Award Title: The Role of Staff and Team Communication in Reducing Seclusion, Restraint and Forced Tranquilisation in Acute Inpatient Mental Health Settings
Funder: Department of Health and Social Care

Abstract: Research Question:      What staff and team communication predicts successful de-escalation of patients displaying aggressive behaviour in acute mental health wards, avoiding the need to use physical restraint (holding to prevent movement), seclusion (locked in isolation) and forced tranquilisation (involuntarily injected with psychotropic medication)?           Background:      In the U.K. over 100,000 patients with severe mental illness (e.g. psychosis) are admitted to acute mental health wards annually, over 40%  admitted involuntarily.1, 2  Patient aggression is managed through communication, known as de-escalation. This usually involves multiple staff (de-escalation team) supporting an individual who communicates directly with the patient (primary de-escalator). Around one third of de-escalations are unsuccessful3 resulting in physical restraint, seclusion, and/or forced tranquilisation.     In England, six restraints occur per hour,4 resulting in physical harm, even death,5 and significant psychological distress.6-10 Patients experience trauma, fear, feeling disempowered and dehumanised.5, 10 Staff feel unsafe and anxious, leading to burn out9, 11, 12 costing the NHS £69M annually.13      NICE guidelines recommend de-escalation but it is not evidence based14 and practice varies.3, 15 The importance of staff and team communication in de-escalation is clear16-18 yet no research has examined what specific communication is effective.     Our research in psychiatric consultations found patients experience better communication with staff who try to understand them and display pro-social nonverbal communication, designed to encourage conversation (i.e. shared gaze, nodding).19, 20 Clear leadership predicts de-escalation success in simulated de-escalations,21 while on wards, introducing regular, honest discussions about aggression management has led to fewer restraints.22          Aim:     To identify the specific staff and team communication that leads to successful de-escalation of patients displaying aggressive behaviour in acute mental health settings, thus avoiding use of restrictive practice.     Objectives:          Identify the communication displayed by (i) primary de-escalators and (ii) de-escalation teams in successful and unsuccessful de-escalations     Observe how patient aggression is anticipated, discussed, planned for and managed on wards, beyond the de-escalation event     Explore patient and staff experience of de-escalation and perceptions of aggression management     Explore the relationship between staff and team communication during successful and unsuccessful de-escalations and ward approaches to aggression management               Methods & Timelines:      Observational study conducted in four acute inpatient mental health wards. Sixty-four de-escalation events (32 successful, 32 unsuccessful) will be recorded from body worn cameras [Months 4-11]  Three Work Packages will address the objectives:           WP1: De-escalation Communication [Months 10-17]      Analyse the verbal and nonverbal communication of the primary de-escalator (pro-social nonverbal behaviour and shared understanding) and the de-escalation team (leadership). Mixed model regression analyses will identify the communication that predicts successful de-escalation.           WP2:  Ward Context [Months 4-16]      Conduct ethnographic observations on wards and one-to-one interviews with patients (n=16) and staff (n=20). Qualitative transcripts will be thematically analysed.           WP3: Data Synthesis [Months 17-19]      Triangulate findings from WP1&2, identifying of the facilitators and barriers to successful de-escalation.           Impact and dissemination:      A multi-disciplinary de-escalation working group will facilitate translation of findings into policy, training and practice.  Research into practice workshops will be delivered at participating Trusts. Results will be disseminated via the project website, Involve and Trust newsletters and peer reviewed publications.

Lay Abstract: Research aims:  The project will identify staff and team communication that lead to successful management of patient aggression 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 sedating 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. Only patients who are extremely unwell are admitted, experiencing symptoms of psychosis (hearing voices), mania or severe depression. In England, 80% of nurses report experiencing patient aggression. Staff manage aggression through communication; talking to patients to try to calm down their aggression. This technique is called  de-escalation . However, often de-escalation is unsuccessful, leading to restraint, seclusion and forced tranquilisation of patients.  In England 60,000 restraints occur annually causing patient harm (even death), trauma and fear. Staff also experience harm, anxiety and burn out, costing the U.K. £69M annually. De-escalation training is not evidence based and staff practice varies. Communication is clearly important but we don t know what type of communication is most effective in managing patient aggression.  This study will analyse how staff communicate when managing patient aggression. Our previous work analysing outpatient psychiatric consultations found that patients experience better communication with doctors who invest effort trying to understand them. Clear leadership and open communication among teams are also linked with better aggression management. This study will be the first to examine staff and team communication in mental health wards, identifying the communication that leads to successful de-escalation.  Design and methods  Four acute inpatient mental health wards will be recruited; two with low and two with high rates of restraint.    Sixty-four de-escalations will be video recorded (32 successful, 32 unsuccessful)  Staff and team communication will be analysed from video using established tools.  Statistical analysis will identify the specific communication that leads to successful de-escalation.  Ward observations will examine how teams discuss and plan for patient aggression.  One-to-one interviews with patients (n=16) and staff (n=20) will examine their experience of de-escalation.   Patient and public involvement  The Service User and carer Group Advising on Research (SUGAR) Group has shaped this study. The lived experience co-applicant will contribute to data collection, analysis, interpretation and dissemination. We will form a working group focused on de-escalation and aggression management in mental health involving, academic, clinical and patient partners.  Dissemination  The findings will be shared through patient organisation and charity websites and in academic publications. Workshops helping staff apply the findings in their own practice will be held at participating Trusts. We will work closely with clinical education groups to share the content of these workshops with mental health staff more widely.

Research Activity Codes: 5.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health Categories: MENTAL HEALTH