Role play in the Context of a Simulation to Support Learning and Teaching for Non-physical Restrictive Practices in Nursing.

Here, Jamie Komeh, Senior Lecturer in Mental Health Nursing considers simulated teaching and learning strategies in developing skills to consider the use of restrictive practice in nursing.

Simulation has the capacity to provide greater opportunities to healthcare professionals and students to improve or enhance their knowledge and experience, and, subsequently, optimises delivery systems to improve patient safety and well-being. In principle, simulation refers to a technique that, not only replace but also amplifies real experiences with guided ones in an interactive way, manner or method. A plethora of research evidence supports the benefits of simulation and the profound impact that it can have on patient safety and well-being (Deutch, 2016; Lateef, 2010).

In addition, the use of simulation in nursing education and training facilitates and provides an opportunity to innovatively approach the ways in which nursing skills and knowledge are taught and learned. It is a strategic pedagogical approach to use in nursing education in developing competent nurses, by capturing error as students can practice a skill as many times as possible in order to master a skill (Brown, 2015).

Simulation situations/simulation-based training are known to be widely used in medical education, however findings supports the use of simulation in healthcare education, which includes nursing education. Hence transferability of learning from the findings is a greater possibility to enhance learning in nursing skills using simulation-based training (Brown et al., 2016; Deutch, 2016; Lateef, 2010; Monrouxe et al., 2018).

There are various forms/methods of simulation routinely used in healthcare training and education; watching video tapes, computer programmes, role modelling, group activity, role play, case scenarios and actors, simulation with standardised patients/actors, virtual realities to name a few (Brown, 2015; Felton and Wright, 2017). This educational enquiry used role play in the context of simulation to support learning and teaching for student Nurses on a specific nursing practice; Reducing Restrictive Practice.

Restrictive practices are deliberate acts on the part of other person(s) that restrict a patient’s movement, liberty and/or freedom to act independently, that is the use of restraints, seclusions, rapid tranquilisations/medication, use of comfort and calming rooms, tilted beds, high furniture to prevent movement, blanket visiting times, locking food cupboard, removing walking aids, tone of voice to intimidate, are some of the common practices (Department of Health (DoH), 2014). Restrictive practices can be categorised as physical, chemical, environmental and psycho-social (National Health Service (NHS) Protect, 2013, Royal College of Nursing (RCN), 2017).

Most often, restrictive practices  are used in response to challenging behaviour, such as agitation and aggression as symptoms of conditions such as those related to behaviour arising from mental health conditions, learning disabilities, dementia,  injury to the head and brain, infections, delirium, cancer, post-operative recovery,   abuse of substance and alcohol and withdrawal. It may also result from other human social factors, such as bereavement, anxiety and fear, adverse reactions to medication and treatment, or a feeling that staff are not paying attention (NHS, 2013). Therefore there has been considerable focus on reducing restrictive practices in nursing, and this principle has now been incorporated as part of nursing education. This is because tackling restrictive practice is essential for protecting patient’s right to autonomy and liberty; as well as facilitating the establishment of therapeutic relationships, enhancing the patient experience and upholding standards of care quality and safety (Hext, Clark and Xyrichis 2018). Furthermore, reducing restrictive practice also leads to reductions in health care costs, arising from costly observations due to episodes of challenging behaviour. However, many well-known reports demonstrate that restrictive practice continue to be commonplace and as a result, this presents a need to alter the way that health care professionals, such as nurses, practise when managing patients who exhibit challenging behaviours (DoH 2014; Royal College of Psychiatrists (RCP), 2018). As opposed to employing restrictive practice, de-escalation skills and other therapeutic and communicative nursing interventions are now recommended, as an effective strategy for managing challenging behaviour (RCP, 2018). Role play is a teaching method that shows promise for enhancing these skills amongst clinical students and may contribute to their learning to reduce the incidence of  restrictive practice in the future (Liebrecht and Montenery 2016; Nair, 2019 ; Rønning and Bjørkly 2019).

Keywords: Restrictive practice, learning and teaching, simulation, Role play

Aim and Objectives

The main objective of this small-scale educational enquiry project was to determine whether using role play to simulate situations where restrictive practice could be used will support the teaching of restrictive practice reduction nursing practices, enhancing learning amongst student nurses.

To assess whether nursing students are satisfied with the use of role play to promote learning regarding the reduction of restrictive practice.

To use reflective discussions to explore students’ experiences of role play to promote learning regarding the reduction of restrictive practice.

Research Question

Is role play a feasible teaching strategy to support the learning of student nurses with regards to the need to reduce the use of restrictive practices in nursing?

How does engaging in role play effect the learning of student nurses in terms of the need to reduce the use of restrictive practices in nursing?

Methodology

Ethical approval from the university (Brighton Research Ethics Application Manager) was obtained before conducting the enquiry in the University’s School of Health Sciences. Informed consent was obtained from student nurses who participated in the study. At the beginning of the session, students were asked to form pairs. Role play case scenarios were prepared in advance – requiring one student to act as the nurse, while the student assumed the role of service user. Each of the case studies described scenarios where service users exhibited challenging behaviour and thus, presented a scenario where restrictive practice could theoretically be employed in nursing practice. None however involved service users exhibiting aggressive or intimidating behaviours, as this was deemed ethically sensitive and would require assessment to ensure participants come to no harm and was not required for these sessions as non-physical restrictive practice was the focus. Each student was also provided with the opportunity to assume the role of both service user and nursing role. At the end of the session, students were then asked to engage in a discussion, reflecting on their experience during the role plays as part of the wider group. This discussion was facilitated by asking the students what they have learnt during the exercise, and areas of learning for future practice. At the end of the session, students were then required to complete a short questionnaire. This questionnaire asked students to rate their satisfaction with the session, and posed the question: has this session contributed to your awareness of, or confidence in, reducing the need for restrictive practice?

Discussion

Thematic analysis was utilised to identify themes (Figure 2) from the student nurses’ discussions, reflecting on their experience during the role plays that enabled further exploration and discussion to answer the research question (Clarke and Braun, 2017). The results from this small-scale education enquiry suggests that role play, as a form of simulation-based teaching, enhances learning regarding the reduction of  restrictive practice amongst nursing students. What became apparent during the reflective discussions with nursing students is that conventional teaching methods, such as those that are lecture-based, may fall short in generating a close to the real world experience of the clinical event  and this would mean that principles underlying the use of restrictive practice remains somewhat abstract for learners. While they comprehend the subject, such conventional teaching methods fail to encourage students to consider the position of service users who are subject to restrictive practice. This includes the experience of being wholly ‘at the mercy’ of nurses who may employ restrictive practice and how service users who exhibit challenging behaviours experience power imbalances in the nurse-patient relationship. Essentially, role play promoted the students’ ability to place themselves in the position of their service users, providing a moment of insight regarding how it must feel to have your basic human rights breached as part of nursing care. Accordingly, this finding is also supported by the wider evidence base, where registered nurses also voice that they had not truly considered the impact of restrictive practice on the individual’s sense of self and wellbeing status. Instead, registered nurses focus on the use of restrictive practice as a means of upholding the principle of patient safety, both for the service user who is subject to restrictive practice, as well as service users who are also receiving care in the same environment (Hext et al., 2018; Rønning and Bjørkly 2019).

It also became apparent that role play resulted in many of the nursing students highlighting the need for education and training on the use of alternative strategies such as de-escalation techniques, as a means of avoiding the use of restrictive practice.  Without such intervention, the nursing students felt that they would have little choice but to use restrictive practice as otherwise, this would likely compromise patient safety. This latter observation is of course justified, as challenging behaviour is indeed recognised to be a phenomenon that can compromise the safety of both the affected service users, other service users within the same environment, and other health care professionals within the setting. Essentially, absent the ability to employ alternative strategies such as de-escalation techniques, nursing students perceived that they would have little choice but to revert to restrictive practice irrespective of their knowledge of the potential adverse impact on the affected service user. Consequently, this raises the urgent need to provide such training and education and raises the implication that role play could also be a useful means of providing such learning. The findings from this small-scale educational enquiry therefore proposes that role play can also be used as a way of training and educating nursing students on the use of non-restrictive practices to tackle challenging behaviour. Potentially, this may also prove more advantageous versus conventional teaching methods, both as a means of acquiring these additional skills and knowledge, as well as further supporting reductions in restrictive practice. The efficacy of such an approach could be explored in a further, small-scale educational enquiry, mimicking the methods used in this study. All attendees completed the exercise in its entirety. During the reflective discussion following the role play and analysing the data gathered from the questionnaires, students conveyed a number of statements which suggested that the exercise had a positive impact on learning (see Figure 1). The findings following thematic analysis has been presented in Figure 2.

 

Evidently, studies and strategies to reducing restrictive practices are focussed mainly in Mental Health and Learning Disabilities Nursing. Restrictive practices common to both nursing practices include use of the Mental Health Act to detain patients in hospital, use of physical restraint and control, seclusion and psychiatric observation to name a few. Although these practices are legal and guided by policies and used as interventions for patients’ safety, their use has been found to be improper in certain instances (Royal College of Psychiatry (RCP), 2018; Care Quality Commission, 2017). Improper use of restrictive practices in Mental health Nursing is deemed to go against patients’ human rights, leads to abuse of patients, delays recovery, causes psychological distress/trauma, poor quality care, culture of negative attitude from staff towards patients, inconsistent approach to challenging behaviour, unsafe environments and staff fatigue and sickness (Department of Health (DoH), 2014; National Health Service (NHS) Protect, 2013; Royal College of Nursing (RCN), 2017; Royal College of Psychiatry (RCP), 2018).

Furthermore the Mental Health Act Code of Practice (2015) expects Mental Health Services to commit to reducing restrictive interventions, such as use of restraint, seclusion and rapid tranquilisation as well as instances of imposed blanket bans that restricted patients’ liberties. The Care Quality Commission (CQC) now examines and inspects Mental Health Services for approaches they are using to reduce restrictive practices.

A number of approaches to reducing restrictive practice has been forwarded by key stakeholders, including positive behavioural support plans, positive engagement and effective communication, value and rights based plans, embarking on projects and programmes with sole focus on reducing restrictive practice, recovery based approach, auditing and monitoring use of restrictive practices and interventions, review of Trust/Hospital policies that are likely to lead to restrictive practice, multi-disciplinary Review of restrictive intervention use and promoting safer and therapeutic services are a few to be mentioned. (Care Quality Commission, 2017; Department of Health, 2014; National Health Service Protect, 2013; Royal College of Nursing, 2017; Royal College of Psychiatry, 2018).

These are all practices that are significant to reducing restrictive practice in mental health nursing.

Figure 1

“I had never truly realised the power I could have as a nurse….. service users really are at the mercy of their nurse when they are presenting with challenging behaviour”   “It must be so frightening to be restrained… as a patient, nurses should be a person you trust and expect to care for you. I don’t think I’d feel that my nurse had compassion for me if they then restrained me”

 

Figure 2

Thematic Analysis Findings   1) Placing the Student ‘in the shoes’ of the Service User Many students conveyed that the role play offered them a first-hand experience of how it must feel to be a service user who is entirely subject to the actions of a health care professional. Many students had not considered how it must feel to be the disadvantaged party in terms of the power imbalance between service users; service users have the knowledge that nurses may restrict their liberty, and that there is nothing that the service user can do to question this power   2) The Responsibility and Power of the Nursing Role There was consensus that they had not previously considered the power that nurses may wield over the freedom of another individual – students voiced an overwhelming sense of duty to be responsible and compassionate in the use of this power Prior to engaging in role play, nursing students perceived that they would have a negative response to a service user who was exhibiting challenging behaviour and therefore, this would contribute to a greater likelihood of employing Restrictive Practice.   3) Versus conventional teaching methods, nursing students voiced that role play bridged the gap between theory and practice.   4) Need for Enhanced Educational Strategies for Managing Restrictive Practices All nursing student participants voiced that they felt poorly prepared to use non-restrictive practices in response to challenging behaviour. Students perceived that a lack of training and education in strategies such as de-escalation techniques would threaten their ability to reduce the use of Restrictive Practice in practice settings.

 

 

Conclusion

Restrictive interventions should only be used as the last resort and in a way that minimises any risk to the patient’s health and safety.  Should bear minimum interference to their autonomy, privacy and dignity, but proportionate to protect the patient and other people.

When a restrictive practice or intervention is used, it must be a reasonable and proportionate response to the likelihood of an imminent harm to the service user or others. It should not be used to inflict pain, humiliate, punish or deprive patients of their liberties.  Embarking on projects and programmes with sole focus on reducing restrictive practice will support student nurses in their practice and approach to challenging behaviours from patients and service users.

The results from this small-scale education enquiry suggest that role play, as a form of simulation-based teaching, enhances learning regarding the reduction of restrictive practice amongst nursing students.

 

 

 

References

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