Reducing the inappropriate use of restrictive interventions Professor Alan Glasper discusses a new Government initiative to reduce the use of restrictive interventions in health and care settings. Such interventions can place service users—and, to a lesser degree, staff and those who provide support—at risk of physical and emotional harm

What is restraint and why is it necessary? Restraints or restraint in healthcare settings are interventions that limit a patient’s movement. Restraints can help keep patients from harming themselves or anyone else, including their caregivers, but should only be used as a last resort. MedlinePlus, which is part of the US National Library of Medicine, suggests that there are a range of interventions that have been used to restrict patient activity (MedlinePlus, 2014), such as: ■■ Where a caregiver holds a patient in a way that restricts their movement ■■ Giving medicines to a patient against their will to restrict their movement ■■ Placing a patient alone in a room or area that they cannot leave on their own ■■ To control or prevent harmful behaviour ■■ In patients who are confused and might scratch their skin, remove catheters and tubes, get out of bed, fall and hurt themselves, or harm other people. Restraints should never cause harm or be used as punishment. Healthcare providers

438

should first try other methods to control a patient and keep them safe.

Growing concerns Increasing concerns about the inappropriate use of restrictive interventions across health and care settings have led the Department of Health to issue this new guidance. A previous publication, Transforming care: A national response to Winterbourne View Hospital (DH, 2012), highlighted the criminal abuse perpetuated on vulnerable people with learning difficulties by care staff. Certain members of staff at Winterbourne View Hospital, whose job it was to care for and help people, routinely mistreated and abused them instead. Regretfully, the management system in place allowed a culture of abuse to flourish and warning signs were not picked up or acted on by health or local authorities. Furthermore, concerns raised by a whistle-blower went unheeded and it took a television documentary to expose fully the failings in the system. The charity MIND has revealed that there is wide variation in the use of physical restraint, with one NHS trust reporting more than 3000 incidents in one year alone. Its report, Mental health crisis care: physical restraint in crisis (MIND, 2013), has also been pivotal in raising awareness of the use of restraint in care settings. Face-down restraint—pinning a client facedown on the floor—is perceived by MIND to be dangerous and can be life-threatening. Since their report, some NHS trusts have abandoned face-down restraint altogether.

The aim of the new guidance The primary aim of this new guidance (DH, 2014) is to provide a framework within which adult health and social care services can develop a culture where restrictive interventions are only ever used as a last resort, and only then for the shortest possible time. The guidance suggests important actions that will better meet people’s needs and enhance their quality of life, reducing the need for restrictive interventions. It also sets out mechanisms

to ensure accountability for making these improvements, including effective governance, transparency and monitoring. This is part of a series of measures that the Government intends to make, to end the unnecessary use of restrictive interventions across all health and adult social care. It is essential that all those responsible for and working in health and social care services, where people who are known to be at risk of being restrained, read this guidance and use it to change the way they deliver services. These include services for: ■■ People with mental health conditions, including detained patients ■■ People with autistic spectrum conditions ■■ People with learning disabilities ■■ People with dementia ■■ People with personality disorders ■■ Older people. It is important to stress that this guidance also applies to all adult health and social care settings where people using services may occasionally present with challenging behaviour. These settings may include care homes where individuals employ their own support staff, and primary, community and secondary care settings. The use of physical restraint in elderly patients in care settings is especially concerning. Bradas et al (2011) believe that the involuntary use of physical restraints such as bed rails can result in injury and exacerbate delirium.

Protecting service users—and staff The new Department of Health guidance applies equally to health and social care staff working in non-health settings, such as police cells, immigration removal centres, and prisons. A range of actions have been detailed, which are designed to ensure that people’s quality of life is enhanced and that their needs are better met. They also aim to reduce the need for restrictive interventions and to ensure that staff and those who provide support are also protected from harm. This is necessary, as there are many instances where NHS staff have been harmed in the pursuit of their caring duties .For example, five members of nursing staff required

© 2014 MA Healthcare Ltd

N

urses use physical restraint as an aspect of patient care in a variety of clinical settings to prevent, for example, agitated patients from prematurely disrupting therapy devices such as catheters (Amato et al, 2006). However, disquiet at the use of physical restraint in some settings prompted the Department of Health (DH, 2014) to publish guidance on reducing the use of restrictive practices in client settings. This guidance, Positive and Proactive Care: reducing the need for restrictive interventions, has been developed for staff working in NHS or local authority health and social care settings. It is known that people who exhibit challenging behaviour in health and social care settings are at higher risk of being subjected to restrictive interventions. Many of these interventions place these service users, and the staff involved in delivering them, at risk of physical or emotional harm.

British Journal of Nursing, 2014, Vol 23, No 8

British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 26, 2015. For personal use only. No other uses without permission. . All rights reserved.

HEALTHCARE POLICY emergency treatment for serious injuries after being attacked by a hospital patient (Mail Online, 2014). In this case, the patient became agitated and violent while being cared for in a hospital and absconded from one ward to another where he began attacking staff who tried to take him back to his bed.

Key guidance actions The new guidance suggests a range of actions that nurses and other carers can take to mitigate the use of restraint in patient populations:

Improving care ■■ Staff

must not deliberately restrain people in a way that has an impact on their airway, breathing or circulation, such as face-down restraint on any surface, not just on the floor ■■ If restrictive intervention is used, it must not include the deliberate application of pain ■■ If a restrictive intervention has to be used, it must always represent the least restrictive option to meet the immediate need ■■ Staff must not use seclusion other than for people detained under the Mental Health Act 1983. (Note: during a hospital inspection, the Care Quality Commission (CQC) will always seek evidence that deprivation of liberty has not been applied inappropriately in patient care) ■■ People who use services, families and carers must be involved in planning, reviewing and evaluating all aspects of care and support. This is part of the Government’s mantra for the health service: ‘No decision about me without me’ ■■ Individualised support plans, incorporating behaviour support plans,must be implemented for all those who use services and are known to be at risk of restrictive interventions. Children, young people and adults who have autism spectrum disorders can be prone to exhibiting challenging behaviour in care settings. Grant (2014) has developed specific ‘do’s and don’ts’ guidance on communicating with people who have these disorders to help nurses and other carers adopt strategies that reduce the need for restriction by improving communication. For example, ‘Do not initiate physical contact without first warning them or explaining what you plan to do’.

Leadership, assurance, accountability © 2014 MA Healthcare Ltd

■■ A

board level (or equivalent) lead must be identified for increasing the use of recovery-based approaches, including, where appropriate, positive behavioural support planning and reduction of restrictive interventions.

British Journal of Nursing, 2014, Vol 23, No 8

■■ Boards

must maintain and be accountable for overarching restrictive-intervention reduction programmes ■■ Executive boards (or equivalent) must approve the increased behavioural support planning and restrictive-intervention reduction to be taught to their staff. Ensuring that the care workforce has the right skills, knowledge and experience to work alongside people who may challenge is an important part of any model of care and support. Skills for Care (2013) has produced a guide for workforce development to address people who may challenge ■■ Governance structures and transparent polices around the use of restrictive interventions must be established by provider organisations. Providers must also have clear local policy requirements and ensure that these are available and accessible to service users and carers ■■ Providers must report on the use of restrictive interventions to service commissioners, who will monitor and act in the event of concerns ■■ Boards must receive and develop action plans in response to an annual audit of behaviour support plans ■■ Post-incident reviews and debriefs must be planned so that lessons are learned when incidents occur in which restrictive interventions had to be used.

Transparency ■■ Providers

must ensure that internal audit programmes include reviews of the quality, design and application of behaviour-support plans, or their equivalents. ■■ Accurate internal data must be gathered, aggregated and published by providers, including progress against restrictiveintervention reduction programmes, and details of training and development in annual quality accounts or equivalent ■■ Service commissioners must be informed by

providers about restrictive interventions used for those for whom they have responsibility ■■ Accurate internal data must be gathered, aggregated and reported by providers through mandatory reporting mechanisms where these apply—for example, the National Reporting and Learning Service (NRLS) and National Mental Health Minimum Data Set (NMHMDS).

Monitoring and oversight ■■ CQC’s

monitoring and inspection against compliance with the regulation on use of restraint and its ratings of providers will be informed by this guidance ■■ CQC will review organisational progress against restrictive-intervention reduction programmes ■■ CQC will scrutinise the quality of behaviour support plans, which include the use of restrictive interventions.

Conclusion The use of physical restraint should only be used as a last resort in care environments. The Government is determined to reduce the use of BJN physical restraint in all care settings. Amato S, Salter JP, Mion LC (2006) Physical restraint reduction in the acute rehabilitation setting: a quality improvement study. Rehabil Nurs 31(6): 235–41 Bradas CM, Sandhu SK, Mion LC (2011) Physical restraints and side rails in acute and critical care settings. In: Boltz M, Capezuti E, Fulmer TT, Zwicker D, OMeara A, eds. Evidence-Based Geriatric Nursing Protocols for Best Practice. 4th edn. Springer, New York Department of Health (2012) Transforming care: A national response to Winterbourne View Hospital. DH, London Department of Health (2014) Positive and Proactive Care: reducing the need for restrictive interventions. DH, London Grant J (2014) Improving the experience of people with Autism Spectrum Disorder in health care settings. http://tinyurl. com/m9nwypc (accessed 10 April 2014_ Mail Online (2014) Five nurses injured by patient. http:// tinyurl.com/prob42v (accessed 10 April 2014) MedlinePlus (2014) Use of restraints. http://www.nlm.nih. gov/medlineplus/ency/patientinstructions/000450.htm (last accessed 10 April 2014) MIND (2013) Mental health crisis care: physical restraint in crisis. MIND, London Skills for Care (2013) Supporting staff working with people who challenge services. Skills for Care, London

KEY POINTS n Disquiet at the use of physical restraint in some settings prompted the Department of Health in April 2014 to publish guidance on reducing the use of restrictive practices in client settings n People who exhibit challenging behaviour in health and social care settings are at higher risk of being subjected to restrictive interventions n The Government is determined that health and social care services develop a culture in which restrictive interventions are only ever used as a last resort n It is important to ensure that nursing staff and those who provide support are also protected from harm

439

British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 26, 2015. For personal use only. No other uses without permission. . All rights reserved.

Reducing the inappropriate use of restrictive interventions.

Reducing the inappropriate use of restrictive interventions. - PDF Download Free
940KB Sizes 3 Downloads 4 Views