FORENSIC MENTAL HEALTH CARE AT A PSYCHIATRIC SECURITY UNIT IN NORWAY GUNNAR EIDHAMMER Centre for Forensic Psychiatry,, Ullevål, Norway www.forensic-psychiatry.no
The Psychiatric Medium Secure Unit Buskerud Hospital Established in 2003 Catchment area: 230 000 6 beds (2 open area seclusion beds) Multidisciplinary treatment team: Unit leader, Social worker, Psychiatrist, Neuropsychologist, Development and Research Nurse, RNs, RPNs
WARD ORGANIZATION Structured approach from admission to discharge in terms of: Violence risk assessment Violence risk management individual treatment and care plans HCR 20 ERM SOAS SWAB REFA VAFA (Webster et al, Fluttert, Palmstierna, Bjørkly) Good collaboration within a sound atmosphere Weekly treatment and group meetings Reliable and predictable decission making
PATIENTS Both male and female Severe Mental Illness Risk of Violence - toward others - toward self - both Civil and forensic patients
SKILLS AND KNOWLEDGE Positive mix of highly skilled and educated nurses and newly educated nurses Pre / De-escalation Verbal Crisis Communication Nurses graduated in risk assessment and management (Further education) Ref. Johnson M 2004 Fishkind A 2001 - Bjørkly S 2003/2006
NURSE-PATIENT RATIO Nurse patient ratio 3:1 One nurse per patient a day-afternoon 4 nurses at nighshift
NURSE - PATIENT RATIO EFFECTS? Remarkebly few incidents, compared to patient history of disrupted behaviour and violence. Nearness vs Distance (Detached Concern) Oportunity to apply flexible approaches Always time for a chat Early signs culture Global and individual signs (BVC ERM) Vigilant observation Early intervention Manpower (and knowledge) to set firm, adequate and predictable limits (Almvik 98/99, Fluttert 2009)
NURSE - PATIENT RATIO EFFECTS? Does not lock patients up in their rooms; neither day nor nights. No security staff (or police) at the ward Gender ratio for nurses: close to 50/50 Statement: Nurses safety forms the base for constructive risk management Patients often state that they feel safe, respected and well treated
STAFF PATIENT RATIO CHALLENGES? Risk of passive and dependent patients Nurses not always sharp and focused (espescially in calm and quiet periods) Overstructured environment Patients - nurses gets too detached
POST CRISIS INTERVENTION (PCI) DEFUSING/DEBRIEFING Defined, predictable and structured approch after a violent or disturbed episode Approach (nursing staff): Leader of PCI - not involved in the episode Create a safe atmosphere All feelings and perceptions are important What happened? - degree of seriousness? Lessons to learn from the episode (alternative)? Leader responsible for enhancing an analytical approach to the incident www.forensic-psychiatry.no
POST CRISIS INTERVENTION DEFUSING/DEBRIEFING Approach (patient(s) involved): Wait until the patient is ready Mediate a non-moralistic and open minded atmosphere We want to talk about the incident to be able to understand -not to acuse or punish you What happened? How to prevent it from happening again? Contribution from patient and nurses www.forensic-psychiatry.no
OPEN AREA SECLUSION OAS OAS: Skjerming Shelter? Regulated by legislation Different local practise in Norway (structure and clinical approach) In our unit: like a small Intencive Care Unit
OPEN AREA SECLUSION OAS (Short term) care and treatment for severe disrupted / hostile / aggressive / suicidal patients Close observation early intervention The patient and his/her mentor-nurse collaborate during the OAS as well Main aim: continuity and predictablity for patient and staff (Bjørkly,97)
OUTPATIENT TREATMENT In some cases our unit follows patients into the community, without involving Rehab units WHY?.. lack of risk management culture and knowledge at Rehab units Relational and patient-specific knowledge in terms of relaps prevention Our experience, combined with evidence based strategies, is our best approach to efficient relapse prevention
FUTURE OUTPATIENT TREATMENT Closer collaboration between PSU and Rehab Forensic Ambulant Teams/ACT teams Closer collaboration between Hospital and Community/Outpatient facilities ERM used in PSU, rehab and outpatient community services (Fluttert, 09)
THANK YOU FOR YOUR ATTENTION! GUNNAR EIDHAMMER eldg@sb-hf.no gunnar.eidhammer@kompetanse-senteret.no Centre for Forensic Psychiatry,,Ullevål, Norway www.forensic-psychiatry.no