Reducing restrictive practices

Mental health nurses play a pivotal role in ensuring inpatient wards deliver safe, therapeutic interventions. To promote recovery on mental health wards is not just about numbers, but effective, therapeutic relationships between nurses and service users.

Use of Force Act 2018 – New Legislation for Mental Health Unit’s in England

In 2010, Olaseni (Seni) Lewis died aged 23, after being restrained on a mental health ward by police officers. At the inquest, the restraint used was deemed to be excessive, unreasonable and disproportionate. Following the death of Seni, Steve Read MP for Croydon North, put forward a bill that would make organisations legally accountable for ensuring the use of force (i.e. restraint) is minimised, reported and effectively reviewed.

Also known as "Seni's Law" The Mental Health Units (Use of Force) Act received Royal ascent in 2018. The Act set out to make provision about the oversight and management of the appropriate use of force in relation to people in mental health units; to make provision about the use of body cameras by police officers in the course of duties in relation to people in mental health units; and for connected purposes.

In August 2021, we published our consultation response to: Mental Health Units (Use of Force) Act 2018 statutory guidance. As the main professional group implementing and delivering care within inpatient mental health services, alongside patients and service users’, it was vital that the voice of nursing staff was heard throughout this consultation and beyond. Our response was developed in collaboration with a range of RCN members and staff.

The RCN’s response directly influenced the formation of the new statutory guidance, and was quoted in the Mental Health Units (Use of Force) Act 2018 statutory guidance - Government response: “Members feel that the definition of ‘use of force’ would benefit from the inclusion of direction around the ‘type of force' used, in relation to the age and cognitive development of the person.” (December 2021 pp: 13).

The new statutory guidance aims to:

• clearly set out the measures that are needed to prevent the inappropriate use of force.
• ensure accountability and transparency about the use of force in mental health units.

It is vital that all nurses, support workers and managers working within mental health units are fully aware and compliant with this new legislation.

Congress 2018

Congress 2018 provided the opportunity to call on RCN Council to commission research into therapeutic staffing levels for mental health nursing and raise awareness of ways to reduce restrictive practices. There remains significant variations across UK services. We want to see improvements across all inpatient services by sharing good practice initiatives and lobbying for safe therapeutic environments and safe staffing levels. This will help to promote creative dialogue, true understanding, trust and coproduced service change with those in our care within mental health settings.

Safe Wards

Current national mental health policy emphasizes reducing use of restrictive practices in inpatient mental health services. The challenges facing staff on psychiatric wards are great.  Mental health nurses play a pivotal role in caring for some of the most vulnerable and disenfranchised people in our society, many of whom struggle to acclimatise to ward environments. It is clear from the numerous follow up studies and testimonials SafeWards has proved to be invaluable to inpatient mental health teams. Armed with staff and patients narratives and positive outcomes, Trust managers now have tangible evidence to demonstrate the cost effectiveness of SafeWards implementation.

The most important part of SafeWards is that patients and their families ‘get it’ and love it. Where the SafeWards model has been introduced, there have been significant reductions in incidents of aggression, violence, self-harm, suicide, absconding and substance use as well as reduced use of medication, physical restraint, seclusion, special observation. Wards are nicer places to visit. Inpatient staff now have tools, knowledge, skills and confidence to deescalate concerns, manage conflict proactively and resolve incidents. This empowerment for both staff and patients has been replicated not only in UK inpatient wards but internationally, evidence of good practice exchanges can be found in SafeWards Facebook social media exchanges with its 8,000 members and its website that is translated into seven languages.

The SafeWards model has led to a safer, calmer working and therapeutic environment for both staff and patients. The work of the researchers and those who are implementing the interventions are testament to the strong ethic that Mental Health Nurses hold - that is seeking to hold the hope and to influence recovery wherever the person, their family and social networks are.  

Safe Wards are designed and evaluated by UK mental health nurses, and are the most robust and efficacious techniques available to our profession. They have been replicated and used nationally and internationally. 

For examples of best practice pre and during COVID-19, see: Royal College of Psychiatrists - Reducing Restrictive Practice Collaborative  

Training

The Restraint Reduction Network is the body who will be putting together Training Standards with Health Education England. In doing so, they note: "The Training Standards will be mandatory for all training with a restrictive intervention component that is delivered to NHS commissioned services for people with mental health conditions, learning disabilities, autistic people and people living with dementia in England. Implementation will be via commissioning requirements and inspection frameworks. This includes services in the independent, private and voluntary sectors."

REsTRAIN YOURSELF

This toolkit covers the REsTRAIN YOURSELF programme which encompasses the six Core Strategies.

The REsTRAIN YOURSELF programme is based on the US model, which was developed through extensive literature reviews and dialogues with experts. Use of this model has successfully reduced the use of restraint and seclusion in a variety of mental health settings, for children and adults across the US and internationally. This programme draws on complex adaptive theory and human factors theory, in order to bring about the changes needed to avoid causing harm to patients through the use of restraint. For more information, see: REsTRAIN YOURSELF.