“Let’s talk about restraint”

1 Let s talkabout restraint Rights, risks and responsibilityAcknowledgementsParticular thanks to Frances Healeyof the NationalPatient Safety Agency and Tracy Paine, Chair nursesworking with older people forum, Operations directorof CLS as the authors of this you to the following for their contributions:Marilyn Beare, Northern Trust, NI Jane Greene, Nurse Consultant, Southern Trust, NI (NWWOP Forum)Roger Clough, Emeritus Professor, Eskrigge Social researchBarry Aveyard, Lecturer in Nursing, SheffieldUniversity (MHOP Forum)Gary Blatch, Dementia nurse specialist, South Essex nhs foundation trust (MHOP Forum)Barry Newman, Consultation in Anaesthesia, CriticalCare and Pain management, Poole Hospital, DorsetRCN Legal Disclaimer This publication contains information, advice and guidance to help members of the RCN.

2 It is intended for use within the UK but readers areadvised that practices may vary in each country and outside the information in this booklet has been complied from professional sources, but it s accuracy is not guaranteed. While every effort has beenmade to ensure that the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in whichit may be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to becaused directly or indirectly by what is contained in or left out of this information and by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN 2008 Royal College of Nursing.

3 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmittedin any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers. Thispublication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in whichit is published, without the prior consent of the COLLEGE OF NURSING1 Let s talk about restraint Rights, risks and responsibilityContentsIntroduction2 Our aims 2 What is restraint?2 Types of restraint2 When might restraint be used?4 Restraint as a last resort4 Ethical issues5 Legal issues for nurses6 What support should employers provide?

4 10 Individual responsibilities11 Appendix oneResources for good practice that will help avoid the need for restraint12 Appendix twoRestraint guidance in specialised settings13 References13 IntroductionThis guidance is applicable to all settings wherenursing care is provided. It replaces Restraintrevisited rights, risks and responsibility;guidance for nursing staff. While again it hasbeen written for all nursing staff, distinctionsare made, where appropriate, between the rolesand responsibilities of registered nurses,nursing students, and health care assistants. Italso sets out what support and guidancenursing staff should expect their employingorganisation to provide.

5 In addition, it may behelpful to regulators and inspectors of healthand social care. This guidance is intended for nurses workingwith adults, with examples and case studiesparticularly geared towards the care of olderpeople. Whilst this guidance is directed at nurses,except in emergencies, decisions about restraintneed to be made after discussion, whereverpossible, with the older person, their relativesand friends, as partners in care. It is importantto involve the whole care team, including otherprofessionals and agencies that may be helpingto support the older person. Whilst we haveused the term clients in this publication, itshould be noted that this term is interchangeablewith patients.

6 2 LET S TALK about RESTRAINTOur aims This guidance aims to help nursing staff to: Understand what restraint is Provide person-centred care that minimises theneed for restraint Understand the legal and ethical frameworksrelevant to restraint Know what to do if they suspect inappropriate orabusive use of restraint Understand the circumstances in which restraintmay be legally or ethically appropriate Understand how to minimise the risks if restraint this document cannot provide all the answers, itsaim is to give nursing staff a framework for decision-making that helps them to provide the best possible carefor every older person in their is restraint?

7 Whilst a basic definition of restraint might be restricting movement or restricting liberty , manynursing interventions may restrict unintendedmovement for example, plaster casts to stop a clientaccidentally displacing a fracture or mayunintentionally restrict movement for example, anursing home locked at night to protect residents andstaff from intruders. According to established international definitions,included within Showing restraint: challenging the use ofrestraint in care homes(Counsel and Care UK, 2002),restraint is defined as the intentional restriction of aperson s voluntary movement or behaviour. In thiscontext, behaviour means planned or purposefulactions, rather than unconscious, accidental or reflexactions.

8 An alternative plain English definition is stopping a person doing something they appear to wantto do. Types of restraint Physical restraint involves one or more members ofstaff holding the person, moving the person, orblocking their movement to stop them leaving. Mechanical restraint involves the use of include specially designed mittens inintensive care settings; everyday equipment, such asusing a heavy table or belt to stop the person gettingout of their chair; or using bedrails to stop an olderperson from getting out of bed. Controls on freedomof movement such as keys, baffle locks andkeypads can also be a form of mechanicalrestraint.

9 Technological surveillance such as tagging,pressure pads, closed circuit television, or dooralarms is often used to alert staff that the person istrying to leave or to monitor their movement. Whilstnot restraint in themselves, they could be used totrigger restraint, for example through physicallyrestraining a person who is trying to leave when thedoor alarm sounds. These methods are increasinglybeing included within an individual agreed plan ofcare, provided they operate within organisationalpolicy, clear guidance and risk assessment. Chemical restraint involves using medication torestrain. This could be regularly prescribedmedication including that to be used as required over-the-counter medication, or illegal drugs.

10 Psychological restraint can include constantly tellingthe person not to do something, or that doing whatthey want to do is not allowed, or is too dangerous. Itmay include depriving a person of lifestyle choicesby, for example, telling them what time to go to bedor get up. Psychological restraint might also includedepriving individuals of equipment or possessionsthey consider necessary to do what they want to do,for example taking away walking aids, glasses,outdoor clothing or keeping the person in nightwearwith the intention of stopping them from an action fits the definition of restraint, it is notautomatically unacceptable or wrong. Malicious andabusive use of restraint can occur, but even for the vastmajority of caring and conscientious nurses, decisionsabout restraint are not easy or straightforward.