Strand 5. Promoting least restrictive practice
It [enhanced observation] feels very restrictive and intrusive… like being in prison." Service user
Restrictive practice, including restraint, seclusion and ‘informal seclusion’, can increase stigma, isolation and the risk of harm; it can adversely affect patients with a trauma background and it reduces the potential to ‘share risk’ between mental health practitioners and patients by reducing the opportunity to build trust and work collaboratively on safety planning that supports a patient’s autonomy and development of coping strategies. Social isolation may actually serve to increase risk, as may having a staff member alongside a patient for a prolonged period of time when this is continually non-interactive. Increased or improved therapeutic intervention and activity may effectively reduce the need for restrictions on activity.
Evidence suggests that when incidents of violence are followed by containment measures, this can escalate to further violence. Preventative de-escalation measures are recommended here, including reducing the potential for conflict on wards, facilitating a calm, less rigid ward environment, and anticipating patients’ needs and responding early to them. The Brøset Violence Checklist (BVC) assesses six factors – confusion, irritability, boisterousness, verbal threats, physical threats and attacks on objects – as an indicator of the likelihood of violence in the next 24-hour period and can help ward staff anticipate and intervene early in a positive way.
Putting guidance into practice
Restrictive practice should be minimised, with ward staff ensuring that any continued periods of individual intervention are temporary and do not resemble informal seclusion or physical containment. Instead of resorting immediately to constant observation following incidences of violence, a cooling-off period, or a clinical pause of one to two hours, should be introduced, reducing enhanced observation and focusing on continuous intervention instead.
Ward staff should
- justify and document any restriction to privacy or activity and ensure that such restrictions are made due to an immediate, significant risk of harm where the patient is assessed as being unable to spend time alone or to safely interact with others
- ensure that the justification for restriction is not simply to ‘prevent or reduce risk’ as this should not be the sole purpose of the intervention – there must be evidence of meaningful goal-directed activity or intervention being planned and offered
- align interventions with the Millan Principles and the Rights in Mind pathway so that patients are free of restrictions on their independence, choice or control, unless those restrictions are for clearly identified and documented reasons and as long as they are the least necessary
- involve patients as much as possible in agreeing to restrictions
- review restrictions regularly to determine whether they are still necessary
- address medical interventions, such as severe violence and aggression associated with novel psychoactive substances (‘legal highs’) in the appropriate medical environment
- de-escalate the situation (in line with BVC guidance) that has triggered concern and/or has potential for continuous intervention and further assessment of risk and clinical needs
- have a debrief with the patient and the clinical team to explore and understand the factors that have triggered the violence or aggression (such as increased distress, a crisis or incident)
- formulate a personalised action plan, developed in collaboration with the patient, the staff who have spent time with the patient during the cooling-off period (and will therefore be familiar and known) and the clinical team to address the triggers for the violent or aggressive incident and put in place specific personalised interventions tailored to the patient’s needs, strengths and protective factors
For more information, please refer to our From Observation to Intervention (PDF) guidance document.