At a glance 16: Managing risk, minimising restraint
Published: October 2009
- Many different actions can constitute restraint, ranging from physically holding someone to unintentionally leaving their walking frame out of reach.
- Understanding what restraint is, and the occasions on which it is acceptable, is the first step towards minimising its use. The Mental Capacity Act (2005) provides some clear guidance.
- Using a five-step framework will help with making informed decisions in situations where the use of restraint is being considered. The five steps are: observe, do some detective work, consider the options, implement the plan, monitor and review the plan.
- Supporting residents to take positive risks helps increase their wellbeing as well as reducing reliance on restraint to maintain their safety.
- Talking openly about restraint with residents, relatives and staff will help promote good practice.
- Using the physical environment to promote a sense of wellbeing can help avoid some of the situations that result in the use of restraint.
- Care staff need opportunities to develop their skills and knowledge, and to share learning about how to respond to the challenges they face.
This At a glance summary examines the use of restraint in care homes and approaches to minimise its use. For staff, residents and relatives it is often not clear what restraint means, whether it is acceptable and in what circumstances, and what is good practice. This summary presents some of the learning from two pieces of work on this topic:
- a review of what the literature tells us about the use of restraint in care homes for older people
- an exploration of practice in care homes, based on discussions with residents, relatives and staff.
Taking the two pieces of work together begins to give us some pointers towards improving practice and minimising the use of restraint:
- being clear about the legal position
- understanding and using an effective decision-making process
- talking about restraint, what it means to different individuals, and what the care home’s policy is on using it
- training and supporting staff to balance different priorities and make difficult decisions
- making sure the environment supports residents to be as independent as possible and minimises restrictions.
What is restraint?
There are many different definitions of restraint, which probably contributes to the sense that it is a difficult issue to understand. A good starting point is a broad, general definition such as:
…anything which interferes with, or stops, a resident doing what they appear to want to do(Clarke and Bright, 2002).
It is also important to be aware of the legal definition from the Mental Capacity Act 2005, which states that:
‘someone is using restraint if they:
- use force – or threaten to use force – to make someone do something they are resisting, or
- restrict a person’s freedom of movement, whether they are resisting or not’.
What type of actions might be restraint?
For many people, the word ‘restraint’ conjures up a picture of residents being tied in chairs or held down with force. These are examples of physical restraint, but residents can also be restrained through the use of medication, a confusing layout, key pad systems or reminders to stay sitting down. Actions that restrain a resident may even be unintentional:
Sometimes I find with some carers they’ll come in, move the table and my Zimmer all the way to the side so that they can sit there, and then when they get up to go away they forget to replace my Zimmer to its original position
Is restraint ever right?
In some circumstances restraint is the right thing to do, and not to do so on these occasions could be considered neglect. Restraint can be used:
- if the person consents to it, perhaps because it makes them feel safer
- if it is part of a care plan agreed by all
- if the person lacks the capacity to consent, but is acting in a way that may cause harm to themselves or others. In this case, The Mental Capacity Act 2005 helps us to understand that restraint can be used if it is believed to be in the individual’s best interests, but it must be the least restrictive option and used for the minimum amount of time.
The Mental Capacity Act 2005 and its Code of Practice explores this area in much more detail, and is crucial to understanding how and when the recently introduced Deprivation of Liberty Safeguards might apply.
It is important to start by developing an understanding about what restraint means, to recognise that it will be right in some situations and wrong in many others, and that staff, residents and relatives may have different views. It is then possible to consider what will help to improve practice.
Understanding the link between risk and restraint
Reasons given for the use of restraint in care homes generally relate to a concern for safety or as a response to agitation. Making good risk assessments and supporting residents to take risks if they wish to, including starting care planning from the perspective of exploring what residents can do, will therefore all help to reduce the use of restraint. Relatives will also need support to cope with their concerns.
Getting the right balance between restraining someone for their own protection and supporting people to take positive risks is not an exact science(Owen and Meyer, 2009)
Talk about restraint
The use of restraint is a topic that people can be reluctant to discuss, but talking about it can be useful in many ways:
- to help staff, residents and relatives understand the care home’s policy on the use of restraint, and the legal position outlined in the Mental Capacity Act 2005
- to explore different views about what might constitute restraint
- to consider alternative solutions and work out what might be right for an individual resident.
Developing knowledge and skills
To improve practice and minimise the use of restraint, a flexible and varied approach to staff development is important. Building on standard training, arranging specialist training, and providing opportunities for staff to support one another and share their learning are all valuable approaches. It is also important for managers to ‘walk the floor’, to model reflective practice (learning from difficult situations) and to build up a library of good resources.
One care home had set aside time for staff to come together to explore some of these [ethical dilemmas]. Another care home had a Friday reflection group where staff were given time to consider the week’s work, the residents and the challenges that they face. One care home working with extremely frail individuals… ensured that all staff attended formal clinical supervision sessions to help support them to cope with the demanding work and to reflect on their practice.
Create a positive environment
How the physical space within a care home is set up can help promote a sense of wellbeing and avoid some of the situations that can result in the use of restraint. Windows with a view to an accessible outside space, good lighting, distinctive colours for different units, open shelves and cupboards inviting individuals to explore the contents, and clear signage are just some of the ways in which the environment can be used positively. Many possible changes can be identified with the help of staff, residents and relatives, and often made with little expense.
Make informed decisions
Although some difficult situations demand an immediate decision about whether to use restraint, most develop over a longer period of time and using this five-step framework will help you to make an informed decision.
Think about the situation that might prompt the need for restraint and consider the following:
- what is the resident saying and how do they look?
- 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?
2. Do some detective work
Try to find out:
- what the behaviour might mean
- what risks are associated with the behaviour
- who it is risky for
- who else should be consulted
- what the legal position is.
3. Consider options and make a decision
- what are some options for how you could respond?
- what works to help this person?
- when are they happiest?
- which is the least restrictive option if restraint is needed?
4. Implement the plan
- how long the approach should be tried before it is reviewed
- what records should be kept
5. Monitor and review the plan
- has the intervention helped?
- who has it helped?
- what does everyone think?
- are any changes needed or do you need to try something different?
Opening a dialogue on managing risk and minimising restraint will depend on relationships being positive between residents, relatives and staff
(Owen and Meyer, 2009)
This At a glance summary is based on the messages from two SCIE publications:
- Report 26: Restraint in care homes for older people: a review of selected literature
- Report 25: Minimising the use of restraint in care homes: Challenges, dilemmas and positive approaches
The learning from this work has been drawn together to form the basis of three e-learning modules – Managing risk, minimising restraint – to support people working in care homes to develop their knowledge and understanding.
A resource to help care homes for older people deliver in-house training has also been developed, and comprises a trainer’s guide and participant’s workbook, based on the content of each e-learning module. A CD version of all restraint materials is available upon request.
For further information on the Mental Capacity Act 2005, visit SCIE's Mental Capacity Act Web resource.