Blog: REsTRAIN YOURSELF - Implementing a restraint reduction approach in mental health - Paul Greenwood

After a fantastic final event last month for the close of The Health Foundation funded REsTRAIN YOURSELF project, I felt it was a great opportunity to share with you some of my thoughts from working on programme.

The aim of REsTRAIN YOURSELF was to reduce physical restraint in mental health inpatient settings through an evidence-based approach.

Despite only meant as a ‘last resort’, physical restraint is a coercive intervention that is commonly used in mental health services. There have been increasing serious concerns over a number of years about its overuse and significant adverse effects on patients.

Over the course of this two-year programme, I’ve had the chance to work closely with a number of teams in ward environments across the North West, to offer training and support the implementation of the restraint reduction approach.

Members who have participated in the programme include:

• 5 Boroughs Partnership NHS Foundation Trust
• Cheshire and Wirral Partnership NHS Foundation Trust
• Cumbria Partnership NHS Foundation Trust
• Lancashire Care NHS Foundation Trust
• Manchester Mental Health and Social Care NHS Trust
• Mersey Care NHS Foundation Trust
• Pennine Care Foundation Trust

Having the opportunity to work alongside staff has been such a positive fulfilling experience. Having spent a number of years as a mental health nurse myself, it wasn’t easy for me to stand back and observe things on extremely busy acute mental health wards; especially when the nurse in me wants to help and get involve

From this work over the past two years we now have a strong body of evidence on restraint reductions, and here are some of my findings:

Teams

The teams faced many challenges to enable change to occur: from juggling with staffing levels, high levels of acutely unwell patients, and always struggling to find a bed. Both staff and patients have really engaged with the project and implemented a range of approaches to dealing with violence on the wards.

Staff focus on trauma-informed care has shifted from a task-orientated ‘them and us’ dynamic, to more reflective, person-centred approach to patient care.

Having been based on wards on a weekly basis, engaging with staff during those moments of violence and aggression, and trying to help them approach situations differently has been a real challenge.

Often, the adrenaline has kicked in and it is hard for staff to pull back from rushing to restrain rather than de-escalate.

However, one of the biggest efforts by teams has been their work to improve care around self-harm, and working with patients, rather than trying to control them with restraint.

This is a very sensitive area of practice in mental health which staff do struggle with. But coaching has allowed them to be more open and stand back, take their time, and work with the patient, to see better outcomes for patients and their team.

This approach has also seen better communication in shift handovers, more formal staff and patient debriefs, more meaningful activities for patients, and the development of sensory rooms.

Patients 

Working with patients directly we also aimed to develop individual safety plans; a self-management tool that helps both staff and patients focus on what triggers violence, and strategies to help calm and de-escalate. After testing these through the Plan, Do, Study, Act (PDSA) process, these plans have been a huge positive for both parties.

To help improve communication between staff and patients, we also developed weather symbols to use in patient community meetings. This helped them to talk about violent incidents and the general mood of the ward in a safe managed environment, using language that all can connect with (Sunny, cloudy and stormy days).

Patients now comment upon their discharge about how they enjoyed the sunny days on the ward; reinforcing to the teams the importance of focusing on working with patients to make sure there are many sunny days on the ward.

A consistent theme for staff is how they now focus more on the potential impact of restraint on patients, rather than the technique, and how this can avoid trauma to both patients and their colleagues. For me, this is a big cultural shift, which I believe over time will improve team cohesiveness and ultimately lead to safer patient care.

Throughout the two years, all the wards we have worked with have made great progress 

and have seen noticeable reductions in restraint. With The Health Foundation-funded programme now at an end, we hope to continue to build on this learning as we commence the AQuA Restraint Reduction programme throughout 2016/17.

I’m really looking forward to working with many of the Trusts who participated in REsTRAIN YOURSELF, and it’s great to also welcome Greater Manchester West NHS Foundation Trust on board for our new programme.

In October we’ll also be sharing the final evaluation report for REsTRAIN YOURSELF will be published by The Health Foundation, which will be available on our website and other communications.

Paul Greenwood is AQuA’s Improvement Advisor for Mental Health. You can contact him on paul.greenwood@srft.nhs.uk, or follow him on Twitter @PaulG_AQuA.