Restrictive Practises - Physical Restraint

Aim:

Support the Patient in developing coping strategies before the use of restraint.

What to do:

Ask patient and carer(s) regarding managing distress with preferred choices and primary, secondary and tertiary strategies; consider capacity.

Consider influence/impact of:

• Environmental factors; ward allocation on admission, bed placement; staff/patient mix.
• Psychological causes; pain, discomfort, need, attention.
• Emotional causes; sensory, stimulation/ reinforcement fear, confusion, delirium, poor customer care.
• Physical causes; substance use, delirium, medication induced confusion,.

Pre-plan care using supporting documentation such as person centred care guides, Safety plans, Positive Behavioural Support plans,  risk assessments and SAFEWARDS etc., to aid formulation of behaviour, to ensure physical restraint is not the first approach to managing challenging behaviour.

Review and update risk assessment.

Aim:

Ensure timely and accurate record keeping. Develop robust systems for the implementation of physical interventions and aftercare.

What to do:

Ensure all staff who are involved in physical interventions have completed mandatory training, specifically including life support training and Trust approved intervention training and support available from L&D training staff.

Ensure all staff involved in the management of challenging behaviour have access to supervision and any learning needs are addressed.

Clear documentation on PARIS of rationale for the use of physical interventions and actions following its commencement, including reference to the primary, secondary and tertiary strategies highlighted in the care plan and capacity and consent decisions.

Update and review the clinical documentation regularly including the care plan and risk assessment.

DATIX to be completed for all incidents.

Review and update risk assessment.

Aim:

Positive and proactive support is provided during restraint which is trauma informed, prioritises the patient experience and is the least restrictive necessary at the time.

What to do:

Consider least restrictive practice principles of the Intervention, taking into account safety, Human Rights, patient choice, capacity and dignity.

Ensure all staff are trained in physical intervention techniques to administer intervention/care.

Ensure correct PPE used.

Team to discuss rationale prior to Intervention

Why are we doing this?

What is the risk of doing this?

What is the plan

Consider: expected outcome, contingencies, what are staff roles within the intervention, what factors indicate that risk has reduced, Is it least restrictive necessary?

Aim:

Develop a robust system that ensures that the patient’s physical health is monitored.

What to do:

Monitor and complete physical observations in line with policy using NEWS2 on admission for baseline.

Consider any pre-existing physical health problems and monitoring of this.

During Restraint - physical health monitoring, as possible.

Post Restraint - physical health monitoring every 15 minutes for the first hour, then hourly for 3 hours. If results are normal, routine monitoring as per policy.

All monitoring to be completed on the NEWS2 form and then embed within the electronic system.

If patient refuses or physical health monitoring, visual observation chart should be completed and uploaded.

Assess effectiveness of current physical care plan Ongoing review of physical health management – consider onward referral and routine treatment and any possible interactions.

*Consider both patients and staff

Aim:

Develop a robust system that ensures that the patient’s psychological and emotion wellbeing is monitored.

What to do:

MD Team to include in next (and subsequent) MDT reviews, active measures to assess and promote

• Psychological and emotional wellbeing
• Protection of Family and private life (article 8)

Formulate active plans for maintaining current level of activity and programme of care.

Consider level of support required by patient/staff following any incident for psychological and emotional impact, taking into account individual vulnerability’s and previous trauma experiences.

Consider level of support required by staff/patient following a change in plan of care, such as increased observations, detention under the act, transfer/referral, as result of an incident.

Aim:

Foster a multi-disciplinary approach to care planning for managing challenging behaviour.

What to do:

Clinical review within 24 hours, including Nursing staff and medical staff to review care plan and future plan including person centred care plans, Positive Behavioural Support plans, Safety plans, SAFEWARDS and risk assessments, alongside information gained from this incident to aid formulation of behaviour, to ensure physical restraint is not the first approach for managing challenging behaviour.

Feedback from clinical review to be included in care plan and risk assessment.

Discuss the incident in next MDT ward round/Clinical team review for the patient.

Assess effectiveness of current care plan – consider diagnosis.

Ongoing review of current care plan and routine treatment and any possible onward referral.

Aim:

Support the patient, carer(s), staff and other witness following an incident where physical interventions were used and support all involved to develop their understanding of what happened.

What to do:

Staff to carry out immediate post-incident debrief as described in P&PS Training.

Review incident that led to physical interventions being used, with the patient, carer and/or advocate and signpost to additional support.

Review the positive behavioural support plan, advanced directives and other clinical documentation.

Ensure witnesses are given the opportunity to reflect on their experience of the incident.

Feedback from debriefs to be included in care plan and risk assessment.

Ensure all staff involved have access to supervision.

Identify training needs.