The princess and the frog!

1. The princess and the frog! Rosaline Kelly Senior Professional Development Officer

2. Today’s aims • Improved understanding of what makes a practice restrictive; • Provide a framework for practice that embeds a rights based approach and puts the person at the centre of decision making processes.

3. Today’s objectives At the end today delegates will: • Understand what could potentially make a practice restrictive • Understand what a rights based approach means • Understand the importance of working within legal, ethical and professional accountability frameworks • Understand the “Three Steps to Positive Practice” process • Reflect on a number of case studies, identifying where the “Three Steps to Positive Practice” framework could be implemented.

4. Take home message – the princess and the frog

5. In my experience, there are very few decisions in nursing that weigh on us more heavily than whether or not to restrain someone.

6. Staff understanding

7. Definitions “Restrictive practices are those that limit a person’s movement, day to day activity or function” Three Steps to Positive Practice, 2017

8. Definitions Put very simply restrictive practice means actions that stop a person from doing something that they want to do, or doing it in a way that they want to do it. Restrictive practices can also mean actions that make a person do something they do not want to do, or preventing a person from having something that they want

9. What makes a practice restrictive? • Some can be easily identified – locked doors, physically restraining a person • Others are more subtle – only allowing a person to watch television for a certain length of time • Psychological – attempting to exert control or force compliance by what is said, how it is said, and/or use of body language and non verbal communication • Care/treatment not intended to restrict but there are restrictive side effects – sleeping tablets • Control or abuse of a person’s finances • Restrictions necessary for one person could have a negative impact on others they live with • Restrictions because of restrictions placed on others – safeguarding reasons

10. Is it wrong to use restrictive practices? • It is recognised that there are occasions when the use of restrictive practice is unavoidable in order to keep the person and/or others safe from harm. • When restrictive practices are as part of a comprehensive therapeutic plan that is outcomes focussed and fully embraces a person’s rights, and when there is no other way to keep people safe, then they can and often should be used. • In these circumstances, care must be safe, effective, person-centred and provided within legal, ethical and professional accountability structures.

12. Legislation

13. Standards & Guidance

14. Let’s talk about consent! “It is a general legal and ethical principle that valid consent must be obtained before commencing an examination, starting treatment or physical investigation, or providing personal care….is a fundamental part of good practice. A health or social care professional who does not respect this principle may be liable both to legal action by the person and action by their regulatory body.” “While there is no statute here setting out the general principles of consent, case law ("common law") has established that touching an individual without valid consent may constitute the civil or criminal offence of battery. “ Reference Guide to Consent for Examination, Treatment or Care, DHSSPS, 2003

15. Who can give consent? Adults must provide consent on their own behalf. No other person such as a family member, friend or carer and no organisation can give or refuse consent to a health or social care service on behalf of an adult service user who lacks capacity to consent unless they have specific legal authority to do so.

16. What is “capacity”? • The ability to independently make decisions that affect any aspect of care/treatment • All adults are presumed to have capacity to make decisions independently unless proven otherwise • All reasonable help and support must be provided to assist in independent decision making • Lack of capacity cannot be based on age, disability, appearance, behaviour, medical condition (including intellectual disability, mental illness, dementia or scores on tests of cognitive function), beliefs, apparent inability to communicate, or the fact that the decision made seems unwise to the health and social care professional.

17. A rights based approach • Human Rights – Fundamental rights enshrined in the European Convention on Human Rights (ECHR) and incorporated into UK law – Human Rights Act 1998 • Core principles and values that should shape practices and services – FREDA principles

18. Human rights • Article 2 – the right to life – protected by law, cannot be deprived of life save in the execution of a sentence of court… (Absolute right) Death through negligence, severe malnutrition, decisions about life saving healthcare treatment, end of life/assisted suicide

19. Human rights • Article 3 – Prohibition of torture – absolute right not to be tortured or subjected to treatment or punishment that is inhumane or degrading Measures used to control behaviours which in reality are shaming and humiliating, for example: not being allowed to have a meal, or being made to stand outside, as a means of managing a perceived “bad behaviour”

20. Human Rights • Article 5 – Right to liberty and security – right not to be deprived of liberty – “arrested or detained” except in limited cases specified in the article – eg – suspected or convicted of a crime – provided there is proper lawful provision – Mental Health (NI) Order 1986 Measures used to prevent behaviours perceived to be a risk to self or others, for example: improper or inappropriate admission/detention to psychiatric care; use of chairs with straps; use of “time out” or seclusion

21. Human Rights • Article 8 – Right to respect for private and family life – the right to respect for private and family life, home and correspondence (can be restricted only in specified circumstances) Measures which prevent participation in family, social and recreational activities, for example: structural adaptions to accommodation which separate/isolate the person form others they live with; preventing or limiting contact with family or friends; use of restrictive clothing to limit perceived self-harm or inappropriate touch

22. Human Rights • Article 14 - Prohibition of discrimination – the right not to be treated differently because of their race, religion, sex, political views or any personal status, unless this can be justified objectively. Everyone must have equal access to Convention rights, whatever their status Reducing access to services or opportunities available because of perception of risk or lack of resources to allow for suitable adaption and support, for example, a reduced school day; exclusion from social clubs

23. FREDA Principles F R E DA FairnessRespectEquality DignityAutonomy

24. At a unit I worked in as a newly qualified nurse we had an open discussion of restraint criteria and practices with clients. The clients instigated this and the idea put forward by senior staff that any use of force was to maintain the safety of everyone in the unit including the person causing the risk had a surprisingly calming effect on the clients and appeared to reduce the number of incidents in the following days

25. Good Medical Practice The Code: Professional standards of practice and behaviour for nurses and midwives

26. Standards of Conduct and Practice for Social Care Workers 2015 Standards of Conduct... • 1. …you must protect the rights and promote the interests and wellbeing of service users and carers • 3. …you must promote the autonomy of service users while safeguarding them as far as possible from danger or harm • 4. …you must respect the rights of service users while seeking to ensure that their behaviour does not harm themselves or other people • 6. …you must be accountable for the quality of your work and take responsibility for maintaining and improving your knowledge and skills

27. Standards of Conduct and Practice for Social Workers 2015 Standards of Practice… • 2. Maintain an up-to-date knowledge and evidence base for social work. • 6. Assess needs, circumstances, rights, strengths and risks in partnership with those involved and respond appropriately. • 7. Use social work interventions to manage risk and improve outcomes for service users. • 8. Develop yourself and others.

28. Three Steps to Positive Practice

29. Step 1 - Consider and plan • consider if the planned intervention is a restrictive practice using the definition • consider other less restrictive measures • consider if the planned intervention is therapeutic in its intention

30. Step 2 – Implement the safeguards • use a rights based approach within professional accountability and legal frameworks to ensure that any restrictive practice is used only when deemed to be in the person’s best interests

31. Step 3 – Review and reflect • ensure that a regular and timely review of the use of a restrictive practice is built into a therapeutic plan to meet the person’s needs • this must include a plan to reduce or remove the restrictive practice as soon as is possible • ensure appropriate use of professional reflection support systems that consider the impact of the use of restrictive practices

32. SCENARIOS

33. Three Steps to Positive Practice • Framework designed to encourage careful consideration and reflection on the use of restrictive practice, before it is implemented and throughout the entire timeline when the practice may in use. • The process is applicable at the points of assessment, implementation, evaluation and review • It is also applicable in situations where the use of restrictive practices has been in place for some time, or are associated with a particular environment

34. Three Steps to Positive Practice Three steps to positive practice embraces a new way of thinking, the creation of a new culture which will support staff to act differently, with an emphasis on a proactive, evidence based and rights based approach to practice I recently worked with a 17 year old health care apprentice who had been taught positive behaviour support at college; her approach and attitude prevented and defused a number of potentially serious events with severely demented residents when the restrictive, restraining, medicating attitudes of more experienced staff were inflaming the situation

35. Three Steps to Positive Practice • Three steps to positive practice is intended to assist staff to ensure that the decisions they make and the actions they take are consistent with legal, ethical and professional accountability frameworks, every time a decision is made or an action is taken

36. Take home message – the princess and the frog

37. References • Three Steps to Positive Practice: a rights based approach when considering and reviewing the use of restrictive interventions 2017 https://www.rcn.org.uk/professional-development/publications/pub-006075 • Three Steps to Positive Practice – video https://www.youtube.com/watch?v=vqWvP8bljg4&feature=youtu.be • Principles of Consent: guidance for nursing staff https://www.rcn.org.uk/professional-development/publications/pub-006047 • The NMC Code: Professional standards of practice and behaviour for nurses and midwives 2015 https://www.nmc.org.uk/standards/code/ • Reference Guide to Consent for Examination, Treatment or Care https://www.health-ni.gov.uk/publications/consent-guides-healthcare-professionals • Regulatory regulations and standards: https://www.rqia.org.uk/guidance/legislation-and-standards/ • Standards of Conduct and Practice for Social Care Workers 2015 https://niscc.info/registration-standards/standards-of-conduct-and-practice

38. https://youtu.be/vqWvP8bljg4