The National Forensic Nurses Research and Development Group

The National Forensic Nurses
Research and Development Group

RESEARCH and DEVELOPMENT

NEWSLETTER

Issue 2
October/November 1997

EDITORIAL

Since 1996 the National Forensic Nurses Research and Development Group has (to borrow a well known phrase), `formed, stormed'`normed' and now we are `performing'. Our membership has continued to grow and develop over the two years and continues to have representatives from forensic health care settings throughout England, Scotland, Wales and Northern Ireland from all levels of secure provision - both NHS and the private sector.

One of our earliest and most important priorities was the dissemination of information. Not just information about research, but about projects which were seen as a benefit to the service's and the patient group - `examples of good practice' - which could be replicated in other sites.

With a programme of dissemination of research and development in mind, and as a way of informing service providers of the existence of the group, a conference was held at Reaside Clinic, Birmingham in June 1997. The Conference was titled `Basing Practice on Evidence in the Real World' and was well attended by more than 60 delegates. The delegates came from a wide range of forensic units, the public and private sector, and from a wide range of disciplines also. The group would like to extend their thanks to the speakers, Chris Butler, Assistant Chief Nursing Officer at the D.O.H.; Dr Greta Mathews, Research and Development Officer at the H.S.P.S.C.B.; Jackie Droogan, (Research Fellow) and Katrina Brannigan (Research Assistant) from the NHS Centre for Reviews and Dissemination. Members of the group spoke about the range of research and development in their own region. Special thanks are extended to Mr Frank Corr (DNS at Kneesworth House Hospital, Hertfordshire) who at the last minute spoke to the Conference about research and development in the private sector.

Since the seminar in June, data collection forms have been distributed to virtually every forensic service in the country (and if we missed you - we apologise - but please let us know so that we can rectify this for the next, updated, version of the database) and were also placed for distribution to delegates at the recent FPNA conference in Brighton.

The abstracts for inclusion into the data base reached a peak, so much so, that the deadline for inclusion had to be pushed back to allow them all to be included.

This collaborative project has now reached fruition and this phase culminates with the `Official' launch of the Centre for Reviews and Dissemination/National Forensic Research & Development Database on 14th November at Rampton Hospital.

The information held in the database is a very valuable resource to all forensic services throughout the country, so we sincerely hope that it is put to good use, not only by researchers and academics, but also by the staff who have the important job of developing and influencing the care which is given to our client group - the staff on the wards.

To support this exciting new venture the National Group also publish a `Research & Development Newsletter on a regular basis - though the frequency does depend upon the volume of submissions for inclusion. In other words, the more submissions we get, the more frequent the Newsletter.

So why do we need a paper newsletter when there is now the facility for electronic dissemination of information regarding research and good practice within the field of forensic mental health care?

The answer is simple, not everybody has immediate access to the technology required, and we have to accept that some people are still not technologically minded and prefer to read from paper rather than from a screen. But the bottom line is, that we are willing and prepared to use every method available to reach as many people as possible to ensure extensive dissemination of this information.

At this time a large amount of the articles and projects mentioned in this and the previous newsletter have either been generated by the members of the National Forensic Nurses' Research and Development Group or have depended on numerous phone calls by a small band of people in an attempt to generate more abstracts for inclusion. This newsletter is for all staff of all disciplines working within Forensic Health Care to use to publicise their particular organisation and their particular projects, so don't feel that it is for the `chosen few' to use, it is for everybody. If we don't have enough submissions then we can't publish the newsletter to support and compliment the CRD database.

If you or any of your staff or colleagues either in your workplace or elsewhere, who are doing research or are involved in projects which can be deemed to be examples of `good practice' then please encourage them to send us an abstract (no more than 250 words please) and we can then include them in the newsletter (addresses at bottom).

We hope to hear from you soon with your abstracts or comments and wish to take this opportunity to thank you for supporting the ventures and projects of the `National Forensic Nurses' Research & Development Group' both now and in the future.

Norman McClelland,
Lecturer in Forensic Psychiatric Nursing,
University of Birmingham and Reaside Clinic
Birmingham Great Park
Rubery,
Birmingham
B45 9BE

and

Stephen D Kirby, Lecturer/Practitioner,
(Forensic Mental Health Nursing),
The Hutton Centre and the University of Teeside
St. Lukes Hospital
Middlesbrough

FROM THE CHAIR

Forensic Database -
IT'S NOT TOO LATE TO RESPOND

The collaboration between NHS Centre for Reviews and Dissemination, Rampton Hospital and the National Forensic Nurses Research and Development Group is an important initiative that will have many benefits and implications for research and development. It will be a first attempt to identify practice developments and research activity across the UK within all health care and related forensic contexts.

Such a database will have many benefits. For example, it will help identify shortfalls in research activity, identify areas of good practice; bring together focus groups; inform systematic reviews and promote multi professional networking and sharing of ideas and information.

Proformas for the database were distributed in early August and these have already started to come back showing some interesting programmes. Deadline for receipts is November. Data is currently being inputted and coded into the main database and will be finalised during November. The NHS Centre for Reviews and Dissemination will finalise coding prior to dissemination in December.

Disks containing the practice development and research details will be circulated free of charge to libraries, academic units and forensic contexts during early November. On 14 November there will be a seminar to launch the first database which will be held at Rampton Hospital Conference Centre in collaboration withe the NHS Centre for Reviews and Dissemination and the National Forensic Nurses Research and Development Group. Proformas to send in your practice/service development initiatives can be obtained from Bridget Bower at Research and Development,

Rampton Hospital. Alternatively proformas can be viewed and sent by E-Mail, see next report Nursing Resource Homepage.

Forensic Nursing Resource Homepage

Phil Woods (Ashworth Hospital) and Professor Val Reed have been busy developing a forensic nursing resource homepage on the Internet. The web page gives information relating to a number of ongoing research projects particularly relating to risk assessment. Here there are many addresses for further web pages linked across the Internet where you can find information of developments in forensic care. In addition there are details about the National Forensic Nurses Research and Development Group, the recent Newsletter and the Forensic Database. The questionnaire can be viewed on screen, completed and sent by E-Mail automatically. This page is a tremendous resource and shows much credit and hard work by Phil Woods. Don't Miss It. The address is http://wkweb4.cableinet.co.uk/pwoods1/index.html

David Robinson
Chairman

EXAMPLE OF GOOD PRACTICE WITHIN THE HUTTON CENTRE "DEVELOPMENT OF A PRACTICE DEVELOPMENT UNIT WITHIN A MEDIUM SECURE LONG STAY ENVIRONMENT"

Farndale Ward is a 13-bedded forensic longer stay rehabilitation ward which is situated in an upgraded ward area within St.Lukes Hospital. It provides care for those clients who require longer term therapies and support than that which is provided by the core in-patient services within the Hutton Centre

The Forensic Service has many years experience specialising in the provision of high quality medium secure care. Delivering this care is a team of professional and highly qualified medical, nursing and therapy staff, whose experience and expertise lies in the provision of care for the mentally disordered offender group.

Farndale Ward was conceived and developed to meet the ever increasing requirement for medium secure continuing care facilities. This requirement has been brought about by an increase in the number of patients residing in the three High Secure Hospitals who, whilst still requiring a degree of security, no longer require the maximum level offered by these establishments. Likewise, it has been recognised that there are a group of patients within mainstream psychiatry who require a level of consistency and security greater than presently available in order to protect both themselves and the public.

Farndale Ward was opened in May of 1995, as the first medium secure longer stay facility of its kind in the country. It was recognised from the outset that Farndale Ward needed to be proactive and radical in its approach to care if it was not to fall into the trap of being a `long stay' ward with all the stigma and negativity associated with this.

Following discussions the decision was taken to seek accreditation as a Practice Development Unit (rather than a Nursing Development Unit - as this concentrates more on the Multi-Disciplinary Team approach as used within the Forensic Division). The time scale for accreditation as a Practice Development Unit has been set for 1998 and to this end work is progressing steadily to attain the required facets.

In essence, the PDU provides an environment which recognises the multidisciplinary teamwork is necessary to provide holistic care and to pilot new approaches to empowering patients and staff.

It must be pointed out though, that the establishment of the PDU is not for the benefit of the nursing staff specifically and the service in general. Practice does not develop without teamwork from all professional disciplines and, most importantly, the active involvement of the patient.

At all stages of the accreditation process the patients were fully involved and informed of the developments as were staff of all disciplines throughout the Forensic Division thus ensuring dissemination of information as and when it happened.

Stephen D Kirby
Lecturer/Practitioner
(Forensic Mental Health Nursing)
The Hutton Centre and the University of Teeside
St. Lukes Hospital
Middlesbrough

RISK ASSESSMENT OF MENTALLY DISORDERED OFFENDERS THE PROJECT

The project was a part of a 2-year course at Edinburgh and Stirling Universities for a MSc in Advanced Social Work Studies in Criminal Justice. The area of investigation that was undertaken was initially because of my interests in assessing "risk" that mentally disordered patients may pose to themselves and the community. Also because media focus on a small number of incidents, mostly in England, of violent offending by mentally disturbed people intensified the debate about the appropriateness of community care for those suffering from mental disorder. These events brought into sharp focus the assessment and management of "risk" in the community.

The area of study focused on the assessment of risk in a particular institutional context, that of the Blair Unit in Royal Cornhill Hospital, Aberdeen and five hostel projects who offer accommodation to mentally disordered offenders within Aberdeen City. Care must therefore be taken before attempting to generalise from these findings.

The study was conducted through a survey of all those professionals involved with the care and assessment of mentally disordered offenders in Aberdeen and investigates the procedures that clinicians, social workers, care managers and project managers use to assess risk. It identifies the criteria which they employ and the information at their disposal to predict future violent behaviour by mentally disordered offenders. It identifies the role that clinical, societal and contextual factors play in the assessment of risk and the extent to which each of these factors is regarded as important by the different groups of professionals.

The study concludes that despite overwhelming research evidence of the lack of a clear association between mental illness and future violent behaviour, professionals still emphasise clinical factors when seeking to predict future violent behaviour and that contextual and societal factors take second place in the assessment of suitability for discharge from hospital and admission to a community care facility.

The study was conducted by semi-structured interviews during which responders were asked questions in three key areas. Firstly, how referral, admission and discharge policy was organised. Secondly, how the professionals assessed risk and thirdly how the professionals managed risk in the community.

Findings

The main findings are reported below. The study found that there was an informal system and network of communicating information about patients between the professional groups which seems to have worked well in the pest and that this may be due to the small number of professionals involved which has enabled the ease of contact between clinicians, social work and the managers of a small number of care facilities. However, with the expansion of care facilities and the introduction of care managers, informal procedures for assessing patients and communicating with each other may no longer be adequate. More formal methods of risk assessment may now be appropriate in which a framework of assessment helps identify distinct aspects of "risk" and enables professionals to identify the patient's "needs".

There appeared no precise method of recording either good or bad behaviour and reports of serious incidents which may come to be identified as a "risk", although written into the Cardex and patient's notes, were conveyed verbally to professionals in the clinical team. This important information therefore may rely on the professionals' memory of events over time and the constancy of staff within the clinical team. This framework of clinical reference over a long period of time may lead clinicians and team members to unintentionally under-emphasise or over-emphasis the seriousness of past offending where the patient's behaviour in hospital no longer gives cause for concern.

It is suggested that the framework of assessment includes distinct areas of assessment such as:-

Historical factors
Clinical factors
Clinical "needs" and "risks"
Social "needs" and "risks".

For further information contact:

Sue Elliott
Social Worker
Royal Cornhill Hospital
Aberdeen AB9 2ZH

FORENSIC PATHWAY PROGRAM DELIVERY MSc HEALTH SCIENCES
at the University of Birmingham

For an International Conference on the Nurses Role in
Criminal Justice System, University of Saskatchewan,
Delta Bessborough Hotel, Saskatoon, Canada 1 - 3 October 1997
Custody and Caring

An action research pilot study has been initiated at Birmingham University's School of Health Sciences. This seeks to identify if there are andragogic benefits from staff, coming from a variety of academic `tribes' with differing learning styles, who may offer a wide range of learning opportunities to students on a Forensic Pathway programme (part of a post experience Diploma/Masters in Health Science). This will result in a survey of approximately fifteen academic staff from diverse disciplines within the School. The study employs the use of a Learning Style Inventory. The recipient student approaches to study will also be assessed, for successive cohorts, on a variety of modules delivered on the pathway by staff. An Approaches to Studying Questionnaire will be used for this purpose. Assessments are to be made for the pathway students throughout periods of modular study. Previous studies have reinforced the observation that predisposition's to particular learning styles clearly have implications for teaching strategy and curriculum design. To support this a further analysis of the cohort performances on selected modules is to be undertaken which incorporates current studies on learning strategy. The outcomes of the study will include a learning style and strategy audit and the proposal of a model which serves to raise the awareness of individual lecturers, trainers and managers to the effectiveness of their styles across different levels and groups. This serves to create a framework for the development and improvement of a management of learning process for academic staff and students in higher education which can support the development of student learning styles and strategies.

Norman A McClelland
Lecturer in Forensic Psychiatric Nursing
University of Birmingham/Reaside Clinic
School of Health Sciences
Edgbaston, Birmingham

Robert J McClelland
Reader in Education Technology
Liverpool Business School
The Liverpool John Moores University

SELF-HARM IN A MEDIUM SECURE UNIT: THE CONTRIBUTION OF SOCIAL AND PHYSICAL ENVIRONMENT

Nineteen patients in a medium secure unit were asked, in semi-structured interviews, what factors reduced, or contributed to, self harm (1). Several factors were mentioned, including aspects of the Unit's social and physical environment. Whilst a few respondents felt that the latter was unimportant, several referred to the importance of ward "atmosphere" and activities, and/or feelings of powerlessness and pressure which contributed to self harm. One individual commented: "When I'm locked up, it gives me a lot of pressure...self harm is more likely because of (confined) space." Another respondent said that some individuals harmed themselves because they felt "intimidated by other patients who've got power over them. They feel weak and can't take any more."

Views about other patients were mixed, with some respondents commenting adversely, and others stating that support from their peers had prevented Self Harm. The quality of communication from nursing staff, and the extent to which they offered support, were also seen as significant by almost all respondents. Some patients stressed the importance of the Unit's "atmosphere" and the extent to which there were interesting activities. One respondent said:

"The atmosphere (in the whole unit) is very tense...But this ward is calmer, staff more friendly....Both patients and staff talk more.... There are more activities."

Respondents' comments in the present study and in other research (2,3,4) suggest that careful consideration needs to be given to the physical and social environments of secure institutions which treat people who self harm. This includes attention to physical design, and the construction of social environments with varied, interesting activities. Also important are skilful nursing interventions to enable patients to receive support from staff, (and where possible, from their peers) and to prevent the intimidation described by a few respondents in the present study. Finally, patients need to be carefully selected for wards with specific social environments which are tailored to their particular needs.

ACKNOWLEDGEMENTS

Our thanks to the patients who gave their views and to colleagues for their support.
Dr Richard Byrt
Research Nurse
Arnold Lodge Medium Secure Unit
Leicester

Ms Judy Reece
Senior Lecturer in Mental Health Nursing
De Montfort University
Leicester

REFERENCES

BYRT, R and REECE, J. 1997 "Patients' Perspectives of Self Harm in a Medium Secure Unit." National Forensic Nurses R and D Group Newsletter Issue No.1.

CREMIN, D, LEMMER, B and DAVISON, S. 1995 "The Efficacy of a Nursing Challenge to Patients: Testing a New Intervention to Decrease Self-Harm Behaviour in Severe Personality Disorder" Journal of Psychiatric and Mental Health Nursing. Vol.2, pp237-246

INCH, H, ROWLANDS P and SOLIMAN A 1995 "Deliberate Self Harm in a Young Offenders Institution". The Journal of Forensic Psychiatry Vol.6 pp161-71

EVIDENCE BASED CARE THROUGH WARD-BASED LEARNING

Evidence based care is becoming a major issue in healthcare delivery. The growing expectations of purchasers mean that providers need to justify the services they deliver. The use of a systematic approach to the delivery of care, through assessment, planning, implementation and evaluation, would enable health professionals to provide the evidence of actions required by purchasers. By using these and other appropriate research skills, knowledge and care could be considerably enhanced. It was decided, therefore, to produce an evidence-based care package which would develop such skills and encourage reflective practice.

The package requires that ward-based practitioners centre their learning on the systematic process of care planning. Practitioners must locate, utilise and disseminate recently published research at all stages of assessment, planning, implementation and evaluation. In doing so they may also identify deficiencies in the literature in relation to identified client problems.

Developing the Learning Pack
The work pack was carefully developed by a range of healthcare practitioners including nurses, team leaders, ward managers, researchers and nurse tutors. Advice and input was also given by principal lecturers and other academics in order to provide an appropriate balance of learning that could be transferred into practical clinical skills. The production of distance learning materials had to address a number of issues including user friendliness and academic rigour.

Although the primary audience for this project is nurses in the highly specialist field of forensic psychiatry, it was also the authors' intention to market the package to health care staff in other nursing disciplines. This ward based learning package has advantages over other methods of educational delivery by:

·Having more relevance to client needs and actively encouraging the participation of the client in the learning process.

Content of the Workbook
The workbook takes approximately 48 hours to work through and draws considerably on related research to promote evidence-based care and reduce the theory-practice gap. Pilot studies have shown positive improvements in learning. Most of the workbook can be undertaken within the clinical context and should form part of everyday clinical activities.

A small amount of time spent away from the clinical area will be required in order to examine the literature. The workbook consists of 27 activities with time to reflect at critical stages. These are carried out within four main sections:

·Assessment of patient need

For further information and to obtain copies of the Distance Learning Package contact:
Veronica Mahoney,
Training & Development,
Rampton Hospital
Retford
Nottinghamshire
DN22 0PD
Tel: 01777 247232

AUTHORS:
Dr David Robinson, Rampton Hospital Authority
Lawrence Whyte, Rampton Hospital Authority
Martin Gajos, Sheffield Hallam University

RISK ASSESSMENT
GUIDANCE FOR MENTAL HEALTH NURSES

Assessing and managing the risk of harm to others from people with mental health problems

The National Forensic Community Mental health Nurses Group set up a working party to compile guidelines for use by mental health nurses to assess risk of harm to others from people with mental health problems.

In recent years there has been increasing interest in the risk of harm associated with people with mental health problems. Mental health nurses have a pivotal role in assessing, planning and reviewing the care received by people with mental health problems in a wide range of services and in different settings. Assessing and managing risk is nothing new to mental health nurses although greater emphasis is now placed on clarifying exactly how this is done. The purpose of this document is to provide guidance to mental health nurses to assist them in developing their approach to assessing and managing the risk of harm to others from people with mental health problems.

Recently there has been a shift in emphasis away from dangerousness towards a broader concept of risk. Whereas dangerousness tends to focus on the personal qualities of an individual, risk assessment and risk management are dynamic, inter-related processes which reflect individual actions and the context in which they occur.

Risk assessment in clinical mental health services attempts to estimate the level of risk taking into account the likelihood, frequency and immediacy of harm and the severity of the possible outcomes. Essentially the assessment of risk is undertaken to decide which risk management measures are required to minimise the risk of harm and increase the likelihood of benefits for the person being assessed and all those concerned.

Risk management may be defined as the systematic organised effort to eliminate or reduce the risk of harm. In order to manage risk effectively measures are required that have a reasonable likelihood of reducing or eliminating the risk. these measures are sometimes referred to as control measures. Due to the connotations of `control' in mental health services a more appropriate term may be risk management measures. Implementing risk management measures should be integrated into the care planning process which the Care Programme Approach should facilitate.

Mike Doyle and Gina Hillis
Co-Chairs,
National Forensic Community Mental Health Nurses Special Interest Group.
Royal College of Nursing

NATIONAL FORENSIC NURSES RESEARCH AND DEVELOPMENT GROUP CONTACT LIST

Dr David Robinson
Senior Nurse Research and Development
Rampton Hospital
RETFORD
Notts
DN22 0PD
Tel: 01777 247245
Fax: 01777 247221
E-Mail: Drobin@Rampton_Hospital.BtInternet.com

Graham Durcan
Senior Researcher
The Sainsbury Centre for Mental health
134-138 Borough High Street
LONDON
SE1 1LB
Tel: 0171 403 8790
Fax: 0171 403 9482
E-Mail: graham_durcan@scmh.ccmail.compuserve.com

Callum McDonald
Health Care Staff Development Officer
Staff Training Unit
HMP Maghaberry
Old Road
Upper Ballinderry
Lisburn
County Antrim
Northern Ireland
Tel: 01846 611888
Fax: 01846 619516

David Sallah
Researcher
Public Sector Management Unit
Aston Business School
BIRMINGHAM
B4 7ET
Tel: 0121 359 3611 (Ext 4605
Fax: 0121 359 1148
E-Mail: dk_sallah@msn.com

Norman McClelland
Lecturer in Forensic Psychiatric Nursing
Reaside Clinic
Birmingham Great Park
Bristol Road South
Birmingham
B45 9BE
Tel: 0121 453 6161
Fax: 0121 453 7181

Carol Watson
Senior Nurse Practice Development
The State Hospital
Carstairs
Lanark
ML11 8RP
Tel: 01555 840293
Fax:01555 840024

Andrew McGleish
Lecturer in Forensic Mental Health Nursing
Caswell Clinic,
Glanrhyd Hospital,
Bridgend,
Wales
CF31 4LN
Tel: 01656 662179
Fax: 01656 662157
E-Mail: amcgleish@netscape.net

Margaret Swanson
Care UK Mental Health Services
Whitewold
13 Mere Lane
Heswall
Wirral
Tel: 0151 342 9664

Mary Gove
SNM for Specialisms
MH Services
Divisional Research Unit
Royal Cornhill Hospital
Aberdeen
AB9 2ZH
Tel: 01224 663131 (Ext. 57443)
Fax: 01224 646201

Steve Kirby
Research & Practice Development Nurse
c/o The Academic Centre
St. Lukes Hospital
Marton Road
Middlesbrough
Cleveland TS4 3AF
Tel: 01642 850850 (Ext.2120)

Richard Byrt
Research Nurse
c/o Arnold Lodge RSU
Cordelia Close
LEICESTER
LE5 0LE
Tel: 0116 246 1262
Fax: 0116 246 0379

Linda Colgan
Mental Health Services of Salford
Bury New Road
Prestwich
Manchester
M25 3BL

Bridget Bower
Secretary
Research and Development Dept
Rampton Hospital
Retford
Notts
DN22 0PD
Tel: 01777 247242
Fax: 01777 247221