Design in Mental Health 2016 Keynotes


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security, and procedural security, but there is a fourth dimension – the philosophy of care and the clinical model of treatment, something that is often missed, and is different in say, a general adult psychiatric ward to a low secure setting, and markedly different in a PICU.” Moving on to describe NAPICU and its


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NAPICU has been in existence for 21 years.


that there were relatively higher rates of conflict (and violence) on such wards day to day. He said: “We can debate whether we, as the clinicians managing PICUs, have got our treatment philosophy right, and, if not, may add to the challenges, but this is the reality in many units. However, there is no doubt that a PICU’s environment and design have a significant impact on levels of disturbance.” Looking at a graph focusing on patients in


PICUs in 2016, the speaker said most were suffering with a psychosis; i.e. mood-related psychoses and schizophrenia-like syndrome. Having been a PICU consultant for the past nine years, Dr Sethi said one of the most satisfying aspects of his work was ‘seeing things change’ for patients and their carers while they were in the units. There was ‘accumulating evidence’ – for example Health of the National Outcome Scales data – which showed ‘the change in people’s needs’ as they came into, and subsequently left, PICUs. Across all diagnostic categories, people improved in their health and social care needs, and were better able to cope with everyday life on leaving a PICU.


STAFF AND INTERVENTIONS Before moving to address the PICU ‘environment’, and the collaboration between NAPICU and DIMHN on the new design guidance, Dr Sethi discussed some of the staff PICU patients would come across, and the different interventions in this ‘dynamic environment’. In his women’s PICU, there were a large number of nursing staff working across a typical week, ‘outnumbering all the other MDT clinicians significantly’. He said: “There is lots of nursing and therapeutic engagement. Although medication is key, it is just one part of the whole system of clinical interventions. Often the way in which the medication is managed is more important than the medication itself.”


A VERY DIFFERENT APPROACH In a PICU, the psychological interventions and occupational therapy provided were different to those in acute and community settings. PICUs would also utilise some restrictive interventions when the risk/benefit considerations required them to do so, including psychiatric observations; administration of medication through injection (rapid tranquilisation); managing a PICU extra-care area, and ‘safe and therapeutic physical restraint and seclusion’.


The multidisciplinary team that patients typically encountered included consultant psychiatrists, junior doctors (psychiatrists), senior nurse clinicians and managers, the PICU nursing team, and PICU pharmacists, occupational therapists, and psychologists. Patients and carers were also likely to also encounter advocates, social workers, physiotherapists, exercise instructors, arts and music therapists, chaplaincy personnel, police liaison officers, security specialists, and forensic psychiatrists. Dr Sethi said: “There is a great deal of professional input that goes into a well- managed, fully functional, and efficacious PICU service.” There were also, he said, ‘so many things


that happen in a PICU that relate to design, planning, and space’, and how well the available space is actually used by staff, based on their skills and expertise. One of his current areas of interest is the environmental and design considerations for seclusion rooms. He said: “It’s not just about design and planning, but also about functionality, process, clinical profiles, and education and training. We are not simply locking a patient in a room and leaving them there for a number of hours; there are so many other things that go into making the experience therapeutic, and part of that is linked to the design debate around the seclusion suite.”


KEY CURRENT ISSUES Touching briefly on a few of the key current issues in the PICU arena, Dr Sethi said there was currently a major focus on restrictive interventions as part of the Department of Health’s ‘Positive & Safe’ programme, and around staff and patient experiences. Other current focuses included how the service interfaced with the criminal justice system, and ‘four-dimensional security’. He elaborated on the latter: “We are used to three dimensions of security – i.e. physical security, relational


‘The treatment given needed to be ‘patient-centred, multidisciplinary, and intensive’, and to have ‘an immediacy of response to critical clinical and risk situations’


goals, Dr Sethi explained that, having been in existence for 20 years, the Association’s aims included improving patient experience and outcomes; promoting staff support and development; improving the delivery of psychiatric intensive care and auditing its effectiveness; promoting research, education, and practice development, and providing best practice guidance in association with national bodies.


AMAZING MULTIDISCIPLINARY TEAM Since its formation the Association had established ‘an amazing multidisciplinary executive team’ – many there since its inception; expanded its membership; would stage its 21st national conference this year, had held over 75 quarterly meetings, and established a website, an academic journal, and two editions of the psychiatric intensive care textbook. NAPICU was also involved in many reviews on practice development, and had published national minimum standards in general adult psychiatric intensive care and CAMHS PICUs. It also had a healthy collaboration with the Royal College of Psychiatrists on AIMS-PICU, and, in the past two months, had published the first ever commissioning guidance on psychiatric intensive care in collaboration with NHSCC (NHS Clinical Commissioners). A number of the NAPICU executive provided


their expertise and input into national committees and networks, including for the Department of Health, and the association also undertook a lot of international liaison. Bringing matters up to date, Dr Sethi


explained that over the coming years NAPICU would be focusing on a few ‘critical areas’: looking to provide leadership and management training for aspiring nurse managers in psychiatric intensive care wards, and to develop postgraduate learning; further developing its journal; working on the next edition of its PICU textbook, and ‘going live’ with its new national survey (such a survey was last conducted over a decade ago). He added: “Most importantly, we have a joint workstream with the Design In Mental Health Network, which I am now going to talk about in more detail.”


EXISTING GUIDANCE Highlighting what guidance already existed on the planning, design, and construction, of PICUs, Dr Sethi said the 2016 NAPICU Guidelines for NHS Clinical Commissioners included only a couple of pages on the environment and physical factors, while of the more detailed 2014 National Minimum Standards for Psychiatric Intensive Care in General Adult Services, ‘about seven pages’ touched on the physical environment. He said: “It’s clearly much more complicated than that. We have a number of guidelines which are clinically or commissioning-focused, yet PICUs manage patients that could end up in low or


THE NE TWORK J u l y 2016 9


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