This article describes the development of social skills activities to improve the behaviour and communication skills of patients in a high-security hospital on a high-/medium-dependency ward.
Claydon,I.(2007) Social skills training in secure mental health settings. www.nursingtimes.net
VOL: 103, ISSUE: 34, PAGE NO: 28-29
Ian Claydon, RMN, DipSocSci, BSc, staff nurse at AshworthHospital, Liverpool
This article describes the development of social skills activities to improve the behaviour and communication skills of patients in a high-security hospital on a high-/medium-dependency ward. It describes better patient outcomes and improvements in patient experience as a result of the project.
High-security hospitals provide care for patients with mental health problems who, because of their criminal or dangerous behaviour, need to be treated within a secure environment. The ward involved in this project was a high-/medium-dependency ward providing care for 20 male patients all with severe and enduring mental health problems, many of whom were considered to be resistive to drug treatments. These individuals could be both verbally and physically aggressive during everyday social interactions and generally had poor social skills, poor levels of hygiene and rarely left the ward for occupational or recreational activities.
As pharmacological management improves, it is easy to lose sight of the importance of psychosocial interventions that nurses can offer to help disturbed and aggressive patients. A programme of social skills training was developed with the aim of improving our patients’ quality of life. The programme included education, regular occupational activities and health promotion sessions both in the personal and environmental aspects of their lives.
Background to the project
It was commonly believed by the ward staff that the lack of occupational activities contributed to patients’ behavioural problems. Of the 20 living on the ward, approximately five attended regular occupational activity and approximately three attended off-ward social activity. Much of the problem appeared to be with patients’ lack of motivation to engage meaningfully with staff and each other. When asked, they would say that they disliked leaving the ward as it disrupted their routine, sometimes they felt they were too tired physically to join activities and poor concentration was often a problem.
Breier and Strauss (1983) pointed out that one factor that increases the likelihood of hallucinations, especially auditory ones, is stressful situations such as family arguments. For high-security patients, the ward community effectively serves as a family group and arguments impact on this community, especially when patients spend time together such as meal times or in the communal ward areas. At times of stress some patients would isolate themselves from the ward situation but others were isolated for longer periods. Breier and Strauss noted that such social isolation and withdrawal can lead to an increase in symptoms, whereas increased involvement in activities enables patients to cope more successfully with psychotic symptoms.
Social skills training
Social skills training can be defined as ‘behavioural techniques or learning activities that enable people to establish or restore practical skills in domains required to meet the interpersonal, self-care and coping demands of community living’ (Liberman et al, 1994). There is evidence to suggest that social skills training, when carefully designed and delivered, can increase patients’ knowledge and skill levels and halve relapse rates (Wallace and Liberman, 1985) and research has indicated that social skills training can be interpreted and carried out in various ways. Marder et al (1996) and Hayes et al (1995) suggested that improvements can be made as long as training can be kept simple and specific.
Social skills training is aimed at solving problems of daily living such as improving personal hygiene, as well as broader issues involving medication concordance, relationships, occupation and friendships (Liberman et al, 1994). Deficits in social and independent living skills are prevalent among those with severe and enduring mental health problems and include deficits in verbal and non-verbal communication skills such as facial expressions (Liberman, 1992). Techniques to help in this area may include role play, use of video and problem-solving groups (Hierholzer and Liberman, 1986).
It was proposed that structured activities were developed and assessed by nursing staff and then reported each week to the multidisciplinary team meeting in order to monitor patients’improvements. For those patients who displayed particularly challenging behaviours, the nursing staff worked alongside other members of the multidisciplinary team, including a psychologist and occupational therapist, to allow individual plans to be formulated. Such plans ensured that all staff were informed of what was expected of them to enable the patient to receive targeted help in achieving their goals.
A tool for scoring each patient’s level of interaction in activities was developed for staff members to judge the level of intervention required (Table 1), as an existing tool could not be identified from the relevant literature. All activitieswere scored from 1 to 4 in order to assess each patient’s ability and achievements. By scoring the activity the patient could easily be monitored and their improvements reported back to her or him as well as the multidisciplinary care team, who would then be able to quantify the patient’s progress. It also helped individual patients to know that they were achieving goals.
Table 1. Scoring tool: examples of the levels at which patients may be expected to function to achieve a given score
Degree of interaction
Piece of paper with some pencils. He will leave on numerous occasions and lasts for short periods. Not able to participate in games without help.
Drawings become more solid and coloured in, less time is spent away from the activity but has difficulty with puzzles without help.
Completes puzzles with between 50 and 250 pieces. Colours pictures appropriately, participates in some games and two-person activities. Participates in bingo and will discuss certain topics when prompted.
Is able to complete more detailed activities using paints and pencils on their own and remaining with the activity until it ends. Participates in group activities and board games. Will discuss issues easily.
One of the first tasks was to develop a range and choice of activities. Activities were initially set up at ward level, including artwork and board games. The aim was to break up each patient’s day with meaningful activity and give him something to concentrate on other than the symptoms of his illness. All patients were encouraged to take part in ward-based activities and time was spent exploring their individual likes and dislikes. Some preferred to do art while others preferred games; many took part in several activities. All 20 patients agreed to participate.
The second task was to have structured off-ward activities in the form of gym and education sessions. Studies have shown that exercise improves patients’ self-esteem (Adams, 2002). It was hoped that it would help our patients in this respect - this was an overall goal of the project. This initially met with resistance from patients, who were very set in their ways and dislike change in their routine. One session each week in the gym was provided and only patients from this ward would be present. The gym staff considered all aspects of each patient’s physical and mental health and their input included providing individual and team sporting activities. Many patients had not undertaken exercise for a number of years and individual programmes were organised if needed.
Staff from the hospital’s education department offered basic English, maths and computer studies sessions. Gilligan (2001) reported that increasing the opportunity for education has an association with reduced levels of offending.
Health advice and monitoring was considered essential for all patients as many had poor dietary intake, smoked heavily and took little or no exercise. Patients were generally receiving substantial doses of medication. They were encouraged to attend a ‘well man’ clinic so that health advice was accessible on an individual basis on such topics as smoking cessation, immunisation and self-awareness in the recognition of testicular cancer. There is some evidence to show that interventions, particularly smoking cessation, can work within mental health settings but, in general, more research is needed to evaluate holistic healthy living interventions (Bradshaw et al,2005).
Communication difficulties arose on the ward due to deficits in patients’ communication skills and the general noisy atmosphere generated by a busy ward environment. Initiatives were introduced on the ward to tackle this. One of the first was noticeboards to inform the patients about what was available in the hospital in order to promote off-ward activities. Other boards displayed the ever-growing amount of artwork that was being produced by the patients and two boards are used for health promotion literature.
At the start of the programme the majority of patient scores were at level 1, but some patients did achieve level 2 at this point. Some rapidly progressed through the levels resulting in quicker transfers to a lower-dependency ward and regional secure units. At the time of writing seven of the original group remained on the ward, demonstrating an improvement on previous transfer time scales. Before the project the patients had all been on the ward for several years with no prospect of moving to a less secure environment as they did not meet the criteria; since the project many have moved on and hopefully the remainder will be able to do so in the near future.
Since the project began in January 2005, activities both on and off the ward apparently yielded benefits as patients’ behaviour became more settled. In addition, the health education programme appeared to result in patients beginning to take pride in their environment as well as themselves. There has also been a dramatic drop in the administration of PRN medication, used to assist the patient to manage distressing symptoms of their mental illness.
An audit of the use of PRN medication on the ward demonstrated that in 2004 a total of 554 individual doses of PRN medication were administered; in 2005 this figure went down to 153 in total (Figure 1 shows the total doses given in each month). It was felt that patients’ increased involvement in therapeutic activities had played a contributing part in the reduction of PRN medication.
Incidents of violence also decreased during the period of the activities programme. In 2004 there were 20 serious incidents compared with 12 in 2005, and in 2004 there were 154 minor incidents compared to 98 in 2005.
As the ward atmosphere settled other noises became more apparent, for example the doorbell, medicine cupboard alarms and the ward office telephone. In a generally quieter ward, these noises now appeared exaggerated and patients began to make comments about how irritating they found them. It was decided by the ward team that attempts would be made to adjust the volume of these sounds so they would be less intrusive. Maintenance staff were contacted and the volumes were reduced.
Nursing staff also recognised that some of the patients had previously enjoyed music sessions, so a music centre was purchased to play in the day area, with volume that could be controlled from the ward office. The music centre was set to a low volume so that it would not be a distraction if people were talking. This appeared to be generally well liked and patients often requested to play their own CDs. Additionally, a radio station was found that played music that suited everyone. The noise levels have been greatly reduced, making for a more peaceful and therapeutic environment for all patients. External visitors, such as solicitorsand members of the clergy, have commented that the atmosphere has improved.
The communication initiative using notice boards has been very useful and an additional board has been introduced to inform patients when members of the multidisciplinary team will be attending the ward. This has reduced the need for patients to request this information, which in turn has reduced their levels of frustration. Other improvements in communication are also manifest - patients have started talking to nursing staff on a more social level than was previously the case.
Monthly meetings to discuss issues with the ward community and to inform patients what is going on at ward level have been introduced. This gives them an opportunity to express their views to staff, the intention being that what patients do not understand can be explained and what is disliked can be attended to when possible. Minutes are also taken and are fed back in the following meeting and posted on the notice board.
The nursing staff have been involved with the continual re-evaluation of patients’ scores and they are recorded in their individual care plans. This includes assessing levels of concentration and the ability to undertake complex skills. Staff are also responsible for ensuring that the relevant information is communicated to patients about the ‘well man’ programme, for example, where and when topics will be discussed and what they will be, such as smoking cessation and testicular cancer detection.
A special folder has now been introduced on the ward in which all up-to-date health information is available and is easily accessible to all members of the team. The nursing staff now keep regular records of baseline observations in this folder and all new laboratory reports are initially filed here until they are reviewed and actions are taken to improve communication.
This project has not been without its problems. Some have been easy to deal with, such as resources that were needed (for example,pens, pencils and paper for the art group to function). Obtaining toiletries for some of the patients was initially a problem. For patients less able to do so, toiletries were bought for them from the hospital shop. Those capable of ordering their belongings were encouraged to purchase their toiletries when they made their weekly purchases from the hospital shop. Although this was a little confusing, we persevered, and on the whole this worked well.
More fundamentally, we encountered difficulties when attempting to implement changes, given some of the restrictions of security and patient safety required within high-security environments. There were also some problems getting other disciplines actively involved, for example, education and the gym staff, as their time is a scarce resource. However, these facilities are now in place following much negotiation, organisation and paperwork.
Other problems included the continual need to request assessments from other disciplines and get support with activities that we undertook on the ward. There are now plans to complete multidisciplinary team teaching sessions that are intended to improve communication and ensure that everyone knows what they have to do and what is expected of them. This should build on improvements.
Over the 12 months since the project started there have been many changes and challenges on the ward. We feel we have only managed to achieve the foundations of the projectbut that this has been a big step for patients on the ward. The project could be extended further by introducing the programme to other wards across the trust site. It has also fuelled many other initiatives that have been taken up by other nursing staff.
The project has been hard work but has been well worth the time and effort as results are slowly becoming apparent to staff and improving the patient experience.
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