Theme Three: Training and supervision

The third theme brings together the findings which identified sources of knowledge that inform restrictive practice. Mental health workers discussed the importance of restrictive intervention training and supervision (the latter was described less frequently and not noted as important except when it followed a significant restraint incident).

4.3.3.1 The restrictive intervention strategies used by staff

As described in chapter one, physical intervention training was mandatory for all staff in practice (for Site one, Positive Behaviour Management or Prevention (PBM) and for site two, Positive Management of Violence and Aggression (PMVA).

This training (both models), commissioned by the host Trust was repeatedly described by mental health workers as being framed by a least restrictive approach. They described an expectation that staff would find solutions to the management, care, treatment of people with dementia which did not require a

'hands on' approach – resolving conflict whenever possible and safe. This was

supported by practice leaders who explained that practice must be governed by various bodies of knowledge (legislation, case law, policy) which mental health

workers cannot always articulate. Mental health workers and practice leaders

failed’ but that the techniques of conflict resolution were reported to be central to practice with people with dementia.

‘In physical behaviour management, we tend to think in terms of restraint and sort of gentle support and guiding away when someone’s becoming a bit physically aggressive but actually there’s a huge part to play in, way before you get to that stage in talking to somebody and finding out why they’re aroused and why they’re distressed and yes, in the sense everybody can see why they are... if they are on a ward and want to go home, there are ways of looking at responsive strategies’ (Participant 1.2)

' I would expect that staff would know where to intervene through a combination of their training, their induction in the Trust, the care plans that the more senior staff have provided for the care assistants. A lead should come from the ward manager, from the consultant and the more senior clinical people on the ward...staff do need that guidance, they need to be able to use ...their personal judgement but I think those ideas need to have some senior back up' (Participant 2.3)

Mental health workers repeatedly reported that they are trained to assess all service users as individuals and to find individual least restrictive solutions which may change over time.

'It's very rare that we use PBM [positive behaviour management] to be honest, it's much better to use your skills...I think PBM is a bit of a failure in your nursing skills really...' (Participant 1.6)

4.3.3.2 Different roles

Mental health workers on the ground described increasing their knowledge and knowledge sources over time (learning from peers, reflecting practice, supervision, formal training). Mental health workers with more years of experience described a different and detailed understanding of that which framed their practice. Mental health workers also described learning from their colleagues. A practice leader described how they were also aware of this learning between staff:

'Not everyone can be trained in everything to the same degree and I think it's about maybe all disciplines accepting and respecting the value of other people's knowledge and skills' (Participant 2.2)

Staff also described practice as shifting and developing. Participants (both mental health workers and practice leaders) described the challenge of this - to keep pace with new knowledge and best practice. A practice leader described the complexity of new knowledge in relation to legislation and emerging case law impacting on an already complex clinical workplace:

'I love mental health nursing. I think it's one of the most fascinating subjects you could get into....I was always learning something new, it never stays the same. When the Mental Capacity Act and Deprivation of Liberty Safeguards were being introduced, I was really interested in it because essentially...it scared me because I thought 'I don't know if I really understand this'...I constantly relate everything to a nurse being

able to deliver the care in line with legislation and best practice at 3 o'clock in the morning after their fourth night shift in a row.

Is this something that somebody can easily deliver and understand?' (Participant 2.1).

4.3.3.3 Reflection and supervision

Reflection and supervision as intentional processes did not feature strongly in the content of interviews. Opportunities to consider or reflect on practice generally or specific examples of restrictive interventions were not frequently described. Mental health workers reported that formal supervision in relation to restrictive intervention management was available if asked for but not mandated or routinely provided. Mental health workers explained that supervision, framed as a de-brief session would be offered if a significant restraint incident had occurred. Mental health workers reported that the ward handover was a source of regular support and information in relation to managing challenging behaviour.

'Give a heads up about behaviour ...if you have used PBM, they must have been quite distressed' (Participant 1.18)

One mental health worker described supervision (described as debriefing) to be an important aspect of ward based practice but this was not a feature of most mental health worker interviews.

''I understand the importance of being able to have a quick de-brief...it can be frightening so it's important to have a de-brief'

'I think it's actually really important and sometimes we have newly ‘qualifieds’ (registered nurses) ...and I'm always very aware for them...and it is traumatic to see somebody really distressed' (Participant 1.12).

4.3.3.4 Emotion and the caring role

Mental health workers also talked about the emotional effort of caring and specifically the impact of working with people with challenging behaviour who exhibit distressed behaviour. They described some positives of working with people with dementia. They talked about feelings of satisfaction and self-worth associated with their roles as mental health care staff. Conversely, some mental health workers described the experience of being subjected to aggression at work. They explained that they understood the relationship between aggression and dementia but that it can be difficult to endure. A practice leader described the challenges faced by front line staff:

‘If you are a carer at work...the bit you don’t particularly like is being sworn at or clobbered, I think people can put up with most things, I think they are quite happy to clear up faeces and urine ...the bits they don’t like are when there are threats to themselves and some of that is just common sense- because it will hurt....I think that for caring people, it’s harder to deal with’ (Participant 2.4).