Good Practice Guidelines for Using LTS with Autistic People
Research type
Research Study
Full title
Consensus Good Practice Guidelines for the use of Long Term Segregation for people with an Autism Spectrum Condition: A Delphi Study
IRAS ID
317686
Contact name
Ben Gilbey
Contact email
Sponsor organisation
University of Nottingham
Duration of Study in the UK
0 years, 4 months, 5 days
Research summary
People with autism spectrum conditions (ASC) are overrepresented in inpatient mental health settings (Tromans et al., 2018; Mandell et al., 2012). They are also more likely to be subject to restrictive interventions such as long-term segregation (LTS), which refers to a specific restrictive intervention that involves preventing a patient from freely mixing with other patients on the ward environment, in order to reduce risk to the patient or others (DoH, 2017). A recent Care Quality Commission (CQC, 2020) report highlighted the frequent poor practice that surrounds LTS for people with ASC. Patients were found to be left for prolonged periods without interaction or meaningful activities. Furthermore, 53 of the 66 people with an ASC that the CQC reviewed in depth were in LTS. Although NHS trusts have local guidance on the use of LTS based on legal frameworks such as the Human Rights ACT 1998, these often vary and are not informed by an understanding of the needs of patients with ASC. There is therefore a need to develop good practice guidelines for the use of LTS for patients with ASC.
The present study aims to develop a set of good practice guidelines for the use of LTS for patients with ASC. Delphi methodology will be used to gather expert opinion from multidisciplinary team and nursing staff, as well as carers on the use of LTS for patients with ASC. Participants will engage in an interview (round 1), which will ask them about their experiences of the use of LTS for people with ASC, what the key challenges are, and for recommendations regarding good practice. Second and third rounds will be used for participants to reflect on their responses and revise them to then produce a consensus.
Summary of study results
By consulting with Multidisciplinary Team (MDT) members with current experience of working with autistic people in LTS, the present study has generated guidance towards improving the quality of care autistic people receive in Assessment and Treatment Units (ATUs). The guidance produced highlights the importance of considering the immediate and wider organisational factors together when implementing an intervention such as LTS, so that LTS can be as therapeutic as possible and grounded in a person’s needs and human rights, when inpatient admission cannot be avoided. Our study provides an initial direction for clinicians and researchers on how to achieve this consistently, by producing a set of guidelines that address both immediate and wider factors around the implementation of LTS with autistic people.Some of the final guidelines endorsed by the panel reflected existing guidelines, such as those included in the Mental Health Act (MHA) Code of Practice, whereas other guidelines went further in specifying care decisions for autistic people when using Long Term Segregation (LTS). This seemed to reflect a tension between clinical judgement and the perceived need to uphold existing guidance. More specifically, the tension could be said to be between two solutions (ward environment vs. LTS), both of which seem far from ideal.
There was a split between guidelines that addressed the immediate use of LTS, and guidelines that focused more on the wider service setting around LTS and how that impacts the use of LTS with autistic people. Wider service setting issues highlighted by the guidelines included the need to ensure LTS is fully staffed, as well as ensuring regular reflective practice for staff specifically focused on the use of LTS with autistic people.The guidelines are applicable not only to MDT members working directly with autistic people in LTS, but staff working at other organisational levels. In particular, the guidelines within the Wider Service Setting section encourage staff who consult them to consider the systemic factors that have an influence on the capacity of an MDT to deliver good quality care for autistic people in LTS, such as the extent of the involvement of Healthcare Assistant (HCAs) in the planning of LTS use, appropriate training, and reflective practice. As such the guidelines provide commissioners with important recommendations on the kinds of support and resources that MDTs are likely to need to offer good care for autistic people in the context of LTS.
The guidelines go further in recommending specific considerations around good practice in using LTS with autistic people than parts of existing guidance (i.e. the MHA Code of Practice 1983), such as reflective practice and ensuring LTS is an engaging environment that is tailored to the individual. Furthermore, because the guidelines are derived from specific NHS contexts, they may have a face validity for MDTs that more decontextualised clinical guidelines lack. This “real-world” quality of the guidelines may enhance their clinical application.
Finally, the guidelines may help to improve how LTS is implemented with autistic people, by offering recommendations that encourage critical reflection on how LTS is being implemented by MDTs. It is hoped that the guidelines can function as a prompt to support MDTs to reflect on their own practice of LTS with autistic people, and increase the development of good practice in the use of LTS with autistic people.REC name
East Midlands - Derby Research Ethics Committee
REC reference
22/EM/0246
Date of REC Opinion
25 Nov 2022
REC opinion
Further Information Favourable Opinion