Reducing Restrictive Practices: Understanding Key Intervention Components

On Wednesday 5 June we held a dissemination event for the COMPARE study. COMPARE is an evidence review of interventions designed to reduce restrictive practices with adults in mental health inpatient settings. The aim of the event was to share preliminary findings from our evidence review with stakeholders (including frontline staff and service users) and provide an opportunity for discussion and feedback before we complete the study.

For anyone who was unable to attend in person, The Mental Elf took the event #BeyondTheRoom on Twitter. This was particularly important as it enabled people to follow along and participate in the discussion using the hashtag #BCTCompare.

In this blog we’ve tried to summarise the highlights from both within and beyond the room. You can also learn more about our motivation for the study, our preliminary findings, and why reducing restrictive practices matters by listening to the podcasts that we recorded before the event.

(1) John Baker sets the scene for the COMPARE study; (2) Krysia Canvin, Ian Kellar and Kathryn Berzins provide an overview of our preliminary findings; (3) Iris Benson describes her lived experience of restrictive practices and why it is important to reduce their use (NB trigger warning)

Setting the scene

John Baker opened the event by outlining why we need to reduce restrictive practices. As John explained, restrictive practices are harmful to everyone involved, so it’s vitally important to identify the most effective ways of reducing their use.

With the backdrop set, John introduced the first speaker, Iris Benson. Iris has lived experienced of restraint and uses her experiences to educate others. As part of this endeavour she has worked with us on COMPARE as an Expert By Experience. Iris spoke passionately about the need to address the use of restrictive practices.

Iris’ talk really set the tone for the rest of the afternoon, acting as a stark reminder of why we are doing this research, but also prompting us to look at the issue from a different perspective. This is why Iris’ involvement in our study has been utterly invaluable. As Iris pointed out, no-one behaves badly when they have experienced the kind of abuse that she has lived with. She asked how would you expect someone who has experienced trauma to behave when frightened? And how would you expect them to respond to being physically restrained?

In her typical fair-minded style, Iris went on to emphasise that she is not interested in blaming individual staff. Instead, she asked us to acknowledge that using restrictive practices can harm staff too and urged researchers, service users and staff to work together in this crucial area.

Following Iris was Tim Kendall who shared some reflections from his early days practicing psychiatry in the asylums. Tim is a co-applicant on the COMPARE study and a Consultant Psychiatrist for homeless people in Sheffield. Equally dedicated to improving reducing restrictive practices, Tim outlined the work he’s leading as National Clinical Director for Mental Health @NHSEngland @NHSImprovement and Director @NCCMentalHealth. It’s a powerful message when people traditionally divided into “them and us” make the same argument for change.

This really summed up the purpose of the afternoon, to bring different stakeholders together to consider how we can move forward in an effective manner. But what does the evidence say?

The intervention landscape

The initial goal of COMPARE was to systematically map all interventions designed to reduce restrictive practices with adults in inpatient mental health settings. Krysia Canvin introduced us to the intervention landscape.

Having sifted through 17,000 records, the team identified 150 unique interventions to reduce restrictive practices.

These interventions comprised all manner of procedures intended to reduce the use of restrictive practices, injuries and “challenging” behaviour or improve staff and service user experiences and safety. These procedures ranged from staff training, debriefing, data review, to introducing sensory rooms and changing staffing levels. Most interventions had multiple procedures.

Krysia explained how most interventions were one-off endeavours, but that we also identified 29 ‘intervention families’ where the same intervention had been used multiple times.

Unfortunately, despite all these good intentions, Krysia said that many of the interventions were poorly described, and few had been subject to high quality evaluation.

Krysia then drew our attention to two further issues. First, that few studies involved service users in the design or delivery of the interventions (and even fewer in their evaluation); and second, that many studies aimed to reduce harm or injury to staff – and subsequently measured the impact on these of their interventions – but only a handful were similarly focused on harm or injury to patients.

Consequently, she suggested, we are left with a disparate, complicated and low-quality evidence base: we simply do not know what the (most) effective way to reduce restrictive practices is. Geoff Brennan (#InTheRoom), founder of Starwards, suggested that rather see this as ‘a problem’ we should be heartened by the fact that there are so many initiatives. Krysia concluded by highlighting the difficulties of making comparisons between so many diverse interventions and how looking at their Behaviour Change Techniques could help.

What are behaviour change techniques?

The next speaker, Ian Kellar, brought a dual perspective. Ian shared his expertise on Behaviour Change Techniques, but also has a son with autism who experiences threats of restraint.

Ian explained what Behaviour Change Techniques (BCTs) are, that is, the very basic components that are used in interventions to change behaviour. Examples include ‘goal setting’ or ‘instruction on how to perform a behaviour’. The idea is that we can use these components to design interventions that target the behaviour we want to change using proven mechanisms. Ian described it as cracking open the ‘black box’ of interventions to see what exactly it is that leads to the change.

Can we use BCTs to avoid reinventing the wheel?

The final part of the COMPARE study involved looking closely at the interventions we found to see which (if any) Behaviour Change Techniques they used. Kathryn Berzins presented these findings, describing how we identified just under half of the available 93 BCTs in the interventions. Most of these BCTs were in the categories of ‘Goals and Planning’, ‘Shaping knowledge’ and ‘Antecedents’ (where the social or physical environment is altered to try to prevent incidents arising).

Kathryn reminded everyone that just because we didn’t detect a BCT in an intervention doesn’t mean it isn’t used, just that it’s not described anywhere. Kathryn explained that even thought lots of these interventions have been shown to reduce different restrictive practices, we don’t know which of their ‘ingredients’ are the active ones. If, however, we can test BCTs (or categories of BCTs) separately we will be able to work out which ones have the most effect and drop some of the others. Equally, there are also a lot of BCTs that don’t seem to have been tested for their potential to reduce restrictive practices that are certainly worth considering.

Kathryn concluded that we need to take a step back and try some more simple interventions (informed by service users themselves) otherwise we risk constantly reinventing the wheel.

The discussion

We asked everyone attending the event as well as those following #BeyondTheRoom to provide us with some feedback on four points.

We’re really grateful to everyone who attended and/or contributed to discussion on Twitter. Some really important points were made that we will think about very carefully.

The event generated much discussion (even the day before!) and we were really pleased to receive some positive feedback.

Most importantly, we hope this is the beginning of an ongoing conversation (and action) between all of us who are working towards reducing restrictive practices. You can join the conversation by tweeting using the hashtag #BCTCompare, commenting below or you can contact us.

Delusions in intensive care: How can healthcare professionals help?

BBC Radio 4 recently aired the series The History of Delusions. One episode focused on delusions specific to people who had been patients on intensive care units.

An intensive care unit (ICU) is a highly specialised area of secondary care. They provide technology-driven treatment for patients in multi-organ failure. Until recently, little attention was paid to the psychological impact of admission to ICU. Delirium, previously referred to as ICU Syndrome or ICU Psychosis, affects around 60% of ICU patients (Brummel and Girard, 2013). Delirium is thought to be caused by critical illness, sleep deprivation, and sedative drugs such as Benzodiazepines. Delirious patients may appear agitated or withdrawn; or display both states alternately. The syndrome is associated with poor post-discharge outcomes, including anxiety and depression (Salluh et al., 2015) and reduced socio-economic function (Griffiths et al., 2013).

“Delusions are false beliefs stemming from an incorrect perception of reality.”

Delusions are one element of delirium and are false beliefs stemming from an incorrect perception of reality. Delusions can also be experienced by non-delirious patients. Post-discharge, former ICU patients report vivid memories of their delusions, often over-powering actual ‘factual’ memories of intensive care. These ‘false’ memories have been linked to the development of post-traumatic stress disorder (Jones, 2010).

Patients report experiencing feelings of motion and of being moved (Svenningsen et al., 2016), which can perhaps be linked to the use of pressure-relieving air mattresses together with the way patients are frequently moved around the unit to accommodate new admissions. As a former ICU sister, I heard numerous beliefs and stories from my patients. One lady accused staff of stealing her organs, one by one, night after night. Another was convinced her sons had left her in intensive care so we could murder her and they could receive their inheritance. Another patient wrote to staff to tell them about his delusions, the memory of which persisted a year after his discharge. He recalled how ‘Satan and his helpers’ visited each patient. I interpreted this as a reference to the consultants’ ward round.

“One lady accused staff of stealing her organs, one by one, night after night.”

The journalist David Aaronovitch reportedly fought off nurses who he believed were using oxygen to tenderise his flesh prior to eating him. Many patients report believing that they are involved in games or challenges, where they feel compelled to do certain tasks ‘or else’.  Such delusions may explain some of the agitation and hypervigilance seen amongst ICU patients. Not all delusions are persecutory, however: one patient told me that he was on a cruise with the greats of Formula 1 motor racing and asked his bemused relatives to bring in his passport and dinner jacket.

“Not all delusions are persecutory, however: one patient told me that he was on a cruise with the greats of Formula 1 motor racing…”

So how can healthcare professionals help?

We have written about how discharged patients value diaries written by their family and ICU staff. The diaries help patients reclaim ownership of lost time and reconstruct their illness narrative. Such diaries should be used alongside multi-disciplinary follow-up support (Teece and Baker, 2017). The recent POPPI Trial explored the use of nurse-led interventions to provide a calm environment and detect signs of psychological distress in patients, and future phases will trial the effectiveness of other interventions. The bedside nurse has an important role to play in screening for delirium, re-orientating, reassuring, and comforting frightened and vulnerable patients.

Do you have any experience of caring for delirious patients, or supporting discharged patients who have experienced delirium whilst in hospital? Comments and questions are very welcome. You can
contact Angela Teece directly or use the comments form below.

References

BRUMMEL, N. E. & GIRARD, T. D. 2013. Preventing delirium in the intensive care unit. Critical Care Clinics, 29, 51-65.

GRIFFITHS, J., HATCH, R. A., BISHOP, J., MORGAN, K., JENKINSON, C., CUTHBERTSON, B. H. & BRETT, S. J. 2013. An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study. Critical Care, 17, 1-12.

JONES, C. 2010. Post-traumatic stress disorder in ICU survivors. Journal of the Intensive Care Society, 11, 12-14.

SALLUH, J. I. F., WANG, H., SCHNEIDER, E. B., NAGARAJA, N., YENOKYAN, G., DAMLUJI, A., SERAFIM, R. B. & STEVENS, R. D. 2015. Outcome of delirium in critically ill patients: systematic review and meta-analysis. British Medical Journal, 350.

SVENNINGSEN, H., EGEROD, I. & DREYER, P. 2016. Strange and scary memories of the intensive care unit: a qualitative, longitudinal study inspired by Ricoeur’s interpretation theory. Journal of Clinical Nursing, 25, 2807-2815. h

TEECE, A. & BAKER, J. 2017. Thematic Analysis: How do patient diaries affect survivors’ psychological recovery? Intensive and Critical Care Nursing, 41, 50-56.

Artwork credit: original artist unknown, but sourced from the Delirium Care Network @deliriumcare