This is a repository copy of Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme ('REsTRAIN YOURSELF').

Accessible summary What is known on the subject? Mental health nursing in the UK and other countries faces an acute workforce crisis. Safe staffing levels are called for, and in some jurisdictions have been legislated for. The evidence base linking staffing levels and patient outcomes is limited. Staffing levels are implicated in adverse experiences of service users and staff within mental health ward settings, and they might contribute to levels of violence and aggression and the application of restrictive practices, such as physical restraint but there is limited research evidence to support this. Programmes such as Safewards, No Force First, the Engagement Model and the Six Core Strategies can reduce the use of restrictive practices. What does this paper add to existing knowledge? Staffing levels on acute mental health wards appeared crucial in the implementation of a restraint minimization project. Both staff and service users implicate insufficient staffing for deficiencies in the relational elements of care, such as lack of face‐to‐face contact between nurses and service users. Similarly, staffing levels are associated with perceived problems in the cause of violence and aggression and responses to it. Despite successes in minimizing restrictive practices in this project, difficulties implementing alternative forms of practice that would reduce use of physical restraint, such as de‐escalation, were also attributed to staffing levels. There is an irony that a project concerned with safety itself provoked concern over safe staffing levels. What are the implications for practice? Efforts to reduce restrictive practices will be hampered without adequate staffing levels. Restrictive practices may justifyably be framed as an employment relations matter. Organisations and policy makers ought to address environmental, contextual and resourcing factors, rather than identify problems exclusively in terms of perceived aberrant behaviour of staff or service users. Abstract IntroductionSafe staffing and coercive practices are of pressing concern for mental health services. These are inter‐dependent, and the relationship is under‐researched. AimTo explore views on staffing levels in a context of attempting to minimize physical restraint practices on mental health wards. Findings emerged from a wider data set with the broader aim of exploring experiences of a restraint reduction initiative. MethodsThematic analysis of semi‐structured interviews with staff (n = 130) and service users (n = 32). ResultsFive themes were identified regarding how staffing levels impact experiences and complicate efforts to minimize physical restraint. We titled the themes—“insufficient staff to do the job”; “detriment to staff and service users”; “a paperwork exercise: the burden of non‐clinical tasks”; “false economies”; and, “you can't do these interventions.” DiscussionTendencies detracting from relational aspects of care are not independent of insufficiencies in staffing. The relational, communicative and organizational developm...

Coercive practices, such as physical restraint, are used globally to respond to violent, aggressive and other behaviours displayed by mental health service users.1 A number of approaches have been designed to aid staff working within services to minimise the use of restraint and other restrictive practices. One such approach, the ‘REsTRAIN Yourself’ (RYS) initiative, has been evaluated in the UK. Rapid ethnography was used to explore the aspects of organisational culture and staff behaviour exhibited by teams of staff working within 14 acute admission mental health wards in the North West region of the English NHS. Findings comprise four core themes of space and place; legitimation; meaningful activity; and, therapeutic engagement that represent characteristics of daily life on the wards before and after implementation of the RYS intervention. Tensions between staff commitments to therapeutic relations and constraining factors were revealed in demarcations of ward space and limitations on availability of meaningful activities. The physical, relational and discursive means by which ward spaces are segregated prompts attention to the observed materialities of routine care. Legitimation was identified as a crucial discursive practice in the context of staff reliance upon coercion. Trauma‐informed care represents a potentially alternative legitimacy.

International efforts to minimize coercive practices include the US Six Core Strategies© (6CS). This innovative approach has limited evidence of its effectiveness, with few robustly designed studies, and has not been formally implemented or evaluated in the UK. An adapted version of the 6CS, which we called 'REsTRAIN Yourself' (RY), was devised to suit the UK context and evaluated using mixed methods. RY aimed to reduce the use of physical restraint in mental health inpatient ward settings through training and practice development with whole teams, directly in the ward settings where change was to be implemented and barriers to change overcome. In this paper, we present qualitative findings that report on staff perspectives of the impact and value of RY following its implementation. Thirty-six staff participated in semi-structured interviews with data subject to thematic analysis. Eight themes are reported that highlight perceived improvements in every domain of the 6CS after RY had been introduced. Staff reported more positively on their relationships with service users and felt their attitudes towards the use of coercive practices such as restraint were changed; the service as a whole shifted in terms of restraint awareness and reduction; and new policies, procedures, and language were introduced despite certain barriers. These findings need to be appreciated in a context wherein substantial reductions in the use of physical restraint were proven possible, largely due to building upon empathic and relational alternatives. However, yet more could be achieved with greater resourcing of inpatient care.

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Restrictive interventions (RI), such as physical restraint, seclusion, and rapid tranquilization, can have negative psychological effects on service users; however, there has been little investigation regarding their effects on women. The aim of this paper was to explore women's experiences of RI within UK inpatient mental health services. Twenty women accessing inpatient mental health services participated in semi-structured interviews. Using thematic analysis (TA), three primary themes were reported from women's experiences: (1) powerlessness, (2) dehumanization, and (3) relationships and communication. Clinical recommendations included ensuring gender-awareness and trauma-informed care training is mandatory for all mental health staff, for RI training to include awareness of gender differences, and for policies to be reviewed with regard to women being invasively searched and ensuring sanitary products are safely available for women within seclusion. Directions for future research include investigating the experiences of RI for women from minority ethnic groups and exploring important moderators and mediators in the relationship between RI and re-traumatization for women.

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