Communication and Restraint Reduction (CARR) study
Research type
Research Study
Full title
The Role of Staff and Team Communication in Reducing Seclusion, Restraint and Forced Tranquilisation in Acute Inpatient Mental Health Settings
IRAS ID
306290
Contact name
Mary Lavelle
Contact email
Sponsor organisation
East London NHS Foundation Trust
Duration of Study in the UK
1 years, 11 months, 31 days
Research summary
Research Summary
This is an NIHR funded research project. The overall aim of the study is to identify the staff communication that characterises successful de-escalation of patients displaying aggressive behaviour in acute mental health settings, avoiding the need to use physical restraint (held to prevent movement), seclusion (locked in isolation),and forced tranquilisation (involuntarily injected with psychotropic medication).
Background:
Over 100,000 patients are admitted to acute mental health wards annually, 40% involuntarily. Wards are under incredible pressure due to high bed occupancy rates and staff shortages. Patients are only admitted if they are extremely unwell, experiencing symptoms of psychosis (hearing voices), mania or severe depression. In England, 80% of nurses report experiencing patient aggression.
Staff manage patient aggression using communication, known as de-escalation. However, one in three de-escalations are unsuccessful and staff use restrictive practices including: restraint, seclusion and forced tranquilisation. In England 60,000 restraints occur annually, leading to patient harm (even death), trauma, fear and feelings of being disempowered and dehumanised. Staff experience harm, anxiety and burn out costing the U.K. £69M annually.
De-escalation practice varies and training is not evidence based. Communication is clearly important in de-escalation but we don’t know what communication is effective.Design and methods
Four adult acute inpatient mental health wards will be recruited.
- Sixty-four de-escalations will be audio-visually recorded.
- Staff and team communication will be analysed from video using established tools.
- Statistical analysis will identify what specific communication predicts successful de-escalation.
- Ethnographic observations will examine how teams discuss and plan for patient aggression.
- One-to-one interviews with patients (n=16), ward staff (n=16) and Trust leads (n=4) will examine their experience of de-escalation.This study will generate much needed empirical evidence to inform professional training of clinical staff in de-escalation and aggression management. Collaborations with educational partners will speed the translation of these findings into practice, improving patient care, staff wellbeing and overall safety.
Summary of Results
This study aimed to understand how mental health staff prevent and respond to distress, and behaviour that challenges, on inpatient wards. It focused on identifying staff communication strategies, team practices, and organisational factors that support effective responses.
Background:
De-escalation is the use of communication to reduce tension and avoid the use of more restrictive practices such as physical restraint (holding to restrict movement) or seclusion in a locked room. Although staff are trained in de-escalation, how it is used varies greatly, and there is little clear evidence about what works best in practice, particularly when staff are under pressure and staff shortages persist.Methods:
This study examined staff practice on seven adult mental health wards in two NHS hospital trusts and involved 110 staff.
Researchers analysed staff communication during 76 real-life de-escalation incidents using footage from staff body-worn cameras recorded routinely on wards. A researcher observed 350 hours of routine work across all seven wards. Fifty members of staff participated in questionnaires about their experience and perceptions of working on wards. Sixteen staff members participated in an interview about their experiences of preventing, responding to and learning from incidents on their ward.
Findings from all sources were combined to identify key themes.Results:
Analysis of de-escalation incidents:
A new framework-DECAF (De-escalation Communication Analysis Framework)-was developed to analyse de-escalation incidents. Staff communication that was calm, respectful, compassionate and attempted to understand the perspective of the service user was effective in preventing the use of restrictive practice. Aligned approaches by team members was also associated with more effective de-escalation.Analysis of contextual factors:
Although wards had systems in place to prevent and learn from incidents, in reality staff shortages and other organisational pressures including administrative duties meant that staff often didn't (or couldn't) engage with these systems as intended. As a result, staff often spent time reactively responding to incidents. Staff recognised the importance of calm relational care but, didn't always feel supported to speak up to highlight the challenges they were facing in balancing the competing demands day to day. This is referred to as psychological safety.Conclusion:
Taken together, reducing restrictive practice requires that organisational priorities and resources are aligned with compassionate, relational care. This alignment must be reinforced by compassionate leadership and a culture of psychological safety. Without these foundations, even the most dedicated and skilled staff are compelled to respond reactively rather than proactively.REC name
Wales REC 3
REC reference
22/WA/0066
Date of REC Opinion
16 Mar 2022
REC opinion
Favourable Opinion