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Since the introduction of the Human Rights Act 1998 and the Mental Capacity Act 2005, there has been more clarity around the rights of vulnerable people and the practice that should be adopted by those caring for them.
Some vulnerable adults may require interventions that include restriction and restraint in order to prevent them from harm and to protect others.
Definition of restriction and restraint
There is no clear definition but we are guided by Codes of Practice relating to particular Acts of Parliament. For instance, the Mental Capacity Act 2005 – Deprivation of Liberty Safeguards states that someone is using restriction or restraint if they:
Use force – or threaten to use force – to make someone do something that they are resisting,
Restrict a person’s freedom of movement, whether they are resisting or not.
What is appropriate restriction and restraint?
National guidance states that:
restraint is appropriate when it is used to prevent harm to the person and it is a proportionate response to the likelihood and seriousness of harm to that person or other people.
However, if the restraint is frequent, cumulative and ongoing, or if there are other factors present, the procedure/s should be reviewed because the person may be being deprived of their liberty.
No one should be deprived of their liberty unless they are detained under the Mental Health Act 1983 or are detained under criminal law.
Reasons for Restriction and Restraint
The following examples are not exhaustive but they are the main reasons for restriction and restraint interventions.
Challenging behaviours frequently pose significant risks either to the person displaying the behaviours or to those around them.
Carers, organisations and paid staff are often required to provide the person with treatment or care that may be against their will, but which is in their best interests. This requires a risk manages approach
Response to an Emergency
Requiring the use of reasonable force to an unforeseen event, for example, someone who is trying to run out of theatre. Any such unplanned action should be recorded .
Restraint can be justified in law where the client gives informed and voluntary consent as part of a planned programme of care.
It is justified in other cases where individuals have a duty of care to restrain the person to protect that person from a greater risk of harm, or to avoid a foreseeable risk of harm occurring to others.
There are a number of Act’s that should be taken into consideration before applying any acts of restriction or restraint. These include: Human Rights Act 1998 (Amended 2004), Health and Social Care Act 2008, Mental Health Act 1983 (Amended 2008), Mental Capacity Act 2005, The Deprivation of Liberty Safeguards 2009, Civil Law and Criminal Law.
Types of Restriction and Restraint
Mechanical and Environmental Restrictions
This may involve the use of equipment. Examples include specially designed mittens; everyday equipment, such as using a heavy table or belt to stop the person getting out of their chair; or using bed-rails to stop the person getting out of bed.
Controls on freedom of movement
Such as baffle locks and keypads; locking doors or sections of the building; restricting the person to particular areas of the building.
Medication is sometimes used as a method of chemically restraining the person, for example, prescribed medication that can induce sedation can also effect restraint.
Medical interventions can sometimes have an unintended outcome of restraining the person. They may require the person to remain in a restricted area, with restrictions around visitors, or any interaction with people other than those paid to care for them.
These types of interventions can impinge on the person’s life such as, catheters or feeding tubes. Additionally, the person may attempt to remove these and restraint could be required to prevent this occurring.
Such medical interventions need to be built into a written procedure and any potential restrictive or restraint practice should be clearly documented.
Psychological restraint includes constantly telling the person not to do something, or that doing what they want to do is not allowed, or is too dangerous. It may include depriving the person of lifestyle choices by, for example, telling them what time to go to bed or get up. Psychological restraint might also include depriving individuals of equipment or possessions that they consider necessary to do what they want to do, for example, taking away walking aids, glasses, outdoor clothing or keeping the person in nightwear with the intention of stopping them from leaving
Physical restraint intervention involves direct physical contact by one person against another with the intent to prevent the person’s freedom of movement.
This type of intervention can involve the use of physical force to ensure that the person does not move around freely, for example using physical pressure to keep an individual seated or holding the person down on the floor. Such restraint should always involve the least restrictive practice and only be carried out by those trained in the restraint technique being employed, and which is in accordance with the restraint procedure for the individual. The training should be proportionate to the situation and should reflect National Minimum Standards at the required level.
Any physical intervention must not intentionally inflict pain and include measures that ensure the person’s airway is not obstructed. Physical restraint that requires the person to be restrained on the floor must ensure that the airway remains clear and there is no compression on the person’s chest that could compromise breathing.
Observation of the person undergoing restraint should continue both during and following the restraint procedure. Medical assistance should be sought if there are any indications that the person is in distress or there are signs of deteriorating health.
Any procedure that involves restriction or restraint should be explicitly set down in writing, dated and signed by those who have responsibility for that procedure e.g. nursing staff.
The following is a guide to what the record should contain, this is not an exhaustive list. However, these should contain at least the following: -
The reason for the restriction or restraint
The names of those consulted
The procedure followed,
The outcome of the restriction or restraint
There are occasions when restriction and/or restraint is necessary to protect an individual or those around them. All restriction and restraint interventions should be carried out in line with national minimum standards and guidelines and documented accurately.
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