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No Force First and Least

Restrictive Practice in AMH“There is no such thing as a forced recovery”

David Waldron, No Force First Project Lead

Dr Gareth Foote, psychologist in AMH Acute Care Network

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Background

� Local No Force First builds on the work of Recovery

Innovations in the United States and Mersey Care

NHSFT

�Drivers:

○ Positive and Proactive Care (DoH)

○ NICE Guideline 10 (Violence and Aggression)

�Participation in IMROC led to No Force First in AMH

�NFF links to the Restrictive Practice and Violence

Reduction Steering Groups

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Why No Force First?

�The use of seclusion and restraint (S/R) is traumatizing to

service users and staff, interrupts the therapeutic

process, and is not conducive to recovery

�National agenda mandates that organisations take steps

to deliver services with the least possible restriction to

service recipients

� “Force elimination is both a necessity and reasonable

goal as we move further down the path of recovery…

There is no such thing as ‘forced recovery’”** Anthony, W. (2006). An Elephant in the living room. Psychiatric Rehabilitaiton Journal, 29, p.155.

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AMH Acute Inpatient CQC report July 2014

� “Patients told us and we observed, that staff were caring and compassionate.”

� “Staff described working to the least restrictive practice with patients and confirmed a low use of restraint was used as a result. Sometimes this was in order to prevent people harming themselves or when treatment was being provided. This way of working was underpinned by the adult mental health service recovery focus model.”

� “De-escalation techniques were used first with restraint used as a last resort. This practice echoed throughout all of the adult inpatient services we visited.”

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But what can we do better?

�Debriefing / post-incident review after restraint or

coercion for both staff and patients

�Reducing incidents leading to injury – staff and

patients

�Reducing or eliminating force and restraint

across our services?

�Removing controlled access?

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Context

� NFF project links to local governance and Trust priorities

� NFF effectiveness depends on “buy in” both from senior

managers and from clinicians on the ground

� Leadership is essential – post supported by Local Services

NICE implementation money

� Primary objective to establish Post Incident Review in acute

ward practice

� Clear, measureable targets that can be audited and reviewed

� 12 month project evaluation will inform future planning

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How?Huckshorn, K. A. (2004). Reducing seclusion & restraint use in mental health settings: core strategies for prevention. Journal of psychosocial nursing and mental health services, 42, 22-33.

�Organizations need to embrace a prevention approach,

implement continuous quality improvement, and develop

a reduction plan individualized for that facility

�Highly visible, consistent, and effective organizational

leadership appears to be the most significant and critical

component in any successful restraint reduction initiative

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How?Ashcraft, L., Bloss, M. & Anthony, W. A. (2012) The development and implementation of “no force first” as a best practice. Psychiatric Services, 63, 415-417

� Define the use of force and coercion as a treatment failure

� Have an active programme to avoid and eliminate the use of force, including seclusion, mechanical restraint, and pharmacological restraint and forced medication:

○ Staff training in effective de-escalation techniques and the NFF process

○ A debriefing that includes the service recipient whenever coercion or force occurs

○ A critical incident review for any use of coercion or force and

○ A performance improvement process that includes tracking and reporting of all types of forced interventions

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The post-incident review

� NFF Lead focused on post-incident review (PIR) following an incident where restraint was used

� 5 questions about the service user’s and staff experience of the incident

� Phenomenological empathy and non-judgemental stance

� PIR validates service user’s and staff’s experiences

� Recommendations inform care planning and therapeutic interventions to reduce use of force

� Information from service users potentially improves therapeutic alliance and reduces incidence of restraint

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Preliminary themes� Unpleasant but accepted

� Traumatic re-enactment

� Control of distress

○ Self-harm

○ Problematic beliefs

○ Hearing voices

� Conflict between patients

○ Racism

○ Hostility

○ Disinhibition

○ Property

� Compulsion

○ Leave

○ Medication

○ Detention

� Communication of distressing news

○ Safeguarding

○ Detention

○ Medication

○ Leave

� Privacy and dignity

○ Gender mix

○ Safe and gentle / less brutal

○ Wanted by patient – no alternative

� Staff enjoy it / can escalate situation

� Resources

○ Space

○ Activities

○ Staff

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Restrictive Practice

�Steering group set up to look at Blanket Restrictions as

part of the Sign Up to Safety plan

�Challenge restrictive practice through a Blanket

Restriction audit in the areas taking part in the project

�Aim is to identify and challenge restrictive practices

within clinical areas and support teams to minimise or

eliminate these practices

�Each area has an identified champion

�Wider aim is to disseminate Positive and Proactive Care

across Local Services and embed into everyday practice

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Restrictive Practice Examples

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Interim summary �At time of writing 57 PIR’s offered, 40 plus staff

trained in the PIR

�Formal review of the experience of restraint has notoccurred routinely in the past

�PIRs have been welcomed by both service usersand staff

�The use of medication remains a significant factorwithin current practice

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Interim summary

�Early analysis of Incident Reporting points towards a

reduction in use of force and an impact on staff practice

�Severity of harm caused to staff during the project has

reduced

�Evaluation of 12 month impact of No Force First and the

Restrictive Practice initiative due autumn 2016

�Thematic analysis will develop understanding of narrative

pathways to restraint

�Sustainability of PIR without leadership is questionable