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….
