Patient Safety Spotlight Interview with Professor Joy Duxbury OBE, Chair of the Restraint Reduction Network

Summary

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Joy talks to us about why we need to reduce the use of restrictive practices in healthcare, the role of research in identifying unsafe practices and how the Restraint Reduction Network shares and helps organisations implement safer approaches to care.

About the Author

Joy Duxbury is a mental health nurse and Professor of Mental Health at the University of Cumbria. She has worked on numerous funded projects in the area of mental health including the exploration of service user perspectives and implementation. Her focus has been on minimising restrictive practices across varied settings in the UK and globally.  Joy has written extensively on the subject of mental health over the past 20 years and secured several large grants to examine coercion and social injustices using participatory and co-creation methods. Joy was Chair of the European Violence in Psychiatry Research Group and currently remains a board member. She is Trustee and Chair of the Restraint Reduction Network. In recognition of her work, she was awarded the Eileen Skellern Award in 2014 and an OBE in 2021.

Questions & Answers

Hi Joy! Please can you tell us who you are and what you do?

I’m Joy Duxbury and I’m Professor of Mental Health and Director of Research for the Institute of Health at the University of Cumbria. I also have a number of other roles—I’m Chair and Trustee of the Restraint Reduction Network and have been a member of the European Violence in Psychiatry Research Group for many years. The group takes a broad look at patient safety in mental health and brings together practitioners, researchers and trainers to try and make change globally. Both of these organisations are open to anyone working in the field and are free to join.

How did you first become interested in patient safety?

Patient safety has been my area of interest from the get-go. I’m a mental health nurse by background, and when I started working as a nurse around 35 years ago it became apparent very quickly that mental health institutions were quite unsafe spaces for both patients and staff. Much of my experience was in acute inpatient care, where I became a ward sister. I often sensed that we were probably doing more harm than good in the way we approached treatment. Our practices were retraumatising people who were already in a very traumatised state. I realised that mental health units were not the safe haven that they were purported to be.

I then found myself asking, “What do we do about it?” Back then, as a single nurse in the system, I did what I could in terms of working with my own teams. But when I went to university, it opened my eyes to the idea that you can support change by understanding the issues through research. It also gave me the opportunity to network with other people who were interested in seeing change in similar areas. I went on to do a PhD looking at conflict in mental health organisations and that opened the door for me to start contributing to research and practice development in the area.

What change have you seen in how restrictive practices are viewed?

It’s hard to believe that there has been significant change, because we often hear in the news about everything that continues to go wrong in mental health services, nationally and globally. But we do have to remember that we have made huge inroads over the past 30 years. For example, the Restraint Reduction Network didn’t exist ten years ago—the fact that we have communities of practice and networks that champion change in a positive way is a testament to how far we have come.

The research field in coercive practices and patient safety has grown enormously over the past 20 years. The range of studies going on and the funding that is now available to support them mark a real change. Two decades ago, it would have been unheard of for the big research councils to fund research in this area, particularly the social science aspects of patient safety. There is a lot more to do as funding for mental health is still woefully scarce, but we have made progress.

Why have restraint practices been so widely used in inpatient mental health settings, and why is it important to try and reduce their use?

Restraint and seclusion practices have been around for many years—we’ve always segregated people who are mentally ill and tried to keep them away from the public gaze. In terms of restraint itself, it's a good question, as you wouldn’t expect it to see these practices used in what are supposed to be safe, therapeutic spaces. 

It’s been going on for a long time, but in terms of formal training, an approach was introduced several years ago called ‘control and restraint’. This approach was adopted from the prison service, which says a great deal about why we should be questioning these practices. Control and restraint were taught to all mental health staff working in the UK, but instructors were not always healthcare professionals. It was a very reactive approach, based on waiting for a crisis to happen and then trying to contain someone.

We’ve moved on significantly since then to really look at why people become distressed and upset in services, which then leads to conflict, and then to containment. We’re concentrating much more now on the human rights of individuals—there is a critical spotlight on how we can continue to subject people to coercive practices going forward.

Which leads into why we’re concerned about them. It’s come to light over many years that the coercive practices we use are by and large very unsafe and there isn’t a strong evidence base for many of them. There is a plethora of evidence that demonstrates how damaging and traumatic these practices are, but it doesn’t take an expert in the field to tell you that being pushed to the floor and held down by multiple people and then locked in a room on your own in a distressed state, will be traumatising.

There have been a significant number of incidents around the world where people have died at the hands of people restraining them when they’ve been in a distressed state and that’s just not acceptable. Alongside the individual cases that we see in the news, there is also now a growing evidence base around the scale of the problem.

What are the key problems that we still need to tackle in patient care in mental health settings?

That’s a tricky question because the more we unpick this wound, the more issues we see that need attention, right across the age spectrum, from young people right up to older people.

One area of concern is that there is a great deal of disproportionality in the way that restrictive interventions are used. For example, it is coming to light that some of these practices are used more on people from ethnic minorities than their White counterparts. We also know that people with learning disabilities and autistic people are disproportionately subjected to these approaches. There’s now an important impetus to start looking at why this is happening and what we can do about it. 

Another key issue is the use of long-term segregation in the UK. It’s a practice that’s really not acceptable in society today, and work is going on to look at how individuals can be supported to live in the community going forward.

When we started looking at coercive practices, our focus was on the more extreme end of interventions, such as seclusion and restraint, and these are still really important areas. But we’re now shining a light on more subtle coercive practices that are traumatising to people who find themselves in services. We’ve done quite a lot of work recently on what are known as ‘blanket restrictions’, which mean that when a person is admitted to an inpatient service, basically everything about them and their identity may be taken away, including access to things they love and care about, which in some cases can include their family. 

We all have different ways of dealing with distress, but when people are admitted for inpatient care, familiar strategies that might aid personal recovery can be taken away from them. The rituals and regimes we impose can be very damaging as they exacerbate an individual’s lack of identity, which in turn restricts their ability to recover. This includes a whole range of things like not being able to make a cup of tea when you want to, not being able to choose what to watch on TV, not having access to an outside space and not having anywhere quiet to go for some peace. So, there’s a much bigger picture we’re looking at about how we treat people with compassion and have some curiosity about their lives, who they are and what they need to recover.

How are groups like the Restraint Reduction Network helping organisations to change their approach?

The Restraint Reduction Network (RRN) has a significant number of members who are doing amazing work in this country and globally. For example, an initiative called Safewards, which is an evidence-based approach to reducing containment and conflict, continues to be implemented in many services. It’s been successful in many respects and although it was particularly targeted at mental health services, it has now expanded way beyond that and there are international groups that come together to share good practice around the approach. There’s also an organisational approach to enacting change called the Six core strategies© targeted in the first instance at reducing seclusion and restraint use. This was developed by Kevin Huckshorn in the early 2000s in the USA. It has been used widely around the world and is about putting systems and processes in place with the aim of avoiding the use of coercive practices. There is evidence that some organisations have managed to eliminate the use of seclusion and restraint altogether. 

The RRN website offers a wide range of practical resources that include assessment tools for staff to look at the current situation in their organisation as well as processes and guidelines for implementing changes. We also have a conference every year and invite people to come and present what they have been doing in their organisations—it’s a great way of sharing good and impactful practice.

What do you think the next few years hold for patient safety?  

One thing we are beginning to look at more is the use of restraint in schools and education settings. We’re hearing a great deal of concern around the use of coercion with young people where there is perceived conflict. The issue is important across the spectrum of educational services and it’s a very important agenda for us going forward. We want to encourage health, education and social care settings to take a more preventative, trauma-informed approach. It will take some time as we need to better understand how widespread the issue is and what’s contributing to conflict in these settings.

If we traumatise children at a young age through the use of coercive practices, this may have an impact on their experiences in and of services as adults. 

If you could change just one thing in the healthcare system right now to improve patient safety, what would it be?

Staff are the key with all of this. It saddens me to say, but the things I would like to see are more compassion, curiosity and kindness. Our staff work in under-resourced, stressful environments and often end up firefighting and being less in tune with the human aspect of the people they are working with. We need to find ways to remember why we do what we’re doing, and that there is a human being at the receiving end of care. We need to endeavour to foster empathy back into the room. 

This ‘one thing’ requires a significant investment to make it happen: more resources, workforce development and more support for staff who are working and struggling in challenging environments. We also need to see much more investment in primary care so that people can be in safe spaces in the community, where they have access to all the things I mentioned before that can support their personal recovery.

Are there things that you do outside of your role which make you think differently about patient safety?

People who know me know that I’m a massive animal lover, and there’s no doubt that we can learn so much from animals and their behaviour. I’m a patron of a horse sanctuary in Cumbria called The Friesian Experience. I don’t get to go up there as often as I’d like, but when I do go up there it reminds me of the benefits of working and being with animals. 

I also love walking in Cumbria and the Lake District—getting out into green space is so important for all of us. Freedom and the opportunity to reflect and communicate are fundamental needs for all humans.