Reducing Restrictive Practice on a Medium Secure High Dependency Forensic Inpatient Unit

Abstract

Aims

Restrictive practice can include physical and chemical restraint and should be utilised as a last resort. It has been found to negatively impact patients causing psychological distress, re-traumatisation, and a sense of helplessness. Restrictive practice also negatively impacts staff, causing emotional distress, moral conflict and the risk of physical harm. Since 2018, there has been a drive to reduce restrictive practice in inpatient mental health wards across England by the National Collaborating Centre for Mental Health, which has been further developed by NHS England in 2021 within the Mental Health Safety Improvement Programme (MH-SIP). This study aims to reduce restrictive practice on a 10-bedded Medium Secure High Dependency Male Forensic Mental Health Unit over a 6-month period, incorporating staff and patient feedback and utilise QI methodology.

Methods

Number of total seclusion hours, seclusion episodes and secluded patients per day were measured at baseline utilising the Rio clinical system and continuously tracked during the study period. Interventions were discussed by a multi-disciplinary team including nurses, pharmacists, health care assistants, occupational therapists, psychologists, and doctors. Patients were invited to give feedback on restrictive practice during ward rounds. Potential interventions were then implemented utilising PDSA methodology with iterative changes tested and analysed. Staff and patients were also invited to complete surveys and semi-structured interviews to give further comments during the study.

Results

Baseline data of monthly activity showed 3,758 total seclusion hours, 10 seclusion episodes and 5.3 seclusions per day. Iterative interventions included; (i) MDT discussions to support positive risk taking (ii) Improved collaborative care planning with patients (iii) Incident calendars for patients (iv) excel spreadsheet indicating progress towards leave / referral to stepdown ward and (v) improving transparency on impact of incidents on progress. Month 6 activity showed 174 total seclusion hours (95% reduction), 1 seclusion episode (90% reduction), and 1 average seclusion per day (82% reduction). A survey completed at the end of the study period showed all patients either strongly agreed or agreed that they understood the process for termination of seclusion, with 100% either responding between “neutral" to "strongly agree” that this had improved.

Conclusion

It was hypothesised that a more collaborative approach with positive risk taking could lead to the reduction of restrictive practice. The interventions enacted have significantly reduced the use of restrictive practice. Further study is recommended into these interventions to review if similar results can be replicated in other inpatient wards.