MENTAL HANDICAP VOL. 18 SEPTEMBER 1990

An evaluation of the effects of relocation within institutions Pam 2. Impiementation at Pmdhoe Hospital

Andy Wood Hugh Firth Rebecca Holtom

Invduntpry relocption within longany institutions has been common. Recent poky has led to the rapid contraction ofmany largehappitpls, withcxmsqmt disruptiontomany of the people livhg in them. Part 1 of this series reviewed the effects of invduntary

relocation. This second article describes the principles and procedures adopted at Pmdhoe Hobpitpl to minimise the adverse effects of such distprboaces 011 individuals. Personal reqmmbh ’ “ty by senior of€icers and carefully thought-througb procedpres enabled disruption to be Limited to the smpl)esf possibk number of people. People who demonstrated a reluctance to move were a h w e d to make some effective choices.

This article provides an account of the action taken at F’rudhoe hospital in order to relocate a large number of hospital residents and so reduce overcrowding. Research findings, and the guidelines described in Part I of this series (Holtom, Firth, and Wood, 1990), were considered. These were used whilst developing implementation procedures in the hope that any adverse effects of relocation might be minimised.

It was evident, from records of previous movement, that people with mental handicaps living at Prudhoe Hospital were often sub to relocation at very short notice. It seemed that ittle effort was made to reduce their concerns about moving during this stressful time. They were rarely given opportunities to make choices, for exam le, and few visits to their new wards were

relocation proposals themselves, their next of kin were rarely consulted in advance of such discussions. This casual approach to relocation has probably been

a common failing within large institutions for many years. It is only relatively recently, with the onset of themes in relation to normalisation, advocacy, and choice, that people living in such establishments have become more involved in their own life styles.

planned. b h en people were unable to comprehend any

Background In 1971, a national policy for hospital contraction was

mapped out in the White Paper Better Services for the Mentally Handicapped (DHSS, 1971). This document

advocated a reduction in reliance on hospital care for ople with mental handicaps. Since then, Prudhoe

f&qital has reduced its bed numbers from over 1,7W in 1971 to 809 in 1989. During this process, however, a great many people have had to undergo involuntary moves.

Recent .contraction, linked to the development of community care, made it necessary to close two wards at short notice in order to release funds for the regional Care in the Community programme. This caused considerable concern about the e f f d that relocation might have on the people involved. This concern led to two developments:

0 the establishment of a group within the hospital to consider ways of ameliomting the e R t s of wad c h u m on the msidents. This group, which held a number of open meetings involving both staff and people living at the hospital, reported to the Management Board which accepted most of its recommendations. These included. the need to plan moves months in advance; the need for individual pro amme plans

considered for a move; the need for an induction programme, to familiarise each of the people who were to move with their new wards; the need for training, for staff and residents, on the importance of relationship and how to maintain old connections and make new ties; the need to evaluate the effects of ward movement on each individual involved (which resulted in the appointment of a research worker to undertake the evaluation).

(IPPs) to be drawn up for ea J? person being

the establishment of a Task Team, involving the regional health authority and the community health council, to consider options to solve the overcrowding problem. Members of this team examined a wide variety of alternative ways of meeting the agreed definition of “minimum” standards, as set out in the Seere of State’s letter to Regional Health Board%etaries

ANDY WOOD is a Deputy Assistant Unit General Manager, Patient Services, HUGH FIRTH is a Top Grade Psychologist, and REBECCA HOLTOM is a Research Worker, all at h d h o e Hospital, Prudhoe, Northumberland, NE42 5NT.

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MENTAL HANDICAP VOL. 18 SEPTEMBER 1990

(DHSS, 1969). These standards, which had never previously been attained throughout the hospital included: 70 square feet of bed space per resident, 48

day space per resident, facilities in relation to

of residents, and adequate of personal possessions.

Continued movement of people within the hospital was clear1 inevitable, given the need for the hospital to close war& as individuals were gradually relocated in their local communities by their respective district health authorities and local authorities. Most large hos itals face the need for repeated movement of this

situation which &eloped in prudhoe Hospital was unusual, however, in that internal and external concern about overcrowdin led to the reopening of wards shortly after they hadkjeen closed. Although this circumstance may be pecuhar to F’rudhoe, the processes involved have a wider application.

kin a as part of the rocem of contraction. The particular

Planning the move Task Team members emphasised the need to

minimise the disruption caused to residents’ lives as a result of implementing the various options examined. Eventually, they recommended a solution which, although requiring 107 residents to move, allowed most eople to transfer in small groups, with only seven ge ing moved “singly”. The preferred option to reduce

overcrowding entailed reopening two wards and amal amating three pairs of semidetached wards

them). The Task Team report was received and accepted in

December 1988, by both Northumberland Health Authority and the Northern Regional Health Authority. A small group - comprising the District General Manager, Chairman of the Health Authority’s Visiting Panel, and a representative of the Community Health Council - met monthly to monitor progress at the hospital during the six months of implementation.

An Implementation Group was convened to expedite the Task Team’s work. It met weekly and comprised the Unit General Manager (as Chairman), the Assistant Unit General Manager (Patient Services), the Deputy Assistant Unit General Manager (Patient Services), and one sub-unit manager, clinical psychologist, consultant psychiatrist, and principal social worker. The Research Worker attended as an observer.

One officer, the Deputy Assistant Unit General Manager (Patient Services), was given responsibility for overseeing planning and implementation of the process h m day to day. He was responsible for detailed monitoring of arrangemeiits for preparing people for a move, for decisions about who should move, and for determining when moves should take place. He was accountable for this work directly to the Unit General Manager and the Implementation Group.

Nurses-in-charge were invited to meetings to discuss the Task Team’s report and its implications. Their sup rt and understanding was critical to the

meetings proved beneficial, giving nursing staff an o portunity to voice concerns and to question sections of

of the report’s contents for discussion with their ward staff.

(whic a did not involve moving the people living in

imp p” ementation of any recommendations. The

t R e report. They also gave them a fuller understanding

Implementing the move Use of research literature on relocation

At this same time the Research Worker was a re rt on the effects of relocating

ado ted for selecting those most suitable for a move (Ho P tom, Firth, and Wood, 1990).

The Im lementation Group accepted this report,

pre aration of people for the move, the environmental

certain individuals to ill effects resulting from relocation. With the latter point in mind it was decided to avoid moving people in the following categories if possible:

fina1isin5 vulnerab e peope p” and the criteria that should be

particulary r the need to pay attention to proper

qua s ity of their new abodes, and the vulnerability of

0 frail, elderly residents; 0 frail, physically ill residents of any age; 0 withdrawn residents with severe or profound

0 residents with additional blindness or deafness; 0 residents with depression or a psychotic illness; 0 residents who had been moved in the previous

0 residents due to move shortly to another

People who might be suitable to move were nominated by qualified nurses who knew them well, usually the nurse-in-charge of the ward in which they lived. Relevant information about each person nominated was recorded on a Profile Form similar to that shown in Figure 1. Three members of the Implementation Group then considered each person nominated in turn, in relation to the criteria for vulnerability. This filtering process was the first of several opportunities for people to withdraw, or be withdrawn, from the proposals.

Initially, 207 people were nominated. Of these, 45 were withdrawn at an early stage as, following the principles established from the literature review, they were considered to be unsuitable for transfer at the time. The most common reasons for their withdrawal were: frailty, self-injurious behaviour, tendencies to be withdrawn, recent moves from one ward to another, and imminent transfer to a community placement.

Nurses in charge were asked for further nominations to replace some of the people whom the Implementation Group considered unsuitable, which resulted in a list of 107 named individuals and a list of 34 reserves. Altogether, the proposed movement to eliminate overcrowding involved 26 of the 33 residential wards in the hospital.

How the move was made The first moves were intended to take place three

months after planning commenced. Small group and individual moves were staggered to take place throughout the following three months. Although dates of particular moves changed during this period, the overall timetable was adhered to.

The Unit General Manager wrote to all next of kin, including relatives of people who were not being moved themselves but who would be af€ected by other people moving in or out of their ward. The next of kin of the residents and reserves nominated to move were invited to an open meeting in the hospital, attended by representatives of the Implementation Group and members of Northumberland Community Health

handicaps;

two years;

placement.

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MENTAL HANDICAP VOL. 18 SEPTEMBER 1990

Council and League of Friends. Naturally, they expressed concern about the likely disruptive effects, and some were unhappy with the prospect of their relative being moved from what was considered to be a caring and pleasant environment %imply” to relieve overcrowding. However, during the course of the meeting most worries were dealt with and the next of kin were reassured that they would be kept informed about progress, as well as being involved in the procedure.

The next of kin were later invited individually by ward staff to attend the individual programme plan (IPP) meetings which were held for their relatives.

The careful introduction of people to their new wards was seen by the Implementation Team as crucial in avoiding, or at least minimising, any adverse physical or psychological effects resulting from the move. It was intended that residents would each receive at least three months’ induction before being transferred to a different ward. The Nurses-incharge planned visits for them - ranging from one hour to an extended weekend stay - to the wards to which it was proposed they would be moving. These plans were sent to Implementation Grou members on an induction programme form, one

the course of that month entries were made on the form to record how each visit had gone. At the end of the month the completed form was sent to the Implementation Grou , where the proposed plan was

asked to document the reasons for any discrepancies. The induction period provided a way for relatives and

nursing staffto spot any detrimental effects or concerns about the appropriateness of each person’s proposed move. During this time several residents showed behaviours which concerned ward staff and Implementation Group members, such as bouts of tearfulness, destruction of ward fittings, a reluctance to move between wards and, in some cases, a determined refusal to visit the proposed ward. Other residents stated verbally that they did not wish to move. In consequence, 16 people who indicated an unwillingness to move were taken off the list. The majority of induction programmes, however, went well. In some cases, residents were reluctant to return to their existin ward and, by virtue of their comments and

envisaged. Through a combination of much careful planning and

negotiation by the officer responsible for the moves, the number of people actually transferred from one ward to another was reduced to 89. Residents who had initially been identified to move but later taken off the movement list remained in their original homes. They were clearly quite happy to do so and did not show any visible signs of disappointment.

mont K before the move was due to take place. During

compared with actual 1 evelopments. Nursing staffwere

deman 3s , were transferred earlier than originally

Documentation and monitoring All ward staff were informed of the importance of

documenting every communication with next of kin and other interested parties in relation to the planned movement. All the residents involved had a movement file in which relevant data was kept. These files were held centrally by the Implementation Group and could be referred to by Group members as and when the need arose. The Group continued to meet weekly throughout the six months of planning and movement, and occasionally after this time to review the situation.

NOMINATION AND PROFILE FORM

Name of resident: ..................... Date of birth ........ Ward: ........

Nominated by: .......................... Date nominated: ......................

What was the reaction of the resident on being informed of the proposed move? ................................................................. .................................................................................................. Is the resident frail? Yes 0 No 0 Is the resident in good physical health? Yes 0 No 0 What is the resident’s degree of mental handicap?

Mild 0 Moderate 0 Severe Profound 0 Yes 0 No 0 Does the resident have a physical

handicap? If so, detail: ............................................................

Is the resident withdrawn, psychotic, depressed? Yes 0 No 0 What treatment is the resident receiving, if any? ................. ................................................................................................ Does the resident show any behaviours Yes 0 No 0 which could be described as anti-social or problematic? If so detail: ....................................................

Is the resident employed? Does the resident have links outside the hospital? Yes 0 No 0 Does the resident have any special Yes 0 No 0 friends and/or enemies? If so, please list: ...............................

.................................................................................................. Yes 0 No 0

Is there any community team involve- ment in connection with relocation of the

Yes No 0

resident? If so give details: ......................................................

FIGURE 1. Resident profile relating to possible relocation

Each person selected to move was provided with an individual programme plan prior to being given an individual induction programme. The hospital IPP forms were amended for this exercise by the addition of six set goals concerned with:

0 relationships; 0 choice; 0 involvement of resident, next of kin, and/or

0 development of each resident as an individual; 0 involvement in an induction programme to ease

Copies of completed IPP forms were sent to the Implementation Group as a means of monitoring people’s progress.

advocates in planning the move;

the proposed move.

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MENTAL HANDICAP VOL. 18 SEPTEMBER 1990

Looking at individuals in isolation is hazardous, and ignores the effects of grou dynamics. To enable nurses-

have a rough icture of the issues that would be most prevalent in tR e "new" wards, a "future" ward profile form was devised. This enabled managers to consider the likely range of age, abilities, sensory handicaps, and out-of-ward activities on each ward and was useful in selecting a suitable mix of residents for the wards before any moves took place.

A simple activity/employment timetable was devised and a copy was completed for each person. This was placed with the person's case notes on the ward to ensure that there was continuity in existing arrangements after the move.

Two weeks prior to any resident's proposed date of transfer, the movement file held by the Implementation Group was reviewed to ensure that all procedures had been properly implemented. If it was felt that the person concerned was not ready for transfer, the date of the move was postponed.

in-charge and members o P the Implementation Group to

Concluding comments This article has described the process of planning

moves between wards at Prudhoe Hospital in a way designed to avoid unnecessary disruption or hurt to the lives of the people involved. The actual effects of ward movement on the residents' health, behaviour, and satisfaction are still being evaluated by the Research Worker appointed for this purpose. A further article will describe the outcome of the actual moves and their effects on residents.

At this stage, however, some overall comments can be made. To some readers it may appear strange to devote so much attention to moves within a hospital, when most attention these days is focused on moves into community care. It is our belief, though, that the disruption that occurs within many large institutions as they contract or close is very considerable in extent. It is probably serious in its effects on many hospital residents who may be uprooted, perhaps repeatedly, in the process.

Having learned from its past mistakes, Prudhoe Hospital made a carefully considered and coherent attempt to minimise any adverse effects of internal relocation. Some people were protected entirely from disruption. Others were allowed not to move because their protests, verbal or non-verbal, were heeded.

A key element in the process was the personal responsibility taken by the Unit General Manager in ensuring the moves took place in accordance with the principles adopted. Individual day-to-day responsibility given to one senior officer was also essential in ensuring that implementation p r d e d as intended.

The principles and policies remain to guide good practice for future hospital contraction. It will not be possible to implement such change without some dama e, hurt, or disruption to some individuals.

Acknowledgements The authors acknowledge all Implementation Group

members for the work they put into developing the procedures, including: Ian Monaghan (Unit General Manager), Alan Jackson (Assistant Unit General Manager-Patient Services), Dr. Stephen Tyrer (Consultant Psychiatrist), and Dennis Gibson (Senior Social Worker). Thanks are also expressed to Martin Tosh, RNMH (Sub Unit Manager), particularly for the work he put into developing implementation procedures. Finally, grateful thanks to Debbie Maughan and Margaret Reed for typing the manuscript.

Hope a lly, it will be possible to minimise such effects.

REFERENCES Holtom, R., Firth, H., Wood, A. An evaluation of the

effects of relocation within inatitutions. Part 1. A review of reaearch - for whom is the risk greatest? Ment. Hand., 1990,18:2,60-63.

De artment of Health and Social Security. Better fewices or the Mentally Handicapped. Cmnd 4683. London: L O , 1971

Degartment of Health Ad Social Security. Secretary of tate's letter, 19 December 1969, to Regional Health Board Secretaries. London: DHSS, 1969.

Any correspondence should be addressed to Dr. Hugh Firth.

VIBRO-MEDICO: producer and supplier of vibro-tactile products for use with people with mental and physical handicaps.

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