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Exclusive: Mental health nurse leads successful drive to reduce use of restraint


A Yorkshire trust is leading the way nationally in eliminating face down restraint from its inpatient wards, following the introduction of nurse-led training for all staff that focuses on defusing difficult situations.

The latest figures released by NHS Benchmarking show Sheffield Health and Social Care NHS Foundation Trust has the lowest level of face down restraint use across England and Wales.

“It has been absolutely one of the best things I have done in my nursing career”

Kim Parker

Kim Parker, senior nurse for quality improvement – who has spearheaded the trust’s new approach to preventing violence and aggression – admitted it had been a real challenge, but said it was “one of the best things I have done in my nursing career”.

The trust starting looking at alternative ways of managing challenging incidents after it was approached by African-Caribbean service users from the MAAT Probe Group, which is keen to reduce what it sees as the disproportionate use of restraint against Black people.

At the same time, the organisation was reviewing its policy on restrictive practices and was keen to explore the options for working with service users and staff, said Ms Parker in an interview with Nursing Times.

They decided on the Respect training approach, which was originally developed by Grimbsy-based health and social care provider Navigo.

“A person can be securely held on the floor without any pressure on them at all”

Kim Parker

The training had all the elements the partners were looking for, Ms Parker told Nursing Times. “We wanted a course that had a lot more service user input about their experiences and how it felt for them,” she said.

“The approach used techniques that didn’t rely on pain to be effective, which was again very important,” she said. “No one likes to inflict pain in any situation.

“And, critically, it didn’t use the face down position, which is something we were very keen to stop using at this trust,” noted Ms Parker.

The training, which was “co-produced” by a team of service users, prioritises de-escalation techniques throughout, with about 70% of the course focusing on ways to actively defuse conflict and difficult situations.

Sheffield Health and Social Care NHS Foundation Trust

Exclusive: Nurse leads successful drive to reduce use of restraint

Kim Parker

When it comes to the most challenging situations, where a significant level of restraint is needed to keep someone – and others – safe, it teaches nurses to use the supine or face-up position.

“This is a technique where people are held securely and safely in a face up position, communication can continue and they can see what is happening around them so they are less likely to panic or get scared,” said Ms Parker. “It has to be seen to be believed, but a person can be securely held on the floor without any pressure on them at all.”

The trust embarked on an intensive training programme in 2012, which saw all inpatient staff complete the Respect course within an 18-week period.

Now all staff at the trust do a level of Respect training. Those working on inpatient wards do the highest level 3, which involves a four-day training course. Those working in the community with face-to-face contact with clients outside hospital do level 2, while all other staff complete level 1.

To date, more than 500 staff, including many nurses, have received the level 3 training. Two members of staff – one nurse and one support worker – were also deployed as senior Respect trainers to support the introduction of the approach on the wards.

This role has since evolved. They may actively assist with the management of incidents but also observe and give feedback, as well as helping with same or next day debriefs for staff and patients.

“In the heat of the situation, it is hard not to revert to what you have known for such a long time”

Kim Parker

Since the training was introduced five years ago, use of face down restraint has reduced year on year. In the past 18 months, there have been no incidents involving the use of face down restraint.

However, a drive to encourage the reporting of all incidents – and the introduction of electronic reporting systems – has seen the total number recorded increase since the training was launched, said Ms Parker.

“There has been a significant rise in low-level incidents – the kind of incident that would not have been reported before – and lower-level holds that you might use when guiding someone away from a situation,” she said. “We can see more of those than actually restraining someone on the floor.

“Inpatient wards across the country are very busy and acuity is high – people are very ill these days,” she said. “However, as acuity and mental health detentions have risen, our rates of restrictive practice have not gone up, which I think is a positive.”

She admitted that introducing the new approach took a long time and was challenging – especially for nurses and others used to more traditional methods.

“We had a very mixed response at the beginning,” she said. “People were concerned some of the holds would not be as secure, or the new approach meant we couldn’t actually restrain people any more – those were the kind of rumours flying around that we quickly tried to challenge.

“It is very difficult to unlearn something that you have been practising for years and years – maybe all of your nursing career – something that is driven by adrenaline,” he noted.

“In the heat of the situation, it is hard not to revert to what you have known for such a long time, which is why we felt we needed to actively support staff with that on the wards,” she said.

“Communication can continue and they can see what is happening around them so they are less likely to panic”

Kim Parker

She told Nursing Times that feedback from the training was “always very positive” and a key factor was the integral role played by service users.

“Hearing service users talk about when they had been restrained, rapidly tranquilised or secluded – hearing that from people sat in front of them was very moving and some staff were brought to tears,” said Ms Parker.

“Service users ask them to think about how it felt to be restrained – how humiliating that might be and the psychological impact,” she said.

While it was difficult to measure the impact of the change among service users – as no one likes being restrained however it is done – she said there was evidence those who had experienced the face-up technique found it less frightening and appreciated the fact they could see what was happening.

The fact there was a steady flow of service users who wanted to help with the training was another sign they felt it was worthwhile.

The trust – which is part of a network of other trusts and organisations that have embraced the Respect approach – is keen to get service users even more involved by actually training them to deliver courses, as opposed to mainly sharing personal experiences.

Ms Parker stressed that embedding the new approach into everyday practice had involved a “massive investment in time and training” and was only possible because of support from the top, including the trust’s chief executive and senior clinicians like the director of nursing.

“You cannot underestimate the amount of time it takes to make this kind of change in an organisation – we’re not just talking a couple of years,” she said.

“Changing this level of practise requires commitment and patience but it has been absolutely one of the best things I have done in my nursing career,” she added.


Readers' comments (4)

  • I have been a control and restraint practitioner and instructor since the 1980's and have always been stunned by the variously inappropriate timing of and applications of the originally taught techniques. "Face down restraint" was only ever taught as part of the standing and walking off procedure. It should never be used as indefinite restraint because, surprise surprise it kills people by compressing their heart and lungs. The so-called "new" techniques advanced here are not new at all. I have always taught restraint as part of a wider more positively based approach or specific programme that respects the individual and seeks opportunities to positively reinforce violence-desisting and replacing negative events with more positive communication and stimulus control, or 'positive behaviour support (PBS) see for example Lavigna & Willis Emergency Management Guidelines, 1983 or Zivolich & Thvedt Assault Crisis Training: Prevention & Intervention, CA Special Ed Counselling Service (1983).

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  • Correction: Brief face down also used for safe exiting of seclusion room.

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  • And NEVER driven by 'adrenalin'.. "'control' and restraint" starts with self-control of the individual(s) applying it otherwise potential chaos and disaster are likely to ensue.

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  • Everything mentioned in this article was covered as long ago as 1976. See Dep of Health & Social Security HC(76)11, including:
    General considerations of patients who may become violent. Impulsivity. Prediction via patterns of recurring behaviour. Determining risk. Supervision levels. Nursing judgement. Skill mix. Group sizing. Personal histories. Therapeutic milieu. Team approaches. Diversion activities. Unavoidable outbursts. Summoning assistance. Total team training. General prevention. Meeting individual need. Discreet surveillance. Establishing trust. Avoidance of emotions. Calming not provoking. Ensuring proper records of any violence or injury or damage and action taken. Establishing 'direction' of aggression as part of management. Later to be know as 'function' in terms of antecedent, behaviour and consequence ABC.

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