SHINE: Safety Care Bundle Health Foundation Funded Project

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SHINE Safety Care BundleHealth Foundation
Funded Project 72,000

• Norman Young Nurse Consultant,
• Dr Mark Haddad Clinical Research Fellow.

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The problem

• Acute inpatient units are complex and challenging
  environments
• As community services have expanded the severity
  of problems has increased.
• 78 of nurses and 37 users report being subject
  to violence or threats (Chaplin et al 2006).
• The Care Quality Commission report that 55 of
  mental health inpatients do not always feel safe
  and 16 do not feel safe at all.

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Effects on services morale performance

• These stressors have an effect on the morale and
  performance of staff.
• NHS staff have relatively high levels of sickness
  absence
• 10.7 days a year,
• - compared to
• 9.7 in public sector,
• 6.4 days in private sector.

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Estimated incidence of self-reported illnesses
caused or made worse by work in Great Britain, by
illness kind, 2007/08
Stress, depression or anxiety Bone, joint or
muscle problem Other type of complaint Infecti
ous disease (virus, bacteria) Heart
disease/attack, other circulatory
system Breathing or lung problems
0 100 200 300 400 500
600 700 800 900
Per 100,000 workers Source Health and Safety
Executive based on Labour Force Survey
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Are NHS workers more stressed than other workers?
Non-NHS workers
NHS workers
Bone, joint, muscular problem Stress, depression
or anxiety Other Infectious disease Breathing
or lung problem Heart disease/attack,
circulatory problem
60 50 40 30 20 10 0 10 20 30 40 50 60
Percentage of workers
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Staff sickness

• Sickness absence rate is high for mental health
  staff
• 5.24 compared with 4.48 for the NHS (2005
  data).
• Sickness rate ranges across different mental
  health trusts (1.95 6.91) indicate that
  factors affecting sickness absence, e.g.
• staff injury rates,
• stress levels,
• job satisfaction,
• - are amenable to interventions.
• dividing the total number of sickness absence
  days by the total number of available days

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Setting Llanfair Unit

• 410 incident reports of aggressive or violent
  behaviour.
• 11 incidents resulting in 3 or more days of work.
• 1 incident more that 6 months leading to a cost
  of approx 42,000
• Currently average sickness cost are 119,352.
• Indirect costs through increased length of stay,
  medication use and one to one nursing.

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The Intervention

• There is evidence that a structured risk
  assessment process carried out twice a day for
  the first three days of admission reduce
  incidence of violence and aggression (Abderhalden
  et al, 2008)

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The Intervention

• A tool and process were developed to
  systematically assess risk for all admissions
• This was accompanied by ward based teaching and
  the use of safety briefings

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Evaluation questions and measures

• Is the care bundle associated with changes in
• Patient safety incidents (incident reports -
  major, minor, severe absconding) management of
  risk (special observations forcible medication
  patient restraint patient seclusion patient).
• of individual patients/ no. episodes

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Evaluation questions

• Bank agency staffing.
• Weekly spend excess in relation to ward staffing
  budget.
• Staff morale staff sickness
• MBI - cross-sectional data, 2 time-points
• Number of full-time equivalent staff days lost to
  sickness absence staff members with sickness
  absence gt7,10, 14, 21 days

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Evaluation questions

• Is the care bundle feasible acceptable in
  routine practice?
• Staff interviews (semi-structured
  quantitative/qualitative interviews with nursing
  staff to examine understanding satisfaction
  with intervention package).
• Patient questionnaires at discharge questions
  adapted from NHS Mental Health Acute Inpatient
  Service Users Survey Questionnaire (NHS, 2008).

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Stepped Wedge Design
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Preliminary findings Burnout and incidents

• Sixty seven completed MBI questionnaires were
  returned 72 completion (n92)
• There were no statistical difference between the
  wards on the measure of burnout.
• However higher scores for exhaustion and cynicism
  were evident on the ward with the highest number
  of incidents (116 over 12-months).

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Preliminary findings Burnout and incidents

• Male staff were reported more cynical attitudes
  than their female colleagues, this was a
  statistically significant difference Independent
  samples t-test t (65)1.591, P0.04.
• Male respondents recorded slightly higher
  exhaustion and slightly less professional
  efficacy.
• Band 3 and 4 staff reported highest levels of
  burnout (cynicism and exhaustion).
• Regression analysis indicates that staff grade
  has a significant influence on cynicism responses
  when other variables are accounted for.

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Process and Outcome Measures
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Good Risk Management
Past
Present
Tools
Clinical Judgement
Patients
The Plan
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Risk

• Male
• Young age
• Socially disadvantaged neighbourhoods
• Lack of social support
• Employment problems
• Criminal peer group

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Risk

• Childhood maltreatment
• History of violence
• First violent at young age
• History of childhood conduct disorder
• History of non-violent criminality
• Clinical history
• Psychopathy
• Substance abuse
• Personality disorder
• Schizophrenia
• Cognitive impairment
• Non-compliance with treatment

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Risk

• Anger
• Impulsivity
• Suspiciousness
• Morbid jealousy
• Criminal/violent attitudes
• Command hallucinations
• Lack of insight

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Early Recognition

• Confused
• Appears to have lost their bearings confused as
  to time or place or personal identity. Not
  limited to cognitive impairment and can include
  psychotic confusion.
• Irritable
• The person is easily irritated or annoyed by
  people or situations. The person is easily
  inflamed or exasperated, they have a poor
  tolerance to frustration.
• Boisterous
• The person is sufficiently noisy rough
  expansive to draw attention to themselves or
  intrudes into others personal space or auditory
  space.

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Early Recognition

• Physically threatening
• The person actively or passively behaves in a way
  that threatens another person physical well-being
  or causes fear of imminent attack. This includes
  threatening gestures, deliberately obstructing
  people, intruding into an individual's personal
  space.
• Verbally threatening
• The use of language which would cause a person
  fear of injury or harm. This can include phrases
  directed at an individual or a group of people.
• Attacking objects
• The person acts in ways that could or actually
  causes damage to property.

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• James a fifty five year old man is on the third
  day of his admission. he has been admitted for
  low mood. He was transfered from recovery
  following carbon monoxide poisoning. During the
  assessment period he has asked several times
  what day it is, and when can he go home. Another
  patient complained that James was in his room and
  would not leave saying it was his room. This led
  to James shouting "get out or you'll get some"
  and clenched his fist at him.

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• Martin a twenty one year old man is admitted to
  the ward from the crisis team. He feels that God
  is inside him and that he has the ability to help
  save lives. He hears the voice of God telling him
  to 'go and save people'. 
• Over the past hour Martin has been in and out of
  his room 7 times and in and out of the office 6
  times. He is chain smoking and walking around the
  ward sitting for 30seconds before getting up. He
  does not have conversation but walks up to people
  and says loudly 'why am I here' 'you are wrong'
  'you are bad people'. Twice he shouts 'bastards'
  towards the office door and once hits a table.