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Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme (‘REsTRAIN YOURSELF’)

Duxbury, Joy and Baker, John and Downe, Soo and Jones, Fiona and Greenwood, Paul and Thygesen, Helena and McKeown, Mick and Price, Owen and Scholes, Amy and Thomson, Gill and Whittington, Richard (2019) Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme (‘REsTRAIN YOURSELF’). International Journal of Nursing Studies. ISSN 0020-7489


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Background Physical restraint is a coercive intervention used to prevent individuals from harming themselves or others. However, serious adverse effects have been reported. Minimising the use of restraint requires a multimodal approach to target both organisational and individual factors. The ‘Six Core Strategies’ developed in America, underpinned by prevention and trauma informed principles, is one such approach. Objective An adapted version of the Six Core Strategies was developed and its impact upon physical restraint usage in mental health Trusts in the United Kingdom evaluated. This became known as ‘REsTRAIN YOURSELF. The hypothesis was that restraint would be reduced by 40% on the implementation wards over a six-month period. Design A non-randomised controlled trial design was employed. Setting Fourteen, adult, mental health wards from seven mental health hospitals in the North West of England took part in the study. Two acute care wards were targeted from all eligible acute wards within each site in negotiation with each Trust. The intervention wards (total n = 144 beds, mean = 20.1 beds per ward) and control wards (total n = 147 beds, mean = 21.0 beds per ward) were primarily mixed gender but included single sex wards also (2 female-only and 1 male-only in each group). All wards offered pharmacological and psychosocial interventions over short admission durations (circa 15 days) for patients with a mixture of enduring mental health problems. Method As part of a pre and post-test method, physical restraint figures were collected using prospective, routine hospital records before and 6 months after the intervention. Restraint rates on seven wards receiving the REsTRAIN YOURSELF intervention were compared with those on seven control wards over three study phases (baseline, implementation and adoption). Results In total, 1680 restraint incidents were logged over the study period. The restraint rate was significantly lower on the intervention wards in the adoption phase (6.62 events/1000 bed-days, 95% CI 5.53-7.72) compared to the baseline phase (9.38, 95% CI 8.19-10.55). Across all implementation wards there was an average reduction of restraint by 22%, with some wards showing a reduction of 60% and others less so (8%). The association between ward type and study phase was statistically significant. Conclusion In conclusion, it is possible that reductions in the use of physical restraint are achievable using a model such as the Six Core Strategies. This approach can be adapted for global settings and changes can be sustained over time with continued support.

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