This chapter summarises the results of the analysis of our broad and extensive searching of databases and the grey literature that identified 175 records containing 150 unique interventions.
Summary of the literature search results
Overview
The overall purpose of the study was to document the range of interventions developed to reduce restrictive practices, describe their characteristics and identify any overarching patterns. The search identified a disparate and complex collection of interventions in many sources and formats, steadily increasing over the 20-year search period since the introduction of the UK National Service Framework for Mental Health in 1999, and peaking in 2017. Most interventions can be found in research reports published in nursing journals. Various mental health-related and other non-governmental organisations provide resources for service providers in the form of links to training providers and examples of good practice in the reduction of restrictive practices.
Characteristics of interventions
The search found a total of 150 unique interventions to reduce restrictive practices. This included 29 intervention families (interventions with multiple records) and 121 standalone interventions (with only single records). Six Core Strategies was the largest intervention family and had been implemented in the broadest range of countries (n = 6) and clinical settings (n = 6). Safewards had also been implemented in multiple countries (n = 3) and clinical settings (n = 2). The highest numbers of interventions (and widest range) were found in the UK and the USA; others were identified in Canada, Australia, New Zealand, Singapore and several European countries. Most interventions were implemented in unspecified adult mental health inpatient settings, but, where more detail was provided, the most common setting in which to undertake an intervention to reduce restrictive practices was an acute ward.
Variation in intervention reporting
Unsurprisingly, given the broad inclusion criteria and the number of interventions subsequently identified, there was enormous variation in intervention reporting. The interventions were often intended to address multiple restrictive practices and related issues (e.g. service user behaviour, staff skills, quality, safety and adverse consequences) in varying combinations. The most common intervention target was seclusion or restraint; however, 11 interventions targeted PRN medication. Similarly, most interventions used multiple procedures, in some cases as many as 10, and, again, in varying combinations. The most common procedure was Training, although Changes to Nursing Approaches and Review of Incident Data were also often used. Despite the popularity of training as a key procedure, detailed descriptions of the training content and providers were often lacking. The least common procedures were Rapid Response Teams and Activities for Service Users. Forty-eight interventions reported involving service users in some way, but the type and extent of their involvement varied greatly. In some cases, service users were involved in multiple ways, whereas in others they had limited roles.
One hundred and three out of the 109 evaluations used a non-randomised design and there were just six RCTs; the remainder were qualitative or mixed-methods studies. Just two evaluations reported service user involvement in the evaluation. Seventy of the evaluations reported multiple outcome measures, and these most frequently focused on the incidence of seclusion or restraint; however, there was limited consistency as some noted the timing of incidents and others the severity. Only 18 made any reference to the cost of implementing the intervention or its financial impact.
Discussion of analysis
The study clearly shows that there has been an upturn in publications and research endeavour in this field in recent years. In the UK, at least, this is possibly a response to the publication of the Department of Health and Social Care’s response to events at Winterbourne View. Restrictive practices began to attract attention following deaths that occurred during their use, and this increased further when the abuse of patients at Winterbourne View Hospital was documented in 2011.244
Nevertheless, regardless of an increase in the volume of the literature, the analysis highlighted gaps and huge inconsistency in study design and units of analysis across both sample size and settings. Reporting was generally poor and inconsistent, despite guidelines such as WIDER,61 which recognises the need to standardise reporting of complex social interventions aimed at changing behaviour and provides tools to address the issue. One explanation for this is that it is difficult to capture or measure who is exposed to the intervention, for what duration and at what intensity. To some extent, the level and clarity of detail provided were determined by the format of the retrieved record, and the nature of the intervention and its procedures. Although training might be conducive to measurement, many other procedures, including changes to policy, nursing approach or the physical environment, could be described as standalone events or as ongoing. Therefore, notwithstanding the advent of tools such as WIDER, the analysis showed that limitations remain when it comes to measuring fidelity, and dose, of interventions designed to reduce restrictive practices.
Discussion of quality assessment
The evidence base for interventions to reduce restrictive practices appears to be small; only six RCTs were identified, and variations in their targets and outcome measures precluded any meta-analysis. Most evaluations were published in nursing journals of low impact. The evaluation methods themselves were often poorly described and, in particular, lacked detail about the interventions or methodology that had been applied or the theoretical basis for the intervention. Forty-one potentially eligible evaluations of interventions were excluded from the analysis as they did not pass the MMAT screening questions.
Issues of quality and reporting are particularly problematic when trying to provide precise descriptions of interventions subject to evaluation because of the implications for replication and meta-analysis: ‘to facilitate replication, further development, and scale-up of the interventions’.61 This clearly had an impact on the ability to apply the taxonomy, make meaningful comparisons of interventions or undertake a meta-analysis of the results. For those studies identified outside the academic literature, experience suggests that other types of reports/formats cannot be relied on to provide comprehensive details of an intervention.
On balance, the evidence suggests that interventions place greater emphasis on service users’ contribution to circumstances that lead to the use of restrictive practices than on the impact that restrictive practices (or their reduction) have on them. Many interventions reported that they sought to improve service user experience by, for example, promoting recovery or providing Trauma-Informed Care and included specific aims to improve quality of care, service user experience, a feeling of safety and recovery. Nevertheless, few reported examining service user outcomes such as injury or perception of safety. Although they measured the incidence, and sometimes duration, of restraint or seclusion, they did not report these incidents in terms of their impact on service users. Although service users were sometimes involved in intervention delivery, they were rarely involved in intervention design or evaluation. A good proportion of the interventions that were reported included procedures aimed at changing service user behaviour and engaging service users in identifying their own triggers, strategies and preferences. In contrast, interventions inviting managers and frontline professionals to reflect on their practice required a focus not on their triggers, for example, but instead on understanding service users’ histories.
