This chapter addresses objective 2 in describing the presence and frequency of BCTs in interventions.
Behaviour change technique clusters identified in interventions
The 43 different BCTs identified in the interventions were contained by 14 out of a possible 19 clusters within the BCT taxonomy. These are shown in . The first four clusters contained over two-thirds of the BCTs; these were cluster 1 ‘goals and planning’, cluster 4 ‘shaping knowledge’, cluster 12 ‘antecedents’ and cluster 2 ‘feedback and monitoring’. The 14 clusters, the content that was coded to BCTs within them and those BCTs that were not identified are described below.
Goals and planning
Behaviour change techniques in the cluster ‘goals and planning’ were those identified most commonly in the interventions, with just over one-fifth (22%) of identified BCTs contained within this cluster (). All the BCTs in this cluster were identified: ‘discrepancy between current behaviour and goal’ (BCT 1.6), ‘behavioural contract’ (BCT 1.8), ‘review for behaviour’ (BCT 1.5), ‘commitment’ (BCT 1.9), ‘review for outcomes’ (BCT 1.5), ‘goal-setting (behaviour)’ (BCT 1.1), ‘goal-setting (outcome)’ (BCT 1.3), ‘action-planning’ (BCT 1.4) and ‘problem-solving’ (BCT 1.2).
Behaviour change technique cluster 1: goals and planning.
Problem-solving refers to when the individual or team is prompted to analyse what is influencing behaviour (unsuccessful de-escalation resulting in increased restrictive practice) and find solutions that attempt to overcome the problems or increase the likelihood of it happening. The ‘problem-solving’ described by interventions occurred in response to a problem of high rates of restrictive practices, or the resulting staff or service user injury. These problems could be identified at different levels: regional level, leading to a change in policy, within a service or in the review of individual service users. These reviews might involve the service user in the problem-solving process by taking place during individual care-planning meetings, debriefing after incidents or communal service user meetings. Problem-solving not involving service users took place during nursing handovers (e.g. McEwan et al.123), staff clinical supervision (e.g. Prescott et al.128) and in response to routine data review:
In weekly clinical supervision sessions, relevant data on seclusions and the circumstances leading up to its use were systematically discussed, in order to find ways to prevent future occurrence.
Mann-Poll et al.212
Sometimes tools were used to support problem-solving, risk assessments and care plans:
A five-item recovery rounds checklist was developed by professional practice to prompt reflection and problem solving.
Hernandez et al.99
A daily nursing assessment was also initiated by nursing staff. This included a brief mental state component . . . and assessment of risk of violence or harm to self or others, [resulting in an] individual service plan for the following 24 hours. This tool was important as its aided communication between nurses.
Sullivan et al.104
‘Action-planning’ and ‘goal-setting’ followed a similar pattern, often as a result of problem-solving: planning with individual service users to try to prevent incidents that could result in restrictive practices, for example McEwan et al.,123 or with staff teams when a ward had a target to reduce the number of episodes of restrictive practices, for example Lo.74 There was also an indication of strategic action-planning and goal-setting, often through the formation of project steering groups to formulate institution-wide action plans to meet and review goals, for example Huckshorn.133 Mention of reviewing goals was usually with reference to an individual service user and the goals documented in their care plan, for example Riemer.156
Fewer interventions described ‘goal-setting’ than ‘action-planning’. Those that did consistently specified the reduction or elimination of restrictive practices, most commonly restraint and seclusion.89 Other goals included improving staff cohesion and service culture:
The goals of the initiative included further reductions in S/R [seclusion and restraint] use and continued culture change to make the psychiatric inpatient and emergency services more patient centered and trauma informed.
Wale et al.196
There were no examples of goal-setting with individual staff to reduce their use of restrictive practices.
Eight interventions24,176,190,201,213–216 described the use of a public ‘commitment’ (BCT 1.9) at strategic level to reduce restrictive practices:
Management has articulated (verbally and in writing) its intention of reducing the use of seclusion and restraint and/or to eliminate their use entirely.
Colton176
One of the more profound policy transformations was initiated by a declaration from the president and chief executive officer of RI [Recovery Interventions, Inc.], Gene Johnson, who mandated that seclusion and restraint practices would no longer be used and that the NFF [‘no force first’] policy would be implemented companywide, including in its crisis centers.
Ashcraft et al.24
Three interventions described behavioural contracts to support individual staff commitment to reducing restrictive practices:16,137,217
[Trainees confirmed] that they would deliver the training when they returned to their service. The intention was that trainees should train end-users in all modules using the training materials they themselves had been trained with, in order to provide consistent training and maintain the integrity of the material.
McEvedy et al.137
One other intervention made reference to a behaviour contract but it was unclear whether it referred to service user or staff behaviour.103
Very few interventions discussed any discrepancy between the goal of the intervention and staff behaviour. Safewards has ‘clear mutual expectations’ that acknowledge this possibility, for instance to ‘. . . encourage the patients to refer to these expectations with staff, when they fail to uphold them’213 whereas Clark et al.217 describe the commitment that staff make to refraining from using restrictive practices, via care plans with individual service users. Clark et al.217 also report that patients are supported to challenge staff:
For example, if a tertiary intervention is used without any attempt at secondary intervention strategies, the patient is well within their rights to state that staff have not fulfilled their side of the contract and that the restrictive practices used may not have been justifiable.
Clark et al.217
In only two instances was a discrepancy between current behaviour and intervention goal detected.213,217
Shaping knowledge
The cluster ‘shaping knowledge’ contained 16% of the overall BCTs and included those that capture the imparted information about ‘antecedents’ (BCT 4.2) (40%; n = 60) and ‘instruction on performing the behaviour’ (BCT 4.1) (90%; n = 136), half of the four BCTs within this cluster (). ‘Re-attribution’ (BCT 4.3) and ‘behavioural experiments’ (BCT 4.4) were not detected. Information about antecedents was detected as being provided at the theoretical, service, ward and individual service user levels.
Behaviour change technique cluster 4: shaping knowledge.
Information about antecedents for individual service users was sought either proactively on admission145,212 or on a regular basis (daily153 or weekly200) and either more broadly in a care plan or as part of a specific safety plan or risk assessment. Very few interventions reported the involvement of family in this process:145,182,212
Implementation of Safety Plans, a collaborative document completed by the patient with the staff that recorded stressors and triggers.
Maguire et al.116
This information could also be sought via debriefing after an episode of restrictive practice:
(d) identify triggers and antecedent behaviors that may have resulted in the use of restraint; (e) discuss alternative behavior and healthy coping strategies that may effectively minimize the future use of restraint should similar situations reoccur.
Riahi et al., 201623
Information about antecedents could be informed by review of aggregate service data:153
Change ideas were developed through sharing theories about why violence was occurring and what would help to mitigate this. A range of stakeholders contributed to this theory-building in a facilitated workshop, including staff of all levels of seniority and different professional backgrounds, service users and the police liaison officer.
Taylor-Watt et al.153
Staff training often included more general information about antecedents:
. . . staff were trained in early recognition of warning signs, thereby improving their risk-assessment skills, and their ability to prevent and manage aggression in early stages.
Georgieva et al.150
‘Instruction on how to perform the behaviour’ (BCT 4.1) was one of the most frequently coded BCTs, present in 91% (n = 136) of interventions. Interventions varied as to how much detail they provided. Some merely reported that staff were trained in de-escalation, whereas others provided more detail. Specific instructions were provided, for example regarding how to resolve conflict and de-escalate situations or use Sensory Modulation strategies. Training often included Trauma-Informed Care (see BCT 13.2: ‘framing/reframing’) as well as avoiding restrictive practices through use of risk assessment, care planning and respectful communication. Many interventions also provided instruction for when de-escalation had failed with elements about managing violence, restraint skills and post-incident care, as well as legal and ethics issues.
Some training involved service users116 and when this was the case this had influenced the content of the training:
PMVA [Prevention Management of Violence and Aggression] training was revamped with much greater focus on communication, de-escalation and building therapeutic alliance.
Lombardo et al.159
Very little mention was made of training supporting staff to regulate their own emotional responses; where it was mentioned it included raising awareness of and control of feelings, especially fear and anger.15,129
Antecedents
The BCT cluster ‘antecedents’, involving factors that might influence whether or not restrictive practices can be avoided, was a theme throughout many interventions, typically in terms of preventing situations where service users might become distressed and conflict occur. ‘Antecedents’ was the third most populated cluster, containing 15% of BCTs (). Half of the six BCTs constituting the antecedents cluster were identified: ‘restructuring the physical environment’ (BCT 12.1), ‘adding objects to the environment’ (BCT 12.5) and ‘restructuring the social environment’ (BCT 12.2). ‘Avoidance/reducing exposure to cues’ (BCT 12.3), ‘distraction’ (BCT 12.4) and ‘body changes’ (BCT 12.6) were not detected. Broader ward- and organisation-level changes to the physical and social environment described here as BCTs that aim to reduce antecedents by addressing individual service user needs are described elsewhere under ‘prompts’.
Behaviour change technique cluster 12: antecedents.
Restructuring the physical environment
‘Restructuring the physical environment’ was a feature of 20% (n = 30) of coded interventions and considered any changes made to the ward itself, including the introduction or removal of specific rooms and changes made to the fabric of the building. Nineteen (13%) interventions included the creation of private rooms (e.g. Lombardo et al.159) with a low-stimulus environment, often created out of a seclusion room, called comfort, sensory, quiet or ‘Snoezelen’ rooms. Although these rooms were aimed at changing service user behaviour, they gave staff an alternative resource to help support their aim of de-escalation. Sivak191 reports that the walls were painted in a pale-green colour; one had a mural and another included an area of chalkboard paint at a convenient height for clients to use if they chose to do so. The noise level was reduced by the installation of drop ceilings, and light panels with sky scenes were used to create a sense of being outside.191
Service users were often involved in deciding how they should be decorated:
[S]uggestion boxes were also placed in both ward sitting rooms [. . .]. Suggestions for the design and decor were made by patients, carers and staff. These included; colours of paint, design of curtains, style of pictures for the walls, types of furniture, brightness/levels of lighting and layout of furniture.
Smith and Millar158
Other changes to the general physical environment included upgrading of wards to make them feel more homely or comfortable:
. . . inexpensive physical changes, including repainting walls with warm colors, placement of decorative throw rugs and plants, and rearrangement of furniture.
Borckardt et al.107
Two interventions included physical restructuring of outside areas with the creation of a ward garden and allotment.83 Some interventions did not create Sensory Rooms but created separate space for service users to watch television or designated quiet areas.158
Adding objects to the environment
Many interventions also added objects to the environment (BCT 12.5). The most frequently mentioned was Sensory Modulation equipment, which was used in 16 interventions; it could be a portable box of equipment or could be equipment kept within a sensory room:
This range of objects included a massage chair, rocking chair, beanbag, faux-fur blankets, weighted blankets, weighted soft toys, ‘stress’ balls, portable audio and DVD [digital versatile disc] players with relaxing sounds and visual scenes, aromatic oils and diffusers, scented hand creams, and adjustable coloured ambient lighting.
Sutton et al.152
Objects such as rugs and plants provided a more homely feel, whereas others were there to provide activities for service users, and included games consoles, reading material, games and puzzles, DVDs and exercise equipment:
. . . exercise machines were added as options to help the service users burn energy and safely manage stress.
Riemer and Corwith192
Another category of object added to the environment were noticeboards displaying information for staff, service users or both. Safewards encouraged staff to have posters of de-escalation tips in their office:
To change the Soft Words poster every day or so. To remind other members of the team as to what the Soft Words are. To draw attention to the Message of the Day poster in the nurses office.
Safewards213
Another category of things added to the environment is items to alert staff of incidents; this includes personal alarms,150 two-way radios,218 pagers74 and closed-circuit television (CCTV),83 all of which were used in at least one intervention.
Restructuring the social environment
This BCT (12.2) is intended to record changes made to the social environment in order to facilitate the performance of a desired behaviour or create barriers to an unwanted behaviour. Many of the interventions made changes to the social environment of the setting including changing the way that people interact with each other, from the strategic through to the individual level. As such, this BCT was divided into four themes: stakeholder involvement, increased access to staff, improved communication and promoting social contact.
Stakeholder involvement
Stakeholders could be service users, relatives or ward staff. The main aspect of interventions coded under this category was that of service user involvement (referred to by 25% of interventions; see Service user involvement in interventions). When detail was provided, it was most often referred to in terms of involvement in individual care, either in care planning or debriefing after an incident of restrictive practice had occurred. Service user involvement that was not related to individual care was mostly consultation on aspects of an intervention, for example the design of a sensory room. Some interventions employed service users as consultants, sometimes in a paid capacity:
Two patients from the ward were recruited and paid for their time and input on the local working party.
Maguire et al.197
A small number of these interventions employed service users to deliver training:
Consumer advocates provided staff education on such topics as respect, therapeutic approaches to providing care, trauma-informed care, and reducing the risk for violence.
Riemer and Corwith192
Other interventions had service user representation on committees, at either ward level or at a more strategic level:
We established a multidisciplinary seclusion/restraint minimisation committee, chaired by a peer specialist.
Ash et al.6
Others consulted existing committees consisting only of service users:
The Consumer Advisory Group, whose membership comprised patient representatives and Consumer Consultants, was regularly consulted.
Ching et al.115
There was very little involvement of relatives and informal carers. Two interventions provided support for families, one by providing education and support and the other by opening a resource centre:
To enhance the role of families in treatment and the organization, the Family Resource Centre opened in 2013 to provide a space for families to share experiences, access resources, attend family-specific groups, and connect with other families for support and encouragement.
Riahi et al.23
The rest of the interventions that made references to families and informal carers did so with reference to either their involvement in care planning or post-incident debriefing.
Some interventions made specific reference to the involvement of ward staff in the development of some interventions. According to Cambridgeshire and Peterborough NHS Foundation Trust,85 all staff were engaged in considering new approaches for initiating proactive care and eliminating the use of force, which helped to promote positive conversations and avoid defensiveness. Ideas about small changes were encouraged and the appreciative inquiry model was used to develop questions, such as:
What are we doing well that we should continue and build on? What should we stop doing? What should we start doing or do differently?
Cambridgeshire and Peterborough NHS Foundation Trust85
The importance of ward staff in the implementation of interventions was acknowledged:
A combined top-down and bottom-up approach was used: leadership and support from the top was seen as essential while acknowledging that changes could not be implemented without the active involvement, participation and fiat of the professionals working on the wards.
Mann-Poll et al.212
Explicit managerial support formed part of many interventions,23,106,116,133,192,212,219 either institutionally or at ward level.106
Six Core Strategies implementation guidance emphasised that staff should be made aware of the involvement and commitment of senior staff in reducing seclusion and restraint, including the chief executive officer (CEO)/administrator, the medical director and other senior staff.133
Many interventions had a specific steering group17,115,116 including senior managers who provided monitoring and strategic direction for the interventions.83 In some interventions (n = 10), the multidisciplinary nature of these groups was emphasised:
Establishment of a project management structure that included consumer consultants, managers, clinicians and academics of all disciplines.
McEwan et al.123
Improved interaction between staff and service users
Improving interaction between service users and staff was attempted in several ways, including increasing the number of staff available and promoting access to existing staff. Increased staffing was a feature of 12 interventions; some interventions simply increased staffing ratios,150,220 either all the time or in crisis situations.109 Several interventions introduced a rapid response team with the aim of providing expertise in a crisis situation, for example Hernandez et al.,99 whereas others added expert practitioners to ward teams:
Two City Nurses were appointed for the project and were recognized clinical experts in acute inpatient care with long experience of practice development work. They worked with the wards’ staff, 3 days per week, using the working model mentioned earlier, to bring about change towards low-conflict, low-containment, high-therapy nursing.
Bowers et al.102
Other interventions sought to improve service user access to staff. One intervention used a direct booking facility for an appointment to see a doctor, whereby doctors’ availability was displayed in the communal area, enabling patients to book a mutually convenient slot.83
However, others encouraged nursing staff to proactively approach service users209 and prioritise service user need over administrative duties or increased observations:113
. . . he asked can we go a walk and I said yes, let’s just go, and he said that he thought he had no chance as you were there on the computer.
McEwan et al.123
Improved communication was a frequent part of the social restructuring of the service setting to reduce conflict. This aimed to improve communication between staff, between service users or between staff and service users. When the aim was to improve communication between staff and service users, it could take place with individual service users, prompting staff to support service users in expressing their feelings and wishes.103,123 It could also be a collective endeavour with supportive ward community meetings to involve both service users and staff.83 Putkonen et al.17 also report the following:
They also suggested new ways and practices to decrease fear, violence, and coercion and brainstormed with staff and doctors about the ward rules and practices during weekly community meetings (45 minutes).
Putkonen et al.17
Communication between staff about individuals and ward issues were enhanced in some interventions via ward meetings,17,212,221 case reviews,23,106 safety huddles or supervision:
. . . the IPCU [intensive psychiatric care unit] safety huddle was subsequently born. This was a 10-minute ‘huddle’ to focus on potential or actual safety issues. The focus was on anticipation and prevention; nursing assistant staff were involved and contributed to its facilitation.
McEwan et al.123
Clinical supervision is an invaluable and objective way of communicating the plan across three shifts. One successful approach uses a single-person contact to meet with each of the employees across shifts.
Visalli and McNasser103
Few interventions mentioned communication with relatives and carers, for example Mann-Poll et al.,212 with the exception of communicating service rules and behavioural expectations:
Clear boundaries and limitations with respect to acting out behavior were communicated at admission.
Mann-Poll et al.212
There was some evidence of communication of behavioural expectations to staff; Safewards used ‘mutual expectations’ and ward rules and expectations of behaviour were publicly displayed:
Step 4, get your mutual expectations printed as a laminated poster to the ward, to your specified design with your specified content. Please hang this in a prominent and public space where it can be read by patients and staff.
Safewards213
One other intervention107 saw the introduction of a strategy to promote respectful communication with service users:
. . . all clinical staff to engage in the following communication behaviors with inpatients: ‘Acknowledge’ patients, ‘Introduce’ themselves, articulate the anticipated ‘Duration’ of the clinical contact, ‘Explain’ the reason for the contact, and ‘Thank’ patients for their cooperation.
Borckardt et al.107
Several interventions included aspects surrounding rules or policy changes. Some rules aimed to change how restrictive practices were governed or recorded.146 Maguire et al.116 report that this involved documentation of care plans to identify conditions and interventions for ending seclusion, allowing ‘transparency for the patient and consistency for the clinical team’. In addition, a project officer was appointed and the changes to practice were captured in a rewritten Seclusion Policy and Procedure.116
Several interventions reviewed existing rules with the intention of ascertaining whether or not they were necessary:107,116,139 For example, guidance for implementation of the 6 Cs draws attention to the need for staff to look critically at a facility’s regulations, identifying that they may be neither logical nor necessary:
Most inpatient facilities have historical rules that are habits or patterns of behavior that are not congruent with a non-coercive, recovery facilitating environment, for instance rules such as putting people who self-abuse in non-lethal ways in restraint, or putting people who are intrusive only in restraint.
Huckshorn133
. . . a team for each unit that was tasked with reviewing and modifying unit rules and policies to be less restrictive to patients or eliminating unit rules that were too restrictive.
Borckardt et al.107
Promoting more flexible responses from staff to service users was an aspect of several reviews of rules:
. . . further flexible approach to supporting patients, e.g. to have several spells of time off the ward to defuse agitation.
McEwan et al.123
Sometimes, increasing flexibility of rules was instigated by ward staff:
From a bottom-up perspective, teams could choose their own package of interventions tailored to their ward. They could for example choose to make their ward rules more flexible.
Mann-Poll et al.212
Service users were occasionally involved in this process:17
Staff and patients collaborated to review the unwritten and arbitrary ‘unit rules’ that often are sources of conflict.
Maguire et al.116
Promoting social contact
One aspect of restructuring the social environment to reduce conflict was promoting socialising, either between staff and service users139 or between service users.83 Although interventions that provided greater opportunities for service users to socialise with each other are not specifically targeting staff behaviour, similar to Sensory Rooms, they give staff a broader repertoire of resources to use in de-escalation.123 The ‘know each other’ aspect of Safewards was the most comprehensively described initiative promoting social interaction between service users and staff:
. . . with consent, capacity and confidentiality considered, staff and patients provide non-controversial information about each other, this could include hobbies, music, TV programmes. This information is then placed in a file and made available in communal areas.
Safewards213
Shared meals featured in some interventions:
Shared lunches with staff and patients on male High Dependency Unit, promoting engagement and establishment of relationships.
Northumberland, Tyne and Wear NHS Foundation Trust83
Other shared tasks promoted closer interaction; one intervention17 focused on restrictive practice. In accordance with patient requests:
. . . some patients and staff volunteered to work together 1 hour per week on building projects . . . Because many patients and staff found it difficult to discuss their experiences of coercion and violence, they wrote, photographed, and illustrated a book together, titled ‘Behind Locked Doors’.
Putkonen et al.17
Only one intervention described creating opportunities for families and carers to socialise:
To enhance the role of families in treatment and the organization, the Family Resource Centre opened in 2013 to provide a space for families to share experiences, access resources, attend family-specific groups, and connect with other families for support and encouragement.
Riahi et al.23
Activities on wards for service users were seen as a way of reducing restrictive practices. Activities might be individual or group-based activities groups were more frequently described. Staff were sometimes trained to deliver group activities or a specific staff member might be responsible; in one example, data analysis showed when incidents were more likely to occur on a female admission unit, and, in response, an activity coordinator was introduced on the unit throughout the week.83
Some groups were explicitly treatment orientated, whereas others were recreational:
. . . treatment-based groups/classes are matched with a person’s assessed needs . . . As an educational endeavour, staff are trained to offer individual groups inside and outside the facility. Treatment groups or classes include communication, managing mental health, anger management, assertiveness training, problem solving, and community housing skills.
Visalli and McNasser139
One intervention recognised the importance of activities being available to all service users, even those in the PICU:133
Has leadership reviewed the facility’s plan for clinical treatment activities in an effort to assure that active, daily, person centered, effective treatment activities are offered to all persons receiving services; that these services are offered off living units preferably; and that persons attending have some personal choice in what activities they attend. The minimal criteria to meet under this objective is to assure that service recipients are not spending their days in enclosed areas with no active effective psycho-social or psychiatric rehabilitation occurring that is effective in teaching living, learning, recreational and working skills.
Huckshorn133
Only one initiative promoting activities – Star Wards – was described as having been developed by service users. Star Wards include 75 ideas for meaningful activities that service users can consider, especially in the evenings or at weekends when there are fewer planned activities. They range from simple changes, such as making magazines and newspapers available, to themed social events and activities.125
Feedback and monitoring
Behaviour change technique cluster 2, ‘feedback and monitoring’, accounted for the monitoring of ward data and, if they were fed back to the ward, in what ways this feedback took place. Eleven per cent of BCTs were in this cluster (BCTs 2.1–2.7) (). Both feedback and monitoring related primarily to outcomes (reduced restrictive practices) of the behaviour (de-escalation) although there was some evidence of monitoring of behaviour. Monitoring was either self-monitoring (including ward-level monitoring) or by others, for example at system level through incident reports. ‘Biofeedback’ (BCT 2.6) was not detected.
Behaviour change technique cluster 2: feedback and monitoring.
Feedback on behaviour
‘Feedback on behaviour’ (BCT 2.2) occurred through post-incident debriefing, team meetings or clinical supervision when near-misses were discussed. This feedback was supported by intervention structures such as the introduction of tools such as safety crosses:
Displaying safety crosses . . . a simple wall calendar that staff can mark in colour to show red days (when there was an incident of physical violence) or green days (incident-free). This evolved to include orange incidents, reflecting a near miss or build-up of hostility – which are not usually recorded in any form.
East London NHS Foundation Trust.
85 Contains public sector information licensed under the Open Government Licence v3.0.
East London NHS Foundation Trust
Self-monitoring of behaviour
‘Self-monitoring of behaviour’ (BCT 2.3) was coded when interventions encouraged ward staff to take the lead on reflecting on not just incidents but near-misses and times when de-escalation had been successfully used:
The nursing team started collecting and recording improvement data on safety crosses regarding safety huddle frequency, daily goal-setting frequency, and restraint incidence. Weekly improvement data were . . . collected on the quality of patient risk assessments and safety plans, as well as the extent of service user involvement in safety planning.
McEwan et al.123
One intervention involved the service user in this process:
If a crisis was averted, staff members and the patient reviewed the crisis management plan and determined which strategies were most effective.
Jonikas et al.180
Only one intervention described staff reflection on the way in which they individually related to service users:
. . . participants practised self-awareness techniques to gain a more profound understanding of their personal habits, ways of behaving on the ward in relation to patients and teams.
Kontio et al.199
Monitoring of behaviour by others without feedback
Only three interventions described monitoring (as distinct from self-monitoring) staff behaviour (BCT 2.1). D’Orio et al.149 used CCTV to monitor the behaviour of staff. Short et al.157 monitored broader staff safety performance data and Hochstrasser et al.110 described monitoring processes to prevent incidents.
Feedback on outcomes of behaviour
Many interventions monitored outcomes of behaviour in terms of the number of restrictive practices that occurred in the setting, for example the number of restraints or duration of seclusion. Most interventions fed back the outcomes of behaviour (i.e. the number of restraints) via institutional recording systems that was fed back at either ward186 or institutional level:132
Each morning the project senior nurse and cultural anthropologist – psychotherapist-counselor discussed with staff the violent incidents that occurred and reported on the practices, restrictions, and alternative methods used, according to the postevent analysis sheet. These meetings identified and praised successful interventions and otherwise helped the staff to improve their practices.
Putkonen et al.17
It needed to capture the essential data relating to ‘how many’ incidents and qualitative information regarding the antecedents through meaningful postincident debriefs with patients and staff. This information enabled the ward team to make real-time changes to patients’ individual care plans. Good reporting practices translated data into usable information.
Lombardo et al.159
Some interventions used debriefing including both service users and staff involved in an incident of restrictive practice.222 This was seen as feedback on the outcomes of the behaviour (and could also include self-monitoring of the outcomes of behaviour), depending on the format of the debrief and whether or not staff were asked to reflect on their practice.
Self-monitoring of behaviour outcomes
Thirty-four interventions described using self-monitoring of outcomes of behaviour (BCT 2.4). This was where wards monitored their own incidents rather than monitoring being a centralised system-level process. Self-monitoring could also be a part of post-incident debriefing depending on how it was described as being carried out.
Monitoring behaviour outcomes without feedback
Feedback as a result of monitoring was not always provided, for example Short et al.157 In a number of cases it was not reported whether or not these data were fed back to ward staff; for example, two studies79,223 were clear that data were being collected without staff knowledge, which led to the assumption these data were not being fed back during the intervention.
Identity
The cluster ‘identity’ referred to the identity of the individual staff members and 9% of the BCTs identified were in this cluster. Two of the five potential BCTs in this cluster were detected: ‘framing or reframing’ (BCT 13.2) and the ‘identification of the self as a role model’ (BCT 13.1). The BCTs ‘incompatible beliefs’ (BCT 13.3), ‘valued self-identity’ (BCT 13.4) and ‘identity associated with changed behaviour’ (BCT 13.5) were not detected ().
Behaviour change technique cluster 13: identity.
Framing/reframing
Framing is the conscious adoption of a different perspective on behaviour in order to change emotions about performing a behaviour. In terms of the interventions, this was dominated by those that introduced changes in nursing philosophy to service user-centred approaches. This is illustrated by the Safewards approach of having positive regard for service users:
Positive words: Aims to create a positive view of the patient at ‘handover’, even when a troublesome behaviour is being reported, by also saying something positive about the patient.
Cabral and Carthy15
Training sought to reframe restraint as avoidable and a true last resort:
Training is provided which gives staff the key competencies and supports the view that restraint is used as a last resort to manage risk behaviour associated with aggression, violence and acute behavioural disturbance.
Restraint Reduction Network214
Different ways of understanding service user distress were a common feature of interventions. Approaches described how behaviour might be affected by environmental/individual interaction. Maybo Conflict Management Training224 follows the principles of Positive Behaviour Support, emphasising how behaviour is used as a form of communication and heavily influenced by both internal and external factors. Participants have a greater empathy for individuals once these factors are understood and a greater appreciation of the depth to which quality of life is compromised. This involved training sessions about sensory processing models, and Trauma-Informed Care in particular:
For trauma-informed care, all unit staff attended a half-day standardized training seminar on the nature of trauma and its effects on patients’ experiences, physiology, and psychological processes, along with instructions on how to minimize engaging in behaviors that could exacerbate trauma related reactions from patients.
Borckhart et al.107
. . . training explains how a client’s history can influence their experience and reaction to seclusion and restraint.
Colton176
Role modelling
Promoting ‘self-identification as a role model’ (BCT 13.1) was achieved in a number of ways. The most common was using a ‘train the trainers’ model, which was used in 16 interventions, for example Visalli and McNasser,139 when select staff members became trainers of their colleagues and often retained a mentoring expert role afterwards. Intervention champions were another commonly used method of role modelling, for example Yakov et al:185
There are Safewards champions for each ward, who provide practical support and help with implementation, training and coaching.
Tees Esk and Wear Valleys NHS Foundation Trust.
85 Contains public sector information licensed under the Open Government Licence v3.0.
Tees Esk and Wear Valleys NHS Foundation Trus
Twelve interventions85,88,90,97,100–103,129,132,135,159,181,185,187,197,225 used expert practitioners on wards to disseminate good practice:
Two City Nurses were appointed for the project, and were recognized clinical experts in acute inpatient care with long experience of practice development work.
Bowers et al.101
Ambassadors from within the teams were appointed to discuss the use of coercive measures with their colleagues and to help stimulate changes in attitudes and practices.
Boumans et al.225
Four interventions made use of information sharing and exchanges between organisations that was coded as role modelling in a broader manner:85,209,221,226
GGZ Nederland, the Dutch mental health umbrella organization, has supported exchange programs that organize quarterly meetings, allowing hospitals to learn from each other.
Noorthoorn et al.221
Social support
The cluster ‘social support’ () accounted for 7% of the BCTs in the interventions and all three possible BCTs were identified as taking place within staff teams at ward level, more broadly within the organisation, or being shared with external agencies. Social support was either ‘unspecified’ (BCT 3.1), or further defined as either ‘emotional social support’ (BCT 3.3) or ‘practical social support’ (BCT 3.2).
Behaviour change technique cluster 3: social support.
Practical support included ‘hands-on’ support in terms of sharing ideas for good practice in reducing restrictive practices. Taxis227 reported that at the outset a ‘weekly RN [registered nurse] discussion group’ was formed, with the goal of addressing practice issues, by raising awareness of the restraint and seclusion incidents, and to ‘build a consensus’ for increased use of less restrictive alternatives. Rather than providing ready-made answers for all situations, the goal was to ‘form a collegial environment in which these matters could be discussed’. This collegiality would serve as an important element as the programme progressed.
Melin69 reported that the meeting was intended to be a forum in which staff involved in treatment could have a positive and constructive dialogue about the interventions and the behaviour of colleagues. Guidelines included making sure that treatment staff were back in control before the meeting started, clarifying what happened, reviewing how staff responded and looking for ways to improve and strengthen responses in the future. Treatment staff were to be supported and encouraged, and trust in colleagues was to be expressed.
Safety huddles were coded as involving practical social support. The Northumberland, Tyne and Wear NHS Foundation Trust83 reported that the Positive Safe Team provide ongoing support including training, consultancy and opportunities for sharing good practice.
Some training providers offered ongoing practical social support for participants228 and, depending on the nature of training, it can offer practical social support in terms of feedback on role play.
The use of rapid response de-escalation teams, which featured in 12 interventions, was classed as providing practical social support.
Associations
As illustrated in , associations were detected in 5% of BCTs in 57 interventions, although only one BCT ‘prompts or cues’ (BCT 7.1). None of the other BCTs in this cluster were detected: ‘cue signalling reward’ (BCT 7.2), ‘reduce prompts or cues’ (BCT 7.3), ‘remove access to the reward’ (BCT 7.4), ‘remove aversive stimulus’ (BCT 7.5), ‘satiation’ (BCT 7.6), ‘exposure’ (BCT 7.7) or ‘associative learning’ (BCT 7.8). Associations were predominantly prompts or cues (BCT 7.1) in the form of standardised assessments for service users on wards relating to risk of violence.127 Mersey Care NHS Foundation Trust229 reported training staff in the PICU in the use of a structured risk assessment tool: the DASA-IV. DASA-IV scores were incorporated into daily care-planning. DASA-IV is a seven-item scale used for daily assessment of inpatients. Higher scores indicate a possible need for increased attention over the following 24 hours to reduce the risk of a serious violent incident.
Behaviour change technique cluster 7: associations.
Other prompts included posters181,213 displayed in offices or wards and flow charts reminding staff of less restrictive practices (e.g. Alberta Health Services).230
Comparison of behaviour
As illustrated in , cluster 6, ‘comparison of behaviour’, comprises three BCTs: ‘demonstration of behaviour’ (BCT 6.1), ‘social comparison’ (BCT 6.2) and ‘information about others’ approval’ (BCT 6.3). Three per cent of detected BCTs were in this cluster and all three BCTs in this cluster were identified. Comparison of behaviour consists of experiencing demonstrations of the behaviour (BCT 6.1), usually as part of training sessions demonstrating successful de-escalation. ‘Social comparison’ (BCT 6.2) was found in everyday practice, through being compared with other wards or wards publicly acknowledging restraint rates, and receiving information about other people’s approval (BCT 6.3).
Behaviour change technique cluster 6: comparison of behaviour.
Thirteen references,16,93,95,96,141,144,162,176,184,198,208,231,232 described de-escalation behaviour being demonstrated (BCT 6.1) as part of their training intervention, either by trainers or through role-play scenarios. ‘The Six Core Strategies intervention used Social comparison’ (BCT 6.2) at ward level, encouraging linked facilities to engage in healthy competition (e.g. by displaying data in open areas).
The Restraint Reduction Network promoted similar social comparison as ‘peer assessment’, in which one team or unit would be responsible for assessing the performance of another. This was felt to be effective in increasing motivation and engagement, and also in enhancing deeper understanding of assessment, and sharing good practice.233
It became a feature at individual staff level within two interventions, one using Safewards. A well-publicised ‘star of the week’ initiative at Northumberland, Tyne and Wear NHS Foundation Trust was enthusiastically supported by staff and patients, and allowed a mild sense of competition between peers.83
‘Information about others’ approval’ (BCT 6.3) was identified when there were descriptions of communication of support and approval from others. At ward level, one study described growing support from a consultant psychiatrist for intervention activities that had been instigated by nursing staff. It was also a feature of the social comparison activities when peers or service users nominated the best de-escalator or ‘star of the week’. Safety crosses were displayed publicly to show when the last incident of restraint had occurred:
Displaying safety crosses in the public area of the ward. This is a simple wall calendar that staff can mark in colour to show red days (when there was an incident of physical violence) or green days (incident-free). This evolved to include orange incidents, reflecting a near miss or build-up of hostility – which are not usually recorded in any form. This was an accessible way to share incident data and provided a focal point on the ward for staff, people using the service and visitors.
East London NHS Foundation Trust.
85 Contains public sector information licensed under the Open Government Licence v3.0.
East London NHS Foundation Trust
Natural consequences
As illustrated in , in the BCT cluster ‘natural consequences’ a distinction is made between natural consequences and scheduled consequences such as a predetermined reward for performing a behaviour. A total of 3% of BCTs identified were in this cluster and included four BCTs: ‘information about health’ (BCT 5.1), ‘information about emotional consequences’ (BCT5.6), ‘salience of consequences (BCT5.2)’, ‘information about social and environmental consequences’ (BCT 5.3). ‘Monitoring of emotional consequences’ (BCT 5.4) and ‘anticipated regret’ (BCT 5.5) were not detected in any interventions.
Behaviour change technique cluster 5: natural consequences.
The consequence of the desired behaviour (defined as successful de-escalation) was the elimination of the harmful effects of restrictive practices. Interventions described consequences of de-escalation failure predominantly on service users, although some interventions also referred to consequences for staff (e.g. Forster et al.).234 Some interventions merely talked about ‘negative’ consequences without specifying what these were, and so these were coded as health consequences. Health consequences (BCT 5.1) were specifically described in 23 interventions, primarily about physical risks to the service user. For example, Space Training235 included emphasis on understanding inherent risks of physical interventions, with a specific focus on ‘positional asphyxia’.
Some interventions (n = 7) emphasised physical and/or emotional health consequences, including interventions with a noticeable focus on the impact of restraint on the service user,123,143,195 and others that focused on health consequences for staff:70,141,236
. . . the goal of the program was both to reduce episodes of seclusion and restraint and reduce staff injuries. This intervention was designed to counteract the frequently encountered attitude that the real outcome of such programs is to place staff members at higher risk.
Forster et al.234
. . . a series of mandated workshops on trauma-informed care, were created that included education on the neurobiological and psychosocial effects of trauma, the relationship of dissociative symptoms and self-harm to posttraumatic stress disorder (PTSD), and the retraumatization that occurs from being restrained or witnessing use of restraints and seclusion.
Chandler201
The broader social and environmental consequences of restrictive practices were referred to by only one study:
Has leadership evaluated the impact of reducing S/R [seclusion and restraint] on the whole environment? (This includes issues such as increased destruction of property; extended time involved in de-escalation attempt, additional admission assessment questions, debriefing activities and processes to document event, etc.)
Huckshorn133
‘Salience of consequences’ (BCT 5.2) was coded when interventions used particular methods to emphasise the consequences of not performing successful de-escalation and restrictive practices being used:
Each staff member experienced 5-point restraints first-hand, and many cited that experience as pivotal in their decision whether or not to restrain a patient in a state of agitation when queried 1 year after the course.
Forster et al.234
The service users educated the project workers in consumer specialist meetings (1 hour per week) about their own experiences with violence and coercion, individual triggers of violence, and effective calming activities.
Putkonen et al17
This often included service user testimony about the consequences of their traumatic experiences of restrictive practices, for example Riley et al.134
Repetition and substitution
As illustrated in , 3% of the BCTs detected were in the cluster ‘repetition and substitution’ and consisted of three of the seven possible BCTs: ‘behavioural practice/rehearsal’ (BCT 8.1), ‘habit formation’ (BCT 8.3) and ‘reversal’ (BCT 8.4). ‘Behaviour substitution’ (BCT 8.2), ‘overcorrection’ (BCT 8.5), ‘generalisation of target behaviour’ (BCT 8.6) and ‘graded tasks’ (BCT 8.7) were not detected in any interventions.
Behaviour change technique cluster 8: repetition and substitution.
Twenty-eight interventions described staff taking part in activities to practise and rehearse de-escalation skills. This was most typically in the form of role-play activities:
These team-building exercises, it was hoped, would highlight the different roles staff members play in the restraint process, crisis intervention, and de-escalation techniques. It was expected that these exercises would help to clarify the roles staff members play in a crisis and allow them to practice crisis management techniques.
Melin69
Detail was rarely provided about whether or not staff played the role of the service user. Some interventions did give details, with one using a fully immersive role-play scenario using actors in other roles.
There was little content in the interventions relating to habit, although one habit formation (BCT 8.3) technique was identified in Safewards, the requirement that staff:
. . . say something good about each patient at nursing shift handover . . .
Bowers et al.16
There was one example of ‘habit reversal’ (BCT 8.4), used within four interventions,16,159,213,222 that encouraged staff to break the habit of saying ‘no’ to service user requests:
This has led to a culture of ‘say yes first’ at the trust, which helps patients to understand what needs to happen for a member of staff to say ‘yes’. The ‘reflect’ acronym helps staff to remember what they need to consider when answering a patient’s request: R – Reframe: What would it have taken to say yes? E – Easy: Was ‘no’ the easy option? F – Feeling: What would it have felt like? L – Listen: Did we listen? E – Explain: Did we explain? C – Creative: Were we creative enough? T – Time: Did we take the time?
East London NHS Foundation Trust, 2017.85 Contains public sector information licensed under the Open Government Licence v3.0
First reflex should be saying ‘yes’, not ‘no’. Do you really need to say ‘no’? Can you justify saying ‘no’? Is this something that with a bit of effort or work or checking, you could say ‘yes’ or at least a partial ‘yes’ to?
Safewards213
Comparison of outcomes
As seen in , cluster 9, ‘comparison of outcomes’, contained 2% of the BCTs with only one detected from the three within this cluster. ‘Pros and cons’ (BCT 9.2) and ‘comparative imagining of future outcomes’ (BCT 9.3) were not identified. The only BCT in this cluster was that of using a ‘credible source’ (BCT 9.1), usually as a way of imparting information. A variety of these credible sources were described within the interventions. Service users were used in 13 interventions:
Behaviour change technique cluster 9: comparison of outcomes.
When staff began to accept peers as co-workers and began to rely on them as a crucial part of the workforce, attitudes toward recovery changed significantly, and the tendency to use seclusion and restraint became more and more remote.
Ashcraft and Anthony193
The psychological impact of restrictive practices was described by service users as part of training or other awareness-raising activities, this was also coded as ‘salience of consequences’ (BCT 5.2):
At the engagement sessions, delivered in partnership with service users, teams are introduced to No Force First and hear accounts of people’s experience of physical intervention.
Riley et al.134
Clinical specialists were also described as credible sources in other interventions, either delivering training or describing the physical impact of restraint on the service user (e.g. a medical director in Madan et al.108). One other type of credible source was academic researchers feeding back intervention data to ward staff (e.g. Mann-Poll et al.212).
Reward and threat
As illustrated in , cluster 10 (‘reward and threat’) contained 4 of the 11 possible BCTs. Future punishment, self-reward/incentive, non-specific reward/incentive and material reward/incentive (behaviour) were not detected. Two per cent of BCTs were in this cluster. Incentives and rewards could be ‘non-specific’ (BCT 10.6, BCT 10.3), ‘material’ (BCT 10.1, BCT 10.2) or ‘social’ (BCT 10.5, BCT 10.4). There could also be ‘self-incentive’ (BCT 10.7) and ‘self-reward’ (BCT 10.9), and could also be associated with ‘behaviour or outcome’ (BCT 10.8, BCT 10.10).
Behaviour change technique cluster 10: reward and threat.
Most of the incentive and reward described within the interventions was of the social variety (BCT 10.4, BCT 10.5). In some interventions, wards or individuals were praised for reducing restrictive practices (e.g. Szypula and Martin89) through awarding certificates, celebrations of success, favourable publicity in service newsletters, and notice boards where positive messages can be left. For instance, a board in a staff office was used for staff to write supportive messages and compliments about the good work they were doing; this proved popular and eventually transferred into the patient area so that both patients and staff could write on it.83
Blair and Moulton-Adelman222 reported the following:
Ongoing recognition of unit successes and individual staff initiatives related to improved patient care is encouraged. Such steps reinforce positive movement toward a therapeutic culture of care and improve overall morale and cohesiveness.
Blair and Moulton-Adelman222
Blair and Moulton-Adelman222 describe that success is acknowledged in many ways, including recognition of individuals in staff meetings, department-wide e-mails, and get-togethers organised across the unit for the purpose of celebrating the achievement of specific milestones. The celebrations help to reinforce awareness of the goals yet to be reached.222
‘Material incentives and rewards’ (BCT 10.1, BCT 10.2) were few, although one intervention had a competition with a prize for the best performing ward, and cinema tickets were raffled among ward staff.237 Continuing professional development (CPD) credits were used in one intervention as an incentive for attending training.115
Regulation
Very few of the interventions used BCTs from the cluster ‘regulation’ (0.6%) and only one of the four possible BCTs was identified. As illustrated in , ‘pharmacological support’ (BCT 11.1), ‘conserving mental resources’ (BCT 11.3) and ‘paradoxical instructions’ (BCT 11.4) were not identified. The only BCT detected in this cluster was ‘reduce negative emotions’ (BCT 11.2), which was targeted at reducing staff stress in order to promote the reduction of restrictive practices. Several interventions (n = 8) described a focus on reducing staff stress in general terms, although some addressed specific aspects of staff stress including anxiety,141 frustration236 or burnout:70
Behaviour change technique cluster 11: regulation.
The strategy of allowing people to vent about possible negative outcomes was needed to create space for possibilities.
Ashcraft et al.24
Other studies focused on reducing staff negative emotions during the post-incident debrief:
Opportunities are provided/scheduled to process the event with staff about their feelings, reactions, and safety.
Colton176
Scheduled consequences
Few aspects of cluster 14, ‘scheduled consequences’ (reward and punishment), were used in the interventions, with only 0.3% of BCTs being in this cluster and only one BCT identified: ‘remove punishment’ (BCT 14.10). ‘Behaviour cost’ (BCT 14.1), ‘punishment’ (BCT 14.2), ‘remove reward’ (BCT 14.3), ‘reward approximation’ (BCT 14.4), ‘rewarding completion’ (BCT 14.5), ‘situation-specific reward’ (BCT 14.6), ‘reward incompatible behaviour’ (BCT 14.7), ‘reward alternative behaviour’ (BCT 14.8) and ‘reduce reward frequency’ (BCT 14.9) were not identified ().
Behaviour change technique cluster 14: scheduled consequences.
The removal of punishment referred to the removal of an unpleasant consequence if the desired behaviour is performed. In five interventions,132,133,159,238,239 this was described as ensuring that debriefing sessions were supportive and not blaming to promote reflection on attempted de-escalation from the staff members involved, even if the episode had resulted in the use of a restrictive practice:
There was a focus on performance, but the approach was one of curiosity and help rather than summative judgement.
Lombardo et al.159
Administrators have carefully fostered a welcoming, nonthreatening atmosphere that helps direct care staff overcome their initial trepidation about attending the meetings in the medical director’s office. Leaders have purposefully avoided any appearance of assigning blame or ‘second guessing’ decisions that have been made by direct care staff.
Allen et al.238
Unused or little used behaviour change technique clusters in interventions
Two clusters of BCTs, ‘self-belief’ and ‘covert learning’, were not detected in any of the interventions (Box 1). The ‘self-belief’ category contains techniques that aim to promote self-efficacy, a determinant that has a key role in reducing lapses and coping with behavioural barriers.240
Behaviour change technique not detected
Some clusters featured only by virtue of one BCT being coded (coded BCT in bold) (Box 2).
Infrequently coded behaviour change techniques
As illustrated in Box 2, there were two little-used BCT clusters: ‘regulation’ and ‘scheduled consequences’. Within these, ‘reduce negative emotions’ (highlighted in italics in Box 2) was coded in relation to stress reduction elements of an intervention, and ‘remove punishment’ (highlighted in italics in Box 2) referred to ensuring that, when de-escalation had failed and restrictive practices had been used, the staff member could debrief reflexively on what could have been done differently, rather than in anticipation of punishment.
It should be noted that, for a BCT to be identified in an intervention, there had to be evidence of its presence within the intervention materials. Therefore, there may be instances where a BCT remained unidentified owing to lack of evidence. See Appendix 14 for a full list of the BCTs that were not identified in the interventions.
Mechanisms of action
In behavioural science, mechanisms of action are posited as the theoretical constructs through which BCTs affect behaviour. Recent work has specified 26 mechanisms of action, drawn from the Theoretical Domains Framework241 and a systematic review of 83 behaviour change theories.242 Understanding how specific BCTs have their effects on behaviour will help us to explain intervention effects and to evaluate interventions and, as evidence accumulates, potentially help us to develop more effective and/or efficient interventions. The Theory and Techniques Tool243 was used to identify the mechanisms of action for which there were identified links with the BCTs identified in studies reporting positive findings.
The BCTs that were used in studies reporting positive findings are shown in relation to their established links with mechanisms of action (). This shows that the most common mechanisms of action linked to BCTs in studies reporting successful findings were ‘environmental context and resources’ and ‘behavioural cueing’. ‘Environmental context and resources’ is defined as changes to aspects of a person’s situation or environment that discourage or encourage the behaviour (in this case de-escalation). BCTs linked with this were ‘restructuring the social environment’ (BCT 12.2), for example introducing social contact with service users; ‘prompts or cues’ (BCT 7.1), such as completing a daily risk assessment’; ‘restructuring the physical environment’ (BCT 12.1), perhaps by removing a seclusion room; and ‘adding objects to the environment’ (BCT 12.5), for example adding a sensory cart to a ward. ‘Behavioural cueing’ indicates processes by which behaviour is triggered from the external environment, from the performance of another behaviour or from ideas appearing in consciousness. The BCTs that used ‘behavioural cueing’ included ‘adding objects’ such as posters, ‘prompts’ such as risk assessment or flow charts, ‘action-planning’ through care-planning or team meetings, and ‘changes to the physical environment’, for example the introduction of a sensory room.
Mechanisms of action for BCTs found in studies with significant positive findings
The second most common was that of ‘behavioural cueing’: processes by which behaviour is triggered from the external environment, the performance of another behaviour, or from ideas appearing in consciousness. The BCTs that used ‘behavioural cueing’ included ‘adding objects to the environment’, such as posters, ‘prompts or cues’ such as risk assessment or flow charts, and ‘action-planning’ through care-planning or team meetings as well as ‘changes to the physical environment’, such as the introduction of a sensory room.
The ‘knowledge’ mechanism of action was targeted by two BCTs. The first was ‘instruction of how to perform the behaviour’ (BCT 4.1), which was coded whenever training in effective de-escalation was present. ‘Information about antecedents’ (BCT 4.2) included education about what kind of factors often lead to incidents, at either an individual or a ward level.
Behavioural regulation was also targeted by the BCTs ‘information about antecedents’ (BCT 4.2) and ‘problem-solving’ (BCT 1.2), which could include discussion with an individual service user about how staff could behave towards them to ensure that incidents involving restrictive practice were avoided. This could also include discussion within staff teams, sometimes in the form of a safety huddle, where the overall needs of the ward were discussed and resources reallocated to avoid incidents developing.
Skill was targeted by ‘instruction on how to perform behaviour’ (BCT 4.1), in which staff were taught specific skills related to de-escalation, for example non-confrontational verbal approaches. Feedback processes were targeted by ‘feedback on outcomes of behaviour’ (BCT 2.7); this commonly involved wards receiving a weekly summary of how many incidents of restrictive practices had occurred. Attitude towards the behaviour was targeted by ‘framing/reframing’ (BCT 13.2). An example of this was when Trauma-Informed Care approaches were introduced to a service and staff were encouraged to view the use of restrictive practices as retraumatising, rather than as a necessary part of clinical work. Memory, attention and decision processes were targeted by ‘prompts or cues’ (BCT 7.1), such as carrying out a risk assessment as part of each admission.
It is worth noting that none of the BCTs in studies that reported significant positive findings targeted optimism, social/professional role and identity, needs, values or emotion. Of these, only emotion has any evidence of links with BCTs and there is only one (BCT 11.2: ‘reduce negative emotion’). As such, it may be that there are methods for targeting these mechanisms of action but no connections have so far been made between them and individual BCTs. Appendix 15 provides further detail regarding the identification of BCTs in evaluations of interventions that reduced restrictive practices.
