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Your ideas about restraint

This chapter will give you an opportunity to reflect on your own experience and practice of restraint in your work setting.

Some care staff say that they never practise restraint - that it is always wrong under any circumstances. Others say it can be vital, for the resident and themselves. Others don't recognise when they are using restraint.

Some organisations have a clear policy on the use of restraint. Others have none.

What is your experience?

Do you know if your organisation has a policy on restraint?

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Your ideas about restraint

Experiences from the past

SCIE conducted a practice survey on restraint (2009) to find out more about good practice on restraint. As part of this we asked experienced care staff to share with us their memories of how restraint has been used, or changed, over the years.

Read below about staff experiences of restraint in the past.

"Each resident's room was marked with a green or red sticker and the culture of the home at night was to ignore calls bells from the rooms marked with red stickers - [the thinking was that] staff would be run off their feet otherwise."

"It was not unusual for people be fed breakfast while sitting on the commode."

"I remember transferring residents into chairs and putting the frames away from them. That would be bad practice now."

"Catheter bags were strapped to the leg or bed and impeded movement. Anyone who was incontinent was automatically catheterised."

"I think restraint happens less now because there has been so much publicity [about it]."

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Your ideas about restraint

Experiences from the past

As these quotes from staff have shown, care practices have changed a lot over the years. A number of practices that would have been seen as reasonable and proper many years ago are now no longer acceptable. This is particularly true when it comes to ideas about restraint.

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Your ideas about restraint

Let's think a bit more about your views on what restraint means in practice in care homes today.

Look at the following pieces of equipment or care practices. Click on the ones you think are an example of restaint.

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Your ideas about restraint

Bedrails

They are all forms of restraint.

If bedrails are used to reduce the risk of residents accidentally slipping, sliding, falling or rolling out of bed, they are not classed as restraint (see NPSA 2007). If bedrails are used for any other purpose - say, to discourage a resident from getting up independently - this would be viewed as restraint. While evidence suggests that bedrails can prevent falls, using them incorrectly can be potentially dangerous, even leading to death (NPSA 2007). The most important thing is to complete a risk assessment based on an individual's needs, and to do a thorough review of the combination of equipment used (grab handles, bed, mattress, bedrails). For guidance on this, see MHRA (2006) and (2007).

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Your ideas about restraint

Keypads for doors

They are all forms of restraint.

If a resident can't recall the keypad code and is therefore locked in, this is a form of restraint. All parties may decide that this is an acceptable restraint, for example, on a front door to a busy street, but not appropriate on a door to the home's back garden. The keypad may also be restricting for all residents, but only be required for a smaller number. Keypads may be used in many places in the home, when actually they are only needed on the front door.

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Your ideas about restraint

Electronic tagging

They are all forms of restraint.

Some say this gives people with dementia a greater quality of life, as they can walk out in the community independently with peace of mind for them and their care-givers. But in some instances, the tagging may lead to restraint: the person is coaxed into not leaving the home at all (perhaps because no one is available to respond if a problem arises outdoors), or a staff member gets involved to limit the person's activities in some way, for example, escorts the person away from the pub when they have gone there for a quick drink.

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Your ideas about restraint

Grabbing a resident's arm as they are about to strike another resident

They are all forms of restraint.

This is clearly a form of restraint. On the face of it, it seems an appropriate one, if it is really clear the resident is just about to strike another resident, and it is not possible to remove the other person. Most care staff will be stronger than residents, so staff need to be careful that their actions are in proportion to the situation. The vital thing is that staff review a situation like this at some point as soon as possible after it occurred: why did it happen, does it fit with any pattern or other presenting problems, and was there anything that could have been done to avoid the situation escalating to the point of assault?

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Your ideas about restraint

Deep-seated chairs

They are all forms of restraint.

For many residents who have trouble walking, deep-seated chairs can be difficult to get up out of, and onto, without help. For residents, having to wait for someone else's help every time you want to get up or down can be very limiting, and in this sense is a form of restraint, particularly if staff are not available when needed.

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Your ideas about restraint

Residents experiencing difficulty getting the attention of staff

They are all forms of restraint.

Sometimes it can seem that care home residents are happy enough minding their own business for long periods of time, and for some people this will be true. But many residents need closer levels of support due to their high levels of needs. By failing to observe and engage with residents, staff are then not able to recognise or respond to their needs - which means they are very likely to be indirectly restraining residents (for example, by not promoting walking, not helping with regular visits to the toilet, not being aware of whether anyone is becoming upset or agitated, and so on.)

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Your ideas about restraint

Antipsychotic medication

They are all forms of restraint.

The value of antipsychotic medication for people with dementia is increasingly being questioned (NICE/SCIE 2006). Except in very difficult situations, it is now thought that many people with dementia would be better off if they were not taking antipsychotic medication, which can make people more likely to fall and to be drowsy during the day time. This medication can be seen to be restraining people, and has been described by some as a 'chemical cosh'. Many other, less restricting ways of helping people should be tried before medication. If prescribed, antipsychotic medication should be reviewed regularly by a medical practitioner.

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Your ideas about restraint

Belts

They are all forms of restraint.

A belt might be used to stop a person from getting up out of a chair, if the person has difficulties with getting up or walking, or is making frequent, unsafe attempts to do so: this is a form of restraint and is not acceptable (see RCN 2008). It's possible that a person who can give consent indicates a preference to use a belt, but this is still a form of restraint.

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Your ideas about restraint

Changing a resident's dirty clothes when thy donot want to

They are all forms of restraint.

This is a form of restraint and is known as 'forced care'. It is difficult for care staff when a resident does not agree to personal care tasks that are thought to be necessary. These may range from refusing to wash or change dirty clothes to refusing medicine or treatment that has been prescribed. It is important to understand why the resident is refusing the care and to find ways of meeting these needs that may be more acceptable to them.

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Your ideas about restraint

No activities on the weekend

They are all forms of restraint.

In many care homes the atmosphere of the home is quieter at the weekends, when fewer staff are about and perhaps no scheduled activities are running. Some residents come to dread this time of the week, and find the days long and depressing. In its widest sense, this too can be seen as a form of restraint as residents are not being helped to meet their full range of needs. Perhaps they need support to go to the local church? Perhaps they need to be linked with other locals with their interests, for example, fellow football supporters?

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Your ideas about restraint

Potentially many things can be considered restraint.

Sometimes it can be the circumstances in which the restraint is used which makes it acceptable. In other circumstances, it may be unreasonable to use the same form of restraint.

An approach which works well for one resident may limit another, and it can be difficult to balance the needs of individuals.

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Your ideas about restraint

When restraint doesn't look like restraint

As you've seen by now, some examples of restraint are clear, but in other situations restraint can be less obvious.

Sometimes care staff may not even realise that they, the staff team or the care environment as a whole are restraining a resident.

Think of a typical home care setting:

A room with a set of high backed chairs, a television placed on the wall which is on continuously, a walking stick leaning up against a wall, a resident who has had their lunch whilst sitting in one of the chairs from a food tray. Member of staff busy at a computer terminal.

Click on the links below to assess if these are restraints or not.

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Your ideas about restraint

Dennis trying to get out of a chair

In each of these situations, the resident's ability to interact with the world around them is being held back, and in this sense they are passive forms of restraint.

Dennis needs help to go to the toilet, but with no help being offered from the staff member, he may become agitated and upset as he feels uncomfortable and helpless.

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Your ideas about restraint

Ron reaching for his walking stick

In each of these situations, the resident's ability to interact with the world around them is being held back, and in this sense they are passive forms of restraint.

Ron needs help to reach his walking frame: staff may (intentionally or otherwise) place a walking frame out of reach of the resident, making them effectively immobile.

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Your ideas about restraint

Hilda with a food tray across the front of her chair

In each of these situations, the resident's ability to interact with the world around them is being held back, and in this sense they are passive forms of restraint.

Hilda needs help to move the furniture: items placed in front of a resident may make it difficult for them to get up from the chair and this may cause distress.

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Your ideas about restraint

Marie is cupping her ear

In each of these situations, the resident's ability to interact with the world around them is being held back, and in this sense they are passive forms of restraint.

Marie needs help to be able to hear better: it would help if the television was off, and if her hearing aid was checked to make sure it's working. This will help her be able to communicate and socialise easily with others.

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Your ideas about restraint

Have you ever been invloved in a situation in which you had to restrain a resident or saw someone being restrained?

Would you expect to see restraint typically in care homes? How common is restraint anyway? To date, no comprehensive study has ever been done on this issue in the UK so we don't know how common it is. The Commission for Social Care Inspection's 2007 survey on restraint asked residents, relatives and professionals to report their experiences and ideas about restraint, but it was not possible to establish a clear picture of how many care homes use restraint.

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Your ideas about restraint

Do you think there are things about care home environments and practices that may make the use of restraint (including unintentional restraint) more likely?

Unintentional or passive restraint - when we limit someone's ability to engage with the world by our actions or failure to act - is a significant problem in care homes. A study by the Alzheimer's Society in 2007 found that the typical care home resident spent only two minutes interacting with staff or other residents over a six-hour period of observation, not counting time spent on care tasks. If care staff don't interact regularly with residents we miss important clues about their needs and situation. This can be considered unintentional restraint: if we don't talk with residents, we won't know what they need.

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Your ideas about restraint

Do you think you may ever have unintentionally restrained an individual?

Research is mounting for the effect of environments on, for example, people with dementia (see Dementia Services Development Centre 2007). Certain elements of the care environment - for example, clear signage and simple layouts - can help people better navigate their way around a care home. This can then support people to engage more easily in life at the home, and make them more likely to take part in activities and social interaction.

When care homes have problems keeping or properly supporting staff, this too can make restraint more likely. Inappropriate use of restraint is also more likely when staff are feeling pressured. If staff do not have time to properly record or reflect, care plans and individualised care suffer. Consistent teamwork, support and training are needed if staff are to work together with confidence to minimise restraint.