Tuesday, 24 March 2015

What if "Restraint" was not an option?

by Freda Lacey

About this time last year the Minister of State for Care and Support, Norman Lamb, wrote about “Positive and safe: reducing the need for restrictive interventions” within health care. Mind’s report from the year before on “physical restraint in crisis” clearly outlined that the use of restraint was used to varying degrees and “face down” (or “prone” restraint as it’s sometimes called) was still being used despite the knowledge that it can cause serious harm and, in some situations, death.  The report made recommendations to the Government that the use of “face down” restraint should never be used in care and treatment settings.

The Mental Health Act Code of Practice, (currently being revised in Wales) devotes an entire chapter to “Managing behaviours that challenge,” and it clearly states that the least restrictive option(s) must be explored and restraint used only as a last resort.

The use of “restraint” and the “how”, when managing patients in hospitals, has been the topic of numerous blogs, reports, white papers, and news articles, particularly over the last few years. The Winterbourne Review spurred a great deal of investigation into the use of restraint, the Care Quality Commission specifically reporting on “Monitoring the Mental Health Act” in 2012/2013” and the use of restraint in hospitals. One of my favourite blogs is written by Mental Health Cop and he has his own views about restraint which may add texture to the topic. I am not going to write about how, when and where restraint is used in mental health settings, this has already been done by people far more knowledgeable than myself.

What I really want to highlight is how I’ve been affected by the topic of “restraint”. During my attendance at the Department of Health’s revision of the “English Mental Health Code of Practice” Expert Reference Group with Jan Rogers, I was privileged to sit in on several of the group meetings discussing changes to “the code”. The chapter called “Safe and therapeutic responses to disturbed behaviour” in the new Code of Practice made the experiences of restraint very real to me.

It was the first time where I listened to people’s direct experiences of being “restrained” in high, medium and acute wards whilst experiencing care under the Mental Health Act. I listened to family members speak of their experiences of witnessing their children’s restraint and the distress this has caused. People openly shared feelings of humiliation, trauma (some of this due to physical injuries they had sustained) and feelings of distrust in the people caring for them. They made direct links to the “way” they were physically restrained, sometimes stating they didn’t know “why” it had happened. I imagined how children or young adults may feel experiencing restraint and the trauma this may hold for them, particularly if abuse has been experienced. What is felt by people with a dementia, what comes up for them as a result of being restrained? As I listened, I wondered what would have happened had restraint never been an option. 

Interestingly around the same time, I caught sight of a national workshop on the management of violence in hospital settings. The workshop was pulled together by the “All Wales Senior Nurse Advisory Group for Mental Health” and their call to action really struck me. “The management of violence and aggression in mental health settings is a key issue for practitioners and educators. The Department of Health have recently consulted on restrictive practices in England along with the Mind publication in 2013; and we want to be at the forefront of planning developments and actions in Wales on behalf of our service users and our staff”. 

Having heard the recent stories from people who had experienced being restrained, I was curious to see and hear how staff approached the subject of restraint. The workshop was well attended by national ward management teams, general nursing staff, senior nurses and senior management.
One of the things that became apparent was that a good many staff felt the need to move away from restraining people and advocated “de-escalation” techniques, or “conflict resolution”. Basically, talking people down from a heightened sense of anger. I could see the difficulty experienced by staff when faced with a patient who is throwing punches and hurting them (one nurse spoke of being punched and having to be off work for some time) where the instinct is to restrain the patient so as to prevent being hurt. If restraint had to be used, then the workshop advocated using “supine” restraint or “face up” which is deemed less injurious and safer for the patient.

I volunteered to experience what it felt like to be restrained as in the afternoon we had a demonstration of using various methods of restraint for adults and older adults with dementia, (for example). Whilst the demonstrators were very careful with me (I was held down by two men and one woman), and pinned down so I couldn’t move and injure myself (and/or them), I was not trying very hard to be aggressive. I could imagine that if someone was very angry and aggressive that it may take some time of being held down and spoken with before the situation may diffuse. I was also startled at how quickly I went from standing to down on the floor and wondered if I was really emotional, angry and distressed, what effect the entire process might have on me. Also, if I were to be restrained by male nurses, how might this feel as a woman and similarly for men.

Hospitals are required to have policies on how to “manage” aggressive behaviour and in reading some policies from different areas I was struck by the following list of some of the things that staff should look out for as factors that may provoke disturbed or violent behaviour:       
  • boredom and lack of environmental stimulation;
  • lack of access to external space;
  • personal frustrations associated with being in a restricted environment;
  • difficulties in communication;
  • emotional distress, e.g. following bereavement;
  • antagonism, aggression or provocation on the part of others;
  • physical illness;
  • and an unsuitable mix of patients. 

It is worth noting that most of the above factors have been encountered by patients we see as part of the Powys Patients’ Council meetings and come up in patients’ feedback to us, so I wonder if these factors will always exist, to some degree, within in-patient units. If they do, then perhaps it’s not a matter of “may” provoke aggression, but that these are constantly having to be managed by staff in ways other than restraining patients.

One staff nurse mentioned that he worked within a high secure unit and that the staff never used restraint, that “conflict resolution” techniques were consistently used successfully. Here in Powys, ward management have mentioned that they don’t use restraint although staff are trained in Safe Physical Intervention Techniques or SPIT as it’s called. In fact, one of the staff on the ward here in Powys is the trainer for all Aneurin Bevan staff (including Gwent) in SPIT.

Another option for all psychiatric patients is to complete what is known as an “advance directive”, or here in Wales: “wishes known in advance” statement (we will be exploring this in more detail in a future blog post). This allows patients to state how they would like to be treated (or not treated) if they are detained by the Mental Health Act. They could quite clearly say that they don’t wish to be physically restrained and whilst an advance directive is not a legally binding document it would be good practice for hospital staff to respect the person’s wishes.

So, what’s the answer to restrain or not to restrain? It may be that while the Mental Health Act (and requisite Code of Practice) results in feelings of deprived liberty by people, there will always exist factors which may provoke people to behave aggressively. If this is the case, then ongoing debate and engagement on this topic will continue to be needed.

Finally, I’m curious to see if people may read something further into the paper outlined from the Department of Health mentioned at the very beginning of this blog post. It states, “This guidance forms a key part of the wider new Positive and Safe programme, which aims to end the unnecessary use of restrictive interventions across all health and adult social care." I wonder….


  1. Interesting. When I was student I blagged a job an orderly in the male medical ward in StJs hospital in Dublin: male medical was either very old and/or demented or diabetic. One of my tasks every night was to tie a demented old buffer to his cot-sides with bandages. As a navy-brat I knew the best knots. The old chap had cot-sides to stop him wandering about the ward at night (not least because he was attached to a urinary catheter), but he'd climbed over the sides and fallen, hence the restraint. I reflected at the time about the irony of using "healing" bandages in such a context. I still feel the pain of watching him trying to remove the catheter by force. With my blunted affect, I wasn't going to take a stand on the ethics of this use of bandages. This was back in the 1970s when staffing levels were much higher but it was fundamentally an issue of not having enough time to handle the old chap's issues in a less direct way.

    1. Thank you Bob for commenting on this blog topic. It's interesting to note your experiences and the lasting effect of having to restrain a patient. I listened to a story recently about a man who had himself managed to get out of bed over a bed rail and had injured himself. Similar issues remain about staffing time constraints, even now, but with new technology, (sound systems/alert systems) there are now other ways of ensuring that patients can be safe and staff alerted without the use of or need for restraining practices.

  2. I think Bob has indirectly hit the nail on the head. Basically you can take the premise out of a reality context and provide guidelines and training on how to manage patients in other ways then restraint, but when you add the reality of the context - unpaid, overworked care workers, orderlies who are working on minimum wage and are not necessarily in the job because of a vocation the picture changes. Add another layer of context in the physical environment, cell like wards, bleak institutions, old and inefficient buildings. The natural reaction of anyone dealing with an emotional or physical lash out would be very different if it took place in a home environment rather then a prison cell, context helps to change behaviour patterns at a very basic and instinctive way. Add the final and probably most damming context from which the others follows, is that many of the patients may have a low or non status, the viewpoint of the community is that they are not fully contributing and stable parts of a community (read keep their troubles to themselves and don't infringe on our own lives) and therefore the value we put on keeping them in humane conditions to be treated with utmost care and respect goes out the window. We keep the mentally and emotionally fragile in the closet in our society, and as such we would rather forget and avoid the realities of their lives, that is until we or someone very close is in need of care.

    1. B, thank you for your comments on this issue. The vocation of staffing, nurses, in the NHS in Wales, is something that senior leadership are concerned about as staffing levels and recruiting new staff (who have a vocation to provide holistic, person centred care) is very challenging currently. In the 1970's in the UK, there was a strong move/emphasis away from "old institutions" and most of the old Victorian sanitoriums have been closed down. People are being cared for, far more now, in community environments, in their own homes, where possible, with the advent of "Crisis/Home Treatment Teams". In extreme or acute cases, where someone needs more specialist care, another push in the 1980's saw people being cared for in general hospital environments in specialist wards. Currently, we see in many areas, purpose build community units newly being built which provide specialist services such as occupational therapy, recovery based services, modern support facilities with multi-disciplinary teams, where people have their own rooms/bathrooms and which cater for the needs of people with complex needs. Your final point around "stigma", still remains a painful issue for people diagnosed with mental "illness". Whilst programmes exist (such as celebrities speaking about their lived experience), eradicating perceptions and judgements of people diagnosed with mental distress remains a crucial need.