Post Title

Restrictive practices are techniques such as physical restraint, seclusion and rapid tranquilisation used to limit a person’s liberties, movements or freedom to act independently in potentially dangerous situations.

The inappropriate or overuse of restrictive practice in mental health services has been identified as an area of concern in healthcare since at least 2015.

Beginning in 2021, the Health Innovation Network has been involved in local efforts to reduce restrictive practice based on the findings of a successful pilot led by the National Collaborating Centre for Mental Health.

We speak to HIN Patient Safety Project Manager Ayobola Chike-Michael, Ward Manager Lola Bakare, and Expert by Experience Igoche Ikwue about the programme team’s recent visit to a female acute mental health ward and their reflections on how sharing personal experiences and perspectives are key for further reducing restrictive practice.

Ayo

In my capacity as project manager for the Mental Health Safety Improvement Programme at the Health Innovation Network, I have had the opportunity to visit a few mental health wards in south London with my colleague Igoche Ikwue, who is an expert by experience.

One of the wards I was privileged to visit was Avery Ward, an acute female psychiatric ward. Despite their busy schedule, the staff welcomed us and we had the chance to meet the ward manager Lola, who later introduced us to other busy members of staff including the clinical consultant.

We had a fruitful conversation about the Ward’s approach to minimising restrictive practice. It was notable that the ward manager makes herself accessible through an open-door policy to both service users and staff. She described her unique approach as ‘we discuss, negotiate and we agree’.

This seems to be a working solution, despite experiencing the same challenge of high staff turnover which is common across these types of services. Situated in a deprived borough, the ward also faces system strain, evident in the long waiting list and pressure for beds.

Despite the dedication of staff, we learned that instances of violence and aggression affect both staff and patients. However, the team employs a range of verbal de-escalation techniques and other activities to de-escalate such as taking fresh air in the garden, and facilitating escorted leave, to manage and defuse tensions.

It was acknowledged that the pressures surrounding the ward can contribute to relapses among patients. We observed that the absence of a sensory room or equipment in the gym and the garden was in need of refurbishment. Nevertheless, plans were already underway to address these improvements and refurbish the ward.

We were told that staff experience emotional trauma from insults and violence from the service users (particularly the male staff). However, body-worn cameras have now been introduced to help take recordings of real time events.

It was evident that the staff have to daily work through a maze of challenges while trying to give quality care to the service users. We were very grateful for the open and honest conversations we had with Lola the ward manager and noted their laudable commitment to providing a safe and collaborative environment for both staff and patients.

Igoche

When I arrived at the ward, I had a positive interaction with a young man who was being discharged. We had a pleasant conversation, and he expressed his excitement about returning to his music. It set a promising tone for my visit.

As I continued exploring the ward, I noticed a slight tension in the atmosphere. There was a central glass office where the staff members and administrators worked. However, it was evident that there was a shortage of staff, which understandably was causing some challenges. Despite this, the ward manager Lola demonstrated true dedication to their role, striving to provide the best care and support possible.

During our conversation with the ward manager, Ayo and I clarified that our purpose was to support the ward and its service users. We discussed several concerns, including issues with the quality of food and the need for improvements, such as the functionality of facilities. Additionally, we addressed the struggle to find bed space for service user babies as the facilities were not designed to accommodate both mother and baby. The manager also mentioned plans to relocate the facility to another building, along with a positive update on recent recruitment. There is a specialised service for mothers and babies, so patient who requires a mother and baby bed will have to be transferred out.

As someone with expertise through personal experience, I firmly believe that staff members play a crucial role in providing care and reducing restrictive practices. It is essential to prioritise the well-being of both the service users and the staff themselves. Creating a safe and open space for caregivers to express their concerns without fear of negative consequences is vital.

Despite the strain caused by system constraints, the dedication and commitment of the staff members were evident. I also observed that the ward manager maintained an open-door policy, encouraging collaboration and engagement among service users and staff.

One particular moment stood out during our visit. As we were leaving the ward, a service user approached me, expressing her strong desire to see her children. Recognising the urgency of her request, I directed her to speak with the ward manager, who promptly attended to her with responsiveness and compassion.

My experience at Avery ward highlighted the importance of providing comprehensive support and care to service users while prioritising the well-being of staff members. The ward manager and their team demonstrated a commitment to creating a safe and collaborative environment throughout our visit. I am grateful for the opportunity to contribute my expertise and be part of the ongoing efforts to improve the ward.

Lola

As a ward manager, my philosophy is that personal relationships are at the heart of creating a calm, safe and positive environment for staff and service users, where the use of restrictive practice is minimised.

I have found that building those personal relationships tends to rely on flexibility and trying to have an understanding of the whole person.

For example, I have my own ‘open door’ policy. Staff and service users can always come to me with their problems and we will do our best to figure out a solution.

Often that means negotiating; realising that both sides have to give and take in order to find a position that works for everyone.

Sometimes it is finding a way to be flexible about the small details which can make the biggest difference. Allowing more flexibility with meal times has been one way where we have seen really positive impact with service users – from a practical point of view it raised some challenges, but I am so glad we worked through them to achieve something that the people on our ward wanted.

We try and make the ward as close to home as possible, whether that means encouraging staff to make the time for escorted visits off site or building relationships with the other people who are important in the lives of our service users.

Often, we find that working with family to overcome challenges is a really effective tactic. We have multi family groups which run once a month. Family/carers and patients are invited to this meeting. Our aim is to try and create one team of people all working together for a positive outcome; that strong team is I think a big reason why we have reduced the level of complaints and of the use of restrictive practice.

Our ward – like many others – has experienced difficulties with staffing in recent years. Our staff are well trained and skilled to deliver job role. As part of my team, I have a professional nurse advocate, who provides restorative supervision for staff, and we offer monthly training days for staff.

The Ward Manager also acts as our See Think Act consultant, helping to develop relational security. This has improved the way we deliver care to our patients; our staff maintain safe and effective relationships with patients in a professional, therapeutic and purposeful way, with understood limits.

Despite the difficulties we sometimes face, I am so proud of my team; they understand how to deliver great care (including reducing the use of restrictive practice) and they are motivated and committed to continuing to get better.