Restraint can cause both physical and psychological harm to patients and staff. As a result the government has published new guidance to reduce the use of this outdated practice in all health and adult care settings and is investing £1.2 million in staff training so they can avoid using restrictive interventions.
The new guidance comes after a government investigation into the Winterbourne View Hospital found restraint being used to abuse patients. A similar study by Mind also found that restrictive interventions were being used for too long, often not as a last resort and even to inflict pain, humiliate or punish.
The new programme, called Positive and Safe, will support staff to avoid the use of all restrictive interventions, which include physical, chemical, medical and mechanical restraint and seclusion.
Care and Support Minister, Norman Lamb, said:
No-one should ever come to harm in the health or care system. Although it is sometimes necessary to use restraint to stop someone hurting themselves or others, the safety of patients must always come first.
This new guidance will stop inappropriate use of all types of restraint, reduce this outdated practice and help staff to keep patients safe.
The new guidance forms part of a two-year strategy to overhaul the outdated use of restrictive interventions – such as face-down restraint, seclusion and rapid sedation – in all health and care services.
The new guidance on the use of face-down restraint and other restrictive interventions has been developed jointly by health and care professionals and people who use services, and led by the Royal College of Nursing. It will make sure staff are given the best possible information and support, enabling them to give high quality care whilst also keeping themselves safe.
Paul Farmer, Chief Executive of Mind, said:
We are delighted to support the launch of this important guidance, which marks a significant step towards changing attitudes to restraint and ending face-down restraint.
We know that healthcare staff do a challenging job and sometimes need to make difficult decisions very quickly. This is comprehensive guidance that looks to address the system as a whole, transforming cultures and attitudes so that difficult situations are less likely to arise and so that staff are supported to use alternatives to restraint when faced with challenging behaviour.
When someone is in a mental health crisis they need help, not harm. Physical restraint can be humiliating, dangerous and even life-threatening and our own research indicates that some trusts are currently using it too quickly. We look forward to seeing this guidance implemented in health and social care services across England for the benefit of all people with mental health problems and the frontline staff who support them through crisis.
The guidance recognises there might be a rare occasion where staff need to restrain people – for example, to stop someone from harming themselves or others – but this new guidance will ensure this is only used as a last resort and for the shortest time possible.
Dr Peter Carter, Chief Executive of the Royal College of Nursing said:
Nobody wants to see a repetition of the horrific events of Winterbourne View. Nurses have been at the forefront of developing the new approach, which is the result of committed co-operation between professionals, and which makes use of the views of those who have experienced physical intervention.
This moment is a major step forward in making difficult situations more manageable, and it is at the heart of compassionate care. The Government’s resolve in bringing about this change is to be applauded and the RCN will be working with them to make this approach a reality for all vulnerable people.
Positive and Safe includes guidance and workforce training plans to create more compassionate health and care settings where people are supported to manage their behaviour in therapeutic environments, so they do not become distressed to the point of needing to be restrained. However, where restraint is absolutely necessary, staff will have the skills and tools to use restrictive interventions safely and in a way that minimises distress.
Notes to editors
About restrictive interventions
Face-down restraint - or prone restraint, is when someone is pinned on a surface and is physically prevented from moving out of this position.
There are concerns that face down, or prone, restraint can result in dangerous compression of the chest and airways and put the person being restrained at risk.
Physical restraint - refers to: ‘any direct contact where the intervener’s intention is to prevent, restrict or subdue movement of the body, or part of the body of another person.’
Mechanical restraint - is defined as: ‘the use of a device to prevent, restrict or subdue movement of a person’s body, or part of the body, for the primary purpose of behavioural control’.
Chemical restraint - is defined as: ‘The use of medication which is prescribed, and administered for the purpose of controlling or subduing disturbed/violent behaviour, where it is not prescribed for the treatment of a formally identified physical or mental illness’.
Seclusion - is defined as: ‘the unplanned, supervised confinement and isolation of a person, away from other patients, in an area which the person is prevented from leaving, through the direct actions of members of staff’.
In 2012 the Department of Health published Transforming Care: A national response to Winterbourne View Hospital. This outlined key actions in response to the abuse and illegal practices witnessed at Winterbourne View Hospital as well as concerns that emerged from the subsequent Care Quality Commission (CQC) inspection of nearly 150 learning disability in-patient services.
CQC inspections found evidence of uncertainty amongst providers regarding the use of restrictive physical interventions, with some services having an over-reliance on the use of ‘restraint’ rather than more proactive approaches such as Positive Behavioural Support (PBS).
About Positive and Safe
Positive and Safe is a two-year programme that incorporates two key pieces of guidance: Positive and Proactive Care and A Positive and Proactive Workforce. These are foundational pieces of guidance that will be built on to bring about changes in leadership and workforce.
The Royal College of Nursing led on reviewing, consulting and developing the new Positive and Proactive Care guidance. The process involved a range of stakeholders and professionals. It received over 400 responses with 95% supportive of the proposed approach.
Skills for Care and Skills for Health produced guidance in A Positive and Proactive Workforce to support the commissioning of training and development of staff in both positive behaviour support and reducing the use of restrictive interventions.
Other related documents have been produced by NHS Protect and the Joint Improvement Partnership. The review of the Mental Health Act Code of Practice this year is also relevant to this work, as are clinical guidelines being developed in the next 12 months by NICE.