The Atlas of Shared Learning

Case study

Addressing unwarranted variation in physical restraint use across adult acute mental health inpatient wards

Leading change

A mental health nurse leader at Salford Royal NHS Foundation Trust has identified and addressed unwarranted variation in the use of physical restraints in mental health services. Introducing additional training and supportive techniques to reduce the use of physical restraints across seven pilot trusts has provided evidence for this work to be rolled out further across the North West of England.

The nursing leadership team have advocated partnership working with patients and carers to reduce the need for physical restraint use as well as empowering staff through additional training, which has tackled the triple aim outcomes of better outcomes, experience and use of resources.

Where to look

A mental health nurse, working both at ward level and as an academic mental health researcher, identified unwarranted variation in the use of physical restraints in mental health services, based on the evidence in the MIND report (2013). Across the country there was variation (from <40 to >3000 restraints used annually per Trust). Salford Royal NHS Foundation Trust, in the North West was in a geographical area where the levels of restraint use were amongst the highest in the country.

What to change

Having identified the unwarranted variation, the mental health nurse leader recognised the opportunity to strive for positive behaviour change on the mental health wards. Nursing teams, supported by Advancing Quality Alliance (AQuA), a regional quality improvement organisation, and by an experienced nurse improvement advisor, led on implementing strategies to observe, challenge and engage the teams in behaviour change management. There was a target to shift the culture of the wards teams in their use of physical restraint as a technique, to avoid use where appropriate to do so, and replace this approach with restraint reduction based techniques.

Guidance has been published aimed at reducing the use restraint of across health and social care ( website; 2014 Lamb Review). The NICE Guidance (2015) also states “Health and social care provider organisations should ensure that all services that use restrictive interventions have a restrictive intervention reduction programme to reduce the incidence of violence and aggression and the use of restrictive interventions.”

Ward champions within nursing teams worked with patients on the ward to support the development of a ‘My Safety Plan’, a self-management tool to help patients identify triggers, early warning signs and strategies to calm themselves down if they were able, aiming to work closely with patients and carers in a personalised, partnership way.

The mental health nurse leader also supported other nurses and colleagues to use visual data (e.g. safety charts and statistical process charts (SPC)) which helped them to have a broader understanding of the real-time context on the ward. This has helped teams to identify variation and seek solutions to reduce it.

The learning from this restraint reduction programme aims to be rolled out across 5 wards per trust in the North West, supporting an evidence based approach to reducing restraint reflecting a focus to lead and drive research to evidence the impact of what we do, reflecting Commitment 7 in LCAV.

How to change

This quality improvement programme was supported by funding from the Health Foundation. It allowed Salford Royal NHS Foundation Trust to identify ward champions from within the nursing teams to lead on implementing the improvements in prevention, restraint reduction and empowering staff to feel confident in decision making around whether restraint was needed.

The mental health nurse leader was affiliated with the University of Central Lancashire as a clinical academic. Seven mental health trusts across the North West were involved in rolling out the restraint reduction approach; Cumbria Partnership NHS Foundation Trust, Lancashire Care NHS Foundation Trust, Five Boroughs Partnership NHS Foundation Trust, Manchester Mental Health and Social Care Trust, Merseycare, Cheshire and Wirral Partnership NHS Foundation Trust and Pennine Care NHS Foundation Trust.

The nurse leaders (champions) implemented a range of tools from debriefs, safety plans, handovers, community meetings, comfort rooms and increased activities on the wards with an aim to reduce physical restraint on acute mental health wards by 80% by June 2017.

Adding value

  • Better outcomes – There have been marked improvements in the use of physical restraint, enhancing patient safety. Across the 7 ‘pilot’ wards, there has been a steady reduction in physical restraint with some wards seeing a 50-60% improvement over the first 18 months. The nursing leadership team will continue to monitor this downward trend and to support the momentum will continue to share the learning to ensure sustainability. The pilot is being rolled out with approximately 40 wards across the North West (5 wards per trust) over time. The team are measuring improved patient safety by reducing the level of unnecessary restraint and this has an impact on also reducing incidents of harm caused to patients and staff. The teams have anecdotal evidence of reducing restraint without increasing the use of PRN/‘as needed’ medication or transferring patients to Psychiatric Intensive Care Units (PICU) or seclusion.
  • Better experience – The nurse leaders have observed increases in patient (and carer) satisfaction. Nurses have been told by patients and carers that they feel increased dignity and respect and reduced distress, which can be experienced by restraint practices. The nurses are planning to use baseline assessments to measure the confidence a ward manager and their team have in implementing these improvements; patient surveys, safety crosses and SPC charts will be used to collect and analyse this data.
  • Better use of resources – The ward teams have expressed that they have been fully supported and trained to incorporate restraint reduction approaches into their high quality patient care. This demonstrates Commitment 8 of LCAV in action, to “have the right education, training and development to enhance skills, knowledge and understanding”.

Challenges and lessons learnt for implementation

  • The opportunity to implement an evidence based programme has been well received and has supported the team’s clinical effectiveness.
  • The project is supporting co-production with patients and service users, particularly promoting the development of peer support worker roles within acute inpatient wards.
  • The team are striving to standardise their approach to continue to reduce restraint in the long term, which will in turn reduce the risks of staff and patient injuries which will impact on sickness rates for staff and recovery rates for patients. This will be monitored over time.

Find out more

For more information contact:

Paul Greenwood

Mental Health Nurse / Academic Researcher

Salford Royal NHS Foundation Trust