Recovery Riders: a cycling project for patients in psychiatric intensive care

Introduction

Recovery Riders was a project that emerged from working with patients detained under the Mental Health Act 1983 who were receiving treatment in a male psychiatric intensive care unit at Scarisbrick Mental Health Inpatient Unit in Ormskirk. Based on an idea of ​​hope and well-being, the project has grown steadily: patients with different capabilities and complexity (in terms of diagnosis, treatment, risk and needs) now regularly undertake physical activity through bike rides. These rides are local and longer distance, supervised and unsupervised.

The project aimed to address the issues of stigma surrounding mental health through real and sustainable meaningful social participation. Reducing restrictive practices – often common in psychiatric intensive care units – and empowering patients were key drivers. It was also a real example of co-production. With a limited budget, a motivated nursing staff member made contacts with the local police, who in turn agreed to donate stolen but unclaimed bicycles to the unit. With the support of a local bicycle repair shop, these have been restored to usable condition.

Recovery Riders has been a greater success than could ever have been expected, with a fantastic response from some of our sickest and longer hospital patients reporting that they have gained a greater sense of meaning and purpose through regular community rides . Nursing staff noted a significant reduction in the use of historical restrictive practices, such as seclusion, restraint, and rapid sedation, after the start of the project. Many patients have successfully continued this journey after discharge thanks to the links made with local cycling groups as part of the project; these groups continue to support former patients on a voluntary basis.

Motivation for the project

Before the start of the project, it was determined that regular use of historical restrictive practices was common in the male psychiatric intensive care setting. Incidents of violence and aggression were higher than the national average and lengths of stay were increased, contributing to a negative patient experience.

Data analysis and triangulation of incidents indicated an overreliance on seclusion, restraint, and rapid sedation as interventions to manage challenging behavior, rather than alternative supportive and therapeutic interventions. Patients described the environment as loud and busy, often lacking coherence and daily structure. They described a sense of ‘stigmatisation’, often being isolated from local communities for long periods, which contributed to the fear and anxiety around redundancy.

Staff also reported a lack of confidence in using the least restrictive approaches, but were keen to create better collaboration with patients to effect change.

Goals

The objectives were:

• Reduce restrictive practices, such as seclusion, restraint and rapid sedation, by at least 30% in the first 12 months;
• Introduce more effective, sustainable means to support patients in crisis;
• Reducing incidents of self-harm, violence and aggression, and building coping capabilities through alternative therapeutic interventions;
• Reduce the stigma associated with admission to a safer environment, thereby increasing rehabilitation and social inclusion during the recovery period;
• Improve the patient experience and create more person-centered goals and ways for patients to interact with those around them;
• Improve staff morale and their reported sense of job satisfaction;
• Take advantage of staff’s hobbies and interests to make work a fun place, improving their ability to care.

Results

Many patients reported improved physical health – including weight loss, increased motivation and improved sleep patterns – and many have also been able to reduce required medication levels naturally thanks to the program. Discharges to the community have improved, with an improvement in the ongoing mental and physical well-being of former patients while at home. Involvement in similar activities continued even after discharge.

There was a significant reduction in the use of restrictive practices, which are embedded in practice: data shows that the use of seclusion in Lathom Ward has fallen by 90% – 60% more than the trust’s target. There has been a reportable 50-60% reduction in incidents of violence and aggression on the ward, and collaboration became commonplace, with staff working closely with patients. The department has celebrated extended periods without seclusion of ≥100 days on several occasions, and a business case is being submitted to close the seclusion area on the ward and convert it into a more meaningful therapeutic space. The length of stay for those on the ward decreased, and positive experiences of moving to acute units and an 80% reduction in readmissions show that recovery has continued.

“This initiative literally allowed people to escape the confines of a safe environment, creating a shift from a custodial approach to a culture change for both users and staff” Judges’ comments

A nurse-led initiative

This project was a co-production between nursing staff and patients, but was mainly led by the nursing team. Senior nurse, Oliver Field, and a healthcare worker, Dave Moss, love cycling and believed in the benefits it could bring to the patients in our care.

The nursing team initiated a quality improvement project looking at the current use of restrictive practices and arranged regular meetings with the patient group to plan the initiative. The nursing team contacted local organizations to gain their support and created a business case for the trust to explain the benefits of the project and the risk mitigation.

The nursing team continued to overcome obstacles and setbacks to ensure the project continued to move forward and patients met their goals. Challenges included: encouraging a positive risk culture; supporting others to overcome their fears; changing the cultural norm about what a psychiatric intensive care unit could and could not do; gain access to bicycles within a set budget; and working with external partners, such as bicycle shop Halfords, to have bicycles restored.

Plans for the future

The project was a greater success than expected, with local and organizational recognition. Plans include a rollout across the organization in Lancashire. It is also hoped that, with a patient and partner led approach and knowledge sharing, similar initiatives in other similar units and acute mental health settings can be helped to grow and become entrenched. Additionally, the results of the project have led to further review of restrictive practices on site and created a collective team passion to continue moving forward.

Looking at the data and feedback from service users, not only are there plans to expand and roll out the initiative, but there is also a strategic motivation to develop a ‘case for change’. This outlines a proposal to dismantle all containment areas in central and west Lancashire, led by our Nursing Advisor/Associate Director of Nursing together with modern matrons. If accepted by the board, this proposal would be the first nurse-led dismantling of its kind within the organization.

Conclusion

Recovery Riders was co-produced by the nursing team and patients held in psychiatric intensive care under the Mental Health Act, with the intention of encouraging positive risk taking, supporting mental and physical wellbeing and reducing the use of historical restrictive practices. Success was evidenced by reported patient experiences, fewer seclusions, rapid sedation, restraint, and length of stay; and continued involvement after discharge.