The recent, high-profile case of Olaseni Lewis who tragically died from hypoxic brain injury during a restraint in Bethlem Hospital continues to highlight the dangers associated with restrictive practices in healthcare settings. The case itself has resulted in the drafting of the Mental Health Units (Use of Force) Bill 2017-19 which is due to be considered in a Public Bill Committee in the House of Commons on the 21st of March. If the bill goes ahead, it will ensure a higher level of accountability on health care providers to use restrictive practices.

Following the national exposure of abuse which took place at Winterbourne View, recommendations were made in 2014, and legislation was changed in 2015, to ensure services adhere to providing care through least restrictive means. Due to the fine line between abuse and restrictive practices, the focus was on using restraint, rapid tranquilisation and seclusion as a very last resort, thus ensuring a focus on protecting the safety, autonomy and subsequent quality of life of service users in learning disability and mental health services. To ensure the provision of care is delivered in the least restrictive way, care providers are being asked to ensure frontline workers are fully trained in de-escalating behaviours which would otherwise result in restraint, rapid tranquillisation and seclusion.

The Risks of Restrictive Practices

Restraint: Olaseni Lewis’s death was not in isolation. Due to the way data on restraint and death is collated, there is no definitive count on the number of fatalities which have been linked to restraint in mental health settings, however, research shows that 78% of all deaths known to be caused by this restrictive practice between 2000 and 2013 were identified as patients detained under the Mental Health Act (1983). Examples of morbidity and mortality in physical restraint include respiratory depression, neuroleptic malignant syndrome, cardiac arrhythmia, positional asphyxia and excited delirium.

Rapid Tranquilisation: Furthermore, physical complications can arise depending on whether a patient is obese, physically disabled, has other physical health complications, and/or is being prescribed certain types of psychotropic/physical medication. As intramuscular medication such as benzodiazepines and antipsychotics come with further risk of seizures, arrhythmias and over-sedation, best practice recommends that rapid tranquilisation should only be used when all attempts to de-escalate violence and aggression have been exhausted.

Seclusion: The same rationale applies to the use of seclusion in mental health settings.Seclusion rooms must comply with standards to ensure patients’ human rights are not compromised. However, although patients are ensured access to a toilet, water, ventilation and furniture which can withstand breakages, the physical restriction caused by seclusion, poses an obstacle for physical healthcare interventions necessitated by restrictive practices. As seclusion is often used in combination with restraint and rapid tranquilisation, the health risks which occur from these can be exacerbated both by the stress seclusion causes, and the physical and psychological barrier which it puts between patient and nurse. Because monitoring of a patient’s vital signs  following restrictive practices is fundamental to safeguarding their physical health, staff are compelled to be near a patient to enable accurate measurement; but where this isn’t possible, the risk of adverse reactions is higher.

Organisational Pressures

Where restrictive practices are believed to have been misused, a patient is within their rights to take legal action against the staff member and the health board, resulting in a costly clinical negligence claim. Add to this the cost of sickness absence for staff injured during restraint, and the time taken to complete body maps, post-incident reviews, incident forms, and the recruitment of extra staff to monitor a patient’s progress post-incident, and it soon becomes apparent that restrictive practices are not only risky for the patient’s health and wellbeing, but for the staff’s and the organisation’s too.

A Focus on De-escalation Training

To counter both the human and financial costs of restrictive practices, best practice guidance guides services to deliver training which focuses on de-escalation. Recommendations suggest that training focuses on psychosocial interventions which are person-centred, have a values approach to care, and which promote the therapeutic relationship between patients and staff. Such interventions would be based on individualised, functional assessment of a patient’s behaviour, but include care fundamentals such as un-prejudiced listening and positive reinforcement.

The right de-escalation training will not only equip staff with the skills to recognise the early signs of agitation, irritation, aggression and violence, but will enable them to understand individual causes, and the context through which such behaviour arises. Furthermore, specific de-escalation training can increase the regularity of staff’s use of techniques which help to distract, calm and reassure patients, thus creating a culture where patients with maladjusted coping methods are enabled to learn new techniques which are dignified, supportive and empowering.

Relias Learning’s flagship De-escalation course is coming soon. This new, highly interactive, scenario-based learning experience, takes the learner on a branching pathway determined by the choices they make with regard to verbal and non-verbal de-escalation techniques. To see the new course at the earliest opportunity, fill out the form below and a member of the Relias team will be in touch to schedule a personalised demonstration.