Across Europe, it is lawful for individuals to be secluded and/or restrained in mental health services and other settings to control or manage their behaviour. Attempts have been made by governments, mental health services and others to reduce and even eliminate the use of restraint and seclusion (see eg Gooding et al., 2020; Hirsch & Steinert, 2019). Two practices were submitted for inclusion in this compendium.

 Lovisenberg diaconal hospital, Clinic for Mental Health – Norway

A concerted effort was undertaken at a major hospital in Oslo, Norway, to reduce the use of mechanical restraint in a psychiatric ward; the initiative led to an 85% reduction in the use of mechanical restraints during the five-year study period (2012-17) (Submission 17A). The hospital, Lovisenberg diaconal hospital, Clinic for Mental Health, is in an area facing significant socio-economic disadvantage.

The project focused on workforce professional development, involving targeted interventions aimed at the health care professionals on the ward. The aim was to improve the staff competence to handle episodes involving aggression through training and guidelines. The intervention had a clear and ambitious goal of reducing the use of mechanical restraint. Elements of the initiative included:

• Removing bed with visible belts used for mechanical restraints from the ward;
• Visualising days of non-mechanical restraint use on a calendar for staff on a daily basis;
• Implementing systematic use of violence assessment of all patients (there exist several tools for this purpose) placing an emphasis on finding the reason for the aggression;
• Implementing standard routine for information to new patients about the ward’s attitudes about aggression and conflict;
• Changing physical environment and staff attitude to emphasise that the person has the opportunity to get out of tense situations and not feel trapped, for example by being offered a blanket on the couch as opposed to being ordered/pushed to go to room if sleepy;
• Facilitate and stimulate principles that promote a 'learning organisation' process. The newly established practice is consistent with contemporary psychological theories of aggression;
• Ward-rules were revised and reduced as much as possible. Some of the existing ward-rules were considered provocative by some patients, and so on.

The project addressed acute admissions sessions and the initial 40 hours on the acute admissions ward. Previous experience shows that most episodes involving the use of mechanical restraints occur during the first six hours after admission to the ward. This supports the importance of planning an intervention that address these first hours after an admission, to be able to prevent the use of mechanical restraints.

Again, in the five years after the initiative began, rates of mechanical restraint dropped 85% (Submission 17A). During this period, there was no registered a rise in injures to staff or sick leave. Mean duration of physical holding was eight minutes for female patients and 13 minutes for male patients. The targeted intervention is now implemented in regular treatment, and the results have reportedly shown stability over time. Health authorities in part of Norway (HelseSørØst) in which the trial took place have decided to implement the principles from the project as regular practice in all the psychiatric hospitals in the region. The practice is now made mandatory by the health authorities and auditing will be undertaken.

The initiative was reportedly cost-neutral, as it did not require more staff resources or extra cost. Service users were reportedly involved in developing the tool for assessing aggressiveness, and service user organisations have expressed support for the project (Submission 17A).

Factors which facilitated the implementation of the practice include: management ownership over the project; involvement of all staff in the project; local development; the simplicity of initiatives; staff being held responsible for the interaction with patients prior to the emergence of conflict; and so on. Barriers to implementation included: the large scale and complexity of hospitals (making it challenging to introduce new practices); the challenge of maintaining new routines; initial reluctance of some staff who criticised the project and claimed that it was not justifiable and professional and may lead to dangerous situations; maintaining good practice during periods with shortage of time and resources, and so on. (For more information see Halvorsen, 2016; Vel et al., 2016).

Six Core Strategies for Reducing Seclusion and Restraint use – Spain and Internationally

In 2017 in Andalusia, Spain, an initiative was introduced to adult psychiatric services based on the ‘Six Core Strategies for Reducing Seclusion and Restraint use’. The result was a reported 15% reduction in the total time mechanical restraint was imposed on service users throughout Andalusia (Submission 9). Andalusia is a large region of Spain (pop. 8.4m) with 20 acute mental health inpatient wards. In 2011, a working group on Human Rights and Mental Health was created under the Regional Mental Health Office of the Andalusian Health Service. The group developed the ‘Comprehensive Mental Health Plan of Andalusia’ which partly sought to apply the CRPD to the daily practices of mental health services. (Other practices that form part of this plan are discussed at p.64).

The ‘Six Core Strategies’ program, which Andalusian health authorities drew upon, has been used in coercion reduction/prevention initiatives in several countries. The Strategies were originally set out in 2005 by the US National Technical Assistance Center (2005), and are set out below.

Six Core Strategies to Reduce the Use of Seclusion and Restraint (US National Technical Assistance Center, 2005)

1. 'Leadership towards organizational change'— articulating a philosophy of care that embraces seclusion and restraint reduction;
2. 'Using data to inform practice' — using data in an empirical, 'non-punitive' way to examine and monitor patterns of seclusion and restraint use;
3. 'Workforce' — developing procedures, practices and training that are based on knowledge and principles of mental health recovery;
4. 'Use of seclusion and restraint reduction tools' — using assessments and resources to individualise aggression prevention;
5. 'Consumer roles in inpatient settings' — including consumers, carers and advocates in seclusion and restraint reduction initiatives; and
6. 'Debriefing techniques' — conducting an analysis of why seclusion and restraint occurred and evaluating the impacts of these practices on individuals with lived experience.

These strategies have been used in services in the United States, Canada, Spain, Australia and New Zealand and are subject to a growing body of research (for more information see Melbourne Social Equity Institute, 2014).

In Andalusia, the reduction initiative was carried out in the following phases:

1. Leadership and formation of a core group: A core group was formed in May 2015 and there were periodic face-to-face meetings with the nursing managers and clinical coordinators of the 20 acute mental health inpatient wards.
2. Analysis of the situation, co-ordination and feedback: A virtual platform was created for communication between the core group and the leaders of the wards. The group shared information on the strategies as well as experiences from the wards themselves, so as to integrate local developments on reduction of mechanical restraint, and so on.
3. Awareness training of the heads of the wards: Nursing managers and clinical coordinators of the 20 acute mental health inpatient wards received a one-day awareness training in 2016.
4. Unified record of mechanical restraint in Andalusia: The core group designed a consistent record for all the episodes of mechanical restraint in all Andalusian hospitalisation wards, for monitoring purposes. This unified record was based on the mechanical restraint records of the 20 wards. They defined key indicators for ongoing evaluation. The database was initiated in July 2016, and since then there has been an ongoing evaluation of the data by the Regional Mental Health Office of the Andalusian Health Service, with active participation of the local clinical leaders.
5. Design of two training courses developed locally in each ward. The materials were made available to the heads of the wards through the virtual platform.

• • A course with a duration of 7 hours was designed in 2017 with the aim of reducing the use of mechanical restraint. The course was initiated in April 2018.
• • In 2018, a training course of 7 hour was designed, aimed at reviewing mechanical restraint episodes, and identifying how they could have been avoided. The course was focused on reflecting on the episodes conducted in the ward in a concrete period of time, and learning to analyse in detail some mechanical restraint episodes among professionals, and to analyse them with service users. The course was initiated in 2019.

The Working Group monitored the percentage of episodes of mechanical restraint, percentage of different persons in mechanical restraint, total number of hours, average duration, bed occupation of the ward at the moment of the mechanical restraint episode, clinical diagnosis, motive and state of the person, sex, and origin of the person (e.g. Spain, Europe, others). They also collected data of the impact of the training courses on staff knowledge.

Between the years of 2017-19, across the whole of Andalusia, the data suggested: a 15% reduction in total hours of mechanical restraint in the period 2017-2019 but with important differences between wards.

The indicators of reduction comprised of the number of episodes, number of different persons and average duration of restraint, all analysed at hospital level.

28 training courses were conducted in all wards in 2018, and 15 courses in 2019. In total, 615 professionals of all categories participated, above all nursing and psychiatry. Global satisfaction with the course was very high (in a scale from 1 to 10 the average rating was 8.7 in 2018 and 9 in 2019).

The involvement of the Andalusian School of Public Health was reportedly key to the initiative, given its expertise on human rights, the CRPD, implementation methodologies, and given its history of work with mental health services of the Andalusian Health Service. Although the Andalusian School of Public Health is part of the Andalusian public health system, it is somewhat independent and does not have a strong clinical focus, which was reportedly ‘important for questioning mechanical restraint from a Human Rights approach’ (Submission 9). Other helpful factors included: involvement of local clinical leaders; the inclusion of restraint reduction as an objective in the broader policy or Mental Health Plan of Andalusia; the capacity for good quality data collection to highlight the large differences between similar wards, which highlighted ‘the enormous impact of ward culture on rates of mechanical restraint’; and the ‘critical public opinion regarding mechanical restraint, and the need [for] elimination of this practice, especially by the service user’s movement’ (Submission 9).

Reported barriers included negative culture on wards, and the competencies (knowledge, skills and attitudes) of the professionals. There were considerable differences between the 20 wards, including different ‘starting points’ in terms of the existing rates of restraint-use. However, the sharing of positive practices across wards has reportedly been a valuable gain. Reportedly, there is also a lack of clear legislation on mechanical restraint in Spain, and the CPRD needs be better integrated into legislation.

Concerns were raised in the submission that several other prominent initiatives for reducing coercive practices were not occurring across Andalusia: such as advance planning, ‘assertive community treatment, home hospitalisation and other alternatives that could prevent hospitalisations, and therefore the risk of receiving coercive measures like mechanical restraint’. Reportedly, the working group is seeking to ensure more state resources for these other initiatives.