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Restrictive Interventions in Inpatient Intellectual Disability Services: How to Record, Monitor and Regulate

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COLLEGE REPORT
CR220
Restrictive interventions
in in-patient intellectual
disability services:
How to record, monitor and regulate
© 2018 The Royal College of Psychiatrists
College Reports constitute College policy. They have been sanctioned by the College via the Policy and Public Affairs Committee
(PPAC).
The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in Scotland (SC038369).
College Report CR220
December 2018
Approved by: The Policy and Public Affairs Committee (PPAC)
Contents 3
Contents
Contents 3
Authors and contributors 4
Acknowledgements 6
Foreword 7
Executive summary and recommendations 8
Definitions and scope 14
Chapter 1: Background and context 18
Chapter 2: Relying on numbers: 23
Issue 1: Practice quality, the last resort, least restrictive,
poor practice and abuse 24
Issue 2: Definitions and degrees of restrictive interventions 28
Issue 3: Outliers 32
Issue 4: Capturing individual
patient progress, the whole
picture
of patient care, and restrictive interventions 34
Issue 5: Lack of a benchmark 37
Chapter 3:
Critique of current
guidance on the recording,
monitoring and regulation of
restrictive interventions 41
Chapter 4: Recommendations on recording, monitoring
and regulation of restrictive interventions 46
Conclusions 55
References 56
College Report CR220 4
Authors and contributors
Author1
Verity Chester, Research and Projects Associate, St Johns House, Diss,
Norfolk; and PhD Candidate, University of East Anglia, Norwich, Norfolk
Editors
Dr John Devapriam, Chair, Quality Network for Learning
Disability (QNLD), Royal College of Psychiatrists, London; Executive
Medical Director, Worcestershire Health and Care NHS Trust; National
Professional Advisor for Learning Disabilities, Care Quality Commission
Dr Regi Alexander, Consultant Psychiatrist, Hertfordshire Partnership
NHS Foundation Trust & Honorary Senior Lecturer, University of Leicester
Working group
Dave Atkinson, Independent Consultant Nurse, Dave Atkinson
Associates Ltd; Senior Programme Manager, NHS Improvement.
Jonathan Beebee, Chief Enablement Officer & Nurse Consultant,
PBS4.
Guy Cross, Regulatory Policy Officer – Mental Health, Strategy and
Intelligence Directorate – Policy and Strategy,Care Quality Commission
Dr Daniel Dalton, Consultant Psychiatrist & Clinical Director,
Hertfordshire Partnership University NHS Foundation Trust.
Ann Norman, Professional Lead for Criminal Justice and Learning
Disability Nursing, Royal College of Nursing.
Prof Peter Langdon, Professor of Clinical and Forensic Psychology, Tizard
Centre, University of Kent, and Clinical Psychologist, Broadland Clinic.
David Kitchen, Retired Behaviour Support and Practice Development
Coordinator, Partnerships in Care Intellectual Disability Services;
Specialist Adviser for Intellectual Disabilities, Care Quality Commission.
1.
Commissioned by the Faculty of Psychiatry of Intellectual Disability and Quality Network
for Learning Disabilities, Royal College of Psychiatrists
Authors and contributors 5
Consultation group
Dr Bijil Arackal, Consultant Psychiatrist, Sussex Partnership NHS
Foundation Trust
Dr Helene Barclay, Specialty Doctor, Hertfordshire Partnership
University NHS Foundation Trust
Dawn Beales, Charge Nurse, Hertfordshire Partnership University
NHS Foundation Trust
Mel Bowman, Interim Service Lead, In-patient services, Hertfordshire
Partnership University NHS Foundation Trust
Debra Chester, Staff Nurse, Mersey Care NHS Foundation Trust
Ben Higgins, Chief Executive,British Institute of Learning Disabilities
Neil James, Senior Lecturer and Course Director for Learning Disability
Nursing, University of East Anglia
Alison Mitchell, Senior Staff Nurse, Danshell Group
Fungai Nhiwatiwa, Hospital Director, St Johns House, Diss, Norfolk
Dr Jean O’Hara, National Clinical Director for Learning Disabilities,
NHS England & Consultant Psychiatrist, South London & the Maudsley
NHS Foundation Trust
Dr Anthony Perini, Consultant Psychiatrist, Danshell Group
Judith Pither, Matron, Agnes Unit, Leicestershire Partnership NHS Trust
Leisa Richards, Case Manager for Transforming Care, NHS England-
Midlands and East
Sarah Leitch, Development Manager for the Centre for the
Advancement of Positive Behaviour Support, British Institute of
Learning Disabilities
Dr Kamalika Mukherjee, Consultant Psychiatrist, Hertfordshire
Partnership University NHS Foundation Trust
Emma Tolhurst, Community Support Leader, Thera Group
Paul Upton, Charge Nurse, Broadland Clinic, Hertfordshire Partnership
University NHS Foundation Trust
College Report CR220 6
Acknowledgements
The author and editors wish to extend their thanks to the following
groups for their valuable feedback on this report during the consul-
tation process:
zLearning Disability Professional Senate
zRoyal College of Nursing
zThe British Institute of Learning Disabilities Restraint Reduction
Network (RRN)
z
The Quality Network for In-patient Learning Disability
Services (QNLD)
Foreword 7
Foreword
This report is both welcome and timely. In our report, The state of care in mental health
services 2014 to 2017, we, the Care Quality Commission (CQC), commented on the “great
variation between wards in how frequently staff use restrictive practices and physical
restraint to de-escalate challenging behaviour. Those wards where the level of restraint is low
or where it is reducing over time have staff trained in the specialised skill required to antic
-
ipate and de-escalate behaviours or situations that might lead to aggression or self-harm”.
We went on to say that “this has also been a development area for CQC – in the past
we may have been too tolerant when we have seen evidence of restraint and restrictive
practices (including blanket restrictions) used too readily. We now want to send a clear
message to providers that we will be asking searching questions when we find services
in which staff frequently resort to restrictive interventions”.
When we published The state of care in mental health services (Care Quality Commission,
2017), we flagged up three issues that limit CQC’s ability to fulfil its commitment to
regulate physical restraint better.
1
There is no widely accepted and used set of definitions of types and levels of
physical restraint.
2
Partly linked to the lack of definitions is the issue that providers are highly inconsistent
in how they report physical restraint.
3 There is no system for assuring the quality of training provided to staff in how to
prevent, minimise and manage challenging behaviour.
As a result, many training providers teach staff a wide range of approaches.
This means that as things stand, we cannot safely conclude that it is of more con-
cern that provider A reports 100 uses of physical restraint each month than provider
B who reports 10 uses each month. It could be the case that staff in provider A are
highly attuned to the issue and that the great majority of incidents reported involve
them gently redirecting a person from possible harm; whereas staff in provider B only
report instances where they have held a person on the ground.
In response to CQC’s concerns, and at the request of the Secretary of State for Health
and Social Care, NHS England and partners are working to develop common definitions,
improve reporting and establish a mechanism for accrediting training. This report will
greatly inform and influence this work.
I welcome the emphasis that this report places on the importance of the culture of care.
Research into the factors that contribute to aggressive behaviour in residential settings
find that most instances are not caused directly by the person’s ‘psychopathology’. Most
are fully understandable at the human and interpersonal level; and are due to everyday
frustrations that come from communal living in a setting where the people lack auton-
omy and control over their lives. If staff can create an environment that minimises these
general frustrations and work with individuals to identify and anticipate specific triggers
that cause them distress, they will reduce the need to resort to restrictive interventions.
Dr Paul Lelliott
Deputy Chief Inspector of Hospitals (Lead for Mental Health)
Care Quality Commission
College Report CR220 8
Executive summary and recommendations
8
College Report CR220 8
Executive summary and
recommendations
This report is concerned with the standards of recording,
monitoring, and regulating restrictive interventions involving
people with intellectual disabilities with mental health and/
or challenging behaviour within in-patient services.
Restrictive interventions, a central concern for all stakeholders
of intellectual disability services, have come under increased
scrutiny following the abuse scandal at Winterbourne View.
Current efforts to monitor them rely almost exclusively on the
numbers of such incidents. This approach is fundamentally
flawed because numbers alone do not assess the quality of a
service’s overall restrictive interventions practice and cannot
be used to infer good or poor standards of practice and abuse.
Further, there are problems with the variable use of definitions,
the failure to distinguish between various degrees of physical
restraint, the impact of outliers, the failure to capture individual
patient progress and the absence of meaningful benchmarking.
Service providers and regulators must therefore rely on other
methods to evaluate the use of restrictive interventions and
move from basing their conclusions on just the total number of
restrictive interventions to one of examining a wider range of
quality parameters.
With representative examples, this document makes
recommendations on how restrictive interventions
should be recorded, monitored, regulated and published.
Recommendations on recording
1
Services should have a good quality system of recording
incidents of restrictive interventions, which incorporates
variables specified by government guidance (Department
of Health, 2014; 2015).
2 Incident records within this system should be well written
and present a cohesive representation of the events leading
to, and during, the restrictive intervention, particularly
focusing on justification for their use, and stating how the
intervention represented the least restrictive option and
what physical health observations were undertaken.
Foreword 9
Executive summary and recommendations 9
Executive summary 9
3 Services should consider moving away from paper-based
recording systems, which have limited utility in the monitoring
of restrictive interventions, in favour of IT software packages
or databases. IT software systems are the preferred mode
of recording due to being more robust and their potential to
improve the quality of quantitative and qualitative restrictive
interventions data.
4 Such systems should be developed in conjunction with all
stakeholders of the software, including the individuals who
will be entering incident reports, and those who will access
the data for monitoring/regulation.
5
Software developers should consider ‘forced response’
formats to ensure that all required data is completed within
incident report entries.
6
Software should be kept up to date, with new patient details
recorded on their admission to the service, new staff member
information recorded on their appointment, and particular
MVA techniques taught in the service.
7
Software should prompt users entering data to ensure
their incident report demonstrates compliance with current
government guidance (Department of Health, 2014; 2015),
with statements such as ‘Describe how this intervention
represented the least restrictive response to the patient’s
behaviour’ or ‘Describe the physical health observations
which were undertaken during the restrictive intervention’.
8
The system should be reviewed and updated on an ongoing
basis, to maintain its quality and utility.
9
It is recommended that staff who are required to write
incident reports as a requirement of their role are given
full training in the correct process. This training must
emphasise the importance of quality incident reports, and
cover government requirements (Department of Health,
2014; 2015).
10
Services should provide supervision and mentoring to staff
in this element of their role.
11
Incident reports should be checked and signed off by a
senior member of staff.
12 Services should regularly audit incident reports to ensure
they meet the required standard.
Recommendations on monitoring and regulation
13
Services should generate statistics/reports on restrictive
interventions as defined by the Department of Health (2014;
2015), for any reasonably requested timeframe on a whole
service, ward, and individual patient level.
College Report CR220 10
Executive summary and recommendations
10
College Report CR220 10
14 Service or ward level reports should include:
a Total frequency of each restrictive intervention
b
Total number, level and type of incidents which do not
result in restrictive intervention
c
Duration of restrictive interventions, with a full categorical
breakdown in addition to average and range
d Holds/techniques used for physical restraint, with a full
categorical breakdown (this figure is likely to be higher
than the total frequency of restrictive interventions, due
to incidents of restraint which utilise more than one
holding technique)
e
Trends in rates over time, day of the week, week in the
month, and month of the year. If incidents peak on particular
days or at certain times, this can direct the exploration of
the activities, procedures, staffing levels and interventions
of an individual/ward/service, as necessary
f
An investigation or analysis of decreases, increases and /
or maintenance
g
Total number and extent of any patient injuries sustained
within restrictive interventions
h
The number of individual patients represented within
the data, expressed as a percentage of total patients
treated within this timeframe
i Progress of all patients against the aims of the services
chosen restrictive intervention programme, ideally using
the ‘traffic light audit’
j
The contribution of individual patient rates to the overall
total for the ward or the service. If there are any outlier(s)
which significantly affect the overall total, or trends,
report rates with and without the outlier data
k Details of how rates compare to a national benchmark
l
Number of beds, and occupancy level of service for
timeframe
m
Cohort characteristics, such as gender, ethnicity,
diagnoses, behavioural and/or offence profile.
15 Individual patient level reports should include:
zItems a−m, as above
zA brief description of a patient’s demographic information,
and psychiatric and forensic history (where relevant)
z
Services should be able to generate statistics on the levels
of restrictive interventions for the entirety of a patient’s
admission and, if available, pre-admission
z
Reports should include details of the patient’s management
plan, e.g. level of observation, medication, level of
engagement, assessments and treatment plans.
Foreword 11
Executive summary and recommendations 11
Executive summary 11
Recommendations to overcome some of the identified
limitations with current restrictive interventions data
16
To truly capture the quality of a service’s restrictive
intervention practice, there must be less focus on the
number of restrictive interventions, and more on a service’s
adherence to the standards outlined by government
guidance (Department of Health, 2014; 2015). This is likely
to encompass restrictive intervention factors such as:
a Staff training in primary and tertiary strategies, training
in safe restrictive intervention techniques, restrictive
intervention reduction programme, the quality of advance
statements and individualised restrictive intervention
care plans, physical health observations and debriefing
processes
b
Wider practice quality issues, such as leadership, staffing
levels, environmental considerations, engagement,
patient assessment, therapies and management.
Assessing the principles of last resort and least restrictive
practice
17
It is recommended that qualitative incident accounts, or
a representative subsample thereof, are inspected on
an incident-by-incident basis in order to assess whether
the record adheres to the principles of least restrictive
practice. For example: Was the decision-making process
for restrictive intervention by staff described? Was this
decision justified for the patient’s own or others’ safety? Was
it reasonable and proportionate? Was it the least restrictive
way the behaviour described could have been managed?
Was the intervention subject to regular review by staff and
curtailed as quickly as possible? This is a much more time-
consuming task but a much more meaningful one and is
dependent on a good standard of written incident reports.
Uncovering poor practice or abuse of restrictive
interventions
18 If it appears that restrictive interventions are being carried
out for any other purpose than to take immediate control
of a dangerous situation, it is recommended that concerns
should be escalated through local safeguarding procedures
and protocols.
19
It is recommended that regulators request information on
the number patient injuries sustained during restrictive
interventions, except where these relate primarily to
instances of self-harm/injury.
20
Regulators should cross reference data on restrictive
interventions with information from other sources, including
their observations, patient and carer reports, safeguarding
referrals, police reports, etc.
College Report CR220 12
Executive summary and recommendations
12
College Report CR220 12
Definitions and degrees of restrictive interventions
21
It is recommended that policymakers develop a framework
of restrictive intervention severity/intensity. This should
encompass the full range of physical restraint techniques
used by multiple training providers, as well as the duration of
physical restraint, seclusion, and long-term segregation. This
would provide an element of standardisation, move towards
more consistent recording between service providers, and
support the comparability of data.
22
It is recommended that in the interim, services should record,
monitor, and report the full framework of techniques used.
23
Services which report comparatively lower numbers of
restrictive interventions should have their practice inspected
as rigorously as those which report higher numbers.
Establishing individual patient progress
24
It is recommended that services provide a breakdown of
restrictive intervention data from the total number for a whole
service, to the ward level, and individual patient level. This
can be done utilising widely available software, Microsoft
Excel, using the Pivot Table function, which can facilitate
the analysis of a large, detailed datasets quickly and easily.
This function can also be used to view the proportion of
restrictive interventions accounted for by individual patients,
and ward or service level data can be viewed and presented
with and without the data of individual outlier patients.
25
Service providers can also report multiple measures of
central tendency, such as the median, in addition to the
mean, which is particularly susceptible to the effects of
outliers.
Establishing individual patient progress
26
Services should analyse the progress of individual patients
for a clearly specified timeframe. This can be achieved using
the ‘traffic light’ audit method. The traffic light method
involves viewing the restrictive interventions rates of all
patients within the service, and then categorising them into
one of the three categories. This can be useful through
the audit cycle or, ideally, the whole duration of a patient’s
admission. This should include the number of patients
treated in the timeframe specified, and the proportion who
have been involved in restrictive interventions.
27
Service providers should report multiple measures of central
tendency, such as the median − not just the mean which is
particularly susceptible to the effects of outliers.
Foreword 13
Executive summary and recommendations 13
Executive summary 13
Capturing the whole picture of patient care and restrictive
interventions
28
Services should monitor and report all types of restrictive
interventions used with an individual patient, using visual aids.
This should take into account any patient preferences as
specified in advance statements or similar, and recognise
that this data represents only one element of patient care,
and does not capture other domains, such as wellbeing,
quality of life, physical health, engagement with friends and
relatives, occupational activities, etc.
The absence of a publicly available benchmark
29
National benchmarking data must be strengthened via
the inclusion of a wider range of variables and be publicly
available to all.
30
Benchmarking processes must consider the highlighted
issues with restrictive interventions data and take steps to
counter these in reports.
Using data to support the reduction of restrictive
interventions
31
Services must demonstrate the use of data to support
restrictive intervention reduction.
a
This might involve regular reviewing of incidents and
subsequent debriefs, identifying any triggers or learning
points and feeding these back into care plans. It could
involve viewing of restrictive intervention rates in team
meetings and care reviews, identifying patterns of use,
and addressing any underlying reasons for these. This
could involve highlighting particular times of day where
incidents peak, particular days of the week, differences
between shift patterns, etc. When reviewing individual
patients, these factors are likely to be highly personalised
and their care plans should reflect this.
b
Services may also choose to record a wider range of
measures in addition to restrictive intervention rates,
as identified by Bowring (2015). These might include
behaviour rating scales, quality of life measures, patient
satisfaction etc.
Publishing
32
Any publication of restrictive intervention data should adhere
to the above guidance.
33 Reports should relate to a clearly specified timeframe.
College Report CR220 14
The scope of this report includes standards of recording, monitoring,
and regulation of restrictive interventions involving people with
intellectual disabilities with mental health and/or challenging
behaviour within in-patient services, terms which are defined in
the below subsections.
Intellectual disability (ID)
Within this report, we will use the term ‘intellectual disability’ or ‘ID’.
Intellectual disability is known by a number of terms which are often
used interchangeably. The UK government uses the term ‘learning
disability’ (Parkin et al, 2018). The previous version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV, American
Psychiatric Association, 1994) used the term ‘mental retardation’,
but have adopted the term ‘intellectual disability’ in the current edition
(DSM-V, American Psychiatric Association, 2013).
The ICD Classification of Mental and Behavioural Disorders: Clinical
Descriptions and Diagnostic Guidelines are also planning to change
their terminology from ‘mental retardation’ in the current edition (ICD-
10, World Health Organization, 1992) to ‘disorders of intellectual
development’ in the forthcoming version, ICD-11 (Cooray, Bhaumik,
Roy, Devapriam, Rai and Alexander, 2015).
Regardless of the exact terms used, intellectual disability is charac-
terised by significant degrees of cognitive impairment together with
deficits in adaptive behaviour manifest from childhood (Carulla, 2011),
and has an onset before the age of 18 (World Health Organization,
1992). The degree can be mild, moderate, severe or profound, with
over 90% of those with ID falling within the mild range (Department
of Health, 2001).
In-patient services
People with ID are reported to suffer from a higher prevalence of
mental health problems when compared with the general population
(Cooper et al., 2007; Bhaumik et al., 2008). When a person with ID
develops co-morbid mental health issues, there is an emphasis on
providing care within the community, but in-patient settings remain
a necessity for some patients (Xenitidis, Gratsa, Bouras, Hammond,
Ditchfield, Holt, Martin, & Brooks, 2004). This may be provided in main-
stream mental health services, or in specialist ID services (Chaplin,
2009).
Definitions and scope
Definitions and scope 15
In 2012, the NHS Confederation defined in-patient mental health
services as units with ‘hospital beds’ that provides 24-hour nursing
care. A unit is able to care for patients detained under the Mental
Health Act, with a consultant psychiatrist or other professional acting
as responsible clinician, but not all patients will be detained. Such a
unit may be in a hospital campus or a community setting, and may
be provided by the NHS or the independent sector. The document
stated that in-patient beds should be distinguished from placements
registered for the provision of care, such as those provided by local
authorities. The report described the scope, typical care pathways
and patients treated within:
zAcute in-patient beds
zPsychiatric intensive care unit (PICU)
zForensic services
zChild and Adolescent Mental Health Services (CAMHS).
The purpose and functions of the different types of specialist in-patient
beds for people with ID in the United Kingdom, within the context of a
tiered model of service provision have been described (Royal College
of Psychiatrists’ Faculty of Psychiatry of Intellectual Disability, 2013).
Tier 1 (enabling role working with other agencies) to tier 3 (intensive
case management in the community) constitute community ID ser-
vices, and tier 4 constitutes the in-patient element of care. Within tier
4, there are subcategories:
zCategory 1: high, medium and low secure forensic beds
zCategory 2: acute admission beds within specialized ID units
zCategory 3: acute admission beds within generic mental health
settings
zCategory 4: forensic rehabilitation beds
zCategory 5: complex continuing care and rehabilitation beds
z
Category 6: other beds including those for specialist
neuropsychiatric conditions.
Challenging behaviour
“Behaviour can be described as challenging when it is of such an
intensity, frequency or duration as to threaten the quality of life and/
or the physical safety of the individual or others and is likely to lead to
College Report CR220 16
responses that are restrictive, aversive or result in exclusion.” (Royal
College of Psychiatrists et al., 2007, p.10).
Challenging behaviour is a socially constructed, descriptive concept
that has no diagnostic significance, and makes no inferences about
the aetiology of the behaviour, covering a heterogeneous group of
behavioural phenomena across different groups of people (Royal College
of Psychiatrists’ Faculty of Psychiatry of Intellectual Disability, 2013).
Among many causes, challenging behaviour has been reported to
(Koritsas & Iacono, 2012):
zrepresent a form of communication
zbe caused by skills deficits
z
be associated with psychiatric disorder or symptoms or physical
illness, or
zdevelop through operant conditioning and reinforcement.
Restrictive practices
The terms ‘restrictive practices’ and ‘restrictive interventions’ are often
used interchangeably, despite their different meanings. Restrictive
practices are defined as “making someone do something they don’t
want to do or stopping someone doing something they want to do”
(Skills for Care & Skills for Health, 2014, p.9).
Restrictive practices therefore include, but are not limited to, restrictive
interventions. In addition to restrictive interventions, restrictive prac-
tices also include deprivations of liberty, as well as broader activities
which restrict people. These restrictions might be used as a routine
feature of someone’s care and support, rather than solely in response
to some form of crisis, may be deliberate or less so, and tend to occur
in one of the following ways (Skills for Care & Skills for Health, 2014):
1
Restrictions that arise because of habit or blanket rules: e.g.
everyone having to be up by a certain time, rules on whether
people can have their phones or doors being routinely locked.
These are sometimes called ‘de facto’ restrictions.
2 Safety: restrictions such as locking a room to keep household
cleaning products or medicine out of someone’s reach. This
could also mean responding to violence or aggression towards
the individual themselves, or to workers or others.
3
Treatment or care: restrictive practices may be used in a planned
or unplanned way in order to provide essential care, support or
medical treatment.
Definitions and scope 17
Restrictive interventions
Restrictive interventions are defined as “deliberate acts on the part of
other person(s) that restrict an individual’s movement, liberty and/or
freedom to act independently in order to take immediate control of
a dangerous situation where there is a real possibility of harm to the
person or others if no action is undertaken” (Department of Health,
2014, p.14).
Restrictive interventions include; physical restraint, mechanical
restraint, rapid tranquillisation, seclusion and long-term segregation
(Department of Health, 2015, p.281).
College Report CR220 18
Chapter 1: Background
and context
In England, which has a population of about 53 million people, around
900 000 adults have an ID (Devapriam, Rosenbach & Alexander,
2015). Of those, approximately 191 000 (21%) are in contact with ID
services (Emerson 2010) and 3 035 (0.3%) are receiving treatment in
in-patient psychiatric units at any point in time (Health and Social Care
Information Centre 2013). The latter number tends to fluctuate and
includes secure or forensic services provided for those with offending
behaviour, whose presentation is currently above a threshold that can
be safely managed in the community. Individuals within in-patient ID
services have predominantly mild levels of ID, and have a number
of co-morbidities in addition to their primary diagnosis, with high
rates of autism spectrum disorder (ASD), epilepsy, schizophrenia and
delusional disorders, bipolar affective disorder, depressive disorder,
anxiety disorders and personality disorders (Xenitidis et al, 2004;
Alexander et al, 2011).
People with ID in in-patient settings can display behavioural challenges
that may present risks to themselves or others (Department of Health,
2015). Challenging behaviour within in-patient services arises from a
complex interaction between factors intrinsic to the individual patient,
and factors intrinsic to the service. Individual factors may include
anger issues (Chilvers & Thomas, 2011), difficulties with social prob-
lem-solving (Larkin, Jahoda & MacMahon, 2013), and communication
issues (McNamara, 2012). Service factors might include excessive
noise and general disruption, overcrowding, boredom, lack of clear
communication by staff with patients, and the excessive or unrea
-
sonable application of demands and rules (Department of Health,
2015). Services which care for people who are liable to present with
challenging behaviour should focus primarily on providing a positive
and therapeutic culture, which focuses on preventing behavioural
disturbances, early recognition, and deescalation
2
. Organisational
responses to challenging behaviour should include primary, secondary
and tertiary strategies which are defined in Table 1.
2.
De-escalation is defined as a secondar y preventative strategy within the Mental Health
Act Code of Practice (Depar tment of Health, 2015). It involves the gradual resolution of
a potentially violent or aggressive situation where an individual begins to show signs
of agitation and/or arousal that may indicate an impending episode of behavioural
disturbance. De-escalation strategies promote relaxation, e.g. through the use of
verbal and physical expressions of empathy and alliance. They should be tailored to
individual needs and should typically involve establishing rapport and the need for
mutual co-operation, demonstrating compassion, negotiating realistic options, asking
open questions, demonstrating concern and attentiveness, using empathic and non-
judgemental listening, distracting, redirecting the individual into alternate pleasurable
activities, removing sources of excessive environmental stimulation and being sensitive
to non-verbal communication.
Chapter 1: Background and context 19
Table 1: Primary, Secondary and Tertiary responses to behavioural
disturbance defined by the Mental Health Act Code of Practice
(Department of Health, 2015)
Primary
Primary preventative strategies aim to enhance a
patient’s quality of life and meet their unique needs,
thereby reducing the likelihood of behavioural
disturbances.
Secondary Secondary preventative strategies focus on
recognition of early signs of impending behavioural
disturbance and how to respond to them in order
to encourage the patient to be calm. Secondary
strategies include de-escalation.
Tertiary Tertiary strategies guide the responses of staff and
carers when there is a behavioural disturbance.
Responses should be individualised and wide
ranging, possibly including continued attempts to
de-escalate the situation, summoning assistance,
removing sources of environmental stress or
removing potential targets for aggression from
the area. Where it can reasonably be predicted
on the basis of risk assessment, that the use of
restrictive interventions may be a necessary and
proportionate response to behavioural disturbance,
there should be clear instruction on their pre-planned
use. Instructions should ensure that any proposed
restrictive interventions are used in such a way as to
minimise distress and risk of harm to the patient.
Statement of principles
This report is primarily concerned with ensuring and evidencing that
the use of restrictive interventions is in line with the following principles.
The principles are derived from values outlined in best practice doc-
uments such as Positive and Proactive Care: reducing the need for
restrictive interventions (Department of Health, 2014) and the Mental
Health Act 1983: Code of Practice (Department of Health, 2015):
1 Restrictive interventions should only be used to:
a
take immediate control of a dangerous situation where there
is a real possibility of harm to the person or others if no action
is undertaken.
b
end or reduce significantly the danger to the person or others.
They should not contain or limit the person’s freedom for longer
than is necessary.
College Report CR220 20
2
When restrictive interventions are unavoidable, providers should
have a robust approach to ensuring that they are used in the
safest possible manner.
3
The nature of techniques used to restrict must be proportionate
to the risk of harm and the seriousness of that harm.
4
Any action taken to restrict a person’s freedom of movement
must be the least restrictive option that will meet the need.
5 Restrictive interventions should be used in a transparent, legal
and ethical manner:
a
Restrictive interventions must comply with the relevant rights
in the European Convention on Human Rights.
b
People must be treated with compassion, dignity and kindness.
c What is done to people, why and with what consequences
must be subject to audit and monitoring and must be open
and transparent.
6
Providers who treat people who are liable to present with
behavioural disturbances should have individualised, ward
and service level restrictive intervention reduction programmes
which emphasise primary and secondary strategies and involve
patients, (family) carers/advocates.
When restrictive interventions are carried out without a clear ethical
basis and appropriate safeguards, such acts may be unlawful, and
should always be escalated through local safeguarding procedures
and protocols. The Panorama documentary ‘Undercover Care: The
Abuse Exposed’ depicted appalling scenes of abuse in an in-pa-
tient unit for patients with intellectual disability and mental health or
behavioural problems (Winterbourne View, BBC, 2011). Much of the
abuse was committed under the guise of restrictive interventions,
and particularly, physical restraint. Yet it is important to recognise that
the ‘physical restraint’ observed at Winterbourne View would not be
recognised as a lawful restrictive intervention. Not only were patients
subjected to clearly illegal actions (e.g. sitting on a chair placed on
top of a vulnerable patient), there were instances of staff provocation
prior to restraint being initiated (Flynn, 2012) and instances of restraint
being used to bully, punish and humiliate. Patients sustained numerous
significant physical injuries following restraint, such as broken bones,
loss of teeth, and carpet burns (Flynn, 2012). Due to their actions,
the staff involved subsequently faced criminal charges and in some
cases, prison sentences (BBC News, 2012).
A core area of the response to Winterbourne View has been a
focus on restrictive interventions, particularly physical restraint. The
Chapter 1: Background and context 21
regulatory body of health and social care services in the UK, Care
Quality Commission (CQC), undertook 150 unannounced inspections
of care providers for people with intellectual disabilities and challeng-
ing behaviours, including 71 NHS trusts, 47 private services and 32
care homes (Care Quality Commission, 2012). In Transforming care:
a national response to Winterbourne View Hospital (Department of
Health, 2012, p.44), the government outlined their response not only
to the Winterbourne View abuse scandal, but also on the wider issues
highlighted by the subsequent review of services by the CQC. This led
to the publication of Positive and Proactive Care: reducing the need
for restrictive interventions (Department of Health, 2014).
Following the scandal, emotions relative to restrictive interventions,
particularly physical restraint, have remained high. Citarella (2013)
repeatedly likened physical restraint to the combative sport of wres-
tling, and stated that there was “no justification for pinning learning
disabled to the ground. Other headlines have said that physical
restraint should be banned altogether (e.g. Calkin, 2012). While
the wrestling comparison may hold up when referring to the illegal
‘restraints’ undertaken at Winterbourne View, the inference that there
is no justification whatsoever for physical restraint does not. There is
a long-established legal framework surrounding the use of physical
restraint, and other restrictive interventions, within the Mental Health
Act (1983, amended 2007) and the accompanying Code of Practice
(Department of Health, 2015) which outlines the most common rea-
sons for needing to consider the use of restrictive interventions:
zphysical assault by the patient
zdangerous, threatening or destructive behaviour
zself-harm or risk of physical injury by accident
z
extreme and prolonged over-activity that is likely to lead to
physical exhaustion
z
attempts to escape or abscond (where the patient is detained under
the Act or deprived of their liberty under the Mental Capacity Act).
The Department of Health’s (2014) definition of restrictive intervention
also indirectly highlights the need for its use where necessary:
“deliberate acts on the part of other person(s) that restrict an individ-
ual’s movement, liberty and/or freedom to act independently in order
to take immediate control of a dangerous situation where there
is a real possibility of harm to the person or others if no action
is undertaken(Department of Health, 2014, p.14).
A number of such situations have been outlined – for example, a patient
running out into a busy road. At such times, the physical restraint by
College Report CR220 22
staff is likely to save a patient from serious injury. Furthermore, in a
statement for a Royal College of Nursing report (2008) the then Chief
Executive of the National Patient Safety Agency, Martin Fletcher, noted
serious problems in services which would not tolerate restraint in their
organisation in any circumstances. These problems included allowing
delirious or suicidal clients get into risky situations, because staff thought
it was wrong to stop a client doing what they wanted to do. He stated:
“if an organisation takes the position ‘it doesn’t happen here’ any
problems just get hidden… if staff don’t have a clear understanding
of the circumstances where restraint is justified or positively required,
they won’t be able to recognise the circumstances where restraint
is wrong or abusive.”
In these situations, the presence of a diagnosis of ID should not
preclude intervention from staff members. The abuse observed in
the Winterbourne View documentary has driven a universal desire to
protect and keep patients within services safe, to avoid such tragedies
happening again. It also reignited widespread criticism on the use of
restrictive interventions within in-patient services. But in condemning
those who abuse patients, we must be careful not to reject all forms
of restrictive interventions. If restrictive interventions are applied safely
and appropriately, they can form part of a responsible provider’s care
package and an individual’s personal care plan. Rather than banning
restrictive interventions, which risks driving the practice underground
and potentially placing patients at further risk, focus should instead be
shifted onto strengthening the process of recording and monitoring
of restrictive interventions practice. While there have been welcome
efforts to adequately monitor and inspect services in which such
interventions take place, this approach has been flawed because of
an almost exclusive reliance on restrictive interventions statistics and
data. It has become increasingly clear that this strategy is not providing
an accurate picture of restrictive interventions practice within in-patient
ID services and that there is a need for further guidance in this area.
The report will go on to:
1
Critique the current, predominantly data-centric, approach to
assessing restrictive interventions practice, and describe some
specific issues which should be considered when interpreting
restrictive intervention data.
2
Describe current guidance on recording, monitoring, publishing
and regulation of restrictive interventions data.
3
Make recommendations and set standards for services wishing to
self-assess their restrictive intervention recording and monitoring
processes, and for regulators wishing to inspect such processes.
4 Promote the use of safe and legal restrictive interventions.
Chapter 2: Relying on numbers: 23
Chapter 2: Relying on
numbers:
The current approach
to reporting, monitoring
and regulating
restrictive intervention
practices
At present, the monitoring and inspecting of practice largely focuses
on the total number of restrictive interventions at the ward or service
level, via service provided data and statistics. Since the Winterbourne
View scandal, these statistics have received unprecedented interest
among the multiple stakeholders of services; patients, families, staff,
clinicians, academics, commissioners, charities, government, the
media and the general public. The complexity of this data is often
unappreciated, and in the best-case scenario references have been
simplistic, reductionist, emotive, and subjective, and in the worst
case, biased, misrepresentative, and sensationalist.
In 2013, Mind published the report Mental Health Crisis Care: Physical
Restraint in Crisis; following freedom of information requests to 51 NHS
mental health trusts. Widely reported within the media, and featured
within Positive and Proactive Care: reducing the need for restrictive
interventions (Department of Health, 2014), the report concluded
there were:
z
excessive and disturbing levels of restraint, with 39 883 incidents
of restraint reported across mental health services in the UK in
one year
z
significant variations in the use of restraint across the country,
with one trust reporting 38 incidents while another reported over
3 000 incidents.
However, the report fails to include important context regarding the
figures quoted. For example, although 39 883 restraints sounds
exceptionally high, a key contextual factor is the number of patients
treated in services during this timeframe. Taking data from the 2010
College Report CR220 24
Count Me In Census (Care Quality Commission and National Mental
Health Development Unit, 2011), there were 29 840 in-patients within
the mental health services of 261 NHS and independent health-
care organisations in England and Wales. Dividing the number of
restraints (39 883) by the number of patients (29 840), equates to
1.3 incidents of restraint per patient through the year. However, the
census stated that not all patients are subject to physical restraint,
with 12% of patients experiencing one or more episodes in the year.
This suggests that 3 581 patients accounted for the 39 883 incidents
of restraint and, assuming this is equally distributed among those
patients, approximately 11 incidents of restraint per patient per year.
Mind (2013) referred to the significant variations in restraint levels
across the country as “appalling”. However, the report took no account
of the differential bed capacity of services. This was reflected on in
a statement by Tees, Esk and Wear Valleys NHS Foundation Trust,
who reported the highest number of incidents at 3 346 (The Guardian,
2013): “The number of incidents may seem high. However, we are
one of the largest mental health and intellectual disability trusts in
the country, with over 1 000 beds and a high proportion of specialist
units caring for people with extremely challenging behaviour. There
is caution therefore needed in interpreting and responding to figures
that may lack a critical appraisal and contextualisation. The following
sections will describe a number of issues which should be taken into
consideration when interpreting and reporting data on restrictive
interventions.
Issue 1: Practice quality, the last
resort, least restrictive, poor
practice and abuse
Numbers and statistics are often used alongside headlines or state-
ments that suggest that due to their frequency of usage, restrictive
interventions are not used as a last resort or that they are over relied
upon. For example, Agenda (2017) stated that “Around 1 in 5 women
(6 393 female patients) admitted to mental health facilities were phys-
ically restrained, despite guidance it should be used as a last resort”.
Guidance states that if a restrictive intervention has to be used, it must
always represent the least restrictive option to meet the immediate
need (Department of Health, 2014).
Unfortunately, looking at numbers alone does not actually provide evi-
dence as to whether physical restraint was the least restrictive option or
used as a last resort, nor does it uncover poor practice or abuse. One
of the most important figures when establishing whether a service uses
restrictive interventions as a last resort is the number of incidents that
Chapter 2: Relying on numbers: 25
are not managed using restrictive interventions but by using primary or
secondary strategies. Numbers alone do not indicate anything about
the standard of a service’s wider restrictive intervention practice, such
as robust policies, training programmes, care plan quality, safety pro-
cesses, debrief procedures, as outlined by the Department of Health
(2014; 2015). An example of this in Box 1, below.
Box 1: Do numbers correlate with poor practice or abuse? – an
illustrative example
Service A and Service B care for a similar patient population
and have the same number of beds and occupancy level.
Service A reports five restraints, while for the same timeframe,
Service B reports 50. Using numbers alone, Service A ‘sounds
better’ than Service B. However, upon further investigation of
the incident accounts, the five restraints reported by Service
A were ‘heavy handed’, carried out by untrained staff using
non-approved techniques, and were ‘unjustified’ in the eyes of
the Mental Health Act Code of Practice (2015), i.e. in response
to low level behaviour which could have been managed via
de-escalation. On the other hand, the 50 restraints reported by
Service B, were justified in response to high-risk behaviour that
was unmanageable by any other short-term method, and fully in
accordance with the Mental Health Act Code of Practice (2015).
The factors which support the development of a culture not reli-
ant on restrictive interventions have been the subject of extensive
research in healthcare settings internationally. Many of these factors
are highlighted in Colton’s (2004) nine domain checklist, which pro-
vides organisations with a systematic approach to the reduction of
seclusion and physical restraint, as detailed in Box 2. When these
areas are systematically addressed, restrictive interventions have been
successfully reduced in services (Bjorkdahl, Hansebo, & Palmstierna,
2013). An example of how this manifests in clinical practice is detailed
in Box 3. Factors considered might include the quality of the service’s
restrictive intervention reduction programme, individualised care plans
and advance statements, the programme of educational and occu-
pational activities, among many others.
College Report CR220 26
Box 2: Summary of Colton’s (2004) checklist
1. Leadership
2. Orientation and training
3. Staffing
4. Environmental factors
5. Programmatic structure
6. Timely and responsive treatment planning
7. Processing after the event (debriefing)
8. Communication and consumer involvement
9. Systems evaluation and quality improvement
Box 3: Colton’s (2004) checklist in clinical practice – an
illustrative example
Rachel, a 42-year-old lady admitted to an in-patient intellectual
disability service, is sitting in an armchair on the corner of a ward,
occasionally muttering to herself and biting her nails.
Scenario 1 Scenario 2
Service A has strong leadership
and management. Staff are
confident that their managers
will support them with
their decisions. There is an
experienced nursing team who
all know Rachel well. The ward
is well staffed, and therefore
staff have time to spend with
patients and respond to their
needs. Her key nurse developed
an extensive care plan which
detailed how Rachel presents
when she is upset or agitated,
and how to respond to her in
these situations. The team know
that when she behaves in this
way, Rachel is experiencing a
problem she needs help with,
as after a previous incident
was reviewed, in which Rachel
became violent and destroyed
property on the ward, trigger
factors were identified and
strategies put in place.
One of Rachel’s support workers
notices she has withdrawn,
and approaches her sensitively,
asking if she would like a chat.
Rachel confides that she has had
an argument with her mum over
the phone and is feeling a bit low
and upset. They talk it through
and Rachel calls her mum back
to resolve things. Rachel feels
better and reengages with
everyone on the ward. There is
no further incident.
Service B is currently
experiencing a staffing crisis.
Leadership is poor, staff
are experiencing stress and
burnout, and there is a high
rate of sickness. The ward
is currently being staffed by
agency workers. Many of them
have never worked on this ward
before, and didn’t get a very
good handover. They haven’t
had any time to read the care
plans and, as Rachel’s key
nurse has been off sick for 6
months, the plans haven’t been
reviewed and updated. The
nurse in charge assumes her
mutterings are due to psychosis,
and, as she is being quiet and
not causing any trouble, pays no
further attention.
Another patient approaches
Rachel and makes a comment
about how miserable she looks.
This is the last straw for her
and she becomes even more
agitated, verbally abusing the
other patient. This escalates
further into a huge argument.
Nurses begin to approach
the situation. One asks if she
could move into a quiet room
to calm down and places a
hand on her arm to direct her.
Rachel perceives this as a
threat and becomes physically
violent, requiring the initiation of
physical restraint and seclusion.
Chapter 2: Relying on numbers: 27
The ‘last resort’ concept has gained prominence in recent years.
The Department of Health (2014, p.9) states that services should
be developing cultures where restrictive interventions are only ever
used when all other alternatives have been exhausted and deemed
ineffective (Bonner et al, 2002; Moran et al, 2009; Riahi, Thomson,
& Duxbury, 2016). This makes sense in many scenarios in which
restrictive interventions could be used, such as when staff observe
early signs of a behavioural incident developing, which may be unique
to an individual patient, and initiate early interventions. However, some
scenarios are too high risk to attempt to use a restrictive intervention
as a last resort, for example if a patient runs out into a busy road. In
this instance, physical restraint is likely to be the first resort. Deveau
and McDonnell (2009) argue that the ‘last resort’ principle has the
major drawback that it is an easily voiced rhetorical device and very
difficult to observe or challenge (p.175). This opinion was echoed by
Citarella (2013, p.1) who noted that all policies concerning physical
restraint emphasise that it should be the “last resort response, indeed
Castlebeck Ltd’s [the service provider of Winterbourne View] own
policy concerning physical restraint was no exception and yet it bore
no resemblance to the practice filmed by an undercover journalist”.
Uncovering poor or abusive practice
The Department of Health (2014) states that if restrictive interventions
are carried out for any other purpose than to take immediate control
of a dangerous situation where there is a real possibility of harm to the
person or others if no action is undertaken, concerns should always
be escalated through local safeguarding procedures and protocols.
Without a clear ethical basis and appropriate safeguards, such acts
may be unlawful. Again, establishing the presence of poor practice, or
indeed abuse, is not possible from figures and data. Lower numbers
are meaningless, if the interventions forming those low numbers were
either unjustified or disproportionate to the risk posed. Establishing
poor or abusive practice is challenging, especially if people are deliber-
ately hiding their wrongdoing, as was the case at Winterbourne View.
A current oversight is the lack of focus on routinely collected data on
patient [and staff] injuries resulting from physical restraint, despite the
findings of the Serious Case Review, which highlighted that patients at
Winterbourne View sustained numerous significant injuries following
restraint, including broken bones and teeth (Flynn, 2012), which was
certainly a missed indicator of the level of abuse.
College Report CR220 28
Issue 2: Definitions and degrees
of restrictive interventions
One of the main problems with restrictive interventions data, par-
ticularly relating to physical restraint, is that the data is self-reported
by service providers who are utilising their own definitions which
may not be aligned with the definitions provided by the government
(Department of Health, 2014; 2015). This is partially related to the
volume of Management of Violence and Aggression (MVA) training
providers commissioned by care services, all of which use different
techniques and terminology. This currently precludes the meaningful
pooling and comparison of data between services.
Commentators tend to perceive the term ‘physical restraint’ as always
involving patients being held on the floor, for example “pinning learning
disabled to the ground” (Citarella, 2013, p.1). However, this is not the
case. The Mental Health Act Code of Practice (Department of Health,
2015, p.295) provide the following definition, “Physical restraint refers
to any direct physical contact where the intention is to prevent, restrict,
or subdue movement of the body (or part of the body) of another
person”. Mind (2011) found that the vast majority (91.4%) of physical
restraints were not in the prone (face down) position.
Within most programmes of taught MVA techniques, there are levels of
restraint from a lower to a higher intensity which are initiated depend-
ing on a number of factors, most importantly the level of behaviour
demonstrated by the patient. Table 2 details an example of the levels/
intensity of physical restraint. As is evident, a stage 1 hold looks very
different and is much less restrictive than a physical restraint in the
prone or supine position. Another important factor is the duration of
the physical restraint, and the interaction between duration and the
holds/techniques used, as there are demonstrated links between
long instances of physical restraint in the prone position, and patient
death (Duxbury, Aiken, & Dale, 2011). The example in Box 4 demon-
strates this point. Little attention is given to these nuances within the
reporting of physical restraint statistics, which means that all types
are collated and reported together.
Chapter 2: Relying on numbers: 29
Table 2: Example of MVA hold/ technique levels/intensity
MVA hold/technique Description
Stage 1 hold Patient held at elbow.
Stage 2 hold Patient held at elbow and wrist.
Figure-of-four hold Patient held at wrist and by over
reaching arm.
Finger and thumb hold More containing hold. Patient held by
arm placed inside the patient’s, and
finger and thumb held without flexion
beyond 45°.
Forearm hold Inside arm hold with hand upon
patient’s wrist.
Palm hold Inside arm hold with hand hold
mirroring patient’s thumb.
Restraint in chair Patient restrained in a chair by staff in
adjacent seats.
Supine Restraint on the ground in a face-up
position.
Prone Restraint on the ground in a face-down
position.
Box 4: Intensity and duration of physical restraint – an
illustrative example
Service A reports five restraints, and Service B reports 50
restraints for the same timeframe. It is assumed that Service A is
demonstrating better practice. However, on further investigation,
all of Service A’s five restraints are in the prone position, for 2 to
3 hours each. On the other hand, 40 of Service B’s restraints are
in the stage 1 hold detailed in Table 2, nine are in a stage 2 hold,
and one is in the prone hold for 2 minutes, prior to turning the
position into supine at the earliest opportunity.
A further area of confusion within recording and reporting is how
to deal with more than one instance of physical restraint occurring
within one overall incident. An example of this is where a person within
restraint appears to be becoming calm, leading to the physical restraint
being ended, but who then begins to become aggressive again as
soon as holds are released. Some services may report this as one
incident in which physical restraint was used twice, while another may
report this as two incidents of physical restraint. This can contribute
to wide discrepancies in rates between services. In such instances,
the antecedent to the physical restraint is likely to be the same as that
immediately prior, with the same staff members involved etc. As such,
it makes sense to have one overall incident report, in which multiple
restraints can be recorded to reduce the burden of paperwork and from
which the exact numbers of physical restraint used can be identified.
College Report CR220 30
Failure to record or under-reporting
There are also instances of staff and services either unintentionally or
intentionally under reporting rates of restrictive interventions. This can
range from poor or inconsistent record-keeping, to the intentional misrep-
resenting of events within incident records or failing to report incidents, in
order to keep levels looking low. In 2012, the CQC (2012, p.42–43) found
that not all service providers recognised that their practices constituted
restrictive interventions, and were therefore not documented as such:
z“We were advised by the registered manager that figure of four
and thumb holds are used… the registered manager did not
recognise this as restraint… it was evident there was not a clear
plan or understanding of… what constituted restraint and what
was reportable as restraint.
z
“We found a number of incidents where seclusion had been used
and not recognised… a patient was being cared for separately
by two staff in the management suite... While it was clear that
this patient needed to be cared for in segregation due to the
threat she posed to other patients and staff, the service was not
managing this as seclusion. The service stated that the patient
was in ’therapeutic segregation’.
This issue was reported as an ongoing concern in the recent Care
Quality Commission report (2017). ‘The state of care in mental health
services 2014 to 2017’, which stated that a number of instances
were found where staff were not recording all incidents of restraint,
seclusion or long-term segregation. Box 5 provides a transcript from
the ‘Undercover Care: The Abuse Exposed’ Panorama documentary
(BBC Panorama, 2011), where the undercover journalist and Wayne
Rogers, the ring leader of the abusive group of staff at Winterbourne
View, are discussing the fraudulent record-keeping of an incident of
physical restraint. A similar transcript could be included from a more
recent documentary which highlighted widespread abuse within a
youth custody centre (BBC Panorama, 2016), in which staff were
deliberately concealing their behaviour out of sight of CCTV and cov-
ering up violent incidents to avoid investigation (Horn, 2016). Clearly,
this practice happens to an unknown extent, and has proved difficult
for regulators to highlight, as noted by Flynn (2012, p.91): “How the
recommendation rendering restraint the intervention of last resort will
address the falsified recording of restraint events witnessed during
the Panorama broadcast is not clear.”
Chapter 2: Relying on numbers: 31
Box 5: Transcript from the “Undercover care: The abuse exposed” Panorama
documentary (2016)
Commentator: “Physical restraint, restraint, is such a serious step that each
time it is used, official records must be kept.”
Undercover
reporter:
“I need to go write that statement from earlier. What were you
saying about it?”
Commentator: “Wayne has to describe exactly what led to him dragging a
patient from her bed. His account could be inspected by the
bosses, or even the regulator, to make sure patients aren’t
being abused.”
Wayne: “…was reluctant to rise this morning and refused to attend
to her personal hygiene. At 8:30 and despite staff’s efforts
to direct her and offer of female support, myself and Joe
attended and she became aggressive and started hitting out
at myself. As a result, she was led her from her bedroom by
myself and Joseph.”
Commentator: “That’s not what happened. But a lot goes on at this hospital
that doesn’t go into official records.”
Services which operate in this way are likely to have substantially lower rates of reported
restrictive interventions, despite using interventions at a similar rate to other services. This
could further explain some of the wide variation in reported rates. The most worrying
aspect of such cases is that restrictive interventions are happening in the absence of
any of the relevant governance processes and safeguards which should accompany
their use, as described in Box 6.
Box 6: Consequences of lack of recognition of restrictive interventions
Service A reports 0 physical restraints, while Service B reports 15. The physical
restraints reported by Service B are thoroughly documented, following the
guidance set out in the Mental Health Act Code of Practice (Department of Health,
2015). Having access to these records means that the manager can look at the
statistics and accurately review the care plans of patients involved, training needs
for staff, and assess whether recommended processes are being followed, such as
conducting a debrief and physical health observations. The managers of
Service A think that their service doesn’t use any physical restraint because their
statistics are so low. Due to this, they don’t offer relevant training or audit whether
procedures are being followed and are out of touch with practices happening on
the ward. However, a patient’s family member complains that their relative has
hand-print bruises on his forearms and that none of the staff will say how they
got there. Upon further investigation, it appears that this person is regularly being
restrained by staff to stop him from hitting himself when distressed.
College Report CR220 32
Issue 3: Outliers
The way total rates of restrictive intervention are reported tends to
assume an even, overall level for a ward or a service. However, this
total figure is contributed to by the rates of individual patients, and the
representation of these individuals’ rates within the overall data do not
tend to follow this even distribution. Rather, there is often one, or a
small number of individuals who utilise the highest level(s) of restrictive
interventions (outliers), followed by a few patients who utilise slightly
more, while some patients are not involved in any incidents at all.
So, a ward may have a relatively low level of restrictive interventions
overall, yet have an outlier that inflates the overall rate, skews data,
and masks underlying trends. Box 7, below, demonstrates the effect
of an outlier.3
Box 7: The effect of an outlier on service-level physical restraint
data
Commissioners and regulators raised concerns about the high
level of physical restraint in a service. However, the service
demonstrated that large proportions of the rate related to one
individual patient, who as seen in the pie chart, accounted for
31% of physical restraint for the total service. This patient had
a counterintuitive relationship with restraint, which for them
served a containing function.
This effect was also reported in a statement issued by Northumberland,
Tyne and Wear NHS trust following publication of the MIND report
(2013): “A small percentage of patients require high levels of restraint
due to the complex nature of their illness. Analysis of our figures has
shown that a small group of less than 50 patients, who demonstrate
very complex and high-risk behaviours, account for over two thirds
of the recorded incidents of restraint” (The Guardian, 2013).
3.
Data used in Box 7, and in Box 8 which follows on, a re from unpublished research
conducted as part of a restrictive intervention audit conducted in 2015. More information
is available from the author on request.
One individual patient
Figure 1: Distribution of physical restraint within the total service
69%
31%
58 other patients
Chapter 2: Relying on numbers: 33
One individual patient
Figure 2: Distribution of physical restraint within the ward
Figure 3: Total number of physical restraints for the ward by month, including the
outlier patient’s data
Figure 4: Total number of physical restraints for the ward by month, excluding the
outlier patient’s data
25%
75%
Total number of physical
restraints for the ward
Total number of physical
restraints for the ward
Box 8: The effect of an outlier on ward-level physical restraint data
The restraint rates of the individual patient from Box 7 had a pronounced effect on ward-level data,
accounting for 75% of physical restraint on the ward.
Figure 3 below shows the total number of physical restraints for the ward by month, including the
outlier patient’s data. Figure 4 shows the rate without this patient’s data. Evidently, the picture
of physical restraint usage for the ward is completely different with this patient’s data removed,
demonstrating how one patient can inflate and skew the overall picture of practice in wards and
services. Despite this, and as shown in Figure 3, the rates of such patients can improve over time,
as longer-term interventions begin to take effect.
0
30
60
90
120
150
0
25
50
75
100
125
150
Jan
Jan
Feb
Feb
Mar
Mar
Apr
Apr
May
May
Jun
Jun
Jul
Jul
Aug
Aug
Sep
Sep
Oct
Oct
Nov
Nov
Dec
Dec
15 other patients
College Report CR220 34
Issue 4: Capturing individual
patient progress, the whole picture
of patient care, and restrictive
interventions
Capturing patient progress
Most providers audit their restrictive intervention reduction pro-
grammes at the service level, looking for a downwards trend on a
bar chart, as seen in Figure 5. This is a useful approach if services
are attempting to measure the effect of a new programme, such
as Positive Behaviour Support (PBS) on overall service restrictive
inter vention rates.
Figure 5: An illustrative example of a decline in restrictive interventions
However, these rates are contributed to by many patients, all at
differing stages of the care pathway. Therefore, these graphs
overlook the progress of individual patients within the service.
The whole picture of patient care and restrictive
interventions
A further consideration when interpreting data is that restrictive inter-
ventions should only be used in instances where staff have to take
immediate control of a dangerous situation in which there is a real
possibility of harm to the person or others if no action is undertaken.
Therefore, this data represents only one element of patient care and
does not capture other domains, such as wellbeing, quality of life,
physical health, engagement with friends and relatives, and occu-
pational activities.
Furthermore, there are often intertwined relationships between dif-
ferent forms of restrictive interventions, such as physical restraint,
mechanical restraint, seclusion, long-term segregation and rapid
0
20
40
60
80
100
120
DecNovOctSepAugJulJunMayAprMarFebJan
Jan
120
100
80
60
40
20
0Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Chapter 2: Relying on numbers: 35
tranquilisation, as detailed in Figure 6. The positive behaviour sup-
port model aims to improve quality of life by better understanding
the function behind challenging behaviour and implementing positive
approaches to address this, thus reducing restrictive interventions.
However, this progression is not always linear. For example, in order to
support the reduction of long-term segregation, an individual patient
is often exposed to a wide range of possible environmental stressors
and this may increase behavioural incidents in the short term, which
may necessitate physical restraint. Yet the patient may simultaneously
experience improved quality of life through the environmental access,
interacting with other people, increased levels of activities, etc.
Figure 6: Inter-related forms of restrictive interventions
It is therefore important to use data to establish the whole picture
of restrictive interventions being utilised for an individual patient or
within a service, such as physical restraint, seclusion and long-term
segregation, alongside other aspects of care. This is to ascertain
that certain restrictive interventions are not being used in place of
another, and to ensure that positive aspects of patients’ care are
also being measured and reported on. This effect is depicted in
Box 9 – Figure 7, which illustrates a seemingly positive decline in
restrictive interventions when viewing physical restraint data in iso-
lation. In this illustrative example, it appears that seclusion is being
used in the place of physical restraint. Therefore, aggregating data
on all restrictive interventions being used with an individual or within
a service provides a more accurate reflection of practice, or the
whole picture of restrictive interventions used with an individual.
Physical retraint
SeclusionLong-term
seclusion
Rapid
tranquilisation
Mechanical
restraint
College Report CR220 36
0
2
4
6
8
10
12
DecNovOctSepAugJulJunMayAprMarFebJan
0
2
4
6
8
10
12
DecNovOctSepAugJulJunMayAprMarFebJan
0
2
4
6
8
10
12
DecNovOctSepAugJulJunM ayAprMarFebJan
0
2
4
6
8
10
12
DecNovOctSepAugJulJunM ayAprMarFebJan
Box 9: Aggregating data on all types of restrictive intervention
The consideration of patients’ wishes is key in the interpretation of
their rates of restrictive interventions, as the experience is highly
subjective. For example, some people with ASD may find the touch
experienced during a physical restraint extremely aversive. Others may
be hypo-sensitive to touch and carry out actions in order to obtain
the deep pressure of physical restraint, or find that physical restraint
provides a ‘containing’ function (Steckley, 2012). For some, the use
of medication may be preferred to physical restraint, for others the
sedative side effects may be too debilitating for them. For some,
Jan
Number of physical restraintsNumber of physical restraints/seclusions
Jan
Feb
Feb
Mar
Mar
Apr
Apr
May
May
Jun
Jun
Jul
Jul
Aug
Aug
Sep
Sep
Oct
Oct
Nov
Nov
Dec
Dec
Figure 7: A
n illustrative example of a decline in the number of
physical restraints
Physical restraint
Seclusion
Figure 8: A
n illustrative example of how aggregating data on all restrictive
interventions provides a more accurate reflection of practice
8
8
10
10
12
12
6
6
4
4
2
2
0
0
Chapter 2: Relying on numbers: 37
the withdrawal of staff during seclusion may be a good outcome,
for others this may be highly aversive. As such, attention must be
paid to individual patients’ preferences in the interpretation of their
restrictive intervention rates, which may be recorded in care plans
or advance statements.
Issue 5: Lack of a benchmark
There is currently limited restrictive intervention benchmarking data
available in the public domain. Benchmarking has a number of advan-
tages in healthcare (Royal College of Nursing, 2017), including:
zproviding a systematic approach to the assessment of practice
zpromoting reflective practice
zproviding an avenue for change in clinical practice
zensuring pockets of innovative practice are not wasted
zreducing repetition of effort and resources
zreducing fragmentation/geographical variations in care
zproviding evidence for additional resources
Benchmarking is essential in order to ensure references to restrictive
intervention rates are not subjective. There is a tendency in official
reports to say that the rate of restrictive interventions is ‘high’- e.g.:
Department of Health (2012). The word ‘high’ is problematic because
it is subjective. What a staff nurse working on a high need medium
secure ward perceives as high may be different to a care worker
employed in a supported living service. A service may appear to
have ‘high rates’ but these are all accounted for by one patient at the
beginning of their care pathway. A service may have high rates, but
these are all restrictive interventions at a lower degree, for example
physical restraints for short durations of time, in low level holds. To
more accurately assess which services truly have the highest levels
(bearing in mind the many reasons why this may be the case), a
benchmark is required which regularly compares rates of restrictive
interventions across services.
A benchmarking exercise was undertaken in 2015 which investi-
gated the use of restraint in mental health, child and adolescent, and
intellectual disability services (NHS Benchmarking Network, 2015).
Data was contributed by 51 NHS trusts and six independent sector
College Report CR220 38
organisations, on 23 415 beds in total, with 2 431 intellectual disability
beds for Phase 2 which captured data for January 2015. Importantly,
the benchmark uses the figure of restraint and prone restraint per 10
beds for one month, which takes service size/capacity into account.
The exercise reported a number of interesting findings. For example,
rates of intervention between secure intellectual disability services
followed a somewhat counterintuitive pattern, see Table 3 and Figure
9. The highest rates of restraint were observed in low secure services
caring for lower risk patients, and the lowest levels of restraint were
reported for high secure services caring for highest risk patients. There
are a number of possible explanations for this. One is that patients
in low secure services demonstrate lower risk but higher frequency
behaviours, and are therefore involved in more restraints. Another is
that patients in high secure services are in a more restrictive physical
and procedural environment, under high levels of observation, or that
higher proportions of patients are treated within conditions of long-
term segregation, all of which affects rates of restraint.
This links back to the point made earlier, about assessing all aspects
of patient care holistically.
Within intellectual disability services of the same category, there were
also significant variations in restraint levels, as evidenced by the ranges
in Table 3. In acute admission, although there was a mean rate of 17.5
restraints per month, individual service rates ranged from 0 to 120. This
was raised by the CQC (2017, p.5): “…we are concerned about the
great variation across the country in how often staff physically restrain
patients whose behaviour they find challenging. This wide variation
is present even between wards that admit the same patient group.”
It is unclear why services of the same category have such varying
rates of intervention. Is the service with the highest rate one to worry
about? Perhaps, but it is also possible they are treating one or a small
number of individuals with high levels of restraint, which has skewed
their service level figure. Or the service may be caring for more com-
plex patients than other services within the same category. Although
services share broad categories, such as ’acute admission, or ‘low
secure’, their patient populations may not be directly comparable.
A number of patient factors have an impact on restrictive interven-
tion rates, which are rarely considered in the interpretation of data.
Recent analysis of restrictive intervention rates have been reported
between patients of differential characteristics within forensic intel-
lectual disability services. Women had significantly higher rates than
men (Chester et al., 2018), and those with ASD had higher rates
than people without ASD (Esan et al., 2015). If service configuration
means that one service has more female patients, or an ASD specific
ward, it might be that rates of restrictive intervention are higher in that
service. While the relationship between mental health problems and
‘challenging behaviour’ in people with ID is complex, multifaceted, and
Chapter 2: Relying on numbers: 39
potentially bidirectional, a more recent study reported that diagnostic
co-morbidity is significantly correlated with aggression, self-injurious
behaviour, and overall challenging behaviour ratings (Painter, Hastings,
Ingham, Trevithick & Roy, 2018). People with more severe mental
health problems exhibited more challenging behaviours, and people
with more severe ASD exhibited more stereotyped behaviours and
challenging behaviour overall.
Occupancy is another factor. If a service has been operating at 80%
capacity, it is likely to have fewer incidents than a comparable service
operating at 100% capacity. Another often-cited disparity between
services of the same category is between those ‘within area’ and
‘out of area’. Out of area services relate to a patient using medium
to long-term services away from their home area (Royal College of
Psychiatrists, 2011) when demand for beds outstrips capacity or
where specialist services are not available locally (Department of
Health, 2012). A number of studies have found that patients sent
to out of area placements are significantly different to those treated
within area. McGill and Poynter (2012) found that out of area patients
were largely young, male, with high rates of challenging behaviour
and⁄or ASD. Allen, et al. (2007) found that predictors of out-of-area
placement included behaviours resulting in physical injury, exclusion
from service settings, a history of formal detention under the Mental
Health Act, the presence of mental health problems, a diagnosis of
ASD and higher rates of behavioural problems. Again, it may be that
services with a high proportion of out of area patients have higher
rates of restrictive interventions.
There were also differences between generic medium and low secure
services, and ID specific secure services, where ID services reported
much higher rates of restraint, see Table 3. This is not an isolated
finding, as a number of research studies have reported increased
rates of incidents among in-patients with ID (O’Shea, et al., 2015;
Fitzgerald et al.; 2013; Uppal & McMurran, 2009). The reasons for
this are unclear. One explanation is that the patients with ID display
more challenging behaviours, or present with increased risks than
patients without ID. This is supported by studies which report elevated
risk assessment scores total and subscale scores among in-patients
with ID, as compared to those without (e.g. Alexander et al., 2012;
Morrissey, Milton & Beeley, 2014).
College Report CR220 40
Table 3: Mean and between service ranges of restraint per 10 beds
for one month in ID services*
Service category Mean Range N services reporting
above mean
Acute admission 17.5 0 − 120 5
Low secure 10.2 0 − 33 5
Medium secure 6.8 0 − 25 4
High secure 0.7 n/a* n/a*
*As there is only one high secure ID service, there is no comparison data.
Throughout chapter 2, we have demonstrated a number of problems
when attempting to assess restrictive interventions practice by solely
relying on total numbers. These problems are summarised in Box 10.
Box 10: Problems with using numbers to assess restrictive
interventions practice
Numbers alone:
zdo not demonstrate over-reliance on restrictive
interventions, last resort/least restrictive practice,
correlate with the overall standard of a service’s restrictive
intervention practices, or uncover poor practice or abuse
zare largely self-reported by services, using their own
definitions of restrictive interventions, and do not
discriminate between degrees of restrictive intervention
zdo not account for the impact of ‘outliers’
zdo not capture the whole picture of care and individual
patient progress
zare difficult to interpret due to the absence of a publicly
available benchmark.
0
2
4
6
8
10
12
Figure 9: Rates of restraint for one month, per 10 beds, ID vs.
generic secure services
8
Generic
high
secure
ID high
secure
Generic
medium
secure
ID medium
secure
Generic
low secure
ID low
secure
10
12
6
4
2
0
Chapter 3: Critique of current guidance on the recording, monitoring and regulation of restrictive interventions 41
It has become clear that there are problems with relying on data and
statistics alone when assessing restrictive intervention practices within
ID services, and that there is a need for further guidance in this area.
This chapter will summarise and critique current guidance on the
recording, monitoring and publishing of restrictive intervention data.
Recording
The primary function of incident records are to document on a micro
level, the behaviour displayed by a particular patient on a given day,
and the way in which this behaviour was managed. These documents
contain critical information on how the staff and service caring for
an individual patient contribute to a developing knowledge of the
patient’s triggers to aggression and violence, the ongoing process of
the assessment and management of risk, and safeguarding. These
documents are kept for a number of years and can be referred to in
the case of litigation by the patients and staff members involved in
the incident.
Regarding the recording of restrictive intervention incidents, the
Department of Health (2014) emphasises the need for rigorous
reporting arrangements and is quite prescriptive about the need for
a combination of quantitative and qualitative data:
“Following any occasion where a restrictive intervention is used…
a full record should be made. This should be recorded as soon as
practicable (always within 24 hours of the incident). The record should
allow aggregated data to be reviewed and should indicate:
zthe names of the staff and people involved
zthe reason for using the specific type of restrictive intervention
(rather than an alternative and less restrictive strategy)
Chapter 3:
Critique of current
guidance on the recording,
monitoring and regulation of
restrictive interventions
College Report CR220 42
zthe type of intervention employed
zthe date and the duration of the intervention
z
whether the person or anyone else experienced injury or distress
zwhat action was taken.”
The Mental Health Act Code of Practice (Department of Health, 2015)
provides slightly different recording guidelines for each type of restric-
tive intervention, as detailed in Table 4. It also makes suggestions,
such as evidencing that:
a
verbal de-escalation is maintained through restrictive
interventions
b a doctor attended in response to staff requests concerning
a psychiatric emergency, whether in relation to medication,
restraint or seclusion (if relevant) (p.295)
c
family members were informed in accordance with any prior
agreements (p.295).
The quality and standards of restrictive intervention records com-
pletion has been criticised. Citarella (2013, p.1) highlighted that at
Winterbourne View, references to patients “having an unsettled day”
were frequently used as justifications for physical restraint. The CQC
(2012, p.23) stated the incident reports they inspected during their
national review of services; “Incident reports were not always com-
pleted appropriately… There was no evidence that the poor recording
of incidents was picked up at any level in the organisation.” This is
not acceptable.
Chapter 3: Critique of current guidance on the recording, monitoring and regulation of restrictive interventions 43
Table 4: Department of Health (2015) restrictive intervention
recording guidelines
Physical restraint Where physical restraint has been used,
staff should record the decision and the
reasons for it, including details about how
the intervention was implemented and the
patient’s response (p.296). A member of staff
should monitor the individual’s airway and
physical condition to minimise the potential
of harm or injury. Observations, including vital
clinical indicators such as pulse, respiration
and complexion (with special attention for
pallor/discolouration), should be conducted
and recorded (p.295).
Mechanical
restraint
The patient’s clinical record should provide
details of the rationale for the decision to
mechanically restrain them, the medical and
psychiatric assessment, the patient’s condition
at the beginning of mechanical restraint, the
response to mechanical restraint and the
outcomes of the medical reviews (p.297).
Rapid
tranquillisation
Records should indicate the reason for the
use of rapid tranquillisation and provide a full
account of both its efficacy and any adverse
effects observed or reported by the patient
(p.299).
Seclusion The seclusion record should provide the
following details (pp.307–308):
who authorised the seclusion
the date and time of commencement of
seclusion
the reason(s) for seclusion
what the patient took into the seclusion
room
if and when a family member, carer and/
or advocate was informed of the use of
seclusion
15-minute recordings by the person
undertaking continuous direct observation
details of who undertook the independent
Multidisciplinary team (MDT) review, their
assessment and a record of the patient’s
condition and recommendations
details of who undertook the scheduled
MDT reviews, their assessment and a
record of the patient’s condition and
recommendations
the date and time seclusion ended
details of who determined that seclusion
should come to an end.
Long-term
segregation
No specific instructions provided on recording
instances where a patient is cared for in long
term segregation.
College Report CR220 44
Monitoring
There has been a recent initiative to move beyond simply recording
or documenting incidents at the micro level, to using this data at
the macro level to monitor and minimise restrictive interventions.
Therefore, ideally, a services’ system of recording will also allow the
exploration of incident reports to facilitate the monitoring of restrictive
interventions. The Department of Health (2014) also emphasises the
importance of collation and monitoring of data on restrictive inter-
ventions, however, the guidance is much less prescriptive here. The
document states that restrictive reduction programmes should be
based on the principles of ‘data-driven quality assurance’ (p.22) and
‘data informed practice’ (p.32). But that is where the guidance ends,
leaving the question, how exactly should restrictive interventions be
monitored in services?
The use of data to support restrictive intervention reduction is a prac-
tice which is patchy across services. Data has been described as a
vital component of the PBS approach, which is concerned with the
science of behaviour change, thus requiring observable measure-
ments (Bowring, 2015). Bowring describes five purposes of data in
relation to PBS:
1
To determine the relevance of PBS interventions, and intervention
should only occur following detailed consideration of the issue
and whether it warrants any intervention.
2
To analyse the function or purpose of any problem behaviour
objectively which helps select the most appropriate, person-
centred intervention.
3
To measure changes in behaviour and study the impact
and effectiveness of interventions, by maintaining direct and
continuous contact with the behaviour under investigation.
4 To measure the acquisition of new skills and to assess whether
these last and are being used in different settings (they have
generalised).
5 To measure lifestyle changes and the achievement of quality of
life outcomes.
Following their national review of services, the CQC (2012, pp.42–
43) highlighted that the services which were compliant with their
inspection criteria recorded incidents of restrictive interventions and
analysed them to look for trends. Services learned from this and fed
information back into people’s care plans to reduce the chances of
restraint being needed in the future. For example: “The care plans
we looked at showed us that incidents of challenging behaviour had
been reviewed and analysed at each weekly meeting. When triggers
Chapter 3: Critique of current guidance on the recording, monitoring and regulation of restrictive interventions 45
to a young person’s challenging behaviour were identified, the care
plan was amended and this was confirmed by the young people we
sp o ke to.”
Publishing
Further to the guidance on reporting, and recommendations on
monitoring, the guidance states that “Accurate internal data must be
published by providers including progress against restrictive restraint
reduction programmes… in annual quality accounts or equivalent”
(Department of Health, 2012, p.11). Again, however, the document
gives no guidance as to exactly what services should be publishing.
Few services routinely publish this data, and as such, there is very
limited information in the public domain. On the other hand, in the
absence of prescriptive guidance on exactly what to publish, services
are currently free to set their own reporting parameters, which could
lead to misleading reports, and further difficulties in comparing rates
between services.
Inspection/regulation
While regulators always ask questions about restrictive interventions
(Kelsall and Devapriam, 2015), inspectors largely rely on data and
statistics to make assumptions about restrictive intervention practice.
This fails to take into account a number of the problems with this
data that have been described earlier in this report. This is a critical
challenge facing regulators. Table 5 describes and critiques the data
typically requested by the CQC prior to and during inspections of
intellectual disability services.
Table 5: Information on restrictive interventions requested by the CQC
Total incidents for a whole
service in the last 6 months:
Seclusion
Long-term segregation
Restraint
Prone restraint
Does not capture:
4Whole service change over
time
4Proportion of restrictive
interventions accounted
for by individual patients,
particularly the impact of
outliers/new admissions
4Individual patient progress
4Information on intensity of
the holds used or intervention
duration
4Any comparison to a publicly
available benchmark
4Information on injuries.
How many of the ‘prone
restraints’ resulted in rapid
tranquilisation?
On how many different service
users was restraint used?
College Report CR220 46
In chapters 2 and 3, the current approach to monitoring of restrictive
interventions in ID services, which relies mainly on the analysis of
service defined and provided data, is critiqued. A number of recom-
mendations are made relating to the recording, monitoring, publishing,
and regulation of restrictive interventions practice.
Recording
Recording recommendations relate to improving the quality of inci-
dent reporting systems and information technology (IT) software/
databases and implementing processes to ensure the quality of
information entered into incident reports. We make the following
recommendations:
1
Services should have a good quality system of recording incidents
of restrictive interventions, which incorporates variables specified
by government guidance (Department of Health, 2014; 2015).
2
Incident records within this system should be well written and
present a cohesive representation of the events leading to,
and during, the restrictive intervention, particularly focusing
on justification for their use, and stating how the intervention
represented the least restrictive option and what physical health
observations were undertaken.
3
Services should consider moving away from paper-based recording
systems, which have limited utility in the monitoring of restrictive
interventions, in favour of IT software packages or databases.
IT software systems are the preferred mode of recording due to
being more robust and their potential to improve the quality of
quantitative and qualitative restrictive interventions data
Chapter 4:
Recommendations on
recording, monitoring and
regulation of restrictive
interventions
Chapter 4: Recommendations on recording, monitoring and regulation of restrictive interventions 47
4
Such systems should be developed in conjunction with all
stakeholders of the software, including the individuals who will
be entering incident reports, and those who will access the data
for monitoring/regulation.
5
Software developers should consider ‘forced response’ formats to
ensure that all required data is completed within incident report entries.
6
Software should bte kept up to date, with new patient details
recorded on their admission to the service, new staff member
information recorded on their appointment, and particular MVA
techniques taught in the service.
7
Software should be set up to prompt users entering data to
ensure their incident report demonstrates compliance with
current government guidance (Department of Health, 2014;
2015), with statements such as ‘Describe how this intervention
represented the least restrictive response to the patient’s
behaviour’ or ‘Describe the physical health observations which
were undertaken during the restrictive intervention’.
8
The system should be reviewed and updated on an ongoing
basis, to maintain its quality and utility.
9 It is recommended that staff who are required to write incident
reports as a requirement of their role are given full training in the
correct process. This training must emphasise the importance
of quality incident reports, and cover government requirements
(Department of Health, 2014; 2015).
10
Services should provide supervision and mentoring to staff in
this element of their role.
11 Incident reports should be checked and signed off by a senior
member of staff.
12 Services should regularly audit incident reports to ensure they
meet the required standard.
Monitoring and regulation
In this section, we make recommendations which will assist services, reg-
ulators, and other stakeholders to analyse, interpret and report restrictive
interventions data, and to assess wider restrictive intervention practice quality.
13
Services should generate statistics/reports on restrictive
interventions as defined by the Department of Health (2014;
2015), for any reasonably requested timeframe on a whole
service, ward, and individual patient level.
College Report CR220 48
14 Service/ward level reports should include:
a Total frequency of each restrictive intervention
b Total number, level and type of incidents which do not result
in restrictive intervention
c
Duration of restrictive interventions, with a full categorical
breakdown in addition to average and range
d
Holds/techniques used for physical restraint, with a full
categorical breakdown (this figure is likely to be higher than
the total frequency of restrictive interventions, due to incidents
of restraint which utilise more than one holding technique)
e
Trends in rates over time, day of the week, week in the month,
and month of the year. If incidents peak on particular days or
at certain times, this can direct the exploration of the activities,
procedures, staffing levels and interventions of an individual/
ward/service, as necessary
f An investigation or analysis of decreases, increases and/or
maintenance
g
Total number and extent of any patient injuries sustained
within restrictive interventions
h
The number of individual patients represented within the data,
expressed as a percentage of total patients treated within
this timeframe
i
Progress of all patients against the aims of the services
chosen restrictive intervention programme, ideally using the
‘traffic light audit’
j
The contribution of individual patient rates to the overall total
for the ward or the service. If there are any outlier(s) which
significantly affect the overall total, or trends, report rates with
and without the outlier data
k Details of how rates compare to a national benchmark
l
Number of beds, and occupancy level of service for timeframe
m
Cohort characteristics, such as gender, ethnicity, diagnoses,
behavioural and/or offence profile.
Chapter 4: Recommendations on recording, monitoring and regulation of restrictive interventions 49
15 Individual patient level reports should include:
zItems a−m, as on the previous page
zA brief description of a patient’s demographic information, and
psychiatric and forensic history (where relevant)
z
Services should be able to generate statistics on the levels of
restrictive interventions for the entirety of a patient’s admission
and, if available, pre-admission
z
Reports should include details of the patient’s management
plan, e.g. level of observation, medication, level of engagement,
assessments and treatment plans.
We also make a number of recommendations in order to overcome
some of the identified limitations with restrictive interventions data.
Overcoming issue 1: Assessing practice quality,
over-reliance, the last resort, least restrictive, poor
practice and abuse
Assessing the quality standard of a service’s restrictive inter-
vention practices:
16
To truly capture the quality of a service’s restrictive intervention
practice, there must be less focus on the number of restrictive
interventions, and more on a service’s adherence to the standards
outlined by government guidance (Department of Health, 2014; 2015).
This is likely to encompass restrictive intervention factors such as:
a
Staff training in primary and tertiary strategies, training in
safe restrictive intervention techniques, restrictive intervention
reduction programme, the quality of advance statements
and individualised restrictive intervention care plans, physical
health observations and debriefing processes
b
Wider practice quality issues, such as leadership, staffing
levels, environmental considerations, engagement, patient
assessment, therapies and management.
College Report CR220 50
Assessing the principles of last resort and least restrictive
practice
17
It is recommended that qualitative incident accounts, or a
representative subsample thereof, are inspected on an incident-
by-incident basis in order to assess whether the record adheres
to the principles of least restrictive practice. For example: Was
the decision-making process for restrictive intervention by staff
described? Was this decision justified, for the patient’s own, or
others’ safety? Was it reasonable and proportionate? Was it the
least restrictive way the behaviour described could have been
managed? Was the intervention subject to regular review by
staff and curtailed as quickly as possible? This is a much more
time-consuming task, but a much more meaningful one, and
is dependent on a good standard of written incident reports.
Uncovering poor practice, or abuse of restrictive interventions
18
If it appears that restrictive interventions are being carried out for
any other purpose than to take immediate control of a dangerous
situation, it is recommended that concerns should be escalated
through local safeguarding procedures and protocols.
19
It is recommended that regulators request information on the
number patient injuries sustained during restrictive interventions,
except where these relate primarily to instances of self-harm/
injury.
20
Regulators should cross reference data on restrictive interventions
with information from other sources, including their observations,
patient and carer reports, safeguarding referrals, police reports, etc.
Overcoming issue 2: Definitions and degrees of
restrictive interventions
21
It is recommended that policymakers develop a framework of
restrictive intervention severity/intensity. This should encompass the
full range of physical restraint techniques used by multiple training
providers, as well as the duration of physical restraint, seclusion,
and long-term segregation. This would provide an element of
standardisation, move towards more consistent recording between
service providers, and support the comparability of data.
22
It is recommended that in the interim, services should record,
monitor, and report the full framework of techniques used.
Chapter 4: Recommendations on recording, monitoring and regulation of restrictive interventions 51
23
Services which report comparatively lower numbers of restrictive
interventions should have their practice inspected as rigorously
as those which report higher numbers.
Overcoming issue 3: Accounting for the impact of
outliers
24
It is recommended that services provide a breakdown of
restrictive intervention data from the total number for a whole
service, to the ward level, and individual patient level. This can
be done utilising widely available software, Microsoft Excel, using
the Pivot Table function, which can facilitate the analysis of a
large, detailed datasets quickly and easily. This function can
also be used to view the proportion of restrictive interventions
accounted for by individual patients, and ward or service level
data can be viewed and presented with and without the data of
individual outlier patients.
25 Service providers can also report multiple measures of central
tendency, such as the median, in addition to the mean, which is
particularly susceptible to the effects of outliers.
Overcoming issue 4: Capturing the whole picture of
patient care and restrictive interventions
Establishing individual patient progress
26
Services should analyse the progress of individual patients for a
clearly specified timeframe. This can be achieved using the ‘traffic
light’ audit method. The traffic light method involves viewing the
restrictive interventions rates of all patients within the service,
and then categorising them into one of the three categories
outlined in Box 11. This can be useful through the audit cycle or,
ideally, the whole duration of a patient’s admission as detailed
in Table 7. This should include the number of patients treated
in the timeframe specified, and the proportion who have been
involved in restrictive interventions.
27
Services should request information about the levels of restrictive
interventions and management plans from the referring service,
report these alongside current levels, and pass on this information
when discharging patients, with clear reporting parameters, if
this information is available.
College Report CR220 52
Box 11: ‘Traffic light’ restrictive intervention audit method: categories
Capturing the whole picture
28
Services should monitor and report all types of restrictive
interventions used with an individual patient, using
visual aids such as the example depicted in Figure 10.
This should take into account any patient preferences as specified
in advance statements or similar, and recognise that this data
represents only one element of patient care, and does not capture
other domains, such as wellbeing, quality of life, physical health,
Table 6: ‘Traffic light’ restrictive
intervention audit method: categories
Increase/new admission
Low or stable
Decrease/discharged
Table 7: An illustrative example of the ‘traffic light’ restrictive intervention audit
method demonstrating an individual patient focus
Patient
name Jan Feb Mar… …Oct Nov Dec Status
Isabelle 11 Increase
Emma 1 315 Increase
Pauline 94New admission
Justine 42 New admission
Fauzia 3 3122Low/stable
Joanne 11 Low/stable
Julia Low/stable
Jessica 34 19 10 16 916 Decrease
Kerry 9911 645Decrease
Michelle 52 82 35 14 714 Decrease
Alia 18 18 11 242Decrease
Jeanette 22 27 30 16 12 19 Decrease
Chapter 4: Recommendations on recording, monitoring and regulation of restrictive interventions 53
engagement with friends and relatives, occupational activities,
etc.
Overcoming issue 5: The absence of a publicly
available benchmark
29
National benchmarking data must be strengthened via the
inclusion of a wider range of variables, and be publicly available
to all.
30 Benchmarking processes must consider the highlighted issues
with restrictive interventions data, and take steps to counter
these in reports.
Using data to support the reduction of restrictive interventions
31
Services must demonstrate the use of data to support restrictive
intervention reduction.
a
This might involve regular reviewing of incidents and
subsequent debriefs, identifying any triggers, or learning
points and feeding these back in to care plans. It could involve
viewing of restrictive intervention rates in team meetings and
care reviews, identifying patterns of use, and addressing any
underlying reasons for these. This could involve highlighting
particular times of day where incidents peak (as demonstrated
in Figure 10), particular days of the week (as demonstrated
in Figure 11), differences between shift patterns, etc. When
reviewing individual patients, these factors are likely to be
highly personalised and their care plans should reflect this.
0
2
4
6
8
10
12
0
2
4
6
8
10
12
DecNovOctSepAugJulJunM ayAprMarFebJan
0
2
4
6
8
10
12
DecNovOctSepAugJulJunM ayAprMarFebJan
0
2
4
6
8
10
12
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Physical restraint Seclusion Rapid tranquilisation
Figure 10: A
n illustrative example of how
restrictive intervention rates for an individual
8
10
12
6
4
2
0
College Report CR220 54
Figure 11: An illustrative example of incident patterns at different times of the day
Figure 12: An illustrative example of incident patterns at different times of the week
b
Services may also choose to record a wider range of
measures in addition to restrictive intervention rates, as
identified by Bowring (2015). These might include behaviour
rating scales, quality of life measures, patient satisfaction etc.
Publishing
32 Any publication of restrictive intervention data should adhere to
the above guidance.
33 Reports should relate to a clearly specified timeframe.
0
2
4
6
8
10
0
5
10
15
20
25
30
7–8 am
8–9 am
9–10 am
10–11 am
11am–12 pm
12–1 pm
1–2 pm
2–3 pm
3–4 pm
4–5 pm
5–6 pm
6–7 pm
7–8 pm
Monday
No. of incidents No. of incidents
30
10
25
8
20
6
15
4
10
2
5
0
0
Tuesday
Wednesday
Thursday Friday Saturday Sunday
Conclusions 55
In the years following the Winterbourne View abuse scandal, there
has been an understandable level of concern surrounding the use
of restrictive interventions involving people with mental disorders
and intellectual disabilities, and a call to reduce such interventions.
This concern has been evident in the reporting of statistics and data
pertaining to such practices, characterised by emotive headlines
and reports. This reporting has arguably contributed to an increasing
contrast between the public face of these interventions, compared to
clinical reality. These points are not intended to downplay concerns
about restrictive intervention use, but to highlight the importance of
transparent, ethical and authentic data reporting ( Marco and Larkin,
2000) to support the shared aim of all stakeholders in restrictive
intervention reduction.
Data monitoring has numerous benefits, including the potential to
support restrictive intervention reduction, but needs to be recognised
as one tool in the toolbox, of a long-term, multicomponent, whole
service approach, such as that described by Colton (2004). Progress
has been made in the form of rigorous recommendations relating to
recording of restrictive interventions at the service level, in Positive
and Proactive Care: reducing the need for restrictive interventions
(Department of Health, 2014). However, the monitoring of data on
restrictive interventions appears to be a neglected and underde-
veloped area within services (CQC, 2012), and guidance on data
monitoring has been less prescriptive. Furthermore, the complexity
of this data is often unappreciated, and its interpretation needs to be
approached in a considered way. This report has highlighted a number
of contextual factors to consider when reporting and interpreting
restrictive interventions data, for all stakeholders. There is clearly a
need for guidance pertaining to the monitoring and communication
of physical restraint and other restrictive intervention data, for both
service providers and regulators, and starting points are offered in
the form of recommendations. These points can be treated both
as self-assessment audit standards for services and guidance for
regulators.
NHS England and partners are currently working to develop common
definitions, improve recording, monitoring and regulation of restrictive
interventions in in-patient settings for people with ID. The recommen-
dations made in this report will be useful to build on existing guidance
especially for people with ID in in-patient settings.
Conclusions
College Report CR220 56
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#LetsMonitorRIBetter
Contents 61
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13 March 2018)
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#LetsMonitorRIBetter
How to cite this report:
Royal College of Psychiatrists (2018). CR220:
Restrictive interventions in in-patient intellectual
disability services: How to record, monitor and
regulate
© The 2018 Royal College of Psychiatrists
For full details of reports available, please visit the College website at
www.rcpsych.ac.uk/publications/collegereports.aspx
Article
Full-text available
Over the past few decades, care for people with intellectual disability in the UK has moved from long-stay hospitals to the community. As in the general population, a number of these people have mental health and behavioural difficulties for which they may require in-patient services. Consequently, psychiatrists need to be aware of the in-patient mental healthcare provision for these individuals. This article describes the different categories of in-patient bed for patients with intellectual disability and ways to monitor the quality and outcomes of in-patient care.