Ideas for changing practice

Collaborative care planning

Having a care plan written in a patient’s own words has helped reduce restrictive practice. This approach ensures the patient is central to their own care, that they understand everything discussed during their review, and allows them to ask questions and take an active part in planning the next steps. 

Here is an example of a collaborative care plan template used by Waveney Ward, Norfolk and Suffolk NHS Foundation Trust. 

Creating a recovery tree

Staff on some wards have painted murals of ‘recovery trees’ on the ward walls, on which patients add Post-it notes to track their recovery and record messages of hope for other people. Often, the murals were made together with patients, who then felt a sense of ownership, hope, and pride in the creation of the tree.

Ward round preparation sheets

The time before and during ward round can be particularly difficult for patients. Some wards on the Reducing Restrictive Practice Collaborative have created templates to help prepare patients for a ward round. The templates give patients and staff the opportunity to prepare for the ward rounds together because patients can add questions they want to ask, note down particular things they want to say, any requests they have and discuss any worries they might have about ward round. 

Knowing patients’ preferences 

If staff aren’t aware of their preferences (such as how they would prefer to be woken up in the morning, what they prefer to be called, and other likes and dislikes), it can feel disempowering and frustrating for patients. Several wards on the Reducing Restrictive Practice Collaborative started using whiteboards, laminated posters or chalkboard paint that are fixed to patients’ bedroom doors and used to note their preferences and key information (see Getting to know each other in the Engagement between patients and staff section below). A member of staff supports each patient to complete it and makes sure it is reviewed regularly. 

Here is an example from Lark Ward and Southgate Ward (Norfolk and Suffolk NHS Foundation Trust), which we have recreated as a downloadable version.

Patient activities

Many wards in the Reducing Restrictive Practice Collaborative found that increasing patient activities and alleviating boredom led to a reduction of their use of restrictive practice. Using data that they recorded, wards were able to identify factors around when the number of incidents were higher and then increased the activities in those times. For similar reasons, some wards also worked on increasing access to their garden, recreation or gym areas. 

Ready-to-grab activity boxes

To encourage all staff to run activities with patients, some wards made ready-to-grab boxes containing everything needed to run various activities. 

Group activities

Some wards in the Reducing Restrictive Practice Collaborative introduced new group activities to their weekly routines, to increase patient participation and opportunities for social interaction, and to alleviate boredom. Groups included:

• Breakfast clubs
• Newspaper/current affairs groups 
• Coffee mornings 
• Music groups
• Walking groups.

Ways to self-soothe

Wards introduced methods for patients to self-soothe, for instance:

• A calm box – a box with items selected by a patient, that they can use when feeling agitated or distressed 
• A calm card – a list of activities a patient would like to try as an alternative to more restrictive interventions for managing their distress, such as listening to music, having someone read to them or doing a crossword.

Positive behaviour support plans and personalised care plans

Many wards introduced individualised positive behaviour support plans and personalised care plans for each patient, written in simplified terms that are easily accessible to all staff. Some wards used a red, amber or green ‘traffic light’ system to record a person’s presentation and behaviour.

Together, the patient and staff then created a plan for what the person might need to prevent them from moving toward higher-risk levels. For example, a person on an ‘amber’ level might need to spend some time in the sensory room or go for a walk with a member of staff to go down to ‘green’. 

Here is an example of a RAG ratings template from Galaxy Ward (Coborn Centre), East London NHS Foundation Trust.

Getting to know each other

Many teams in the Reducing Restrictive Practice Collaborative were told by patients that they’d like to get to know the ward staff better. Staff responded positively, seeing it as a way to improve the therapeutic relationships with patients and to understand and respond to their needs more effectively. Some of the ways the wards approached this were:

• ‘Getting to know each other’ boards – accessible display boards on the ward that share information about the multidisciplinary team, with staff photos, interests and hobbies. Here is an example from Chine Ward (Dorset Healthcare NHS Foundation Trust).

• Information boards on bedroom doors – with the name the patient prefers to be called by, their personal interests, de-escalation techniques and times of important meetings, such as multidisciplinary team reviews and tribunals (see Knowing patients’ preferences in the Patients being active participants in their care section above). Here is an example from Afton Ward (Isle of Wight NHS Trust).

Shared mealtimes

Several of our teams have introduced shared mealtimes on their wards, so that staff and patients can sit down together for breakfast, lunch or dinner. They also introduced: 

• Breakfast clubs
• Staff and patients preparing meals together
• Patients in long-term seclusion joining the ward for meals. 

Mutual help meetings

Several of our teams hold regular voluntary meetings every morning for all patients and all staff on duty. The meeting can be held at any time; it follows a structured agenda and is about how everyone can help each other during the rest of the day. The meetings have helped to reduce difficult incidents through a more preventative and proactive approach. 

For more information on mutual help meetings, please see the Safewards website. 

What matters to you?

Improvements in culture, daily practice and person-centred care on your ward are important to recognise and celebrate as much as improvements in your data. Asking, ‘What matters to you?’, is a great starting point to improve culture on your ward and offer more personalised care. You can use the What matters to you, other ward staff and patients? resource, which has a number of starter questions, to create better conversations with staff and patients on your ward.

Regular QI meetings

One of the biggest learning points from the Reducing Restrictive Practice Collaborative was the importance of finding regular time for QI project team meetings. In them, we reviewed progress, generated change ideas, planned PDSA cycles and delegated tasks.

The wards that were able to hold team meetings like this found it much easier to integrate QI methodology into their ward’s everyday practice and, as a result, saw greater reduction of their use of restrictive practice and greater improvements in the culture on their ward. Our teams meet anywhere between one and four times monthly for 15 to 90 minutes. The important thing is that you find a time and space that best suits your ward’s needs. 

Standing agenda items

Our teams have also been successful in introducing and maintaining QI methodology and reducing restrictive practice to the wider ward. Several have introduced QI and/or reducing restrictive practice as a standing agenda item in regular staff and patient meetings. 

Protected time for staff

A number of teams across the Reducing Restrictive Practice Collaborative were supported to make use of protected time for QI project leads to facilitate, review and plan the QI work on the ward. This ensured the work maintains momentum and that any difficulties or areas for improvement were promptly addressed.

Using a safety cross

A safety cross is a visual data collection tool that can be used to count the thing you wish to improve over a time period. It is a calendar in the shape of a cross onto which staff record occurrences of a particular event. On the Reducing Restrictive Practice Collaborative, we encouraged all participating wards to use a safety cross to record the number of times they used restrictive practice.

Each type of restrictive practice being measured (seclusion, rapid tranquillisation, restraint) was assigned a colour and, each time one was used, staff added a coloured dot to that date on the safety cross. It is a quick, simple and accurate way to record the frequency of an event, and it makes the measurement transparent and clearly visible to staff, patients and visitors. 

We created two safety crosses for the Reducing Restrictive Practice Collaborative: 

• Safety cross by shift pattern
• Safety cross per day

Some wards also created their own safety crosses to use:

Visual displays

Wards created QI/RRP display boards in their day areas to share information about restrictive intervention data, the change ideas being tested on the ward, newsletters, and copies of their safety cross and run/SPC charts. Ward staff, patients and visitors were kept informed by the board and could see the positive work the teams were doing.

The boards also encouraged the ward and the trust to be transparent about their use of restrictive practice and what they were doing to address it, which encouraged wider discussion and the generation of new change ideas that could be tested.

Patient safety climate survey

The patient safety climate survey can help you gather feedback from patients on how they feel about their safety on the ward and the use of restrictive practices. This tool was originally created by mental health service users and carers for the Scottish Patient Safety Programme, and we adapted it for wards on the Reducing Restrictive Practice Collaborative to use. 

Safety huddles

To improve communication in teams, wards had ‘safety huddle’ meetings. The regular, brief huddles gave an opportunity for teams to discuss any patient safety issues and staff concerns. Some wards scheduled the huddles to take place twice a day, covering early and late shifts.

To further improve consistency of care, teams adopted safety huddles as their ‘daily management multidisciplinary team meetings’ in which teams met to discuss a few patients with the consultant each day, allowing regular review of patient needs, risks and treatment. 

Ward temperature readings

To measure how safe the ward feels, teams took ‘ward temperature readings’. This might be with visual ‘barometers’, which were on display and used to record how patients feel in the ward environment. They can also be used to record the level of staff morale so that teams can communicate more clearly about how the ward feels at any given time, understand what contributes to staff stress and then find ways to address any difficulties promptly. 

Juniper Ward, Barnet, Enfield and Haringey Mental Health NHS Trust developed a staff morale barometer to check how staff are feeling at work.

Tools

Wards have used tools to predict, prevent and/or manage violence and aggression to help them reduce the use of restrictive practices. 

Broset Violence Checklist (BVC) recording in seclusion

Teams across the Reducing Restrictive Practice Collaborative have worked hard to ensure that the use of seclusion is a last resort and the time spent there is kept to an absolute minimum. Some wards used the BVC, an instrument that predicts violence in the short term, to help reduce the amount of time a patient spends in seclusion. Wards found different ways of displaying and reviewing the information recorded from the BVC – one ward created this visual display board: 

Prevention and management of violence and aggression – briefing tools

Some wards made use of briefing tools on the prevention and management of violence and aggression, to increase the confidence of staff in managing challenging situations and to provide clear structure to interventions.

Here is an example of a prevention and management of violence and aggression briefing tool from Waterloo Ward, West London NHS Trust.  

Training

Wards have provided additional training for staff to help them develop skills and knowledge to better support patients and reduce the need to use restrictive practices. 

Positive behaviour support training

To support staff to respond to challenging behaviours and situations, some wards used the positive behaviour support framework as a basis for training. The training included basic awareness of the framework and techniques for interventions to support patient needs. It can be provided by a ward psychologist and included in staff inductions.

Skills workshops

Many wards created workshops for staff that aim to improve staff confidence and increase their skills and knowledge. These have included: 

• QI workshops
• Care plan workshops 
• Workshops delivering sensory sessions to staff (including developing the sensory profiles of patients, and also staff’s own sensory profiles to increase understanding)
• Simulated de-escalation and observations training for staff. 

Reflective practice

Working in an inpatient environment is challenging, and there can be detrimental effects on staff levels, morale and retention. A number of wards on the Reducing Restrictive Practice Collaborative introduced or increased reflective practice opportunities for staff, either through separate groups or as an integral part of the supervision process.

Reflective practice enables staff to reflect on their knowledge and actions, understand those actions, the behaviour of others and their experiences, and learn from feedback in a process of continuous improvement. 

Monthly clinical supervision 

To increase awareness of the purpose and value of supervision, promote reflective practice and reduce staff stress levels, some teams on the Reducing Restrictive Practice Collaborative took different approaches to providing regular and effective supervision. For example:

• One team assigned a clinical supervisor for each member of staff
• Some teams created a rota for staff supervision, enabling protected time for staff
• Others have identified staff who had the competences to provide supervision.

Going home checklist

Wards that needed to focus on staff wellbeing came up with numerous ideas to encourage stronger, more resilient teams. To better support staff to feel valued and heard, enable them to reflect on their experiences at work and debrief at the end of a shift, some wards introduced a ‘going home checklist’. 

Here is an example of a going home checklist from Amber Ward, Sussex Partnership NHS Foundation Trust.

Teams made this checklist part of the daily ward routine, working through it together before the end of each shift.

Creating a chill-out/sensory room

A chill-out room on a ward can be used as a space in which patients can relax, as a primary de-escalation space and an alternative to other restrictive practice. The chill-out rooms created since the start of the Reducing Restrictive Practice Collaborative included various multi-sensory resources: comfortable seating, reading materials chosen by patients, aromatherapy, light projectors and music systems. You can find out more about this idea on the Star Wards website. 

Chalkboard paint

By painting a wall in a communal area with chalkboard paint, wards were able to share important information and create artwork that both staff and patients can contribute to. Some teams painted a wall in each of the patient’s bedrooms with chalkboard paint. Patients used the wall to express themselves, and staff used it to write welcome messages and leave information about upcoming meetings, such as ward rounds and activity groups. 

Improving outdoor space

Making the best use of any available outdoor space on your ward can help you to create a more therapeutic environment. Several wards expanded the planted area in their garden to grow flowers or produce that could be used for cooking and as an activity for patients. Other wards redesigned their outdoor spaces by installing gym equipment, table tennis and picnic benches. 

Although some blanket restrictions can be justified as necessary and proportional, wards on the Reducing Restrictive Practice Collaborative found that many of these restrictions had become part of normal practice and were not reviewed regularly.

In many instances, this had a detrimental effect on the therapeutic environment and contributed to an increased use of restrictive practice. Restrictions that wards on our Collaborative have reviewed, relaxed or removed include:

• fortnightly meetings with patients, introduced to review the blanket ward rules in place
• the introduction of mutually agreed expectations, designed by patients and staff together, instead of ward rules
• television lounge open 24 hours
• increased access to mobile phones
• access to a patient’s own phone charger; to reduce risk, some wards have provided short-lead phone chargers
• Salto wristbands for patients to open doors
• activity room kept open all the time; in one case this was achieved by removing ligature risk
• airlock door unlocked when not in use, allowing patients to take themselves to de-escalation
• patients able to take toiletry bottles into the shower
• increasing access to the garden area
• reducing the frequency of staff observations in the outdoor area.

Morning groups

Several of the teams on the Reducing Restrictive Practice Collaborative introduced different kinds of morning groups on their ward. Not only did they offer additional activities, they provided a space in which to build therapeutic relationships and improve wellbeing by encouraging patients to develop and/or continue a daily routine. Examples include:

• Breakfast club where staff and patients prepare and eat breakfast together
• Coffee morning
• Morning check-in with patients.

Walking groups

Some wards started regular walking groups, for patients to take walks around the hospital site. This improved engagement with patients and increased the amount of exercise they could take. Other wards organised step or pedometer challenges, as a fun way to move more. 

See also the above section on Increased participation in activities.