which staff and consumers could meet to talk about concerns, experiences, and ideas for improvement.
Exposure to trauma results in wide ranging and long-term consequences for consumers, as well as resulting implications for those working in mental health care and mental health services in general. It has been widely recognized that trauma symptoms arising from consumers' pasts can create a significant barrier for partnering with health professionals in effective care and treatment (Walsh & Boyle, 2009).
The examples from the inpatient ward demonstrate how the concept of TICP can be developed in the culture and practices in this context. Strong leadership, opportunities for staff and consumer empowerment, and sustainability strategies are vital to the ongoing success of these efforts. In addition, access to reflective clinical supervision, debriefing, and support for staff are vital, particularly for nursing staff, as they are expected to work therapeutically for long periods with individuals with high levels of emotional and behavioral disturbance. Mental health nurses need to comprehend how the history of the consumer is re-enacted through his/her interactions (Cleary & Hungerford, 2015), meaning that mental health nurses are responsible for navigating interactions with consumers regardless of the situation or consumer's predicament.
Developing and maintaining a culture and associated practices of TICP is only possible when health professionals know about trauma and its effects on the individual and are competent in practicing within this context (Gatz, Brounstein, & Noether, 2007). Central to this approach is that nurses provide recovery-focused and growth-enhancing practices and interventions to those at risk of retraumatization (Cleary & Hungerford, 2015). In addition, it has been suggested that inpatient units in particular could do more to ensure that the physical environment is one that supports caregivers in the provision of trauma-informed care rather than emphasizing security (Walsh & Boyle, 2009).
Conclusion and Implications for Practice
Given the significance between childhood trauma and the need for mental health services in adulthood, the current authors believe it is imperative that a trauma-informed approach to care and treatment be adopted by mental health professionals. The outcomes reported in the current project demonstrate the benefits to professional practice and ward culture through facilitating culture change and promoting TICP in an inpatient mental health ward. The collaborative and participatory methodology used to promote improvement to patient care was underpinned by the principles of TICP. This is not a completed project, but part of a continuing process of change.
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