Longer-Term Psychiatric Inpatient Care for Adolescents

Front matter

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© — Longer-Term Psychiatric -~M Inpatient Care for g- Adolescents

A Multidisciplinary I Treatment Approach

Contents

Introduction Philip Hazell

The Physical Environment Stephen Ho and Steve Hoare

The Milieu Fran Nielsen, Ariel Diaz, Meng Du, Kahlia Pollock, Jaileen Alonzo, and Mark Rawlinson

CHAPTER 1 Philip Hazell

Abstract The purpose of this book is to describe the multidisciplinary model of care delivered by a long stay high severity psychiatric unit for adolescents. We acknowledge that many jurisdictions do not have the resources to establish a unit that fulfils such a specialized role within the system of mental health care. Nevertheless, we hope that the learnings derived from the unit may generalize to other specialist adolescent mental health inpatient settings.

Keywords Adolescent e Inpatients e Mental disorders e Length of stay e Patient care team

Mental disorders are the most prevalent illnesses in adolescence and have the potential to carry the greatest burden of illness (WHO, 2014) and stigma into adult life. Governments in higher income countries have responded to this challenge by allocating more resources for

P. Hazell (2) Walker Unit, Concord Centre for Mental Health, Concord, NSW, Australia

The University of Sydney, Sydney, NSW, Australia e-mail: Philip. Hazell@health.nsw.gov.au

© The Author(s) 2022 1 P. Hazell (ed.), Longer-Term Psychiatric Inpatient Care for Adolescents, https://doi.org/10.1007/978-981-19-1950-3_1 community-based and inpatient mental health treatment services directed to youth (Health Service Executive (Ireland), 2012; House of Commons Health Committee, 2014; National Mental Health Development Unit, 2009; NSW Health, 2011; Royal College of Psychiatrists, 2015). However, options remain limited for those young people with severe mental illness requiring secure inpatient care. Specialist child and adolescent mental health (CAMH) inpatient units are typically designed to provide shortterm care when the acute phase of a mental illness poses danger to the young person or the community. The aims are to assess and to stabilize the young person then discharge them to treatment in the community. Length of stay is usually measured in weeks rather than months (Hazell et al., 2016). Unfortunately, some young people experience either repeated or unremitting episodes of mental illness requiring longer periods of inpatient treatment. Delivering such treatment in an acute mental health unit is feasible, but it requires the diversion of already limited resources to develop a customized treatment plan in an environment that is not fit for purpose (Thompson et al., 2021). In addition, repeated exposure to newly admitted, acutely unwell patients, can destabilize young people with chronic mental illness. Owing to the limited number of specialist acute CAMH beds, a proportion of young people experiencing chronic or relapsing mental disorders are redirected to adult mental health inpatient facilities (Hazell et al., 2016; Wheatley et al., 2004). In recognition of this problem the Ministry of Health for the state of New South Wales (NSW), Australia in a draft planning document stated

To improve care for young people with significant impairment who require treatment in an inpatient setting due to continuing risk, two new additional specialist non-acute inpatient units will be established with state-wide roles and appropriate design and staffing arrangements for those who are still receiving involuntary treatment. NSW does not currently have specialised units of this type for young people. Care pathways to and from these units will be carefully considered and the allocations will need to factor access to families/carers and other community supports with appropriate accommodation options for visitors. (referenced in NSW Health, 2011)

Funding for the first of these units was announced in 2007, to be situated on the campus of a newly opened psychiatric hospital, and in close proximity to other CAMH services and a general hospital. After a planning phase of approximately 18 months, the unit opened in 2009. The purpose of this book is to describe the multidisciplinary model of care delivered by the

1 INTRODUCTION 3 unit. We acknowledge that many jurisdictions do not have the resources to establish a unit that fulfils such a specialized role within the system of care. Nevertheless, we hope that the learnings derived from the unit may generalize to other specialist CAMH inpatient settings. We are also mindful that longer stay inpatient care runs counter to the trend towards briefer hospital admissions within the context of a continuum of care (Blanz & Schmidt, 2000). We share the view that most young people experiencing mental health problems can be managed by community resources, augmented if necessary by brief admissions for crisis resolution. We do question how helpful such crisis admissions are, since the capacity to deliver therapeutic intervention is limited. For new patients such admissions may afford the clinical team time to arrange comprehensive community support. For a patient with a chronic or relapsing psychiatric condition this is no longer relevant. There is, as argued above, a subgroup of young people with serious mental disorders for whom a longer hospitalization is the optimal care.

The Walker Unit (named for nineteenth century NSW colonial politician, merchant banker and philanthropist Thomas Walker) was thus established as a specialist longer-term adolescent inpatient unit as part of the “phase of illness model of care” at the Concord Centre for Mental Health (CCMH). The “phase of illness model” delineates patient groups in order to target phase-specific treatments to improve patient outcomes. The Walker Unit is one of seven phase-specific mental health units at CCMH. Indications for the psychiatric hospitalization of children and adolescents include the need for intensive observation or investigation to inform diagnosis, to manage significant risk associated with a psychiatric condition or its treatment, or to manage medical complications of a psychiatric condition (Perkes et al., 2019). It was anticipated the reason for admission to the Walker Unit would mostly involve the management of risk arising from one or more of the following:

severe and unremitting psychotic disorders

severe and unremitting mood disorders

unremitting suicidality and dangerous deliberate self-harm behavioural disturbance arising from neuropsychiatric conditions such as autism pe Dopo j=

Chronic and unremitting eating disorder was also considered, but lack of sufficient medical support especially for children under the age of 16 has precluded the admission of patients who are physically compromised. In addition, treatment for severe eating disorder is available from statewide specialized inpatient units for adults and for young people operating from other hospitals in NSW. Young people with a history of criminal behaviour may be admitted to the Walker Unit, but there is a statewide juvenile forensic mental health inpatient facility operating from another location. Admission to the Walker Unit has, however, been used as a stepdown from forensic hospital and to facilitate progressive re-integration to the community.

Most patients admitted to the Walker Unit have had a substantial period of treatment in an acute inpatient setting. Some patients are received through inter-hospital transfer, while others are admitted during a time when they are living in the community. Most have a high level of risk of self-harm and/or harm to others. A history of prolonged school disengagement or school dysfunction is a feature common to most young people attending the programme. Many also experience a family history of mental illness and/or chronic dysfunction and interpersonal difficulties, which have served to precipitate and/or exacerbate the severity and persistence of the mental illness and associated problems. While it was anticipated most patients would be detained under the provisions of the NSW Mental Health Act, the experience of the unit during the period 2015 to 2020 was that this was the case for only a minority (28%). The five most common primary diagnoses in the period 2015-2020 were depression (37%), schizophrenia (16%), post-traumatic stress disorder (12%), autism (7%) and obsessive-compulsive disorder (7%). We are aware that using the primary diagnosis to describe a patient population has its limitations. We examined data from structured diagnostic interviews conducted on a subgroup of patients admitted in the period 2020-2021. When all concurrent diagnoses were considered, the most common psychopathologies were anxiety (27%), depression (23%), non-schizophrenic psychosis (10%) attention-deficit/hyperactivity disorder (10%) and oppositional defiant disorder (10%). The second set of diagnoses more accurately reflects the day to day work of the Walker Unit.

Treatment at the Walker Unit includes multimodal strategies. The longer length of admission at the Walker Unit enables pharmacotherapy to be carefully reviewed and optimized. Most young people are prescribed less psychotropic medication on discharge than at admission. The psychotherapeutic treatments include evidence-based and novel interventions delivered via individualized, group-based and family-based formats to assist in

1 INTRODUCTION 5 the development and recovery of the young person. Weekly family therapy is designed to promote the lasting change required within the family system in order to help the young person maintain their mental health post discharge. An admission to the Walker Unit involves several phases encompassing assessment, the establishment of a therapeutic alliance, defining therapeutic goals, implementation of treatment strategies, and finally, planning transfer of care to facilitate re-integration into community-based treatment. Education programmes delivered by the Walker Unit Learning Centre provide essential components of rehabilitation and restoration of developmental tasks.

The short to medium term goal of the Walker programme is a reduction or remission in the presenting symptoms. The longer term goal is to achieve a level of independent functioning in the young person that is consistent with their mental age. Coexisting physical conditions requiring medical monitoring or support are managed through consultation with the relevant subspecialty unit of the adjacent general hospital, or in some instances with the nearest paediatric hospital. All young people are discharged to stable accommodation, but in some cases not to the care of their families. All young people have an established educational or vocational pathway on discharge, although this may not be a return to the previous school of enrolment. The experience of the unit has been that young people who have a mental illness severe enough to require intensive longer stay inpatient treatment typically need the support of a special needs school or program.

The Walker Unit endeavours to tailor its programme to meet the particular needs of the young person. In the early phases of an admission, most young people reside in the unit seven days a week. As the admission progresses, patients are granted increasing amounts of leave off the ward including overnight leave, used as part of re-integration to home and education. Although length of stay varies, in the period 2015 to 2020, goals were achieved within six months for 64% of patients. Admissions extended beyond a year for 6% of patients owing to exceptional circumstances. Long admissions were avoided where possible because of the risk of institutionalization and disengagement with resources in the community.

In the chapters that follow, we will examine the physical environment of the unit, and the adaptations that have been made to ensure its functionality. We will consider the therapeutic milieu and the role played by multidisciplinary team members individually and collectively in its maintenance. We will describe clinical processes such as admission and discharge planning, formulation and case review. We will consider the specific roles of professionals including nurses, teachers, psychotherapists, psychologists, social workers, art therapists, music therapists, speech therapists, occupational therapists, dieticians, pharmacists and medical staff. We will describe the suite of therapies offered to patients. We will describe the steps taken to maintain and enhance the physical wellbeing of patients, including the optimization of pharmacotherapy. We will describe how the unit operates within the framework of the Mental Health Act. We will consider training and education. Finally, we will describe how the unit responded to challenges caused by the COVID-19 pandemic.

Acknowledgement Parisa Fani-Molky (medical student, The University of Sydney) assisted in the preparation of this chapter by retrieving descriptive data and standardized measures from the electronic medical records.

Blanz, B., & Schmidt, M. H. (2000). Preconditions and outcome of inpatient treatment in child and adolescent psychiatry. Journal of Child Psychology and Psychiatry, 41(6), 703-712.

Hazell, P., Sprague, T., & Sharpe, J. (2016). Psychiatric hospital treatment of children and adolescents in New South Wales, Australia: 12-year trends. BJPsych Open, 2(1), 1-5. https://doi.org/10.1192/bjpo.bp.115.000794

Health Service Executive (Ireland). (2012). Fourth annual child and adolescent mental health service report 2011-2012. http://www.hse.ie/eng/services/ Publications /services/Mentalhealth/camhs20112012annualreport.pdf.

House of Commons Health Committee. (2014). Children and adolescent's mental health and CAMHS. Third report of session 2014-2015 (Vol. 2015). House of Commons.

National Mental Health Development Unit. (2009). Working together to provide age-appropriate environments and services for mental health patients aged under 18. A briefing for commissioners of adult mental health services and child and adolescent mental health services. http://www.nmhdu.org.uk/silo/files/ publication-working-together-to-provide-ageappropriate-environmentsand-sces-.pdf

NSW Health. (2011). Children and Adolescents with Mental Health Problems Requiring Inpatient Care. PD2011_016. NSW Health.

Perkes, I. E., Birmaher, B., & Hazell, P. L. (2019). Indications for psychiatric hospitalization of children and adolescents. The Australian and New Zealand Journal of Psychiatry, 53(8), 729-731. https://doi.org/10.1177/000 4867419835930

1 INTRODUCTION 7

Royal College of Psychiatrists. (2015). Faculty report CAP/O1: Survey of in-patient admissions for children and young people with mental health problems. Royal College of Psychiatrists.

Thompson, A., Simmons, S., & Wolff, J. (2021). Nowhere to go: Providing quality Services for Children with Extended Hospitalizations on acute inpatient psychiatric units. Journal of the American Academy of Child and Adolescent Psychiatry, 60(3), 329-331. https://doi.org/10.1016/j.jaac.2020.09.009

Wheatley, M., Waine, J., Spence, K., & Hollin, C. R. (2004). Characteristics of 80 adolescents referred for secure inpatient care. Clinical Psychology and Psychotherapy, 11(2), 83-89.

WHO. (2014). Health for the World’s adolescents. A second chance in the second decade.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the chapter’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

CHAPTER 2 Stephen Ho and Steve Hoare

Abstract Many readers will have worked in facilities that were once stateof-the-art in design, but have become unfit for the purpose. Capacity to modify the physical environment of a psychiatric unit in response to changing clinical need or practice is essential. The Walker Unit differs from adolescent units at other locations because of its larger internal footprint and greater secure outdoor space. Substantive modifications to the Walker Unit over time have included requisitioning of space to create a learning centre, modification of some bedrooms to create a parent retreat, the establishment of a sensory room, and repurposing of the seclusion area to become a de-escalation suite. The chapter will describe the physical environment of the Walker Unit referenced to Australasian Health Facility Guidelines, and current best practice.

Keywords Adolescent e Inpatients e Health facilities

S. Ho ¢ S. Hoare (24) Walker Unit, Concord Centre for Mental Health, Concord, NSW, Australia e-mail: Stephen. Ho@health.nsw.gov.au; Steve. Hoare@health.nsw.gov.au

© The Author(s) 2022 9 P. Hazell (ed.), Longer-Term Psychiatric Inpatient Care for Adolescents, https://doi.org/10.1007/978-981-19-1950-3_2

10 Ss. HO AND S. HOARE

The Australian Health Facility Guidelines stipulate that inpatient mental health units for young people require “a conscious balancing of the requirement to provide an effective therapeutic environment for acute mentally ill young people with the need to provide them and their families’ visitors and staff with a pleasant, spacious light filled, comfortable and homely facility” (Australasian Health Infrastructure Alliance, 2016). Domestic style furnishings and décor should be homely not custodial, and in shared spaces should be movable to make adjustments for activities.

The environment should support the provision of safety and privacy of young people, allow for spaces where individual therapy can be conducted confidentially, group therapy and educational activities can be conducted for larger groups and recreational activities can be planned and undertaken. The environment should have capacity to offer smaller containing zones that can be used to separate young people experiencing distress, away from the wider patient group to prevent what Sergeant (2009) describes as the “Domino effect” where distress spreads among young people. These containing areas should enable distraction and sensory modulation activities to take place and reduce the noise created during distress from affecting the wider ward area. In situations where there is an event of behavioural disturbance such as aggression, the ability to move the wider group of patients to a different area where the programme can continue, reduces the need for physical restraint.

HISTORY

The public announcement that an adolescent unit would be established on the Concord Centre for Mental Health campus was made when the Centre was partially built (see Fig. 2.1). The ward allocated for this purpose was originally intended as an adult extended care unit. As such, considerable modification to the design was required from the outset to accommodate the needs of mentally unwell adolescents. Fortunately, some of these modifications were made while the original build was in progress. For example, the areas labelled “Arts and Crafts” and “Group Room” in Fig. 2.2 were redesigned to accommodate the Learning Centre, while the area labelled “Activities” became the Art Therapy space. Subsequent modifications have been made to respond to the need for structural improvement,

Fig. 2.1 Phase of build at the time the ward was repurposed from an adult extended stay unit to an adolescent high severity longer-stay unit repurposing of space, privacy, infection control, and Occupational Health and Safety (OH&S) concerns.

The responsibility for facility planning first rested with the health district’s Director of Child and Adolescent Mental Health Service (CAMHS), the nursing unit manager of an existing adjacent medium severity adolescent mental health unit, the principal of the school providing learning centre support to the unit, and the Mental Health Facility Planner. They worked from the floor plan illustrated in Fig. 2.2. The Director recalls the challenge of trying to imagine from the floor plan how the unit would look in real life, as 3-D imaging was not available to the team. After commissioning responsibility for facility planning, it was transferred to the unit’s newly appointed nursing unit manager and psychiatrist director, supported by the CAMHS and Mental Health Service executives.

12. S$. HO AND S. HOARE

Fig. 2.2 The Walker Unit floor plan at the time of commissioning

MODIFICATIONS

Since the Walker Unit opened in 2009, there has been extensive modification to address clinical risks and to ensure that the environment is both therapeutic and safe. The original fit out of the building posed a number of safety hazards. For example, fire extinguishers were placed in common areas, where they could have been used by an assaultive patient as weapons. Bedrooms contained items that could be misappropriated for self-harm, such as exposed metal screws in the light fittings and metal strips under the doors. Once identified these hazards were removed and replaced. As the clinical programme evolved, use of the available space within the unit changed. For example, the adoption of trauma informed care principles has altered greatly the way in which the seclusion area is used. Originally used for time out, and sometimes the emergency administration of medication, it now forms part of a suite of low stimulus options for young people who are emotionally and behaviourally not regulated.

A quality project as well as a needs analysis were conducted over a two year period from 2012-2014 incorporating physical environment, practices and policies through several Plan, Do, Study, Act (PDSA) cycles. An inventory and stocktake of what we had and what we required and wished for was discussed through several planning meetings. The design of several spaces such as the development of the parents retreat room and sensory spaces were envisaged and planned for future implementation.

Since the original building was completed, there have been a number of capital work adaptations:

1. Creation of a parent retreat room, including en-suite bathroom and overnight facilities such as a sofa-bed, within an accessible bedroom and en-suite.

2. Extending an interview room and creating a purpose built sensory room.

3. Changing a high secure bedroom into a quiet room and then into a staff resource room.

4. Adding secure doors to the main corridor and opening up two bedrooms to create the High acuity POD, which includes a bedroom, en-suite and living area that can be securely maintained as a containment area.

5. Creating a purpose built musical instrument store in the space where music therapy is undertaken.

DESCRIPTION OF CURRENT WARD PHYSICAL ENVIRONMENT

The Walker Unit is a large inpatient unit offering 11 bedrooms, 6 of which are located off a secure corridor, a number of lounge areas, three outdoor courtyards, a sensory room, art room and de-escalation suite all surrounding a central nursing office, secure kitchen and dining area. The unit contains a two-roomed Learning Centre, parent’s retreat room, and two interview rooms. Managing risk and supporting safety is a key feature of the physical environment. Safety checks are undertaken by staff before young people enter the unit to ensure an environment free from items that can be used to cause harm. Delaney et al. (2018) describe inpatient CAMHS units as providing an “aseptic” environment free from fixtures and furnishings that can be used for the purpose of self-harm; some of the modifications made at the Walker Unit are depicted below (Figs. 2.3, 2.4 l4 S.HO AND S. HOARE

‘Cupboards in room to ceiling

Reinforced covering of emergency lights} ee

Fig. 2.3 Adaptations made to improve safety and 2.5). All windows have thickened secure glass, all doors accessing the ward area have viewing windows to prevent young people absconding when doors open. A duress alarm system works throughout the unit spaces.

SEPARATING SPACES

The Walker Unit was designed so that it could function as two separate zones. When a young person needed a more secure space to support their safety and privacy away from other young people, it was common practice to move either the young person or the wider group into the other zone. However, when the second side was used to support an individual, access to some facilities was compromised. In 2021, capital works were undertaken to create a “High acuity POD”. This area can now be locked off from the rest of the unit, provide a living and dining space, bedroom and en-suite bathroom and securely contain a young person with lesser restrictions on space for the wider group. This POD space is located by the parent retreat room and has secure access to a courtyard. This space provides

Fig. 2.4 Adaptations to improve safety containment for acutely unwell young people on admission to the Walker Unit. When this space is not required for containment, it is kept open and offers a third lounge area and seating area that can be used to provide group or family therapy.

SINGLE BEDROOMS

Each young person has their own bedroom with shared single use bathrooms. Each bedroom contains a tamper-proof bed preventing a hiding place for contraband, fixed shelving, desk and bedside table and a magnetic locked cupboard. The bedrooms have blinds between the window panes so no curtains, which could provide ligature fixtures, are required. Six of the bedrooms are accessed via a secure corridor adjacent to the nursing station allowing for close observation. In the secure corridor, the bedroom doors are fitted with a window with integrated blinds that can be operated from the outside to enable regular checking on the young people’s wellbeing. Bedrooms in the secure corridor can have their doors l6 S.HOANDS. HOARE wii.

Bedroom cupboard doors modified f Li rr

Fig. 2.5 Adaptations to improve safety removed to prevent barricading by a young person who may attempt being unsafe. The use of single bedrooms and bathrooms allow for capacity to accommodate gender diverse young people without having to make obvious environmental adjustments, supporting both their needs and confidentiality. Young people are encouraged to bring in bedding and decorations from home to make their room feel homely and inviting. Bedrooms are locked during the hours of the therapy programme, but can be accessed on request as needed.

MULTIPURPOSE SPACES

The main lounge and dining area provides space for all young people and staff to eat meals, run group activities, hold community meetings and farewell events at discharge, and run school assemblies. It is within view of the nursing station. The other ward areas; interview rooms, art room, sensory room and de-escalation suite routinely are spaces used for individual therapy sessions, smaller family meetings or supporting individuals experiencing difficulties away from the busier area offering more privacy and reduced sensory stimulation.

OUTDOOR SPACES

There are three courtyards available at the Walker Unit, offering access to a trampoline, basketball rings, exercise bike, rowing machine and punching bag. One courtyard is specifically designed as a sensory garden, with musical instrument fixtures, artificial grass, water sprinklers, orange and lime trees and a sand pit (see Chap. 13). All the courtyards have modified designs that include anti-climb fencing and walls. Access to a courtyard is supervised by staff and duress sensors can detect alarms in these areas. As with the internal spaces, frequent environmental searches must take place in the courtyard to remove items that could be used to self-harm with such as broken glass or sharp objects. During the warmer months, each Friday lunch, the unit has a barbeque and all the staff and young people dine together outside.

STAFF PRESENCE AND AVAILABILITY

Engaging young people in meaningful activities, learning centre or programme activities, or relaxing and social recreational activities in the evening is central to being able to observe young people’s behaviour and the dynamics amongst the wider group so as to provide support or intervention when required. In a large space such as the Walker Unit, the ability to plan activities with young people and manage the space, so that staff can observe and engage does include the ability to close the space down and open spaces in a planned way to account for the needs of the young people.

Ir WE KneEw THEN WHat WE Know Now l. Outdoor space should be well maintained, plants and bushes trimmed to allow clear view underneath to prevent hiding of contraband items. Outdoor spaces should be well lit so they can be used in evenings when it becomes dark as a space to offer a variety of de-escalation activities.

18 se HO AND S. HOARE

2. Consider having spaces available that can be closed into more private, containing space, to be able to support young people in distress away from the wider unit population. Distressful noise can contribute to a cascade effect, disturbing other young people and triggering distress.

3. Have the capacity to close the wider areas of a unit down in the evening, as part of the night time routine and focus activities in fewer spaces.

The physical environment of an adolescent inpatient unit is a constantly changing one. Several modifications and improvements have been made to the Walker Unit to address risk and safety, which have necessitated in minor capital works and changing practices. The balance of being a therapeutic space versus safety and containment is always a challenge, however, just as young people learn from practical experience, so do the staff adapt with ongoing practical solutions.

Australasian Health Infrastructure Alliance. (2016). Australasian health facility guidelines. Part B- Health Facility Briefing and Planning. 0132-Child and Adolescent Mental Health Unit.

Delaney, K. R. (2018). Nursing in child psychiatric milieus: What nurses di: An update. Journal of Child č Adolescent Psychiatric Nursing, 201730), 201-208. https://doi.org/10.111/jcap.12204

Sergeant, A. (2009). Working within child and adolescent mental health inpatient services: A practitioners handbook. Quality Network for inpatient CAMHS. U.K.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the chapter’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

CHAPTER 3 Fran Nielsen, Ariel Diaz, Meng Du, Kahlia Pollock

Jaileen Alonzo, and Mark Rawlinson

Abstract Given the typical length of admission young people hospitalised at the Walker Unit may spend somewhere in the vicinity of 3—5% of their current lifespan living in the facility. It is imperative therefore that the admission affords the opportunity for engagement in a developmentally appropriate therapeutic programme, while at the same time maintaining safety. Patient mix, including phase of recovery, has an important impact on the ward milieu. Safety is maintained through observation and engagement. A level system the young people have helped design promotes and rewards skill development and prosocial behaviour. The chapter will describe the strategies the Walker Unit uses to maintain safety while at the same time addressing adolescent needs such as access to social media, interaction with peers, and sexual safety.

Keywords Adolescent e Inpatients e Aggression e Self-injurious behaviour e Atmosphere

F. Nielsen (%4) è A. Diaz ° M. Du ° K. Pollock è J. Alonzo e M. Rawlinson Walker Unit, Concord Centre for Mental Health, Concord, NSW, Australia e-mail: Fran. Nielsen@health.nsw.gov.au; Ariel. Diaz@health.nsw.gov.au; Meng. Du@health.nsw.gov.au; Kahlia.Pollock@health.nsw.gov.au; Jaileen.Alonzo@health.nsw.gov.au; Mark.Rawlinson@health.nsw.gov.au

© The Author(s) 2022 21 P. Hazell (ed.), Longer-Term Psychiatric Inpatient Care for Adolescents, https://doi.org/10.1007/978-981-19-1950-3_3

Central to the young person’s experience on a mental health ward is the milieu. This can be an integral aspect of their recovery and to be successful a therapeutic milieu needs to maintain the safety of both patients and staff (Baeza et al., 2013; Creed et al., 2021; Thibeault et al., 2010). The policies and practices are formulated to maximise the possibility of creating a therapeutic milieu. In turn, the milieu can have an impact on the young person’s behaviour and potential for recovery. One of our nurses has said, “An effective nursing environment has to have the capacity to ‘hold’ and guide the individual through the downs as well as identify the ups.”