Audit of breakaway techniques (Rogers et al)

An audit of the use of breakaway techniques in a large psychiatric hospital: a replication study

Short title: Audit of breakaway techniques

Authors:
G. Dickens (Corresponding author, address below)
G. Rogers
C. Rooney
A. McGuiness
D. Doyle

This paper describes an audit study of the effectiveness of breakaway training conducted in a specialist inpatient mental health hospital. Breakaway techniques comprise a set of physical skills to help separate or breakaway from an aggressor in a safe manner, but do not involve the use of restraint Staff (N=147) were assessed on their ability to breakaway from simulations of potentially life threatening scenarios in a timely manner, and using the techniques taught in annual breakaway or refresher training. We found that only 14% (21/147) of participants correctly used the taught techniques to breakaway within ten seconds. However, 80% of people were able to break away from the scenarios within ten seconds, but did not use the techniques taught to them. This audit reinforces questions about breakaway training raised in a previous study. It further demonstrates the need for a national curriculum for physical intervention training and development of the evidence base for the content of such training as a priority.

Keywords: Aggression, Violence, Training, Breakaway, Audit, Inpatient


Introduction
Violent and aggressive behaviour towards clinical staff in mental health inpatient settings remains a serious problem. Nurses appear to be at particular risk: A recent survey indicated that 46% of nurses employed in working age psychiatric services and 64% in older people’s psychiatric services had been the victim of a physical assault at work (Healthcare Commission 2007a; 2007b). The National Institute for Mental Health in England (NIMHE, 2005) have recommended that staff who are exposed to violence and aggression should be trained in physical intervention skills, including ‘breakaway’ techniques. These techniques are defined by the National Institute for Clinical Excellence (NICE) (2005) as “a set of physical skills to help separate or breakaway from an aggressor in a safe manner… [and] do not involve the use of restraint”. The Nursing & Midwifery Council (2001) have also recommended that staff, including non-clinical employees, be trained in the use of de-escalation techniques and breakaway skills. A call for allied healthcare professionals who work in mental health settings to adopt similar training on pre-registration training courses has also been made (Stubbs & Dickens, 2008).

There appears, then, to be a level of political will to equip staff with the skills and techniques to avoid harm or injury due to physical assault. However, on closer examination the subject is less clear. Despite progress made in the development of a theoretical basis for a national syllabus for physical skills intervention, including breakaway training (NHS Security Management Service, 2005), such a programme has not yet been implemented. Even the fundamental question of what, precisely, constitutes breakaway training remains open. Rogers et al (2007) identify that the dominant model of training in ‘physical interventions’, including breakaway skills, was that developed within the prison service of England & Wales in the 1980’s. At the outset this training was highly regulated but since the late 1980’s multiple variations on techniques have been introduced by trainers working in both the NHS and private business ‘as they saw fit’. Furthermore, there are differences in the United Kingdom in terms of how frequently breakaway training should be provided. In England and Scotland there is no guidance on which techniques should be taught, whilst in Wales there are (ibid). An observational study of a one-day breakaway training course at Broadmoor high secure hospital (Rogers et al, 2007) found that 21 different techniques were taught over the day, each technique being demonstrated on average for just under seven minutes and being practiced by attendees for nearly six and a half minutes. The authors argue that it is ‘not plausible’ to train staff in so many techniques in such a short time.

It appears that the vast majority of staff, at least in acute psychiatry, receive training in some form of breakaway techniques: Wright et al (2005) report a figure of 85% among nurses surveyed in a national UK study. There is, however, no nationally recorded data on the use of breakaway techniques and empirical data is fairly scant. Southcott & Howard (2007) recorded just seven uses during the course of a prospective three-year study in a Psychiatric Intensive Care Unit, with five episodes facilitating escape. Rogers et al (2006) state that no participants (registered nurses and Healthcare Assistants employed at a medium secure unit) who they recruited into their audit of breakaway training reported having used any breakaway technique in the preceding year. Wright et al (2005) report that 70% of their sample had not used breakaway techniques on at least one occasion when they had been assaulted, suggesting that the techniques they had learned may not have been useful for many examples of assault.

Finally, we must ask whether breakaway training is actually effective in reducing injuries from assault. A NICE (2005) review found that staff felt satisfied and slightly more confident as a result of breakaway training, but this cannot be said to demonstrate effectiveness. In a recent paper (Rogers et al, 2006), which the current study aims to replicate, reported that 40% of nursing staff working on one medium-secure psychiatric unit in the United Kingdom were unable to breakaway from a simulated life threatening situation within ten seconds. The lead author is reported (Parish, 2007) as saying “there is little evidence that breakaway training actually works… Nurses are being sent on 70,000 training days a year because it seems a good idea”.
One of the recommendations made by Rogers et al (2006) was that their study be replicated to ensure that their findings are transferable. This paper therefore describes a similar audit study in a UK specialist inpatient mental health hospital. Given that all staff employed by the organisation in the current study are trained in breakaway techniques, and receive an annual training refresher, the opportunity to expand the audit to include non-nursing staff was taken.

Method
Aims
The study aimed to ascertain the recollection and implementation of breakaway training techniques taught to staff at a large psychiatric hospital. The current study therefore largely replicated a previously published audit (Rogers et al, 2006) though some alterations were made to take into account local variations in practice.
Setting

The study was conducted at St Andrew’s Hospital, Northampton, a charitable provider of specialist inpatient services for approximately 500 adults and adolescents with mental disorder, learning disability or acquired brain injury. Many patients have challenging behaviours. All staff (approximately 2000) are trained in breakaway techniques on their initial induction and refresher updates are provided annually. Breakaway training forms one of the organisation’s ‘Key Performance Indicators’ and annual attendance is mandatory. High levels of attendance (98% +) are attained. Clinical staff, of course, undertake further prevention and management of aggression and violence training but it is the breakaway component that forms the focus of this study.
Design

A cross-sectional audit design was utilised to evaluate the effectiveness of breakaway training at the hospital. The definition of clinical audit endorsed by NICE (2002) is :
“a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery.”

Essentially, clinical audit measures existing practice against an explicit standard or ‘best practice’ criteria. In a clinical research trial, two or more alternative interventions are tested head-to-head to establish which is the most effective, but clinical audit tests whether the currently approved routine intervention is being implemented correctly. Clinical audit projects do not require approval from an NHS Research Ethics Committee, although of course that does not mean there are no ethical implications. The study was approved by the hospital’s Healthcare Governance Department and Training and Development Board.

As in Rogers et al (2006) study an explicit standard was adopted in order to measure the current performance of breakaway training. The standard chosen was whether participants correctly recalled and implemented the techniques taught to them to ‘breakaway’ from a simulated life threatening situation, and did so within an appropriate time-frame (ten seconds). The rationale for this time frame was that, in a real life situation, failure to breakaway within 10 second would be likely to lead to unconsciousness or death (ibid).

Participants
Potential participants were any members of clinical or non-clinical staff, ward-based or otherwise. Sampling was opportunistic. Staff were approached, given information about the study and requested to participate. It was emphasised that the study aimed to ascertain the effectiveness of breakaway training and was not aimed at assessing their ability. Three exclusion criteria were used: individuals were not included in the study if they did not feel physically able to take part, if they had not been trained in breakaways or received an update in the past 12 months, or if they did not wish to take part.

Procedure
The audit team consisted of three conflict management advisors, all were previously healthcare assistants who have subsequently received extensive specialist training. One of the three, the lead auditor, was assigned to play the role of violent assailant while the other two independently assessed the participant’s use of breakaway techniques to escape from the hold. The use of two independent raters aimed to ascertain the extent to which the measures developed for the study could claim to have inter-rater reliability.
Demographic details including age, gender, occupation and experience were collected from participants. Eligible participants were taken into a safe, prepared, and screened area where the procedure was fully explained by the lead auditor. Participants were requested to randomly select one of five unmarked envelopes. Each envelope contained one of the following scenarios:

a straight arm strangle hold from the front
a hair pull from the front
neck lock
bar neck lock
a bear hug with arms trapped

The lead auditor read aloud the scenario and gave the participant 5 seconds to think about the situation before the simulation commenced. If the participant had not escaped within 10 seconds the simulation was halted. The two independent raters completed the audit measures during the scenario. Participants were given a chance to discuss the experience afterwards.

Measures
As noted by Rogers et al (2006), there are no agreed national standards on which breakaway techniques should be taught, and there is variation between taught courses. This means that audit measures will need to directly reflect the particular techniques that are taught in the study setting. Therefore five audit tools, one for each ‘hold’ outlined above, were developed by the study team. The tools were extensively discussed and agreed amongst the team as accurately reflecting the taught method for breaking away from each hold. An example of the method taught to break away from a strangle hold is provided in Appendix I. Independent raters were required to judge whether each step in the technique had been completed as per the training received, and also whether the participant managed to escape from the hold within ten seconds.

Data analysis
Data were entered into SPSS Version 16.0 (SPSS, 2007). Adherence to the audit standard was gauged by simple descriptive statistics. Pearson’s chi square test for distribution with Yates’ continuity correction was employed to identify differences between groups in terms of achieving the audit standard. Inter-rater reliability between two independent raters was tested using the kappa (ĸ) measurement.

Results
In total, 175 employees were approached to participate in the audit. Twenty eight potential participants were excluded because they had not received breakaway training or an update in the past year, because they did not feel physically able to participate or because they did not agree to participate. This left a sample of 147 participants, a response rate of 84%. The 28 non-participants did not differ significantly from participants on any of the demographic variables collected.

The κ measurement for each of the two outcomes showed excellent inter-observer agreement (κ=1 for whether the participant had managed to breakaway, κ=0.97 for whether the participant had used the taught technique to breakaway). This means that for the outcome ‘successful’ breakaway’ both raters were always in agreement and for the outcome ‘used taught technique’ there was 1/147 (0.7%) case where raters disagreed as to whether the taught technique had been used.

Table 1 shows the descriptive characteristics of the participants, the number (%) of those using the taught techniques to breakaway and the number (%) of those actually managing to breakaway irrespective of whether the taught techniques were used. Only 21 (14.3%) of the sample fully employed the taught techniques to remove themselves from dangerous situations. However, 117 (79.6%) managed to effect their breakaway though not necessarily using the taught techniques. Post hoc statistical analysis suggests that nursing staff (combined nurses and healthcare assistants) were significantly less likely to effect escape using any method than were other clinical and non clinical staff (68.8% v 88%, Pearson’s chi square = 7.063, d.f.=1, p<0.01). Table 2 displays a breakdown of results for each particular hold; there was no statistically significant difference in successful breakaway between the various holds.

Use of breakaway techniques
About one in five of our participants had used breakaway techniques in clinical situations in the past year and about two in five had used breakaway techniques in clinical situations ever. None (0%) of the 47 participants in the Caswell study (Rogers et al, 2006) had used breakaway techniques in the past 12 months. We asked participants to describe the occasions when they had used breakaway but there was too little data reported for analysis.

Discussion
In the current study, staff’s ability to recall and implement taught breakaway techniques in potentially life threatening scenarios was very poor (14%) and compared very unfavourably with results from an audit of breakaway training at the Caswell Regional Secure Unit (60% success rate) reported in Rogers et al (2006). Fortunately, in the current study, 80% of staff were able to breakaway from simulated holds, although they did not use the taught techniques to do so.

More staff at St Andrew’s reported having used breakaway in a clinical situation within the past 12 months than did staff at the Caswell clinic (21% at St Andrew’s compared with 0% at the Caswell). Participants were requested to provide descriptive accounts of their use of breakaway but, unfortunately, there was insufficient information to draw any conclusions. Differences between the two study settings could account for the difference in breakaway use. The Caswell Clinic is a medium-secure unit for adults, whilst the services at St Andrew’s are provided for a much more heterogeneous group including older adults, adolescents and brain-injured patients.

How can the relatively poor performance in this study be explained? A number of differences between study settings, training programmes taught within the study settings and study design could go some way to explaining the contrast. In the Caswell audit only nursing staff (nurses and healthcare assistants) were recruited, whilst the current study also recruited non-nursing clinicians (occupational therapists, psychiatrists and psychologists) and non-clinicians. However, the performance of nursing and non-nursing staff was broadly similar and neither group approached the success rate of nurses at the Caswell. The profession of participants does not, therefore, appear to be the major determinant of recollection and implementation of breakaway skills. Recruitment bias should also be considered as a confounding factor. The audit study at the Caswell was undertaken over several months and whilst recruitment was not random approximately 50% of nursing staff were sampled. In the current study, data was collected over four day-long sessions; 147 staff was sampled from a total population of about 2000. It is therefore possible that there was systematic bias in the current study sample. However, the most likely effect of this is that those who were less confident about their abilities simply avoided recruitment into the study. If this were true, results would actually be an inflation of the true proportion of staff able to implement taught techniques.

Different ‘holds’ to those included in the study at the Caswell were audited in the current study. In addition, one of the holds audited (bar neck lock) does not end with escape, but with the ‘pit’ (security alarm) having been pulled. However, staff did not perform significantly worse on this hold than on any others, and the type of hold audited does not appear to be the most significant element in accounting for the results of the audit.


There was no statistically significant difference in successful outcome between those staff who had been trained very recently (past 3 months) compared with those who had been trained more than 3 months but less than one year ago. This suggests that simply increasing the regularity of breakaway training will not necessarily enhance recall and performance.


Differences between breakaway training taught by staff at St Andrew’s and the Caswell are likely to contribute to the results of the audit. Annual breakaway training refreshers at the Caswell last for two days and are conducted by registered nurses. In the current study setting, annual refreshers last for two hours and are conducted by especially employed conflict management advisors, who are not registered nurses. The effectiveness of breakaway training in this study setting must therefore be seriously questioned, and the implications for the national policy agenda addressed.


Rogers et al (2006) concluded similarly that the effectiveness of breakaway training must be questioned, and in subsequent work (Rogers et al, 2007) have indicated that one of the main causes of the ineffectiveness of breakaway training is the complexity and sheer number of different techniques that are taught. As a result of the current study a local review of breakaway training programmes is being conducted. The conflict management tutor team is reviewing the number of techniques taught, the manner in which they are taught, the ways in which people learn, and the theoretical components of the training programme. An analysis of training needs with reference to personal safety and breakaway training is planned using a model developed by Kidd & Stark (1995). This will help inform appropriate levels of training across different clinical and non-clinical roles. A further audit of breakaway training is planned following these changes; clearly the current study provides a baseline against which to measure.


At national policy level, the findings of this audit appear to reinforce the points raised by Rogers et al (2006) that recall of training is variable. This raises the question of whether breakaway training is fit for purpose in its current form. There needs to be a thorough examination of these issues, particularly in view of the financial costs and personal safety implications. For the future, there is a need for a consistent, evidence based training programme delivered by accredited trainers. As identified in the introduction, the theoretical basis for this is well established through the Promoting Safer and Therapeutic Services Syllabus (NHS Security Management Service, 2005), however there remains no national syllabus for physical intervention skills training. Development of an evidence based national programme should be a key priority. There is some emerging evidence that the evidence base of motor learning in sports science could be developed to inform breakaway training (Benson et al, 2008).

Study limitations
The technique of using simulated scenarios of life-threatening situations clearly has limited ecological validity. Whilst the scenarios reflect potential real-life situations, in reality the audit team do not make every effort to maintain their hold on participants at all costs as this would be dangerous. In addition, we only audited implementation of techniques taught in the study setting and it is possible that participants implemented techniques taught elsewhere. The artificiality of the audit scenarios could also affect the ability of participants to recall the taught techniques. Perhaps, more plausibly, in the heightened state of arousal caused by a real assault people would use any techniques that seemed to work at the time. Our finding that 80% of participants managed to breakaway successfully without using the taught techniques does give some credence to this, suggesting that breakaway methods that centre on natural instinct as opposed to highly technical manoeuvres are likely to be recalled more successfully.


The priorities for future research and audit evaluation has already been well established (Rogers et al, 2007), and this study reinforces this agenda. Specifically, epidemiological data is required on the type and frequency of violence faced by staff in mental health settings. Randomised controlled trials are needed to ascertain the effectiveness of varying methods of taught physical skills for use in emergency situations.


Despite the acknowledged limitations, the current study employed a useful audit method that tapped into real skills. There were no managerial/performance-related consequences for participants as the aim was to audit the effectiveness of breakaway training and not individual performance. This probably enhanced participation rate, and made the audit an enjoyable experience. Other skills-related training could potentially be audited using similar techniques. This study provides further evidence that current breakaway training may not equip staff with the skills to remove themselves from potentially serious situations and a policy response at a national level is urgently required.


References
Benson, R., Allen, J., Miller, G., Rogers, P. & Patterson, B. (2008). Motor skills learning in breakaway training using the evidence base of sports science. Proceedings of the first International Conference on Workplace Violence in the Healthcare Sector. KAVANAH: The Netherlands.
Healthcare Commission (2007a). National audit of violence 2006-7. Final report – working age adult services. Royal College of Psychiatrists Centre for Quality Improvement.
http://www.rcpsych.ac.uk/PDF/!removed--WAA%20Nat%20Report%20final%20for%20Leads%2010%2012.pdf [Accessed 12 June 2008]
Healthcare Commission (2007b). National audit of violence 2006-7. Final report –older people’s services. Royal College of Psychiatrists Centre for Quality Improvement. http://www.rcpsych.ac.uk/PDF/OP%20Nat%20Report%20final%20for%20Leads.pdf [Accessed 12 June 2008]
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[Accessed 1 December 2008]
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Kidd, B. and Stark, C. (1995). Management of Violence and Aggression in Health Care (Eds). Gaskell, London.
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National Institute for Mental Health in England (2005). Health policy implementation guide: Developing positive practice to support the safe therapeutic management of aggression and violence in mental health in-patient settings. http://www.positive-options.com/news/downloads/NIMHE_-_Developing_Positive_Practice_-_2004.pdf [Accessed 1st December 2008]
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Parish, C. (2007). Research reveals that nurses are not using complex breakaway techniques. Nursing Standard, 21(23), 8.
Rogers, P., Ghroum, P., Benson, R., Forward, L. & Gournay, K. (2006). Is breakaway training effective? An audit of one medium secure unit. Journal of Forensic Psychiatry and Psychology, 17(4), 593-602.
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Wright, S., Sayer, J., Par, A.M.., Gray, R., Southern, D., & Gournay, K. (2005). Breakaway and physical restraint techniques in acute psychiatric nursing: Results from a national survey of training and practice. The Journal of Forensic Psychiatry & Psychology, 16(2): 380-398.
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Table 1: Characteristics of the sample, the number (%) using the taught technique to breakaway within 10 seconds and the number (%) of those breaking away within 10 seconds though not using the taught technique

Pearson Chi Square = 8.806, df=3, p< 0.05
Table 2: Characteristics by ‘hold’ employed of the sample, the number (%) using the taught technique to breakaway within 10 seconds and the number (%) of those breaking away within 10 seconds though not using the taught technique


APPENDIX I

Example of audit tool

Breakaway Audit

Rater: A / B

Hold: Straight arm strangle from the front

1. Adopt a sideways stance Yes / No

2. Chin down, shoulders raised Yes / No

3. Arms straight out at shoulder height Yes / No
, fists clenched

4. Dip away from exit for added momentum Yes / No

5. Bring arm over keeping it straight Yes / No
And close to ear

6. Make your exit Yes / No


Completed within 10 seconds Yes / NoEnter your text here...