Title: Establishing components of programmes to reduce restrictive practices: an evidence synthesis
Funder: Department of Health and Social Care

Abstract: Background: Incidents involving violence and aggression are a frequent occurrence in adult mental health inpatient settings. They are managed by use of restrictive interventions such as restraint, seclusion, injection of sedating drugs and constant observation. Use of these interventions carries significant risks, including physical and psychological harms to both patients and staff. Interventions are costly in terms of staff sickness and litigation as well as extra staffing resources required to implement them. As such, numerous staff training programmes have been developed to try to reduce the use of restrictive interventions. These seek to modify practice using a variety of behaviour change techniques (BCTs). Although some programmes have been evaluated, research into their effectiveness is hampered by a lack of attention to their specific components. Over recent years the MRC has supported work to develop a taxonomy of BCTs to standardise and improve the reporting of such non-pharmacological interventions. It provides a common language with which to specify the content and mechanisms by which behaviour is changed. Aim and objectives: The study aim is to identify, standardise and report the effectiveness of components of programmes that seek to reduce restrictive interventions in UK adult mental health inpatient settings using the BCT taxonomy. The study objectives are to: 1. Provide an overview of programmes aimed at reducing restrictive interventions. 2. Classify components of programmes in terms of behaviour change techniques and determine their frequency of use. 3. Explore the evidence of effectiveness by examining behaviour change techniques and programme outcomes. 4. Identify and prioritise behaviour change techniques showing most promise of effectiveness and that require testing in future high quality evaluations. Design: An evidence synthesis of published and unpublished literature, including detailed coding of programme content using the BCT Taxonomy. Data review: 1. Identify all manualised programmes. Data will be extracted about the characteristics of each programme including participants, setting, programme type, outcome measures, fidelity, acceptability, recommendations and quality (Obj. 1). 2. The content of programmes will be extracted to allow their components to be coded using the BCT taxonomy (Obj. 2). 3. Programmes that have been coded for BCT components will have information about their outcomes extracted in order to relate this back to these components (Obj.s 3 & 4). Analysis: We will analyse the evidence to produce a synthesis of: 1. Overview of programme characteristics (Obj. 1). 2. Programme content components in relation to behaviour change techniques, both type and frequency (Obj. 2). 3. Description of programme outcomes where BCTs have been identified and comparison of outcomes between programmes that contain a BCT or type of BCT with those that do not.(Obj.3). 4. Acceptability (Obj. 1). 5. Recommendations for future trials (Obj. 4). Impact: The study will generate the first synthesis of the evidence on the content and effectiveness of programmes to reduce restrictive interventions. This new knowledge will inform NHS managers’decision making about staff training, highlight gaps in the evidence and enable NIHR to commission further specific research in this area. We intend to use the findings to inform the development and testing of different models to reduce restrictive interventions.

Lay abstract: Background: patients can become upset, aggressive and violent in mental health wards. When this happens staff use a range of skills to calm the situation (de-escalation). If this fails they might restrain a person, keep them own their own (seclude), or inject them with drugs. These are called ‘restrictive measures’. We know that these measures can be dangerous for both patients and staff. As such, staff get a lot of training to learn how to prevent violence and how to manage it in the safest possible way. Training programmes use different ways of trying to change staff behaviour, for example, they might get staff to practice how to talk to somebody they think might become aggressive. It is hoped that if the staff member practices doing this during training, they will be able to do it when a real life situation occurs. When programmes to reduce restrictive measures have been tested to see whether they work this has been difficult as there has been no standard way to describe what staff behaviours they consist of. A list of 93 behaviours (taxonomy) has been developed over recent years to make it easier for researchers to describe complicated interventions like training programmes. It is similar to a dictionary; you can look up the term that describes what parts of training consist of. It is useful as it provides a standard way to describe the different parts of programmes and the way they change behaviour. Research aim: Firstly, use the BCT list (taxonomy) to describe the content of programmes that try to reduce restrictive measures. Secondly, to look at how successful these programmes have been and what they tend to consist of. Design and methods: The study is an ‘evidence synthesis’, which is a summing up of all available documents about reducing the use of restrictive measures. To do this we will first identify all programmes and collect all the information we can about them. We will then organise this into categories such as participants, location, how success is measured, whether participants thought it was useful. We will then look in detail at the contents of programmes and use the list (taxonomy) to label them. The programmes that have been labelled in this way will then be examined to see if they have reported any successes. We will compare programmes that contain specific BCTs with those that do not to test whether the presences of specific BCTs affects the efficacy of the programme. Our report will be a summary of the different types of programme to reduce restrictive measures. It will be a detailed examination of the way they try to change behaviour and whether they have been successful. It will then make recommendations for future research. Impact: The study will be the first to describe these programmes in a standard way that other researchers, policy makers and clinicians can understand. It will allow the development of better described and understood programmes to reduce restrictive measures. Better understanding of how programmes work will ultimately lead to increased safety for both patients and staff.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH