Care plans minimise the use of restraint

An award-winning practice development team has devised care plans that are reducing the use of restraint for mental health patients.

RCN head of education Stephanie Aiken is full of praise for the work of Susan Burns, Craig Smith, Simon Young and Godwill Tsvamuno. ‘The mental health nurse team that introduced restraint care plans at Black Country Partnership NHS Trust have incredible passion that really stands out,’ she says.

‘It is absolutely all about their patients. The plans start with the patient and work for the patient and you can see that is what they are passionate about.’

The practice development team has created and introduced care plans preventing violent behaviour and reducing the need for restraint. Person-centred physical intervention protocols (PCPIP) establish a common approach – the nurse and individual develop it together, identifying measures that can reduce crisis behaviours, helping to de-escalate incidents at an early stage. 

Underpinning the protocol is a link nurse system to ensure sustainability, and a rolling programme of clinical in-reach to bridge the policy-to-practice gap.

Senior practice development nurse Susan Burns says: ‘Nationally people have struggled with this – we think we’ve cracked it. And the plans go beyond legal requirements and national initiatives. We sit down with the individual service user and ask them “what do you want your stay on the ward to look like? What frustrates you and triggers crisis situations?”. Then staff can avoid those triggers and stop the crisis building.’

Restraint might be unavoidable, but the care plans ensure there has been an open and honest discussion. ‘We make sure service users know what it looks like and how it will happen,’ says Ms Burns. ‘They might not want to be face down on floor or be held by male teams because of previous trauma.’

The PCPIP also takes into account physical health, whether the individual is obese, a smoker, has diabetes or has been on long-term anti-psychotics. ‘If we do have to restrain, it means we do it safely,’ says Ms Burns. Patients appreciate the approach, because historically restraint is something beyond their control. The care plan also lays out what the person needs after restraint to help them recover – for example, to call a relative or friend.

Patient’s voice 

‘The simple things can make a massive difference and the PCPIP empowers patients to say “this is what I need”,’ says Ms Burns. ‘They are in crisis and we need to minimise the impact of that as much as possible. The protocol is all about listening to the patient and it is important to hear the patient voice.’

To implement the care plan, the practice development nurses first set up a working party to agree a draft protocol, then consult widely involving all ward managers, service leads and the professional head of nursing. ‘We did not want it to be a stand-alone document – we needed to get ground staff on board, as they would drive its development,’ says Ms Burns. ‘A huge focus for the team was that it needed to be clinically relevant or else it becomes a paper exercise.’

This has been key to its successful implementation in 15 wards. ‘It has not been two steps forward, one step back, but slow, methodical steps forward, and we have taken our teams with us,’ says Ms Burns.

The protocol itself is a ‘live’ document, so nurses and patients are constantly discussing it, whether it is working or needs changing. If an aspect is not working, it is considered at one of the twice-yearly link nurse meetings, to see how it can be improved. 

The PCPIPs are spot audited by the team and audited monthly by ward link nurses. The team supports staff with clinical in-reach, sitting down with patients and nursing staff to see how the plans are working.

Feedback from staff and patients has been positive. Staff report a reduction in the severity of crisis behaviours and say they feel more confident in dealing with a crisis, with a better team approach. 

Nurse Norbert Machisa says: ‘The plans clearly put the patient at the centre of this type of care. In most situations, staff have got to know their patients better and this has reduced the number of physical restraints. When restraint goes wrong it can put the patient and staff at risk, so any plans that improve patient safety will always get my support.’

Innovative approach

Black Country Partnership Foundation Trust deputy director of nursing and professional practice Joyce Fletcher says: ‘The team plays a significant role in ensuring we provide safe person centred and proactive care. The implementation of the care plan has made a huge contribution to staff teams in the management of some of our most vulnerable and acutely unwell patients.’

The team won the Mental Health Practice category of the prestigious RCNi Nurse Awards 2016, the profession’s top accolade. Specialist judge Clair Carson, Pennine Care NHS Foundation Trust assistant director of operations mental health, said: ‘The PCPIP is a focused approach to restraint – a difficult area that people have really struggled with. Using the link system in this area to get everyone engaged is an innovative approach.’ 

The care plans will continue to develop, says Ms Burns. Since winning the award, the team have revised PCPIPs to encompass Safe Wards, and also produced a comprehensive how-to guide to complete the protocol. 

Before, staff might have found it easier to avoid a difficult conversation with the service user – especially with restraint in the spotlight. With the plans, Ms Burns says, staff are keen to start conversations about aggression because they see the difference it makes to patients: ‘The behaviour is a care need and should be care planned. If the individual had a bedsore they would have a care plan, so why is distress not seen like that? It is massive when looking at a person’s road to recovery. 

It can sometimes be hard to change cultures but we’ve turned the focus off the person’s behaviour and back on to the person. And who wouldn’t want to embrace that?’