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A framework for decision on restraint

In this chapter, we'll consider five practical steps that could help when making decisions about risk and restraint.

Some difficult situations demand an immediate decision about restraint. But most develop over a longer period of time - perhaps days or weeks, even months.

At some point, a decision needs to be made about the use of restraint.

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A framework for decision on restraint

For the difficult situations that develop over a long period of time, using the five-step framework below will help you make an informed decision. Each stage should be considered in turn, but sometimes it will be necessary to go back and revisit an earlier stage if a situation changes.

Click on each step to find out more.

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A framework for decision on restraint

Observe

In this first step of the framework, we focus on observing the difficult situations that may prompt the need for restraint.

You will need to spend time as a staff group, manager included, thinking about the following questions:

  • What is the resident saying in the difficult situations, and what do they look like?
  • What are they doing?
  • What are the staff saying?
  • When is it happening?
  • Who is it a problem for?
  • Is anyone else involved or present?

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A framework for decision on restraint

Do some detective work

In this second step you will need to talk to the resident, to family and to staff and try to find out:

  • What might the behaviour mean? (Could the explanation lie in a clue from the person's past? Could it be related to a physical problem which the person cannot express, such as pain?)
  • What risks are associated with the behaviour?
  • Who is it risky for?
  • Who else should be consulted? Is specialist input available, say from a community mental health team?
  • What is the legal position in this situation?

The Newcastle Challenging Behaviour Service (a service for older people with mental health problems in care homes) say that professionals need to take on the role of a detective in difficult situations and to consider a range of explanations - some obvious, some not so (for more on this, see James and Stephenson, 2006).

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A framework for decision on restraint

Consider the options and make a decision

Hopefully, the background work will pay off and a solution, or possible solutions, will become clear. There are so many alternatives to restraint - and now is the time to consider them. At this point, think about the following:

  • What are some options for how we could respond?
  • What works to help this person? When are they happiest?
  • Which is the least restrictive option if restraint is needed?

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A framework for decision on restraint

Implement the plan

If the decision has been well thought through, with good reasons, and is supported by most (if not all) involved, all that remains is to implement it: see what difference it makes. First, agree on these points:

  • How long should the team continue the approach before it is reviewed: a week, a month?
  • What record should be kept of the actions taken?

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A framework for decision on restraint

Monitor and review the plan

At the point of review, consider the following:

  • Has the intervention helped?
  • Who has it helped?
  • What does everyone think?
  • Are any changes needed or do you need to try something else?

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A framework for decision on restraint

We are now going to consider a situation involving a man called Reg and see how this framework might help us to better understand Reg's needs. Click below to find out more about Reg and his situation from Mary, the care home manager, at the home where Reg is a resident.

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A framework for decision on restraint

Introducting Reg

Hi. My name is Mary and I'm the manager of Elm Tree Lodge care home.

Reg is an outgoing 81-year-old widower who has lived at Elm Tree Lodge for two months. Prior to this, Reg was living independently until he had a series of falls.

He had a stroke ten years ago, which affected his walking and he now relies on a walking frame. He was diagnosed with Alzheimer's three years ago and has noticed his hearing is getting worse.

Reg doesn't have many visitors, and although his daughter, Irene, visits weekly she finds these times difficult.

Reg used to run several betting shops locally and was well known in the area. He enjoys watching horse racing on television and listening to music on the radio.

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A framework for decision on restraint

The situation

At first the placement seemed to go well, but over the past few weeks Reg has become increasingly agitated and distressed. We have found him urinating in corridors, the dining room and other residents' bedrooms.

When we find Reg, he is angry and refuses to move away from the room or to change his clothing for some time. He shakes his fists and swears. Other residents are becoming very upset about Reg's behaviour and have started being aggressive towards him. No one wants to sit beside him at mealtimes either so these have become more awkward for Reg too.

I have also noticed that he is no longer joining in any activities. The staff seem wary and tense with Reg, and fear he will hit them at one of these times. We need to think carefully now and make some decisions about what to do if this does happen and we need to restrain him.

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A framework for decision on restraint

Step 1 - Observe

Transcript

Mary

The incidents are happening mainly in the morning and only occasionally in the afternoon.

When staff first discover Reg he looks frightened for a moment but then he looks angry and fierce. He almost always swears a lot, telling staff to **** off and to leave him alone. This usually draws a crowd which doesn’t help ease the situation

Most of the staff react to this with fear and annoyance in their voices. They often start by saying things like, 'Oh no... What have you gone and done here to Bessie's room? What are we doing to do with you?'. They are beginning to think that it's an impossible situation and that Reg will have to leave here.

It is really becoming a problem for Reg but also for other residents and staff. His daughter also finds it difficult and says that she doesn't recognise her Dad anymore.

Only one member of staff, Rosie, has had any success in handling the situations without Reg becoming distressed.

Over to you

  • Firstly we need to observe the situation. Thinking about Reg and what you have read so far, what information do you think might be important at this stage? Use the notepad to make some notes.

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A framework for decision on restraint

Step 2 - Do some detective work

Transcript

Mary

We all sat down together to think through the situation. It seemed that Reg's difficulties were linked to him struggling to manage his toileting needs.

Rosie and I met with Reg's daughter and she explained that "My dad was always a very dignified man. He's probably feeling embarrassed and exposed living here, and he'll be feeling strange being the outsider as he was always the life of the party. I think he’s having problems adjusting to his new environment.

This helped us realise that when a problem arises, Reg doesn't want to admit it and lashes out. What he's really saying is that he just wants to be left alone and doesn't need us interfering.

This means that there are two main risks: that Reg is physically violent towards a staff member or another resident when confronted, and that he or another resident falls during one of these episodes. If a situation arises suddenly where Reg goes to strike someone, we have agreed that it would be reasonable to try and prevent this by physically restraining him. We would then need to try to find other less restrictive solutions to the problem.

We also need to arrange for Reg's physical health to be investigated thoroughly by a GP and possibly a specialist: there may be something physical behind these problems. The local incontinence advisory service may be able to assist.

After discussing the situation with the staff, I noticed that they were looking at Reg more kindly and saying things like “He is obviously a man in difficulty. We need to help him tackle this toilet problem (the sooner the better) and to find his way around here too.

Over to you

  • Now you know a bit more, what information might be useful for your detective work? Use the notepad to make some notes.

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A framework for decision on restraint

Step 3 - Consider the options and make a decision

Over to you

  • Spend some time finding out more about what Reg's needs are now, by clicking on the boxes opposite. Using this and the other information gathered so far, can you think of some ideas for what you might do to try to improve the situation? Use the notepad to make some notes.

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A framework for decision on restraint

Step 3 - Consider the options and make a decision

When's Reg happiest?

Reg is at his happiest when he is watching the horse-racing on the television. Is there a big meet coming up? Could the home make a special event of an upcoming race day, such as the Grand National? Reg could be invited to be special guest for this event, explaining the world of horse-racing to those not 'in the know'. This could help him feel more a part of the home community, and to feel special rather than a burden. His daughter could be invited too.

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A framework for decision on restraint

Step 3 - Consider the options and make a decision

Least restrictive options

The least restrictive options are to respond as calmly and sensitively as possible when distressing situations arise, and to only use physical restraint if Reg continues to be very distressed, and clearly at risk of hurting himself or others. The goals now are to support Reg to become more oriented within the home, and to help Reg better manage his toileting independently.

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A framework for decision on restraint

Step 3 - Consider the options and make a decision

What works for Reg?

Rosie has a very calm approach. She's worked with a resident in a similar situation some years ago, she remembers that it was a temporary thing, and that it really helped to not blame them or expect them to be able to do something which clearly they were struggling with - this only inflames the situation. Rosie speaks clearly and sensitively, and conveys with her words and tone that she is not making a fuss and won't be telling the world what has happened. Reg feels safe in her hands, as though they have an understanding; she helps sort him out and, with her, he accepts assistance.

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A framework for decision on restraint

Step 3 - Consider the options and make a decision

What are the staff, family and Reg saying?

What Reg is saying at this point: "I don't know what all the fuss is about. I can sort myself out. This place doesn't quite add up to me though."

What staff are saying at this point: "We've come up with quite a few different ideas to try. We'll just have to wait and see whether they work."

What family are saying at this point: "I so hope this place works out for dad. I don't know how I'd cope if we had to find somewhere else.

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A framework for decision on restraint

Step 3 - Consider the options and make a decision

Some ideas to try.

  1. Interestingly, the problems are taking place much more in the morning - when staff are at their busiest and least able to follow Reg's movements. For an agreed period of time one more staff member will work part of the morning shift, to attend more closely to Reg and to offer more regular assistance with going to the toilet.
  2. One staff member, Rosie, is managing the situation with Reg with reasonable success. If possible, schedule her to work on morning shifts for a two-week period, and review how things are going. Rosie to lead on sharing her approach with other staff and asking them to follow this same approach.
  3. Agree that only one, and if absolutely necessary, two staff will intervene in the difficult situations. Direct other residents away.
  4. Try to work on better involving Reg in mealtimes and activities, particularly morning activities, and any that involve music. His exclusion is only making matters worse.
  5. Review signage, particularly for toilets, within the home - could this be improved? Is there some way of making Reg's room more obvious to him - for example, several large photographs of him and his family on the door?
  6. Refer to GP with a view to specialist input if necessary, and then incontinence service if appropriate.

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A framework for decision on restraint

Step 4: Implementing the plan.

Transcript

Mary

We decided to try all six ideas to improve the situation. We were able to try some within 1 or 2 weeks, but others took longer to plan.

We also decided to keep a record of the things we were trying in a special diary. I thought this would help us to monitor Reg's situation carefully, as well as make sure that everyone in the team could find this information easily during a shift.

Just talking about it and planning what to try seemed to make everyone feel more positive. The staff seemed to believe that they could provide the help Reg needed to settle in, and he was saying 'Some of the girls here, they're alright you know'. Reg's daughter seemed so relieved, and said she felt we had taken on board the things she had said and hoped that it would make a difference for her Dad.

Over to you

  • Using the ideas from the last step and your own thoughts, how would you ensure the plan was implemented effectively?

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A framework for decision on restraint

Step 5: Monitoring and reviewing the plan.

The team had agreed to review the situation at 2 weeks, 4 weeks, and again at 6 weeks. Explore the timeline below to find out more

Over to you

  • Using what you know so far, how would you monitor the plan over the next 6 weeks?

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A framework for decision on restraint

Step 5: Monitoring and reviewing the plan.

Two weeks

After two weeks we held a review, and Rosie told us how things had been going: there had been three further incidents, but this was definitely fewer than before, and they all occurred at the weekend. I asked Rosie if she would work a weekend shift, to spend time talking with staff then about the best approach for working with Reg and how to respond when he becomes distressed. The GP had seen Reg and decided, based on staff reports, that he'd prefer to wait to see how things progressed before referring Reg for further specialist intervention. Staff also explained that they are spending time with Reg, showing him around the home and helping him learn where things are. This seemed to have made a big difference.

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A framework for decision on restraint

Step 5: Monitoring and reviewing the plan.

Four weeks

At the 4-week review, Reg's situation seemed so much better. He was getting more involved in music sessions each week, and had become friends with another resident, Bill, who used to visit his betting shop. They now share all their meals at the same table. One of the photos on Reg's door prompted Bill's daughter to make the connection.

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A framework for decision on restraint

Step 5: Monitoring and reviewing the plan.

Six weeks

The 6-week review followed our Grand National celebrations, and Reg was the star of the show. We were all so pleased that his situation had improved, and that we had not needed to restrain him.

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A framework for decision on restraint

You've seen how each stage of the framework related to Reg's situation. Read the video transcirpt below to find out how his situation improved.

Transcript

Mary

I think that all the interventions have played a part in improving the situation, although it turns out there was probably no medical reason for Reg's difficulties. We were able to end the extra staffing for morning shifts after a month. Some residents are still wary of Reg, but generally everyone has benefitted from the changes. Reg quite likes being here now and knows there are people available to help him if he needs them. The staff feel that their hard work has been worthwhile, and have found that Reg is a very interesting man.

And Reg's family are so pleased, particularly after the Grand National party. His daughter said to me 'Dad just seemed to feel so much happier here, so much more himself. Like he was understood.' And that's true.

Finding out more about Reg, his personality and interests, and helping him link with other residents better is now our main focus.

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A framework for decision on restraint

You've now worked your way through the five-step framework. Do you think this could help in your care home's decision making processes, particularly in relation to restraint?

If you'd like to read more about this type of approach, read our resources section for some suggested reading.