Journal of Psychiatric and Mental Health Nursing, 2014, 21, 383–390
An appraisal of service users’ structured activity requirements in an Irish forensic setting S . R A N I 1 Ph D, MSc , MA, HDi p Nu r s i n g ( Ed ) , & F. M U L H O L L A N D 2 B S c ( H o n o u r s )
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Placement Coordinator, Training and Development Department, and 2Occupational Therapist, Occupational Therapy Department, National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, Ireland
Keywords: activities, activity steering
Accessible summary
group, forensic mental health, pillars of care, service user involvement,
•
web-based monitoring Correspondence: S. Rani Training and Development Department National Forensic Mental Health Service Central Mental Hospital Dundrum Dublin, 14 Ireland E-mail:
[email protected] Accepted for publication: 2 June 2013 doi: 10.1111/jpm.12096
• • •
Studies have indicated that forensic mental health service users who have a lack of structured meaningful time use are at increased risk for recidivism. In this paper, we report the outcome of a survey measuring the use of activities in an Irish forensic mental health setting, and we make recommendations for practice. Findings suggest that patients placed on units of higher security participate in less structured activity. Service user involvement in planning and implementing activities is vital as well as tailoring the activities to meet the changing needs of service users.
Abstract Participating in purposeful and structured daily activities is an important factor contributing to the health and well-being of forensic service users. A survey was carried out in an Irish forensic mental health setting to identify whether service users meet the standard of 25-h weekly activities, a standard set by the Quality Network for Forensic Mental Health Services, London. The findings indicate that 57 (61%) out of 93 service users fully meet the criteria. Furthermore, service users within the mediumand low-security environments appear to be engaging to an increased number of structured activities in comparison to those in acute units.
Introduction Forensic mental health services exist in order to treat mentally ill offenders, as well as to ensure the public’s safety (Lindstedt et al. 2004). In the past, the very intent of forensic mental health services was to prevent offenders from engaging in activities and occupations as a form of punishment (Couldrick 2003). This lack of opportunity to engage in varied and meaningful activities can lead to boredom, depression, apathy, loss of skills, learned dependency and even recidivism among forensic mental health service users (Farnworth 1998, Wilcock 1998, Whiteford 2000, Haney 2002, Craik et al. 2010). More © 2013 John Wiley & Sons Ltd
recently, forensic mental health services have changed its focus from a punitive framework to a more rehabilitative one (Llyod 1995). This change in focus has increased the opportunities for forensic mental health service users to engage in structured activities. Llyod (1995) recommends that members of the multidisciplinary team facilitate structured activities in order to provide service users with a sense of self-efficacy as well as a means to develop or maintain skills required for community living. This paper sets out to explore the use of structured activity within the Irish forensic mental health setting and make recommendations for increasing service users’ engagement in meaningful activity. 383
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Table 1 Units, number of beds and level of security across three clusters in the forensic mental health service, Ireland Cluster
Unit
Level of security
Number of beds
Acute cluster
Acute admission unit, male Acute admission unit, female Continuing care unit, male Selective adaptive behaviour unit, male Rehabilitation unit, male Rehabilitation unit, male Slow stream rehabilitation unit, male Hostel Male
High Medium to high Medium to high Medium to high Medium Low to medium Low Low
12 10 16 6 16 15 9 10
Medium cluster
Rehabilitation and recovery cluster
National Forensic Mental Health Service, Ireland – pathway of care The model for forensic mental health service in Ireland is a national service that is integrated within the wider mental health system (O’Neill et al. 2002). This service caters for those individuals with a mental disorder, who either have been found not guilty by reason of insanity for an index offence, or are beyond the scope of mainstream psychiatric or criminal justice services, and are in need of care and treatment in a therapeutically secure setting (Kennedy 2006). Accordingly, this forensic setting provides high-, medium- and low-secure inpatient services within a single campus and additionally incorporates a court diversion scheme, prison in-reach clinics and community services (Timmons 2010). The service delivery in this forensic setting is guided by five pillars of care: pillar 1 – physical health, pillar 2 – mental health, pillar 3 – drugs and alcohol, pillar 4 – harmful behaviours and pillar 5 – social, occupational, rehabilitation and recovery (Gill et al. 2010, Kennedy et al. 2010, O’Dwyer et al. 2011). These pillars map a pathway of care that should all be addressed prior to the discharge of a service user. The Irish forensic mental health service has seven units and a hostel grouped into three clusters based on the service users’ stage of illness and level of security required. Three clusters include acute (high secure), medium (medium to high secure), and recovery and rehabilitation cluster (low secure) (Pillay et al. 2008) (Table 1).
Table 2 QNFMHS (2008) criteria in relation to service user’s activities A94 ‘There is a planned programme of treatment with a minimum of 25 hours per week per service user of structured activity which is reviewed quarterly’ A94.1: The programme of treatment includes occupational therapy A94.2: The programme of treatment includes psychological sessions A94.3: The programme of treatment includes substance misuse therapy A94.4: The programme of treatment includes offence related therapy A94.5: The programme of treatment includes access to real opportunities to work A94.6: The programme of treatment includes structured activity programmes A94.7: The programme of treatment includes structured leisure time A94.8: The programme of treatment includes unstructured free time
service annually. The QNFMHS has set out certain standards that it expects every member service to achieve. In relation to therapeutic activities, QNFMHS (2008) proposed that each service has a minimum of 25 h of structured activity per week per service user that is reviewed quarterly. The criteria recommended by the QNFMHS (2008) are given in Table 2, which indicate different activities that may be included to achieve 25-h weekly activities. As a part of the QNFMHS, it was important for our service to capture the degree and types of activity that all service users are accessing on a day-to-day basis.
Methods Process of review in the National Forensic Mental Health Service, Ireland In the Irish forensic setting, the review of service user activities takes place in two tiers: internal and external. Internally, the activities across the units, five pillars of care and disciplines are coordinated and monitored by a multidisciplinary Programme Planning Committee that meets every month. Externally, the Quality Network for Forensic Mental Health Services (QNFMHS), London, reviews the 384
Aim The aim was to review service users’ structured activity and to identify whether service users meet the standard of 25-h weekly activities.
Objectives The objective was to measure the number of hours each service user was engaged in activity per week, as classified © 2013 John Wiley & Sons Ltd
Survey on structured activity requirements
by the QNFMHS (2008), and to categorize the activities across the five pillars of care.
Design Studies conducted in Australia, Sweden and the United Kingdom exploring use of time in mental health and forensic institutions have utilized time use evaluations in order to gather data (Bejerholm & Eklund 2004, Farnworth et al. 2004, Sturidsson et al. 2007, O’Connell et al. 2010). These evaluations often require staff and service user interview. Because of the fact that every service user’s activity level needed to be measured, a survey design was adopted for this study. It was felt that this would be more appropriate in terms of staff and time resources.
Operational definition Lang (2011) defines activity as ‘time spent doing an activity on one’s own or with others which is personal and important to the service user, impacts on the way the service user feels and which drives his/her treatment and recovery’. For the purpose of this survey, structured activities includes any activity or occupation under taken by the service user across five pillars of care.
Sample The structured activities of all service users in the Irish forensic setting were included for this survey. In total, the forensic setting had 94 inpatients at the time of data collection. However, one of the service users was discharged during the data collection period, which left a sample size of 93 service users.
2010) where every multidisciplinary team member records in one individualized progress note book. Stage 3: both the authors liaised with the unit managers in order to inform each service users’ level of participation in activities of daily living (for example, showering and shaving). An average of 4 weeks of activities was taken into account for service users’ weekly activities. A list of activities considered for the survey is given in Table 3.
Ethical consideration Ethical approval to carry out the survey was provided by the service’s Research, Audit, Effectiveness and Ethics committee.
Data analysis Data were entered across five pillars of care on the Excel spread sheets. Data were analysed using averages and percentages. A sum of weekly activities was calculated, and an average of 4 weeks of activities was drawn. Further, service users’ time spent on each ‘pillars of care’ was captured.
Results Overall, 57 (61%) service users fully met the criteria of 25-h structured weekly activities. Figure 1 shows findings of the unit analysis. Furthermore, an analysis of which activities fall under each pillar can be seen in Fig. 2. In summary, one unit in the acute cluster, two units in the medium cluster and one unit in the rehabilitation and recovery cluster met the 25-h weekly activity criteria as set out by the QNFMHS. The majority of activities occurred in pillar 5 – social, occupational, rehabilitation and recovery pillar.
Data collection Prior to collecting data, a letter was sent to the unit managers to inform them of the survey. Data were gathered from the daily report book and the service user’s progress notes. The data collection took place in three stages: Stage 1: the first author checked the daily report book to record the activities on a spread sheet for a 4-week period. A daily report book is completed by the nurse manager on each unit/hostel. It has a brief summary of service users’ activities and any critical incidents which are reported to the nursing management. Stage 2: both the authors checked the progress notes of all 93 service users to record the activities that may have been omitted in the daily report. This forensic setting has adapted a system of integrated care pathway (Gill et al. © 2013 John Wiley & Sons Ltd
Discussion and recommendations The fourth annual report of the QNFMHS (2009–2010) which summarizes the aggregated results of the reviews undertaken across 64 medium-secure units in England, Wales and Ireland found that 54% (34 medium-secure units) of the services met the 25 h of structured activity per service user per week criteria (QNFMHS, 2010). The Irish forensic setting is one of the 30 member units who identified 25-h activity criteria as an area of challenge. Findings of this survey suggest that three of the four units that did not meet the 25-h weekly activity criteria were the ones that accommodate more acute service users. Similar finding was reported by the QNFMHS fourth annual report, which 385
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Table 3 Activities considered for the survey across the ‘five pillars of care’ Pillar 1 – Physical health Assessment Health promotion group Ball alley walk Relaxation Cycling group Summertime team sports events Daily lunchtime football game Take charge diabetic group Indoor games Individual walking sessions Walking groups Solutions for wellness programme Education on diet/mental health Pillar 2 – Mental health (illness insight, wellness and recovery) Assessment/risk assessment ICP review Wellness lite programme Case conference 1:1 Psychology work Medical review/seclusion review 1:1 Sessions by primary nurses Mental Health Commission-related activities (Second opinion, Mental Health Review Board) Pillar 3 – Drugs and alcohol Assessment AA Information programme Get sorted programme Relapse prevention Pillar 4 – Harmful behaviour Assessment Dialectical behaviour therapy Meta cognitive therapy Family therapy 1:1 Fitness to stand trial 1:1 Psychology work Pillar 5 – Social and occupational rehabilitation and recovery Assessment Summer musical Art and creative activities Service user forum Community outings Spiritual development ADLs Housing Drama and poetry group Irish Advocacy Network Family visits Current affairs groups Garden project and barbeque Basin club Annual leisure games Unit-based BBQ Community meeting OT task groups Day plenary meeting Drama rehearsals Plant world Open university courses 1:1 Literacy work OT vocational exploration Industrial Therapy Department OT activity group Music classes and sessions OT community access training OT ‘healthy eating, healthy being’ group
Yoga Wi – Keep fit Couch to 5 K Swimming Gym sessions Fitness classes
MDT meetings GROW WRAP
Quit smoking After care
SAM 1:1 CBT
Word games Occupational therapist’s review Leisure games Quiz group Ward chores Horitculture Film club Bingo Leave
AA, alcoholics anonymous; ADL, activities of daily living; BBQ, barbecue; CBT, cognitive behaviour therapy; GROW, Grow Ireland Group; ICP, Integrated Care Planning; MDT, Multidisciplinary Team; OT, Occupational Therapy department led; SAM, Stress and Anxiety Management Group; WRAP, Wellness Recovery Action Plan. Shading was used to separate the five pillars.
indicated that service users on acute wards were more difficult to engage in regular structured activity (QNFMHS, 2010). It is evident from the findings that the service users residing on units that have higher physical and relational security fail to meet the 25-h structured activity criteria. With higher levels of security come greater obstacles to engaging in meaningful occupation or activities (Whiteford 1997, 2000, 2010). One of the main reasons for this barrier is the risk management strategies on secure units (Flood 1997, Forward et al. 1999, Cronin-Davis et al. 2004). For example, a service user may be prohibited from attending programmes that occur outside of the unit, or kept from using certain tools and equipment because of an individualized risk assessment. Greater structure and security is also associated with a reduction in the opportunities for service user’s self-advancement and self-improvement through 386
activity (Wright 1993). There may also be a reliance on unit-based staff to structure and supervise activities (O’Connell et al. 2010) that may be difficult to deliver because of staff shortages (O’Neill 2011) and the need for unit-based staff to work within a busy and demanding environment within the acute units (O’Donovan & O’Mahony 2009). When priority on a unit shifts to more acutely ill service users, it leaves little time for the unitbased staff to facilitate activities for the service users. Finally, internal barriers such as low motivation are prevalent especially among those who have been recently detained and residing in more acute secure settings (Martin 2003). Despite these reasons that cannot be resolved immediately, it is important that the needs of these acute service users are catered for. Molineux & Whiteford (1999) suggest the importance of providing choice, autonomy and © 2013 John Wiley & Sons Ltd
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16 14
Number of Service Users
12 10 Above 25 h 8 Less than 25 h 6 4 2 0 Acute Cluster Female
Acute Cluster Male
Medium Cluster Medium Cluster Medium Cluster Medium Cluster Medium Cluster Rehabilitation and Slow Stream Recovery Cluster Continuing Care Rehabilitation Selective Adaptive Rehabilitation Unit – Male Unit – Male Behaviour Unit Low-Secure Unit Rehabilitation Hostel – Male Unit – Male Male Male
Figure 1 Number of service users who meet the 25-h activity per week criteria vs. number of service users who do not meet this criterion across different units in the forensic setting
Breakdown of Activities across Five Pillars of Care
Pillar 1 22% Pillar 5 47% Pillar 4 7%
Pillar 3 11%
Pillar 2 13%
Figure 2 Percentage of activities occurring within each pillar of care
opportunities for engagement in personally meaningful occupations. In this regard, employment of multidisciplinary staff, including occupational therapists, could assist in enriching the environment and overcoming the barriers to participation (Hills 2003). Findings also suggest that the delivery of structured activities under certain pillars of care should be ‘phased’ to take place when the service user is sufficiently prepared. An acutely ill person may not be able to benefit from the more demanding forms of psychoeducational programmes (Radcliffe & Smith 2007). Supported task-based activities may have more value at this stage of recovery (Alred 2003). Furthermore, the percentage of activities that are occurring under each pillar of care indicate that just under half (47%) of the activities are those considered to be social, occupational, rehabilitative and recovery-based in nature. © 2013 John Wiley & Sons Ltd
This pillar of care encompasses a wide range of work, education, leisure, self-care and family-related elements, and therefore, it is not surprising that most of the participants’ activities occur under this pillar. While there are no studies that are directly comparable with this, previous time use studies have indicated that the majority of service users’ time is spent engaged in leisure and passive occupations (Farnworth et al. 2004, Sturidsson et al. 2007, O’Connell et al. 2010). Passive occupations, sleeping and mealtimes were not considered as ‘structured activity’ in this survey and therefore were not included as they were for those studies. In the study by Sturidsson et al. (2007), ‘treatment’ that included nursing, occupational therapy, psychology and psychiatry consultation took up less than 1.3% of the participants’ day. In the study by Farnworth et al. (2004), less than 5% of time was spent in group programming. Again, while this survey only focused on 387
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meaningful activity and therefore cannot be directly compared with more general time use studies, it appears that a significant portion of engagement time (31%) occurred in programmes aimed to reduce the risk of relapse or recidivism under the pillars of mental health, drugs and alcohol, and harmful behaviours. Based on the findings and discussion the authors make the following recommendations to practice:
1. Overcoming barriers for service users in higher-security units Less number of service users meeting the 25-h weekly activity criteria on the high-security units could be explained by several barriers discussed earlier, which appears to be the case in other higher-secure units internationally (Craik et al. 2010, Whiteford 2010). Potential solutions need to be considered by further analysing environmental factors having an impact on participation (Hills 2003). An example of a solution may be to create a variety of meaningful and risk-assessed activity opportunities within the limits of the unit such as flowering pots and plastic tools, portable library or board games (Alred 2003, Cronin-Davis et al. 2004). Also, future studies need to explore the perceptions of service users and staff in order to gather the potential solutions (Fazio 2008).
2. Service user involvement and personal weekly timetables Service user involvement in planning and service provision is widely advocated by the national and international bodies (Department of Health & Children, Ireland 2006, Mental Health Commission Ireland 2007, 2008, 2010, National Health Service UK 2007). It is envisaged that encouraging members of the multidisciplinary team to collaborate with each service user in creating and negotiating a personal weekly timetable would be beneficial. A weekly timetable may include all activities carried out by the service users that are personally meaningful to a service user’s weekly routine. It is advocated that members of the multidisciplinary team regularly review such timetables along with each service user’s care plan and that the timetables reflect the service user’s goals and recovery objectives (Lang 2011). This allows for defining meaningful activity in service user’s own terms and may help to increase motivation as activity is linked with recovery plans (Reeve 2010). In order to plan and monitor service user activities, Lang (2011) suggests forming a ‘therapeutic activity steering group’ that should have service user representation and members from all the disciplines. 388
Persons with schizophrenia have been shown not to experience control when social activities were externally initiated (Bejerholm & Eklund 2004). Therefore, another way to enhance service user involvement would be to encourage service users to organize and facilitate activities with support from staff (Lang 2011). For example, if there were service users who were particularly interested in reading, they could create a book club with their peers, supported by staff. User-run peer support groups can be successful with good managerial support, staff involvement and adopting a robust recovery-based approach (Duffield 2009).
3. Development of a web-based recording system Lang (2011) advocates for the use of an electronic database in order to capture service users’ participation in activities. Developing and designing a web-based recording system specifically to meet the needs of mental health service users is essential in order to monitor activities accurately, to make reporting simple and quick to use. The recording system needs to be reliable and secure where every staff member who conducts, observes or facilitates service users in engaging in activities should be able to document the number of hours spent on those activities. Within the recording system, there should also be an option to indicate the level of participation in the activity (high, medium or low). Recording the reasons for nonattendance and engagement levels would give additional information on service user participation. Such recording system also assists in conducting regular internal audits. The authors acknowledge that these recommendations require financial resources, time and commitment from staff. In the current economic scenario, designing and implementing web-based recording system can be expensive. Also, meeting the criteria of 25-h weekly activity may be viewed as an additional work and time consuming. However, it is envisaged that in the long term, such investment will bring about a service user-friendly and costeffective care and treatment.
Limitations There are a number of limitations to this survey: 1. While the importance of engagement in meaningful activity for service users within forensic settings has been discussed, we did not measure whether the activity captured in this study is meaningful or not to the service user. 2. This survey was only able to explore the use of structured activity in a forensic setting. © 2013 John Wiley & Sons Ltd
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3. Other elements that were not captured in this study were the reasons why service users did not attend activities if they declined, whether the service user had a perceived choice in participation of such activity and the level of participation in those activities. 4. Furthermore, this survey relied heavily on reviewing documentation in order to ascertain service users’ engagement in structured activity. If a person’s participation in structured activity was not recorded, then this datum was not captured.
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