The term 'restraint' can conjure of disturbing images of people being tied up
restricted in movement against their will, their human rights restricted and even abused.
The depiction of care homes, hospitals and institutional environments in the media following
instances of abuse may suggest these practice are still commonplace.
However, practice in health and social care has improved considerably over the past 40 years
or so and there is compelling evidence that inappropriate applications of restraint are
no longer widespread.
But the term itself conjures up so many negative connotations that many people
working in care are afraid to openly discuss the use of restraint.
And when topics aren't discussed openly, progress can be hampered.
It's a very emotive word, so most health and social care professionals and care workers say
they never use restraint but actually that's because they're not understanding the
complexity of the terminology and everything that goes round it really.
I think we absolutely need to discuss restraint more.
I think it's only through discussing it that we can uncover some of the bad practices,
that we can share experience in some of the good practices and that we can make sure
we're doing the best for staff and for patients and service users.
But, what exactly is restraint? How is it defined?
Well I think often when people think about restraint they think about
stopping people from doing things.
Restricting their movement in some way, preventing them from doing what they want.
And that's absolutely right, that is restraint.
But restraint is more than that.
It can also be about making people do things they don't want to do.
There are actually a number of different definitions of restraint,
but an important one is enshrined in law through The Mental Capacity Act of 2005.
According to the Mental Capacity Act, someone is using restraint if they:
use force - or threaten to use force - to make someone do something
they are resisting, or,
restrict a person's freedom of movement, whether they are resisting or not.
Sometimes people mistake, they think, well, I'm doing restraint because it's in this person's
best interests, it's right for them.
Therefore it can't be restraint.
No. It still is restraint.
The reason you do it doesn't dictate whether or not the act is restraint.
But is it always wrong to use restraint?
There are definitely occasions when it is appropriate to use restraint.
But that needs to be very carefully considered.
And it's quite a dramatic thing to take away someone's right to autonomy.
And what would happen is, there would be a decision-making process that would
include assessing the risks and looking at all the options to mitigate those risks.
And thinking about the least restrictive option.
So, restraint isn't always wrong - in a minority of situations it can be the right thing to do
and not to do so on those occasions might be considered neglect.
But the Mental Capacity Act tells us that in all instances restraint should be used only as a
last resort when other options have been eliminated and its use
must always be minimised.
However, minimising restraint remains a challenge for many providers of health and
social care, particularly those working with our frailest citizens, who may need to be protected
from harming themselves or indeed others under particular circumstances.
So, what are the various forms that restraint can take?
It isn't just this sterotype of someone being held down or strapped down into a bed.
Sometimes it can be more subtle things than that.
Many different actions can constitute restraint.
The common public perception of restraint include physically holding someone,
the use of lap belts, wrist and vest restraints,
all of which should only be used under strict, documented procedures.
But there are less obvious forms of restraint such as:
the arrangement of furniture to keep people in bed, to stop people getting up or creating
an obstacle to part of the room
the raising of bedrails, which are designed principally to keep people from falling
out of bed and hurting themselves
the deprivation of walking aids or means to summon assistance such as calling bells
the locking of doors, stopping people from gaining access to certain parts of a building
over-medication, causing people to be too drowsy to move
and even staff instructions or institutional rules or practices may be seen as restraint,
for example rules about entering the kitchen, residents not being encouraged to
express freedom, choice and control. In fact, applying any such form of restraint,
even minimally - from holding someone down to the deprivation of a walking aid -
should only be considered as a last resort, once other options have been exhausted.
So, when can restraint be used?
According to the Mental Capacity Act, restraint can be used:
if the person consents to it, perhaps
because it makes them feel safer
if it is part of a care plan agreed by all
or under certain conditions, if the person lacks the capacity to consent
but is acting in a way that may cause harm to themselves or others.
The Mental Capacity Act helps us understand that the first part of the process
is to assess someone's capacity.
If they lack capacity and we want to give them care and treatment
that has been agreed is in their best interests that may involve a restrictive
practice then there's a process that we need to go through in whatever setting.
Whether that's a major medical intervention or something that's deemed part of
daily routine care we have to still go through those same steps.
And the mental capacity act helps us understand that and guides us to assessing
that individual and then using the least restrictive intervention to enable
that care and treatment to take place.
In Health and Care environments, it is important to be mindful of when we might
be restricting someone from doing what they want to do particularly
when we might be making an assumption about their capacity to make decisions.
When you become disabled or ill, you may not always feel able to make choices.
You can still make some.
And I think staff have to go back to that basic that people can make choices.
We now have processes in place which are about not doing risk assessment
to someone but with someone.
And how do we safeguard someone
and involve them in that decision making process.
How do we respect their rights.
And so we've seen moves now from people who, the safest option
was to keep them restrained in a particular situation to now we have people living
independently in the community.
So I think you've got to get to know the person.
That's absolutely critical and that should be part of your care planning anyway.
You have to look at all of the options and think as widely as possible.
Use like a balance sheet approach to decide what are the risks and benefits of each option
to determine which is the one that is going to be in this person's best interest.
Through the Mental Capacity Act, we have a guide in the law to the way we should
treat people in care environments
putting them at the heart of decision making, assuming capacity and delivering care
in the least restrictive way.
So, in addition to the Mental Capacity Act, what do people working in care need to
be aware of when a situation arises where restraint seems necessary?
Well human rights are vital in care settings because human rights are about those
basic things that we all need to live with dignity, that we need to live respectful lives.
They are about the very things that are at the heart of our health and social care system.
And when we think about, kind of, restraint, thinking about people's human rights
we're thinking, well actually, what sort of rights is this engaging.
So, are we talking about somebody's right to respect for private and family life?
Is what we're doing stopping them from having a bit of privacy?
Is it maybe impinging on their mental or physical wellbeing?
Is it stopping them from being with other people?
Is it something that might be affecting their right to liberty?
So, not just the right to do whatever you want but the right to kind of not have
unjustified restrictions on your movement.
And really, in a nutshell, that's what a human rights approach is.
It's thinking, OK what are the rights that are protected by the law and is what I'm doing
proportionate to restrict those rights?
So it's really practical and it's really simple and it's the kind of thing that care staff
across the board can be thinking about in day to day practice.
People who work - or who are training to work - in health and social care
need to think about the rights of the people they work with,
patients and users of services.
Everyone has human rights and we have a duty to promote them.
Health and social care workers also need to be aware of how accessing public services
often involves an imbalance of power between those providing services
such as medical professionals, and those using them such as patients and families.
For many of us working in health and social care, we're looking at very vulnerable
adults and children, so it's crucial we understand that dignity and respect and
human kindness and compassion is in our care.
We should be keeping people safe but not from a controlling, power-ridden situation
but from sharing the power and the control with people.
We should always remember to keep sight of our humanity in care services sometimes
we can get overly obsessed with some of the procedural aspects of safeguarding and
keeping people safe which, although vital, aren't the only thing about good quality care.
And no one's pretending that that process is easy but I think, you know, talking openly
about the difficulties that are involved in keeping that balance are a good start.
Professionals working in health and social care need to be aware of just what restraint is and
must talk about the subject freely and openly - without taboo.
...and trying to prevent that individual from harming themselves and people around them
It's done in a safe way and minimise all the risk. I know you canot remove all the risk.
But then constantly reassessing it and seeing whether like the situation has changed or is
different in different circumstances.
I don't think anyone should jump in and use that as their first option.
You know, an holistic approach for that service user.
That's what's going to meet the needs of that service user.
working relationship them.
Yes because you can talk to her. (You can talk to her. Great.)
Yes, you seek her views.
And you just have to treat them, you know, as a human being regardless of what it is.
The duty of care is... underlines everything else.
I think you have to put the service user first and see what the best possible outcome
for that service user is.
Respect for the person, self-determination their personal rights
and also treating them with dignity.
SCIE has a number of resources providing further insight to the subject of restraint,
including practical guidance on making informed decisions in situations where
the use of restraint is being considered.
It's only through talking about these issues that we're going to be able to kind of practice
prevention rather than cure.
So rather than waiting 'til we get to a situation where things are going really wrong that
we're able to identify that beforehand and put in place the kind of policies and the practices
that are going to influence staff behaviour to achieve the best for the patients and the
service users that they're caring for.