Restrictive interventions: understanding and reducing their use in mental health settings
Intended for healthcare professionals
CPD    

Restrictive interventions: understanding and reducing their use in mental health settings

Nutmeg Hallett Lecturer in mental health nursing, School of Nursing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England
Paul McLaughlin Lead nurse, East London NHS Foundation Trust, London, England

Why you should read this article:
  • To enhance your awareness of the ethical issues and legal frameworks associated with the use of restrictive interventions

  • To read about strategies that have been implemented to reduce the use of restrictive interventions

  • To contribute towards revalidation as part of your 35 hours of CPD (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Restrictive interventions, which include enhanced observations, seclusion and restraint, are associated with significant and far-reaching harm for patients, staff and those who witness their use. They should only ever be used as the last resort. However, mental health professionals often encounter patient behaviours that challenge, which can include violence, which may prompt them to use restrictive interventions. The primary prevention of patient behaviours that challenge is crucial to reduce the need for restrictive interventions in mental health settings.

This article discusses the different types of restrictive interventions and describes some strategies that can support reduction of their use in mental health settings. The authors also consider some of the legal and ethical aspects of restrictive interventions and identify the importance of adopting a trauma-informed approach to care.

Mental Health Practice. doi: 10.7748/mhp.2022.e1620

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@dr_nutmeg

Correspondence

n.n.hallett@bham.ac.uk

Conflict of interest

None declared

Hallett N, McLaughlin P (2022) Restrictive interventions: understanding and reducing their use in mental health settings. Mental Health Practice. doi: 10.7748/mhp.2022.e1620

Published online: 23 August 2022

Aims and intended learning outcomes

The aim of this article is to give an overview of restrictive interventions in mental health settings and to describe strategies that can be adopted to reduce their use. After reading this article and completing the time out activities you should be able to:

  • Distinguish between the different types of restrictive interventions.

  • Describe the ethical issues and legal framework around restrictive interventions.

  • Explain why restrictive interventions must be delivered in a trauma-informed way and should be followed by a post-incident debrief.

  • Discuss strategies to prevent behaviour that challenges and thereby reduce the need for restrictive interventions.

  • Cite examples of programmes and interventions designed to reduce the use of restrictive interventions.

Introduction

Key points

  • Maintaining the safety of patients is crucial, but in some circumstances, this requires using interventions that limit or constrain a patient’s movement

  • Restrictive interventions should only ever be used as a last resort

  • If used, restrictive interventions must be delivered in a trauma-informed way

  • A post-incident debrief should be held after each use of a restrictive intervention

  • A range of strategies can be used to reduce the need for, and use of, restrictive interventions in mental health settings

Maintaining the safety of patients is a crucial role of mental health professionals, however, in some circumstances this requires the use of interventions that limit or constrain a patient’s movement. These are termed restrictive interventions. Evidence shows that restrictive interventions can be associated with significant harm for patients and for staff, including those who witness their use. In the UK, legislation was introduced in 2018 which seeks to reduce the use of restrictive interventions and consequently the harm they can cause. Guidance recommends that some restrictive interventions, namely seclusion and physical restraint, should only ever be used as a last resort (National Institute for Health and Care Excellence (NICE) 2015).

Restrictive interventions

Types of restrictive interventions

Restrictive interventions include enhanced observations, seclusion and restraint.

Enhanced observations

Enhanced observations can be undertaken intermittently, with staff observing the patient every 15 to 60 minutes, or continuously with the patient remaining within eyesight or at arm’s length of staff (NICE 2015). Enhanced observations are likely the least invasive type of restrictive interventions and are sometimes referred to as ‘therapeutic observations’. However, in patients’ experience they can be untherapeutic. Some patients have reported feeling safer and less anxious with enhanced observations (Reen et al 2020), but others have reported feeling controlled and coerced (Collins et al 2022). Despite the widespread use of enhanced observations on adult inpatient psychiatric wards, one systematic review concluded that there is limited evidence of their efficacy in maintaining patient safety (Reen et al 2020).

Seclusion

Seclusion is defined as ‘the supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving’ (Department of Health and Social Care (DHSC) 2021). The Mental Health Act 1983 Code of Practice (Department of Health (DH) 2015) states that seclusion should only be undertaken in a room or suite of rooms that has been specifically designed and designated for that purpose and serves no other function. However, any action taken to keep a patient away from others and prevent them from leaving the premises is regarded as seclusion (DH 2015). When seclusion is used in the long term, it is described as long-term segregation (Care Quality Commission 2020). In a systematic review of the effects of seclusion and restraint in adult psychiatry, Chieze et al (2019) found that patients often reported that seclusion was unhelpful and that they experienced it as a form of punishment, although it appeared to be more acceptable than forced medication (chemical restraint).

Restraint

Restraint is described by the Royal College of Nursing (2008), in accordance with established international definitions, as ‘the intentional restriction of a person’s voluntary movement or behaviour’. Restraint is sometimes used inappropriately to control people’s behaviour, particularly with older adults (Robins et al 2021) and people with learning disabilities (Public Health England 2015).

Restraint can be physical, mechanical, chemical, environmental and psychological:

  • Physical restraint involves holding a person or blocking their movement.

  • Mechanical restraint involves using equipment such as straps or buckles to restrict a person’s movement.

  • Chemical restraint, which includes rapid tranquilisation, involves using medication to ‘prevent, restrict or subdue movement of any part of the patient’s body’ (DHSC 2021).

  • Environmental restraint involves restricting a person’s free access to the environment, for example by locking ward doors.

  • Psychological restraint may involve constantly telling a person that they cannot or should not do something or stopping a person from choosing when to eat or sleep (Negroni 2017).

Physical, mechanical and chemical restraint, along with enhanced observations and seclusion, come under the umbrella of ‘restrictive interventions’, while environmental and psychological restraint are often referred to as ‘restrictive practices’ and are inextricably linked to inpatient mental health settings (Restraint Reduction Network 2022). This article uses ‘restrictive interventions’ as the overarching term for any form of restriction on a patient’s movement.

Where other forms of restraint are used reactively, for example in response to violent behaviour by a patient, Tomlin et al (2020), who conducted a qualitative study of 18 patients in secure hospitals in England, suggested that psychological restraint and environmental restraint are often used proactively and applied to all patients whether they are regarded as posing a risk or not. This infers that many patients may experience these practices as coercion even when staff do not think they are acting coercively.

TIME OUT 1

Reflect on an incident when a patient experienced a form of restraint. Consider the following:

The risks and benefits to the patient, the staff involved, other patients and any witnesses

How restraint may have made the patient feel and how it made you feel

How the incident and its management may have altered your way of thinking and/or your practice

Harm associated with restrictive interventions

The harm associated with restrictive interventions, for patients and for staff, is far-reaching. In the UK, the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness reported that between 2005 and 2015 there had been 24 deaths within 24 hours of restraint (University of Manchester 2017). Patients have reported experiencing re-traumatisation as a result of restrictive interventions (Judd et al 2009). These practices have been cited as a significant contributory factor in delaying patients’ recovery (Social Care Local Government and Care Partnership Directorate 2014). Chieze et al (2019) found that the incidence of post-traumatic stress disorder following seclusion or restraint in adult psychiatry ranged between 25% and 47%, noting that this was ‘not negligible’, particularly for those with past traumatic experiences.

Involvement in the physical restraint of patients is the most common cause of staff injuries in UK mental health trusts (Renwick et al 2016). The use of restraint can be distressing for staff, trigger memories of previous incidents – which suggests that there may be a cumulative harmful effect – and result in negative psychological responses (Cusack et al 2018).

Disparities in the use and effects of restrictive interventions

In a briefing on the use of restraint in women and girls, Agenda (2017) reported that around one in five women admitted to mental health facilities in England were physically restrained and that in some trusts women were substantially more likely to be restrained than men. Women may be more likely than men to experience restrictive interventions as traumatic, in part because the prevalence of childhood abuse in women is higher (Mauritz et al 2013).

There is also evidence of disparities according to ethnicity. A study that analysed the relationship between ethnicity and restrictive interventions used to manage violent or aggressive behaviour in patients in inpatient settings across an NHS mental health trust found that black patients and patients of a mixed ethnic background were more likely to undergo restrictive interventions than white patients (Payne-Gill et al 2021). It can be argued that the institutional racism in mental healthcare described by McKenzie and Bhui (2007) continues today, evidenced by inadequate access to effective interventions and by the negative outcomes experienced by black people and people from minority ethnic backgrounds (Nazroo et al 2020).

Ethical issues and legal framework

Restrictive interventions are not necessarily wrong or unacceptable. However, given the potential harm associated with their use, they should only ever be the last resort (NICE 2015). The risks involved in using a restrictive intervention must be balanced against the risks of not using it, and the decision to restrain or seclude a patient must be made with due consideration of all associated legal, ethical, practical and professional requirements (Hawsawi et al 2020).

With the Human Rights Act 1998 and the Care Act 2014, UK legislation affords greater protection to vulnerable adults who receive mental healthcare. Human rights form a central element of the background against which, in the recent past, mental health legislation has been revised in England (Mental Health Act 2007) and in Ireland (Mental Health Act 2001) (Kelly 2012). The Restraint Reduction Network (2019) has described a ‘positive obligation’ under the Human Rights Act 1998 to protect people from any immediate risk of serious harm.

However, in mental health settings it can be challenging to find a balance between a person’s right to autonomy and people’s right to protection (DHSC 2018). In the context of restrictive interventions, and in the context of a compulsory admission to hospital under the Mental Health Act 1983, the right to protection is at odds with Article 3 (prohibition of torture and inhuman or degrading treatment) and Article 5 (right to liberty and security) of the Human Rights Act 1998. Numerous legal cases have been brought and won by people who have argued that their rights under Article 3 of the Human Rights Act 1998 – which translates into UK law the rights and freedoms set out in the European Convention on Human Rights – were violated while they were patients in a mental health setting (Curtice 2010).

UK legislators have sought to reduce restrictive interventions. The Mental Health Units (Use of Force) Act 2018 aims to reduce the use of force, and ensure accountability and transparency about the use of force, in mental health units (DHSC 2021). It is also known as Seni’s Law, named after Olaseni Lewis who died after being physically restrained by 11 police officers in a mental health unit in England (Rethink 2022).

The intention of Seni’s Law is that patients in mental health units be treated fairly and with dignity regardless of ethnicity, gender or other characteristics (Rethink 2022). The Act’s statutory guidance details the legal obligations of organisations and individuals in relation to the use of force (DHSC 2021). They include a requirement that all relevant organisations appoint a person responsible for ensuring that the organisation complies with the Act, have an up-to-date policy on the use of force and train staff effectively in safe trauma-informed care. The statutory guidance also identifies that the composition of staff should reflect the diversity of the local community (DHSC 2021).

TIME OUT 2

Read the articles of the Human Rights Act 1998 online at www.legislation.gov.uk/ukpga/1998/42/schedule/1

Do you think any aspects of the care you provide to patients may contravene their human rights, specifically under Article 3 and Article 5? Discuss this with a colleague or with your team

Trauma-informed approach

Inpatient mental healthcare in general can expose an already vulnerable population to further psychological trauma (Berry et al 2013). Negative experiences such as those produced by restrictive interventions may compound existing trauma and create new trauma. Mental health professionals should be aware of this and work towards providing trauma-informed care (Sweeney et al 2016). According to Sweeney et al (2016), being trauma-informed means acknowledging and addressing patients’ past trauma and recognising the risk of re-traumatisation in healthcare services. This is embedded in the Mental Health Act 1983 which states that factors that may contribute to ‘behavioural disturbance’ include ‘exposure to situations that mirror past traumatic experiences’ (DH 2015).

Adopting a trauma-informed approach in healthcare requires shifting the focus from ‘what is wrong with you?’ to ‘what has happened to you?’ Trauma-informed healthcare professionals seek to (Center for Health Care Strategies 2021):

  • Recognise the signs and symptoms of trauma in patients, families and staff.

  • Recognise the widespread effects of trauma and understand paths for recovery.

  • Actively avoid re-traumatisation.

  • Integrate knowledge about trauma into organisational policies, procedures and practices.

Restrictive interventions may seem at odds with a trauma-informed approach, but any intervention can be delivered in a trauma-informed way. The Mental Health Units (Use of Force) Act 2018 statutory guidance emphasises the importance of using a trauma-informed approach, which includes understanding the negative effects that the use of force can have on patients with a history of trauma and abuse (DHSC 2021). Providing opportunities for collaboration between patients and staff, developing trust and prioritising safety can support staff to practise in a trauma-informed way (Isobel et al 2021).

TIME OUT 3

The US Substance Abuse and Mental Health Services Administration (2014) describes a trauma-informed approach as involving adherence to six principles. Read these principles online at store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf and consider how you could apply each of them in your practice in relation to restrictive interventions

Post-incident debrief

Restrictive interventions and the events that lead to them can be harmful to the patients and staff involved, and to witnesses, therefore everyone involved should have an opportunity to reflect on, and learn from, the incident. In its guideline on the short-term management of violence and aggression in mental health, health and community settings, NICE (2015) recommends an immediate post-incident debrief after every restrictive intervention apart from enhanced observations. While the guideline provides a framework for debrief, NICE notes that, despite the importance of debrief in terms of the patient’s dignity and human rights, there is limited empirical evidence to guide the development and implementation of post-incident debrief interventions. The literature on post-incident debrief shows that although patients and staff value such opportunities, debrief happens infrequently for staff and even more rarely for patients (Sutton et al 2014).

Debrief should be non-punitive and supportive (Wilson et al 2015), strength-based, person-centred, trauma-informed and recovery-oriented (Hammervold et al 2019). NICE (2015) describes the aims of debrief as follows: ‘to identify and address physical harm to service users or staff, ongoing risks and the emotional impact on service users and staff, including witnesses.’ This acknowledges that witnessing restrictive interventions can be distressing (Cusack et al 2018), so those who do so should also be offered an opportunity to debrief. Ward community meetings can be an optimal setting to discuss the effects of incidents on patients and staff. Meetings can be conducted in a way that protects confidentiality, for example by discussing how the incident made people feel rather than giving specific details about the incident and the person involved.

TIME OUT 4

What is your workplace policy on debrief for patients following an incident requiring a restrictive intervention? Are there barriers to implementing this policy? If so, how might these barriers be addressed?

Strategies for reducing restrictive interventions

Prevention

Prevention is central to reducing the use of restrictive interventions and engagement with patients is at the core of prevention. To reduce restrictive interventions, the focus must be on reducing the need for them and therefore on reducing the likelihood of violent or aggressive behaviour in patients (Hallett 2018). Primary prevention focuses on reducing the likelihood of behaviour that challenges, including violence, while secondary and tertiary prevention focus on imminent and actual behaviour that challenges respectively. Therefore, primary prevention should receive the most attention.

Restrictive interventions are sometimes used as a response to behaviour that challenges (DH 2015), so preventing such behaviour should reduce the need for restrictive interventions. Figure 1 shows a three-tiered model for the primary, secondary and tertiary prevention of behaviour that challenges (Hallett 2018). All the actions listed in Figure 1 for primary prevention represent useful strategies for reducing the need for restrictive interventions. Many activities that take place in mental health inpatient settings – for example, activities aimed at reducing patients’ boredom or training activities for patients and staff – can be considered primary prevention, although they may not be described as such (Hallett 2018).

Figure 1.

Three-tier model for preventing behaviour that challenges

mhp.2022.e1620_0001.jpg

A positive social climate is likely to promote the primary prevention of restrictive interventions. Social climate has been described as the environment of a particular setting which may affect the mood and behaviour of people in that setting (Robinson et al 2016) or as the interplay between system, staff, patients and the environment (Doyle et al 2017). One method of assessing the social climate of inpatient settings is through the Fifteen Steps Challenge (NHS England 2017), a suite of tools that explores healthcare settings from the viewpoint of patients and carers, including whether a ward feels welcoming, safe, caring, involving, well-organised and calm. A version of the Fifteen Steps Challenge has been developed specifically for inpatient mental health services. Its tools support staff to listen to service users and carers, understand their experiences and involve them in quality assurance processes (NHS England 2017).

The DH (2014) guidance on reducing the need for restrictive interventions recommends a range of approaches including:

  • Recovery-based approaches, which promote a human rights-based approach to care, enhance personal independence, honour patients’ choices and increase social inclusion.

  • Positive behaviour support, which provides a framework for understanding patient behaviour to inform the development of supportive environments as well as skills that can enhance the person’s quality of life.

  • Whole service approaches, which promote therapeutic engagement, avoidance of conflict situations and the safe support of people at times of behavioural crisis.

Monitoring

Restrictive interventions – which, as explained above, should only be used as a last resort (NICE 2015) – involve staff taking control of a challenging situation where safety is at risk. The intention should be to assist the patient and preserve staff and patient safety, but patients may experience restrictive interventions as a form of abuse or punishment (Hammervold et al 2019). Additionally, as shown by enquiries into failures of care such as the Francis (2013) report, staff sometimes intentionally use restrictive interventions to abuse or punish patients. Healthcare organisations must therefore monitor the use of restrictive interventions and assess their effects on patients to ensure they are always used as a last resort and to support their reduction.

In the UK, the Mental Health Units (Use of Force) Act 2018 requires healthcare organisations to collect data on each instance of the use of force, including the reason why force was used, the efforts made to avoid the use of force and whether the restrictive intervention used featured in the patient’s care plan. Such data can act as a catalyst to improve practice (Riahi et al 2016). Using data to inform practice is one of the six core prevention strategies for reducing seclusion and restraint in mental health settings proposed by Huckshorn (2004).

Reflection

To reduce restrictive interventions, staff need to examine and reflect on their use of power, individually and in their teams. Participation in reflection groups has been shown to increase staff awareness of formal and informal coercion and may assist them to identify alternative ways of managing a situation in which they feel challenged by a patient’s behaviour (Hem et al 2018). Staff who have participated in such groups reported that they developed a more critical attitude towards coercion and more openness towards patient involvement and partnership working (Hem et al 2018).

Programmes and interventions

A range of programmes and interventions has been developed and implemented in mental health settings to reduce the need for, and use of, restrictive interventions. Safewards is a widely used programme that aims to reduce conflict and containment measures – which include restrictive interventions – in mental health settings through identification of ‘flashpoints’ or ‘triggers’ and generation of ideas for change (Bowers et al 2015). There is growing evidence that Safewards is effective in reducing conflict and associated restrictive interventions in general mental health settings (Finch et al 2022).

The Royal College of Psychiatrists’ Reducing Restrictive Practice Collaborative (2018) was established to encourage peer-to-peer learning between mental health wards across England with the aim of reducing restrictive practices. The 38 participating wards were provided with tools and resources to develop their own ideas and quality improvement plans and supported to implement these through learning days and working with quality improvement coaches. Over 18 months there was an overall 15% reduction in the use of restrictive interventions on the 38 participating wards.

The Safety Bundle developed by East London NHS Foundation Trust used a mix of four interventions: daily staff ‘safety huddles’; violence risk assessments; safety crosses; and discussions with patients about safety during ward community meetings (Taylor-Watt et al 2017). A safety cross is a calendar in the shape of a cross on which staff mark incident-free days in green and days when incidents have occurred in red, with the aim of visualising trends and eventually reducing the number of incidents. After the implementation of the Safety Bundle, the incidence of patient violence decreased significantly in the four acute admissions wards and two psychiatric intensive care units involved in the project (Taylor-Watt et al 2017).

TIME OUT 5

As part of the Reducing Restrictive Practice Collaborative set up by the Royal College of Psychiatrists, 38 mental health wards tested change ideas that you can read about here: www.rcpsych.ac.uk/improving-care/nccmh/reducing-restrictive-practice/ideas-for-changing-practice

Are some of these ideas applicable to your practice area?

Which one(s) would you select to change practice in your workplace?

Conclusion

The use and reduction of restrictive interventions in mental health settings is complex. When restrictive interventions are used, they should be the last resort and must be delivered safely, legally and in a way that respects the patient’s human rights. A trauma-informed approach, which acknowledges previous trauma and the risk of re-traumatisation, is required when delivering restrictive interventions as well as any other intervention in mental health. The patient and staff involved in a restrictive intervention, and anyone who has witnessed it, should be offered a post-incident debrief. Mental health services have a duty to reduce the use of restrictive interventions, which they can do through primary prevention of behaviours that challenge, such as violence, monitoring and data collection and implementing relevant programmes and interventions. They should encourage staff to reflect on their use of power and coercion and foster a positive work culture and ethos on mental health wards.

TIME OUT 6

Identify how understanding and reducing the use of restrictive interventions in mental health settings applies to your practice and the requirements of your regulatory body

TIME OUT 7

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account

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