A national directive to reduce seclusion rates was taken as a serious challenge at Tairawhiti District Health Board (DHB), where seclusion rates were one of the highest in the country.

Early in 2012 the team was challenged by their clinical director to see what they could do differently to actively reduce seclusion and restraint events and improve the inpatient experience for people.

The national seclusion rates for Maori are significantly higher than other populations and this was certainly true for Te Whare Awhiora, the Tairawhiti DHB acute mental health unit.

A dramatic drop in the seclusion rates for Maori and all service users at Te Whare Awhiora is the outcome of 18 months of collaboration towards a therapeutic clinical model, says Debbie Barrow, service manager for the acute mental health service.

A second story on our website explores Tairawhiti DHB's journey from the consumer perspective... read it here

“Collaboration has happened across the service from senior management across all staff involved, and that has made all the difference,” she adds.

These changes in practice are supported by the senior management within the DHB, including the mental health clinical director.

“What we’re doing has shown a marked improvement but there is still a lot of work to be done. We had a close look at our environment, including building cultural support and strengthening service user input and looking at ways to de-escalate people,” says Debbie.

Addressing issues for Maori tangata whaiora and whanau

A significant factor has been the strengthened involvement and visibility of the Cultural Service throughout the ward. This is particularly important in a DHB with the highest Maori population in New Zealand. The Cultural Service now also supports people when in seclusion and offers advice and support to the nursing staff.

“Without this the kind of experience our team is very clinical,” says Debbie.

The presence of a cultural service, that includes the Koroua, Kuia, a cultural assessment team and a kaupapa Maori activities co-ordinator, provides continuity with cultural practice on the ward. “This supports people in connecting or reconnecting to their culture”, says Debbie. ”When this cultural intervention was not taking place, the journey through the inpatient unit for service users was not as smooth.”

Dave and Molly Para play an integral part as Koroua and Kuia. They are visible on the ward every day. They spend time with people ensuring people’s cultural needs are met.  Whether that’s by having a cuppa, chatting and finding out what people are needing culturally, or doing waiata or karakia together. “Their person centred, rather than clinical centred approach, really helps de-escalate situations, This opens up opportunities for compromise and positive outcomes. They find compromises that clinically, I as a nurse, can’t reach,” says Debbie.

Dave says his role is simply to respond to people at whatever level they wish to connect. He had only recently taken up the role of Koroua when talk of this change in practice began. "I’ve been around other services where ideas such as these had been discussed but they didn’t go anywhere so I’ve been very impressed with the delivery that has occurred so far. People have collectively taken up the challenge seriously and that is a great thing to be part of,” says Dave.

He says there have been ups and downs but the emphasis and belief is well established. “A lot has improved but no one is resting on their laurels. We keep at it every day, every week. The key thing to me is that we work in an environment where there is strong trust with colleagues and clients.”

Another unique aspect about the cultural services within Tairawhiti DHB is that the crisis team and the cultural assessment team work alongside each other during assessment and admission.

“This has made a big difference to how we respond to people when they are admitted,” says registered nurse Anne Prince.

The cultural assessment team is available to the ward 24/7. This means if in the evening or weekend, for example, a person is becoming distressed, agitated and overwhelmed a cultural team member is able to speak with them. This develops the rapport, and they can use cultural practices such as saying karakia or drawing on whanau connections.

Other Strategies

Mental health nurse Gavin Smith says, “An action plan was developed to promote best practice. This incorporated a range of innovative strategies to give staff more options, ones they felt safe to use. An increased overall awareness of the culture around seclusion was needed, along with a collective change of consciousness within the staff on the ward.”

From the outset the focus was on preventative measures. This included establishing rapport and working to help people recognise triggers and early warning signs with the intention of defusing agitation. The plan had a strong focus on a therapeutic model and included making the ward more homely and relaxed. Engaging staff in service improvements helps ensure the cultural needs of people are met.

With support from senior management, a therapeutic sensory modulation room was set up that included a massage chair and rocking chair. Sensory perspectives were also used throughout the unit to make it more comfortable and welcoming. Many cultural approaches such as miri miri, waiata, karakia, kapahaka, manaakitanga work well in their alignment with sensory work.

“An important aspect of sensory modulation is to teach service users how to recognise when they are moving into an altered state, and develop strategies that assist them in moderating the intense emotions,” says registered nurse Anne Prince.

“For example, to reduce adrenalin, anxiety and agitation levels, someone may use a specially weighted blanket that is placed over their body to help ground them. Or someone may choose to utilise the sensory modulation room because the ambient lighting reduces the stimulation around them.” 

A team of three staff became sensory modulation trainers after attending a sensory modulation train the trainer workshop facilitated by Te Pou. They then trained the wider ward team and service user staff from Te Kupenga Net Trust, an NGO provider who employs peer support workers, consumer leaders, advisors and advocates. The joint training allowed staff and people who had experienced using services including seclusion and restraint to come together and learn about each other’s perspectives and a new way of working.

There was also a renewed emphasis in the unit on keeping people occupied with meaningful activities. Service users are encouraged to  engage with activities during the day including using the small gym or working on a garden project - both areas that were developed during the changes.

“Overall, there has been a very pleasing commitment from the DHB, including the recognition that equipment and resources are required to maintain this change in practice,” explains service manager Debbie Barrow.

There have also been improvements to the admission and assessment process for the ward. Gavin introduced an admission tick-box questionnaire, asking people being admitted about their triggers and how they best coped. The information not only informs staff but helps people become more aware of their state of mind and the strategies that help when they are feeling distressed.

Because the emphasis is now more on preventative measures, the point of high aggression that might require seclusion has become less frequent and an unusual event, states Gavin.

“Seclusion is no longer a tool. When it does occur there is a lot more reflection about what led up to it and how to prevent it. This includes reviewing events with the person who was secluded.“ - Gavin Smith, mental health nurse

Overall change

While pointing out she can’t speak for all people using the service, consumer leader Chloe Fergusson says her own experience and the experience of a number of people at Te Whare Awhiora is that a culture change is noticeable and positive.

“Instead of feeling like someone is doing you a favour, it now feels right to be at the centre of care. Te Whare Awhiora translates as House of Healing and that is what we’re aspiring to," says Debbie.  

It is a holistic approach that is service user centred, rather than nurse centred, adds Anne. “So service users also change their ways of thinking and it does take time for the change to be effective.”

You might also be interested in...

  • Strategies to reduce the use of seclusion and restraint with Maori - research shows Maori are more likely to be restrained than non-Maori. This report gathers Maori clinical, cultural and consumer perspectives on potential strategies and initiatives considered likely to facilitate reduction in the high rates of seclusion and restraint.

  • Six Core Strategies to reduce seclusion and restraint - the Six Core Strategies checklist was originally produced in the USA. Te Pou have adapted the checklist for the New Zealand context. It contains proven strategies for reducing seclusion and restraint events.

  • Story on Tairawhiti DHB's involvement of consumers in their work to reduce seclusion and restraint with Maori and all people using services - read it here.