3 Defences It keeps people safe - PowerPoint Presentation

3 Defences It keeps people safe It is a clinical intervention Its used as a last resort Duxbury (2015) Eileen Skellern Lecture JPMHN

Increasing evidence ‘Going in strong ’ (Whittington) Show of force model Restraint is used primarily to keep people safe, however decisions are also influenced by nurses perceptions of patients (Goethals et al 2012) Violence was rarely mentioned as a cause for restraint in records scrutinised (Ryan and Bowers 2006)Reactivity re absconding, medication conflict, boundaries You get the feeling they’re enjoying it, held me down, humiliated (Paterson 2006) Research indicates that cultural and social bias may exist. Other studies have indicated that being restrained can lead to feelings of anger, fear, panic, and sense of feeling dismissed ( Bowers et al., 2012; Sequeira & Halstead, 2004; Bonner et al., 2002)

Last Resort Deveau and McDonnell (2009) suggest the “reliance upon the ‘last resort’ principle has the major drawback that it is an easily voiced rhetorical device and very difficult to observe or challenge” (p.175). Control and containment measures, such as restraint, are often common first line interventions within healthcare settings (Cowin et al., 2003; Foster et al., 2007; Kynoch et al., 2009, Dixbury 2015) Absent exploration of the decision-making factors that influence the use of restraint as a last resort. Some studies have examined the use of restraint. Varied reasons for it reported: violence, , abscondment, staff denying a request, patient agitation, refusal of medication, self-harm, verbal aggression and property damage (Bowers et al., 2012; Ryan & Bowers, 2006; Gudjonsson et al., 2004; Southcott et al., 2002), O nly a few qualitative studies have explored reasons (Moran et al., 2009; Bonner et al., 2002). Soininen et al. (2013) explored patients’ perceptions. Patients felt that seclusion and restraint were ‘hardly’ necessary and that their opinions were not included in treatment planning.

Where are we now? DH Guidance Replace 2002 guidance PBSPerson Centred PrinciplesMinimisation modelsProne RestraintTargeted roll outRRNwww.restraintreductionnetwork.org NICE Due now Coercion Reduction Models are being explored in UK Safe Wards (Bowers 2013) 6CS (Huckshorn) REsTRAIN Yourself (Duxbury et al 2014) NFF

UK Guidance Positive and Proactive Care: reducing the need for restrictive interventions , Department of Health, 2014Meeting needs and reducing distress Guidance on the prevention and management of clinically related challenging behaviour NHS Protect, 2014A positive and proactive workforce: a guide to workforce development for commissioners and employers seeking to minimise the use of restrictive practices in social care and health Skills for Health/Skills for Care, 2014

Positive and Safe: A two year programme to end the use of out dated and damaging restraint and restrictions in health and care services Our 10 shared commitments – We believe thatHealth and care services should be positive, caring and safe.Physical restraint and restrictive practices have no place in a modern, compassionate health services - they are used too much and we need to change this. R estraining people can be a traumatic and distressing experience for both them and the members of staff involved. It should only ever be used as a last resort. D eliberately putting patients face down and holding them there for a sustained period has to end. There is a clear evidence base for alternative, positive practices. U sing other negative practices is not an acceptable alternative to negative care environments, poor quality training and support for staff. The best way to keep both patients and staff safe is to promote a therapeutic environment

We all have a duty to be open, honest and transparent about the use of restrictive practices. In the exceptional cases where they are used, they must be recorded and reported openly. Patients and families should be communicated with. Leaders must ensure they build in a process for reviewing all cases when restraint has been used, understanding the root causes so that they can be tackled properly and introducing measures to minimise usage. There must be genuine co-production of organisations’ policies and training. Training that does not involve or has not been produced with people who are experts by their own experience is not good training. Policies and training must include alternative, positive measures and de-escalation.Leaders should stand up to out dated and damaging restrictive practices in health and care services to keep everyone safe. Assault is assault. The intentional use of pain, restraint or restrictions to punish, hurt or humiliate is never acceptable.

DH Roll out over 2 years F ive key themes which the programme of action are centred around: Standards, guidance and maintaining complianceTraining and developmentContracts and commissioningCulture and leadershipTransparency: monitoring, recording and reporting

DH recommendations on restraint Floor holds (prone or supine) should be avoided and must not arise from intentional acts to forcibly control an individual.Physical interventions and breakaway techniques must not involve the deliberate application of pain by staff, An individual’s physical condition must be monitored closely throughout any period of restraintA member of the care team must monitor the individual’s airway at all times, if they raise concerns, restraint must stop immediately. Staff should continue to monitor the individual for signs of immediate emotional / physical distress for a period of time (up to two hours) following the application of restraint. Support staff should communicate with the service users throughout any period of restraint

NICE 2015 Manual Restraint Use the supine (face up) position if possible orIf the prone (face down) position is necessary, use it for as short a time as possible. Do not use manual restraint in a way that interferes with the service user's airway, breathing or circulation, for example by applying pressure to the rib cage, neck or abdomen, or obstructing the mouth or nose.Do not use manual restraint in a way that interferes with the service user's ability to communicate, for example by obstructing the eyes, ears or mouth.Undertake manual restraint with extra care if the service user is physically unwell, disabled, pregnant or obese.Aim to preserve the service user's dignity as far as possible during manual restraint. Do not routinely use manual restraint for more than 10 minutes. Consider rapid tranquillisation or seclusion as alternatives to prolonged manual restraint (longer than 10 minutes). Ensure that the level of force applied during manual restraint is justifiable, appropriate, reasonable, proportionate to the situation and applied for the shortest time possible. One staff member should lead throughout the use of manual restraint. Monitor the service user's physical and psychological health after using manual restraint.

Interventions designed to reduce conflict and containment on inpatient wards in UK Package Positive wordsTalk downKnow each otherDischarge messagesBad news mitigationReassuranceMutual help meetingClear mutual expectationsSoft wordsCalm down methods REsTRAIN YOURSELF Safewards https://youtu.be/ 9fF4z2Mv6Wo

Services must ensure that: Make public policy Staffing levels are appropriate – RCN Staff are rotated to work with a range of services users to avoid risk of burnoutThe multi-disciplinary team collaborate in the use of reduction strategies There is a cultural change in organisations which emphasises that the use of restrictive practices is a treatment failure.Embed principles of trauma informed care and recovery to train staff and change culture is changed. Efforts are focussed on reducing use of restrictive interventions - Visibility Strategies to engage and empower services users are implemented. Leaders set expectations to reduce use of restrictive practices. Local policies on use are reviewed, to promote reduction . Board level buy in, accountability and reporting mechanisms Walk arounds 15 steps Organisational Leadership

Challenges to all approaches Complex models Needs to be significant organisational ‘buy in’ and strong leadership. Union opposition – See 3 defences (Duxbury 2015) Challenge MythsPrevious training Fear, attitudes and prejudice Inconsistent implementation Getting hung up on RED HERRINGS!!! Contextual and multi-model factors leading to aggression

Overcoming barriers Front -line staff with non-restraint values provide personal leadership – Low hanging fruitServices work to ensure that staff regard restraint reduction as a priority Networks and forums - SalutogenesisServices use assessment tools to track negative attitudes over time, at both organisational and individual levels – MAVAS (Duxbury 2003)Data is used to identify staff members and individual units that have reduced restraint to facilitate shared learningClinical staff have access to an incident management system to track performance indicators for restrictive intervention minimisation DON ’ T FOCUS ON MINIMISATION AT THE EXPENSE OF ALL THE PREVENTION STRATEGIES https ://youtu.be/QBMKlP5u29Y

Perfect Storm The death of a patient during a physical intervention in a health care environment adds an element of irony Suffice to say a reduction in the number of restraint episodes would certainly lead to a decrease in the exposure to the risk of patient death and staff injury Three biggest contributory factorsDuration of the eventDrug interactionUntrained and/or chaotic responseDamien Martin Australian Hospital and Healthcare Bulletin, Autumn 2010, pp 78-80

Final Thought (Duxbury 2015) “There can be no justification for the sustained and repeated use of the restraint of vulnerable people whilst services continue to neglect to embrace strategies, which can reduce the reactive and uncontrolled use of such approaches. Despite the growing evidence that physical restraint is potentially counter-therapeutic, traumatic, unnecessary and can be life threatening (Curran, 2007; Aiken et al., 2011), nurses continue to rely upon this practice. The use of restraint is seen as one of the few options clinicians view as effective in managing violence and aggression, in the absence of a real evidence base (Cutcliffe & Santos, 2012).”

Previous Stance!

The perfect storm