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Like-minded organisations in pursuit of restraint-free services

The use of floor restraint

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CPI Senior Vice President and member of the Restraint Reduction Network Steering Group, Chris Stirling, examines the ongoing debate surrounding the use of floor restraint.

In recent years there has been a lot of debate about floor restraint and in particular, whether ‘prone’ or face down restraint should be banned. Indeed the issue has become such a key topic, it is a focus of the new regulatory inspections by CQC. Whilst there is a great potential for many organisations to re-evaluate their practice and indeed achieve a ‘prone-free’ or even ‘restraint-free’ services in accordance with the ambitions of the Restraint Reduction Network, there will always be some emergency situations in some services where manual restraint, including both prone and supine restraint, is a necessary emergency response to keep service users and others safe.

One of the difficulties with the debate regarding the banning of prone restraint is the fact that many organisation do not fully understand the complexities of the risks attributed to this issue and often cite that there is a need to ban prone restraint because ‘prone restraint causes positional asphyxia’. Positional asphyxia is a multi-factorial event, with body position being one of a range of causative factors. Contrary to popular understanding, restraint-related deaths have occurred in standing, seated, prone and supine positions so the real issue of concern is whether or not any form of manual restraint compresses the chest, compromises breathing along with additional risk factors which may increase the likelihood of an adverse outcome.

A ban on floor restraint (prone or supine) also suggests that staff are actively choosing to undertake such practice. In working towards restraint-free care, organisations have a responsibility to ensure their staff are fully equipped to prevent conflict and other situational factors that are known to be the precursor to containment regardless of the method of containment.  If we can become better at delivering person-centred support and working in ways which minimise conflict and other trigger factors, we can reduce crisis behaviour thereby reducing the use of restraint. However, we must be careful to recognise that in those organisations supporting the most complex individuals, some precipitating events cannot always be prevented.  In circumstances when containment includes the use of manual restraint, it is the organisation’s responsibility to ensure that the use of restraint is not misused or abused.

Additionally, a ban on prone restraint may suggest that supine or other restraint positions are safe and acceptable thereby reinforcing tolerance.  The fact remains that any form of restraint is unpalatable, a potential breach of human rights, and an unwarranted and unjustified event if you are the recipient.  Although legally and professionally we can justify restraint as a risk management intervention designed to protect people from harm, I would never wish to be restrained myself and know that I would fight and struggle to get free.

The recent revision of the Mental Health Act Code of Practice(1) and NICE guidelines(2) reinforce the Department of Health Positive and Proactive Care(3) 2015 publication by giving some clarity on this matter. Rather than suggesting floor or prone restraint be banned, the new guidance says such interventions should be avoided wherever possible and time limited if used in an emergency.  This new guidance will hopefully help organisations give clear and safe policy guidance to employees and will help to ensure the likelihood of a restraint-related death is avoided.

Staff who are required to manually restrain the people they support take on a huge responsibility.  When using restraint to keep people safe, staff have to ensure that such interventions do not harm the individual.  Whilst restraint-related deaths are rare, the impact for everyone concerned is devastating.  As such, manual restraint should only be used as a last resort when all other preventative methods have failed.  As much as is reasonably possible, staff should plan interventions around the specific needs of individuals taking account of any risk factors that might place the person in a more vulnerable position of an adverse outcome arising from the use of manual restraint.   As with any emergency procedure, staff should be competent in the use of manual restraint, must be able to identify the medical warning signs associated with restraint-related harm and must be taught how to respond to a medical emergency should it arise.

1 Mental Health Act 1983: Code of Practice (2015).  London: HMSO
2 National Institute for Health and Social Care Excellence (2015) violence and aggression: short-term management in mental health, health and community settings.  London: NICE
3 Department of Health (2014) Positive and Proactive Care: reducing the need for restrictive interventions.  London: HMSO