The Use of Physical Intervention in Acute Mental Health Care:

1. The Use of Physical Intervention in Acute Mental Health Care: Decision-making and Rationalisation among Healthcare Staff Dr Helen Prosser Centre for Social Justice Research University of Salford Professor Liz Perkins & Dr Richard Whittington Health and Community Care Research Unit University of Liverpool

2. Context • Physical intervention (PI) is “a skilled hands-on method of physical restraint involving trained designated healthcare professionals (aiming) to prevent individuals from harming themselves, endangering others or seriously compromising the therapeutic environment.” (NICE, 2005:9) • Why did we study decision-making among healthcare staff? • A local acute NHS Trust wanted to better understand why physical restraint is used and in what circumstances in order to inform efforts to effect change and safer practice

3. Although intended as a protective strategy, PI a controversial aspect of psychiatric care. • PI has caused physical injury, fatalities and experienced by service users as distressing and abusive. • Incompatible with claims of best practice and values of respect, dignity and autonomy. • PI should be restricted to a very small number of highly risky situations.

4. Restraint • Vertical- The service user is physically restrained in a standing or sitting position. • Horizontal – The service user is physically restrained by taking the individual down to the floor. Training, emphasises that horizontal restraint should be avoided wherever possible, while restraining on the floor in a prone/face-down position should be used as an absolute exception.

5. Aim and Objectives • To explore the factors that influence the use of horizontal and vertical physical restraint • To explore the circumstances in which physical restraint occurs from the perspective of nursing staff. • To explore how nursing staff account for the decision to use physical restraint. • To explore nursing staffs’ experiences, feelings and attitudes towards the use of physical restraint.

6. Data Collection • 30 participants • 17 individual semi-structured interviews (critical incident technique) • 4 focus groups - 3 nursing staff; 1 ward managers Study Design • Setting • An acute Mental • Health Trust in • NW England Sampling Purposive sampling; recruitment based on staff involvement in a recent episode of restraint • Analysis • Interviews/focus • groups audio-recorded • & transcribed verbatim • Thematic content • analysis

7. Findings • In the majority of incidents, the service user was moved to the floor and restrained in a horizontal position. • Antecedents – aggression/violence, self-harm, absconding & the planned administration of medication

8. Definitions of Restraint • A management strategy to prevent harm and protect the safety of the service user and others in the context of aggressive and violent incidents: • I suppose it’s about controlling the situation, taking control of situations, it’s about safely managing situations…. Safety, maintaining safety to either self or others. (Interview 5) • A strategy of ‘last resort’

9. Discursive Accounts of PI • 5 inter-related themes through which PI is rationalized • The specifics, severity and magnitude of service user behaviour • Routinisation • Control • Risk perception and uncertainty • Individual staff ideologies, values and approaches

10. Service User Behaviour • Staff perceptions of the severity of the behaviour • Initially he was standing up, we had his arms, trying to get his arms down his side, just to stop him from lashing out and hitting us, that was proving unsuccessful because of his fitness and the excitement of the patient himself. He was quite threatened by this and I think that made him a lot more hostile to us initially, and it finished up we just had to pull him on the floor just to make sure. (I:6) • Step-wise approach in some incidents

11. Actual or threatened violent assault OR • Sudden and unexpected acts of violence or aggression = immediate horizontal restraint • she was going to hit him…..we just restrained her, we took her down. (I:3) • He carried on walking towards the dining room at first I thought he might be trying to go for the front door, even though they are automatically locked. I placed again my hand on him to try and ask him to come back to his room, with his other arm he went to swing at me and the other member of staff grabbed him, we restrained him. (I:3)

12. Routinisation she actually lashed out at myself, so she raised her fist and attempted to strike me, so then we put hands on automatically……I didn’t think she was a major risk anyway, to anyone I think she lashed out then on the spur of the moment, but once we got the situation under control and was able to speak to her for 5 minutes, I felt safe she was no longer a risk to anyone (I:17) Instinctive/Intuitive; standardized ‘rules of thumb’ Normative practice I suppose you have to see it as part of the job, it goes with the territory. (I:9)

13. We had to use restraint, there was no other option of controlling him. (I:12) Routinisation through lack of options A Necessary Evil You need it because it’s for your safety and other people’s safety. Because, you just need it there because if you didn’t have it, people could get hurt. I mean I know it’s not the nicest thing, and it is uncomfortable, but you have got to look at it, at the safety aspects of what could happen if we don’t use restraints. (I:2)

14. Actually I have never used vertical restraint. In most situations I have been in I have always had to take the person down to the floor, you have more control when you take people down to the floor. (I:4) Taking Control • A technique to rapidly suppress aggressive and violent behaviour It’s a lot easier to manage an incident when you are restraining someone on the floor, because they have got less movement, they’re more restricted, you’ve got more control, people become more compliant a lot quicker. (I:12) • A management strategy to maintain order and stability in the organisational setting When you are working on a ward like this, I am always well aware that shouting, screaming, commotions on a ward affects all the other patients and there is a lot of people here with anxiety problems and things, so I felt I needed to calm the situation down. (I:17)

15. The minute you lay hands on, the incident that originally got you to that point, is lost, it then becomes a situation of well you know, get off me, I will calm down when you get off me, and then the retort from the staff side is well no, when you have calmed down, and the service user then says well I will calm down when you get off me, and it then becomes a stalemate … (I:1) • ‘Us & Them’ approach • PI a site for the contention of power and control between staff and service user The physical resistance. You know every time you loosen your hold or take any pressure away, if he is trying to get up and fight you then you say, ‘no, just lie still, we don’t like to do this anymore than you do, erm, just relax, let the medication work.’ (I:6)

16. Risk Perception and Uncertainty

17. Risk Perception and Uncertainty • Assessment of the concurrent level of threat, the attribution of intent and the interpretation of a given behaviour are critical mediators: • if she hadn’t been put on the floor at that time, she probably would have lamped someone. She would have punched them, so we had to get her on the floor to restrain her, to calm her down. (I:13) • Ability to control risk • At the time of the incident I thought it was quite dangerous, it was a quite dangerous situation considering I was, it was only me and in between 2 doors, really. (I:12) • I didn’t feel I was in a great deal of danger, per se, certainly not in this instance. I always felt I was in control of the situation…it sounds odd in the sense that I was physically and verbally threatened, but I always felt that certainly two of us could control that situation. (I:14)

18. Risk Perception and Uncertainty • Tolerance of risk & uncertainty • Restraint a strategy for resolving risk ambiguities • I mean you know its fear of getting smacked, let’s just get it over with now and cut down the possibility of getting smacked. (I:10) • I don’t think you can take the chance to think well maybe they won’t strike out again. I don’t think you can wait to be hit. I think you just automatically…when someone is actually aggressive towards you, putting hands on keeps everyone safe. (I:17) • Knowledge of service user • The previous night he’d actually attacked another member of staff and punched him three times in the head, so I was already on alert... We had to take him down to the floor. He was still non-compliant, struggling and because of the previous event and the fact that he was still being verbally abusive we decided we had no option but to take him down to the floor. (I:8)

19. Well really on restraining and taking someone down, we wouldn’t know how it happens because it happens that quick, that you just, it’s just a scrap to be quite honest. It is a scrap. I mean you get taught all these methods …It doesn’t work. To be quite honest it’s dog eat dog. You get them down, which you don’t want to say that do you, you don’t want to, but you have got to. If you don’t, if she hadn’t been put on the floor at that time, she probably would have lamped someone. She would have punched them (I:13) Tension between urgency and safety

20. Ideologies, values and approaches There are different staff attitudes and some staff can be aggressive, which doesn’t help the situation. If you’re highly charged and you’ve got a member of staff who comes in bluntly, saying ‘calm down’, it can have the opposite effect. Some staff are better at dealing with patients than others, it’s their attitude. (I:9) • Negative Attitudes • Anger, aggression, lack of patience, over-zealous • Importance of inter-relationships between staff and service users • Effective communication, interpersonal skills, rapport I spent virtually about an hour and a half talking to her, on and off throughout the hour and a half and in the end it worked, she just walked away and calmed herself down. (I:10)

21. Ideologies, values and approaches PI rationalised by perceptions of mental state and personality attributes • Mental illness = violence & aggression • Reinforcement of restraint it’s driven by mental illness, and basically they are not so much aware of what they are doing, they are not really responsible for what they are doing, and because of their mental illness you don’t know how far they would go, so they are really dangerous, … (I:17)

22. Conclusions • Accounts reveal the ambivalent constructs of PI as a protective device and as a strategy for management and control. • PI a routine part of mental health care rather than part of ‘best practice’ - a ‘necessary evil’ rather than a last resort.

23. Pervasive Cycle

24. Implications for Practice • Improved training: rebalancing the amount of time devoted to early intervention skills • Improved reflective practice: a system of mandatory clinical supervision and rigorous post-incident review • Incident and trends analysis with a view to highlighting good practice