Restraint reduction during psychiatric intensive care: a controlled bi-phasic time series evaluation of a culture change intervention

Background

Restrictive practices (ie, physical restraint, rapid tranquilisation and seclusion) are used to manage risk of harm to self and/or others during inpatient psychiatric admissions. Restrictive practices can be physically and psychologically hazardous for both patients and staff, but there have been few well-controlled evaluations of interventions to reduce restrictive practices.

Objective

To conduct a controlled evaluation of the implementation of a culture change intervention on a psychiatric intensive care unit (PICU) compared with a control PICU on use of restraint.

Methods

A new staff role was created on the intervention PICU (ie, the reducing restrictive interventions advocate; RRIA). The RRIA met with patients/carers and advised, trained, supervised and debriefed the multidisciplinary team concerning restraint. Mixed methods evaluated the effectiveness of the RRIA role. Restraint outcomes on the intervention and the control PICU were compared pre (19 months) and post intervention (19 months). Qualitative interviews were conducted with the RRIA, the PICU ward manager and the RRI organisational lead.

Results

On the intervention PICU, there were significant reductions in the use of seclusion, full restraint and use of standing holds. Qualitatively, positive changes to the safety culture of the intervention PICU were reported, and these were consistently rated as important, impactful and unlikely without the RRIA role.

Conclusions

PICU safety culture can improve when specific roles focused on changing ward practices around restraints are implemented. More controlled evaluations of reducing restraint interventions on PICUs are needed.