PROGRESS: the PROMISE governance framework to decrease coercion in mental healthcare.

Reducing physical intervention in mental health inpatient care is a global priority. It is extremely distressing both to patients and staff. PROactive Management of Integrated Services and Environments (PROMISE) was developed within Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) to bring about culture change to decrease coercion in care. This study evaluates the changes in physical intervention numbers and patient experience metrics and proposes an easy-to-adopt and adapt governance framework for complex interventions. PROMISE was based on three core values of: providing a caring response to all distress; courage to challenge the status quo; and coproduction of novel solutions. It sought to transform daily front-line interactions related to risk-based restrictive practice that often leads to physical interventions. PROactive Governance of Recovery Settings and Services, a five-step governance framework (Report, Reflect, Review, Rethink and Refresh), was developed in an iterative and organic fashion to oversee the improvement journey and effectively translate information into knowledge, learning and actions. Overall physical interventions reduced from 328 to 241and210 across consecutive years (2014, 2015-2016 and 2016-2017, respectively). Indeed, the 2016-2017 total would have been further reduced to 126 were it not for the perceived substantial care needs of one patient. Prone restraints reduced from 82 to 32 (2015-2016 and 2016-2017, respectively). During 2016-2017, each ward had a continuous 3-month period of no restraints and 4 months without prone restrains. Patient experience surveys (n=4591) for 2014-2017 rated overall satisfaction with care at 87%. CPFT reported fewer physical interventions and maintained high patient experience scores when using a five-pronged governance approach. It has a summative function to define where a team or an organisation is relative to goals and is formative in setting up the next steps relating to action, learning and future planning.

Is restraint a 'necessary evil' in mental health care? Mental health inpatients' and staff members' experience of physical restraint.

Restraint in mental health care has negative consequences, and guidelines/policies calling for its reduction have emerged internationally. However, there is tension between reducing restraint and maintaining safety. In order to reduce restraint, it is important to gain an understanding of the experience for all involved. The aim of the present study was to improve understanding of the experience of restraint for patients and staff with direct experience and witnesses. Interviews were conducted with 13 patients and 22 staff members from one UK National Health Service trust. The overarching theme, 'is restraint a necessary evil?', contained subthemes fitting into two ideas represented in the quote: 'it never is very nice but…it's a necessary evil'. It 'never is very nice' was demonstrated by the predominantly negative emotional and relational outcomes reported (distress, fear, dehumanizing, negative impact on staff/patient relationships, decreased job satisfaction). However, a common theme from both staff and patients was that, while restraint is 'never very nice', it is a 'necessary evil' when used as a last resort due to safety concerns. Mental health-care providers are under political pressure from national governments to reduce restraint, which is important in terms of reducing its negative outcomes for patients and staff; however, more research is needed into alternatives to restraint, while addressing the safety concerns of all parties. We need to ensure that by reducing or eliminating restraint, mental health wards neither become, nor feel, unsafe to patients or staff.

Repertoires of responsibility for diabetes management by adults with intellectual disabilities and those who support them.

The limited existing research on diabetes management and intellectual disabilities (ID) highlights the need for further exploration of the concept of responsibility. This study explored repertoires of responsibility in accounts of managing diabetes for adults with ID. Fourteen semi-structured interviews were conducted in the UK with seven adults with mild/moderate ID and type 1 or 2 diabetes and seven people who they nominated as supporting their diabetes management. A discursive psychological analysis found that interpretative repertoires relating to competence, independence and accountability were drawn on to construct multiple and sometimes conflicting versions of responsibility. Within these repertoires people with ID were positioned in conflicting ways; as competent, personally responsible, and entitled to independence and choice, but as also lacking competence, dependent on others and incapable of overall accountability. People with ID often took up empowering positions defending against an incompetent identity. Supporters built accounts which negotiated dilemmatic repertoires on the dual responsibilities of empowering adults with ID to self-manage and managing risk to support good and safe care. The implications of available discursive resources and the ways in which they are mobilised are considered.