10. Regulating and accrediting physical restraint

Forensic Nursing Forum

(R) That this meeting of RCN Congress asks Council to lobby UK governments to review, accredit and then regulate national guidelines of approved models of physical restraint

Result

The resolution was passed.

For: 99.8% (470)
Against: 0.2% (1)
Abstain: 1

Debate report

At this lively debate, proposer David King from the Forensic Nursing forum called for a “thorough review” into how physical restraint is taught, accredited and regulated; asserting in his opening argument that “nurses everywhere are dealing with this practical, ethical and moral dilemma every day”. 

Members overwhelmingly spoke in favour of the resolution, calling for the development of consistent and nationally agreed standards, and reiterating the importance of using de-escalation techniques before resorting to physical restraint. 

John Hill from the Scunthorpe branch stressed the particular significance of this issue for nurses working in paediatric and neo-natal settings where it is often necessary to use mild restraint; a view shared by Angela Lee from the Children and Young People: Acute forum.

Catriana Forsyth from the UK Safety Representatives forum pointed out that physical restraint training is required for all door staff in bars and clubs, asking: “How have our patients not been given the same consideration?”. Many highlighted the need for guidelines to take into account the different restraint required for different patients, with Lynne Phair from the Older Peoples’ forum asserting that “one system does not fit all”. 

In his closing comments, David thanked members for giving Congress “so much to think about”. The motion was passed with 99.8 per cent voting in favour.  

Background

Physical Intervention is described by the National Institute for Health and Clinical Excellence (NICE) as ‘a skilled, hands-on method of physical restraint involving trained dedicated healthcare professionals to prevent individuals from harming themselves, endangering others or seriously compromising the therapeutic environment. Its purpose is to safely immobilise the individual concerned’ (NICE, 2005).

The guidance containing this definition is aimed at staff working in in-patient psychiatric settings and emergency departments, and describes what training should be offered to staff. Included in the list are physical interventions, de-escalation techniques, observation and engagement, searching and rapid tranquillisation. However, the guidance offered by NICE fails to specify any particular model of restraint. Consequently, there are many models of training available, from statutory and private providers. The provision of such training is a major business, and the quality of the training can vary. A Google search for “restraint training providers UK” yields over 7,000,000 web hits.

Furthermore, the guidance fails to address the practice of nurses and other clinicians in any of the many other areas of health care practice. For example, the Care Quality Commission recently expressed concern over the lack of regulation over training programmes, and had concerns about the recording and monitoring of restraint practices in a quarter of the 150 hospitals and care homes for people with a learning disability. These concerns arose following the BBC Panorama programme showing physical abuse at the Winterbourne View residential home near Bristol.

There is no regulatory body that oversees the nature and quality of physical interventions training, though some oversight of theoretical content is provided by the National Health Service Counter Fraud and Security Management Service (NHSCFSMS) in their training curriculum, which sets ten mandatory learning outcomes in its publication “Promoting Safer and Therapeutic Services” (NHSCFSMS, 2005).

The Scottish Commission for the Regulation of Care also produced guidance in 2010 which highlighted current legislation. The National Care Standards (2000) make specific reference to the risks, safety of residents and restraint. The RCN in Scotland is expecting the Standards to be reviewed during 2013. In Northern Ireland, current guidance on restraint and seclusion dates from 2005 and is published by the DHSSPS on an advisory basis. The Northern Ireland Human Rights Commission also published general advice from a legal perspective.

NICE is expected to review its guidance on the management of violence and aggression, and this review is likely to include reference to the way in which staff restrain patients (and others) in order to manage violent or risky behaviours.

References and further reading

NHS Security Management Service (2005) Promoting safer and therapeutic services: implementing the National Syllabus in Mental Health and Learning Disability Services London: NHS Security Management Service. Available at: http://62.164.179.12/cms/ImageCache/669D878381A74B1CA1A5A7BB1C15DB0B/277458E85E0F4CBE91BD3C4291DA3F44/PS/psts_implementing_syllabus.pdf (accessed 13/03/13) (Web).

National Institute for Clinical Excellence (2005) Violence: the short-term management of disturbed/ violent behaviour in in-patient psychiatric settings and emergency departments London: NICE. Available at: www.nice.org.uk/nicemedia/pdf/cg025niceguideline.pdf (accessed 13/03/13) (Web).

Scottish Commission for the Regulation of Care (2010) Adult services regulation: guidance on the regulation and the use of restraint Dundee: Care Commission. Available at: www.scswis.com/index2.php?option=com_docman&task=doc_view&gid=357&Itemid=703 (accessed 13/03/13) (Web).