Carolyn Fitzgibbon 30/12/22 Carolyn Fitzgibbon 30/12/22

Therapy rooms and waiting rooms: designing for sensory needs

At Sensory Modulation Brisbane, we have been advocating for Universal Design in Mental Health Units for Sensory Sensitivities and we would recommend that this is expanded to therapy rooms, waiting rooms and all health care spaces.

Many people who attend Therapy practices have sensory processing patterns that are more sensitive, more avoiding, or more seeking or more missing of sensations than others and this can vary between different senses. This includes:

· Autistics have sensory processing differences recognised as a diagnostic criteria. (DSM5)

· People with PTSD often have reactivity and hypervigilance to certain sensations

· People with schizophrenia often have auditory processing and visual perception challenges.

· ADHDers frequently have sensory processing differences (Schulze 2020)

· A high percentage of people with mental illness have interoceptive difficulties

Therapy room with grey lounge, green cushions, a white blanket and a plant on a small table. We would remove the aromatherapy sticks though!

At Sensory Modulation Brisbane, we have been advocating for Universal Design in Mental Health Units for Sensory Sensitivities and we also recommend this for therapy rooms, waiting rooms and all health care spaces.

· Autistics have sensory processing differences recognised as a diagnostic criteria. (DSM5)

· People with PTSD often have reactivity and hypervigilance to certain sensations

· People with schizophrenia often have auditory processing and visual perception challenges.

· ADHDers frequently have sensory processing differences (Schulze 2020)

· A high percentage of people with mental illness have interoceptive difficulties

It can be useful to design for people with sensory sensitivities as it is easier to add sensory input if needed rather than take it away.

Lighting

· Ideally a dimmable light that is set at the preference level of an individual client

· Curtains or Blinds to block out light

· If there is a florescent light, turn it off and use lamps instead.

Sound

· Improving office acoustics can be very beneficial for everyone in terms of privacy and also reducing distractions and sensory sensitivities and overload.

· It is preferable to not use music in a waiting room environment as people who want music can usually access this on their phone.

Scent

· Scents can be a trauma trigger, allergy trigger or lead to sensory sensitivity and overload. So having a low scent therapy room and waiting room can be very important. For this reason, we do not recommend diffusers in public spaces.

· Sometimes it may be necessary to neutralise odours. Try nil odour drops.

Interoception needs

Sometimes therapy is the place where people relax a little and notice that they need to go to the toilet, drink some water or have some snacks. They may not have noticed these interoceptive needs earlier. Close proximity to toilets, water and food can be useful.

Comfortable Seating

There are many people in pain or who have hypermobility and are attending therapy offices. Comfortable seating can make a big difference.

Calming tools

At Sensory Modulation Brisbane, our favourite sensory tools for offices including a weighted cushion, a box of fidgets, icy water or ice packs and invitations to reduce the lighting or turn on or off the pink/brown/white noise machine.

Visual Movement

Ideally design waiting rooms so that there is not a lot of visual movement eg people walking past, traffic etc. Or provide options to be able to not face this visual movement.

Clear Pathways

It is useful for pathways to be clear and obvious and for signage to be clear. It can also be useful to take pictures of landmarks and have this available on website or new starter information .

Personal preferences

It can be useful to invite individuals to use their preferred fidgets, earplugs, sunglasses, back cushion etc so that they are comfortable

Nature

Access to nature can be calming. A plant or a picture of nature can be good additions to an office

Previous blog posts have discussed changing sensory input within a psychiatric hospital:

http://sensory-modulation-brisbane.com/sensory-modulation-blog/replace-the-torch-light-mental-health-unit-design

http://sensory-modulation-brisbane.com/sensory-modulation-blog/auditory-sensitivities-mental-health-unit

Training:

https://sensorymodulationbrisbane.ticketspice.com/sensory-modulation-using-a-sensory-lens-with-clients

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Marcel Schulze, Silke Lux, Alexandra Philipsen et al. Sensory Processing in Adult ADHD – A Systematic Review, 10 September 2020, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-71514/v1]
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://assets.researchsquare.com/files/rs-71514/v1/d616340b-9b38-4732-b56f-7c249e0632f7.pdf?c=1631855030

Sugiyama, S., et al(2021). The Auditory Steady-State Response: Electrophysiological Index for Sensory Processing Dysfunction in Psychiatric Disorders. Frontiers in psychiatry, 12, 644541.

Sensory Modulation Resource Manual

Carolyn Fitzgibbon 1/10/22 Carolyn Fitzgibbon 1/10/22

Using alternatives to torch light monitoring in Mental Health Unit Design

This blog will outline some of the challenges involved in using torch light to observe clients in mental health units at night and also provide some alternative options. Part of routine mental health care on mental health units is regular observations of people while they are sleeping/lying in bed. These routine observations are undertaken due to their perceived benefit in ensuring safety and wellbeing and to reduce the risk of suicide or severe harm. Nursing staff may need to complete observations up to 4 times per hour overnight and torch light is frequently used.

Veale et al (2019) researched the lived experience of these observations and found that these observations interrupted sleep through the torch light, sounds of staff opening and closing bedroom doors and staff talking to each other. People also reported that they found having somebody enter the room in the middle of the night intimidating and unsettling. For many people, this interruption can then make it difficult to return to sleep.

Improving sleep quality on mental health units is important to improve mental health and reduce suicide risk and decrease use of hypnotic medications. (Gardiner 2022) Improving sleep quality has been found to reduce aggressive incidents for psychiatric inpatients residing in secure facilities such as forensic psychiatric hospitals. (Van Veen et al 2020)

Alternatives to torch light that have been discussed have included remote monitoring systems, location trackers and video trackers. The majority of people found the remote monitoring systems acceptable (Veale et al 2019) but the location tracking and video monitoring have been identified as unsuitable due to privacy concerns. (Guardian, 2022)

Sensory Modulation Brisbane has identified the following remote monitoring systems as possible options to replace torch light observations:

At Sensory Modulation Brisbane, we are calling for Universal Design in Mental Health Units for Sensory Sensitivities and this would include replacing torch light observations. The rationale is that so many mental health diagnoses have people with sensory sensitivities. This would also assist Autistics who were on mental health units. People with other sensory processing preferences could also be catered for through adding in personally preferred input from a base of catering for sensory sensitivities.

Sensory Modulation Brisbane also has recorded an online course which includes information on the importance of changing the environment in healthcare settings: tinyurl.com/4yz7hb4k

https://sensorymodulationbrisbane.ticketspice.com/sensory-modulation-using-a-sensory-

lens-with-clients

#Universaldesigninmentalhealthunitssensorysensitivities #sensory #mental health #autistic #mentalhealth_community #schizophrenia #sensoryprocessingawareness #sensoryprocessingsensitivity #psychiatric #occupationaltherapy

More Information:

“This paper argues that intermittent nursing observations of in-patients at night do not reduce the risk of suicide or severe self-harm. Suicides between 23.00 h and 07.00 h are rare, and these overwhelmingly occur under intermittent observations. Such observation is purely a defensive intervention to document that a patient is safe at a particular time, as there is no engagement. For the large majority of in-patients, it has the unintended consequence of causing sleep deprivation. The intervention may cause harm to in-patients by making their disorder worse and increase their risk during the day. If patients are judged to be at immediate risk, then they should be placed on constant observation. If they are not, then optimising sleep is important for treating a psychiatric disorder and they should be placed on general observations.”

Veale D. Against the stream: intermittent nurse observations of in-patients at night serve no purpose and cause sleep deprivation. BJPsych Bull. 2019 Aug;43(4):174-176. doi: 10.1192/bjb.2018.116. Epub 2019 Feb 11. PMID: 30739621; PMCID: PMC6642991

“For psychiatric inpatients residing in secure facilities such as forensic psychiatric hospitals, worse sleep quality and higher insomnia scores significantly relate to aggression, hostility and violent incidents (Kamphuis et al., 2014). Thus, targeting inpatient sleep quality can help to reduce aggressive incidents in these populations, which is paramount to continued successful psychiatric treatment (Van Veen et al., 2020).”

Maaike M. Van Veen, Julie Karsten, Robbert-Jan Verkes & Marike Lancel (2020) Sleep quality is associated with aggression in forensic psychiatric patients, independent of general psychopathology, The Journal of Forensic Psychiatry & Psychology, 31:5, 699-713, DOI: 10.1080/14789949.2020.1785526

“A systematic search of the literature on the environment and nursing observations at night revealed few studies conducted on a psychiatric ward. A meta-analysis identifies the problems of sleep deprivation through noise on medical wards (DuBose & Hadi, 2016). There are also studies identifying that the large majority of psychiatric inpatients experience insomnia without focusing on the determinants”.

(Haynes, Parthasarathy, Kersh, & Bootzin, 2011; Horne, Hay, Watson, & Anderson, 2018; Keeley, 2010; Muller, Olschinski, Kundermann, & Cabanel, 2016). Improving sleep is important because sleep deprivation makes a psychiatric disorder worse (Krystal, 2012) and increases the risk of suicide (Malik et al., 2014).

“Importantly, sleep duration is negatively correlated with subsequent length of time in hospital (Langsrud, Vaaler, Kallestad, & Morken, 2016). The treatment of insomnia has been shown to lessen psychotic experiences (Freeman et al., 2017), mania, (Harvey et al., 2015), depression and anxiety (Ye et al., 2015).”

Veale, D., Sabriha, A., Pagageorgio, A., Gornay, K (2019) The psychiatric ward environment and nursing observations at night: A qualitative study VL - 27 DO - 10.1111/jpm.12583 JO -Journal of Psychiatric and Mental Health Nursing

“Another procedure of which all patients expressed an overall disapproval was the use of light during night observations. They reported being severely disturbed by the use of torches or by bedroom lights being turned on without warning.

“I probably didn’t really go to sleep. They kept coming in every 15 minutes. Sometimes they turn the florescent room lights on in the night, that’s horrible. They would turn the light on until I made some movement or showed I am ok. Sometimes they would use torches as well but better than lights being turned on. (Participant 1)

“Descriptions of night observations were always followed by a reference by the interviewee to the negative impact it had on their emotional state. In some patients, this contributed to a constant state of anxiety and a feeling of being unsettled.”

“The nurses try to use a lower voltage bulb in an attempt not to startle you. But when the room is dark to begin with any light looks so bright. (Participant 6) “

“Startling is when they come in and I see a silhouette, it really frightens me! (Participant 7)”

“At the end of each interview, participants were encouraged to provide their feedback regarding practices that might improve disturbances in night wards. Suggestions in respect to minimizing light disturbances included the use of night-vision glasses or a CCTV camera (only during night-time). Concerning the reduction of noise, suggestions included the following: installing floor coverings, using soft closing doors or applying foam to the doors to soundproof them. Recommendations for safety concerns included the installation of an alarm in the bedroom and for privacy concerns, neon gas windows which could be controlled by both staff members and patients.”

Barrera A, Gee C, Wood A, Gibson O, Bayley D, Geddes J. Introducing artificial intelligence in acute psychiatric inpatient care: qualitative study of its use to conduct nursing observations. Evid Based Ment Health. 2020 Feb;23(1):34-38. doi: 10.1136/ebmental-2019-300136. Erratum in: Evid Based Ment Health. 2021 May;24(2): PMID: 32046991; PMCID: PMC7034347.

Poppy May Gardiner, Florence-Emilie Kinnafick, Kieran C. Breen, Alessandra Girardi & Iuliana Hartescu (2022) Behavioural, medical & environmental interventions to improve sleep quality for mental health inpatients in secure settings: a systematic review & meta-analysis, The Journal of Forensic Psychiatry & Psychology, 33:5, 745-779, DOI: 10.1080/14789949.2022.2111320

https://www.tandfonline.com/doi/full/10.1080/14789949.2022.2111320

“NHS trust criticised over system that films mental health patients in their bedroom “ The Guardian, 2022 https://www.theguardian.com/society/2021/dec/13/nhs-trusts-urged-to-ditch-oxevision-system-covert-surveillance-mental-health-patients

https://www.nsw.gov.au/news/trial-of-pulse-monitoring-for-suicide-prevention

Experience of night environment on the ward survey https://onlinelibrary-wiley-com.ezproxy.library.uq.edu.au/doi/full/10.1111/jpm.12583

This survey may be useful to gather data for pre-post intervention changing the torch light

on the wards.

“The categories identified were used to develop a questionnaire to monitor the ward environment and impact of observations at night (Appendix 2). This could be used in a Quality Improvement Project to improve the quality of sleep on a ward. Ideally, the questionnaire would be used in conjunction with a light and decibel metre and measure of sleep quality to obtain more accurate estimations about the ward environment at night.”