The Olive Carter Unit, a 10-bedded registered mental health hospital, is located at Christchurch Group’s Hunters Moor site in Birmingham. It is a specialist neurobehavioural unit caring for service users with complex presentations and needs (including those who are very distressed and displaying high levels of challenging behaviours) and service users who are detained under the Mental Health Act (1983).
To provide details of a service user’s individual needs, and tailored care plans which include how to support the service user when distressed and displaying behaviours that challenge, staff on this unit complete ABC (antecedent, behaviour and consequence) behaviour monitoring charts which record details relating to incidents such as duration, what was happening, as well as where and how the incident was managed. These charts and incident reports are reviewed by the home’s Psychology team. Recently, following a review of such data for one service user, Dr. Wheeler (Chartered Clinical Psychologist) postulated that the environment of his bedroom was too overwhelming and over stimulating, due to his heightened sensitivity to sensory information which is a common consequence of a brain injury. She wondered if the magnolia walls, neon lights, detailed posters, and large windows might be triggering his distress. Plans were made to make this space more therapeutic, in an effort to see if this would reduce the number of incidents and increase his well-being.
Redecorating was discussed with the service user, who expressed that he likes blues and greens and also nature such as trees. Consequently, duck egg blue was chosen for the walls and a pale grey for the ceiling and woodwork, to reduce the brightness and reflectiveness of his room which may have been causing him visual distress, especially when the lights were on. Decals/wall stickers of a tree silhouette were chosen to adhere to the service user’s love of nature and being outdoors whilst also being simplistic enough to not result in him being overstimulated.
The service user expressed much positivity for his new room, and he has appeared more relaxed and at ease in his space, which has resulted in a decrease in the number of incidents.
Having seen the impact of this environmental change for one service user, Christchurch Group Directors requested a wider review of the environment of the Olive Carter Unit. Dr Wheeler worked alongside her colleagues Nicky John and Dean Walker to present this review to other colleagues who worked in the 2 further units, who have expertise in other challenging neurological injuries and behaviours. The team researched the evidence base to learn more about best practice, attended care shows to look at new innovations, and also visited similar units to review their environments.
A decision was made to improve the following:
- Lighting – the neon spot and strip lights were too harsh to the eye, so adding dimmer switches enabled the glare from these lights to be softened.
- Furniture – as the previous furniture has proved to not be robust enough for the environment of this unit, and there was a frequent turnover of broken and damaged furniture, it was acknowledged that specialist weighted furniture was needed. The team also wanted something that was sleek and modern, so appealed to the young adult service users who typically reside on this unit. Robust furniture was introduced from a reputable supplier of furniture within environments that experience high levels of behaviours that challenge in the low stimulation colours of grey and black.
- Paint colours – it was recognised that the light was reflecting off the magnolia walls creating glare and associated visual distress. Other colours such as shades of white, are proved to be overwhelming for service users, who have perceptual processing difficulties as a result of a brain injury. This can lead to visual stress and incidents of behaviours that challenge. Dr Wheeler, with support from Honorary Assistant Psychologist, Hannah Allan, researched colour ways which are more supportive and therapeutic. Consequently, a pale grey wall colour was found to be best for corridors and as the main base colour in all rooms, along with a contrasting dark grey for the woodwork. Accent low stimulation colours of sage green, mineral blue, duck egg, pale yellow and slate grey were selected for feature walls in main rooms and bedrooms. As the bedrooms on the unit are all different sizes and shapes, with varying numbers of windows, the accent colour chosen for the feature wall depended upon the brightness of the room and what would be most therapeutic.
- Furnishings – Having painted the unit, suitable wall decals, were sought to enhance the environment. Much time and consideration was needed for this aspect to ensure that the overall environment remained low stimulation and conducive to feelings of safety and well-being. A number of suitable decals were found by the working party. These were then shown to staff, colleagues, and some service users, to gain their thoughts and opinions in order to finalise the choice and the locations of these decals. Some fern leaves and a photo tree were selected for corridors, whilst a plate and cutlery scene was added to the kitchen wall, and some plants in pots were chosen for the lounge.
- Clocks – Circadian rhythm disturbances have been frequently reported in people who are recovering from traumatic brain injury; this means that awareness of time of day/night is affected. To support with orientation, new clocks were purchased. This provision now enables staff to refer to these clocks in their interactions with service users, so as to help service users learn that such aids can help them know what the date is, what time it is, what happens on the unit at specific times, and timings of their individual sessions on their personal timetables. The clocks also feature day and night pictures to help reduce service users’ confusion.
- Bed linen – the working party selected some possible bed linen options which were light grey and, therefore, low stimulation and most supportive. These options were then shared with service users on the unit, so as to capture their preferences. There was a request for dark grey pillow cases and elasticated fitted sheets, so these were purchased to compliment the light grey bed linen. Pale grey anti-ligature blinds were also fitted in all rooms for safety.
Since the furniture has been in place and the unit has been painted, service users have continued to be very positive about how it feels to sit at the tables and use the chairs, as well as relax on the sofas. A very distressed service user (who exhibits high levels of challenging behaviours) now enjoys spending time moving between the chairs around the table, and reports finding the chairs comfortable to sit on. The beneficial changes to the communal lounge have resulted in this service user being more comfortable and relaxed in this setting, and staff can now sit and engage in long conversations of 30-40 minutes with this service user, which has never previously happened. An evaluation of the beneficial effects of making the unit environment more therapeutic is continuing through monitoring of the number of incidents, as well as capturing feedback from service users living on the unit and their families.