In B. Burstow, B. A.. LeFrancois and S. L. Diamond (eds) Psychiatry disrupted: theorizing resistance and crafting the (r)evolution. Montreal, QC: McGill/Queen's ...
McKeown M and Foley P. (2015) Reducing physical restraint: an employment relations perspective. Mental Health Nursing 35(1): 12-15.
Introduction There has been much debate about the use of restraint to control aggressive and violent patients in health and social care services. Although concerns apply across different sectors of service provision it is often thought to be a more significant issue in mental health settings. Furthermore, it appears that forcible restraint is more readily accepted as legitimate within the mental health system (Paterson et al 2013). Even appropriate and justified use of restraint can prove to be problematic, and there has been considerable recent strategic interest in addressing adverse consequences of physical restraint practices. Such concerns have been brought into sharp focus by scandals like Winterbourne View, where some staff were seen to systematically abuse patients and, in particular, misuse physical restraint (DH 2012).
This article reviews the employment relations implications of managing violence and aggression within mental health services, with a particular focus on use of physical restraint. These matters are of particular concern to public sector trade unions and their members. We are both actively involved in UNISON, and are interested in highlighting the workforce issues in this context. The benefit of taking systematic measures to train and organise the work of mental health teams is advocated. Although broader measures, including optimising the care setting and safe staffing levels are as important.
We examine a specific approach to team and practice development as set out in the Six Core Strategies (Huckshorn 2008), and we draw attention to a major research project funded by the Health Foundation: the ResTrain Yourself study. A research and development team led by Professor Joy Duxbury, involving the universities of Liverpool, Manchester and Central Lancashire and AQUA (Advancing Quality Alliance), aim to evaluate if these methods are useful in a UK context. With the support of eight key NHS Trusts, this initiative includes sixteen wards in the North West of England, eight who will receive a tailored Six Core Strategies intervention, and eight control wards who will also eventually be included in the intervention. The project is notable for having significant service user involvement and one of the research assistants has been employed on this basis.
Problems with coercion Today, health and social care services are increasingly aware of the complications and difficulties surrounding the deployment of coercive measures to manage the behaviour of patients and public. These complexities are particularly present in a mental health environment. This may be because of the nature of people’s problems or the circumstances by which they arrive at mental health care having an impact upon the ease with which communication and therapeutic relations can be established.
In mental health services front-line staff are routinely trained in a variety of physical restraint techniques as part of ensuring health and safety at work obligations are met (Farrell et al. 2010, Livingston et al. 2010). The focus is ostensibly designed to minimise harm to disturbed individuals. It is often argued that by deploying such control measures patients are protected from harming themselves or others. Lack of appropriate training, however, leads to lack of confidence which in turn contributes to a lack of control. This potent cocktail can result in raising rather than reducing the risk of harm to patients or staff. Recent Department of Health (2014) guidance makes the point that more appropriate management of violence and aggression can be achieved at the same time as minimising the deployment of physical restraint measures. Furthermore, it is argued that the harm associated with failing to do so fall, albeit unequally, on both staff and service users.
Various commentators have suggested that rather than constituting an intervention of last resort, to some extent physical restraint has become a fairly routine response, bypassing the deployment of more proactive de-escalation measures (Pereira 2006, Perkins et al. 2012). There is great variability in recorded use of physical restraint in mental health services (Janssen et al. 2011) and critical commentary is often bound up with wider critique of the extent of compulsion and coercion within psychiatric services (Szmukler et al. 2008). The Mind campaign for excellence in crisis care (2013) includes a focus upon the complete eradication of face down restraint, which has been implicated in numerous deaths in custody (Duxbury et al. 2011).
Ensuring safe settings: an employment relations issue
Violence and aggression in mental health services has increasingly become an important element in employment relations. This is largely due to concerns over the reported increase in levels of violence against NHS staff. The increasing levels of violence and aggression may also contribute, directly or indirectly, to absenteeism, staff turnover, or leaving nursing altogether (Edward et al. 2014). In 2012-13, the most recent year for which figures are available, in the NHS as a whole there were 63,199 recorded physical assaults on staff. Some 43, 700 of these, around 70%, were in mental health care (NHS Protect 2014). Violence in the health sector is a worldwide problem. In response to growing concerns, the International Labour Organisation (ILO) (2002) together with the International Council of Nurses (ICN), World Health Organisation (WHO) and Public Service International (PSI) initiated a significant programme of work and produced guidelines relevant to considering violence in the workplace as an employment relations issue. This programme found that violence affects one in two healthcare professionals worldwide with nurses having three times higher possibility of being exposed to violence than any other health professional group.
Hence, the safety of staff, and protecting them from violent assault, has become an important and emotive element of health and social care trade union policy. It is not unusual for union delegate conferences to hear upsetting first hand stories from front line staff who have experienced shocking and grievous attacks at the hands of patients or members of the public, leading to serious injury and extended absences from work. To some extent, programmes of staff training in physical restraint techniques are a health and safety measure predicated upon employer and union concerns over such victimisation. Conversely, staff can, at the very least, have mixed feelings about the use of physical restraint, preferring if possible to pursue treatment goals consensually and avoid conflict (Perkins et al. 2012). Nurses have also been critical of some colleagues for over-zealous use of physical restraint (Lee et al. 2003).
To date, unions have declared almost unequivocal support for government initiatives such as Zero Tolerance against violence campaigns. As a result, the NHS successfully sought sanctions in 599 of the cases of assault on mental health care staff in 2012-13, an increase on the previous year (NHS Protect 2014). These, Zero Tolerance measures however, do not always translate comfortably into mental health settings. Unsophisticated trade unionism can be seduced by the appeal of Zero Tolerance approaches, not least because they offer an immediate sense that something is being done about a serious issue but also because the
right for staff to be free from assault or abuse is clearly emphasised. Nevertheless, we need to pose questions as to whether seeking prosecutions for every case of violence is the right thing to do from a trade union perspective. This is not same as denying a need to protect our members, but rather we need alternatives.
Perhaps because of this, some union policy resolutions call for better attention to environmental, contextual and resourcing factors, which do not attempt to locate the problem exclusively in terms of individual behaviour. Hence the focus is shifted onto a range of concerns about built environment, staffing levels, low pay, over-use of agency staff (leading to an unstable workforce), access to training, availability of meaningful occupation for patients and sundry other factors relevant to aggressive behaviour outbursts. Such a refocusing places union negotiations on more traditional territory, arguing effectively for increased resources, or at least minimising cuts, to assist staff to do the best job possible.
That said, it is arguably the case that unions’ strategic thinking on workplace violence is not always joined up and can be confused or contradictory. A number of other employment relations issues flow from these circumstances, not least the potential for union activists and members to become embroiled in discipline and grievance procedures following violent incidents and the use of physical restraint. Since Francis the NMC have reported a significant rise in misconduct case referrals. Trade Unions have questioned whether this might be a reflection of NHS organisations passing the buck for the investigation of complaints and service failings on to the NMC rather than directly address systemic problems (Ford 2012).
For unions attempting to renew themselves on organising lines, proliferation of representation demands can be an unwelcome distraction, taxing the capacity of overstretched shop stewards who might prefer to be engaged in building the strength of the union (Dickens 2012). The fact that a key union organising objective is to reach out in solidarity to communities and seek alliances with, for example, autonomous service user groups (McKeown et al. 2014) could, arguably, be jeopardised by oppositional positioning on these issues of physical restraint. This point alone urges more nuanced analyses of the causes of violence and aggression, not least the complexities surrounding the legitimate
expression of dissent, frustration and anger in contexts framed by compulsion and coercion (Hopton 1995).
From critique to concordat Support for initiatives designed to reduce the use of restraint ought to be bread and butter for trade unionists who wish to do something constructive rather than reactive with regard to aggression and violence on wards. Interestingly, this can also connect with other more wholesome union objectives, which go to the heart of efforts towards union renewal and transforming the public image of trade unions as a positive force in society.
High levels of coercive care can be detrimental to therapeutic alliances and leave both service users and staff estranged from each other (Strout 2010) contributing to an ‘us and them’ culture (Barker et al. 1999). Given the rise of new managerialism and risk averse cultures (Tonkens et al. 2013) staff are increasingly corralled into offices, consumed with paperwork, with a relative absence of supportive engagement. This is arguably detrimental to the psychological well-being of both patients and staff. In the absence of opportunities to make constructive, therapeutic use of self, to paraphrase Erich Fromm (1969), contemporary psychiatric inpatient services can be seen as housing alienated patients who are treated by alienated staff possessing few alternatives to alienating technologies. Thus, it is worth bemoaning the demise of more communal, relational approaches to care, such as therapeutic communities or democratic alternatives, such as Soteria and Open Dialogue (Calton et al. 2008; Calton & Spandler 2009; Spandler and Stickley 2011).
The media clamour surrounding notable service failings has become wrapped up with an alleged compassion deficit, feeding into and out of political rhetoric and policy making, and calling into question the very legitimacy of professional groups such as nursing. Rabid right wing commentators, notably in the Daily Mail, call for heads to roll regardless of evidence that might demonstrate clear-cut culpability. An unholy trinity of politicians, press barons, and private business interests outbid each other to denigrate the health care workforce as part of a much broader neo-liberal antipathy towards public services. This media blame-game fuels defensive or aggressive managerial tactics, exacerbating the prevailing escalation in discipline and grievance cases. Of course, trade unions do strategically challenge negative
and inaccurate media coverage but do not find it easy to mobilise positive media stories, given the aforementioned control of media outlets.
The Winterbourne Scandal put the spotlight upon abuses of physical restraint, and quite rightly a number of staff were disciplined and sacked and the private employing organisation was severely criticised, eventually losing the contract to provide the service. Arguably, however, gross examples such as Winterbourne can be a diversion from thinking more critically about the deleterious consequences of routine, legitimate coercive practices. From a trade union point of view, any review of ordinary practice would ideally involve the workforce and trade unions in its deliberations. Indeed, a key element of the Six Core Strategies approach is to thoroughly and inclusively debrief critical incidents.
In contemporary services, beset with funding cuts, unstable staffing, workforce anxieties surrounding job security, and a media and indeed some elements of the public demanding someone be held to account for alleged failings, optimum conditions do not exist for truly honest exchange of views (Randall & McKeown 2014). This might especially be the case if it involves the potential to own up to mistakes, even if these are made in good faith. This is compounded with employers’ fears over potential litigation by service users. Additionally, it has been long recognised in public services of all types that when the workforce comes under pressure it can become all too easy to scapegoat service users as the cause of problems, losing sight of the reasons a service exists in the first place (see Wadsworth & Epstein 1998). One way to solve such tensions is to instigate a no blame system for reviewing errors and service failings. Another is to think about democratising communication.
Democratic nurse leadership for violence prevention and management There has been a recent emphasis on clinical leadership, particularly nursing leadership, which was seen to be inadequate in Mid Staffordshire (Francis 2013). But is this singular focus really the answer? As trade unionists we contend that there needs to be a more systematic, whole workforce development approach. A truly transformative strategy would have to involve and empower front line staff, such that they feel ownership of implementation approaches. One such approach, which would also be compatible with a no blame culture, would be to think seriously about notions of workplace democracy (McKeown & Carey, submitted). This ought to be congruent with the stated public sector commitment to
partnership working and the exhortation of important groups such as the Health and Safety Executive that employees should be closely involved in discussion and planning for safety at work (see HSE Safe and Sound at Work webpages: http://www.hse.gov.uk/involvement/doyourbit/index.htm). Such aspirations are also enshrined in the NHS Constitution.
Thinking afresh about the prevention and management of violence and aggression, including implementation of the Six Core Strategies, represents at least part of the answer. Such an approach also speaks of issues unions are interested in like mediation, no blame policies, and democratic voice. A democratisation of the organisation and planning of mental health work might be a means by which nursing in particular recovers some of its legitimacy. Health-workplace democracy would inevitably have to be inclusive of both staff and service user voices. As such, alternative more peaceful, consensual care approaches might emerge through deliberative dialogue and interaction between pluralities of voices, affording a remedy to some of the alienating characteristics of care work and patient experience alike. Middle managers would become facilitators and democrats, rather than bosses who direct the work of others, freeing up their time to contemplate more expansive matters of evidence or innovation.
Conclusion There have been many studies on the impact of violence on staff in the health sector, and this has emerged as a key focus of interest for international trade unions. The ILO sponsored Joint Programme on Workplace Violence in the Health Sector identified the physical and emotional impact of violence on health workers (di Martino, 2003). Such studies have emphasised the cost of violence in terms of compensation payments and lost working days. However, most such reports concentrate on the need for employers to adopt policies to protect staff. Recognising that this is extremely important, inquiry has largely examined what generates a violent response from patients and clients. If we are going to tackle violence in a structured way which will benefit staff and patients then a new approach is needed.
The ResTrain yourself programme, having elements of participatory involvement and democratic reflection and decision-making, is presented as initiative worthy of trade union
support. Adoption of these measures into practice and the support of the workforce and unions would also make a difference to notions of union legitimacy, by offering a positive, progressive view of union interests. Ultimately, the potential to reduce, or even eradicate the use of physical restraint in mental health practice would be beneficial for both staff and service users and potentially remove a significant aspect of conflict in workplace relations. If we could achieve this state of affairs democratically and inclusively, then stronger unions in alliance with a dynamic service user movement would represent a desirable outcome indeed.
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