1. Chapter 38 CLINICAL HOLDING FOR CARE, TREATMENT OR INTERVENTIONS Philomena Morrow and Patricia McGuiness

2. Introduction This presentation will explore the individual assessment and planning of appropriate holding techniques for children, young people and vulnerable adults. It will also review professional, ethical and legal issues that require consideration in holding and restraining practices. Part 1 – Restraint and Immobilisation Part 2 – Parental Involvement and Support

3. Principles Please note that while the following principles are applicable to all in health and social care settings, the techniques may vary depending on the area of practice.

4. In each situation the following require consideration: Physical effects Psychological effects Ethical, legal and safety issues The justification in practice is that the use of restraint is in the child or vulnerable adult’s best interest. It is carried out to prevent them or others from suffering, or being likely to suffer significant harm.

5. Accountability requires a demonstration that the actions or inactions have been those of a reasonable and competent practitioner. Failure to prove this by the nurse may attract penalties, depending on the seriousness of the action or inaction and its consequences. (Horsburgh 2004).

6. PART 1: Restraint and Immobilisation

7. Restraint is defined as: A positive application of force with the intention of overpowering the individual (DOH 2002). Immobilisation is to: Render him or her fixed or incapable of movement. The difference between the two terms is the inclusion of force in order to accomplish restriction. (Hardy and Armitage 2002) Immobilisation may therefore be referred to as restriction to which the child, young person or vulnerable adult has consented. Restraint may be referred to as restriction to which consent has not been given. Clinical holding has been described as positioning the individual so that a medical procedure can be carried out in a controlled manner, wherever possible with the patient’s consent. (Lambrenos and McArthur 2003)

8. Involuntary restraint of patients who are competent to consent or refuse treatment is both unethical and illegal. (Van Norman and Palmer 2001) Intervention without consent in adults constitutes battery in law, unless the patient is incapable of giving consent.

9. Ethical implications arise: In situations where treatment interventions are invasive, painful and frightening but are paramount for the welfare of the child, young person or vulnerable adult. Forcing anyone to undergo treatment without negotiating with them or finding other ways of achieving the same outcome is unacceptable professional behaviour and may constitute abuse. In situations where there is justification for holding a child or young person, the practice may be resisted by persons with parental responsibility. This may lead to a conflict between the welfare of the child or young person and the values and choices of the child’s parental figure. Ethical Implications

10. Skills required throughout each stage of the implementation of care, treatment or intervention include: Verbal and non-verbal communication, which enable effective negotiation, facilitation, and participation by all involved. Multidisciplinary collaboration is essential, as careful consideration of the procedure’s necessity is required. An emergency situation may prohibit the exploration of alternative strategies to holding a child, young person or vulnerable adult for specified care, treatment or interventions. The McGuinness (2007) framework presents a strategy for informing the decision-making process in relation to clinical holding for care, treatment or interventions. This framework should be included within a policy and procedure document, which has been developed in conjunction with members of the multidisciplinary team. Framework for Practice

11. The need to communicate and cooperate in the implementation of policies and procedures and the responsibility of management in ensuring that staff are adequately prepared and updated in practices in restraint and holding techniques are standard recommendations issued by the European Committee for the Prevention of Torture and Inhumane or Degrading Treatment or Punishment (2005). In addition, concerns about practices should be actively addressed and staff at all levels should feel comfortable in discussing issues which may have implications for the child, young person or vulnerable adult.

12. Careful individualised assessment and planning is required to support decision making, with reference to relevant guidelines and locally developed policies (Folkes 2005) during the preintervention, intervention and post intervention periods.

13. Preintervention Care Good preparation for procedures may prevent the need for holding. Assessment of the individual’s needs in relation to the intended care, treatment or intervention should be undertaken within the context of a multidisciplinary team, within an environment of care and respect. It should also include the following: Age Developmental stage of child, young personor vulnerable adult Their ability to understand why the intervention is necessary How and where it will be undertaken Who will be involved

14. PART 2: Parental Involvement and Support at all Stages

15. Procedural Stages The child, young person or vulnerable adult should be: Given preparation through play Given consideration regarding prior experiences and previous outcomes of painful procedures Allowed to highlight concerns. Any concerns, as well as any wishes regarding the procedure, should be ascertained and time should be taken to internalise the information Given time to reflect

16. The necessary time should be taken to: Ensure the patient understands the risks and benefits of the proposed intervention before consent is sought. Ascertain any parental wishes in relation to their involvement in the procedure. Time should also be taken to ensure their understanding of the needs, risks and benefits of the proposed intervention before consent is sought. Ascertain the necessary psychological preparation to support appropriate behavioural strategies aimed at reducing anxiety. This should include play therapists. Discuss and agree on the positions to be maintained during the intervention period.

17. Position for oral examination Position for ear examination

18. Where necessary, consideration should be given to pharmaceutical strategies such as the use of conscious sedation, which should be prescribed, administered and monitored by experienced medical and nursing staff. Assess the risk of, and anticipate, situations that may arise during the procedure (Mohr et al 2003) The preintervention phase must include: Preparation of the environment. All necessary equipment to ensure that once the care, treatment or intervention is commenced it is carried out as quickly and efficiently as possible.

19. Where procedures are planned, and pain can be predicted, the opportunity should be taken to prepare children through play and education, and to plan pain relief for use during the procedure (Department of Health, 2003)

20. Intervention Agreements made during the preintervention period should be adhered to as far as is possible and should include: Sufficient staff members and the availability of equipment such as appropriate toys for children to effectively engage in distraction techniques. Support for parents to participate as planned. Sensitive support for child, young person or vulnerable adult when unaccompanied by family member. During clinical holding you should avoid: Putting pressure against joints Restricting breathing Inflicting added pain (Tomlinson 2004)

21. Holding Child for Administration of Inhaled Drugs

22. Appropriate positioning, holding and distraction during venepuncture During the procedure it is important to ensure that all involved in carrying out the treatment or care face the individual, and that the procedure is thoroughly explained throughout.

23. Postintervention Care The following should be considered in the postintervention phase: Immediately inform the child, young person or vulnerable adult when the care, treatment or intervention is complete Praise and give rewards for having endured a difficult or painful procedure Ensure the individual is made comfortable and provide appropriate follow up support and necessary information Monitor for complications that may arise as a result of physical or psychological effects of the intervention The assessment, care plan and evaluation of the care, treatment or intervention should be carefully documented