Nurse threatening an elderly man

Restraint Reduction Language

James Hourihan, Author

Restraint Reduction

The term Restraint Reduction is a fairly logical description of what we are trying to achieve during our training. It’s clear and concise. The problem is, in our experience the primary focus is on physical restraint. It doesn’t address breakaway or other forms of more subtle restraint. As an organisation we are firmly behind the Restraint Reduction Network and our training is certified by BILD Act.

Most organisations we work in partnership with have been engaged in restraint reduction for years. They’re at a point where any restraint they engage in is the minimum in the circumstances, has been reduced over a period of time and they can evidence this through record keeping and consistent language.

Unintended Consequences

In some of our recent experiences, we’ve found a minority of staff and organisations have started to use alternative terminology to describe restraint. We believe this is partly due to the negative connotations of the word restraint and the emphasis on ‘restraint reduction’.

We’ve been hearing more restraint “euphemisms” as a way for organisations to demonstrate they’re using less restraint than they did before. We’ve also encountered organisations who tell us that they’ve reduced the use of restraint, only to find that they’ve been secluding people more frequently or “upping their medication” to manage their behaviour.

What is restraint?

In November 2021 we were in the process of working with an organisation to deliver our BILD Act Certified training to their staff. Part of the process involved a discussion with the organisation about their needs, based on a TNA (Training Needs Analysis). In the course of our conversations, we were both using the word ‘restraint’ to describe some of the requirements of the training. We were pleased to discover that their TNA had identified that any training which included restraint would be minimal. However, on further discussion they kept using the terminology, “full restraint”. When we asked what they meant, they responded, “you know, prone position restraint”.

It became apparent that they only used restraint as a description when the person was being held face down on the floor. If they were held stood up or sat down, they referred to it as “supported holds” or “guidance holds”. This raised alarm bells with us, as it also did with CQC inspectors who queried the techniques being used, the recording of incidents and the circumstances in which techniques were applied. This process of CQC involvement is now ongoing and the organisation has been placed in special measures. But, realistically, it shouldn’t require the CQC to identify problems, we would expect care managers and their staff to identify these problems themselves.

Language

This leads us back to why people use the euphemisms we’ve encountered over the last few years.

  • “I encouraged him to a safe space”
  • “We removed him from the classroom”
  • “They used therapeutic holding”
  • “We guided him to his room” or 
  • “We helped him to sit down”. 

Clearly, a major concern of staff and organisations is that because “restraint” is seen as something negative, they don’t want to be associated with using it on vulnerable people in their care. This can lead them into a game of verbal gymnastics to try to avoid saying they restrained someone. The reality is, all they’ve done is change the language, not the behaviour.

Minimise Impact of Trauma

A major objective of restraint reduction is to minimise the trauma experienced while being restrained. A change in language but not behaviour, does not minimise this trauma.

Far from reducing the trauma, it can belittle the impact restraint has on the person. If, we make it sound like the experience of the person was positive, when in fact it was negative, then we’ve belittled their experience. If we carry on with our restraint behaviours, but dress it up in language to make it sound better, then those people with lived experience have their experiences of restraint downplayed. So, what can we do to minimise the actual trauma rather than downplay it?

Six Core Competencies

In Timian we’d start with the Six Core Competencies(c) These competencies form the backbone of the Restraint Reduction Network approach to reducing restraint and seclusion in health and social care. These include

  • Leadership in organisational culture change.
  • Using data to inform practice.
  • Workforce development.
  • Inclusion of families and peers.
  • Specific reduction interventions (using risk assessment, trauma assessment, crisis planning, sensory modulation and customer services).
  • Rigorous debriefing.

Is There a Solution?

Although the 6 Core Strategies model is a very good place to start. In Timian, we also spend a significant proportion of our courses discussing Core Values. With an emphasis on developing healthy relationships, empowerment, trust and communication. With these in place we can then discuss Invitational Theory and dealing with mistakes.

Discussing and training in core values enables empathy and a foundation for understanding trauma informed care. We examine whether we could implement strategies to avoid restraint, understand why that person is in crisis and ensure we record everything clearly, concisely and honestly.

If we truly want to reduce restraint in education, health and social care we need an open and honest dialogue. We all need to agree when we’re using restrictive interventions and what they are. We need to be clear why restraint is taking place. Restraint needs to be justified in each and every case; ethically, legally and it must be based on trauma informed approaches with staff who are trained to a high standard not just in restraint techniques, but all other aspects of behaviour support.

Restraint can increase trauma and just changing the name of the technique won’t reduce the trauma of the person with lived experience. We need to create a sense of trust between those delivering care services and people with lived experience. Only then can we all say:

In this place and with these people I feel safe

This blog post is an updated post from July 2020

#restraintreduction #training #restraint #healthandsocialcare

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