DESIGN IN MENTAL HEALTH CONFERENCE 2019
A ‘paradigm shift’ in inpatient care
The use of seclusion and restraint in mental healthcare settings, and how such practices use can be reduced in line with ‘more 21st century’ thinking, and more ‘humane’ ways of dealing with extremely distressed or, on occasions, violent service-users, was the subject of an afternoon session on the first day of this year’s Design in Mental Health 2019 conference. During it, Dave Riley, mental health nurse, and Quality Improvement Partner for Perfect Care at Mersey Care NHS Foundation Trust, described the Trust’s award-winning ‘No Force First’ approach.
This conference session – entitled ‘Safe in seclusion? Examining seclusion use and design in contemporary care’ – was introduced by Paula Reavey, Professor of Psychology & Mental Health at London South Bank University, who is also director of the Design in Mental Health Network’s Research and Education stream, and the co- author of a number of DiMHN publications. Later in the session, the Professor spoke jointly with Dr Hamid Alhaj, a consultant psychiatrist and director of Medical Education at the National Association of Psychiatric Intensive Care & Low Secure Units (NAPICU), about an ongoing joint DiMHN and NAPICU study on the impact that the physical ward environment, and different ‘environmental’ factors, can have in reducing the use of restraint and seclusion (The Network – July 2019).
However, Professor Reavey’s initial task was to introduce the session’s first speaker, Dave Riley, from Mersey Care NHS Foundation Trust, a mental health nurse who has spent the past six years working with clinical teams at the organisation to reduce the use of physical interventions when people become distressed on inpatient units. The programme he is involved in, ‘No Force First’, has won a number of national awards in the UK – most recently a 2019 Patient Safety Award for Culture Change – and been recognised as a key driver for change.
A cultural, rather than a physical, re-design
Dave Riley began by explaining that his presentation would be focusing very much on the recent ‘cultural redesign’ of mental health services at his Trust, rather than highlighting the impact of the physical environment on service-users and staff. Expanding on this, he said: “I will be looking at our journey over the past six years in changing our approach to restrictive intervention – in terms of elements such as physical restraint and seclusion of service- users – something we were tasked with focusing on back in 2013.” He continued: “Fundamentally, the clinical and nursing
THE NETWORK | OCTOBER 2019
Dave Riley explained Mersey Care’s work to reduce the use of restraint and seclusion in line with more ‘21st-century’ thinking, and more ‘humane’ ways of dealing with distressed/violent service-users.
staff at Mersey Care are fantastic people striving to do their best for our service- users. However, when we proposed some changes to try to reduce the use of restrictive intervention back in 2013, not everybody was fully on board.” Some staff, he explained, felt that the management team was ‘being patronising’ – they felt they had been taking such an approach for many years on their own initiative anyway, and that restraint and seclusion were already only used as a ‘last resort’; they also doubted that further improvements in this area were practical.
Attitude and attribution Dave Riley said: “We also had some issues about attitude and attribution, and why staff believed people with mental health issues became ‘challenging’, and sometimes resorted to physically challenging behaviours. Some staff told us they felt service-users in inpatient facilities generally ‘know what they are doing’ when they assault us or other service-users, i.e. they believed some of the challenging behaviour we encounter on our inpatient units was malicious and deliberate. That was something we had to work through, because we couldn’t make such significant ‘cultural’ changes while such beliefs prevailed.”
Dave Riley and his team also heard concerns expressed that reducing the amount of physical intervention could put staff at risk. He elaborated: “Some staff believed that by even proposing changes – trying to make this impact on ‘culture’ – we were saying that staff could not protect themselves if they faced physical aggression – which we were certainly not suggesting. What I hope we have done, six years on, is to change staff’s perception that we are simply here to provide care, and that any problems we encounter will always be the fault of service-users. I hope we have changed that whole debate.”
High levels of restraint
The ‘fundamental issue’ that Dave Riley and his colleagues were tasked with addressing was the high level of physical restraint being used within Mersey Care’s inpatient services. He said: “Although instances were not increasing, they weren’t coming down either; it seemed an intractable issue.” Time constraints would, he told the audience, preclude him going into detail on all his team’s ‘interventions’ over the past six years; rather he would look to give delegates a sense of how team members had managed to change practices and some of the contributing factors. He explained: “In 2014 we were spurred on by a
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