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In defence of the indefensible: The use of restraint in health care settings

Joy Duxbury is Professor of Mental Health Nursing at the University of Central Lancashire and leads on research into mental health and wellbeing within the Faculty of Health and Wellbeing. She has a clinical background in forensic mental health although her focus in more recent years has been on acute adult psychiatric settings.

Emma Sandon-Hesketh, Research Development Manager and Alison Naylor joined Joy in her office in Brook Building to find out more about her research and work of the Centre for Mental Health & Wellbeing.

As lead for the Centre for Mental Health & Wellbeing, can you give an overview of the research currently being undertaken within the Centre?

We take the lead for mental health research within the School of Health. One of our main focuses of research is service user engagement, partnership working and collaboration. We all have different interests with regards to this, which has led to 5 specific strands of activity within our Centre. One area of investigation led by myself is that of coercive practice in psychiatry.

Joy Duxbury

This includes some elements of social justice with a focus on the in-patient setting and has resulted in a strong national and international reputation in this area. I am a board member of the European Violence in Psychiatry Research Group (EViPRiG) and has been invited to take over as President in October 2013. I have also been co-opted onto the NICE Guideline Development Group for a review of existing guidelines on the prevention and management of violence in healthcare settings in the UK. Karen Newbigging leads on advocacy. She has been influential in informing policy related to advocacy services in the UK and has worked alongside a dedicated group of services users on a recently funded DH project. Dr Mick McKeown has an interest in secure mental health services, critical social theory and action research. He explores the ways in which service users can make a real difference to therapeutic practices and is recognised for his research and critical thinking on service user involvement, linking activism and the academy. Professor Tim Thornton and Dr Gloria Ayob major in the philosophy of mental health and have a particular interest in recovery and delusional ideation. Both give an important theoretical and philosophical underpinning to the work that we do. Dr Sue Hacking works closely with colleagues in Social Work and explores the value and impact of art on mental health.

We each have a number of research students who are aligned to the work that we do.

Additionally, a number of lecturing staff from the Mental Health division of the School work closely with the Research Centre. Karen Wright and David Pulsford, for example, are working on projects aligned to self-harm, eating disorders and older people’s services. Working closely with teaching staff means that we are in an ideal position to promote research informed teaching.

Your work involves service user engagement and the exploration of patient views. Can you comment on how your work has impacted in NHS settings?

Service user involvement is high on the agenda across the spectrum of health and social care. Additionally, funding bodies expect you to demonstrate that there has been public and patient involvement in all aspects of research. UCLan has been ahead of the game for some time in that we have COMENSUS (The Community Engagement and Service User Support Group). This motivated and innovative group has had a huge impact on the student experience at the university and in the preparation of practitioners. They are actively involved in teaching, conferences, writing papers, contributing to research and have led on the 1 in 4 Film Festival at UCLan for a number of years now.

My own research involving service users has made a difference in that by endeavouring to understand patients’ and carers’ perspectives, one can target or shape interventions or approaches that are most meaningful. If you only focus on the views of practitioners you can get a very one sided, paternalistic view. Furthermore, when compared to the views of services users, their responses can be somewhat different. This has been highlighted in a range of my work to date.

Dr Mick McKeown has conducted a number of studies using a method called appreciative inquiry. This approach examines in-depth issues and informs participants in an endeavour to promote positive practices. Services user involvement is central to this design. This echoes some of our proposed research using Experience Based Co-Design.

A number of our students are also actively engaged in participatory action research.

My own work on aggression has informed both policy and practice with regards to exploring the views of patients and using this to shape services and therapeutic approaches that are more proactive. The Management of Aggression and Violence Attitude Scale (MAVAS), which I developed in 2003, has been particularly influential.

Your work on aggression and violence has also resulted in the development of an attitude scale to explore and compare perspectives – can you explain this?

The MAVAS identifies 27 statements about attitudes that underpin theories of aggression and violence. So for example, there are 3 theoretical underpinnings in the literature as to why patients might become aggressive or violent in health care settings. They represent what I call ‘internal’, ‘external’ and ‘situational’ factors. Mental illness is an example of an internal factor. Then there are environmental factors, for example in-patient settings and ritualistic behaviours, which may contribute to aggression and violence.

One example that was relayed to me recently involved the televising of an England football game, which had gone into extra time. On a mental health unit, there was a ‘rule’ that the television was to be turned off at a set time in the evening. The night-shift staff arrived and a nurse turned the television off and walked away. The patients had been watching the match. Well you can imagine! Mayhem ensued. Sometimes we have to be flexible dependent on the situation and circumstances. The environment can also include physical features such as heat, cold, and overcrowding etc. The biggest influential factor in the development of aggression, however, in my view, is what I call situational/interactional factors. In other words the interaction between staff and patients in a specific context can be hugely indicative of the relationships formed and the practices employed. From using MAVAS I have found that patients will always score highly on their views about the impact of interpersonal relationships and how they can lead to aggression and violence. Staff less so. Some staff may score more highly on the internal and environmental items of the scale.

The idea is that MAVAS can also be used to ascertain the views of both patients and staff about different approaches, for example restraint, seclusion, medication, and de-escalation. In this way, comparisons can be shared to inform strategies such as advance directives. The MAVAS has become so popular that it has been translated into a number of languages and used worldwide.

When restraint is applied there is the potential for a criminal charge to be made – to what extent does this happen and what impact do you think the potential for a criminal charge to be levied has on the practice of that?

It is not just mechanical restraint to be truthful. On the whole in the UK we no longer use mechanical restraint except in a small number of forensic services or special hospitals. However, I am hugely opposed even to this. I think there are other ways of dealing with challenges and I think there are other approaches that we can use. The whole idea of using mechanical restraint on people who have a mental health problem feels philosophically wrong to me. With regards to criminal charges, if you were to physically restrain someone illegally, then the chances of criminal prosecution may be high. The arguments, legally and ethically, on anything like this revolve around the principles of necessity, immediacy, duty of care, and reasonableness. It’s the same with the use of force in any situation, not just restraint, or when employing breakaway techniques. Clearly if somebody approached you in a threatening manner and you threw them to the floor and beat them over the head repeatedly, that would not be viewed to be proportionate or acceptable. It is about the context. All factors have to be considered when balancing self-preservation with self-presentation.

What is so awful about mechanical restraint? Why is it worse than the alternatives?

In truth, and its no surprise, I don’t like restraint per se. However, it is a difficult one because there will always be incidents when people may be at risk. Consequently there have to be ways to deal with such occurrences. My problem with the use of restraint is that it can be overused and not always adopted as a last resort. There are innovations in the USA that we should look to more. For example the Six Core Strategies (6CS). This approach is in response to a number of patient deaths whilst in mechanical restraints, particularly when in the ‘prone position’ where somebody is laid face down. From the work we conducted for the Ministry of Justice last year, on medical theories of restraint related deaths, we found the ‘prone position’ to be particularly dangerous. The respiratory system can be compromised. There have been reported cases where practitioners have failed to notice that a patient is suffering respiratory distress, assuming that their silence equals co-operation. I would like to see a significant reduction in restraint and more research on the implementation and impact of restraint reduction models. The 2005 NICE guidelines on the prevention of aggression and violence are due for review this year and I am delighted to have been invited to join the guideline development group. Restraint is something I will be keen to talk about.

If you take out restraint what are the alternatives in those situations? Is this Six-Core Strategy an alternative?

Yes. It is not an alternative in the truest sense because it does not replace like by like. It is an organisational model that aims to put mechanisms and philosophies in place that focus on prevention rather than reaction.

In the States, they have seen significant reductions in the use of mechanical restraint and seclusion as a result of this model. However, because it is an organisational model it requires significant ‘buy in’ at a very senior level. It is called the Six Core Strategies because it has six stages. One of the key strategies is ‘root cause analysis’. Just by implementing root cause analysis and putting restraint high on the organisational agenda, people become more accountable and restraint incidents reportedly reduce. If there is a restraint incident, at whatever time of day or night, there is a review and a critical incident analysis of the event. This requires an exploration of the precipitators, who was involved, how the situation was dealt with, and the possible alternatives. The 6CS also incorporates a great deal of service user involvement, promotes the ideology of trauma informed care, and education and practice that fosters partnership working.

Would you agree that an organisation should have a protocol that talks about restraint as utterly exceptional? That it must only be used as last resort?

Restraint should only be used as a last resort. This viewpoint is well articulated in the UK but effective implementation appears less well actioned upon. People need to think more before they react. We have recorded 38 restraint related deaths in the UK, 7 of which were in mental health services. Training needs to focus more on trauma informed care. Practitioners need to be reminded that when they lay hands on somebody and restrain them, there are psychological as well as physical implications. There are recommendations on the principles of restraint, but no definitive guidelines on what should and shouldn’t be used. We don’t have a good evidence base. Our Ministry of Justice report, therefore, is of significant value. There is now an independent advisory panel dedicated to this issue.

You have actually concluded in your ‘Restraint Related Deaths Report’ that there is no safe restraint technique?

That is correct but it’s not straightforward.

For example, if we suggest from what we know that it is only the prone position that is particularly risky, we ignore some of the literature, albeit scarce, reporting injuries and trauma related to restraint more broadly. There have been some reported deaths in America when patients have been placed in the supine position. Rather than focusing solely on positions and profiles, I am much more in favour of promoting positive interpersonal relationships, cultures, attitudes and therapeutic partnerships.

Picking up on your point about cultural aspects, one of the things that the Bennett Enquiry did pick up was that there was reported institutional racism. To what extent does what you have seen bear that out?

I think that we still have long way to go.

In our review whilst we were only able to look at tentative trends related to 38 deaths, there were notable patterns with regards to individuals with mental health problems, learning disabilities, people from black and ethnic minorities and men between the ages of 30 and 40. Additionally persons with predetermined medical conditions, for example, underlining cardiac problems or obesity may be at significant risk particularly

if these matters are not recognised. Patients from certain minority groups are reportedly more likely to be arrested and still more likely to be institutionalised as a result of a psychotic illness. I hope that our review can add to the evidence base in this area.

To what extent do you think that any increase in mental health illness is because of substance and alcohol abuse?

We know that there is an association between psychotic episodes and substance abuse. There has been a long standing argument that ‘softer’ drugs such as Cannabis are not damaging, when in fact there is increasing evidence that this is not the case, particularly with regards to anxiety related disorders and depression. My concerns however with regards to focusing upon an association between aggression and violence and substance abuse, specifically in inpatient settings, is that there are many more variables to consider. The Royal College of Psychiatrists in 1998 suggested a profile of aggressive patients identifying somebody who was male, young, with drug and alcohol problems and a history of mental health illness to be most violent. This can be damaging if taken out of context. It goes back to my point that aggression is multidimensional and is often the result of a mix of internal, external and interpersonal variables in healthcare settings.

A profile of this sort sounds more like prejudice than empirical evidence?

Yes, I have been critical of this perception, which in my view can lead to a blame culture. In fact, it can precipitate ineffective campaigns such as the ‘Zero Tolerance Campaign’ in the late 1990s. Remnants can still be seen in Emergency Departments and GP surgeries. The incidence of aggression and violence is often more to do with the environment than the illness, or relationships and interpersonal communication. Local evaluation of needs and perspectives is hugely important. Whether this is an evaluation of a hospital, or a ward, whatever the problems, they will be very specific and individual to that environment and context. Organisations need to be proactive and use strategies such as the MAVAS and advanced directives. They need to audit their environment and conduct root cause analysis, and they need to speak to people in order to build a picture of reported difficulties in order to address them in a targeted and meaningful fashion. The blanket and indiscriminate application of national and regional policies and standards is not always the answer.