Injuries sustained during physical interventions (PI) within one secure service

1. Injuries sustained during physical interventions (PI) within one secure service Research team: Professor Andy Lovell (University of Chester) Paula Johnson (Research Lead, Calderstones NHS Foundation Trust) Debbie Smith (Research Assistant, University of Chester)

2. Physical Intervention Definition • “A method of responding to the challenging behaviour of people with learning disability and/or autism which involves some degree of direct physical force which limits or restricts the movement or mobility of the person concerned.” (Physical Intervention code of practice, BILD) • “Physical intervention I should only be used as a last resort to control aggressive and untoward incidents where it is necessary to protect the person/or others from harm and is proportionate to the risk of harm” (Calderstones, 2011, Procedure no. 27.2)

3. Physical Intervention Methods – CITRUS & Enhanced PI • The CITRUS Training model was developed by Calderstones Partnership NHS FT in 1997 • Last resort, least restrictive possible • NO “pain compliance” techniques, use of T-supine position • Accredited by the British Institute of Learning Disabilities • Used by 20 services mainly in NW England. • Enhanced Physical Intervention procedures • Introduced in 2006 for individual service users • “Pain compliant”  techniques involve wrist flexion and prone restraints, safe transfer to seclusion • Accredited by Merseycare NHS Trust

4. Background to use of Physical Intervention • Historically PI used in both mental health and LD secure services (Murphy et al., 2003) • NICE (2005) • No guidance published specifically for LD • There is risk of injury to staff and clients during PI (Hill & Spreat 1987) • Parkes et al (1996) found the introduction of PI on an MSU led to an increase in staff injury • Staff injury rates reported consistently higher than client injury • Lancaster (2008)- staff injury more likely when assault occurs prior to PI

5. Background to current research - Staff/Client Injury Rates from review 2011 • Service review January to September 2011 – staff injury rates • Range over 9 months from 6%-13% = average of 8% staff injury vs average of 2% client injury over 9 months • Consistent with published findings from similar services • Lancaster et al (2008): 17% vs 4% • Stubbs et al (2009): 6.5% vs ,1% • Lee et al (2003) reported that not only were staff injuries more frequent, the injuries sustained were often more serious

6. Background to current research – Discussion of findings • Injuries caused by assaults on staff by service user account for 84% of injuries • Similar findings to Wynn (2003)- 70% of staff assaulted in connection with PI • Lancaster et al. (2008) - assault on staff prior to the incident was highly significant • However, most of the data is from psychiatric hospitals, not LD services

7. Current research approach Research Questions: • To examine specific incidents of aggression involving service users and necessitating the decision for physical restraint to be implemented. • To identify the points at which staff injuries are sustained (i.e. prior to, during the process of restraint, or during re-escalation). • To examine how the circumstances surrounding injuries sustained relate to the process of physical intervention. Specific objectives: • To ascertain how staff injuries are sustained during incidents involving physical interventions. • To assess the effectiveness of the CITRUS and EPI systems in minimizing staff injuries.

8. Methodology • Qualitative framework to complement the statistics derived from the clinical review. • 10 incidents involving PI & staff injuries selected. • Multiple sources of data collection (semi-structured interviews; PRISM notes; violent incident forms). • Some demographic information (age, gender, qualifications, length of experience). • University & Trust Research Ethics Committees successfully negotiated.

9. Sample • 2 staff members selected for interview from each of the 10 incidents. • 1 qualified and 1 unqualified staff. • Participant Information Sheet provided to each participant. • Informed Consent obtained. • Semi-structured interview schedule devised and utilised.

10. Data Analysis • Triangulation: analysis of interview material + clinical records + incident reports – data analysed collaboratively. • Thematic framework (Braun & Clarke, 2006): data subject to systematic analysis for codes and categories; relevant themes subsequently produced. • The qualitative software package MAXqda was employed to assist the analysis.

11. Initial findings: Individuality of service users • “you wouldn’t want the ward to go to a level where there’s people who don’t know the clients….we’ve also got people with autism you know, who’ve got particular needs around the familiar and a routine…one particular man who, if he doesn’t know you, you know, he doesn’t trust you” [qualified staff member] • “it was only my third day of working on there; I’d only met the lady twice and the other member of staff I was working with didn’t know her either…I went to physically restrain her; both of us obviously didn’t know what technique she was written up for, what de-escalation worked best for her, didn’t know her risks, so she managed to bite me on the arm” [qualified staff member]

12. Changing profile of service users • “the sort of clients that are coming through now, they’re not your stereotypical…you know, people with just learning disabilities; there’s a lot of social problems with people obviously coming from…you know, like young adolescents coming from prisons and things; I think the clientele is changing a bit” [qualified staff member] • “they’re getting more streetwise…younger, substance misuse, more personality disorder, more mental health, there’s just a change. I’ve seen it over the last few years, it’s really altered” [unqualified staff member]

13. Restraint techniques • “when you’ve not got the physical body capacity to get hold of somebody who’s like 2 foot taller than you, and who’s arm doesn’t fit your grip, you know…you’re not physically able to do it even though your techniques are the same as anybody else's and with the men, they tend to be quite big” [qualified staff member] • “the training that you do, it’s very measured and you go down on one knee and that’s…and I think sometimes when you’re actually in that situation, you know, that that person isn’t fighting and isn’t a strong person, with adrenaline; it’s a lot different to what you will learn in training and I think everybody would agree with that, that’s the difficulty [qualified staff member]

14. Effects of aggression and injuries on staff • “you get verbally abused every day…you are like saying ‘was it my fault [the assault], have I done something to upset her?’ You kind of go over it in your head” [unqualified staff member] • “I hate taking time off, I was absolutely devastated; I mean, the ward…it was really busy…it was very, very upsetting on so many levels for me, it made me realise how being assaulted affects not just your physical self but your mental self [qualified member of staff] • “nothing I have done warrants me getting assaulted and it’s very frustrating and it’s very distressing when it does happen” [qualified staff member]

15. Staff skills • “I would try and give them time; if they’re just having a bang about, banging walls and just having a shout…if you just run in, you know you’re going to make that situation worse” [unqualified staff member] • “it’s just being aware…and everyone in the situation, in the intervention, being aware of what that client is capable of, you know, using your skills that you’re taught and seeing, watching”[qualified member of staff] • “a lot of people with learning disabilities are going to have mental health problems and I think learning disability nurses lack that and I think they’ve put too much focus on the learning disability rather than the behavioural problems and the mental health issues” [qualified member of staff]

16. Summary of findings • Individuality – knowing the client, routines, risks, issues • Changing service user profile – streetwise, young, stronger, different background (e.g. prison), dual diagnosis • Physical restraint issues – size, weight. Simulated training – can it be applied to real life situation? (adrenaline, fuelled emotions, unpredictability) • Effect of violence/aggression on staff – tolerance, emotional and mental effects, self-blame, frustration and distress • Staff skills – Importance of de-escalation techniques, relationship building, listening/empathy, skill-set requirements changing ?