Prevention and Management of the Use of Restraint

The policy framework has been informed by Section 7 of the Local Authority and Social Services Act (1970) and more recently by Valuing People (Department of Health, 2001), Human Rights Act (1998), MHA (1983), Mental Capacity Act (MCA, Department of Health, 2005a) and Care Standards Act (2000).

Definition

For the purpose of this Policy for Good Practice, a very broad definition of restraint has been adopted which is: “Anything that prevents someone from doing something.”

This definition would apply whatever the reason for restraint being used, and however the person that is subject to the restraint feels about it.

The term restraint could be used to describe both appropriate and inappropriate methods of restraining an individual.

By using such a broad definition, it is hoped that all decisions regarding the use of restraint will be made carefully, appropriately considered and documented. This will help to promote high standards of practice and accountability.

In the context of caring for vulnerable adults, restraint can take many forms. They include apparent forms such as:

Physical restraint of an individual.
Use of mechanical restraint, for example, lap strap or ‘bed rails’.
Locked doors
The use of medication – ‘chemical’ restraint

Or more subtle but equally restrictive forms such as:

Restricting individuals’ choices.
Some types of assistive technology, such as door alarms
Withholding information.

The above is not an exhaustive list.

General Principles

The main aim of the policy is to promote the prevention and minimize the use of restraint.

The policy is set within a philosophy of non-invasive interventions, increasing peoples’ skills and status, and helping individuals and teams make sound judgments by taking only those actions that are appropriate in an assessed situation.

Appropriate actions are those which are legal and consistent with the aims and philosophies of the organization and are in the best interests of the people we serve. They should take full account of the principles set out in the Mental Capacity Act (Department of Health, 2005a) and other relevant legislation.

As a general rule, any form of restraint is not acceptable unless it has been agreed as part of the individual’s plan of care. Other options for managing the situation must have been considered first. All use of restraint must be agreed, risk assessed, recorded, and reviewed by a multidisciplinary team. However, there will be occasions when restraint results from an unforeseen/emergency situation.

Restraint should always be the last resort, when all other less intrusive methods of management of the problem have failed to achieve desired outcomes. The least restrictive alternative for managing the situation should be used. The reasons for the restraint should be fully documented by a multidisciplinary team. The use of restraint should be honestly and openly acknowledged. It is the intention of the policy to encourage openness and ensure robust monitoring and review of procedures.

Restraint should not cause injury, pain, distress, or psychological trauma. It should not undermine dignity, humiliate, or degrade the service user.

All use of restraint must be agreed, recorded and reviewed, and support should be identified for those operating a restraint, or seeking to remove a restraint. It is the responsibility of line managers to ensure that all staff have access to appropriate support, which is likely to vary in line with individual needs.

The distinction between abuse and restraint can sometimes be a fine one. If an alternative to restraint is identified and yet the restraint continues to be used, the use of the restraint will be deemed to be an abusive act. Appropriate Safeguarding Adults Procedures should then be followed (e.g., South Yorkshire Safeguarding Adults Procedures).

Inappropriate use of restraint is unlawful. It may be an unlawful breach of Article 5 of the European Convention of Human Rights (1950) and/or an offence under section 44 (ill-treatment or neglect) of the Mental Capacity Act (2005).

Prevention

The reasons for any behavior or circumstance that is known to have the potential to lead to the use of restraint must be fully explored and understood. The question of why the behavior or circumstance is a problem and to whom, and what function the behavior serves for the individual must be addressed.

Clients’ needs should always be met in ways that minimize the necessity for restraint. A record must be made of what solutions to the issue have been proposed, their rationale, and outcome.

Restraints are usually employed by staff or family carers to manage circumstances which are likely to cause injury to individuals or serious damage to property. The use of restraint should be minimized by adopting primary and secondary prevention strategies and risk assessment.

Primary Prevention

Primary prevention is action(s) to stop the circumstance from arising in the first place. Some examples of primary prevention are:

Promoting a culture that values our clients
Helping clients to avoid situations which are known to provoke violent or aggressive behavior.
Establishing and monitoring care plans that are responsive to individual needs and building positive behavior support plans where required to meet individuals’ needs
Creating opportunities for clients to engage in meaningful activities that include opportunities for choice and a sense of achievement.
Ensuring that clients’ communication (in whatever form this may take) is understood and responded to.
Developing staff expertise in working with service users who present challenges to services.

Secondary Prevention

This involves recognizing the early stages of a sequence or episode that is likely to develop and employing strategies to avert any further escalation. These strategies should be person-centered and relevant to the individual and the situation. Some examples of secondary prevention:

Not responding to challenging behaviors
At the same time attempting to cue in or reinforce alternative, more positive behaviors
Removing demands
Diversion to a reinforcing or compelling event or activity
Strategic capitulation (giving the person the thing that they want)
Low arousal approaches where others stay calm, quiet, and non-threatening (e.g., by maintaining interpersonal space) and try to avoid escalating arousal and the risk of physical violence (Bush, Ball, and Emerson, 2004)

All prevention strategies should be carefully selected and reviewed to ensure that they do not unnecessarily constrain opportunities or have an adverse effect on the clients’ welfare or quality of life. Some prevention strategies in themselves may be forms of restraint. A judgment needs to be made about the relative risks and potential benefits arising from different proposed strategies. This will require a detailed risk assessment.

Risk Assessments

Whenever it is foreseen that a service user might require some form of restraint, a risk assessment must be carried out that identifies the benefits and risks associated with intervention strategies. This risk assessment must be in detail and recorded in the client’s care plan.

Although the focus must always be on the needs of the service user, agencies must not lose sight of other relevant issues such as duty of care, service user, public, and staff safety.

When a restraint is proposed, it is important that appropriate steps are taken to minimize the risk to both clients and staff.

Among the main risks to clients are that a restraint may:

Be used unnecessarily, that is when other less intrusive methods could have achieved the desired outcome.
Cause injury and/or death.
Cause pain, distress, or psychological trauma.
Undermine the dignity of the service user or otherwise humiliate or degrade.
Create distrust and undermine personal relationships.

The main risks to staff may include the following:

As a result of applying a restraint, the staff member suffers injury.
As a result of applying a restraint, they experience distress or psychological trauma.
The legal justification for the use of a restraint is challenged in the courts.
Disciplinary action.

The main risks of not intervening may include the following:

The service user may experience serious harm, injury, or even death.
Other clients, staff members, or members of the public may be injured.
Property or possessions may be damaged.
The individual’s behavior may escalate and become more challenging to manage in the future.
Legal and regulatory consequences for the organization and staff members involved.

To minimize these risks, the following steps should be taken:

Develop a clear policy and procedure for the use of restraint, including a definition, types of restraint, decision-making processes, and reporting mechanisms.
Train staff in understanding the risks and benefits of restraint, when it is appropriate to use restraint, and how to apply it safely and effectively.
Ensure that service users and their families are informed about the organization’s policy on restraint and have access to information about their rights and how to make a complaint.
Regularly review and update the risk assessment for each service user who may require restraint, taking into account their changing needs, preferences, and circumstances.
Monitor and review the use of restraint within the organization to ensure that it is used as a last resort and in accordance with best practice guidelines.

In conclusion, the use of restraint in care settings should always be considered as a last resort, and prevention strategies should be prioritized. It is essential to have a clear policy and procedure, proper staff training, and ongoing monitoring to ensure that restraint is used safely and effectively when it is absolutely necessary. By adopting a person-centered approach and focusing on prevention, organizations can minimize the need for restraint and promote the well-being of both service users and staff.