Hot Spots and Hot What’s in Sensory Modulation Interventions

Mental Health Units, Emergency Departments and other hospital and care environments are places where higher levels of aggression and frustration can occur. Within these environments there can be specific locations/areas which have an even greater concentration of aggression and frustration. These locations can be described as Hot Spots. (Gillespie et al 2018).   In the safe wards literature, the physical environment is one of six domains or categories of factors that can give rise to flashpoints, which have the capacity to trigger conflict and/or containment.  (Bowers, 2014).

This article will explore how to identify Hot Spots (and Hot What’s) and some solutions to address them.

To assist with identifying Hot Spots:

1.       Listen to lived experience reports and complaints of locations/areas on the units that have negative sensory or other aspects. Eg noisy scraping of chairs in kitchen,  loud alarm near nursing station.

2.       Use a map of the unit and mark any incidents on the map. Any area that contains a greater frequency of incidents is considered a Hot Spot (Cygnet 2024).

Once the Hot Spots are identified, the next step is to identify the Hot What’s – meaning what sensory or other input is problematic and resulting in the area becoming a Hot Spot.

Hot What’s can be identified by:

1.       Listening to lived experience reports and complaints of problematic sensations

2.       Completing a sensory audit of the Hot Spot/s, for example identify the sensory input of that place. Using the sensory audit ‘sensory input in mental health units’ might be a good starting point.

3.       Completing a sensory audit at the time or not long after the incident. Using the sensory audit tool ‘Sensory Factors in the home environment’ might be helpful.

Solving Hot Spots and Hot What’s:

After identifying the location of the Hot Spots and the Hot What input, it is important to then identify locally achievable solutions. Options to consider include -

1.       Change the sensory input (eg replace loud alarms with vibration alarms)

2.       Reduce the sensory input for the individual (eg supply sensory modulation items to reduce sensory input such as earplugs, personal scents* to mask other scents. ). Scent needs to be personalised and self applied/not diffused through public spaces. Refer to blog for more information:

3.       Support the individual to move away from the input (eg to go outside for a break, offer a different room or a different ward that does not contain the problematic input).

A similar process could be used in a range of different environments including schools, support facilities and housing/accommodation options.

Case Study

An outcome of training conducted by Sensory Modulation Brisbane for Cygnet Health Care in the UK  has been greater identification of Hot Spots. The Cygnet OTs were able to identify Hot Spots and then develop sensory modulation plans to change the sensory input or make other changes (eg move the person to another room or space). This process resulted in a significant decrease in  seclusion and restraint incidents.

 Definition

Hot What’s = Sensory Modulation Brisbane term to describe the sensory input that is present at hot spots.

 References

Bowers L. Safewards: a new model of conflict and containment on psychiatric wards. J Psychiatr Ment Health Nurs. 2014 Aug;21(6):499-508. doi: 10.1111/jpm.12129. Epub 2014 Feb 19. PMID: 24548312; PMCID: PMC4237187.

Cygnet 2024. Sensory Modulation Brisbane completed training at Cygnet and an outcome of this training was greater identification of hot spots. The Cygnet OTs identified hot spots and developed sensory modulation plans to change the sensory input or make other changes.

Gillespie A, Reader TW. Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind Spots in Quality and Safety. Milbank Q. 2018 Sep;96(3):530-567. doi: 10.1111/1468-0009.12338. PMID: 30203606; PMCID: PMC6131356.

Safe Wards: https://www.safewards.net/model/technical

Using your senses for self-care

Self-care is increasingly identified as a foundation for physical and mental health and wellbeing. It can be explained as self-directed activities a person engages in with the goal of moving towards a more optimal level of health. Self-care activities involve general daily living tasks (such as healthy eating, getting enough sleep and regular exercise) and can incorporate additional self-initiated activities that may be viewed as relaxing (yoga, meditation), pampering (massage, facial, movie) or a social outlet (date night, catching up with friends).

Self-care is important for everyone, but especially for those who:

·         experience heightened levels of stress

·         work in helping professions (such as health, welfare and education sectors)

·         care for others

Individuals who address their own self-care are better equipped to support other people in meeting their needs. Diminished opportunity or ability to prioritise self-care can contribute to higher levels of burnout and compassion fatigue.

Sensory modulation is the targeted use of sensory input (touch, taste, smell, sight, sound and movement) to change how you feel, and is a fast and highly effective way of addressing self-care. Sensory modulation can turn down stress and anxiety, reduce feelings of anger and overload, or increase feelings of calm, pleasure and safety, by either adding or turning down specific sensory input. In doing this, self-care needs can be better met. Everyone’s preferences are unique, so sensory input must be specific, appropriate, individualised and meaningful. For example, one person may find reclining on the sofa in a quiet corner with a good book the best self-care for them, while others might like to do a work out at the gym or catch up with friends at a bustling restaurant.

Sensory modulation can be used in a variety of ways to promote self-care. If incorporated into daily routines, people can strive for an optimal level of sensory input to help them feel more regulated and in control. At times of distress, sensory input can be used in that moment to reduce stress and turn down intense emotions. Engaging in sensory input/activities with other people can help all parties to self sooth and calm together. This is known as co-regulation and is a very effective way of supporting everyone to develop skills in self-care.

Ways sensory input can be used as part of a person’s daily routine:

·         Use your favourite smelling soap or shower gel when showering

·         Listen to preferred music while traveling to work or preparing dinner

·         Go for a walk during your lunch break to gain movement sensory input

·         Have pot plants, flowers or pictures in your home that you enjoy looking at

·         Add favourite flavours/herbs/spices into cooking

 Ways sensory input can be used in the moment to change feelings:

·         Use a cold washer over your eyes and holding your breath to evoke the dive reflex and turn down the stress response.

·         Stretch or tense and release muscle groups to provide deep pressure stimulation, to reduce agitation or anxiety and promote calm.

·         Chew something with an intense flavour (lemon, mint, spice, chili) to help shift intense feelings in the moment or assist with focus.

·         Smell a strong and scent (lavender, eucalyptus, cinnamon) to feel more grounded and connected.

·         Squeeze or fidget with something in your hands (stress ball, elastic band) to improve attention and maintain focus.

Ways sensory input can be used to co-regulate and promote ‘collective’ self-care:

·         Sensory boxes or spaces in the classroom for students to utilise provides opportunities for self-regulation. Encourage students to create their own sensory kits.

·         Classroom sensory ‘moments’ throughout the day to support learning, assist with focus and help with transitions to new learning and tasks.

·         Sensory informed activities in aged care or other diversional/ centre based group programs

·         Push a child on a swing, or swing next to them, or help them climb a wall, balance on a beam or similar in the playground.

·         Reading with a loved one on the sofa with a throw rug on your laps.

For more information on sensory modulation, strategies to promote self-care, co-regulation, sensory kits and sensory diets, see ‘The Sensory Modulation Resource Manual’, available at:

·         www.amazon.com

·         TES teacher resources at www.tes.com

·         bookstores.

Using a Safety Tool or Personal Safety Plan in Emergency Departments or Mental Health Inpatient Wards.

Safety Tools are being found to be very useful in emergency departments and on mental health inpatient wards, as they incorporate aspects of trauma informed care and also provide some options for using sensory modulation in the hospital environment.

Safety Tools are sometimes also known as personal safety plans. Many hospitals have their own versions, developed in collaboration with consumer consultants.

A safety tool includes;

Warning signs of anger or distress

• This section often includes internal sensations and also body language signals that others could observe.

Triggers

• This includes sensory and personal triggers. When discussing a safety plan with clients, it can be a safe way to identify triggers without needing to discuss the trauma.

• For example a client once said that she couldn’t stand the feel of metal. It was not necessary to re-traumatise her by asking why or what the event was, as this was not the focus of the inpatient unit. Instead clinicians were able to know that this was something that was best avoided so that she was not triggered.

Using our senses to calm and soothe

• This section can list the sensory modulation items or spaces available on an impatient unit. This is useful as it also is orientating clients to what is available.

• Clients can identify likes, dislikes or items that can be useful to calm them.

• Often the sections are divided into each sense.

• The options available on a ward need to be screened for safety considerations.

An example of a Personal Safety Plan is available in the Sensory Modulation Resource Manual.

Feedback on the Sensory Modulation Resource Manual from different professional groups

The Sensory Modulation Resource Manual was published earlier in 2018 as an ebook and paperback. We have been getting some feedback from different people and professional groups about what they find useful about the book. We have had feedback from Nurses, Teachers, Occupational Therapists, Parents, Architects, Dentists, Non-Government workers and many others.

Nurses:

Clinical Nurses in Mental Health are finding that the book provides useful resources for using sensory modulation to reduce seclusion and restraint in the inpatient unit. This includes information on designing different spaces or zones within the inpatient unit for different sensory input (sensory spaces), suggestions for equipment for the sensory spaces and a guide to getting starting in using sensory modulation with a client. In June 2018, the NSW government allocated $20 million to improve therapeutic environments within mental health units. The Sensory Modulation Resource Manual is a useful resource for this project. 

Teachers:

Teachers are reporting that the Sensory Modulation Resource Manual is useful in understanding the individual sensory preferences of the children in the classrooms and tailoring strategies to the individuals. The section on calming strategies has been popular, in particular using the playground for calming. High school teachers and Guidance Officers have liked the lists of strategies to improve focus, and decrease anxiety.

Occupational Therapists:

Mental Health OTs are benefitting from the resource section of the book eg handouts on sensory modulation,  sensory kits, self soothing and strategies for anger and agitation. New graduate and student OTs are reporting that the section on getting started with using Sensory Modulation as an intervention is very useful. Student OTs are the ones who are purchasing the ebook in the greatest numbers (this is the cheapest option) however other OTs are preferring the paperback version.

There are increasing numbers of OTs in the physical and paediatric areas who are finding Sensory Modulation is able to be applied to their area of practice.

Parents:

Parents of adolescents have been interested in the section on alternatives to self harm, developing sensory kits, substance use and understanding sensory seeking in adolescents. A number of parents are finding that their children are using weighted items and cold water to calm down.

Architects

Architects have been positive about the information on understanding sensory processing and the chapter on Sensational Spaces, and the impact that the environment has on changing how people are feeling.

Allied Health/Health Practitioners/Support Workers

The Sensory Modulation Resource Manual has been of interest to a wide range of people who work in the health field. This has included chiropractors, ophthalmologists, dieticians and dentists. Interest areas have included the information on the senses and sensory preferences, and strategies to assist the particular individuals that they are working with.

Sensory Modulation Resource Manual

E-book: available on Amazon

Paperback: available at bookstores including Barnes and Noble, Avid Reader, Book Depository, Amazon.

Reviews on Amazon:

"A fantastic resource and contribution to the field of sensory modulation and occupational therapy in mental health."

"Excellent practical book which brings together the neuroscience and strategies that work in practice!!"

 "This is an excellent resource for all teachers, counsellors and those in school leadership. It will open our eyes to adapting our enviornments to suit the diverse needs of learners."

Having a heavy dog sit on your lap can be calming!

Water can cool down a temper in the playground

Designing a sensory space - lots of ideas in the book