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“It is more the case of our being a model to others, than of our imitating anyone else” Pericles |
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Is doing nothing an option?
By Gerard O’Dea
Physical restraint – Gaining clarity on an emotive issue
Working with vulnerable groups in society is an extremely demanding and complex task, more so because those delivering services to such groups have a range of policy, legislative and practice issues to balance up when making day to day decisions, sometimes with little or no margin for error.
Legislation, policy and practice around the use of physical intervention are perhaps some of the most challenging issues faced by managers and front line staff. Often we try to avoid having a discussion about these things, preferring to cross that particular bridge when we have to.
Clearly this is not safe practice and indeed by not adequately preparing for the possibility of using physical intervention we might be leaving ourselves open to accusations of failing to exercise our duty of care, not only to service users but equally to our staff and colleagues.
Although this may feel uncomfortable for some, the legislative and regulatory context within which health and social service professionals (and others) have to work necessitates that agencies have in place suitable training and policies relating to physical intervention.
For example, where the potential exists for violence and aggression within the work environment, agencies must ensure suitable risk assessments are carried out and that staff are trained in the management of such circumstances which may include the use of physical restraint.
Over recent years, we have greatly improved our understanding of the causes and management of challenging behaviour and there are some excellent training material and courses devoted to resolving conflict within the work setting. We know that much of the conflict that arises can be dealt with quickly and effectively by using some basic techniques and being sensitive to needs of those involved.
However, there are times when the situation is outwith the normal approaches, when certain factors combine to produce a flash point and physical restraint may be needed to protect the aggressor and or those around him or her from serious injury or harm.
Imagine for a moment that you or a colleague witnessed a child or vulnerable adult being punched and kicked by someone stronger, or perhaps that a colleague is being assaulted.
What would you expect of yourself or a colleague in those circumstances? Now think about what the parents or other family members of the person being attacked would expect? What might the parent or family of the perpetrator expect from you? And, what would the law expect of you?
Of course, these would be exceptional circumstances for most of us but they are circumstances that could potentially arise at any time over the course of a working week. Is doing nothing an option?
Incredibly, there are some organisations that seem to think so. Some teams don’t have a physical restraint or intervention policy in their organisation. Sometimes they cite ethical or professional reasons, sometimes they claim that they never experience violence or aggression from service users and so have no cause for a policy, which is a bit like saying ”we don’t have fires around here and we don’t like the idea of ever having a fire, so we have a no-fires policy”. But what if a fire broke out? Would their staff know how to keep themselves and their clients safe?
“What isn’t measured, isn’t managed” Top of Page
Most organisations that claim to have a “no restraint” policy do in fact use such measures when the need arises, but what this tells us is that the practice within such organisations is neither approved nor managed properly and therefore the risks to staff and service users alike are greater. The increased risks associated with these kinds of informal restraint policies and practices include serious injury, a culture of fear, disharmony within teams, and personal and organisational liability.
Being confronted by serious violence or threats of violence and or self harm provokes a tremendous amount of anxiety and indecision - How to respond? What is appropriate? What is allowed? What is to be avoided? This is why it is important to have a clear policy on physical restraint and intervention and a staff training strategy that is meaningful and reflects the legal context within which the organisation has to operate.
Reasonable force Top of Page
“In exceptional circumstances, where avoidance and resolution strategies fail, workers may have to use physical force in response to a situation. Workers have the fundamental right to use 'reasonable force’; however individual interpretations vary widely and are not always accurate, which can increase personal and organisational risk. So, what really is 'reasonable force?’”- Protecting Scottish Public Service Workers, Feb 2008
There may be particular scenarios in which physical intervention to control high-risk behaviour might be necessary and those dealing with such behaviour need to feel supported to make decisions with confidence.
Within the legal context, the use of force must be ‘reasonable in the circumstances’. The following scenarios are typical ones which would indicate the possible need for physical restraint:
In all these situations, the use of force to control a client’s behaviour would still have to be governed by sound ‘use of force’ legal and ethical principles.
Deciding to use physical force on a person without a lawful reason might lead to serious criminal and or professional liability. Equally, deciding not to intervene when an intervention is indicated can possibly be viewed as a failure in terms of the duty of care owed to those involved and might contravene Human Rights legislation. It is in this area where the need for training is most critical.
Training
Effective training on physical restraint and “safe holding” must develop good judgment as well as knowledge and skill and any programme must include the following components:
The field of restraint training is continually evolving and there is greater professionalism and standardisation of approaches. However, some training providers are being left behind by advances in legislation, guidance and technical progress. For example, the once-taught ‘basket-holds’ are now accepted as being highly dangerous and inappropriate, and yet they are still found in some instructional content today.
The issue of professional competence is hugely important when choosing a training provider. Commissioning agencies need to feel secure in the knowledge that trainers are well insured, have the relevant qualifications, and are committed to continuous professional development.
The training should be documented and risk-assessed and the trainers should have current qualifications in their field, so you know you are receiving training which is up-to-date with best-practice
The educational content of the programme should be quality-assured by a nationally recognised awarding agency, and the technical methods being taught must be approved by a professional governing body for this type of practice. In this way, the risk of injury is minimised and manual handling considerations are addressed effectively.
Without these checks in place, commissioning agencies could ironically be increasing their risk and liability.
Trainers should also understand the unique challenges facing public service workers and the values, principles, and ideals which underpin pubic service more generally.
Effective physical intervention strategies are part of a holistic approach to the care management of vulnerable people. Physical intervention is only used when there is absolutely no alternative and when other approaches have been discounted as inappropriate. Even then, the emphasis is on “caring control” and the response must be strictly proportional to the circumstances.
Good policies and training in physical intervention will always be congruent with a wider care management ethos, will have a strong legislative component, foster sound judgment and enable trainees to respond appropriately to a range of situations they might encounter.
At the end of the day, commissioning agencies need to satisfy themselves that the training is of a high standard and meets the requirements of their operations. For this reason, it is imperative that they carry out due-diligence with the training provider they are considering.
Ignorance - The biggest risk! Top of Page
Not knowing the correct methods for using physical restraint can be every bit as damaging as doing nothing. Allegations of physical or sexual assault are not uncommon during restraint interventions and of course there have been a number of high profile fatalities linked to positional asphyxia, for example. For the most part these can be traced to poor staff training or the use of outdated and high-risk methods of restraint.
As Martin Fletcher, Chief Executive of the National Patient Safety Agency points out in the Royal College of Nursing Guidance,” if staff don’t have a clear understanding of the circumstances where restraint is justified or positively required, they won’t be able to recognise the circumstances where restraint is wrong or abusive.”
Wherever your staff might potentially need to physically intervene in a situation, they should feel confident that they know when, how and why restraint is appropriate.
Gerard O‘Dea Director, dynamis insight, Edinburgh
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