Centre for research and education in forensic psychiatry

Transkript

1 Centre for research and education in forensic psychiatry Early Recognition Method (ERM) Pilot Project Report Gunnar Eidhammer Maria Knutzen Frans Fluttert Project Report

2 Early Recognition Method (ERM) Pilot Project Report Gunnar Eidhammer Maria Knutzen Frans Fluttert Kompetansesenterets prosjektrapport

3 2010 Kompetansesenter for sikkerhets-, fengsels- og rettspsykiatri for Helseregion Sør-Øst Avdeling for forskning og utvikling - psykisk helse og avhengighet Oslo universitetssykehus HF Denne elektroniske utgaven ISBN Også tilgjengelig som trykksak ISBN på

4 Innhold Preface Introduction The violence risk field then and now Description of Early Recognition Method (ERM) Data and method Setting Pilot study research objectives Method Ethical considerations Clinical data Data collection and processing of clinical data Qualitative interviews Organization Project organisation Management foundation at Buskerud Hospital Trust Finance Results Testing ERM at the medium security unit of Buskerud Hospital Trust Mapping experiences of nursing staff involved Discussion Conclusion References Attachments

5 Preface This report is from the pilot study Early Recognition Method (ERM), a collaboration between Frans Fluttert, MSc (FPC Dr. S. Van Mesdag/University Utrecht The Netherlands), the psychiatric medium security unit at the psychiatric ward at Buskerud Hospital Trust, the Research and Development Unit at the psychiatric clinic at Buskerud Hospital Trust, the psychiatric ward management at Buskerud Hospital Trust and Centre for Research and Education in Forensic Psychiatry for the South-Eastern Norway Regional Health Authority. We made contact with Frans Fluttert via Professor Stål Bjørkly at the conference Violence in Clinical Psychiatry in Amsterdam in 2007, where Fluttert had a presentation on ERM. We found the ERM concept very relevant for the Norwegian context and invited Fluttert to visit us in Norway the following spring. In April 2008, Fluttert held a video transmitted presentation on ERM. The presentation was organised by the Centre for Research and Education in Forensic Psychiatry targeting all interested psychiatric security Units in the South-Eastern Norway health region. Later that day, Fluttert also held the same presentation for invited guests from the Centre for Research and Education in Forensic Psychiatry for the South-Eastern Norway, Regional Health Authority, Regional high security unit in the South- Eastern Norway health region and Buskerud Hospital Trust. Buskerud Hospital Trust initiated collaboration with Fluttert to test ERM in the Norwegian context at the psychiatric medium security unit at Buskerud Hospital Trust. ERM was financially and scientifically founded at the Centre for Research and Education in Forensic Psychiatry for the South-Eastern Norway health region. Prior to the pilot study, we went on a study tour to visit Fluttert in the Netherlands and we were informed about ERM in clinical practice. Oslo Gunnar Eidhammer, Maria Knutzen & Frans Fluttert 4

6 1 Introduction 1.1 The violence risk field then and now The Norwegian Directorate of Health has published Tiltaksplan for redusert og kvalitetssikret bruk av tvang i psykisk helsevern (IS-1370), an action plan for reduction and quality improvement in use of coercion in psychiatric health care. There are expectations that the clinical environments should aim for quality improvement and reduction in the use of coercion. Research shows that coercion is used most frequently in acute mental health care wards and in forensic psychiatry. In 2000 and 2001, the project Gjennombruddsprosjekt psykiatri Bruk av tvang was completed. The project investigated use of coercion and results showed that intervention can reduce use of coercion in clinical practice (Mathisen and Føyn, 2002). There has been no systematic monitoring of the reduction in use of coercion, neither have there been any investigations into whether the measures developed in Gjennombruddsprosjektet are still used in clinical practice. However, there is an increasing focus on the use of coercion and possible interventions to reduce use of coercive means. The most common focus area is measures used as a result of violent incidents. A mapping tool and instruments for systematic assessment of risk of violence and management strategies have been developed, e.g. BVC, SOFA, REFA, VAFA, HCR-20 and START and SOAS-R. Psychiatric nurses are faced with challenges in clinical practice, especially when dealing with patients with potentially violent and aggressive behaviour (Johnson 2001, Lauvrud et al. 2009, Martin & Daffern 2006, Mason et al. 2008). Even though considerable research has been done on violent behaviour in psychiatric health care, empirical intervention studies are lacking (Fluttert et al. in progress, Harris & Rice, 1997). Dealing with potentially violent patients is a multi-faceted challenge, which can affect the nurses perception of security (Jansen et. al, 2005, Martin & Daffern 2006). Individual patient approach is expected to be combined with a therapeutic environment for all patients in the unit, as well as creating a safe environment for oneself and other colleagues (Fluttert et al. in press b, Meehan et al. 2006). The patient perspective and the patient s actual influence on his or her own treatment is a growing focus area in forensic psychiatry (Duxburry & Whittington 2005, Faulkner & Morris, 2003, Meehan et al. 2006). 5

7 Dealing with violent patients is in the literature often defined as short-term or long-term violence risk management (NICE guideline 2005, Department of Health, National Risk Management Programme 2007). Short-term violence risk management relates to dealing with spontaneous acting out and violence at present here and now. The nurses are dealing with this using their knowledge and wisdom, such as: being decisive, providing a sense of security, being calm, using verbal and non-verbal communication skills, relations management and deescalation approaches. It is important to describe, analyse and understand the threatening situation, in order to implement appropriate measures/approaches (Johnson & Hauser, 2001). Long-term violence risk management relates to establishing treatment measures and plans in collaboration with the patient in order to prevent violence recidivation, also called relapse prevention (Bjørkly 2004, Department of Health, National Risk Management Programme, 2007). Violence risk management of mentally unstable or mentally ill patients has changed considerably over the past 40 years. In research, the stages are often referred to as generations: First generation risk assessments are often referred to as unstructured clinical risk assessments. An assessment is made solely on one expert s opinion of another person s risk of relapsing into violence. The assessment is based on the expert s observations and conversations with the patient being observed. This method was widely criticised, as it defined non-dangerous persons as being dangerous, resulting in a large number of false positives. Researchers have later concluded that it was equivalent to flipping a coin and the accuracy in terms of predicting relapse was lower than 50 per cent (Grann, 2002). Second generation risk assessments are in many ways an answer to the criticism of the unstructured assessments. Researchers, headed up by Monahan (Monahan, 1984), focused on what was called actuarial risk assessments. These assessments focused on the static and statistical factors making violence relapse probable. The most well-known actuarial tool is Violence Risk Appraisal Guide (VRAG), which was developed by mapping characteristics of 680 mentally unstable persons with a history of violence before they were released from prison in Canada (Harris et al., 1993). ICT and COVR are other actuarial instruments, socalled decision or classification trees (Monahan et al, 2000 & 2005). The actuarial instruments have proved to be better predictors of future relapse into violence than 6

8 unstructured assessments. Actuarial assessments have also been subjected to considerable criticism, as they focus solely on unchangeable/static factors. Third generation risk assessment was more or less developed by Canadian researchers in Vancouver. Actuarial research was combined with clinical dynamic factors and future risk management factors. The researchers developed Historical Clinical Risk Management 20 (HCR 20) (Webster, et al., 1997), consisting of 10 historical items, 5 clinical items and 5 risk management items, which could influene relevant factors preventing relapse by for example discharge. In the past few years, focus has increasingly been on individual factors. Both Bjørkly and Fluttert are representatives of the individual approach to violence risk assessment. Stress, vulnerability, early warning signs and triggers are important factors. Sensing and identifying individual warning signs prior to a violent incident can make intervention made before the violent incident occurs. We refer to Bjørkly and Centre for Research and Education in Forensic Psychiatry for the South-Eastern Norway Regional Health Authority s courses in violence risk assessment, VIVO1 (15 credits) and violence risk management, VIVO2 (15 credits). Over the past few years, intervention methods have been developed, based on the theory of preventing unfortunate mental processes leading to for example psychosis; Early warning signs of psychoses (Birchwood et al., 1998, Meijel et al. 2003) and violent behaviour; Signature risk signs (Fluttert et al., 2008). Fluttert has developed a method to prevent development of violent behaviour. The so-called Early Recognition Method (ERM) has a strong patient focus. One of the main elements of the Early Recognition Method (ERM) is that the patient should develop an understanding of his or her own early warning signs and thus be able to intervene in order to prevent relapse. 1.2 Description of Early Recognition Method (ERM) ERM focuses on identification of early warning signs of relapse in patients suffering from mental illnesses such as violent and dangerous behaviour, suicidal behaviour or other behaviour with negative consequences. Identifying early warning signs is done in order to prevent such behaviour and further reduce the use of different types of coercion, enforcement measures, isolation and serious aggressive incidents, shown in Fluttert s research (Fluttert 7

9 et.al in press a). In conversation with the patient, the nursing staffs inform him or her of the method and together they map the patient s motivation, condition, understanding and social network. (Attachment 1) Based on the introduction and mapping, further measures are identified. The method s next step involves defining and actively dealing with the early warning signs. (Attachment 2) When identifying early warning signs, it is very important that the patient uses his or her own words and descriptions in order to recognize the early warning signs and changes in the description of his or her behaviour. This way, the patient and/or staff can intervene before relapse and early enough in the process to prevent a crisis, which violent behaviour can often be. By identifying early warning signs as early as possible, the patient will also be able to enable positive self-management measures to prevent the situation from becoming insuperable. The active involvement of the patient is important, as the patients thoughts and actions are in focus. Nursing staff/patient interaction demands collaboration. The patient s family and social network may be invited into the collaboration when appropriate. On consent of the patient, family or someone from his or her network can describe their experiences of the patient s early warning signs. Family/network is taking a more active role in the care of the patient. The nursing staff s observations of the patient s early warning signs are also described at this stage. The nursing staff and the patient agree on 3-5 early warning signs to focus on. They will then work on what the patient perceives to be the most important early warning signs. The nursing staff can also add warning signs which he/she has observed and which the patient does not necessarily recognize or want to work on. The aim is to develop an individually tailored plan, focusing on identifying the patient s idiosyncratic signs of relapse, making the process predictable for the patient, staff and family/network. Should the patient refuse to co-operate or if the patient s condition indicates that he or she is not able to participate and use ERM, the nursing staff will work on the early warning signs they have identified based on observation and professional assessment. The method s decision processes are described in detail in a decision tree which is part of the ERM introduction document. Each early warning sign is graded in three levels, depending on the force/strength of the early warning sign. The patient s own words are used to describe the different levels. (Should the patient not wish or be able to participate, the nursing staff describes the levels, on which the observations are based). 8

10 1= stable phase. The patient says he is ok and the early warning signs are not stressful for the patient. 2 = moderate phase. The patient perceives the defined early warning sign as moderately present and somewhat stressful. 3 = serious phase. The patient is very afflicted /stressed. The defined early warning sign is strongly present. An early warning sign can be a patient s sleeping pattern. The patient sleeps well, is on level 1 and says he feels alright. If the patient says he has not slept well, maybe for a few nights in a row, it can be a major stress factor for the patient. The patient defines himself to be on level 3 and says the consequences are that he is very irritable and has difficulties being with other people. Another example can be intoxication. The patient may have a drug or alcohol problem in addition to his/her mental illness and the abuse may have led to unfortunate incidents for the patient. The stable phase can be: I think about using, but it is not stressful. Moderate phase can be: I think about using and see the advantages of doing it. I would feel good to get high/drunk. Serious phase can be: I have a craving and I am thinking about bringing drugs into the ward. I get stressed out by it. An action plan is developed in collaboration with the patient if he/she wishes and is able to. The measures are divided into sections of what the patient and staff can and should do and what family and network can do and should avoid doing. Measures are carried out strictly individually, when the patient shows signs of becoming unstable. Examples of measures can be to ask for a talk, play cards or withdrawing to the patient s room as the stress level increases. 9

11 2 Data and method 2.1 Setting The pilot study was carried out in the period of September 2008 to September 2009 at the psychiatric medium security unit at Buskerud Hospital HF. The unit is defined as a local security unit and was established in The security unit is responsible for patients in Buskerud County, with a catchment area of approximately 240,000 people. The patients at the unit often have complex psychopathology consisting of serious mental illness, drug or alcohol abuse risk and aggression issues. Patients are often admitted for violence risk assessment and mapping and development of appropriate risk management strategies. The unit has a nurse/patient ratio of 3/1. Permanent personnel consist of: chief physician/senior consultant, neuropsychologist, nurses (with and without additional qualifications), social educators (with or without additional qualifications), auxiliary nurses (with or without additional qualifications) and a clinical social worker. Several staff members have the following qualifications: VIVO 1 and 2 (violence risk assessment and management studies), drug abuse, network/family, rehabilitation, SEP REP and Master of Clinical Health Care. 2.2 Pilot study research objectives 1. Test ERM in collaboration with 3 patients at the psychiatric medium security unit at Buskerud Hospital HF. 2. Map ERM experiences of the nursing staff directly involved in the pilot study 2.3 Method The pilot project was focusing on development in violence risk assessment/management and research. Development in the violence risk assessment field involved testing ERM in collaboration with 3 patients in clinical practice. Frans Fluttert trained staff in ERM in October 2008, including nursing staff in permanent positions working day and evening shifts. They were in the primary group of the 3 patients who were to be included in the pilot study. The research part of the pilot project consisted of interviews with the nursing staff who participated in the pilot study. 10

12 2.4 Ethical considerations Application was obtained by the Regional Committee for Medical and Health Research Ethics (REK) on both parts of the pilot study. Testing of ERM at the medium security unit at Buskerud Hospital Trust was approved as a quality improvement project and the nursing staff interviews at the security unit were approved as a research project. Norwegian Social Science Data Services also obtained approval of the interviews. 2.5 Clinical data After the training, one of the nursing staff from each of the groups had a conversation with his/her respective patient and informed the patient of the method. They systematically went through the ERM introduction plan (attachment 1). The time used was depended on the individual motivation and condition of the patient. One of the patients completed the introduction in 30 minutes while another patient had several talks over a number of days. 2.6 Data collection and processing of clinical data Each month clinical data were collected from documents used in the pilot study and transferred to an Excel-file (attachment 3 is one example). We collected the following data: Dates and number of interventions between patient and nursing staff Mapping of early warning signs and warning sign levels Anonymised Excel-files show clinical data for the three patients. Early warning sign levels were coded with traffic light colours in the file. Stable was coded green, moderate was yellow and serious was red. This colour chart visualised the level of stability of each patient over time. The patients were shown the chart and found it interesting to see their own level of stability illustrated this way. Number of aggressive incidents. SOAS-R - a tool for mapping aggression was used during aggressive incidents (attachment 4). 11

13 2.7 Qualitative interviews Qualitative interview objective: Nursing staff experiences from introducing and using Early Recognition Method. Research questions qualitative interviews: What experiences did the nursing staff have after using ERM for 3 months? Is ERM relevant for the nursing staff s patients? In the nursings staffs opinion what are the strengths of ERM? What weaknesses and challenges have nursing staff identified using ERM? Data collection qualitative interviews Semi-structured interviews were conducted on 8 of the nursing staff who participated in the pilot study. All informants received an information letter and a consent form containing information on where and when the interview would take place, information on the option of withdrawing from the study at any time, data storage and anonymisation and that the interviews would be taped. The informants were asked to sign the consent form. They also received a theme guide prior to the interviews. All 8 interviews were conducted in the office of the interviewer. The interviews lasted between 15 and 25 minutes. Even though the theme guide was followed during the interviews, the informants were invited to reflect openly on each theme. Data were collected on a tape recorder and kept in a secure locked cabinet when not in use for transcription. The interviewer and an external consultant did the transcriptions. The tape recordings were deleted immediately after completion of the transcription. Two focus group interviews were also carried out. The first interview was held after the 8 individual interviews in February 2009 and the other was completed at the end of August 2009, as part of completing the pilot study Data processing qualitative interviews Data were collected by sound recording. The recordings were stored in a locked cabinet, inaccessible to other than the main author. After transcription, the recordings were deleted. A de-identified code list was made and kept in a securely locked cabinet at the hospital. The list is stored as journal data. The code list is to be considered a code key to identifying the anonymised data of each informant. 12

14 3 Organization 3.1 Project organisation Project administrator: Head of Centre for Research and Education in Forensic Psychiatry for the South-Eastern Norway Regional Health Authority, Oslo University Hospital, Ullevål who initianted the collaboration with Fluttert, was Dr Bjørn Østberg. After his retirement the new leader Ingar Tufte prolonged the collaboration. Project manager: Maria Knutzen, Cand. San, Project Manager, Head of Centre for Research and Education in Forensic Psychiatry for the South-Eastern Norway Regional Health Authority, Oslo University Hospital, Ullevål. Local project manager: Gunnar Eidhammer, MKIH, Medium Security Unit, Psychiatric Ward, Buskerud Hospital Trust. Reference group: The reference group was responsible for coordinating the project: Stål Bjørkly (Reference Group Leader), Professor at Molde University College Nina Helen Mjøsund, Cand. San., Psychiatric Nurse, Head of Research and Development, Psychiatric Clinic, Buskerud Yngve Ystad, Chief Psychiatrist/Senior Consultant Bjørn Heimdal, Head Nurse and Psychiatric Nurse Gunnar Eidhammer, Master of Clinical Health Care, Psychiatric Nurse and Local Project Manager of all three security units, Psychiatric Ward, Buskerud Hospital Trust Maria Knutzen, Cand. San. Project Manager, Centre for Research and Education in Forensic Psychiatry for the South-Eastern Norway Regional Health Authority, Oslo University Hospital, Ullevål Christine Soot Sandlie, Master of Clinical Health Care Psychiatric Nurse, Centre for Research and Education in Forensic Psychiatry for the South-Eastern Norway Regional Health Authority, Oslo University Hospital, Ullevål Frans Fluttert, Fellow Researcher FPC Dr. S. Van Mesdag / Phd promovendus Utrecht University 13

15 The local steering committee at Buskerud Hospital Trust: Bjørn Heimdal, Head Nurse, Medium Security Unit, Psychiatric Ward, Buskerud Hospital Trust Gunnar Eidhammer, Local Project Manager, Medium Security Unit, Psychiatric Ward, Buskerud Hospital Trust Nina Helen Mjøsund, Cand. San., Psychiatric Nurse, Head of Research and Development, Psychiatric Clinic, Buskerud Lars Erik Selmer Psychiatric nurse and Key Nurse of the ERM project 3.2 Management foundation at Buskerud Hospital Trust Head Nurse of the medium security unit, Bjørn Heimdal, has been positive about the project during the whole period of the pilot study and has prepared for good progression. He has prioritised the project and made resources available to secure progress in the daily operations. He has carefully informed his superiors (the ward management) of ERM and at regular intervals asked the nursing staff about status and progress. Bjørn Heimdal has also been available to and has prioritised to spend time with Frans Fluttert, both professionally and socially, during his visits in Norway. Heimdal found it important to participate in the study tour to the Netherlands prior to the pilot study. The pilot study has an interdisciplinary profile. The chief physician, the neuropsychologist and the security unit s clinical social worker all see the benefits and the relevance of implementing ERM as part of the patient treatment at the unit. Our experience is that the management foundation has been a very important factor for the progress of the pilot study and the synergy effects we have observed (please see page 21). 3.3 Finance The pilot study was financed by the Centre for Research and Education in Forensic Psychiatry for the South-Eastern Norway Regional Health Authority. The centre financed a local project manager in a 30 per cent position in the period of September 1, 2008 to September 1, In addition, the centre financed a study tour for Gunnar Eidhammer and Maria Knutzen to the Netherlands prior to the pilot study and has financed Frans Fluttert s four trips and stays in Norway during the project period. 14

16 4 Results 4.1 Testing ERM at the medium security unit of Buskerud Hospital Trust All three patients who were invited to participate in the pilot study participated during the whole period. Experiences show that all three patients benefited from systematically dealing with their own defined early warning signs. Two of the patients did not have any aggressive incidents in the pilot period and the last patient has not had any aggressive incidents since the end of January 2009 (SOAS-R registration). ERM was tested according to the project description, i.e. in collaboration with 3 patients at the medium security unit at Buskerud Hospital Trust. All patients were transferred from the security unit to other treatments. Two patients continued using ERM in their respective municipalities and one patient continues to use ERM at a secure rehabilitation unit. Two of the patients have expressed that they find the method useful to get to know themselves better. One of the patients expresses the benefits in an interview in the Norwegian Journal of Nursing Bladet Sykepleien 7/09 (Attachment 4). One of the patients was very motivated from the start, while the two other patients spent more time to reach their decision. All three patients participated in identifying their own early warning signs. The frequency of mapping early warning sign levels was agreed with the patients. The patients in the pilot study had conversations about their early warning signs approximately once a week and when the patient or observations by the nursing staff indicated a change. For example, one of the patients early warning sign was anxiety. He agreed with his group that each Friday they would talk about his anxiety level over the past few days. If he felt that his anxiety level increased between the regular talks he contacted the staff, had a talk and registered it in the ERM plan. This had a good effect on the patient and the same procedure was used on the other patients. We experienced that the ERM talks alone worked as good preventive measures. The patient talked about problem areas and systematically approached them at the same time. When the patient experienced a high degree of instability, other measures tailored to the patient were adopted. Measures were developed in collaboration with the patient and family/network and based on professional assessments. 15

17 One patient did activities in his room, such as games, films and music when he felt unstable and needed to gain control of himself. Another measure for the sae patient was talks with familiar staff. Another patient s measure was to go for a walk with someone he knew when he started feeling anxious /unstable. All three patients collaborated with the nursing staff defining their early warning signs and expressed something about the levels of the defined early warning signs during talks. The conversations about early warning signs are possibly the most important measure leading to the patient s development of reflection and understanding of his/her early warning signs. Two of the patients in particular identified what they do themselves to stabilise, when they feel unstable. One of the patients goes to his room and listens to music or contacts the staff to have a talk. Another patient claims that physical activity is important for his stability. All three patients were stabilised on adequate medication before or during the pilot study period. Based on professional assessment, only one of the pilot patients had a network, which seemed appropriate to invite to collaborate. The patient approved of the nursing staff talking to the mother and a support person. They both identified the patient s early warning signs independent of each other. 4.2 Mapping experiences of nursing staff involved The results present the total findings from the individual interviews and focus group interviews. The same theme was discussed but in different contexts. Findings from the last focus group interview are presented last of the results. The interviews was analyzed by using content analyzes Experiences after 3 months using ERM The most important findings in the study were that ERM was a positive experience for the nursing staff interviewed. The method has great relevance for development of the practice. One finding from the individual interviews was that all 8 informants started taking positively about their experiences using ERM. 16

18 The nursing staff pointed out the importance of Frans Fluttert s presence and they had an entire day of training with him. The interviewees further agreed that his presence later in the testing period was also positive. I would like to say that I find it really exciting being a part of this and I clearly see many positive influences through working with the method. I would like to say that I think ERM is an interesting and exciting approach Strengths and relevance of ERM implementation We have good prerequisites to implement ERM in a satisfactory manner through the way we work with the primary group principle and the high nurse/patient ratio and The advantage is that we see it a lot earlier and we are observant of the early warning signs. Among the most prominent statements from the informants was that ERM could strengthen our collaboration with the patients, the patients self management and the collaboration with the care institutions taking further care of the patient. In addition, ERM can contribute to refine our operations and strengthen our profession and subject area ERM challenges and weaknesses Implementing new measures can sometimes be slightly intimidating and challenging. Some found the ERM concept a little complicated before they got to know it. other challenges are doing this as simple as possible. I am under the impression that we believe it is more complicated than it really is, instead of thinking simple. Others have noticed that the motivation of the patient also influences their own motivation. The patient in my group is a little bit on and off in terms of wanting to participate in this or not Summarizing the pilot The last focus group interview summed up the pilot study. The challenges of the method matched the challenges discussed by the group in the February interview, e.g. improvement areas in the training, which one tends to think it is complicated and that it is important to continue using the method after the patient has been discharged from the medium security unit. 17

19 The main findings in the last focus group interview were that ERM is useful for the patient in terms of getting to know his or her early warning signs better and prevent crisis. ERM contributes to professional development through focusing on core areas, working systematically and documentation. ERM strengthens the collaboration between nursing staff and the patient. Last but not least, ERM has proved to be an efficient factor for collaboration between specialist health services and the municipal health care. The last part of the interview was mainly dedicated to the collaboration between hospitals and municipalities. Consensus was that ERM is important in that matter and it is crucial that the patient continues to use the method when transferred to his/her municipality after hospitalisation. 18

20 5 Discussion Management and assessment of patients representing violence risk, has for many years focused on predictions, assessment and mapping of the patient, on behalf of the patient. Early Recognition Method is likely to bring working with these patients to a new level by focusing on patient involvement. ERM invites the patient to actively participate in his or her own treatment and family and network can also participate. The strong user and network involvement, in addition to individual benefits, the systematic method and documentation, was in many ways crucial for Buskerud Hospital wanting to test the method. All three patients invited to participate in the pilot study accepted and are still using the method as part of their treatment. It seems that it is important for the patients to work with themselves in a way that on one hand is systematic, visual and focusing on results and on the other hand provides for reflection and talks about important problem areas, i.e. the early warning signs. After Radio Norge had interviewed one of the authors about ERM, one of the patients said that he had heard him talk about our method on the radio. That statement could reflect ownership to a method, which the patient can relate to. One of the patients has periodically shown little motivation to work on his early warning signs. This resulted in discussions in the staff group about whether this method was relevant to use in collaboration with the patient. The staff chose to continue describing the levels of his early warning signs based on observation. The patient was on and off in terms of motivation to actively participate in ERM. Another patient did not want to discuss his drug abuse with the staff. Having identified drug abuse as an observed early warning sign, the patient gradually showed more interest and is now actively participating. The patient can see that the staff is working systematically around him and it could be an approach to making him curious about his own early warning signs. Fluttert has similar experiences from his work in the Netherlands. Patients, who were negative or refused to participate in ERM, became active participants after a while. Clinical experiences show that the patient gradually develops more knowledge about their own early warning signs of relapse. A patient now treated in his municipality, has his own ERM plan in his apartment and works on it together with staff from the municipality. He has developed increased his knowledge about his own illness and has become more aware of early warning signs that could develop into risk behaviour. 19

21 The interviews with the nursing staff in the pilot study provided good data on working with ERM. The purpose of the interviews was to get a balanced picture of the experiences of the nursing staff in relation to ERM. We chose a qualitative design combining individual interviews and focus group interviews. It was important to do the focus group interviews in the beginning and at the end of the pilot study. The reason is that the first phase of a new project can give a positive effect which decreases over time. Was it possible that the participants in first period of the study had very positive experiences with ERM, which would later diminish? The results from the study do not support this theory. The first phase was characterised by a combination of very positive reactions and challenges related to doing something new and complicating something unknown. Some of the staff said that it was systemising what they were already doing. The interviews mainly gave positive feedback. It is interesting to see that the last focus group interview focused on 10 months of experiences with ERM. The challenges and weaknesses identified in this interview were the same as in the February interview: The training could have been better, all the documents should have been complete and translated and the thoughts on using ERM were too complicated. On the other hand it is interesting to see that they describe the process of using ERM mainly using positive words. Several point out that they had positive experiences collaborating with the patient and that it has strengthened the documentation. Several of the informants also point out several synergies, meaning experiences that were not described in the project description. In particular, collaboration with municipal health care was highlighted as an important theme. A positive finding is the use of the method in collaboration with the patient both in a secure hospital ward and in municipal health care. We find it interesting that one method can be used in collaboration with the patient both in a closed hospital ward and in municipal health care. This provides a breeding ground for strengthening patient collaboration between different levels of health care and increasingly securing continuity in the treatment of a patient. It can also be important in a patient perspective. Instead of starting a new data collection in terms of important problem areas, as early warning signs often are, ERM can contribute to securing continuity from one health care level to another. Testing ERM in the Norwegian context has in many ways been an exciting and positive process. In a patient perspective we find that it has been successful. One of the patients stresses the importance of being able to identify his warning signs and working on them to prevent a crisis. He even reminded new primary contact persons to become familiar with the ERM method when he was moved from the security unit to another unit. Another patient 20

22 identified the early warning signs together with the staff and is having talks about the warning signs. Prior to ERM, he did not want to work on his warning signs. This has lead to a larger degree of receptiveness in terms of the patient s core problem areas and better opportunities of establishing preventive and developing measures. The ERM talks with the patients varied from a few minutes to one hour. We experienced that the less stable the patient was, the longer the conversations were. The experience from the pilot project unit is that systematic relations management between patient and nursing staff, in addition to identifying and working on the individual (idiosyncratic) early warning signs, are important factors in terms of obtaining a sense of security and good treatment conditions. The nursing staffs have provided elaborate descriptions of their experiences from the pilot study. These experiences are important in the further ERM work. The management has been a positive driving force both financially and professionally and this has been one of the keys to success. ERM has become part of the interdisciplinary collaboration, which all parties see the benefits from. Our experiences and the degree of synergies, indicates that ERM is a method, which has a future in Norwegian psychiatric health care. The pilot also generated some synergy effects: External interest: Several hospitals have been in touch and shown interest for the method. Media: Gunnar Eidhammer was interviewed by Radio Norge and explained the method and the pilot study. The interview was done in relation to the triple murder case in Tromsø. The Magazine Bladet Sykepleien 7/09 featured a 6 page article on ERM and interviewed one of the patients in the project (attachment 4). Presentations: Eidhammer has had 12 internal and external presentations on ERM. Frans Fluttert and Gunnar Eidhammer had a lecture on this year s security seminar on November 13, There is more information about the lectures at Jane Nordhagen and Gunnar Eidhammer had a presentation on ERM as an approach to collaboration between outpatient community services and specialist health care at the conference for social services managers in Buskerud at Kongsberg on November 5, The Olsen Committee: The Olsen committee, appointed by the Ministry of Health and Care Services, was informed about ERM in September. The committee gave positive 21

23 feedback about our project and said they would take bring the information with them in their future work. The list of pilot study synergies supports our experiences of the ERM concept being interesting, relevant and important. Feedback from external interested parties indicates that ERM can contribute to professional development and strengthening collaboration with patients. 22

24 6 Conclusion Frans Fluttert s Early Recognition Method (ERM) has for the first time been tested in Norway. The medium security unit at Buskerud Hospital Trust carried out a 12-month pilot study to test experiences and possible effects of using ERM both for patients and nursing staff. According to the plan, we included three patients in the project. All three patients accepted the invitation to take part in the study and participated throughout the whole period. The three patients continue to use ERM as part of their treatment after hospitalisation at the medium security unit and after the completion of the pilot study. Our experiences with ERM are positive, despite the small sample of patients to draw conclusions from. The nursing staffs using ERM in collaboration with their patients has corresponding experiences. The use of ERM is increasing in specialist health services in Vestre Viken and in municipal health care. 23

25 7 References Birchwood M., Smith J., Macmillan F., Hogg B., Prasad R., Harvey C., Bering S (1989): Predicting relapse in schizophrenia: the development and implementation of an early signs monitoring system using patients and families as observers, a preliminary investigation. Psychological Medicine, 19, Bjørkly S. (1997): Aggresjon og vold teori, analyse og terapi. Cappelen Akademisk Forlag AS Bjørkly S, (2004) Risk Management in Transitions between Forensic Institutions and the Community: A Literature Review and an Introduction to a Milieu Treatment Approach. International Journal of Forensic Mental Health Vol 3, No 1, pages Department of Health. United Kingdom. (2007). Best Practice in Managing Risk principles and evidence for assessment and management of risk to self and others in mental health services Duxbury J & Whittington R. (2005). Causes and management of patient aggression and aggression: staff and patient perspectives. Journal of Advanced Nursing, 50(5), Faulkner & Morris (2003) NHS National Programme on Forensic Mental Health Research and Development National R&D Programme on Forensic Mental Health c/o HaCCRU, the University of Liverpool Fluttert F., Van Meijel B., Webster C., Nijman H., Bartels A., Grypdonck M. (2008) Risk management by early recognition of warning signs in forensic psychiatric patients. Archives of Psychiatric Nursing 22, nr. 4, Fluttert F., Van Meijel B., Nijman H., Bjørkly S., Grypdonck M. (In press a).preventing aggressive incidents and seclusions in forensic care by means of the Early Recognition Method. Journal of Clinical Nursing 24

26 Fluttert, F., Meijel, B. Van, Nijman, H., Bjorkly, S. & Grypdonck, M. (in press-b). Detachedconcern of Forensic Mental Health Nurses in Therapeutic Relationships with Patients. The application of the Early Recognition Method related to detached-concern. Archives of Psychiatric Nursing Grann M. (2002) Riskbedömningar Möjligheter och omöjligheter. Bilaga till Betänkandet:26 (utredningen Ju2000:10) om Villkorlig frigivning av livstidsdömda. Stockholm, Sweden: Fritzes Offentliga Publikationer Harris G., & Rice M., (1997) Risk Appraisal and Management of Violent Behavior. Psychiatric Services, 48, Harris GT, Rice ME, Quinsey VL. (1993) Violent recidivism of mentally disordered offenders. The development of a statistical prediction instrument. Criminal Justice and Behavior. ; 20: Jansen GJ, Dassen ThWN & Groot Jebbink G (2005). Staff Attitudes towards Aggression in Health Care: a Review of the Literature. Journal of Psychiatric and Mental Health Nursing 12, 3-13 Johnson, M E., Hauser, P M. (2001) The practises of expert psychiatric nurses: Accompanying the patient to a calmer space. Issues in Mental Health Nursing, 22: Mason T, Coyle D, Lovell A. (2008b). Forensic psychiatric nursing: skills and competencies: II clinical aspects. Journal of Psychiatric and Mental Health Nursing. 15, Meehan, T., McIntosh, W., & Bergen, H. (2006). Aggressive behaviour in the high-secure forensic setting: the perceptions of patients. Journal of Psychiatric and Mental Health Nursing, 13, Meijel, B van, Gaag, M. v.d, Kahn, R.S., & Grypdonck, M. (2003). Relapse prevention in patients with schizophrenia. Archives of Psychiatric Nursing, 17(3): Monahan J. (1984) The prediction of violent behavior: Towards a second generation of theory and policy. American Journal of Psychiatry; 141,

27 Monahan J, Steadman HJ, Appelbaum PS, et al: (2000) Developing a clinically useful actuarial tool for assessing violence risk. British Journal of Psychiatry 176: Monahan J, Silver E, Appelbaum PS, et al: (2001) Rethinking Risk Assessment: The Macarthur Study of Mental Disorder and Violence. New York, Oxford University Press Monahan J, Steadman HJ, Robbins PC, et al: (2005) An actuarial model of violence risk assessment for persons with mental disorders. Psychiatric Services 56: National Institute for Health and and Clinical Excellence. (2006). Violence The short term management of disturbed/violent behavior in in-patient psychiatric settings and emergency departements. Royal College of Nursing Nijman, H.L.I., Campo, J.M.L.G, Ravelli, D.P., & Merckelbach, H.L.G.J. (1999). A tentative model of aggression on inpatient psychiatric wards. Psychiatric Services, 50, Rapport om Gjennombruddsprosjekt psykiatri bruk av tvang, Mathisen og Føyn (Red.)(2002): Skriftserie for leger, Utdanning og kvalitetsutvikling. Tiltaksplan for redusert og kvalitetssikret bruk av tvang i psykisk helsevern (2006):Sosial helsedirektoratet. (IS 1370) Steadman H, Mulvey E, Monahan J, Robbins P, Applebaum P, Grisso T, Roth L, Silver E. (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry;55: Webster CD, Douglas KS, Eaves D, Hart SD. (1997) HCR-20: Assessing the Risk for Violence. Vancouver: Mental Health, Law, and Policy Institute, Simon Fraser University 26

28 8 Attachments Attachment 1 Introduction to Early Recognition Method This is an information and introduction document used in the prefase of ERM. In conversation with the patient, the nursing staffs inform him or her of the method and together they map the patient s motivation, condition, understanding and social network. (Attachment 1) Based on the introduction and mapping, further measures are identified. Attachment 2 Min ERM plan This is the detection plan used in clinical care. This document describes and measures the patients early warning signs. It also describes an actions plan Attachment 3 Excel file This is an example over intervention data, from the detection plan Attachment 4 Bladet Sykepleien Norwegian Journal of Nursing 27

29 Attachment 1 Introduksjon til Early Recognition Method Kompetansesenterets prosjektrapport

30 Norsk ERM Protokoll INTRODUKSJON TIL EARLY RECO GNITION METHO D 2009 Pasientens navn: Primærkontakts/ navn: 2009 Frans Fluttert, Berno van Meijel, Gunnar Eidhammer, Maria Knutzen. Alle rettigheter er forbeholdt. Ingenting i denne publikasjonen kan reproduseres, lagres på data filer eller utgis i noe annet format eller på noen annen måter, hverken elektronisk, mekanisk eller ved kopiering eller noen form for lagring uten forfatterenes forhåndsbevilgede, skriftlige samtykke. Oversatt til Norsk av Gunnar Eidhammer (eldg@sb-hf.no) Kontakt: faj.fluttert@gmail.com Tel: No to be reproduced without permission of Frans Fluttert Version Lier Attachment 1 - Page 1 of 18

31 Innledning Denne arbeidsprotokoll er ment for miljøtpersonalet som har fått opplæring i å arbeide med ERM, og har oppnådd kunnskaper om denne metoden. Protokollens mål Protokollens mål er å forebygge at pasienten får tilbakefall i forhold til for eksempel voldelig atferd og suicidalforsøk. Situasjonsanalyse sammen med pasienten og relevante tiltak, er ment å bidra den til å redusere sjansene for tilbakefall Utgangspunktene for vellykket anvendelse av Early Recognition Method 1. Pasientens subjektive opplevelser og erfaringer er utgangspunktet. Forutsetningene for miljøterapeuts arbeid er: pasientens tilstand at målene er satt i sammarbeid med pasienten det språket og de begrepene pasienten snakker og forstår 2. Metoden er indivuduelt tilpasset. 3. Arbeidet med metoden er et felles prosjekt mellom pasienten, miljøpersonalet og (hvis mulig) pasientens sosiale nettverk (f.eks. familien). 4. Metoden krever kontinuerlig evaluering. 5. Miljøpersonalets holdning er støttende, positiv og oppmuntrende. Protokollens hoved faser 1. Forberedelses fasen 2. Beskrivelse av forvarslene. 3. Kartlegging og nivåbeskrivelse av forvarslene. 4. Utvikling av en tiltaksplan 2009 No to be reproduced without permission of Frans Fluttert Version Lier Attachment 1 - Page 2 of 18

32 BESKRIVELSE AV METODEN: Fase 1: Forberedelse 1. Introduksjons tema: å arbeide med ERM 2. Pasientens og det sosiale nettverks egenskaper Pasient-relaterte faktorer Motivasjon / motstand / handikap Pasientens syn på egen sykdom og bevissthet om mottakelse av behandling Aksept av psykisk lidelse Pasientsymptomer (som påvirker arbeidet med metoden). Andre karakteristikka (f.eks. kultur, personlighetsforstyrrelse) Sosialt nettverk: hvem er tilgjengelig, hvem er i stand til å støtte? 3. Handlinger (med fokus på å skape stabilitet og gunstige forhold for pasienten) Fase 2: Beskrivelse av forvarslene 1. Intervju/samtale med pasienten Fase 2: Beskrivelse av forvarsler 2. Intervju/samtale med sosialt nettverk 3. Informasjon/observasjoner fra miljøpersonalet Fase 3: Observasjon og Kartlegging av forvarslene og nivåbeskrivelse sammen med pasienten. Pasient Sosialt nettverk Miljø personale Forvarsler Observasj forvarsler Fase 4: Tiltaksplan 1. Pasientens tiltak unngå stress lære å klare seg bedre utvikle akseptable og hensiktsmessige handlinger beskyttende handlinger 2. Sosialt nettverks tiltak 3. Helsepersonells tiltak 4. Fordeling av planen for forebygging av tilbakefall (hvem har kopi av pasientens plan?) Sjekk Liste Tidlige Tegn (1): Dato Nivåbeskrivelse av forvarslene Nivå 3: Forvarsler forekommer alvorlig Nivå 2: Forvarsler forkommer moderat Nivå 1: Situasjonen er normal/stabil Nivå 3: alvorlig Nivå 2: moderat Nivå 1: stabil 2009 No to be reproduced without permission of Frans Fluttert Version Lier Attachment 1 - Page 3 of 18