Mersey Care Foundation Trust has reduced the use of physical restraint through the ‘No Force First’ programme. It subsequently won the Patient Safety Improvement category in the 2017 Nursing Times Awards
National care scandals, such as that at Winterbourne View, illustrated that using restraint in mental health care and learning disability services was, at the very best, an unhelpful approach. In 2013, Mersey Care Foundation Trust launched a project called ‘No Force First’ with the aim of eliminating the use of restraint. The programme rests on a genuine collaboration with staff and service users, and has reduced restrictive interventions, assaults on staff and work-related absences.
Citation: Riley D et al (2018) No Force First: eliminating restraint in a mental health trust. Nursing Times [online]; 114: 3, 38-39.
Authors: Dave Riley is mental health nurse and improvement lead for perfect care; Iris Benson is improvement lead for perfect care (lived experience); Jennifer Kilcoyne is clinical director; Danny Angus is senior clinical nurse; all at Mersey Care Foundation Trust.
For generations, it was assumed that conflict and challenging behaviour in mental health and learning disability care settings were inevitable and could only be addressed by the use of restraint, whether physical or medication-led.
Over the last decade, however, the overuse and abuse of restraint has been exposed in a number of national care scandals, notably that of Winterbourne View (Flynn, 2012), while disturbing variation between services in the use of restrictive interventions has been revealed (Mind, 2013). At Mersey Care Foundation Trust, we set ourselves the goal of eliminating physical and medication-led restraint altogether.
In 2013, we began working on ‘No Force First’, a programme originating in ‘recovery innovations’ in the US, which seeks to transform the experience of service users by reducing – and eventually eliminating – the use of interventions such as physical restraint, seclusion and rapid tranquilisation.
“The organisation has completely changed the culture of how staff interact with patients” (Judges’ feedback)
What prompted the project
Mersey Care Foundation Trust provides inpatient and community services in 48 sites across North West England. It has 760 inpatient beds and over 7,000 staff providing specialist inpatient and community mental health, learning disability, addiction, acquired brain injury, community physical health, and secure mental health services. Between May 2016 and April 2017, the trust provided care to 20,621 people.
The No Force First project was prompted by our determination to reduce the levels of physical intervention used at the trust and our difficulty in achieving systematic reductions. We made the reduction and eventual elimination of restraint one of our key quality improvement priorities.
From ‘containment’ to ‘recovery’
Although staff disliked using restrictive interventions, preferring a compassionate and person-centred approach, they did not always know what to use instead. Appealing to their best instincts, skills and creativity, we aimed to move towards more recovery-focused care (Repper and Perkins, 2013).
Our goal was to move from the idea of ‘containment’ to that of ‘recovery’. Underpinned by recovery principles – giving hope, control and opportunity to people, and believing in everyone’s potential to live a meaningful and fulfilling life – the programme encourages staff to try innovative approaches (Box 1). They are also encouraged to try their own ideas for improvement; for example, one ward made a video exploring what a recovery-focused nursing handover meant to the team; another worked with service users to create a statement of values around a ‘perfect’ 24-hour experience; an older people’s ward invited families to visit their relatives outside visiting hours to assist with meals.
Box 1. Approaches to avoid the need for restraint
- Reviews of restrictive practice – encouraging clinical areas to listen to service users and remove or reduce restrictions and ‘blanket rules’ that cause frustration and conflict
- Positive handovers – ensuring nursing handovers are positive, objective and recovery-focused, and that challenging behaviour is explored and understood in relation to the impact of past trauma
- Healthy communities – empowering service users by giving them a sense of belonging and an opportunity to contribute to how the unit functions
- Individualised meaningful day – offering activities that suit service users’ individual needs, interests and aspirations, as fulfilling occupation reduces conflict
- Debriefing – giving service users and staff the opportunity to reflect on adverse events and identify areas for improvement and learning together
Service users’ narratives
At the centre of No Force First are narratives of people who have experienced restrictive interventions. We elicited personal stories from some service users showing how traumatic restraint can be – these were shared with frontline staff to connect with them on an emotional level.
Service users helped design and produce a range of educational materials that have transformed our staff training. This collaboration between the people who use services and those who deliver them meant that the message of trauma-informed care became the dominant narrative.
Structure and process
No Force First was piloted in four inpatient units between February 2013 and March 2015, then rolled out across the trust. The project is supported by the trust’s Centre for Perfect Care, which helps clinical areas to implement quality improvement, collates incident data and conducts research. It involves:
- Initial engagement sessions;
- Quality improvement changes undertaken through ‘plan do study act’ cycles;
- Data evaluation;
- Adoption of the No Force First guide;
- Ongoing support.
At the engagement sessions, delivered in partnership with service users, teams are introduced to No Force First and hear accounts of people’s experience of physical intervention. The No Force First guide helps units to implement change and measure its effects. Wards receive weekly incident data updates – these highlight trends, generate friendly competition, keep teams engaged and enable us to identify areas of positive practice and those who may need additional support.
No Force First costs approximately £60,000-70,000 a year, which pays for staff time at the Centre for Perfect Care, project leadership, educational materials, and national and international collaborations on restraint reduction.
Outcomes so far
In the pilot phase, two wards reduced the use of physical restraint by over 60% and the other two by around 25%. Between April 2016 and August 2017, its use across inpatient areas involved in No Force First decreased by 37% from baseline.
The year to August 2017 saw a 23% reduction in the number of assaults on staff across Mersey Care Foundation Trust. In 2012/13, the trust was 8% above the national average for serious assaults on staff; in 2015/16 the figure had dropped to 65% below the national average (NHS Protect, 2016; 2013).
Work-related absences and associated costs have also decreased; for example, our secure mental health division saved £249,069 in the year to August 2017 on the costs of replacing absent staff.
Culture change is challenging, but No Force First is now firmly established in our organisation and we are embedding a culture of continuous improvement in this area. When challenging behaviour does occur, staff know that they will be supported and recognised for using non-restrictive interventions. When restraint is used, we use a robust learning process to prevent it from being used again in the future. Box 2 lists lessons we have learned from the No Force First process.
Box 2. Lessons learned
- Place the service user’s experience at the centre
- Coproduce strategy and training with service users
- Use quality improvement methodology
- Drive improvement through data
- Celebrate good practice
- Ensure staff feel safe to innovate
The project has been recognised by the Care Quality Commission (2017) and Department of Health, and acknowledged in 2014 by Norman Lamb, then minister of state for care and support, in a speech.
All inpatient units had engagement sessions and have developed plans to implement the programme. We are keen to sustain our progress and share best practice through collaboration. We also want to involve more service users in helping us address this highly controversial area of practice. One of our new initiatives is to involve service users in personal safety training for staff: some users are currently working on a new training curriculum, which they will help deliver.
- The overuse of restraint in mental health and learning disability services has been highlighted in recent years
- The narrative in mental health needs to change from ‘containment’ to ‘recovery’
- Recovery-focused care involves giving service users hope, control and opportunity to get involved
- Offering activities that suit service users’ needs and aspirations reduces conflict
- Involving service users in the design and delivery of services helps improve collaboration and reduce conflict
Care Quality Commission (2017) Mental Health Act: A Focus on Restrictive Intervention Reduction Programmes in in-Patient Mental Health Services.
Flynn M (2012) Winterbourne View Hospital: A Serious Case Review.
NHS Protect (2013) Physical assault data, 2012/13.
NHS Protect (2016) Physical assault data, 2015/16.
Repper J, Perkins R (2013) The Team Recovery Implementation Plan: A Framework for Creating Recovery-focused Services.