Te Pou's seclusion reduction project focuses on supporting safe and effective methods and practices to reduce seclusion and restraint in district health board acute inpatient settings. This is occurring through a coordinated rollout of sensory modulation training (through both familiarisation and train the trainer workshops), and the development of a number of tools that will assist with implementation. The project is assessing and promoting both international and New Zealand evidence for the effectiveness of sensory modulation.
A number of research studies show that a reduction in seclusion and restraint means either no increase in staff injuries or service user injuries, or a decrease in these – sometimes on a significant scale.
There are a range of reduction programmes that are successful in reducing the frequency and duration of seclusion and restraint use in acute mental health and addiction settings, while at the same time maintaining a safe environment. The research literature cites the need for adequate support and training for staff and a culture change led by management to ensure a reduction in the use of seclusion and restraint.
There is small but promising research literature showing that sensory modulation can be one component of training and practice that can reduce seclusion and restraint. It is likely that, for change to occur, sensory modulation needs to be part of a range of strategies.
The current Te Pou work Seclusion: Time for change, is focused on helping acute inpatient clinicians implement sensory modulation.
Sensory modulation denotes a range of prevention tools identified in the Six Core Strategies© advocated by the US National Association of State Mental Health Program Directors (NASMHPD), to help limit the use of seclusion and restraint.
Te Pou has been involved in research evaluating the effectiveness of sensory modulation. The initial data suggests that sensory modulation is a very useful, easy to learn suite of skills that is well considered by service users, and that supports clinicians to utilise other best practices. Te Pou is supporting further research examining the current usage of sensory modulation in some New Zealand acute mental health inpatient units.
Welcome to Introducing sensory modulation to your clinical area: Eight steps to a successful introduction. This series of eight steps is designed to help you, as a clinician or manager, successfully introduce sensory modulation to your clinical area.
Sensory modulation is, of course, a relatively new clinical innovation in New Zealand. Some clinicians and managers have successfully introduced sensory in their clinical areas. Feedback from some of them suggests that a structured change management approach is helpful in ensuring successful implementation.
The eight steps in this package are based upon John P. Kotter’s 8 Steps to Successful Change1. We would also like to thank Colette Adrian, clinical nurse educator, Child and Family Unit, Starship Hospital, Auckland for her input in developing this package.
We hope you find the eight steps helpful in your work.
1 Kotter, J. P. (1996). Leading Change, Harvard Business School Press
- Who is the identified leader that has the necessary skills to drive this project (sensory modulation implementation) and create a sense of urgency?
- How have you convinced all stakeholders that this change (implementing sensory modulation) is absolutely necessary?
- How have you communicated a sense of urgency regarding the need to implement sensory modulation in your area?
- How have you planned to shift staff out of their comfort zone in order to implement sensory modulation? For example, are clinicians sufficiently trained to understand sensory modulation? Do clinicians and management understand what it is, and how it can affect practice and service users’ experiences?
- How have you communicated the consequences of not implementing sensory modulation?
Plan this stage well and spend time preparing so that sensory modulation is the phrase on everyone’s lips at the same time. You will need to spend a good deal of time on this phase, and the overall plan, before anything is launched. Consider if you are a good planner, but struggle to launch or follow through. Be realistic, and get help with your least strong areas. You can’t be great at everything!
- Who has a vested interest in sensory modulation introduction (service users, clinicians, managers, planners and funders)?
- How have you involved the key managers and key stakeholders?
- How have you identified and ensured that influential and powerful people in your organisation will support the introduction of sensory modulation? Who are they?
Find out early who supports or doesn’t support the introduction of sensory modulation. Think about how you will find this out. There are also differences between those who truly support change, and those who say they do, but will not actively assist.
- Do you have a clear idea of what you want to achieve? What is your vision?
- What processes are in place for refining the vision as and when required?
- How do you communicate the vision in a clear and concise manner?
- How will you know staff understand and commit to the vision?
- What strategies have you developed to support achieving the vision?
A mentor might be helpful. Find this person yourself, in order to ensure they have some experience and successes in change management. A highly visible wall planner with timelines may be the best way to get information across.
- How are people at all levels of management routinely communicating the vision of implementing sensory modulation to staff?
- What methods are they using to communicate the vision to staff?
- What is the plan to communicate the vision at every opportunity and how is it part of your daily operations?
- How do you sell the likely gains of sensory modulation?
- What supports and education are available for staff to progress the development of the implementation of sensory modulation in practice?
Get down to detail about who is on certain groups and what Terms of Reference and expectations are. You want to avoid ‘seat warming’: people who have no active participation. Have the Terms of Reference signed off by participants, managers, and other relevant people. They will need to know the time and resource expectations. Have a plan prepared to deal with non-productive participants.
You need to be clear about the difference between steering groups and working groups.
Decide on reporting lines and meetings/people to feed into, and out of, and diarise when this will happen for duration.
You should communicate minutes of meetings to non-attenders like managers to keep them abreast of work and so they can keep the notion of sensory modulation ‘alive’ when they attend other meetings.
- What are the obstacles (people or things) that stand in the way of success?
- How will you remove them?
- How are people given time and space to act on the vision of implementing sensory modulation?
- What systems support people to act on the vision?
- How are you rewarding those who act on the vision?
Find out what other peoples obstacles were in other projects within your organisation. Big institutions often have similar systems issues that hold things up.
Ensure your schedule allows time to work on obstacles. Get support when dealing with obstacles, as they can drain energy.
- What are the short term goals? (These might be in, for example, getting staff trained, getting policies written, and setting up the room.)
- What resources are available to ensure short term goals are met?
- How will people (including clinicians, service users, managers, funders and planers) know these goals are met?
- How will you publicly recognise and reward people responsible for meeting these short term goals?
- How will you measure performance improvements (in the longer term)? To do this you need to be clear why you are implementing sensory modulation in the first place (for example, do you think sensory modulation will change seclusion rates or practices? Prn rates? Improve service user experiences?). Once you know this you can decide how you will measure it.
Measuring improvements can feel like another whole piece of work. Be clever about this from the start and consider this in your preparation time. Can IT do some of this for you? Can participants measure themselves? Use processes already in place (but maybe need strengthening), like PDRP and performance appraisals.
- How have you celebrated the improvements?
- Which systems, structures, policies, and people . are not consistent with the transformation vision?
- What are your plans to change these?
- In what ways are you promoting and developing clinicians who can and will implement the vision of sensory modulation?
- What are the processes for identifying new sensory modulation projects, themes and change agents that will produce more change?
How has the work been embedded into business as usual? For example, is it having a change of focus for seclusion and restraint forms? The service user debrief may be the first thing to be written to highlight what can happen differently next time.
Is acute inpatient nurse note-writing structured so that sensory modulation events and outcomes can be included?
- In what ways have the changes in staff knowledge, attitudes and behaviours improved clinical outcomes?
- Do people understand the connection between the implementation of sensory modulation and improved clinical outcomes?
- What processes are in place to ensure the changes continue even if key people leave? Who will be the ‘champions’ of sensory modulation? How will new staff be trained?
- How are new staff, at all levels, introduced to sensory modulation and given the opportunity to participate?
If you can answer these questions, it’s time to celebrate!
Links to graphs of improvement are visual ways of showing change.
Tick off those things completed and you can see at a glance where it’s at as a whole and in bits.