Restrictive interventions in in-pt and communitysettings Ian Hulatt: professional lead for mental health

Background Winterbourne View Transforming Services RCN Congress resolution MIND report on restraint Positive and Safe programme Positive and proactive care; reducing the need for restrictive interventions

Key issues Improving care Leadership, assurance and accountability Transparency Monitoring and oversight Seclusion: clarity Police /Health interface Current audit in England

The view from the “floor” “Restriction should never punish, humiliate or intentionally cause pain. Pain can be caused accidentally when preventing a person from harm. There are occasions when restraint is necessary to prevent harm. I have had to undertake restraint to prevent a person with dementia harming himself but only AS A LAST RESORT.”

A service user perspective I have experienced seclusion, physical and medical restraint and this has had a negative impact on my recovery and (I) think restraint most definitely needs (to)be used as a last resort.

The unintended trigger I was held face-down over a bed by at least four people to be injected with drugs I had actually agreed to - this over-reaction (after I had already bent over the bed) was uncalled-for and unnecessary.

Co production in action “I have seen first-hand how very measured approaches to restraint can be used to good effect. Being involved in my own care, i.e. helping to write my own care plan is also something I have benefitted from.”

A service vision (not a dream) “A recovery approach is central to the way we approach behaviour management to ultimately try and avoid the use of restrictive practices. We do this through a respectful, collaborative approach aimed at avoiding the build-up of difficult emotions that may lead to aggression

A systemic solution We have recorded a 35% reduction in the last 12 months across all services in the use of restraint through the implementation of a restraint & violence reduction programme - we have developed a Safety Assurance Tool that uses live data inputted from our electronic incident reporting system, this captures live data relating to the use of restraint including time of day, whereabouts etc AND more importantly, it also captures when restraint wasn't used and when other less restrictive interventions were used such as talking etc.

A transparent approach At a unit I worked in as a newly qualified nurse we had an open discussion of restraint criteria and practices with clients one day. The clients instigated this and the idea put forward by senior staff that any use of force was to maintain the safety of everyone in the unit including the person causing the risk had a surprisingly calming effect on the clients and appeared to reduce the number of incidents in the following days

The importance of investment I am presently a community based learning disabilities challenging behaviour nurse. From my observations of organisations I work with I have observed significant reductions in restraint when staff have been firstly educated/trained in principles of PBS and secondly supported by their management to consistently enact positive interventions

Community responses …an individual who because of his challenging behaviours and risks was not able to have a kitchen in his flat and he was only allowed restricted access to the communal kitchen. Care staff implemented a person centred PBS programme and his behaviour improved as a result of this. Consequently, a multiagency risk meeting agreed it was appropriate to fit a kitchen in his flat.

Mundane restrictions Limiting egress Restricting movement Use of medication Psycho-social restrictions Relational barriers

Cultural issues I recently worked with a 17 year old health care apprentice who had been taught positive behaviour support at college; her approach and attitude prevented and defused a number of potentially serious events with severely demented residents when the restrictive, restraining, medicating attitudes of more experienced staff were inflaming the situation

A final thought and challenge Coercion in care is a cultural attachment, not a clinical necessity!”