Abstract

BackgroundThe use of physical restraint on vulnerable people with learning disabilities and mental health problems is one of the most controversial and criticised forms of restrictive practice. This paper reports on the implementation of an organisational approach called “No Force First” within a large mental health organisation in England, UK. The aim was to investigate changes in violence/aggression, harm, and physical restraint following implementation.MethodsThe study used a pretest-posttest quasi-experimental design. Recorded incidents of violence/aggression from 44 inpatient mental health and learning disabilities (including forensic) wards were included (n = 13,599). Two study groups were created for comparison: the “intervention” group comprising all incidents on these wards during the 24 months post-implementation (2018–2019) (n = 6,551) and the “control” group comprising all incidents in the 24 months preceding implementation (2015–2016) (n = 7,048). Incidents recorded during implementation (i.e., 2017) were excluded (n = 3,705). Incidence rate ratios (IRR) were calculated with 95% confidence intervals (95% CI). Multivariate regression models using generalised estimating equations were performed to estimate unadjusted and adjusted prevalence ratios (aPR) of physical restraint and harm, using type of wards, incident, and violence/aggression as key covariates.ResultsA significant 17% reduction in incidence of physical restraint was observed [IRR = 0.83, 95% CI 0.77–0.88, p < 0.0001]. Significant reductions in rates of harm sustained and aggression/violence were also observed, but not concerning the use of medication during restraint. The prevalence of physical restraint was significantly higher in inpatients on forensic learning disability wards than those on forensic mental health wards both pre- (aPR = 4.26, 95% CI 2.91–6.23) and post-intervention (aPR = 9.09, 95% CI 5.09–16.23), when controlling for type of incident and type of violence/aggression. Physical assault was a significantly more prevalent risk factor of restraint use than other forms of violence/aggression, especially that directed to staff (not to other patients).ConclusionsThis is a key study reporting the positive impact that organisational models and guides such as “No Force First” can have on equipping staff to focus more on primary and secondary prevention as opposed to tertiary coercive practices such as restraint in mental health and learning disabilities settings.

Highlights

  • The assumption that conflict in mental health and learning disability settings is inevitable and could only be dealt with by force and physically or medically restraining service users has been challenged for decades in psychiatry [1]

  • While the frequency of physical restraint on mental health inpatients differs from one country to another and one service to another, ranging from 3.8 to 51.3%, evidence suggests that this has been on the increase in the last decades [15,16,17]

  • The present study aimed to evaluate the impact following the implementation of a “No Force First” informed program of interventions within inpatient mental health and learning disability settings

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Summary

Introduction

The assumption that conflict in mental health and learning disability settings is inevitable and could only be dealt with by force and physically or medically restraining service users has been challenged for decades in psychiatry [1]. The use of physical restraint on people with learning disability and mental health difficulties is the most controversial and debated form of restrictive practice—it has no therapeutic value [2, 3] and it is against people’s human rights [4,5,6]. It can traumatise patients, lead to injuries and burnout for staff, frustration and reduced quality of life for carers [3, 7,8,9,10] and it can have significant negative economic impact on organisations [11, 12]. The aim was to investigate changes in violence/aggression, harm, and physical restraint following implementation

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