Staff Injury Prevention within Mental
Intellectual Disability (MHAID) Services
Updated January 2019
Report prepared for:
Report prepared by:

Health

Addiction

and

Commissioner, Southern District Health Board
Heather Casey, Director of Nursing, MHAID

Executive summary
A significant programme of work has been underway since 2015 specifically focusing
on eliminating injuries to staff as a result of patient distress/aggression as MHAID
noted an increasing trend in the numbers of staff injuries. This work was formalised in
2016 when a joint union/MHAID steering group was formed, NZNO have been active
participants throughout but unfortunately PSA have never been able to attend.
Alongside of this a weekly/fortnightly (depending on need) meeting looks at all staff
injuries in detail and some ‘near misses’ to identify in a timely manner strategies that
could be utilised to prevent reoccurrence. Factors assessed are the physical
environment, staffing resources, the patient care planning and the nurse’s care and
ongoing support needs. This process is undertaken by the CNSs and is separate to the
line manager’s investigation into the incident.
Data is continually being looked at - analysed to identify relationships between acuity,
occupancy, staffing, verbal aggression, complaints etc. Reducing aggression within
services will also decrease patient injuries and incidents overall. The Safety for All
concept underpins many other activities in MHAID
 zero seclusion (3,4)
 safewards model of care including safety huddles and walkabout (RTC
infromed) (2)
 SPEC (de-escalation and restraint) (2,4, 10)
 increased use of NRT to minimise nicotine withdrawal (9)
 focusing on assessment period prior to admission (ED, Police),use of sensory
modulation activities and education around trauma informed care (TIC) (8,12)
 risk assessment and management tools and education (2,7)
 Increasing nursing leadership and staff numbers after hours (13,15)
There are many more projects that are linked but these are the main ones.
The areas we have been unable to progress are the use of security to support inapti4nt
units on the Wakari site and the changes required to physical environments to support
MOC changes (p.12)
The 2019 update is attached to provide more detail on the specific activities.

Staff Injury Prevention within Mental Health
Addiction and Intellectual Disability Services
Updated March 2019

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 No staff injury is the MHAIDs ultimate goal. This goal continues to drive our
work to eliminate staff injuries. This work has been ongoing over many years and
this paper updates in italics a report that was initially developed in 2016 and has
guided the direction of the work in MHAID to reach the goal of no staff injuries.
Incident reporting processes – all incidents are investigated by charge nurse
managers as per organisational wide Safety 1st processes.

Due to the increasing concern at the number and extent of staff injuries occurring
particularly within the inpatient MHAID services, the following activities have been
undertaken and continue to progress to minimise the potential for or eliminate
staff being injured as a result of patient aggression.

1. A

weekly
meeting
is
established
involving
clinical
nurse
specialists/Occupational Health and Safety to investigate circumstances
and support injured staff. The aim of this in depth exploration is to prevent
staff injuries occurring and to ensure that staff who were injured were
supported in an ongoing way. The injury incident review focuses on patient
care prior and surrounding the incident, the physical environment, the
resources available, the staff actions and training and education needs to
identify anything that could have been done differently to prevent injury
occurring.

January 2018 update. On-going – the function of this group and ToR have
been reviewed to ensure meeting is making a difference. Meeting now
occurs two weekly as opposed to weekly due to decrease in staff injuries.
If need arises for weekly meetings in terms of timeliness of response then
frequency will be increased.
January 2019 update. Ongoing. Meeting frequency changes to
meet needs. Constantly reviewing effectiveness of this meeting
however continue on as timeliness and comprehensive review of
each situation is helpful in preventing further incidents and
identifying learnings.

1. A resource to provide information for staff on workplace aggression was
released in 2014
January 2018 update.
This is reviewed and updated as new
research/resources become available.
January 2019 update. As above. It is helpful having an
occupational health and safety representative as part of the
weekly/fortnightly group due to their knowledge of changes to
legislation and resources.

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Addiction and Intellectual Disability Services
Updated March 2019

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 2. The Safewards model was formally launched in November 2015 but
Safeward interventions commenced in 2014. The focus of the Safewards
model is safer wards for patient and staff.
January 2018 update. Rollout of interventions continues, currently an
auditing programme in place to ensure consistency and effectiveness.
Part of relevant training modules including Safe Practice Effective
Communication (SPEC).
January 2019 update. Safewards continues to be the model used
by all inpatient areas. The main areas where progress has been
made is developing the use of a risk identification tool (DASA), deescalation training (SPEC), in the last two years 85% of staff have
undertaken this national training, the use of community meetings
to listen to and respond to feedback and identify expectations of
all in a ward environment.

3. Te Pou, New Zealand’s organisation for mental health research and
workforce development, recommended that the seclusion and restraint
programme known as the ‘Six Core Strategies’ (National Association of
State Mental Health Directors (NASMHPD, 2006) be utilised within New
Zealand’s Mental Health Services.
January 2018 update In MHAID reducing restraint and seclusion work has
been ongoing using the Six Core Strategies framework.
The six core strategies all have leads and bodies of work they are
undertaking.

Strategies include: Strategy One- Leadership towards

organisational change, Strategy Two- Using data to inform practice,
Strategy Three- Workforce Development, Strategy Four- Use of seclusion
and restraint reduction tools, Strategy Five- Service user/consumer roles in
inpatient units, and Strategy Six- Debriefing techniques.
January 2019 update. The HQSC reducing restrictive interventions
– zero seclusion work has superseded the 6 core strategy
framework.

It is important to note here that the aim is toward

elimination and this is the focus of the work.
areas

being

withdrawal,

tested
the

use

at
of

the

moment

medication

are
prior

Some of the key

managing
to

nicotine

admission,

the

appropriateness of admitting people who are intoxicated to an
acute MH facility. The link between zero seclusion and staff injury
is the level of distress/aggression people present with often
results in restraint and seclusion and this is the time the majority
of staff injuries occur. Staff injury is usually a result of to patient
aggression.
4.

There is a positive link between reducing restraint and seclusion and
decreasing the number of injuries that occur as a result of patient
aggression and during the use of restraint and seclusion.

Staff Injury Prevention within Mental Health
Addiction and Intellectual Disability Services
Updated March 2019

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 January 2018 update. Overall the decreasing trend continues in the use of
seclusion however increased periods of seclusion correspond with increased
occupancy and overcrowding. All types of incidents increase during these periods
including staff injuries. Nationally an issue but locally a bed management project
was completed to assist in managing peaks in demand.
January 2019 update. The bed management project was completed and
despite some good outcomes being implemented there are still
sustained periods of bed usage/overcapacity.

5. A workshop was held in 2014 with multi-disciplinary team members to
ensure all were aware of the extent of staff injuries and also to brainstorm
what more we could be doing as a service to prevent staff injuries
occurring.
January 2018 update. A health and safety manager was employed in
2016(Glen) who was experienced using a cause and effect methodology
which we have referred to as ‘Bow tie’’. Another workshop was held to
identify if there was more we could be doing to prevent staff injuries. A
Violence Aggression Action Plan was developed from this workshop which
we have steadily been working through.
Actions are all nearing
completion.
January 2019 update.
Actions are all compete except the
contribution of organisational security services to assist. This now
sits with security in their 2019/20 budget considerations.
A
significant risk for the organisation as not consistent with other
hospital sites in Southern or nationally.

6. A steering group was developed involving unions, occupational health and
MHAID leadership to progress themes that emerged from the workshop.
January 2018 update. On-going – meet 2 monthly, some of the key
achievements have been review of all policies, addition of other relevant
policies, and development of a resource identifying Personal Protective
Equipment (PPE) that could be used, review of alarm systems, agreement
with unions that if PPE or alarms are provided they must be used by staff.
There are duress alarms in clinical areas and some areas also have
cameras in place.
Designated parking for shift workers close to building has been put in
place. MHAID reception areas were also reviewed following the WINZ
incident. A Lone Worker app has been trialled and is progressively being
rolled out to staff working in the community. All community based teams
have systems in place to account for staff at the end of the working day.
January 2019 update. Ongoing – it is invaluable having all multiple
perspectives – unions, consumer’s families, having oversight and
also being part of the problem solving.

7. The Dynamic Appraisal of Situational Aggression (DASA) is a risk
assessment tool that predicts the likelihood of aggression over a very short

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Addiction and Intellectual Disability Services
Updated March 2019

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 time period (24hrs). The DASA tool has been introduced to inpatient units
to focus on individualised risk assessment of aggression to others.
January 2018 update. Implemented in all relevant areas. DASA is a
prediction tool – currently we are looking at ways in which this information
could be utilised with a preventative focus.
January 2019 update. Ongoing as previously described, as more
information and research becomes available we are updating our
knowledge and training. Risk assessment and management is
always changing and developing in line with latest research.

8. Sensory modulation (assessment and interventions) are established within
all inpatient services.
January 2018 update. On-going, focus now on use of Sensory Modulation
in the community setting, i.e. the use of weighted dog in EPS recently
helped the person to decrease anxiety about admission as they took the
dog with them. A simple but effective intervention.
January 2019 update.
Ongoing, ED now have sensory packs
available to support people to manage their anxiety and distress
associated with the assessment process.

9. There are more assertive interventions prior to someone being admitted to
hospital. People will be medicated earlier in the assessment period rather
than waiting until someone is admitted to hospital. This action has made a
significant impact on the levels of aggression when people are admitted,
the need for restraint and seclusion.
January 2018 update. On-going with constant review to identify new
opportunities to intervene early
January 2019 update. Still a work in progress. Use of NRT early to
support people with nicotine withdrawal is the latest focus.
10. All staff are trained and revalidated annually in restraint techniques, have
de-escalation, and risks assessment and management training.
January 2018 update. A major area of change. Safe Practice Effective
Communication (SPEC) is a national de-escalation programme being rolled
out. A significant undertaking - a four day course occurring approximately
every two weeks to get all staff within Inpatient and Crisis services
through. To date approximately 230 across the district have attended this
training. Positive feedback on the theory and skills taught.
All MHAID staff undertake orientation and regular mandatory training.
January 2019 – ongoing – now BAU
11. All staff have access to regular professional supervision (not line
management supervision).
January 2018 update. On-going.
January 2019 – ongoing
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Addiction and Intellectual Disability Services
Updated March 2019

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 12. Trauma informed care principles are starting to underpin all education and
training provided in the service.
January 2018 update. On-going – part of all training developed including
SPEC
January 2019 ongoing within MHAID. Education is being provided
to ED and police to ensure a good understanding of the impact of
previous trauma to a person’s current presentation and strategies
to recue distress.

13. Occupancy levels within inpatient services are monitored daily and beds
are seen as districtwide to mitigate risks associated with overcrowded
ward environments.
January 2018 update. Although work is on-going in this area and a bed
management report completed this area remains a significant challenge
and when demand exceeds resourced beds and staffing resources higher
incident rates occur. This is a national issue but locally remedies still being
sought. Occupancy of 85% is regarded as best practice to support patient
flow in and out of acute mental health inpatient units.
Note MH compulsory assessment and treatment legislation means we
don’t have choices about limiting or delaying admissions to hospital.
January 2019 – ongoing – note introduction of afterhours nursing
leadership as part of safe staffing.

14. Restraint practices have changed over the years to ensure best practice
for patient care and also to accommodate the imitations that exist because
of our aging workforce.
A national programme is being developed.
Aspects of this programme are informed by the changes southern DHB has
made. MHAID are in process of adapting current training to meet national
programme requirements.
January 2018 update. As above when discussing SPEC.
January 2019 – ongoing – now BAU

15. Roster skill mix changes occur as a result of patient demographic changes
i.e. changes to Intellectual Disability Legislation. Ward 10a is changing
skill mix from untrained to trained Enrolled nurses from 2016/17 budget
year.
January 2018 update. Changes occurring as planned. EN orientation
package has been developed across the service to accommodate this
group of recently graduated ENs.

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Addiction and Intellectual Disability Services
Updated March 2019

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 Data reporting processes.
Context
The majority of MH injuries from assault are a result of inpatients actions. The
main areas that generate staff injuries are the intellectual disability ward where
patients are admitted because of their ‘challenging behaviour’. They often don’t
have language to describe what is happening to them and are sometimes deaf
and/or blind and severely intellectually disabled.
The forensic service admit patients because of their mental illness, the
combination of mental illness, addictions and criminal behaviours are a challenge
to manage in all environments.
Other areas are our intensive care ward (MH) – patients are admitted because
they are a high risk to themselves or others and they have acute mental illness.
Injuries can occur as a result of attempting to protect the patient from harming
themselves or other people.
Reporting processes do not specifically identify injuries due to patient aggression
in a clear and consistent manner. The graph below indicates all staff injuries were
decreasing in 2014 and this was promising however staff continued to be injured.

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Addiction and Intellectual Disability Services
Updated March 2019

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 

Assault can mean – verbal or physical and for the purposes of reporting in
the incident system this can range from verbal abuse, spitting,
inappropriate behaviour, throwing items, hair pulling, scratching, biting to
pushing, and punching plus restraint type injuries.



Due to requirements all assaults are reported but sometimes no harm
comes from them.



Some of these incidents involve elderly, who can be often confused or
demented in the hospital setting, and intellectually disabled people who
have communication difficulties. Therefore this context should be factored
into the overall number of assaults.

Staff events resulting in injuries
The most recent data is an attempt to limit reporting to actual staff injuries
caused through patient aggression. Many of the mental health incidents relate to

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Addiction and Intellectual Disability Services
Updated March 2019

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 the same patient. In context, this means that there are a very small proportion of
unwell people causing injuries to staff.

2015/17

Note the peak in March to May – this corresponded with sutained period
of over occcupancy on the acute/intesive care wards.
2018 udpated graph

Staff Injury Prevention within Mental Health
Addiction and Intellectual Disability Services
Updated March 2019

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 Staff Injury Prevention within Mental Health
Addiction and Intellectual Disability Services
Updated March 2019

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 2018 updated graph

Note the maked variation month to month. This is mainly due to individual
paitents. Scratching is more likely to occur within Ward 6c, Mental Health Older
Persons, during physical cares and bites are more likely to occur within the ID
services when epople are acutly distrubed.

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Addiction and Intellectual Disability Services
Updated March 2019

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 Summary
Staff injury numbers continue to fluctuate and although in 2014 we were seeing
an overall decrease in total injuries the most recent data shows the trend
increasing again and significnat variation in number of injuries per month. This is
often more to do with individual patients rather than an icreasing level of
aggression within services.
The number of staff injury events reported does not provide any detail aorund
severity or impact of injuries. Anecdotely although numbers have increased
severity and impact have decreased. There is a link in the literature to reducing
restraint and seclusion and decreasing numbers of staff injuries.
January 2018 update
Although overall we are seeing a steady decrease the month to month variation is
concerning. A recent piece of work looked at the issue of seclusion as an
intervention and the relationship to the number of admissions, overcrowding,
acuity, and staff injury.
There is a positive correlation between the increase in admissions and the flow-on
with an increase in occupancy / overcrowding, both steadily rising over the past 3
years.
In the context of this, seclusion rates have reduced steadily despite some
variability.
There is a weak correlation between the peaks in seclusion events and overall
acuity, and acuity has certainly increased over the past 3 years in line with
occupancy and number of admissions.
It is noted that reports of staff injury tend to increase when seclusion events are
high. We plan to look at this information in more detail this year.

Many of the strategies are ongoing however 2018 will see the following
progressed.
1. 24/7 Security presence at Wakari Hospital and as required within wards to
assist with episodes of aggression. A joint paper from MHAID and Building
and Property will be presented to the Executive in February recommending
and increased presence 24 hours a day, seven days a week on the Wakari
site.
2019 progress. As previously stated. BC for security input is now
with security. An additional 4.9 FTE MHAs have been employed
for the Wakari site and are currently being orientated.

2. Physical layout of ward 9b will be prioritised as model of care changes are
occurring. Alternative spaces need to be available to enable a range of
restrictive practices to be reduced.
2019 progress. Part of wider hospital and MH service
redevelopment. Not a quick fix.
3. Reducing restraint, the focus to date has been on reducing seclusion and
as we make progress with this target we are also focusing on reducing
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Addiction and Intellectual Disability Services
Updated March 2019

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 restraint as a number of staff injuries occur during the process of
restraining someone.

4. HQSC. One of the priority areas for this programme is recusing the use of
restraint and seclusion, so new methodology will assist. It is pleasing to
see a reduction in seclusion events, and the number of people secluded in
context of these challenges. It is noted that reports of staff injury tend
increase when seclusion events are high. We plan to look at this
information in more detail this year.
2019 progress

January 2019 update
Work continues looking at the relationship between staff injuries and
use of seclusion. There is not a conclusive correlation but our working
hypothesis is that during the process of restraint and placing people
within a seclusion facility staff are more likely to receive injuries.
5. Staffing – The 2018/19 budget process will include additional staffing is
being sought to assist with increased demand.
2019 progress. The budget process didn’t result in additional
staffing but the safe staffing agreement in the NZNO MECA did.
6.9 FTE – all but 1.FTE has been used to support inpatient services
or sites with inpatient services.

6. Bed management is ongoing and 2018 will see roll out of some new
initiatives. The organisational restructure will assist as there is now one
manager across MHAID system, for example, currently NGOs will not
accept people who are incontinent and they remain in inpatient beds.
Incontinence is very much a characteristic of our aging population of
people with enduring mental illness, so plans are in place to ensure
contracts accommodate this need. The subsequent flow of patients
through the system will assist with acute inpatient bed management.
2019 progress. Ongoing, challenges remain, the appointment of 2
people (1 FTE) to undertake the afterhours nursing leadership will
assist with bed demand after hours. There roles are part of the
safe staffing fTE and have just commenced.
7. The area not covered in this report is the support staff receive when they
are injured as the focus of this reporting has been what we are doing to
prevent staff injuries. This has been another aspect of the work involving
the police, ED and developing our own in house model of support (like
debriefing but contemporary).
2019 Progress. ED flow chart to decrease wait times for staff who
have been injured is complete. Two recent complaints to police
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Addiction and Intellectual Disability Services
Updated March 2019

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 post assault have not result in charges being laid – we are
currently addressing these issues with Police. Manners model is
being implemented into MH

8. We remain very concerned about the condition and layout of the inpatient
wards on the Wakari site. These for the most part are original 1990s
condition and do not support the delivery of safe (for patients and staff)
contemporary acute and sub-acute mental health care. A paper on the
current state was submitted to the Executive in late 2017.

The MHAID Directorate Leadership Team would be happy to meet with the
Commissioners to discuss any aspect of this paper.

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Addiction and Intellectual Disability Services
Updated March 2019

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