Dr. Daniel Rippon, a lecturer at the University of Northumbria, writes about his recent research into the effects of restrictive practice on the stress and well-being of frontline mental healthcare staff.
There has been much debate about the use of restrictive practices to de-escalate the distress of care recipients in healthcare settings. In 2017, figures from 40 mental healthcare trusts were released showing that there were 59,808 reported incidences in which care recipients had been subjected to a restrictive practice. Restrictive practices can consist of manual restraint, mechanical restraint, pharmacological restraints or seclusion.
There is a wealth of literature which suggests that the use of restrictive practices have the potential to elicit non-therapeutic outcomes in care recipients, such as physical harm and re-traumatisation. Thus, the use of restrictive practices could trigger or perpetuate traumas that have previously been experienced by care recipients. In 2017, the Department of Health and Social Care introduced an initiative which aimed to reduce the use of restrictive practices as a strategy to improve standards of inpatient mental healthcare.
However, it must be noted that the use of restrictive practices can also implicate the well-being of frontline staff, who either witness or are involved in the application of restraints in a healthcare setting. The statistics released in 2017 also revealed that there were 1,847 reported injuries sustained by frontline mental healthcare staff who had been involved in administering a restrictive practice. The Health and Safety Executive has identified that frontline mental healthcare staff are an occupational group that could be vulnerable to the onset of work-related stress. We must therefore consider how reducing or negating the use of restrictive practices could also be beneficial in enhancing the occupational well-being of, as well as offsetting stress levels experienced by, frontline mental healthcare staff.
According to medical ethics, healthcare professionals should ensure patient autonomy and justice, and act with beneficence and non-maleficence when providing care. Ultimately, and ideally, healthcare professionals should ensure that care recipients have a choice in the type of care they receive, and that they do not experience harm during their treatment. It goes without saying that most healthcare professionals who enter into this occupation have a genuine vocation to care for people. Therefore, it is often the case that the thought of manually restraining a care recipient against their will is at odds with the personal and professional ethics of some frontline mental healthcare staff. Such professionals can experience ethical dilemmas when encountering care recipients who self-harm, where non-invasive de-escalation strategies have been ineffective. Thus, cognitive dissonance can occur within healthcare professionals who apply a restraint in order to prevent a care recipient form experiencing further harm, but are ill at ease with the process of manually holding a person against their will within a care setting. When restrictive practices have been applied to prevent a care recipient from further self-harm, it is therefore necessary to consider how best to support frontline staff who may feel that they have breached their own professional ethics by applying a restraint.
Unfortunately, there is some literature which suggests that many frontline staff receive inadequate or no offer of post-incident debriefing from suitably qualified professionals as a means to alleviate the stress which accompanies being involved in challenging situations where restrictive practices have been used. We must be mindful that some frontline healthcare staff may have experienced their own traumatic life events, which could be triggered by witnessing or being involved in the application of a restrictive practice. The process of witnessing care recipients self-harm can also be a traumatic experience in itself. However, the process of being involved in a restrictive practice has the potential to elicit re-traumatisation within frontline staff. Even in the event that a restrictive practice has been used as a last resort to prevent a care recipient from experiencing further harm, we cannot assume that members of frontline staff who were involved in the restraint walk away without any negative consequences to their well-being.
Research has suggested that structured debriefing sessions, which provide emotional and educational support immediately following incidences of behaviours that challenge, can contribute to the reduced use of restrictive practices. However, there is also literature to suggest that the process of discussing incidences in which restrictive practices have been used can be traumatic for both care recipients and frontline staff involved in the restraint. This illustrates a conundrum as to how the aftermath of a restrictive practice can be effectively managed in order to prevent care recipients and staff from experiencing further trauma. In an ideal world, the simple answer would be to implement working practices that prevent challenging incidences from occurring in the first place. Some schools of thought actually advocate that the use of restrictive practices should never be used to reduce the distress of care recipients in healthcare settings.
As my research interests concern the occupational welfare of frontline healthcare professionals, I am always keen to understand ways in which work-related stress can be alleviated in caring professions. It could be that healthcare environments which place an emphasis on reducing or negating the use of restrictive practices may help in ensuring not only the well-being of care recipients, but also of frontline staff. Some philosophies of care, such as Bloom’s Trauma Informed Sanctuary Model, advocate that mental health inpatient services comprised of therapeutic environments which are non-violent may help to ensure the biopsychosocial well-being of care recipients. Models of inpatient care that are underpinned by the principles of Trauma Informed Care, such as Safewards, have also been shown to reduce the use of restrictive practices and assist with harnessing therapeutic environments for care recipients. Studio 3’s Low Arousal approach also places a strong emphasis on diffusing the distress of care recipients without the use of aversive or restrictive interventions. My recent research has focused on ascertaining whether the application of such healthcare philosophies, encouraging the use of non-invasive techniques to reduce distress in care recipients, are also conducive to ameliorating stress levels in mental healthcare professionals.
There is a plethora of research which suggests that providing frontline mental healthcare can be a stressful occupation. Witnessing or being directly involved in a restrictive practice could be one of a number of factors that contributes to the work-related stress experienced by frontline mental healthcare professionals. Trauma-informed care and Low Arousal approaches can provide guides as to how to avoid the use of restrictive practices as a means of ensuring the well-being of and preventing re-traumatisation in care recipients. It is also necessary to consider how avoiding the use of restrictive practices could be beneficial in enhancing the well-being of and reducing work-related stress in frontline staff with a vocation to provide care for vulnerable people.
Dr. Daniel Rippon
Lecturer in Psychology
University of Northumbria, Newcastle