An Evaluation of the Implementation of a “No Force First” Informed Organisational Guide to Reduce Physical Restraint in Mental Health and Learning Disability Inpatient Settings in the UK

Abstract

BackgroundThe use of physical restraint on vulnerable people with learning disabilities and mental health problems is one of the most controversial and criticised forms of restrictive practise. This paper reports on the implementation of an organisational approach called “No Force First” within a large mental health organisation in England, UK. The aim was to investigate changes in violence/aggression, harm, and physical restraint following implementation.MethodsThe study used a pretest-posttest quasi-experimental design. Recorded incidents of violence/aggression from 44 inpatient mental health and learning disabilities (including forensic) wards were included (n = 13,599). Two study groups were created for comparison: the “intervention” group comprising all incidents on these wards during the 24 months post-implementation (2018–2019) (n = 6,551) and the “control” group comprising all incidents in the 24 months preceding implementation (2015–2016) (n = 7,048). Incidents recorded during implementation (i.e., 2017) were excluded (n = 3,705). Incidence rate ratios (IRR) were calculated with 95% confidence intervals (95% CI). Multivariate regression models using generalised estimating equations were performed to estimate unadjusted and adjusted prevalence ratios (aPR) of physical restraint and harm, using type of wards, incident, and violence/aggression as key covariates.ResultsA significant 17% reduction in incidence of physical restraint was observed [IRR = 0.83, 95% CI 0.77–0.88, p < 0.0001]. Significant reductions in rates of harm sustained and aggression/violence were also observed, but not concerning the use of medication during restraint. The prevalence of physical restraint was significantly higher in inpatients on forensic learning disability wards than those on forensic mental health wards both pre- (aPR = 4.26, 95% CI 2.91–6.23) and post-intervention (aPR = 9.09, 95% CI 5.09–16.23), when controlling for type of incident and type of violence/aggression. Physical assault was a significantly more prevalent risk factor of restraint use than other forms of violence/aggression, especially that directed to staff (not to other patients).ConclusionsThis is a key study reporting the positive impact that organisational models and guides such as “No Force First” can have on equipping staff to focus more on primary and secondary prevention as opposed to tertiary coercive practises such as restraint in mental health and learning disabilities settings.

Forensic mental health nurses' experiences of rebuilding the therapeutic relationship after an episode of physical restraint in forensic services in Ireland: A qualitative study

“…FMHNs require skills in dynamic risk assessment, de‐escalation and the proportionate skilled use of restrictive and intrusive interventions (Kennedy et al, 2020; Markham, 2021). Studies by Duxbury et al (2019) and Haines‐Delmont et al (2022) indicate the need to reflect critically on the interplay of practices, procedures and policies in forensic care settings given the negative outcomes resulting from restrictive measures. The theme Rebuilding a Therapeutic Relationship provides similar understanding of the interplay of barriers and facilitators to rebuilding therapeutic relationships following physical restraint.…”

“…The use of physical restraint on people with mental health problems is one of the most controversial and criticized forms of restrictive practice. Studies indicate that the use of physical restraint has a negative impact on outcomes for people with mental health problems, and has traumatizing effects on patients, their careers and staff (Duxbury et al, 2019; Equality and Human Rights Commission, 2019; Goulet et al, 2017; Haines‐Delmont et al, 2022; Lee et al, 2021; Riahi et al, 2016; Rose et al, 2017). Despite the growing evidence and introduction of policies aimed at reducing the use of restraint, the use of physical restraint on people with mental health problems is still a common feature in inpatient mental health services (Maguire et al, 2020; Power et al, 2020; Riley, 2018; Thomann et al, 2021).…”

Healthcare staff's experiences of using manual physical restraint: A meta‐synthesis review

“…The findings of this review and previous reviews of service users' experiences of manual restraint indicate that manual restraint is a predominantly negative practice for healthcare staff and service users alike. Consequently, the implementation of multimodal restraint and restrictive intervention minimization programs such as “Safewards” (Bowers et al, 2015), “No Force First” (Ashcraft & Anthony, 2008; Haines‐Delmont et al, 2022) and “REsTRAIN Yourself” (Duxbury, Baker, et al, 2019) in relevant healthcare settings are important initiatives and would be assumed to be welcomed by healthcare staff and service users alike. Notwithstanding, it is important that such minimization programs clearly acknowledge and validate the manual restraint‐related challenges that healthcare staff might face (e.g., emotional distress, tension between reducing restraint and maintaining safety), as opposed to focusing disproportionately on change and the benefits of manual restraint reduction, so that healthcare staff do not interpret these programs as “an unfounded criticism of their professionalism” (Duxbury, Thomson, et al, 2019, p. 848).…”

“…Notwithstanding, it is important that such minimization programs clearly acknowledge and validate the manual restraint‐related challenges that healthcare staff might face (e.g., emotional distress, tension between reducing restraint and maintaining safety), as opposed to focusing disproportionately on change and the benefits of manual restraint reduction, so that healthcare staff do not interpret these programs as “an unfounded criticism of their professionalism” (Duxbury, Thomson, et al, 2019, p. 848). Such an approach may increase healthcare staff's willingness towards adopting restraint minimization practices and translate into improved manual restraint reduction rates beyond the 19%–26% reported in the literature (Bowers et al, 2015; Duxbury, Baker, et al, 2019; Haines‐Delmont et al, 2022). Indeed, individuals are much more likely to be willing to change when they feel heard and validated (Bertolino, 2018; Day, 2008).…”

“…This is not surprising considering that manual restraint has been linked to service user death (Duxbury et al, 2011; Nunno et al, 2022), service user and staff distress (Bigwood & Crowe, 2008; Cusack et al, 2018), staff misuse (Brophy et al, 2016; Lee et al, 2003), and staff and service user injury (Lee et al, 2003; Wilson et al, 2017). The development and implementation of multimodal restraint and restrictive intervention minimization programs such as “Safewards,” “No Force First,” and “REsTRAIN Yourself” have successfully led to reductions in manual restraint rates ranging from 19% to 26% within inpatient mental health, older adult, and learning disability settings (Bowers et al, 2015; Duxbury, Baker, et al, 2019; Haines‐Delmont et al, 2022), highlighting that not all instances of manual restraint are necessary. However, while healthcare staff report a desire to reduce and, where possible, eliminate manual restraint (Kodua & Eboh, 2023), insufficient time and staffing levels, environmental limitations, and a lack of effective alternative strategies have all been cited as barriers in this endeavor (McKeown et al, 2019; Muir‐Cochrane et al, 2018; Wilson et al, 2018).…”