Is there a role for digital technologies in ATUs?
In this article Jessica lister, Consultant nurse in learning disability, explores the advent of new technologies within an Assessment and Treatment environment.
Jessica Lister
Consultant Nurse Learning Disabilities
North Staffordshire Combined Healthcare NHS Trust
Jessica sets out both the context for such change alongside the rationale for how these technologies can enhance care delivery.
Having worked in learning disability services for the past 23 years, I have had the privilege of observing and being part of some extraordinary care. I have seen the impossible be achieved; people considered “too risky to ever be discharged from hospital” have successfully made the transition to the community, securing their own tenancy’s, developing new friendships and neighbours and being gainfully employed. I have seen people who were judged as “never being able to be a good parent” going on to successfully raise their own children. I have seen people believed to be “too challenging to be able to use mainstream services”, access their local services and comply with intrusive procedures.
The one thing they all had in common was a Learning Disability nurse who helped to believe that anything is possible with the right support.
As Learning Disability nurses, we have a duty to advocate for those we care for and we play an important role in driving continuous improvement. We use our knowledge, skills, experience, creativity and holistic thinking to promote equity, challenge discrimination, preserving the rights of the individuals we support by often looking for new ways of doing things.
To achieve this we need to be lifelong learners, reflective in our practice and to be curious about potential ways to improve people’s lives in order to continuously learn from past lessons, apply new evidence and to enable people to realise their own hopes dreams and desires.
As a Consultant Nurse in the field of Learning Disability, part of my role is to be able to anticipate and raise awareness of people’s needs, to identify evidenced based solutions and to lead service development, thereby ensuring staff and the environments in which we support people are equipped to deliver safe, person centred, effective care.
It was my involvement in our local Assessment and Treatment Unit redesign proposals, that led me to reflect upon a number of clinical challenges relating to the care environment and search for new evidence and potential use of reasonable adjustments in order to meet the needs of the people we care for and support.
Background and current practice
The investment in community services from the ‘Transforming Care’ agenda is one example of how Learning Disability care has transformed and evolved; and has assisted in reducing the numbers of people requiring hospital admission.
Given these changes, we are finding that those people who ultimately are admitted to an Assessment and Treatment Unit often present with much more complex needs. This can result in a range of environmental challenges and ordinarily requires adjustments to the staffing establishment and clinical settings; which historically, by comparison to other mental health services, have not always benefitted from the same level of development or investment.
The Equality Act (2010) places a legal requirement on services to undertake thorough assessments in order to predict needs and to make subsequent reasonable adjustments to support people to access services. Learning disability nurses are highly skilled at developing and implementing such adjustments; and in many examples are considered to be the ‘reasonable adjustment’. But is this enough?
The service in which I work readily acknowledges that our assessment and treatment environment and staffing establishment is no longer fit for purpose and needs to be transformed to prevent people being transferred to alternative hospitals far from the individual’s local community. Following an extensive literature review, feedback from families and service users, narrative taken from focus groups with staff, and by networking with other assessment and treatment providers, a new model has been proposed to achieve this ambition.
Interestingly, networking with other assessment and treatment units highlighted a number of commonly experienced challenges and identified that many are operating at 50% bed occupancy in order to manage risk, implement person centred care and support plans, ensure safe staffing presence and enable effective management of environmental contributors to a person’s presentation.
Furthermore, a shared experience appeared to exist between colleagues working in assessment and treatment units of feeling under frequent pressure to justify why they can no longer safely operate at historic bed occupancy numbers.
Defining new evidence base
The provision of new and emerging evidence can greatly support the direction of clinical and service improvements and there is a wealth of relevant resources available for us to consult.
‘Building the Right Support’ (2015) for example, tells us that assessment and treatment units should be of high quality and be equipped to meet an individual’s behavioural, communication and sensory needs.
In my experience, a high proportion of individuals requiring assessment and treatment unit admission have either autism and or sensory needs in addition to their learning disability. As a result, their individualised sensory preferences and needs can be difficult to fully determine; particularly where there are also communication barriers to address; as this can take time to fully understand. Unfortunately, when individual sensory needs/preferences are not able to be met, these can become triggers which lead to distress (challenging behaviour).
The NICE (2016) Endorsed resource – A Checklist for Autism-Friendly Environments provides helpful pointers as to the environmental adjustments which may be required for this population. The guidance highlights how smells, sounds and the visual environment can “cause a person with autism anything from mild discomfort to acute pain and a deterioration in functioning”.
It could be argued therefore that assessment and treatment units are not only a necessary provision under the Equality Act, but they too are required to consider the impact of their environment upon this population; making reasonable adjustments to prevent related “discomfort, pain and deterioration in functioning”.
Positive Behaviour Support
NICE Guidance (2015) recommends that people with challenging behaviour be supported using a Positive Behavioural Support (PBS) approach as this can improve the quality of a person’s life using a person-centred approach by helping them to lead a meaningful life, learn new skills and be supported without unnecessary restrictions.
Over the years, Positive Behaviour Support has become an integral part of our value base, our assessment processes and the formulation of individualised care plans. It is a core component of many Learning Disability nursing academic teachings and clinical placement skill acquisition.
In practice however, we can find that despite the creative and person centred thinking of staff, delivering Positive Behaviour Support effectively may be compromised by the clinical environment and suboptimal staffing structures. For example, where the staffing structure is based upon safe staffing (observation acuity) levels as is the case in many assessment and treatment units, this can result in the person being allocated a lower level of staffing than is required to meet their support needs. Where this occurs, it can result in staff being unable to safely support the individual engage in their individualised PBS planned activities (such as accessing the community, using a kitchen). This limits the services ability to effectively support the person in line with best practice recommendations to expedite their discharge. In a number of examples, some services do not have the environments that are conducive to assisting people with their activities of daily living such as an ADL kitchen, or vehicles or petty cash to support community participation.
Interestingly, Cheshire and Wirral Partnership Foundation recognised the variation between safe staffing numbers and a person’s support needs, and developed what they have coined the ‘Universal Needs Resource Analysis’ (UNBRA); a helpful tool to measure resources required to support an individual in an inpatient setting and which assesses peoples support needs more rigorously.
In practice, the variation between support needs and safe staffing can mean that despite best efforts, people may be at risk of not being able to fully benefit from the objectives of their PBS plan, and may actually lose skills, and experience a reduction in available activities which help them to stay well. This is a particular issue given that lengths of admissions to assessment and treatment units can be extremely protracted and an increase in to a person’s support needs can make it increasingly difficult to identify suitable discharge options.
To some degree, this presents an impossible situation; with the environmental factors significantly influencing the person’s engagement and reaction, which in turn, increases their distress. Such factors include noise, confined spaces with bright lighting and poorly regulated room temperatures. These factors then increase the person’s dependence and limit their opportunities to partake in meaningful activities.
The response to increased risk can often be to increase staff presence and initiate other restrictions such as reduced community / activity access, while environmental triggers for anxiety and aggression remain unmanageable and unchanged. This continuous high staffing presence, compounded by environmental triggers can lead to increased anxiety, sensory overload, hospital acquired trauma and the experience of “cabin fever” for both staff and patients.
It may also appear counterintuitive that the development of person-centred care plans and behavioural management strategies rely heavily upon behavioural observations and analysis, to which some people can experience increased anxiety from ‘being policed’ or “followed around all day by a person who writes down everything I do or say!”. Maintaining a therapeutic relationship in these situations is imperative and requires adjustments and creative solutions on the nurse’s part.
Additionally, results of recommended clinical observations such as pulse rate or blood pressure monitoring can be unachievable for individuals who experience hypersensitivity to touch, which adds additional complexities to clinical decision-making and can make other aspects of care inaccessible.
So, could we do better? In these times, where smart devices have the capabilities to provide real time clinical data, such as, how many steps you have taken, your pulse rate and blood pressure, or information from a sleep and stress tracker, shouldn’t we be exploring alternative methods for assessment and treatment units to embrace this technology, and obtain essential clinical and behavioural observations, without causing the person harm or distress?
Moving forward
We would all agree that, it is not acceptable that people with learning disabilities and autistic people, should be negatively impacted by the models of care we deploy or that care environments can directly exacerbate a person distress. This is aside from the fact that hospital admission can lead to people being unable to maintain or develop independence skills or partake in activities of any real value.
Having the right assessment and treatment environment which delivers effective sensory stimuli, for many, is an essential component of their support plan and requires careful management of lighting, sound, temperature, presence of others in order to create a low stimulus environment which is sensitive to specialist needs and enables a person-centred approach in a Trauma informed and Autism Friendly environment.
Likewise, opportunities to reduce high levels of staff presence which can heighten anxiety, trigger risky behaviours and may result the use of restrictive holds or even the enactment of long term segregation, need to be considered an essential component to delivering specialist inpatient care.
However, we need to continue pioneering alternative conventions to replace often inaccessible or anxiety provoking traditional methods for conducting clinical observations and delivering care. So what potential solutions are there to these complex challenges and what can we learn from others?
Vision-based technology
A statement by the National Mental Health and Learning Disability Nurse Directors Forum informed that “Oxevision is currently being used by almost half the mental health Trusts in England as an assistive system to support (not replace) staff with patient safety in inpatient services”. It was recognised an effective tool for contributing towards patient safety at the HSJ Awards 2021.
Oxehealth (as seen in pic 1), is a vision based monitoring platform that works to complement staff support using sensors in the clinical environment (located in a tamper proof box pictured above the patients bed) to provide staff with contact-free location and activity based reposts, safety alerts (pic 2), and vital sign measurements (pulse and breathing at rest). It gives the ability to check the patient visually, using a hand held tablet (pic 3) or office PC to support on-the-spot decision making.
Picture 1: The oxehealth system.
Pic 2- Activity Monitoring.
Pic 3- Nurse Hand held tablet.
Research indicates that patients being cared for by staff with Oxevision, report an improved sense of safety, less disturbed sleep and an increased sense of privacy. Staff report a reduction in serious injury and harm, self-harm and assaults, and improved physical health monitoring.
Recommendations for practice
We have identified the need to reduce the number of staff physically present for some, while being able to obtain and maintain clinical observations and introduce new ways to obtain vital signs without having to touch individuals who find touch intolerable. We have discussed the challenges where clinical environments are not autism friendly and the consequences of not having adequate staffing establishments to successfully deliver Positive Behaviour Support.
It appears that in some services, transformation is long overdue. I believe technologies such as Oxehealth not only improve assessments by giving real time activity reports and touch free vital signs, it supports a reduction in the use of restrictive practices by removing the need for staff (or high numbers of staff) to be visually present for behavioural observations; thus significantly improving many peoples experience of care.
People need to be supported by a care environment which is not only tolerable, but which is therapeutic to those who are using it. By utilising evidenced based tools such as the Checklist for Autism-Friendly Environments to self-assess the areas we work in, we can raise awareness and gain the evidence required to justify subsequent requests for highlighting the need for environmental adaptations.
Tools such as UNBRA can assist in highlighting how support levels can vary for those with learning disability and thus address the shortfall in staffing numbers.
As nurses we are bound by our professional code of conduct and have a duty to prioritise people; “to make their care and safety our main concern, to ensure that their dignity is preserved and their needs are recognised, assessed and responded to” (NMC).
Each of us has an important role to play in raising awareness of people’s needs, keeping up to date and advocating where there are areas of practice which need to be modernised and transformed. As learning disability nurses and system leaders we need to think big and be creative if we are to change pervasive healthcare culture; and in doing so, raise the expectations for the people we care for and the families we support.
Jessica Lister
Consultant Nurse Learning Disabilities
North Staffordshire Combined Healthcare NHS Trust